Research in emergency medicine in Europe Miró, O`scar; Burillo-Putze, Guillermo
European journal of emergency medicine,
2012-April, 2012-Apr, 2012-04-00, 20120401, Letnik:
19, Številka:
2
Journal Article
Recenzirano
Health research is fundamental for clinical excellence, a fact that applies equally to emergency medicine (EM). Although European scientific publication rates in EM have traditionally been lower than ...those of other medical specialties, from 1995 steady progress has been made. To increase the scientific output in EM it is necessary to resolve issues that hinder this progress, including the fact that EM is a new specialty, or even nonexistent in many European countries. This has resulted in a relative lack of scientific culture and training in research methodology of emergency physicians, of explicit recognition of scientific work, or of emergency physician competitiveness to apply to national and European grants for research projects. In addition, it is necessary to improve representation of European journals indexed in the category of EM and to receive a firm boost to EM research from the European Society for Emergency Medicine as well as from all European national societies. This study reviews these aspects and offers a personal perspective on where European EM research should be going.
A limitation in the use of classic neuroleptic drugs is the eventual appearance of extrapyramidal symptoms. Some studies, mainly based on experimental situations, have related these symptoms with a ...defect in the mitochondrial electron transport chain (ETC), especially with complex I (CI). One of the advantages of the "atypical" neuroleptics is a lower incidence of movement disorders. We studied peripheral blood mononuclear cells from naive schizophrenic patients (n = 25) and patients under chronic treatment with 1 "typical" neuroleptic (haloperidol, n = 15) or 1 "atypical" neuroleptic (risperidone, n = 23; or clozapine, n = 21). Patients were on standard clinical situation, on treatment for at least 28 months, and did not present signs or symptoms of extrapyramidal dysfunction. Absolute enzyme activities of ETC complexes I to IV were spectrophotometrically quantified, and oxygen consumption with substrates of different complexes was measured polarographically. As an indirect measure of oxidative damage, we quantified membrane lipid peroxidation through the loss of cis-parinaric acid fluorescence. We found differences among groups when comparing the activity of CI, which was decreased in patients receiving neuroleptics, either assessed enzymatically or through oxygen consumption. This effect was lower for atypical neuroleptics than for haloperidol. Haloperidol was also associated with a significant increase of peripheral blood mononuclear cell membrane peroxidation. We conclude that antipsychotics given at clinical standard doses, either typical or atypical, inhibit CI of the ETC. It remains to be established if this finding in a nontarget tissue for antipsychotics may account for the lower incidence of movement disorders observed in patients on atypical agents.
Background/Purpose
We investigated the incidence, risk factors, clinical characteristics and outcomes of acute pancreatitis (AP) in patients with COVID‐19 attending the emergency department (ED), ...before hospitalization.
Methods
We retrospectively reviewed all COVID patients diagnosed with AP in 62 Spanish EDs (20% of Spanish EDs, COVID‐AP) during the COVID outbreak. We formed two control groups: COVID patients without AP (COVID‐non‐AP) and non‐COVID patients with AP (non‐COVID‐AP). Unadjusted comparisons between cases and controls were performed regarding 59 baseline and clinical characteristics and four outcomes.
Results
We identified 54 AP in 74 814 patients with COVID‐19 attending the ED (frequency = 0.72‰, 95% CI = 0.54‐0.94‰). This frequency was lower than in non‐COVID patients (2231/1 388 879, 1.61‰, 95% CI = 1.54‐1.67; OR = 0.44, 95% CI = 0.34‐0.58). Etiology of AP was similar in both groups, being biliary origin in about 50%. Twenty‐six clinical characteristics of COVID patients were associated with a higher risk of developing AP: abdominal pain (OR = 59.4, 95% CI = 23.7‐149), raised blood amylase (OR = 31.8; 95% CI = 1.60‐632) and vomiting (OR = 15.8, 95% CI = 6.69‐37.2) being the strongest, and some inflammatory markers (C‐reactive protein, procalcitonin, platelets, D‐dimer) were more increased. Compared to non‐COVID‐AP, COVID‐AP patients differed in 23 variables; the strongest ones related to COVID symptoms, but less abdominal pain was reported, pancreatic enzymes raise was lower, and severity (estimated by BISAP and SOFA score at ED arrival) was higher. The in‐hospital mortality (adjusted for age and sex) of COVID‐AP did not differ from COVID‐non‐AP (OR = 1.12, 95% CI = 0.45‐245) but was higher than non‐COVID‐AP (OR = 2.46, 95% CI = 1.35‐4.48).
Conclusions
Acute pancreatitis as presenting form of COVID‐19 in the ED is unusual (<1‰ cases). Some clinically distinctive characteristics are present compared to the remaining COVID patients and can help to identify this unusual manifestation. In‐hospital mortality of COVID‐AP does not differ from COVID‐non‐AP but is higher than non‐COVID‐AP, and the higher severity of AP in COVID patients could partially contribute to this increment.
Highlight
Miró and colleagues found that acute pancreatitis was less frequent in COVID patients than in non‐COVID patients attending the emergency department, suggesting the absence of a direct relationship with SARS‐CoV‐2. This report is the first to present the distinctive characteristics of COVID patients at increased risk of presenting acute pancreatitis.
Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at ...primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.
Objectives
To evaluate whether the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) scale for 30‐day prediction of mortality is applicable to elderly adults with acute heart failure (AHF) ...in emergency departments (EDs) and whether discriminatory power is added with the inclusion of the Barthel Index (BI) to this scale (BI‐EFFECT scale).
Design
BI‐EFFECT is a multipurpose, nonintervention, multicenter cohort study.
Setting
Twenty EDs.
Participants
Individuals aged 65 and older with AHF.
Measurements
Information on baseline and episode characteristics and 30‐day mortality was collected, and participants were categorized according to the EFFECT scale. Baseline degree of functional dependence was measured using the BI. Receiver operating characteristic (ROC) curves were made of the EFFECT and BI‐EFFECT scales to predict mortality.
Results
One thousand sixty‐eight participants were included. Thirty‐day mortality was 5.1% and was directly and independently associated with high and very high risk categories of the EFFECT scale and with severe dependence. These two variables remained significant after adjustment of the model for both (OR = 4.5, 95% CI = 1.8–11.1 and OR = 2.9, 95% CI = 1.6–5.4, respectively). The EFFECT and the BI‐EFFECT scales had significant ROC curves (area under the ROC curve (AUC) = 0.69, 95% CI = from 0.62 to 0.76; and AUC = 0.75, 95% CI = 0.69–0.81, respectively), and the difference in discriminatory power between the second and the first was also statistically significant (P = .02).
Conclusion
The EFFECT scale may be applied in the elderly population, and inclusion of functional status according to the BI in the new BI‐EFFECT scale significantly improves the model for the prediction of 30‐day mortality.
Objective
To investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF).
Methods
We analyzed AHF patients enrolled in 11 ...Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference.
Results
Of 1800 patients meeting entry criteria (median age 84 years (IQR = 77–89), 56% female), their median QTc was 453 ms (IQR = 422–483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00–3.45), and increased up to OR = 10.5 (2.25–49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04–6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30–49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc OR = 1.45 (1.00–2.09) for QTc = 381 ms, OR = 5.88 (1.25–27.6) for the shortest QTc of 200 ms, and also increasing for prolonged QTc OR = 1.06 (1.00–1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00–4.62) for QTc = 588 ms. QTc was not associated with prolonged hospitalization.
Conclusion
In ED AHF patients, initial QTc provides independent short-term prognostic information, with increasing QTc associated with increasing mortality, while both, shortened and prolonged QTc are associated with need of hospitalization.
Graphical abstract
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