Comment on Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357.

We read the article of Savioli G. et al. [...].

Dependence of bronchoconstrictor and bronchodilator responses on thoracic gas compression volume.

BACKGROUND AND OBJECTIVE: During forced expiration, alveolar pressure (PALV ) increases and intrathoracic gas is compressed. Thus, 1-s forced expiratory volume measured by spirometry (FEV1-sp ) is smaller than 1-s forced expiratory volume measured by plethysmography (FEV1-pl ). Thoracic gas compression volume (TGCV) depends on the amount of gas within the lung when expiratory flow limitation occurs in the airways. We therefore tested the hypothesis that bronchoconstrictor and bronchodilator responses using FEV1-sp are biased by height and gender, which are major determinants of lung volume. METHODS: We studied 54 asthmatics during methacholine challenge and 55 subjects with airway obstruction (FEV1-sp increase >200 mL and >12% after salbutamol) measuring at the same time FEV1-sp or FEV1-pl . RESULTS: During methacholine challenge, TGCV increased more in males than females, correlated with PALV , total lung capacity (TLC) and height, and the provocative dose was lower using FEV1-sp than FEV1-pl . With salbutamol, FEV1-pl increased <200 mL and <12% in 28 subjects, predominantly tall males, with larger TLC, TGCV and PALV . CONCLUSIONS: Bronchoconstrictor and bronchodilator responses are overestimated by standard spirometry in subjects with larger lungs because of TGCV.

Short-term variability in respiratory impedance and effect of deep breath in asthmatic and healthy subjects with airway smooth muscle activation and unloading.

Inspiratory resistance (RINSP) and reactance (XINSP) were measured for 7 min at 5 Hz in 10 subjects with mild asymptomatic asthma and 9 healthy subjects to assess the effects of airway smooth muscle (ASM) activation by methacholine (MCh) and unloading by chest wall strapping (CWS) on the variability of lung function and the effects of deep inspiration (DI). Subjects were studied at control conditions, after MCh, with CWS, and after MCh with CWS. In all experimental conditions XINSP was significantly more negative in subjects with asthma than in healthy subjects, suggesting greater inhomogeneity in the former. However, the variability in both RINSP and XINSP was increased by either ASM activation or CWS, without significant difference between groups. DI significantly reversed MCh-induced changes in RINSP both in subjects with asthma and healthy subjects, but XINSP in the former only. This effect was impaired by CWS more in subjects with asthma than in healthy subjects. The velocity of RINSP and XINSP recovery after DI was faster in subjects with asthma than healthy subjects. In conclusion, these results support the opinion that the short-term variability in respiratory impedance is related to ASM tone or operating length, rather than to the disease. Nevertheless, ASM in individuals with asthma differs from that in healthy individuals in an increased velocity of shortening and a reduced sensitivity to mechanical stress when strain is reduced.

Factors influencing desired and received analgesia in emergency department.

Oligoanalgesia in Emergency Departments (ED) is known to be common. The aim of our study is to determine how often patients in pain desire and receive analgesics while in the ED. Four main outcomes have been considered: desire of analgesics, administration of analgesics in the ED, correlation between initial analgesic administration and triage priority scores, patients' satisfaction at discharge during the ED visit. Pain severity was evaluated by a 10-point numerical rating scale (0 = no pain, 10 = worst possible pain) A total of 393 patients were enrolled in the study. The majority were non-Hispanic whites with a median age of 62 years. Of the 393 patients, 202 expressed desire for analgesics, but only 146 received a treatment. Among patients refusing analgesics (48.6%), the most common reasons were to diagnose pain causes and pain tolerance. In multivariate analysis, pain score severity was significant factor that predicted wanting analgesics, whereas desiring analgesics was predictive factor to receive them. On the other hand, patients with pain localized in lower extremities and in nose or ear less probably received analgesia. In conclusion, the underuse of analgesics in the ED continues to represent a problem and our study demonstrates that half of all ED patients in pain desire analgesics and that only half of those wanting analgesics receive them. Patients that desired and received analgesic treatment represented the group with a higher degree of satisfaction.

Nontraumatic headaches in the emergency department: evaluation of a clinical pathway.

OBJECTIVE: To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED). BACKGROUND: Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence-based operative protocol are lacking. METHODS: A before-after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6-month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED. RESULTS: A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: -11.3%, 95% confidence intervals [CI]: -18.7% to -3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: -5.7%, 95% CI: -10.6% to -0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: -3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 +/- 102 minutes vs 180.5 +/- 105 minutes, difference: -9.8 minutes, 95% CI: -20.3 to 5.7; P = .09). A 6-month follow-up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: -0.33%, 95% CI: -2.1% to 0.9%; P = .5). CONCLUSIONS: Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.

Multiple abscesses in brucellosis with Wright's test negativity.

We report a case of metastatic abscesses caused by a chronic form of brucellosis in a shepherd. When she was admitted the patient was cachectic with haematological signs of phlogosis. An abdominal computed tomography scan revealed the presence of multiple hepatic and renal abscesses with a fluid mass in the abdominal wall. The blood cultures, tuberculin skin test, and Wright reaction all gave negative results, but the brucellosis Coombs test for Brucella species was highly positive. Diagnosis was confirmed by a high titre of anti-Brucella IgM antibodies. The patient started antibiotic treatment with a progressive clinical improvement, but after discharge she was lost to follow-up and died 7 months later.

Mechanical response to methacholine and deep inspiration in supine men.

The effects of supine posture on airway responses to inhaled methacholine and deep inspiration (DI) were studied in seven male volunteers. On a control day, subjects were in a seated position during both methacholine inhalation and lung function measurements. On a second occasion, the whole procedure was repeated with the subjects lying supine for the entire duration of the study. On a third occasion, methacholine was inhaled from the seated position and measurements were taken in a supine position. Finally, on a fourth occasion, methacholine was inhaled from the supine position and measurements were taken in the seated position. Going from sitting to supine position, the functional residual capacity decreased by approximately 1 liter in all subjects. When lung function measurements (pulmonary resistance, dynamic elastance, residual volume, and maximal flows) were taken in supine position, the response to methacholine was greater than at control, and this was associated with a greater dyspnea and a faster recovery of dynamic elastance after DI. By contrast, when methacholine was inhaled in supine position but measurements were taken in sitting position, the response to methacholine was similar to control day. These findings document the potential of the decrease in the operational lung volumes in eliciting or sustaining airflow obstruction in nocturnal asthma. It is speculated that the exaggerated response to methacholine in the supine posture may variably contribute to airway smooth muscle adaptation to short length, airway wall edema, and faster airway renarrowing after a large inflation.