Is the fast-track process efficient and safe for older adults admitted to the emergency department?

BACKGROUND: The efficiency of the fast-track (FT) process in the management of patients in Emergency Departments is well demonstrated, but there is a lack of research focused on older adults. The aim of our study was to verify whether the FT process is efficient and safe for older adults admitted to ED. METHODS: Observational case-control single-centre study. RESULTS: Five hundred four cases and 504 controls were analysed. The mean age was 75 years, and there was a predominance of women. In total 96% of subjects were classified with a "less-urgent" tag. The length of stay was significantly lower in the fast-track group than in the control group (median 178 min, interquartile range 184 min, and 115 min, interquartile range 69 min, respectively, p < 0.001), as well as the time spent between the ED physician's visit and patient discharge (median 78 min, interquartile range 120 min, and median 3 min, interquartile range 6 min, respectively, p < 0.001). There weren't any increases in the number of unplanned readmissions within 48 h, 7 days and 30 days. CONCLUSIONS: The fast-track appears to be an efficient and safe strategy to improve the management of older adults admitted to the ED with minor complaints.

Heavy metals in human amniotic fluid: a pilot study.

OBJECTIVE: Many heavy metals are essential nutrients for a healthy life. However, significant evidence supports prolonged prenatal exposure as a risk factor for several adverse health effects. The aim of this study is to evaluate the presence of heavy metals in human amniotic fluid (AF) to demonstrate that there is an early fetal in utero exposure. METHODS: The concentrations of a variety of heavy metals, including Be, Ag, Ba, Pb, U, Hg, Sr, Cu, Mn, V, Pd, Sn, Sb, Te, Pt, Sc, Tl, Ni, As, Co, Zn and Se, were measured in 25 AF samples obtained from amniocentesis between 15 and 18 weeks of gestational, after informed consent. RESULTS: Be, Ag, Ba, Pb, U, Cu, Sr, Mn, V, Sn, Te, Pt, As, Tl, Sb, Co, Se and Zn concentrations were detected in measurable amounts in second trimester AF. Mg levels are elevated in all samples. Pd, Ni, Sc and Hg concentrations are below the detection limits in all samples. CONCLUSION: This study demonstrates that heavy metals pass into and accumulate in AF from a very early stage of gestation. Other studies are needed to evaluate the long-term health effects of this early exposure.

Environment and women's reproductive health.

BACKGROUND: There is significant evidence that continuous and prolonged exposure to several endocrine disrupting chemicals (EDC) is a risk factor for reduced fertility and fecundity in women. There is also evidence that ED exposure has trans-generational effects. In this systematic review, we evaluate the evidence for an association between EDC exposure and women's reproductive health. METHODS: Studies were found by searching the PubMed database for articles published up to 2010. Associations between ED exposure and women's reproductive health reported in the PubMed database are summarized and classified as fertility and fecundity, pregnancy outcomes, transgenerational exposure and effects. RESULTS: Epidemiological studies on EDCs are not always consistent, in part due to limitations imposed by practical constraints. In order to make progress in this field, we recommend taking advantage of biomonitoring and biobanks, including the development of appropriate biomarkers, and taking into greater consideration modulating factors such as genetic polymorphisms and dietary habits. Further human studies are warranted with particular focus on impaired fertility/fecundity associated with currently widespread ED (e.g. bisphenol A, phthalates and polybrominated flame retardants). CONCLUSIONS: A detailed appraisal of compounds specifically related to adverse reproductive outcomes is very important for prevention and risk-communication strategies. Besides research needs, the current evidence is sufficient to prompt precautionary actions to protect women's reproductive health.

Serum CA125 level modifications in women undergoing repeated IVF cycles.

In the present paper, serum CA125 modifications in patients undergoing their first IVF cycle were compared with those of patients in their second attempt. A significant increase of this marker was detected in each group of patients at day 14 after embryo transfer. However, the level of CA125 monitored in the patients in their second attempt was significantly higher than that determined in patients undergoing their first ovarian stimulation. This condition does not influence either ovarian response or oocyte and embryo quality. Moreover similar IVF outcome was obtained. Therefore we propose that patients undergoing repeated assisted reproductive technology (ART) cycles may suffer from ovarian surface epithelial damage and/or altered cellular growth rate.

Signal-averaged ECG abnormalities in haemodialysis patients. Role of dialysis.

BACKGROUND: Late potentials (LP) on the signal-averaged electrocardiogram (SAECG) are predictive of malignant ventricular arrhythmias and sudden cardiac death in patients with ischaemic and non-ischaemic cardiomyopathy. Cardiac dysfunction, both regional and global, as well as supraventricular and ventricular arrhythmias are reported in a high percentage of patients with end-stage renal failure (ESRF). The aim of the study was to assess the prevalence of LP and the effects of haemodialysis on the SAECG of ESRF patients. METHODS: SAECG was recorded immediately before and within 30 min after the end of dialysis in 48 patients in sinus rhythm, free of conduction disturbances on ECG and of signs of congestive heart failure. Serum electrolytes were sampled together with the SAECG recordings. An echo-Doppler exam was performed within 2 weeks of the study. SAECGs were adequate for analysis in 45/48 patients. LP were present when at least two of the following criteria were fulfilled: QRS duration < or = 115 ms, LAS40 < or = 38 ms, RMS40 > or = 38 microV at 40 Hz high pass bidirectional filter, and noise <0.7 microV. RESULTS: LP were detected in 12/45 patients (25%) on the SAECG before dialysis; of these 12 patients, seven had a history of a previous myocardial infarction and two had documented coronary artery disease (CAD). A significant greater wall motion score index--calculated on a 16 segment model--was reported in patients with LP (1.20+/-0.20 vs 1.01+/-0.03, P<0.01), while left ventricular mass was comparable in the two groups of patients. At the end of dialysis, a significant prolongation of fQRS duration was found both at 25 and 40 Hz filters (from 98+/-11 to 106+/-16 ms and from 97+/-12 s to 102+/-13 ms, respectively, P<0.001). A significant inverse relationship was seen between the percentage of dialysis-induced serum potassium reduction and fQRS changes at 40 Hz (r=-0.68, P<0.001). CONCLUSIONS: LP were detected in a significant proportion of dialysis patients, probably related to underlying CAD with left ventricular dysfunction. Prolongation of fQRS after dialysis could be explained by the acute reduction in serum potassium levels.

Modification of inositol 1,4,5-trisphosphate concentration of human erythrocytes under "in vivo" physiological conditions.

The concentration of inositol 1,4,5-trisphosphate (InsP3) in erythrocytes from volunteers has been found to modify following strenuous physical exercise. The basal value was almost regained within some 75 min after the completion of the effort. The concurrent variations of pH and blood lactate have also been evaluated. Our results represent, to our knowledge, the first evidence of in vivo induced intraerythrocyte InsP3 modification. They reinforce the idea of the participation of its precursor phosphatidylinositol 4,5-bisphosphate (PtdIns4,5-P2) in red bood cell shape regulation by contributing to the interactions between membrane and cytoskeleton components.

[Reflex syncope as a preliminary symptom of a rhinopharyngeal lymphoma. A case report]. / Sincope riflessa come sintomo d'esordio di un tumore del rinofaringe. Descrizione di un caso clinico.

The authors report a 57 year old patient affected by rhinopharyngeal NH lymphoma that appeared as a parapharyngeal space lesions-syncope syndrome. The activation of a cardioinhybitory reflex by the stimulation of the glossopharyngeal nerve seems to be the pathogenetic basis for his syndrome.

[Changes in pacemakers and the wearers of pacemakers as a result of the use of different electromagnetic energy sources]. / Alterazioni nei pacemaker e nei portatori dei pacemaker in conseguenza dell'uso di varie sorgenti di energia elettromagnetica.

Over the past decade there have been considerable advances in cardiac electrostimulation technologies. However, there are still reports of electromagnetic interference with pacemakers and pacemaker patients. We have studied the effects of various electromagnetic sources (short-wave diathermy, electrosurgical knives, electrotherapy and radiofrequencies) on both humans and animals. The results of the studies were completely negative and, therefore, we are convinced that today's pacemakers are much more reliable and hence less subject to interference from external electromagnetic sources. We performed the following tests: (a) Short-wave diathermy: various electrode positions in pigs and 8 patients with pacemakers. (b) Electrosurgical knives: several tests on pigs with unipolar electrosurgical knife; 6 tests on humans during automatic defibrillator implantation using two-pole electrosurgical knives; 23 pacemaker patients underwent abdominal surgery (3 inguinal hernias, 12 gastric resections; 6 cholecystotomies, 2 aortic aneurysms-with two-pole electrosurgical knives). (c) Electrotherapy (TENS): on pigs. (d) Radiofrequency (RF) for transcatheter ablation-several tests on pigs.

Methanol detoxification by enzyme-loaded erythrocytes.

Alcohol oxidase (AlOx) from Pichea pastoris (a methylotrophic yeast) was encapsulated into human and murine erythrocytes up to 2 units/ml of packed cells. This enzyme has a much higher affinity for methanol than for ethanol, thus making the loaded erythrocytes useful cellular bioreactors able to catabolize methanol. Enzyme-loaded erythrocytes showed an increased rate of the hexose-monophosphate-shunt activity and a significant methaemoglobin production. However, the in vivo survival of these cells does not seem to be significantly affected by methanol catabolism. In vivo, mice receiving AlOx-loaded erythrocytes were able to keep the blood methanol concentrations below values that were about 50% of those found in mice receiving unloaded cells and similar amounts of methanol. Thus AlOx-loaded erythrocytes may add an important contribution to the detoxification protocol against methanol poisoning.

[Risk stratification in patients with a first myocardial infarct based on simple clinico-instrumental variables]. / Stratificazione del rischio in pazienti con primo infarto miocardico in base ad alcune semplici variabili clinico-strumentali.

UNLABELLED: It is an acknowledged fact that the prognosis for patients with a first myocardial infarction depends mainly on the degree of residual left ventricle function. We wanted to evaluate the importance that certain simple clinical and instrumental variables can have in stratifying post-infarction cardiovascular risk with particular emphasis on chronic obstructive lung disease (COLD). We selected 97 out of the 512 patients treated in the coronary intensive care unit (CICU) from February 1, 1988 to October 31, 1990 according to the following criteria: First myocardial infarction; no cardiogenic shock; no serious concomitant diseases with considered negative prognosis within 6 months. The following variables were considered for all the patients: age; sex; positive family history for ischemic heart disease; history of diabetes mellitus; arterial hypertension; previous cerebrovascular incident; history of obstructive arteriopathy of the lower limbs, of angor and COLD. The following tests were performed on all the patients: echocardiogram prior to discharge form the CICU; angiocardioscintigraphy with Tc-99 between the 20th and 30th day following the acute event; bicycle ergometer stress test on the 30th day. END POINTS: general mortality; cardiac mortality; non-fatal reinfarction; residual angina at 3 months. All the patients were treated with aspirin (325 mg/die) and/or heparin (12,500 units subcutaneously). All 97 patients were monitored for a mean follow-up time of 19.8 months. General mortality was 2.08% (for reinfarction) 24 (24.7%) non-fatal cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)

Red blood cells as an antigen-delivery system.

The use of adjuvants is usually required to induce strong immunological responses to protein antigens. However, in many cases these adjuvants cannot be extensively applied in human and veterinary vaccinations because of associated inflammatory reactions or granuloma formation. We show here that protein antigens (bovine serum albumin, hog liver uricase, and yeast hexokinase), coupled to autologous red blood cells by way of a biotin-avidin-biotin bridge, elicit an immunological response in mice similar to or higher than that obtained by the use of Freund's adjuvant. Quantities as low as 0.5 micrograms/mouse are high enough to generate these immunological responses. Furthermore, splenocytes of mice immunized by red blood cell-coupled antigens can be used to generate hybridomas secreting monoclonal antibodies. Thus, the delivery of antigens by autologous red blood cells is an effective way to avoid the use of adjuvants for producing anti-peptide antibodies and possibly to generate peptide vaccines.

Glucose 1,6-bisphosphate-overloaded erythrocytes: a strategy to investigate the metabolic role of the bisphosphate in red blood cells.

Human erythrocytes overloaded with glucose 1,6-bisphosphate were prepared in order to establish the metabolic significance of this phosphorylated sugar in the intact red cell. The intracellular glucose 1,6-bisphosphate concentration was increased six- and twofold over the normal level by encapsulating (i) the commercially available compound and (ii) the glucose 1,6-bisphosphate synthase obtained from rabbit skeletal muscle, respectively. In both experimental conditions, a reduction of glucose utilization by the loaded cells was observed after reequilibration to the steady state. At the steady state, the concentrations of the glycolytic intermediates and of the adenine nucleotides appeared substantially unmodified when compared with those of controls, with the exception of a 50% reduction of glucose and fructose 6-phosphate measured in erythrocytes encapsulated with exogenous glucose 1,6-bisphosphate. Under the considered experimental conditions, the elevated intracellular glucose 1,6-bisphosphate appears to display an inhibitory effect on hexokinase that overcomes the possible activation of phosphofructokinase or pyruvate kinase.

Human red blood cells as bioreactors for the inactivation of harmful xenobiotics.

Human red blood cells are able to inactivate lipophilic electrophiles by conjugation with reduced glutathione. This metabolic ability was found to be limited by the rate of permeation of the xenobiotic into erythrocytes and by the amount of available reduced glutathione. By a procedure of hypotonic dialysis, isotonic resealing and reannealing human red blood cells were overloaded with increasing amounts of reduced glutathione up to three- to fourfold the normal level without modification of their metabolic functions or of their energetic state. These overloaded erythrocytes were able to conjugate increasing amounts of xenobiotics and to export the resulting conjugates from the cells. These properties of glutathione overloaded erythrocytes are significant for the use of carrier erythrocytes in cases of acute intoxication by lipophilic electrophiles.

Cell age dependent decay of human erythrocytes glutathione S-transferase.

Human red blood cells contain both glutathione S-transferase sigma (GST sigma) and glutathione S-transferase rho (GST rho). While the first isozyme does not change in red blood cell fractions of different mean density (age), GST rho, the main isozyme, shows a pronounced cell age dependent decay. Ion-exchange chromatographic experiments show that GST rho consists of only one isozymic form in young erythrocytes but is present in two components, with different electric charge, in mature and old cells. The "secondary" GST rho isozyme is more heat stable than the "primary" GST rho isozyme with the result that the total GST activity shows an apparent increase in heat stability during cell aging due to the formation of "secondary" isozymes. The kinetic properties and specificity of this enzyme do not show appreciable modifications during cell ageing. The data reported in this paper suggest that red blood cell aging is associated with a reduced detoxifying ability due to GST rho decay.

Purine nucleoside phosphorylase from human erythrocytes: a kinetic study of the fully separated isoenzymes.

Human red cell lysates contain at least seven electrophoretically distinct isoenzymes of purine-nucleoside phosphorylase (PNPase); the proportion of more anodal bands increases as the erythrocyte ages, suggesting that the native enzyme is subjected to progressive post-translational modifications. The age dependent electrophoretic changes observed in the hemolysate are associated with the downward curvature of the Lineweaver-Burk double reciprocal plot at high inosine-substrate concentrations unlike the single-banded PNPase from tissue cultures of rapidly dividing cells. Thanks to the high resolution power of the ion-exchange HPLC technique utilized we have been able to fully separate all the seven isoenzymes and correlate structural to functional modifications in PNPase from human erythrocytes. Our results indicate that the downward curvature of Lineweaver-Burk plot is not due to a mixture of isoforms with low and high Km for inosine but that the allosteric activation by the inosine substrate is the direct consequence of structural modification(s) on the "primary" form of the enzyme.

Specificity of glucose 1,6-bisphosphate synthesis in rabbit skeletal muscle.

1. To compare glucose 1,6-bisphosphate synthesis in different types of cells, we partially purified (2000-fold) a glycerate 1,3 P2-dependent glucose 1,6-bisphosphate synthase from rabbit skeletal muscle. 2. In agreement with the results reported by others for mouse brain and pig skeletal muscle, the enzyme can be separated from bulk phosphoglucomutase (PGM) activity by DEAE-cellulose chromatography of crude cellular extract. This cannot be achieved on human hemolysates where glycerate 1,3-P2-dependent glucose 1,2-bisphosphate synthesis is displayed only by multifunctional PGM2 isoenzymes. 3. The Km values for glycerate 1,3-P2 (0.50 microM), glucose 1-phosphate (90 microM), Mg2+ (0.22 mM), and also pH optimum (7.8) and mol. wt (70,000) of the rabbit skeletal muscle enzyme are similar to those of the enzymes from mouse brain and human red blood cells, but they differ from those reported for the pig skeletal muscle enzyme.