Magnesium sulphate in the Emergency Department: an old, new friend.

With our study, we searched the medical literature to find magnesium (Mg) correlation with Emergency situations or its use in Emergency Medicine. Our aim is to fill the gap that we find in our daily routine between Mg studies on its role in Emergency and the real conception that doctors have of it in medical practice. We searched the literature for terms as magnesium or magnesium sulphate, magnesium in emergency, eclampsia, arrhythmias, acute asthma exacerbation, magnesium, and pediatric population. After a thorough research, we divided our discoveries into chapters to sort out a large amount often discordant articles.

Endocarditis sustained by Streptococcus viridans with normal levels of procalcitonin: an unexpected finding.

OBJECTIVE: Procalcytonin is a useful marker of bacterial infections. Several studies have reported elevated serum levels of PCT in patients with infective endocarditis (IE) and/or other infections sustained by cocci. We report a rare case of IE attributed to Streptococcus viridans in whom levels of PCT were normal. CASE REPORT: A 67 years-old male was admitted to the Emergency Department for a 25-day history of recurring night fever. Upon admission, patient underwent blood test, including PCT, showing normal levels, except for a slight increased creatinine concentration (1.6 mg/dl). CBC showed WBC levels of 10.24 x 10^9/l with neutrophil concentration of 8.64 x 10^9/l. Three blood culture were performed, and all of them were positive for Streptococcus viridans (S. oralis). Dosage of PCT was then repeated two times within the next 2 days after the admission, with negative results. An echocardiogram was performed, showing a lesion of the left anterior aortic leaflet. This finding was confirmed by a transoesophageal echocardiogram. The patient was then treated with G penicillin (6 million of Units quid) for 3 weeks; during the course of antibiotic therapy fever disappeared and blood cultures become negative. CONCLUSIONS: In the literature, there are just few data about the association between PCT levels and endocarditis and sepsis but there are not etiological differentiations particularly for those sustained by Streptococcus viridans. Only one study suggests that a Streptococcus viridans' infection could reduce PCT accuracy in diagnosis oh endocarditis. So, our observation although come from a single case, could merits, further investigation.

A bedside test for Clostridium Difficile infection: an Emergency Department use. Preliminary results.

OBJECTIVE: Clostridium Difficile (CD) infection is a severe cause of diarrhea in patients with prolonged hospitalization and/or previously treated with antibiotics. CD's A and B toxins are responsible for either diarrhea or septical status as well as other complications including toxic megacolon. Toxins isolation, usually performed by a central microbiological laboratory (CML), is mandatory for the final diagnosis of the disease. The clinical suspect of CD infection (CDI) results in the isolation of the patients, until the fecal test does not exclude the disease. Positive patients need to maintain isolation and start a specific antibiotic therapy. The aim of this study was to verify the sensitivity and specificity of a rapid test for the diagnosis of CDI. PATIENTS AND METHODS: We enrolled 20 (13F/7M, mean age 70 ± 12 yrs) consecutive pts who accessed the Emergency Department (ED) with diarrhea and a clinical suspect of CDI. An immune-enzymatic bedside test (Beta Dignostici, Messina, Italy) for the detection of GDH, toxin A and B of CD was used. The results of this test were then compared to the CML one's, on the same patient. RESULTS: 6 patients resulted positive to the bedside test compared to 7 of CML test (86% of concordance). In this patient, the bedside test showed a strong positivity for GDH without signs of toxin, meanwhile the CML test revealed the toxins. Possibly, the lower toxins concentration in this patient was responsible for such discordance. Both tests showed a full concordance for negative patients. Another interesting finding is that the bedside test provides results in only 5 minutes, compared to several hours (even 48) of CML test. CONCLUSIONS: The bedside test is a rapid and affordable tool for rapid diagnosis of CD infection especially in a ED where the positivity of the test affects either hospitalization or treatment.

Paracetamol-codeine compared to ketorolac for pain control in the Emergency Department.

OBJECTIVE: Paracetamol /codeine has shown a strong analgesic activity in several studies conducted among different kind of subjects, including those with trauma. Nevertheless, its efficacy in patients accessing the Emergency Department (ED) for different kind of pain has never been tested. PATIENTS AND METHODS: This is a cross-sectional, observational, prospective, cohort study. Inclusion criteria were patients > 18 year old presenting to the ED for localized traumatic or inflammatory pain involving only extremities. Numeric scale (NRS) was recorded thirty minutes and two hours after the administration of the analgesic therapy, consisting of 15 mg of ketorolac or 1000 mg/60 mg of paracetamol/ codeine, both orally. RESULTS: Two-hundred patients were consecutively enrolled; 87 were treated with paracetamol/codeine and 113 with ketorolac. The combination paracetamol/codeine resulted to be not inferior to ketorolac in non-traumatic pain group and trauma group (p = 0.635 and p = 0.482, respectively). Compared to ketorolac, the combination paracetamol/codeine exerted a significantly higher analgesic activity in patients with fractures and muscular pain (p = 0.044) and was more effective in acute pain (p = 0.002), with a significant effect two hours after the administration (p = 0.029). CONCLUSIONS: Paracetamol/codeine is equivalent to ketorolac in non-traumatic pain and post-traumatic pain, but is superior in acute pain and in patients with fractures and muscular pain. Those results play in favor of the use of the combination paracetamol/codeine in patients accessing the ED for non-traumatic or traumatic pain of the extremities.

Safety and efficacy of the combination acetaminophen-codeine in the treatment of pain of different origin.

BACKGROUND: Pain is the most common reason people see doctors in developed Countries and a very common cause of access in Emergency Department (ED). The combination acetaminophen/codeine represents the standard medication in the second step of the WHO analgesic scale and codeine is one of the most commonly used opioid analgesic for a variety of pain conditions. However, many aspects related to safety and efficacy are still undefined. AIM: To summarize and review the results of the most relevant studies on the efficacy and safety profile of acetaminophen/codeine combination in the treatment of pain of different origin. MATERIALS AND METHODS: We performed a literature search to identify and evaluate all relevant english-language randomized controlled trials (RCTs), meta-analyses and reviews about the codeine plus paracetamol combination in the treatment of pain from any source. RESULTS: Acetaminophen/codeine combination is effective in the treatment of moderate to severe pain in all setting analyzed in this study, which include headache, postoperative, osteoarticular and post-traumatic. The best results in terms of safety and efficacy have been obtained in postoperative pain. Efficacy of acetaminophen/codeine combination is not inferior to NSAIDs. CONCLUSIONS: Acetaminophen/codeine combination is effective in the treatment of pain, through a synergistic action of the two molecules, and is not inferior to NSAIDs. Side effects of acetaminophen/codeine are usually minor, differently from NSAIDs, which may induce some potentially life threatening conditions.

Assessment of baseline characteristics and risk factors among Emergency Department patients presenting with recent onset atrial fibrillation: a retrospective cohort study.

BACKGROUND: The Cardioversion of Atrial Fibrillation in Emergency (CAFE) study was an observational, retrospective, multicenter study focusing on patients with recent onset atrial fibrillation (AF) seen in six different Emergency Departments (ED) of Rome, Italy. AIM: The aim of this study was to present the baseline characteristics and risk factors of the patients enrolled to the CAFE study. MATERIALS AND METHODS: We retrospectively reviewed 3085 eligible patients diagnosed with recent onset AF in any of the EDs between January 2008 and December 2009. Inclusion criteria required documented ICD-9 primary discharge/admission diagnosis of AF in the ED and stable hemodynamic conditions at presentation (systolic blood pressure > 90 mmHg). Exclusion criteria were permanent AF or an ongoing acute coronary syndrome. RESULTS: Median age was 71 years (interquartile ranges, 62-78 years) and 50.8% were men. Palpitations was the most common symptom at ED presentation and was present in 73.5% of the study subjects. Hypertension was the most prevalent comorbidity, affecting 59.3% of the patients evaluated, and the presence of previous episode(s) of AF was also common (52.3%). Regarding home treatment, the drugs most prescribed were antiplatelets (31.2%) and diuretics (25.2%). A CHADS2 score of 0 was found in 814 patients (26.4%), while a CHADS2 score of 1 was reported in 1114 patients (36.1%). Finally, a CHADS2 score ≥ 2 was reported in 1157 patients (37.5%). CONCLUSIONS: The present study represents an important snapshot of demographics, comorbidities, risk factors and anticoagulation management about patients with recent onset AF. Disparities were noted in anticoagulation management, suggesting that this is still a main problem among patients with AF.

Recurrent use of the Emergency Department in patients with anxiety disorder.

OBJECTIVE: Panic disorder is characterized by the spontaneous and unexpected occurrence of panic attacks. During panic attacks, patients (pts) refer to the Emergency Department (ED). The diagnostic work-up for any panic attack is expensive since symptoms at presentation mimic other diseases such acute coronary syndrome or neurological emergencies. The aim of the present study was to describe a 10 years cohort of pts diagnosed with panic disorder in the ED in terms of ED visit recurrence. METHODS: Case-control study, in a tertiary care, involving pts presenting to the ED and diagnosed with panic attack according to the International Classification of Diseases 9nt Revision (ICD-9). From January 2001 to Dec 2009 were extracted from the electronic clinical database 469 pts and were divided into "recurrent ED visit" (multiple ED access for panic attack) (N=361) and "no recurrent ED visit" (only one ED access for panic attack in 9 years) (N=108). RESULTS: At univariate analysis cases and controls differed for male prevalence (p < 0.01), neurological symptoms at presentation (p = 0.02) and history of other psychiatry disorder (p < 0.01). In multivariate analysis independent predictors were male gender, age under 40 year old, palpitations at presentations, 1 or more cardiovascular risk factors and previous other psychiatry conditions. CONCLUSIONS: Male under 40 years old with palpitations or cardiovascular risk and other psychiatric diseases, have a higher recurrence of panic attacks. General psychiatric evaluation and treatment with benzodiazepine in ED is not useful to prevent recurrences. Identifying those patients at high risk of panic attack and ED visit recurrence might be useful to establish ad-hoc interventions, improve patients' morbidity and save precious resources.

A critical review of the efficacy and safety in the use of low-molecular-weight heparin in acute ST-elevation myocardial infarction: a Bayesan approach.

BACKGROUND: ST segment elevation myocardial infarction (STEMI) is an important risk factor of death worldwide. Significant clinical research has been done to assess ideal reperfusion strategies in the setting of STEMI, including the role of the antithrombin agents: unfractionated heparin (UFH) and low molecular weight heparin (LMWH). Given the evidence that LMWH may be safer than UFH in the treatment of other thrombotic disorders, its role in the management of STEMI needs to be more defined. OBJECTIVE: To assess the safety and efficacy of LMWH compared to UFH and/or placebo for the treatment of STEMI. MATERIALS AND METHODS: The Cochrane Library, MedLine and EMABASE databases were searched for randomized controlled trials pertinent to the study objective. Selection criteria included all randomized controlled trials comparing LMWH to either UFH or placebo in the treatment of STEMI through December 2010. Two Authors performed the search independently.After identifying appropriate studies, a random effect model and Bayesian sensitivity analysis were used to combine results from original trials and assess the consistency of results. RESULTS: We identified 13 studies that met the described selection criteria; 8 comparing LMWH to UFH and 5 to placebo in STEMI patients. The combined Odd's ratio was 0.79 with a 95% confidence interval of 0.67-0.94 for all studies and 0.74 (0.54-1.02) for those comparing LMWH to UFH only. A trend toward more frequent hemorrhagic events was identified in the LMWH group (Odd's ratio 1.40) which did not meet statistical significance (95% confidence interval 0.80-2.47). Sensitivity analysis demonstrated clinical benefits of 6% and 12.5% with probabilities of 99% and 95% respectively. CONCLUSION: Compared to placebo or UFH, LMWH is effective as a first line treatment of STEMI patient with no significant increase in major hemorrhagic events.

Acetaminophen plus codeine compared to ketorolac in polytrauma patients.

INTRODUCTION: The management of pain in polytrauma patients is mandatory. While non-steroidal anti-inflammatory drugs (NSAIDs) represent the most used drugs in polytrauma patients, their use may be associated with an increased risk of haemorrhage. Opioids may represent a valid alternative to NSAIDs either alone or in combination with acetaminophen. Whether their efficacy is comparable to that produced by NSAIDs in polytrauma patients has never been studied. PATIENTS AND METHODS: 60 polytrauma patients were enrolled for this study. 30 patients were treated with acetaminophen 1000 mg plus codeine 60 mg tid for 24 hours (Group A), while the remaining 30 with ketorolac 10 mg qid for 24 hours (Group B). Pain intensity has been evaluated using an analogical visual scale (VAS) ranging from 0 (no pain) to 10 (very severe pain). The level of pain was valuated at enrolment (TO) as well as after 2 (T2), 12 (T12) and 24 (T24) hours from the starting of the analgesic therapy. Results obtained by the group A were compared with those reported by the group B. RESULTS: T0: Group A mean score was 6.4 +/- 1.5 compared with 6.6 +/- 1.5 of Group B (p= ns); T2: Group A mean score was 3.4 +/- 2.8, compared with 3.5 +/- 2.4 of group B (p = ns); T12: Group A mean score was 3.4 +/- 3.4, compared with 3.5 +/- 3 of Gorup B (p = ns); T24: Group A mean score was 2.9 +/- 1.5, compared to 3.0 +/- 1.6 of Group B (p = ns). All those drugs determined a significant reduction of pain intensity during the course of therapy. CONCLUSIONS: Acetaminophen plus codeine is effective in pain control in polytrauma patients at least in our series. It may represent a valid alternative to NSAIDs, especially in patients with a documented haemorrhage or with a high hemorrhagic risk.

Natriuretic peptides and atrial fibrillation.

BACKGROUND AND OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia in the medical practice, it is associated with an increased total and cardiovascular mortality, as well as cardiovascular morbidity, including stroke and heart failure. AF is encountered in different medical specialties including cardiology, family medicine and emergency medicine as well. Treatment goal is to minimize stroke risk but also taking into account the quality of life. Therefore rate or a rhythm control strategies must be carefully selected. This review focuses on natriuretic polypeptides (NPs) as potential useful markers in AF patients management. EVIDENCE AND INFORMATION SOURCES: Pubmed was searched for natriuretic peptides and atrial fibrillation. Pertinent abstracts were reviewed by the Authors and the articles fully evaluated when considered pertinent. STATE OF THE ART: NP biology and physiology is described and general application in heart failure outlined. With regard to AF, the role of NP as predictor of cardioversion is reviewed and discussed. Patients eligible for rhythm control not always respond to treatment. Classic markers for a suitable cardioversion, such an echocardiography, are not immediately available in most settings. NP might be a resource predicting cardioversion (or not) upon patient's presentation. PROSPECTIVES: Biomarkers, such NPs, might be used to predict treatment response other than in heart failure. CONCLUSIONS: In AF management, NT-ProBNP is a promising tool helping physicians to choose rhythm or rate control strategy.