Improving technical and non-technical skills of emergency medicine residents through a program based on high-fidelity simulation.

We evaluated the effectiveness of a training program with high-fidelity simulation (HFS) to improve technical (TS) and non-technical skills (NTS) of residents in Emergency Medicine. We conducted a 2-year training program for the management of a critical patient based on HFS (6 sessions for every year, four teams who performed 4 scenarios per session). At the beginning of the training program, all participants received a presentation of Crisis Resource Management (CRM) principles. Each session covered a different topic in Emergency Medicine Curriculum. TSs were measured as the proportion of completed tasks in the following areas: airway, breathing, circulation, disability and exposure (ABCDE) assessment and management, completion of anamnesis based on AMPLE (allergy, medications, previous illness, last meal and event) scheme, diagnostic and therapeutic assessment. NTSs were rated by the Clinical Teamwork Scale (CTS). Scores' values and the percentage of correctly performed actions were presented as median with interquartile range. Friedmann non-parametric test was employed to evaluate the trend of TS and NTS over the following sessions. Among the TS, the assessment and management of ABCDE and completion of therapeutic tasks improved (all p < 0.05). The completion of diagnostic tasks (p = 0.050) tended toward significant improvement. The overall CTS score (first session 61 ± 17, last session 84 ± 16, p < 0.001) as well as Communication (first 13.7 ± 3.6, last 18.7 ± 3.5, p < 0.001), Situational Awareness (first 5.3 ± 1.8, last 6.4 ± 1.4, p = 0.012) and Role Responsibility subscores (first 9.7 ± 2.8, last 12.1 ± 3.7, p < 0.001) increased through the following sessions. Therefore, HFS has proven to be an effective instrument to improve TS and NTS among Emergency Medicine residents.

Plasma PCSK9 levels and sepsis severity: an early assessment in the emergency department.

The aim of the study is to evaluate the prognostic value of early PCSK9 levels in non-intubated septic patients admitted to the emergency department. This report utilized a portion of the data collected in a prospective study, with the aim of identifying reliable biomarkers for an early sepsis diagnosis. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit from the emergency department with a diagnosis of sepsis. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24). The primary endpoint was in-hospital mortality rate. PCSK9 circulating levels were higher than the normal value (≤ 313 ng/mL): at T0 661 ± 405 ng/mL, at T6 687 ± 417 ng/mL, at T24 718 ± 430 ng/mL. We divided the study population based on T0 quartiles distribution (≤ 370, 370-600, 600-900 and > 900 ng/ml). At T0, patients with normal PCSK9 showed the highest mortality compared to those in higher quartiles (T0: 39%, 20%, 23% and 18%, p = 0.036). By T6, the mortality curve tended to become U-shaped, with the lowest mortality among patients in the intermediate subgroups and an adverse prognosis in the presence of normal or very high levels of PCSK9 (35%, 26%, 18% and 23%, p = 0.235). A Kaplan-Meier analysis showed an increased mortality in patients with T0 and T6 PCSK9 ≤ 313 ng/ml (T0: 55 vs. 80%, p = 0.001; T6: 62 vs. 78%, p = 0.034). In subgroups with increasing levels of PCSK9, we found the best prognosis in the intermediate subgroups and an increased mortality among patients with normal and high values.

Traumatic iatrogenic chylothorax after external electrical cardioversion.

Chylothorax, an uncommon cause of pleural effusion, results from the accumulation of lymph in the pleural space due to damage or obstruction of the thoracic duct. Chylothorax can be due to several aetiologies, many of which are rare, and it is often a diagnostic challenge to identify the cause. This case report refers to a patient with rapid recurrent episodes of bilateral pleural chylothorax due to damage of the thoracic duct after external electrical cardioversion treatment. The diagnosis took place by the method of exclusion, when all known causes of chylothorax, both non-traumatic and traumatic, were ruled out. A review of the literature on chylothorax was performed using PubMed to assess the different aetiologies, investigations, and treatments usually performed. Chylothorax is usually secondary to malignancy, trauma, congenital diseases, and infections. However, even non-invasive thoracic procedures, such as the one described in our case report, can be the cause.

Prognostic value of serial lactate levels in septic patients with and without shock.

To analyze the prognostic value of lactate levels for day-7 and in-hospital mortality, in septic patients with and without shock. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis of sepsis. Lactate dosage was performed at ED-HDU admission (T0), after 2 h (T2), 6 h (T6) and 24 h (T24); lactate clearance was calculated at T2 and T6 [T2: ((LAC T0-LAC T2/LAC T0)*100)]; T6: [(LAC T0-LAC T6/LAC T0)*100]. The end-points were day-7 and in-hospital mortality. At every evaluation, the lactate level was higher in patients with shock than in those without (T0 3.8 ± 3.8 vs 2.4 ± 2.1; T6 2.9 ± 3.2 vs 1.6 ± 1.1; T24 3.0 ± 4.4 vs 1.4 ± 0.9 meq/L, all p < 0.001). Among patients with shock, an analysis for repeated measures confirmed a more marked lactate level reduction in survivors compared with non-survivors, both by day-7 and in-hospital mortality (p = 0.057 and p = 0.006). A Kaplan-MeIer analysis confirmed a significantly better day-7 survival in patients with T6 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) and T24 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) lactate ≤ 2 meq/L, compared with patients with higher levels. A T6 lactate clearance > 10% was more frequent among in-hospital survivors in the whole study population (57% vs 39%) and in patients with shock (74% vs 46%, all p < 0.05). Higher lactate levels and decreased clearance were associated with an increased short-term and intermediate-term mortality regardless of the presence of shock.

Correlation of Dietary Advanced Glycation End Products with the Hematological and Biochemical Markers of Patients with Chronic Kidney Disease Undergoing Hemodialysis.

Aim The advanced glycation end products (AGEs) are among the mechanisms responsible for the pathogenesis and development of chronic kidney disease. The aim of this study was to estimate the dietary AGE intake and to assess its correlation with hematological and biochemical markers of patients with end-stage renal disease (ESRD) undergoing hemodialysis. Materials and methods For this study, a structured questionnaire of the exogenous AGEs was developed, whose reliability and validity were evaluated in the pilot phase of the study including 50 participants. The questionnaire was issued to 605 participants (305 ESRD patients undergoing hemodialysis and 300 controls), and a blood sample was obtained through which hematological and biochemical markers were analyzed. Results It was noted that patients with ESRD consume large quantities of dietary AGEs not only in absolute values but also in comparison with control subjects (p = 0.001), attributed mainly to the methods of product processing as well as cooking. It was also ascertained that dietary AGEs were correlated (p < 0.005) with fasting glucose and glycated hemoglobin (HbA1c) and with lipidemic profile markers, such as triglyceride, as well as inflammation markers, such as erythrocyte sedimentation rate, ferritin, and C-reactive protein. All the aforementioned markers show abnormally increased levels in patients with ERSD and diabetes compared with healthy subjects. Conclusion Patients with ESRD consuming foods favoring AGE formations combined with increased endogenous AGE burden the body with their harmful action. If the specific group of patients adopt dietary habits contributing to the containment or the inhibition of AGE formation, then this would lead to the improvement of their hematological and biochemical markers and in terms of the effects of AGEs on their health is deemed imperative through the creation of consulting and prevention programs.

Prognostic value of sepsis-induced coagulation abnormalities: an early assessment in the emergency department.

To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients. This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011-December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin-antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%. D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG-, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14-6.11, p = 0.023), after adjustment for SOFA score and lactate level. Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.

THE TRANSLATION, VALIDATION AND CULTURAL ADAPTATION OF FUNCTIONAL ASSESSMENT OF CHRONIC ILLNESS THERAPY - SPIRITUAL WELL-BEING 12 (FACIT-SP12) SCALE IN GREEK LANGUAGE.

BACKGROUND: According to World Health Organization (WHO), spirituality is an important domain of quality of life especially in terminal, life threatens chronic diseases. For many people spirituality and religion are not just very important dimensions of their existence, but also a source of support that contributes to wellbeing and coping with everyday difficulties of life. AIM: Aim of the study was the translation of the Facit Spiritual Well Being Scale (Facit-Sp12) in Greek language and the validation of the scale for the Greek population. MATERIAL AND METHODS: The Facit-Sp12 questionnaire is an anonymous self-administered questionnaire that contains twelve, four point Likert scale, closed questions (0=Not at all, 1=A little bit, 2=Some-what, 3=Quite a bit, 4=Very Much). The questionnaire was translated into Greek language and then back translated in the English in order to be checked for any inconsistencies. The sample of the study was 183 chronic kidney disease patients, undergoing hemodialysis. Exploratory factor analysis, with principal components analysis with Varimax rotation was performed for checking the construct validity of the questionnaire. The test-retest reliability and the internal consistency were also examined. Statistical analysis performed by the use of SPSS 21.0. Statistical significance level was set at p=0.05. RESULTS: The final Greek version of the questionnaire includes all of the twelve questions. The mean age of the participants was 61.81±13.9. Three factors were exported from the statistical analysis. The Cronbach-α coefficient was 0.77 for the total questionnaire and for each subscale was 0.70 for "meaning", 0.73 for "peace" and 0.87 for "faith". Between the three subscales "meaning" had the highest score (mean 12.49, SD=2.865). CONCLUSIONS: The Facit Spiritual Wellbeing Scale-Facit-Sp12, is a valuable and reliable questionnaire of three dimensions that can be used for assessing spirituality and spiritual wellbeing in Greek population.

Measuring Health: Related Quality of Life in Hemodialysis Patients. Psychometric Properties of the Missoula-VITAS Quality of Life Index (MVQOLI-15) in Greece.

Different measuring tools have been used to understand the outcomes of end-stage renal disease (ESRD) therapies. However, survival, cost-effectiveness and quality of life (QOL) are the main parameters to evaluate treatment of ESRD. The current study meant to assess the psychometric properties (reliability and validity) of the Missoula-VITAS Quality of Life Index (MVQOLI-15) translation to Greek in patients undergoing hemodialysis (HD). A total sample of 79 HD patients voluntarily participated in this pilot study. Domain analysis of MVQOLI-15-Greek was conducted based on the collected data at initial assessment. The reliability properties of the instrument were tested using the following measures; internal consistency, repeatability, test-retest reliability and convergent validity. Domain analysis demonstrated that all domains of the questionnaire had good variability. MVQOLI-15-Greek internal consistency was satisfactory with an overall Cronbach's a at 0.74. Pearson's r and intraclass correlation coefficient revealed strong correlations (ranging from 0.91 to 0.98) between initial assessment and re-assessment. MVQOLI-15-Greek convergent validity analysis indicated that the domains were strongly related to the same construct. The findings of the study indicate that the Greek version of MVQOLI-15 provided satisfactory psychometric properties supporting its use within pathological populations and in the context of national QOL measurement.

Phase II study of gemcitabine plus docetaxel as second-line treatment in malignant pleural mesothelioma: a single institution study.

OBJECTIVE: The combinations of cisplatin-pemetrexed and cisplatin-gemcitabine are considered the standard systemic therapy for malignant pleural mesothelioma (MPM), which is a rapidly progressive tumor. The purpose of the present study is to evaluate the efficacy, safety, and clinical benefit of the gemcitabine plus docetaxel regimen in the second-line treatment of this disease. PATIENTS AND METHODS: A total of 37 patients with MPM were treated with the combination of docetaxel (80 mg/m) and gemcitabine (1000 mg/m) on day 1 and 14 of a 28-day cycle. The regimen was repeated for a maximum of 6 cycles or until disease progression or unacceptable toxicity. RESULTS: There was partial response of the disease in 7 patients (18.9%), whereas it remained stable in 23 patients (62.2%) and progressed in 7 patients (18.9%). The median time to disease progression was 7 months (range: 5.8-8.2 months) with a mean survival of 16.2 months (range: 13-19.3 months). CONCLUSION: The biweekly administration of docetaxel and gemcitabine, along with granulocyte colony-stimulating factor support, constitutes a safe, tolerable, and convenient regimen for the treatment of MPM, suggesting that this combination may be a viable option, especially in previously treated patients.

Docetaxel plus gemcitabine as first-line treatment in malignant pleural mesothelioma: a single institution phase II study.

BACKGROUND: The cisplatin-pemetrexed and cisplatin-gemcitabine combinations are considered the standard treatment for malignant pleural mesothelioma. The purpose of this study was to examine the efficacy of gemcitabine plus docetaxel in the first-line setting, as this combination has not been investigated in mesothelioma before. PATIENTS AND METHODS: Twenty-five consecutive patients with malignant pleural mesothelioma were enrolled. They received 80 mg/m(2) of docetaxel and 1,000 mg/m(2) of gemcitabine on days 1 and 14 of a 28-day cycle. The treatment was scheduled for a maximum of 6 cycles or until disease progression or unacceptable toxicity. RESULTS: A total of 7 out of our 25 patients (28%) responded to treatment. In 14 patients (56%), the disease remained stable, while in 4 (16%) it progressed. The median time to progression was 7 months (range: 5.4-8.6 months) and the median overall survival was 15 months (range: 12.4-17.5 months). CONCLUSION: The administration of gemcitabine and doctaxel appears to be promising first-line therapy for patients with mesothelioma, as it is well tolerated and appears to improve survival.

El consentimiento informado y la medicina transfusional / Informed consent and transfusional medicine

Resulta indispensable en la actualidad contar con el consentimiento informado de los pacientes previo a la realización de cualquier estudio y/o tratamiento relacionado con el ejercicio de la medicina transfusional. Así lo establecen las leyes nacionales, decretos reglamentarios y resoluciones ministeriales que regulan el ejercicio de dicha especialidad. Brindar al paciente una información veraz, detallada, eficaz y obtener su autorización para la realización de determinado estudio o tratamiento importa en la actualidad no sólo un resguardo judicial sino, sobre todo, el cumplimiento de un imperativo moral.

El consentimiento informado y la medicina transfusional / Informed consent and transfusional medicine

Resulta indispensable en la actualidad contar con el consentimiento informado de los pacientes previo a la realización de cualquier estudio y/o tratamiento relacionado con el ejercicio de la medicina transfusional. Así lo establecen las leyes nacionales, decretos reglamentarios y resoluciones ministeriales que regulan el ejercicio de dicha especialidad. Brindar al paciente una información veraz, detallada, eficaz y obtener su autorización para la realización de determinado estudio o tratamiento importa en la actualidad no sólo un resguardo judicial sino, sobre todo, el cumplimiento de un imperativo moral. (AU)