[The potential role of improvisation training to optimize communication in emergency care]. / Az improvizációs tréningek lehetséges szerepe a kommunikáció optimalizálására a sürgosségi ellátásban.

INTRODUCTION: One of the most common challenges in acute care is the time- and space-limited communication with patients, relatives and colleagues. There is ample evidence, however, that the quality of care, patient and staff satisfaction can be improved, measured and researched using simple communication tools (e.g., training). OBJECTIVE: This improvement was what we focused on when carrying out voluntary participation surveys with the staff of the Department of Emergency Medicine of the Clinical Centre of the University of Pécs. METHOD: With the help of a trained psychologist-actor and a senior specialist in medical communication, we investigated the potential impact of applied improvisation on medical communication by testing the participants in various situations simulating communication challenges after having completed an improv-based communication training full of exercises, games and tasks. After warm-up games taken from improv, the participants completed pre-defined tasks and finished every session with discussion and self-reflective feedback. Questionnaire (Interpersonal Confidence Questionnaire - ICQ) was used to check the potentially positive impact of improvisation on emergency communication. RESULTS: Our studies confirmed that the applied elements of medical improvisation, developing communication skills through play not only make participants more assertive and empathic, but also - after preparation - lead to a smoother and more effective exchange of information. Positive feedback from participants in the training sessions also confirms this. DISCUSSION: Our aim is to develop an improvisation-based communication training focused specifically on acute care providers, which, based on our initial experience, could optimize communication with patients, relatives and also between professionals. CONCLUSION: Application of improvisational techniques in this segment of acute care studied by us might open new perspectives to improve communication. Orv Hetil. 2023; 164(19): 739-746.

[Bedside ultrasound in adult primary care.] / Ágy melletti ultrahangvizsgálat az alapellátásban.

It is hard to imagine a modern hospital ward without a mobile ultrasound, bedside (point-of-care) sonography (POCUS) is a technique of the 21st century, which in emergency medicine settings (for example during primary survey) might replace the stethoscope at times. In emergency medicine - which is the hospital discipline closest to primary care - bedside ultrasound is part of the routine care by now, and its use is based on evidences of thorough research. Given that the emergency outpatient population is getting closer to primary care patients both in presentation and demography, we believe that the current POCUS evidences are probably applicable to primary care as well. Based on the clinical experience gained in emergency medicine, we assume that bedside ultrasound may also be helpful in general practice reliably diagnosing certain, potentially life-threatening pathologies, reducing the length of time until definitive treatment, increasing the success rate of certain interventions, improving patients' experience, and potentially alleviating staff burnout. The present article summarizes experiences with bedside sonography in the Anglo-Saxon world and tries to find its place in the Hungarian primary care. The widespread use of bedside ultrasound, however, in the Hungarian general practice is still lagging due to numerous barriers, the most pressing of those are training, legal responsibility and financing. Regardless, we believe, that even in this early, unregulated phase, it is worth considering to introduce bedside ultrasound into daily primary care. Competent use, however, requires continuous practice; based on the average adult patient turnover in an urban Hungarian "adult only" surgery, it might take six months to gain the necessary skills to provide high level, safe patient care. Orv Hetil. 2022; 163(52): 2067-2071.

How to best handle vaccine decliners: scientific facts and psychological approach.

There is currently no curative drug therapy for COVID-19. The spread of the virus seems relentless despite the unprecedented epidemiological measures. Prevention remains the only feasible option to stop the pandemic; without population-level vaccination, we are unlikely to regain the quality of social life and the unrestricted economy/commerce we enjoyed before. Anti-vaxxers and conspiracy theorists are seemingly oblivious to the detrimental effect of COVID-19 both at an individual and societal level. These groups have (and probably will) continue to attempt to undermine efforts to eradicate the virus despite the fact that the major reduction in morbidity/and mortality of infectious diseases of the past century was achieved through the development of vaccines and improved hygiene. Conspiracy theories are directly associated with reduced vaccine uptake and unfortunately neither anti-vaxxers nor vaccine hesitants cannot be persuaded (debunked) with logical arguments; hence, prescribers must not only be aware of the truth underlying the dense web of misinformation but must fully understand the psychological aspects as well to be able to efficiently counsel about the potential benefits and harms. Such knowledge is pivotal to help the lay public to make informed decisions about SARS CoV-2 in general and vaccination in particular; as the COVID-19 situation can probably be best controlled with mass inoculation and novel immune therapies. The lessons learnt regarding the importance of efficient communication and the adherence to the proven epidemiological measures hopefully would be leaving us better prepared for the future if challenged by novel communicable diseases of pandemic potential.

Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit.

BACKGROUND: Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. CASE SERIES: Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. METHODS: To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital's electronic medical record system to reassess all consecutive adult chest pain patients. RESULTS: The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71-553.37], twenty times higher than suggested by prevalence data. DISCUSSION: In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. CONCLUSION: Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.

Mortality benefit of crystalloids administered in 1-6 hours in septic adults in the ED: systematic review with narrative synthesis.

BACKGROUND: Based on the 2018 update of the Surviving Sepsis Campaign, the Committee for Quality Improvement of the NHSs of England recommended the instigation of the elements of the 'Sepsis-6 bundle' within 1 hour to adult patients screened positive for sepsis. This bundle includes a bolus infusion of 30 mL/kg crystalloids in the ED. Besides the UK, both in the USA and Australia, compliance with similar 1-hour targets became an important quality indicator. However, the supporting evidence may neither be contemporaneous nor necessarily valid for emergency medicine settings. METHOD: A systematic review was designed and registered at PROSPERO to assess available emergency medicine/prehospital evidence published between 2012 and 2020, investigating the clinical benefits associated with a bolus infusion of a minimum 30 mL/kg crystalloids within 1 hour to adult patients screened positive for sepsis. Due to the small number of papers that addressed this volume of fluids in 1 hour, we expanded the search to include studies looking at 1-6 hours. RESULTS: Seven full-text articles were identified, which investigated various aspects of the fluid resuscitation in adult sepsis. However, none answered completely to the original research question aimed to determine either the effect of time-to-crystalloids or the optimal fluid volume of resuscitation. Our findings demonstrated that in the USA/UK/Australia/Canada, adult ED septic patients receive 23-43 mL/kg of crystalloids during the first 6 hours of resuscitation without significant differences either in mortality or in adverse effects. CONCLUSION: This systematic review did not find high-quality evidence supporting the administration of 30 mL/kg crystalloid bolus to adult septic patients within 1 hour of presentation in the ED. Future research must investigate both the benefits and the potential harms of the recommended intervention.

Cannabidiol in low back pain: scientific rationale for clinical trials in low back pain.

INTRODUCTION: The pooled worldwide prevalence of low-back pain-related presentations in primary care varies between 6.8% and 28.4% in the high-income countries rendering it a major healthcare/economy problem. To best manage this complex bio-psycho-social condition a 360-degree approach is needed, as the psycho-social components are often more important than the scant pathophysiology. Pattern analysis of cannabis users suggested that attempts to alleviate musculo-skeletal pain is often seen as a major drive to use cannabinoids. AREAS COVERED: Unlike NSAIDs/opioids, cannabidiol might directly affect more than one modality of pain signaling/perception. The 2019 guideline of the National Institute for Clinical Excellence recommended further studies with cannabidiol in pain medicine because of its excellent safety profile and presumed therapeutic potential. Therefore, we have researched relevant databases for pharmaco-physiological papers published between 2000 and 2021 to collate evidence in a narrative fashion to determine the clinical rationale for this cannabinoid in low-back pain. EXPERT OPINION: Observational research reported good results with CBD in pain and fear reduction, which are both key factors in low-back pain. Given the paucity of high-quality evidence, further research is needed to determine the efficacy/non-inferiority of CBD in primary/emergency care setting, using multimodal assessment of various patient-reported outcomes.

[Cannabis use among patients with inflammatory bowel disease]. / Kannabiszszármazékok használatának gyakorisága gyulladásos bélbetegségben.

Összefoglaló. Gyulladásos bélbetegségben (IBD) a fájdalomérzés komplex szomatikus és pszichés jelenség. Ez utóbbi komponens pontosabb megértése segíthet a megfelelo kezelési stratégia megállapításában. A szorongásos hangulati zavarok és egyes maladaptív viselkedési minták (dohányzás és alkoholfogyasztás) elofordulási gyakorisága jól dokumentált IBD-ben, a kannabiszhasználat hatása ugyanakkor kevésbé ismert. A szerzok szisztematikus áttekintést végeztek annak megértéséhez, hogy vajon magasabb-e a marihuánahasználat gyakorisága felnott IBD-s betegek között egészséges kontrollpopulációhoz viszonyítva, és ha igen, akkor melyek a szerhasználat legfontosabb jellemzoi. A kutatási periódust szándékosan az elmúlt 7 évre korlátoztuk, ugyanis 2013-tól jelentos változások álltak be a kannabinoidok jogi és orvosi megítélésében az USA-ban. Öt elsodleges és több másodlagos adatbázisban kutattunk elore meghatározott kulcsszavak segítségével 2013 óta teljes szöveggel megjelent, angol nyelvu felnott IBD-s populációt vizsgáló epidemiológiai tanulmányok vonatkozásában. 143 rekord közül 7 cikk felelt meg a beválogatási kritériumoknak. Eredményeink szerint a kannabiszhasználat gyakorisága IBD-ben szenvedo felnott betegek körében valószínuleg magasabb, mint a kontrollpopulációban: a "valaha, bármikor" használók aránya 54-70% között változott (szemben a 46-60% gyakorisággal a kontrollcsoportban), míg az "aktív használók" esetén a gyakoriság 6,8-25% között változott (vs. a kontrollcsoportban tapasztalt 8,6-14%-kal). A prevalenciaadatok széles variabilitása arra utal, hogy a beválogatott epidemiológiai tanulmányok valószínuleg vagy nem voltak megfeleloen tervezve, vagy jelentos heterogenitással bírtak. A pszichés tényezok ellentmondásos mintája azt sugallja, hogy a kannabinoidok egyes esetekben ronthatták, más esetben valószínuleg javították bizonyos prominens tünetek megélését. Javasoljuk ezért, hogy a valós prevalencia megállapítása érdekében a keresztmetszeti vizsgálatok mellé ismételt pszichometriai vizsgálatokon alapuló vizsgálatok is bekerüljenek a további kutatásba. Orv Hetil. 2021; 162(12): 443-448. Summary. Pain perception in inflammatory bowel disease (IBD) is beyond a purely somatic process. In-depth understanding of psychologic elements might enable more effective management in this patient group. Anxiety disorders and certain maladaptive coping strategies like smoking and alcohol consumption are well-documented in IBD, unlike the scarcely researched cannabis use. The authors designed a systematic review, to investigate if the prevalence of cannabis use is higher in IBD that in unselected controls. The research window was intentionally set to cover for the past 7 years, as in 2013 major legislative changes took place in the cannabis decriminalisation process in the United States. 5 primary and several secondary databases were researched with a pre-formulated algorithm registered at PROSPERO for full text epidemiological studies published in English language involving adult IBD patients. Out of 143 records, 7 articles met the in/exclusion criteria. Our results suggest that cannabis use among adult patients with IBD is likely to be higher than in the unselected control population. The proportion of "ever" users varied from 54% to 70% (vs. 46-60% in the control group); and for 'active users', the prevalence ranged between 6.8% to 25% (vs. 8.6-14% in the control group). The wide variability in prevalence data suggests that the selected epidemiological studies were either inappropriately designed or were too heterogeneous (or both). The contradictory pattern of psychological factors suggests that cannabinoids might improve or worsen IBD depending on case by case basis. We therefore opine that in addition to cross-sectional papers, studies based on repeated psychometric analysis are needed to establish the real prevalence and inform cannabinoid prescription and holistic management in inflammatory bowel disease. Orv Hetil. 2021; 162(12): 443-448.

Corona vaccine review / Koronavírusvakcina-vademecum.

Összefoglaló. A SARS-CoV-2 okozta megbetegedés (COVID-19) a cikk megírásáig a világon több mint 82 millió embert érintett, a halálos áldozatok száma 1,8 millió (2,2%). Hazánkban eddig 300 000 feletti esetszámot regisztráltak, a cikk megjelenésének idején már várhatóan több mint 10 000 halottal (3%). Habár a megbetegedésnek oki gyógyszeres terápiája egyelore nincs, egyes antivirális szerek és a rekonvaleszcens plazma alkalmazása a tapasztalatok szerint csökkentik a vírusterhelést, és ezzel hozzájárulnak a beteg gyógyulásához. Az eddig példa nélküli epidemiológiai rendelkezések nem tudták megállítani, csak lelassítani a betegség terjedését, ezért a megelozés tunik az egyetlen, a közeljövoben tömegek számára is elérheto megoldásnak. A jelen cikk nem egy virológiai vagy biotechnológiai szakmunka, sokkal inkább egy összefoglaló házi- és általános orvosok számára, amely ismerteti a jelenleg engedélyezett, illetve a közeljövoben forgalomba kerülo védooltások elonyeit és hátrányait a COVID-19 tágabb kontextusában. Írásunkban bemutatjuk a leggyakoribb álhíreket, rémhíreket is, valamint ezek cáfolatát is annak érdekében, hogy kollégáink felkészültebben tudják betegeiket informálni, valamint segíteni a vakcináció fontosságával kapcsolatos döntéshozatalt. Egy járvány megfékezésének legkézenfekvobb módja a társadalmi szintu védettség megvalósítása. A nyájimmunitás kialakulása nélkül nagy valószínuséggel e jelenlegi pandémia sem állítható meg. Amennyiben egyéni és társadalmi szinten is vissza szeretnénk térni a vírus elotti életünkhöz, újra élvezve az akadálytalan áru- és kereskedelmi forgalom jelentette elonyöket, akkor a tömeges oltás tunik a leghatékonyabb eszköznek ennek eléréséhez. A fertozo betegségek számának és mortalitásának a 20. században tapasztalt jelentos csökkenése egyértelmuen a társadalmi szintu átoltottságnak, valamint a higiénés körülmények javulásának köszönheto. Az oltás ugyan önkéntes, de felvételének kérdése pandémiás helyzetben valószínuleg nemcsak egyéni döntés, de társadalmi felelosségvállalás kérdése is. Orv Hetil. 2021; 162(8): 283-292. Summary. Out of more than 82 million people worldwide, 1.8 million (2.2%) succumbed to SARS-CoV-2 disease (COVID-19). In 2020, more than 300 000 cases were registered in Hungary, and by the time of publication of this article, the death toll would probably exceed 10 000 (3%). Currently no causative drug therapy is available, however, observational evidence suggests that certain antivirals and the use of convalescent plasma may change the disease course. The unprecedented, strict epidemiological provisions managed to slow down the spread of the disease though they could not stop it. It seems that prevention remains the only readily available option to beat COVID-19. This is not a virology or biotechnology paper, but an unbiased review for general practitioners, aiming to summarize the advantages/disadvantages of the (emergency) authorized and soon-to-be-launched vaccines in the wider context of COVID-19. We also intended to address and debunk the most common misconceptions, aiming to help both doctors and patients to make a fact-based, informed decision about vaccination. Herd immunity is paramount to combat COVID pandemic. Without population-level vaccination, we are unlikely to regain the quality of life, the freedom of travel and the unrestricted economy/commerce we enjoyed before. It is obvious that the significant reduction in morbity/mortality of infectious diseases in the 20th century was achieved through advancements in vaccinology and improved hygiene. Albeit voluntary, vaccination in a pandemic situation is probably not only an individual decision, but social responsibility as well. Orv Hetil. 2021; 162(8): 283-292.

The role of vitamin E acetate (VEA) and its derivatives in the vaping associated lung injury: systematic review of evidence.

Small scale observational evidence suggested that Vitamin E (VE) might play beneficial role in human and animal respiratory conditions of various origin by stabilizing surfactant functions. The intra-aleveolar VE level is directly proportionate to the lung's response to inflammation. Electronic cigarette or vaping associated lung injury was a dominantly respiratory syndrome in the United States with seemingly strong association between potential Vitamin E acetate inhalation exposure and the onset of symptoms. This systematic review intended to assess if there was previous evidence of any potential respiratory/gastrointestinal toxicity associated with Vitamin E acetate or any of its derivatives. A systematic review was constructed and prospectively registered at PROSPERO to search important clinical databases between 2000 and 2020 for full text human articles investigating the effect of VEA or any of its derivatives administered via any route (oral/parenteral/aerosolised) in adults with any respiratory conditions. Out of 363 records investigating the effect of VEA and/or its derivatives/isomers in (any) lung injury (inflammatory, oxidative, infective, asthma/COPD) seven articles qualified. The papers reported various surrogate outcomes (APACHEII score, spirometry, etc) with equivocal results. There was one case report of harmful exposure to both Vitamin E (intramuscular) and Vitamin E acetate (topical). The present review found evidence of neither harm nor any significant clinical improvement associated with the administration of VEA or any derivatives via any route in adult inflammatory lung conditions however, the articles were of low-level evidence. Further studies are needed to correct flaws in research to explore the role of Vitamin E in pulmonology.

Actual questions about the electronic cigarette associated lung injury / Égeto kérdések. Merre tartunk az e-cigarettázással összefüggésbe hozható tüdobetegséggel?

The electronic cigarette and vaping associated lung injury (EVALI) syndrome was first described in the United States (US) and was presumably strongly associated with cannabinoid vaping and exposure to vitamin E acetate, an oily additive used to dilute/cut cannabinoids vape liquids. As the case numbers were relatively low (epidemiologically) and the available data was inconsistent, several assumptions were made to explain the phenomenon. The lack of standardization of sampling, the self-reported, inhomogeneous user habits, the huge number of potential etiologies, and certain trade/legal loopholes (such as online distribution, black market penetration, or the inefficient regulatory control regarding the quantity and/or quality of ingredients/cutting agents) might question the validity of the data and the consequent conclusions. Furthermore, an interesting but by no means negligible question is the fact why no EVALI cases have been registered outside the US when electronic cigarettes and vapes have become increasingly popular worldwide. The present review seeks to answer whether vitamin E acetate is indeed the cause of this complex syndrome, what potentially non-healthcare related factors might have contributed to the rapid increase and decline in EVALI cases, and last but not least the minimum standards of safe vaping (as potential for drug delivery route for cannbinoids). Orv Hetil. 2020; 161(31): 1281-1285.

Smouldering ashes: burning questions after the outbreak of electronic cigarette or vaping-associated lung injury (EVALI).

In the summer of 2019, the Center for Disease Control and Prevention (CDC) declared an emergency of electronic cigarettes and/or vaping (vaping)-associated lung injury (EVALI) in the USA. The outbreak abated by January 2020, which the CDC attributed to heightened public awareness, 'user actions to reduce risk' and potentially the removal of vitamin E acetate (VEA) from vaping products (VEA is an oily chemical cutting agent, strongly associated with the disease). Even though the EVALI outbreak appears to be over, numerous epidemiological and medical questions are left still open. First, why were there practically no cases outside the USA, which represents nearly a quarter of the global vaping market? Comparative studies to map the differences in device/fluids/user habits between countries might be needed urgently. Second, what is the pathomechanism that sickens vapers irrespective of VEA exposure? VEA was only confirmed in about half of the cases and the presumed toxicity is yet to be determined. Aetiology/epidemiology focused research is needed to investigate/interpret the broader context to explain the outbreak. Third, could any socioeconomic/environmental factors have influenced the course of the outbreak? Finally, what should we expect in the years to come? Was EVALI a serious but reversible emergency medicine condition or is vaping as detrimental to long-term health as smoking? Besides the complex legislative, regulatory, ethical aspects of EVALI, biomedical research is also difficult: in-vitro experiments have limited inferential value to real real-life vaping due to its complexity; user habits are self-reported and under-researched; there is an active black market pouring unknown quality counterfeit products and, in the USA, federal restrictions limit cannabis research. Vaping is a toxicological, multidimensional conundrum; therefore, stringent quality control, transparent legal/ethical boundaries, meticulous international research and user education are paramount to prevent potential future outbreaks and determine the parameters safe vaping (if these exist).

[Vaping-associated lung injury]. / Az e-cigarettázással összefüggésbe hozható tüdobetegség.

Over 1000 respiratory cases have been linked to vaping at the Centers for Disease Control and Prevention (Atlanta, GA, USA). So far at least 800 cases were confirmed as vaping-associated lung injuries (VALI) with 18 patients succumbing to the illness. To our present knowledge, vape fluids may contain certain compounds with toxic properties. It is not yet understood though what component or components are responsible for the cluster of cases. However, federal and state investigators are focusing on vape cartridges that likely contained cannabinoids as most patients vaped legal or illegal cannabinoids. Until recently, USA and UK public health authorities have welcomed vaping as a safer alternative to smoking. In countries where cannabis has been legalised, vaporizers became an increasingly popular form of administration, however, no human studies have been performed with vaporized cannabinoid oils, hence the safety of such device is unknown. A 2018 review concluded that although vaping might not necessarily be safe, it is still preferable for both patients and their environment to smoking cannabis. Since 2015, Hungarian, Australian and European scientific bodies have called for ban on the unregulated e-cigarettes, but encouraged future research to understand all aspects of vaping cannabinoids. Should vaping itself prove harmless, it might open new avenues for research and potential administration of medical cannabis, however, the contrary may cause landslide in the tobacco industry. Orv Hetil. 2020; 161(11): 413-418.

Antibiotics administered within 1 hour to adult emergency department patients screened positive for sepsis: a systematic review.

OBJECTIVE: The 2018 Surviving Sepsis Campaign update recommended instigating the Sepsis-6 bundle within 1 h; however, the supporting evidence is weak. The objective was to systematically review the literature to determine whether there is mortality benefit (hospital or 28/30-day survival) associated with administration of antibiotics <1 h to adult emergency department (ED) patients screened positive for sepsis using systemic inflammatory response system criteria. METHODS: A systematic review and meta-analysis were conducted. Embase, CINAHL, Medline, Pubmed, Cochrane Library and grey literature were searched for articles published between 2012 and 2019. RESULTS: From 232 identified articles, seven met the inclusion criteria. Due to the small number of articles that fit the inclusion criteria and the considerable heterogeneity (I = 92.6%, P < 0.001), only the results of the systematic review are reported. Three of the seven studies demonstrated survival benefit for patients who screened positive for sepsis who were administered antibiotics ≤1 h after presentation to the ED. Four studies reported no statistically significant improvement in survival associated with administration of antibiotics within 1 h of ED presentation. Interestingly, two studies reported worse outcomes associated with early administration of antibiotics in patients with low acuity sepsis. CONCLUSION: There is equivocal evidence of in-hospital or 28/30-day survival benefit associated with antibiotics administered ≤1 h after presentation to the ED for patients who screened positive for sepsis. Further research is needed to identify the exact patient group, which would truly benefit from initiation of antibiotics <1 h after ED presentation.