Evaluation of a model to improve collection of blood cultures in patients with sepsis in the emergency room.

Sepsis begins outside of the hospital for nearly 80% of patients and the emergency room (ER) represents the first contact with the health care system. This study evaluates a project to improve collection of blood cultures (BCs) in patients with sepsis in the ER consisting of staff education and completion of the appropriate BC pre-analytical phase. A retrospective observational study performed to analyse the data on BC collection in the ER before and after a three-phase project. The first phase (1 January to 30 June 2015) before the intervention consisted of evaluation of data on BCs routinely collected in the ER. The second phase (1 July to 31 December 2015) was the intervention phase in which educational courses on sepsis recognition and on pre-analytical phase procedures (including direct incubation) were provided to ER staff. The third phase (1 January to 30 June 2016; after the intervention) again consisted of evaluation. Before the intervention, out of 24,738 admissions to the ER, 103 patients (0.4%) were identified as septic and had BCs drawn (359 BC bottles); 19 out of 103 patients (18.4%) had positive BCs. After the intervention, out of 24,702 admissions, 313 patients (1.3%) had BCs drawn (1,242 bottles); of these, 96 (30.7%) had positive BCs. Comparing the first and third periods, an increase in the percentage of patients with BCs collected (from 0.4% to 1.3% respectively, p < 0.0001) and an increase in the percentages of patients with true-positive BCs (from 0.08% to 0.39% of all patients evaluated respectively, p < 0.0001) were observed. The isolation of bacteria by BCs increased 3.25-fold after project implementation. These results can be principally ascribed to an improved awareness of sepsis in the staff associated with improved pre-analytical phase procedures in BC collection.

A rapid D-dimer assay in patients presenting at the emergency room with suspected acute venous thrombosis: accuracy and relation to clinical variables.

BACKGROUND AND OBJECTIVES: The measurement of D-dimer is claimed to have potential value in excluding deep vein thrombosis (DVT). New rapid methods have been proposed, but few clinical trials have assessed their performance in an emergency context. The different accuracies found between the D-dimer assays have been related to the test used (latex or ELISA), but other variables (such as population investigated, thrombus extension, duration of symptoms or concomitant heparin treatment) may be important, even if not sufficiently investigated. DESIGN AND METHODS: We evaluated the accuracy of a rapid semi-quantitative D-dimer test (Dimertest, Dade Behring), with reference to: a) its use at an emergency unit; b) concomitant heparin administration; c) location of venous thrombosis (VT) (in the deep or superficial venous system limited to the great saphenous vein) and d) symptoms older than 14 days. RESULTS: Two hundred and ninety-eight patients suspected of having DVT and 116 suspected of thrombosis of the great saphenous vein (GSV) were investigated. In the DVT patients, the sensitivity, specificity, positive and negative predictive values were 77.4% (95% CI 68.9-85.9), 81.4% (95% CI 76.1-86.7), 65.4% (95% CI 56.5-74.3) and 88.8% (95% CI 84.2-93.4), respectively. Excluding patients receiving heparin and those with symptoms older than 15 days, the sensitivity and negative predictive value increased to 86.3% (95% CI 78.4-94.2) and 92.8% (95% CI 88.4-97.2), respectively. In patients with GSV thrombosis, the sensitivity, specificity, positive and negative predictive values were 48% (95% CI 34.5-61.5), 90.6% (95% CI 83.2-97.9), 80.6% (95% CI 66.6-94.6) and 68.2% (95% CI 57.8-78.6), respectively. Excluding patients receiving heparin and those with symptoms older than 15 days, did not change the sensitivity or negative predictive value significantly. INTERPRETATION AND CONCLUSIONS: Our results show that previous or concomitant heparin administration, non-acute symptoms and thrombosis localized to superficial veins reduce the clinical usefulness of the D-dimer test as the rate of false negative results is increased.

[Evaluation of a protocol of health surveillance for the personnel exposed to inhalation anesthetics in a sample of 3 operating rooms]. / Valutazione di un protocollo di sorveglianza sanitaria per il personale esposto ad anestetici inalatori in tre sale operatorie campione.

OBJECTIVES: To verify the results of a health surveillance protocol for personnel exposed to inhalation anaesthetics. DESIGN: Yearly follow-up of operating room personnel. SETTING: Operating theatres of a university hospital; one "clean" room with waste anaesthetic scavengers, a second older room an thus "dirty", a third room with appropriate technical requirements, but with a considerable environmental emission of anaesthetics. PATIENTS OR PARTICIPANTS: Twenty-four technical surgical assistants and anaesthesiologists. INTERVENTION OR METHODS: Determination of the number of changes of air by means of concentration decay; determination of the baseline and final value of the environmental anaesthetics by infrared photoacoustic spectroscopy; analysis of the microclimate and inspection of the equipment. Determination of anaesthetics in the urine of personnel at the end of the work shift, using a gas-chromatograph with head space. Yearly medical check-up and blood tests. RESULTS: In the first year of observation we found values of nitrous oxide in one room and of isoflurane in all three rooms which exceeded the upper limit value. Acceptable values in all the rooms were detected during the second year. The values of anaesthetics found in urine samples reflected those measured in the rooms. Personnel reported subjective symptoms, but no blood alterations related to exposure were found. CONCLUSIONS: The application of the protocol has allow us to estimate the level of pollution and to suggest behavioral rules and technical precautions that have decreased the emission of anaesthetics in the environment. Blood tests are not a valid index of possible damage caused by exposure.

[Effectiveness of ketanserin in the treatment of light-to-moderate arterial hypertension]. / Efficacia della ketanserina nel trattamento dell'ipertensione arteriosa lieve-moderata.

The above study was undertaken in order to demonstrate the efficacy of ketanserin in mild to moderate essential arterial hypertension. Twenty-two patients, mean age 49.7 yrs., were studied during 36 months. After a 15-day washout period with clinical and instrumental assessment of basal conditions, treatment with 40 mg ketanserin every 12 hrs. was started. Pressure, blood chemistry and instrumental investigation were carried out systematically and showed the hypotensive action of ketanserin as well as a significant (about 12%) rise in HDL-cholesterol.

Medical and surgical treatment of sustained and recurrent post-infarction ventricular tachycardia.

Over a five-year period 57 patients (pts) with sustained, recurrent, post-infarction ventricular tachycardia (VT) refractory to conventional antiarrhythmic treatment were evaluated. In 28 (49%) pts VT was controlled by amiodarone (A) in a dose of 3000 mg week-1. During long-term follow-up 5/28 (18%) pts died; no severe side-effects were observed with this dosage. In 17 of the 29 pts not controlled by this regimen, the dosage of A was increased to 6000-8000 mg week-1; short-term control of VT was achieved in 9/17 (53%) pts, but over a long-term follow-up 5/9 (56%) died and severe side-effects (11% pulmonary fibrosis and 11% hepatitis) occurred in 22%. Twenty pts, resistant to a low (12 pts) or high (8 pts) doses of A, underwent map-guided surgical treatment. In conclusion A is superior to conventional drugs in the treatment of sustained, recurrent, post-infarction VT, but when high doses are necessary to prevent VT, long-term results are poor and severe side-effects frequent. In pts refractory to standard doses of A, map-guided surgery is the treatment of choice.

Analgesic treatment in acute myocardial infarction: a comparison between indoprofen and morphine by a double-blind randomized pilot study.

On the basis of the results of an earlier study, showing that i.v. indoprofen induced no clinically significant changes in hemodynamic parameters of patients with acute myocardial infarction (AMI), a double-blind randomized trial was carried out in 40 AMI patients to evaluate the analgesic activity of 400 mg i.v. indoprofen in comparison with 10 mg i.m. morphine hydrochloride. Pain severity was recorded before and at several intervals within 24 h after drug administration. The average analgesic response was prompt and progressive up to the 6th hour in both treatment groups, with no significant difference between drugs in various pain descriptors. However, the proportion of responding patients in indoprofen group was greater than in morphine group at all observation times, indicating a significant difference (p less than 0.05) in favor of indoprofen. In view of its good tolerability, i.v. indoprofen is worth considering in early AMI as an alternative to morphine in those patients in whom non-opiate analgesia might be preferable.