Internal and emergency medicine
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Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. ⋯ Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.
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Review
Circulating biomarkers in diagnosis and management of cardiac amyloidosis: a review for internist.
Cardiac amyloidosis (CA) is due to extracellular myocardial deposition of misfolded proteins resulting in severe cardiac dysfunction and death. The precursors of amyloid fibrils, able of determining a relevant cardiac infiltration, are immunoglobulin-free light chains (AL amyloidosis) and transthyretin (TTR) (both wild and mutated types). ⋯ In AL amyloidosis, biomarkers such as free light chains, natriuretic peptides and troponins are the most extensively studied and validated; they have proved useful in risk stratification, guiding treatment choice and monitoring hematological and organ response. A similar biomarker-based prognostic score is also proposed for ATTR amyloidosis, although studies are small and need to be validated for wild-type and mutant forms.
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Treatment of OSA with CPAP is currently the recommended treatment and has the greatest evidence of efficacy on AHI, symptoms and comorbidities. Symptomatic patients with moderate-severe OSA generally have good adherence to CPAP therapy, while those with mild OSA, female, young and generally paucisymptomatic, have lower CPAP adherence, especially in the medium and long term. ⋯ Mandibular advancement devices (MAD), positional therapy (PT) and hypoglossal nerve stimulation (HSN) are recent and personalized alternative therapies on which there is promising and encouraging data but with still little strong scientific evidence. The purpose of this review is to compare the efficacy, adherence and costs of various therapeutic options for OSA patients in the light of recent evidence and to provide useful guidance for specialists.
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Fibrinogen to albumin ratios (FAR) have shown to be a promising prognostic factor for improving the predictive accuracy in various diseases. This study explores FAR's prognostic significance in critically ill patients with acute kidney injury (AKI). All clinical data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Database III version 1.4. ⋯ Multivariate analysis demonstrated that higher FAR was an independent predictor of in-hospital mortality after adjusting for potential confounders (HR, 95% CI 1.23, 1.03-1.48, P = 0.025). A nonlinear relationship between FAR and in-hospital mortality was observed. FAR may serve as a potential prognostic biomarker in critically patients with AKI and higher FAR was associated with increased risk of in-hospital mortality among these patients.
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Several indicators reflect the quality of care within emergency departments (ED). The length of stay (LOS) of emergency patients represents one of the most important performance measures. Determinants of LOS have not yet been evaluated in large cohorts in Germany. ⋯ We identified different factors influencing the duration of LOS in the ED. Total LOS was dependent on patient-related factors (age), disease-related factors (presentation complaint and triage level), and organizational factors (weekday and admitted/non-admitted status). These findings are important for the development of management strategies to optimize patient flow through the ED and thus to prevent overcrowding.