Internal and emergency medicine
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Practice Guideline
Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations.
In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind. ⋯ This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.
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Multicenter Study
Risk of hospitalisation associated with benzodiazepines and z-drugs in Italy: a nationwide multicentre study in emergency departments.
Benzodiazepines (BZD) and z-drugs (ZD) are a widely prescribed group of medicines. They are often used inappropriately, and this is associated with adverse events (AEs), which may cause emergency department (ED) visits. The present study aimed to describe the characteristics of BZD and ZD related AEs leading to emergency department (ED) visit and hospitalisation in Italy, considering their plasma half-life. ⋯ Parenteral and rectal formulations were associated with a lower risk of hospitalisation compared to oral formulations. Our findings underlined the dangers in the use of BZD and ZD in Italy, particularly in women and older adults. ED clinicians must always take into account that the higher risk in terms of hospitalisation related to the use of BZD and ZD can be observed in patients treated with oral formulations, in those exposed to more than one sedative-hypnotics, and in patients exposed to compounds with intermediate or long plasma half-life.
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Practice Guideline
Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment.
Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. ⋯ Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.
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Observational Study
Cardiorespiratory function and VO2 kinetics after sleeve gastrectomy: a follow-up analysis.
Although poor cardiorespiratory function is a powerful predictor of mortality in patients with obesity, functional evaluation has been given little attention after laparoscopic sleeve gastrectomy (LSG). The aim of this study was thus to investigate the impact of LSG on functional capacity analysing a shorter and longer post-surgical follow-up. In this observational study, 24 patients with severe obesity (BMI 44.04 ± 5.84 kg/m2, age 47.0 ± 9.0 years) performed cardiopulmonary exercise testing 7 months pre-, 6 and 16 months post-LSG. ⋯ Although patients showed an improved peak work capacity after LSG, parameters of maximal absolute aerobic capacity demonstrated a significant decrease, which was confirmed also in the follow-up analysis. Furthermore, the time constant Tau (τ) of the fundamental component of VO2 kinetics was altered by LSG, however, within the 16 months of follow-up it returned towards baseline values. It can thus be concluded that LSG improved peak work capacity along with a lower maximal absolute aerobic capacity, which might be due to a loss of muscle mass and potentially impaired peripheral oxidative muscle metabolism. However, VO2 kinetics might suggest an initial restoration of peripheral oxidative muscle capacity after a longer follow-up.
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For some years now, direct-acting oral anticoagulants (DOACs) have entered the clinical practice for stroke prevention in non-valvular atrial fibrillation (NVAF) or for prevention and treatment of venous thromboembolism (VTE). However, there is uncertainty on DOACs' use in some clinical scenarios that are not fully explored by clinical trials, but commonly encountered in the real world. We report a Delphi Consensus on DOAC use in VTE patients. ⋯ Votes 1-2 were considered as disagreement, while votes 3-5 as agreement. For each statement an agreement of ≥ 66% among the respondents was considered consensus. A brief discussion about the results for each topic is also reported.