Bartolomeo Lorenzati

Oral Hypoglycemic Drugs: Pathophysiological Basis of Their Mechanism of Action

Type 2 diabetes is a syndrome characterized by relative insulin deficiency, insulin resistance and increased hepatic glucose output. Medications used to treat the disease are designed to correct one or more of these metabolic abnormalities. Current recommendations of the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) include diet and exercise as first-line therapy plus hypoglycemic drugs. Actually there are seven distinct classes of anti-hyperglicemic agents, each of them displaying unique pharmacologic properties. The aim of this review is to describe the pathophysiological basis of their mechanism of action, a necessary step to individualize treatment of diabetic people, taking into proper consideration potential benefits and secondary effects of drugs.

Perirenal Fluid Collection: An Uncommon Cause of Septic Shock

An 83-year-old woman was brought by ambulance to the Emergency Department (ED) with worsening dyspnea, hypotension, fever, and diffuse abdominal pain for 2–3 days. Her past medical history was significant for vascular dementia. She was a resident in a nursing home institution. She was taking no medications. Upon arrival at the ED, the patient was unresponsive, hemodynamically unstable, and febrile. Vital signs were: heart rate 130 beats/min, right arm blood pressure 80/55 mm Hg, temperature 39 C (102.2 F), and respiratory rate 30 breaths/min. Oxygen saturation was 92% on room air. The physical examination revealed abdominal tenderness in the upper-right quadrant with no rebound and normoactive bowel sounds. There were no palpable mass lesions or renal bruits. The lung sounds were clear and symmetrical with no wheezes or crackles. The heart sounds were regular but tachycardic and without murmurs. Femoral pulses were thready and equal. The

Trying to prolong life no matter what, or to dignify it till the end: the dilemma of modern medicine—comment

The unplanned hospital admission of advanced cancer or end-stage chronic organ failure patients is a crucial topic in modern medicine. Thus, we read the paper of Mercadante et al. [1] and the commentary of Cotogni et al. [2] with interest. As Cotogni et al. report, the availability of in-hospital acute palliative care units (APCU) and the possibility of early palliative care consultation in the Emergency Department (ED) is very limited [2]. Nonetheless, all over the world, EDs are visited with surprising frequency by severely ill patients whose death paths are approaching, but these wards are not designed to provide end-of-life care and are poorly suited to do so because the often overcrowded and seemingly chaotic nature of the emergency department may add more suffering to the stress that patients and their families feel. The Emergency Department is the hospital “entrance door”, and everyday more advanced cancer and end-stage chronic organ failure patients are entering these doors, due to the complexity of their symptoms, their growing number due to demographic reasons (baby boomers are crossing the “geriatric” threshold, their millennial kids are fewer and less available to take care of them full time), the not yet availability of home palliative care. Thus, palliative care is now becoming an important tool for emergency physician taking care of these patients in the ED. Gomes et al. [5] report that in England and Wales, home deaths have been decreasing while home death proportions fell from 31 to 18% overall, and if recent trends continue, fewer than one in ten patients will die at home in 2030. An impressive paper reports that most cancer patients spend about 1/3 of the last months of their life in hospital, with half of them receiving chemotherapy or aggressive treatments in the last month of life [3, 4]. It is easy to think that we could find the same figures for end-stage chronic organ failure patients, but unfortunately, fewer data can be found in the medical literature about useless/harmful treatments in the last months, weeks or days of life in these patients. High-tech modern medicine, such as emergency medicine, intensive care medicine, hemodialysis, intensive care cardiology and oncology are widely available in the Western world and close to all potential beneficiaries receive it. Although very successful, high-technology medicine can sometimes elicit ethical questions revolving around just distribution of resources, it is hard for the physician to know when the above mentioned technology can be considered “useless” or even “harmful” for the patient, with the apparent dichotomy between “prolonging life” and “dignifying death”. The human mind is prompt to choose the easy way to solve problems: we cannot face them, so we repress them. Thus, usually for an in-hospital clinician, the availability of a high-technology therapeutic option is easy to choose, and seems better than withdrawal of life support or not starting the treatment that involves in depth discussions between the health-care professional, patient and the family to identify the patient’s values, priorities and preferences for future care. Each specialist has an ace up the sleeve: emergency physicians use non-invasive-mechanical ventilation (NIMV) and norepinephrine, intensive care physicians use orotracheal intubation and norepinephrine, nephrologists use hemodialysis, oncologists use the last (often experimental) chemotherapy protocol, cardiologists use PTCA and amine, but unfortunately patients die, too, paying a huge physical and emotional price trying to squeeze out a few more months or days of life, most of the time not even having asked for it. * Bartolomeo Lorenzati lorebato@gmail.com

We have to “think” before prescribing an opioid in Italian Emergency Department?

We read with interest the article of Smulowitz et al. examining the rise of opioids use/abuse and variation in opioids prescriptions between ED in the past decade in US [1]. Surprisingly, we read that US, Australia, Canada and also Germany are facing a deep crisis of opioid prescriptions, and that the focus on improved pain management, which has received increased emphasis in the past two decades, contributes to this current crisis [2]. The authors have studied the variation in opioid prescription of their own institution’s emergency medicine (EM) providers observing a great disparity, but they did not explain the reason for the reported variation. It could be interesting knowing if the prescribers’ gender, age, religion, years of training, years of clinical experience could influence the prescribing patterns. In Italy, Bortolussi et al. [3], in 2004, reported a very low opioid consumption rate that was the lowest in economically developed countries. They indicate as possible reasons for this trend, a lack of systematic education of health care professionals regarding pain control, a sort of ‘‘opiophobia’’ induced by measures designed to control the improper use of drugs, and the chaotic environment of the Emergency Department (ED). Thus, for about a decade in Italy, a promotional campaign sought to increase the use of opioids by providers for chronic and acute pain management in the ED. Two years ago, we analyzed the opioid prescription behavior of emergency physicians of our institution observing the same level of variation reported from Smulowitz et al. As a result of these data, we conducted a before-and-after observational study to ameliorate the quality of pain treatment, and the appropriateness of prescribing pain medications in the ED. First, we organized a 6-h training program, and then, we analyzed changes in pain management 3 months (T0) prior to the training program and 3–6 (T1–T2) months following it. We enrolled all consecutive adults (16 years old or older) admitted with acute pain or complaining of pain after admission. A total of 10,169 patients were sampled in the first control period (T0), and, respectively, 10,577 in the second period (T1, 3 months after the training), and 9696 in the third period (T2, 6 months after the training). Each period was comparable as race, gender and age. We considered the use of opioid, NSAIDs and paracetamol in endovenous or oral formulation and we expressed it in vials for 1000 patients. The use of opioid increased from 22.9 vials/1000 patients in the control phase to 44.2 vials/1000 patients in the second phase and 38.9 vials/1000 patients in the third phase; both differences between the control phase and the second phase (T0–T1) and between the control phase and the third phase (T0–T2) are statistically significant (p\ 0.001). Probably, we can identify the answer of the title in this dataset. Smulowitz et al. show a mean rate of total opioid prescriptions per 1000 visits of 127 (122–132, 95% CI) that is very far from the 22.9, 44.2 or 38.9 vials per 1000 patients/visits observed in our study in different phases. The opioid’s reported prescription rate in US is three times as much as we observed in Italy. On the one hand, we can assume that Italian physicians are ‘‘opiophobic’’, and the promotional campaign seeking & Bartolomeo Lorenzati lorebato@gmail.com

Discharge communication is an important underestimated problem in emergency department

We read with interest the recent article by Margaret Jane Linet et al. examining comprehension of emergency department (ED) discharge instructions of patients who receive discharge instructions for ‘‘abdominal pain’’, ‘‘chest pain’’ and ‘‘nausea and vomiting’’ [1]. They showed that patients’ perception of their understanding of discharge instructions does not necessarily correlate with actual understanding of discharge instructions. In general, patients rate a higher understanding of instructions compared with physician evaluation of their understanding. This lack of correlation is pronounced in patients with higher education levels and of the male gender. We are extremely convinced that communication at discharge is an important part of high-quality emergency department (ED) care and discharge from the hospital is a period of significant potential vulnerability for patients. Patients leaving the hospital after inpatient admission often fail to understand important elements of their discharge and home care plan, leaving them at potential risk of a medical error, adverse drug event or re-admission in ED for the same problem [2, 3]. An ongoing pilot study in our Emergency Department (S. Croce and Carle Hospital, Cuneo, Italy) regarding comprehension of discharge instructions for non-traumatic and chronic low back pain demonstrates that patients commonly remain confused about aftercare information following treatment in the ED. In this pilot study, we enrolled 50 consecutive adult patients who complained about chronic low back pain in a fixed period of 3 months. During the month following the discharge, a telephone interview was conducted by a nurse using a standardized questionnaire. We use five questions with simple possible answers: (1) What is your education level? (2) Did you understand the discharge instructions? (3) Which part of the discharge instructions was not completely clear? (4) Did you need any help to understand it (ED re-admission, General Practitioner, Pharmacist)? (5) Have you resolved your health problem? We observe that patients who do not understand the discharge instructions have a language problem (foreigners) or of low education level, and they are between the ages of 35 and 51 years. However, the most interesting results are that 46 % of the enrolled patients do not understand discharge instructions, and 37 % of them need a second ED visit to fully understand the prescriptions. We also observe that 75 % of patients during the telephone interview are dissatisfied because they have not resolved the health problem. We believe that if we are able to provide clear and understandable instructions at discharge we might partially reduce inappropriate usage of the ED due to chronic disease, reduce costs and satisfy the patients’ needs.

Adult corkscrew ureter

A 35-year-old man with a history of type 1 diabetes, diabetic neuropathy and moderate to severe chronic renal disease was admitted to our hospital because of bilateral obstructive hydronefrosis secondary to fibroepithelial polyps of the bladder and of the ureter. Double J ureteral stents were inserted with complete hydronephrosis resolution and polyps were removed. The patient was lost at follow-up. Six months later he came to the Emergency …