Estudo retrospectivo de ferimentos cardíacos ocorridos em Manaus/AM

OBJETIVO: Avaliar as formas de tratamento empregadas e os principais aspectos relacionados à morbidade e à mortalidade dos ferimentos cardíacos.. MÉTODOS: Estudo retrospectivo de 102 doentes com lesão cardíaca, atendidos nos dois prontos socorros de Manaus (Pronto Socorro Municipal 28 de Agosto e Hospital Pronto Socorro Dr. João Lúcio P. Machado) no período de janeiro de 1998 a junho de 2006. RESULTADOS: Dos 102 doentes, 95,1% eram homens; a média de idade foi 27 anos; ferimentos por arma branca representaram 81,4% dos casos, contra 18,6% por arma de fogo; cardiorrafia foi realizada em 98,1% dos casos. As câmaras cardíacas atingidas foram: VD: 43,9% (36,2% isoladamente e 7,7% associada a outras câmaras); VE: 37,2%; AD: 8,5% e AE: 10,4%, com mortalidades específicas de 21%, 23%, 22% e 45%, respectivamente. Lesões de duas câmaras associadas alcançaram mortalidade de 37,5%, sendo 20% para VD+AD, 100% para VD+VE e zero para VD+AE. O pulmão correspondeu a 33,7% de 89 lesões associadas. Os tempos médios de cirurgia e de internação foram de 121 minutos e 8,2 dias, respectivamente. Cerca de 22,5% complicaram representando 41 complicações. A mortalidade foi 28,4%. Lesões grau IV e V corresponderam a 55% e 41% dos casos, com mortalidade específica de 26% e 15%, respectivamente. Todos os doentes com lesão grau VI morreram. CONCLUSÃO: O ferimentos cardíacos por arma branca estiveram associados a menor mortalidade, as lesões cardíacas grau IV estiveram associadas à maior mortalidade e um menor tempo operatório esteve associado à maior gravidade e mortalidade.

Accessibility and demand at an Emergency Care Unit: the user's perspective

AIM: To analyze the search for Emergency Care (EC) in the Western Health District of Ribeirão Preto (São Paulo), in order to identify the reasons why users turn to these services in situations that are not characterized as urgencies and emergencies. METHODS: A qualitative and descriptive study was undertaken. A guiding script was applied to 23 EC users, addressing questions related to health service accessibility and welcoming, problem solving, reason to visit the EC and care comprehensiveness. RESULTS: The subjects reported that, at the Primary Health Care services, receiving care and scheduling consultations took a long time and that the opening hours of these services coincide with their work hours. At the EC service, access to technologies and medicines was easier. CONCLUSION: Primary health care services have been unable to turn into the entry door to the health system, being replaced by emergency services, putting a significant strain on these services' capacity.

The use of remote sensing imagery for monitoring recovery in the aftermath of a natural disaster: the Hurricane Katrina Case

Although Recovery is often defined as the less studied and documented phase of the Emergency Management Cycle, a wide literature is available for describing characteristics and sub-phases of this process. Previous works do not allow to gain an overall perspective because of a lack of systematic consistent monitoring of recovery utilizing advanced technologies such as remote sensing and GIS technologies. Taking into consideration the key role of Remote Sensing in Response and Damage Assessment, this thesis is aimed to verify the appropriateness of such advanced monitoring techniques to detect recovery advancements over time, with close attention to the main characteristics of the study event: Hurricane Katrina storm surge. Based on multi-source, multi-sensor and multi-temporal data, the post-Katrina recovery was analysed using both a qualitative and a quantitative approach. The first phase was dedicated to the investigation of the relation between urban types, damage and recovery state, referring to geographical and technological parameters. Damage and recovery scales were proposed to review critical observations on remarkable surge- induced effects on various typologies of structures, analyzed at a per-building level. This wide-ranging investigation allowed a new understanding of the distinctive features of the recovery process. A quantitative analysis was employed to develop methodological procedures suited to recognize and monitor distribution, timing and characteristics of recovery activities in the study area. Promising results, gained by applying supervised classification algorithms to detect localization and distribution of blue tarp, have proved that this methodology may help the analyst in the detection and monitoring of recovery activities in areas that have been affected by medium damage. The study found that Mahalanobis Distance was the classifier which provided the most accurate results, in localising blue roofs with 93.7% of blue roof classified correctly and a producer accuracy of 70%. It was seen to be the classifier least sensitive to spectral signature alteration. The application of the dissimilarity textural classification to satellite imagery has demonstrated the suitability of this technique for the detection of debris distribution and for the monitoring of demolition and reconstruction activities in the study area. Linking these geographically extensive techniques with expert per-building interpretation of advanced-technology ground surveys provides a multi-faceted view of the physical recovery process. Remote sensing and GIS technologies combined to advanced ground survey approach provides extremely valuable capability in Recovery activities monitoring and may constitute a technical basis to lead aid organization and local government in the Recovery management.

L'eccezione è la regola: ricerca espolorativa sul fenomeno del commissariamento nel settore culturale italiano

Di fronte al moltiplicarsi di episodi di commissariamento nella pubblica amministrazione italiana e in particolare nel settore culturale, la presente ricerca mira a comprendere gli obiettivi, le modalità di intervento ed i risultati raggiunti mediante la nomina di commissari straordinari. Si tratta di un intervento anomalo ed inusuale a livello internazionale (la stessa voce commissariamento risulta intraducibile in inglese), dove la ricerca di possibili termini di paragone, effettuata passando in rassegna la letteratura di disaster management, quella sul riaccentramento amministrativo e quella sugli interventi di turnaround nel settore pubblico, restituisce un quadro estremamente specifico del fenomeno, per lo più interno ai confini nazionali. Nello studio, caratterizzato da un forte approccio esplorativo e phenomenon driven, vengono analizzati quattro casi di commissariamento nel settore culturale italiano: due aree archeologiche (quella di Napoli e Pompei e quella di Roma e Ostia) e due Fondazioni Liriche (Teatro Carlo Felice di Genova e Arena di Verona). Dalla ricerca emerge un quadro profondamente critico delle gestioni commissariali. Gli obiettivi ambigui e l’elevata discrezionalità concessa al commissario non sono accompagnati da un’adeguata trasparenza nei processi di nomina, proroga e sostituzione dei commissari, con la prevalenza di rapporti di tipo personale o ‘feudale’. Dal punto di vista dei risultati il commissariamento non incide sulla routine dell’amministrazione ordinaria, rappresentando nel migliore dei casi una parentesi temporanea di buona gestione, o, nel peggiore, perseguendo interventi non legittimi rispetto ai valori professionali che regolano le organizzazioni analizzate. Se considerato alla luce del più generale processo di riforma in senso manageriale che ha coinvolto le istituzioni analizzate dalla fine degli anni ’90, il commissariamento esalta ed intensifica gli aspetti maggiormente critici dell’approccio italiano al New Public Management, in termini di scarsa trasparenza e accountability, elevata influenza della politica nei processi decisionali e generale incoerenza dei disegni di riforma.

Applicazione e confronto di modelli per lo studio della vulnerabilita da maremoto nel golfo di siracusa

Il lavoro svolto in questa tesi s’inserisce e sviluppa soprattutto nel campo dell’analisi della vulnerabilità relativa agli tsunami ed è centrato sull’analisi della vulnerabilità di strutture ed edifici. Per la precisione si è focalizzata l’attenzione su un’area geografica specifica, cioè si è considerata l’ipotesi che un maremoto colpisca le coste orientali della Sicilia ed in particolare della città di Siracusa. Questo lavoro di tesi prenderà in considerazione due modelli distinti per la stima della vulnerabilità: il modello SCHEMA (SCenarios for Hazard-induced Emergencies MAnagement) che prende il nome dal progetto europeo in cui è stato sviluppato e il modello PTVA (Papathoma Tsunami Vulnerability Assessment) introdotto da Papathoma et al. (2003) e successivamente modificato da Dominey-Howes et al. (2007) e da Dall’Osso et al. (2009). Tali modelli sono esempi dei due possibili approcci (quantitativo e qualitativo). Nei seguenti capitoli si sono trattate le curve di fragilità e di danno, in particolare seguendo la metodologia di Koshimura et al. (2009) ed il lavoro di Valencia et al. (2011). A seguire sono stati descritti i due metodi utilizzati per lo studio della vulnerabilità (SCHEMA, PTVA) ed il lavoro che è stato condotto nell’area di Siracusa. Il lavoro di tesi si è concluso mostrando i risultati della classificazione di vulnerabilità evidenziando e discutendo differenze e similarità delle mappe risultanti dai due metodi applicati.

Metodi per l'analisi della vulnerabilità da maremoti applicati ad Augusta in Sicilia orientale

Obiettivo del lavoro di tesi è l’analisi della vulnerabilità delle strutture della città di Augusta, che è una delle aree campione scelte dal progetto europeo ASTARTE, riguardante fra l’altro la stima e la mitigazione del rischio da tsunami nei mari europei. Per prima cosa sono state ricercate le strutture tettoniche che possono dare origine a terremoti di grande magnitudo, e che possono causare in seguito devastanti tsunami, nella zona della Sicilia orientale. La Scarpata Maltese è risultata essere la caratteristica morfologica dominante in questa zona del Mediterraneo. Per l’analisi di vulnerabilità sono state utilizzate due diverse metodologie: il modello SCHEMA (SCenarios for Hazard-induced Emergencies MAnagement) e il modello PTVA-3 (Papathoma Tsunami Vulnerability Assessment). Il metodo SCHEMA, di tipo quantitativo, è un metodo più semplice in quanto si avvale della fotointerpretazione per assegnare ad una costruzione la classe di appartenenza in base alla sua tipologia. Poi, attraverso le matrici del danno, si assegna un livello di danno (da D0, nessun danno, a D5, collasso) in base all’altezza della colonna d’acqua. Il metodo PTVA-3, di tipo qualitativo, risulta invece essere più complicato. Infatti, per arrivare all’assegnazione dell’indice di vulnerabilità relativa (RVI), che fornisce una stima del danno subito da una data struttura, si ha bisogno di assegnare un certo numero di attributi. L’indice RVI è dato dalla somma pesata tra la vulnerabilità strutturale e la vulnerabilità dovuta all’intrusione d’acqua (percentuale di piani inondati). In conclusione si è fatto un confronto tra i due metodi, ottenendo una sovrastima del metodo PTVA-3 rispetto al metodo SCHEMA nella quantificazione del livello di danneggiamento degli edifici.

Supply sensitive services in Swiss ambulatory care: an analysis of basic health insurance records for 2003-2007

Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation') whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated.

A feasibility study for the provision of electronic healthcare tools and services in areas of Greece, Cyprus and Italy

Background Through this paper, we present the initial steps for the creation of an integrated platform for the provision of a series of eHealth tools and services to both citizens and travelers in isolated areas of thesoutheast Mediterranean, and on board ships travelling across it. The platform was created through an INTERREG IIIB ARCHIMED project called INTERMED. Methods The support of primary healthcare, home care and the continuous education of physicians are the three major issues that the proposed platform is trying to facilitate. The proposed system is based on state-of-the-art telemedicine systems and is able to provide the following healthcare services: i) Telecollaboration and teleconsultation services between remotely located healthcare providers, ii) telemedicine services in emergencies, iii) home telecare services for "at risk" citizens such as the elderly and patients with chronic diseases, and iv) eLearning services for the continuous training through seminars of both healthcare personnel (physicians, nurses etc) and persons supporting "at risk" citizens. These systems support data transmission over simple phone lines, internet connections, integrated services digital network/digital subscriber lines, satellite links, mobile networks (GPRS/3G), and wireless local area networks. The data corresponds, among others, to voice, vital biosignals, still medical images, video, and data used by eLearning applications. The proposed platform comprises several systems, each supporting different services. These were integrated using a common data storage and exchange scheme in order to achieve system interoperability in terms of software, language and national characteristics. Results The platform has been installed and evaluated in different rural and urban sites in Greece, Cyprus and Italy. The evaluation was mainly related to technical issues and user satisfaction. The selected sites are, among others, rural health centers, ambulances, homes of "at-risk" citizens, and a ferry. Conclusions The results proved the functionality and utilization of the platform in various rural places in Greece, Cyprus and Italy. However, further actions are needed to enable the local healthcare systems and the different population groups to be familiarized with, and use in their everyday lives, mature technological solutions for the provision of healthcare services.

CROSS-SECTORAL COORDINATION OF DISASTER RELIEF

Coordinating organizational activity across different sectors is crucial in disaster management. We analysed the response of 291 aid workers to the Haiti earthquake in 2010 and found that common incentives and a high degree of equality among aid organizations positively affected perceived network coordination. Large and public organizations were more likely to take leadership roles and high numbers of public organizations involved in the disaster response network led to improved network coordination. These results indicate the need for mechanisms that enable smaller and non-profit organizations to participate in network coordination and leadership.

C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption

Exsanguinating hemorrhage is the major cause of death in patients with pelvic ring disruption.

Damage control in severely injured trauma patients - A ten-year experience

This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality.

Sexual activity-related emergency department admissions: eleven years of experience at a Swiss university hospital

PRINCIPALS: Most people enjoy sexual intercourse without complications, but a significant, if small, number need to seek emergency medical help for related health problems. The true incidence of these problems is not known. We therefore assessed all admissions to our emergency department (ED) in direct relation to sexual intercourse. METHODS: All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was scanned for the standardised key words: 'sexual intercourse' (German 'Geschlechtsverkehr') or 'coitus' (German 'Koitus'). RESULTS: A total of 445 patients were available for further evaluation; 308 (69.0%) were male, 137 (31.0%) were female. The median age was 32 years (range 16-71) for male subjects and 30 years (range 16-70) for female subjects. Two men had cardiovascular emergencies. 46 (10.3%) of our patients suffered from trauma. Neurological emergencies occurred in 55 (12.4%) patients: the most frequent were headaches in 27 (49.0%), followed by subarachnoid haemorrhage (12, 22.0%) and transient global amnesia (11, 20.0%). 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract. The most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%) and epididymitis (19, 12.0%). A sexually transmitted disease (STD) was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. 118 (43.0%) of the patients with a possible infection requested testing for an STD because of unsafe sexual activity without underlying symptoms. CONCLUSIONS: Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.

Why do walk-in patients prefer a busy urban emergency department during office hours? A pilot survey of 200 consecutive patients from Switzerland

In Switzerland, more and more patients go directly to the emergency department, bypassing general practitioners. However, a mixture of non-urgent walk-in patients and acute emergencies in the same emergency department can inevitably make it more difficult to provide genuine emergencies with rapid treatment, leading to deterioration in the quality of emergency services, and tending to increase on-floor mortality and morbidity, together with higher overall costs.

Transvaginal ultrasound in fertile patients with suspected appendicitis: an experience report of current practice

Background. Transvaginal ultrasound (TVU) in female patients with acute right lower quadrant (RLQ) abdominal pain is time and infrastructure intensive and not always available. This study aims to evaluate the role of TVU in these patients. Methods. Retrospective analysis identified 224 female patients with RLQ pain and TVU. Results. TVU revealed an underlying pathology in 34 (15%) patients, necessitating a diagnostic laparoscopy in 12 patients. Six patients (2%) had a true gynaecological emergency. The remaining 23 patients did not require surgery. The other 190 patients with RLQ pain had a bland TVU; 127 (67%) were discharged, while 63 patients (33%) received a diagnostic laparoscopy. Conclusion. The incidence of true gynaecological emergencies requiring urgent surgical intervention is very low in our patient cohort. TVU is a helpful tool if performed by a physician who is well trained in TVU.