Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

OBJECTIVE: Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital. MATERIALS AND METHODS: Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients. RESULTS: Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i. e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers. CONCLUSION: Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

The implementation of the Medical Regulation Office and Mobile Emergency Attendance System and its impact on the gravity profile of non-traumatic afflictions treated in a University Hospital: a research study

Abstract Background The public health system of Brazil is structured by a network of increasing complexity, but the low resolution of emergency care at pre-hospital units and the lack of organization of patient flow overloaded the hospitals, mainly the ones of higher complexity. The knowledge of this phenomenon induced Ribeirão Preto to implement the Medical Regulation Office and the Mobile Emergency Attendance System. The objective of this study was to analyze the impact of these services on the gravity profile of non-traumatic afflictions in a University Hospital. Methods The study conducted a retrospective analysis of the medical records of 906 patients older than 13 years of age who entered the Emergency Care Unit of the Hospital of the University of São Paulo School of Medicine at Ribeirão Preto. All presented acute non-traumatic afflictions and were admitted to the Internal Medicine, Surgery or Neurology Departments during two study periods: May 1996 (prior to) and May 2001 (after the implementation of the Medical Regulation Office and Mobile Emergency Attendance System). Demographics and mortality risk levels calculated by Acute Physiology and Chronic Health Evaluation II (APACHE II) were determined. Results From 1996 to 2001, the mean age increased from 49 ± 0.9 to 52 ± 0.9 (P = 0.021), as did the percentage of co-morbidities, from 66.6 to 77.0 (P = 0.0001), the number of in-hospital complications from 260 to 284 (P = 0.0001), the mean calculated APACHE II mortality risk increased from 12.0 ± 0.5 to 14.8 ± 0.6 (P = 0.0008) and mortality rate from 6.1 to 12.2 (P = 0.002). The differences were more significant for patients admitted to the Internal Medicine Department. Conclusion The implementation of the Medical Regulation and Mobile Emergency Attendance System contributed to directing patients with higher gravity scores to the Emergency Care Unit, demonstrating the potential of these services for hierarchical structuring of pre-hospital networks and referrals.

Alternative management of diabetic ketoacidosis in a Brazilian pediatric emergency department

DKA is a severe metabolic derangement characterized by dehydration, loss of electrolytes, hyperglycemia, hyperketonemia, acidosis and progressive loss of consciousness that results from severe insulin deficiency combined with the effects of increased levels of counterregulatory hormones (catecholamines, glucagon, cortisol, growth hormone). The biochemical criteria for diagnosis are: blood glucose > 200 mg/dl, venous pH <7.3 or bicarbonate <15 mEq/L, ketonemia >3 mmol/L and presence of ketonuria. A patient with DKA must be managed in an emergency ward by an experienced staff or in an intensive care unit (ICU), in order to provide an intensive monitoring of the vital and neurological signs, and of the patient's clinical and biochemical response to treatment. DKA treatment guidelines include: restoration of circulating volume and electrolyte replacement; correction of insulin deficiency aiming at the resolution of metabolic acidosis and ketosis; reduction of risk of cerebral edema; avoidance of other complications of therapy (hypoglycemia, hypokalemia, hyperkalemia, hyperchloremic acidosis); identification and treatment of precipitating events. In Brazil, there are few pediatric ICU beds in public hospitals, so an alternative protocol was designed to abbreviate the time on intravenous infusion lines in order to facilitate DKA management in general emergency wards. The main differences between this protocol and the international guidelines are: intravenous fluid will be stopped when oral fluids are well tolerated and total deficit will be replaced orally; if potassium analysis still indicate need for replacement, it will be given orally; subcutaneous rapid-acting insulin analog is administered at 0.15 U/kg dose every 2-3 hours until resolution of metabolic acidosis; approximately 12 hours after treatment initiation, intermediate-acting (NPH) insulin is initiated at the dose of 0.6-1 U/kg/day, and it will be lowered to 0.4-0.7 U/kg/day at discharge from hospital.

Hedonic analysis of cell phones sold with post-paid service plans in Brazil

The aim of this paper is to analyze the determining factors for the pricing of handsets sold with service plans, using the hedonic price method. This was undertaken by building a database comprising 48 handset models, under nine different service plans, over a period of 53 weeks in 2008, and resulted in 27 different attributes and a total number of nearly 300,000 data registers. The results suggest that the value of monthly subscriptions and calling minutes are important to explain the prices of handsets. Furthermore, both the physical volume and number of megapixels of a camera had an effect on the prices. The bigger the handset, the cheaper it becomes, and the more megapixels a camera phone has, the more expensive it becomes. Additionally, it was found that in 2008 Brazilian phone companies were subsidizing enabled data connection handsets.

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.

Epidemiological and clinical characteristics of injuries among adolescents attended at an emergency service in the city of Ribeirão Preto, São Paulo

CONTEXT AND OBJECTIVE: Injuries are an important cause of morbidity during adolescence, but can be avoided through learning about some of their characteristics. This study aimed to identify the most frequent injuries among adolescents attended at an emergency service. DESIGN AND SETTING: Retrospective descriptive study on adolescents attended at the emergency service of the Teaching Health Center, Faculdade de Medicina de Ribeirão Preto (FMRP), between January 1, 2009, and September 30, 2009. METHODS: Age, sex, type of injury, site, day and time of occurrence, part of body involved, care received, whether the adolescent was accompanied at the time of injury and whether any type of counseling regarding injury prevention had been given were analyzed. RESULTS: Among 180 adolescents attended, 106 (58.8%) were boys and 74 (41.1%) were girls. Their ages were: 10 to 12 (66/36.6%), 12 to 14 (60/33.3%) and 14 to 16 years (54/30%). The injuries had occurred in public places (47.7%) and at home (21.1%). The main types were bruises (45.1%) and falls (39.2%), involving upper limbs (46.1%), lower limbs (31%) and head/neck (13.1%). The injuries occurred in the afternoon (44.4%) and morning (30%), on Mondays (17.7%) and Thursdays (16.6%). Radiological examinations were performed on 53.8%. At the time of injury, 76.1% of the adolescents were accompanied. Some type of counseling about injury prevention had been received by 39.4%. CONCLUSIONS: Although the injuries were of low severity, preventive attitudes need to be incorporated in order to reduce the risks and provide greater safety for adolescents.

Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a Pediatric emergency room

OBJECTIVE: To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS: This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS: 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS: The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Sustainable improvement of water networks : to achieve best decisions for rehabilitation plans using advanced GIS and statistical techniques

Many of developing countries are facing crisis in water management due to increasing of population, water scarcity, water contaminations and effects of world economic crisis. Water distribution systems in developing countries are facing many challenges of efficient repair and rehabilitation since the information of water network is very limited, which makes the rehabilitation assessment plans very difficult. Sufficient information with high technology in developed countries makes the assessment for rehabilitation easy. Developing countries have many difficulties to assess the water network causing system failure, deterioration of mains and bad water quality in the network due to pipe corrosion and deterioration. The limited information brought into focus the urgent need to develop economical assessment for rehabilitation of water distribution systems adapted to water utilities. Gaza Strip is subject to a first case study, suffering from severe shortage in the water supply and environmental problems and contamination of underground water resources. This research focuses on improvement of water supply network to reduce the water losses in water network based on limited database using techniques of ArcGIS and commercial water network software (WaterCAD). A new approach for rehabilitation water pipes has been presented in Gaza city case study. Integrated rehabilitation assessment model has been developed for rehabilitation water pipes including three components; hydraulic assessment model, Physical assessment model and Structural assessment model. WaterCAD model has been developed with integrated in ArcGIS to produce the hydraulic assessment model for water network. The model have been designed based on pipe condition assessment with 100 score points as a maximum points for pipe condition. As results from this model, we can indicate that 40% of water pipeline have score points less than 50 points and about 10% of total pipes length have less than 30 score points. By using this model, the rehabilitation plans for each region in Gaza city can be achieved based on available budget and condition of pipes. The second case study is Kuala Lumpur Case from semi-developed countries, which has been used to develop an approach to improve the water network under crucial conditions using, advanced statistical and GIS techniques. Kuala Lumpur (KL) has water losses about 40% and high failure rate, which make severe problem. This case can represent cases in South Asia countries. Kuala Lumpur faced big challenges to reduce the water losses in water network during last 5 years. One of these challenges is high deterioration of asbestos cement (AC) pipes. They need to replace more than 6500 km of AC pipes, which need a huge budget to be achieved. Asbestos cement is subject to deterioration due to various chemical processes that either leach out the cement material or penetrate the concrete to form products that weaken the cement matrix. This case presents an approach for geo-statistical model for modelling pipe failures in a water distribution network. Database of Syabas Company (Kuala Lumpur water company) has been used in developing the model. The statistical models have been calibrated, verified and used to predict failures for both networks and individual pipes. The mathematical formulation developed for failure frequency in Kuala Lumpur was based on different pipeline characteristics, reflecting several factors such as pipe diameter, length, pressure and failure history. Generalized linear model have been applied to predict pipe failures based on District Meter Zone (DMZ) and individual pipe levels. Based on Kuala Lumpur case study, several outputs and implications have been achieved. Correlations between spatial and temporal intervals of pipe failures also have been done using ArcGIS software. Water Pipe Assessment Model (WPAM) has been developed using the analysis of historical pipe failure in Kuala Lumpur which prioritizing the pipe rehabilitation candidates based on ranking system. Frankfurt Water Network in Germany is the third main case study. This case makes an overview for Survival analysis and neural network methods used in water network. Rehabilitation strategies of water pipes have been developed for Frankfurt water network in cooperation with Mainova (Frankfurt Water Company). This thesis also presents a methodology of technical condition assessment of plastic pipes based on simple analysis. This thesis aims to make contribution to improve the prediction of pipe failures in water networks using Geographic Information System (GIS) and Decision Support System (DSS). The output from the technical condition assessment model can be used to estimate future budget needs for rehabilitation and to define pipes with high priority for replacement based on poor condition. rn

Sviluppo di un business plans. Il caso fruit prodaction S.R.L

Esperienza di sviluppo di business plan aziendale

Emergency response to railroad accidents involving hazardous materials

The chemical industry has to face safety problems linked to the hazards of chemicals and the risks posed by the plants where they are handled. However, their transport may cause significant risk values too: it’s not totally possible to avoid the occurrence of accidents. This work is focused on the emergency response to railway accidents involving hazardous materials, that is what has to be done once they happen to limit their consequences. A first effort has been devoted to understand the role given to this theme within legislations: it has been found out that often it’s not even taken into account. Exceptionally a few countries adopt guidelines suggesting how to plan the response, who is appointed to intervene and which actions should be taken first. An investigation has been made to define the tools available for the responders, with attention on the availability of chemical-specific safety distances. It has emerged that the ERG book adopted by some American countries has suggestions and the Belgian legislation too establishes criteria to evaluate these distances. An analysis has been conducted then on the most recent accidents occurred worldwide, to understand how the response was performed and which safety distances were adopted. These values were compared with the numbers reported by the ERG book and the results of two devoted software tools for consequence analysis of accidental spills scenarios. This comparison has shown that there are differences between them and that a more standardized approach is necessary. This is why further developments of the topic should focus on promoting uniform procedures for emergency response planning and on a worldwide adoption of a guidebook with suggestions about actions to reduce consequences and about safety distances, determined following finer researches. For this aim, the development of a detailed database of hazardous materials transportation accidents could be useful.

A method for automated generation of radiotherapy treatment plans for lung cancer

La radioterapia è una tecnica molto impiegata per la cura del cancro. Attualmente la somministrazione avviene principalmente attraverso la intensity modulated radiotherapy (IMRT, sovrapposizione di campi ad intensità modulata), un cui sviluppo recente è la volumetric modulated arc therapy (VMAT, irradiazione continua lungo un arco ininterrotto). La generazione di piani richiede esperienza ed abilità: un dosimetrista seleziona cost functions ed obiettivi ed un TPS ottimizza la disposizione dei segmenti ad intensità modulata. Se il medico giudica il risultato non soddisfacente, il processo riparte da capo (trial-and-error). Una alternativa è la generazione automatica di piani. Erasmus-iCycle, software prodotto presso ErasmusMC (Rotterdam, The Netherlands), è un algoritmo di ottimizzazione multicriteriale di piani radioterapici per ottimizzazione di intensità basato su una wish list. L'output consiste di piani Pareto-ottimali ad intensità modulata. La generazione automatica garantisce maggiore coerenza e qualità più elevata con tempi di lavoro ridotti. Nello studio, una procedura di generazione automatica di piani con modalità VMAT è stata sviluppata e valutata per carcinoma polmonare. Una wish list è stata generata attraverso una procedura iterativa su un gruppo ristretto di pazienti con la collaborazione di fisici medici ed oncologi e poi validata su un gruppo più ampio di pazienti. Nella grande maggioranza dei casi, i piani automatici sono stati giudicati dagli oncologi migliori rispetto ai rispettivi piani IMRT clinici generati manualmente. Solo in pochi casi una rapida calibrazione manuale specifica per il paziente si è resa necessaria per soddisfare tutti i requisiti clinici. Per un sottogruppo di pazienti si è mostrato che la qualità dei piani VMAT automatici era equivalente o superiore rispetto ai piani VMAT generati manualmente da un dosimetrista esperto. Complessivamente, si è dimostrata la possibilità di generare piani radioterapici VMAT ad alta qualità automaticamente, con interazione umana minima. L'introduzione clinica della procedura automatica presso ErasmusMC è iniziata (ottobre 2015).

Emergency direct: studio e implementazione di un'applicazione android per disseminazione di messaggi d'allarme in reti spontanee

In questa tesi inizialmente ci si è occupati di definire ed approfondire le caratteristiche della tecnologia Wi-Fi Direct, illustrandone il funzionamento, l’architettura e gli scenari di utilizzo. Successivamente è stata sviluppata un’applicazione basata su tale tecnologia, con lo scopo di fornire un servizio di disseminazione di messaggi d’aiuto in situazioni di emergenza o di catastrofi naturali, nelle quali la rete cellulare viene inevitabilmente meno. In queste occasioni c’è il bisogno di avere uno strumento che permetta di comunicare in maniera facile, veloce e che sia alla portata di tutti. Caratteristiche e qualità proprie di uno smartphone, dispositivo che oggigiorno è presente nelle tasche di ognuno di noi. L’obiettivo finale infatti, sarebbe quello di creare un applicativo che possa idealmente essere preinstallato in ogni nostro dispositivo, un servizio che sia diffuso, compreso ed utilizzabile istantaneamente da tutti, in modo tale da essere una sicurezza e un aiuto di vitale importanza in situazioni di pericolo. Per lo sviluppo di una tale applicazione ci si è basati sul sistema operativo Android, che è il più diffuso tra gli utenti di tutto il mondo. Nel primo capitolo ci si è occupati di di presentare ed approfondire la tecnologia Wi-Fi Direct, definendone gli ambiti generali di utilizzo e le problematiche che vengono affrontate. Nel secondo capitolo si prosegue con la presentazione della tecnologia in ambiente Android, descrivendo le API fornite da Google per l’utilizzo del servizio in questione. Nel terzo capitolo, dopo un’analisi dei progetti che coinvolgono tale tecnologia, viene illustrata l’applicazione creata, le sue funzionalità e caratteristiche ed eventuali casi d’uso. Nel quarto capitolo è stata inserita la parte più tecnica, dove illustro i problemi incontrati e le modalità di risoluzione degli stessi, insieme alle strutture ed agli oggetti messi a disposizione da Java che sono stati utilizzati. Infine nel capitolo conclusivo è stato fatto un riepilogo del lavoro svolto, indicando le difficoltà incontrate ed eventuali possibili miglioramenti e sviluppi futuri del mio progetto.

Prehospital ultrasound in emergency medicine: incidence, feasibility, indications and diagnoses

Sonography is an established diagnostic procedure in hospitals, but is not routinely used in prehospital emergency medicine. Several studies have addressed the use of ultrasound during helicopter flights and in emergency rooms, few in prehospital settings, but most focused on abdominal blunt trauma. Several case reports describe crucial decisions distinguished by ultrasound.

Emergency skill training--a randomized controlled study on the effectiveness of the 4-stage approach compared to traditional clinical teaching

The "4-stage approach" has been widely accepted for practical skill training replacing the traditional 2 stages ("see one, do one"). However, the superior effectiveness of the 4-stage approach was never proved.