#SettimanaPS15: Il Pronto soccorso va in scena in Lombardia

@SilviaAlparone

Il teatro è protagonista della Settimana del Pronto soccorso in Lombardia: dopo il convegno che ha anticipato la Settimana 2015 il 14 e 15 maggio a Pavia “Itinerari di pronto soccorso” e le attività di Brescia rivolte ai ragazzi delle scuole con esercitazioni di intervento salva vita, domani, giovedì 21 maggio, si torna a Pavia, nella sala di Santa Maria Gualtieri, per “Dietro la porta del Pronto soccorso“.

Dietro la porta del pronto soccorso, Pavia, 21 maggio 2015

Si tratta di una rappresentazione teatrale sulla vita concitata del pronto soccorso, cuore e pancia di tutto l’ospedale. Tempi lunghi di attesa, tempi rapidissimi d’intervento, una scena quotidiana e reale su cui si intrecciano le vite di chi cura, medicie e infermieri, e quelle di chi viene curato, i pazienti.

Sarà ancora il linguaggio teatrale a chiudere la settimana del Pronto in Lombardia, questa volta a Milano: lunedì 25 maggio al Policlinico, per la sperimentatissima serie Casi clinici in scena, il titolo dello spettacolo sarà “Una giornata in Pronto soccorso“, sulla gestione dei casi più impegnativi dell’emergenza sanitaria, realizzato dalla Fondazione Ircss Ca’ Granda Ospedale Maggiore Policlinico in collaborazione con l’Università degli Studi di Milano.

Una giornata al pronto soccorso, Milano, 25 maggio 201

Memories …

Juicy FruitA sweet little lady was brought to the emergency department by her caregiver after having difficulty breathing at home. She got a few breathing treatments and some steroids and was doing much better an hour or so later.

When I went back in the room to evaluate her, several family members were present.
“Oooh. You got the good doctor. No wonder you’re doing better.”

I thanked them because … obviously they were right … but I mentioned that I didn’t recall seeing their mother in the emergency department before.
“She hasn’t been here in a long time. You took care of our father.”
“Oh. I see. How is he doing?”
“He died a little more than a year ago.”
One of the family members could obviously see the confusion in my face.
“He was dying from cancer and he came to the emergency department many times before he died. One of the last times he was here, he was having trouble swallowing and his mouth was dry. You started the IV on him and gave him some fluids. Got him feeling better. He kept saying that all he wanted was some Juicy Fruit gum. So you went to the vending machine and got him a pack of Juicy Fruit gum. That was all he talked about after that day … how his doctor in the ER went and got him some gum when his mouth was dry.”

At that point, I realized several things.
First, it showed me that patient opinions of medical care can be arbitrary. I was judged as being a “good” doctor because I did something nice for a patient, not because of the medical care I provided. This interaction just reinforces my belief that our current means of rating medical care is woefully inadequate and inappropriate.
Second, this family’s story showed me how small acts of kindness can have a tremendous ripple effect. Something I had long forgotten had made a lasting impact on the patient which in turn made a lasting impact on the family and will probably continue to be a story that is always associated with our emergency department.
Finally, this interaction reiterates a quote from Maya Angelou that I frequently paraphrase when talking to residents and even in some of my lectures: Patients may not remember your medical knowledge and they may not remember your diagnostic acumen, but they will ALWAYS remember how you made them feel.

Pretty good returns for an investment of a 35-cent pack of gum …

JC: An International Clinical Trials Day Special

St Emlyns - Meducation in Virchester #FOAMed

International Clinical Trials Day 2015 is on 20th May.  To mark the occasion we’re going to run an extra special critical appraisal.  This time, let’s look at an awesome piece of work I came across in the literature.  It’s not exactly hot off the press – but it’s an inspirational piece of work that I’m […]

The post JC: An International Clinical Trials Day Special appeared first on St Emlyns.

Graphene: The Next Medical Revolution

The 2010 Nobel Prize for Physics went to two scientists who found a simple way to isolate a single layer of graphite, called graphene. It is a 2D sheet of carbon atoms arranged in a hexagonal lattice, that makes for the thinnest, most electrically and thermally conductive material in the world, while also being flexible, transparent and incredibly strong. Graphene’s myriad of outstanding properties earned it the name “wonder material”, and many believe that the 21st century will become the ‘Graphene Age’.

grapheneGraphene is indeed a much-researched, heavily-hyped material, with the potential to revolutionize every aspect of our lives: from selective membranes that may solve the world’s water shortage, through replacing silicon in electronics to achieve amazing performance in miniature sizes, to enabling a multitude of next-gen energy solutions. Graphene’s prospects of spearheading innovations, however, do not stop at ‘green power’ solar cells or cell phone batteries that recharge within minutes; Graphene’s compatibility with various biomedical applications, like drug delivery, cancer therapies and biosensing, is extensively and vigorously researched. The material’s unique properties, like a large surface area, good biocompatibility and chemical stability, deem it worthy of intensive examination and high hopes.

Artificial implants are a medical staple, and graphene could play a crucial role in the future of these devices. Graphene’s biocompatibility, coupled with its mechanical strength, is beneficial for various composite bio-materials and its electrical conductivity can be used for organs that require such attributes, like nerve tissues and spinal elements. In fact, researchers at the Michigan Technological University are gaining progress in their work to 3D print replacement nerves using 3D bioprinting techniques. The team has developed polymer materials that can act as a scaffold for growing tissues and is working on integrating graphene as the electrical conductor.

Bio-sensing is a growing field, with many medical applications that come to mind. Many avenues are explored along these lines, with graphene showing exceptional performance in detecting food toxins, environmental pollution, specific germs and bacteria and more. Graphene-oxide, an oxygenated form of graphene, binds to the protein-like structure of specific toxins to produce an enhanced signal that enables hyper-sensitive sensors that detect toxins at level of about 10 times lower than conventional sensors. Another example is a sensor that predicts heart attacks, using graphene-oxide’s ability to detect specific microparticles in the blood that are released prior to heart attacks. Various similar sensors are currently under research and development for the detection of a multitude of diseases, toxins and biomarkers.

graphene-chip

Graphene-Oxide based chip prototypes for biopsy-free early cancer diagnosis

 

Graphene has great potential for the detection and treatment of cancer. As far as sensitive detection goes, Chinese scientists developed a single-cell sensor based on graphene field-effect transistors, able to detect even a single cancer cell! But perhaps more interesting is graphene’s potential in cancer treatment; University of Manchester scientists found that graphene oxide may act as an anti-cancer agent that selectively targets cancer stem cells. Combined with existing treatments, this could lead to tumor shrinkage as well as preventing the spread of cancer and its recurrence after treatment. Graphene is also vastly studied for applications in cancer drug delivery, mostly due to its large surface area that allows it to transport massive amounts of drugs to specific sites in the body. In addition to cancer detection and drug delivery, graphene itself is studied as an anti-cancer agent – focusing, for instance, on its thermal conductivity and ability to convert non-ionizing radio waves into heat energy at microscopic levels and create enough heat to eliminate proteins and DNA inside cancer cells.

graphene-graphicDNA sequencing, or determining the sequence of bases in DNA that make up the genome, is of great importance for not only gaining a better understanding of the human make-up, but also for comprehending any number of genetic diseases, cancer types and the human immune systems. Graphene-enabled DNA sequencing is usually based on creating a graphene membrane, immersing it in conductive fluid and applying a voltage to one end so DNA can be drawn through the graphene’s miniscule pores. This method is called nanopore sequencing and it would allow DNA to be analyzed one nucleotide at a time (each nucleotide affecting the membrane differently due to its unique dimensions and electrical properties). Additional concepts involve graphene-based DNA sensors, and other alternative ways of making DNA sequencing faster and more efficient.

Nanomedicine is currently still in its infancy, and so is the use of graphene for medical applications. Its great promise to enter and revolutionize many medical fields, however, encourages much research and development efforts, and the future will hopefully see more effective, longer lasting preventative and treatment methods with enabled by graphene.

The post Graphene: The Next Medical Revolution appeared first on Medgadget.

Graphene: The Next Medical Revolution

The 2010 Nobel Prize for Physics went to two scientists who found a simple way to isolate a single layer of graphite, called graphene. It is a 2D sheet of carbon atoms arranged in a hexagonal lattice, that makes for the thinnest, most electrically and thermally conductive material in the world, while also being flexible, transparent and incredibly strong. Graphene’s myriad of outstanding properties earned it the name “wonder material”, and many believe that the 21st century will become the ‘Graphene Age’.

grapheneGraphene is indeed a much-researched, heavily-hyped material, with the potential to revolutionize every aspect of our lives: from selective membranes that may solve the world’s water shortage, through replacing silicon in electronics to achieve amazing performance in miniature sizes, to enabling a multitude of next-gen energy solutions. Graphene’s prospects of spearheading innovations, however, do not stop at ‘green power’ solar cells or cell phone batteries that recharge within minutes; Graphene’s compatibility with various biomedical applications, like drug delivery, cancer therapies and biosensing, is extensively and vigorously researched. The material’s unique properties, like a large surface area, good biocompatibility and chemical stability, deem it worthy of intensive examination and high hopes.

Artificial implants are a medical staple, and graphene could play a crucial role in the future of these devices. Graphene’s biocompatibility, coupled with its mechanical strength, is beneficial for various composite bio-materials and its electrical conductivity can be used for organs that require such attributes, like nerve tissues and spinal elements. In fact, researchers at the Michigan Technological University are gaining progress in their work to 3D print replacement nerves using 3D bioprinting techniques. The team has developed polymer materials that can act as a scaffold for growing tissues and is working on integrating graphene as the electrical conductor.

Bio-sensing is a growing field, with many medical applications that come to mind. Many avenues are explored along these lines, with graphene showing exceptional performance in detecting food toxins, environmental pollution, specific germs and bacteria and more. Graphene-oxide, an oxygenated form of graphene, binds to the protein-like structure of specific toxins to produce an enhanced signal that enables hyper-sensitive sensors that detect toxins at level of about 10 times lower than conventional sensors. Another example is a sensor that predicts heart attacks, using graphene-oxide’s ability to detect specific microparticles in the blood that are released prior to heart attacks. Various similar sensors are currently under research and development for the detection of a multitude of diseases, toxins and biomarkers.

graphene-chip

Graphene-Oxide based chip prototypes for biopsy-free early cancer diagnosis

 

Graphene has great potential for the detection and treatment of cancer. As far as sensitive detection goes, Chinese scientists developed a single-cell sensor based on graphene field-effect transistors, able to detect even a single cancer cell! But perhaps more interesting is graphene’s potential in cancer treatment; University of Manchester scientists found that graphene oxide may act as an anti-cancer agent that selectively targets cancer stem cells. Combined with existing treatments, this could lead to tumor shrinkage as well as preventing the spread of cancer and its recurrence after treatment. Graphene is also vastly studied for applications in cancer drug delivery, mostly due to its large surface area that allows it to transport massive amounts of drugs to specific sites in the body. In addition to cancer detection and drug delivery, graphene itself is studied as an anti-cancer agent – focusing, for instance, on its thermal conductivity and ability to convert non-ionizing radio waves into heat energy at microscopic levels and create enough heat to eliminate proteins and DNA inside cancer cells.

graphene-graphicDNA sequencing, or determining the sequence of bases in DNA that make up the genome, is of great importance for not only gaining a better understanding of the human make-up, but also for comprehending any number of genetic diseases, cancer types and the human immune systems. Graphene-enabled DNA sequencing is usually based on creating a graphene membrane, immersing it in conductive fluid and applying a voltage to one end so DNA can be drawn through the graphene’s miniscule pores. This method is called nanopore sequencing and it would allow DNA to be analyzed one nucleotide at a time (each nucleotide affecting the membrane differently due to its unique dimensions and electrical properties). Additional concepts involve graphene-based DNA sensors, and other alternative ways of making DNA sequencing faster and more efficient.

Nanomedicine is currently still in its infancy, and so is the use of graphene for medical applications. Its great promise to enter and revolutionize many medical fields, however, encourages much research and development efforts, and the future will hopefully see more effective, longer lasting preventative and treatment methods with enabled by graphene.

The post Graphene: The Next Medical Revolution appeared first on Medgadget.

Finally, an End to Tamulosin for Renal Colic?

Most urologic professional societies recommend “medical expulsive therapy” for ureterolithiasis, with an expectation of increased stone expulsion, improved time-to-passage, and reduced need for analgesia.

As I’ve covered before – breaking down a pro-tamulosin Cochrane Review – the evidence in support of this practice is junk.  David Newman, Anand Swaminathan, and Salim Rezaie agree.  The last time I posted, I posited there was probably some small benefit to a subgroup of patient with renal colic, but, alas, we would probably never have high-quality evidence.

I was wrong.

This study in The Lancet tested MET by randomizing patients with CT-confirmed ureterolithiasis to three arms – placebo, nifedipine, or tamulosin.  The randomization algorithm balanced the arms between stone size and stone location.  The primary outcome was need for urologic intervention at 4 weeks, with secondary outcomes of patient-reported time to stone passage and pain medication use.

With 1,167 patients randomized – 31 of which were excluded or lost to follow-up – there was no difference in need for urologic intervention between groups: 20% placebo, 19% tamulosin, 20% nifedipine.  Secondary outcomes – measured by follow-up questionnaire – were likewise similar, with no differences detected in the number of pain medication nor days until stone passage.

Now, urologic intervention is a rather imprecise surrogate outcome for evaluating the efficacy of MET for promoting stone passage.  And, only 62% of patients returned the surveys regarding the secondary outcomes of subjective stone passage and analgesic use.  This is high-quality evidence, but hardly infalliable.  The authors also state no subgroup showed benefit – which is not entirely true.  MET was slightly beneficial (86% vs. 82%) for patients with lower ureteral tract stones, with a p-value of 0.099.  Giving into the tyranny of p-values, yes, there’s no benefit – but using the p-value akin to a likelihood ratio, judged against the larger context of other (albeit, low-quality) trials showing benefit, I would not find it unreasonable to contest the totality of these authors’ conclusion.

Regardless, the empiric use of tamulosin has simply been an urban legend taken one step too far.  Short of large stones in the lower urinary tract, the benefit is fleeting at best – and the magnitude of the benefit may be too low to matter.

“Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60933-3/abstract (oa)