Table of Contents
Avoiding the apocalypse: a call for global action
Author: Francesco Chirico*
*Health Service State Police, Ministry of Interior, Italy
Keywords: global health; international cooperation; inequalities.
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Special Article in Emergency
Mass gatherings in Italy: a study from the 2015 Milan Expo
Authors: Pietro Marino*, Enzo Albergoni**, Aida Andreassi**, Gianluca Chiodini***, Lucia Colombi**, Cristina Corbetta**, Gabriella Nucera*, Marco Salmoiraghi****, Alberto Zoli**
*Department of Emergency, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy. Piazza Principessa Clotilde 3, Milan, Italy.
**Pre-Hospital Emergency Company (AREU), Lombardy Region, Italy. Via A.Campanini, 6, Milan, Italy.
***ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy. Piazza dell’Ospedale Maggiore, 3, Milan, Italy.
****ASST Santi Paolo e Carlo, Milan, Italy. Via Pio II, 3, Milan, Italy.
Introduction: A mass gathering (MG) is when a large number of people come together in a parti- cular location for a specific purpose. Expo 2015 was an universal exposition hosted by Milan, Italy. The Pre-Hospital Emergency Company (AREU) of Lombardy Region (Milan-Italy) was involved in planning and managing the emergency rescue response inside the Expo 2015 area in Milan. In this paper, we review the AREU medical and public health response for the 2015 Milan Expo.
Methods: Existing risk-assessment processes for MGs were used (the Arbon Predictive Score and Maurer Score) to define the expected resources and the impact on the health systems. The objecti- ve of the plan was to reduce the impact of the event by adopting the model of First Aid Points (advanced medical posts) deployed in the event site acting as ‘first health filters’ for the hospital network in Milan.
Results: Our data indicate that 13,579 visitors were rescued in the ‘Red Area’ from 1 May to 31 October (with an average of 73 cases per day); 9,501 of them needed initial treatment or obser- vation time at the First Aid Points, 1,289 of them were hospitalised (1% Red code, 29% Yellow code, 70% Green code); 65% of patients (57% female, with a mean age of 37 years old) had medical problems. Fatigue, light- headedness, dizziness, syncope, loss of consciousness and headache were the prevalent medical diagnoses.
Conclusions: Our study confirms that environmental factors, such as the weather, can contribute to large numbers of ill people at MGs. Overall, the AREU of Lombardy Region demonstrated excel- lent preparation for the Expo 2015 MG. Flexibility, integration and strong cooperation between the pre-hospital settings and hospitals were incorporated into the application of the plan. The final data showed the effectiveness of the adopted model and the reduced impact on the hospital network.
Keywords: public health; mass gatherings; 2015 World Exposition; disaster planning; health care systems.
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Viewpoint in Occupational Medicine
Psychological fitness for work: do we still have a long way to go?
Author: Giuseppe Ferrari*
*Italian Society of Integrative Psychotherapy for Social Development (SIPISS)
In Italy, the absence of adequate regulatory instruments and guidelines for the proper classification of psychiatric disorders in occupational medicine denies occupational physicians the opportunity to adequately evaluate employees’ psycho-physical fitness for work through health surveillance. This applies particularly to the categories of workers who could potentially ‘endanger’ the health and safety of third parties in the workplace. Although each business organization tries to internally manage these cases, there is an increasingly need to have a common reference framework. It is becoming increasingly urgent that both legal experts and scientific researchers address this issue together to define the psychological requirements necessary for the performance of given activities according to the nosological classification of psychiatric disorders from the DSM-5; this will protect the health and safety of both the workers and third parties.
Keywords: occupational medicine; psychology, medical; psychiatry; occupational diseases; safety.
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Review Article in Dermatology
Complications of tattoos and tattoos removal: state-of-the-art in Italy
Author: Mirko Campisi*
*Health Service Department, State Police, Ministry of Interior, Italy.
Introduction: Modern tattoo removal began as a science approximately 20 years ago, and relatively few advances have been made since then. The aim of this study is twofold: first, to review the complications of tattoos and tattoo removal methods and second, to investigate both the epidemiology and legal issues of this phenomenon in Italy.
Discussion: Complications of medical tattoos are changes in colour, leading to colour mismatch. The complications of decorative tattoos include infections and allergic and foreign body reactions. Tattoos are popular in Italy, especially among the younger generations. As these people age, the demand for tattoo removal will continue to grow. Q-switched (QS) lasers are widely considered the gold standard for tattoo removal. Although Q-switched lasers are capable of removing tattoos without harming the skin, removal often requires numerous treatments and it can still be incomplete, especially when attempting to remove multi-coloured tattoos. Moreover, complications can occur, with an incidence of about 5%. Immediate complications include pain, blisters, crusting and pinpoint haemorrhage. Delayed complications include pigmentary changes, either hypopigmentation or hyperpigmentation. Developments leading to removable tattoo inks, feedback systems to detect the absorbance characteristics of tattoo inks, dermal clearing agents and, perhaps, even shorter pulse-duration lasers should result in improvements in tattoo removal in the near future.
Conclusions: In Italy there is no specific prescriptive legislation for tattooing, and there is also a great diversity in terms of regional regulatory approaches. Future educational campaigns by school counsellors and primary care physicians should also be aimed at specific groups that are more likely to get tattoos, such as minors and women.
Keywords: lasers; laser treatment; Q-Switched Lasers; tattoo; tattoo removal.
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Original Article in Oncology
Prospective evaluation through questionnaires of the emotional status of cancer patients in the waiting rooms of a department of oncology
Authors: Roberta Resega*, Sheila Piva**, Annalisa Bramati**, Christian Lurati*, Nicla La Verde**, Marco Riva*, Marina Chiara Garassino***, Anna Moretti**, Claudio Mencacci*, Valter Torri****, Gabriella Farina**, Maria Chiara Dazzani**
*Department of Mental Health, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy. Piazza Principessa Clotilde 3, Milan, Italy.
**Department of Oncology, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy. Piazza Principessa Clotilde 3, Milan, Italy.
***Department of Medical Oncology, Thoracic Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, Italy.
**** Laboratory of Methodology for Biomedical Research, IRCCS – Istituto di Ricerche Farmacologiche “Mario Negri”, via La Masa 19, 20156 Milan, Italy.
Objective: The aim of this study is to better identify the prevailing emotions and feelings of cancer patients during their stay in waiting rooms in a department of oncology.
Methods: In July 2014, patients in the waiting rooms of our Department of Oncology were asked to fill out dedicated questionnaires. Patients had to choose sentences that best described their feelings, thoughts and experiences; this part was differentiated according to the waiting rooms (Consultation Rooms versus Day Hospital). In another section, patients were asked to choose their prevailing primary emotions: joy, fear, sadness, anger, disgust or surprise.
Results: Two hundred eighty questionnaires were considered valid for statistical analysis. Regarding feelings, all patients in the Day Hospital and Consultation Rooms stated that they feel anxious (48% and 53%, respectively). By differentiating patients according to the setting, patients in the Day Hospital answered that they will face chemotherapy, thinking that it will be useful to defeat the disease (56%), and patients in Consultation Rooms answered that time in the waiting rooms goes more slowly (65%). Regarding the prevailing emotions experienced by patients, sadness was the most selected, followed by fear and surprise.
Conclusions: A prevalent emotional and cognitive state while waiting is anxiety, followed by positive thoughts. Patients presented anxiety and fear independently from the setting of care. We believe that each oncologist should be aware of the degrees of fear and sadness that patients experience during an oncological examination because these emotions can have an impact on communication and understanding.
Keywords: cancer; emotions; survey and questionnaires; patients’ rooms.
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Case Report in Cardiology
An unusual case of chest pain
Authors: Gabriella Nucera*, Giulia Cantoni*, Pietro Marino*
* Department of Emergency, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy.
We report the case of a 40-year-old woman presenting during the night to the emergency department for thoracic pain and pain in the upper arm. An electrocardiogram (ECG) showed diffuse ST segment elevation. A coronarography (CVG) showed spontaneous dissection of the interventricular anterior artery. Many patients present with chest pain to emergency departments (ED). Spontaneous coronary artery dissection (SCAD) should be considered in any young patient, especially young women, without a history of coronary heart disease or risk factors, who presents with an acute myocardial infarction or cardiac arrest.
Keywords: coronary artery disease; myocardial ischemia; coronary vessel; dissection; acute coronary syndrome; spontaneous coronary artery dissection.
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Case Report in Neurology
A fulminant case of JC virus encephalopathy supporting a novel syndrome associated with JC virus infection of cortical neurons
Authors: Matteo Ciocca*, Marta Pirovano*, Monica Lodi**, Antonino Romeo**, Vincenza Fetoni*
* Department of Emergency, ASST Fatebenefratelli Sacco, PO Fatebenefratelli, Milan, Italy.
** Department of Neuroscience, Regional Center for Epilepsy, ASST Fatebenefratelli Sacco, Milan, Italy.
The JC virus (JCV) is well known for causing progressive multifocal leukoencephalopathy (PML), a potentially fatal, demyelinating disease of the central nervous system (CNS). PML almost exclusively affects immunosuppressed patients, whereas it is rare in immunocompetent subjects. Recently, a new clinical entity, named JCV encephalopathy (JCVE), has been observed. We present the case of a 62-year-old male, with no identifiable immunosuppression, who developed aphasia and progressive reduction in consciousness. He had a six months insidious history of psychiatric symptoms. He passed away 3 weeks after onset of symptoms. On admission, brain MRI demonstrated a prominent grey matter involvement. Serological tests and cerebrospinal fluid analysis were all negative for infectious diseases. A whole-body CT scan was negative for cancer. Several EEGs showed a diffuse anterior theta activity with bilateral parietal epileptic periodic discharges. A second MRI imaging showed a more prominent non-enhancing grey and white matter involvement, compatible with PML. Finally, CSF- PCR for JCV was performed and resulted positive. To the best of our knowledge, our report is the second case of JCVE described so far. Similarly to our patient, the previous case developed symptoms consistent with a CNS disease with progressive clinical course. MRI abnormalities were initially restricted to the hemispheric grey matter and only later extended to the subcortical regions. Our case suggests that JCV infection should be considered even in immunocompetent patients presenting with unexplained cortical lesions and rapidly progressive encephalopathy.
Keywords: leukoencephalopathies; JC virus; leukoencephalopathy, progressive multifocal.
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Case report in cardiology
Supraventricular tachyarrhythmia as a first sign of aortic aneurysm
Authors: Antonio Villa*, Alfredo Corticelli**, Gerarda Russo**, Dimitra Zarifi*, Andrea Bona*, Simona Armieri*
* Department of Emergency, ASST Monza, PO Desio, Monza, Italy. Via G. Mazzini,1 20832 Desio (MB), Italy.
** Department of Cardiology, ASST Monza, PO Desio, Monza, Italy. Via G. Mazzini,1 20832 Desio (MB), Italy.
We report the case of a 50-year-old man who presented with palpitations, without any other symptoms. An electrocardiogram (ECG) showed rapid supraventricular tachyarrhythmia (atrial flutter 2:1). Transthoracic echocardiography showed severe left ventricular dilatation and left atrial enlargement, sustained by the severe dilatation of the aortic root and an ascending aortic aneurysm. A computed tomography (CT) scan of the chest confirmed the aortic dilatation. Thoracic aortic disease presents in many different ways, often incidentally after a chest X-ray is performed for other reasons. Our patient had no such risk factors for an aortic aneurysm. The existing literature features some reports of aortic dissection presenting with supraventricular arrhythmias, but to our knowledge, this is the first report of an arrhythmia as the first sign of an aortic aneurysm (not dissected). The guidelines for the management of atrial fibrillation do not specify the timing of performing echocardiography. We think that during the assessment of a patient who is in the emergency room with paroxysmal tachyarrhythmias, performing echocardiography early can be very useful.
Keywords: aortic aneurysm; arrhythmias,cardiac; echocardiography.
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Images in Medicine
Edematous striae distensae in nephrotic syndrome
Authors: Swarup Kumar Patnaik*, Sandeep Lamoria*, Vishal Sharma*
* Department of Gastroenterology, PGIMER And DR RML Hospital, Delhi, India
Keywords: edema/pathology; striae distensae; nephrotic syndrome.
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