Munchausen syndrome in the emergency department mostly difficult, sometimes easy to diagnose: a case report and review of the literature

Munchausen syndrome is a rare psychiatric disorder in which patients inflict on themselves an illness or injury for the primary purpose of assuming the sick role. Because these patients can present with many different complaints and clinical symptoms, diagnosis is often made at a later stage of hospitalisation. In contrast we report a case of a 40-year old woman very easy to diagnose with Munchausen syndrome

Endogenous angiotensin II in the regulation of hypoxic pulmonary vasoconstriction in anaesthetized dogs

INTRODUCTION: The role played by several vasoactive mediators that are synthesized and released by the pulmonary vascular endothelium in the regulation of hypoxic pulmonary vasoconstriction (HPV) remains unclear. As a potent vasoconstrictor, angiotensin II could be involved. We tested the hypothesis that angiotensin-converting enzyme inhibition by enalaprilat and type 1 angiotensin II receptor blockade by candesartan would inhibit HPV. METHODS: HPV was evaluated in anaesthetized dogs, with an intact pulmonary circulation, by examining the increase in the Ppa–Ppao gradient (mean pulmonary artery pressure minus occluded pulmonary artery pressure) that occurred in response to hypoxia (inspiratory oxygen fraction of 0.1) at constant pulmonary blood flow. Plasma renin activity and angiotensin II immunoreactivity were measured to determine whether activation or inhibition of the renin–angiotensin system was present. RESULTS: Administration of enalaprilat and candesartan did not affect the Ppa–Ppao gradient at baseline or during hypoxia. Plasma renin activity and angiotensin II immunoreactivity increased during hypoxia, and subsequent measurements were consistent with effective angiotensin-converting enzyme inhibition after administration of enalaprilat, and with angiotensin receptor blockade after administration of candesartan. CONCLUSION: These results suggest that, although the renin–angiotensin system was activated in hypoxia, angiotensin II is not normally involved in mediating acute HPV

Role of Community Health Volunteers Since the 2015 Nepal Earthquakes: A Qualitative Study

Objective: Nepal female community health volunteers (FCHVs) were the first available health personnel in communities during the 2015 Nepal earthquakes. This study explored the facilitating factors and barriers of the FCHVs during health emergencies. Methods: In-depth interviews with 24 FCHVs and 4 health managers from 2 districts in Nepal (Gorkha and Sindhupalchowk) were conducted using semi-structured interview guides. The qualitative data were analyzed using thematic analysis methods. Results: FCHVs were the first responders to provide services after the earthquakes and were well accepted by the local communities. Different models of supervision existed, and differences in the workload and remuneration offered to FCHVs were described. A wide range of disaster-related knowledge and skills were required by FCHVs, and lack of prior training was an issue for some respondents. Furthermore, lack of access to adequate medical supplies was a major barrier for FCHVs in the 2015 earthquakes. The 5 identified themes were discussed. Conclusion: Providing regular disaster response training for FCHVs and strong leadership from the public sector with sustained investments will be essential for increasing the capacities of community health workforces to prepare for and reduce the impacts of future health emergencies in resource-poor settings

Feasibility of AmbulanCe-Based Telemedicine (FACT) Study:Safety, Feasibility and Reliability of Third Generation Ambulance Telemedicine

Telemedicine is currently mainly applied as an in-hospital service, but this technology also holds potential to improve emergency care in the prehospital arena. We report on the safety, feasibility and reliability of in-ambulance teleconsultation using a telemedicine system of the third generation.A routine ambulance was equipped with a system for real-time bidirectional audio-video communication, automated transmission of vital parameters, glycemia and electronic patient identification. All patients ( ≥ 18 years) transported during emergency missions by a Prehospital Intervention Team of the Universitair Ziekenhuis Brussel were eligible for inclusion. To guarantee mobility and to facilitate 24/7 availability, the teleconsultants used lightweight laptop computers to access a dedicated telemedicine platform, which also provided functionalities for neurological assessment, electronic reporting and prehospital notification of the in-hospital team. Key registrations included any safety issue, mobile connectivity, communication of patient information, audiovisual quality, user-friendliness and accuracy of the prehospital diagnosis.Prehospital teleconsultation was obtained in 41 out of 43 cases (95.3%). The success rates for communication of blood pressure, heart rate, blood oxygen saturation, glycemia, and electronic patient identification were 78.7%, 84.8%, 80.6%, 64.0%, and 84.2%. A preliminary prehospital diagnosis was formulated in 90.2%, with satisfactory agreement with final in-hospital diagnoses. Communication of a prehospital report to the in-hospital team was successful in 94.7% and prenotification of the in-hospital team via SMS in 90.2%. Failures resulted mainly from limited mobile connectivity and to a lesser extent from software, hardware or human error. The user acceptance was high.Ambulance-based telemedicine of the third generation is safe, feasible and reliable but further research and development, especially with regard to high speed broadband access, is needed before this approach can be implemented in daily practice

Development and Pilot Testing of 24/7 In-Ambulance Telemedicine for Acute Stroke:Prehospital Stroke Study at the Universitair Ziekenhuis Brussel-Project

Background: In-ambulance telemedicine is a recently developed and a promising approach to improve emergency care. We implemented the first ever 24/7 in-ambulance telemedicine service for acute stroke. We report on our experiences with the development and pilot testing of the Prehospital Stroke Study at the Universitair Ziekenhuis Brussel (PreSSUB) to facilitate a wider spread of the knowledge regarding this technique. Methods: Successful execution of the project involved the development and validation of a novel stroke scale, design and creation of specific hardware and software solutions, execution of field tests for mobile internet connectivity, design of new care processes and information flows, recurrent training of all professional caregivers involved in acute stroke management, extensive testing on healthy volunteers, organisation of a 24/7 teleconsultation service by trained stroke experts and 24/7 technical support, and resolution of several legal issues. Results: In all, it took 41 months of research and development to confirm the safety, technical feasibility, reliability, and user acceptance of the PreSSUB approach. Stroke-specific key information can be collected safely and reliably before and during ambulance transportation and can adequately be communicated with the inhospital team awaiting the patient. Conclusion: This paper portrays the key steps required and the lessons learned for successful implementation of a 24/7 expert telemedicine service supporting patients with acute stroke during ambulance transportation to the hospital. (C) 2016 S. Karger AG, Base

Team Dynamics and Nontechnical Skills Perception During the Disaster Response in Mozambique in 2019: A Survey Study Among the Italian Emergency Medical Team

Objective:Team dynamics and nontechnical skills in general are crucial for emergency medical teams (EMT). No study has ever examined these important issues during a real mission in the field. This study aimed to better investigate team dynamics and nontechnical skills for EMTs; it tried to understand if a real mission, when the people are obliged to work together for the first time, without a prior specific training focused on teamwork, is enough or not to work as an effective team in the field. Methods:The study is designed as a pre-test/post-test survey study, and it collected data from 51 people deployed to Mozambique in 2019. Three indexes (the self-efficacy (SE), the teamwork (TW), and the overall team's performance (TW12)) were calculated as the average value of the rating given by all the participants. Open text feedback was also collected. Results:A positive trend was observed comparing the "post" data to the "pre" data, but results did not show a statistical significance, with the only exception of stratified analyses showing a P-value less than 0.05 for SE and TW12 for some categories. Conclusions:According to the study findings, humanitarian workers feel good but not at their best; training programs focused on team dynamics can be really useful to improve self-confidence of people leaving for a mission

The Use of the Health Belief Model in the Context of Heatwaves Research: A Rapid Review

As heatwaves increase and intensify worldwide, so has the research aimed at outlining strategies to protect individuals from their impact. Interventions that promote adaptive measures to heatwaves are encouraged, but evidence on how to develop such interventions is still scarce. Although the Health Belief Model is one of the leading frameworks guiding behavioral change interventions, the evidence of its use in heatwave research is limited. This rapid review aims to identify and describe the main themes and key findings in the literature regarding the use of the Health Belief Model in heatwaves research. It also highlights important research gaps and future research priorities. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 10 articles were included, with a geographic distribution as follows: United States (n = 1), Australia (n = 1), Pakistan (n = 1), and China (n = 1), as well as Malaysia (n = 2), Germany (n = 1), and Austria (n = 1). Results showed a lack of research using the Health Belief Model to study heatwaves induced by climate change. Half of the studies assessed heatwave risk perception, with the 2 most frequently used constructs being Perceived Susceptibility and Perceived Severity. The Self-efficacy construct was instead used less often. Most of the research was conducted in urban communities. This review underscores the need for further research using the Health Belief Model

Scenario-Based e-Simulation Design for Global Health Education: Theoretical Foundation and Practical Recommendations

Electronic simulation (e-simulation)-particularly scenario-based e-simulation (SBES)-is an increasingly used, promising educational strategy for global health education that can address gaps in training access, effectiveness, and cost. However, there is little guidance for educators on how to develop an SBES, and guidance is lacking outside the clinical context. Moreover, literature on medical education rarely uses the theoretical basis for e-simulation design and development, including for SBES. Hence, we aim to differentiate and describe the concept, design elements, and theoretical basis of SBES with examples from different topics in global health. In addition to enhancing the understanding of the potential of SBES for global health education, this manuscript also provides practical recommendations for global health educators in designing and developing SBESs based on the existing literature and authors' experiences. Overall, this manuscript will be useful for global health educators as well as other medical educators seeking to develop an SBES for similar skill sets

Mental health and psychosocial support for the war-wounded: A retrospective cohort study from the Democratic Republic of Congo, Mali and Nigeria.

BackgroundFor more than 150 years, war surgery has been at the heart of the humanitarian assistance offered by the International Committee of the Red Cross (ICRC) in conflict zones around the world. Mental health and psychosocial support (MHPSS) is increasingly recognized as an integral part of the medical care offered to this highly vulnerable group of patients. This study seeks to identify patient characteristics associated with high distress prior to MHPSS and predictors of improvement following it.MethodsBetween October 2018 and April 2020, 2,008 weapon-wounded patients received MHPSS in ICRC-supported hospitals in the Democratic Republic of Congo (DRC), Mali and Nigeria. The 21-item Depression and Anxiety Scale (DASS21), the Impact of Events Scale Revised (IES-R) and the ICRC functionality scale for Africa were administered before and after the MHPSS response. Logistic regression models were used to measure associations between outcome and exposure variables. Data was initially collected for monitoring purposes and analyzed retrospectively for the sake of this study.ResultsThe main reasons for surgery were firearms (65%), other weapons (13%) and mines (5%). Linear trends were found between increasing number of days between violence and first consultation and decreased likelihood of presenting high levels of anxiety (aOR 0.75, p = 0.014), and stress (aOR 0.78, p = 0.032). Violence committed by military/armed group was associated with increased likelihood of reporting high levels of anxiety (aOR 2.47, p = 0.047). On the IES-R, high scores at baseline were more likely to be found among illiterate patients (aOR 0.08, p = 0.042) and having been wounded by firearms considerably increased the likelihood of reporting high levels of PTSD (aOR 21.34, p = 0.035). Following MHPSS, 92.28% of the patients showed a reduction in symptoms on the DASS21, 93.00% showed a reduction in symptoms on the IES-R and 83.04% showed an improvement on the ICRC Africa functioning scale. On the DASS21, factors negatively associated with improved anxiety included lack of social support (aOR 0.17, p = 0.047) and suffering from a chronic medical/physical condition (aOR 0.40, p = 0.013). Patients with reduced IES-R scores were more likely to have a high level of education (aOR 8.95, p = 0.029) and to have received MHPSS that lasted between 22 and 30 days (aOR 8.73, p = 0.008). Predictors of improved functioning included being 35-44 years of age (aOR 3.74, p = 0.004) and suffering from a severe or chronic medical condition (aOR 1.66, p = 0.044).ConclusionsClinical implications of this study include the increased involvement of family and other caregivers in the MHPSS and longer-term follow-up of patients with severe and/or chronic medical conditions. Further research is needed with regard to joint psychological and physical outcomes, the role of the patient's education level and the personal styles and techniques used by the counsellors

Assessing primary healthcare disaster preparedness: a study in Northern Italy

Aim: The aim of this paper is to outline the steps taken to develop an operational checklist to assess primary healthcare (PHC) all-hazards disaster preparedness. It then describes a study testing the applicability of the checklist.Background: A PHC approach is an essential foundation for health emergency and disaster risk management (H-EDRM) because it can prevent and mitigate risks prior to disasters and support an effective response and recovery, thereby contributing to communities' and countries' resilience across the continuum of the disaster cycle. This approach is in line with the H-EDRM framework, published by the World Health Organization (WHO) in 2019, which emphasizes a whole-of-health system approach in disaster management and highlights the importance of integrating PHC into countries' H-EDRM. Nevertheless, literature focusing on how to practically integrate PHC into disaster management, both at the facility and at the policy level, is in its infancy. As of yet, there is no standardized, validated way to assess the specific characteristics that render PHC prepared for disasters nor a method to evaluate its role in H-EDRM.Methods: The checklist was developed through an iterative process that leveraged academic literature and expert consultations at different stages of the elaboration process. It was then used to assess primary care facilities in a province in Italy.Findings: The checklist offers a practical instrument for assessing and enhancing PHC disaster preparedness and for improving planning, coordination, and funding allocation. The study identified three critical areas for improvement in the province's PHC disaster preparedness. First, primary care teams should be more interdisciplinary. Second, primary care services should be more thoroughly integrated into the broader health system. Third, there is a notable lack of awareness of H-EDRM principles among PHC professionals. In the future, the checklist can be elaborated into a weighted tool to be more broadly applicable