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Casarin C, Pirot AS, Gregoire C, Van Der Haert L, Vanden Berghe P, Castanares-Zapatero D, Dechamps M. Improving the performance of a triage scale for chest pain patients admitted to emergency departments: combining cardiovascular risk factors and electrocardiogram. BMC Emerg Med 2022; 22:118. [PMID: 35788195 PMCID: PMC9251936 DOI: 10.1186/s12873-022-00680-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/24/2022] [Indexed: 11/28/2022] Open
Abstract
Background The triage of patients presenting with chest pain on admission to the emergency department uses scales based on patient clinical presentation or an electrocardiogram (ECG). These scales have different sensitivity and specificity. Although a good sensitivity allows for the prompt identification of high-risk patients, specificity prevent ED overcrowding. Moreover, ECG at triage avoids missing ST elevation myocardial infarction, which requires urgent revascularization. Our study therefore aimed to investigate whether a scale combining ECG and cardiovascular risk factors (CVRF) improves the diagnostic performance of ED chest pain triage scale. Methods and results In this prospective single-center observational study involving 505 patients, the standard ECG-based FRENCH scale was compared to a scale combining the ECG-based FRENCH scale and the patients CVRF. The new scale was called the “modified” FRENCH. The accuracy of patient CVRF collection was evaluated by comparing the results of triage nurses and ED physicians. Compared with the standard FRENCH scale, the modified FRENCH scale had an increased sensitivity (61% versus 75%) but a decrease in specificity (76% versus 64%) resulting in a similar diagnostic performance. Using CVRF collected by the ED physicians, the modified FRENCH scale had a sensitivity of 87% and a specificity of 56% with a significant improvement in his diagnostic performance compared with standard FRENCH scales. This improvement can be explained by an accurate collection of the CVRF by physicians compared with nurses, as suggested by the weak to moderate correlation between their respective data collection. Conclusion In conclusion, combining ECG and accurately collected cardiovascular risks factor improves the diagnostic performance of the ECG based chest pain triage in the ED. Trial registration Trial registration number: NCT03913767.
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Affiliation(s)
- Chiara Casarin
- Emergency Department, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Anne-Sophie Pirot
- Emergency Department, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Charles Gregoire
- Emergency Department, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium.,Institute of Neuroscience (IoNS), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Laurence Van Der Haert
- Cardiovascular Intensive Care Unit, Saint-Luc University Hospital, UCLouvain, Brussels, Belgium
| | - Patrick Vanden Berghe
- Emergency Department, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Diego Castanares-Zapatero
- Intensive Care Unit, Saint-Luc University Hospital, UCLouvain, Brussels, Belgium.,Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium
| | - Melanie Dechamps
- Cardiovascular Intensive Care Unit, Saint-Luc University Hospital, UCLouvain, Brussels, Belgium. .,Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), UCLouvain, Brussels, Belgium.
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2
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Golino M, Marazzato J, Blasi F, Morello M, Chierchia V, Cadonati C, Matteo F, Licciardello C, Zappa M, Ageno W, Passi A, Angeli F, De Ponti R. High-Sensitivity Cardiac Troponin T and the Diagnosis of Cardiovascular Disease in the Emergency Room: The Importance of Combining Cardiovascular Biomarkers with Clinical Data. J Clin Med 2022; 11:jcm11133798. [PMID: 35807089 PMCID: PMC9267782 DOI: 10.3390/jcm11133798] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 01/27/2023] Open
Abstract
Background. Nowadays, it is still not possible to clinically distinguish whether an increase in high-sensitivity cardiac troponin (hs-cTn) values is due to myocardial injury or an acute coronary syndrome (ACS). Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scarce. This monocentric retrospective study aimed to improve the knowledge and interpretation of this cardiac biomarker in daily clinical practice. Methods. Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing changes and variations were correlated with the clinical presentation and the type of diagnosis. Subsequently, multivariable models were built to assess which clinical/laboratory variables most influenced hospital admissions in the investigated population analyzed according to the final reason for hospitalization: (1) cardiovascular vs. non-cardiovascular diagnosis, and (2) ACS vs. non-ACS one. Results. A total of 4660 patients were considered, and, after a first screening, 4149 patients were enrolled. Out of 4129 patients, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized with the following types of diagnosis: ACS (182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values and significant hs-cTnT variations were found in the ACS group (p < 0.01). The mean percentage of variation was higher in patients with ACS, intermediate in those with non-ACS cardiovascular disease, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02−0.39, p < 0.01 and OR: 0.9988, 95% CI: 0.9979−0.9998, p = 0.02, respectively) or CRP (OR: 0.9948, 95% CI: 0.9908−0.9989, p = 0.01) and NT-proBNP (OR: 1.0002, 95% CI: 1.0000−1.0004, p = 0.02) were independent predictors of a cardiovascular disease diagnosis. On the other hand, only chest pain (OR: 22.91, 95% CI: 3.97−132.32, p < 0.01) and eGFR (OR: 1.04, 95% CI: 1.004−1.083, p = 0.03) were associated with the ACS diagnosis. Conclusions. Differently from the investigated biomarkers, in this study, only clinical variables predicted hospitalizations in different patients’ subgroups.
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Affiliation(s)
- Michele Golino
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- Correspondence:
| | - Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Federico Blasi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Matteo Morello
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- School of Cardiology, University of Brescia, 25121 Brescia, Italy
| | - Valentina Chierchia
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
| | - Cristina Cadonati
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
- School of Cardiology, University of Brescia, 25121 Brescia, Italy
| | - Federica Matteo
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Claudio Licciardello
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Martina Zappa
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049 Tradate, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Alberto Passi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049 Tradate, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (V.C.); (F.M.); (C.L.); (M.Z.); (W.A.); (A.P.); (F.A.); (R.D.P.)
- Ospedale di Circolo, ASST Settelaghi, 21100 Varese, Italy; (M.M.); (C.C.)
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Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, Bonora A, Giudiceandrea A, Rella E, Paulmichl R, Pfeifer N, Turcato G. Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain. Am J Cardiol 2021; 161:12-18. [PMID: 34635312 PMCID: PMC9336201 DOI: 10.1016/j.amjcard.2021.08.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 12/01/2022]
Abstract
The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.
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4
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Moldovan DC, Ismaiel A, Fagoonee S, Pellicano R, Abenavoli L, Dumitrascu DL. Gut microbiota and cardiovascular diseases axis: a review. Minerva Med 2021; 113:189-199. [PMID: 33969961 DOI: 10.23736/s0026-4806.21.07527-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Gut microbiota, a term that includes microorganisms present in the gastrointestinal tract, has become very attractive lately due to its propensity to act as a virtual organ with endocrine functions, generating various bio-active metabolites, while playing an important role in human health and diseases, including cardiovascular diseases (CVDs). Focusing on the latter field, gastrointestinal dysbiosis, that is the imbalance in the gut microbiota composition, has been linked to various pathologies such as hypertension, atherosclerosis, myocardial infarction and heart failure. Several pathways were demonstrated to play a role in the complex and intertwined association between the gut microbiota and host, including metabolic endotoxemia, alteration of pattern recognition receptors and short-chain fatty acids, uremic toxins, bile acids and trimethylamine-N-oxide levels, leading to CVDs. Understanding these pathways can allow to identifying metabolites that could be useful predictors for detecting incipient CVDs stages and potential therapeutic targets. In this review, we summarize the pathways associating the gut microbiota with CVDs.
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Affiliation(s)
- Dora C Moldovan
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Internal Medicine, Regional Institute of Gastroenterology and Hepatology O. Fodor, Cluj-Napoca, Romania
| | - Abdulrahman Ismaiel
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania - .,2nd Department of Internal Medicine, Cluj-Napoca, Romania
| | - Sharmila Fagoonee
- Institute of Biostructure and Bioimaging, National Research Council, Molecular Biotechnology Center, Turin, Italy
| | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette-SGAS Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University Magna Graecia, Catanzaro, Italy
| | - Dan L Dumitrascu
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,2nd Department of Internal Medicine, Cluj-Napoca, Romania
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5
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Bellan M, Sainaghi PP, Gavelli F, Patrucco F, Avanzi GC, Pirisi M, Castello LM. Lessons from the Italian COVID-19 frontline. Minerva Med 2020; 111:303-305. [DOI: 10.23736/s0026-4806.20.06664-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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6
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Gavelli F, Castello LM, Patrucco F, Bellan M, Sainaghi PP, Avanzi GC. Insights from Italy: the Novara-COVID Score for rapid destination of COVID-19 patients at Emergency Department presentation. Minerva Med 2020; 111:300-302. [DOI: 10.23736/s0026-4806.20.06609-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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7
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Extra-Esophageal Presentation of Gastroesophageal Reflux Disease: 2020 Update. J Clin Med 2020; 9:jcm9082559. [PMID: 32784573 PMCID: PMC7465150 DOI: 10.3390/jcm9082559] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) is defined by the presence of symptoms induced by the reflux of the stomach contents into the esophagus. Although clinical manifestations of GERD typically involve the esophagus, extra-esophageal manifestations are widespread and less known. In this review, we discuss extra-esophageal manifestations of GERD, focusing on clinical presentations, diagnosis, and treatment. Common extra-esophageal manifestations of GERD include chronic cough, asthma, laryngitis, dental erosions, and gingivitis. Extra-esophageal involvement can be present also when classic GERD symptoms are absent, making the diagnosis more challenging. Although available clinical studies are heterogeneous and frequently of low quality, a trial with proton pump inhibitors can be suggested as a first-line diagnostic strategy in case of suspected extra-esophageal manifestations of GERD.
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8
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Bellan M, Gavelli F, Hayden E, Patrucco F, Soddu D, Pedrinelli AR, Cittone MG, Rizzi E, Casciaro GF, Vassia V, Landi R, Menegatti M, Gastaldello ML, Beltrame M, Labella E, Tonello S, Avanzi GC, Pirisi M, Castello LM, Sainaghi PP. Pattern of emergency department referral during the Covid-19 outbreak in Italy. Panminerva Med 2020; 63:478-481. [PMID: 32549532 DOI: 10.23736/s0031-0808.20.04000-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The coronavirus disease (COVID-19) outbreak is putting the European National Health Systems under pressure. Interestingly, Emergency Department (ED) referrals for reasons other than Covid-19 seem to have declined steeply. In the present paper, we aimed to verify how the Covid-19 outbreak changed ED referral pattern. METHODS We retrospectively reviewed the clinical records of patients referred to the ED of a University Hospital in Northern Italy from 1st March to 13th April 2020. We compared the following data with those belonging to the same period in 2019: number of EDs accesses, rate of hospital admission, frequencies of the most common causes of ED referral, priority codes of access. RESULTS The number of ED referrals during the Covid-19 outbreak was markedly reduced when compared to the same period in 2019 (3059 vs. 5691;-46.3%). Conversely, the rate of hospital admission raised from 16.9% to 35.4% (p<0.0001), with a shift toward higher priority codes of ED admission. In 2020, we observed both a reduction of the number of patients referred for both traumatic (513, 16.8% vs. 1544, 27.1%; χ2=118.7, p<0.0001) and non-traumatic (4147 vs. 2546) conditions. Among the latter, suspected Covid-19 accounted for 1101 (43.2%) accesses. CONCLUSIONS The Covid-19 pandemic completely changed the pattern of ED referral in Italy, with a marked reduction of the accesses to the hospitals. This could be related to a limited exposure to traumas and to a common fear of being infected during EDs in-stay. This may limit the misuse of EDs for non- urgent conditions, but may also delay proper referrals for urgent conditions.
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Affiliation(s)
- Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy - .,CAAD, Centre for Autoimmune and Allergic Diseases, Novara, Italy - .,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy -
| | - Francesco Gavelli
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Eyal Hayden
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
| | - Daniele Soddu
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Anita R Pedrinelli
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Micol G Cittone
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Eleonora Rizzi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Giuseppe F Casciaro
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Veronica Vassia
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Raffaella Landi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Mirta Menegatti
- Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Maria L Gastaldello
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Michela Beltrame
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Emanuela Labella
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Stelvio Tonello
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
| | - Gian C Avanzi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Luigi M Castello
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
| | - Pier P Sainaghi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,CAAD, Centre for Autoimmune and Allergic Diseases, Novara, Italy.,Internal Medicine and Emergency Medicine Divisions, "AOU Maggiore della Carità", Novara, Italy
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