Population-based breast cancer screening in Pavia (northern Italy) in 2016-2018: Key performance indicators and sensitivity estimate

BACKGROUND AND AIM

This study aims to assess the quality of the population-based breast cancer screening programme in Pavia, northern Italy computing its key performance indicators and estimating its sensitivity for the years 2016-2018.

METHODS

Invitation and examination coverage, participation rate, recall rate, detection rate and positive predictive values were computed on the basis of data provided yearly to the Italian Ministry of Health. Sensitivity was estimated identifying interval cancers in the local Cancer Registry and computed with the proportional incidence method.

RESULTS

In 2016-2018 the adjusted invitation coverage was 90%, and the adjusted participation rate was 62%. Recall rate was 8.4% for first screenings and 3.9% for subsequent ones. The number of screen-detected cases was 268, corresponding to a detection rate of 6.6‰ for first screenings and 4.6‰ for subsequent screenings. The number of interval cancers observed was 110 over the study period; the proportional incidence was 22% for the first interval year and 50% for the second interval. The overall sensitivity of the screening program was 64%.

CONCLUSIONS

The analysis of performance indicators and sensitivity estimates for the Pavia programme indicates that the programme performance is in line with the quality standards set by the European Union and the Italian reference scientific society (GISMa).

The Effect of COVID-19 Pandemic on Overall and Cause-Specific Mortality in Pavia, Northern Italy: Updated Estimates for the Year 2021

Excess mortality estimates are considered relevant indicators of direct and indirect pandemic effects on the population. Scant data have been published on cause-specific excess mortality. Using individual-level administrative data covering the Pavia province of Italian northern Lombardy region, we provided all-cause and cause-specific raw (RMR) and age-standardized (ASMR) mortality rates in 2021 and 2015-2019, the rate ratio, and 95% confidence intervals, overall and by sex. We obtained the excess deaths in 2021 as the difference between the number of observed and expected deaths from all causes and the two leading causes of death (all neoplasms and circulatory system diseases) by fitting over-dispersed quasi-Poisson regression models, accounting for temporal, seasonal and demographic changes. The total ASMR in 2021 was 972.4/100,000 (6836 certified deaths), with the highest ASMRs for circulatory system diseases (272.6/100,000) and all neoplasms (270.3/100,000), followed by COVID-19 (94.8/100,000 and 662 deaths). Compared to the expected, we estimated a total of 6.2% excess deaths in 2021 (7.2% in males and 5.4% in females), with no excess deaths from all neoplasms and a 6.2% reduction from circulatory system diseases. COVID-19 continued to affect total mortality in 2021, albeit to a lesser extent than in 2020, consistently with national patterns.

Wine putrescine abatement by bentonites: From ideal case to practice

Herein, we demonstrated that bentonites can be incisively used to reduce wine BAs content, especially putrescine molecules. Pioneering kinetic and thermodynamic studies of putrescine adsorption onto two commercially available bentonites (optimal concentration of 0.40 g dm^-3) were performed resulting in ca. 60% removal by physisorption mechanism. Both bentonites showed also promising results in more complex systems, resulting in a lower putrescine adsorption due to the competition with other molecules (as proteins, polyphenols), typically present in wines. Nonetheless, we managed to reduce the putrescine content below 10 ppm both in red and white wines.

Hyponatremia as a predictor of outcome and mortality: results from a second-level urban emergency department population

BACKGROUND

Hyponatremia is the most common electrolyte disorder and it has been associated with increased mortality.

AIMS

This study evaluated hyponatremia as a prognostic factor for severity and mortality.

METHODS

We compared the prevalence of hyponatremia among patients who died during the year 2017 (from 1 January 2017 to 31 December 2017) with the prevalence of hyponatremia among subgroups of patients, i.e. outpatients, patients hospitalized for more than 2 days and patients admitted in the intensive care unit (ICU). We also described the mortality rate and the prevalence of comorbidities among hyponatremic patients, according to hyponatremia degree (slight, moderate, severe), basal characteristics, comorbidities and their outcome (discharged, hospitalized or died).

RESULTS

In our population of a public hospital setting, hyponatremia was present at admission in 17% of deaths, and the comparison between hyponatremic and normonatremic patients in terms of mortality confirms the hypothesis that this disorder is in anyway strictly associated with vulnerability and with a poor prognosis.

CONCLUSIONS

We conclude that hyponatremia is a predictive marker for a bad clinical course, therefore patients with this electrolyte disorder should be carefully monitored.

Neurodevelopmental outcome of Italian preterm ELBW infants: an eleven years single center cohort

BACKGROUND

Preterm extremely low birth weight infants (ELBWi) are known to be at greater risk of developing neuropsychiatric diseases. Identifying early predictors of outcome is essential to refer patients for early intervention. Few studies have investigated neurodevelopmental outcomes in Italian ELBWi. This study aims to describe neurodevelopmental outcome at 24 months of corrected age in an eleven-year single-center cohort of Italian ELBWi and to identify early risk factors for adverse neurodevelopmental outcomes.

METHODS

All infants born with birth weight < 1000 g and admitted to the Neonatal Intensive Care Unit of the "Fondazione IRCCS Policlinico San Matteo" hospital in Pavia, Italy, from Jan 1, 2005 to Dec 31, 2015 were eligible for inclusion. At 24 months, Griffiths' Mental Developmental Scales Extended Revised (GMDS-ER) were administered. Neurodevelopmental outcome was classified as: normal, minor sequelae (minor neurological signs, General Quotient between 76 and 87), major sequelae (cerebral palsy; General Quotient ≤ 75; severe sensory impairment). Univariate and multivariate multinomial logistic regression models were performed to analyze the correlation between neonatal variables and neurodevelopmental outcome.

RESULTS

176 ELBWi were enrolled (mean gestational age 26.52 weeks sd2.23; mean birthweight 777.45 g sd142.89). 67% showed a normal outcome at 24 months, 17% minor sequelae and 16% major sequelae (4.6% cerebral palsy on overall sample). The most frequent major sequela was cognitive impairment (8.52%). In the entire sample the median score on the Hearing-Speech subscale was lower than the median scores recorded on the other subscales and showed a significantly weaker correlation to each of the other subscales of the GMDS-ER. Severely abnormal cUS findings (RRR 10.22 p 0.043) and bronchopulmonary dysplasia (RRR 4.36 p 0.008) were independent risk factors for major sequelae and bronchopulmonary dysplasia for minor sequelae (RRR 3.00 p 0.018) on multivariate multinomial logistic regression.

CONCLUSIONS

This study showed an improvement in ELBWI survival rate without neurodevelopmental impairment at 24 months compared to previously reported international cohorts. Cognitive impairment was the most frequent major sequela. Median scores on GMDS-ER showed a peculiar developmental profile characterized by a selective deficit in the language domain. Severely abnormal cUS findings and bronchopulmonary dysplasia were confirmed as independent risk factors for major sequelae.

P263 ROLE OF VITAL SIGNS AND INDICES OF SHOCK DERIVED FROM THEM IN THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN ELDERLY: THE ER AS A WINDOW ON REAL LIFE

Purpose

Assess which vital parameters or shock parameters, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can be of help to early suspect it.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Anni), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We assess the correlation of vital parameters and shock indexes with the presence of massive pulmonary embolism. We took into consideration: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these, 85 (34.4 %) presented with massive pulmonary embolism. There is no correlation between blood pressure, systolic and diastolic values, respiratory rate with the presence of massive pulmonary embolism (p &gt; 0.05). However, there is a strong statistical correlation between heart rate values and the presence of massive pulmonary embolism (p &lt; 0.0001). The shock index correlates with the presence of massive pulmonary embolism with good statistical strength (p &lt; 0.001); the modified shock index correlates with the with even greater statistical strength (P = 0.0005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p &lt; 0.0001).

Conclusions

The study suggests that the alteration of shock indices, in particular of the AGE–shock index, correlate with the condition of massive pulmonary embolism. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the correct procedure therapeutic diagnostic.

P275 HOLDING AREA IN EMERGENCY DEPARTMENT : A STRATEGY TO IMPROVE ADHERENCE TO INTERNATIONAL GUIDELINES IN CASES OF PULMONARY EMBOLISM IN ELDERLY

Premises

Pulmonary embolism is a disease still characterized by high mortality. Despite a great development of the guidelines it is not clear what adherence to them is in real life, especially in the emergency room.

Purpose of the Study

See if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the area to which the patient is addressed.

Methods

Monocentric retrospective observational study, on a group of geriatric patients (&lt;75 y) that include all the people accessed to our ED, where they received acute PE dignosis. Enrolment started on 2016 and finished on 2019. We collected data from medical history, physical examination, lab tests, imaging; we calculated characteristic scores from the diagostic/therapeutic algorhitm, both regarding PE risk (Wells, Geneva and Years), and the 30–day mortality risk presentazione (sPESI). We then analized guidelines adherence in three decision–making turning–points: 1 Correct applicarion of decisional scores examined, which classify the patient in low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct therapy administration since the ED as suggested by the guidelines; 3 The eventual observation in the medium–intensity care area with close monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzymes impairement (considered at high risk of short–term shock and mortality).

Results

we enrolled 249 patients, with a mean age of 83 years and female prevalence (F = 62%). Of these, 69% were referred by Triage to medium–high intensity of care, the remaining 31% was directed to low intensity of care. 42.5% of the total patients were referred to OBI. The two areas of intensity of care showed similar adherence to guidelines (approximately 50%) without there being a statistically significant difference between the two areas (p &gt; 0.05) Adherence to guidelines was higher in the holding area – OBI (75 %) compared to that of those managed in theaters (50%) in a statistically significant way (p &lt; 0.001).

Conclusions

The study suggests that holding areas located in Emergency Departments can considerably increase adherence to international guidelines.

P271 DOES SENILITY AFFECT THE MANIFESTATION AND MANAGEMENT OF PULMONARY EMBOLISM? EXPERIENCE OF AN ED

Premises

Acute pulmonary embolism is a pathology characterized by high mortality. The elderly population is destined to increase, becoming, according to some authors, 30% of the population in the developed countries.

Purpose of the Study

see if and how, in the real life of an Emergency Department, age can affect the manifestation (more severe or milder forms of pulmonary embolism; typical symptoms and atypical symptoms), patient management and adherence to guidelines. We considered subjects over 75 years of age to be elderly, as per the latest indications of the guidelines.

Methods

Single–center retrospective observational study on all patients who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed the hospitalization rate, in–hospital mortality rate, the hospitalization rate in resuscitation and the length of hospitalization. We then analyzed adherence to the guidelines valid in the period under study.

Results

We enrolled 487 patients, with equal gender distribution (F = 52%). 247 were older than 75 (50.7%). Age has a positive correlation with the presence of massive pulmonary embolism, in a statistically significant way (p &lt; 0.05), and with the presence of organ damage, touching on statistical significance (p = 0.05). On the other hand there is no statistically significant difference in the prevalence of typical or atypical symptoms in the two groups. The vital parameters were instead comparable in the two groups with no statistically significant difference (p &gt; 0.05). Long–term outcomes such as mortality, need for hospitalization, ICU stay and length of stay in hospital are also comparable results without statistically significant difference (p &gt; 0.05). Adherence to international guidelines is also comparable between the two groups (p &gt; 0.05).

Conclusions

The study suggests that age correlates with more severe forms of pulmonary embolism but does not affect either patient management or short–term outcomes.

P278 WHEN HARRY MET SALLY. DESCRIPTION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM ARRIVING IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Premises

Pulmonary embolism represents one of the major causes of mortality linked to cardiovascular events. The range of symptoms is extremely wide and its recognition difficult. The patients who therefore come to the emergency room are a diverse population.

Purpose

to describe the population that refers to the emergency room and finds there a diagnosis of acute pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes, severity scores.

Results

We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Among those subjected to blood gas analysis 11% showed alteration of pH, 16% showed alteration of pCO2, 8% showed alteration of pO2, 5% of BE, 2% of lactate. 34% showed massive PE, 32% showed organ damage. In particular, 21% showed pulmonary artery dilation, 16% pulmonary infarction and 19% right ventricular dilation. 40% showed elevation of myocardiospecific enzymes. 41% were considered to be at high risk of long–term mortality according to European guidelines, 41% at intermediate risk and 18% at low risk of mortality. 1.4% underwent thrombolysis, 2.4% required intubation. 2.8% needed an operating room for mechanical thrombolysis; 8% of hospitalization in the intensive ward during hospitalization. In–hospital mortality was 7.7%. 5% experienced bleeding during hospitalization following anticoagulation therapy.

Conclusions

The population that arrives in ED for pulmonary embolism presents extremely varied symptomatological pictures, but an overall high degree of clinical risk and assistance and therapeutic complexity.

P267 EFFECTIVENESS OF SHOCK INDICES AND ALTERATION OF VITAL PARAMETERS IN THE DIAGNOSTIC SUSPICION OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: THE EMERGENCY ROOM AS A WINDOW ON REAL LIFE

Aim

Assess which vital parameters and shock indices correlate with the presence of organ damage from pulmonary embolism to see which ones can help to suspect this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage. We have considered as shock indices: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these 79 (32%) have organ damage from pulmonary embolism. There is no correlation between the values of blood pressure, systolic and diastolic, respiratory rate with the presence of organ damage (p &gt; 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p &lt; 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p &lt; 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P &lt; 0.005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p &lt; 0.001).

Conclusions

The alteration of the shock indices, in particular the AGE–shock index, correlate with the condition of organ damage. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, which can be easily performed in the various Italian situations, can help to raise the suspicion of organ damage from pulmonary embolism early and address more quickly the patient towards the therapeutic diagnostic process.

P264 ROLE OF BLOOD GAS ANALYSIS AND D–DIMER IN RAISING THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN GERIATRIC PEOPLE: THE EMERGENCY ROOM AS A WINDOW INTO REAL LIFE

Premise

Massive pulmonary embolism is burdened with high mortality. Raising suspicion and recognizing this condition early allows to avoid delays in the diagnostic and therapeutic process.

Purpose

Assess which parameters of blood gas analysis, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can help to suspect it early.

Methods

single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We looked at all the blood gas analyzes performed at the emergency room access. We then had all chest CTs retested by an experienced radiologist.

Results

We enrolled 247 patients, with a mean age of 83 years with prevalence of female prevalence (F = 63%). Of these, 85 (34.4%) have massive pulmonary embolism. Lactates do not correlate with the presence of massive pulmonary embolism (p &gt; 0.05). The pCO2 values correlate inversely with the presence of massive pulmonary embolism with excellent statistical strength (p &lt; 0.0001). The reduction in pO2 values also correlates with the presence of massive pulmonary embolism, with good statistical strength (p &lt; 0.005). The increase in pH values also correlates with the presence of massive pulmonary embolism, albeit with a lower statistical strength (p &lt; 0.05). The D–Dimer shows a strong association with massive pulmonary embolism values (p &lt; 0.0001).

Conclusions

The study suggests that the reduction of pCO2 values, with an increase in pH and D–Dimer show a strong correlation with the condition of massive pulmonary embolism. Similarly, the pO2 can play a role in the identification of this condition, while no role would seem to have the alteration of lactates. Taking into consideration these parameters, which are quickly available and easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the therapeutic diagnostic process.

P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?

Purpose of the Study

Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …)

Methods

Single–center retrospective observational study on all geriatric patients (&gt;75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p &gt; 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p &gt; 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p &lt; 0.05).

Conclusions

The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.

P274 GUESS WHO‘S COMING TO REANIMATION? ANALYSIS OF THE ELDERLY PATIENT WITH EMBOLISM IN NEED OF HOSPITALIZATION IN INTENSIVE CARE: REAL LIFE IN THE EMERGENCY ROOM

Premise

Pulmonary embolism is a disease still characterized by high mortality and which may require hospitalization in intensive care.

Purpose

Evaluate which parameters, in the real life of an Emergency Department, correlate with the need and the duration of hospitalization in intensive care.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75) who refer to our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these 12 (14 %) required hospitalization in intensive care from the emergency room. Regarding the need for hospitalization in resuscitation, age and vital parameters (arterial pressure, respiratory rate, heart rate), as well as derived shock indices are not correlated (p &gt; 0.05). Only the systolic blood pressure values and it show a trend which however does not reach statistical significance (p = 0.06). Among the blood gas analysis parameters, only low pCO2 has a slight correlation (p &lt; 0.05). The D–Dimer (p &lt; 0.01) and creatinine values (p &lt; 0.05) show correlation between the blood chemistry tests. Regarding the length of stay in resuscitation, age and vital parameters (blood pressure, respiratory rate, heart rate), as well as derived shock indices, do not show any correlation (rho∼0; p &gt; 0.05). A weak correlation is instead present with high values of D–Dimer (rho∼0.25; p &lt; 0.005) and creatinine (rho∼0.33; p &lt; 0.0005). The presence of massive pulmonary embolism shows no correlation (p &gt; 0.5). The presence of organ damage, on the other hand, correlates in a statistically significant manner (p &lt; 0.0005). Excellent correlation is shown by the sPESI index (p &lt; 0.0001). Discrete correlation showed the alteration in pH (rho∼0.61; p &lt; 0.0001). Correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests a reduced significance of vital parameters and indices derived from them for the need and duration of hospitalization in resuscitation. Presence of organ damage, low pCO2 values and high D–Dimer and creatinine values are associated with both the need for hospitalization in resuscitation and duration.

P268 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM IN ELDERLY: DOES ADHERENCE TO INTERNATIONAL GUIDELINES INCREASE IN THE MOST SERIOUS CASES?

Premises

Pulmonary embolism is a pathology still characterized by high mortality. Some international studies have actually shown that adherence to guidelines is generally quite low in both primary and secondary care and ranges, depending on the studies, between 40 and 60%.

Purpose of the Study

see if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the severity of the acute pulmonary embolism. We understood this severity as the presence of organ damage or massive pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt;75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We therefore analyzed adherence to the guidelines in three decisional turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 62%). Of these, 81 (32.7%) have organ damage and 86 (34.7%) have massive pulmonary embolism. Patients with organ damage received treatment with a higher adherence to the guidelines (68%) than those who did not have organ damage (51%) in a statistically significant way (p &lt; 0.01). Patients with massive pulmonary embolism received treatment with a higher adherence to the guidelines (69 %) than those with peripheral pulmonary embolism (50%) in a statistically significant way (p &lt; 0.005).

Conclusions

The study suggests that patients with organ damage or massive pulmonary embolism are more likely to receive treatment in the emergency room with greater compliance with international guidelines.

Acute Effects of Self-Correction on Spine Deviation and Balance in Adolescent Girls with Idiopathic Scoliosis

Background: Adolescent idiopathic scoliosis (AIS) is a three-dimensional deformity of spine and trunk with a higher incidence in girls. AIS alters and reduces postural control and balance. Self-correction movement (SCM) is a well-known non-invasive approach to ameliorate spine curve in AIS subjects. We aimed to evaluate the effects of SCM on the spine and on the balance of adolescents with AIS with a new non-invasive instrumentation. Methods: A total of 38 girls with AIS were recruited. To evaluate the acute effects of SCM and the oscillations of center of pressure (COP), we used LiDAR technology combined with a stabilometric platform to evaluate both changes in spinal curves and balance at the same time. Two tests were carried out simultaneously using the two instruments: before the execution of SCM, in the spontaneously assumed position of each subject (SP) and after the execution of SCM, during the achieved position (SC). Sway area, COP medio-lateral and antero-posterior directions, eccentricity of the ellipse and vertebral lateral deviation were recorded. The two conditions were compared with a Wilcoxon signed-rank test. Results: In general, all measures showed lower values in SC condition (p < 0.05), except the variation along the Y axis. Conclusions: Thanks to objective measured data, the therapists observed real-time changes during the performance of SCM, appreciating its efficacy on curve correction.

Kidney Transplants From Donors on Extracorporeal Membrane Oxygenation Prior to Death Are Associated With Better Long-Term Renal Function Compared to Donors After Circulatory Death

Donation after circulatory death (DCD) allows expansion of the donor pool. We report on 11 years of Italian experience by comparing the outcome of grafts from DCD and extracorporeal membrane oxygenation (ECMO) prior to death donation (EPD), a new donor category. We studied 58 kidney recipients from DCD or EPD and collected donor/recipient clinical characteristics. Primary non function (PNF) and delayed graft function (DGF) rates, dialysis need, hospitalization duration, and patient and graft survival rates were compared. The estimated glomerular filtration rate (eGFR) was measured throughout the follow-up. Better clinical outcomes were achieved with EPD than with DCD despite similar graft and patient survival rates The total warm ischemia time (WIT) was longer in the DCD group than in the EPD group. Pure WIT was the highest in the class II group. The DGF rate was higher in the DCD group than in the EPD group. PNF rate was similar in the groups. Dialysis need was the greatest and hospitalization the longest in the class II DCD group. eGFR was lower in the class II DCD group than in the EPD group. Our results indicate good clinical outcomes of kidney transplants from DCD despite the long “no-touch period” and show that ECMO in the procurement phase improves graft outcome, suggesting EPD as a source for pool expansion.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

1124 Is Delayed Presentation A Prognostic Factor for The Survival of Patients with Esophageal Atresia More Than Associated Anomalies? Comparison Between Different Social Realities

Background

The aim is to evaluate if different social reality could represent a prognostic factor as associated anomalies affecting survival of neonates with esophageal atresia (EA).

Method

Retrospective analysis of records of neonates with EA with or without Tracheoesophageal Fistula (TEF) from January 2011 to September 2018 at Policlinico San Matteo Pavia, Italy(SMAT) and the All India Institute of Medical Sciences New Delhi, India (AIIMS).Survival was correlated with the presence of anomalies, different types and the number of organ systems involved.Age at presentation and birth weight were considered to find an association with mortality.

Results

Out of 180 patients,162 were from AIIMS and 18 from SMAT.The overall mortality was 28.85%, which occurred at AIIMS, being 0% at SMAT.83.33% at SMAT and 72.84% at AIIMS had associated anomalies.The mortality was 25% for neonates without an anomaly, being 26.15% for those with one (p &gt; 0.05).No statistically significant correlation between outcome and associated anomalies was found.Instead, survival declines gradually as the age at presentation increases.

Conclusions

The presence of associated anomalies paradoxically does not affect the outcome because incidence of delayed presentation has a stronger effect than the presence of associated anomalies. Sensibilization is necessary to improve survival in EA neonates in developing countries, such as India.

Major Trauma in Elderly Patients: Worse Mortality and Outcomes in an Italian Trauma Center

Introduction:

Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes.

Methods:

We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018–January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75).

Results:

We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; P = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; P < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients (P = 0.01).

Conclusions:

The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

The Effects of Insole-Based Visual Feedback on Weight-Bearing in Patients Undergoing Total Hip Replacement

This study aimed to investigate the visual biofeedback effect of a sensorized system for plantar pressure dynamic evaluation of in patients with a total hip replacement. Experimental group followed the rehabilitation training wearing sensorized insoles that provided images on three monitors. The control group followed the verbal instructions of physiotherapists during training. Weight bearing percentage healthy limb (WBPH), weight bearing percentage surgical limb (WBPS), swing healthy limb (SWH) and swing surgical limb (SWS) improved significantly more in the experimental group. The results underline the effectiveness of visual biofeedback based on sensorized system with dynamic evaluation of the plantar pressure.

The impact of disease extent and severity detected by quantitative ultrasound analysis in the diagnosis and outcome of giant cell arteritis

OBJECTIVES

To develop a quantitative score based on colour duplex sonography (CDS) to predict the diagnosis and outcome of GCA.

METHODS

We selected patients with positive CDS and confirmed diagnosis of GCA recruited into the TA Biopsy (TAB) vs Ultrasound in Diagnosis of GCA (TABUL) study and in a validation, independent cohort. We fitted four CDS models including combinations of the following: number and distribution of halos at the TA branches, average and maximum intima-media thickness of TA and axillary arteries. We fitted four clinical/laboratory models. The combined CDS and clinical models were used to develop a score to predict risk of positive TAB and clinical outcome at 6 months.

RESULTS

We included 135 GCA patients from TABUL (female: 68%, age 73 (8) years) and 72 patients from the independent cohort (female: 46%, age 75 (7) years). The best-fitting CDS model for TAB used maximum intima-media thickness size and bilaterality of TA and axillary arteries' halos. The best-fitting clinical model included raised inflammatory markers, PMR, headache and ischaemic symptoms. By combining CDS and clinical models we derived a score to compute the probability of a positive TAB. Model discrimination was fair (area under the receiver operating characteristic curve 0.77, 95% CI: 0.68, 0.84). No significant association was found for prediction of clinical outcome at 6 months.

CONCLUSION

A quantitative analysis of CDS and clinical characteristics is useful to identify patients with a positive biopsy, supporting the use of CDS as a surrogate tool to replace TAB. No predictive role was found for worse prognosis.

Comparison of Two Analytical Methods for Busulfan Therapeutic Drug Monitoring

BACKGROUND AND OBJECTIVES

Busulfan (Bu) is an old drug, but is still well recommended as an alkylating agent during conditioning therapy, before hematopoietic stem cell transplantation. Although its dose administration is standardized and based on patient weight, therapeutic drug monitoring is required in order to maintain its exposure [as area under the concentration-time curve (AUC) from 0 to infinity AUC_0-∞] within a narrow therapeutic range and, if necessary, to adjust the dose with as short a lead time as possible. The aim of the study is to evaluate the agreement (as calculated AUC) between a gold standard analytical method and a new one that is faster and easier.

METHODS

We analyzed 221 plasma samples from 37 children (0.25-16 years; 4-62.5 kg) and 11 adults (21-59 years; 45-80 kg), corresponding to 52 AUC values (ng h/mL). The drug exposure was calculated, simultaneously, by two validated analytical methods. The reference method was a high-performance liquid chromatography (HPLC) assay combined with an ultraviolet detector (UV). The test method had a triple quadrupole mass spectrometer (MS) as detector; the clean-up procedures of the samples were different and faster.

RESULTS

The agreement between the two methods (reference and test) was evaluated in terms of Bu exposure differences based on Lin's concordance correlation coefficient (CCC) and represented by the Bland-Altman plot. The CCC between the AUC of the two methods was excellent (0.868; 95% CI: 0.802-0.935). The precision of the measures (expressed by Pearson's italic "r") was 0.872, and the accuracy (accounted by the bias correction factor) was 0.996.

CONCLUSIONS

We can conclude that the HPLC-MS/MS assay represents a very good alternative to the reference.

Preparing for the Maximum Emergency with a Simulation: A Table-Top Test to Evaluate Bed Surge Capacity and Staff Compliance with Training

Introduction

The sudden increase in the number of critically ill patients following a disaster can be overwhelming.

Study Objective

The main objective of this study was to assess the real number of available and readily freeable beds (“bed surge capacity”) and the availability of emergency operating rooms (OR) in a maximum emergency using a theoretical simulation.

Patients and Methods

The proportion of dismissible patients in four areas (Medical Area, Surgical Area, Sub-intensive Care Units, Intensive Care Units) and three emergency OR was assessed at 2 and 24 hours after a simulated maximum emergency. Four scenarios were modeled. Hospitalization and surgical capacities were assessed on weekdays and holidays. The creation of new beds was presumed by the possibility of moving patients to a lower level of care than that provided at the time of detection, of dislocation of patients to a discharge room, with care transferred to lower-intensity hospitals, rehabilitation, or discharge facilities. The Phase 1 table-top simulations were conducted during the weekday morning hours. In particular, the 24-hour table-top simulations of a hypothetical event lasted about 150 minutes compared to those conducted at 2 hours, which were found to be longer (about 195 minutes). Phase 2 was conducted on two public holidays and a quick response time was observed within the first 40 minutes of the start of the test (about 45% of departments).

Results

The availability of simulated beds was greater than that indicated in the maximum emergency plans (which was based solely on the census of beds). Patients admitted to Intensive Care and The Sub-Intensive Area may be more difficult to move than those in low-intensity care. The availability of emergency OR was not problematic. Age influenced the possibility of remitting/transferring patients.

Conclusion

Simulation in advance of a maximum emergency is helpful in designing an efficient response plan.

Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care

Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.

Electroretinographic Assessment in Joubert Syndrome: A Suggested Objective Method to Evaluate the Effectiveness of Future Targeted Treatment

INTRODUCTION

Joubert syndrome (JS) is an autosomal recessive disorder characterized by a congenital malformation of the mid-hindbrain and a large spectrum of clinical features including congenital retinal dystrophy. The function of different retinal elements (rod, cone, bipolar cells) can be objectively evaluated by electroretinogram (ERG) recordings. Our work aims to evaluate the retinal function (by ERG recordings) in patients with JS with or without congenital retinal dystrophy. In addition, since clinical trials should be performed in the near future in JS, our results could provide information about the possible usefulness of ERG recordings in the assessment of the efficacy of treatments targeted to improve the retinal involvement.

METHODS

In this observational and prospective study, 24 children with genetic identification for JS (mean age 10.75 ± 6.59 years) and 25 healthy age-similar normal control subjects (control group, mean age 10.55 ± 3.76 years) were enrolled. On the basis of the presence/absence of retinal dystrophy at fundus examination, patients with JS were divided into two groups: patients with JS with retinal dystrophy (16 children, mean age 11.00 ± 6.74 years, providing 16 eyes; JS-RD group) and patients with JS without retinal dystrophy (8 children, mean age 10.50 ± 6.45 years, providing 8 eyes; JS-NRD group). In patients with JS and controls, visual acuity (VA), dark-adapted, light-adapted, and 30-Hz flicker ERGs were performed according to International Society for Clinical Electrophysiology of Vision (ISCEV) standard protocols.

RESULTS

When compared to controls, patients in the JS-RD and JS-NRD groups showed significant abnormalities of the values of dark-adapted, light-adapted, and 30-Hz flicker ERG parameters. The ERG and VA changes were not significantly correlated.

CONCLUSIONS

Our results suggest that a dysfunction of photoreceptors and bipolar cells occurs in patients with JS with or without retinal dystrophy. The retinal impairment can be detected by ERG recordings and this method should be proposed to evaluate the effectiveness of adequate treatment targeted to improve the retinal impairment in patients with JS.

Pain management in the emergency department: results from an observational longitudinal prospective study in a second-level urban hospital

Although a correct assessment of pain and an adequate analgesia represent a priority in the setting of emergency care, many studies documented an inadequate pain control. The purpose of our study is to characterize the present status of a second level Emergency Department in Italy in terms of pain assessment and treatment. Our survey investigates the multidimensional aspects of pain, the accomplishment of appropriate pain evaluation by the medical and nursing staff and the effectiveness of the treatment, in terms of pain reduction and also of customer satisfaction.

Mild head trauma in elderly patients: experience of an emergency department

INTRODUCTION

We evaluated the risk profile of elderly patients who came to the emergency department for mild head trauma. The primary goal was to determine the difference in the incidence of posttraumatic intracranial hemorrhage (ICH) after minor head injury (MHI). The secondary objective was to assess worse outcome, such as: hospitalization rate, rate of re-admission, need of neurosurgery. We also assess the admission process times and length of hospital stay. The ultimate goal was to optimize the diagnostic-observational management of minor head trauma in elderly patients.

MATERIAL AND METHODS

We evaluated all patients with MHI who came to our emergency department during 2017 and 2018. All patients underwent computed tomography.

RESULTS

We enrolled 2325 patients, of whom 1094 were 75 years of age or older. The population was divided into two categories according to age: The "elderly population" was 75 or older, and the younger patients were younger than 75. The elderly population, in comparison with the younger patients, had a higher rate of ICH (12.1% versus 5.1%), a higher hospitalization rate (11.7% versus 5.5%), and a higher rate of readmission within 30 days (6.8% versus 3.2%). The elderly population also had longer admission process times (8 h, 25 min, versus 4 h, 09 min) and longer lengths of hospital stay (9 h, 41 min, versus 5 h, 29 min). Of the younger patients, 92% (versus 41% of the elderly population) did not take any drugs, 6% (versus 39%) were receiving antiplatelet therapy, 1% (versus 13%) took vitamin K antagonists, and 1% (versus 7%) took oral direct-acting anticoagulants. Logistic regression models revealed that a 1-year increase in age raised the risk of bleeding by 2% on average; this finding was statistically significant (odds ratio [OR], 1023/year, p < 0.001). The rate of ICH increased significantly after the age of 75, by 180% (OR, 2.82; p < 0.001).

CONCLUSIONS

These data suggest that age is an independent risk factor for ICH, whereby the age of 75 entails a 180% increase in the risk of bleeding.

Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists

Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.

Morpho-functional survey in children suspected of inherited retinal dystrophies via video recording, electrophysiology and genetic analysis

PURPOSE

To present a detailed study matching functional response and video imaging with genetic analysis in children suspected of inherited retinal dystrophy (IRD).

METHODS

Sixteen children underwent fundus examination via video recording (Heine Omega 500 indirect ophthalmoscope with DV1 camera) and electroretinogram (ERG) under general anesthesia to investigate the cause of suspected low vision. The patients [median age 12 (interquartile range 8-57.5) months] had associated genetic analysis performed with next-generation sequencing or array-comparative genomic hybridization.

RESULTS

Four children had potential pathogenic variants in genes involved in Leber congenital amaurosis and Joubert syndrome (NMNAT1, CEP290, KCNJ13, IMPDH1); 1 child had a 16p11.2 microdeletion and 1 in 2q22.1. The ERG was altered in 6 patients, fundus imaging showed serious abnormality matching an IRD in 7 children, and less severe fundus alterations were found in 2 subjects.

CONCLUSION

Fundus imaging associated with ERG may be significant in IRD diagnosis and visual impairment prognosis, alongside genetic analysis and therapy in selected cases.

Role of a Brief Intensive Observation Area with a Dedicated Team of Doctors in the Management of Acute Heart Failure Patients: A Retrospective Observational Study

Background and objectives: Acute heart failure (AHF) is one of the main causes of hospitalization in Western countries. Usually, patients cannot be admitted directly to the wards (access block) and stay in the emergency room. Holding units are clinical decision units, or observation units, within the ED that are able to alleviate access block and to contribute to a reduction in hospitalization. Observation units have also been shown to play a role in specific clinical conditions, like the acute exacerbation of heart failure. This study aimed to analyze the impact of a brief intensive observation (OBI) area on the management of acute heart failure (AHF) patients. The OBI is a holding unit dedicated to the stabilization of unstable patients with a team of dedicated physicians. Materials and Methods: We conducted a retrospective and single-centered observational study with retrospective collection of the data of all patients who presented to our emergency department with AHF during 2017. We evaluated and compared two cohorts of patients, those treated in the OBI and those who were not, in terms of the reduction in color codes at discharge, mortality rate within the emergency room (ER), hospitalization rate, rate of transfer to less intensive facilities, and readmission rate at 7, 14, and 30 days after discharge. Results: We enrolled 920 patients from 1^st January to 31^st December. Of these, 61% were transferred to the OBI for stabilization. No statistically significant difference between the OBI and non-OBI populations in terms of age and gender was observed. OBI patients had worse clinical conditions on arrival. The patients treated in the OBI had longer process times, which would be expected, to allow patient stabilization. The stabilization rate in the OBI was higher, since presumably OBI admission protected patients from “worse condition” at discharge. Conclusions: Data from our study show that a dedicated area of the ER, such as the OBI, has progressively allowed a change in the treatment path of the patient, where the aim is no longer to admit the patient for processing but to treat the patient first and then, if necessary, admit or refer. This has resulted in very good feedback on patient stabilization and has resulted in a better management of beds, reduced admission rates, and reduced use of high intensity care beds.

Trauma Coagulopathy and Its Outcomes

Background and Objectives: Trauma coagulopathy begins at the moment of trauma. This study investigated whether coagulopathy upon arrival in the emergency room (ER) is correlated with increased hemotransfusion requirement, more hemodynamic instability, more severe anatomical damage, a greater need for hospitalization, and hospitalization in the intensive care unit (ICU). We also analyzed whether trauma coagulopathy is correlated with unfavorable indices, such as acidemia, lactate increase, and base excess (BE) increase. Material and Methods: We conducted a prospective, monocentric, observational study of all patients (n = 503) referred to the Department of Emergency and Acceptance, IRCCS Fondazione Policlinico San Matteo, Pavia, for major trauma from 1 January 2018 to 30 January 2019. Results: Of the 503 patients, 204 had trauma coagulopathy (group 1), whereas 299 patients (group 2) did not. Group 1 had a higher hemotransfusion rate than group 2. In group 1, 15% of patients showed hemodynamic instability compared with only 8% of group 2. The shock index (SI) distribution was worse in group 1 than in group 2. Group 1 was more often hypotensive, tachycardic, and with low oxygen saturation, and had a more severe injury severity score than group 2. In addition, 47% of group 1 had three or more body districts involved compared with 23% of group 2. The hospitalization rate was higher in group 1 than in group 2 (76% vs. 58%). The length of hospitalization was >10 days for 45% of group 1 compared with 28% of group 2. The hospitalization rate in the ICU was higher in group 1 than in group 2 (22% vs. 14.8%). The average duration of ICU hospitalization was longer in group 1 than in group 2 (12.5 vs. 9.78 days). Mortality was higher in group 1 than in group 2 (3.92% vs. 0.98%). Group 1 more often had acidemia and high lactates than group 2. Group 1 also more often had BE <−6. Conclusions: Trauma coagulopathy patients, upon arrival in the ER, have greater hemotransfusion (p = 0.016) requirements and need hospitalization (p = 0.032) more frequently than patients without trauma coagulopathy. Trauma coagulopathy seems to be more present in patients with a higher injury severity score (ISS) (p = 0.000) and a greater number of anatomical districts involved (p = 0.000). Head trauma (p = 0.000) and abdominal trauma (p = 0.057) seem related to the development of trauma coagulopathy. Males seem more exposed than females in developing trauma coagulopathy (p = 0.018). Upon arrival in the ER, the presence of tachycardia or alteration of SI and its derivatives can allow early detection of patients with trauma coagulopathy.

Depressive symptoms and maternal psychological distress during early infancy: A pilot study in preterm as compared with term mother-infant dyads

BACKGROUND

Preterm birth does not only affect infants but also represents an unexpected and traumatic event for parents. There are few reports on parenting stress during early infancy comparing preterm and term mothers, with the results being somewhat inconsistent.

METHODS

As part of a longitudinal study, preterm mother-infant and term mother-infant dyads were enrolled. Dyads were assessed twice: during hospitalisation in the neonatal intensive care unit (NICU) and at 3 months of infant age (corrected age for preterm). Each mother completed a self-report set of psychological questionnaire in both time points. All the children underwent a neurological examination at 40 weeks post conceptional age and at 3 months (corrected age for preterm).

RESULTS

20 preterm and 20 term dyads were included. NICU mothers reported elevated postnatal depressive symptoms and high stress level, even if the preterm infants were with low perinatal risk and normal neurological examination. Comparing preterm infant with low perinatal risk and normal neurological examination with term-born children at 3 months, we found higher parental stress in term mothers than in preterm mothers.

LIMITATIONS

This study was limited by a relatively small sample size; findings are preliminary and warrant further investigation in larger-scale study.

CONCLUSIONS

Findings confirm that becoming a mother of a preterm infant is an event associated with emotional distress. These symptoms may resolve with time, and sometimes are independent of the infant's clinical severity. Assessing parental sources of stress and subsequent follow-up is essential to promote parental support, both for preterm and term mothers.

Diagnostic Performance and Accuracy of the 3 Interpreting Methods of Breast Strain Elastography: A Systematic Review and Meta-analysis

There are 3 methods of interpreting breast strain elastography: the elastographic-to-B-mode length ratio (E/B), a 5-point color scale (5P), and the strain ratio (SR). This meta-analysis assessed which method is superior to the others. A systematic search of the medical literature was performed in July 2017. Studies were eligible for inclusion if they fulfilled the following criteria: (1) had biopsy-proven or long-term stability as the reference standard; (2) used either the E/B, 5P, or SR to interpret results; and (3) had at least 50 cases. A total of 220 records were retrieved; 60 full-text articles were examined, and 46 were included in the meta-analysis. Publication years ranged from 2007 and 2017. The quality of studies was generally high. The mean age of women was 48 years; 12,398 lesions (4242 malignant) were analyzed. For the 5P method, the sensitivity was 77%; specificity, 87%; positive likelihood ratio (LR), 5.3; and negative LR, 0.24. For the SR method, sensitivity was 87%; specificity, 81%; positive LR, 4.8; and negative LR, 0.16. For the E/B method, sensitivity was 96%; specificity, 88%; positive LR, 7.1; and negative LR, 0.03. Of the 3 methods, the E/B had the highest sensitivity, and the E/B and 5P had the highest specificity. With a negative LR of 0.03, the E/B method can downgrade lesions with a pretest probability of 50% to a 2% probability of malignancy.

Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age

The pediatric ultrasound measurement of the inferior vena cava (IVC) and aorta (AO) with the study of the collapsibility index (CI) and of IVC-to-AO ratio (IVC/AO) can provide clinicians in the acute care setting with information on abnormal volume status but one of the major limitations is a lack of reference normal values by body surface area (BSA) and age. The aim of this study was to provide reference ranges for the sonographic measurement of IVC, AO, and IVC/AO ratio in healthy Caucasian Italian children.

METHODS

We enrolled prospectively 516 healthy Caucasian Italian children aged between 1 month and 16 years. Echocardiographic IVC and AO diameters were collected and presented separately for children aged ≤1 year and for children aged over 1 year. For children >1 year we categorized subjects into 3 years classes. CI and IVC/AO for the systolic aortic diameter were then calculated. For children over 1 year, age reference ranges were age-related or BSA-related; for children of ≤1 year, reference ranges were determined with their 90% confidence intervals regardless of age and of BSA.

RESULTS

Tables and charts with reference ranges for all the echocardiographic measurements are presented for children aged >1 year according to age and BSA. The equations to obtain percentile and Z-score for each echocardiographic measurement are provided. The reference ranges for children aged ≤1 year are shown considering the small 90% confidence intervals for upper and lower limits. CI was 30% (SD 17%) in children >1 year and 36% (SD 16%) in children <1 year. IVC/AOs showed age-dependent values from 0.83 (SD 0.20) age <1 year to 1.22 (SD 0.31) in older subjects.

CONCLUSIONS

We report reliable reference ranges for echocardiographic measurement of IVC, AO, CI, and IVC/AO for a Caucasian Italian healthy pediatric population.

Focused extracorporeal shock wave therapy for greater trochanteric pain syndrome with gluteal tendinopathy: a randomized controlled trial

OBJECTIVES:

To investigate if focused extracorporeal shock wave therapy (f-ESWT) is an effective treatment in a population affected by greater trochanteric pain syndrome (GTPS).

DESIGN:

Randomized controlled trial, with blind outcome assessors.

SETTING:

Outpatients, University Hospital.

SUBJECTS:

A total of 50 patients affected by GTPS with gluteal tendinopathy.

INTERVENTIONS:

The study group was assigned to receive f-ESWT, the control group received ultrasound therapy (UST).

MAIN MEASURES:

We assessed hip pain and lower limb function by means of a numeric rating scale (p-NRS) and the Lower Extremity Functional Scale (LEFS scale), respectively. The first follow-up evaluation (2M-FUP) was performed two months after the first treatment session, the second (6M-FUP) was carried out six months later.

RESULTS:

The mean age of the population was 61.24 (9.26) years. A marked prevalence of the female sex was recorded (44 subjects, 86%). The statistical analysis showed a significant pain reduction over time for the study group and the control group, the f-ESWT proving to be significantly more effective than UST ( P < 0.05) at the 2M-FUP (2.08 vs 3.36) and at the 6M-FUP (0.79 vs 2.03). A marked improvement of the LEFS total score was observed in both groups as well, but we found no statistical differences in the comparisons between groups.

CONCLUSION:

Our findings support the hypothesis that f-ESWT is effective in reducing pain, both in the short-term and in the mid-term perspective. We also observed a functional improvement in the affected lower limb, but, in this case, f-ESWT showed not to be superior to UST.

Impact of asbestos on public health: a retrospective study on a series of subjects with occupational and non-occupational exposure to asbestos during the activity of Fibronit plant (Broni, Italy)

The goal of this study is to understand more about the role of asbestos in causing human diseases, first of all mesothelioma, by investigating a large series of deaths due to asbestos-related diseases (ARDs). The main aim is to clarify if even very low amounts of asbestos can cause mesothelioma and other ARDs, as well as to find out if a different individual vulnerability can be important. This retrospective study included 188 subjects who died from asbestos related diseases in 2000-2017 in the area around Broni, Italy, where an important asbestos cement factory had been active from 1932 until 1993. In each case, a forensic autopsy has been performed. In order to perform the present study, the records were retrieved, including the clinical files, the autopsy, and the histological report. The statistical analysis performed showed that there was a significant relation between the cause of death (mesothelioma, lung cancer or asbestosis) and the kind of exposure (occupational, neighborhood or household), showing that all the subjects not exposed occupationally (and, therefore, exposed to lower amounts of asbestos) died from mesothelioma, whereas the individuals who used to work at the plant died also from other caused (asbestosis, lung cancer). Significant differences were highlighted examining the distribution of the causes of death according to the smoking habits. Moreover, among the mesothelioma patients, the survival time was shorter in the subjects with a neighborhood or household exposure than in the occupationally exposed individuals. The study provided meaningful data about the role of asbestos in causing human pathologies. In particular, the present data appear to support the hypothesis that even an exposure to a very little amount of asbestos can cause mesothelioma in hypersusceptible subjects (probably, on a genetic basis).

Agreement Between an Automated Volume Breast Scanner and Handheld Ultrasound for Diagnostic Breast Examinations

OBJECTIVES

To compare the agreement and interobserver variability of diagnostic handheld ultrasound (US) and a single volume on an automated breast volume scanner (ABVS) and to determine whether there was a significant difference if the ABVS was used by a sonographer or mammographic technologist.

METHODS

Ninety patients scheduled for diagnostic US examinations were randomized to either handheld US or the ABVS first. The AVBS was randomized between a sonographer and a mammographic technologist performing the study. The studies were blinded, randomized, and read by 2 radiologists. The lesion with the highest Breast Imaging Reporting and Data System (BI-RADS) score was used in the analysis. Final diagnoses were made by core biopsy or follow-up for 2 years. Lesions included 9 malignant and 81 benign.

RESULTS

The 90 patients had a mean age ± SD of 53.1 ± 16.3 years. The κ value for agreement between the ABVS and handheld US was 0.831 (95% confidence interval, 0.744-0.925), whereas the global agreement for a 7-point BI-RADS score was 0.488 (0.372-0.560). The agreement between the ABVS and handheld US was nearly the same when the ABVS was used by a mammographic technologist (κ = 0.858 [0.723-0.963]) or sonographer (κ = 0.803 [0.596-1.000]; P = .47). The areas under the receiver operating characteristic curves for characterization by the ABVS were 0.91 (0.84-0.96) for reader 1 and 0.91 (0.83-0.96) for reader 2; those for handheld US were 0.91 (0.84-0.96) for reader 1 and 0.83 (0.74-0.90) for reader 2, with no statistical difference. The agreement based on pathologic images was κ = 0.831 (0.718-0.944); for handheld US, κ = 0.795 (0.623-0.967); and for the AVBS, κ = 0.869 (0.725-1.000).

CONCLUSIONS

Performing a single-view diagnostic ABVS examination has good agreement with a handheld diagnostic US workup. There is no difference if the ABVS is used by a sonographer or mammographic technologist.

Birmingham epidermolysis severity score and vitamin D status are associated with low BMD in children with epidermolysis bullosa

Bone status impairment represents a complication of generalized forms of epidermolysis bullosa (EB); however, the prevalence and the main determinants of this event in localized forms remain poorly defined. Birmingham epidermolysis bullosa severity (BEBS) score and 25-hydroxyvitamin D levels are strongly associated with low bone mass, suggesting that vitamin D may play a potential beneficial role in bone health. Further longitudinal studies are needed in order to confirm this hypothesis.

INTRODUCTION

Bone status impairment represents a complication of generalized forms of EB; thus, we aimed to estimate the prevalence of low bone mass, to examine mineralization differences in various EB subtypes and to identify the most important determinants of bone impairment in children with either generalized or localized EB.

METHODS

An observational study of 20 children (11 males; mean age ± standard deviation, 11.7 ± 3.9 years) with EB was performed. Clinical history, physical examination, laboratory studies, X-ray of the left hand and wrist for bone age, and dual energy X-ray absorptiometry scans of the lumbar spine were obtained. Areal bone mineral density (aBMD Z-scores) and bone mineral apparent density were related to the BEBS score.

RESULTS

Areal BMD Z-score (mean -1.82 ± 2.33, range, -7.6-1.7) was reduced (<-2 SD) in 8 patients (40%), whereas aBMD Z-score adjusted for bone age was low in 7 patients (35%). BEBS score and 25-hydroxyvitamin D serum levels were the most important elements associated with aBMD (P = 0.0001 and P = 0.016, respectively). A significant correlation between the aBMD Z-score and area of skin damage, insulin-like growth factor-1, C-reactive protein, and sodium serum levels was also found.

CONCLUSIONS

Low aBMD can be considered a systemic complication of EB, primarily associated with BEBS score and 25-hydroxyvitamin D levels. Therefore, longitudinal evaluation of bone status is ongoing in these patients to define whether vitamin D supplementation would prevent, or at least reduce, bone status impairment.

Comparison of the Diagnostic Accuracy of Three Rapid Tests for the Serodiagnosis of Hepatic Cystic Echinococcosis in Humans

BACKGROUND

The diagnosis of cystic echinococcosis (CE) is based primarily on imaging, in particular with ultrasound for abdominal CE, complemented by serology when imaging results are unclear. In rural endemic areas, where expertise in ultrasound may be scant and conventional serology techniques are unavailable due to lack of laboratory equipment, Rapid Diagnostic Tests (RDTs) are appealing.

METHODOLOGY/PRINCIPAL FINDINGS

We evaluated the diagnostic accuracy of 3 commercial RDTs for the diagnosis of hepatic CE. Sera from 59 patients with single hepatic CE cysts in well-defined ultrasound stages (gold standard) and 25 patients with non-parasitic cysts were analyzed by RDTs VIRapid HYDATIDOSIS (Vircell, Spain), Echinococcus DIGFA (Unibiotest, China), ADAMU-CE (ICST, Japan), and by RIDASCREEN Echinococcus IgG ELISA (R-Biopharm, Germany). Sensitivity, specificity and ROC curves were compared with McNemar and t-test. For VIRapid and DIGFA, correlation between semiquantitative results and ELISA OD values were evaluated by Spearman's coefficient. Reproducibility was assessed on 16 randomly selected sera with Cohen's Kappa coefficient. Sensitivity and Specificity of VIRapid (74%, 96%) and ADAMU-CE (57%, 100%) did not differ from ELISA (69%, 96%) while DIGFA (72%, 72%) did (p = 0.045). ADAMU-CE was significantly less sensitive in the diagnosis of active cysts (p = 0.019) while DIGFA was significantly less specific (p = 0.014) compared to ELISA. All tests were poorly sensitive in diagnosing inactive cysts (33.3% ELISA and ADAMU-CE, 42.8% DIGFA, 47.6% VIRapid). The reproducibility of all RDTs was good-very good. Band intensity of VIRapid and DIGFA correlated with ELISA OD values (r = 0.76 and r = 0.79 respectively, p<0.001).

CONCLUSIONS/SIGNIFICANCE

RDTs may be useful in resource-poor settings to complement ultrasound diagnosis of CE in uncertain cases. VIRapid test appears to perform best among the examined kits, but all tests are poorly sensitive in the presence of inactive cysts, which may pose problems with accurate diagnosis.

Hypoxanthine-guanine phosphoribosyltransferase deficiency and erythrocyte synthesis of pyridine coenzymes

Purine and pyridine metabolism were studied in ten Lesch-Nyhan patients, with virtually no hypoxanthine-guanine phosphoribosyltransferase (HPRT) activity in erythrocytes. Increased NAD erythrocyte concentrations were found in all patients. Raised activities of two enzymes catalysing NAD synthesis from nicotinic acid (nicotinic acid phosphoribosyltransferase: NAPRT, and NAD synthetase: NADs) was found in erythrocyte lysates from all patients. The two enzymes had normal apparent Km for their substrates and increased Vmax. The rate of synthesis of pyridine nucleotides from nicotinic acid by intact erythrocytes in vitro was also increased in most patients. These findings suggest that raised NAD concentrations in HPRT- erythrocytes are due to enhanced synthesis as a result of increased enzyme activities.

11Beta-hydroxysteroid dehydrogenase expression in first trimester human trophoblasts

This study evaluated the levels and the enzymatic characteristics of 11beta-hydroxysteroid dehydrogenase activity (11beta-HSD) of chorionic villi isolated from first trimester human placenta. The results demonstrated a predominant expression of the NAD-dependent dehydrogenase isoform (11beta-HSD2) over the NADP-dependent oxoreductase (11beta-HSD1). Thus, in tissue homogenates exogenous NAD increased the conversion of corticosterone to 11-dehydrocorticosterone of about 14-fold while NADP was ineffective. There was no conversion of 11-dehydrocorticosterone to corticosterone either with NADH or NADPH demonstrating the lack of reductase activity. In keeping with these results, RT-PCR analysis indicated a mRNA for 11beta-HSD2 in villous tissue while 11beta-HSD1 mRNA levels were undetectable. In addition, immunohistochemical staining localized the 11beta-HSD2 protein to syncytiotrophoblasts and cell columns of the chorionic villi. These results suggest roles for the trophoblast-associated 11beta-HSD2 oxidative activity in modulating the exposure of the embryo to active glucocorticoids in the early gestation and in regulating trophoblasts invasion of the uterine wall.