Diagnosis of lung cancer following emergency admission: Examining care pathways, clinical outcomes, and advanced NSCLC treatment in an Italian cancer Center.

Background: Lung cancer patients diagnosed following emergency admission often present with advanced disease and poor performance status, leading to suboptimal treatment options and outcomes. This study aimed to investigate the clinical and molecular characteristics, treatment initiation, and survival outcomes of these patients. Methods: We retrospectively analyzed data from 124 patients diagnosed with lung cancer following emergency admission at a single institution. Clinical characteristics, results of molecular analyses for therapeutic purpose, systemic treatment initiation, and survival outcomes were assessed. Correlations between patients' characteristics and treatment initiation were analyzed. Results: Median age at admission was 73 years, and 79.0 % had at least one comorbidity. Most patients (87.1 %) were admitted due to cancer-related symptoms. Molecular analyses were performed in 89.5 % of advanced non-small cell lung cancer (NSCLC) cases. In this subgroup, two-thirds (66.2 %) received first-line therapy. Median overall survival (OS) was 3.9 months for the entire cohort, and 2.9 months for patients with metastatic lung cancer. Among patients with advanced NSCLC, OS was significantly longer for those with actionable oncogenic drivers and those who received first-line therapy. Improvement of performance status during hospitalization resulted in increased probability of receiving first-line systemic therapy. Discussion: Patients diagnosed with lung cancer following emergency admission demonstrated poor survival outcomes. Treatment initiation, particularly for patients with actionable oncogenic drivers, was associated with longer OS. These findings highlight the need for proactive medical approaches, including improving access to molecular diagnostics and targeted treatments, to optimize outcomes in this patient population.

Changes in volumes and severity of surgical urgencies during the first two COVID-19 pandemic waves in a regional hospital network.

Background and aim This study analyses the impact of the first two pandemic waves on surgical urgencies/emergencies and their consequences on an entire provincial hospital network's surgical activities. Methods  Clinical and epidemiological data of urgent/emergent surgical admissions and interventions in the Autonomous Province of Trento's hospital network were collected from the internal common electronic database. The investigation periods were March-May 2019 (reference period), March-May 2020 (phase-I), June - August 2020 (phase-II), and October - December 2020 (phase-III). The same data were divided and grouped for the six most represented diagnoses. Results: The number of admissions for surgical emergencies in the studied periods showed a sinusoidal trend. In the reference period of 2019, 957 patients were admitted in urgency, while in the three pandemic phases, urgent admissions were 511, 888 and 633 respectively (-47% in phase I, - 8% in phase II, -34% in phase III). This trend was also observed by stratifying admissions for single disease, except for gastrointestinal perforations and pancreatitis, which showed a slight increasing trend in phase-I. Among the studied population, the surgical rate was 35.2% in phase-I and 34.3% in phase-III; these data were significantly higher than in 2019 (25.6%).  Conclusions The effect of the COVID pandemic on surgical emergencies and urgencies (SUEs) was mainly indirect, manifesting itself with a significant reduction in the number of surgical admissions, particularly in phases-I and-III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019.

Impact of COVID-19 pandemic waves on changes in surgical urgency volumes and severity in the regional hospital network of Trento (Northern Italy): a descriptive epidemiological analysis.

OBJECTIVES: to analyse both direct and indirect impacts on surgical admissions, surgical rates, and clinical picture severity of the two COVID-19 pandemic waves in a hospital network covering an entire province (Trento, located in Trentino-Alto Adige Region, Northern Italy). DESIGN: retrospective epidemiological study. SETTING AND PARTICIPANTS: data regarding the patient load of the Surgical Urgencies/Emergencies flows (SUEs) of the Local Health Authority of the Autonomous Province of Trento derived from the Hospital Discharge Record (HDR) information flow. The population in study was that of patients hospitalized in the entire Province of Trento. This study compares the volume and characteristics of urgent/emergency surgery during the 2020 COVID-19 pandemic with the homologous period in 2019, subdividing the analysed pandemic period in 3 separated groups: • phase I (March-May 2020); • phase II (June-August 2020); • phase III (October-December 2020). The 3 groups represent, respectively: the 1st pandemic wave proclamation of national lockdown from 9 March to 18 May; the summer pandemic remission; the 2nd pandemic wave with partial restrictions on circulation and commercial activities. Clinical and surgical records of SUE population among these 3 periods (March-May; June-August; October-December) of both 2020 and 2019 were analyzed and compared. MAIN OUTCOME MEASURES: the overall number of admissions and surgical rates for SUEs in the study periods were chosen as primary outcomes. The same outcomes were analysed for the most represented diagnoses in the SUEs population: diverticulitis, intestinal obstruction, appendicitis, cholecystitis, gastrointestinal (GI) perforations, pancreatitis, traumas. To assess the degree of clinical picture severity, variables coming from the hospital discharging charts, commonly associated to worst outcomes in term of mortality and morbidity, such as age, length of hospital stay, DRG weight, and patients not discharged at home were extrapolated from the electronic database. A numerical weight was then assigned to each variable, obtaining a scoring system from 0 to 15 (severity index). RESULTS: the number of admissions for SUEs in the studied period showed a sinusoidal trend, with a dramatic decrease in phase I and III (-46.6% and -31.6%, respectively). This trend was also observed even by stratifying admissions for the most frequent pathologies, except for gastrointestinal perforations and pancreatitis. The surgical rate among hospitalised patients for SUEs was 35.2% in phase, significantly higher than that of 2019 (25.6%). Considering the most frequent diagnoses individually, some had a progressive increase in the surgical rate in phases I and II (diverticulitis, bowel obstructions, cholecystitis), others showed an initial decrease and then settled on values ​​not far from those of 2019 (GI perforations and appendicitis), others again had an initial significant increase and then gradually returned to values ​​similar to those of 2019 in phase III (traumas). The mean patients age was significantly higher in phase I than in 2019 (p-value <0.001) and in phase II (p-value <0.05). Consistently with the trend of the number of urgent admissions, even the severity index calculated on the SUEs population showed a sinusoidal trend with and evident increase during the two pandemic waves. CONCLUSIONS: the effect of the COVID-19 pandemic on SUEs was mainly indirect, manifesting itself with a significant reduction in surgical admissions, particularly in phases I and III. Conversely, in the same phases, the surgical rate showed a significant increase compared to 2019. The stratified analysis confirmed these findings for the most frequent diagnoses except for GI perforations and pancreatitis. The clinical pictures were more severe in the two pandemic waves than in the reference period of 2019. Although with a slight numerical attenuation, in general, the second pandemic wave confirmed the first one findings.

Susoctocog-alfa (Obizur®) in the treatment of nine elderly patients with acquired haemophilia A: an Italian multicentre real world experience.

BACKGROUND: In 2016, a new recombinant B-domain deleted porcine FVIII (rpFVIII) was licensed in Italy for the treatment of acquired haemophilia A (AHA), but only a few cases of patients receiving this have been reported in the literature. Here we report the largest registry of the use of rpFVIII for the treatment of AHA. The objective of this retrospective study was to describe the efficacy and the safety of susoctocog-alfa for AHA. MATERIAL AND METHODS: We studied a population of nine patients, recruited in five Italian haemophilia centres presenting AHA, and treated with Obizur® as first- or second-line therapy. RESULTS: rpFVIII was used as a first-line therapy in one-third of the patients. The median delay between clinical onset and diagnosis was 16 days. Initial bolus of infused susoctocog-alfa was 100 IU/kg, lower than the recommended dose. The treatment was maintained for a median of four days. Only one patient with serious co-morbidities and recurrent infections was treated for 32 days. All patients reached a complete resolution of AHA, and no recurrences were reported. Two patients developed a low-titre inhibitor against rpFVIII, neither experienced any complications. DISCUSSION: In our real world experience, susoctocog-alfa was proven to be an effective and safe therapeutic option for patients with AHA, also at a lower than recommended dosage. In our report, the appearance of low-titre inhibitors against rpFVIII, was not found to be clinically significant.

An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome.

BACKGROUND: The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors. METHODS: This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled. RESULTS: Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2. CONCLUSIONS: Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.

Characteristics of current heart failure patients admitted to internal medicine vs. cardiology hospital units: the VASCO study.

The majority of patients hospitalized for heart failure (HF) are admitted to internal medicine (IM) rather than to cardiology (CA) units, but to date few studies have analyzed the characteristics of these two populations. In this snapshot survey, we compared consecutive patients admitted for HF in six IM units vs. one non-intensive CA unit. During the 6-month survey period, 467 patients were enrolled (127 in CA, 27.2% vs. 340 in IM, 72.8%). IM patients were almost 10 years older (CA 75 ± 10, IM 82 ± 8 years; p < 0.001), more frequently female (CA 39%, IM 55%; p = 0.002) and living at home alone (CA 12%, IM 21%; p = 0.017). The leading cause of hospitalization in both groups was acute worsening of HF (CA 42%, IM 53%; p = 0.031), followed by atrial fibrillation (CA 29%, IM 12%; p < 0.001) and infections (CA 24%, IM 27%; p = 0.563). Ischemic (CA 43%, IM 30%; p = 0.008) and dilated cardiomyopathy patients (CA 21%, IM 12%; p < 0.001) were primarily admitted to CA unit, whereas those with hypertensive heart disease to IM (CA 3%, IM 39%; p < 0.001). Left ventricular ejection fraction (LVEF) was available in 96% of CA patients, but only in 60% of IM patients (p = 0.001). Among patients with LVEF measured, those with LVEF < 40% were predominantly admitted to CA (CA 60%, IM 14%; p < 0.001), whereas those with LVEF ≥ 50% were admitted to IM (CA 21%, IM 33%; p = 0.019); 26% of IM patients were discharged without a known LVEF. Medical treatments also significantly differed, according to patients' clinical and instrumental characteristics in each unit. This study demonstrates important differences between HF patients hospitalized in CA vs. IM, and the need for a greater interaction between these two medical specialties for a better care of HF patients.

Multicentre Italian analysis on cardiovascular diseases: impact of immigrants' referral to emergency department.

During the recent years, immigration in Italy has increased. There are few data on the health status of immigrants and there is a need to improve their healthcare. Cardiovascular disorders account for 7.6% of immigrants' diseases and cause 3.6% of the total deaths. Lack of healthcare services to general medicine support and prescriptions leads immigrants to contact the Emergency Department (ED) to receive medical assistance. Primary endpoints of this study were to assess the use of national healthcare system by immigrants and to determine the incidence of cardiovascular diseases, and the frequency and type of risk factors for cardiovascular diseases in these patients. A no-profit, observational, multicentre study was conducted from April to September 2012. We studied 642 foreign patients referring to the ED for various symptoms/signs. One hundred and fourteen patients referred for suspected cardiovascular disease and 105 had a confirmed final diagnosis of cardiovascular disease. The more represented ethnic origin was Caucasian (59%), whereas the most represented country was Romania (24%). The main symptom recorded at ED arrival was chest pain (37.1%). Final cardiovascular diagnoses were represented by: hypertensive crisis (28.5%), acute coronary syndrome (20%), acute heart failure (12.3%), atrial fibrillation (10.4%) and chest pain (10.4%). Past medical history of cardiovascular disease, hypertension, obesity and male sex showed independent significant predictive value for cardiovascular disease diagnosis.Our study provides support for the development of specific primary prevention of cardiovascular risk factors in immigrants with the important role of culturally competent education of individuals and families. Better outpatient management seems to be needed in order to limit the need for emergency room referral.

Potential effect of PCV13 introduction on Emergency Department accesses for lower respiratory tract infections in elderly and at risk adults.

Liguria, an administrative region in northern Italy characterized by a decade of high PCV coverage in paediatric age group, has issued new PCV13 recommendations for free active immunization in adults with risk factors and subjects aged ≥ 70 years old. Main aims of this study are: (1) a descriptive epidemiology of the clinical burden of lower respiratory tract infections (LRTI) in adults ≥18 years of age; and (2) a crossover evaluation of the effect of introduction of PCV13 vaccination in adults aged ≥70 years old, in terms of ED accesses for LRTI, obtained by a Syndrome Surveillance System (SSS). The ED access, chief complaint based SSS will allow an active surveillance of a population cohort of >430 000 individuals resident in Genoa metropolitan area, aged ≥18 years old, for a period of 60 months. During pre-PCV period, annual cumulative incidence of ED accesses for LRTI was equal to 7/1000 and 2% in ≥65 and ≥85 year adults, respectively. In ≥65 years adults, more than 70% of subjects identified by the SSS has at least one risk condition, with a peak of 87% in ≥85 year cohort. New Ligurian PCV13 recommendations can potentially reach more than 75% of ED accesses for LRTI. Data highlights the heavy impact of LRTI in terms of ED accesses, especially in the elderly and subjects with chronic conditions and the usefulness of SSS tool for monitoring PCV vaccination effect.

Thirty and ninety days mortality predictive value of admission and in-hospital procalcitonin and mid-regional pro-adrenomedullin testing in patients with dyspnea. Results from the VERyfing DYspnea trial.

INTRODUCTION: Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea. METHODS: To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF). RESULTS: Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P < .001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P < .0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR-proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days. CONCLUSIONS: In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days.

Additive value of blood neutrophil gelatinase-associated lipocalin to clinical judgement in acute kidney injury diagnosis and mortality prediction in patients hospitalized from the emergency department.

INTRODUCTION: Acute kidney injury (AKI) is a common complication among hospitalized patients. The aim of this study was to evaluate the utility of blood neutrophil gelatinase-associated lipocalin (NGAL) assessment as an aid in the early risk evaluation for AKI development in admitted patients. METHODS: This is a multicenter Italian prospective emergency department (ED) cohort study in which we enrolled 665 patients admitted to hospital from the ED. RESULTS: Blood NGAL and serum creatinine (sCr) were determined at ED presentation (T0), and at: 6 (T6), 12 (T12), 24 (T24) and 72 (T72) hours after hospitalization. A preliminary assessment of AKI by the treating ED physician occurred in 218 out of 665 patients (33%), while RIFLE AKI by expert nephrologists was confirmed in 49 out of 665 patients (7%). The ED physician's initial judgement lacked sensitivity and specificity, overpredicting the diagnosis of AKI in 27% of the cohort, while missing 20% of those with AKI as a final diagnosis. CONCLUSIONS: Our study demonstrated that assessment of a patient's initial blood NGAL when admitted to hospital from the ED improved the initial clinical diagnosis of AKI and predicted in-hospital mortality. Blood NGAL assessment coupled with the ED physician's clinical judgment may prove useful in deciding the appropriate strategies for patients at risk for the development of AKI.See related commentary by Legrand et al., http://ccforum.com/content/17/2/132.

Splenic Doppler resistive index for early detection of occult hemorrhagic shock after polytrauma in adult patients.

The objective of this study was to evaluate whether direct assessment of splenic circulation by splenic Doppler resistive index (Doppler RI) is a clinically useful noninvasive method for an early detection of occult hemorrhagic shock after polytrauma in adult patients. Splenic Doppler RI was measured in 49 hemodynamically stable adult patients admitted to the emergency department because of polytrauma. Renal Doppler RI was also determined in 20 patients. Spleen size, Injury Severity Score, systolic blood pressure, heart rate, blood lactate, standard base excess, pH, hemoglobin, and inferior vena cava diameter values were recorded at admission and at 24 h. Patients were grouped according to whether signs of hemorrhagic shock did (n = 22) or did not (n = 27) occur within the first 24 h from admission. Patients who developed hemorrhagic shock had significantly higher splenic and renal Doppler RI, higher Injury Severity Score, and lower standard base excess at admission. By multivariate logistic regression, splenic Doppler RI resulted to be a predictor of hemorrhagic shock development within the first 24 h from admission. Splenic Doppler RI may represent a clinically useful noninvasive method for early detection of occult hemorrhagic shock and persistent occult hypoperfusion after polytrauma in adult patients.

Considerations for early acute myocardial infarction rule-out for emergency department chest pain patients: the case of copeptin.

The evaluation of patients admitted at the emergency department (ED) for chest pain is challenging and involves many different clinical specialists including emergency physicians, laboratory professionals and cardiologists. The preferable approach to deal with this issue is to develop joint protocols that will assist the clinical decision-making to quickly and accurately rule-out patients with non life-threatening conditions that can be considered for early and safe discharge or further outpatient follow-up, rule-in patients with acute coronary syndrome and raise the degree of alert of the emergency physicians on non-cardiac life-threatening emergencies. The introduction of novel biomarkers alongside the well-established troponins might support this process and also provide prognostic information about acute short-term or chronic long-term risk and severity. Among the various biomarkers, copeptin measurement holds appealing perspectives. The utility of combining troponin with copeptin might be cost-effective due to the high negative predictive value of the latter biomarker in the rule-out of an acute coronary syndrome. Moreover, in the presence of a remarkably increased concentration (e.g., more than 10 times the upper limit of the reference range), to reveal the presence of acute life-threatening conditions that may not necessarily be identified with the use of troponin alone. The aim of this article is to review current evidence about the clinical significance of copeptin testing in the ED as well as its appropriate placing within diagnostic protocols.

Hemorrhagic shock in polytrauma patients: early detection with renal Doppler resistive index measurements.

PURPOSE: To investigate whether renal Doppler resistive index (RI) changes occur early during posttraumatic bleeding and may be predictive of occult hypoperfusion-and thus hemorrhagic shock-in patients with polytrauma. MATERIALS AND METHODS: This study was approved by the institutional ethics committee, and informed consent was obtained from all patients. The renal Doppler RI was measured in 52 hemodynamically stable adult patients admitted to the emergency department (ED) because of polytrauma. Renal Doppler RI, hemoglobin, standard base excess, lactate, systolic blood pressure, pH, heart rate, and inferior vena cava diameter values were recorded at admittance and correlated with outcome (progression or nonprogression to hemorrhagic shock). Logistic regression analysis was performed to assess the risk factors for progression to hemorrhagic shock. RESULTS: Twenty-nine patients developed hemorrhagic shock, and 23 did not. At univariable analysis, the hemorrhagic shock group, as compared with the nonhemorrhagic shock group, had higher renal Doppler RI (mean, 0.80 ± 0.10 [standard deviation] vs 0.63 ± 0.03; P < .01), injury severity score (mean, 36 ± 11 vs 26 ± 5; P < .01), and standard base excess (mean, -4.0 mEq/L ± 4 vs 1 mEq/L ± 3; P = .04) values. At logistic regression analysis, a renal Doppler RI greater than 0.7 (vs less than or equal to 0.7) was the only independent risk factor for progression to hemorrhagic shock (odds ratio, 57.8; 95% confidence interval: 10.5, 317.0) (P < .001). CONCLUSION: In polytrauma patients who are hemodynamically stable at admittance to the ED, renal cortical blood flow redistribution occurs very early in response to occult bleeding and might be noninvasively detected by using the renal Doppler RI. A renal Doppler RI greater than 0.7 is predictive of progression to hemorrhagic shock in polytrauma patients.

Syndrome surveillance and molecular epidemiology for early detection and tracing of an outbreak of measles in Liguria, Italy.

The performances of surveillance systems for measles in Europe are poorly investigated, despite the fundamental role they should play in the early detection of outbreaks and in the assessment of the progress towards elimination. A new chief complaint syndrome surveillance system has been developed in Genoa, Italy, using data from the Emergency Department records of the regional reference university hospital and its ability to early detect an outbreak of measles that began during the winter months of 2007/2008 was evaluated. For the 23-month period from January 2007 to November 2008, the Emergency Department registration and triage software was used to obtain the time series of daily counts, that were related with cases notified by the statutory notification system and detection and characterization data from the measles regional reference laboratory. One hundred fifty five cases of measles-like illness were identified by the syndrome surveillance system. Two epidemic threshold breakthroughs were able to anticipate the first notified case by 54 and 11 days. Globally, the new syndrome surveillance system allows the activation of the alert state with a specificity of 94.3% and a sensitivity of 91%. Molecular investigation showed the spread of the virus from United Kingdom to Piemonte and then to Liguria and allowed us to exclude the re- circulation of strains circulating in Northern Italy during the previous seasons. Syndrome surveillance integrated with a rapid detection and characterization of the agent responsible for the disease could be an effective, specific and sensitive tool for measles surveillance.