Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study.

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

Is the National Early Warning Score able to identify nursing activity load? A prospective observational study.

BACKGROUND: The National Early Warning Score scale correlates well with the intensity of the patient's acute condition. It could also correlate with the nursing activity load and prove useful in defining and redistributing nursing resources based on the acuity of patients. AIM: To assess whether patients' National Early Warning Score at hospital admission correlates with objective nursing demands and can be used to optimize the distribution of available care resources. METHODS: This single-center prospective study included patients admitted to the Department of Internal Medicine at the Civil Hospital in Altovicentino (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first three days after admission and standardized to the daily mean as performance/5 min/patient/day. Linear regression was used to assess the correlation between nursing demands for different National Early Warning Scores. RESULTS: This study included 333 patients. Their mean National Early Warning Score was 3.9 (standard deviation: 2.9), with 61 % (203/333) in the National Early Warning Score <5 category, 19.5 % (65/333) in the National Early Warning Score 5-6 category, and 19.5 % (65/333) in the National Early Warning Score >6 category. Their average daily care requirements increased from 22 (16-30) activities/5 min/patient/day in the low National Early Warning Score category to 30 (20-39) activities/5 min/patient/day in the intermediate National Early Warning Score category (p < 0.001) and 35 (23-45) activities/5 min/patient/day in the high National Early Warning Score category (p < 0.001). CONCLUSION: The National Early Warning Score correlates with nursing care activities for patients with an acute condition and can be used to optimize the distribution of available care resources.

Impact of the COVID-19 pandemic, its related social restriction measures and vaccination campaign on emergency department attendances for epileptic seizures: An interrupted time-series analysis.

AIM: To investigate the impact of the outbreak of the COVID-19 pandemic, its related social restriction measure (national lockdown) and vaccination campaign on emergency department (ED) accesses for epileptic seizures. METHODS: Retrospective observational analysis conducted on a consecutive cohort of patients who sought medical care at the ED of the General Hospital of Merano, Italy, from January 1, 2015, to December 31, 2021. We investigated the monthly ED attendances for epileptic seizures between the periods before and after the outbreak of the COVID-19 pandemic and the national lockdown (March 2020) using an interrupted time-series analysis with data standardized for 1000 accesses/month. As a further temporal cutoff, we used the start of the national vaccination campaign. RESULTS: Between January 1, 2015, and December 31, 2021, a total of 415,005 ED attendances were recorded; 1,254 (0.3 %) were due to epileptic seizures. No significant difference was found in the rate of standardized ED accesses for epileptic seizures in March 2020 (time point of interest) to the pre-pandemic trend (0.33/1000; 95 %CI: -1.05 to 1.71; p = 0.637). Similarly, there was no difference between the pre- and post-pandemic trends (-0.02/1000; 95 %CI: -0.11 to 0.06; p = 0.600). When adopting January 2021 as time point of interest, we found no difference to the pre-vaccination trend (0.83/1000; 95 %CI: -0.48 to 2.15), and no difference in the pre- and post-vaccination trends (-0.12/1000; 95 %CI: -0.27 to 0.04). CONCLUSIONS: The COVID-19 pandemic and its related social restrictions (lockdown), as well as the COVID-19 national vaccination campaign, had little impact on ED accesses for epileptic seizures.

The role of lactate-to-albumin ratio to predict 30-day risk of death in patients with sepsis in the emergency department: a decision tree analysis.

BACKGROUND: Accurately estimating the prognosis of septic patients on arrival in the emergency department (ED) is clinically challenging. The lactate-to-albumin ratio (LAR) has recently been proposed to improve the predictive performance of septic patients admitted to the ICU. OBJECTIVES: This study aims to assess whether the LAR could be used as an early prognostic marker of 30-day mortality in patients with sepsis in the ED. METHODS: A prospective observational study was conducted in the ED of the Hospital of Merano. All patients with a diagnosis of sepsis were considered. The LAR was recorded on arrival in the ED. The primary outcome measure was mortality at 30 days. The predictive role of the LAR for mortality was evaluated with the area under the ROC curve, logistic regression adjusted for the Charlson Comorbidity Index value, National Early Warning Score, and Sequential Organ Failure score, and with decision tree analysis. RESULTS: 459 patients were enrolled, of whom 17% (78/459) died at 30 days. The median LAR of the patients who died at 30 days (0.78 [0.45-1.19]) was significantly higher than the median LAR of survivors (0.42 [0.27-0.65]) (p < 0.001). The discriminatory ability of the LAR for death at 30 days was 0.738, higher than that of lactate alone (0.692), and slightly lower than that of albumin alone (0.753). The decision trees confirmed the role of the LAR as an independent risk factor for mortality. CONCLUSION: The LAR can be used as an index to better predict the 30-day risk of death in septic patients.

Human intelligence versus Chat-GPT: who performs better in correctly classifying patients in triage?

INTRODUCTION: Chat-GPT is rapidly emerging as a promising and potentially revolutionary tool in medicine. One of its possible applications is the stratification of patients according to the severity of clinical conditions and prognosis during the triage evaluation in the emergency department (ED). METHODS: Using a randomly selected sample of 30 vignettes recreated from real clinical cases, we compared the concordance in risk stratification of ED patients between healthcare personnel and Chat-GPT. The concordance was assessed with Cohen's kappa, and the performance was evaluated with the area under the receiver operating characteristic curve (AUROC) curves. Among the outcomes, we considered mortality within 72 h, the need for hospitalization, and the presence of a severe or time-dependent condition. RESULTS: The concordance in triage code assignment between triage nurses and Chat-GPT was 0.278 (unweighted Cohen's kappa; 95% confidence intervals: 0.231-0.388). For all outcomes, the ROC values were higher for the triage nurses. The most relevant difference was found in 72-h mortality, where triage nurses showed an AUROC of 0.910 (0.757-1.000) compared to only 0.669 (0.153-1.000) for Chat-GPT. CONCLUSIONS: The current level of Chat-GPT reliability is insufficient to make it a valid substitute for the expertise of triage nurses in prioritizing ED patients. Further developments are required to enhance the safety and effectiveness of AI for risk stratification of ED patients.

Estimated plasma volume status is a simple and quick tool that could help define the severity of patients with infection on arrival at the emergency department.

BACKGROUND: Infectious states are subtle and rapidly evolving conditions observed daily in the emergency department (ED), and their prognostic evaluation remains a complex clinical challenge. Recently, estimated plasma volume status (ePVS) has been suggested to have a prognostic role in conditions where volemic alteration is central to the pathophysiology. The aim of this study was to verify whether ePVS recorded at ED admission can provide prognostic indications of 30-day mortality in patients with infection. METHODS: A prospective observational study was performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital. All patients with infection were enrolled. ePVS values were derived from haemoglobin and haematocrit measured on the immediate arrival of patients in the ED. The predictive power of ePVS for 30-day mortality was assessed using a multivariate model adjusted for severity, comorbidity and urgency. Kaplan-Meier analysis was also performed. RESULTS: Of the 949 patients with infection enrolled in the study (47.9%, SOFA ≥2), 8.9% (84/949) died at 30 days. The median ePVS value was higher in patients who died at 30 days than in patients who survived (5.83 vs. 4.61, p < 0.001). Multivariate analysis revealed that ePVS in both continuous and categorical form around the median was an independent risk factor for 30-day mortality even after adjusting for severity, comorbidity and urgency. Kaplan-Meier analysis confirmed an increased risk of death in patients with high ePVS values. CONCLUSIONS: ePVS recorded on ED admission of patients with infection was an independent predictor of risk for 30-day mortality.

The Role of Early Intubation in Status Epilepticus with Out-of-Hospital Onset: A Large Prospective Observational Study.

Background: this study aimed to evaluate the role of early airway management and intubation in status epilepticus (SE) with out-of-hospital onset. Methods: We included all patients with out-of-hospital SE onset referred to the emergency department of the Academic Hospital of Modena between 2013 and 2021. Patients were compared according to out-of-hospital airway management (intubation versus non-intubation) and a propensity score was performed for clinical variables unevenly distributed between the two groups. Results: We evaluated 711 patients with SE. A total of 397 patients with out-of-hospital SE onset were eventually included; of these, 20.4% (81/397) were intubated before arrival at the hospital. No difference was found in the clinical characteristics of patients after propensity score matching. The 30-day mortality in the propensity group was 19.4% (14/72), and no difference was found between intubated (7/36, 19.4%) and non-intubated (7/36, 19.4%) patients. No difference was found in SE cessation. Compared to non-intubated patients, those who underwent out-of-hospital intubation had a higher risk of progression to refractory or super-refractory SE, greater worsening of mRS values between hospital discharge and admission, and lower probability of returning to baseline condition at 30 days after SE onset. Conclusions: Early intubation for out-of-hospital SE onset is not associated with improved patient survival even after balancing for possible confounders. Further studies should evaluate the timing of intubation and its association with first-line treatments for SE and their efficacy. In addition, they should focus on the settings and the exact reasons leading to intubation to better inform early management of SE with out-of-hospital onset.

Prognostic role of albumin, lactate-to-albumin ratio and C-reactive protein-to-albumin ratio in infected patients.

INTRODUCTION: The prognostic evaluation of the septic patient has recently been enriched by some predictive indices such as albumin concentration, lactate/albumin ratio (LAR) and C-reactive protein/albumin ratio (CAR). The performance of these indices has been evaluated in septic patients in intensive care, but until now their performance in infected patients in the Emergency Department (ED) has not been evaluated. AIM: To investigate the potential prognostic role of albumin, LAR and CAR in patients with infection in the ED. METHODS: Single-centre prospective study performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital (Italy). All patients with infection were enrolled. The study outcome was death within 30 days. The predictive ability of albumin, LAR and CAR was assessed by area under the receiver operating characteristic curves (AUROCs). A multivariate logistic regression model was used to examine the association of the indices with 30-day mortality, with comorbidity, acute urgency and severity of infection as covariates. RESULTS: The study enrolled 962 patients with an infectious status. The overall 30-day mortality rate was 8.9% (86/962). The AUROC of albumin was 0.831 (95% CI 0.795-868), while for LAR this was 0.773 (CI95% 0.719-0.827) and for CAR 0.718 (CI95% 0.664-0.771). The odds ratio for 30-day mortality for albumin was 3.362 (95% CI 1.904-5.936), for ln(LAR) 2.651 (95% CI 1.646-4.270) and for ln(CAR) 1.739 (95% CI 1.326-2.281). CONCLUSIONS: All three indices had a good discriminatory ability for the risk of short-term death in patients with infection, indicating their promising use in the ED as well as in the ICU. Further studies are needed to confirm the better performance of albumin compared to LAR and CAR.

Real requirements of nursing activities and patient-related factors related to nursing overload in an internal medicine department.

Adequate nursing care can be decisive for the outcome of a patient admitted to an internal medicine ward. Individual prediction of nursing activity at the time of a patient's admission could improve the work process. This study aimed to assess the objectively assessed nursing requirements of patients admitted to a medical setting and to identify clinical factors that correlate with high demands. This is a prospective and pragmatic observational study that enrolled patients admitted to the Internal Medicine ward at the Altovicentino Civil Hospital (Italy) between September 1 and December 31, 2022. Nursing activities were recorded for the first 3 days of hospitalization and standardized as performance/5 min/patient. Patients requiring more than the 75th percentile of performance/5 min/patient were considered nursing over-activities. Multivariable models were used to assess patient-related risk factors associated with nursing over-activity. This study enrolled 333 patients (mean age: 74.2; 55.6% male). Their mean Charlson Comorbidity Index (CCI), Clinical Frailty Scale (CFS), Chronic Barthel Index, and Sistema Informtativo della Performance Infermieristica (SIPI) scores were 5.3, 4.2, 62.4, and 53.7, respectively. Mean National Early Warning System (NEWS) on admission was 3.9 (standard deviation: 2.8). A median of 73 (interquartile range [IQR]: 54-109) nursing care activities/5 min/patient were performed. NEWS score (odds ratio [OR]: 1.372, 95% confidence interval [95%CI]: 1.216-1.547, p < 0.001) and Acute Barthel Index (OR: 0.983, 95%CI: 0.967-0.999, p = 0.041) were independent risk factors for nursing over-activities. NEWS and the Acute Barthel Index could help reorganize nursing resources within internal medicine wards, allowing for an equal distribution between patients who require more resources and those who require less.

The Clinical Utility of Albumin with Sequential Organ Failure Assessment (SOFA) in Improving 30-Day Mortality Prediction in Patients with Infection in the Emergency Department.

BACKGROUND: The Sequential Organ Failure Assessment (SOFA) score is currently the primary prognostic tool used in patients with infections to predict sepsis and mortality, although its predictive role remains debated. Serum albumin values have been recently found to correlate with the severity of sepsis. The purpose of this study is to evaluate the clinical usefulness of albumin dosage on SOFA score prediction in infected patients. METHODS: This prospective single-centre observational study was performed in 2021. We used the net reclassification improvement (NRI) technique to evaluate the additional prognostic value of serum albumin used together with the SOFA score in infected patients. The discriminatory abilities of the SOFA score alone, of albumin levels alone, and of the albumin levels together with (but not incorporated into) the SOFA score was evaluated by comparing the area under the curve of the corresponding receiver operating characteristic (ROC) curves. RESULTS: We included 949 patients with an infectious status; 8.9% (84/949) died within 30 days of ED admission. The AUROC for the SOFA score was 0.802 (95% CI: 0.756-0.849) and the albumin level was 0.813 (95% CI: 0.775-0.852). The NRI found that serum albumin improved SOFA score predictions of 30-day mortality by 24.3% (p < 0.001), yielding an AUROC of 0.881 (95% CI: 0.848-0.912; p < 0.001). CONCLUSIONS: Using serum albumin values together with the SOFA score can improve prognostic prediction in patients with infections evaluated in the ED.

Multi-centric study for development and validation of a CT head rule for mild traumatic brain injury in direct oral anticoagulants: the HERO-M nomogram.

BACKGROUND: Nomograms are easy-to-handle clinical tools which can help in estimating the risk of adverse outcome in certain population. This multi-center study aims to create and validate a simple and usable clinical prediction nomogram for individual risk of post-traumatic Intracranial Hemorrhage (ICH) after Mild Traumatic Brain Injury (MTBI) in patients treated with Direct Oral Anticoagulants (DOACs). METHODS: From January 1, 2016 to December 31, 2019, all patients on DOACs evaluated for an MTBI in five Italian Emergency Departments were enrolled. A training set to develop the nomogram and a test set for validation were identified. The predictive ability of the nomogram was assessed using AUROC, calibration plot, and decision curve analysis. RESULTS: Of the 1425 patients in DOACs in the study cohort, 934 (65.5%) were included in the training set and 491 (34.5%) in the test set. Overall, the rate of post-traumatic ICH was 6.9% (7.0% training and 6.9% test set). In a multivariate analysis, major trauma dynamic (OR: 2.73, p = 0.016), post-traumatic loss of consciousness (OR: 3.78, p = 0.001), post-traumatic amnesia (OR: 4.15, p < 0.001), GCS < 15 (OR: 3.00, p < 0.001), visible trauma above the clavicles (OR: 3. 44, p < 0.001), a post-traumatic headache (OR: 2.71, p = 0.032), a previous history of neurosurgery (OR: 7.40, p < 0.001), and post-traumatic vomiting (OR: 3.94, p = 0.008) were independent risk factors for ICH. The nomogram demonstrated a good ability to predict the risk of ICH (AUROC: 0.803; CI95% 0.721-0.884), and its clinical application showed a net clinical benefit always superior to performing CT on all patients. CONCLUSION: The Hemorrhage Estimate Risk in Oral anticoagulation for Mild head trauma (HERO-M) nomogram was able to predict post-traumatic ICH and can be easily applied in the Emergency Department (ED).

Albumin as a prognostic marker of 30-day mortality in septic patients admitted to the emergency department.

BACKGROUND: Assessing the evolutive risk of septic patients in the emergency department (ED) is very complex. Predictive tools are available, but at an early stage, none of them can detect the tissue microvascular alterations underlying the septic process. Hypoalbuminemia is present in critically ill patients in the ICU, and some early indications also suggest its early role in septic patients. AIM: To investigate the role of serum albumin concentration in predicting 30-day mortality among patients with sepsis at their first evaluation in the ED. METHODS: Prospective observational study enrolling all patients with sepsis evaluated consecutively at the ED of the Merano Hospital from January to December 2021. The serum albumin concentration on admission was measured immediately upon patient arrival. A multivariate logistic regression model adjusted for possible confounders assessed the association between albumin levels at admission and 30-day mortality. Kaplan-Meier survival analysis was used to evaluate 30-day mortality between groups, and receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory ability of albumin in predicting mortality. RESULTS: 459 patients with community-acquired sepsis were included. 17% (78/459) of patients died within 30 days. In surviving patients, the mean albumin level was 3.6 g/dL (SD 0.5), while among non-survivors it was 3.1 g/dL (SD 0.4), p < 0.001. The area under the ROC was 0.754 (95% CI 0.701-0.807). Multivariate analysis found that albumin was an independent risk factor for 30-day mortality, with an adjusted risk ratio of 2.991 (95% CI 1.619-5.525, p < 0.001) for each 1 g/dL decrease in albumin. CONCLUSIONS: Serum albumin concentration measured during initial ED assessment can be a useful prognostic marker of 30-day mortality in septic patients.

Comparison of the status epilepticus severity score and the epidemiology-based mortality score in predicting 30-day mortality and status epilepticus cessation.

OBJECTIVE: To evaluate the role of the Status Epilepticus Severity Score (STESS) and the Epidemiology-based Mortality score (EMSE) in predicting 30-day mortality and SE (Status epilepticus) cessation, and their prognostic performance in subgroups of patients with specific characteristics. METHODS: We reviewed consecutive episodes of SE occurring in patients aged ≥14 years at Baggiovara Civil Hospital (Modena, Italy) from 2013 to 2021. We evaluated the predictive accuracy of EMSE and STESS for 30-day mortality and SE cessation through stepwise regression binary logistic models adjusted for possible univariate clinical confounders. RESULTS: Seven hundred and eleven patients were enrolled. The mean value of STESS was 3.2 (SD 1.7) and of EMSE was 80.1 (SD 52.6). Within 30 days of the onset of SE, 28.4% of patients (202/711) died. EMSE had higher discriminatory ability for 30-day mortality compared with STESS (AUROC: 0.799; 95% CI: 0.765-0.832 versus 0.727; 95% CI: 0.686-0.766, respectively; p = 0.014). SE cessation within 1 h for convulsive SE and within 12 h for nonconvulsive SE was achieved in 35.3% (251/711) of patients. No significant difference was found between EMSE and STESS in discriminatory ability for SE cessation (AUROC: 0.516; 95% CI: 0.488-0.561 and 0.518; 95% CI: 0.473-0.563, respectively; p = 0.929). EMSE was superior to STESS in predicting 30-day mortality in patients with specific characteristics. No difference between the two scores was found in predicting SE cessation in subgroups of patients with specific characteristics. CONCLUSIONS: EMSE seems superior to STESS in predicting 30-day mortality, particularly in specific patient categories. Conversely, there is no difference in the ability of these scores in predicting SE cessation, which is overall rather low.

Long term follow-up of a multicentre cohort of COVID-19 patients with pulmonary embolism: Anticoagulation management and outcomes.

BACKGROUND AND AIMS: Pulmonary embolism (PE) is a frequent complication in COVID19 hospitalized patients. Inflammatory storm and endothelial dysfunction due to the virus seem to be the two major risk factors for PE. Consequently, PE related to COVID19 could be consider as triggered by a transient inflammatory acute phase and treated for no longer than 3 months. However, few data are available on management of anticoagulation and risk of venous thromboembolic (VTE) recurrences in these patients and guidelines are still undefined. Aim of the present study is to evaluate the long-term follow-up of a cohort of covid-19 patients with PE. METHODS: We conducted a retrospective multicenter study in four Italian hospitals between March 1st, 2020, and May 31st, 2021 in patients who experienced a PE during hospitalization for a COVID-19 pneumonia, excluding patients who died during hospitalization. Baseline characteristics were collected and patients were grouped according to duration of anticoagulant treatment (< 3 months or > 3 months). The primary outcome was incidence of VTE recurrence while secondary outcome was the composite of deaths, major hemorrhages and VTE recurrence during follow-up. RESULTS: 106 patients with PE were discharged, of these 95 (89.6 %) had follow up longer than 3 months (seven patients were lost to follow up and four died within three months). The median follow-up was 13 months (IQR 1-19). Overall, 23 % of subjects (22/95) were treated for 3 months or less and 76.8 % (73/95) received anticoagulation for >3 months. Of patients in the short treatment group, 4.5 % died, compared with 5.5 % of those in the longer treatment group (p = NS); no difference was shown in risk of VTE recurrence (0 % vs 4.1 %, p = NS), major bleeding (4.5 % vs 4.1 %, p = NS) or in composite outcome (9.1 % vs 11 %, p = NS). No difference was found between the two treatment groups for composite outcome using the Kaplan-Meier analysis (Log Rank Test p = 0.387). CONCLUSION: In our retrospective multi-center cohort, prolongation of duration of anticoagulation seems not to affect risk of VTE recurrences, deaths and bleeding after a PE related to COVID-19.

Prognostic Role of Serum Albumin in Predicting 30-Day Mortality in Patients with Infections in Emergency Department: A Prospective Study.

BACKGROUND: Infections in emergency departments (EDs) are insidious clinical conditions characterised by high rates of hospitalisation and mortality in the short-to-medium term. The serum albumin, recently demonstrated as a prognostic biomarker in septic patients in intensive care units, could be an early marker of severity upon arrival of infected patients in the ED. AIM: To confirm the possible prognostic role of the albumin concentration recorded upon arrival of patients with infection. METHODS: A prospective single-centre study was performed in the ED of the General Hospital of Merano, Italy, between 1 January 2021 and 31 December 2021. All enrolled patients with infection were tested for serum albumin concentration. The primary outcome measure was 30-day mortality. The predictive role of albumin was assessed by logistic regression and decision tree analysis adjusted for Charlson comorbidity index, national early warning score, and sequential organ failure assessment (SOFA) score. RESULTS: 962 patients with confirmed infection were enrolled. The median SOFA score was 1 (0-3) and the mean serum albumin level was 3.7 g/dL (SD 0.6). Moreover, 8.9% (86/962) of patients died within 30 days. Albumin was an independent risk factor for 30-day mortality with an adjusted hazard ratio of 3.767 (95% CI 2.192-6.437), p < 0.001. Decision tree analysis indicated that at low SOFA scores, albumin had a good predictive ability, indicating a progressive mortality risk reduction in concentrations above 2.75 g/dL (5.2%) and 3.52 g/dL (2%). CONCLUSIONS: Serum albumin levels at ED admission are predictive of 30-day mortality in infected patients, showing better predictive abilities in patients with low-to-medium SOFA scores.

Minimal is not minor also in patients with mild traumatic brain injury on oral direct anticoagulant therapy.

Currently, all patients, regardless of the type of head injury, should undergo a head computerized tomography (CT) if on oral anticoagulant therapy. The aim of the study was to assess the different incidences of intracranial hemorrhage (ICH) between patients with minor head injury (mHI) and patients with mild traumatic brain injury (MTBI) and whether there were differences in the risk of death at 30 days as a result of trauma or neurosurgery. A retrospective multicenter observational study was conducted from January 1, 2016, to February 1, 2020. All patients on DOACs therapy who suffered head trauma and underwent a head CT were extracted from the computerized databases. Patients were divided into two groups MTBI vs mHI all in DOACs treatment. Whether a difference in the incidence of post-traumatic ICH was present was investigated, and pre- and post-traumatic risk factors were compared between the two groups to assess the possible association with ICH risk by propensity score matching. 1425 with an MTBI in DOACs were enrolled. Of these, 80.1% (1141/1425) had an mHI and 19.9% (284/1425) had an MTBI. Of these, 16.5% (47/284) patients with MTBI and 3.3% (38/1141) with mHI reported post-traumatic ICH. After propensity score matching, ICH was consistently found to be more associated with patients with MTBI than with mHI (12.5% vs 5.4%, p = 0.027). Risk factors associated with immediate ICH in mHI patients were high energy impact, previous neurosurgery, trauma above the clavicles, post-traumatic vomiting and headache. Patients on MTBI (5.4%) were found to be more associated with ICH than those with mHI (0.0%, p = 0.002). also when the need for neurosurgery or death within 30 days were considered. Patients on DOACs with mHI have a lower risk of presenting with post-traumatic ICH than patients with MTBI. Furthermore, patients with mHI have a lower risk of death or neurosurgery than patients with MTBI, despite the presence of ICH.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study.

BACKGROUND: An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. METHODS: All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event. RESULTS: Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). CONCLUSIONS: ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.