Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review.

INTRODUCTION: There is an increasing interest in platelet-rich plasma (PRP) injection as a treatment for chronic plantar fasciopathy (PF). We wished to evaluate the evidence for the use of PRP in PF/fasciitis. SOURCES OF DATA: We performed a systematic review on the effects of PRP in PF. In June 2014, we searched Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each PRP preparation and 'plantar' (with its associated terms). We only included prospectively designed studies in humans. AREAS OF AGREEMENT: Eight articles met the inclusion criteria, three of them were randomized. All studies yielded a significantly greater improvement in symptoms between baseline and last follow-up assessment. None of the papers recorded major complications. AREAS OF CONTROVERSY: Only three randomized studies were identified; none of them had a true controlled group treated with placebo and one of the three studies had a very short (6 week) follow-up. A non-randomized study evaluating PRP versus corticosteroids (CCS) injections, and a randomized controlled trial comparing PRP and dextrose prolotherapy reported no statistical significant differences at 6 months. Most studies did not have a control group and imaging evaluation. GROWING POINTS AND AREAS FOR RESEARCH: Evidence for the use of PRP in PF shows promising results, and this therapy appears safe. However, the number of studies available is limited and randomized placebo-controlled studies are required. Characterizing the details of the intervention and standardizing the outcome scores would help to better document the responses and optimize the treatment.

Nickel free-diet enhances the Helicobacter pylori eradication rate: a pilot study.

BACKGROUND: The Helicobacter pylori eradication rate with standard triple therapy is very low. H. pylori is known to require the nickel-containing metalloenzymes urease and NiFe-hydrogenase to survive at the low pH environment in the stomach. AIM: To compare the H. pylori eradication rate of a nickel free-diet associated with standard triple therapy and standard triple therapy alone as the first-line regimen. METHODS: Fifty-two sex- and age-matched patients at the first diagnosis of H. pylori infection were randomized 1:1 into two different therapeutic schemes: (1) standard LCA (26 patients): lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1,000 mg bid for 7 days with a common diet; (2) standard LCA plus a nickel free-diet (NFD-LCA) (26 patients). Patients followed 30 days of a nickel-free diet plus a week of lansoprazole 15 mg bid, clarithromycin 500 mg bid and amoxicillin 1,000 mg bid starting from day 15 of the diet. RESULTS: All patients completed the study. A significantly higher eradication rate was observed in the NFD-LCA group (22/26) versus LCA group (12/26) (p < 0.01). Only a few patients (9 of 52) reported the occurrence of mild therapy-related side effects, without any significant differences between the two groups. CONCLUSIONS: The addition of a nickel-free diet to standard triple therapy significantly increases the H. pylori eradication rate. The reduction of H. pylori urease activity due to the nickel-free diet could expose the bacterium to gastric acid and increase H. pylori's susceptibility to amoxicillin. Further studies are necessary to confirm this preliminary result.

A2A adenosine receptor function in patients with vasovagal syncope.

AIMS: Adenosine is a possible mediator in vasovagal syncope (VVS) via the activation of its receptors. High expression of adenosine A2A receptors (A2AR) has been reported in VVS. The function of these over-expressed receptors in this population has never been evaluated. METHODS AND RESULTS: We used Adonis, a specific-made antibody with A2AR agonist properties, to evaluate binding parameters (i.e. dissociation constant KD) and cAMP production (i.e. EC50) by peripheral blood mononuclear cells of 16 VVS patients. Eight healthy volunteers served as controls. A2AR expression was higher in patients than controls; mean: 11.5 ± 1.2 vs. 7.7 ± 0.8 AU, P = 0.04. Also, KD values were higher in patients than controls: 2.1 ± 0.02 × 10(-7) vs. 5 ± 1 × 10(-8) M, P < 0.01 In controls, KD values were lower than EC50 (5 ± 1.7 × 10(-8) vs. 2.8 ± 0.4 10(-7) M, P < 0.01), but in patients, KD values did not differ from EC50: 2. ± 0.2 × 10(-7) vs. 2.5 ± 0.4 × 10(-7) M, P > 0.05. However, four patients had lower EC50 (3.5 ± 0.3 × 10(-8) M) than KD (2.9 ± 1.2 × 10(-7) M; KD/EC50 = 9.6), suggesting the presence of spare receptors. CONCLUSION: The function of A2AR of patients with VVS was preserved since their stimulation by Adonis led to cAMP production with an EC50 comparable with those in controls. However, their affinity was lower than those of controls. Our results suggest that A2AR are implicated in the physiopathology of VVS.

Recurrent use of the Emergency Department in patients with anxiety disorder.

OBJECTIVE: Panic disorder is characterized by the spontaneous and unexpected occurrence of panic attacks. During panic attacks, patients (pts) refer to the Emergency Department (ED). The diagnostic work-up for any panic attack is expensive since symptoms at presentation mimic other diseases such acute coronary syndrome or neurological emergencies. The aim of the present study was to describe a 10 years cohort of pts diagnosed with panic disorder in the ED in terms of ED visit recurrence. METHODS: Case-control study, in a tertiary care, involving pts presenting to the ED and diagnosed with panic attack according to the International Classification of Diseases 9nt Revision (ICD-9). From January 2001 to Dec 2009 were extracted from the electronic clinical database 469 pts and were divided into "recurrent ED visit" (multiple ED access for panic attack) (N=361) and "no recurrent ED visit" (only one ED access for panic attack in 9 years) (N=108). RESULTS: At univariate analysis cases and controls differed for male prevalence (p < 0.01), neurological symptoms at presentation (p = 0.02) and history of other psychiatry disorder (p < 0.01). In multivariate analysis independent predictors were male gender, age under 40 year old, palpitations at presentations, 1 or more cardiovascular risk factors and previous other psychiatry conditions. CONCLUSIONS: Male under 40 years old with palpitations or cardiovascular risk and other psychiatric diseases, have a higher recurrence of panic attacks. General psychiatric evaluation and treatment with benzodiazepine in ED is not useful to prevent recurrences. Identifying those patients at high risk of panic attack and ED visit recurrence might be useful to establish ad-hoc interventions, improve patients' morbidity and save precious resources.

Safety and efficacy of the combination acetaminophen-codeine in the treatment of pain of different origin.

BACKGROUND: Pain is the most common reason people see doctors in developed Countries and a very common cause of access in Emergency Department (ED). The combination acetaminophen/codeine represents the standard medication in the second step of the WHO analgesic scale and codeine is one of the most commonly used opioid analgesic for a variety of pain conditions. However, many aspects related to safety and efficacy are still undefined. AIM: To summarize and review the results of the most relevant studies on the efficacy and safety profile of acetaminophen/codeine combination in the treatment of pain of different origin. MATERIALS AND METHODS: We performed a literature search to identify and evaluate all relevant english-language randomized controlled trials (RCTs), meta-analyses and reviews about the codeine plus paracetamol combination in the treatment of pain from any source. RESULTS: Acetaminophen/codeine combination is effective in the treatment of moderate to severe pain in all setting analyzed in this study, which include headache, postoperative, osteoarticular and post-traumatic. The best results in terms of safety and efficacy have been obtained in postoperative pain. Efficacy of acetaminophen/codeine combination is not inferior to NSAIDs. CONCLUSIONS: Acetaminophen/codeine combination is effective in the treatment of pain, through a synergistic action of the two molecules, and is not inferior to NSAIDs. Side effects of acetaminophen/codeine are usually minor, differently from NSAIDs, which may induce some potentially life threatening conditions.

Assessment of baseline characteristics and risk factors among Emergency Department patients presenting with recent onset atrial fibrillation: a retrospective cohort study.

BACKGROUND: The Cardioversion of Atrial Fibrillation in Emergency (CAFE) study was an observational, retrospective, multicenter study focusing on patients with recent onset atrial fibrillation (AF) seen in six different Emergency Departments (ED) of Rome, Italy. AIM: The aim of this study was to present the baseline characteristics and risk factors of the patients enrolled to the CAFE study. MATERIALS AND METHODS: We retrospectively reviewed 3085 eligible patients diagnosed with recent onset AF in any of the EDs between January 2008 and December 2009. Inclusion criteria required documented ICD-9 primary discharge/admission diagnosis of AF in the ED and stable hemodynamic conditions at presentation (systolic blood pressure > 90 mmHg). Exclusion criteria were permanent AF or an ongoing acute coronary syndrome. RESULTS: Median age was 71 years (interquartile ranges, 62-78 years) and 50.8% were men. Palpitations was the most common symptom at ED presentation and was present in 73.5% of the study subjects. Hypertension was the most prevalent comorbidity, affecting 59.3% of the patients evaluated, and the presence of previous episode(s) of AF was also common (52.3%). Regarding home treatment, the drugs most prescribed were antiplatelets (31.2%) and diuretics (25.2%). A CHADS2 score of 0 was found in 814 patients (26.4%), while a CHADS2 score of 1 was reported in 1114 patients (36.1%). Finally, a CHADS2 score ≥ 2 was reported in 1157 patients (37.5%). CONCLUSIONS: The present study represents an important snapshot of demographics, comorbidities, risk factors and anticoagulation management about patients with recent onset AF. Disparities were noted in anticoagulation management, suggesting that this is still a main problem among patients with AF.

Treatment of fever and associated symptoms in the emergency department: which drug to choose?

OBJECTIVE: Fever is a frequent cause of admission to the Emergency Department (ED) worldwide. Although it can be caused by a wide range of conditions, the most effective treatment based on its etiology is still undetermined. PATIENTS AND METHODS: This prospective, single-center, observational study enrolled adult patients who accessed the ED for fever. Physicians were free to administer paracetamol 1,000 mg (P), the combination paracetamol 500 mg/ibuprofen 150 mg (PI) or Ibuprofen 600 mg (I). The primary endpoint was both 1-degree and 1-point reduction in body temperature for all associated symptoms on the Numerical Rating Scale (NRS) after 1 hour (T1). The secondary endpoint was the reduction of at least 2 points on the NRS after two hours (T2). Adverse events, the need for rescue therapy, and the response based on the underlying etiology (bacterial, viral, or immune/neoplastic) were also evaluated. RESULTS: 324 patients (170 males, mean age 71±6 years) were enrolled: 187 had bacterial, 80 viral, and 57 neoplastic/inflammatory fever. Fever was treated with Paracetamol 1,000 mg (P) in 189 patients and with Paracetamol/Ibuprofen 500/150 mg (PI) in 135 subjects, while none of the patients were primarily treated with I. Based on the fever etiology P was administered to 113 patients with bacterial fever (59.8%), 48 patients with viral fever (25.4%), and 28 subjects with neoplastic/inflammatory fever (14.8%). PI was administered to 74 patients with bacterial fever (54.8%), 32 patients with viral fever (23.7%), and 29 subjects with neoplastic/inflammatory fever (21.5%). The primary endpoint was achieved by 126 patients, 70 of them (37.0%) were treated with P and 56 (41.5%) with PI (p=0.418). The secondary endpoint was achieved by 295 patients, 171 (90.5%) of them treated with P and 124 (91.9%) treated with PI (p=0.669). No significant differences were found between groups treated with P and PI concerning rescue therapy (15 vs. 6 patients; p=0.893). Interestingly, PI was more effective than P in patients with bacterial fever at T1 (P 33.6% vs. PI 48.6%; p=0.040), while efficacy of P and PI was similar at T2 for all kind of fever. CONCLUSIONS: Paracetamol 1,000 mg represents the first choice for the treatment of fever in the ED, followed by Paracetamol/Ibuprofen 500/150 mg. Interestingly, Paracetamol/Ibuprofen combination resulted in being more effective in patients with bacterial fever one hour after its administration.

Evaluation of procalcitonin in hemorrhagic shock: a pilot study.

Abstract: An increased secretion of procalcitonin (PCT) is primarily due to systemic inflammation of bacterial origin, as PCT is used to diagnose and manage sepsis. However, other conditions can induce high plasma levels of PCT, and hemorrhagic shock may be one of these as we found in clinical practice. The aim of this pilot, observational and prospective study was to investigate the role of PCT in hemorrhagic shock and if it could help in distinguishing between different types of shock. We enrolled 15 patients who entered the shock room of our Emergency Department (ED) with a diagnosis of hemodynamic shock, defined as hypotension (systolic blood pressure < 90 mmHg, or medial arterial pressure < 65 mmHg), and/or elevated lactate level (> 2 mmol/L), with one or more signs of cerebral or systemic hypoperfusion. For all the patients we dosed PCT at the time of admission, and we collected them into three different groups - septic, hemorrhagic and mixed shock - based on clinical presentation and laboratory and instrumental examination. First results did not show a significant increase of PCT in patients with hemorrhagic shock alone (average 0.12 ± 0.07 ng/mL), while PCT levels were similarly high in those with septic and mixed shock (17.63 ± 32.16 and 24.62 ± 33.02 respectively). PCT is not a marker of bleeding shock and does not help in distinguishing if bleeding or sepsis have the major impact on hemodynamics in those with mixed shock. However, patients with sepsis usually access the ED a few days after the initial infectious and inflammatory process has begun, while those with a major bleeding ask for intervention at the very first beginning. Thus, it may be helpful to see is PCT levels rise after some time from the bleeding start, or to investigate a different biomarker that rises earlier in course of systemic disfunction, such as presepsin. Finally, we also aimed at investigating if PCT levels would show any correlation with age of patients, regardless of the type of shock: results provided an higher PCT in individuals ≥ 80 years old, than in those < 80 years old.

The role of integrative and complementary medicine in the management of breast cancer patients on behalf of the Integrative Medicine Research Group (IMRG).

The aim of this conference was to explain the role of integrative and complementary medicine in breast cancer patients. The topics covered are numerous and their peculiarities are the multidisciplinary characteristics of the researchers involved. The Integrative Medicine Research Group (IMRG) believes in the complementary and integrative approach in cancer patients to improve the quality of life in this particular setting.

Using fluorescent promoter-reporters to study sugar utilization control in Bifidobacterium longum NCC 2705.

Bifidobacteria are amongst the first bacteria to colonize the human gastro-intestinal system and have been proposed to play a crucial role in the development of the infant gut since their absence is correlated to the development of diseases later in life. Bifidobacteria have the capacity to metabolize a diverse range of (complex) carbohydrates, reflecting their adaptation to the lower gastro-intestinal tract. Detailed understanding of carbohydrate metabolism regulation in this genus is of prime importance and availability of additional genetic tools easing such studies would be beneficial. To develop a fluorescent protein-based reporter system that can be used in B. longum NCC 2705, we first selected the most promising fluorescent protein out of the seven we tested (i.e., mCherry). This reporter protein was then used to study the carbohydrate mediated activation of PBl1518 and PBl1694, two promoters respectively predicted to be controlled by the transcriptional factors AraQ and AraU, previously suggested to regulate arabinose utilization and proposed to also act as global transcriptional regulators in bifidobacteria. We confirmed that in B. longum NCC 2705 the AraQ controlled promoter (PBl1518) is induced strongly by arabinose and established that the AraU controlled promoter (PBl1694) was mostly induced by the hexoses galactose and fructose. Combining the mCherry reporter system with flow cytometry, we established that NCC 2705 is able to co-metabolize arabinose and glucose while galactose was only consumed after glucose exhaustion, thus illustrating the complexity of different carbohydrate consumption patterns and their specific regulation in this strain.

Management of maxillary artery pseudoaneurysm in Emergency Department: a narrative review.

Abstract: Tooth extraction is a common procedure that is performed routinely and is associated with very few risks. The formation of a pseudoaneurysm as a direct result of tooth extraction has not been widely reported in published studies; it is more frequent as a complication of orthognathic surgery (1). The purpose of this paper is to describe the literature of maxillary artery pseudoaneurysm and its diagnosis and treatment in the Emer-gency Department. The search engine we used is Pubmed. 39 studies were analyzed; mainly, they were case reports. In this study, we will analyze the cases of pseudoaneurysm formation following dental extraction and orthognotia surgery which are reported in literature.

Could serum procalcitonin play a role in an emergency setting for patients with pyogenic spondylodiscitis?

OBJECTIVE: Spinal infections, represent quite rare but often severe conditions. However, due to symptoms' non-specificity and the lack of specific laboratory tests, diagnosis is often delayed with serious consequences for the patient's outcomes. The present investigation aimed at evaluating the role of procalcitonin (PCT) and other clinical features on the risk stratification and the clinical outcomes in spondylodiscitis patients treated in our Emergency Department. PATIENTS AND METHODS: The present investigation represents a single-center retrospective study. Clinical records of consecutive patients admitted to our Emergency Department from 1 January 2015 to 31 March 2021 were evaluated and patients with spondylodiscitis diagnosis in this period were recruited. Our primary outcome was the degree of autonomy of patients following the acute event. Our secondary outcome was the resolution of the infection. RESULTS: In the study period, a total of 345 patients were evaluated. Among these, 165 met the inclusion criteria, and constituted the study cohort. Concerning the primary outcome, we observed that the most significant predictive factors for being non-autonomous were elevated serum creatinine (> 1.05 mg/dl), Blood Urea Nitrogen (BUN) > 23 mg/dl, Lactate dehydrogenase > 228 U/L, PCT > 0.11 ng/mL. Patients with higher PCT (PCT > 0.11 ng/mL) and higher BUN (BUN > 23 mg/dl) had higher odds of infection persistence (the Odd Ratio, OR, were respectively 3.78 for PCT and 3.14 for BUN). CONCLUSIONS: PCT assay may play a role in diagnosing spondylodiscitis in an emergency setting. A PCT value > 0.11 ng/mL should be considered as a red flag, a predictor of worse clinical outcomes and persistence of infection.

Management of Small Bowel Obstruction (SBO) in older adults (>80 years): a propensity score-matched analysis on predictive factors for a (un)successful non-operative management (NOM).

OBJECTIVE: Small Bowel Obstruction (SBO) is a common emergency in older patients. The most appropriate treatment strategy is still matter of debate. The aim of this study was to compare a non-operative management (NOM) vs. a surgical procedure for patients ≥ 80 years with SBO. PATIENTS AND METHODS: All patients ≥ 80 years admitted to our Emergency Department (ED) for SBO between January 1st, 2015, and December 31st, 2020 were included in this study. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was to compare the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and in-hospital length of stay (LOS). RESULTS: A total of 561 patients were enrolled. After propensity score matching (PSM) analysis, 302 patients (151 each group) were included in the analysis. Mortality did not differ between the two groups. After PSM mechanical ventilation, sepsis, cumulative major complications, and LOS were significantly higher in the operative treatment group [15.9% vs. 1.5%, 9.4% vs. 4.1%, 27.6% vs. 19.2%, and 9.4 (6.4-14.3) days vs. 8.1 (4.5-13.3) days, respectively; p<0.001, p=0.013, p=0.025, and p=0.003, respectively]. CONCLUSIONS: In patients ≥ 80 years with SBO, a NOM could yield similar results, in terms of overall mortality, compared to a surgical management. Thus, particularly in patients with multiple comorbidities or functional impairments, a conservative approach should always be considered.

A critical review of the efficacy and safety in the use of low-molecular-weight heparin in acute ST-elevation myocardial infarction: a Bayesan approach.

BACKGROUND: ST segment elevation myocardial infarction (STEMI) is an important risk factor of death worldwide. Significant clinical research has been done to assess ideal reperfusion strategies in the setting of STEMI, including the role of the antithrombin agents: unfractionated heparin (UFH) and low molecular weight heparin (LMWH). Given the evidence that LMWH may be safer than UFH in the treatment of other thrombotic disorders, its role in the management of STEMI needs to be more defined. OBJECTIVE: To assess the safety and efficacy of LMWH compared to UFH and/or placebo for the treatment of STEMI. MATERIALS AND METHODS: The Cochrane Library, MedLine and EMABASE databases were searched for randomized controlled trials pertinent to the study objective. Selection criteria included all randomized controlled trials comparing LMWH to either UFH or placebo in the treatment of STEMI through December 2010. Two Authors performed the search independently.After identifying appropriate studies, a random effect model and Bayesian sensitivity analysis were used to combine results from original trials and assess the consistency of results. RESULTS: We identified 13 studies that met the described selection criteria; 8 comparing LMWH to UFH and 5 to placebo in STEMI patients. The combined Odd's ratio was 0.79 with a 95% confidence interval of 0.67-0.94 for all studies and 0.74 (0.54-1.02) for those comparing LMWH to UFH only. A trend toward more frequent hemorrhagic events was identified in the LMWH group (Odd's ratio 1.40) which did not meet statistical significance (95% confidence interval 0.80-2.47). Sensitivity analysis demonstrated clinical benefits of 6% and 12.5% with probabilities of 99% and 95% respectively. CONCLUSION: Compared to placebo or UFH, LMWH is effective as a first line treatment of STEMI patient with no significant increase in major hemorrhagic events.

Effect of beta-glucan, inositol and digestive enzymes in GI symptoms of patients with IBS.

BACKGROUND: Irritable bowel syndrome (IBS) is a very common functional gastrointestinal (GI). Diagnosis of IBS is based on the fulfilment of the Rome III criteria. Common GI symptoms are lower abdominal pain, bloating and disturbed defecation, such as urgent diarrhoea and/or episodes of chronic constipation. Many agents have been employed in the management of IBS, although only few have been demonstrated to show a relevant efficacy. AIM: To evaluate the effectiveness of the administration of a mixture of beta-glucan, inositol and digestive enzymes (Biointo) in improving GI symptoms in patients affected by IBS. PATIENTS AND METHODS: 50 IBS patients (20 males, 30 females; mean age 51 +/- 19) were treated with Biointo (group A) while another group consisting of 40 IBS patients (15 males, 25 females; mean age 50 +/- 18) did not receive any therapy (group B). RESULTS: Biointol administration improved significantly bloating, flatulence and abdominal pain, with a slight increasing of urgency for bowel movements. On the contrary, Biointol did not show any significant effect on the other IBS symptoms. CONCLUSIONS: Currently, only few agents used in the management of IBS have been proven to be effective. Biointol administration has shown to improve some IBS symptoms, such as bloating, flatulence and abdominal pain, all connected to the presence of gas inside the intestinal lumen.

Nutritional aspects of Helicobacter pylori infection.

H. pylori is a gram-negative pathogen, etiologically associated with atrophic and non-atrophic gastritis, peptic ulcer, primary gastric B-cell lymphoma and gastric carcinoma. Several observations demonstrated a correlation between H. pylori and malabsorption of essential nutrients; epidemiological studies have shown an association between H. pylori infection and iron deficiency anemia, while the absorption of some vitamins such as vitamin B12, vitamin A, vitamin C, folic acid and Vitamin E may be affected by the infection. The main mechanism related to malabsorption of this components is the modified intragastric pH (hypo- achlorhydria) due to H. pylori infection. Moreover H. pylori is also able to determine a modification of gastrointestinal hormones by reducing plasma levels of ghrelin and increasing those of leptin and gastrin, thus affecting appetite and promoting the occurrence of dyspeptic symptoms. On the other hand, H. pylori eradication has been shown to improve serum level of iron and vitamin B12, has some effects on Vitamin A and Vitamin E absorption and has a late effects on ghrelin levels. As a consequence of those effects, H. pylori is also associated with childhood malnutrition in developing countries either for the occurrence of malabsorption or for an increased susceptibility to enteric infections caused by hypochlorhydria.

Barotrauma during non-invasive ventilation for acute respiratory distress syndrome caused by COVID-19: a balance between risks and benefits.

Ventilatory support is vital for the management of severe forms of COVID-19. Non-invasive ventilation is often used in patients who do not meet criteria for intubation or when invasive ventilation is not available, especially in a pandemic when resources are limited. Despite non-invasive ventilation providing effective respiratory support for some forms of acute respiratory failure, data about its effectiveness in patients with viral-related pneumonia are inconclusive. Acute respiratory distress syndrome caused by severe acute respiratory syndrome-coronavirus 2 infection causes life-threatening respiratory failure, weakening the lung parenchyma and increasing the risk of barotrauma. Pulmonary barotrauma results from positive pressure ventilation leading to elevated transalveolar pressure, and in turn to alveolar rupture and leakage of air into the extra-alveolar tissue. This article reviews the literature regarding the use of non-invasive ventilation in patients with acute respiratory failure associated with COVID-19 and other epidemic or pandemic viral infections and the related risk of barotrauma.

How social intimidation interferred with the increasing number of improper accesses at the E.R.: a first-month COVID19 outbreak evaluation.

ABSTRACT: SARS Cov 2 pandemic outbreak caused countless changes in the daily habits among people in the entire World. National Health Systems were highly stressed and at severe risk of collapse. In the first months of 2020, it was expected a worsening of the typical overcrowding working flow. Quite the opposite, we found out an unexpected decrease throughout the daily ED visits. We evaluated the ER visits of a University Metropolitan Hospital in Rome in March 2020, comparing them with the same month in 2019. We highlight the sharp decline in ED visits for deferrable urgencies, considered among the leading causes of ED overcrowding. On the contrary, the rate of visits for "time-dependent" pathologies is superimposable for those pathologies mainly centralized through the Out-of-Hospital Emergency System. In a historical period where significant outpatient activity restrictions took place, we expected an increase in ED visits for deferred emergencies. On the contrary, it was undergoing a considerable decrease. The critical decrease in accesses recorded in March 2020 can be considered an indicator of ED's improper use. Probably, the fear of a possible coronavirus-related infection might have to lead the population to refer to the ED just in case of real emergency condition or severe medical issues, as it should "normally" be. The critical decrease in accesses recorded in March 2020 can be considered an indicator of ED's improper use. We would highlight the need to sensitize people to proper use of Emergency Medical Services, avoiding overcrowding and overuse. This unexpected event, lead by a global pandemic, could help reorganize the whole Health System.

Patient safety recommendations and management in patients with COVID-19 pneumonia suspicion: a retrospective study.

OBJECTIVE: Since December 2019, new pneumonia of unknown aetiology broke out in Wuhan, Hubei province, China. Subsequently, a virus, later named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the causative agent of the disease. Currently, the epidemic has spread all over the world. The most common manifestations of COVID-19 are fever, fatigue and dry cough. At the moment, the nuclide acid test is the gold standard method for the diagnosis of this infection. METHODS: In the present paper, we report our experience with all patients who came to the Emergency Department from March 1 to April 1, 2020, with suggestive symptoms of COVID-19 infection. Patients: they all underwent a first oropharyngeal and nasopharyngeal swab in the emergency department and, if negative, a second one after at least 24 hours. RESULTS: Our study shows how the results obtained at time zero are usually identical to the ones obtained after 24 hours. We thus suggest, in patients with high suspicion of COVID19 and a negative result at the first swab, to repeat the test after at least 48 hours, during which patients with symptoms of COVID-19 pneumonia disease should be kept in isolation to avoid the risk of contagion. CONCLUSIONS: these measures and in particular the early identifica-tion of cases with consequent isolation will allow the containment of the spread of the virus, representing one of the fundamental measures to guarantee and strengthen the control of the infection to reduce hospital admissions, the overload of national health service and health costs.