HEAR SCORE: A Proposal to Use Only Anamnestic and EKG Data to Evaluate Patients with Very Low Risk Chest Pain.

Purpose: Chest pain in a common symptom in patients attending Emergency Department worldwide and can be related to an extensive variety of disorders, so it represents a diagnostic and logistic challenge for Emergency physicians. The aim of this study is to identify a subgroup of patients with a low pre-test probability of major adverse cardiac events, for which there is no need of troponin testing, to avoid potential harm from false-positive testing and long length stay in ED. Patients and Methods: We retrospectively analyzed data of patients that attended ED of Siena complaining chest pain from January 2019 to August 2021. We used a modified HEART score, only evaluating history, EKG, age and risk factors. A 0-1 HEAR score was considered at very low risk for adverse cardiac events. Sensitivity, specificity, PPV, NPV and incidence of adverse cardiac events were calculated. The accuracy of HEAR score was evaluated with ROC curve. The correlation of adverse cardiac events with HEAR score 0-1 was evaluated with Fisher test. Results: In this study, we included 2046 patients, of which 279 were classified at very low risk. The incidence of adverse cardiac events in this population was 0.36%. Sensibility was 97.5%, sensitivity 61%, PPV 36.8%, NPV 99.1%. The AUC for global accuracy of HEAR score was 0.945. Chi-square's P value for the association between adverse cardiac events and HEAR score 0-1 was <0.001. Conclusion: The draft presented in this study answers to the necessity to make a personalized path for patients attending ED with chest pain. The choice to avoid troponin testing may appear risky, but data from this study and from other similar show that a careful evaluation of clinical data and EKG allows to correctly discriminate which patients will not have adverse cardiac events, reducing the length of stay in ED.

Monocyte distribution width and the fighting action to neutralize sepsis (FANS) score for sepsis prediction in emergency department.

BACKGROUND AND AIMS: The aim of this study was to evaluate the diagnostic accuracy of sepsis markers and to develop a multiparametric score, using demographic and clinical variables as well as laboratory parameters to predict sepsis in patients admitted in the ED with suspected symptoms. MATERIALS AND METHODS: Patients with clinical presentation of suspected sepsis were enrolled in the ED of San Donato Hospital in Arezzo between September 2019 and May 2020. Anagraphic, anamnestic, clinical and laboratory data were collected for all subjects. PCT, MDW, WBC, MPV and BT were utilised to formulate FANS score. RESULTS: The AUC of the FANS score, PCT, MDW and CRP was 0.87, 0.80, 0.77 and 0.71, respectively, when used to predict sepsis in all 308 subjects. Instead, the AUC of the FANS (Fighting Action To Neutralize Sepsis) score, PCT, MDW and CRP was 0.93, 0.84, 0.83 and 0.77, respectively, when used to predict sepsis excluding subjects with infection (clinically classified as the Infections group). CONCLUSIONS: The results obtained with PCT, PCR and MDW confirm the results of these markers for the identification of sepsis obtained from other studies. The multiparametric approach, obtained from the statistical study of the parameters using binary logistic regression, identified those PCT, WBC, MPV, BT and MDW as the most significant and effective clinical classifiers for diagnosing sepsis.

The role of Monocyte Distribution Width (MDW) in the prognosis and monitoring of COVID-19 patients.

The new parameter derived from the standard deviation of the monocyte distribution width (MDW) has shown a good diagnostic efficacy in COVID-19 patients. In this study, we propose MDW as a prognostic and monitoring parameter in patients with severe forms of COVID-19. Sixty SARS-CoV-2-positive patients admitted to the San Donato Hospital in Arezzo were enrolled. A blood sample taken to measure the complete blood count was used for the determination of MDW using a UniCel DxH 900 instrument (Beckman Coulter). For each patient, a mean of 6 ± 2 measurements of MDW were taken. The difference between the last and first MDW results was reported as the ΔMDW variable. The ΔMDW and age were significantly correlated to the outcome. In non-survivors patients, the difference in the mean of the MDW between the first and other points was not significant, while in survivors, the first point was higher than the other points (p < 0.005), with the exception of the mean of the second point (p-value = NS). The ΔMDW area under the curve (AUC) was 0.84, and with a cut-off lower than 0.00 the sensitivity and specificity were 88% and 81%, respectively. The most important result of this study is the ΔMDW calculated on the basis of the difference between the first and third measurement, after approximately the 5-7th day of hospitalisation. A ΔMDW less than one was indicative of an unfavourable prognosis. The data reported suggest that MDW could be used to support monitoring and surveillance, alongside other tests such as procalcitonin, in critically ill patients in the ICU.

[Point-of-care blood gas analysis as a tool for COVID-19 patients: a prehospital setting experience.] / L'emogasanalisi point-of-care come strumento discriminante sui pazienti positivi a covid-19: l'esperienza di Arezzo in ambiente preospedaliero.

Portable blood gas analyzers are intended for blood Point-of-care testing (POCT); they make it possible to perform the examination directly at the patient's bed. During the SARS-CoV-2 pandemic, this device proved useful in emergency medical service for the early assessment of respiratory distress, allowing the appropriate care level to be determined for each patient. 25 cases of covid-19 positive patients in the province of Arezzo were analyzed; POCT blood gas analysis made it possible to evaluate and treat at home about half of the patients (52%) and to admit the others directly to the most appropriate ward. However, some critical issues were found; the limited sample size suggest further research to assess the actual impact of this technology.

Point-of-care ultrasound (POCUS) as the keystone investigation in undifferentiated dyspnoea.

Dyspnoea is defined as a subjective perception of laboured breathing. It is a common cause of access to the emergency department (ED), it has a high rate of intensive care unit admission and a high mortality. The most common causes of dyspnoea in the adult include pneumonia, heart failure, chronic obstructive pulmonary disease, pulmonary embolism and asthma. Due to the high variety of dyspnoea's causes, the need for a rapid and accurate diagnosis puts the emergency physician in trouble. Moreover, standard tests such as chest radiography, B-type natriuretic peptide and d-dimer require time and may be less useful in patients with respiratory failure who require urgent therapy. Point-of-care ultrasound (POCUS) is rapid, non-invasive, repeatable and a useful tool in evaluating patients with acute and severe dyspnoea. This case report demonstrates the usefulness of POCUS in a patient with undifferentiated respiratory failure presenting to the ED.

Unusual solution to abdominal pain with contrast enhanced ultrasound.

Splenic infarction might be the symptom onset of an important underlying disease. The possibility of splenic infarction must be inserted into differential diagnosis in all those patients who have pain in the upper left quadrant and/or on the left flank. When faced with a case of splenic infarction in a patient who has flown or climbed to high altitudes, it is appropriate to consider the possibility of an haemoglobinopathy. The diagnosis is far from being obvious for emergency physicians. For these reasons, it is very important to proceed as a multidisciplinary team with appropriate diagnostic examinations. The European Guidelines for non-hepatic applications of contrast enhanced ultrasound suggest the usage of this tool for investigation of suspected ischaemic lesions of the spleen.