Discharge from the emergency department and early hospital revaluation in patients with COVID-19 pneumonia: a prospective study.

OBJECTIVE: The national health systems are currently facing the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We assessed the efficacy of outpatient management for patients with SARS-CoV-2 related pneumonia at risk of progression after discharge from the emergency department. METHODS: This was a single-center prospective study. We enrolled patients with confirmed SARS-CoV-2 pneumonia, without hypoxemic respiratory failure, and at least one of the following: age ≥ 65 years or the presence of relevant comorbidities or pneumonia extension > 25% on high resolution computed tomography. Patients with pneumonia extension > 50% were excluded. An ambulatory visit was performed after at least 48 hours, when patients were either discharged, admitted, or deferred for a further visit. As a control, we evaluated a comparable historical cohort of hospitalized patients. RESULTS: A total of 84 patients were enrolled (51 male patients; mean age, 62.8 years). Two-thirds of the patients had at least one comorbidity and 41.6% had a lung involvement > 25% on high resolution computed tomography; the mean duration of symptoms was 8.0 ± 3.0 days, and the mean PaO2/FiO2 ratio was 357.5 ± 38.6. At the end of the follow-up period, 69 patients had been discharged, and 15 were hospitalized (mean stay of 6 days). Older age and higher National Early Warning Score 2 were significant predictors of hospitalization at the first follow-up visit. One hospitalized patient died of septic shock. In the control group, the mean hospital stay was 8 days. CONCLUSION: Adopting a "discharge and early revaluation" strategy appears to be safe, feasible, and may optimize hospital resources during the SARS-CoV-2 pandemic.

Predictors of readmission requiring hospitalization after discharge from emergency departments in patients with COVID-19.

INTRODUCTION: Little is known on prevalence of early return hospital admission of subjects with COVID-19 previously evaluated and discharged from emergency departments (EDs). This study aims to describe readmission rate within 14 days of patients with COVID-19 discharged from ED and to identify predictors of return hospital admission. METHODS: We performed a retrospective cohort study of adult patients with COVID-19 discharged from two EDs. Return hospital admission was defined as an unscheduled return ED visit within 14 days after initial ED evaluation and discharge. We compared the group of patients who had a return hospital admission to those who did not. We also evaluated selected clinical characteristics (age, neutrophilia, SOFA, lactate dehydrogenase, C-reactive protein and D-dimer) associated with return hospital admission. RESULTS: Of 283 patients included in the study, 65 (22.9%) had a return ED visit within 14 days. 32 of those patients (11%) were then hospitalized, while the remaining 33 were again discharged. Patients requiring a return hospital admission was significantly older, had higher pro-calcitonin and D-dimer levels. Major predictors of return hospital admission were cognitive impairment (OR 17.3 [CI 4.7-63.2]), P/F < 300 mmHg (OR 8.6 [CI 1.6-44.3]), being resident in geriatric care facility (OR 7.6 [CI 2.1-26.4]) and neutrophilia (OR 5.8 [CI 1.6-22.0]). CONCLUSION: Several factors are associated with 14-day return hospital admission in COVID-19 subjects. These should be considered when assessing discharge risk in ED clinical practice.

Heart transplant recipient patient with COVID-19 treated with tocilizumab.

A heart transplant 62-year-old patient referred for coronavirus-19 disease (COVID-19) pneumonia. At admission, he was febrile, tachypnoeic, and mild hypoxic with dry cough; during hospitalization, a diffuse morbilliform skin rash appeared. He was treated with tocilizumab with symptoms improvement, without a complete pulmonary function recovery. Skin rash, highly suggestive for COVID-19 cutaneous involvement, persisted for ten days despite tocilizumab administration.

Bosentan for chronic thromboembolic pulmonary hypertension: findings from a systematic review and meta-analysis.

BACKGROUND: After acute pulmonary embolism, chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in about 1% of patients. We performed a systematic review and meta-analysis aimed at assessing the effects of bosentan therapy in patients with CTEPH. METHODS: We searched in MEDLINE and Embase using the terms 'pulmonary hypertension' AND 'bosentan'. Papers were included in this review if they reported on patients with objectively confirmed CTEPH treated with bosentan. Efficacy measures were the improvement in NYHA class, in 6 minute walking distance (6 mwd) and in hemodynamics (cardiac index, pulmonary artery pressure, pulmonary vascular resistance). Mortality and safety were also assessed. RESULTS: Overall, 543 papers were found. Eight single-arm cohort studies (175 patients), one randomized double-blind study, one case-control study and one case report were included in the analysis. A 35.9 meters weighted mean increase in 6 minute walking distance was observed after 3-6 months of treatment (9 studies, 208 patients) (95% CI 33.6 to 38.2; p<0.001) and an additional increase of 21 meters after one year (4 studies, 80 patients). About 25% of patients had an improvement on functional NYHA class at 3-6 months. Data on hemodynamics were available in seven studies, 185 patients. The mean weighted increase in cardiac index at 3-6 months was 0.23 l/min/m2 (95% CI 0.22 to 0.25); the mean weighted decrease in pulmonary artery pressure at 3-6 months was 2.62 mmHg (95% CI 2.44 to 2.80). Three patient died within 3-6 months (1.4%) and 3 additional patients died within one year. CONCLUSIONS: Bosentan therapy is associated with an improvement of hemodynamics and probably exercise capacity in patients with CTEPH. Controlled data on mortality and time to clinical worsening in patients with CTEPH are needed.