Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department.

The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.

The prognostic value of lung ultrasound score (LUSS) in patients with COVID-19 admitted in Emergency Department: a prospective observational study.

BACKGROUND: The Lung Ultrasound (LUS) is routinely used as a point-of-care imaging tool in Emergency Department (ED) and its role in COVID-19 is being studied. The Lung UltraSound Score (LUSS) is a semi quantitative score of lung damage severity. Alongside instrumental diagnostic, the PaO2/FiO2 (P/F) ratio, obtained from arterial blood gas analysis, is the index used to assess the severity of the acute respiratory distress syndrome (ARDS), according to the Berlin definition. OBJECTIVES: The primary objective of the study was to evaluate a possible correlation between the LUSS score and the P/F Ratio, obtained from the arterial sampling in COVID-19 positive patients. MATERIALS AND METHODS: This was a cross-perspective monocentric observational study and it was carried out in the Emergency Department of the "AOU delle Marche" (Ancona, Italy), from 1 January 2023 to 28 February 2023. The study foresaw, once the patient was admitted to the ED, the execution of the LUS exam and the subsequent calculation of the LUSS score. RESULTS: The sample selected for the study was of 158 patients. The proportion of LUSS ≤4 was statistically higher in those with a P/F >300 (76.2%), compared to those with a P/F ≤300 (13.2%). On the other end, the proportion of LUSS >4 was lower in those who have P/F >300 (23.8%), while it was higher in those who have P/F ≤300 (86.8%). Those patients with a LUSS >4 were 1.76 (95% CI: 1.57 - 1.99) times more likely to have a P/F ≤300, compared to those with LUSS ≤4. The Odds Ratio of having a P/F ≤300 value in those achieving a LUSS >4, compared to those achieving a LUSS ≤4, was 21.0 (95% CI: 8.4 - 52.4). The study identified pO2, Hb and dichotomous LUSS as predictors of the level of P/F ≤300 or P/F >300. DISCUSSION: We found that the LUSS score defined by our study was closely related to the P/F ratio COVID-19 positive patients. Our study presented provides evidence on the potential rule of the LUSS for detecting the stage of lung impairment and the need for oxygen therapy in COVID-19 positive patients.

Minor head injury in anticoagulated patients: performance of biomarkers S100B, NSE, GFAP, UCH-L1 and Alinity TBI in the detection of intracranial injury. A prospective observational study.

OBJECTIVES: Data in literature indicate that in patients suffering a minor head injury (MHI), biomarkers serum levels could be effective to predict the absence of intracranial injury (ICI) on head CT scan. Use of these biomarkers in case of patients taking oral anticoagulants who experience MHI is very limited. We investigated biomarkers as predictors of ICI in anticoagulated patients managed in an ED. METHODS: We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The outcome was delayed ICI (dICI), defined as ICI on the second CT scan after a first negative CT scan. We assessed the sensitivity (SE), specificity (SP), negative predictive value (NNV) and positive predictive value (PPV) of the biomarkers S100B, NSE, GFAP, UCH-L1 and Alinity TBI in order to identify dICI. RESULTS: Our study population was of 234 patients with a negative first CT scan who underwent a second CT scan. The rate of dICI was 4.7 %. The NPV for the detection of dICI were respectively (IC 95 %): S100B 92.7 % (86.0-96.8 %,); ubiquitin C-terminal hydrolase-L1 (UCH-L1) 91.8 % (83.8-96.6 %); glial fibrillary protein (GFP) 100 % (83.2-100 %); TBI 100 % (66.4-100 %). The AUC for the detection of dICI was 0.407 for S100B, 0.563 for neuron-specific enolase (NSE), 0.510 for UCH-L1 and 0.720 for glial fibrillary acidic protein (GFAP), respectively. CONCLUSIONS: The NPV of the analyzed biomarkers were high and they potentially could limit the number of head CT scan for detecting dICI in anticoagulated patients suffering MHI. GFAP and Alinity TBI seem to be effective to rule out a dCI, but future trials are needed.

Early administration of tofacitinib in COVID-19 pneumonitis: An open randomised controlled trial.

BACKGROUND: Controversies on sub-populations most sensitive to therapy and the best timing of starting the treatment still surround the use of immunomodulatory drugs in COVID-19. OBJECTIVES: We designed a multicentre open-label randomised controlled trial to test the effect of prompt adding of tofacitinib to standard therapy for hospitalised patients affected by mild/moderate COVID-19 pneumonitis. METHODS: Patients admitted to three Italian hospitals affected by COVID-19 pneumonitis not requiring mechanical ventilation were randomised to receive standard treatment alone or tofacitinib (10 mg/bid) for 2 weeks, starting within the first 24 h from admission. RESULTS: A total of 116 patients were randomised; 49 in the experimental arm completed the 14-day treatment period, 9 discontinued tofacitinib as the disease worsened and were included in the analysis, and 1 died of respiratory failure. All 58 control patients completed the study. Clinical and demographic characteristics were similar between the study groups. In the tofacitinib group, 9/58 (15.5%) patients progressed to noninvasive ventilation (CPAP) to maintain SO2 > 93%, invasive mechanical ventilation or death by day 14 was 15.5%, significantly less than in the control group (20/58, 34.4%, RR 0,45, RRR -55%, NNT 5; p = .018). No differences in severe adverse effect incidence had been observed across the groups. CONCLUSION: High-dose tofacitinib therapy in patients with COVID pneumonitis is safe and may prevent deterioration to respiratory failure.

Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review.

Flexible bronchoscopy (FB) has become a standard of care for the triad of inspection, sampling, and treatment in critical care patients. It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit (ICU). Less is known about its role outside the ICU, particularly in the intermediate care unit (IMCU), a specialized environment, where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided. In the IMCU, the leading indications for a diagnostic work-up are: To visualize airway system/obstructions, perform investigations to detect respiratory infections, and identify potential sources of hemoptysis. The main procedures for therapeutic purposes are secretion aspiration, mucus plug removal to solve atelectasis (total or lobar), and blood aspiration during hemoptysis. The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients. Serious adverse events related to FB are relatively uncommon, but they may be due to lack of expertise or appropriate precautions. Finally, nowadays, during dramatic recent coronavirus disease 2019 (COVID-19) pandemic, the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined. Hence, we provide a concise review on the role of FB in an IMCU setting, focusing on its indications, technical aspects and complications.

[Patient reported outcomes measures (PROMs): definitions and perspectives for their use as quality indicators in emergency rooms.] / Patient-reported outcomes measures (PROM): definizioni e prospettive per il loro impiego quali indicatori di qualità nei Pronto Soccorso.

There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. This recent interest has spawned the rapid development and testing of patient-reported outcome measures (PROMs), through which patients report on their perception of the outcomes of the care they received. Their use has moved significantly from medical research toward applications in the clinical setting, quality measurement, and system accountability. While the use of as measures of clinical or treatment effectiveness, especially in chronic conditions, is widespread, their use in the emergency department (ED) setting is currently limited. In ED care, PROMs could offer promise since 80% of patients are discharged without any other way to track outcome. We explore the development and use of PROMs in publications on benchmarks and patient-centered care.

Patient-Reported Outcome Measurements (PROMs) After Discharge From the Emergency Department: A Cross-Sectional Study.

BACKGROUND: The purpose of a patient-reported outcome (PRO) is to elicit the perspectives of patients and translate them into a reliable measurement questionnaire. OBJECTIVES: The objective of this cross-sectional study was to detect a set of PROs and PRO measurements (PROMs) about patients with isolated trauma of the limbs receiving emergency department (ED) care. METHODS: A survey was performed in the ED using a questionnaire among the enrolled patients to identify which proposed outcomes were perceived as important by the patients according to their expectations. RESULTS: Ninety-six consecutive patients were conveniently enrolled. For each item of the questionnaire, the percentage of patients who agreed to perceive it important were calculated. Three items were perceived important by almost 85% of the patients: getting an x-ray (91%; 95% CI: 88%-98%), obtaining a written therapy (94%; 95% CI: 87%-97%), and feeling the physicians' and nurses' empathy (97%; 95% CI: 91%-99%). The ED system was able to satisfy 2 of the 3 agreed PROs in at least 85% of the cases: getting an x-ray (97%; 95% CI: 91%-99%) and obtaining a written therapy (97%; 95% CI: 91%-99%). Moreover, in 30/96 patients (31%; 95% CI: 22%-41%), all the PROs were satisfied, and in 75/96 patients (78%; 95% CI: 69%-85%), all agreed PROs were satisfied. CONCLUSIONS: Our study shows an example of core of PROs proposed by the ED physicians and agreed by the patients. Moreover, we presented a set of PROMs which could be used to measure the quality of an ED.

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.

Predictors of Worse Prognosis in Young and Middle-Aged Adults Hospitalized with COVID-19 Pneumonia: A Multi-Center Italian Study (COVID-UNDER50).

Obesity as well as metabolic and cardiovascular comorbidities are established, significant predictors of worse prognosis in the overall COVID-19 population, but limited information is available on their roles in young and middle-aged adults (aged ≤ 50 years). The main objectives of the present Italian multi-center study were to describe clinical characteristics and role of selected prognostic predictors in a large cohort of young and middle-aged hospitalized patients. Nine pulmonology units, across north and center of Italy, were involved in this retrospective study. Comorbidities were classified according to their known or potential association with COVID-19. A total of 263 subjects were included. The prevalence of obesity was 25.9%, mechanical ventilation (MV) was needed in 27.7%, and 28 in-hospital deaths occurred (10.6%). Obesity and older age were the only independent, significant predictors for MV. Comorbidities, such as hypertension, diabetes, asthma, and increased D-dimer levels were significantly associated with higher mortality risk, regardless of age, body mass index, and MV. Obesity in young and middle-aged adults is a strong predictor of a more complicated COVID-19, without, however, evidence of a significant effect on in-hospital mortality. Selected comorbidities, including hypertension, diabetes and asthma, significantly impact survival even in a younger population, suggesting the need for prompt recognition of these conditions.

Rituximab for eosinophilic granulomatosis with polyangiitis: a systematic review of observational studies.

OBJECTIVE: To analyse the available evidence about the use of rituximab (RTX) and other biologic agents in eosinophilic granulomatosis with polyangiitis (EGPA) patients and to provide useful findings to inform the design of future, reliable clinical trials. METHODS: A systematic review was performed. A systematic search was conducted in PubMed/MEDLINE, Scopus, Web of Science and the Cochrane library databases on RTX, and an extensive literature search was conducted on other biologic agents. RESULTS: Forty-five papers pertinent to our questions were found: 16 retrospective cohort studies, 8 case series, 3 prospective cohort studies and 18 single case reports, for a total of 368 EGPA patients. More than 80% of evaluable patients achieved complete or partial remission with a tendency towards a higher rate of complete response in the pANCA-positive subgroup. CONCLUSION: Although the majority of the evaluable EGPA patients treated with RTX appears to achieve complete remission, we strongly believe that a number of sources of heterogeneity impair a clear interpretation of results and limit their transferability in clinical practice. Differences in design, enrolment criteria, outcome definition and measurement make a comparison among data obtained from studies on RTX and other biologic agents unreliable.

Patients with isolated pulmonary embolism in comparison to those with deep venous thrombosis. Differences in characteristics and clinical evolution.

BACKGROUND: Patients with acute pulmonary embolism (PE) often have leg deep vein thrombosis (DVT); sometimes, however, a DVT is not detected (isolated PE, I-PE). We aimed at assessing the proportion of patients with I-PE, and their characteristics and clinical evolution compared to those with DVT with/without PE (DVT/PE). METHODS: Among 3573 patients included in the START2-Register for a venous thromboembolic event, 2880 (80.6%) had DVT/PE, the remaining I-PE (19.4%). RESULTS: Patients with I-PE were older [(≥75 years, OR 1.4 (95%CI 1.13-1.69)], and more frequently females [OR 1.4 (1.19-1.67)]. Young females (aged ≤ 50 years) with an index event occurring during hormonal contraception (HC), were more prevalent in I-PE [OR 1.96 (1.26-3.03)]. At multivariate analysis, age > 75 years, female sex, heart failure, cancer and use of HC were risk factors significantly associated with I-PE, whereas thrombophilic alterations were associated with DVT/PE. During a follow-up of 4504 years (during anticoagulation), the rate of bleeding events was 1.1% patient/years and 1.0% patient/years in I-PE and DVT/PE, respectively. Venous thromboembolic events were equally prevalent in DVT/PE or I-PE (1.94% vs 0.86%, ns), whereas arterial complications were more prevalent in the latter group (1.01% vs 0.28%, p = 0.008). CONCLUSION: I-PE and DVT/PE have important differences. Older age, female sex, heart failure and cancer, were risk factors for I-PE; thrombophilic alterations were associated with DVT/PE. HC use was more frequent in the I-PE group. The prevalence of arterial complications was higher in patients with I-PE. Further studies, specifically designed on this issue, are warranted.

Pulmonary embolism: a retrospective comparative study between patients with atypical vs typical clinical presentation

Background: Natural history and outcomes of patients with pulmonary embolism (PE) without typical symptoms (atypical PE) remain unclear. The aim of the study is to compare the clinical characteristics and the prognosis between typical PE and atypical PE. Methods: We retrospectively analyzed data from consecutive patients admitted to the Emergency Department (ED) because of a diagnosis of PE and classified them in two groups: typical PE and atypical PE. We defined PE to be typical in presence of almost one of the following symptoms or signs: dyspnea, chest pain, hemoptysis or signs of deep vein thrombosis. Results: Of the 191 patients with PE, 154 (81%) had typical PE and 37 (19%) had atypical PE. Patients with atypical and typical PE seemed to had similar prognostic factor such as high risk sPESI (73% vs 65%, p=0.3), right ventricular dysfunction (30% vs 26%, p=0.6) and central PE at chest CT scan (38% vs 36%, p=0.8). The rate of 30 day mortality was 7% in the typical group and 8% in the atypical group (p=0.8). The length of stay in hospital was the same in the two groups (6 days; p=0.2). Conclusions: We found that atypical and typical PE seem to be related diseases with a similar short term prognosis. Therefore, we could speculate that a missed diagnosis of PE in ED could expose the patients to a worsen prognosis. Further perspective studies are required for better investigate this diagnostic challenge.

Management of spontaneous soft-tissue hemorrhage secondary to anticoagulant therapy: A cohort study.

STUDY OBJECTIVE: The optimal management of patients receiving heparin, warfarin or direct anti-coagulant therapy who experience spontaneous, severe, life-threatening soft-tissue hemorrhage (SSTH) is unclear. The purpose of this study is to investigate efficacy and safety of the interventional protocol implemented in our department. METHODS: In this retrospective cohort study, we analyzed data from 80 consecutive patients with SSTH secondary to anticoagulation therapy diagnosed by the appropriate computed tomography scan. All patients received a structured clinical pathway, including aggressive resuscitation, reversal of coagulopathy when indicated, Interventional Radiology procedures by transcatheter embolization (TE), clinical observation and repeated laboratory controls. RESULTS: We enrolled 80 patients from 2013 to 2017. Angiography was performed in 60 patients (75%). It revealed the bleeding site in 46 cases, and a TE was performed in all. The rates of technical success of TE, primary clinical success and bleeding control were 98% (45/46), 91% (73/80) and 89% (71/80) respectively. In 5 patients (6%) the control of the bleeding was obtained with a second TE. Short-term and 30-day mortality was 5% (4 patients) and 11% (9 patients), respectively. No adverse events were observed. CONCLUSION: A structured clinical pathway, including TE seems to be an effective and safe method to manage the patients with SSTH due to anticoagulant treatment.

Emergency Department Non-Urgent Visits and Hospital Readmissions Are Associated with Different Socio-Economic Variables in Italy.

OBJECTIVE: The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits. METHODS: The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use. RESULTS: Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32-6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65-84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37-52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38-15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3-7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30-0.90). CONCLUSIONS: In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization.

[Burnout syndrome in pre-hospital and hospital emergency. Cognitive study in two cohorts of nurses]. / Il burnout in emergenza preospedaliera e ospedaliera. Indagine conoscitiva in due coorti di infermieri.

INTRODUCTION: Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties. The emergency department and the pre-hospital healthcare services are highly stressful environments. Little is known about the BOS in critical care nursing staff. The objective of the study is to compare the incidence of BOS and its three domains, namely, emotional exhaustion, depersonalization and reduced professional accomplishment, in two cohorts of critical care nurses: a pre-hospital and a hospital emergency service. METHODS: A survey using a questionnaire (the Maslach Burnout Inventory-General Survey, MBI-GS), among nurses of two Italian emergency services has been performed: a hospital emergency service (HES, Emergency Department or "Pronto Soccorso") and a pre-hospital emergency service (PHES, territorial healthcare service or "Centrale Operativa 118"). RESULTS: All 60 nurses surveyed (82% female) filled the questionnaires. BOS-related symptoms have been identified in at least 50% of the nurses in the HES: 50% suffered a medium-high emotional exhaustion, 75% had a medium-high depersonalization and 92.5% had a medium-high reduced professional accomplishment. Among the PEHS nurses, BOS-related symptoms have been identified in at least 60% of the respondents: 60% had a medium-high emotional exhaustion, 70% had a medium-high depersonalization and 95% had a medium-high reduced professional accomplishment. Moreover, the likelihood that a nurse has a severe BOS, that is at least one degree of high burnout or ≥2 degrees of medium burnout, is significantly higher in the group of the PHES than in the HES (90% vs 60%, p <0.02). CONCLUSION: At least two-thirds of critical care nursing staff had a severe BOS. The incidence of BOS appeared to be similar among PHES and HES nurses with a higher trend for the former. Further interventional studies are needed to investigate the determinants of BOS among critical care nurses and the potentially preventive strategies.

[The nursing approach to pre-hospital pediatric emergencies: cognitive study in 2 cohorts of nurses]. / L'approccio infermieristico all'emergenza pediatrica pre-ospedaliera: indagine conoscitiva in due coorti di infermieri.

Pediatric emergencies have a relatively low incidence compared to the total number of pre-hospital events. The quality of emergency care for pediatric patients can be improved by specific training, a dedicated team and uniformity of pediatric protocols. The aim of this study is to assess how nurses perceive pediatric emergencies in a non-hospital environment by means of two questionnaires issued to two cohorts of nurses working on ambulances. The results of the study show that nursing care of pediatric patients in critical situations seems to depend on adequate training, not only formal but also with simulations, paying particular attention to the emotional situation nurses have to face, and complete equipment of the ambulance and emergency personnel.

Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.

STUDY OBJECTIVE: Patients receiving warfarin who experience minor head injury are at risk of intracranial hemorrhage, and optimal management after a single head computed tomography (CT) scan is unclear. We evaluate a protocol of 24-hour observation followed by a second head CT scan. METHODS: In this prospective case series, we enrolled consecutive patients receiving warfarin and showing no intracranial lesions on a first CT scan after minor head injury treated at a Level II trauma center. We implemented a structured clinical pathway, including 24-hour observation and a CT scan performed before discharge. We then evaluated the frequency of death, admission, neurosurgery, and delayed intracranial hemorrhage. RESULTS: We enrolled and observed 97 consecutive patients. Ten refused the second CT scan and were well during 30-day follow-up. Repeated CT scanning in the remaining 87 patients revealed a new hemorrhage lesion in 5 (6%), with 3 subsequently hospitalized and 1 receiving craniotomy. Two patients discharged after completing the study protocol with 2 negative CT scan results were admitted 2 and 8 days later with symptomatic subdural hematomas; neither received surgery. Two of the 5 patients with delayed bleeding at 24 hours had an initial international normalized ratio greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. The relative risk of delayed hemorrhage with an initial international normalized ratio greater than 3.0 was 14 (95% confidence interval 4 to 49). CONCLUSION: For patients receiving warfarin who experience minor head injury and have a negative initial head CT scan result, a protocol of 24-hour observation followed by a second CT scan will identify most occurrences of delayed bleeding. An initial international normalized ratio greater than 3 suggests higher risk.