A 4C mortality score based dichotomic rule supports Emergency Department discharge of COVID-19 patients

BACKGROUND

For COVID-19 patients evaluated in the Emergency Department (ED), decision on hospital admission vs. home discharge is challenging. The 4C mortality score (4CMS) is a prognostication tool integrating key demographic/clinical/biochemical data validated for COVID-19 inpatients. We sought to derive and validate a dichotomic rule based on 4CMS identifying patients with mild outcomes, suitable for safe ED discharge.

METHODS

Derivation was performed in a prospective cohort of ED patients with suspected COVID-19 from two centers (April 2020). Validation was pursued in a prospective multicenter cohort of ED patients with confirmed COVID-19 from 6 centers (October 2020 to January 2021). Chest X-ray (CXR) images were independently scored. The primary composite outcome was all-cause 30-day mortality or hospital admission. Secondary outcomes were ED re-visit, oxygen therapy and ventilation.

RESULTS

In a derivation cohort of 838 ED patients with suspected COVID-19, 4CMS≤8 was associated with low outpatient mortality (0.4%) and was thus selected as a feasible discharge rule. In a validation cohort of 521 COVID-19 outpatients, the mean age was 51±17 years; 97 (18.6%) patients had ≥1 CXR infiltrate. The 4CMS had an AUC of 0.82 for the primary outcome and 0.93 for mortality, outperforming other scores (CURB-65, qCSI, qSOFA, NEWS) and CXR. In 474 (91%) patients with 4CMS≤8, the mortality rate was 0.2% and the hospital admission rate was 6.8%, versus 12.8% and 36.2% for 4CMS≥9 (P<0.001). CXR did not provide additional discrimination.

CONCLUSIONS

COVID-19 outpatients with 4CMS≤8 have mild outcomes and can be safely discharged from the ED. [NCT0462918].

Syncope: a worrisome presenting symptom during the first wave of COVID-19 in Italy

Background

COronaVIrus Disease 19 (COVID-19) pandemic is a global health emergency. Since the first reported cases in Asia, the virus has now spread worldwide. Given its high contagiousness, one of the greatest challenges is early detection of infected patients. People affected by COVID-19 have had a wide range of presenting symptoms, from very mild to severe, including fever, cough, shortness of breath, gastrointestinal upset, anosmia and ageusia among others. Syncope as the presenting symptom of COVID-19 has been reported in case series or small sample size retrospective studies with variable results in terms of incidence, characteristics and outcomes.

Purpose

The aim of the present analysis is to investigate all consecutive patients with COVID-19 who presented with syncope during the first wave of the pandemic to a high-volume Emergency Department (ED) in Italy.

Methods

A total of 569 patients diagnosed with COVID-19 by positive nose and throat swab and admitted to the hospital between February 20th, 2020 (day of first reported COVID-19 case in Italy) and April 23rd, 2020 were retrospectively evaluated.

Results

Syncope has been reported as the initial symptom which prompted medical attention in 46 out of 569 patients (8%). Mean age of patients presenting with syncope was 72±15 years, 28 were males. Baseline patients' clinical characteristics are reported in Table 1. In 18 out of 46 patients (39%) syncope was an isolated finding, being fever and cough the two most commonly associated symptoms. Arrhythmic etiology was excluded since no arrhythmia was observed at device interrogation or with ECG/prolonged heart monitoring during hospitalization. No significant abnormalities were present at baseline ECG. At the time of admission, all patients were normotensive, median O2 saturation was 94.5%, median D-dimer 362 ng/ml. One-third of the patients presenting with syncope had a complicated clinical course with quite rapid deterioration requiring non-invasive ventilation (30%) and intensive care unit admission with intubation (11%).

In our group of consecutive patients with COVID-19 who presented with syncope, the mortality rate was surprisingly high, 15/46 (32%), compared to the mortality rate of the COVID population admitted to our hospital with other symptoms 93/523 (18%), p=0.023. Six out of 15 patients died in the ED, mainly during their first day of hospitalization. The other 9 had a quite rapid deterioration in the following days and died within a week (median syncope-to-death time was 7 days).

Conclusion

Despite our new finding needs confirmation in studies with larger sample size, our report shows how syncope may be the presenting symptom of COVID-19. Whether the exact mechanism has to be demonstrated, the mortality rate in patients presenting with syncope is higher than the mortality rate of patients presenting with other symptoms; therefore COVID-19 patients presenting with syncope should be on a watch list for rapid deterioration.

Funding Acknowledgement

Type of funding sources: None.

After the first wave and beyond lockdown: long-lasting changes in emergency department visit number, characteristics, diagnoses, and hospital admissions

The first wave (FW) of COVID-19 led to a rapid reduction in total emergency department (ED) visits and hospital admissions for other diseases. Whether this represented a transient "lockdown and fear" phenomenon, or a more persisting trend, is unknown. We divided acute from post-wave changes in ED flows, diagnoses, and hospital admissions, in an Italian city experiencing a FW peak followed by nadir. This multicenter, retrospective, cross-sectional study involved five general EDs of a large Italian city (January-August 2020). Percent changes were calculated versus 2019, using four 14-day periods (FW peak, early/mid/late post-wave). ED visits were 147,446 in 2020, versus 214,868 in 2019. During the FW peak, visits were reduced by 66.4% (P < 0.001). The drop was maximum during daytime (69.8%) and for pediatric patients (89.4%). Critical triage codes were unchanged. Reductions were found for all non-COVID-19 diagnoses. Non-COVID-19 hospital admissions were reduced by 39.5% (P < 0.001), involving all conditions except hematologic, metabolic/endocrine, respiratory diseases, and traumas. In the early, mid, and late post-wave periods, visits were reduced by 25.4%, 25.3% and 23.5% (all P < 0.001) respectively. In the late period, reduction was greater for female (27.9%) and pediatric patients (44.6%). Most critical triage codes were unchanged. Oncological, metabolic/endocrine, and hematological diagnoses were unchanged, while other diagnoses had persistent reductions. Non-COVID-19 hospital admissions were reduced by 12.8% (P = 0.001), 6.3% (P = 0.1) and 12.2% (P = 0.001), respectively. Reductions in ED flows, led by non-critical codes, persisted throughout the summer nadir of COVID-19. Hospital admissions for non-COVID-19 diseases had transient changes.

Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial

AIMS

Although acute decompensated heart failure (ADHF) is a common cause of dyspnoea, its diagnosis still represents a challenge. Lung ultrasound (LUS) is an emerging point-of-care diagnostic tool, but its diagnostic performance for ADHF has not been evaluated in randomized studies. We evaluated, in patients with acute dyspnoea, accuracy and clinical usefulness of combining LUS with clinical assessment compared to the use of chest radiography (CXR) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in conjunction with clinical evaluation.

METHODS AND RESULTS

This was a randomized trial conducted in two emergency departments. After initial clinical evaluation, patients with acute dyspnoea were classified by the treating physician according to presumptive aetiology (ADHF or non-ADHF). Patients were subsequently randomized to continue with either LUS or CXR/NT-proBNP. A new diagnosis, integrating the results of both initial assessment and the newly obtained findings, was then recorded. Diagnostic accuracy and clinical usefulness of LUS and CXR/NT-proBNP approaches were calculated. A total of 518 patients were randomized. Addition of LUS had higher accuracy [area under the receiver operating characteristic curve (AUC) 0.95] than clinical evaluation alone (AUC 0.88) in identifying ADHF (P < 0.01). In contrast, use of CXR/NT-proBNP did not significantly increase the accuracy of clinical evaluation alone (AUC 0.87 and 0.85, respectively; P > 0.05). The diagnostic accuracy of the LUS-integrated approach was higher then that of the CXR/Nt-proBNP-integrated approach (AUC 0.95 vs. 0.87, p < 0.01). Combining LUS with the clinical evaluation reduced diagnostic errors by 7.98 cases/100 patients, as compared to 2.42 cases/100 patients in the CXR/Nt-proBNP group.

CONCLUSION

Integration of LUS with clinical assessment for the diagnosis of ADHF in the emergency department seems to be more accurate than the current diagnostic approach based on CXR and NT-proBNP.

Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study

BACKGROUND

Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.

METHODS

We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.

RESULTS

The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.

CONCLUSIONS

The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.

TRIAL REGISTRY

Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.

[Tracheal resection-anastomosis in carcinoma of the thyroid infiltrating the airways. A case report]

The Authors report a case of thyroid carcinoma with tracheal involvement. Since the neoplastic invasion of the trachea was 3 cm long total thyroidectomy with sleeve tracheal resection and immediate reconstruction with end-to-end anastomosis were performed. The diagnostic and therapeutic approach is discussed and the Literature data reviewed.

The effect of neurohypophysial hormones on the amphibian oviduct in vitro, with some remarks on the histology of this organ

SUMMARY

The effect of neurohypophysial hormones has been tested in vitro on oviducts of four species of urodele and three species of anuran Amphibia. Contractile responses were obtained with all the hormones used but 8-arginine oxytocin (vasotocin) was usually most potent. The sensitivity of the oviducts varied widely from species to species; there were also pronounced seasonal differences within a species. Histological investigations yielded some information on the abundance and arrangement of muscle fibres in amphibian oviducts. A simple and sensitive (magnification up to × 1000) recording system for isotonic contractions is described.