A Computational Approach in the Diagnostic Process of COVID-19: The Missing Link between the Laboratory and Emergency Department

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the COVID-19 pandemic and so it is crucial the right evaluation of viral infection. According to the Centers for Disease Control and Prevention (CDC), the Real-Time Reverse Transcription PCR (RT-PCR) in respiratory samples is the gold standard for confirming the disease. However, it has practical limitations as time-consuming procedures and a high rate of false-negative results. We aim to assess the accuracy of COVID-19 classifiers based on Arificial Intelligence (AI) and statistical classification methods adapted on blood tests and other information routinely collected at the Emergency Departments (EDs).

METHODS

Patients admitted to the ED of Careggi Hospital from April 7th-30th 2020 with pre-specified features of suspected COVID-19 were enrolled. Physicians prospectively dichotomized them as COVID-19 likely/unlikely case, based on clinical features and bedside imaging support. Considering the limits of each method to identify a case of COVID-19, further evaluation was performed after an independent clinical review of 30-day follow-up data. Using this as a gold standard, several classifiers were implemented: Logistic Regression (LR), Quadratic Discriminant Analysis (QDA), Random Forest (RF), Support Vector Machine (SVM), Neural Networks (NN), K-nearest neighbor (K-NN), Naive Bayes (NB).

RESULTS

Most of the classifiers show a ROC >0.80 on both internal and external validation samples but the best results are obtained applying RF, LR and NN. The performance from the external validation sustains the proof of concept to use such mathematical models fast, robust and efficient for a first identification of COVID-19 positive patients. These tools may constitute both a bedside support while waiting for RT-PCR results, and a tool to point to a deeper investigation, by identifying which patients are more likely to develop into positive cases within 7 days.

CONCLUSIONS

Considering the obtained results and with a rapidly changing virus, we believe that data processing automated procedures may provide a valid support to the physicians facing the decision to classify a patient as a COVID-19 case or not.

Retrospective analysis of the diagnostic accuracy of lung ultrasound for pulmonary embolism in patients with and without pleuritic chest pain

Background

Lung ultrasound (LUS) has a role in the diagnosis of pulmonary embolism (PE) mainly based on the visualization of pulmonary infarctions. However, examining the whole chest to detect small peripheral infarctions by LUS may be challenging. Pleuritic pain, a frequent presenting symptom in patients with PE, is usually localized in a restricted chest area identified by the patient itself. Our hypothesis is that sensitivity of LUS for PE in patients with pleuritic chest pain may be higher due to the possibility of focusing the examination in the painful area. We combined data from three prospective studies on LUS in patients suspected of PE and extracted data regarding patients with and without pleuritic pain at presentation to compare the performances of LUS.

Results

Out of 872 patients suspected of PE, 217 (24.9%) presented with pleuritic pain and 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS for PE in patients with and without pleuritic chest pain was 81.5% (95% CI 70–90.1%) and 49.5% (95% CI 42.7–56.4%) (p < 0.001), respectively. Specificity of LUS was similar in the two groups, respectively 95.4% (95% CI 90.7–98.1%) and 94.8% (95% CI 92.3–97.7%) (p = 0.86). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better both in terms of sensitivity (93%, 95% CI 80.9–98.5% vs 90.7%, 95% CI 77.9–97.4%) and negative predictive value (96.2%, 95% CI 89.6–98.7% vs 93.3%, 95% CI 84.4–97.3%). Efficiency of Wells score + LUS outperformed the conventional strategy based on Wells score + d-dimer (56.7%, 95% CI 48.5–65% vs 42.5%, 95% CI 34.3–51.2%, p = 0.02).

Conclusions

In a population of patients suspected of PE, LUS showed better sensitivity for the diagnosis of PE when applied to the subgroup with pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performed better to exclude PE than the conventional strategy combining Wells score and d-dimer.

The presentations/physician ratio predicts door-to-physician time but not global length of stay in the emergency department: an Italian multicenter study during the SARS-CoV-2 pandemic

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R² = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R² = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

Diagnostic Accuracy of Point-of-Care Ultrasound Integrated into Clinical Examination for Acute Diverticulitis: A Prospective Multicenter Study

PURPOSE

 Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis.

MATERIALS AND METHODS

 This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan.

RESULTS

 Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 ± 102 vs. 330 ± 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity.

CONCLUSION

 Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

Comparison of out of hospital cardiac arrest due to acute brain injury vs other causes

BACKGROUND

Acute brain injury (ABI) can cause out of hospital cardiac arrest (OHCA). The aim of this study was to compare clinical features, mortality and potential for organ donation in patients with OHCA due to ABI vs other causes.

METHODS

From January 2017 to December 2018, all adult patients presenting to ED for OHCA were considered for the study. Two physicians established the definitive cause of OHCA, according to clinical, laboratory, diagnostic imaging and autoptic findings. Clinical features in patients with OHCA due to ABI or other causes were compared.

RESULTS

280 patients were included in the analysis. ABI was the third most frequent cause of OHCA (21, 7.5%); ABIs were 8 subarachnoid hemorrhage, 8 intracerebral hemorrhage, 2 ischemic stroke, 2 traumatic spinal cord injury and 1 status epilepticus respectively. Neurological prodromes such as seizure, headache and focal neurological signs were significantly more frequent in patients with OHCA due to ABI (OR 5.34, p = 0.03; OR 12.90, p = 0.02; and OR 66.53, p < 0.01 respectively) while among non-neurological prodromes chest pain and dyspnea were significantly more frequent in patients with OHCA due to other causes (OR 14.5, p < 0.01; and OR 10.4, p = 0.02 respectively). Anisocoria was present in 19% of patients with OHCA due to ABI vs 2.7% due to other causes (OR 8.47, p < 0.01). In 90.5% of patients with ABI and in 53.1% of patients with other causes the first cardiac rhythm was non shockable (OR 8.1; p = 0.05). Multivariate logistic regression analysis revealed that older age, active smoking, post-traumatic OHCA, neurological prodromes, anisocoria at pupillary examination were independently associated with OHCA due to ABI. Patients with ABI showed a higher mortality compared with the other causes group (19 pts., 90.5% versus 167 pts., 64.5%; p = 0.015). Potential organ donors were more frequent among ABI than other causes group (10 pts., 47.6% vs 75 pts., 28.9%) however the difference did not reach the statistical significance (p = 0.07).

CONCLUSIONS

ABI is the third cause of OHCA. Neurological prodromes, absence of chest pain and dyspnea before cardiac arrest, anisocoria and initial non-shockable rhythm might suggest a neurological etiology of the cardiac arrest. Patients with OHCA due to ABI has an unfavorable outcome, however, they could be candidate to organ donation.

Laryngotracheal aspiration test reduce the false negative rate in patients with suspected SARS-COV-2 pneumonia despite a negative nasopharyngeal swab

BACKGROUND

In the emergency department (ED) definitive diagnosis of SARS-COV-2 pneumonia is challenging as nasopharyngeal swab (NPS) can give false negative results. Strategies to reduce false negative rate of NPS have limitations. Serial NPSs (24-48 h from one another) are time-consuming, sputum can not be collected in the majority of patients, and bronchoalveolar lavage (BAL), the most sensitive test, requires specific expertise. Laryngotracheal aspiration (LTA) is easy to perform and showed a similar accuracy to BAL for diagnosis of other pulmonary diseases, however it was not studied to diagnose SARS-COV-2 pneumonia.

OBJECTIVE

An observational cross-sectional study was performed to evaluate the negative predictive value of LTA in patients with suspected SARS-COV-2 pneumonia despite a negative NPS.

METHODS

In the EDs of two university hospitals, consecutive patients with suspected SARS-COV-2 pneumonia despite a negative NPS underwent LTA performed with a nasotracheal tube connected to a vacuum system. Final diagnosis based on all respiratory specimen tests (NPS, LTA and BAL) and hospital data was established by two reviewers and in case of discordance by a third reviewer.

RESULTS

117 patients were enrolled. LTA was feasible in all patients and no patients experienced adverse events. Fifteen (12.7%) patients were diagnosed with community-acquired SARS-COV-2 pneumonia: 13 LTA positive and only 2 (1.7%) LTA negative. The negative predictive value of NPS and LTA was 87.3% (79.9% - 92.7%) and 98.1% (93.3%99.8%) respectively.

CONCLUSIONS

LTA resulted feasible, safe and reduced false negative rate in patients with suspected SARS-COV-2 pneumonia despite a negative NPS.

Blood-brain barrier leakage and hemorrhagic transformation: The Reperfusion Injury in Ischemic StroKe (RISK) study

BACKGROUND AND PURPOSE

In patients with acute ischemic stroke treated with reperfusion therapy we aimed to evaluate whether pretreatment blood-brain barrier (BBB) leakage is associated with subsequent hemorrhagic transformation (HT).

METHODS

We prospectively screened patients with acute ischemic stroke treated with intravenous thrombolysis and/or endovascular treatment. Before treatment, each patient received computed tomography (CT), CT angiography, and CT perfusion. We assessed pretreatment BBB leakage within the ischemic area using the volume transfer constant (K^trans ) value. Our primary outcome was relevant HT, defined as hemorrhagic infarction type 2 or parenchymal hemorrhage type 1 or 2. We evaluated independent associations between BBB leakage and HT using logistic regression, adjusting for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6, treatment type, and onset-to-treatment time.

RESULTS

We enrolled 171 patients with available assessment of BBB leakage. The patients' mean (±SD) age was 75.5 (±11.8) years, 86 (50%) were men, and the median (interquartile range) National Institutes of Health Stroke Scale score was 18 (12-23). A total of 32 patients (18%) received intravenous thrombolysis, 102 (60%) underwent direct endovascular treatment, and 37 (22%) underwent both. Patients with relevant HT (N = 31;18%) had greater mean BBB leakage (K^trans 0.77 vs. 0.60; p = 0.027). After adjustment in the logistic regression model, we found that BBB leakage was associated both with a more than twofold risk of relevant HT (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.03-6.03 per K^trans point increase; OR 2.34; 95% CI 1.06-5.17 for K^trans values > 0.63 [mean BBB leakage value]) and with symptomatic intracerebral hemorrhage (OR 4.30; 95% CI 1.13-13.77 per K^trans point increase).

CONCLUSION

Pretreatment BBB leakage before reperfusion therapy was associated with HT, and may help to identify patients at risk of HT.

Chest X-ray in the emergency department during COVID-19 pandemic descending phase in Italy: correlation with patients' outcome

PURPOSE

The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients' outcome.

MATERIALS AND METHODS

We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients' outcome.

RESULTS

CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients' outcome.

CONCLUSION

In our study, admission CXR showed a fair specificity and a good correlation with patients' outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Diagnostic accuracy of physician's gestalt in suspected COVID-19: Prospective bicentric study

Objectives

Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results.

Methods

From April 1 to April 30, 2020, patients with suspected COVID‐19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID‐19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x‐ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30‐day follow‐up data.

Results

Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID‐19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID‐19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT‐PCR had a sensitivity of 98.4% for COVID‐19 (p < 0.01 vs. RT‐PCR alone) compared to 95.9% for CG plus RT‐PCR (p = 0.05).

Conclusions

In suspected COVID‐19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT‐PCR plus low probability based on CBIIG can rule out COVID‐19 with a relatively low number of false‐negative cases.

Development and Validation of a Simplified Probability Assessment Score Integrated With Age-Adjusted d-Dimer for Diagnosis of Acute Aortic Syndromes

Background

When acute aortic syndromes (AASs) are suspected, pretest clinical probability assessment and d‐dimer (DD) testing are diagnostic options allowing standardized care. Guidelines suggest use of a 12‐item/3‐category score (aortic dissection detection) and a DD cutoff of 500 ng/mL. However, a simplified assessment tool and a more specific DD cutoff could be advantageous.

Methods and Results

In a prospective derivation cohort (n=1848), 6 items identified by logistic regression (thoracic aortic aneurysm, severe pain, sudden pain, pulse deficit, neurologic deficit, hypotension), composed a simplified score (AORTAs) assigning 2 points to hypotension and 1 to the other items. AORTAs≤1 and ≥2 defined low and high clinical probability, respectively. Age‐adjusted DD was calculated as years/age × 10 ng/mL (minimum 500). The AORTAs score and AORTAs≤1/age‐adjusted DD rule were validated in 2 patient cohorts: a high‐prevalence retrospective cohort (n=1035; 22% AASs) and a low‐prevalence prospective cohort (n=447; 11% AASs) subjected to 30‐day follow‐up. The AUC of the AORTAs score was 0.729 versus 0.697 of the aortic dissection detection score (P=0.005). AORTAs score assessment reclassified 16.6% to 25.1% of patients, with significant net reclassification improvement of 10.3% to 32.7% for AASs and −8.6 to −17% for alternative diagnoses. In both cohorts, AORTAs≥2 had superior sensitivity and slightly lower specificity than aortic dissection detection ≥2. In the prospective validation cohort, AORTAs≤1/age‐adjusted DD had a sensitivity of 100%, a specificity of 48.6%, and an efficiency of 43.3%.

Conclusions

AORTAs is a simplified score with increased sensitivity, improved AAS classification, and minor trade‐off in specificity, amenable to integration with age‐adjusted DD for diagnostic rule‐out.

Diagnosis and management of acute aortic syndromes in the emergency department

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

AIMS

The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation.

METHODS AND RESULTS

This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6-97.1%) and a failure rate of 1.9% (95% CI 0.9-3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0-1.2%).

CONCLUSION

FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs.

Integrated Use of Conventional Chest Radiography Cannot Rule Out Acute Aortic Syndromes in Emergency Department Patients at Low Clinical Probability

OBJECTIVES

Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AASs) if the pretest clinical probability is low. However, the diagnostic impact of CR integration for the rule-in and rule-out of AASs is unknown.

METHODS

We performed a secondary analysis of the ADvISED multicenter study. Emergency department outpatients were eligible if an AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (ME) and other signs.

RESULTS

In 2014 through 2016, a total of 1,129 patients were enrolled and 1,030 were analyzed, including 48 (4.7%) with AASs. ADD-RS/ME and ADD-RS/any CR sign (aCRs) integration were more accurate than ADD-RS alone (area under the curve = 0.8 and 0.78 vs. 0.66, p < 0.001). The sensitivity and specificity of the integrated strategies were 66.7% (95% confidence interval [CI] = 51.5% to 79.9%) and 82.5% (95% CI = 79.9% to 84.8%) for ADD-RS/ME and 68.8% (95% CI = 53.6% to 80.9%) and 76.5% (95% CI = 73.7% to 79.1%) for ADD-RS/aCRs, respectively. The sensitivity and specificity of CR per se were 54.2% (95% CI = 39.2% to 68.6%) and 92.4% (95% CI = 90.5% to 93.9%) for ME and 60.4% (95% CI = 45.3% to 74.2%) and 85.2% (95% CI = 82.9% to 87.4%) for aCRs. The agreement (κ) between attending physicians and radiologists for ME was 0.44 (95% CI = 0.35 to 0.54). ADD-RS/ME rule-in (ADD-RS ≤ 1 and ME-present, or ADD-RS > 1) applied to 204 versus 130 patients with ADD-RS > 1, including 14 with AAS and 60 false-positives (FP). ADD-RS/aCRs rule-in (ADD-RS ≤ 1 and aCRs-present, or ADD-RS > 1) applied to 264 patients, including 15 with AAS and 119 FP. ADD-RS/ME rule-out (ADD-RS ≤ 1 and ME-absent) applied to 826 (80.2%) patients, including 16 with AAS (33.3% of cases). ADD-RS/aCRs rule-out (ADD-RS ≤ 1 and aCRs-absent) applied to 766 patients (74.4%), including 15 with AAS (31.3% of cases).

CONCLUSIONS

CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out.

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.

Fingerprinting Acute Digestive Diseases by Untargeted NMR Based Metabolomics

Precision medicine may significantly contribute to rapid disease diagnosis and targeted therapy, but relies on the availability of detailed, subject specific, clinical information. Proton nuclear magnetic resonance (¹H–NMR) spectroscopy of body fluids can extract individual metabolic fingerprints. Herein, we studied 64 patients admitted to the Florence main hospital emergency room with severe abdominal pain. A blood sample was drawn from each patient at admission, and the corresponding sera underwent ¹H–NMR metabolomics fingerprinting. Unsupervised Principal Component Analysis (PCA) analysis showed a significant discrimination between a group of patients with symptoms of upper abdominal pain and a second group consisting of patients with diffuse abdominal/intestinal pain. Prompted by this observation, supervised statistical analysis (Orthogonal Partial Least Squares–Discriminant Analysis (OPLS-DA)) showed a very good discrimination (>90%) between the two groups of symptoms. This is a surprising finding, given that neither of the two symptoms points directly to a specific disease among those studied here. Actually herein, upper abdominal pain may result from either symptomatic gallstones, cholecystitis, or pancreatitis, while diffuse abdominal/intestinal pain may result from either intestinal ischemia, strangulated obstruction, or mechanical obstruction. Although limited by the small number of samples from each of these six conditions, discrimination of these diseases was attempted. In the first symptom group, >70% discrimination accuracy was obtained among symptomatic gallstones, pancreatitis, and cholecystitis, while for the second symptom group >85% classification accuracy was obtained for intestinal ischemia, strangulated obstruction, and mechanical obstruction. No single metabolite stands up as a possible biomarker for any of these diseases, while the contribution of the whole ¹H–NMR serum fingerprint seems to be a promising candidate, to be confirmed on larger cohorts, as a first-line discriminator for these diseases.

Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism

Evaluating the diagnostic performance of focused cardiac ultrasound (US) alone and combination with venous US in patients with shock and suspected pulmonary embolism (PE). Consecutive adult patients with shock and suspected PE, presenting to two Italian emergency departments, were included. Patients underwent cardiac and venous US at presentation with the aim of detecting right ventricular (RV) dilatation and proximal deep venous thrombosis (DVT). Final diagnosis of PE was based on a second level diagnostic test or autopsy. Among the 105 patients included in the study, 43 (40.9%) had a final diagnosis of PE. Forty-seven (44.8%) patients showed RV dilatation and 27 (25.7%) DVT. Sensitivity and specificity of cardiac US were 91% (95% CI 80-97%) and 87% (95% CI 80-91%), respectively. Venous US showed a lower sensitivity (56%, 95% CI 45-60%) but higher specificity (95%, 95% CI 88-99%) than cardiac US (both p < 0.05). When cardiac and venous US were both positive (22 out of 105 patients, 21%) the specificity increased to 100% (p < 0.01 vs cardiac US), whereas when at least one was positive (54 out of 105 patients, 51%) the sensitivity increased to 95% (p = 0.06 vs cardiac US). Focused cardiac US showed good but not optimal sensitivity and specificity for the diagnosis of PE in patients presenting with shock. Venous US significantly increased specificity of cardiac US, and the diagnosis of PE can be certain when both tests are positive or reasonably excluded when negative.

SURF1 knockout cloned pigs: Early onset of a severe lethal phenotype

Leigh syndrome (LS) associated with cytochrome c oxidase (COX) deficiency is an early onset, fatal mitochondrial encephalopathy, leading to multiple neurological failure and eventually death, usually in the first decade of life. Mutations in SURF1, a nuclear gene encoding a mitochondrial protein involved in COX assembly, are among the most common causes of LS. LSSURF1 patients display severe, isolated COX deficiency in all tissues, including cultured fibroblasts and skeletal muscle. Recombinant, constitutive SURF1-/- mice show diffuse COX deficiency, but fail to recapitulate the severity of the human clinical phenotype. Pigs are an attractive alternative model for human diseases, because of their size, as well as metabolic, physiological and genetic similarity to humans. Here, we determined the complete sequence of the swine SURF1 gene, disrupted it in pig primary fibroblast cell lines using both TALENs and CRISPR/Cas9 genome editing systems, before finally generating SURF1-/- and SURF1-/+ pigs by Somatic Cell Nuclear Transfer (SCNT). SURF1-/- pigs were characterized by failure to thrive, muscle weakness and highly reduced life span with elevated perinatal mortality, compared to heterozygous SURF1-/+ and wild type littermates. Surprisingly, no obvious COX deficiency was detected in SURF1-/- tissues, although histochemical analysis revealed the presence of COX deficiency in jejunum villi and total mRNA sequencing (RNAseq) showed that several COX subunit-encoding genes were significantly down-regulated in SURF1-/- skeletal muscles. In addition, neuropathological findings, indicated a delay in central nervous system development of newborn SURF1-/- piglets. Our results suggest a broader role of sSURF1 in mitochondrial bioenergetics.

Reperfusion Injury after ischemic Stroke Study (RISKS): single-centre (Florence, Italy), prospective observational protocol study

INTRODUCTION

Treatments aiming at reperfusion of the acutely ischaemic brain tissue may result futile or even detrimental because of the so-called reperfusion injury. The processes contributing to reperfusion injury involve a number of factors, ranging from blood-brain barrier (BBB) disruption to circulating biomarkers. Our aim is to evaluate the relative effect of imaging and circulating biomarkers in relation to reperfusion injury.

METHODS AND ANALYSIS

Observational hospital-based study that will include 140 patients who had ischaemic stroke, treated with systemic thrombolysis, endovascular treatment or both. BBB disruption will be assessed with CT perfusion (CTP) before treatment, and levels of a large panel of biomarkers will be measured before intervention and after 24 hours. Relevant outcomes will include: (1) reperfusion injury, defined as radiologically relevant haemorrhagic transformation at 24 hours and (2) clinical status 3 months after the index stroke. We will investigate the separate and combined effect of pretreatment BBB disruption and circulating biomarkers on reperfusion injury and clinical status at 3 months. Study protocol is registered at http://www.clinicaltrials.gov (ClinicalTrials.gov ID: NCT03041753).

ETHICS AND DISSEMINATION

The study protocol has been approved by ethics committee of the Azienda Ospedaliero Universitaria Careggi (Università degli Studi di Firenze). Informed consent is obtained by each patient at time of enrolment or deferred when the participant lacks the capacity to provide consent during the acute phase. Researchers interested in testing hypotheses with the data are encouraged to contact the corresponding author. Results from the study will be disseminated at national and international conferences and in medical thesis.

TRIAL REGISTRATION NUMBER

NCT03041753.

Management of patients presenting with haemoptysis to a Tertiary Care Italian Emergency Department: the Florence Haemoptysis Score (FLHASc)

We analysed the clinical features and diagnostic workup of patients presenting with haemoptysis to an Italian teaching hospital to derive an easy-to-use clinical score to guide risk stratification and initial management in the emergency department (ED). We retrospectively reviewed clinical records of consecutive patients with haemoptysis over 1 year. A pre-specified set of variables, including demographic data, vital signs, type of expectorate (pure blood vs. blood-streaked sputum), comorbidities, and diagnostic tests and treatments was originally registered. The primary outcome was a composite of any of the following: death from any cause, invasive or non-invasive ventilation, Intensive Care Unit admission, blood transfusions or invasive haemostatic procedures. We investigated associations between the pre-specified clinical variables and the primary outcome using a logistic regression analysis. Finally, we derived a score (the Florence Haemoptysis Score, FLHASc) giving a proportional weight to each variable according to the Odds Ratios (OR). We included 197 patients with a median age of 60 years. The first radiological study was a plain chest X-ray in 128 patients (65%). For 33 (17%) patients, a chest computer tomography (CT scan) was the first radiological study. The most common diagnosis was lung malignancy (19% of cases). The diagnosis remained undetermined in one-third of patients. The primary outcome was met by 11.2% of the study population. Systolic blood pressure <100 mmHg (OR 9.7), a history of malignancy (OR 3), the expectoration of pure blood (OR 2.8), and more than 2 episodes of haemoptysis in the prior 24 h (OR 2.5) are found as independent predictors of the primary outcome. The FLHASc ranges from 0 to 6 with a prognostic accuracy of 78% (IC 95%, 68-88%). The primary outcome incidence is 2.4% (IC 95%, 0.2-8.2%) in patients with a FLHASc equal to zero (n = 85, 43%) versus 13.4% (IC 95% 7.8-21.1%) in patients with a FLHASc > 0 (p < 0.01). Among patients with a FLHASc equal to zero, a negative chest X-ray study identifies patients who may be safely discharged. Patients who presented to the ED with haemoptysis experience a heterogeneous management. We derive a simple clinical prognostic score that may rationalize their diagnostic workup.

Duplex Sonography of Vertebral Arteries for Evaluation of Patients with Acute Vertigo

We evaluated the role of vertebral artery extracranial color-coded duplex sonography (VAECCS) in predicting vertebrobasilar stroke in consecutive patients presenting to the emergency department with vertigo of suspected ischemic origin. The final diagnosis was established by a panel of experts consisting of an emergency physician, a neurologist, and an otoneurologist. Vertebrobasilar stroke was diagnosed when an acute brain ischemic lesion congruent with symptoms was detected by neuroimaging during the index visit or a stroke was diagnosed within a 3-mo period after emergency department presentation. Among 126 patients, 28 (22%) were diagnosed with vertebrobasilar stroke. Fifteen (75%) of 20 patients with abnormal VAECCS results and 13 (12%) of 106 with normal VAECCS results had a final diagnosis of vertebrobasilar stroke. The sensitivity and specificity of VAECCS were 53.6% and 94.9%, respectively. Detecting an abnormal flow pattern at VAECCS significantly increased the risk of vertebrobasilar stroke (odds ratio = 21.5). The flow patterns most frequently related to vertebrobasilar stroke were absence of flow and high resistance pattern velocity (odds ratio = 9.3 and 22.7, respectively). VAECCS predicts vertebrobasilar stroke and could be a useful bedside screening tool in patients with vertigo.

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

Objective

We investigated the reliability and accuracy of a bedside diagnostic algorithm for patients presenting with vertigo/unsteadiness to the emergency department.

Methods

We enrolled consecutive adult patients presenting with vertigo/unsteadiness at a tertiary hospital. STANDING, the acronym for the four-step algorithm we have previously described, based on nystagmus observation and well-known diagnostic maneuvers includes (1) the discrimination between SponTAneous and positional nystagmus, (2) the evaluation of the Nystagmus Direction, (3) the head Impulse test, and (4) the evaluation of equilibrium (staNdinG). Reliability of each step was analyzed by Fleiss’ K calculation. The reference standard (central vertigo) was a composite of brain disease including stroke, demyelinating disease, neoplasm, or other brain disease diagnosed by initial imaging or during 3-month follow-up.

Results

Three hundred and fifty-two patients were included. The incidence of central vertigo was 11.4% [95% confidence interval (CI) 8.2–15.2%]. The leading cause was ischemic stroke (70%). The STANDING showed a good reliability (overall Fleiss K 0.83), the second step showing the highest (0.95), and the third step the lowest (0.74) agreement. The overall accuracy of the algorithm was 88% (95% CI 85–88%), showing high sensitivity (95%, 95% CI 83–99%) and specificity (87%, 95% CI 85–87%), very high-negative predictive value (99%, 95% CI 97–100%), and a positive predictive value of 48% (95% CI 41–50%) for central vertigo.

Conclusion

Using the STANDING algorithm, non-sub-specialists achieved good reliability and high accuracy in excluding stroke and other threatening causes of vertigo/unsteadiness.

Comparison of clinical scores for identification of patients with pulmonary embolism at intermediate-high risk of adverse clinical outcome: the prognostic role of plasma lactate

To compare the prognostic accuracy of the 2014 risk model of the European Society of Cardiology (ESC) and of Bova and TELOS scores for identification of normotensive patients with pulmonary embolism (PE) at high risk for short-term adverse events (i.e., intermediate-high risk patients), we retrospectively applied these tests to a prospective cohort of 994 normotensive patients with objectively confirmed PE. Sixty-three (6.3 %) patients reached the primary outcome, a composite of hemodynamic collapse and death within 7 days from diagnosis. The Bova and TELOS scores classified the same proportion of patients in intermediate-high risk category (5.9 and 5.7 %, respectively), with a similar primary outcome rate (18.6 and 21.1 %, respectively). The 2014 ESC model classified in the intermediate-high risk category the largest proportion of patients (12.5 %, p < 0.001 vs Bova and TELOS), with the lowest primary outcome rate (13 %, p = ns vs Bova and TELOS). When lactate determination was added to the Bova score, 112 patients (11.2 %) were classified in the intermediate-high risk category (p < 0.05 vs Bova and TELOS), with a slight increase in the primary outcome rate (25.9 %, p = 0.014 vs 2014 ESC model), allowing the recognition of a twofold higher number of patients reaching the primary outcome (29 vs 15, 11 and 12 patients in the 2014 ESC model, Bova and TELOS scores, respectively, p < 0.01 for all). The 2014 ESC model, Bova and TELOS scores identify a small number of intermediate-high risk patients with PE, without differences among tests. Adding plasma lactate to the Bova score significantly improves the identification of intermediate-high risk patients.

Diagnostic Performance of Wells Score Combined With Point-of-care Lung and Venous Ultrasound in Suspected Pulmonary Embolism

OBJECTIVE

Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated.

METHODS

We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis.

RESULTS

A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied.

CONCLUSIONS

A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE.

Point-of-Care Ultrasonography for Evaluation of Acute Dyspnea in the ED

BACKGROUND

Acute dyspnea is a common symptom in the ED. The standard approach to dyspnea often relies on radiologic and laboratory results, causing excessive delay before adequate therapy is started. Use of an integrated point-of-care ultrasonography (PoCUS) approach can shorten the time needed to formulate a diagnosis, while maintaining an acceptable safety profile.

METHODS

Consecutive adult patients presenting with dyspnea and admitted after ED evaluation were prospectively enrolled. The gold standard was the final diagnosis assessed by two expert reviewers. Two physicians independently evaluated the patient; a sonographer performed an ultrasound evaluation of the lung, heart, and inferior vena cava, while the treating physician requested traditional tests as needed. Time needed to formulate the ultrasound and the ED diagnoses was recorded and compared. Accuracy and concordance of the ultrasound and the ED diagnoses were calculated.

RESULTS

A total of 2,683 patients were enrolled. The average time needed to formulate the ultrasound diagnosis was significantly lower than that required for ED diagnosis (24 ± 10 min vs 186 ± 72 min; P = .025). The ultrasound and the ED diagnoses showed good overall concordance (κ = 0.71). There were no statistically significant differences in the accuracy of PoCUS and the standard ED evaluation for the diagnosis of acute coronary syndrome, pneumonia, pleural effusion, pericardial effusion, pneumothorax, and dyspnea from other causes. PoCUS was significantly more sensitive for the diagnosis of heart failure, whereas a standard ED evaluation performed better in the diagnosis of COPD/asthma and pulmonary embolism.

CONCLUSIONS

PoCUS represents a feasible and reliable diagnostic approach to the patient with dyspnea, allowing a reduction in time to diagnosis. This protocol could help to stratify patients who should undergo a more detailed evaluation.

Diagnostic accuracy of lung ultrasonography combined with procalcitonin for the diagnosis of pneumonia: a pilot study

BACKGROUND

The diagnostic value of lung ultrasonography (LUS) and procalcitonin (PCT) in the diagnosis of lung infections is known. No studies evaluated the combination of LUS and PCT for the diagnosis of pneumonia in the emergency department (ED). We evaluated the diagnostic accuracy of the combination of LUS and PCT in the diagnosis of pneumonia.

METHODS

Patients with respiratory symptoms of unexplained origin who underwent a chest CT in ED were included in the study if PCT assay was available. LUS was performed before CT and was targeted to the detection of lung consolidations with the morphologic features of pneumonia. A PCT assay was performed at presentation, and cut-off of 0.25 and of 0.5 ng/ml were used to rule-out and rule-in pneumonia. The final diagnosis of pneumonia was established by independent clinicians, on the basis of clinical chart review including CT results.

RESULTS

We enrolled 128 patients and pneumonia was the final diagnosis in 61 (47.7%). In 38 patients (29.7%) LUS and PCT were negative (PCT < 0.25 ng/ml). The overall accuracy, sensitivity and negative predictive value of LUS/PCT were 88.8, 96.7 and 94.7% respectively. Sensitivity of the LUS/PCT test was significantly superior to LUS alone (85.2%) and PCT alone (73.8%) (p < 0.05 for both). Specificity and positive predictive value of the combination of positivity of LUS/PCT (PCT > 0.5 ng/ml) were 94% and 83.3% respectively. Specificity of LUS/PCT was not significantly different to LUS alone (88.1%) (p = 0.125).

CONCLUSIONS

The sensitivity of the combination of LUS with PCT for the diagnosis of pneumonia was significantly superior when compared with the sensitivity of LUS and PCT alone.

Louse-Borne Relapsing Fever with Meningeal Involvement in an Immigrant from Somalia to Italy, October 2015

INTRODUCTION

Borrelia recurrentis, transmitted by Pediculus humanus humanus, is the etiological agent of louse-borne relapsing fever (LBRF). Currently the main focus of endemicity of LBRF is localized in East African countries. From July 2015 to October 2015, 36 cases of LBRF have been diagnosed in Europe in immigrants from the Horn of Africa. Here we report a case of LBRF with meningitis diagnosed in Florence, Italy, in an immigrant arrived from Somalia.

CASE STUDY

In October 2015, a 19-year-old Somali male presented to the emergency department of the Azienda Ospedaliero Universitaria Careggi, Florence, Italy, with a 3-day history of high fever. The patient had disembarked in Sicily 10 days before admission after a long migration trip from his country of origin. On clinical examination, neck stiffness was found. Main laboratory findings were thrombocytopenia, increased procalcitonin, and increased polymorphonucleates in the cerebrospinal fluid. Suspecting a possible meningitis, the patient was treated with ceftriaxone, pending results of laboratory testing for malaria, and developed severe hypotension that was treated with fluid resuscitation and hydrocortisone. Hemoscopic testing revealed the presence of spirochetes and no malaria parasites. The patient rapidly improved with doxycycline for 7 days and ceftriaxone for 11 days, then was lost to follow-up. Total DNA from blood was extracted, and amplification and sequencing with universal 16S rDNA primers D88 and E94 revealed a 100% identity with B. recurrentis A1.

CONCLUSIONS

LBRF is a rare but emerging infectious disease among vulnerable displaced immigrants from the Horn of Africa. Since immigrants from endemic areas can carry the vector with them, the infection should be suspected even in subjects with compatible clinical features living in the same place where new arrival immigrants are hosted. Healthcare providers should be aware of this condition to implement adequate diagnostic, therapeutic, and public health measures.

"Timing" of arrival and in-hospital mortality in a cohort of patients under anticoagulant therapy presenting to the emergency departments with cerebral hemorrhage: A multicenter chronobiological study in Italy

Therapy with oral anticoagulants (OACs) is a risk factor for cerebral hemorrhage (CH). Although different studies have been undertaken to investigate the timing of the onset of major cardiovascular events, no data exist on temporal patterns of the onset of CH in subjects treated with OACs. The aim of this study is to evaluate the timing of CH in patients treated with OACs. All patients who developed CH under OACs therapy and admitted to 28 Italian Emergency Departments (EDs) between September 2011 and July 2013 were enrolled. Age, sex, time and location of the hemorrhagic lesion, type of the bleeding events (idiopathic or post-traumatic), anticoagulant therapy (warfarin or new oral anticoagulants - NOAs) and time of ED admission (i.e., hour, day, month and season) were recorded. Five hundred and seventeen patients (63.2% male aged 80 ± 7.9 yrs) with CH were involved. Warfarin was taken by 494 patients (95.6%), and NOAs by 23 (4.4%). In-hospital mortality (IHM) was recorded in 208 cases (40.2%). Cosinor analysis showed a peak of CH arrival between 12:00 and 14:00 h both in the whole population (PR 73.9%, p = 0.002) and the male subgroup (PR 65.2%, p = 0.009), whereas females showed an anticipated morning peak between 08:00 and 10:00 h (PR 65.7%, p = 0.008). A further analysis between idiopathic and post-traumatic CH confirmed the presence of a 24 h pattern with a peak between 12:00 and 14:00 h (PR 58.5%, p = 0.019) and between 08:00 and 10:00 h (PR80.1%, p < 0.001) for idiopathic events and post-traumatic hemorrhages, respectively. Moreover, a seasonal winter peak was identified for idiopathic forms (PR 74%, p = 0.035), and a summer peak for post-traumatic forms (PR 77%, p = 0.025). The present study suggests the presence of a temporal pattern of ED arrivals in CH patients treated with OACs.

Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors.

138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure <90 mmHg than in 107 normotensives (42% versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58–3.73; p<0.0001), while RiHT characteristics did not. Patients with RiHT had higher pulmonary embolism mortality than controls (19% versus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02).

30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls.

Chest Abdominal-Focused Assessment Sonography for Trauma during the primary survey in the Emergency Department: the CA-FAST protocol

PURPOSE

To evaluate the feasibility of a new protocol, Chest Abdominal-Focused Assessment Sonography for Trauma (CA-FAST), during the primary survey and to estimate its diagnostic accuracy when compared with thoracoabdominal computed tomography (CT) scan.

METHODS

A prospective accuracy study was performed from November 2012 to November 2013 at the Emergency Department. Only adult trauma patients who underwent a CA-FAST examination prior to a thoracoabdominal CT scan were enrolled. In addition to standard patterns detected by Extended-FAST (E-FAST) such as pneumothorax (PTX), hemothorax (HTX), pericardial and intraabdominal effusion, CA-FAST protocol also included the research of lung contusions (LCs).

RESULTS

Six hundred and one patients were enrolled. The mean time for protocol execution was 7 ± 3 min. Chest ultrasonography showed the following results (all p < 0.001): LCs sensitivity 59 %, specificity 98 %, positive predictive value (PPV) 92 %, negative predictive value (NPV) 86 %, accuracy 87 %; PTX sensitivity 84 %, specificity 98 %, PPV 93 %, NPV 95 %, accuracy 95 %; HTX sensitivity 82 %, specificity 97 %, PPV 87 %, NPV 95 %, accuracy 94 %. The standard 4-views FAST examination showed a diagnostic accuracy of 91 % with a sensitivity of 75 %, specificity of 96 %, PPV of 81 % and NPV of 94 %.

CONCLUSION

According to our results CA-FAST protocol proved to be a rapid bedside method, with good accuracy and high NPV in detection of ultrasonographic patterns suggestive of serious injury in trauma patients; moreover, the additional research of LCs did not cause a delay in the diagnosis. Ultrasonography should be used as initial investigation during the primary survey, sending to further diagnostic studies (CT scan) only those patients not clearly classified.

Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study

BACKGROUND

Pneumoperitoneum is a rare cause of abdominal pain characterized by a high mortality. Ultrasonography (US) can detect free intraperitoneal air; however, its accuracy remains unclear. The aims of this pilot study were to define the diagnostic performance and the reliability of abdominal US for the diagnosis of pneumoperitoneum.

METHODS

This was a prospective observational study. Four senior and two junior physicians were shown, in an unpaired randomized order, abdominal US videos from 11 patients with and 11 patients without pneumoperitoneum. Abdominal US videos were obtained from consecutive patients presenting to ED complaining abdominal pain with the diagnosis of pneumoperitoneum established by CT. Abdominal US was performed according to a standardized protocol that included the following scans: epigastrium, right and left hypochondrium, umbilical area and right hypochondrium with the patient lying on the left flank. We evaluated accuracy, intra- and inter-observer agreement of abdominal US when reviewed by senior physicians. Furthermore, we compared the accuracy of a "2 scan-fast exam" (epigastrium and right hypochondrium) vs the full US examination and the accuracy of physicians expert in US vs nonexpert ones. Finally, accuracy of US was compared with abdominal radiography in patients with available images.

RESULTS

Considering senior revision, accuracy of abdominal US was 88.6 % (95 % CI 79.4-92.4 %) with a sensitivity of 95.5 % (95 % CI 86.3-99.2 %) and a specificity of 81.8 % (95 % CI 72.6-85.5 %). Inter- and intra-observer agreement (k) were 0.64 and 0.95, respectively. Accuracy of a "2 scan-fast exam" (87.5 %, 95 % CI 77.9-92.4 %) was similar to global exam. Sensitivity of abdominal radiography (72.2 %, 95 % CI 54.8-85.7 %) was lower than that of abdominal US, while specificity (92.5 %, 95 % CI 79.5-98.3 %) was higher. Accuracy (68.2 %, 95 % CI 51.4-80.9 %) of junior reviewers evaluating US was lower than senior reviewers.

CONCLUSIONS

Senior physicians can recognize US signs of pneumoperitoneum with a good accuracy and reliability; sensitivity of US could be superior to abdominal radiography and a 2 fast-scan exam seems as accurate as full abdominal examination. US could be a useful bedside screening test for pneumoperitoneum. Trial registry ClinicalTrials.gov; No.: NCT02004925; URL: http://www.clinicaltrials.gov.

Can emergency physicians accurately and reliably assess acute vertigo in the emergency department?

OBJECTIVE

To validate a clinical diagnostic tool, used by emergency physicians (EPs), to diagnose the central cause of patients presenting with vertigo, and to determine interrater reliability of this tool.

METHODS

A convenience sample of adult patients presenting to a single academic ED with isolated vertigo (i.e. vertigo without other neurological deficits) was prospectively evaluated with STANDING (SponTAneousNystagmus, Direction, head Impulse test, standiNG) by five trained EPs. The first step focused on the presence of spontaneous nystagmus, the second on the direction of nystagmus, the third on head impulse test and the fourth on gait. The local standard practice, senior audiologist evaluation corroborated by neuroimaging when deemed appropriate, was considered the reference standard. Sensitivity and specificity of STANDING were calculated. On the first 30 patients, inter-observer agreement among EPs was also assessed.

RESULTS

Five EPs with limited experience in nystagmus assessment volunteered to participate in the present study enrolling 98 patients. Their average evaluation time was 9.9 ± 2.8 min (range 6-17). Central acute vertigo was suspected in 16 (16.3%) patients. There were 13 true positives, three false positives, 81 true negatives and one false negative, with a high sensitivity (92.9%, 95% CI 70-100%) and specificity (96.4%, 95% CI 93-38%) for central acute vertigo according to senior audiologist evaluation. The Cohen's kappas of the first, second, third and fourth steps of the STANDING were 0.86, 0.93, 0.73 and 0.78, respectively. The whole test showed a good inter-observer agreement (k = 0.76, 95% CI 0.45-1).

CONCLUSIONS

In the hands of EPs, STANDING showed a good inter-observer agreement and accuracy validated against the local standard of care.

Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate

BACKGROUND

Strategies for identifying normotensive patients with acute symptomatic PE at high risk of PE-related complications remain to be defined.

METHODS

This prospective cohort study aimed to determine the role of plasma lactate levels in the risk assessment of normotensive patients with acute PE. Outcomes assessed over the 7 days after the diagnosis of PE included PE-related mortality and haemodynamic collapse, defined as need for cardiopulmonary resuscitation, systolic blood pressure <90 mm Hg for at least 15 min, need for catecholamine administration, or need for mechanical ventilation.

RESULTS

Between December 2012 and January 2014, the study enrolled 496 normotensive outpatients with acute symptomatic PE. PE-related complications occurred in 20 (4.0%; 95% CI 2.5% to 6.2%) of the 496 patients. These patients had higher baseline lactate levels (median 2.66 mmol/L; IQR 1.56-5.96 mmol/L) than patients without complications (1.20 mmol/L; IQR 1.20-2.00 mmol/L) (p<0.001). Overall, 135 patients (27.2%) had plasma lactate ≥2 mmol/L. Fourteen (10.4%) of them had PE-related complications versus 6 of 361 patients with low lactate (negative predictive value 98.3%; p<0.001). Patients with elevated plasma lactate had an increased rate of PE-related complications (adjusted OR 5.3; 95% CI 1.9 to 14.4; p=0.001) compared with those with low lactate. The combination of elevated plasma lactate with markers of right ventricular dysfunction (by echocardiogram) and myocardial injury (by cardiac troponin) was a particularly useful prognostic indicator (positive predictive value 17.9%; 95% CI 6.1% to 36.9%).

CONCLUSIONS

Plasma lactate represents a powerful predictor of short-term PE-related complications and may provide guidance for decision-making in PE care.

Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography

OBJECTIVES

Despite emerging evidences on the clinical usefulness of lung ultrasound (LUS), international guidelines still do not recommend the use of sonography for the diagnosis of pneumonia. Our study assesses the accuracy of LUS for the diagnosis of lung consolidations when compared to chest computed tomography (CT).

METHODS

This was a prospective study on an emergency department population complaining of respiratory symptoms of unexplained origin. All patients who had a chest CT scan performed for clinical reasons were consecutively recruited. LUS was targeted to evaluate lung consolidations with the morphologic characteristics of pneumonia, and then compared to CT.

RESULTS

We analyzed 285 patients. CT was positive for at least one consolidation in 87 patients. LUS was feasible in all patients and in 81 showed at least one consolidation, with a good inter-observer agreement (k = 0.83), sensitivity 82.8% (95% CI 73.2%-90%) and specificity 95.5% (95% CI 91.5%-97.9%). Sensitivity raised to 91.7% (95% CI 61.5%-98.6%) and specificity to 97.4% (95% CI 86.5%-99.6%) in patients complaining of pleuritic chest pain. In a subgroup of 190 patients who underwent also chest radiography (CXR), the sensitivity of LUS (81.4%, 95% CI 70.7%-89.7%) was significantly superior to CXR (64.3%, 95% CI 51.9%-75.4%) (P<.05), whereas specificity remained similar (94.2%, 95% CI 88.4%-97.6% vs. 90%, 95% CI 83.2%-94.7%).

CONCLUSIONS

LUS represents a reliable diagnostic tool, alternative to CXR, for the bedside diagnosis of lung consolidations in patients with respiratory complains.