Publications by authors named "Giuliano Bertazzoni"

38 Publications

Viral community acquired pneumonia at the emergency department: Report from the pre COVID-19 age.

J Med Virol 2021 Mar 30. Epub 2021 Mar 30.

Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy.

The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre-coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and in-hospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled-up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co-infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB-65. All intra-ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB-65 score ≥2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one-third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests.
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http://dx.doi.org/10.1002/jmv.26980DOI Listing
March 2021

Interplay between Nox2 Activity and Platelet Activation in Patients with Sepsis and Septic Shock: A Prospective Study.

Oxid Med Cell Longev 2020 27;2020:4165358. Epub 2020 Oct 27.

Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.

Background: Although preclinical studies highlighted the potential role of NADPH oxidase (NOX) in sepsis, only few studies evaluated the oxidative stress in patients with sepsis and septic shock. The objective of the study is to appraise the oxidative stress status and platelet function in patients with sepsis and septic shock compared to healthy controls.

Methods And Results: Patients with sepsis or septic shock admitted to the hospital Policlinico Umberto I (Sapienza University, Rome) underwent a blood sample collection within 1 hour from admission. Platelet aggregation, serum thromboxane B2 (TxB2), soluble NOX2-derived peptides (sNox2-dp), and hydrogen peroxide breakdown activity (HBA) were measured and compared to those of healthy volunteers. Overall, 33 patients were enrolled; of these, 20 (60.6%) had sepsis and 13 (39.4%) septic shock. Compared to healthy controls ( = 10, age 67.8 ± 3.2, male 50%), patients with sepsis and septic shock had higher platelet aggregation (49% (IQR 45-55), 60% (55.75-67.25), and 73% (IQR 69-80), respectively, < 0.001), higher serum TxB2 (77.5 (56.5-86.25), 122.5 (114-131.5), and 210 (195-230) pmol/L, respectively, < 0.001), higher sNox2-dp (10 (7.75-12), 19.5 (17.25-21), and 33 (29.5-39) pg/mL, respectively, < 0.001), and lower HBA (75% (67.25-81.5), 50% (45-54.75), and 27% (21.5-32.5), respectively, < 0.001). Although not statistically significant, a trend in higher levels of serum TxB2 and sNox2-dp in patients who died was observed.

Conclusions: Patients with septic shock exhibit higher Nox2 activity and platelet activation than patients with sepsis. These insights joined to better knowledge of these mechanisms could guide the identification of future prognostic biomarkers and new therapeutic strategies in the scenario of septic shock.
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http://dx.doi.org/10.1155/2020/4165358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641261PMC
October 2020

qSOFA as a new community-acquired pneumonia severity score in the emergency setting.

Emerg Med J 2020 Oct 6. Epub 2020 Oct 6.

Department of Public Health and Infectious Diseases, University of Rome La Sapienza, Roma, Lazio, Italy.

Background: Quick Sequential Organ Failure Assessment (qSOFA) score is a bedside prognostic tool for patients with suspected infection outside the intensive care unit (ICU), which is particularly useful when laboratory analyses are not readily available. However, its performance in potentially septic patients with community-acquired pneumonia (CAP) needs to be examined further, especially in relation to early outcomes affecting acute management.

Objective: First, to compare the performance of qSOFA and CURB-65 in the prediction of mortality in the emergency department in patients presenting with CAP. Second, to study patients who required critical care support (CCS) and ICU admission.

Methods: Between January and December 2017, a 1-year retrospective observational study was carried out of adult (≥18 years old) patients presenting to the emergency department (ED) of our hospital (Rome, Italy) with CAP. The accuracy of qSOFA, qSOFA-65 and CURB-65 was compared in predicting mortality in the ED, CCS requirement and ICU admission. The concordance among scores ≥2 was then assessed for 30-day estimated mortality prediction.

Results: 505 patients with CAP were enrolled. Median age was 71.0 years and mortality rate in the ED was 4.7%. The areas under the curve (AUCs) of qSOFA-65, CURB-65 and qSOFA in predicting mortality rate in the ED were 0.949 (95% CI 0.873 to 0.976), 0.923 (0.867 to 0.980) and 0.909 (0.847 to 0.971), respectively. The likelihood ratio of a patient having a qSOFA score ≥2 points was higher than for qSOFA-65 or CURB-65 (11 vs 7 vs 6.7). The AUCs of qSOFA, qSOFA-65 and CURB-65 in predicting CCS requirement were 0.862 (95% CI 0.802 to 0.923), 0.824 (0.758 to 0.890) and 0.821 (0.754 to 0.888), respectively. The AUCs of qSOFA-65, qSOFA and CURB-65 in predicting ICU admission were 0.593 (95% CI 0.511 to 0.676), 0.585 (0.503 to 0.667) and 0.570 (0.488 to 0.653), respectively. The concordance between qSOFA-65 and CURB-65 in 30-day estimated mortality prediction was 93%.

Conclusion: qSOFA is a valuable score for predicting mortality in the ED and for the prompt identification of patients with CAP requiring CCS. qSOFA-65 may further improve the performance of this useful score, showing also good concordance with CURB-65 in 30-day estimated mortality prediction.
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http://dx.doi.org/10.1136/emermed-2019-208789DOI Listing
October 2020

Xerostomia, gustatory and olfactory dysfunctions in patients with COVID-19.

Am J Otolaryngol 2020 Nov - Dec;41(6):102721. Epub 2020 Sep 10.

Department of Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA.

Background: The novel Coronavirus Disease-19 (COVID-19) continues to have profound effect on global health. Our aim was to evaluate the prevalence and characterize specific symptoms associated with COVID-19.

Methods: This retrospective study included 326 patients with confirmed SARS-CoV-2 infection evaluated at the Emergency Department of the Umberto I Polyclinic Hospital, Rome, Italy between March 6th and April 30th, 2020. In order to assess xerostomia, olfactory and gustatory dysfunctions secondary to COVID-19, a telephone-based a modified survey obtained from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 for taste and smell disorders and the Fox Questionnaire for dry mouth were administered to 111 patients (34%) after discharge between June 4th and June 12th.

Results: Taste dysfunction was the most common reported symptom (59.5%; n = 66), followed by xerostomia (45.9%; n = 51) and olfactory dysfunctions (41.4%; n = 46). The most severe symptom was olfactory dysfunction with a median severity score of 8.5 (range: 5-10). Overall 74.5% (n = 38) of patients with xerostomia, 78.8% (n = 52) of patients with gustatory dysfunctions and 71.1% (n = 33) of patients with olfactory dysfunctions reported that all symptoms appeared before COVID-19 diagnosis. Overall, the majority of patients reported one symptom only (45.9%, n = 51), 37 (33.3%) reported the association of two symptoms, and 23 (20.7%) patients reported the association of three symptoms at the same time.

Conclusion: Xerostomia, gustatory and olfactory dysfunctions may present as a prodromal or as the sole manifestation of COVID-19. Awareness is fundamental to identify COVID-19 patients at an early stage of the disease and limit the spread of the virus.
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http://dx.doi.org/10.1016/j.amjoto.2020.102721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482593PMC
November 2020

Copeptin Kinetics in Acute Ischemic Stroke May Differ According to Revascularization Strategies: Pilot Data.

Stroke 2019 12 21;50(12):3632-3635. Epub 2019 Oct 21.

Department of Human Neurosciences (M.D.M., S.L., E.C.I., A.F., F.L., D.T.), Policlinico Umberto I Hospital, Sapienza University, Rome, Italy.

Background and Purpose- Prognostic value of copeptin in acute ischemic stroke has been widely reported. This study aimed to evaluate copeptin temporal profile according to revascularization strategies and the development of brain edema and hemorrhagic transformation. Methods- Plasma copeptin and brain edema and hemorrhagic transformation assessed by computed tomography/magnetic resonance imaging were evaluated upon admission (), at 24 hours (), and between the third and fifth day of hospitalization () in 34 acute ischemic stroke patients. Results- Median copeptin concentration was 50.71 pmol/L at , 18.31 pmol/L at , and 10.92 pmol/L at . Copeptin at was higher in patients with medium/severe brain edema at (32.25 versus 13.67 pmol/L; =0.038) and hemorrhagic transformation at (93.10 versus 13.67 pmol/L; <0.003) and (85.70 versus 14.45 pmol/L; =0.024). Copeptin level drop (CopΔ) was significantly steeper in patients receiving revascularization, particularly in those undergoing combined therapy (-129.34 versus -5.43 pmol/L; =0.038). Δ also correlated with Thrombolysis in Cerebral Infarction score (<0.001). Conclusions- Copeptin resulted associated with brain edema and hemorrhagic transformation in acute ischemic stroke, and its drop at 24 hours may mirror effective brain vessel recanalization.
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http://dx.doi.org/10.1161/STROKEAHA.119.025433DOI Listing
December 2019

Impact of the 2017 measles outbreak on the emergency care system of a large tertiary-care teaching hospital in Italy: a retrospective analysis.

Eur J Public Health 2019 10;29(5):966-971

Department of Emergency Medicine, University of Rome Sapienza,Rome, Italy.

Background: A large outbreak of measles has spread across Italy over the year 2017. Its impact on emergency department (ED) of a tertiary-care teaching hospital and the related critical issues in public health were evaluated.

Methods: Medical records of adults discharged from January to December 2017 with diagnosis of 'measles' or 'measles suspicion' were collected and analyzed.

Results: From a total of 58 579 admissions, 218 medical records matched enrollment criteria. Measles infection was confirmed in 55.3% of patients, excluded in 26.2%, and judged as possible or probable in 18.3% of cases. Considered that the vaccination status was unknown in 89.2% of patients, the mean time spent in temporary isolation rooms (TIRs) waiting serological results was 1.7 ± 0.8 days. Measles-free patients spent a mean of 1.9 ± 0.9 days in TIRs, meaning a cumulative unnecessary time of isolation of 106.4 days. Despite most of patients were pauci-simptomatic and with a low burden of comorbidities, only 28.6% of them reported a previous out-of-hospital medical contact. Moreover an assessment of moderately critical conditions was assigned to 89.6% of cases, representing an over-valuation of the severity of the cases. Antibiotic therapy had been prescribed in 69.0% of cases and 57.7% of patients were hospitalized. We found no differences in terms of median time spent in TIRs, rate of hospitalization and antibiotic prescription between measles cases and measles-free patients.

Conclusion: A preventable high-infective disease outbreak can lead to a misapply of ED facilities in terms of unjustified admissions, time spent in TIRs, antibiotic prescription and in hospitalization rate.
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http://dx.doi.org/10.1093/eurpub/ckz056DOI Listing
October 2019

Corticosteroid Use and Incident Myocardial Infarction in Adults Hospitalized for Community-acquired Pneumonia.

Ann Am Thorac Soc 2019 01;16(1):91-98

1 Department of Internal Medicine and Medical Specialties.

Rationale: Adults hospitalized for community-acquired pneumonia (CAP) have an increased risk of myocardial infarction. Corticosteroid treatment lowers CAP morbidity and mortality, but it is not known whether it influences in-hospital myocardial infarction.

Objectives: The aim of the present study was to investigate the potential interplay between corticosteroid treatment and in-hospital myocardial infarction in adults with CAP.

Methods: We retrospectively analyzed adults with CAP referred to the University Hospital Policlinico Umberto I (Rome, Italy), consecutively recruited, and prospectively followed until discharge. The primary outcome was the occurrence of myocardial infarction during hospitalization. We used propensity score-adjusted Cox models to examine the association between corticosteroid use and myocardial infarction.

Results: Seven hundred fifty-eight patients (493 males, 265 females; mean ± standard deviation age, 71.7 ± 14.4 yr) were included in the study. Of these, 241 (32%) were treated with systemic corticosteroids (methylprednisolone, betamethasone, or prednisone). During follow-up, 62 (8.2%) had a myocardial infarction during their hospitalization (incidence, 0.72 per 100 person-days; 95% confidence interval [CI], 0.55 to 0.92). Those treated with corticosteroids had a lower incidence of myocardial infarction (0.42 per 100 person-days) than those not treated with corticosteroids (0.89 per 100 person-days; absolute rate difference, -0.48 per 100 person-days; 95% CI, -0.85 to -0.10). In a propensity score-adjusted Cox model, corticosteroid use was associated with a lower incidence of myocardial infarction (hazard ratio, 0.46; 95% CI, 0.24 to 0.88; P = 0.02).

Conclusions: We found that in-hospital corticosteroid treatment was associated with a lower incidence of myocardial infarction in adults hospitalized with CAP.
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http://dx.doi.org/10.1513/AnnalsATS.201806-419OCDOI Listing
January 2019

Dabigatran Reversal with Idarucizumab in an Emergency Lumbar Puncture: A Case Report.

Curr Drug Saf 2019 ;14(1):40-42

Emergency Department Stroke Unit, Policlinico Umberto I Hospital in Rome, "Sapienza University of Rome", Rome, Italy.

Introduction: The widespread use of direct oral anticoagulants (DOACs) has been increasing the conditions in which emergency physicians are forced to rapidly reverse anticoagulation in case of life-threatening bleeding or need of urgent surgery or invasive procedures. The recent approval of Idarucizumab, a humanized monoclonal antibody fragment (Fab), offered the opportunity to rapidly and safely neutralize the anticoagulant effect of Dabigatran. However, real-world experience of its effective use in different emergency setting is now required. Lumbar Puncture (LP) is recognized as an invasive procedure at major bleeding risk and is, therefore, contraindicated in anticoagulated patients.

Conclusion: We report a successful use of Idarucizumab in an emergency LP of a young woman with a possible diagnosis of encephalitis and a previous history of venous thromboembolism on long-term treatment with Dabigatran 150 mg twice a day.
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http://dx.doi.org/10.2174/1574886313666180816125234DOI Listing
May 2019

Early decrease of oxidative stress by non-invasive ventilation in patients with acute respiratory failure.

Intern Emerg Med 2018 03 15;13(2):183-190. Epub 2017 Sep 15.

I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.

Oxidative stress plays an important role in chronic respiratory diseases where the use of non-invasive ventilation seems to reduce the oxidative damage. Data on acute respiratory failure are still lacking. The aim of the study is to investigate the interplay between oxidative stress and acute respiratory failure, and the role of non-invasive ventilation in this setting. We enrolled 60 patients suffering from acute respiratory failure (PaO/FiO ratio <300): 30 consecutive patients treated with non-invasive ventilation and 30 consecutive patients treated with conventional oxygen therapy. Serum levels of soluble Nox2-derived peptide (sNOX2-dp), a marker of NADPH-oxidase activation, and 8-iso-PGF2α and HO, markers of oxidative stress, were evaluated at baseline and after 3 h of treatment. At baseline, higher values of sNOX2-dp, 8-iso-PGF2α and HO are associated with lower values of PaO/FiO ratio (p < 0.001). After 3 h, serum levels of sNOX2-dp, HO, and 8-iso-PGF2α significantly decrease in patients treated with non-invasive ventilation, but not in patients treated with conventional oxygen therapy. Delta changes of oxidative stress parameters correlate inversely with the delta changes of PaO/FiO (R = -0.623, p < 0.001 for sNOX2-dp; R = -0.428, p < 0.001 for HO; R = -0.548, p < 0.001 for 8-iso-PGF2α). In the acute respiratory failure setting, treatment with non-invasive ventilation reduces the levels of oxidative stress in the first hours. This reduction is associated with an improvement of PaO/FiO ratio as well as in a reduction of NADPH-oxidase activity.
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http://dx.doi.org/10.1007/s11739-017-1750-5DOI Listing
March 2018

[Venous thromboembolism in critically ill patients: analysis of the main age-related risk factors and definition of specific scores.]

Recenti Prog Med 2016 Sep;107(9):480-484

Medicina Interna, Università "Cattolica", Policlinico Gemelli, Roma.

Introduction: Venous thromboembolism (VTE) is the third most common cardiovascular illness after acute coronary syndrome and stroke and and the most common preventable cause of hospital-related death. Several studies have demonstrated a significant reduction of fatal pulmonary embolism attributed to the introduction of thromboprophylactic measures and changes in hospital practices. However, the influence of some demographical variables, especially age, has largely been under appreciated.

Methods: Using the date of the TEVere study, we have studied 187 patients with VTE and 350 case-control, and we proceeded to analyze the major risk factors for venous thromboembolism, separately for three age groups (≤60 years, 60-75 years, >75 years). Patients came from the departments of internal medicine and emergency medicine for 21 hospitals. In this subgroup, we have examined the main risk factors for the individual classes of age and have proposed, through a logistic regression analysis, 3 different types of scores, specific for each age class. We then compared the individual scores obtained with the Kucher's score.

Results: It was found that in the class of patients with a lower age of 60, the main risk factors found to be estrogen-progestagen treatment (p=0.004) and family history of VTE (p=0.047), while in older patients (>75 years) the main risk factors were immobilization (p=0.005) and chronic venous insufficiency (p=0.001). In common for the three classes the presence of an evolutionary malignancy and previous episodes of VTE. Through the ROC curve analysis, it was found that the results for the three proposed scores improved sensitivity compared to Kucher's score. However our results showed that the only score of the intermediate class showed a statistically significant difference for prediction of the thromboembolic risk (p=0.0264 (AUROC 0.7946; 95% CI, 0.75 to 0.80, AUROC 0.7042; 95% CI, 0.68. to 0.72).

Discussion: Our study emphasizes the importance of carrying a correct stratification, which also consider the patient's age and therefore the concomitant pathologies. In fact, although the age of the patient cannot be considered as the only criterion to start the thromboprophylaxis, as highlighted in literature, you need to consider each individual patient, with its own peculiarities.

Conclusion: This study showed the difficulty in identifying the key risk factors that are responsible for thromboembolic disease and has emerged the opportunity to be evaluated by larger studies, the use of specific scores by age groups.
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http://dx.doi.org/10.1701/2354.25228DOI Listing
September 2016

Impaired flow-mediated dilation in hospitalized patients with community-acquired pneumonia.

Eur J Intern Med 2016 Dec 7;36:74-80. Epub 2016 Oct 7.

Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy.

Background: Community-acquired pneumonia (CAP) is complicated by cardiovascular events as myocardial infarction and stroke but the underlying mechanism is still unclear. We hypothesized that endothelial dysfunction may be implicated and that endotoxemia may have a role.

Methods: Fifty patients with CAP and 50 controls were enrolled. At admission and at discharge, flow-mediated dilation (FMD), serum levels of endotoxins and oxidative stress, as assessed by serum levels of nitrite/nitrate (NOx) and isoprostanes, were studied.

Results: At admission, a significant difference between patients with CAP and controls was observed for FMD (2.1±0.3 vs 4.0±0.3%, p<0.001), serum endotoxins (157.8±7.6 vs 33.1±4.8pg/ml), serum isoprostanes (341±14 vs 286±10 pM, p=0.009) and NOx (24.3±1.1 vs 29.7±2.2μM). Simple linear correlation analysis showed that serum endotoxins significantly correlated with Pneumonia Severity Index score (Rs=0.386, p=0.006). Compared to baseline, at discharge CAP patients showed a significant increase of FMD and NOx (from 2.1±0.3 to 4.6±0.4%, p<0.001 and from 24.3±1.1 to 31.1±1.5μM, p<0.001, respectively) and a significant decrease of serum endotoxins and isoprostanes (from 157.8±7.6 to 55.5±2.3pg/ml, p<0.001, and from 341±14 to 312±14 pM, p<0.001, respectively). Conversely, no changes for FMD, NOx, serum endotoxins and isoprostanes were observed in controls between baseline and discharge. Changes of FMD significantly correlated with changes of serum endotoxins (Rs=-0.315; p=0.001).

Conclusions: The study provides the first evidence that CAP is characterized by impaired FMD with a mechanism potentially involving endotoxin production and oxidative stress.
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http://dx.doi.org/10.1016/j.ejim.2016.09.008DOI Listing
December 2016

Severe hypoglycemia in patients with known diabetes requiring emergency department care: A report from an Italian multicenter study.

J Clin Transl Endocrinol 2016 Sep 20;5:46-52. Epub 2016 Aug 20.

Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy.

Aims: To describe the characteristics and associated risk factors of patients with established diabetes who required Emergency Department (ED) care for severe hypoglycemia.

Methods: We performed an observational retrospective study to identify all cases of severe hypoglycemia among attendees at the EDs of three Italian University hospitals from January 2010 to December 2014.

Results: Overall, 520 patients with established diabetes were identified. Mean out-of-hospital blood glucose concentrations at the time of the hypoglycemic event were 2.2 ± 1.3 mmol/L. Most of these patients were frail and had multiple comorbidities. They were treated with oral hypoglycemic drugs (43.6%), insulin (42.8%), or both (13.6%). Among the oral hypoglycemic drugs, glibenclamide (54.5%) and repaglinide (25.7%) were the two most frequently used drugs, followed by glimepiride (11.3%) and gliclazide (7.5%). Hospitalization rates and in-hospital deaths occurred in 35.4% and in 2.3% of patients, respectively. Cirrhosis (odds ratio [OR] 6.76, 95% confidence interval [CI] 1.24-36.8, p < 0.05), chronic kidney disease (OR 2.42, 95% CI 1.11-8.69, p < 0.05) and center (Sapienza University OR 3.70, 95% CI 1.57-8.69, p < 0.05) were the strongest predictors of increased rates of hospital admission.

Conclusions: Severe hypoglycemia is a remarkable burden for patients with established diabetes and increases the risk of adverse clinical outcomes (in-hospital death and hospitalization), mainly in elderly and frail patients. This study further reinforces the notion that careful attention should be taken by health care providers when they prescribe drug therapy in elderly patients with serious comorbidities.
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http://dx.doi.org/10.1016/j.jcte.2016.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644438PMC
September 2016

Perception of Thromboembolism Risk: Differences between the Departments of Internal Medicine and Emergency Medicine.

Keio J Med 2016 ;65(2):39-43

Emergency Department, Fatebenefratelli Isola Tiberina Hospital, Rome, Italy.

The latest developments in emergency medicine (EM) have introduced new typologies of patients that have not been taken into account in previous studies of venous thromboembolism (VTE) risk. The aim of the current study was to evaluate by comparing the main international risk scores whether different perceptions of VTE risk exist in internal medicine (IM) departments and in EM departments. This cross-sectional observational study involved 23 IM and 10 EM departments of 21 different hospitals. The patient data were collected by physicians who were blinded to the purpose of the study. The data were analyzed using the main international risk scores. We analyzed 742 patients, 222 (30%) hospitalized in EM departments and the remaining 520 (70%) in IM departments. We found that fewer patients at risk for VTE were treated with low-molecular-weight heparin (LMWH) in EM departments than in IM departments. Moreover, there was significant statistical difference in the use of LMWH between IM and EM departments when the Padua score and immobilization criteria were used to assess the risk. The infrequent use of LMWH in EM patients may have several causes. For example, in EM departments, treatment of acute illness often takes higher priority than VTE risk evaluation. Moreover, immobilization criteria cannot be evaluated for all EM patients because of the intrinsic time requirements. For the aforementioned reasons, we believe that a different VTE risk score is required that takes into account the peculiarities of EM, and establishing such a score should be the object of future study.
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http://dx.doi.org/10.2302/kjm.2015-0004-OADOI Listing
April 2017

Hospitalization for Pneumonia is Associated With Decreased 1-Year Survival in Patients With Type 2 Diabetes: Results From a Prospective Cohort Study.

Medicine (Baltimore) 2016 Feb;95(5):e2531

From the Department of Public Health and Infectious Diseases (FM, RA, PP, FA, VV, VM); Department of Internal Medicine and Medical Specialties (TG, CR, VF); Faculty of Medicine (GL, ME); Department of Emergency Medicine (BG); and Department of Clinical Medicine, "Sapienza" University of Rome, Rome, Italy (TG).

Diabetes mellitus is a frequent comorbid conditions among patients with pneumonia living in the community.The aim of our study is to evaluate the impact of hospitalization for pneumonia on early (30 day) and late mortality (1 year) in patients with type 2 diabetes mellitus.Prospective comparative cohort study of 203 patients with type 2 diabetes hospitalized for pneumonia versus 206 patients with diabetes hospitalized for other noninfectious causes from January 2012 to December 2013 at Policlinico Umberto I (Rome). Enrolled patients were followed up to discharge and up to 1 year after initial hospital admission or death.Overall, 203 patients with type 2 diabetes admitted to hospital for pneumonia were compared to 206 patients with type 2 diabetes admitted for other causes (39.3% decompensated diabetes, 21.4% cerebrovascular diseases, 9.2% renal failure, 8.3% acute myocardial infarction, and 21.8% other causes). Compared to control patients, those admitted for pneumonia showed a higher 30-day (10.8% vs 1%, P < 0.001) and 1-year mortality rate (30.3% vs 16.8%, P < 0.001). Compared to survivors, nonsurvivor patients with pneumonia had a higher incidence of moderate to severe chronic kidney disease, hemodialysis, and malnutrition were more likely to present with a mental status deterioration, and had a higher number of cardiovascular events during the follow-up period. Cox regression analysis found age, Charlson comorbidity index, pH < 7.35 at admission, hemodialysis, and hospitalization for pneumonia as variables independently associated with mortality.Hospitalization for pneumonia is associated with decreased 1-year survival in patients with type 2 diabetes, and appears to be a major determinant of long-term outcome in these patients.
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http://dx.doi.org/10.1097/MD.0000000000002531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4748878PMC
February 2016

[The overuse of thromboprophylaxis in medical patients: main clinical aspects].

G Ital Cardiol (Rome) 2015 Nov;16(11):639-43

Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Roma.

Background: Overuse of thromboprophylaxis is not an infrequent behavior in internal medicine. However, differently from underuse, overuse of thromboprophylaxis is rarely taken into account, and only few studies have addressed this issue. The purpose of our study was to try to understand the reasons behind this phenomenon.

Methods: Using data from the TEVERE study, we evaluated 279 patients hospitalized in 21 hospitals of the Lazio Region in Italy. Only patients who were negative to major risk scores as established in the scientific literature were included. We assessed the frequency of thromboprophylaxis in acutely ill medical patients hospitalized in emergency and internal medicine wards, and we performed a comparative analysis for each risk factor among patients who received or not received thromboprophylaxis.

Results: Forty-seven patients (16.5%) with negative risk scores were given thromboprophylaxis during hospitalization. On backward stepwise logistic regression analysis, severe infection (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.25-4.35) and chronic venous insufficiency (OR 3.02; 95% CI 1.96-4.67) were found to be the strongest predictors of the use of thromboprophylactic treatment with heparin. The subgroup of patients who did not exhibit risk factors was also analyzed, and age was found to be the main factor in the decision-making process regarding heparin administration in the absence of other risk factors (74.9 ± 11.8 vs 63.7 ± 18.1, p=0.002).

Conclusions: Our findings suggest that thromboprophylaxis is associated with considerable uncertainty, which results in its overuse. Further research is needed to better understand thromboembolic risk factors in hospitalized medical patients.
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http://dx.doi.org/10.1714/2066.22436DOI Listing
November 2015

Relation of Cardiac Complications in the Early Phase of Community-Acquired Pneumonia to Long-Term Mortality and Cardiovascular Events.

Am J Cardiol 2015 Aug 22;116(4):647-51. Epub 2015 May 22.

Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy. Electronic address:

Community-acquired pneumonia (CAP) is complicated by cardiac events in the early phase of the disease. Aim of this study was to assess if these intrahospital cardiac complications may account for overall mortality and cardiovascular events occurring during a long-term follow-up. Three hundred one consecutive patients admitted to the University-Hospital, Policlinico Umberto I, with community-acquired pneumonia were prospectively recruited and followed up for a median of 17.4 months. Primary end point was the occurrence of death for any cause, and secondary end point was the occurrence of cardiovascular events (cardiovascular death, nonfatal myocardial infarction [MI], and stroke). During the intrahospital stay, 55 patients (18%) experienced a cardiac complication. Of these, 32 had an MI (29 non-ST-elevation MI and 3 ST-elevation MI) and 30 had a new episode of atrial fibrillation (7 nonmutually exclusive events). During the follow-up, 89 patients died (51% of patients with an intrahospital cardiac complication and 26% of patients without, p <0.001) and 73 experienced a cardiovascular event (47% of patients with and 19% of patients without an intrahospital cardiac complication, p <0.001). A Cox regression analysis showed that intrahospital cardiac complications, age, and Pneumonia Severity Index were significantly associated with overall mortality, whereas intrahospital cardiac complications, age, hypertension, and diabetes were significantly associated with cardiovascular events during the follow-up. In conclusion, this prospective study shows that intrahospital cardiac complications in the early phase of pneumonia are associated with an enhanced risk of death and cardiovascular events during long-term follow-up.
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http://dx.doi.org/10.1016/j.amjcard.2015.05.028DOI Listing
August 2015

Individualizing risk of multidrug-resistant pathogens in community-onset pneumonia.

PLoS One 2015 10;10(4):e0119528. Epub 2015 Apr 10.

Department of Public Health and Infectious Diseases, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.

Introduction: The diffusion of multidrug-resistant (MDR) bacteria has created the need to identify risk factors for acquiring resistant pathogens in patients living in the community.

Objective: To analyze clinical features of patients with community-onset pneumonia due to MDR pathogens, to evaluate performance of existing scoring tools and to develop a bedside risk score for an early identification of these patients in the Emergency Department.

Patients And Methods: This was an open, observational, prospective study of consecutive patients with pneumonia, coming from the community, from January 2011 to January 2013. The new score was validated on an external cohort of 929 patients with pneumonia admitted in internal medicine departments participating at a multicenter prospective study in Spain.

Results: A total of 900 patients were included in the study. The final logistic regression model consisted of four variables: 1) one risk factor for HCAP, 2) bilateral pulmonary infiltration, 3) the presence of pleural effusion, and 4) the severity of respiratory impairment calculated by use of PaO2/FiO2 ratio. A new risk score, the ARUC score, was developed; compared to Aliberti, Shorr, and Shindo scores, this point score system has a good discrimination performance (AUC 0.76, 95% CI 0.71-0.82) and calibration (Hosmer-Lemeshow, χ2 = 7.64; p = 0.469). The new score outperformed HCAP definition in predicting etiology due to MDR organism. The performance of this bedside score was confirmed in the validation cohort (AUC 0.68, 95% CI 0.60-0.77).

Conclusion: Physicians working in ED should adopt simple risk scores, like ARUC score, to select the most appropriate antibiotic regimens. This individualized approach may help clinicians to identify those patients who need an empirical broad-spectrum antibiotic therapy.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0119528PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393134PMC
April 2016

Lower mortality rate in elderly patients with community-onset pneumonia on treatment with aspirin.

J Am Heart Assoc 2015 Jan 6;4(1):e001595. Epub 2015 Jan 6.

Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy (R.C., C.C., F.B., F.V.).

Background: Pneumonia is complicated by high rate of mortality and cardiovascular events (CVEs). The potential benefit of aspirin, which lowers platelet aggregation by inhibition of thromboxane A2 production, is still unclear. The aim of the study was to assess the impact of aspirin on mortality in patients with pneumonia.

Methods And Results: Consecutive patients admitted to the University-Hospital Policlinico Umberto I (Rome, Italy) with community-onset pneumonia were recruited and prospectively followed up until discharge or death. The primary end point was the occurrence of death up to 30 days after admission; the secondary end point was the intrahospital incidence of nonfatal myocardial infarction and ischemic stroke. One thousand and five patients (age, 74.7±15.1 years) were included in the study: 390 were receiving aspirin (100 mg/day) at the time of hospitalization, whereas 615 patients were aspirin free. During the follow-up, 16.2% of patients died; among these, 19 (4.9%) were aspirin users and 144 (23.4%; P<0.001) were aspirin nonusers. Overall, nonfatal CVEs occurred in 7% of patients, 8.3% in nonaspirin users, and 4.9% in aspirin users (odds ratio, 1.77; 95% confidence interval, 1.03 to 3.04; P=0.040). The Cox regression analysis showed that pneumonia severity index (PSI), severe sepsis, pleural effusion, and PaO(2)/FiO(2) ratio <300 negatively influenced survival, whereas aspirin therapy was associated with improved survival. Compared to patients receiving aspirin, the propensity score adjusted analysis confirmed that patients not taking aspirin had a hazard ratio of 2.07 (1.08 to 3.98; P=0.029) for total mortality.

Conclusions: This study shows that chronic aspirin use is associated with lower mortality rate within 30 days after hospital admission in a large cohort of patients with pneumonia.
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http://dx.doi.org/10.1161/JAHA.114.001595DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330080PMC
January 2015

Platelet activation is associated with myocardial infarction in patients with pneumonia.

J Am Coll Cardiol 2014 Nov 27;64(18):1917-25. Epub 2014 Oct 27.

I Clinica Medica, Sapienza University of Rome, Rome, Italy. Electronic address:

Background: Troponins may be elevated in patients with pneumonia, but associations with myocardial infarction (MI) and with platelet activation are still undefined.

Objectives: The aim of this study was to investigate the relationship between troponin elevation and in vivo markers of platelet activation in the early phase of hospitalization of patients affected by community-acquired pneumonia.

Methods: A total of 278 consecutive patients hospitalized for community-acquired pneumonia, who were followed up until discharge, were included. At admission, platelet activation markers such as plasma soluble P-selectin, soluble CD40 ligand, and serum thromboxane B2 (TxB2) were measured. Serum high-sensitivity cardiac troponin T levels and electrocardiograms were obtained every 12 and 24 h, respectively.

Results: Among 144 patients with elevated high-sensitivity cardiac troponin T, 31 had signs of MI and 113 did not. Baseline plasma levels of soluble P-selectin and soluble CD40 ligand and serum TxB2 were significantly higher in patients who developed signs of MI. Logistic regression analysis showed plasma soluble CD40 ligand (p < 0.001) and soluble P-selectin (p < 0.001), serum TxB2 (p = 0.030), mean platelet volume (p = 0.037), Pneumonia Severity Index score (p = 0.030), and ejection fraction (p = 0.001) to be independent predictors of MI. There were no significant differences in MI rate between the 123 patients (45%) taking aspirin (100 mg/day) and those who were not aspirin treated (12% vs. 10%; p = 0.649). Aspirin-treated patients with MIs had higher serum TxB2 compared with those without MIs (p = 0.005).

Conclusions: MI is an early complication of pneumonia and is associated with in vivo platelet activation and serum TxB2 overproduction; aspirin 100 mg/day seems insufficient to inhibit thromboxane biosynthesis. (MACCE in Hospitalized Patients With Community-acquired Pneumonia; NCT01773863).
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http://dx.doi.org/10.1016/j.jacc.2014.07.985DOI Listing
November 2014

Is NOX2 upregulation implicated in myocardial injury in patients with pneumonia?

Antioxid Redox Signal 2014 Jun 14;20(18):2949-54. Epub 2014 Mar 14.

1 I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome , Rome, Italy .

In the present study, we tested the hypothesis that oxidative stress could be implicated in myocardial damage during the acute phase of pneumonia. NOX2 activation, the catalytic subunit of NADPH oxidase, and high-sensitivity cardiac troponin T (hs-cTnT) elevation have been analyzed in two hundred forty-eight consecutive patients hospitalized for community-acquired pneumonia. Serum NOX2-derived peptide (sNOX2-dp), a marker of NOX2 activation, and 8-isoprostaglandin F2α (8-iso-PGF2α), a marker of oxidative stress, were measured upon admission; serum hs-cTnT and ECG were measured every 12 and 24 h, respectively. One hundred thirty-five patients (54%) showed elevated serum levels of hs-cTnT (>0.014 μg/L). A logistic regression analysis showed sNOX2-dp (p<0.001), Pneumonia Severity Index score (p<0.001), renal failure (p=0.024), and ejection fraction (p<0.001) as independent predictors of elevated serum levels of hs-cTnT. Serum sNOX2-dp was linearly correlated with hs-cTnT (Rs=0.538; p<0.001) and 8-iso-PGF2α (Rs=0.354; p<0.001). The study provides the first evidence of a significant association between serum cardiac Troponin T elevation and NOX2 upregulation in patients with pneumonia. This finding raises the hypothesis that NOX2-derived oxidative stress may be implicated in myocardial injury and that its inhibition could be a novel therapeutic strategy to limit it.
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http://dx.doi.org/10.1089/ars.2013.5766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038979PMC
June 2014

Guidance for diagnosis and treatment of acute angioedema in the emergency department: consensus statement by a panel of Italian experts.

Intern Emerg Med 2014 Feb 4;9(1):85-92. Epub 2013 Sep 4.

Medicina Interna, Ospedale Luigi Sacco, Università degli Studi di Milano, Milan, Italy,

Angioedema attacks, characterized by the transient swelling of the skin and mucosae, are a frequent cause of visits to the emergency department. Swellings of the oral cavity, tongue, or larynx can result in life-threatening airway obstruction, while abdominal attacks can cause severe pain and often lead to unnecessary surgery. The underlying pathophysiologic process resulting in increased vascular permeability and plasma extravasation is mediated by vasoactive molecules, most commonly histamine and bradykinin. Based on the mediator involved, distinct angioedema forms can be recognized, calling for distinct therapeutic approaches. Prompt recognition is challenging for the emergency physician. The low awareness among physicians of the existence of rare forms of angioedema with different aetiologies and pathogenesis, considerably adds to the problem. Also poorly appreciated by emergency personnel may be the recently introduced bradykinin-targeted treatments. The main objective of this consensus statement is to provide guidance for the management of acute angioedema in the emergency department, from presentation to discharge or hospital admission, with a focus on identifying patients in whom new treatments may prevent invasive intervention.
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http://dx.doi.org/10.1007/s11739-013-0993-zDOI Listing
February 2014

[Management strategies and choice of antithrombotic treatment in patients admitted with acute coronary syndrome--executive summary for clinical practice. Consensus Document of the Regional Chapters of the Italian National Association of Hospital Cardiologists (ANMCO) and of the Italian Society of Emergency Medicine (SIMEU)].

Monaldi Arch Chest Dis 2013 Mar;80(1):7-16

Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO).

This document has been developed by the Lazio regional chapters of two scientific associations, the Italian National Association of Hospital Cardiologists (ANMCO) and the Italian Society of Emergency Medicine (SIMEU), whose members are actively involved in the everyday management of Acute Coronary Syndromes (ACS). The document is aimed at providing a specific, practical, evidence-based guideline for the effective management of antithrombotic treatment (antiplatelet and anticoagulant) in the complex and ever changing scenario of ACS. The document employs a synthetic approach which considers two main issues: the actual operative context of treatment delivery and the general management strategy.
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http://dx.doi.org/10.4081/monaldi.2013.86DOI Listing
March 2013

Improving quality through clinical risk management: a triage sentinel event analysis.

Intern Emerg Med 2012 Jun 13;7(3):275-80. Epub 2011 Dec 13.

Medicina d'Urgenza e Pronto Soccorso, Sapienza Università di Roma, Rome, Italy.

"Triage" is a useful tool used in emergency departments (EDs) to prioritize the care of patients. Through a methodical process of different sequential steps, the triage nurse assigns a color code which goes from red-critical patient with immediate access to medical examination-to a white code that represents no urgency. Clinical studies have shown that patients can be victims of errors during the process of care, especially in complex systems such as EDs. To reduce errors it is essential to map the risks in order to identify the causes (both individual and organizational); the introduction of corrective changes cannot be postponed. The incorrect assessment at triage represents one of the major errors in EDs. By monitoring this activity, through the analysis of sentinel events we can reduce adverse consequences. Missed recognition of a red code indicates a sentinel event. We used a "root cause analysis" to explain an episode of missed recognition of red code at triage. A nurse without specific training in triage and inexperienced in critical care was identified as the "root cause" of the sentinel event. To make improvements we planned a triage training course (for newly employed nurses and a refresher course for existing staff) and created a team of dedicated triage nurses.
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http://dx.doi.org/10.1007/s11739-011-0742-0DOI Listing
June 2012

Rhinovirus frequently detected in elderly adults attending an emergency department.

J Med Virol 2011 Nov;83(11):2043-7

Laboratory of Virology, Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy.

The general aim was to investigate the burden of respiratory virus illness in a hospital emergency department, during two different epidemic seasons. Consecutive patients attending an emergency department during two study periods (February/March 2009 and 2010) were enrolled using broad inclusion criteria (fever/preceding fever and one of a set of ICD-9 codes suggestive of respiratory illness); nasopharyngeal washes were tested for the most common respiratory viruses using PCR-based methods. Influenza A virus was detected in 24% of samples collected in February/March 2009, whereas no samples tested positive for influenza during February/March 2010 (pandemic H1N1 Influenza A having circulated earlier in October-December 2009). Rhinovirus (HRV) was detected in 16% and 8% of patients recruited over the two study periods, respectively. Other respiratory viruses were detected rarely. Patient data were then analyzed with specific PCR results, comparing the HRV-positive group with virus-positive and no virus-detected groups. Individuals over 65 years old with HRV presented with signs, symptoms and underlying conditions and were admitted to hospital as often as the other enrolled patients, mainly for dyspnoea and chronic obstructive pulmonary disease acute exacerbation. Conversely, younger individuals with HRV, although presenting with respiratory signs and symptoms, were generally diagnosed with non-respiratory conditions. HRV was detected frequently in elderly patients attending the emergency department for respiratory distress without distinguishing clinical features. Molecular diagnosis of lower respiratory tract infections and surveillance of infectious diseases should include tests for HRV, as this virus is associated frequently with hospitalization of the elderly.
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http://dx.doi.org/10.1002/jmv.22205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7166537PMC
November 2011

Disparities in management of new-onset atrial fibrillation in the emergency department despite adherence to the current guidelines: data from a large metropolitan area.

Intern Emerg Med 2011 Apr 13;6(2):149-56. Epub 2011 Feb 13.

Department of Emergency Medicine, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168, Rome, Italy.

Atrial Fibrillation management is still a matter for debate. Past research has largely been based on the outpatient setting in which patients are followed during ambulatory visits. Very little data exist on the optimal management of AF in the Emergency Department (ED). This study investigated which factors drive different AF treatments in the ED, describing their use in different hospitals. Finally, the efficacy of different strategies in terms of cardioversion in the ED was analyzed. Charts of patients treated for atrial fibrillation (AF) were collected in 6 EDs in a large metropolitan area over a 24-consecutive month period and were reviewed and analysed. Demographics, comorbidities, treatment strategy and ED outcome were collected. Inclusion criteria were symptom onset <3 weeks and stable hemodynamic conditions at presentation. A propensity score was used to adjust for baseline clinical characteristics and to compare the efficacy of different treatments. 3,085 patients were included in the analysis. Variables associated with a rhythm control strategy were onset of symptoms <48 h, age, dyspnea, palpitations, renal failure and the presence of a mechanical valve. Different EDs applied different strategies in terms of drugs used and the electrocardioversion rate, showing heterogeneity in AF management. Adjusting for the propensity score, electrocardioversion and antidysrhythmic drugs of class Ic were more effective than a wait-and-watch strategy in the ED. Despite international guidelines being respected, AF management is heterogeneous in different ED settings. A rhythm control strategy with electrocardioversion and Class Ic drugs is more effective than a wait-and watch approach during the ED visit. Further research, toward an evidence-based approach to the emergent management of AF in the ED, is still needed.
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http://dx.doi.org/10.1007/s11739-011-0537-3DOI Listing
April 2011

Rescuing the drowned: cardiopulmonary resuscitation and the origins of emergency medicine in the eighteenth century.

Intern Emerg Med 2011 Aug 22;6(4):353-6. Epub 2010 Dec 22.

Section of History of Medicine, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.

The concept of a medical emergency, i.e., a time when immediate action is required to stabilize and restore the vital functions, is absent in the tradition of ancient medicine, which seeks to cure the sick. The theoretical and conceptual development of a prompt medical assistance definitely owes much to the refinement of instruments and surgical techniques that were develop in the early modern age, allowing the extension of therapeutic action to "healthy" individuals who are suddenly life-threatened due to an accident or to some external events that affect their vital functions. But it is especially in the eighteenth century that the epistemic basis of medical emergency is structured, when the Enlightenment gave rise to the ethical and political imperative of public assistance that required the planning of first aid at multiple levels, and medicine developed the concept of life-saving treatment. In particular, eighteenth century medicine, studying systems to assure immediate relief to the victims of accidents-especially to the drowned-allowed the development of specific and methodological systems of resuscitation and emergency treatment.
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http://dx.doi.org/10.1007/s11739-010-0495-1DOI Listing
August 2011

In-hospital percentage BNP reduction is highly predictive for adverse events in patients admitted for acute heart failure: the Italian RED Study.

Crit Care 2010 16;14(3):R116. Epub 2010 Jun 16.

Emergency Medicine Department, II Medical School University La Sapienza, Sant'Andrea Hospital, via di Grottarossa, 1039 Roma 00189, Italy.

Introduction: Our aim was to evaluate the role of B-type natriuretic peptide (BNP) percentage variations at 24 hours and at discharge compared to its value at admission in order to demonstrate its predictive value for outcomes in patients with acute decompensated heart failure (ADHF).

Methods: This was a multicenter Italian (8 centers) observational study (Italian Research Emergency Department: RED). 287 patients with ADHF were studied through physical exams, lab tests, chest X Ray, electrocardiograms (ECGs) and BNP measurements, performed at admission, at 24 hours, and at discharge. Follow up was performed 180 days after hospital discharge. Logistic regression analysis was used to estimate odds ratios (OR) for the various subgroups created. For all comparisons, a P value < 0.05 was considered statistically significant.

Results: BNP median (interquartile range (IQR)) value at admission was 822 (412 - 1390) pg\mL; at 24 hours was 593 (270 - 1953) and at discharge was 325 (160 - 725). A BNP reduction of >46% at discharge had an area under curve (AUC) of 0.70 (P < 0.001) for predicting future adverse events. There were 78 events through follow up and in 58 of these patients the BNP level at discharge was >300 pg/mL. A BNP reduction of 25.9% after 24 hours had an AUC at ROC curve of 0.64 for predicting adverse events (P < 0.001). The odds ratio of the patients whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was >46% was 4.775 (95% confidence interval (CI) 1.76 - 12.83, P < 0.002). The odds ratio of the patients whose BNP level at discharge was >300 pg/mL and whose percentage decrease at discharge was <46% compared to the group whose BNP level at discharge was <300 pg/mL and whose percentage decrease at discharge was >46% was 9.614 (CI 4.51 - 20.47, P < 0.001).

Conclusions: A reduction of BNP >46% at hospital discharge compared to the admission levels coupled with a BNP absolute value < 300 pg/mL seems to be a very powerful negative prognostic value for future cardiovascular outcomes in patients hospitalized with ADHF.
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http://dx.doi.org/10.1186/cc9067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911763PMC
January 2011

Diminished presynaptic GABA(B) receptor function in the neocortex of a genetic model of absence epilepsy.

Neurosignals 2009 29;17(2):121-31. Epub 2009 Jan 29.

Montreal Neurological Institute and Departments of Neurology and Neurosurgery, and Physiology, McGill University, Montréal, Que., Canada.

Changes in GABA(B) receptor subunit expression have been recently reported in the neocortex of epileptic WAG/Rij rats that are genetically prone to experience absence seizures. These alterations may lead to hyperexcitability by downregulating the function of presynaptic GABA(B) receptors in neocortical networks as suggested by a reduction in paired-pulse depression. Here, we tested further this hypothesis by analyzing the effects induced by the GABA(B) receptor agonist baclofen (0.1-10 microM) on the inhibitory events recorded in vitro from neocortical slices obtained from epileptic (>180 day-old) WAG/Rij and age-matched, non-epileptic control (NEC) rats. We found that higher doses of baclofen were required to depress pharmacologically isolated, stimulus-induced IPSPs generated by WAG/Rij neurons as compared to NEC. We also obtained similar evidence by comparing the effects of baclofen on the rate of occurrence of synchronous GABAergic events recorded by WAG/Rij and NEC neocortical slices treated with 4-aminopyridine + glutamatergic receptor antagonists. In conclusion, these data highlight a decreased function of presynaptic GABA(B) receptors in the WAG/Rij rat neocortex. We propose that this alteration may contribute to neocortical hyperexcitability and thus to absence seizures.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878904PMC
http://dx.doi.org/10.1159/000197864DOI Listing
July 2009

Neurosteroids and epileptogenesis in the pilocarpine model: evidence for a relationship between P450scc induction and length of the latent period.

Epilepsia 2009 Jan;50 Suppl 1:53-8

Dipartimento di Scienze Biomediche, Università di Modena e Reggio Emilia, Modena, Italy.

Purpose: Cytochrome P450 cholesterol side-chain cleavage enzyme (P450scc) catalyzes the initial step in the biosynthesis of neurosteroids within the brain. We sought to determine which cells express P450cc and whether neurosteroids play a role in the regulation of epileptogenesis following pilocarpine-induced status epilepticus (SE).

Methods: Rats experienced uninterrupted SE or SE terminated with diazepam at 60, 120, and 180 min. P450scc induction in CA3 hippocampus was determined by double immunolabeling with P450scc antiserum and monoclonal antibodies against GFAP (astrocytes), RIP (oligodendrocytes), or heme oxygenase-1 (microglia).

Results: SE was associated with P450scc induction in many astrocytes and a small number of microglia and oligodendrocytes in the hippocampal CA3 strata radiatum and lacunosum-moleculare. The extent of P450scc induction increased with increasing SE duration. Paradoxically, increased P450scc induction in rats experiencing SE for 180 min or more was associated with the delayed onset of spontaneous recurrent seizures. Treatment with the 5 alpha-reductase inhibitor finasteride (100 mg/kg/day for 25 days), which inhibits the synthesis of gamma-aminobutyric acid (GABA)(A) receptor modulating neurosteroids such as allopregnanolone, was associated with a significant reduction in time to the onset of spontaneous seizures in rats exposed to 180-min but not 90-min SE.

Discussion: P450scc is induced by SE in a diverse population of hippocampal glia. Induction of P450scc is associated with the delayed onset of spontaneous seizures. Conversely, inhibition of neurosteroid synthesis accelerated the onset of spontaneous seizures, but only in animals exhibiting significant increases in P450scc. These findings suggest that induction of neurosteroid synthesis in reactive glial cells is associated with delayed onset of spontaneously recurrent seizures.
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http://dx.doi.org/10.1111/j.1528-1167.2008.01971.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873280PMC
January 2009

Prognostic significance of interleukin-6 measurement in the diagnosis of acute myocardial infarction in emergency department.

Clin Chim Acta 2007 Jun 12;381(2):151-6. Epub 2007 Mar 12.

Department of Laboratory Medicine & Advanced Biotechnologies, IRCCS San Raffaele Pisana, Rome, Italy.

Background: Markers of inflammation may predict both coronary artery disease (CAD) and adverse outcomes in patients with known CAD. Here, we investigated the role of interleukin-6 (IL-6) in the "triage" and risk assessment of patients admitted to emergency department (ED).

Methods: Serum IL-6 and high sensitivity C-reactive protein (hs-CRP) levels were prospectively evaluated in 88 patients with a history of precordial chest pain or shortness of breath of recent onset (<6 h).

Results: Of the 88 patients, 21% were discharged from the ED with diagnosis of non-ischemic chest pain (NICP), 39% had a final diagnosis of unstable angina (UA) and 40% experienced an acute myocardial infarction (AMI). Median IL-6 (p<0.001) and hs-CRP (p<0.01) levels on admission were significantly increased in patients with AMI compared with patients with NICP or UA. IL-6 levels correlated with hs-CRP (p<0.01). Multivariate analyses including known risk factors showed that elevated creatine kinase-MB (p<0.05) and IL-6 levels (p<0.01) were independently associated with a final diagnosis of AMI. Elevated IL-6 levels significantly predicted the risk of AMI (OR=2.47, p=0.006) in chest pain-enzyme negative patients.

Conclusions: IL-6 may behave as an adjunctive diagnostic tool to assist in the risk assessment of enzyme-negative patients with precordial chest pain of recent onset.
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http://dx.doi.org/10.1016/j.cca.2007.03.002DOI Listing
June 2007