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Backgroud. The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. Methods. A quasiexperimental pre–post study was performed at the general ED of our hospital. During the pre phase (June 2013–July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014–October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Results. Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70–88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15–2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39–3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42–3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43–0.94; P = .026). Conclusion. Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.

Since a few years ago health systems in the western countries have a new problem to face: being a Medical Doctor (MD), especially a hospital or a general practice physician, is less and less appealing for the young generations. [...]

The world is facing a new pandemic that sets the national health systems, their structures and professionals in a crisis never experienced before. (...)

The overuse of medical services is regarded as a growing problem in Western countries, accounting for up to 30% of all delivered care, and carrying a higher risk of morbidity and mortality. One of the leading drivers toward medical overuse is the so-called defensive medicine, which is commonly defined as ordering of tests, procedures, and visits, or, at variance, avoidance of high-risk patients or procedures, aimed to reduce exposure to malpractice liability. Defensive medicine may increase the amount of care provided to the patients (i.e., additional tests or therapies), change care or setting of care (i.e., patients referred to another specialist or another healthcare facility), or impair the optimal care (i.e., refusing risky patients). Some studies seem to confirm a large utilization of defensive medicine in the emergency departments. This article tries to analyze some key points capable to pave the way to a consistent reduction of defensive medicine, thus defining a hierarchical list of priorities, keeping the patient’s health always at the center of the matter.

Cardiac troponins T and I (cTnT and cTnI) are the main markers of acute myocardial cell damage and then of Acute Coronary Syndrome (ACS) if associated with compatible symptoms. Although their cardio-specificity, the cTn may be increased in various clinical conditions but only few recent studies have reported their trends with age. This is a single-center retrospective observational study on two groups of adults consecutive patients, with age ≥65 years, admitted to the Emergency Department of the Sant'Orsola-Malpighi Hospital of Bologna, Italy, with chest pain as chief complaint. In the first group was dosed cTnT (N=617), in the second group cTnI (N=569). The patients with final ACS’s diagnosis (N=255) or an incomplete report of blood tests (N=17) were excluded. The definitive database included 471 patients in the first group and 443 in the second one. The observed differences between clinical parameters, patients with cTnT≤14ng/L and those with cTnT>14ng/L (N=207, 44%) are: older age, greater prevalence of diabetes, lower values of Hb e ALT, higher values of white blood cells, INR, glycemia, urea, creatinine, BNP e PCR. In multiple logistics regression (N=333) only 4 variables resulted independently associated to cTnT increase: age (P<0.0001), PCR (P=0.01), creatinine (P=0.02) and urea (P=0.04), R2=0.30. The differences between patients with cTnI≤40ng/L and those with cTnI>40ng/L (N=46, 10%) are: older age, Hb values equal and higher values of white blood cells, INR, glycemia, urea, creatinine, total bilirubin, AST, BNP e PCR. In multiple logistics regression (N=259) the only 4 variables independently associated to increase of cTnI are age (P<0.0001), glycemia (P=0.004), PCR (P=0.01) and white blood cells (P=0.02), R2=0.17. Furthermore, the number of patients with high level of cTn significantly increase by age (cTnT: 65-74 years 22.2%, 75-84 years 48.5%, ≥85 years 79.5%; cTnI: 65-74 years 4.3%, 75-84 years 8.1%, ≥85 years 22.5%, P<0.0001). In our study, cTnI showed fewer false positives than cTnT and seems to be less influenced by kidney failure. Furthermore, the acute phase of inflammation was associated with the rise of troponins. High cTn values were found in elderly subjects, without acute coronary syndromes, particularly cTnT. Then the age seems to be the most important factor related to this highelevated troponin levels.

Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea. To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF). Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P < .001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P < .0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR-proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days. In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days.