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In patients with acute circulatory failure, we tested the feasibility of the evaluation of the fluid-responsiveness (FR) by a combined approach with echocardiography and lung ultrasound. We enrolled 113 consecutive patients admitted to the Emergency Department High-Dependency Unit of Careggi University-Hospital from January 2015 to June 2020. We assessed: (1) inferior vena cava collapsibility index (IVCCI); (2) the variation of aortic flow (VTIAo) during the passive leg raising test (PLR); (3) the presence of interstitial syndrome by lung ultrasound. FR was defined as an increase in the VTIAo > 10% during PLR or IVCCI ≥ 40%. FR patients were treated with fluid and those non-FR with diuretics or vasopressors. The therapeutic strategy was reassessed after 12 h. The goal was to maintain the initial strategy. Among 56 FR patients, at lung ultrasound, 15 patients showed basal interstitial syndrome and 4 all-lung involvement. One fluid bolus was given to 51 patients. Among 57 non-FR patients, 26 patients showed interstitial syndrome at lung ultrasound (basal fields in 14, all lungs in 12). We administered diuretics to 21 patients and vasopressors to 4 subjects. We had to change the initial treatment plan in 9% non-FR patients and in 12% FR patients (p = NS). In the first 12 h after the evaluation, non-FR patients received significantly less fluids compared to those FR (1119 ± 410 vs 2010 ± 1254 ml, p < 0.001). The evaluation of the FR based on echocardiography and lung ultrasound was associated with the reduction in fluid administration for non-FR patients compared with those FR.

The aim of this study was to assess the incidence of deep vein thrombosis (DVT) of the lower limbs, using serial compression ultrasound (CUS) surveillance, in acutely ill patients with COVID-19 pneumonia admitted to a non-ICU setting. Multicenter, prospective study of patients with COVID-19 pneumonia admitted to Internal Medicine units. All patients were screened for DVT of the lower limbs with serial CUS. Anticoagulation was defined as: low dose (enoxaparin 20-40 mg/day or fondaparinux 1.5-2.5 mg/day); intermediate dose (enoxaparin 60-80 mg/day); high dose (enoxaparin 120-160 mg or fondaparinux 5-10 mg/day or oral anticoagulation). The primary end-point of the study was the diagnosis of DVT by CUS. Over a two-month period, 227 consecutive patients with moderate-severe COVID-19 pneumonia were enrolled. The incidence of DVT was 13.7% (6.2% proximal, 7.5% distal), mostly asymptomatic. All patients received anticoagulation (enoxaparin 95.6%) at the following doses: low 57.3%, intermediate 22.9%, high 19.8%. Patients with and without DVT had similar characteristics, and no difference in anticoagulant regimen was observed. DVT patients were older (mean 77±9.6 vs 71±13.1 years; p = 0.042) and had higher peak D-dimer levels (5403 vs 1723 ng/mL; p = 0.004). At ROC analysis peak D-dimer level >2000 ng/mL (AUC 0.703; 95% CI 0.572-0.834; p = 0.004) was the most accurate cut-off value able to predict DVT (RR 3.74; 95%CI 1.27-10, p = 0.016). The incidence of DVT in acutely ill patients with COVID-19 pneumonia is relevant. A surveillance protocol by serial CUS of the lower limbs is useful to timely identify DVT that would go otherwise largely undetected.

Pregnancy is a complex time characterized by major transformations in a woman, which impact her physical, mental, and social well-being. How a woman adapts to these changes can affect her quality of life and psychological well-being. The literature indicates that pregnant women commonly experience psychological symptoms, with anxiety, stress, and depression being among the most frequent. Hence, promoting a healthy lifestyle focused on women's psychological well-being is crucial. Recently developed digital solutions have assumed a crucial role in supporting psychological well-being in physiologically pregnant women. Therefore, the need becomes evident for the development and implementation of digital solutions, such as a virtual coach implemented in a smartphone, as a support for the psychological well-being of pregnant women who do not present psychological and psychiatric disorders. This study aims to assess the feasibility, acceptability, and utility of a mindfulness-based mobile app. The primary objective is to explore the feasibility of using a virtual coach, Maia, developed within the TreC Mamma app to promote women's psychological well-being during pregnancy through a psychoeducational module based on mindfulness. Finally, through the delivery of this module, the level of psychological well-being will be explored as a secondary objective. This is a proof-of-concept study in which a small sample (N=50) is sufficient to achieve the intended purposes. Recruitment will occur within the group of pregnant women belonging to the pregnancy care services of the Trento Azienda Provinciale per i Servizi Sanitari di Trento. The convenience sampling method will be used. Maia will interact with the participating women for 8 weeks, starting from weeks 24 and 26 of pregnancy. Specifically, there will be 2 sessions per week, which the woman can choose, to allow more flexibility toward her needs. The psychoeducational pathway is expected to lead to significant results in terms of usability and engagement in women's interactions with Maia. Furthermore, it is anticipated that there will be improvements in psychological well-being and overall quality of life. The analysis of the data collected in this study will be mainly descriptive, orientated toward assessing the achievement of the study objectives. Literature has shown that women preferred web-based support during the perinatal period, suggesting that implementing digital interventions can overcome barriers to social stigma and asking for help. Maia can be a valuable resource for regular psychoeducational support for women during pregnancy. RR1-10.2196/53890.

Overwhelming inflammatory reactions contribute to respiratory distress in patients with COVID-19. Ruxolitinib is a JAK1/JAK2 inhibitor with potent anti-inflammatory properties. We report on a prospective, observational study in 34 patients with COVID-19 who received ruxolitinib on a compassionate-use protocol. Patients had severe pulmonary disease defined by pulmonary infiltrates on imaging and an oxygen saturation ≤ 93% in air and/or PaO2/FiO2 ratio ≤ 300 mmHg. Median age was 80.5 years, and 85.3% had ≥ 2 comorbidities. Median exposure time to ruxolitinib was 13 days, median dose intensity was 20 mg/day. Overall survival by day 28 was 94.1%. Cumulative incidence of clinical improvement of ≥2 points in the ordinal scale was 82.4% (95% confidence interval, 71–93). Clinical improvement was not affected by low-flow versus high-flow oxygen support but was less frequent in patients with PaO2/FiO2 < 200 mmHg. The most frequent adverse events were anemia, urinary tract infections, and thrombocytopenia. Improvement of inflammatory cytokine profile and activated lymphocyte subsets was observed at day 14. In this prospective cohort of aged and high-risk comorbidity patients with severe COVID-19, compassionate-use ruxolitinib was safe and was associated with improvement of pulmonary function and discharge home in 85.3%. Controlled clinical trials are necessary to establish efficacy of ruxolitinib in COVID-19.

We evaluated the effectiveness of a training program with high-fidelity simulation (HFS) to improve technical (TS) and non-technical skills (NTS) of residents in Emergency Medicine. We conducted a 2-year training program for the management of a critical patient based on HFS (6 sessions for every year, four teams who performed 4 scenarios per session). At the beginning of the training program, all participants received a presentation of Crisis Resource Management (CRM) principles. Each session covered a different topic in Emergency Medicine Curriculum. TSs were measured as the proportion of completed tasks in the following areas: airway, breathing, circulation, disability and exposure (ABCDE) assessment and management, completion of anamnesis based on AMPLE (allergy, medications, previous illness, last meal and event) scheme, diagnostic and therapeutic assessment. NTSs were rated by the Clinical Teamwork Scale (CTS). Scores’ values and the percentage of correctly performed actions were presented as median with interquartile range. Friedmann non-parametric test was employed to evaluate the trend of TS and NTS over the following sessions. Among the TS, the assessment and management of ABCDE and completion of therapeutic tasks improved (all p < 0.05). The completion of diagnostic tasks (p = 0.050) tended toward significant improvement. The overall CTS score (first session 61 ± 17, last session 84 ± 16, p < 0.001) as well as Communication (first 13.7 ± 3.6, last 18.7 ± 3.5, p < 0.001), Situational Awareness (first 5.3 ± 1.8, last 6.4 ± 1.4, p = 0.012) and Role Responsibility subscores (first 9.7 ± 2.8, last 12.1 ± 3.7, p < 0.001) increased through the following sessions. Therefore, HFS has proven to be an effective instrument to improve TS and NTS among Emergency Medicine residents.

In the context of sepsis, we tested the relationship between echocardiographic findings and Troponin, and their impact on prognosis. In this prospective study, we enrolled 325 septic patients (41% with shock), not mechanically ventilated, between October, 2012 and June, 2019 among those admitted to our High-Dependency Unit. By echocardiography within 24 h from the admission, sepsis-induced myocardial dysfunction (SIMD) was defined as left ventricular (LV) systolic dysfunction (speckle-tracking-based global longitudinal peak systolic strain, GLS, >  – 14%) and/or right ventricular (RV) systolic dysfunction (Tricuspid Annular Plane Systolic Excursion, TAPSE < 16 mm). Troponin I levels were measured upon admission (T0) and after 24 h (T1); it was considered normal if > 0.1 ng/mL. Mortality was assessed at day-7 and day-28 end-points. One-hundred and forty-two patients had normal Troponin level at T0 and T1 (G1), 69 had abnormal levels at T0 or T1 (G2) and 114 showed abnormal Troponin levels at both T0 and T1 (G3). Compared to G1, patients in G3 had worse LV and RV systolic function (GLS  – 11.6 ± 3.4% vs  – 14.0 ± 3.5%, p < 0.001; TAPSE 18 ± 0.5 vs 19 ± 0.5 mm, p = 0.047) and greater day-28 (34% vs 20%, p = 0.015) mortality. In a Cox survival analysis including age, Troponin and SOFA score, mortality was predicted by the presence of SIMD (RR 3.24, 95% CI 1.72–6.11, p < 0.001) with no contribution of abnormal Troponin level. While abnormal Troponin levels were associated with SIMD diagnosed by echocardiography, only the presence of SIMD predicted the short- and medium-term mortality rate, without an independent contribution of increased Troponin levels.

To analyze the prognostic value of lactate levels for day-7 and in-hospital mortality, in septic patients with and without shock. In the period November 2011–December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis of sepsis. Lactate dosage was performed at ED-HDU admission (T0), after 2 h (T2), 6 h (T6) and 24 h (T24); lactate clearance was calculated at T2 and T6 [T2: ((LAC T0—LAC T2/LAC T0)*100)]; T6: [(LAC T0—LAC T6/LAC T0)*100]. The end-points were day-7 and in-hospital mortality. At every evaluation, the lactate level was higher in patients with shock than in those without (T0 3.8 ± 3.8 vs 2.4 ± 2.1; T6 2.9 ± 3.2 vs 1.6 ± 1.1; T24 3.0 ± 4.4 vs 1.4 ± 0.9 meq/L, all p < 0.001). Among patients with shock, an analysis for repeated measures confirmed a more marked lactate level reduction in survivors compared with non-survivors, both by day-7 and in-hospital mortality (p = 0.057 and p = 0.006). A Kaplan–MeIer analysis confirmed a significantly better day-7 survival in patients with T6 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) and T24 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) lactate ≤ 2 meq/L, compared with patients with higher levels. A T6 lactate clearance > 10% was more frequent among in-hospital survivors in the whole study population (57% vs 39%) and in patients with shock (74% vs 46%, all p < 0.05). Higher lactate levels and decreased clearance were associated with an increased short-term and intermediate-term mortality regardless of the presence of shock.

We evaluated the prevalence and prognostic value of left (LV) and right (RV) ventricular systolic dysfunction in the presence of overt and cryptic shock. In this prospective study, between October 2012 and June 2019, we enrolled 354 patients with sepsis, 41% with shock, among those admitted to the Emergency Department High-Dependency Unit. Patients were grouped based on the presence of shock, or by the presence of lactate levels ≥ (LAC +) or < 2 mmol/L (LAC-) evaluated within the first 24 h. By echocardiography performed within 24 h from the admission, LV systolic dysfunction was defined as global longitudinal strain (GLS) > -14%; RV systolic dysfunction as Tricuspid Annular Plane Systolic Excursion (TAPSE) < 16 mm. All-cause mortality was assessed at day-7 and day-28 follow-up. Mean values of LV GLS (-12.3 ± 3.4 vs -12.9 ± 3.8%) and TAPSE (1.8 ± 0.7 vs 1.8 ± 0.5 cm, all p = NS) were similar in patients with and in those without shock. LV GLS was significantly worse in LAC + than LAC- patients (− 11.2 ± 3.1 vs − 12.9 ± 3.7%, p = 0.001). In patients without shock, as well as in those LAC-, LV dysfunction was associated with increased day-28 mortality rate (78% vs 57% in non-survivors and survivors without shock and 74% vs 53% in non-survivors and survivors LAC-, all p < 0.01). LV (RR 2.26, 95% CI 1.37–3.74) and RV systolic dysfunction (RR 1.85, 95% CI 1.22–2.81) were associated with increased 28-day mortality rate in addition and independent to LAC + (RR 1.81, 95% CI 1.15–2.84). In conclusion, LV and RV ventricular dysfunction were independently associated with an increased mortality rate, altogether with the presence of cryptic shock.

To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients. This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011–December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin–antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%. D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG−, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14–6.11, p = 0.023), after adjustment for SOFA score and lactate level. Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.

We evaluated the ability of a stress-test (Str-T) to improve the risk stratification based on prognostic scores in patients presenting to the ED with chest pain. Between 2008, June and 2013, December, 1082 patients with chest pain were evaluated with an imaging Str-T. With a retrospective analysis, patients were stratified according to: (1) Florence Prediction Rule as low (0–1, LR-FPR), intermediate (2–4, IR-FPR), high risk (5–6, HR-FPR), respectively, 26, 50 and 24% of patients; (2) HEART score as LR-HEART, (0–3) and HR-HEART (≥4), respectively, 36 and 64%; (3) likelihood of CAD according to NICE guidelines, 10–29% LR-NICE, 30–60% IR-NICE and > 60% HR-NICE, respectively, 12, 18 and 70%. Scores’ diagnostic performance was calculated with Str-T as reference. One-month follow-up by a phone call was performed, to investigate the occurrence of new cardiovascular events. In LR and HR patients, FPR and NICE score showed sensitivity 66 vs 93%, specificity 59 vs 19% (both p < 0.001), Positive Predictive Value (PPV) 36 vs 31%, Negative Predictive Value (NPV) 83 vs 87%. Among LR-HEART patients, Str-T was positive for inducible ischemia in 53 (14%) patients and 12 (4%) of them underwent a percutaneous coronary revascularization. The Str-T was negative for inducible ischemia in 760 (70%) patients, positive in 272 (25%), inconclusive in 50 (5%); among patients in the LR and IR subgroups, incidence of CAD (1.3 and 1.6%) and the cumulative incidence of significant events at 1-month follow-up (both 1%) was very low Str-T improved prognostic scores’ diagnostic performance in LR- and HR-subgroups.