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Highlights • Elevated LDH and CRP serum concentrations are associated to respiratory failure in CoVID-19 patients., Objective The dramatic worldwide CoVID-19 infection requires the identification of a reliable and inexpensive tool to quickly discriminate patients with a more unfavorable outcome. Methods We performed routine laboratory tests suitable to identify tissue damage and inflammatory status in 123 consecutive CoVID-19 patients admitted to the Emergency Department of the hospital of Piacenza (Emilia-Romagna, Northern Italy). The results were correlated with patients’ respiratory function evaluated by the partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2). Results: The most common laboratory abnormalities were lymphocytopenia and elevated values of C-reactive protein (CRP) and lactate dehydrogenase (LDH). Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine kinase (CK) were also increased. The respiratory performance (PaO2/FiO2) showed a strong inverse correlation with LDH (r= 0.62, r2 0.38, p value< 0.0001) and CRP (r= 0.55, r2 0.31, p value< 0.0001). PaO2/FiO2 values also showed a significant inverse correlation with age (r= -0.37, p< 0.0001), AST (r= -0.31, p

Dysregulation of iron metabolism and hyper-inflammation are two key points in the pathogenesis of coronavirus disease 2019 (COVID-19). Since high hepcidin levels and low serum iron can predict COVID-19 severity and mortality, we decided to investigate iron metabolism and inflammatory response in 32 COVID-19 adult patients with a diagnosis of COVID-19 defined by a positive result of RT-PCR nasopharyngeal swab, and admitted to an Italian emergency department for acute respiratory failure at different degree. Patients were stratified in 3 groups based on PaO2/FiO2 ratio at admission: 13 (41%) were normoxemic at rest and suffered from exertional dyspnea (group 1); 14 (44%) had a mild respiratory failure (group 2), and 5 (15%) a severe hypoxiemia (group 3). White blood cells were significantly higher in group 3, while lymphocytes and hemoglobin were significantly reduced. Serum iron, transferrin saturation, non-transferrin-bound iron (NTBI) and ferritin were significantly increased in group 2. All the groups showed high hepcidin levels, but in group 3 this parameter was significantly altered. It is noteworthy that in group 1 inflammatory and oxidative indices were both within the normal range. We are aware that our study has some limitations, the small number of enrolled patients and the short period of data collection, but few works have been performed in the Emergency Room. However, we strongly believe that our results confirm the pivotal role of both iron metabolism dysregulation and hyper-inflammatory response in the pathogenesis of tissue and organ damage in COVID-19 patients.

We describe the case of a 68-year-old man with a known history of hypertension and diabetes mellitus presented to our Emergency Department, complaining of hematuria and vomiting in the last 12 hours, stypsis and urinary incontinence in the last week, and worsening hyporexia in the last 6 months. Bedside ultrasound documented a slight right pleural effusion with B lines in the middle and basal right field, gastrectasis, dilated fluid-filled bowel loops, potential signs of gas in the upper right quadrant, grade 3 bilateral hydronephrosis, and bladder globe. Abdominal CT scan confirmed the bilateral hydroureteronephrosis and showed the right kidney with Emphysematous Pyelonephritis (EPN) with extension into the perinephric and muscular planes for 24 cm, and initial EPN in the left kidney. A RT-PCR nasopharyngeal swab for SARS CoV-2 was negative. A diagnosis of ileum paretic, acute renal failure and urosepsis due to EPN was made.

Introduction: The early identification of patients with SARS-CoV-2 infection is still a real challenge for emergency departments (ED). First, we aimed to develop a score, based on the use of the lung ultrasonography (LUS), in addition to the pre-triage interview, to correctly address patients; second, we aimed to prove the usefulness of a three-path organization (COVID-19, not-COVID-19 and intermediate) compared to a two-path organization (COVID-19, non-COVID-19). Methods: We retrospectively analysed 292 patients admitted to our ED from 10 April to 15 April 2020, with a definite diagnosis of positivity (93 COVID-19 patients) or negativity (179 not-COVID-19 patients) for SARS-COV-2 infection. Using a logistic regression, we found a set of predictors for infection selected from the pre-triage interview items and the LUS findings, which contribute with a different weight to the final score. Then, we compared the organization of two different pathways. Results: The most informative factors for classifying the patient are known nasopharyngeal swab positivity, close contact with a COVID-19 patient, fever associated with respiratory symptoms, respiratory failure, anosmia or dysgeusia, and the ultrasound criteria of diffuse alveolar interstitial syndrome, absence of B-lines and presence of pleural effusion. Their sensitivity, specificity, accuracy, and AUC-ROC are, respectively, 0.83, 0.81, 0.82 and 0.81. The most significant difference between the two pathways is the percentage of not-COVID-19 patients assigned to the COVID-19 area, that is, 10.6% (19/179) in the three-path organization, and 18.9% (34/179) in the two-path organization (p = 0.037). Conclusions: Our study suggests the possibility to use a score based on the pre-triage interview and the LUS findings to correctly manage the patients admitted to the ED, and the importance of an intermediate area to limit the spread of SARS-CoV-2 in the ED and, as a consequence, in the hospital.

Background: Cancer patients are considered a highly fragile group in the current coronavirus disease 2019 (COVID-19) pandemic. Material & methods: In this study, patients with COVID-19 and cancer, hospitalized in Piacenza, Italy, from 4 April to 4 May 2020 were included. Risk factors for death were analyzed. Results: Fifty-one COVID-19 cancer patients were included, of which the median age was 71.02 years (range: 51–86) and 70.59% were male. Cancer types included gastrointestinal (25.49%), genitourinary (25.49%) and lung (23.53%). Forty-five (88.24%) patients received hydroxychloroquine-based therapy. In addition, 25 of 51 patients died (49%): 12 of 51 (23.53%) owing to cancer and 13 of 51 (25.49%) owing to COVID-19. Conclusion: The risks for death were related to later onset of treatment for COVID-19, severe/critical COVID-19, age, elevated basal CRP and elevated lactate dehydrogenase., Lay abstract The effect of COVID-19 on cancer patients is of high concern during the COVID-19 outbreak. Here we expand on our initial analysis of 25 patients, presenting 51 patients with COVID-19 and cancer and examining their risk factors for mortality considering indicators such as age and treatment history. We confirm that risk of mortality is greater for cancer patients, and also confirm well-known risk factors for mortality in this group.

The most relevant manifestation of coronavirus disease 2019 (COVID-19) is interstitial pneumonia. Several lung ultrasound (US) protocols for pneumonia diagnosis are used in clinical practice, but none has been proposed for COVID-19 patients' screening in the emergency department. We adopted a simplified 6-scan lung US protocol for COVID-19 pneumonia diagnosis (LUSCOP) and compared its sensitivity with high resolution computed tomography (HRCT) in patients suspected for COVID-19, presenting to one Emergency Department from February 21st to March 15th, 2020, during the outbreak burst in northern Italy. Patients were retrospectively enrolled if both LUSCOP protocol and HRCT were performed in the Emergency Department. The sensitivity of LUSCOP protocol and HRCT were compared. COVID-19 pneumonia's final diagnosis was based on real-time reverse-transcription polymerase chain reaction from nasal-pharyngeal swab and on clinical data. Out of 150 suspected COVID-19 patients, 131 were included in the study, and 130 had a final diagnosis of COVID-19 pneumonia. The most frequent lung ultrasonographic features were: bilateral B-pattern in 101 patients (77%), B-pattern with subpleural consolidations in 26 (19.8%) and lung consolidations in 2 (1.5%). LUSCOP Protocol was consistent with HRCT in correctly screening 130 out of the 131 COVID-19 pneumonia cases (99.2%). In one case COVID-19 pneumonia was excluded by both HRCT and lung US. LUSCOP protocol showed optimal sensitivity and can be proposed as a simple screening tool for COVID-19 pneumonia diagnosis in the context of outbreak burst areas where prompt isolation of suspected patients is crucial for patients' and operators' safety.

In the so called COVID19 era, headache, fever and gastrointestinal symptoms are highly suggestive for SARS-CoV-2 infection, but in all the cases presenting to the emergency room, clinicians should always keep in mind alternative diagnoses, particularly if the patient is pregnant. Life-threatening diseases, such as eclampsia and posterior reversible encephalopathy syndrome (PRES), should be promptly recognized and treated. Eclampsia is defined as a seizure occurring in association with pre-eclampsia, and it represents one of the major and serious obstetric disorders associated with significant maternal and perinatal morbidity and mortality. PRES is a distinctive clinical and imaging syndrome characterized by acute headaches, visual impairment, seizures, and altered sensorium, that can be associated with severe eclampsia. Emergency clinicians should always consider eclampsia in the differential diagnosis of headache in pregnant women. The prompt and accurate diagnosis of eclampsia/PRES is crucial to prevent adverse maternal and perinatal outcomes. Here we describe the case of a young pregnant woman admitted to our emergency department for fever, dyspnea, headache, nausea and vomiting, who developed generalized tonic clonic seizures and a subsequent status epilepticus due to eclampsia and PRES.

CoVID-19 is a global health emergency, which has paralyzed most of the worldwide health systems. Italy is struggling hard with CoVID-19 pandemic since the end of February 2020, to avoid the collapse of its health system. The number of CoVID-19 patients and deaths are increasing day by day. At time of writing, in Italy there are 102253 infected patients and 19899 deaths. Despite being a relatively small city, Piacenza is one of the epicentres of the Italian epidemic, and our own hospital - Guglielmo da Saliceto - has quickly become a "CoVID-19 hospital". Fully 80% of beds in our hospital are reserved for ill CoVID-19 patients and ICU has tripled the number of beds. All these changes have required a great effort for all the medical staff to avoid the collpase of the local health system. We struggled to maintain our normal standard of care for each patient, but the severity of the disease and the high number of critically ill patients frustrated our efforts. Here we report our experience and challenge with managing such a disaster. We hope it could be useful for other Emergency Departments trapped in this global pandemic.

COVID-19 (coronavirus disease 19) is an infectious disease caused by coronavirus 2019-nCoV. Since its detection in China at the end of 2019, the novel coronavirus has rapidly spread throughout the world and has caused an international public health emergency. The most common manifestation is flu-like symptoms. Mild infections usually improve within a few days, but COVID-19 can cause severe pneumonia with acute respiratory distress syndrome and death. Gastrointestinal symptoms are less common but possible and more difficult to recognize as part of a COVID-19 syndrome. In line with the current opinion of the WHO, we strongly believe that preventive measures and early diagnosis of COVID-19 are crucial to interrupt virus spread and avoid local outbreaks. We report the cases of COVID-19 patients admitted to our Emergency Department who complained of gastrointestinal symptoms at admission. LEARNING POINTS The novel COVID-19 infection is a severe public health problem which is causing an increasing number of deaths worldwide. Although uncommon, there may be a relationship between gastrointestinal symptoms and COVID-19, as reported in recent studies. Early detection and isolation of patients with COVID-19 infection is the only way to control and limit the global spread of this virus. Keywords: COVID-19 infection, abdominal pain, diarrhoea, gastrointestinal symptoms INTRODUCTION The coronaviruses are a large family of viruses that can cause respiratory infections ranging from mild symptoms to severe pneumonia. 2019-nCoV is a new type of coronavirus which was first identified in China. Since its detection in humans at the end of 2019, it has rapidly spread worldwide causing respiratory infections of various degrees of severity. The most common symptoms, which develop within 2–14 days of exposure, are dry cough, fever and fatigue[1, 2]. Mild infections may be self-limiting in few days, but in some cases the respiratory symptoms can develop into acute respiratory distress syndrome (ARDS) with a high risk of death from multiorgan failure. Nasopharyngeal and oropharyngeal swabs can be used to confirm the presence of 2019-nCoV. A CT scan of the chest is the gold standard for diagnosis and assessment of lung involvement. Ground-glass opacity and crazy-craving patterning are the most common radiological signs of COVID-19 pneumonia. CT is commonly used to evaluate lung damage during recovery[3]. Recently, we investigated the role of lung US in the early detection of COVID-19 pneumonia and showed a strong correlation between lung US and CT scans in all investigated patients[4]. No specific treatment or vaccines against COVID-19 are currently available. COVID-19 patients can be treated with antivirals but there is no clear evidence of benefit [5]. The most important way to fight this viral infection is to detect COVID-19 early, isolate cases, trace contacts and deliver the correct information to the general public [6]. Gastrointestinal involvement, such as abdominal pain, nausea, vomiting and diarrhoea, has been recently reported in the literature[7]. Diarrhoea occurs secondary to the interaction between ACE2, highly expressed in the human small intestine, and 2019-nCoV cell entry receptor ACE2. Recent studies show that 2019-nCoV RNA has been detected in stool samples, confirming faecal–oral transmission. According to the literature, the incidence of diarrhoea could be underestimated[8]. In the current case report, we consider COVID-19 infection in the differential diagnosis of gastrointestinal symptoms in 10 patients who referred to our Emergency Department in February 2020, at the beginning of the spread of COVID-19 in Italy.

We report the experience of prone ventilation in selected patients treated with helmet non-invasive ventilation (NIV) continuous positive airway pressure (CPAP) for acute respiratory failure in COVID-19 pneumonia. Preliminary results showed an improvement in the PaO2value and PaO2/FiO2ratio after 1 hour of prone ventilation. No variation of the lung ultrasound pattern before and after prone ventilation has been detected. At the time of writing, we attempted proning with helmet NIV CPAP in 10 patients. In 4 out of 10 patients, the attempt failed due to lack of compliance of the patient, scarce pain control even with ongoing treatment and refusal by the patient to prone positioning.

Coronavirus disease 19 (COVID-19) is a worldwide infection which was recently declared a global health emergency by the WHO Emergency Committee. The most common symptoms are fever and cough, which can progress to pneumonia, acute respiratory distress syndrome (ARDS) and/or end-organ failure. Risk factors associated with ARDS and death are older age, comorbidities (e.g., hypertension, diabetes, hyperlipidaemia), neutrophilia, and organ and coagulation dysfunction. Disseminated intravascular coagulation and coagulopathy can contribute to death. Anticoagulant treatment is associated with decreased mortality in severe COVID-19 pneumonia. In this report we describe two patients with COVID-19 pneumonia who developed venous thromboembolism. LEARNING POINTS Deep vein thrombosis and pulmonary embolism can occur in patients with COVID-19 pneumonia. Low-molecular-weight heparin prophylaxis does not decrease the risk of venous thromboembolism (VTE) in COVID-19 pneumonia. In the presence of clinical signs and/or suspicion of VTE, compression ultrasound and echocardiography should be always performed, irrespective of disease stage.

Background: Thrombolysis in the elderly is still a matter of debate. Recently, the Third International Stroke Trial (IST-3) suggested that recombinant tissue plasminogen activator (rt-PA) improves functional outcome, without a substantial absolute increase in symptomatic intracranial hemorrhage, even in older patients. The aim of the current prospective study is to describe safety and functional outcome in a cohort of patients treated by intravenous rt-PA in an Italian stroke unit “real world setting”. Methods: All the consecutive patients treated with rt-PA between 2006 and 2010 in an Italian province with 290,000 inhabitants were enrolled. Total and symptomatic (associated with a 4-point worsening on the National Institutes of Health Stroke Scale [NIHSS] score) hemorrhages were evaluated, as safety measures, along with disability (at 3-month modified Rankin scale) as effectiveness measure. Results: One hundred and eighty-seven patients were treated with rt-PA; 90 males (48.1%); average age 75.1 (±11.9) years; 79 (42.2%) patients aged ≥80 years. Patients aged ≥80 years had a higher NIHSS score at stroke onset (13.5 vs. 10.9). No significant difference was found between patients aged

Some diseases, such as renal colic and atrial fibrillation, display an association with microclimatic variations. In particular, despite a correlation has been reported between incidence of primary spontaneous pneumothorax (PSP) and meteorological variations, the evidence remains poor and conflictual. The aim of this study was to assess the influence of day-by-day meteorological variations on the number of visits for PSP in the Emergency Department (ED). All PSP cases were retrieved from the hospital database from January 2008 to December 2014. For all the observational days, meteorological data about the Parma Province were obtained from the Environment and Climate Regional Agency. The correlation between ED visits for PSP and variation of air temperature (T°), atmospheric pressure (hPa) and humidity (%) was then tested. The chronological data of all the visits for PSP were correlated with climate data by univariate linear regressions analysis. A total number of 608.215 ED visits were recorded during the observational period, with an average of 238 patients per day. Overall, 257 PSP cases were observed (mean age 37±21 years), 79% males and 21% females. No significant correlation between average daily visits for SP and daily change of average temperature, humidity, or atmospheric pressure was observed throughout the observational period (p>0.05 for all). The results of the study show that the incidence of PSP is not significantly associated with changes of microclimatic variables.Â

Wake-up stroke (WUS) patients are typically excluded from reperfusion treatment, as the time of symptoms onset is unknown. The purpose of this study is to evaluate the clinical outcome and safety of intravenous thrombolysis with rt-PA in patients with WUS eligible for therapy using computed tomography perfusion criteria (CTP), compared to patients treated with rt-PA within 4.5 h of symptoms onset (non-WUS). This is an experimental, open-label trial, controlled against the best therapy currently in use. Primary endpoints were functional independence after 3 months [modified Rankin scale (mRS) ≤ 1] for clinical outcome and symptomatic intracerebral hemorrhage (SICH) for safety. Secondary endpoints were no or only mild disability after 3 months (mRS ≤ 2) for clinical outcome, total intracerebral hemorrhage (TICH) and contrast-induced nephropathy (CIN) for safety. 170 patients were treated, 143 non-WUS patients and 27 patients with WUS. Strokes of cardioembolic origin were most common in WUS patients (p < 0.001). Primary endpoints: mRS ≤ 1 was found in 35.8 % (non-WUS: 36.4% vs. WUS 33.3%; p = 0.62) and SICH was observed in 3.4 % of non-WUS patients and in WUS patients (p = 0.32). Secondary endpoints: mRS ≤ 2 was observed in 66.4 % of patients (non-WUS: 67.1% vs. WUS 62.9%; p = 0.67), TICH in 13.5 % of patients (13.9 % non-WUS vs. 11.1 % WUS; p = 0.69). CIN was documented in 3.7 % of WUS patients. rt-PA treatment carried out in WUS patients selected on the basis of CTP data demonstrate comparable clinical outcome and safety with respect to non-WUS patients. The study supports the hypothesis that a selected group of WUS patients may be suitable for thrombolysis.

The activity of the hypothalamic-GH-insulin-like growth factor (IGF) network declines with age. It has recently been shown that increased cardiovascular mortality occurs in adults with GH deficiency. As hypercholesterolemia is common in GH-deficient adults, and because there is experimental evidence that GH may play a role in regulating plasma cholesterol, we decided to investigate the activity of the GH-IGF axis in an elderly population by measuring serum IGF-I, IGF-II, and IGF-binding protein-3 (IGFBP-3) levels and to study their relationship with blood lipid levels. One hundred and thirty-two elderly subjects, 52 men and 80 women, were studied (age range, 60–91 yr). Men had significantly lower levels of IGFBP-3, high density lipoprotein cholesterol (HDL-C) and apoprotein A1 (ApoA1) compared to the women, whereas IGF-I and IGF-II were only slightly lower. Using linear regression analysis, we observed an inverse relationship of age with IGF-I (r = −0.35; P < 0.001), IGF-II (r = 0.40; P < 0.001), IGFBP-3 (r = 0.52; P < 0.001), body mass index, and lipid levels. Univariate regression analysis showed a strong and positive correlation of both IGF-I and IGFBP-3 with HDL-C and ApoA1. Partial correlation analysis, after adjustment for age and body mass index, showed that IGFBP-3 and IGF-II were still significantly and positively related to HDL-C and ApoA1. Furthermore, a strong association was documented among IGF-I, IGF-II, and IGFBP-3. These data demonstrate that even in an elderly population, further aging is accompanied by a progressive decline in circulating IGF-I, IGF-II, and IGFBP-3, suggesting a continuing diminution of the GH-IGF axis throughout aging. Moreover, the strong correlation between HDL-C and an index of GH secretion, such as IGFBP-3, suggests that GH might play an important role in lipid metabolism in healthy elderly subjects.