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Abstract The treatment of tracheal pathologies remains challenging.Nanotechnology allows adding substances to decellularized human amniotic membrane (DHAM), such as 15-Deoxy-∆12,14ProstaglandinJ2 nanoparticles (15D-PGJ2-NC).This study performed a tracheotomy in rabbits randomized into three groups.The tissue repair process was evaluated when treated with DHAM associated or not with 15D-PGJ2-NC.The average of the area in the control group was 54.76% smaller than DHAM group and 41.98% smaller than DHAM + 15D-PGJ2-NC group (p=0.004 for both).The DHAM + 15D-PGJ2-NC group had significantly more immature cartilage (p=0.015).DHAM impregnated with 15D-PGJ2-NC could provide support for the healing of the tracheal defect and may prevent reduction of its lumen.

Biological scaffolds have become an attractive approach for repairing the infarcted myocardium and have been shown to facilitate constructive remodeling in injured tissues. This study aimed to investigate the possible utilization of bacterial cellulose (BC) membrane patches containing cocultured cells to limit myocardial postinfarction pathology. Myocardial infarction (MI) was induced by ligating the left anterior descending coronary artery in 45 Wistar rats, and patches with or without cells were attached to the hearts. After one week, the animals underwent echocardiography to assess for ejection fraction and left ventricular end-diastolic and end-systolic volumes. Following patch formation, the cocultured cells retained viability of >90% over 14 days in culture. The patch was applied to the myocardial surface of the infarcted area after staying 14 days in culture. Interestingly, the BC membrane without cellular treatment showed higher preservation of cardiac dimensions; however, we did not observe improvement in the left ventricular ejection fraction of this group compared to coculture-treated membranes. Our results demonstrated an important role for BC in supporting cells known to produce cardioprotective soluble factors and may thus provide effective future therapeutic outcomes for patients suffering from ischemic heart disease.

Bone marrow-derived stem cells (BMDSCs) play an essential role in organ repair and regeneration. The molecular mechanisms by which hormones control BMDSCs proliferation and differentiation are unclear. Our aim in this study was to investigate how a lack of ovarian or/and thyroid hormones affects stem cell number in bone marrow lineage. To examine the effect of thyroid or/and ovarian hormones on the proliferative activity of BMDSCs, we removed the thyroid or/and the ovaries of adult female rats. An absence of ovarian and thyroid hormones was confirmed by Pap staining and Thyroid Stimulating Hormone (TSH) measurement, respectively. To obtain the stem cells from the bone marrow, we punctured the iliac crest, and aspirated and isolated cells by using a density gradient. Specific markers were used by cytometry to identify the different BMDSCs types: endothelial progenitor cells (EPCs), precursor B cells/pro-B cells, and mesenchymal stem cells (MSCs). Interestingly, our results showed that hypothyroidism caused a significant increase in the percentage of EPCs, whereas a lack of ovarian hormones significantly increased the precursor B cells/pro-B cells. Moreover, the removal of both glands led to increased MSCs. In conclusion, both ovarian and thyroid hormones appear to have key and diverse roles in regulating the proliferation of cells populations of the bone marrow.

Acute diarrhea represents a major public health issue, and the management of adult patients admitted to the emergency department (ED) for this problem is still challenging. In a retrospective analysis on more than 20,000 patients visiting a tertiary ED for acute diarrhea and then being discharged home, we found that age > 65 years, onset of symptoms > 24 h since ED admission, refusal of hospitalization, and a history of chronic renal and liver diseases were independently associated with ED readmission for abdominal symptoms within 7 days. In the younger group, the presence of comorbidities significantly impacted on ED readmission, while fever and alteration of serum creatinine were the main determinants in the older group. Antibiotics were prescribed in about 25% of patients, although diarrhea etiology (viral or bacterial) was usually not available. According to international guidelines, fluoroquinolones were the most prescribed class, showing an inverse correlation to ED readmission. However, β-lactams and probiotics were also commonly prescribed; the latter were independently correlated to ED readmission in the elderly group. A comprehensive, guideline-based approach, including a detailed clinical history and laboratory and comorbidity assessment, should be encouraged to support physicians in the management of different age subgroups of adults admitted to the ED for acute diarrhea.

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are often coexisting conditions, but their interrelationship has not yet been clarified. This study investigated the clinical characteristics and prognostic impact of AF among older patients with HFpEF hospitalized for acute HF (AHF). The study included patients 65 years of age and older who were admitted to the Emergency Department due to AHF from 1 January 2016 to 31 December 2019. Patients were divided into two groups according to the presence of AF. The primary endpoint was all-cause, in-hospital mortality. Overall, 770 patients with HFpEF were included, mean age 82 years, 53% were females. Nearly, a third (30%) of these patients had a concomitant AF and they were significantly older and had higher N-Terminal pro-B-type natriuretic peptide (NT-proBNP) values. Overall, the in-hospital mortality rate was much higher among HFpEF patients with AF compared to those without AF (11.4% vs 6.9%, respectively; p = 0.037). At multivariate analysis, AF emerged as an independent risk factor for death (OR 1.73 [1.03-2.92]; p = 0.038). Among older patients with HFpEF admitted for AHF, the coexistence of AF was associated with a nearly twofold increased risk of all-cause in-hospital mortality. Patients with HFpEF and AF describe a phenotype of older and more symptomatic patients, with higher NT-proBNP, left atrial enlargement, right ventricular dysfunction, and higher CV mortality., (© 2024. The Author(s).)

Psychiatric conditions, such as depression, anxiety, bipolar disorder, and schizophrenia, are increasingly recognized as significant risk factors for cardiovascular disease (CVD). This review systematically analyzes evidence from various databases to provide a comprehensive understanding of the impact of psychiatric illnesses on the incidence, management, and prognosis of CVD. Key findings suggest a bidirectional relationship between psychiatric disorders and CVD, indicating that mental health conditions can predispose individuals to CVD, while CVD can exacerbate or trigger psychiatric symptoms. The review explores the underlying mechanisms of these associations, including behavioral factors, stress responses, and medication side effects. It also examines the challenges in managing CVD patients with comorbid psychiatric conditions, emphasizing the importance for integrated care approaches. This review underscores the necessity of considering mental health as an integral component of cardiovascular care and calls for further research to develop tailored management strategies for these complex conditions, ultimately aiming to improve patient outcomes and quality of life. This comprehensive analysis provides valuable insights for future investigations and guides clinicians in optimizing care for patients with both psychiatric and cardiovascular conditions.

Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy-to-use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56-81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849-0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848-0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort ( P =0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.

In febrile patients with known systemic autoimmune disease, early discrimination between infection and disease flare often represents a clinical challenge. This study aimed at evaluating the efficacy of procalcitonin (PCT) and other common inflammatory biomarkers in discriminating disease flare from bacterial infections in the Emergency Department (ED). In a cross-sectional observational retrospective study, we identified consecutive febrile patients with a known diagnosis of systemic autoimmune disease, admitted to the ED, and subsequently hospitalized. Flare vs infective disease was defined on clinical records at hospital discharge. Dosage of common inflammatory markers was performed at ED admission. Out of 177 patients, those with infection were most commonly elderly, frail, and with reduced peripheral oxygen saturation at admission. When compared to C-reactive protein (CRP) and white blood count (WBC), PCT showed the best performance in discriminating infections vs flare. However, only at a very high threshold value of 2 ng/ml, the PCT had a satisfactory negative predictive value of 88.9%, although with a very low specificity of 13.6% and a positive predictive value of 35.8%. Our data suggest that in the ED setting, the early PCT determination has low accuracy in the differentiation of disease flare from infection in patients with known rheumatologic disease. However, the PCT could be useful in elderly and comorbid subjects, in supporting clinical assessment and in recognizing those febrile patients needing prompt antibiotic treatment., (© 2022. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

We evaluated the clinical features of patients admitted to the ED with acute vertigo, verifying symptoms after one month and one year to establish epidemiological factors and predictors of resolution. We reviewed 233 records of patients admitted to ED for acute vertigo (125 F and 85 M, mean age 56.12 years). We analyzed the correlation between time of resolution (at one month and one year) and symptoms duration (subjective and/or objective vertigo, instability, cervical pain, audiological, neurological, and neurovegetative symptoms), comorbidities, and therapies, the result of the clinical and instrumental vestibular examination. Resolution of acute vertigo occurred in 81.1%, while persistence of vertigo one year after ED access was reported in 18.8%. There were 135 patients who recovered in one month. The presence of instability, auditory and neurovegetative symptoms, and neck pain represents a significant factor for recovery within one year. Age over 65 and a history of hypertension are associated with a worst recovery. Patients with spontaneous Nystagmus or positive HIT showed a significant difference in symptoms recovery within one month and one year. Presence of positional Nystagmus represents a positive prognostic factor. Our findings emphasize the importance of clinical evaluation of the acute vertigo, helping the clinicians to define central or peripheral diagnosis and predict the resolution of vertigo.

Objective: In Guillain-Barre syndrome (GBS), respiratory failure is the most serious manifestation and mechanical ventilation (MV) is required in approximately 20% of the patients. In this retrospective study, we aimed to evaluate clinical factors that can be evaluated in the Emergency Department which may influence the short-term prognosis of GBS patients., Methods: Data were acquired regarding age, sex, antecedent infections, neurological signs and symptoms, cerebrospinal fluid examination, nerve conduction studies, treatment of GBS, need for MV, length of stay in the hospital, and discharge destination (home or rehabilitation). Charlson Comorbidity Index and modified Erasmus GBS outcome score (mEGOS) were collected on admission., Results: Seventy-eight GBS patients were recruited with a mean age of 53.9 (range 19-81). Sixty-nine (88.46%) were diagnosed with GBS and nine (11.54%) had classic Miller-Fisher syndrome. Mean values for the Charlson Comorbidity index were 1.20 ± 1.81, and the values of mEGOS were 2.4 ± 1.6. The rate of home discharge and rehabilitation was similar between elderly and younger patients. Patients who required MV had higher mEGOS (p-value=0.061). Regarding the electrophysiological subtypes, we did not observe a significant difference between AIDP and AMAN/AMSAN concerning the need for MV, the type of discharge, values of mEGOS and Charlson Comorbidity Index., Discussion: A significant correlation was found between mEGOS and the need for MV. Age did not influence the short-term prognosis of GBS patients. mEGOS may be a useful tool for predicting outcomes in patients with GBS and higher mEGOS scores on admission significantly correlated with poor outcomes.

Objective: Small Bowel Obstruction (SBO) is a common emergency in older patients. The most appropriate treatment strategy is still matter of debate. The aim of this study was to compare a non-operative management (NOM) vs. a surgical procedure for patients ≥ 80 years with SBO., Patients and Methods: All patients ≥ 80 years admitted to our Emergency Department (ED) for SBO between January 1st, 2015, and December 31st, 2020 were included in this study. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was to compare the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and in-hospital length of stay (LOS)., Results: A total of 561 patients were enrolled. After propensity score matching (PSM) analysis, 302 patients (151 each group) were included in the analysis. Mortality did not differ between the two groups. After PSM mechanical ventilation, sepsis, cumulative major complications, and LOS were significantly higher in the operative treatment group [15.9% vs. 1.5%, 9.4% vs. 4.1%, 27.6% vs. 19.2%, and 9.4 (6.4-14.3) days vs. 8.1 (4.5-13.3) days, respectively; p<0.001, p=0.013, p=0.025, and p=0.003, respectively]., Conclusions: In patients ≥ 80 years with SBO, a NOM could yield similar results, in terms of overall mortality, compared to a surgical management. Thus, particularly in patients with multiple comorbidities or functional impairments, a conservative approach should always be considered.

Objectives: This study aimed to assess the effects of frailty and the perceived quality of life (QOL) on the long-term survival (at least 1 year) of patients ≥ 80 years hospitalized for COVID-19 and the predictors of frailty and QOL deterioration in survivors. Design: This is a single-center, prospective observational cohort study. Setting and Participants: The study was conducted in a teaching hospital and enrolled all COVID-19 patients ≥80 years old consecutively hospitalized between April 2020 and March 2021. Methods: Clinical variables assessed in the Emergency Department (ED), and during hospitalization, were evaluated for association with all-cause death at a follow-up. Frailty was assessed by the clinical frailty scale (CFS), and the QOL was assessed by the five-level EuroQol EQ-5d tool. Multivariate Cox regression analyses and logistic regression analyses were used to identify independent factors for poor outcomes. Results: A total of 368 patients aged ≥80 years survived the index hospitalization (age 85 years [interquartile range 82-89]; males 163 (44.3%)). Compared to non-frail patients (CFS 1-3), patients with CFS 4-6 and patients with CFS 7-9 had an increased risk of death (hazard ratio 6.75 [1.51, 30.2] and HR 3.55 [2.20, 5.78], respectively). In patients alive at the 1-year follow-up, the baseline QOL was an independent predictor of an increase in frailty (OR 1.12 [1.01, 1.24]). Male sex was associated with lower odds of QOL worsening (OR 0.61 [0.35, 1.07]). Conclusions and Implications: In older adults ≥80 years hospitalized for COVID-19, the frailty assessment by the CFS could effectively stratify the risk of long-term death after discharge. In survivors, the hospitalization could produce a long-term worsening in frailty, particularly in patients with a pre-existing reduced baseline QOL. A long-term reduction in the perceived QOL is frequent in ≥80 survivors, and the effect appears more pronounced in female patients., Competing Interests: The authors declare no conflict of interest.

Clostridioides difficile infection (CDI) represents a significant cause of morbidity and mortality, mainly in older and frail subjects. Early identification of outcome predictors, starting from emergency department (ED) admission, could help to improve their management. In a retrospective single-center study on patients accessing the ED for diarrhea and hospitalized with a diagnosis of CDI infection, the patients’ clinical history, presenting symptoms, vital signs, and laboratory exams at ED admission were recorded. Quick sequential organ failure assessments (qSOFA) were conducted and Charlson’s comorbidity indices (CCI) were calculated. The primary outcomes were represented by all-cause in-hospital death and the occurrence of major cumulative complications. Univariate and multivariate Cox regression analyses were performed to establish predictive risk factors for poor outcomes. Out of 450 patients, aged > 81 years, dyspnea at ED admission, creatinine > 2.5 mg/dL, white blood cell count > 13.31 × 109/L, and albumin < 30 µmol/L were independently associated with in-hospital death and major complications (except for low albumin). Both in-hospital death and major complications were not associated with multimorbidity. In patients with CDI, the risk of in-hospital death and major complications could be effectively predicted upon ED admission. Patients in their 8th decade have an increased risk independent of comorbidities.

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

While there is evidence of high use of wide-spectrum antibiotics in children evaluated in the pediatric emergency departments, determinants of this behavior are still unclear. This study was aimed at defining the demographic, social, clinical, and laboratory factors that affect antibiotic prescriptions in children discharged from the emergency department. We performed a retrospective observational study of children aged younger than 18 years discharged from a pediatric university hospital between Jan. 1, 2015 and Dec. 31, 2020. We determined the proportion and type of antibiotic prescription according to demographic, social, clinical, laboratory, and imaging data, as well as doctor's expertise. Fifty-one thousand six hundred thirty-three children were included, and 13,167 (25.5%) received an antibiotic prescription. Amoxicilline/clavulanate (Am/Cl) was the most prescribed antibiotic (8453, 64.2% of all prescriptions). Factors independently associated with an antibiotic prescription were older age (OR = 1.62 [1.53-1.73] for age 2-5 years, OR = 1.77 [1.64-1.91] for age 6-10 years, OR = 1.36 [1.25-1.49] for age 11-18 years, p < 0.001 for all groups); being evaluated by a physician with > 3 years of pediatric expertise (OR = 1.22 [1.13-1.31], p < 0.001); fever peak higher than 40 °C (OR = 1.37 [1.21-1.54], p < 0.001); abnormal findings on auscultation (OR = 1.95 [1.75-2.17], p < 0.001), CRP values (OR = 1.63 [1.26-2.10] for CRP < 50 mg/L, and OR = 3.78 (2.75-5.21) for CRP ≥ 50 mg/L with respect to CRP not requested; p < 0.01); CXR results whatever positive (OR = 4.47 [3.62-5.52], p < 0.001) or negative (1.82 [1.62-2.04], p < 0.001); being diagnosed with upper respiratory tract infections (OR = 4.27 [4.04-4.51], p < 0.001), lower respiratory tract infections (OR = 5.35 [4.88-5.85]; p < 0.001), and UTI (OR = 9.33 [8.14-10.71], p < 0.001).    Conclusions: Overprescription of antibiotics, including Am/Cl, is relevant in pediatric emergency departments. Factors associated with overprescription are not limited to the clinical characteristics of the treated patients. These findings highlight the need for a new and comprehensive approach to ensure successful antibiotic stewardship initiatives in the emergency departments. What is Known: • Antibiotic resistance is a growing problem in medical practice, including in pediatrics. • Antibiotics are overprescribed in children assessed in the emergency department, but comprehensive and large studies are lacking. What is New: • Factors associated with overprescription are not limited to the clinical characteristics of the patients. • Non-clinical factors such as environmental variables, doctor's expertise, and attitudes to laboratory and radiological examinations affect prescription., (© 2022. The Author(s).)

Objectives: To evaluate, in a cohort of adults ≥80 years old, the frailty status at the emergency department (ED) admission, for the in-hospital death risk stratification of patients needing major surgical procedures., Design: Single-center prospective observational cohort study., Setting and Participants: The study was conducted in the ED of a teaching hospital. We enrolled all patients ≥80 years old consecutively admitted to the ED for conditions requiring urgent surgical procedures, between 2018 and 2021., Methods: Clinical variables and frailty status assessed in the ED were evaluated for the association with all-cause in-hospital death. The parameters evaluated were frailty [assessed by the Clinical Frailty Scale (CFS)], comorbidities, physiological parameters, type of surgery needed, laboratory values at admission. Cox regression analysis was used to identify independent risk factors for poor outcomes., Results: The study enrolled 1039 patients aged ≥80 years [median age 85 years (interquartile range 82-89); 445 males (42.8%)]. Overall, 127 patients (12.2%) were classified as nonfrail (CFS score 1-3), 722 (69.5%) as mild frail (CFS score 4-6), and 190 (18.3%) as frail (CFS score 7-9). The covariate-adjusted analysis revealed that severe frailty [hazard ratio (HR) 12.55, 95% CI 2.96-53.21, P = .016], ≥3 comorbidities (HR 2.08, 95% CI 1.31-3.31, P = .002), shock at ED presentation (HR 3.58, 95% CI 2.16-5.92, P < .001), anemia (HR 1.88, 95% CI 1.17-3.04, P = .009), and neurosurgery procedures (HR 3.97, 95% CI 1.98-7.96, P < .001) were independent risk factors for in-hospital death., Conclusions and Implications: In patients aged ≥80 years undergoing urgent surgical procedures, the evaluation of functional status in the ED could predict the risk of in-hospital death. Frail patients have an increased risk of death and major complications, whereas those with mild frailty have a similar prognosis compared with the more fit ones. Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80 years needing neurosurgery or abdominal surgery., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To analyse and compare the clinical outcomes between patients ≥80 years and 65-79 years, who presented to our emergency department (ED) with the two most common gastric emergency (GE) clinical presentation, that is, gastric bleeding and gastric perforation., Design: Single-centre retrospective cohort study., Participants: A total of 1011 patients were enrolled: 421 patients aged ≥80 years were compared with a group of 590 patients aged 65-79 years., Primary and Secondary Outcome Measures: The primary outcome was to compare the overall mortality. Secondary outcomes included major complications, in-hospital length of stay (LOS) and need for surgical procedures., Results: Patients ≥80 years with GE had different presentations at ED compared with younger patients: they had higher gastrointestinal bleeding (24.9% vs 16.3%, p=0.001), anemisation (14.5% vs 8.8%, p = 0.005) and shock (10.9% vs 5.1%, p=0.001) rates. Median LOS, cumulative major complications and mortality rates were similar among the two groups.Multivariate analysis identified shock, gastric malignancy and gastric fistula as independent predictors for survival., Conclusions: Patients ≥80 years with GE did not have a higher mortality rate and cumulative major complications as compared to younger elderly patients. Invasive treatments were not associated with a different prognosis in this age group., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy. Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan., Methods: We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model., Results: In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411-4.703; p = .002 and HR 1.9; 95% CI 1.004-3.735; p = .0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit., Conclusions: In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients' management and DOAC safety profile compared to VKA in mild TBI., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Acute cholecystitis (AC) is a life-threatening emergency in elderly patients., Aims: To compare the commonly used management strategies for elderly patients with AC as well as resulting morbidity, mortality and length of hospital stay (LOS)., Methods: All patients ≥ 65 years admitted to our emergency department for AC between January 1st, 2014 and December 31st, 2018 were included in the study. We compared patients that received medical treatment to patients who received operative procedures. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and LOS., Results: A total of 1075 patients were enrolled: 483 patients received a medical treatment and 592 patients underwent interventional procedures. After PSM, 770 patients (385 for each treatment group) were included in the analysis. The analysis revealed that both mortality and cumulative major complications were similar in medical and interventional group. We found that among comorbidities, Charlson comorbidity index and congestive heart failure were significantly higher in the medical treatment group (5 [4-6] vs. 4 [3-6] and 11.7% vs. 4.7%, respectively; p<0.001). LOS was slightly lower in the medical treatment group (7.0 days [4.9-11.1] vs. 7.9 [4.9-13.5]; p = 0.046)., Conclusion: Medical management outcomes for AC in elderly patients were similar to operative treatments in terms of mortality and cumulative major complications. A conservative approach should always be considered., Competing Interests: Conflict of interest None declared., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Intra-abdominal infection (IAI) is a wide range of intra-abdominal disease. Management involves empirical therapy and source control. Procalcitonin (PCT) has been suggested to assist in defining individual infection status and delivering individualized therapy. The aim of this study was to investigate the effects on patient outcomes of an early procalcitonin (PCT) assessment (in the emergency department [ED]) in patients with IAI. Methods: This was a retrospective, mono-centric study evaluating consecutive patients admitted to the ED from 2015 to 2019 with diagnosis of IAI. According to whether there had been PCT determination in the ED, patients were divided into no ePCT determination (no-ePCT) and early PCT determination in the ED (ePCT). The primary endpoint was the intra-hospital mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay (LOS). The propensity score match (PSM) was generated using a logistic regression model on the baseline covariates considered to be potentially influencing the decision to determine PCT in the ED and confounding factors identified as significant at a preliminary statistical analysis with respect to in-hospital death. Results: A series of 3,429 patients were included. The ePCT group consisted to 768 (22.4%), whereas the no-ePCT group contained 2,661 patients (77.6%). When the PSM was matched to the two groups, no significant difference was observed. Considering patients with uncomplicated infections, the PCT determination was associated with a higher mortality rate. We found no significant differences regarding outcomes with the exception of LOS, which was slightly longer in the ePCT group. However, we observed a tendency toward a minor difference in the number of complications in the ePCT group, in particular a reduced rate of progression to sepsis. Conclusion: Early PCT determination could be irrelevant in IAIs. The PCT value may be cost-effective and possibly improve the prognosis in cIAIs. Further research is needed to understand the optimal use of PCT, including in combination with other emerging diagnostic tests.

Objectives: To evaluate, in a cohort of adults aged ≥80 years, the overlapping effect of clinical severity, comorbidities, cognitive impairment, and frailty, for the in-hospital death risk stratification of COVID-19 older patients since emergency department (ED) admission., Design: Single-center prospective observational cohort study., Setting and Participants: The study was conducted in the ED of a teaching hospital that is a referral center for COVID-19 in central Italy. We enrolled all patients with aged ≥80 years old consecutively admitted to the ED between April 2020 and March 2021., Methods: Clinical variables assessed in the ED were evaluated for the association with all-cause in-hospital death. Evaluated parameters were severity of disease, frailty, comorbidities, cognitive impairment, delirium, and dependency in daily life activities. Cox regression analysis was used to identify independent risk factors for poor outcomes., Results: A total of 729 patients aged ≥80 years were enrolled [median age 85 years (interquartile range 82-89); 346 were males (47.3%)]. According to the Clinical Frailty Scale, 61 (8.4%) were classified as fit, 417 (57.2%) as vulnerable, and 251 (34.4%) as frail. Severe disease [hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.31-2.59], ≥3 comorbidities (HR 1.54, 95% CI 1.11-2.13), male sex (HR 1.46, 95% CI 1.14-1.87), and frailty (HR 6.93, 95% CI 1.69-28.27) for vulnerable and an overall HR of 12.55 (95% CI 2.96-53.21) for frail were independent risk factors for in-hospital death., Conclusions and Implications: The ED approach to older patients with COVID-19 should take into account the functional and clinical characteristics of patients being admitted. A sole evaluation based on the clinical severity and the presence of comorbidities does not reflect the complexity of this population. A comprehensive evaluation based on clinical severity, multimorbidity, and frailty could effectively predict the clinical risk of in-hospital death for patients with COVID-19 aged ≥80 years at the time of ED presentation., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: To date, mainly due to age-related vulnerability and to coexisting comorbidities, older patients often face a more severe COVID-19. This study aimed to identify at Emergency Department (ED) admission the predictors of in-hospital mortality and suitable scores for death risk stratification among COVID-19 patients ≥ 80 years old., Methods: Single-centre prospective study conducted in the ED of an university hospital, referral center for COVID-19 in central Italy. We included 239 consecutive patients ≥ 80 years old with laboratory-confirmed COVID-19. The primary study endpoint was all-cause in-hospital mortality. Multivariable Cox regression analysis was performed on significant variables at univariate analysis to identify independent risk factor for death. Overall performance in predicting mortality of WHO severity scale, APACHE II score, NEWS score, and CURB-65 was calculated., Results: Median age was 85 [82-89] and 112 were males (46.9%). Globally, 77 patients (32.2%) deceased. The presence of consolidations at chest x-ray and the hypoxemic respiratory failure were significant predictors of poor prognosis. Moreover, age ≥ 85 years, dependency in activities of daily living (ADL), and dementia were risk factors for death, even after adjusting for clinical covariates and disease severity. All the evaluated scores showed a fairly good predictive value in identifying patients who could experience a worse outcome., Conclusions: Among patients ≥ 80 years old hospitalized with COVID-19, not only a worse clinical and radiological presentation of the disease, but also the increasing age, dementia, and impairment in ADL were strong risk factors for in-hospital death, regardless of disease severity., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background and Objectives. Fever is one of the most common presenting complaints in the Emergency Department (ED). This study aimed at evaluating the prognostic role of serum Procalcitonin (PCT) measurement among adult patients admitted to the ED with fever. Materials and Methods. This is a retrospective cross-sectional study including all consecutive patients admitted to ED with fever and subsequently hospitalized in a period of six-year (January 2014 to December 2019). Inclusion criteria were age > 18 years, fever (T ≥ 38 °C) or chills within 24 h from presentation to the ED as the main symptom, and availability of a PCT determination obtained <24 h since ED access. The primary endpoint was overall in-hospital mortality. Results. Overall, 6595 patients were included in the study cohort (3734 males, 55.6%), with a median age of 71 [58-81] years. Among these, based on clinical findings and quick sequential organ failure assessment (qSOFA), 422 were considered septic (36.2% deceased), and 6173 patients non-septic (16.2% deceased). After correction for baseline covariates, a PCT > 0.5 ng/mL was an independent risk factor for all-cause in-hospital death in both groups (HR 1.77 [1.27-2.48], and 1.80 [1.59-2.59], respectively). Conclusions. Among adult patients admitted with fever, the PCT assessment in ED could have reduced prognostic power for patients with a high suspicion of sepsis. On the other hand, it could be useful for sepsis rule-out for patients at low risk. In these latter patients, the prognostic role of PCT is higher for those with a final diagnosis of bloodstream infection.

Objective: Mild Traumatic Brain Injury (MTBI) in anticoagulated patients is a common challenge for Emergency Department (ED) Physicians. Anticoagulation is considered a risk factor for developing delayed intracranial hemorrhage (ICH) after MTBI. The occurrence of this event in patients on Vitamin K Antagonists (VKA) or Direct Oral Anticoagulants (DOACs) remains unclear. Primary endpoint: to analyze the role of anticoagulants as risk factors for developing delayed ICH after MTBI and evaluate the indications to repeat a cranial computed tomography (CT) after a period of observation. Secondary endpoint: to assess the difference in the prevalence rate of delayed ICH in patients on VKA versus those on DOACs., Patients and Methods: We evaluated all consecutive patients admitted to our ED for MTBI, which had a control CT for late ICH after a negative CT at admission. We used a propensity score match (PSM) on factors affecting the need for oral anticoagulation to adjust the comparison between anticoagulated vs. non-anticoagulated patients for the baseline clinical characteristics., Results: Among 685 patients enrolled, 15 (2.2%) developed ICH at control CT. After PSM, the incidence of ICH, although slightly higher, was not statistically different in anticoagulated patients vs. non-anticoagulated (2.3% vs. 0.6%, p=0.371). Among the 111 patients on VKA, 5 (4.5%) had a late ICH, compared to 4 out of 99 (4.0%) on DOACs; the difference was not statistically significant (p=0.868)., Conclusions: The risk of developing delayed ICH after MTBI in patients on anticoagulation therapy is low. After correction for baseline covariates, the risk does not appear higher compared to non-anticoagulated patients. Thus, a routine control CT scan seems advisable only for patients presenting a clinical deterioration. Larger, prospective trials are required to clarify the safety profile of DOACs vs. VKA in MTBI.

Background and Objectives: Fever is one of the most common presenting complaints in the Emergency Department (ED). The role of serum procalcitonin (PCT) determination in the ED evaluation of adults presenting with fever is still debated. The aim of this study was to evaluate if, in adults presenting to the ED with fever and then hospitalized, the early PCT determination could improve prognosis. Materials and Methods. This is a retrospective, mono-centric study, conducted over a 10-year period (2009-2018). We analyzed consecutive patients ≥18 years admitted to ED with fever and then hospitalized. According to quick sequential organ failure assessment (qSOFA) at admission, we compared patients that had a PCT determination vs. controls. Primary endpoint was overall in-hospital mortality; secondary endpoints were in-hospital length of stay, and mortality in patients with bloodstream infection and acute respiratory infections. Results. The sample included 12,062 patients, median age was 71 years and 55.1% were men. In patients with qSOFA ≥ 2 overall mortality was significantly lower if they had a PCT-guided management in ED, (20.5% vs. 26.5%; p = 0.046). In the qSOFA < 2 group the mortality was not significantly different in PCT patients, except for those with a final diagnosis of bloodstream infection. Conclusions. Among adults hospitalized with fever, the PCT evaluation at ED admission was not associated with better outcomes, with the possible exception of patients affected by bloodstream infections. However, in febrile patients presenting to the ED with qSOFA ≥ 2, the early PCT evaluation could improve the overall in-hospital survival.

The prevalence of acute diverticulitis (AD) has progressively increased in recent decades, with correspondingly greater morbidity and mortality. The aim of the study is to develop a predictive score to identify patients with the highest risk of complicated AD. The clinical records of 1089 patients referred to the emergency department (ED) over a five-year period were reviewed. In multivariate analysis, male sex ( p < 0.001), constipation ( p = 0.002), hemoglobin < 11.9 g/dL ( p < 0.001), C reactive protein > 80 mg/L ( p < 0.001), severe obesity ( p = 0.049), and no proton pump inhibitor treatment ( p = 0.003) were independently associated with complicated AD. The predictive assessment of complicated (PACO)-diverticulitis (D) score, including these six variables, was applied to the retrospective cohort and then validated prospectively in a cohort including 282 patients. It categorized patients into three risk classes for complicated AD. The PACO-D score showed fair discrimination for complicated AD with an area under the receiver operating characteristic curve of 0.674 and 0.648, in the retrospective and prospective cohorts, respectively. The PACO-D score could be a practical clinical tool to identify patients at highest risk for complicated AD referred to the ED so that appropriate diagnostic and therapeutic resources could be appropriately allocated. Further external validation is needed to confirm these results.

Background/objectives: Several scoring systems have been specifically developed for risk stratification in COVID-19 patients., Design: We compared, in a cohort of confirmed COVID-19 older patients, three specifically developed scores with a previously established early warning score. Main endpoint was all causes in-hospital death., Setting: This is a single-center, retrospective observational study, conducted in the Emergency Department (ED) of an urban teaching hospital, referral center for COVID-19., Participants: We reviewed the clinical records of the confirmed COVID-19 patients aged 60 years or more consecutively admitted to our ED over a 6-week period (March 1st to April 15th, 2020). A total of 210 patients, aged between 60 and 98 years were included in the study cohort., Measurements: International Severe Acute Respiratory Infection Consortium Clinical Characterization Protocol-Coronavirus Clinical Characterization Consortium (ISARIC-4C) score, COVID-GRAM Critical Illness Risk Score (COVID-GRAM), quick COVID-19 Severity Index (qCSI), National Early Warning Score (NEWS)., Results: Median age was 74 (67-82) and 133 (63.3%) were males. Globally, 42 patients (20.0%) deceased. All the score evaluated showed a fairly good predictive value with respect to in-hospital death. The ISARIC-4C score had the highest area under ROC curve (AUROC) 0.799 (0.738-0.851), followed by the COVID-GRAM 0.785 (0.723-0.838), NEWS 0.764 (0.700-0.819), and qCSI 0.749 (0.685-0.806). However, these differences were not statistical significant., Conclusion: Among the evaluated scores, the ISARIC-4C and the COVID-GRAM, calculated at ED admission, had the best performance, although the qCSI had similar efficacy by evaluating only three items. However, the NEWS, already widely validated in clinical practice, had a similar performance and could be appropriate for older patients with COVID-19., (© 2020 The American Geriatrics Society.)

Aims: To identify the most accurate early warning score (EWS) for predicting an adverse outcome in COVID-19 patients admitted to the emergency department (ED)., Methods: In adult consecutive patients admitted (March 1-April 15, 2020) to the ED of a major referral centre for COVID-19, we retrospectively calculated NEWS, NEWS2, NEWS-C, MEWS, qSOFA, and REMS from physiological variables measured on arrival. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and the area under the receiver operating characteristic (AUROC) curve of each EWS for predicting admission to the intensive care unit (ICU) and death at 48 h and 7 days were calculated., Results: We included 334 patients (119 [35.6%] females, median age 66 [54-78] years). At 7 days, the rates of ICU admission and death were 56/334 (17%) and 26/334 (7.8%), respectively. NEWS was the most accurate predictor of ICU admission within 7 days (AUROC 0.783 [95% CI, 0.735-0.826]; sensitivity 71.4 [57.8-82.7]%; NPV 93.1 [89.8-95.3]%), while REMS was the most accurate predictor of death within 7 days (AUROC 0.823 [0.778-0.863]; sensitivity 96.1 [80.4-99.9]%; NPV 99.4[96.2-99.9]%). Similar results were observed for ICU admission and death at 48 h. NEWS and REMS were as accurate as the triage system used in our ED. MEWS and qSOFA had the lowest overall accuracy for both outcomes., Conclusion: In our single-centre cohort of COVID-19 patients, NEWS and REMS measured on ED arrival were the most sensitive predictors of 7-day ICU admission or death. EWS could be useful to identify patients with low risk of clinical deterioration., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The Coronavirus Disease 2019 (COVID-19) pandemic mainly involves respiratory symptoms, though gastrointestinal (GI) symptoms are increasingly being recognized. In this context, the presence of comorbidities appears to be associated with adverse outcomes. However, the role of digestive manifestations is not yet well defined. The primary aim of this study was to assess the prevalence of GI symptoms and digestive comorbidities in a cohort of patients with COVID-19 compared to controls. The secondary aim was to determine the association of GI-symptoms and digestive comorbidities with clinical outcomes., Patients and Methods: Inpatients with COVID-19 and controls with similar symptoms and/or radiological findings were enrolled. Symptoms at admission and throughout hospitalization were collected as they were comorbidities. The measured clinical outcomes were mortality, intensive care unit admission and cumulative endpoint., Results: A total of 105 patients were included: 34 with COVID-19 and 71 controls. At admission, the prevalence of GI symptoms among COVID-19 patients was 8.8%. During hospitalization, the frequency of GI symptoms was higher in patients with COVID-19 than in controls (p=0.004). Among patients with COVID-19, the mortality and a cumulative endpoint rates of those with GI symptoms were both lower than for those without GI symptoms (p=0.016 and p=0.000, respectively). Finally, we found digestive comorbidities to be associated with a milder course of COVID-19 (p=0.039 for cumulative endpoint)., Conclusions: Our results highlighted the non-negligible frequency of GI symptoms in patients with COVID-19, partly attributable to the therapies implemented. In addition, the presence of GI symptoms and digestive comorbidities is associated with better outcomes. Most likely, digestive comorbidities do not hinder the host's immune response against SARS-COV-2, and the occurrence of GI symptoms might be linked to a faster reduction of the viral load via the faecal route.

Aim: The aim of the present study was to describe the clinical presentation of patients aged ≥80 years with coronavirus disease 2019 (COVID-19), and provide insights regarding the prognostic factors and the risk stratification in this population., Methods: This was a single-center, retrospective, observational study, carried out in a referral center for COVID-19 in central Italy. We reviewed the clinical records of patients consecutively admitted for confirmed COVID-19 over a 1-month period (1-31 March 2020). We excluded asymptomatic discharged patients. We identified risk factors for death, by a uni- and multivariate Cox regression analysis. To improve model fitting and hazard estimation, continuous parameters where dichotomized by using Youden's index., Results: Overall, 69 patients, aged 80-98 years, met the inclusion criteria and were included in the study cohort. The median age was 84 years (82-89 years is interquartile range); 37 patients (53.6%) were men. Globally, 14 patients (20.3%) presented a mild, 30 (43.5%) a severe and 25 (36.2%) a critical COVID-19 disease. A total of 23 (33.3%) patients had died at 30 days' follow up. Multivariate Cox regression analysis showed that severe dementia, pO 2 ≤90 at admission and lactate dehydrogenase >464 U/L were independent risk factors for death., Conclusions: The present data suggest that risk of death could be not age dependent in patients aged ≥80 years, whereas severe dementia emerged is a relevant risk factor in this population. Severe COVID-19, as expressed by elevated lactate dehydrogenase and low oxygen saturation at emergency department admission, is associated with a rapid progression to death in these patients. Geriatr Gerontol Int 2020; ••: ••-••., (© 2020 Japan Geriatrics Society.)

Objective: Spontaneous thyroid gland hemorrhage is a rare event. The present retrospective study considered its clinical impact and management in a referral center. Methods: Clinical records of adult patients accessed in the last 10 years (2009-2018) in the Emergency Department of Policlinico Gemelli IRCCS were reviewed to study patients with spontaneous thyroid nodule hemorrhage. All demographic and radiologic or surgical parameters were included, with special attention to the characteristics of thyroid disease and clinical management. Results: Among the 631,129 adults who were registered during the period considered, 59 consecutive patients were included in the study. The mean age was 48.3 ± 14.3 years, with a prevalence of females. The main symptoms were acute neck pain, dyspnea, and dysphagia. All patients underwent ultrasound evaluation; computed tomography scan was performed on only 3 patients, finding one case of active intranodular bleeding requiring urgent surgery. Six patients required hospitalization; the others were discharged and referred for ambulatory endocrinology follow-up. Among them, 7 patients underwent surgery in the next 6 months, with malignant disease found in 3 cases (5.1%). Conclusion: Intrathyroidal spontaneous hemorrhage is a rare event, occurring in multinodular as well as in single-nodule thyroid disease. Although the clinical course is mostly benign, this condition should be carefully evaluated as, in rare circumstances, active bleeding could induce airway obstruction with the need for emergency surgery. Patients should be referred to endocrinology ambulatory follow-up because bleeding could arise as the first sign of malignant lesions in some cases. Abbreviations: CT = computed tomography; ED = emergency department; FNA = fine-needle aspiration; US = ultrasound.

Objective: Acute pancreatitis (AP) may present an aspecific clinical picture without abdominal symptoms (atypical AP). We compared clinical outcomes between typical and atypical AP., Patients and Methods: Thirty out of 1163 patients (2.6%) presented an atypical AP. Demographic, clinical data, laboratory and radiological findings, management type, length of hospital stay (LOS) and mortality rate were retrospectively reviewed. A case match analysis 2:1 was performed. The final groups comprised 50 typical APs (TAP group) and 25 atypical APs (AAP group)., Results: The AAP patients presented fever (36%), syncope (32%) and dyspnea (16%) as the most frequent symptoms. Laboratory values showed similarity between the two groups. We noted a comparable edematous AP rate in both groups (p=0.36). Ten (20%) TAP and 3 (12%) AAP patients needed ERCP, respectively (p=0.38). Cholecystectomy was similarly performed in both cohorts (p=0.81). One TAP patient underwent a percutaneous drainage and subsequent surgical necrosectomy compared to none in the AAP cohort (p=0.47). LOS and mortality rate were comparable (p=0.76 and 0.3, respectively)., Conclusions: Similar outcomes have been reached in the two groups. Routine evaluation of the serum amylase values fundamentally contributed to early diagnosis and appropriate treatment.

To investigate the prognostic role of procalcitonin (PCT) assessment and blood culture (BC) acquisition in the emergency department (ED) in patients with urinary tract infection (UTI) or urosepsis. We enrolled patients admitted for UTI to our ED over a 10-year period. Mortality and in hospital length of stay (LOS) were compared between patients with UTI or urosepsis who had sampling for PCT levels and BC taken in the ED (ePCT group-eBC group) and those who had not (no-ePCT group-no-eBC group). 1029 patients were analyzed, 52.7% of which were female. Median age was 77 [65-83]; 139 patients (13.5%) had complicated UTI. Median LOS was 10 [7-17] days. In the ePCT group, LOS was 10 [7-16] days, vs. 10 [7-17] (p = 0.428) in the no-ePCT group. In the eBC group, LOS was 10 [6-16] days vs. 10 [7-17] days (p = 0.369) in the no-eBC group. The overall mortality rate was 6.6%. The mortality rate was not affected by early PCT determination (6% in the ePCT group vs. 6.9% in the no-ePCT group, p = 0.584). Similarly, the mortality rate was not different in the eBC group as compared to the no-eBC group (5.4% vs. 6.9%, p = 0.415). Performance of ePCT or eBC testing made no significant difference in terms of improvement of mortality rates in septic patients (11.4% vs. 7.2%; p = 0.397 and 8.8% vs. 9.8%; p = 0.845, respectively). The prognostic relevance of early evaluation of PCT and BC in the ED of patients with febrile UTI appears limited. In complicated UTI patients, PCT and BC testing may be more appropriate in the context of improving antibiotic stewardship, or as an integral component of PCT-guided standardized protocols.

Introduction: Well recognized guidelines are available for the use of cranial computed tomography (CCT) in traumatic patients, while no definitely accepted standards exists to for CCT in patients without history of head injury. The aim of this study is to propose an easy clinical score to stratify the need of CCT in emergency department (ED) patients with suspect non-traumatic intracranial pathology., Methods: We retrospectively evaluated patients presenting to the ED for neurological deficit, postural instability, acute headache, altered mental status, seizures, confusion, dizziness, vertigo, syncope, and pre-syncope. We build a score for positive CCT prediction by using a logistic regression model on clinical factors significant at univariate analysis. The score was validated on a population of prospectively observed patients., Results: We reviewed clinical data of 1156 patients; positivity of CCT was 15.2%. Persistent neurological deficit, new onset acute headache, seizures and/or altered state of consciousness, and transient neurological disorders were independent predictors of positive CCT. We observed 508 patients in a validation prospective cohort; CCT was positive in 11.3%. Our score performed well in validation population with a ROC AUC of 0.787 (CI 95% 0.748-0.822). Avoiding CT in score 0 patients would have saved 82 (16.2%) exams. No patients with score 0 had a positive CCT findings; score sensitivity was 100.0 (CI 95% 93.7-100.0)., Conclusions: A score for risk stratification of patients with suspect of intra-cranial pathology could reduce CT request in ED, avoiding a significant number of CCT while minimizing the risk of missing positive results., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Acute pancreatitis (AP) incidence in the elderly population has increased in the last years. However, the role of age as influencing factor on the AP clinical course is still debated. Methods: We reviewed clinical records of consecutive patients admitted with diagnosis of AP. Patients were divided in elderly (≥65 years) and non-elderly  (<65 years). Primary endpoint was comparison of overall mortality. Secondary endpoint included ICU admission, in-hospital length of stay (LOS) and surgical procedures. Results: We enrolled 352 elderly and 532 non-elderly patients. A higher mortality rate (7.4% vs 1.9%; p  < .001), ICU admission rate (18.9% vs 6.3%; p  < .001) and prolonged length of hospital stay (9 (6-14) vs 7 (5-11.7) days; p  = .01) were registered in the ≥65 years group. Multivariate analysis identified age (OR: 3.5; 95% CI:1.645-7.555; p  = .001), a higher Ranson score at admission (OR: 5.52; 95% CI:1.11-27.41; p <.001) and necrotic pancreatitis (OR: 8.6; 95% CI:2.46-30.27; p  = .001) as independent predictors of mortality. Conversely age and necrotic pancreatitis were independent risk factors for higher LOS and ICU admission. Conclusions: Patients with AP and age ≥65 years have a higher mortality, ICU admission and prolonged LOS. Early recognition and prompt treatment are key elements to improve outcomes in this population.

Objectives: Globally, the average age of the population is increasing. Patients aged >65 years attending hospital emergency departments (EDs) differ from younger patients; in particular, they often present with multiple comorbidities. Our retrospective study evaluates the number of attendances at our ED by elderly patients in the 12 years from January 2005 to December 2017. Our first aim was to evaluate differences presented by elderly patients regarding symptoms, clinical features, color code (i.e. priority assigned to the case, where red is highest and yellow is medium), waiting time and outcome., Patients and Methods: We analyzed data from 201,580 patients aged >65, divided into two groups: 65-84 years and >85 years. Clinical and demographic data were collected from the computerized clinical record (GIPSE®)., Results: 201,580 patients fulfilled the inclusion criteria, of whom 93,262 (46.3%) were male. There were 162,373 patients aged 65-84, and 39,207 aged >85. Patients aged >85 presented more complex cases, and were admitted more frequently with a red color code and were more frequently hospitalized. Larger proportions of this group had dementia, and attended the ED for trauma or gastrointestinal bleeding. The group aged 65-84 were admitted more frequently with a yellow color code and then discharged. They typically attended the ED for chest and abdominal pain., Conclusion: There is an increase in the request for health care especially in an emergency setting. The hospitalization of elderly patients is associated with a deterioration in motor skills and quality of life. Being able to reduce hospitalization in the elderly means avoiding disruption to the home care of people with dementia, and reducing both the risk of falls and hospital infections. In Italy, a program (as already experimented with in the USA) dedicated to the elderly who attend hospital EDs is desirable., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: the role of microbes and chronic inflammation in the pathogenesis of Alzheimer' disease (AD) has been postulated by many authors. On the other hand, several studies have reported the main role of H. pylori infection and/or GUT microbiota alteration in promoting chronic inflammation, thus possibly influencing both occurrence and evolution of AD. In this article, we analyze the most important and recent studies performed on this field both on humans and animals and provide possible pathogenic explanations., Results: all main and most recent animal, human, epidemiological and in-silico studies, showed a role of H. pylori and/or dysbiosis in AD, mostly through the promotion of systemic chronic inflammation and/or by triggering molecular mimicry mechanisms. In particular, H. pylori infection seems to be related to a poorer cognitive performance., Conclusions: Indeed, bacteria have been shown to affect neurodegeneration by promoting inflammation, inducing molecular mimicry mechanisms and accumulation of Aβ into the brain. These findings open the way for H. pylori eradicating trials and/or GUT microbiota remodulating strategies. Therefore, further studies are now needed in order to test whether antibiotics, pre and/or probiotics may exert a beneficial effect in the prevention of AD.

Study Objective: We evaluated the performance of Troponin T (cTnT) for acute coronary syndrome (ACS) diagnosis in elder compared to younger patients., Materials and Methods: We retrospectively evaluated 2688 patients admitted to our Emergency Department for suspected ACS. All patients received ECG, serum creatinine determination, and serial cTnT samplings. Patients were considered positive for cTnT if they had a cTnT above our reference standard (>0.03 microg/L) in any determination obtained within 6 hours from admission. ACS diagnosis, either acute myocardial infarction or unstable angina, was based on reviewed data and discharge diagnosis hospital. Patients were divided in three groups according to age: <65-years-old, elders > or =65 and <80 years, and very elders > or =80 years. CTnT diagnostic accuracy for ACS was compared in these three groups in patients <65 years., Results: Two thousands six and hundred eighty-eight patients (35.3% female) were enrolled in this study. 1087 patients (40.4%) were <65 years old, while 1205 patients (44.8%) were >or =65 and <80 years, and 396 patients (14.8%) were > or =80 years. The overall sensitivity of cTnT for ACS diagnosis was 0.57 (CI 95% 0.54-0.60) with a specificity of 0.71 (CI 95% 0.69-0.73). In older cohorts cTnT showed a reduced performance for ACS diagnosis. Area under the receiver operating characteristic curve of abnormal cTnT for ACS was 0.70 (0.66-0.73) in <65 years, 0.61 (95% CI 0.60-0.66) in > or =65 and <80 years, and 0.59 (0.53-0.65) in > or =80 years., Conclusion: Compared to younger patients cTnT showed a reduced performance for ACS diagnosis in elders > or =65 and <80 years; cTnT performance was further reduced in patients > or =80 years.

Background: Cardiovascular and metabolic comorbidities are dramatically increased in severe obesity, a condition highly resistant to nonsurgical therapy., Objective: The objective was to identify predictors of weight loss and reversal of comorbidity in obese patients undergoing malabsorptive bariatric surgery., Design: Morbidly obese men and women (n = 107) were studied before and 2 y after biliopancreatic diversion (BPD). Body composition, serum lipid profile, oral glucose tolerance, and blood pressure were measured. Insulin sensitivity was determined by use of a euglycemic clamp. The length of the small intestine was measured during surgery., Results: Intestinal length was 671 +/- 99 cm, and the residual absorbing intestine after BPD ranged from 54% to 24% of initial length. Patients lost an average of 36% of their initial weight, with approximately 50% of them reaching a body mass index (in kg/m(2)) < 30. Serum cholesterol decreased (from 4.58 +/- 1.11 to 3.34 +/- 0.73 mmol/L; P < 0.0001), as did serum triacylglycerols (from 1.52 +/- 0.59 to 0.88 +/- 0.35 mmol/L; P < 0.0001), whereas insulin sensitivity rose 150% (from 26 +/- 4 to 64 +/- 11 micromol . min(-1) . kg fat-free mass(-1); P < 0.0001). Diabetes (in 23% of patients before surgery) and hypertension (in 83%) were reduced (by 88% and 96%, respectively) after surgery. In a multivariate model (including sex, age, intestinal length, presence of diabetes, insulin sensitivity, and initial fat mass), age and diabetes were independent, negative predictors of weight loss, whereas initial fat mass was a strong positive predictor (r(2) = 0.51)., Conclusions: Two years after BPD in morbidly obese patients, comorbidities are largely corrected and insulin resistance is fully reversed despite persistent obesity. Initial fat mass, but not residual intestinal length, is the strongest predictor of weight loss after BPD.