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Assessing patient frailty during triage evaluations has become increasingly relevant in Emergency Departments (ED). This study aimed to externally validating the Triage Frailty and Comorbidity (TFC) tool. This prospective study was conducted from June 1 to December 31, 2023. During this period, 12 triage nurses applied the TFC tool during triage evaluation of ED patients. We used receiver operating characteristic (ROC) curves and Decision Curve Analysis to assess the predictive ability of the TFC tool for a 90-day mortality (the same endpoint used during tool development) and a 30-day mortality. 1270 patients were included and 56 of them died within 90 days. The TFC tool had an AUROC of 0.894 (0.858-0.929) for 90-day mortality and 0.885 (0.834-0.938) for 30-day mortality. In Decision Curve Analysis, it yielded higher net benefits up to a threshold probability of 0.30. The externally validated TFC tool appears very effective at identifying patients with increased risk of 90-day mortality after ED attendance. It could be implemented in clinical practice and enhance the predictive ability of standard triage systems., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background: Emergency Departments (EDs) across Italy use different triage systems, which vary from region to region. This study aimed to assess whether nurses working in different EDs assign triage codes in a similar and standardized manner., Methods: A multicenter observational simulation study involved the EDs of Bolzano Hospital, Merano Hospital, Pisa University Hospital, and Rovereto Hospital. All participating nurses were given 30 simulated clinical cases (vignettes) and asked to assign triage codes according to the triage systems used in their EDs. Subsequently, we assessed inter-rater agreement and evaluated if code assignment had different performance among hospitals in relation to different clinical outcomes., Results: Eighty-seven nurses participated in this study. There was marked variation in assigned triage codes both across hospitals and among individual operators. The kappa values for inter-rater agreement were 0.632 for Bolzano Hospital, 0.589 for Merano Hospital, 0.464 for Pisa University Hospital, and 0.574 for Rovereto Hospital. Sensitivity and specificity levels varied considerably for the same outcomes when comparing different hospitals., Conclusion: There is a high degree of subjectivity in triage code assignment by ED nurses. In the interest of equitable care for patients, this variability within the same country is hardly acceptable., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Aim: This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS)., Design: Prospective observational study., Methods: The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC)., Results: The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment., Conclusions: The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Aims and Objective: The study aimed to assess the triage nurse's skill in the recognition of abnormal electrocardiogram during actual clinical practice and to identify nurse- and patient-related factors associated with errors in electrocardiogram interpretation., Background: The nurse's ability to interpret the electrocardiogram has only been evaluated in simulation settings and has reported conflicting results., Design: A prospective single-centre observational study., Methods: During the evaluation of a patient with a cardiovascular symptom, the triage nurses were asked to define whether the 12-lead electrocardiogram performed during the triage evaluation was pathological or non-pathological for the presenting symptom. Patient characteristics and some nurse-related variables were recorded. Inter-rater agreement between the physician and nurse in the electrocardiogram interpretation was considered the primary outcome, while the association of a major acute cardiovascular event related to patient access in the Emergency Department was the secondary outcome. We have followed the STROBE checklist for the preparation of this manuscript., Results: Twenty nurses agreed to participate to the study and collect data. Of the 644 patients enrolled, 21.6% (139/644) reported a pathological electrocardiogram according to the ED Physician. The concordance between nurse and physician was modest with Cohen's Kappa of 0.666. An error in the electrocardiogram interpretation was present in 11% of the patients. Nurses who performed an electrocardiogram course within 1 year and studied electrocardiogram interpretation autonomously presented a lower error rate, while older patients and patients with more previous cardiovascular disease were found to be more associated with an error in electrocardiogram interpretation., Conclusions: The study demonstrates that triage nurses have a fair ability to interpret the electrocardiogram., Relevance to Clinical Practice: Specific educational programmes for electrocardiogram interpretation could improve the skill of electrocardiogram interpretation by the nurse and enable this instrument to become an indispensable tool in triage assessment., (© 2023 John Wiley & Sons Ltd.)

Aims: The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms., Design: Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy., Methods: For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen's kappa analysis., Results: Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%., Conclusion: Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events., Impact for Nursing: Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events., Reporting Method: The study was reported according to the STROBE guidelines., No Patient or Public Contribution: The study did not involve any patients during its conduction., (© 2023 John Wiley & Sons Ltd.)

Aims: The objective was to evaluate whether the error rate in the application of the triage system decreased after the introduction of daily auditing, and it was also evaluated if the agreement rate between physician and nurse on triage priority levels increased after the introduction of daily auditing and if the error-related variables in the pre-intervention period changed in the post-intervention period., Design: A quasi-experimental study was performed with a pre-post design, between June 2019 and June 2021 in one emergency department., Methods: The accuracy and error rate of triage in the pre- and post-intervention period were compared. Univariate and multivariate logistic regression analyses were performed to explore the relationships between the variables related to the error. The comparison between the priority level assigned by the physician and the triage nurse was analysed using Cohen's K., Results: Nine hundred four patients were enrolled in the pre-intervention period and 869 in the post-intervention period. The error rate in the pre-intervention period was 23.3% and in the post-intervention period was 9.7%. The concordance between the degree of priority expressed by the physician and the nurse varied from a quadratically weighted Cohen's K of 0.447 in the pre-intervention period to 0.881 in the post-intervention period., Conclusion: Daily auditing is a clinical procedure that improves the nurse's application of the triage system. Daily auditing has reduced errors by the nurse, improving performance and concordance with the physician., Impact: Triage systems are a key point for the stratification of the priority level of patients and it is therefore evident that they maintain high-quality standards. Through the practice of daily auditing, not only a reduction in the error rate, which ensures patient safety, but also an improvement in triage performance has been demonstrated., No Patient or Public Contribution: The study did not involve any patients during its conduction., (© 2022 John Wiley & Sons Ltd.)

Background: The exponential growth of tourism worldwide could have consequences for healthcare services in tourist locations. The impact of the tourist population on access to emergency departments (EDs) is currently unknown., Aim: To describe the characteristics of tourist access in an ED of an alpine tourist area in a period prior to the COVID-19 pandemic., Methods: All patients evaluated at the ED of the Merano Hospital from January 1, 2017, to December 31, 2019, were considered and divided into two study groups: locals and tourists. Analyses were conducted to assess the impact of tourists in terms of weighted ED admissions and differences in admission characteristics. Finally, for tourist patients only, an analysis of severity according to their type of healthcare system of provenance was performed., Results: A total of 208,875 ED presentations were considered, of which 90.7% (189,406) were by local patients and 9.3% (19,469) were by tourists. The median ED admission rate was 1.65 admissions per 1000 overnight stays for locals versus 0.90 admissions per 1000 overnight stays for tourists. The time series analysis revealed a greater seasonal variation in accesses by tourists than by resident patients. A higher proportion of accesses with a severe code was found among tourist patients, while the local population exhibited a higher proportion of patients with a non-urgent code. In the tourist population, patients from a country with a free-market healthcare system had a higher number of ED presentations for severe conditions or that required hospitalisation than tourists from countries with Bismarck or Beveridge healthcare systems., Conclusions: The tourist population can have an important impact on EDs in high-impact tourist areas. The seasonality of the tourist population indicates the need for health policies that focus on educating the tourist population on the correct use of the ED., Competing Interests: Declaration of competing interest There is no conflict of interests., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: It is known that there has been an increase over the years in attacks by patients admitted to the emergency department (ED) on healthcare workers; it is unclear what effect the COVID-19 pandemic has on these attacks., Aim: to verify through a long-term time analysis the effect of COVID-19 on ED attacks on healthcare workers., Mothods: a quasi-experimental interrupted time-series analysis on attacks on healthcare workers was performed from January 2017 to August 2021. The main outcome was the monthly rate of attacks on healthcare workers per 1000 general accesses. The pandemic outbreak was used as an intervention point., Results: 1002 attacks on healthcare workers in the ED were recorded. The rate of monthly attacks on total accesses increased from an average of 13.5 (SD 6.6) in the pre-COVID-19 era to 27.2 (SD 9.8) in the pandemic months, p < 0.001. The pandemic outbreak led to a significant increase in attacks on healthcare workers from 0.05/1000 attacks per month (p = 0.018), to 4.3/1000 attacks per month (p = 0.005)., Conclusions: The COVID-19 pandemic has led to a significant increase in attacks on healthcare workers in the ED. Trends compared to pre-pandemic months do not seem to indicate a return to normality. Health institutions and policymakers should develop strategies to improve the safety of the working environment in hospitals and EDs., Competing Interests: Declaration of Competing Interest There is no conflict of interests., (Copyright © 2022. Published by Elsevier B.V.)

Background: The COVID-19 pandemic brought important changes in access to the Emergency Department (ED). At present, an analysis of how the COVID-19 pandemic has changed not only the number but also the nature of the urgency of ED access is not available. This study aimed to verify the effect of the COVID-19 pandemic on the urgency of patients admitted to the ED utilizing timebased analyses., Methods: A quasi-experimental interrupted time series analysis based on a retrospective review of data from all ED admissions occurring at the Merano Hospital (Italy) from 1 January 2015 to 30 June 2021 was conducted., Results: From January 2015 to June 2021, 416,560 patients were admitted to the ED. Since the pandemic outbreak, the trend of urgent patients (classified as orange and red by triage) remained unchanged compared to the pre-pandemic period (p = 0.095, p = 0.155). In contrast, patients classified as blue (non-urgent) increased exponentially since the outbreak of the pandemic (p < 0.001)., Conclusion: The present study reported stability in urgent codes (orange and red) since the pandemic outbreak while a dramatic increase in non-urgent codes (blue and green) is reported. The results of the study may indicate the need to find health policy solutions to manage this large increase in nonurgent patients requiring assessment in EDs since the outbreak of the pandemic., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients., Methods: Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR., Results: Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy., Conclusion: Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain., Methods: A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access., Results: Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days., Conclusions: The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage., Relevance to Clinical Practice: The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients., (© 2021 John Wiley & Sons Ltd.)

Study Objective: Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications., Design: A prospective cohort study., Setting: Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy)., Patients: Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany)., Interventions: One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied., Measurements and Main Results: The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group., Conclusion: Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

The septate uterus is the most common congenital uterine malformation and is treated by hysteroscopic metroplasty. There are few studies on the fundal uterine changes that occur after surgery. We designed a pilot prospective observational study to evaluate by three-dimensional transvaginal ultrasound (3D-TVS) the changes not only of the internal fundal uterine profile, but also of the external one, after hysteroscopic metroplasty. Sixty women who underwent hysteroscopic metroplasty for partial or complete uterine septum (U2a and U2b subclasses of ESHRE/ESGE classification) were enrolled. We performed 3D-TVS after surgery confirming optimal removal of the septum. However, at ultrasound follow-up after three months, we observed a significant increase ( p < 0.001) in the residual septum (Zr) (3.7 mm (95% CI: 3.1-4.4)), the myometrial wall thickness (Y) (2.5 mm (95% CI: 2.0-3.0)) and the total fundal wall thickness (Y + Zr) (6.2 mm (95% CI: 5.5-6.9)). Forty-three patients (72%) required a second step of hysteroscopic metroplasty. Moreover, the shape of uterine fundus changed in 58% of cases. We actually observed a remodeling of the uterine fundus with modifications of its external and internal profiles. Therefore, we propose to always perform a second ultrasound look at least three months after the metroplasty to identify cases that require a second- step metroplasty.

Background: Nurses play a crucial role in correctly prioritizing patients entering emergency departments. However, little is known of the accuracy of nurse-led triage systems., Objectives: (1) To determine the frequency of nurse-led triage errors within the Manchester Triage System; (2) to explore patient, work environment and individual nurse factors associated with triage errors; and (3) to explore associations between triage errors and patient outcomes (i.e., length of emergency department stay, hospitalization, and 7- and 30-day mortality)., Setting: This study was conducted in one emergency department in Northern Italy., Participants: A random sample of 5% (n = 1,929) of all eligible patients accessing the emergency department over an 18-month period., Methods: For this retrospective observational study, electronic health record data on triage errors (i.e., incorrect presentational flowchart, specific discriminator and/or priority level) and triage nurses were combined with routine data on patient characteristics, outcomes and the work environment. To explore relationships between these variables, we performed univariate and multivariate logistic regression analyses., Results: We observed triage errors in 16.3% of patients (n = 314). These were significantly associated with patients' emergency department and hospital stays. Analyses revealed that when > one patient was triaged every 15 min (OR: 2.112;95%CI: 1.331-3.354), older patients (OR: 1.009; 95%CI: 1.003-1.015) with > than two chronic conditions (OR: 1.506; 95%CI: 1.091-2.081) and orange or red priority codes (OR: 1.314; 95%CI: 1.046-1.651,) whose triage nurse had previous experience with another triage system (OR: 3.189; 95%CI: 2.455-4.14) had higher odds of triage errors., Conclusion: We provided primary evidence on triage errors. Confirming our findings on the prevalence, nature and consequences of such errors will require further prospective multicenter studies. Considering patient factors (e.g., age, polychronicity) as additional discriminators could make the nurse-led triage process using the Manchester Triage System more accurate. Investigating the roles of triage nurses' training and background and the emergency department work environment on their mental models regarding the triage process will require qualitative research., (Copyright © 2020. Published by Elsevier Ltd.)

Endometrial cancer (EC) is the fourth largest female cancer in Europe and North America. In 5% of cases, the diagnosis is made in women who wish to become pregnant. In our retrospective study, we reported our experience about fertility sparing treatment of G1 endometrioid endometrial cancer (G1 EEC) or atypical endometrial hyperplasia/endometrial intraepithelial neoplasm (AEH/EIN) in young women desiring pregnancy treated in our Center. Conservative treatment was based on operative hysteroscopy and hormone therapy with megestrol acetate (160 mg/die for 9 months). For the first time we included women with G1 EEC with minimal myometrial infiltration. The minimum follow-up period was two years and consisted of serial outpatient hysteroscopies with endometrial biopsies. Among the 36 women with G1 EEC we observed one case of disease persistence and four recurrences and four recurrences among the 46 women diagnosed with AEH/EIN. To date, 35 live births were obtained in both groups. Our results advance the hypothesis that conservative treatment can represent a safe and feasible alternative to propose to young women with desire for pregnancy. Further randomized and multicentric studies are needed to arrive at unambiguous and standardized guidelines on the surgical and medical treatment of young women with EEC or AEH/EIN.

Objective: Up to 15% of patients arrive in the emergency department suffering from fever. Triage is their first contact and is responsible for the stratification of patients according to the severity of the condition for which they are presenting at the emergency department. The aim of this study is to assess the predictive validity of the Manchester Triage System in patients with fever for sepsis or septic shock and seven-day mortality., Methods: The sensitivity, specificity and negative predictive value of the Manchester Triage System was assessed by priority code allocation towards seven-day mortality and the diagnosis of sepsis or septic shock., Results: A total of 3831 patients were evaluated in the emergency department for fever between 1 January 2017 and 30 June 2019. Of these, 1.9% were diagnosed with sepsis or septic shock. Using the Manchester Triage System to predict diagnosis of sepsis or septic shock provided a sensitivity of 88.7%, a specificity of 50.1% and a negative predictive value of 99.5%. For seven-day mortality, sensitivity was 44.4%, specificity was 92.3% and the negative predictive value was 99.3%., Conclusion: The Manchester Triage System has demonstrated high sensitivity and negative predictive value in patients with fever diagnosed with sepsis or septic shock. For patients with sepsis or septic shock one-third of cases with an incorrectly assigned priority code were caused by incorrect application of the Manchester Triage System., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Recognising patients with pulmonary embolism continues to be a clinical challenge. In the Emergency Department, up to 50% of patients with pulmonary embolism can be delayed or even misdiagnosed. The ability of a triage system to correctly prioritise suspected embolism in these patients is fundamental for determining diagnostic-therapeutic procedures., Aim: To verify the effectiveness of the Manchester Triage System in risk prioritisation of patients with pulmonary embolism who present with dyspnoea, chest pain, or collapse., Methods: In this observational, retrospective, study the sensitivity, specificity, and positive and negative predictive values of the Manchester Triage System were calculated using the triage classification for these patients, and their established diagnoses. The analysis included baseline characteristics and triage evaluations., Results: During the two-year study period, 7055 patients were enrolled. Pulmonary embolism episodes were 2.1% of all cases, while severe pulmonary embolisms were 0.8%. The estimated specificity of the Manchester Triage System was 72.5% (CI 95%, 71.5-73.6), and the negative predictive value was 98.1% (CI 95%, 97.7-98.5). The results suggest that clinical characteristics leading to a high Manchester Triage System priority are similar to those characterising a pulmonary embolism episode., Conclusions: Although pulmonary embolism is difficult to diagnose, the Manchester Triage System is an effective tool for prioritising patients with symptoms of this disease., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding., Objectives: In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS., Methods: A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation., Results: During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001)., Conclusions: Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The proximity to areas of intensive pesticide application is a risk factor that favors xenobiotic exposure. Pesticides may interfere with hormonal function and cause alterations in the reproductive system, pregnancy complications, and adverse fetal development. We evaluated potential endocrine disruption and the evolution of the third trimester of pregnancy in women residing in a rural area of Argentina with intense pesticide applications, and the characteristics of their newborns. Blood samples were collected from healthy women in the third trimester of pregnancy during the pesticide spraying (SP) (n = 26) and nonspraying (NSP) (n = 27) periods. Plasma cholinesterase activity and cortisol and DHEA-S levels were lower in SP than in NSP. The percentage of preterm premature rupture of membranes was higher in SP than in NSP. Macrosomia at birth was17% in both periods. This study reinforces the importance of preventing potential cases of cumulative toxicity during the perinatal period through monitoring and epidemiological studies., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To report hysteroscopic treatment combined with levonorgestrel-releasing intrauterine device (LNG-IUD) to treat women with early well differentiated endometrial cancer (EC) at high surgical risk., Methods: Nine women diagnosed with stage IA, grade 1 endometrioid EC which was contraindicated or refused standard treatment with external beam radiation therapy with or without brachytherapy were enrolled in our prospective study. Endo-myometrial hysteroscopic resection of the whole uterine cavity and the placement of LNG-IUD for 5 years was performed. Response rate, perioperative complications, and recurrence of disease were evaluated., Results: None had intra or post-operative complications and all were discharged no later than the third day of hospitalization. After 6 months from surgery, all the women showed a complete regression of the lesion. All the women completed the 5 years follow-up and in no case was detected sign of recurrence. Two women died for causes unrelated to the tumor or the ongoing therapy., Conclusion: The alternative treatment with endo-myometrial hysteroscopic resection and LNG-IUD in women with stage IA, grade 1 endometrioid EC showed initial encouraging outcomes in terms of effectiveness and safety., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2019. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology.)

Background: Two different mitochondrial fractions (MFs) have been characterized in the human placenta: the "light" and "heavy" fractions (LMF and HMF). Although these organelles are the main source of reactive oxygen species, an imbalance between their production and the rate of detoxification represents a serious threat to mitochondrial homeostasis and, in the case of the placenta, also to the fetus. The aim of this study was to evaluate the antioxidant capacity and susceptibility to oxidative stress in both types of MFs., Methods: Human MFs were isolated from healthy donors (n = 11) and either incubated or not with H 2 O 2 . Catalase (CAT) activity, and reduced glutathione (GSH), lipid peroxidation (LP), and protein carbonylation (PC) levels were determined., Results: H 2 O 2 treatment increased LP and PC levels and decreased CAT activity. GSH levels were similar in control and treated MFs., Conclusion: H 2 O 2 caused oxidative damage in both LMF and HMF and the antioxidant system measured in these two MFs responded similarly. To the best of our knowledge, this is the first partial description of the antioxidant defense in placental HMF and LMF performed in a cell-free assay. The small number of antioxidant system parameters measured did not allow detecting differences between HMF and LMF., (© 2018 Wiley Periodicals, Inc.)

In rural populations, the proximity to areas with intensive pesticide application represents a risk factor of xenobiotic exposure. Here, we investigated whether newborns born to mothers residing in an area with intensive pesticide application show alterations in placental and neonatal morphometric standards, umbilical cord blood (UCB) biochemical parameters, and/or biomarkers related to oxidative stress and oxidative damage. Samples were collected from 151 healthy pregnant women residing in a rural area (rural group; RG) during the pesticide spraying (SS) and nonspraying (NSS) seasons, as well as from women from an urban population (control group; CG), and grouped according to the delivery type (vaginal or cesarean). In the vaginal delivery group, the placental weight and placental index were higher in the RG groups than in the CG (p = 0.01), whereas in the cesarean delivery group, newborn weight was lower in the RG-SS group than in the CG. In the RG-SS group, UCB erythrocyte osmotic fragility and the DNA damage index (DI) were higher, and superoxide dismutase (SOD) activity was lower than in the RG-NSS group. Acetylcholinesterase and SOD activities were found to be inversely correlated with the DI.

The impact of environmental organophosphate (OP) pesticide exposure on respiratory complexes, enzymatic antioxidant defense activities, and oxidative damage markers in the syncytiotrophoblast and cytotrophoblast mitochondria was evaluated. Placental progesterone (PG) levels and endothelial nitric oxide synthase (eNOS) expression were studied. Samples from women non-exposed (control group-CG) and women living in a rural area (rural group-RG) were collected during pesticide spraying season (RG-SS) and non-spraying season (RG-NSS). In RG-SS, the exposure biomarker placental carboxylesterase decreased and syncytiotrophoblast cytochrome c oxidase activity increased, while 4-hydroxynonenal levels decreased. PG levels decreased in RG-SS and in the RG. Nitric oxide synthase expression decreased in RG, RG-SS and RG-NSS. No significant changes in mitochondrial antioxidant enzyme activities were found. These results suggest that the alteration of syncytiotrophoblast mitochondrial complex IV activity and steroidogenic function may be associated to pesticide exposure. Reduction in placental PG and eNOS expression may account for low newborn weight in RG., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Although non-innervated, the placenta contains both cholinesterases (ChEs), butyrylcholinesterase (BChE) and acetylcholinesterase (AChE). These enzymes are well-known for their multiple molecular forms. In a first approach, we used recognized specific inhibitors, substrate preferences and non-denaturating gel electrophoresis in order to characterize the ChE profile of term placenta from uncomplicated pregnancy. Results strongly suggest that the predominant cholinesterasic form present was tetrameric BChE. It is well established that both ChEs are targets of cholinesterase-inhibiting organophosphates (OP), one of the most important classes of chemicals actively applied to the environment. However, we have previously reported increased ChEs activity in placenta of rural residents exposed to OP. In the present work, we have studied: 1) whether this finding was reproducible and, 2) whether AChE or BChE up regulation is behind the increase of placental ChE activity. The population studied included forty healthy women who live in an agricultural area. Samples were collected during both the OP pulverization period (PP) and the recess period (RP). The placental ChEs activity increased in PP, evidencing reproducibility of previous results. The analysis of non-denaturating gels revealed that increased activity of total ChE activity in placenta from women exposed to OP may be attributable to tetrameric BChE up-regulation.

The impact of environmental organophosphate pesticide exposure on the placenta oxidative status was assessed. Placental samples were collected from women residing in an agricultural area during pesticide pulverization period, non-pulverization period and from control group. Carboxylesterase activity was significantly decreased in pulverization period group. Enzymatic and non-enzymatic defense system, the oxidative stress biomarkers and the nuclear factor erythroid 2-related factor levels showed no differences among groups. However, in the pulverization period group, an inverse association between catalase activity and placental index, a useful metric for estimating placental inefficiency, was found. This result suggests that catalase may serve as a potential placental biomarker of susceptibility to pesticides. Further studies designed from a gene-environment perspective are needed., (Copyright © 2014 Elsevier B.V. All rights reserved.)

To evaluate the cytokine balance and enzymatic alterations induced by environmental pesticide exposure during pregnancy, this transversal study explored placentas derived from non-exposed women (control group-CG), and from women living in a rural area (rural group-RG), collected during intensive organophosphate (OP) pesticide spraying season (RG-SS) and during non-spraying season (RG-NSS). The exposure biomarkers blood cholinesterase and placental carboxylesterase (CaE) were significantly decreased in RG-SS. Among the cytokines studied IL-8, IL-6, TNFα, IL-10, TGFβ and IL-13, the expression frequency of IL-13 increased in RG-SS. Arginase and ornithine decarboxylase (ODC) enzymes were induced in syncytiotrophoblast and endothelial cells. Interestingly, the decrease in CaE activity was associated with arginase and ODC activity induction. These findings suggest that environmental pesticide exposure impacts the placenta by increasing the expression frequency of the anti-inflammatory cytokine IL-13, which may be related to the up-regulation of enzymes implicated in tissue repair., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Blood cholinesterases and tissue carboxylesterases (CEs) are sensitive indicators of environmental organophosphate pesticides (OPs) exposure. The aim of this pilot study was to assess the impact of OP exposure on placental CE activity and lipid composition. We performed a study of 40 healthy women who live in agricultural farms. Samples were collected during the pulverization period (PP) and recess period (RP). The plasma cholinesterase and placental CE activity decreased in PP, suggesting that women were exposed to OPs and that these pesticides reached the placenta. The cardiolipin content increased and the phosphatidylethanolamine content decreased in the light mitochondrial fraction while total cholesterol and sphingomyelin increased in the nuclear fraction. These changes in lipid profiles suggest repair by hyperplasia of the cytotrophoblast. Decreased CE activity may have clinical and toxicological implications and thus entail potential risks to damage fetal growth and development., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In utero exposure is the first point of contact with environmental xenobiotics that may affect the maternal-placental-fetal balance. Considering that maternal pathophysiological changes affect intrauterine development, this pilot study was conducted to address how environmental exposure to organophosphate pesticides (OPs) during pregnancy may contribute to maternal endocrine disruption and disturbed hepatic function. A prospective study was carried out with pregnant women (n=97) living in a rural area of the Rio Negro province where OPs are intensively applied throughout 6 months of the year. Blood samples were obtained and biomarkers of OPs exposure (cholinesterases and β-glucuronidase), cortisol (CT) and progesterone (PG) levels, as well as glycemia, were determined. Parameters of liver injury were assayed by measuring aspartate aminotransferase (AST) and alanine aminotransferase (ALT); liver function was assayed by measuring albumin. Biomonitoring carried out during the pre-spraying period (PreS) and spraying period (SP) showed that the population studied was exposed to OPs, proven by the fact that plasma (PCh) and erythrocyte cholinesterase (AChE) decreased very significantly (p<0.01) during SP. CT values increased very significantly (p<0.01) in the first trimester of pregnancy during SP with respect to PreS. Individual values above the upper limit of the CT and PG reference range were found both in PreS and SP. This finding could be associated with changes in hormone metabolism pathways produced by OPs exposure. During the second trimester of pregnancy there were increases in ALT values and the AST/ALT ratio in SP, suggesting subclinical hepatotoxicity. In SP, glycemia was unchanged while albuminemia increased. Although anthropometric newborn parameters and pregnancy alterations were within normal values for the general population, the increase in CT in the maternal compartment may lead to impaired newborn health later in life., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A pilot study was conducted to evaluate the usefulness of salivary cholinesterase and carboxylesterase as biomarkers of exposure to environmental organophosphate pesticides. Ninety samples were obtained from women and 62 samples from their preschool-aged children who live near an agricultural area of the Upper Valley of the Negro River (Patagonia, Argentina) where pesticides are applied 6 months a year. Each participant donated two samples under similar conditions: one in the pre-exposure period and another during the pulverization period. Demographic information, potential confounders, and risk behaviors were registered. Active or passive smoking had no effect on these enzyme activities in either group. During the pulverization period, cholinesterase activity was not detectable in 76% of the children's samples and 23% of the mothers' samples. Comparing samples collected during the pulverization period with respect to the pre-pulverization period, the average mother and child cholinesterase activity decreased by 65.7% (p < 0.001) and 85.8% (p < 0.001), respectively. Also, mother and child carboxylesterase activity decreased by 27.5% (p < 0.001) and 41.9% (p < 0.01), respectively. Child carboxylesterase activity in the pulverization period was associated to the habit of eating dust outdoors (p < 0.01). The most frequent inhibition levels observed for cholinesterase and carboxylesterase activity were between 70-100% and 0-29%, respectively, in both groups studied. This shows that at the same level of exposure, cholinesterase was more sensitive to inhibition than carboxylesterase. Therefore, carboxylesterase might more properly reflect the degree of environmental organophosphate exposure and may have potential as a novel tool for biomonitoring.

Epidemiological data have associated environmental organophosphate insecticide (OP) exposure during pregnancy with fetal growth deficits. To better understand OP injury that may adversely affect pregnancy, we used the JEG-3 choriocarcinoma cell line, which provide a recognized in vitro model to study placental function. The effects of the OP phosmet (Pm) and chlorpyrifos (Cp) on JEG-3 cells viability, proliferation, cell cycle and inflammatory molecule production were evaluated. Both insecticides affected cellular viability in a concentration- and time-dependent manner, inducing apoptosis and decreasing [(3)H]-thymidine incorporation. However, only Pm reduced DNA synthesis independently of cellular death and decreased the cell percentage at the S-phase. Unlike apoptosis, TNFα production varied with the concentration tested, suggesting that other TNFα independent mechanisms might trigger cell death. No induction of the inflammatory molecule nitric oxide was detected. The mRNA levels of pro-inflammatory IL-6, IL-17 and the anti-inflammatory IL-13 cytokines were differentially modulated. These findings show that Pm and Cp generate a specific toxicity signature, altering cell viability and inducing an inflammatory cytokine profile, suggesting that trophoblasts may represent a possible target for OP adverse effects., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Organochlorine pesticides have been detected in placenta. The ability of heptachlor (HC) and 1,1,1-tricholoro-2-(2-chlorophenyl)-2-4-chlorophenyl)ethane (o-p'DDT) to interfere with protein phosphorylation was evaluated. In vitro incubations of cell-free placental villi homogenates with a concentration range 1-100 microM were performed. In particulate fractions, total serine/threonine kinase activity was increased by 10 microM HC and o-p' DDT (59% and 82%, respectively). Maximum eightfold increase was observed with 10 microM o-p' DDT on protein kinase A activity. By contrast, protein kinase C activity was reduced by 10 microM HC and o-p' DDT (40% and 52%, respectively). Endogenous substrate phosphorylation studies demonstrated that slight but significant increase in 24-kDa band labeling was produced in nuclear samples with 1, 10, and 100 microM HC and 100 microM o-p' DDT. Exposition to 100 microM HC increased 85-kDa band labeling. In mitochondrial fractions, 10 microM HC and o-p' DDT increased 24- and 65-kDa bands' labeling. These data indicate that both pesticides affect protein kinase activities in particulate fraction. Nuclear compartmentalization of these compounds, insertion in membranes, and chemical stress production may be associated to the observed effects, thus suggesting deleterious consequences in signaling pathways.

Unlabelled: Witnessing a cardiopulmonary resuscitation is a dramatic event for health care workers and for the relatives of those involved, especially for parents and relatives of children., Method: A literature review was performed on MedLine, PubMed, Ebsco, with the following keywords: Family presence, Relatives, Parents presence, Pediatric Resuscitation, Cardiopulmonary Resuscitation (CPR), Pediatric intensive care unit, to explore if parents should be allowed to witness or not and their need of support., Results: Most paediatric guidelines favour the presence of relatives during CPR and the results of surveys are consistent in reporting that parents prefer to see what is happening to their child. The benefits for health care workers include an improvement of the relationship with family members, thus facilitating the flow of information and health education. Years of education and experience, together with specific protocols may help health care workers to accept the presence of relatives during critical events.