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BackgroundIt is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses.MethodsTo conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated.ResultsA total of 1710 patients (844 men; median age, 54 years (IQR: 34–75)) and 35 nurses (15 men; median age, 37 years (IQR: 33–48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89).ConclusionAMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.

BackgroundThe Canadian Syncope Risk Score (CSRS) has been proposed for syncope risk stratification in the emergency department (ED). The aim of this study is to perform an external multicenter validation of the CSRS and to compare it with clinical judgement.MethodsUsing patients previously included in the SyMoNE database, we enrolled subjects older than 18 years who presented reporting syncope at the ED. For each patient, we estimated the CSRS and recorded the physician judgement on the patients’ risk of adverse events. We performed a 30-day follow-up.ResultsFrom 1 September 2015 to 28 February 2017, we enrolled 345 patients; the median age was 71 years (IQR 51–81), 174 (50%) were men and 29% were hospitalised. Serious adverse events occurred in 43 (12%) of the patients within 30 days. The area under the curve of the CSRS and clinical judgement was 0.75 (95% CI 0.68 to 0.81) and 0.68 (95% CI 0.61 to 0.74), respectively. The risk of adverse events of patients at low risk according to the CSRS and clinical judgement was 6.7% and 2%, with a sensitivity of 70% (95% CI 54% to 83%) and 95% (95% CI 84% to 99%), respectively.ConclusionThis study represents the first validation analysis of CSRS outside Canada. The overall predictive accuracy of the CSRS is similar to the clinical judgement. However, patients at low risk according to clinical judgement had a lower incidence of adverse events as compared with patients at low risk according to the CSRS. Further studies showing that the adoption of the CSRS improve patients’ outcomes is warranted before its widespread implementation.

Clinical deterioration of COVID-19 patients is still a challenging event to predict in the emergency department (ED). The present study developed an artificial neural network using textual and tabular data from ED electronic medical reports. Predicted outcomes were 30-day mortality and ICU admission. Consecutive patients between February 20 and May 5, 2020, from Humanitas Research Hospital and San Raffaele Hospital, in the Milan area, were included. COVID-19 patients were 1296. Textual predictors were patient history, physical exam, and radiological reports. Tabular predictors were age, creatinine, C-reactive protein, hemoglobin, and platelet count. Tabular-textual model performance indices were compared to a model implementing only tabular data. For 30-day mortality, the combined model yielded slightly better performances than the tabular model, with AUC 0.84 ± 0.02, F-1 score 0.56 ± 0.04 and an MCC 0.44 ± 0.04. Tabular model performance was: AUC 0.84 ± 0.02, F-1 score 0.55 ± 0.03 and MCC 0.43 ± 0.04. As for ICU admission, the combined model was not superior to the tabular one. The present data points to the effectiveness of a textual and tabular model for COVID-19 prognosis prediction. Also, it may support the ED physician in their decision-making process.

Study Objective Patients with syncope are frequently admitted to the hospital, but whether this improves outcome is unknown. We tested whether hospitalization reduced mortality in patients who presented to emergency departments (EDs) with syncope. Methods We conducted a propensity analysis of the outcomes of patients ≥18 years old presenting to EDs with a primary diagnosis of syncope in April 2004–March 2013. The model used 1:1 nearest‐neighbor matching to predicted admission using age, sex, urban residence, household income, and 14 significant comorbidities from 4 administrative databases of the province of Alberta. The primary outcome was death. Results There were 57,417 ED patients with a primary diagnosis of syncope; 8864 were admitted, and 48,553 were discharged in

Reduction of the inappropriate use of antibiotics in clinical practice is one of the main goals of the Societa Italiana di Medicina Interna (SIMI) choosing wisely campaign. We conducted a systematic review of secondary studies (systematic reviews and guidelines) to verify what evidence is available on the duration of antibiotic treatment in Pneumonia. A literature systematic search was performed to identify all systematic reviews and the three most cited and recent guidelines that address the duration of antibiotic therapy in pneumonia. Moreover, a meta-analysis of non-duplicate data from randomized controlled trials (RCTs) considered in the enrolled systematic reviews was performed together with a trial sequential analysis to identify the need for further studies. Two systematic reviews on antibiotic duration in community-acquired pneumonia (CAP) for a total of 17 RCTs (2764 patients) were enrolled in our study. Meta-analysis of non-duplicate RCTs show a non-significant difference in rate of treatment failure between short (≤ 7 days) and long (> 7 days) antibiotic treatment course: RR 1.05 (95% CI, 0.82–1.36). The trial sequential analysis suggests that further data would not affect current evidence or become clinically relevant. Selected guidelines suggest consideration of a short course, with a low grade of evidence and without citing the already published systematic reviews. Antibiotic treatment of CAP for ≤ 7 days is not associated with a higher rate of treatment failure than longer courses and should thus be taken in consideration. Guidelines should upgrade the evidence on this topic.

Healthcare workers experienced high degree of stress during COVID-19. Purpose of the present article is to compare mental health (depressive and Post-Traumatic-Stress-Disorders—PTSD—symptoms) and epigenetics aspects (degree of methylation of stress-related genes) in front-line healthcare professionals versus healthcare working in non-COVID-19 wards. Sixty-eight healthcare workers were included in the study: 39 were working in COVID-19 wards (cases) and 29 in non-COVID wards (controls). From all participants, demographic and clinical information were collected by an ad-hoc questionnaire. Depressive and PTSD symptoms were evaluated by the Patient Health Questionnaire-9 (PHQ-9) and the Impact of Event Scale—Revised (IES-R), respectively. Methylation analyses of 9 promoter/regulatory regions of genes known to be implicated in depression/PTSD (ADCYAP1, BDNF, CRHR1, DRD2, IGF2, LSD1/KDM1A, NR3C1, OXTR, SLC6A4) were performed on DNA from blood samples by the MassARRAY EpiTYPER platform, with MassCleave settings. Controls showed more frequent lifetime history of anxiety/depression with respect to cases (χ2 = 5.72, p = 0.03). On the contrary, cases versus controls presented higher PHQ-9 (t = 2.13, p = 0.04), PHQ-9 sleep item (t = 2.26, p = 0.03), IES-R total (t = 2.17, p = 0.03), IES-R intrusion (t = 2.46, p = 0.02), IES-R avoidance (t = 1.99, p = 0.05) mean total scores. Methylation levels at CRHR1, DRD2 and LSD1 genes was significantly higher in cases with respect to controls (p p = 0.03 and p = 0.03, respectively). Frontline health professionals experienced more negative effects on mental health during COVID-19 pandemic than non-frontline healthcare workers. Methylation levels were increased in genes regulating HPA axis (CRHR1) and dopamine neurotransmission (DRD2 and LSD1), thus supporting the involvement of these biological processes in depression/PTSD and indicating that methylation of these genes can be modulated by stress conditions, such as working as healthcare front-line during COVID-19 pandemic.

Use of antigen tests for the diagnosis of COVID-19 has become widespread. The aim of this study was to evaluate the diagnostic accuracy of the nasopharyngeal rapid antigen diagnostic (RAD) immunoassay LumiraDx UK in an Emergency Department (ED). All patients admitted to our ED between November 11 and December 8, 2020, and had both a RAD test and a real-time-reverse-transcription-polymerase-chain-reaction (RT-PCR) test were enrolled. RAD was considered as the index test and RT-PCR test was used as the reference standard. Sensitivity, specificity, negative and positive predictive values, and likelihood ratios were calculated with the 95% confidence interval. The sensitivity and specificity of RAD were 34.2% and 92.3%. Positive and negative likelihood ratios were 4.4 and 0.71. Our results demonstrate that the diagnostic accuracy of the LumiraDx RAD test is too low for routine use as a diagnostic method in the ED.

Eventos adversos; Arritmia; Resultados Adverse events; Arrhythmia; Outcomes Esdeveniments adversos; Arítmia; Resultats Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients’ data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7–10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7–10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7–10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7–10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial. This research received no external funding.

Background : In the spring of 2020, Italy experienced a significant reduction in the number of emergency department (ED) presentations during the first wave of the COVID-19 pandemic. If ED access has an impact on patients’ prognosis, such a reduction in ED presentations would be expected to correlate with a parallel increase in the mortality rate of the corresponding population. The aim of the present study was to evaluate the impact of reduced ED presentations on the all-cause mortality of the general population. Methods Absolute and relative variation in ED accesses from March 1 to April 30 of both 2019 and 2020 in three hub hospitals in areas with different COVID-19 prevalence and age-standardized mortality data from January 1 to June 30 in 2019 and 2020 of the same areas were evaluated. Results : During March and April 2020, ED consults were decreased of approximately 50% in all three hospitals, as compared with the same months in 2019. There was a marked increase in cumulative mortality in Milan (high SARS-CoV2 infection spread zone) compared with the same period in 2019. In the other two municipalities (Ferrara and Perugia), which had intermediate and low levels of infection spread, the mortality in 2020 was not substantially changed from that of 2019. Conclusions : Taking into account the increase in mortality due to SARS-CoV-2, reductions in ED access did not seem to affect death rates. If this finding will be confirmed, ED organization and access would need to be reconsidered.

Background Arrhythmia is one of the most worrisome causes of syncope. Electrocardiographic (ECG) monitoring is crucial for the management of non-low-risk patients in the emergency department (ED). However, its diagnostic accuracy and optimal duration are unknown. We aimed to assess the diagnostic accuracy of ECG monitoring in non-low-risk patients with syncope in the ED. Methods This prospective multicenter observational study included adult patients presenting to the ED after syncope. Patients without an obvious etiology after ED evaluation who were classified by ED physicians as being at non-low risk of adverse events underwent ECG monitoring. We assessed sensitivity, specificity, and diagnostic yield (defined as the proportion of patients with true-positive ECG monitoring findings) of ECG monitoring in the identification of 7- and 30-day adverse and arrhythmic events according to monitoring duration. Results Of 242 patients included in the study, 29 patients had 7-day serious outcomes. Ten additional patients had serious outcomes at 30 days. The overall sensitivity, specificity, and diagnostic yield of ECG monitoring in the identification of 7-day adverse events were 0.55 (95% confidence interval [CI] = 0.36 to 0.74], 0.93 (95% CI = 0.89 to 0.96), and 0.07 (95% CI = 0.04 to 0.10), respectively. The sensitivity, specificity, and diagnostic yield of >12-hour ECG monitoring in the identification of 7-day adverse events were 0.89 (95% CI = 0.65 to 0.99), 0.78 (95% CI = 0.67 to 0.87), and 0.18 (95% CI = 0.12 to 0.28), respectively. Similar results were observed for 30-day adverse events. The median (interquartile range) ECG monitoring time was 6.5 (6 to 15) hours. ECG monitoring findings were positive in 31 patients. Conclusions Although the overall diagnostic accuracy of ECG monitoring is fair, its sensitivity at >12 hours' duration is substantially higher. These results suggest that prolonged (>12 hours) monitoring is a safe alternative to hospital admission in the management of non-low-risk patients with syncope in the ED.

Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.

Background In the emergency department (ED) definitive diagnosis of SARS-COV-2 pneumonia is challenging as nasopharyngeal swab (NPS) can give false negative results. Strategies to reduce false negative rate of NPS have limitations. Serial NPSs (24–48 h from one another) are time-consuming, sputum can not be collected in the majority of patients, and bronchoalveolar lavage (BAL), the most sensitive test, requires specific expertise. Laryngotracheal aspiration (LTA) is easy to perform and showed a similar accuracy to BAL for diagnosis of other pulmonary diseases, however it was not studied to diagnose SARS-COV-2 pneumonia. Objective An observational cross-sectional study was performed to evaluate the negative predictive value of LTA in patients with suspected SARS-COV-2 pneumonia despite a negative NPS. Methods In the EDs of two university hospitals, consecutive patients with suspected SARS-COV-2 pneumonia despite a negative NPS underwent LTA performed with a nasotracheal tube connected to a vacuum system. Final diagnosis based on all respiratory specimen tests (NPS, LTA and BAL) and hospital data was established by two reviewers and in case of discordance by a third reviewer. Results 117 patients were enrolled. LTA was feasible in all patients and no patients experienced adverse events. Fifteen (12.7%) patients were diagnosed with community-acquired SARS-COV-2 pneumonia: 13 LTA positive and only 2 (1.7%) LTA negative. The negative predictive value of NPS and LTA was 87.3% (79.9% – 92.7%) and 98.1% (93.3%99.8%) respectively. Conclusions LTA resulted feasible, safe and reduced false negative rate in patients with suspected SARS-COV-2 pneumonia despite a negative NPS.

Background During the recent outbreak of COVID-19 (coronavirus disease 2019), Lombardy was the most affected region in Italy, with 87,000 patients and 15,876 deaths up to May 26, 2020. Since February 22, 2020, well before the Government declared a state of emergency, there was a huge reduction in the number of emergency surgeries performed at hospitals in Lombardy. A general decrease in attendance at emergency departments (EDs) was also observed. The aim of our study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy, and provide possible explanations for the observed phenomena. Methods This retrospective, observational study assessed the volume of emergency surgeries and attendance at an ED during the course of the pandemic, i.e. immediately before, during and after a progressive community lockdown in response to the COVID-19 pandemic. These data were compared with data from the same time periods in 2019. The results are presented as means, standard error (SE), and 95% studentized confidence intervals (CI). The Wilcoxon rank signed test at a 0.05 significance level was used to assess differences in per-day ED access distributions. Results Compared to 2019, a significant overall drop in emergency surgeries (60%, p Conclusions During the COVID-19 outbreak the volume of urgent surgeries and patients accessing our ED dropped. Currently, it is not known if mortality of people who did not seek care increased during the pandemic. Further studies are needed to understand if such reductions during the COVID-19 pandemic will result in a rebound of patients left untreated or in unwanted consequences for population health.

Background During the COVID-19 pandemic, the number of individuals needing hospital admission has sometimes exceeded the availability of hospital beds. Since hospitalization can have detrimental effects on older individuals, preference has been given to younger patients. The aim of this study was to assess the utility of hospitalization for elderly affected by COVID-19. We hypothesized that their mortality decreases when there is greater access to hospitals. Methods This study examined 1902 COVID-19 patients consecutively admitted to three large hospitals in Milan, Italy. Overall mortality data for Milan from the same period was retrieved. Based on emergency department (ED) data, both peak and off-peak phases were identified. The percentage of elderly patients admitted to EDs during these two phases were compared by calculating the standardized mortality ratio (SMR) of the individuals younger than, versus older than, 80 years. Results The median age of the patients hospitalized during the peak phase was lower than the median age during the off-peak phase (64 vs. 75 years, respectively; p Conclusions Greater access to hospitals during an off-peak phase did not affect the mortality rate of COVID-19-positive elderly patients in Milan. This finding, if confirmed in other settings, should influence future decisions regarding resource management of health care organizations.

In recent years, machine learning (ML) has been promisingly applied in many fields of clinical medicine, both for diagnosis and prognosis prediction. Aims of this narrative review were to summarize the basic concepts of ML applied to clinical medicine and explore its main applications in the emergency department (ED) setting, with a particular focus on syncope management. Through an extensive literature search in PubMed and Embase, we found increasing evidence suggesting that the use of ML algorithms can improve ED triage, diagnosis, and risk stratification of many diseases. However, the lacks of external validation and reliable diagnostic standards currently limit their implementation in clinical practice. Syncope represents a challenging problem for the emergency physician both because its diagnosis is not supported by specific tests and the available prognostic tools proved to be inefficient. ML algorithms have the potential to overcome these limitations and, in the future, they could support the clinician in managing syncope patients more efficiently. However, at present only few studies have addressed this issue, albeit with encouraging results.

Background Syncope may be caused by intermittent complete heart block in patients with bundle branch block. Electrophysiology studies (EPS) testing for infra-Hisian heart block are recommended by the European Society of Cardiology syncope guidelines on the basis of decades-old estimates of their negative predictive values (NPVs) for complete heart block. Objective The aim of this study was to determine the NPV of EPS for complete heart block in patients with syncope and bundle branch block. Methods We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL without language restriction from database inception to October 2019 for Medical Subject Headings terms and keywords related to “syncope,” “heart block,” and “programmed electrical stimulation.” A random effects meta-analysis was conducted with a primary outcome of the proportion of patients with a negative EPS who later presented with complete heart block, diagnosed with surface electrocardiographic (ECG) recordings vs continuous implantable cardiac monitor (ICM). Results Ten reports contained 12 cohorts with 639 patients who met the inclusion criteria. The mean age was 69 ± 7 years; 35% ± 10% were women; and 85% of patients had bifascicular block. Seven cohorts recorded clinical outcomes with external ECG recordings, and 5 cohorts featured ICMs. The mean prespecified His-to-ventricle interval criterion was ≥70 ms. In studies featuring surface ECG recordings, there were 7% (95% confidence interval 7%–17%) patients who developed complete heart block compared with 29% (95% confidence interval 24%–35%) in the studies featuring ICM (P = .0001). Conclusion The NPV of EPS in patients with syncope and bundle branch block is 0.71, sufficiently low to question its use.

Several guidelines on the evaluation of patients with suspected cervical spine trauma in the Emergency Department (ED) exist. High heterogeneity between different guidelines has been reported. Aim of this study was to find areas of agreement and disagreement between guidelines, to identify topics in which further research is needed and to provide an evidence-based cervical spine trauma algorithm for ED physicians. The three most relevant guidelines published on cervical spine trauma in the last 10 years were selected screening websites of the main scientific societies and through the comparison of a normalized Google Scholar and SCOPUS citation index. We compared the selected guidelines through seven a-priori defined questions. In case of disagreement between the guidelines or if the quality of evidence appeared low, evidence from published systematic reviews on the topic was added to build an evidence-based algorithm for approach to spinal trauma in the ED. The three selected guidelines were: NICE 2016, Eastern Association for the Surgery of Trauma 2009 and American Association of Neurological Surgeons and Congress of Neurological Surgeons 2013. We found complete agreement on one question, partial agreement for one questions, no agreement for two questions, while agreement was not assessable for 3 questions. The agreement between different guidelines and the evidence on which recommendations are based is low. An attempt to build an evidence-based algorithm has been made. More studies are needed on many topics.

Key Points Question Are US physician malpractice claims rates associated with hospital admission rates after emergency department visits among patients with lower-risk syncope? Findings In this cross-sectional study of 519 724 emergency department visits for syncope between 2008 and 2017, 19% of patients with lower-risk syncope were admitted to the hospital. A 7% absolute increase in the admission rate was found for every 1 in 100 000–person increase in the malpractice claims rate. Meaning The study’s findings indicated that most lower-risk patients with syncope were not admitted to the hospital; however, increases in physician malpractice claims rates were associated with substantial increases in hospital admission rates and admission-associated costs among patients with lower-risk syncope., Importance The US Government Accountability Office has changed its estimate of the annual costs of defensive medicine, largely because it has been difficult to objectively measure its impact. Evaluating the association of malpractice claims rates with hospital admission rates and the costs of admitting patients with low-risk conditions would help to document the impact of defensive medicine. Although syncope is a concerning symptom, most patients with syncope have a low risk of adverse outcomes. However, many low-risk patients are still admitted to the hospital, with associated costs of more than $2.5 billion per year in the US. Objective To assess whether hospital admission rates after emergency department visits among patients with lower-risk syncope are associated with state-level variations in malpractice claims rates. Design, Setting, and Participants This cross-sectional study of emergency department visits among patients with lower-risk syncope used deidentified data from the Clinformatics Data Mart database (Optum). Lower-risk syncope visits were defined as those with a primary diagnosis of syncope and collapse based on International Classification of Diseases, Ninth Revision, Clinical Modification code 780.2 or International Classification of Diseases, Tenth Revision, Clinical Modification code R55 that did not include another major diagnostic code for a condition requiring hospital admission (such as heart disease, cancer, or medical shock) or an inpatient hospital stay of more than 3 days. These data were linked to publicly available data from the National Practitioner Data Bank pertaining to physician malpractice claims between January 1, 2008, and December 31, 2017. The 2 data sets were linked at the state-year level. Data were analyzed from October 2, 2019, to September 12, 2020. Main Outcomes and Measures The association between the rate of hospital admission after emergency department visits among patients with lower-risk syncope and the rate of physician malpractice claims was assessed at the state-year level using a state-level fixed-effects model. Standardized costs obtained from the Clinformatics Data Mart database were adjusted for inflation and expressed in 2017 US dollars using the Consumer Price Index. Results Among 40 482 813 emergency department visits between 2008 and 2017, 519 724 visits (1.3%) were associated with syncope. Of those, 234 750 visits (45.2%) met the criteria for lower-risk syncope. The mean (SD) age of patients in the lower-risk cohort was 71.8 (13.5) years; 141 050 patients (60.1%) were female, and 44 115 patients (18.8%) were admitted to the hospital, representing an extra cost of $6542 per admission. The mean rate of physician malpractice claims varied from 0.27 claims per 100 000 people to 8.63 claims per 100 000 people across states and across years within states. A state-level fixed-effects regression model indicated that, for every 1 in 100 000–person increase in the physician malpractice claims rate, there was an absolute increase of 6.70% (95% CI, 4.65%-8.75%) or a relative increase of 35.6% in the hospital admission rate, which represented an additional $102 million in costs associated with this lower-risk cohort. Conclusions and Relevance In this study, increases in physician malpractice claims rates were associated with increases in hospital admission rates and substantial health care costs for patients with lower-risk syncope, and these increases are likely associated with the practice of defensive medicine., This cross-sectional study assesses the association between physician malpractice claims rates and hospital admission rates after emergency department visits among patients with lower-risk syncope in the US.

Introduction: During the recent outbreak of COVID-19 (Corona VIrus Diseases 2019), Lombardy was the Italian region most affected, with 87,000 patients and 15,876 deaths (until May 26). Since February 22, well before the Government declared the state of emergency, a huge reduction of emergency surgeries was seen in Lombardy Hospitals, with a generalized drop of attendances in the Emergency Departments (EDs).Study Objective: The aim of this study is to report the experience of the ED of a third-level hospital in downtown Milan, Lombardy (IRCCS Foundation Cà Granda Ospedale Maggiore Policlinico), and try to explain the causes of the observed phenomena.Methods: A retrospective, observational study was performed assessing the volume of emergency surgeries and of the attendances in the ED during the course of the pandemic, i.e. immediately before, during and after progressive community lockdown in response to the COVID-19 pandemic, comparing the same time periods in 2019.Results: Compared to the previous year, in 2020 a significant overall drop of emergency surgeries (60%, p and of ED attendances (66%, p≅0) was observed. The drop was significant for medical ( 40%), surgical (74%), specialist fast track (92%), and psychiatric (60%) complaints, for domestic violence accesses (59%) and for patients who left the ED without being seen (LWBS) (76%). Conversely, deaths raised by 196%.Conclusion: During the COVID-19 outbreak the volume of urgent surgeries and the volume of patients accessing ED dropped. At the moment, it is not known if mortality of people who did not seek care increased during the pandemic. Further studies are needed to try to understand if such reductions during the COVID-19 pandemic will result in a rebound of patients left untreated, or in unwanted consequences on population health.

The Italian Society of Internal Medicine (SIMI) Choosing Wisely Campaign has recently proposed, among its five items, to reduce the prescription of long-term intravenous antibiotics if not indicated. The aim of our study was to assess the available evidences on optimal duration of antibiotic treatment in pyelonephritis through a systematic review of secondary studies.We searched for all guidelines on pyelonephritis and systematic reviews assessing the optimal duration of antibiotic therapy in this type of infection. We compared the recommendations of the three most cited and recent guidelines on the topic of interest. We extracted data of non-duplicated RCT from the selected systematic reviews and performed meta-analyses for clinical and microbiological failure. A trial sequential analysis (TSA) was also achieved to identify the need for further evidence.We identified 4 systematic reviews, including data from 10 non-duplicated RCTs (1536 patients). The meta-analysis showed a higher rate of clinical cure for short-course antibiotic treatment (RR for clinical failure 0.70, 95% CI [0.53-0.94]). No significant difference in the rate of microbiological failure (RR 1.06, 95% CI [0.75-1.49]) was observed. In terms of clinical cure, the TSA suggests that current evidence is sufficient to consider short course at least as effective as long-course treatment. Selected guidelines recommend considering shorter courses, but do not cite most of the published RCTs.Short-course antibiotic treatment is at least as effective as longer courses for both microbiological and clinical success in the treatment of acute uncomplicated pyelonephritis.

Background Mild traumatic brain injury (TBI) is a common event and antiplatelet therapy might represent a risk factor for bleeding. Objective The aim of this study was to evaluate the risk of intracranial hemorrhage (ICH) after mild TBI in patients on antiplatelet therapy through a systematic review and meta-analysis. Methods We conducted a systematic review and meta-analysis of prospective and retrospective observational studies on patients with mild TBI on antiplatelet therapy vs. those not on any antithrombotic therapy. The primary outcome was the risk of ICH in patients with mild TBI based on the first computed tomography scan. Secondary outcome was the risk of mortality and neurosurgery. Results Nine studies and 14,545 patients were included. The incidence of ICH ranged from 3.6% to 29.4% in the antiplatelet group and from 1.6% to 21.1% in the control group. Patients on antiplatelet therapy had a higher risk of ICH after a mild TBI compared with patients that were not on antithrombotic therapy (risk ratio 1.51; 95% confidence interval 1.21–1.88). No difference was found in the composite outcome of mortality and neurosurgery. Conclusions Patients on antiplatelet therapy have an increased risk of ICH after mild TBI compared with patients not on antithrombotic therapy. However, the risk is just slightly increased, and the need to perform a computed tomography scan in patients on antiplatelet therapy after a mild TBI should be evaluated case by case, but always considered in patients with other risk factors.

Infective endocarditis (IE) is a serious and potentially life-threatening disease, and accurate diagnosis is essential. We performed a systematic review and meta-analysis to assess the diagnostic accuracy of transthoracic echocardiography (TTE), with transesophageal echocardiography (TEE) as the reference standard, in patients with suspected IE of the native valves. We performed a systematic search in MEDLINE, EMBASE and Cochrane Library searching for studies that enrolled adult patients with suspected native valves IE where data about both TTE and TEE could be extracted. We included 11 studies, for a total of 2209 patients. The overall sensitivity, specificity, negative and positive likelihood ratios (LR) of TTE are 0.71 (95% CI 0.56-0.82), 0.80 (95% CI 0.58-0.92), 0.37 (95% CI 0.20-0.68) and 3.56 (95% CI 1.3-9.72), respectively. The subgroup analyses of the studies considering different cut-off levels show that the strict negative criteria (i.e., managing indeterminate results as positive) have the highest sensitivity and the lowest LR-. On the contrary, when managing indeterminate results as negative (standard criteria), the specificity and LR+ are the highest. We observed no differences between the studies performed with older and more recent technologies. In conclusion, our study results support the use of a negative TTE as a single rule-out test in patients with a low pre-test probability. In selected cases, the use of strict negative criteria might exclude IE in intermediate-risk patients, and a positive TTE might be considered as a single rule-in test with no need for TEE if TEE results would not change the patient's management.

Syncope is the common clinical manifestation of different diseases, and this makes it difficult to define what outcomes should be considered in prognostic studies. The aim of this study is to critically analyze the outcomes considered in syncope studies through systematic review and expert consensus. We performed a systematic review of the literature to identify prospective studies enrolling consecutive patients presenting to the Emergency Department with syncope, with data on the characteristics and incidence of short-term outcomes. Then, the strengths and weaknesses of each outcome were discussed by international syncope experts to provide practical advice to improve future selection and assessment. 31 studies met our inclusion criteria. There is a high heterogeneity in both outcome choice and incidence between the included studies. The most commonly considered 7-day outcomes are mortality, dysrhythmias, myocardial infarction, stroke, and rehospitalisation. The most commonly considered 30-day outcomes are mortality, haemorrhage requiring blood transfusion, dysrhythmias, myocardial infarction, pacemaker or implantable defibrillator implantation, stroke, pulmonary embolism, and syncope relapse. We present a critical analysis of the pros and cons of the commonly considered outcomes, and provide possible solutions to improve their choice in ED syncope studies. We also support global initiatives to promote the standardization of patient management and data collection.

Objective Myotonic dystrophy type 1 (DM1) is a hereditary myopathy characterized by an autosomal dominant inheritance with important cardiovascular and autonomic deregulation. DM1 patients have a high prevalence of obstructive sleep apnea (OSA), but the effects of this comorbidity on cardiovascular autonomic control (CAC) are unknown. The present study aimed to investigate CAC during sleep–wake cycle in DM1 patients, taking into account the effects of OSA comorbidity. Method Twenty-three patients with a diagnosis of DM1, and a control group, underwent a complete polysomnographic study (PSG). Electrocardiogram and respiration were extracted from PSG, divided according to the sleep stages, and analyzed using spectral analysis (SpA) of heart rate variability (HRV). SpA identified three components: very low frequency (VLF), low frequency (LF), a marker of sympathetic modulation, and high frequency (HF), a marker of vagal modulation. Results The results showed that in DM1 patients, the sympathovagal balance shifted towards a vagal predominance during non-rapid eye movement (NREM) sleep and a sympathetic predominance during rapid eye movement (REM) sleep. Second, this preserved cardiac autonomic modulation was not affected by the comorbidity with obstructive sleep apnea syndrome (OSAS). Third, in DM1 patients, OSAS comorbidity was associated with a reduction in HRV during the whole sleep–wake cycle. Lastly, in DM1 patients with OSA, cardiorespiratory coupling was reduced compared to controls. Conclusions DM1 patients had preserved cardiac autonomic dynamics during NREM and REM sleep, and this phenomenon was not affected by the presence of OSA. However, the comorbidity with OSA was characterized by a reduction in total HRV, which is a marker of the ability of autonomic control to respond to stressors stimuli.

The optimal target of blood pressure (BP) in the acute phase of intracranial haemorrhage (ICH) is still controversial. Our aim was to evaluate safety and efficacy of intensive BP lowering compared to standard BP treatment in ICH. We conducted a systematic review and meta-analysis of all available randomized controlled trials recruiting patients with elevated BP in acute spontaneous ICH to intensive or standard BP-lowering treatment. Our primary outcomes were 3-month mortality, disability (modified Rankin Scale 3-5) and combined death or disability. Secondary outcomes were early neurological deterioration at 24 h, substantial haematoma enlargement within 24-72 h and 3-month non-fatal serious adverse events. We included six studies for a total of 4385 patients (mean age 62 years, 62.3% men). No differences were detected between the two treatment groups in 3-month mortality (RR = 0.99, 95% CI 0.83-1.17), disability (RR = 0.96, 95% CI 0.89-1.03) and combined death and disability (RR = 0.97, 95% CI 0.90-1.03). The rate of patients with early neurological deterioration, substantial haematoma enlargement and non-fatal serious adverse events was similar in the two treatment groups (RR = 1.03, 95% CI 0.88-1.19, RR = 0.85, 95% CI 0.70-1.03, RR = 1.07, 95% CI 0.90-1.28, respectively). An intensive BP control in the acute phase of ICH is not beneficial and should not be recommended. Therefore, the systolic BP target of less than 140 mmHg that is now suggested by guidelines needs to be reconsidered.

Background Several studies have demonstrated that adjuvant therapies as exercise and breathing training are effective in improving cardiac autonomic control (CAC) in patients with affective spectrum disorders. However, the effects of Sudarshan Kriya Yoga (SKY) on autonomic function in this population is unknown. Our objective was to test the hypothesis that SKY training improves CAC and cardiorespiratory coupling in patients with anxiety and/or depression disorders. Methods Forty-six patients with a diagnosis of anxiety and/or depression disorders (DSM-IV) were consecutively enrolled and divided in two groups: 1) conventional therapy (Control) and 2) conventional therapy associated with SKY (Treatment) for 15 days. Anxiety and depression levels were determined using quantitative questionnaires. For the assessment of CAC and cardiorespiratory coupling, cardiorespiratory traces were analyzed using monovariate and bivariate autoregressive spectral analysis, respectively. Results After 15-days, we observed a reduction of anxiety and depression levels only in Treatment group. Moreover, sympathetic modulation and CAC were significantly lower while parasympathetic modulation and cardiorespiratory coupling were significantly higher in the Treatment compared to Control group. Conclusions Intensive breathing training using SKY approach improves anxiety and/or depressive disorders as well as CAC and cardiorespiratory coupling. These finding suggest that the SKY training may be a useful non-pharmacological intervention to improve symptoms and reduce cardiovascular risk in patients with anxiety/depression disorders.

Background Guidelines recommend that implantable loop recorders (ILRs) are used in the evaluation of people with recurrent unexplained syncope in the absence of high-risk criteria, and in high-risk patients after a negative evaluation. The aim of this systematic review was to analyze the diagnostic yield of ILRs in these patients. Methods We performed a systematic search in order to retrieve studies enrolling adults undergoing ILR implantation for undetermined syncope. The primary outcome was the overall diagnostic yield, defined as the proportion of patients with syncope recurrence and an available ILR recording or an automatic detection of a significant arrhythmia. Secondary outcomes were the proportions of patients with the specific etiologic diagnoses on the total of subjects and the proportion of an analyzable ECG recording during symptoms. We used a random effects model for the meta-analyses. Results Forty-nine studies, enrolling 4381 subjects, were included. The overall diagnostic yield was 43.9% (95% CI=40.2%, 47.6%; I 2 =79.8%). The proportions of subjects finally diagnosed with arrhythmic syncope, ventricular arrhythmias, supraventricular arrhythmias and bradyarrhythmias were 26.5%, 2.7%, 4.9% and 18.2%, respectively. The proportion of an analyzable ECG recording during symptoms was 89.5% (95% CI=86.1%, 92.1%; 1236 subjects; 36 studies; I 2 =44.9%). Median time to diagnosis was 134days. Heterogeneity is an important limitation to be acknowledged. Conclusions About a half of unexplained syncope subjects implanted with an ILR were diagnosed, and around 50% of them had an arrhythmia. Life-threatening arrhythmias as well as ILR complications and death due to arrhythmic events were very rare.

Background: Enrollment of large cohorts of syncope patients from administrative data is crucial for proper risk stratification but is limited by the enormous amount of time required for manual revision of medical records. Aim: To develop a Natural Language Processing (NLP) algorithm to automatically identify syncope from Emergency Department (ED) electronic medical records (EMRs). Methods: De-identified EMRs of all consecutive patients evaluated at Humanitas Research Hospital ED from 1 December 2013 to 31 March 2014 and from 1 December 2015 to 31 March 2016 were manually annotated to identify syncope. Records were combined in a single dataset and classified. The performance of combined multiple NLP feature selectors and classifiers was tested. Primary Outcomes: NLP algorithms&rsquo, accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F3 score. Results: 15,098 and 15,222 records from 2013 and 2015 datasets were analyzed. Syncope was present in 571 records. Normalized Gini Index feature selector combined with Support Vector Machines classifier obtained the best F3 value (84.0%), with 92.2% sensitivity and 47.4% positive predictive value. A 96% analysis time reduction was computed, compared with EMRs manual review. Conclusions: This artificial intelligence algorithm enabled the automatic identification of a large population of syncope patients using EMRs.

The aims of this study were (1) to identify research publications studying noninvasive electrocardiogram (ECG) monitoring devices, (2) to define and categorize current technology in noninvasive ECG recording, and (3) to discuss desirable noninvasive recording features for personalized syncope evaluation to guide technological advancement and future studies. We performed a systematic review of the literature that assessed noninvasive ECG-monitoring devices, regardless of the reason for monitoring. We performed an Internet search and corresponded with syncope experts and companies to help identify further eligible products. We extracted information about included studies and device features. We found 173 relevant papers. The main reasons for ECG monitoring were atrial fibrillation (n = 45), coronary artery disease (n = 10), syncope (n = 8), palpitations (n = 8), other cardiac diseases (n = 67), and technological aspects of monitoring (n = 35). We identified 198 devices: 5 hospital telemetry devices, 12 patches, 46 event recorders, 70 Holter monitors, 23 external loop recorders, 20 mobile cardiac outpatient telemetries, and 22 multifunctional devices. The features of each device were very heterogeneous. There are a large number of ECG-monitoring devices with different features available in the market. Our findings may help clinicians select the appropriate device for their patients. Since there are only a few published articles analyzing their usefulness in syncope patients, further research might improve their use in this clinical setting.

Syncope is a commonly encountered and challenging problem in medical practice. Presentations are variable, and the causal mechanism often remains elusive even after extensive (and often expensive) evaluation. Clinical practice guidelines have been developed to help guide the multidisciplinary approach necessary to diagnose and manage the broad spectrum of patients presenting with syncope. The American College of Cardiology/American Heart Association, in collaboration with the Heart Rhythm Society, published its first syncope guidelines in 2017. The European Society of Cardiology released the fourth iteration of its syncope guidelines in 2018. This review highlights the differences and congruencies between the 2 sets of recommendations, their implications for clinical practice, the remaining gaps in understanding, and areas of future research.

Providing care to the elderly patient with syncope poses problems that are unusual in their complexity. The differential diagnosis is broad, and sorting through it is made more difficult by the relative lack of symptoms surrounding the faint. Indeed, distinguishing faints from falls is often problematic. Many elderly patients are frail and are at risk of trauma if they should have an unprotected faint or fall to the ground. However, not all elderly patients are frail, and definitions of frailty vary. Providing accurate, effective, and appropriate care for the frail elderly patient who faints may require a multidisciplinary approach.

Short sleep duration has a substantial influence on the overall health of an individual. Short sleep time can be a consequence of lifestyle habits, environmental factors, or the presence of a sleep disorder, such as insomnia or sleep-disordered breathing. Short sleep time is associated with increased morbidity and mortality, mainly from cardiovascular disorders (including coronary artery disease, arrhythmias, and hypertension). Several biological mechanisms have been proposed as a possible link between short sleep duration and these diseases, such as involvement of the autonomic nervous system, endothelial function, metabolic regulation, inflammation, and the coagulation system. In this Review, we provide an overview on the effects of short sleep duration on cardiovascular health and diseases and discuss the main pathophysiological mechanisms involved, taking into account both experimental data and clinical evidence.