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Objectives: An unprecedented wave of patients with acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) hit emergency departments (EDs) in Lombardy, starting in the second half of February 2020. This study describes the direct and indirect impacts of the SARS-CoV-2 outbreak on an urban major-hospital ED. Methods: Data regarding all patients diagnosed with COVID-19 presenting from February 1 to March 31, 2020, were prospectively collected, while data regarding non-COVID patients presenting within the same period in 2019 were retrospectively retrieved. Results: ED attendance dropped by 37% in 2020. Two-thirds of this reduction occurred early after the identification of the first autochthonous COVID-19 case in Lombardy, before lockdown measures were enforced. Hospital admissions of non-COVID patients fell by 26%. During the peak of COVID-19 attendance, the ED faced an extraordinary increase in: patients needing oxygen (+239%) or noninvasive ventilation (+725%), transfers to the intensive care unit (+57%), and in-hospital mortality (+309%), compared with the same period in 2019. Conclusions: The COVID-19 outbreak determined an unprecedented upsurge in respiratory failure cases and mortality. Fear of contagion triggered a spontaneous, marked reduction of ED attendance, and, presumably, some as yet unknown quantity of missed or delayed diagnoses for conditions other than COVID-19. [ABSTRACT FROM AUTHOR]

The hormone known as atrial natriuretic factor (ANF) is secreted by the atria of the heart in response to increased blood pressure. It induces direct relaxation of the vasculature (vessels) and excretion of sodium in the urine, both of which serve to decrease blood pressure. ANF may also interact with the autonomic nervous system, or the nerves that control the heart and blood vessels (among other organs). Studies investigating the role of ANF in humans have generally used pharmacological (high) doses, and this makes reaching conclusions about the function of endogenous (produced by the body) ANF problematic. No data are currently available concerning the possibility of ANF involvement in the development of hypertension (high blood pressure). A study was carried out with five male patients suffering from mild or moderate uncomplicated hypertension. Negative pressure was applied to the lower body; this activates reflex nerve pathways, causing an increase in blood pressure and heart rate. The extent of blood-vessel constriction was measured in the forearm. When low doses of an ANF analog were infused into the general circulation, the vasoconstriction was abolished. ANF analog infusion directly into the forearm, where it would presumably interact only with the local vasculature, did not abolish the vasoconstrictor response to lower body negative pressure application. This suggests that the effect of the drug was not the result of a direct relaxing action, but more likely an interaction with more central blood pressure control centers. (Consumer Summary produced by Reliance Medical Information, Inc.)

Keywords: angiotensin receptor antagonists; COVID-19; longitudinal studies; renin-angiotensin system; SARS virus EN angiotensin receptor antagonists COVID-19 longitudinal studies renin-angiotensin system SARS virus e10 e12 3 07/10/20 20200801 NES 200801 ACE (angiotensin-converting enzyme) 2 - an enzyme that physiologically counters the activation of the renin-angiotensin-aldosterone system (RAAS) - is the functional receptor for SARS-CoV-2 - the virus responsible for the coronavirus disease 2019 (COVID-19) pandemic. 2004, 171, 1349-1352, doi: 10.1503/cmaj.1040398 4 Guo J, Huang Z, Lin L, Lv J. Coronavirus disease 2019 (COVID-19) and cardiovascular disease: a viewpoint on the potential influence of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on onset and severity of severe acute respiratory syndrome coronavirus 2 infection. Angiotensin receptor antagonists, COVID-19, longitudinal studies, renin-angiotensin system, SARS virus. [Extracted from the article]

Background: Respiratory infections can be complicated by acute brain failure. We assessed delirium prevalence, predictors and outcomes in COVID-19 ED patients., Methods: This was a retrospective observational study conducted at the San Raffaele ED (Italy). Patients age >18 years attending the ED between 26 February 2020 and 30 May 2020 and who had a positive molecular nasopharyngeal swab for SARS-CoV-2 were included. The Chart-Based Delirium Identification Instrument (CHART-DEL) was used to retrospectively assess delirium. Univariable and multivariable logistic regression analyses were used to evaluate delirium predictors. Univariable binary logistic regression analyses, linear regression analyses and Cox regression analyses were used to assess the association between delirium and clinical outcomes. Age-adjusted and sex-adjusted models were then run for the significant predictors of the univariable models., Results: Among the 826 included patients, 123 cases (14.9%) of delirium were retrospectively detected through the CHART-DEL method. Patients with delirium were older (76.9±13.15 vs 61.3±14.27 years, p<0.001) and more frequently living in a long-term health facility (32 (26%) vs 22 (3.1%), p<0.001). Age (OR 1.06, 95% CI 1.04 to 1.09, p<0.001), dementia (OR 17.5, 95% CI 7.27 to 42.16, p<0.001), epilepsy (OR 6.96, 95% CI 2.48 to 19.51, p<0.001) and the number of chronic medications (OR 1.09, 95% CI 1.01 to 1.17, p=0.03) were significant predictors of delirium in multivariable analyses. Delirium was associated with increased in-hospital mortality (adjusted HR 2.16, 95% CI 1.55 to 3.03, p<0.001) and with a reduced probability of being discharged home compared with being institutionalised (adjusted OR 0.39, 95% CI 0.25 to 0.61, p<0.001)., Conclusions: Chart review frequently identified ED delirium in patients with COVID-19. Age, dementia, epilepsy and polypharmacy were significant predictors of ED delirium. Delirium was associated with an increased in-hospital mortality and with a reduced probability of being discharged home after hospitalisation. The findings of this single-centre retrospective study require validation in future studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)