5th Italian GREAT Network Congress

Soluble ST2 and troponin I combination: useful biomarker for predicting development of stress-induced cardiomyopathy in patients admitted to the medical ICU

H. Yang¹, H. Kim², S. Kim³, M. Hur², S. Di Somma⁴

¹Konkuk University Medical Center, Cardiovascular Medicine, Seoul, South Korea, ²Konkuk University Medical Center, Laboratory Medicine, Seoul, South Korea, ³Konkuk University Medical Center, Respiratory Medicine, Seoul, South Korea, ⁴Sapienza University, Emergency Medicine, Sant’andrea Hospital, Rome, Italy

Background: Stress-induced cardiomyopathy (SCM) not infrequently developed in patients with non-cardiac medical illness; however, cardiac imaging is not a screening tool, and a unique biomarker has not been established. We tested the hypothesis that the novel soluble ST2 has additional predictive value in SCM.

Methods: Between May 21 and August 20, 2014, we prospectively enrolled 85 patients admitted to the medical ICU—finally we analyzed 81 patients (excluded 2 for coronary, 2 for technical issues). We performed echocardiography on the day of ICU admission (D0) and on the third day (D2) to diagnose the development of SCM, with a corresponding measurement of plasma soluble ST2. Routine biomarkers (Troponin I, BNP) were measured on D0. We compared the biomarkers between the SCM and non-SCM groups.

Results: Of the 81 patients (Age 64±18 years, Male 49), 5 patients died within 48 hours of admission. SCM was diagnosed in 22%. The SCM group (n=18) showed higher Troponin I and ST2max levels than the non-SCM group (n=58): 0.461±0.780 vs. 0.059±0.124 ng/ml, p=0.038; 223.3±42.3 vs. 192.2±87.9 ng/ml, p=0.050, respectively. BNP revealed no significant difference (896±1378 vs. 360±847 pg/ml, p=0.133). In receiver operator characteristic (ROC) analysis, Troponin I had an AUC of 0.687 (p=0.017); in patients with normal Troponin I ( < 0.3 ng/ml; n=69), the ST2(D2) predicted better than Troponin I (AUC 0.682, p=0.072; AUC 0.599, p=0.327, respectively), of an optimal cutoff value of 227.5 ng/ml.

Conclusions: A combination strategy of Troponin I and ST2 seems useful in predicting SCM. The addition of ST2 for those with normal Troponin I resulted in a significant improvement in the predictive power regarding the development of SCM in a medical ICU.

Great lps - research proposal of an international survey on diagnostic lumbar punctures and the management of post dural puncture headache

I. Weichert

The Ipswich Hospital Nhs Trust, Ipswich, United Kingdom

Background: Diagnostic lumbar punctures are frequently performed in internal medicine and its affiliated specialties to aid in the diagnosis of various infectious and neurological conditions. Complications are closely linked to the preparation, choice of needle and the procedure itself. For example, the correct choice of needle type and size alone has been proven to reduce the risk of post dural puncture headache from 36 % to 0-9 % percent. The management of this very distressing condition does also vary significantly.

Unfortunately, clinicians have been slow in adapting their tradition based practise to long known and well-founded evidence.

Methods: A United Kingdom wide survey into lumbar puncture techniques and also of the management of the most frequently encountered complication of post dural puncture headache has already been designed and my group has started to collect responses.

Questions regarding the pre procedural preparation, the choice of needle type and size, and the procedures itself, as well as the management of post dural puncture headache are being asked. The questionnaire does not take more than 5 minutes to complete. Most questions allow answers in multiple choice format with the possibility of an alternative written “other” answer.

A sample version of the questionnaire can be accessed at https://www.surveymonkey.com/s/2NQ3CHQ.

Whilst other smaller surveys into lumbar punctures have been published in the past, this is the most comprehensive so far. I would like to extend this survey to other member nations of this GREAT organisation. The questionnaire can easily be translated and adapted and then with the help of interested co-investigators distributed within the member countries of GREAT.

Results: The results are easily analysed using simple descriptive statistics. These will be published correlating best evidence based practise with the results of the survey.

Conclusions: This is a very simple and easily performed research project. Nevertheless, it is relevant to our day to day clinical practice and the risk of exposing our patients unnecessarily to possible harm. I am hoping to reduce the risks and side effects of the procedure itself and as such improve overall patient care. A wide participation and high number of responses would allow our organisation to become more involved in the creation of guidelines throughout our member nations.

ST2 marker might help to stratify in-hospital high risk patients with tako-tsubo cardiomyopathy

O. Vriz¹, R. Minisini², M. Rucio¹, G. Limongelli³, M. Pirisi², E. Bossone⁴, P. Calabro’³

¹Ospedale San Antonio, Cardiology/Emergency San Daniele, Udine, Italy, ²Università Del Piemonte Orientale, Novara, Italy, ³Cardiologia, Ospedale Monaldi Seconda Università Di Napoli, Napoli, Italy, ⁴Dipartimento Di Cardiochirurgia, Policlinico San Donato Milanese, Milano, Italy

Background: The use of a marker able to detect high risk cardiovascular disease patients for adopting the best actions to reduce the worsening of clinical condition is fundamental. Takotsubo cardiomyopathy (TTC) is a disease that mimics acute coronary syndrome (CAD) at presentation with a good prognosis and with a complete left ventricular function recovery. The aim of the study was to asses if ST2, marker of myocardial fibrosis and of outcome prognosis has potential aid in risk stratification in TTC patients.

Methods: We studied 21 subjects with clinical and angiographic diagnosis of TTC and 43 patients with the diagnosis of CAD (63.3±12.5 years versus 69.5±16.0 years, p=ns for TTC and CAD patients respectively).All subjects underwent clinical and instrumental workout, such as troponin I (cTnI) echocardiography and angiography. ST2 concentration was determined in plasma samples by mean of the ELISA (highly sensitive Presage® ST2 Assay), following the manufactor instructions. The difference between the 2 groups was assessed by unpaired Student t-test.

Results: Baseline haemodynamic and clinical characteristics were not different among the two groups but heart rate (91.7±23.6 vs 79.3±18.6bpm, p=0.03 for TTC and CAD patients respectively). Although TTC patients had lower values for ST2, cTnI and ejection fraction, the difference did not reach the statistical significance. The TTC and CAD patients were then divided according to the upper fourth quartile of ST2 concentration (95 ng/ml). In the TTC group, 4 patients had high ST2 values (193.3±62 versus 30±4.8 ng/ml, p=0.003) and 8 in the CAD group (352.7±200 vs 34.17 ±48.6 ng/ml, p<0.0001). Among the TTC group with high ST2 there were 1 in-hospital death, 1 cardiac surgery, 1 stent implant and 1 patients had no events. Eight patients with CAD had high ST2 (352.7 ± 200 vs 34.17 ± 48.6 ng/ml, p<0.0001). Four patients had stent implanted, one patient had concomitant severe aortic stenosis, 3 patients died due to cardiogenic shock. All CAD patients with low ST2 underwent stent implantation, and 1 patient had heart surgery. Patients with high ST2 concentration were more likely to have increased cTnI and EF but the difference did not reach the statistical significantly.

Conclusions: ST2 may be a useful marker for helping stratify high risk patients with TTC, considered a benign disease with a very good prognosis.

The utility of pyrogenic cytokine (IL-1beta, TNF-alpha and IL-6) detection in risk stratification of critically ill febrile patients in emergency department

F. Travaglino¹, G. Salerno², V. Russo¹, Mt. Corsetti¹, R. D’Urso², P. Cardelli², Mr. Torrisi², V. Visco², S. Di Somma¹

¹Emergency Department, Faculty Of Medicine And Psychology University Of Rome Sapienza, Rome, Italy, ²Department Of Clinical And Molecular Medicine, Faculty Of Medicine And Psychology University Of Rome Sapienza, Rome, Italy

Background: Aim of our study was to evaluate the prognostic value of pyrogenic cytokines (IL-1beta, TNF-alpha and IL-6) detection associated with Mid regional pro-Amedullin (MR-proADM) and the APACHE II score in febrile patients admitted to the Emergency Department (ED).

Methods: 64 patients in the Emergency Room (ER) during a period of 12 months with body temperature > 37 °C were enrolled for this study. In order to compare MR-proADM and cytokine values, a control group of 40 healthy volunteers was recruited. For each subject the APACHE II score was calculated.

Results: MR-proADM and cytokines were significantly higher in patients compared to controls (p<0.0001). When APACHE II score was correlated to MR-proADM and cytokines and grouped into quartile, it showed a significant increase in TNF-alpha and IL-6 levels (p<0.0001). A significant stepwise increase in MR-proADM in accordance with IL-6 quartile levels was observed (p<0.0001). The receiver operating characteristic (ROC) curve showed the ability of those combined biomarkers to predict hospitalization.

Conclusions: The combined use of MR-proADM and cytokines can help the febrile patient’s management in the ED, predicting a subsequent hospitalization of such individuals.

Use of pre-hospital ultrasound in the patient with dyspnoea: evaluation of diagnostic accuracy in Pavia’s reality

R. Virtuani¹, G. Ricevuti², M. Raimondi³, V. Sgromo³, S. Moschi⁴, S. Negri¹

¹School Of Emergency Medicine, University Of Pavia, Pavia, Italy, ²Director Of The School Of Emergency Medicine, University Of Pavia, Pavia, Italy, ³Aat 118 Pavia Areu Lombardia, Pavia, Italy, ⁴Student Of Medicine, University Of Pavia, Pavia, Italy

Background: The use of pre-hospital ultrasound for chest examination, especially in dyspnoeic patients, has always been discussed over the years, this due to a lack of standard protocols and to the fact that the chest ultrasound is based on artefacts identification, not on echografic signs and images as for the other body segments.

A research by Daniel Lichtenstein and Gilbert Mezière, published in Chest in 2008, assessed the performance of the pulmonary ultrasound examination in 301 adult patients with acute respiratory failure: the Authors developed a protocol, the BLUE PROTOCOL (Bedside Lung Ultrasound in Emergency) that, through the evaluation of few echografic signs, leads to different diagnostic hypotheses. The echographic signs that have to be investigated are: lung sliding, presence of A and B lines, lung point, possible presence of pulmonary consolidation or pleural effusion and a compression ultrasound has to be performed.

Methods: We evaluated and critically analysed the records of all dyspnoeic patients examined with pre-hospital ultrasound on the supervising area of AAT Pavia through the period between January 1st, 2014 and June 30th, 2014, for a total of 94 patients.

Results: The 38% of those 94 patients had received a pre-hospital diagnosis of acute pulmonary oedema, another 38% was generically diagnosed with dyspnoea, 9% with pneumonia, 12% with COPD and 3% with pleural effusion.

For every patient, we evaluated if the pre-hospital diagnosis was consistent with the one made at the Emergency Room discharge: in 85% of the patients, the diagnosis was the same. The maximum concordance was seen for pleural effusion (100%); regarding the patients with pre-hospital diagnosis of acute pulmonary oedema and generic dyspnoea, the congruity with the Emergency Room diagnosis was 86% for the first group and 89% for the second one. The maximum variance concerned the diagnosis of pneumonia and COPD: only 38% and 18%, respectively, were consistent with the E.R. discharge diagnosis.

Conclusions: As concerning the diagnostic accuracy (assessed comparing the pre-hospital diagnosis with the Emergency Room discharge one) in dyspnoeic patients evaluated with ultrasound examination, our data show excellent results regarding the identification of pathological conditions like pleural effusion and acute pulmonary oedema, in which early diagnosis and treatment are essential for a better outcome of the patient.

US examination in pre-hospital scenarios: the experience of AAT 118 Pavia

R. Virtuani¹, V Sgromo², M Raimondi², G Ricevuti³, S Negri¹, S Moschi⁴

¹School Of Emergency Medicine, University Of Pavia, Pavia, Italy, ²Aat 118 Pavia, Areu Lombardia, Pavia, Italy, ³Director Of The School Of Emergency Medicine, University Of Pavia, Pavia, Italy, ⁴Student Of Medicine, University Of Pavia, Pavia, Italy

Background: The applications of ultrasound examination in pre-hospital scenarios are increasing more and more, a demonstration of this being the large number of studies and guidelines published over the last decade on the subject. The ultrasound examination has a relevant role, especially for clinical pictures such as dyspnoea, trauma, chest pain and cardiac arrest.

Methods: We evaluated and critically analysed all the records of patients examined in pre-hospital setting of the supervising area of AAT Pavia through the period between January 1st, 2014 and June 30th, 2014: the clinical presentations contemplated were dyspnoea, chest pain, cardiac arrest, trauma, abdominal pain, shock, pregnancy-related conditions and syncope. An analysis of the time schedule was performed and were evaluated its compliance to guidelines and the performances for each clinical presentation.

Results: The records of 1433 patients were examined: 128 with cardiac arrest, 401 with dyspnoea, 294 with trauma, 363 with chest pain, 73 with abdominal pain, 140 with syncope, 2 with shock and 18 with pregnancy-related conditions.

We evaluated the percentage of ultrasound examinations performed for each clinical picture: the best performances were in cardiac arrest (61%), dyspnoea (49%) and trauma (53%) management. We also compared the time spent on the patient, whereas the ultrasound examination was or was not performed: in the first case, the times are, on the average, 6 minutes longer. Specifically, 3 minutes longer for trauma, 5 for dyspnoea and 9 for cardiac arrest. No differences, instead, were seen as for chest pain and pregnancy-related conditions.

Conclusions: The AAT Pavia performances regarding the use of ultrasound in pre-hospital settings were excellent and are consistent with the training programmes offered to the physicians working in our reality.

As for the time schedule analysis, they are consistent with the international guidelines.

Cost-effectivness evaluation of Vscan in patient referring to ED for abdominal pain

F. Vetrone¹, B. De Berardinis¹, C.S. Gori¹, A. Ianni¹, M. Corsino¹, A. Picone¹, S. Di Somma¹

¹Department Of Medical-Surgery Sciences And Translational Medicine, University Sapienza Rome, Sant’Andrea Hospital, Roma, Italy

Background: Acute abdominal pain is commonly defined as pain of less than 1 week’s duration.1 In USA abdominal pain was the principal reason offered by patients for visiting Emergency Department’s (ED) in 2000 and accounting for 8 million (7%) of the 119 million ED visits in 2006.2 Economically, it is estimated that pain costs to society $61.2 billion annually in lost productivity 3. In our hospital the incidence of acute abdominal pain is about 9%/year (4.356 pts).

Bedside ultrasonography can be used to quickly evaluate patients for free intraperitoneal fluid, volume status, and presence of aortic, renal, bladder and cholecyst pathology. With Vscan examination we could reduce the use of diagnostic procedures, length of stay and hospital admission and increase ED staff productivity.

Methods: Our study is a prospective observational study. The enrolment will be leaded on 200 consecutive patients arriving to ED with acute abdominal pain characteristics of renal colic, biliar colic, cholecystitis, abdominal aortic aneurysm, aortic dissection, acute urinary retention and ascites. The decision will be take on clinical judgment of Emergency Physician (EP) on the base of clinical history, physical examination and laboratory exams. An expert trained fellow will perform a Vscan bedside exam and the results will blinded to EP which will manage every patient on the base of clinical practice guidelines for each disease. Laboratory tests and radiologic exams (ultrasonography, X-ray, computed tomography) will be performed according to standard of care. EP will not take decisions on basis of results derived by Vscan examination.

At the end of the enrolment we will verify the agreement between clinical judgment, Vscan examination, others diagnostic tests and final diagnose.

Results: It seems to be a correlation between Vscan exam and standard diagnostic tests in patients with acute abdominal pain.

Conclusions: The final conclusions will be presented with the poster at the conference.

Hidden pheochromocytoma unmasked by steroids administration in dea. Case report

M. Vella¹, C. Capiaghi², G. Ricevuti³, M. Cantoreggi⁴, S. Carisi⁵, D. Demagistri⁶, F. De Pari⁷, M. Bianchi⁸, F. Perlasca⁹

¹Azienda Ospedaliera Ospedale Di Circolo e Fondazione Macchi Dea, Varese, Italy, ²Università Degli Studi Di Pavia Scuola Di Specializzazione In Medicina d’Emergenza ed Urgenza, Pavia, Italy

Background: Diagnosticate pheochromocytoma (Phe) in Emergency Department (ED) is difficult, due above all to the infrequency of this lesion, and the unspecific manifestations, frequently overlapping with other syndromes. There are evidences of hidden Phes disclosed after administration of drugs properly utilized to treat several dysfunction. A very small number of cases have been related to administration of steroids up to now.

Methods: Case Report.

Results: A M 63 yo patient (P), suffering from Hypertension, was referred to ED after multiple honey-bee stings with diffuse weal rash. Due to a known mild allergy to hymenopters, he had already self-administered oral steroids at home. At the first evaluation, transient disconfort, vomit, headache, and skin symptons have already been regressed; haemodynamic data and EKG were normal. Because of the history of allergy, the P was admitted for clinical monitoring. After three hours the P betrayed of sweating, vomit, headache, palpitations and chest pain. Laboratory Tests were normal and EKG showed sinus tachycardia. X-ray showed impending pulmonary congestion.Sudden cardiopulmonary failure occurred. Quick onset of acute respiratory failure (pO2/FO2:100) and methabolic acidosis occurred, while run of ventricular tachycardia were noted upon severe sinus tachycardia. The P was first treated with diuretics, B-Blockers and NIMV in ER; Cardiac US was normal, FE conserved. No evidence of toxic or anaphylactic response to honey-bee poison. A diagnosis of mixed heart and lung failure was assumed and treatment with nitrate and methylprednisolone was planned. No clinical improvement was noted after treatment. Persistent respiratory failure forced to orotracheal intubation, and the P was admitted in the ICU. Multiple crisis of hypertension and severe tachycardia resistant to treatment occurred, and inadequacy of respiratory gas exchanges persisted inspite of MV. Resuscitative efforts were stopped after three days. The post-mortem examination stressed a hidden Phe.

Conclusions: We could find only 15 cases of symptomatic crisis in known or hidden Phe following administration of steroid drugs reported up to know. The way of administration seems not to be significant. The most common symptoms recorded are: nausea, vomit and chest pain, acute pulmonary oedema and heart failure, death.

In the case reported, symptoms and clinical history seems to suggest one more symptomatic manifestation of hidden Phe with high probability of relation to steroids administration.

Study of coagulation and platelet function in patients with infectious and non-infectious systemic inflammatory response syndrome (SIRS) in the emergency department (ED)

M. Ulla¹, C. Galluzzo¹, E. Pizzolato¹, M. Maggiorotto¹, M. Masoero¹, S. Raso², M. Lucchiari², A.R. Vitale², M. Berardino³, S. Battista¹, G. Mengozzi²

¹Emergency Medicine, A.O.U. Città Della Salute E Della Scienza, Turin, Italy, ²Clinical Biochemistry, A.O.U. Città Della Salute E Della Scienza, Turin, Italy, ³Anesthesia And Icu 5, A.O.U. Città Della Salute E Della Scienza, Turin, Italy

Background: SIRS can match with numerous infectious or non-infectious conditions and is often characterized by early alterations of the clotting system and platelets, with major thrombotic and bleeding complications. Early identification of SIRS is a prime target and the application of point-of-care (POC) technologies would increase diagnostic effectiveness and speed. Aim of this work is to evaluate the diagnostic role of viscoelastic and aggregometric POC in patients with SIRS in the ED.

Methods: Thromboelastometry (Rotem®) is a viscoelastic method able to assess the whole coagulation process according to different activation pathways; Impedance Aggregometry (Multiplate®) evaluates global platelet function in response to different stimuli. 87 patients with clinical diagnosis of SIRS (34 sepsis, 26 severe sepsis/septic shock; 27 severe trauma with Injury Severity Score> 15) were enrolled in the study. Clinical and Lab values were recorded, together with Rotem® tests and Multiplate® tests.

Results: Patients with trauma (T) were compared to sepsis (S) and severe sepsis / septic shock (SS) patients, as well as group with non-infectious SIRS (T) to infectious SIRS (S + SS). A significant difference was observed in mean values of Intem clotting time (CT) between T, S and SS populations (p=0.031). Significant differences in the analysis of clot firmness (MCF and A10) in Extem (p=0.016) and Fibtem (p<0.0001) were observed among T, S and SS in favor of the latter. Rapidity of clot formation (α angle) was also significantly increased in the population with infectious SIRS in Extem and Aptem tests. Multiplate® analysis demonstrated a widespread tendency to hypo-aggregability in populations with infectious SIRS via ADP test (p = 0.005), COL test (p=0.001) and TRAP test, which also been shown distinguished (p=0.002) the group with severe sepsis/septic shock from others. Diagnostic accuracy of POC tests in discriminating infectious forms of SIRS was good and far superior to classical lab variables and clinical scores.

Conclusions: This work represents the first example of joint application of POC methods for the evaluation of plasma coagulation and platelet function in cases of infectious and non-infectious SIRS in the ED. Peculiar and early alterations of the coagulation system and platelet aggregation were observed in patients with sepsis, severe sepsis and septic shock, able to distinguish with good accuracy the infectious etiology of SIRS.

Psychopathology and HIV infection in the emergency department. Epidemiology and gender differences

G. Melis¹, G. Pia², I. Piras², M. Tusconi³

¹Local Health Unit No. 1, Sassari, Italy, ²Emergency Department Holy Trinity Hospital Local Health Unit, Cagliari, Italy, ³Department Of Public Health, Clinical And Molecular Medicine - Section Of Psychiatry, University Of Cagliari, Cagliari, Italy

Background: The management of patients with HIV infection who have comorbidity psychiatric disorders, is a problem that arises relatively frequently in Emergency Departments.

Methods: This retrospective study aims to evaluate the characteristics of HIV-infected patients who have been admitted to an Emergency Department of Sardinia, Italy, in 2013. The sample was selected from triage by choosing as the main problem at the entrance a state of agitation and/or acute intoxication (n=1245) or other symptoms or disorders not defined at the time of access to the Emergency Department (n=12125).

Results: From an initial sample of 13370 patients, representing 38.8% of total accesses in ED (n=34468), has been selected a cohort of 216 cases with clinical history of HIV infection. The sample, analyzed by software SPSS 21.0 is composed of 170 males (78.7% of total, mean age=45.4±6.8) and 46 females (21.3% of total, mean age=44.5±4.5) (t=1.076, df=108.9, p=0.284), this data has been confirmed by the Mann-Whitney U test for independent samples (p=0.136). Regarding the associated psychiatric condition (25.5% of total sample), the 46.3% had mood disorders, the 38.9% psychotic disorders and the 14.8% anxiety disorders, with no significant gender differences (p=0.329). The analysis of the sample showed that 29.2% (m=26.4%, f=2.8%) declared drug abuse, while 70.8% (m=52.3%, f=18.5%) reported not to take any drugs (p=0.007). A concomitant infection with HBV and/or HCV was found in the anamnesis in 54.6% (m=44.9%, f=9.7%) of patients. Only in 24.5% of cases (n=53) was administered a drug treatment in urgency (Pre-Hospital/ED) and an admission to hospital was necessary in 34.3% of the total sample analyzed. Among the admissions, in 70.4% has been decided for a department of infectious diseases, and of these, only 54.4% had already at the entrance to the Emergency Department signs of acute infection (fever, pneumonia, etc). The poor patient compliance often makes it difficult to manage, as the analysis of the data shows, so that 16.2% of patients (n=35) appeared to be gone from the emergency room before physical examination or have completed the expected diagnostic process.

Conclusions: From these data show the predominant role of emergency departments in the management of a complex disease such as HIV infection, aggravated by the state of emergency and comorbidity with mental illness.

Mental disorders in emergency in elderly and adolescents

G. Melis¹, G. Pia², G. Iasiello³, I. Piras², M. Loche³, M. Tusconi⁴

¹Local Health Unit No. 1, Sassari, Italy, ²Emergency Department Holy Trinity Hospital Local Health Unit, Cagliari, Italy, ³Central Office 118 South Sardinia, Cagliari, Italy, ⁴Department Of Public Health, Clinical And Molecular Medicine - Section Of Psychiatry, University Of Cagliari, Cagliari, Italy

Background: The management of patients with psychiatric issues is different depending on the age of the individual. The geriatric patient in the emergency room is a patient that appears to be complex, both for the multiple problems from which is often affected by, than to the difficulty in collecting an adequate history in a little time. Psychiatric disorders and acute intoxications represent a problem difficult to manage especially if they relate to the adolescent years.

Methods: The study aimed to assess the epidemiology of dementia and psychiatric illnesses and poisonings in adolescents in emergency. All data analysis was performed using SPSS software (SPSS, Inc., Chicago, IL).

Results: The 46.3% of the total ER was transported by ambulance with volunteers, 39.5% occurred independently, while 10% (n=96) came on ambulance with physician (p=0.009). The sample is analyzed on the basis of gender, had a diagnosis of anxiety disorder in 13.7% of cases; Bipolar disorder in 16.5%, psychosis in 27.7% (p <0.001), depression in 17.1% (p=0.004). For the 11.2% of the patients it was necessary to carry out a drug treatment urgency (118/ER). The drugs taken are: psychoactive drugs 46.2%; alcohol 22.6%; mixed drugs and alcohol abuse 13,7% (p<0.001). Out of a total sample 117 were classified as attempted suicide or expressed suicidal ideation. This sample, representing 0.34% of total accesses, is composed of 74 males (mean age 41.9±11.8) and 43 females (mean age 51.5±12.4) (p=0.001). The statistical analysis based on gender showed that 40.2% of the sample is affected by depression (m=53, f=17) (p=0.001), 17.9% Bipolar Disorder (m=11, f=10) (p=0.254) and 17.2% Psychosis (m=19, f=1) (p=0.001). Anticonservative behaviours required pharmacological treatment in emergency in the 10.3% of cases, while in 46.2% of cases it has been necessary to be admitted to the hospital ward.

Conclusions: From the analysis of the sample shows that the management of people with psychiatric problems appears to be very complex especially for the young and old patients.

Management and epidemiology of mental disorders in emergency

G. Melis¹, G. Pia², I. Piras², M. Tusconi³

¹Local Health Unit No. 1, Sassari, Italy, ²Emergency Department Holy Trinity Hospital Local Health Unit, Cagliari, Italy, ³Department Of Public Health, Clinical And Molecular Medicine - Section Of Psychiatry, University Of Cagliari, Cagliari, Italy

Background: Access to emergency services by patients in a state of agitation and its management, appears to be a complex problem characterized by many aspects. Aims of this study was to assess the management of the state of agitation in a Emergency Room (ER).

Methods: The total sample analysed includes 34468 patients. In 2013 at an emergency room of Sardinia, were 958 (2.8 % of the total), the main problem with access to the ’state of agitation’. Retrospective analyses were performed on data on access to the Emergency Department for the years 2012 and 2013; the reference population are outpatients with intoxication reported as the main problem. The sample includes patients of all ages with acute intoxication by psychoactive drugs and abuse of drugs (psychoactive drugs and alcohol). All data analysis was performed using SPSS software (SPSS, Inc., Chicago, IL).

Results: The 46.3% of the total ER was transported by ambulance with volunteers, 39.5% occurred independently, while 10% (n=96) came on ambulance with physician (p=0.009). The sample is analyzed on the basis of gender, had a diagnosis of anxiety disorder in 13.7% of cases; Bipolar disorder in 16.5%, psychosis in 27.7% (p <0.001), depression in 17.1% (p=0.004). For the 11.2% of the patients it was necessary to carry out a drug treatment urgency (118/ER). The drugs taken are: psychoactive drugs 46.2%; alcohol 22.6%; mixed drugs and alcohol abuse 13,7% (p<0.001). Out of a total sample 117 were classified as attempted suicide or expressed suicidal ideation. This sample, representing 0.34% of total accesses, is composed of 74 males (mean age 41.9±11.8) and 43 females (mean age 51.5±12.4) (p=0.001). The statistical analysis based on gender showed that 40.2% of the sample is affected by depression (m=53, f=17) (p=0.001), 17.9% Bipolar Disorder (m=11, f=10) (p=0.254) and 17.2% Psychosis (m=19, f=1) (p=0.001). Anticonservative behaviours required pharmacological treatment in emergency in the 10.3% of cases, while in 46.2% of cases it has been necessary to be admitted to the hospital ward.

Conclusions: According to the study, it is clear the central role of ER in diagnostic and treatment of patients with mental illnesses and their management and transfer to the most appropriate structure.

Management of pain in femoral fractures in the elderly in the emergency department

G. Melis¹, G. Pia², I. Piras², M. Tusconi³

¹Local Health Unit No. 1, Sassari, Italy, ²Emergency Department Holy Trinity Hospital Local Health Unit, Cagliari, Italy, ³Department Of Public Health, Clinical And Molecular Medicine - Section Of Psychiatry, University Of Cagliari, Cagliari, Italy

Background: Pain is the main symptom observed in the emergency room; despite this, patients do not receive optimal management in emergency departments around the world, as amply demonstrated in the scientific literature available.

Methods: The aim of this study was to evaluate the epidemiology and treatment of pain in femoral fractures in the elderly a first level Department of Emergency. All data analysis was performed using SPSS software (SPSS, Inc., Chicago, IL).

Results: Out of an initial sample of 9850 patients, aged 65 years, who have had access to an emergency Department in Sardinia, Italy, in 2013 (28.6% of total) were selected 209 cases that had a discharge diagnosis of femoral fracture. Based on the statistical analysis, the mean age of the patients was found to be 82.8±7.6 years, with a minimum age of 65 years and a maximum recorded age of 103 years, and about the gender, 25.8% were males (n=54) and 74.2% females (n=155). The patient has been transported to the ER by volunteers ambulance in 90.4% of cases (n=189). The code assigned to the triage was Yellow in almost all of cases (n=202), and despite the patient experiences pain at the entrance, this has not been quantified with appropriate scales. In 66.3% of cases the trauma occurred at home with a prevalence for females (75.9%) than males (24.1%). Regarding the timing of patient management has been able to record a mean time between triage and take-over by the doctor of 29.3±38.6 minutes and a time of 96.3±66.6 between triage and discharge. Pain therapy was administered in 12.0% of cases: in 72.0% of patients were used NSAIDs, paracetamol in the 16.0 %, and in the remaining 12.0% were used opioids. An analysis of the treatment based on gender has detected a statistically significant difference (p=0.03) for which the patients were males in 8.0% of cases and in 92.0% females, as likely to be correlated to the increased representation in our study of sample of women than men.

Conclusions: Based on these results it is necessary to carry out an awareness-raising for the treatment of pain in emergency departments and especially in the short term to create a protocol for pain therapy for elderly patients with femoral fracture.

Research proposal: risk scores, biomarkers and multidimensional evaluation in heart failure prognostic stratification: multiparametric assessment of prognosis in heart failure: (MAP-HF) – study design

M. Tinti¹, G. Pulignano¹, D. Del Sindaco², A. Di Lenarda³, L. Tarantini⁴, G. Cioffi⁵, G. Minardi¹, M. Uguccioni¹

¹1st Cardiology/C.C.U. Unit, Cardiovascular Department, San Camillo Hospital, Rome, Italy, ²2nd Cardiology Unit, Department Of Cardiology, San Giovanni Hospital, Rome, Italy, ³Cardiovascular Center And University, Trieste, Italy, ⁴Heart Failure Clinic, Division Of Cardiology, San Martino Hospital, Belluno, Italy, ⁵Heart Failure Clinic, Division Of Cardiology, Villa Bianca Hospital, Trento, Italy

Background: Heart failure (HF) has increased its prevalence in general population to epidemic proportions, being one of the first cause of mortality, hospital admissions and disability, despite optimal medical and device therapy. The individual patient prognostic assessment is difficult and unreliable because of the heterogeneity of the disease.

Hence an affordable prognostic stratification represents the point for targeting patients in disease management programs and for the appropriate selection of the model of care.

MAP-HF is a pilot multicentric, observational, prospective study aimed at evaluating the role of instrumental variables, risk scores, biomarkers and multidimensional assessment (cognitive status, frailty, quality of life) in assessing prognostic predictors of HF patients with different aetiologies and clinical profiles in common practice.

Methods: MAP-HF is designed as a cohort longitudinal study with a planned inclusion of at least 350 consecutive outpatients of 50 years or older, diagnosed with stable CHF (NYHA class II-IV) basing on ESC guidelines. Inclusion criteria are: EF>40% at recruitment, BNP>100 pg/ml and/or a previous hospitalization for HF. Exclusion criteria are: recent myocardial infarction (<1 month) or acute decompensated HF (<3 months), dementia or psychiatric diseases, previous stroke, active cancer, hemodialysis, life expectancy<1 year, HF due to alcoholic or peripartum cardiomyopathy or tachycardiomyopathy. All patients will undergo at baseline and 12 months follow-up a complete clinical and instrumental evaluation including NYHA class, Seattle HF and 3-CHF scores, EuroQOL score, 6-minute walk test, 4-meter walk test, echocardiogram, BNP and ST2 plasma levels dosage and, for patients aged>70y, a self-sufficiency and independence assessment with BADL and IADL scales and cognitive status with MiniCog screening test and MOCA. At 1 and 3 months from recruitment all patients will undergo a clinical and laboratory follow-up.

MAP-HF complies with the Declaration of Helsinki and informed consent will be obtained from patients.

Results: The primary endpoint is death of any cause; secondary outcomes are cardiovascular death, non-cardiovascular death, HF hospitalizations, hospitalizations not related to HF, functional impairment as a lower score in ADL-IADL scales in patients aged>70 years. Univariate and multivariate statistical analyses (Kaplan-Meier and Cox proportional hazards survival regression analysis) will be used to examine the impact of single variables in determining pre-specified primary and secondary outcomes. The accuracy of the logistic regression models will be evaluated by C-statistic.

Elevated plasma levels of N-terminal pro-brain natriuretic peptide observed in both clinical and pathophysiological settings in patients with asymmetric hypertrophic cardiomyopathy

M. Tesic¹, J. Seferovic², V. Giga¹, A. Djordjevic-Dikic¹, D Trifunovic¹, I. Jovanovic¹, B. Beleslin¹, P. Seferovic¹, A. Ristic¹, J. Stepanovic¹, S. Di Somma³, B. Vujisic-Tesic¹

¹Clinic For Cardiology, Clinical Center Of Serbia, Belgrade, Serbia, ²Clinic Of Endocrinology, Diabetes And Metabolic Disorders, Clinical Center Of Serbia, Belgrade, Serbia, ³Department Of Medical-Surgery Sciences And Translational Medicine, La Sapienza University, Sant’andrea Hospital, Rome, Italy

Background: N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is excellent marker of abnormal left ventricular (LV) wall stress, but may also result from ischemia. In patients with hypertrophic cardiomyopathy (HCM) ischemia is common finding due to microvascular dysfunction which is reflected by decreased coronary flow reserve (CFR). Extravascular compressive forces due to elevated LV filling pressure, LV wall stress and significant left ventricular outflow tact gradient (LVOTG) might additionally worsen ischemia. Ratio of early transmitral flow velocity to early diastolic lateral mitral annulus velocity (E/e’) has been shown to be accurate noninvasive predictor of elevated LV filling pressure. The aims of this study are to: 1. analyze values of plasma concentrations of NT-pro-BNP in various clinical and echocardiographic features in HCM patients; 2. explore possible relation between plasma levels of NT-pro-BNP with microvascular function and extravascular compressive forces.

Methods: In 61 patients (mean age 49±16 years; 26 male) with asymmetric HCM (20 patients with significant LVOTG and 41 patients without obstruction) plasma levels of NT-pro-BNP were obtained. The NT-proBNP level was analyzed by electrochemiluminescence immunoassay technique (ECLIA, Roche Diagnostics). Standard transthoracic examination with measurement of CFR in LAD was done.

Results: Mean natural logarithm value of NT-proBNP was 7.11±0.95pg/ml for the whole population. NT-proBNP was significantly higher in patients with NYHA II compared to NYHA I (p=0.003), while the levels were not statistically different in patients with or without angina, syncope and heart rhythm abnormalities. Values of NT-proBNP were significantly higher in obstructive compared to the non-obstructive HCM (p=0.021), in moderate compared to mild mitral regurgitation (p=0.003), in increased left atrial volume index (LAVI) compared to normal LAVI (p=0.011), in the presence of diastolic dysfunction (p<0.001) and in decreased CFR (p<0.001). Levels of NT-proBNP correlated with the ratio of E/e’(r=0.534, p<0.001), LAVI (r=0.443,p<0.001), LVOTG (r=0.503,p=0.024), while inversely correlated with CFR LAD (r=-0.569,p<0.001).

Conclusions: Plasma levels of NT-ProBNP are significantly higher in obstructive HCM, patients with NYHA II, moderate mitral regurgitation, diastolic dysfunction, enlarged LAVI and decreased CFR. Extravascular compressive forces such are the presence of significant LVOTG and elevated filling pressure additionally increase levels of NT-proBNP. Also microvascular dysfunction might further increase NT-proBNP. Thus, elevated NT-proBNP does not only reflect LV wall stress but might also be result of cardiac ischemia.

Heart failure with preserved and reduced left ventricular ejection fraction - from hospital presentation to outcome

B. Stojcevski¹, V. Celic^1,2, B. Pencic-Popovic¹, A. Majstorovic¹, A. Sljivic¹

¹University Clinical Hospital Center Kbc Dr Dragisa Misovic- Dedinje, Cardiology Department, Belgrade, Serbia, ²Faculty Of Medicine, University Of Belgrade, Belgrade, Serbia

Background: Heart failure with preserved left ventricular ejection fraction (HFpEF) (LVEF) is a metter of growing interest, due to unsufficient data about its characteristics and outcomes. The aim of this study was to investigate the differences in hospital presentation and long term survival between acute heart failure (AHF) patients (pts) with HFpEF, and reduced LVEF (HFrEF).

Methods: We included 168 patients (pts) (mean age 72±8.3 years, 60.1% male) hospitalized due to AHF. Routine laboratory measures and physical examination were done at presentation. LVEF was measured by standard two-dimension echocardiography. HFpEF was defined as HF with LVEF>45%. Based on LVEF, pts were divided in two groups: Group I (HFrEF; 70.2%) and Group II (HFpEF). The outcome of interest was death during one year after hospitalisation.

Results: Mean LVEF was 32.2% in Group I, and 51.9% in Group II (p<0.001). There were no differences between groups with regard to: age, clinical presentation (New York Heart Association- NYHA Class, heart rate, peripheral oedema, rales, hepatomegaly, diastolic arterial tension), presence of comorbidities (arterial hypertension, atrial fibrillation, chronic kidney failure, diabetes mellitus, chronic obstructive pulmonary disease), tobacco use, HF etiology, de-novo AHF rate. Pts with HFpEF had higher systolic tension (146.2 vs. 137.3mmHg, p=0.029) and lower haemoglobin (116.4 vs. 129g/l, p=0.001). HFrEF was associated with male gender (83.2 vs. 62.7%, p=0.003), higher end-diastolic diameter (EDD) (62.3 vs. 54.8mm, p<0.001), N-terminal brain natriuretic prohormone (NT-proBNP) (7442.2 vs. 5212pg/ml, p=0.007), bilirubin (20.9 vs. 16.3umol/l, p=0.041), aspartat and alanin transaminase (61.2 vs. 34.7 IU/l, p=0.014; 60.3 vs. 33.1 IU/l, p=0.046), gama-glutamyl transferase (101.5 vs. 59.1 IU/l, p=0.003), alcochol use (86.4 vs. 71%, p=0.043). Other laboratory parameters were similar in both groups. All pts were similarly treated after hospitalization, except for calcium channel blockers, which were more used in Group II (32.4 vs. 15.1%, p=0.019). Forty-one patient died during one year follow up (28.5%) and 24 were lost. LVEF wasn’t associated with the one year death event, and pts from both groups had similar outcome risk (p=0.137).

Conclusions: At hospital presentation, patients with HFrEF are usually men with higher NT-proBNP, liver ensymes and EDD, comparing to HFpEF patients who only show higher systolic arterial tension. Despite this presentation differences end echocardiographic measures, long term outcome of HFpEF is as poor as for HFrEF.

Frailty syndromes for risk prediction in the elderly: a prospective observational study

J. Soong, L. Vaughan, D. Bell

Imperial College London, Department Of Medicine, London, United Kingdom

Background: The assessment and management of older patients in acute care is a pressing challenge in acute care. Existing frailty scales have demonstrated poor predictive power within this setting. We have previously shown the utility of Frailty Syndromes (Cognitive impairment, reduced mobility, falls, incontinence, anxiety/depression, pressure sores) for risk prediction within a national (England) retrospective administrative data (GREAT VII). We report a prospective trial of this model in the clinical setting.

Methods: Prospective observational study of patients over 65 years with acute medical admission via the Acute Medical Unit in a Central London Teaching Hospital by convenience sampling between June to November 2013 (6m). Data collected include demographics, presentation, co-morbidity, prescriptions, medical and nursing assessments and outcomes (inpatient mortality, 7 & 30 Day emergency readmission and institutionalization). Frailty syndromes were coded (New/Active and Historic). Logistic regression was used to build the risk model and Receiver Operator Characteristic (ROC) curves to assess predictive power.

Results: 482 patients were recruited where frailty syndromes were common (Table 1). 3 models were created: Historic Frailty Syndromes, New/Active Frailty Syndromes and Frailty Syndromes + (Table 2). There was mild improvement for predictive power between coding for new or active frailty syndromes compared with the historic model. The addition of routinely collected clinical data to frailty syndromes improves risk prediction to thresholds of clinical utility (>0.80) (Table 3).

Conclusions: Improvement in predictive power from historic to new/active frailty syndromes may suggest that a clinical deterioration (from baseline) is more predictive in frailty syndromes than just the presence of one. For clinical utility, other routinely collected variables can improve the utility of frailty syndromes for risk prediction in patients over 65 requiring acute medical admission. The addition of biomarkers may further improve risk stratification and should be explored.

Diagnostic performance of hs-TnT and poct-tnt in clinical routine

A. Slagman¹, J. Searle¹, J. Von Recum¹, F. Holert², D. Meyer-Zum-Büschenfelde², C. Müller², M. Möckel¹

¹Department Of Cardiology, Division Of Emergency Medicine Cvk, Ccm; Charité University Medicine, Berlin, Germany, ²Department Of Laboratory Medicine And Clinical Chemistry; Charité University Medicine, Berlin, Germany

Background: NSTEMI is defined as a rise and/or fall of cardiac troponin with at least one value above the 99th percentile of a healthy reference population in patients with signs or symptoms of acute ischemia.

The cut-off value used is recommended to have a coefficient of variation of less than 10%. Point of care (POC)-systems do usually not meet these criteria at the 99th percentile.

In this analysis, the diagnostic performance of a POC-test for TnT in the ED is compared to the high-sensitive TnT test performed in the hospital central laboratory.

Methods: All patients with routine troponin T (TnT) testing in the Emergency Department (ED) were enrolled (n=4,946). TnT was measured simultaneously: contemporary sensitive in EDTA whole blood on the AQT 90 (Radiometer – contemporary sensitive) and high sensitive in heparin plasma on the Cobas 602 (Roche analytical systems). Only internal patients (n=4.304) with both Troponin measurement (n=3.396) were analyzed. Patients with STEMI were excluded from analysis (n=33). The diagnostic performance was statistically analyzed at two different cut-offs for each Tn-test: hsTnT at 14ng/L and 50ng/L and AQT-TnT at 16ng/L and 30ng/L. Endpoint was the hospital main diagnoses at discharge.

Results: Of all 3,423 patients with suspected NSTE-ACS, 57.2% were male (n=1,959) and the median age was 61 years (IQR: 45-73). 7.8% had a final diagnosis of unstable angina pectoris (UAP; n=267) and 3.6% had NSTEMI (n=124). A coronary angiography (CA) was performed in 10.4% (356) and PCI was required in 42% of patients with CA (n=149). For the high-sensitive TnT assay, 28.4% and for the AQT-TnT-assay, 75.7% of all values were at or below the lower limit of detection. The diagnostic performance of the respective TnT-assays at different cut-offs is shown in table 1.

Conclusions: In our cohort the diagnostic performance of conventional POC-testing at admission was comparable to hsTn. HsTnT in clinical routine provides information about slightly elevated Tn-values which might be of added prognostic value and for shorter diagnostic evaluation. The implementation of a 99th percentile cut-off is accompanied by a major decrease in specificity, PPV and overall accuracy while NPV only increases slightly, thus challenging the clinical benefit.

Ceus in low energy isolated abdominal trauma: a retrospective case-series study

B. Sessa, S. Ianniello, M. Trinci, M. Galluzzo, V. Miele

S. Camillo Hospital, Department Of Emergency And Cardiovascular Imaging, Rome, Italy

Background: Contrast-enhanced ultrasound (CEUS) has an high accuracy in the detection of abdominal traumatic lesions.

In this study we evaluate the sensibility of CEUS in the identification and grading of abdominal traumatic lesions in patients with low-energy isolated abdominal trauma in comparison with baseline-ultrasound (US) and contrast-enhanced computed tomography (CE-MDCT), considered the gold standard.

Methods: A total of 128 consecutive patients who arrived in our Emergency Department between January 2008 and December 2012 (78 males, 50 females, 4-82 years, mean age 35 years), with a history of low-energy isolated abdominal trauma were analyzed.

All patients underwent US, CEUS with the use of a second-generation contrast agent (Sonovue, Bracco-Milan, Italy) and MDCT.

The sensibility (SE) in the detection of lesions for US and CEUS and in the grading of lesions for CEUS was calculated comparing with CT findings, according with the AAST criteria.

Results: CE-MDCT identified 42 abdominal traumatic lesions (liver=14, spleen=17, Kidney=11).

US and CEUS depicted respectively 25/42 and 40/42 traumatic injuries.

Sensibility for the identification of traumatic abdominal lesions were 59% for US and 96% for CEUS.

CEUS had successfully staged 36/42 traumatic lesions with a sensibility of 88%.

Conclusions: In patients with low-energy isolated abdominal trauma US should be replaced by CEUS as the first line approach, showing a high sensibility both in the detection and grading.

CE-MDCT must always be performed in CEUS positive patients to exclude active bleeding and urinomas.

Non invasive detection of arrhythmogenic myocardium

R. Pirisino¹, P. Pizzichini¹, L. Antonini², F. Scopinaro¹

¹University Hospital S. Andrea, Rome, Italy, ²S. Filippo Hospital, Rome, Italy

Background: Sudden cardiac death occours in 1/3 to half of patients with chronic heart failure ( HF); As shown by multicentre studies such as COMPANION and DEFINITE, the cardioverter-defibrillators (ICD) have important impact in reducing both mortality and hospitalization rate in patients with symptomatic HF, irrespective of the nature of cardiomyopathy. Of course, if all the patients with HF and potential arrhythmia would have placed an ICD, the costs for every health care system would be extremely high. I-123 meta-iodo-benzylguanidine (MIBG), a radiolabelled norepinephrine analogue is able to image the bio-distribution of the function of the autonomic nervous system. Failure in nervous afference to viable myocardium is an important factor in triggering and sustaining a variety of malignant ventricular arrhythmias. Thus scintigraphy with MIBG can take on an important role in selecting patients who would benefit from ICD by identifying those at increased risk for potentially fatal arrhythmias. In this study we evaluated if integration between perfusional, vitality and adrenergic innervation imaging in patients with ICD could help in identifying arrhythmogenic foci and selecting candidates for ICD placement.

Methods: After having studied 3 patients scheduled for PET and 99mTc-Sestamibi (MIBI) studies for non cardiac reasons, we enrolled 10 patients in whom Parkinson disease was excluded, with left ventricular dysfunction, EF<35%, and previously implanted ICD for primary or secondary prevention. All patients underwent rest planar scan and early-late single photon emission tomography (SPECT) with 123I-MIBG plus rest GATED SPECT imaging with 99mTc MIBI and PET/CT imaging with the viability tracer flourodeoxyglucose (18F-DFG). Patients were followed up for at least six months.

Results: Normal patients did not show mismatches The EF measured by gated SPECT was 25.6, SD 3.6. All the patients who showed mismatch between MIBG and MIBI showed also mismatch between MIBG SPECT and DFG PET. Two patients did not show MIBI-MIBG mismatch but showed mismatch between MIBG and DFG. The patients who showed mismatches experienced ICD discharges during the follow-up, whereas the 2 patients without mismatch did not.

Conclusions: The analysis of mismatch zones between MIBG SPECT and MIBI SPECT and/or DFG PET is an accurate non invasive method to discover arrhythmogenic myocardium. DFG PET is more expensive but also more sensitive to this end.

Importance of Legal Advice in an Emergency Department

P. Schinco¹, R. Arione¹, A. Cibelli², G. Manzoli², C. Fini²

¹Direzione Sanitaria Presidio Molinette- Aou Città Della Salute e Della Scienza, Torino, Italy, ²Centro Supporto Vittime Di Violenza - Aou Città Della Salute e Della Scienza, Torino, Italy

Background: Demonstrate the importance of legal advice in an emergency department. In the specific case is given the experience of the Centre Support and Listening Victims of Violence Demetra to the Hospital of Turin - City University of Health and Science of Turin, where some operators volunteers (employees of the company lawyers or law graduates with specific expertise in the field) in 2007 make a legal advice service to victims.

Methods: The legal advice is carried out in two ways: 1) immediate action on call in the emergency room which is facing the victim of violence; 2) appointment with the subject that will appeal to the Centre. In both cases, the subject is informed of his rights (period for bringing any lawsuit, conditions for access to free legal aid) and possible criminal justice initiatives and civil legal action to be taken.

Results: The victims of violence are reassured and strengthened having become more aware of their rights and of the initiatives to be undertaken without downtime and loss of energy. Where possible, these are in fact addressed to institutional bodies with specific training and expertise as well as when they wish to contact an attorney shall be informed of the existence of ’register kept by the Council of the BAR.

Conclusions: The service provided by the Legal Advice Service Centre Demetra gave positive feedback with a high index of satisfaction of users and approval by the health workers of the emergency department who are relieved of a task which sometimes do not feel adequate. The provision of advice by those who, given their status as civil servants, however, could not plead in its victims, helps them to externalize their feelings more freely and fears resulting from the establishment of judicial actions and receive a legal opinion released from any future actions.

Intimate Partner Violence in Emergency Room

P. Schinco, R. Arione, B. Pattarino, B. Cimini, D. Calcagno, R. Vendrame

Direzione Sanitaria Presidi Molinette/Sgas-Aou Citta Della Salute E Della Scienza, Torino, Italy

Background: Receiving Intimated Partner Violence ( IPV) victims in Emergency Room is a relatively common occurrence for the medical staff, who is however rarely willing to intervene effectively. Important issues are often not tackled, sequelae are not considered and the experience of the victims themselves is minimised with a serious impact on their mental health, including removal from further health proceedings.

Methods: When the Triage nurse suspects a case of IPV (Intimate Partner Violence) applies the standard procedure by making a clinical evaluation and initial assigns a priority code adequate to reduce excessive waiting time and will ensure the maximum level of privacy inside the ER. He/Her will ask question tactfully, will has a reassuring attitude by being open and willing to listen. The nurse will immediately alert all the relevant services available at the time. The nurse will inform the doctor and services involved in managing such cases. The health personnel may use techniques of counselling to people who have been victims of IPV that occur in the Emergency Room. The nurse guides and encourages the patient to seek out of the various support options avalaible, enhancing her ability to cope with stress and to make her own choices among various options. The presence of health personnel that uses techniques of counselling from the first moment is part of an overall care strategy for the benefit of the patient and any family members who may be involved. Environmental, physical, psychological, relational and communication factors are taken in consideration.

Results: We have treated 259 cases of IPV in 2013. 103 of which accepted an interview counselling. 63 victims have welcomed a second intervention counseling after the visit and the first interview (24,3 % of all cases and 61,1% of those who did the first).

Conclusions: We believe that this approach can reduce the underestating of the phenomenon IPV by improving the quality of care and adherence support programs for victims of violence.This approach provides for rapid access to a psychic examination of an ER of measurable symptoms as tremor, anxiety, fear, dizziness, dissociative amnesia, reticence, flashbacks and symptom of arousal. It was accepted by a good part of patients. Reduces the exposure to stress of the health personnel.

Integrated intervention in maxi-traffic accidents emergencies: a case study

N. Scala¹, P. Cestra²

¹Private, Rome, Italy, ²Italian Traffic Police, Rome, Italy

Background: Today Italian roads are witness of many traffic accidents, every two hours there is a fatality as result of an average of 590 traffic accidents occurring daily. Many of them involving several vehicles and a lot of people need operators who manage the accident.

It is important to develop a strategy of early intervention, and an appropriate psychological support for rescuers to reduce in them the risk of Trauma and Stress Related (DSM V, 2013).

Methods: This paper aims to present operators’ work during an intervention carried out following the occurrence of an accident in which 40 people die.

The study is focused on the idea that operators can develop, in the near and distant future, aspects of Trauma and Stress Related Disorder or symptoms.

The model used is a cognitive behavioral (Clark, D.A., and Beck, A.T. 2011), able to reduce negative emotional and behavioral responses following a trauma. The protocol used is “Critical Incident Stress Management” (J. Mitchell, 1983, 1991). The processes are intended to help individuals manage their normal stress reactions to abnormal events. The protocol used foresees, for the 35 operator volunteers, a Defusing, immediately after the intervention, a Debriefing after 24 hours and a follow up after one and two months to check how the event influenced behavior and feelings of operators.

Results: This experience has demonstrated that when an integrated intervention occurs in maxi-traffic accident emergencies, Defusing, Debriefing (Solomon, Macy, 2003) and follow up after one and two months from the event, the percentage of Trauma and Stress Related Disorder, of 35 operators interviewed, using the Critical Incident Stress Debrifing (J. Mitchell, 1983, 1991) is minor than the percentage reported in other studies (W. Berger; F. Coutinho, I. Figueria, C.Marquez-Portella, M. Pires Luz, T. C. Neyland, C.R. Marmar, M.V. Mendlowicz, 2011;) where the average per entage of Post Traumatic Stress Disorder symptoms was of 10%, and the Acute Stress Disorder (C.S. Fullerton, R.J.Ursano, L. Wang, 2004) was 25,6%.

Conclusions: The work analyzes the intervention, as well as discrepancies, gaps, strengths and opportunities for discussion, in order to build dynamic evolution of the known for the improvement; it shows that a correct psychological approach to all rescuers involved, will ensure, a lower risk of trauma and psychopathology.

Brain natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL) and bioelectrical impedance vector analysis (BIVA) for the prediction of cardiovascular events in heart failure

S. Santarelli¹, V. Russo², B. De Berardinis³, I. Lalle⁴, L. Magrini⁵, H. Villacorta⁶, S. Di Somma

¹Emergency Department Azienda Ospedaliera Sant’Andrea, Faculty Of Medicine and Psychology Sapienza University, Rome, Rome, Italy, ²Universidade Federal Fluminense, Departimento De Ciencias Cardiovasculares, Rj, Rio De Janeiro, Brazil, ³Emergency Department Azienda Ospedaliera Sant’Andrea, Faculty Of Medicine And Psychology Sapienza University, Rome, Rome, Italy

Background: Heart Failure is a chronic disease with high prevalence and with frequent relapses worldwide. For these reasons, acute heart failure (AHF) is a common leading cause of admission to Emergency Department and hospitalization. The aim of this study was to investigate about the ability of Brain Natiruretic Peptide (BNP), Neutrophil Gelatinase-Associated Lipocalin (NGAL) and peripheral congestion detected by Bioelectrical Impedance Vector Analisys (BIVA), to identify patients who are more likely to develop events in the upcoming 90 days.

Methods: This is an observational, prospective study performed in the Cardiology ward of Fluminense Federal University of Rio de Janeiro (Brasil), and in the Emergency Medicine Ward of Sant’Andrea Hospital in Rome (Italy). AHF patients performed BNP and NGAL measurements at arrival in the ward. BIVA was performed at discharge. A 90 days follow up phone call was made to evaluate cardiovascular events (death or rehospitalization).

Results: 295 patients were enrolled. BNP levels were higher in AHF patients with events (p<0.01), and ROC curve showed that BNP had a prognostic role for rehospitalization at 90 days (AUC 0.59, p<0.01). NGAL between the two groups was not statistically significant (p<0.35) but ROC analysis showed its predictive role for death at 90 days (AUC 0.74, p<0.001). Hydration Index (HY), Resistance (R), and reactance (Xc), showed statistical significant difference in patients with events vs no events (p<0.001). At ROC analysis, BIVA showed high prediction for death: HY (AUC 0.712, p<0.01), Xc (AUC 0.715, p<0.001), R (AUC 0.65, p< 0.01).

Conclusions: In AHF patients, BNP allows to identify patients who will be readmitted before 90 days, while NGAL seems to identify patients at high risk of death. BIVA have a good prognostic value for total events and in particular for cardiovascular death.

Role of point of care lung ultrasound and procalcitonin in the diagnosis of pneumonia in emergency department. Research proposal

S. Santarelli, V. Russo, B. De Berardinis, L. Magrini, S. Di Somma

Emergency Department Azienda Ospedaliera Sant’Andrea, Faculty Of Medicine And Psychology Sapienza University, Rome, Italy

Background: Pneumonia is a common and potentially lifethreatening disease worldwide and it represents the first cause of mortality related to infectious diseases in western countries, and the major cause of sepsis and septic shock. Recently bedside lung ultrasound (LUS) and procalcitonin (PCT) have shown to be very useful tools for the emergency physician in the diagnosis of pneumonia. The aim of this study proposal is to determine the diagnostic accuracy of LUS and PCT combined and alone for the diagnosis of pneumonia in the Emergency Department (ED).

Methods: Adult patients arriving to ED with a suspected diagnosis of pneumonia will be enrolled, during a period of one year. Each patient will receive the ordinary clinical practice care including blood exams (included PCT dosage), Chest-X ray and, when indicated, Thorax CT. In addition LUS will be performed, in the ED, for each patient by trained sonographers, and physicians will be blinded to its result.

Results: On the bases of our statistical preliminary annalysis it is expected to enroll almost 300 patients.

Conclusions: LUS is expected to be a promising alternative to Chest-X ray, and its use combined with PCT blood levels could improve the diagnostic accuracy with consequent immediate decision making for the emergency physician useful both for treatment and for disposition of patients.

Pneumomediastinum in emergency department: is possible to adopt a conservative approach in selected patient?

M. Rossi¹, C. Canetta², G. Acquistapace^1,3, D. Camisa², C. Valcarenghi², P. Piccioni¹, M. Buvoli¹, A. Manelli¹, G. Ricevuti³

¹Pronto Soccorso Ospedale Maggiore Lodi, Lodi, Italy, ²Pronto Soccorso Ospedale Melegnano, Melegnano, Italy, ³Università Degli Studi Di Pavia: Medicina D’emergenza-Urgenza, Pavia, Italy

Background: The term pneumomediastinum describe a pathologic condition characterized by the presence of air in the mediastinum; It is most commonly caused by oesophageal rupture (for example in Boerhaave syndrome) asthmatic attack or other conditions leading to alveolar rupture, but in most cases the origin remains obscure.

Many cases of pneumomediastinums are treated conservatively: the tissues in the mediastinum will slowly resorb the air in the cavity. Some cases need surgery approach for repair the hole in the trachea, esophagus or bowel.

Methods: We collected 3 cases with a final diagnosis of pneumomediastinum, presented at the Emergency Department (ED) with heterogeneous medical conditions, in 2014.

Case 1: a 29y-old female presented at Melegnano’s ED referring neck pain arised after a decelerative road accident with cervical and chest blunt trauma occurred the day before.

Case 2: a 22y-old male, affected by cyclic vomiting syndrome, presented at Melegnano’s ED complaining for neck pain, difficulty swallowing and hoarseness following recurrent vomiting.

Case 3: a 16y-old male referred to Lodi’s ED, complaining about sudden chest pain after an asthmatic attack in smoker subject with untreated asthma.

Results: In all patients Chest/Neck CT without contrast demonstrated the presence of air reaching the diaphragm in the mediastinum and the absence of lesions in the pharyngo-larynx and esophagus district. No vital signs impairment were recorded; all patients were admitted and received conservative treatment, including high-flow oxygen and antibiotic prophylaxis,. The patient 3 underwent bronchoscopy that confirmed the absence of significant tracheal lesions. In all cases the pneumomediastinum resulted in a progressive resorption without complications, with a mean length of stay of 5 days.

Conclusions: CT scan is useful in identifying patients with a high likelihood of serious aerodigestive tract injury, and may be used as initial screening tool for selecting patients that can be safely observed and those in need of further evaluations. In the absence of a concomitant pneumothorax or severe illnesses, after an adequate period in observation units in the ED patients with pneumomediastinum could probably be treated on outpatient basis. Diagnostic procedures performed for identifying an underlying anatomic cause (eg. esophageal or tracheobronchial rupture) have a low yield and seem to be unnecessary in these cases.

Exertional heat stroke associated to hypoxic hepatitis and rhabdomyolysis

V. Benedetti¹, A. Sciolla¹, C. Serraino^1,2, E. Pizzolato^1,2, G. Racca¹, P. Cosio^1,2, B. Tartaglino¹

¹Emergency Department, Santa Croce And Carle Hospital, Cuneo, Italy, ²School Of Medicine, University Of Turin, Turin, Italy

Background: On June 2014 a 36 year-old athlete was admitted to our Emergency Department due to syncope occurred during an uphill running competition (distance 12 km, ascent 470 m, outside temperature was 30° C) about 20 minutes after the start. He presented with hypotension (90/50 mmHg), high heart rate and body temperature (125 beats/minute and 39.5°C respectively), regular oxygen saturation (95% without oxygen support) and respiratory rate (16 acts/minute). He appeared diaphoretic and confused with a Glasgow Come Scale of 10, amnesic for the syncope. His blood pressure values normalized after a fluid challenge of about 1500 mL; hyperthermia was treated with ice-positioning. Urinary toxicological and blood alcohol tests were negative. Because of psychomotor agitation he necessitated endovein sedation. Preliminary investigations showed: glucose 75 g/dL, creatinine 1.9 mg/dL, potassium 4.6 mEq/L and sodium 143.5 mEq/L. Brain Computerized Tomography scan was regular. An amount of 5 L of fluids were infused during the stay in Intensive Care Unit. His mental status progressively improved: 12 hours later he was orientated and felt well. The patient denied water intake during the competition. Blood investigations performed the day after revealed elevated Creatinine Phosphokinase values (CPK), Glutamic Pyruvic Transaminase (GPT) and Glutamic Oxaloacetic Transaminase (GOT) levels (4109 U/L, 2871 U/L and 1888 U/L respectively). Abdomen ultrasounds didn’t show any signs of liver diseases; liver viral and autoimmune screen laboratory tests were negatives. The final diagnosis was exertional heat stroke associated to rhabdomyolysis and hypoxic hepatitis. Four days later, the patient was discharged: CPK, GPT and GOT were progressively decreasing (511 U/L, 336 U/L and 1450 U/L respectively). He was advised to continue oral hydration and to stay at rest for few days. He was suggested to maintain oral hydration during heavy physical efforts in hot-humid seasons.

Hypoxic hepatitis is a very uncommon event in young healthy patients: cases of acute liver impairment are reported in literature associated to heat stroke and rhabdomyolysis. Its management involves fluid administration and inotropic support, when necessary. Low evidence exists on N-acetyl cysteine use in hypoxic hepatitis. About exertional heat illness, the American College of Sports Medicine and the National Athletic Trainers Association recommend immediate cooling, preferably, with ice water immersion.

The great illusionist

L. Pagani¹, I.F. Ceresa², S. Negri¹, M. Bonzano¹, G. Savioli², F. Geraci³, G. Ricevuti¹, M.A. Bressan²

¹Scuola Di Specializzazione Di Medicina D’emergenza E Urgenza Università Degli Studi Di Pavia, Pavia, Italy, ²Struttura Complessa Pronto Soccorso Accettazione (Sc Psa) Irccs Policlinico San Matteo, Pavia, Italy, ³Ssuem 118, Pavia, Italy

Background: The epidemiology of Polmonary Embolism (PE) is difficult to determine because it may remain asymptomatic or its diagnosis may be an incidental finding; sometimes the first presentation may be sudden death.

Results: A 45 year old woman came in Emergency room (ER) for pain in the left hip radiating along left ureter course of the exacerbated by the breath, the movements and pyrexia. Gravity code green, no disease in history, smoke in estrogen-progestin therapy. Vital signs and clinical examination were normal. At the US evaluation there was no evidence of hydronephrosis, although the urine stick found ketones, protein and red blood cells. At the lab tests renal function was normal but there was a neutrophilic leukocytosis. It has been administrated to the patient analgesic therapy bringing to pain resolution. The patient was also subject to urological assessment and was later discharged. Next day afternoon the patient returned in ER, complaining of pain similar to the previous day, but also located at the left hemithorax base associated with dyspnea and fever. Vital signs were normal except HR 125 bpm. Objectively she appeared tachypneic, tachycardia, pain in the left hip. At the US evaluation dubious left hydronephrosis and B lines at the lung left base. The patient was subjected to ECG with sinus tachycardia and EGA with hypocapnia in normoxia. Lab tests showing an increase in neutrophilic leukocytosis and positive D-dimer. In view of the clinical presentation, the US pattern, thromboembolic risk factors and lab data, it has been decided to submit the patient to chest and abdominal CT with and without contrast to rule out or confirm the suspicion of PE or nephritic problems. The CT scan showed a EP lower left lobar branches associated with lung infarction and inflammatory thickening associated with pleural effusion. Anticoagulation therapy was started and the patient was hospitalized in pneumology.

Conclusions: The case show how it can be treacherous the PE diagnosis. The first time in ER, the clinical and the lab tests defined a clear clinical picture of renal colic. The second time symptoms, vital signs, instrumental examinations and lab tests brought to suspect PE in a patient with risk factors. Everytime the clinical presentation raises PE suspicion it should be done further objective testing.

Pink code project: “violence against women- multidisciplinary health and social intervention protocols”

E. Montibello¹, F. Formisano¹, C. Ferraiuolo¹

¹Health And Medical Education Department, Public Health Authority Of The Northern Province Of Naples, Pozzuoli (Napoli), Italy

Background: The Public Health Authority of the Northern Province of Naples (ASL NA2 Nord) has a population of about 1.100.000 residents and its General Manager is G. Ferraro. It covers a territory divided into 32 municipalities with 2 Islands: Ischia and Procida. It has 4.500 employees and 2.500 affiliated professionals. The ASL NA2 Nord is composed of 13 Health Districts and 5 Hospitals.

Methods: The training course “Pink Code: Violence against women”, in accordance with the law of the Campania Region n.22 of 21/07/2012 and the Istanbul Convention of May 2011, organized in May 15, 22, 29 and June 5, 12, 2014 at ASL NA2 Nord, was addressed to 75 public health and social care professionals (Doctors, Psychologists, Nurses, Sociologists, Social Workers, etc.) for the formation of multidisciplinary teams specializing in various areas to be used for the construction of the “Pink Code Project”. The proposed model identifies a process of recognition and acceptance of victims accessing the Emergency Department in the Public Hospital (identified as a place of first aid) and a network with a Corporate Observatory/Task Force that connects the Hospital, Health Districts, Territories, General Practitioners, Police, Local Authorities, Associations on the territory and Legal Advisers. The Corporate Observatory is formed by staff with specialized skills (Psychologists, Doctors, Healthcare Professionals, etc.).

Results: The task of the hospital team is to: draw up an initial screening of victims that access the Emergency Unit to then entrust them to the Health Districts and Territories for the successive taking in charge to send back doubtful cases to the Observatory for their validation to produce an effective reporting for discussion during assessment. The Health Districts and Territories have the specific task of taking detected cases in charge and of sending the data to the Observatory for the definition of a protected path for the victim. The Corporate Observatory team acts within the competence of Strategic Direction.

Conclusions: The ASL NA2 Nord network in accordance to skills and territoriality is divided into a set of health and social services that together with psychological counseling and legal advice will support the victim on a path out of violence and on the way to the construction of a new condition of life.

A nutritional deficiency causing a cardiogenic shock: a case report

A. Mazzarri¹, V. Gionti², M. Cottini², G. De Ferrari³, G. Ricevuti⁴

¹School Of Emergency Medicine, Pavia, Italy, ²School Of Cardiology, Pavia, Italy, ³Irccs Policlinico San Matteo-Dept Of Cardiology, Pavia, Italy, ⁴Chair Of Emergency Medicine, Pavia, Italy

Background: Thiamine is an important cofactor in carbohydrate metabolism, with limited body stores leading to the possibility of a deficit after few days of not assumption. Chronic deficiency may present as Wernicke-Korsakoff encephalopathy, polyneuropathy and high output heart failure possibly leading to cardiogenic shock. Presently severe thiamine deficiency is uncommon in developed countries although possible in malnourished patients.

Methods: A 58 year old man was admitted to the General Surgery Department for a severe pyloric stenosis at the level of a previous gastro-duodenal anastomosis. He presented with severe vomit that prevent him adequate feeding for more than 3 weeks. During the hospital stay the patient developed neurological symptoms with confusion and memory deficit without radiological signs.

In the following days he developed shortness of breath and chest pain. The ECG disclosed previously absent negative T wave in anterior leads, associated with positive levels of TnI. Echocardiography showed severe left ventricle dilation and dysfunction (LVEF 30%) with normal right ventricle. BGE showed high arterial lactate levels reaching 8.6 mmoli/l, high central venous hemoglobin saturation (SvO2 83%). His condition rapidly deteriorated despite treatment with cPAP ventilation, nitrates and diuretics and, in few hours, he developed hemodynamic shock requiring inotropic support.

On the basis of these findings and on the patient’s history of CABG, under the hypothesis that myocardial ischemia could have contributed to the development of cardiogenic shock, he underwent coronaryangiography that showed normally functioning grafts and severe stenosis of a branch of intermediate size treated successfully with PCI and stent implantation. Septic shock was excluded.

Due to the recent history of malnutrition, we suspected thiamine deficiency as the major mechanisms of cardiogenic shock. Accordingly, we administered 100 mg iv. thiamine.

Results: In the following 3 hours, we observed a rapid improvement of the hemodynamic conditions with resolution of shock, normalization of arterial lactate levels and venous saturation and almost complete regression of ECG with significant improvement of echocardiographic abnormalities.

Conclusions: Thiamine deficiency is a very rare cause of heart failure. In this case, the mild coronary abnormality likely contributed to the precipitation of heart failure into cardiogenic shock, but the high central saturation level strongly favored thiamine deficiency as the main underlying mechanisms. This hypothesis appeared confirmed by the rapid improvement following treatment.

Diagnosis of severe plasmodium falciparum malaria in emergency department: a case report

F. Marino¹, D. Stassaldi², M. Poli², M. Salvetti³, M.L. Muiesan³

¹Scuola Di Specializzazione In Medicina D’emergenza-Urgenza, Università Degli Studi Di Brescia, Brescia, Italy, ²Dipartimento Di Emergenza-Urgenza, Pronto Soccorso, Ospedale Di Gardone Val Trompia, Gardone Val Trompia, Italy, ³Dipartimento Di Scienze Cliniche E Sperimentali, Università Degli Studi Di Brescia, Brescia, Italy

Background: The incidence of imported malaria is about 20000 cases/year, with a mortality rate of 150 cases/year. An early investigation for Plasmodium spp. infection should be done in all patients admitted to Emergency Departments (E.D.) with fever or signs of sepsis and being at high risk of infection (i.e. travelers or immigrants coming from endemic regions not undergone to the chemoprophylaxis).

Methods: We present a case of severe sepsis by Plasmodium Falciparum malaria observed at the E.D. of Gardone Val Trompia hospital.

Results: A 50 years-old man was admitted to the E.D., complaining fever lasting from 2 weeks, worsening dyspnea and cough. Symptoms started few days after his return to Italy from Senegal; he didn’t undergo the standard antimalarial chemoprophylaxis.

At physical examination fever (38,5°C), tachypnea, tachycardia (140 b.p.m.), normal pulmonary and abdominal findings, a dry and hypohydrated skin were present. Oxygen saturation was 92%, arterial blood pressure (BP) was 150/90 mmHg.

Blood laboratory tests showed anemia (hemoglobin 6,4 g/dl), thrombocytopenia (34000 platelets/cc), a normal white blood cells count, creatinine 1,5 mg/dl, total bilirubin 2,3 mg/dl, elevated reactive C protein (P.C.R.), lactacidemia 12 mmol/l (normal values 0,6-1,2).

In the suspicion of malaria infection, a thick blood smear observation was performed, with a positive finding of Plasmodium Falciparum, and with a parasite rate of 30%, consistent with the diagnosis of severe P. Falciparum malaria.

A thorax CT-scan excluded any pulmonary, pleural or mediastinal lesions. Oxygen therapy at low flows by nasal mask, i.v. acetaminophen and i.v. fluids were administered. Still feverish but haemodinamically stable, the patient was admitted to the Infectious Disease Unit of Spedali Civili General Hospital in Brescia and underwent the specific antimalarial combination therapy, red blood cells transfusions and i.v. fluids.

A fast improvement of clinical conditions and of laboratory tests (hemoglobin 9,8 g/dl, platelets 225000/cc, creatinine 0,8 mg/dl, normal values of P.C.R.), and a complete negativization of the parasite research on thick blood smear, were observed in the following days and the patient was discharged from the hospital 7 days after the admission.

Conclusions: This case-report shows how the early diagnosis of P. Falciparum malaria done at the Emergency Department allows a timely specific antimicrobial therapy and a complete recovery from severe sepsis, preventing fatal complications.

A case of major bleeding during vka anticoagulant therapy for deep venous thrombosis, atrial fibrillation and a mechanical mitral valve; a series of unfortunate complications

M. Marini

Università Degli Studi Di Brescia, Brescia, Italy

Background: Major bleeding is a complication of all the known anticoagulant therapy available; the availability of reversing agent for each of them is a necessity in the emergency department.

Methods: A woman aged 69 came to the ED complaining pain of acute onset of the left haunch without prior traumatic injury. The patient was affected by G4 stage renal disease for IgA glomerulonephritis; she was in VKA anticoagulation both for permanent atrial fibrillation and for a mechanical mitral valve; her INR at admission was 2.4, underestimated for the range expected.A venous scan of the leg showed deep venous thrombosis of the left common femoral vein. LMWH was started and warfarin was potentiated. At day 4th INR was 3.4 but the pain was still worsening, radiated on the back and in the left quadrants of the abdomen, heart rate was 115bpm and blood pressure was 85/60 mmHg; Hb was 8,6 gr/dl (Hb at admission:11.9gr/dl); an ultrasound of the abdomen showed massive hemoperitoneum with multiple focuses of active bleeding. The patient underwent angiographic procedure of embolization of the bleeding focus.. At day 12th the patient became tachycardic, Hb 7,7 gr/dl; the patient underwent angiographic procedures with embolization of multiple focuses of bleeding in massive hemoperitoneum and hemothorax. A large spectrum antibiotic therapy was started as the patient presented in the abdomen a wide hematoma(17x15x9cm) that was organising with compression of the nearest structures, causing both subocclusive syndrome and lymphedema of the left leg that was turning into dermohypodermite; inflammation index remained increased leading to the doubt of a potential infection of the hematoma. At day 34th clostridium difficile was found in faeces specimen, while renal function worsened to an end stage renal disease until dyalitic treatment. At the day 43th of recovery the patient was found in cardiorespiratory arrest. From both blood and urine specimen collected two days before death klebsiella pneumoniae resistant to the current antibiotic therapy was isolated.

Results: The aging of the population lead to the emergency department patient of greater complexity with multiple pathology. Most of the studies for the safety of the anticoagulants agents often excluded patients of such complexity.

Conclusions: The bad control of major bleeding in patient with multiple pathology can lead to an unfortunate series of events.

BNP and pct utility in the management of acute heart failure patients (AHF) with or without infections

G. Adducchio¹, I. Lalle¹, L. Magrini¹, S. Di Somma¹

¹Emergency Department Azienda Ospedaliera Sant’Andrea, Faculty Of Medicine And Psychology Sapienza University, Rome, Italy

Background: Procalcitonin (PCT) has been used for the early diagnosis of sepsis, differential diagnosis between bacterial and viral infections, and antibiotic guide in clinical treatment. Infections are one of the common causes of acute decompensated heart failure and the PCT detection was found to be useful in the diagnosis of bacterial infection complicated by heart failure.

Methods: this was a retrospective analysis conducted on patients admitted in emergency medicine ward from 2012 and 2013. All patients were admitted from emergency room for dyspnea with a final diagnosis of acute heart failure (AHF) with or without infection.

We analyzed the serum level of PCT in these patients in terms of prognostic role for in-hospital mortality.

Results: We collected data from 187 patients with diagnosis of heart failure with (n 42) and without (n 145) infection. All data were collected at the time of arrival in emergency department.

BNP levels were not significantly different in patients with AHF (466 pg/ml) and in patients with AHF and infection (605 pg/ml) (p 0.15)

As for BNP, the median value of PCT was not significantly different in these two subgroups: 0.11 in patients with AHF vs 0.17 in patients with AHF and infection, p 0.16.

Because a “not-negative” PCT value, 74/145 patients with acute heart failure without diagnosis of infection, received antibiotic therapy. Analyzing the PCT value, patients who received antibiotic therapy showed significantly higher level of PCT compared to patients who did not (median value 0.15 ng/ml vs 0.09 ng/ml, p 0.0006)

Otherwise, while median values of BNP were not different, AHF patients died during hospitalization showed higher level of PCT (0.35 pg/ml vs 0.11 pg/ml, p 0.001).

Furthermore, compared to BNP, PCT showed a better prognostic value in predicting in-hospital mortality (AUC 0.77 p <0.0001 vs AUC 0.63 p 0.039)

Conclusions: The results showed that patients with heart failure had serum levels of PCT not significantly different than the group of patients with heart failure and infection. This finding could suggest that heart failure may interfere with PCT expression.

The data in this study suggested that PCT could have a prognostic value in predicting worse outcome in patients hospitalized for acute heart failure with or without infection.

Advanced management of patients with acute respiratory failure using noninvasive mechanical ventilation combined with biomarkers

C. Bucci¹, I. Lalle¹, B. De Berardinis¹, V. Russo¹, S. Santarelli¹, F. Travaglino¹, G. Salerno², P. Cardelli², S. Di Somma¹

¹Emergency Department Azienda Ospedaliera Sant’Andrea, Faculty Of Medicine And Psychology Sapienza University, Rome, Italy, ²Clinical And Molecular Medicine Department Azienda Ospedaliera Sant’Andrea, II School Of Medicine Sapienza, Rome, Italy

Background: Acute respiratory failure (ARF) is a common emergency department (ED) presentation. According to several randomized controlled trials, the non-invasive ventilation (NIV) has gained acceptance as the preferred ventilatory modality to treat ARF due to acute exacer-bations of chronic obstructive pulmonary disease (AECOPD), cardiogenic pulmonary edema. During NIV, the parameters of clinical course are PaCO2, PaO2/FiO2 ratio, pH and respiratory rate: their improvement in the first two hours is the best predictor of NIV success. Recent literature demonstrated the diagnostic and prognostic role of several biomarkers in critically ill patients. In particular, the role of ST2 as a prognostic biomarkers was examined in different conditions frequently observed in ED, such as acute myocardial infarction, congestive heart failure and non-cardiac dyspnea.

The aim of the study was to evaluate the individual and collective ability of BNP, PCT and ST2 for predicting in-hospital mortality in patients presenting in ED with ARF, treated with NIV and hospitalized.

Methods: This is a prospective, observational study, enrolling patients admitted to our ED for acute respiratory failure, requiring noninvasive mechanical ventilation and hospitalization; as ventilation’s mode, pressure support ventilation (PSV) will be used. The blood samples for biomarkers measurements and gas-analysis were performed: before starting NIV, 24 hours (T1) after the start of NIV and after 48 hours (T2).

Results: We enrolled 31 patients: the causes of ARF requiring NIV were pulmonary edema, AE-COPD, ARDS and pneumonia/sepsis.

11/31 (35%) patients died during hospitalization.

While at the time of presentation (T0) and after 24 hour (T1) from starting NIV, the mean serum levels of ST2 were non significantly different in survivors and non survivors (82±44 vs 72.2 ± 52, p 0.5 and 76.6±44 vs 73.0 ± 38, p 0.85 ), significant differences were noted in ST2 levels at T2 (after 48 hours). In fact compared with survivors, the patients who died during hospitalization showed significantly higher levels of ST2 (78.1 ± 30 vs 47.8 ± 21, p 0.03). Furthermore, levels of ST2 after 48h from start of NIV showed a significant prognostic power in predicting in-hospital mortality (AUC 0.8, p 0.04)

Conclusions: From these preliminary results ST2 seems to be a new biomarker for prognostic stratifica-tion of patients with acute respiratory failure needing NIMV.

Mild therapeutic hypothermia for patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention (unicorn). Research proposal

J. Kubica

Department Of Cardiology And Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

Background: The existing data regarding effectiveness and safety of mild therapeutic hypothermia (MTH) for treatment of out-of-hospital cardiac arrest (OHCA) survivals are inconsistent. Observations from small randomized trials and several observational studies revealed beneficial effects of this method. According to the European guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation guidelines released in 2012 MTH is indicated “early after resuscitation of cardiac arrest patients who are comatose or in deep sedation” (class of recommendation I, level of evidence B). However, recently published results of the biggest randomized trial are contradictory - in unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not show a benefit as compared with a targeted temperature of 36°C. Moreover, we found the methodology applied in this trial questionable. Therefore we propose a prospective, observational, multicentre study: Mild therapeUtic hypothermia for patieNts wIth acute CORoNary syndrome and cardiac arrest treated with percutaneous coronary intervention (UNICORN).

Primary objective: To assess whether mild therapeutic hypothermia applied in patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention is associated with higher 180-days survival rate as compared to therapy without hypothermia. Secondary objective: 1) To assess the influence exerted by additional treatment with mild therapeutic hypothermia on the neurological outcome at discharge from hospital; 2) To assess whether evaluated therapy is associated with increased rate of early stent thrombosis (up to 30 days); 3) To assess impact of evaluated therapy on in-hospital clinical outcomes with regard to safety (bleeding, infectious complications, rhythm and conductions disorders).

Methods: Study design and duration: prospective, multicentre, international, observational, matched case-control study testing the influence of mild therapeutic hypothermia applied in patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention on 180 days clinical outcome. Two groups of centers will enrol patients into the study: 10 centers performing therapeutic hypothermia procedures (250 patients) and 10 centers treating comatose patients without hypothermia (250 patients). The SIRIO Medicine Group will provide an independent data and safety monitoring.

Results: To be defined.

Conclusions: To be defined.

Milld therapeutic hypothermia for patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention. A single center study

J. Kubica, K. Pstragowski, M. Kozinski, M. Kasprzak, K. Obonska, J. Kubica

Department Of Cardiology And Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland

Background: There is a paucity of data regarding clinical outcomes associated with the integration of a mild therapeutic hypothermia (MTH) protocol into a regional network dedicated to treatment of patients with acute coronary syndromes (ACS). Observations from small randomized trials supported by several observational studies revealed beneficial effects of this method. However, recently published results of the biggest randomized trial are contradictory. Nevertheless we found the methodology applied in this trial questionable. The goal of our study was to assess the clinical effectiveness and safety of MTH program using a previously established ACS network in consecutive comatose OHCA survivors.

Methods: We conducted a prospective historically controlled single centre study. The primary and secondary efficacy end points were hospital survival with a favourable neurological outcome (Cerebral Performance Category of 1 or 2) and all-cause in-hospital mortality, respectively. The primary safety end point was occurrence of definite stent thrombosis, while the development of pneumonia, presence of positive blood cultures, occurrence of probable stent thrombosis, any bleeding complications, the need for red blood cell transfusion and presence of rhythm and conductions disorders during hospitalisation constituted secondary safety end points.

Results: Comatose OHCA survivors (n = 69) were referred to our Department based on ECG recording transmissions or directly admitted from the Emergency Department. Compared with controls (n = 35), they were more likely to be discharged from hospital with a favourable neurological outcome (49.3% vs. 25.7%; p=0.032; number needed to treat [NNT] = 4.24) and experienced lower all-cause in-hospital mortality (26.1% vs. 54.3%; p=0.002; NNT = 3.55). Among safety end points only positive blood culture results were higher in hypothermia group (56.5% vs 34.3%; p=0.032). According to multivariate analysis following factors were defined as independent predictors of hospital survival with favourable neurological outcome: OHCA with shockable rythm (OR 12.36, CI 95% 1.15-132.4, p=0.035), treatment with MTH (OR 4.65, CI 95% 1.19-18.25, p=0.0250, reanimation duration (OR 0.57, CI 95% 0.38-0.85, p=0.005) and age (OR 0.41, CI 95% 0.25-0.69, p=0.0006).

Conclusions: Our study indicates that a regional system of care for OHCA survivors may be successfully implemented based on an ACS network, leading to an improvement in neurological status and to a reduction of in-hospital mortality in patients treated with MTH.

Acute dilated cardiomyopathy: are men and women different?

J. Krejci¹, P. Hude¹, H. Poloczkova¹, E. Ozabalova¹, D. Mlejnek¹, V. Zampachova², L. Spinarova¹

¹St. Anne’S University Hospital, Icrc,1st. Internal Department - Cardioangiology, Masaryk University, Brno, Czech Republic, ²St. Anne’S University Hospital, Department of Patologic Anatomy, Masaryk University, Brno, Czech Republic

Background: According to some studies, women are more likely to improve the function of the left ventricle (LV) in recently occurred dilated cardiomyopathy (RODCM). It is also assumed that sex-hormones have influence on the development and course of myocarditis, which may be the cause of certain group of RODCM.

Methods: 140 patients, 28 females (20%) and 112 males (80%), symptoms duration at the time of diagnostic EMB was 3.1 ± 2.7 months, age 47 ± 11 years. Baseline echocardiography was performed ± 1 day since the EMB, control echocardiography was performed after 6 months. As a positive EMB finding was considered the presence of >14 CD45+ cells/mm2 and/or the presence of >7 CD3+ cells/mm2.

Aim of the study was to compare the evolution of echocardiographic parameters in group of women and men with RODCM and to assess the impact of the myocardial inflammation detected by endomyocardial biopsy (EMB) on these changes in both sexes.

Results: In the female group left ventricular ejection fraction (LVEF) improved from 24 ± 8% to 39 ± 14%; in the male group from 24 ± 7% to 33 ± 11% (both p <0.001), difference between the sexes was significant (p < 0.05). Myocarditis was detected in 58 patients (41%), in 50% of women and in 39% of men. The change in LVEF in patients with myocarditis was 20 ± 12% in females and 13 ± 13% in men (both p <0.001), the difference between both groups was not significant (p = 0.094). Statistically significant difference in the change in LVEF between subgroups with or without myocarditis in the female group (20 ± 12% vs 9 ± 14%; p < 0.05) as well as in the male group (13 ± 13% vs 5 ± 9%; p <0.001) was observed.

Conclusions: Male and female patients with RODCM showed significant improvement in LVEF and other echocardiographic parameters in the 6-month follow-up. LVEF changes in female group were more expressed. In patients with myocarditis was LV function improvement bigger then in patients without myocardial inflammation in males as well as in females with trend to more pronounced changes in women.

Acknowledgements: This work was supported by grant IGA CR No. NT14087.

Lung ultrasound impact on first-line pneumothorax major trauma management: multidetector computed tomography comparison

S. Ianniello, V. Di Giacomo, I. Di Giampietro, M. Trinci, B. Sessa, V. Miele

Radiologia D’urgenza – Az. Osp. S. Camillo - Forlanini, Roma, Italy

Background: This study aimed to evaluate the diagnostic accuracy of Bed-side Lung Ultrasound, performed as Extended-FAST in detecting pneumothorax during the Primary Survey, in patients with major trauma (ISS>15) and both stable and unstable hemodynamics. From literature is well known that chest radiography alone has poor sensitivity for the detection of pneumothorax and US is superior to CXR. In cases in which the patient requires urgent surgery or another urgent intervention before undergoing CT, chest US seems applicable to rule out pneumothorax.

Methods: This was a retrospective, observational, single-centre study, at a tertiary referral hospital (850 beds).

We evaluated 780 severely injured patients (ISS>15) admitted to our Emergency Department from January 2012 to January 2014.

All ultrasound examinations (780 extended-FAST), during Primary Survey, were performed at the bedside, in Emergency Room, by using the same US imaging unit; in 780/780, the exam was extended to chest, with anterior and lateral scans of thorax.

Right and left lung were considered separately for each patient to diagnose pneumothorax.

In every patient included in the study, Total Body MultiDetector Computed Tomography scanning was assumed as the diagnostic gold-standard for comparison.

Results: From January 2012 to January.2014 we performed 780 Extended-FAST in 780 Major Trauma patients (ISS>15).

E-FAST identified 137 Pneumothoraces, during the time of Primary Survey (within the first 5 minutes) allowing a rapid and useful diagnosis, to lead a correct interventional (pleural drainage or decompressive minitoracotomy) or conservative (observational) patient management.

MDCT scan, the diagnostic gold standard, found 140/140 Pneumothoraces.

In 3 False Negative cases, the Pneumothoces missed by E-FAST exam was <5 mm.

In our experience, pneumothorax lung ultrasound diagnosis, during Primary Survey of Major Trauma, has Sensibility 97.8% (137/140), Specificity 100% (640/640), P.P.V. 100% (137/137), N.P.V. 99.5%, Accuracy 99.6% (777/780).

Conclusions: During the time of Primary Survey (within the first 5 minutes) Lung ultrasound, performed as extended to thorax - FAST, allow a rapid and useful diagnosis of pneumothorax, to lead a correct interventional or conservative patient management.

In this study, bedside Lung Ultrasound confirmed to be a rapid and accurate method for detecting traumatic pneumothorax. Therefore, bedside Thoracic Ultrasound can be an effective diagnostic tool to definitively rule out this potential life-threatening condition in the Major Trauma patient.

Lung ultrasound integrated with chest-XR in first diagnosis of pediatric pneumonia: its role in follow-up

S. Ianniello, B. Sessa, V. Di Giacomo, M. Galluzzo, V. Miele

Radiologia D’urgenza – Az. Osp. S. Camillo - Forlanini, Roma, Italy

Background: Aim of this prospective study was to evaluate the role of lung ultrasound integrated with Chest XR for the first diagnosis of pediatric pneumonia, and to define its role during the follow-up, to exclude complications. In the first diagnosis, we compared for the two tecnique (LUS and CXR), in double blinded study, sensibility, specificity, accuracy, PPV and NPV.

<IMAGE ABSTRACT>Fig.1 Chest XRay: A.C., 3y, fever and cough; mild, bilateral interstitial increase; not alveolar consolidation.

https://services.aimgroup.it/ASPClient/files/3134/Abstract/49_20140910151404.jpg

Methods: Observational prospective study with evaluation of 50 children(3 to10 years; 6y median; 28 M e 22 F) with clinical signs of cough, fever(more than 3 days); at L.US. (with linear and convex probe) we evaluated both anterior and posterior lung (seated or lie down); we reported every consolidation with size, pleural effusion (with quantification; CXR made in 2 projection; only LUS follow-up (after 5 and 10days) in positive patients.

Fig.2 Lung Ultrasound: A.C., 3y, fever and cough; alveolar consolidation in retrocardiac, on left side; same image, with enhanced blood supply at colordoppler.

<IMAGE ABSTRACT> https://services.aimgroup.it/ASPClient/files/3134/Abstract/49_20140910153333.jpg

https://services.aimgroup.it/ASPClient/files/3134/Abstract/49_20140910153534.jpg

Results: In our preliminar study (N=50), we found with LUS 35/50 pneumonic consolidations((size from 1.5 to 7 cm); with ChestXR only 26/50; with LUS we had 1 false negative (retroscapolar region). We followed-up with LUS 36=50 and found 3/36 small pleural effusion (less than 50ml). LUS had sensitivity of 97% (vs CRX 72%), specificity and PPV of 100% (CXR 100%), NPV 93% (CXR 60%) accuracy 98% (CXR 80%).

Fig.3 Lung Ultrasound: A.C., 3y, fever and cough; FOLLOW-UP: reduction of alveolar consolidation in retrocardiac, on left side (after 10 days).

https://services.aimgroup.it/ASPClient/files/3134/Abstract/49_20140910151404.jpg

Conclusions: In our limited and preliminary experience, Lung Ultrasound, integrated with Chest XR, revealed to be an accurate method to identify also small pneumonic consolidations, specially for “CXR-occult” and for pleural effusion’s early diagnosis; furthermore, LUS follow-up allows to verify complications and outcome avoiding other XR exposure.

Finn-akva-2: chain of pre- and in-hospital management of acute heart failure in Helsinki metropolitan area

P. Harjola¹, M. Kuisma², J. Boyd², J. Mattila³, R. Koski², V.-P. Harjola³

¹Helsinki University, Helsinki, Finland, ²Helsinki University Central Hospital, Division of Prehospital Emergency Medicine, Helsinki, Finland, ³Helsinki University Central Hospital, Division of Emergency Medicine, Helsinki, Finland

Background: Acute heart failure (AHF) is one of the most common causes of admission to emergency department (ED) and death among elderly people. A lot of attention is focused on early management in ED but data are scarce. Moreover, even less is known about the effect of pre-hospital emergency care on patients’ clinical manifestation on admission to ED and to prognosis. Our aim is to investigate the role of pre-hospital emergency care and improvement of patients’ condition from home to ED and early in-hospital management in real life. Our interest is also in the effect of the early pre- and in-hospital treatment on patients’ hospital stay and both short- and long-term survival.

Methods: Data is retrospectively collected from the electronic patient records from pre-hospital emergency care and three hospitals of Helsinki University Central Hospital in Helsinki metropolitan area. Patients who had been admitted to ED either after pre-hospital care or without such care - and diagnosed for AHF between 1.7.2012 and 31.7.2013 were included. The data includes the clinical type of heart failure, comorbidities, clinical findings and treatment in the pre-hospital emergency care and during the first 24 hour hours in hospital recorded in 4-8 hour intervals, the cause of the AHF and the treatment of it, relevant long-term medication on admission and at discharge, the length of stay in the hospital and one-year mortality.

Results: We have collected data from 500 patients. The database is currently finalized and will be analysed with SPSS. The results will be available for the 5th Italian GREAT Network Congress.

Conclusions: The study shows the real-life management in pre-hospital and early in-hospital emergency care of acute heart failure patients. The study describes the role of pre-hospital emergency care and improvement of patients’ condition from home to ED and early in-hospital management in real life. The effect of the early pre- and in-hospital treatment on patients’ hospital stay and both short- and long-term survival will also be analyzed.

New biomarkers in the management of sepsis in emergency medicine: role of galectin-3

C. Galluzzo¹, E. Pizzolato¹, M. Rende², M. Lucchiari², S. Raso², A. Vitale², M. Masoero¹, M. Ulla¹, G. Mengozzi², S. Battista¹

¹Emergency Medicine Department, Città Della Salute E Della Scienza University Hospital, Torino, Italy, ²Clinical Biochemistry Laboratory, Città Della Salute E Della Scienza University Hospital, Torino, Italy

Background: Sepsis, severe sepsis and septic shock are among the leading causes of death in critically ill patients: prompt diagnosis is one of the keys to improve survival. Procalcitonin (PCT) displays good diagnostic and prognostic accuracy, but it has limited specificity: increased levels are also found in non-infectious conditions. Presepsin is a promising biomarker: it reaches higher concentrations in sepsis than in SIRS (Systemic Inflammatory Response Syndrome). Furthermore it shows important prognostic capability. Galectin-3 is a lectin expressed by macrophages: it takes part to the inflammatory response and fibrosis process. In this study we compared Galectin-3 with Presepsin and PCT as markers of sepsis in the Emergency Department (ED) of “Città della Salute e della Scienza” University Hospital of Turin. We enrolled patients affected by SIRS, with or without a suspicion of infection; diagnostic and prognostic efficacy of each biomarker were evaluated.

Methods: 108 patients were enrolled: 37 with sepsis, 39 with severe sepsis/septic shock and 32 with SIRS. Controls included patients with SIRS secondary to trauma, burns and other medical diseases. The biomarkers were assessed at the first medical evaluation in the ED, together with routine laboratory tests and arterial blood gas analysis; APACHE II and SOFA score were calculated. Definitive diagnosis and in-hospital survival rates at 60 days after enrollment were obtained through analysis of medical records.

Results: Galectin-3 distinguished the population with severe sepsis/septic shock from patients with sepsis (p=0.053) but not from patients with SIRS (p>0.05). Presepsin was increased in severe sepsis/septic shock compared with controls (p=0.036); PCT was higher in severe sepsis/septic shock group than in septic patients and controls (p<0.001). The ROC curve analysis of Galectin-3 was significant: AUC (Area Under the Curve) was 0.66; higher concentrations were associated with poor prognosis (p=0.0238). Galectin-3 was correlated with leukocytes (p=0.0145) and PCT (p=0.0391). The Cox regression analysis showed that, when combined with other clinical and laboratory parameters, Galectin-3 is the only statistically significant prognostic factor (p=0.0013).

Conclusions: Galectin-3 is a promising marker in the clinical management of sepsis: it is able to identify cases of sepsis associated with acute organ damage. Finally Galectin-3 showed a role as an independent prognostic factor, stratifying the population of subjects with sepsis associated with poor prognosis according to its increasing concentrations.

From accutni to accutni+3: effect of a change in troponin assay and chest pain protocol on los, safety and efficiency of an observation ward - an ongoing study

M. Gallitelli¹, M. Gion², R. Dittadi², F. Rigo³, G. Grassi⁴, M. Alzetta¹

¹Emergency Medicine, Ospedale Santi Giovanni e Paolo, Venezia, Italy, ²Laboratory Medicine, Ospedale Santi Giovanni e Paolo, Venezia, Italy, ³Cardiology, Ospedale Dell’Angelo, Venezia - Mestre, Italy, ⁴Cardiology, Ospedale Santi Giovanni e Paolo, Venezia, Italy

Background: A new troponin assay (AccuTnI+3, Beckman Coulter - CV of <=10% at the 99° percentile) has recently replaced the previous assay (AccuTnI - CV of 14% at the 99° percentile).

With the adoption of the new assay we reduced the observation curve from 12 to 6 hours; we expect the new protocol/assay to be as safe and efficient as the old one.

The study will be completed by December 2014 including the 2 months follow up.

Methods: The patients observed for 6 months before the implementation of the new protocol will be compared with the patients observed under the new protocol.

Samples were drawn every 6 hours from admission for a total of 12 hours observation under the old protocol; with the new protocol samples are drawn every 3 hours for a total of 6 hours observation; patients’ ECG is monitored with continuous telemetry under both protocols.

A 2 months follow up is being carried out: outcomes measured are death and new hospital admissions with a definitive diagnosis of ACS.

Results: 182 patients (101 males, mean age 61.6 years, mean TIMI risk score 1.43) were observed for chest pain under the old protocol; patients’ ECG was monitored for an average of 13 hours and 20 minutes. 6.6% of patients (12/182, all males, mean age 60.9 years, mean TIMI risk score 3) were admitted with the suspicion of an ACS based on ECG monitoring (4), on troponin changes (6) and both on ECG monitoring and troponin changes (2). For 10/12 an ACS was confirmed. At 2 months follow up 2 patients were admitted with a suspected ACS: for 1 ACS was confirmed.

Preliminary analysis of data after two months of the implementation of the new protocol. During this time 63 patients (45 males, mean age 60.3 years, mean TIMI risk score 1.38) have been observed for chest pain; patients’ ECG has been monitored for an average of 7 hours and 12 minutes. 7.9% of patients (5/63, 4 males, mean age 60.1 years, mean TIMI risk score 2.8) were admitted with the suspicion of an ACS on ECG monitoring (1), on troponin changes (3) and on a ischemic stress ECG (1). For 4/5 ACS was confirmed.

Conclusions: So far the two protocols seem similar.

Safer: study of atrial fibrillation in the emergency room. An observational study of af patients presenting to two emergency departments in the southwest of England

J. Gagg¹, C. Mann¹, A. Appelboam²

¹Musgrove Park Hospital, Emergency Department, Taunton, United Kingdom, ²Royal Devon & Exeter Hospital, Emergency Department, Taunton, United Kingdom

Background: Atrial fibrillation (AF) is the most common sustained disorder of cardiac rhythm with a prevalence of 8.8% by 80-89years. It is associated with a fivefold increase in the incidence of stroke. It has been previously reported that up to 55% of ’warfarin eligible’ patients presenting to Emergency Departments (EDs) in America are inappropriately anticoagulated. This may be changing with the introduction of the novel oral anticoagulants. We aim to define the population of AF patients presenting to two EDs in the Southwest of England to identify if an ’at risk’ population exists.

Methods: Patients attending EDs at Musgrove Park Hospital, Taunton and the Royal Devon & Exeter Hospital identified to be in AF on ECG were logged over a 12 week period to obtain a convenience sample of patients. The case notes were reviewed to record patient demographics, type of AF (known/unknown), current oral anticoagulant (OAC)/antiplatelet therapy and CHA2DS2-VASc/HASBLED scores. Current NICE guidelines were used to establish the appropriateness of medication.

Results: 446 patients were recruited (222 male:224 female). AF was a known diagnosis in 346 (77.6%) of patients and a first presentation in 100 (22.4%). The mean age was 78years (25-98years), the mean CHA2DS2-VASc score was 3.9 (range 0-9) and HASBLED score 2 (range 0-9). 8 patients had no drugs listed and 3 were on an OAC when not indicated. Of the remaining 337 patients, 118 (35%) were not on correct medication. Patients were not on an OAC when indicated by CHA2DS2-VASc score in 27% of those with a HASBLED score >=3 and 40% for those with a HASBLED score <3. Of those with a first presentation of AF, 80% warranted consideration of starting an OAC based on CHA2DS2-VASc score.

Conclusions: Two main areas of risk have been identified: those patients who are known to be in AF who could have their treatment optimised (35%) and those attending with a first presentation who need treatment (80%). It is apparent that a greater proportion of patients are not anticoagulated if they fall into the lower risk group with regard to bleeding (HASBLED<3). As a notes review, there are limitations to this study, however it suggests that there is an opportunity in ED to identify ’at risk’ patients in AF which warrants further investigation.

One brain for two scores

F. Fossati, S. Geniere Nigra, G. Ricevuti

University Of Pavia - School Of Emergency Medicine, Pavia, Italy

Background: A 35 years old man presents himself to the ED with an acute onset of high fever, dry cough, sharp right hemithorax pain during deep breaths and dyspnoea. Remote medical history: severe obesity (BMI 44), psoriasis. Family history of diabetes mellitus type 2. Physical examination: alert, cooperative, eupneic. Chest VM bilaterally presents. Crackles and rales at the right base during inspiration, vocal resonance increate at the right base. Normal cardiac and abdominal objectivity. Neurologically normal. GCS 15.

BP 135/80 mmHg HR 130 bpm RR 36 bpm SO2 89% AA T 38.5°C.

Home therapy: none Deny drug allergies.

Methods: First ABG in VM 35%: PH 7.459 PO2 58.1 PCO2 35 HCO3- 25.1 BE 0.4 SO2 91.9 P/F 166

Blood tests

Chest X-ray:Pleural effusion on the right.Small circle congestion.

The patient performs a CT scan and two blood cultures, starts empirical antibiotic therapy and finally hospitalized.

Results: Does this patient really need to be hospitalized?

We can use both CURB-65 and PSI to help us decide if this patient needs to be hospitalized or not.

• By applying the CURB-65 the result is 1 with a 3.2% mortality at 30 days.

This score suggests us not to hospitalize the patient

• By applying the PSI the result is 115, class IV, with a 8,2 – 9,3% mortality at 30 days

This score suggests us to hospitalize the patient.

Both PSI and CURB65 are useful tools to identifying patients with a low risk of complications/mortality, reducing therefore the number of hospitalizations.

The PSI has a higher sensitivity (but low specificity)

The CURB-65 has a low sensitivity and it is simple to apply, but it does not consider variable ’oxygenation’¹²

So? What can I do?.........Use brain first!

Conclusions: 1.A Prediction Rule to Identify Low-Risk Patients with Community-Acquired Pneumonia Michael J. Fine, M.D., Thomas E. Auble, Ph.D., Donald M. Yealy, M.D., Barbara H. Hanusa, Ph.D., Lisa A. Weissfeld, Ph.D., Daniel E. Singer, M.D., Christopher M. Coley, M.D., Thomas J. Marrie, M.D., and Wishwa N. Kapoor, M.D., M.P.H. N Engl J Med 1997; 336:243-250

2.Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, Lewis SA, Macfarlane JT. Thorax 2003 May;58(5):377-82.

Research proposal: use of biomarkers for risk prediction in patients with infective endocarditis

R. Focaccia Siciliano¹, D.M. Gualandro, F.G.M Braga, B. Caramelli, T.M.V. Strabelli, C. Mueller, S. Di Somma, M.T. Oliveira Jr

¹Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil, ²University Hospital, Basel, Switzerland, ³University ’La Sapienza, Rome, Italy

Background: Evidence regarding biomarkers for risk prediction in patients with infective endocarditis is limited. In a previous retrospective study of patients admitted with endocarditis in our institution, we showed that high BNP levels at admission are related to in-hospital death. Considering the potential of the new prognostic biomarkers in heart failure and sepsis, we propose a pilot study to evaluate their individual or combined role in predicting death or cardiac surgery in patients with infectious endocarditis.

Aims:

• Evaluate the use of biomarkers as predictors of in-hospital death in patients with endocarditis

• Evaluate the use of biomarkers as predictors of a combined endpoint (in-hospital death or cardiac surgery) in patients with endocarditis

Methods: Patients Selection

Consecutive patients admitted to the Emergency Department with suspected endocarditis will be included.

Inclusion Criteria•

• >18 years

• Suspected endocarditis

• Patients who sign the Informed Consent Form

Exclusion Criteria

• Patients do not fulfill Duke’s criteria for possible or definite endocarditis

• Use of intravenous antibiotic for more than 72h before enrollment

Procedures

Two pairs of blood culture will be collected and an echocardiogram will be performed in all patients with suspected endocarditis. Empirical or specific antibiotic treatment and cardiac surgery recommendations will follow the European Society of Cardiology Guidelines.

Blood sample for biomarkers and exhaled air for determination of acetone will be obtained at study inclusion and stored at -80oC. Another blood sample for biomarkers evaluation and exhaled air for acetone determination will be obtained on day 8 after antibiotic initiation in patients with possible or definite infective endocarditis. Results will be available only after the end of follow-up, and will not be disclosed to the attending physicians during patient’s treatment.

The follow biomarkers will be studied: C-reactive protein, Procalcitonin, BNP, high-sensitivity cardiac troponin, ST2, Exhaled acetone, Copeptin, Soluble urokinase-type plasminogen activator receptor and mature adrenomodullin.

We intent to include sixty patients for this pilot study.

Statistical analysis

The primary endpoint will be In-hospital death and secondary endpoint will be in-hospital death or need for surgical replacement of the infected valve. A ROC curve will be constructed for each biomarker to find the best cut-off value. Univariate and multivariate models will be performed to establish correlation between biomarkers and endpoints.

Preliminary comparative clinical study between serum procalcitonin, poct mbs method and urine sticks for a fast detection of urinary tract infections

V. Ferrante¹, V. Cellitti¹, A. Arienzo¹, F. Losito², A. Mari², F. Cristofano³, S. Di Somma³, P. Visca¹, G. Antonini^1-4

¹Department Of Sciences, University Roma Tre, Roma, Italy, ²Mbs Srl, Roma, Italy, ³Department Of Emergency Medicine, S. Andrea Hospital And Sapienza University Of Rome, Roma, Italy, ⁴Inbb Interuniversity Consortium Of Structural And Systems Biology, Roma, Italy

Background: The presence of urinary tract infections (UTIs) should be confirmed by urine culture that often requires long response times (1-2 days) while a rapid diagnosis is essential to avoid damage to the renal parenchyma. Procalcitonin (PCT) is produced ubiquitously in response to bacterial infections, such as UTI. The MBS method is a POCT device produced by MBS srl (Roma Tre University spin-off). POCT MBS method is based on a colorimetric test performed in single-use and ready-to-use reaction vials and it is able to make a diagnosis of UTI in less than 5 hours. Urine sticks are widely used for fast and cheap diagnosis of UTI when positive for both leukocytes and nitrite. Aim of this work was to analyze the effectiveness of the serum levels of PCT, POCT MBS method and urine sticks in diagnosing UTI in comparison with the long-lasting reference method of urine cultures.

Methods: Samples were collected from patients hospitalized in the Department of Emergency Medicine of the S. Andrea Hospital in Rome and were analyzed by the Hospital Laboratory for bacterial load in urine by traditional plate counting method and for the serum levels of procalcitonin. Urine samples were also analyzed with POCT MBS method and with urine sticks. PCT was taken as positive serum with a serum level of PCT equal or greater than 0.05-0.5 ng/ml (considered to be diagnostic of a bacterial infection focus), POCT MBS method was taken as positive when the bacterial load in urine is equal or greater than 10ˆ5 CFU/ml (limit for the diagnosis of UTI) and urine sticks were taken as positive when they showed positivity for both leukocytes and nitrite.

Results: Out of 31 patients with positive urine cultures, all of them were positive to PCT, 26 of them were positive to POCT MBS method and 8 of them were positive to urine sticks.

Out of 74 patients with negative urine cultures, 73 of them were positive to PCT, 70 of them were negative to POCT MBS method and 64 of them were negative to urine sticks.

Conclusions: In conclusion, the POCT MBS method was found to be a better rapid screening method for the detection of UTI in comparison with either serum procalcitonin levels or urine sticks.

The prediction of 1-year mortality risk in elderly patients admitted for congestive heart failure: a clinical score

M. Feola¹, M Testa², L Leto²

¹Cardiovascular Rehabilitation-Heart Failure Unit, Fossano, Italy, ²School Of Geriatry University Of Turin, Torino, Italy

Background: Prognostic evaluation in patients with acute heart failure is particularly important especially when the choice of better setting of care have to be discussed with patients, families and caregivers.

The aim of this study is to assess the utility of a bedside clinical score in predicting clinical adverse events, in a cohort of elderly heart failure (HF) patients admitted to hospital for an episode of acute decompensation.

Methods: Forty-four elderly patients (14 females, mean age 76 years), consecutively admitted for acute HF, were studied. Besides demographic, clinical and laboratory data, functional information referred to disease severity (NYHA class, 6-minute walking-test) and ata on cognitive (MMSE, MOCA test) and behavioural state (GDS) were recorded; echocardiography evaluation and hydration analysis were performed. Adverse clinical events (decompensation of heart failure, hospital admission and death) were recorded after a follow-up period of 1 year. A clinical score, including creatinine plasma level, left ventricular ejection fraction (LVEF), NYHA class, BNP levels, Barthel index and corrected MOCA test, was calculated (Table 1). A score between 0 and 2 was attributed to each single element; the maximum score was 11. The total score was related to adverse events, especially 1-year mortality.

Results: During the follow-up period, six patients (13.6%) died; the man time between index hospital admission and death was 2.8 months. The patients with a poorer prognosis, compared to alive subjects, showed a greater impairment of renal function (creatinine plasma level: 2.1±0.9 vs. 1.4±0.5 mg/dl, p=0.01), higher BNP (2904.3±2155.8 vs 886.8±1094.1 pg/ml, p=0.02) and RDW (19.1±3.0% vs. 16.3±1.7%, p=0.01), lower sodium sieric level (136.7±3.8 vs. 140.1±3.2 mEq/l, p=0.02), a higher hydration (84.7±3.8% vs.77.5±5.9%, p=0.02), greater Barthel index and worse cognitive performance (MOCA test 13.3±4.3 vs. 17.9±4.9, p=0.03). A score more/= than 6 identified a one-year mortality risk with a sensitivity of 83%, a specificity of 84%, a positive predictive value of 45% and a negative predictive value of 97%; ROC curve presented an area under the curve of 0.84 (IC95%: 0.67-0.99, p<0.01).

Conclusions: Our clinical score, including six parameters easily detectable at bedside, was able to predict with a good accuracy a one-year probability of survival in a cohort of elderly patients readmitted for HF. Studies on greater population are necessary to confirm these promising results.

Enhanced adsorption dialysis: a new dialysis technique to treat acute cast nephropathy in multiple myeloma

P. Fabbrini¹, F. Pieruzzi¹, E. Casiraghi¹, M.R. Vigano’¹, A. Stella¹

¹Nephrology Clinic, San Gerardo Hospital, University Milano Bicocca, Monza, Italy

Background: Renal recovery in multiple myeloma (MM) cast nephropathy is correlated to an early reduction of serum free light chians (sFLC) concentrations obtained through chemotherapy combined to extracorporeal sFLC removal. We previously reported that polymethylmethacrylate (PMMA) membranes (BK-F; Toray Inc., Japan) can adsorb high quantities of sFLC especially with a new dialysis procedure called “enhanced adsorption dialysis” (EAD). During 4 hours EAD a specific designed circuit (implemented in our division Fig.1) allows to safely use 2 dialyzers sequentially without treatment interruption (FIg1). Nevertheless no clinical data are available on EAD efficacy in renal recovery. We report our experience of EAD treatment in incident MM patient with dialysis dependent renal failure.

Methods: we treated 12 incident patients with dialysis-dependent renal failure and high levels of sFLC. All patients had highly suspicious (n=8) or biopsy proven (n=4) cast nephropathy. In all patients a bortezomib based chemotherapy was started together with daily EAD treatment to reduce sFLC levels. Through daily sFLC measurement we scheduled dialysis treatments aiming to the greatest sFLC reduction in the shortest time. Renal outcome was measured as dialysis independence at 1, 6 and 12 months. Results are reported as average and (min-max) values.

Results: At presentation eGFR and sFLC levels were 9,7 ml/min (4,3-31,8) and 7868,5 mg/l (2300-25118) respectively. We performed on average 5 (1-8) EAD sessions for patient obtaining a sFLC removal of 36,7% /session (-13 to 71%). sFLC were reduced by 59,2%(0-92%) at 12 days and by 70,2%(0-99%) at 21 days. At present 11 out of 12 patients completed 1 and 6 months follow up while one patient died. At 1 and 6 month follow up 50% and 83,5% of patients recovered renal function respectively. Only 9 patients completed one year of follow up and we registered 78% of dialysis independence(1 dead and 1 ESRD).

Conclusions: PMMA enhanced adsorption dialysis together with bortezomib based chemotherapy was able to efficiently reduce sFLC levels and to promote an high rate of persistent dialysis independence

Medical wards organized by care intensity: effects on patient’s outcome of institution of high dependency unit (hdu) in medical ward

G. Di Pietro¹, N. Previati¹, M. Arboit¹, S. Giannini¹, A. Saller¹, F. Fabris¹

¹Dipartimento Di Medicina Dimed, Clinica Medica 1, Università E Azienda Ospedaliera, Padova, Italy

Background: High Dependency Units (HDU) existing in some Italian hospitals are part of a general reorganization according to a model based on intensity of care. This has represented so far a good response to the social-demographic changes of our country and the consequent need to avoid any waste of money and take care of old, polipathologic patients, suffering from chronic diseases. We still need to clarify how the admission to HDU can affect patient’s outcome and duration of hospital stay, and to establish the association between alteration of biochemical parameters and risk of a bad outcome (mortality/transfer to ICU).

Methods: Between June 2012 and December 2013 we recruited 120 patients from an internal medicine ward having a clinic instability index (National Early Warning Score=NEWS>4); 60 patients were followed in a high dependency area (cases=CA) and 60 in the normal intensity area (controls=CO). We also analyzed the association of clinical outcome, biochemical parameters and NEWS in a larger cohort of 249 patients admitted to the same ward between June 2012 and May 2014.

Results: The mean age of patients was 80 years, 60% were women. The most frequent causes of admission were heart failure, respiratory failure and sepsis. There was no statistically significant difference neither in mortality (23.3 vs 23.3%; CA vs CO; p=0.80) nor in the average duration of stay (11±7 vs 10±7 days; CA vs CO; p=0.47). However, a statistically significant difference was found in mortality of patients admitted because of sepsis (21.4 vs 100%; CA vs CO; p=0.03): this demonstrated how the outcome of septic patients is positively affected by admission to a HDU.

Alteration of the following biochemical parameters had a significant negative impact on patient’s outcome: leukocytes (p=0.0001), CRP (p=0.0007), troponin (p=0.0006), BNP (p=0.0005), INR (p=0.0008), creatinine (p=0.002), blood glucose (p=0.008). All these parameters had a significant correlation with NEWS: leukocytes (r=0.209, p=0.0009), CRP (r=0.401, p<0.0001), troponin (r=0.296, p<0.0001), BNP (r=0.302, p=0.0003), INR (r=0.294, p<0.0001), creatinine (r=0.281, p<0.0001), blood glucose (r=0.201, p=0.002).

Conclusions: The benefits on patient’s outcome of hospitalization in HDU are evident so far for patients admitted because of sepsis. It is therefore necessary to further work on ward’s management, in order to extend the positive effects to patients with other diseases.

CTA scans in early stroke patient (within 4.5 h). Neuroimaging findings and correlation with clinical outcome after fibrinolytic therapy

A. Di Napoli¹, A. Romano¹, R. Jäger², A. Bozzao¹

¹Nesmos Department, Neuroradiology - University Of Rome, Sapienza, Roma, Italy, ²Neuroradiological Academic Unit, Department Of Brain Repair And Rehabilitation, Ucl Institute Of Neurology Queen Square, London, United Kingdom

Background: Noncontrast Computed Tomografy (NCCT) is the standard diagnostic protocol for patients suspected of stroke in most hospital worldwide. Since this exam doesn’t provide informations concerning the status of the intracranial vessels Computed Tomography Angiography (CTA) was tested to understand whether this exam can improve stroke patient’s management.

Methods: We retrospectively analyzed images (NCCT at arrival and at 24h and CTA at arrival) of 86 patients with a clinical diagnosis of stroke involving the anterior circulation. All patients had been assigned a NIHSS score at arrival and at 24h and received fibrinolytic therapy within 4.5h. On NCCT and CTA we calculated ASPECTS. On MIP reconstructions, an estimate of collateral score. In addiction we have obtained the PBV parameter (a surrogate of cerebral blood volume) and, on that, we calculated ASPECTS. We divided the patients in two subgroups: those with an occluded vessel and those without occlusions. We correlated all ASPECTS with NIHSS values and the Collateral Score with the clinical outcome.

Results: Of 86 patients 56 (65.11%) did not show any occlusion at the CTA. T-student test showed statistically significant difference (p=.001) between mean ASPECTS values on NCCT (8.42), CTA (7.45) and PBV (4) in occluded subgroup. The same test did not show any difference between mean ASPECTS values in not occluded subgroup. Correlation between ASPECTS (on NCCT and PBV) and both NIHSS values showed that PBV is the only statistically significant parameter in both subgroups. Correlation between ASPECTS at arrival and ASPECTS at 24h has demonstrated that both NCCT and PBV are significant in occluded subgroup. Analysis of Collateral Score showed only one patients with no collateral (CS=0), 9 patients with CS=1, 8 patients with CS=2 and 9 patients with CS=3. Correlation between Collateral Score and clinical outcome showed CS=2 as the only statistically significant value.

Conclusions: CTA is a fast and easily achievable exam that does not delay the start of fibrinolytic therapy. In our study we found that most of the patients treated with fibrinolytic therapy did not show vessel occlusion. Collateral Score is a predictor of clinical outcome, since only patients with good collaterals benefit from the fibrinolytic therapy. Finally we found that PBV is a valid parameter to predict both clinical outcome and infarct volume in stroke patients.

Single-incision laparoscopic appendectomy is comparable to conventional laparoscopic and laparotomic appendectomy: our single center single surgeon experience

C. Di Grazia¹, F Ceci, S. Corelli, A Napoleoni, S Nicodemi, B Cipriani, S Orsini, A. Tudisco, R Mosillo, F. Stagnitti

¹Osp. Fiorini Polo Pontino La Sapienza, Terracina, Italy

Background: Laparoscopic appendectomy is now considered the gold standard for appendectomy(1). In numerous studies, when the conventional laparoscopic appendectomy (VL-A) is compared with laparotomy (O-A), it has advantages of reduced pain, reduced hospital stay and enhanced aesthetic effect (2). Multiple comparative analyses have recently described single-port surgery (3,4).

In this study we examine the application and the safety of SILS-A by comparing single-incision laparoscopic an appendectomy whit a conventional laparoscopic appendectomy and laparotomy.

Methods: The retrospective study involves 12 patients who received laparoscopic single-port appendectomy (SILS-A), compared with 14 patients who received conventional laparoscopic appendectomy (VL-A) and 12 patients who received laparotomic appendectomy performed by the same surgeon (C.F.) at a single institution. Written informed consent was provided by all the patients. Medical records were used to conduct a retrospective comparative analysis

Results: Postoperative period was characterized by fever only in 4 (30%) of 12 cases of SILS-A, 6 (43%) of the 14 VLS-A and 5 (42%) in O-A. 58,3 % of SILS-A had neutrofil leukocytosis in the 1st post-operative day (from 11.05 to 14.48 ×10ˆ3 u/l), as 42% in VLS-A (from 11.47 to 26.36 ×10ˆ3u/l), and 41,6% in O-A group (from 9.25 to 21.83 ×10ˆ3). The leukocytosis decreased in 2nd post-op day in all groups.

Sutures of surgical wounds were removed in 8th postoperative day in all groups. None of the SILS-A patients show a wound complications. In VLS-A one case of FID abdominal wall abscess; a wound seroma in O-A.

Mean hospital stay was 3,5 days in VLS-A, 4 days in SILS-A and in O-A.

In immediate postoperative days we had a good pain control, as after the discharge. We observed postoperative complications in 1 (7,1%) of VLS-A, a pelvic peritonitis treated with laparotomy and abdominal drainage and discharged in 10th p.o.d.;

Conclusions: In conclusion, no significant differences were found when parameters compare between SILS-A an VLS-A, while an evident improvement shows versus O-A, even though not statistically significant. SILS-A and VLS-A showed not much difference in relation to surgical outcomes and performance, but SILS was more effective in decreasing the risk of postoperative wound infection.

Because of the small number of patients compared between the three technique, supplementary studies need to performed in the future to acquire more objective results.

Value of contrast-enhanced ct in detecting active hemorrhage associated to major pelvic trauma and guiding angiographic treatment

I. Di Giampietro¹, G.L. Buquicchio, V. Di Giacomo, G. Menichini, M. Galluzzo, M. Trinci, S. Pieri, V. Miele

¹Azienda Ospedaliera S.Camillo Forlanini, Rome, Italy

Background: In patients with major abdominal trauma, pelvic fractures associated to active hemorrhage are a common cause of hemodynamic instability. Therapeutic option depends on source and entity of bleeding: arterial hemorrhage requires angiographic embolization; the venous one or that from bone ends is treated conservatively with pelvic packing or external fixator. Our purpose is to establish the role of CT in the detection of active hemorrhage after major pelvic trauma compared to angiography.

Methods: Between 9/2010 and 12/2012, 773 patients with major trauma underwent a CT examination in emergency department. Pelvic fractures were present in 180/773 patients. In all patient affected by pelvic fracture the presence of pelvic hematoma, intra-or retroperitoneal and/or in the soft tissue (glutes, adductors muscles), was searched. Authors look also for the presence of active contrast blush during the early arterial, the portal phase and near the stumps of bone fracture. Angiography was performed in 67 patients after CT detection of active bleeding or in case of not explained hemodynamic instability.

Results: Among 180 patients with pelvic injury,163 showed a pelvic hematoma; 27 a soft tissue hematoma. At CT active hemorrhage was identified in 47/180 cases (29 bleedings were visible in the arterial phase; 9 in the venous one; 2 in both of them; 11 near bone ends). All 47 patients underwent arteriography who showed hemorrhage in 22/29 cases of arterial bleeding, 3/9 case of venous phase bleeding, 2/11 cases of bleeding near bone ends. 20 patients underwent arteriography without evidence of active bleeding at CT; 4/20 showed active extravasation of contrast material. 2/20 underwent internal ilyac embolization even in absence of extravasation.

Conclusions: CT has high sensitivity to detect active bleeding and to establish its origin, thus guiding the optimal therapeutic option. Our experience suggest to perform arteriography even in case of bleeding from bone ends or of venous origin, and when there is an hemodynamic instability without relevant CT findings.

Interim analysis of the need-speed trial: epidemiology of patients with sirs criteria in different settings

M. De Nardo¹, A. Occhipinti¹, F. Mearelli¹, L. Castello², R. Marino⁴, E. Colonetti³, S. Santarelli⁴, G.C. Avanzi², M.L. Muiesan³, G. Montrucchio⁵, E. Lupia⁵, S. Di Somma⁴, G. Biolo¹

¹Department Of Medical, Surgical And Health Sciences, University Of Trieste, Trieste, Italy, ²Department Of Medical Sciences, University Of Eastern Piedmont A. Avogadro, Novara, Italy, ³Department Of Clinical And Experimental Sciences, University Of Brescia, Brescia, Italy, ⁴Emergency Medicine, Sant’Andrea Hospital, Università La Sapienza, Roma, Italy, ⁵Department Of Medical Sciences, University Of Turin, Torino, Italy

Background: Patients with Systemic Inflammatory Response Syndrome (SIRS) at presentation may suffer from sepsis, a leading cause of mortality in hospitalized patients. Around 50% of European patients with sepsis are managed in the emergency departments (ED), while the remaining, based on severity of the condition, prognosis, and patients’ frailty, are admitted in medical wards (MW). Whether patients with SIRS criteria in ED and MW have different presentation, management and clinical outcome is not well known. Such an uncertainty, should discourage from application in MW of diagnostic and therapeutic approach conducted in the emergency departments.

Methods: NEED-SPEED trial is a prospective multicenter study for the identification of biomarkers of sepsis among patients with SIRS clinical presentation. The present interim analysis focuses on characteristics of inclusion criteria, comorbidities, management and outcome between SIRS patients admitted into an ED and those in MW of 5 Italian hospitals.

Results: From March 1th 2013 until August 20th 2014, 439 patients have been enrolled and validated by an independent committee. They were mainly men, and vast majority (86%) were above 65 years of age.

Admission criteria: ED patients were more feverish, while tachypnea was the most frequent disorder of MW group. Around 20% had already been taking an antibiotic at home.

Comorbidities: heart failure, cerebrovascular disease and hemiplegia were the most frequent comorbidities in MW, this significantly increasing also the Charlson score in this group. Glasgow coma scale was higher in MW patients, while SOFA score was overlapping between the two groups.

Diagnosis: the prevalence of sepsis among SIRS patients was around 85%, in both ED and MW groups; 30% suffered from severe sepsis and 7% of septic shock, again with no difference between ED and MW. Among the microbiologically proven sepses, patients with more than one microorganism growing were mainly from MW.

Mortality: in patients with non-infective SIRS, all causes mortality was similar in ED and MW groups at 7 and 30 days, while in those with sepsis, prevalence of mortality in ED was slightly higher at 7 days after admission, but not at 30 days.

Conclusions: This first “ad interim” report shows that, in spite of different clinical presentation and comorbidity, patients with SIRS criteria show an overall similar outcome when compared to the department of admission.

Prediction of cerebral and cardiovascular events by a smart intelligence method

R, Izzo¹, M. Mirra¹, Fi Laurino¹, M. Santoro¹, A. Pepe¹, L. Pecchia¹, N. Ide Luca¹

¹Università Degli Studi Federico II, Napoli, Italy

Background: There is consensus that Heart Rate Variability is associated with the risk of vascular events. However, Heart Rate Variability predictive value for vascular events is not completely clear. The aim of this study was to develop novel predictive models based on data-mining algorithms to provide an automatic risk stratification tool for hypertensive patients.

Methods: A database of 142 Holter recordings with clinical data of hypertensive patients followed up for at least 12 months were collected ad hoc. Subject who experienced a vascular event (i.e. myocardial infarction, stroke, syncopal event) were considered as high-risk subject. Several data-mining algorithms (such as support vector machine, tree-based classifier, artificial neural network) were used to develop automatic classifiers and their accuracy was tested by assessing the receiver-operator characteristics curve. Moreover, we tested the echographic parameters which have been showed as power predictors of future vascular events.

Results: The best predictive model was based on artificial neural network and enabled to identify high-risk hypertensive patients with sensitivity and specificity rates of 94.1% and 88.0%, respectively. The Heart Rate Variability based classifier showed higher predictive values than the conventional echographic parameters, which are considered as significant cardiovascular risk factors

Conclusions: Combination of Heart Rate Variability measures, analyzed with data-mining algorithm, could be a reliable tool for identifying hypertensive patients at high risk to develop future vascular events.

Variation in clinician reported pretest probability and chest X-ray interpretation in dyspneic ED patients with potential acute heart failure: experience doesn’t matter

R. Dawood³, B. Steinhart^1,2, G. Moe¹, M. Mcgowan¹, H. Vandenberghe¹, D. Clark⁴, G. Devlin¹, C. Mazer⁵, P. Levy³

¹Emergency Medicine, St. Michaels Hospital, Toronto, Canada, ²Department Of Medicine, University Of Toronto, Toronto, Canada, ³Emergency Medicine, Wayne State University, Detroit, Usa, ⁴Emergency Medicine, St. Boniface, Winnipeg, Canada, ⁵Anesthesia And Critical Care Medicine, Keenan Research Centre For Biomedical Science And Li Ka Shing Knowledge Institute, Toronto, Canada

Background: Acute heart failure (AHF) is one of the most important conditions treated by emergency physicians yet uncertainty for the diagnosis remains common. How much this relates to variability in clinician derived pretest probability of AHF and divergence in associated chest x-ray (CXR) interpretation is not known.

Methods: This was a subanalysis of a prospective multicenter, randomized trial evaluating prediction-model based natriuretic peptide use in ED patients with undifferentiated dyspnea (NCT01193998). Patients assigned a pretest probability of AHF between 21% and 79% served as the target population. Those with dyspnea due to chest trauma or chronic obstructive pulmonary disease (COPD), and those with renal failure or acute coronary syndrome (ACS) within one month were excluded. All enrolled patients were evaluated by two ED physicians and agreement for a diagnosis of AHF was determined by the % net reclassification in pretest probability for the 2° (vs. 1°) ED physician. Level of agreement was further assessed by Bland Altman analysis and calculation of intraclass correlation coefficient (ICC). Lastly, we compared agreement for CXR findings of AHF and COPD between ED physicians and between ED physicians and radiologists using Fleiss’ Kappa statistic.

Results: 154 patients (mean age 63 years; 36% male; 49% and 43% with a history of HF and COPD, respectively) were enrolled at 4 different sites. The 1° physician (100% faculty; avg work experience = 14 years) average pretest probability of AHF was 48%; for 2° physicians (25% staff [avg work experience = 10 years] and 75% post-graduate trainee [avg work experience = 2.2 years]) it was 49%. Net reclassification was 17% with 7% changing to a pretest probability of less/equal to 20% and 10% to greater/equal to 80%. There was modest agreement for pretest probability on Bland-Altman analysis (Figure) and on ICC (0.717). However, as shown by Fleiss’ Kappa calculations, agreement for all CXR findings between 1°/2° ED physicians and ED physicians/radiologists was poor (Table).

Conclusions: Among ED patients with undifferentiated dyspnea and an intermediate likelihood of AHF, agreement on pretest probability between 1° and 2° ED physician evaluators was moderate with a relatively low rate of net reclassification but agreement on CXR findings was poor. Of note, neither clinical estimate of AHF nor radiographic interpretation differed by years of work experience.

The role of emergency department in a chronic disease: osteoporosis

G. D’antuono¹, P. Malamani¹, E. Taratynova¹, C. Sepe², M. Soccio², G. Ricevuti¹

¹Università Degli Studi Di Pavia, Pavia, Italy, ²Ospedale Di Esine, Esine, Italy

Background: Osteoporosis is a complex pathological condition characterized by low bone mass and qualitative alterations of macro and micro-architecture of bone which is associated with increased risk of fracture even in case of modest trauma. The incidence of osteoporotic fractures increases with age, especially and abruptly in women in post-menopausal period. It is estimated that in Italy there are now about 3.5 million women and 1million men affected by osteoporosis. In the next 20 years the percentage of the Italian population above 65 years will increase by 25%, as a result we should expect a proportional increase in the incidences of osteoporosis. The most affected sites are the spine, femur and wrist.

Methods: We analyzed data from patients older than 50 years with hip, vertebral and wrist fractures treated at the E.D. of Esine-Edolo Hospital starting from January 2014 until June 2014. We evaluated if the lesion was osteoporotic, if patients were in treatment, and if the physicians, who had visited them, prescribed the therapy or provided the necessary information.

Results: These patients have a high incidence of osteoporosis. The majority of them were not treated pharmacologically and the risk of fracture was not perceived either by patients nor by physicians, unlike, for example, the cardiovascular risk. This is our current situation although osteoporosis now represents a disease of social importance affecting the majority of the population beyond the eighth decade of life.

Conclusions: Because of the high number of patients seen in our E.D., we have created a quick and simple questionnaire to evaluate the risk of fracture for the patients over 50 years old who come to our emergency department, with the aim to make our patients and physicians aware of the disease, so that a prevention can be made, and a diagnostic process or treatment can be started. In this way, we would reduce the incidence of osteoporotic fractures.

Investigation on IPV: the progetto ginestra in the ER of the Galliera hospital

V. Roccati¹, E. Longo², A. Schena¹, M. Ameri³, L. Fontana³, G. Cremonesi⁴

¹Emergency Department, Galliera Hospital, Genoa, Italy, ²Department Of Environment And Primary Prevention, Italian National Institute Of Health, Rome, Italy, ³Economy Department, University Of Genoa, Genoa, Italy, ⁴Postgraduate School In Emergency Medicine, University Of Genoa, Genoa, Italy

Background: IPV (Intimate Partner Violence) is a serious public health problem that affects millions of women [European Agency for Fundamental Rights, 2014]. The investigation started in 2010 in the ER of Hospital Galliera in Genoa and is part of the “Progetto Ginestra” that is about the psychological, physical and/or sexual abuses, repeated in time and within intimate relationships (family/friends) and school or work context. The project focuses mainly on IPV patients and the main goals are clinical and statistical to identify and evaluate the main risk factors associated to IPV.

Methods: The project is based on the statistical analysis of the data provided by the patients involved in the project and that gave their consent to participate to the pathway offered in the Galliera ER that includes a counseling with the psychologist.

The counseling allows the psychologist to collect important data about the victim, the aggressor and the circumstances of the violence. In particular, the psichologist fills an anonymous questionnaire composed of 82 questions divided in 5 different sections:

1) anagraphic details and medical record

2) victim profile, personal information

3) characteristics and context of the violence

4) aggressor profile

5) collaboration with the local network for a holistic approach

Results: The investigation focuses mainly on the violent episode affecting women, repeated in time, by the husband-partner.

The first data analysis, that included 329 episode of IPV, showed that victims are between 40 and 49 years old (27%), has no children (42%) and the aggressor is the husband (40%). 60% of them is italian and 40% is foreign. Moreover, there are significant statistical differences about work condition, income and education.

The principal diagnosis is contusion/hematoma/bruise (22%), trauma (19%), traumatic brain injury (17%) and anxiety (16%).

Conclusions: Through the implementation of a Protocol that outlines health care and treatment and the collection of data about the victims of violence, the ER has become a privileged monitoring unit for IPV.

The integration of clinical data with the one provided by the psichologist through the counseling allows to identify risk factors associated to the episode of IPV, to provide proper indication about the prevention of this phenomenon and as a consequence to implement good practices within the Emergency Departments.

Implementation of a lean model in the ER of Galliera hospital for IPV patients health care

V. Roccati¹, E. Longo², P. Cremonesi¹, M. Ameri³, L. Fontana³, G. Cremonesi⁴

¹Emergency Department, Galliera Hospital, Genoa, Italy, ²Department Of Environment And Primary Prevention, Italian National Institute Of Health, Rome, Italy, ³Economy Department, University Of Genoa, Genoa, Italy, ⁴Postgraduate School In Emergency Medicine, University Of Genoa, Genoa, Italy

Background: Since 2010, the ER of Galliera Hospital in Genoa has started the “Progetto Ginestra” about reception, care and support for victims of intimate partner violence (IPV) who access the ER, with reference to women and minors. In 2012 a new Protocol was introduced in the Hospital. It includes an appropriate, lean, multydisciplinary and competent pathway based on the Lean Model introduced for the first time by Toyota.

The main goal of the Lean Model is the reduction of wasted resources (money, waiting time, spaces, repeated action), to guarantee a better efficiency, quality and better answer to specific needs of IPV patients. IPV patients are constantly followed by medical, nursing and psychological staff from triage until they are sent to the local network. The psychologist, after a counseling, fills out a questionnaire to evaluate the patient condition, the characteristics of the violence and the type of pathway in the ER. Thanks to the questionnaire it was possible to verify the efficiency of the Lean Model.

Methods: Two principal devices have been introduced:

1) the “Value stream map”

2) the statistical analysis

The main goals were: to understand better the IPV phenomenon to create an appropriate pathway; to involve more and more patients in the project; to improve the patient medical care and to reduce the waiting time; to improve the relational skills of staff with the patient during the triage, the medical examination and the psychological assessment.

Results: The data collected during the psychological assessments in 2011 were compared to 2013.

In 2011, IPV patients who accessed in the ER were 370. 68 out of 370 accepted the counseling with the psychologist. 44 of them were Italian and 24 foreign.

In 2013, they were 95, 52 Italian and 43 foreign.

The majority of the IPV patients was between 30 and 45 years old.

From the data collected it was underlined that the waiting time was reduced to 0-30 minutes (58% in 2013 and 44% in 2011). Only 13% in 2011 and 4% in 2013 had more than 3 hours of waiting time.

Conclusions: The Project is a good model for secondary prevention, assessment of risk factors and start of new pathway to protect and cure the victims of abuse and violence.

Capecitabine induced angina: a case report

E. Colonetti¹, C. Donini¹, B. Petroboni¹, C. Corbellini¹, A. Paini¹, M. Salvetti¹, M.L. Muiesan¹

¹Spedali Civili Di Brescia - Università Degli Studi Di Brescia, Brescia, Italy

Background: Capecitabine is an oral prodrug of 5-fluorouracil and it is commonly used in the treatment of multiple cancer types because of its convenient oral administration and favorable pharmacokinetics. Although cardiac toxicity of 5-FU is well known, capecitabine induced cardiotoxicity has been reported rarely, and in few cases the occurrence of coronary vasospasm has been described.

Methods: Case report.

Results: Case presentation: A 49 years-old woman with no known cardiovascular risk, treated with capecitabine for a stage IV colon adenocarcinoma, was admitted to the ED for a chest pain episode associated to nausea and dyspnoea. In the emergency room the patients was completely asymptomatic and hemodynamically stable. ECG and Troponin I were within the normal limits. She was admitted to the emergency medicine unit where she further complained of chest pain with ST-T depression in V1-V3 and diffused peaked T waves at the ECG. She was treated with nitroglycerin, ASA and LMWH with complete regression of symptoms and ECG changes within 20 minutes. Troponin I remained within the normal range and echocardiography revealed a transient mild hypokinesia of the basal inferoseptal and anteroseptal wall with preserved EF. A coronary-CT angiography was performed showing a normal coronary artery tree. Hence therapy with capecitabine was discontinued and a calcium channel blocker (verapamil) was introduced. The patient was discharged a few days later completely asymptomatic.

Conclusions: Although the true incidence of cardiotoxicity has not been well defined it may occur more frequently than previously reported. Cardiotoxicity is transient and often reversible, but capecitabine must be withdrawn or at least re-evaluated with the oncologist. Therefore emergency physician should be trained to promptly recognize it, as cause of chest pain, in order to start the most adequate teatment.

Sub intensive care unit (SICU) as a model of health economics?

G. Colombo¹, Lr Del Vecchio¹, F Pace¹, A Tavanti¹, G Aguglia¹, G Carlotti¹, M Vitto¹, Mm Schiano¹, Gm Ricciuto¹, E Guglielmelli¹

¹Uoc Medicina D’urgenza e Cure Differenziate H. San Camillo, Roma, Italy

Background: In acute care hospitals can be selected a patient population not requiring intensive care, but a better management than provided in regular ward (1). Especially elderly with a mean age> 70 years, presence of chronic conditions, high frequency of co-morbidity, high complexity, poly pharmacotherapy and fragility, are managed in areas not appropriate in terms of staff resources, service, technology and space. After hospitalization, patients presenting with critical clinical conditions, may have a worse prognosis if treated in regular ward, compared to those who deteriorate in ICU (2). Some Authors also suggest that the survival of critically ill patients admitted to SICU, in a situation of shortage of ICU beds, it could be better (3).

Methods: We evaluated the management of all patients admitted to SICU comparing 2012 and 2013 data.

Results: In 2012 were hospitalized 489 patients (253 males – 51.7% and 236 women - 48.3%), mean age 73.8 y, mean SAPS II 39.2, median stay 3 days, with 0.98 occupancy rate, 81.50 turnover rate, mortality 13.50% and ICU transfer rate of 11.5%. In 2013 470 patients (256 males – 54.4% and 214 women - 45.6%), mean age 72.7 y, mean SAPS II 37.6, median stay 3 days, with 1.0 occupancy rate, 78.33 turnover rate, mortality 14.0% and ICU transfer rate of 11.7%. The main group of admitted to SICU was patients with acute and critical respiratory failure due to COPD and pneumonia, which accounted for 33.9% of total admissions in 2012 and 30.8% in 2013.

Conclusions: If daily cost of ICU bed can be up to € 1500 and significantly lower for the SICU (4) the objective of the creation and expansion of these units could lead, reducing direct and inappropriate ICU accesses, to a reduction of the total hospitalization cost. Especially in patients with COPD exacerbation, management with usual medical care and non-invasive ventilation, reducing the length of stay, the need for oro-tracheal intubation and improving survival (3), could lead to a reduction for the inappropriate ICU access, with repercussions on the health care management costs.

1. American College of Critical Care Medicine, Crit Care Med 1998.

2. Simchen E Crit Care Med 2007.

3. Simchen E Crit Care Med 2004.

4. Cavallo MC Min Anest 2001.

Acute respiratory failure in the elderly fragile: two-year experience in copd management

G. Colombo¹, Lr Del Vecchio¹, F Pace¹, A Tavanti¹, G Aguglia¹, G Carlotti¹, M Vitto¹, Mm Schiano¹, Gm Ricciuto¹, E Guglielmelli¹

¹Uoc Medicina D’urgenza e Cure Differenziate H. San Camillo, Roma, Italy

Background: Actually critical patients are managed in areas not appropriate in terms of staff resources, service, technology and space. Common experience is the hospitalization of the elderly with a mean age> 70 years, presence of chronic conditions, high frequency of co-morbidity, high complexity, poly pharmacotherapy and fragility. In acute care hospitals, however, can be selected a patient population, fragile, not requiring intensive care, but a better management than normally provided in a regular ward, with frequent monitoring of vital signs and necessity of particular therapeutic and nursing interventions (1).

Methods: Patients, border line and particularly complex, could be managed in a Sub Intensive Care Unit (SICU), such as the elderly with acute respiratory failure secondary to COPD exacerbation. We evaluated the management of patients admitted to SICU with acute respiratory failure, comparing 2012 and 2013 data.

Results: In 2012 were hospitalized 489 patients (253 males - 51.7% and 236 women - 48.3%), mean age 73.8 y, mean SAPS II 39.2, median hospital stay 3 days: 202 patients (41.3%) with acute respiratory failure (54 % COPD exacerbation, 28.7% pneumonia and 12.4% pulmonary embolism). In 2013, 470 patients were hospitalized (256 males -54.4% and 214 women - 45.6%), mean age 72.7 y, mean SAPS II 37.6, median hospital stay 3 days: 185 patients (39.4%) with acute respiratory failure (55.1 % COPD exacerbation, 28.6% pneumonia and 2.2% pulmonary embolism). According to guidelines (2) in the COPD group was performed an usual medical therapy and non-invasive ventilation (NIV), with an increase in the values of PH (normal range) and improvement in PaO2 / FiO2 (>200) in 59.3% of patients treated in 2012 and 61.6% of patients in 2013.

Conclusions: Critically ill patients hospitalized in SICU, in a situation of shortage of ICU beds, may show a better survival comparing with those admitted to regular ward and ICU (3). The use of the combined approach of medical therapy and NIV in SICU, reducing oro-tracheal intubation and improving survival (2), would be effective not only through the reduction of respiratory muscle fatigue and improve gas exchange but especially when performed by a well-trained physicians and nurses team.

1. American College of Critical Care Medicine, Crit Care Med 1998.

2. Working Group Ontario HTAS 2012.

3. Simchen Crit Care Med 2004.

The first aid in the circuit and the hospitalization: two realities that need to communicate in a renewed way

S. Collini¹, E. Berardi², F. Troisi³

¹Dipartment Of Medical Surgical Sciences And Translational Medicine University Sapienza Of Roma, Roma, Italy, ²World Circuit Marco Simoncelli, Misano Adriatico, Italy, ³Sant’andrea Hospital, Roma, Italy

Background: The driver’s trauma treatment in a modern circuit, has nowadays achieved high levels of skills and efficiency. The organization of an international motor or motorcycle race, the presence of top teams, the media interest, led to a rise in quality standards of medical service.

What, above all, distinguishes the rescue in a circuit from the territory one’s is the time interval: if 3-5 min. are considered a correct result for national emergency service 118, in a racetrack, under live closed Tv circuit control, the maximum tolerance is about 30-45 seconds.

Methods: The time factor has necessitated a revision of the emergency guidelines, preferring the line of stay and play, rather than the immediate transport to the nearest Hospital, because of the resuscitation equipment available and the doctor’s skills. The staff of the National Service of 118 identified the differences in terms of approach and organization of first aid, changing, in case of motor and motorcycle sport assistance, their own guidelines.

Results: For this reason, the CSAI (Italian Motor Sport Commission) under the auspices of the ACI ( Italian Automobile Club), in accordance with the guidelines of the FIA (Federation Internationale de l’Automobilisme), identified three circuits, Monza, Vallelunga and Bari, for training doctors, nurses, rescue workers, volunteers of Civil Protection, in the different emergency theatres and the specific maneuvers of driver’s disengaging and extrication.

Conclusions: The circuit’s area Hospitals still remain in a borderline position when, during the most important events, are involved up to 150 people, to guarantee the emergency service, as well as numerous vehicles (ambulances, fast cars) and helicopter. The possibility to communicate directly between the chief medical doctor (CMO) and the hospital’s first aid would allow the optimization of the golden hour, avoiding transport in inadequate or too crowded hospitals. Rx, TC and e-fast, in circuit’s equipped medical center, could economize hospitals cost and time, shortening the diagnostic and therapeutic course.

The incidence of epistaxis episodes is strongly associated with mean temperature variations. Results of a ten-year survey in a large urban emergency department

I. Comelli¹, M. Benatti¹, E. Sartori¹, V. Vincenti², G. Cervellin¹

¹Academic Hospital Of Parma, Parma, Italy, ²University Of Parma, Parma, Italy

Background: Several disorders, such as renal colics, atrial fibrillation, psychiatric emergencies and others, are epidemiologically associated with seasonality and microclimatic variations. Epistaxis accounts for about 1 in 200 ED visits in the United States. Some Authors have shown a correlation between epistaxis and seasonality, with higher incidence during wintertime (4,5), but the data are poor and somewhat conflictual (6). Aim of this study was to assess the influence of day-by-day climate changes on the number of epistaxis-related visits in the ED of the University Hospital of Parma, in northern Italy.

Methods: All the cases of epistaxis episodes were retrieved from the ED’s database during a period of 3653 days (January 2003 to December 2012). Only the cases whose onset was recorded within 12 hours from ED visit were selected. For all the 3653 observed days, the meteorological data about the Parma Province were obtained from Environment and Climate Regional Agency. We therefore checked for correlation between epistaxis-related visits and variation of mean air temperature. The chronological data of all the selected cases were interfaced with the climate data in an univariate linear regressions analysis using the program Mathematica7®.

Results: Our ED recorded 819.590 visits over the observational period, with an average of 224 patients per day. A total of 5,414 epistaxis cases were observed during the study period, being males 56%, and females 44% (mean age 63±21 yrs). During all the observational period significant peaks of epistaxis episodes have been observed in winter months, showing a clear seasonality. We demonstrate the existence of a strong significant inverse correlation between the average number of daily visits for epistaxis and the daily change of average temperature (R=-0.92; p<0.001).

Conclusions: The incidence of epistaxis episodes is strongly associated with mean temperature variations, showing peaks during wintertime. There is also a strong negative correlation with changes of the mean temperature. Further studies are needed to clarify if comorbidities and drug therapies could influence these findings.

Preliminary evaluation of the poct mbs method to assess the antibiotics susceptibility of bacteria causing urinary tract infections (UTI)

V. Cellitti¹, V. Valeria¹, A. Arienzo¹, F. Losito², A. Mari², F. Cristofano³, S. Di Somma³, P. Visca¹, G. Antonini^1-4

¹Department Of Sciences, University Roma Tre, Roma, Italy, ²Mbs Srl, Roma, Italy, ³Department Of Emergency Medicine, S. Andrea Hospital And Sapienza University Of Rome, Roma, Italy, ⁴Inbb Interuniversity Consortium Of Structural And Systems Biology, Roma, Italy

Background: The presence of a urinary tract infection (UTI) and the susceptibility/resistance to antibiotics of its etiologic agent should be assessed in the shortest time possible to start the most appropriate therapy. A rapid test performed at the Point of Care (POCT) could achieve these objectives. MBS srl (Roma Tre University spin-off) has developed a new POCT microbiological device for the diagnosis of UTI. The analytical results on the bacterial load into urine provided by POCT MBS method were very similar to the analytical results provided by the traditional method of urine culture carried out by the Hospital laboratory, demonstrating that POCT MBS method can provide a diagnosis a UTI in less than 5 hours. The aim of this work was to demonstrate the possible use of the POCT MBS method for a qualitative analysis of the susceptibility/resistance of bacteria detected in urine, providing in short time information on the specific antibiotic therapy to be administered.

Methods: Urine samples were collected from patients hospitalized in the Department of Emergency Medicine of the S. Andrea Hospital in Rome and were analyzed both with the POCT MBS method using vials supplemented of antibiotics in the same Department of Emergency Medicine and with the traditional antimicrobial susceptibility tests in the Hospital Laboratory. The analytical results by POCT MBS methods were obtained in 5 hours, while the traditional antimicrobial susceptibility tests in the Hospital Laboratory provided analytical results after several (3-5) days.

Results: The comparison between the results of the two methods: on a total of 34 patients positive for a UTI, in 18 cases there was a full correlation between the two methods as concerning antibiotic susceptibility/resistance of the bacteria detected in the urine. In 16 cases there wasn’t full agreement, possibly because the very high level of bacteria in some urine samples resulted in an analytical time of the POCT MBS method too short to allow the antibiotics effect on bacteria.

Conclusions: In conclusion, encouraging results were obtained, demonstrating the great potential of the POCT MBS method to evaluate the susceptibility/resistance of bacteria in the urine. The research will continue to achieve a better correspondence between the POCT MBS method and the traditional antimicrobial susceptibility test, even though the analytical time could possibly increase.

Acute abdominal pain in an emergency department of a university hospital in italy

N. Caporale¹, A.M. Morselli-Labate¹, E. Nardi¹, R. Cogliandro¹, V. Stanghellini¹, M. Cavazza²

¹Department Of Medical And Surgical Sciences Dimec, University Of Bologna, Bologna, Italy, ²Department Of Emergency Medicine, St. Orsola-Malpighi Polyclinic, Bologna, Italy

Background: Acute abdominal pain (AAP) is one of the most common reasons for referral to an Emergency Department (ED), but information on its impact on emergency care activities is limited.

Aims of this work were to define the prevalence of AAP among ED visits of a University Hospital and to analyze its main clinical features.

Methods: All patients admitted at the S.Orsola–Malpighi University Hospital of Bologna ED on 12 a priori selected sample-days in 2013 were included. Clinical data were obtained from the ED clinical record databases. Gender, nationality, year of birth, triage severity code, ambulance transportation and chief complaint at admission were recorded for each patient. Furthermore, 192 clinical variables were recorded for each patient referred to the ED with AAP.

Results: During the observed period the ED assisted 2667 patients with a mean ± SD daily admission rate of 222 ± 19.6. Of these, 249 patients presented AAP (prevalence = 9.3%), with a higher prevalence on holidays vs workdays (10.1% vs 8.9%; P=0.008). Compared to patients with other complaints, AAP patients were younger (median age 43 vs 58 yrs; P<0.001), more frequently females (59.0% vs 50.0%; P=0.006), more non-native (19.7% vs 12.6%; P=0.003), and classified with higher severity admission codes (P=0.016). The most frequent ED operative diagnoses were: non-specific abdominal pain (n=91, 36.5%), GI tract related pain (n=83, 33.3%; n=20 upper GI, n= 63 lower GI), urogenital related pain (n=52, 20.9%), hepatopancreatic related pain (n=23, 9.2%).

Conclusions: AAP is a common cause of referral EDs. Despite technological advances, non-specific abdominal pain is still the main operative diagnosis in ED. Analysis of AAP features can help to improve management strategies in emergency care.

Chest pain. A case of heterotopic pregnancy

G. Civitavecchia¹, A. Bottani¹, M. Ripoll Pons¹, A. Voza¹, G. Ricevuti²

¹Istituto Clinico Humanitas - Pronto Soccorso EAS, Rozzano, Milano, Italy, ²Università Degli Studi Di Pavia, Pavia, Italy

Background: Heterotopic pregnancy (HP) was first described in 1078 (1) and it’s incidence is estimated approximately 1/30000 pregnancies (2). Clinical symptoms can be misleading.

Methods: A woman, 35 yo, presented to the ED reporting acute chest pain (ACP), shoulder tip pain (STP), nausea and vomit. She reported regular menstruation.

PMH: 2 pregnancies.

Physical examination: BP 130/80 mmHg, HR 100/min, O2 saturation 99%. NRS 5. Normal cardiac and thoracic objectivity. Abdomen not painful nor tender, negative Blumberg and Murphy signs.

Blood tests: WBC 13,300/mm3, Hgb 13,4 g/dl, CRP, negative D-Dimer and Troponine I.

ECG: negative for ACS, STEMI, NSTEMI.

Chest X-RAY: no consolidations, no pleural effusion, normal cardiac shadow.

Abdomen U.S.: little free fluid in Douglas pouch.

Therapy: Ranitidine, Metoclopramide and Tramadol in normal saline solution.

After the therapy the patient referred pain remission and got discharged with the suggest to assume pain relief therapy,antiemetic and PPI.

She returned in the ED 15 days later, reporting ACP.

Physical examination was unchanged, vitals signs were stable and blood tests showed slight anemia (Hgb 11,7 g/dl), WBC 11100/mm3, CRP 2,51 mg/dl, negative D-Dimer and TnI. ECG and chest X-RAY were normal. Heart US: Minimum posterior pericardial separation.

Suspecting a pericarditis, the patient was kept in the ED. During the night she referred abdominal pain. In the morning abdomen was painful in hypogastrium and abdomen US showed plentiful free fluid. HGB dropped to 8,8 g/dl, so a contrast CT scan was performed. It showed free blood, possible left retroperitoneal hematoma and thickening of the uterus walls. B-HCG was 5591 mIU/ml and a gynecologist visit was performed.

Transvaginal US showed an intrauterine pregnancy and equivocal left tubaric pregnancy.

Results: The patient was then taken to the OR to perform an uterine revision and left salpingetomy.

The discharge letter reported an intrauterine non evolutive pregnancy and an ectopic left tubaric pregnancy (HP) with hemoperitoneum.

Conclusions: HP may present with nonspecific findings, including STP, caused by diaphragmatic irritation due to intraperitoneal bleeding (3).

The pain radiates to the shoulder even in 20% of patients with hemoperitoneum (50 to 3500 mL) (4)

The emergency physician should never understimate the potential life-threatening HP in fertile female patients with typical (abdominal tenderness and pain) and atypical (ACP and STP) presentation.

Beware of cervical trauma

M. Bonzano¹, L. Pagani¹, I.F. Ceresa², S. Marra¹, F. Panizzardi¹, M. Perrone², G. Ricevuti¹, M.A. Bressan²

¹Scuola Di Specializzazione Di Medicina D’emergenza E Urgenza Università Degli Studi Di Pavia, Pavia, Italy, ²Struttura Complessa Pronto Soccorso Accettazione (Sc Psa) Irccs Policlinico San Matteo, Pavia, Italy

Background: The cervical spine is involved in 60% of cases in spinal trauma. The lesions of the odontoid are a relatively common even representing more than 60% of fractures involving the Axis which in turn are the 10-18% of all cervical spine fractures.

Results: A 74 years old woman had an accidental fall from stairs at 5:30 a.m., coming at our observation 2 hours later the accident, she had a short time of loss of consciousness. Clinical story of chronic ischemic heart disease in pharmacological treatment and history of benzodiazepines abuse. She complained of dizziness and pain at right knee, cervical and lombar spine, swelling at right hand; the physical and neurological examination were normal. The patient was subjected to RX scan without evidence of fractures and cerebral CT scan without evidence of extra or subdural hematomas, intraparenchymal or subarachnoideal hemorrhages and fracture of braincase and splanchnocranium. The cervical spine was examined also with CT scan with detection of fracture at base of dens at its attachment to body of C2 involving the left lateral masses (type III). The displacement of fractured dens determined spinal canal reduction. No paravertebral or epidural hematomas. At lab tests only mild leukocytosis and elevation of CPK. The patient was evaluated by the neurosurgeon and subsequently admitted to the neurosurgery and underwent conservative therapy.

Conclusions: It’s has to be supposed that all patients, with blunt trauma of the neck and head, have a spine injury, especially if there is compromised sensorium. Until the contrary is proved, the column must be adequately protected until a possible lesion has not been identified, stabilized or excluded. Anderson and D’Alonzo created a classification: type I: fracture of the upper part of the odontoid dens; type II: fracture at the base of the odontoid dens; and type III: fracture affecting the body of the axis. Treatment is guided by the type of odontoid fracture. It’s fundamental to exclude cervical lesions with the worst prognosis as C1 fracture or dislocation atlantoaxial epistrofea. Pure C1-C2 dislocations, are rare because they can only be caused by a violent flexion mechanism with rupture of the transverse ligament, projection of the odontoid dens to the neural canal, and spinal cord trauma that is generally incompatible with life.

Venous mesenteric ischemia and acute arterial mesenteric ischemia with reperfusion: similarities and differences

D. Berritto¹, F. Iacobellis¹, M.A. Mazzei², C. Rossi¹, S. Cozzolino³, L. Saba⁴, R. Grassi¹

¹Institute Of Radiology, Second University Of Napoli, Napoli, Italy, ²Department Of Surgical Sciences, University Of Siena, Siena, Italy, ³Biotechnology Center, A.O.R.N. Cardarelli, Napoli, Italy, ⁴Department Of Radiology, Azienda Ospedaliero Universitario Di Cagliari, Cagliari, Italy

Background: Mesenteric ischemia that encompasses a broad spectrum of diseases due to an acute or chronic decrease of small bowel blood supply that may present occlusive (arterial-venous) or nonocclusive ethiopathogenesis. Despite advances in diagnosis and therapy, the overall mortality from mesenteric ischemia remains high with rates reaching 80%. The findings of mesenteric ischemia caused by venous thrombosis are well described in literature. From the analysis of the available literature seems that reperfusion after acute arterial ischemia (Ischemia-Reperfusion) and mesenteric venous ischemia may present similar findings. This represents a challenging issue because these two conditions require different treatments. Early diagnosis is fundamental for a correct therapeutic approach in order to reduce mortality rates.The aim of this study is to compare the VMI (venous mesenteric ischemia) and I-R (Ischemia-Reperfusion) pathways in an experimental model by using a 7 Tesla Magnetic Resonance Imaging (7T MRI) system, attempting to identify radiological findings that may help the surgeon in the distinction between these 2 conditions.

Methods: Thirty adult Sprague-Dawley rats were divided into 2 groups that then underwent different surgical models and ischemic damage monitoring. Group I was subjected to superior mesenteric vein (SMV) ligation whereas Group II underwent superior mesenteric artery (SMA) ligation followed by reperfusion after 1 hour. At different time-points (1 hour, 2 hours, 4 hours, 6 hours, 8 hours) 3 rats from each group were imaged by 7T MRI, euthanized and macroscopically-histologically analyzed.

Results: The hypotonic reflex ileus (HRI) was detectable only in I-R rats; congested mesentery was evident in the Group II rats, starting from the first hour after reperfusion, as well as in the Group I rats from the first hour after SMV ligation. In both groups free fluid was present; the bowel wall thickening and hyper-intense signal in T2-W sequence was visible in both groups from the second hour. Paralytic ileus (PI) was visible from the sixth hour and wall pneumatosis was observed in only 1 VMI rat from the eighth hour.

Conclusions: Results of this study suggest that radiological findings of SMV occlusion and reperfusion after arterial occlusion overlap except for the HRI detectable only in early stage of I-R.

Epidemic meningoencephalitis (West Nile Virus)

A. Bazza¹, M. Salvetti², F. Marino¹, M.L. Muiesan²

¹Postgraduate School Of Emergency Medicine - University Of Brescia, Brescia, Italy, ²Department Of Clinical Sciences - University Of Brescia, Brescia, Italy

Background: A 67-year-old man was suffering from first relapse of acute myeloid leukemia (NPM1 mutated) in re-induction chemotherapy, chronic ischemic and hypertensive heart disease.

In September 2013 he was admitted to “Spedali Civili” Hospital in Brescia (North Italy) with fever and headache. During the hospitalization his level of consciousness deteriorated, he became lethargic, disoriented in space and time, presenting acute hypoxemic respiratory failure, flaccid paralysis, mild rigor nucalis, bilateral nystagmus. Clinical parameters were: BP 130/80mmHg, HR 120bpm, steady pancytopenia at the complete blood count, procalcitonin 0.5ng/ml, CRP 3.1mg/L, blood and urine cultures were unremarkable. The electroencephalogram recorded signs of global cerebral distress with widespread slow-irritative anomalies, moderate depression of brain rhythms to the left. The brain CT scan excluded acute lesions.

A sudden episode of generalized seizure followed by respiratory arrest required endotracheal intubation and moving to ICU. After lumbar puncture, the cerebrospinal fluid (CSF) was colorless, limpid, the protein was 83mg/dL, the glucose 159mg/dL, the cell count 14/mm3 predominantly neutrophilis, CSF direct microscopy examination and culture were negative.

Methods: Magnetic resonance imaging demonstrated severe encephalomyelitis and abnormal findings consistent with West Nile Virus (WNV). The diagnosis was confirmed by a positive WNV IgM in two different serum samples. Coma persists up to a poor prognosis.

Results: The WNV is a Flavivirus transmitted through the bite of mosquito (Culex species). It was first isolated in a febrile woman with flu-like symptoms in Uganda in 1937; since 2008 first cases had been recorded in Italy with neuroinvasive disease.

Nearly all human infections of WNV are due to mosquito bites; other potential routes include transfused blood and transplanted organs. In humans, viremia is short-lived. There is currently no defined antiviral therapy for WNV infection. The treatment is prevention and supportive therapy (rehydration, pain control, neurological alertness monitoring, airway protection). There is no vaccine for humans.

Conclusions: The 2013 disease surveillance in humans in Lombardia (Italy) confirmed 10 native cases of WNV meningo-encephalitis occurred in August and September. The 30% of patients were aged between 45 and 65 and 9 out of 10 were male. Two patients, a 89-year-old male and 67-year-old male, with comorbidities, died of WNV disease. The 2014 surveillance (untill 4 September 2014) reported one more case in Pavia.

The relationship between hypertensive crisis and biomarkers

V. Amadoro¹, L. Magrini, S. Di Somma

¹Sant’Andrea Hospital - Department Of Medical-Surgery Sciences And Translational Medicine Emergency Department, Rome, Italy

Background: The aim of this study is to detect the role of some biomarkers (BNP, and NGAL) in the course of hypertensive crisis in an emergency setting; to evaluate their possible role in the differential diagnosis between hypertensive emergencies or urgencies and to investigate the relationship between their concentrations and blood pressure.

Methods: We studied, for a period of 3 months, 28 patients (M/F 17/11; mean age 63.6±16.8 years) arriving in our Emergency Department (ED) of a 400-bed hospital university with signs and symptoms of hypertensive crisis. Past history was mainly hypertension (75%), diabetes (42.8%), coronary artery disease (7.1%), chronic kidney failure (17.8%), cerebrovascular disease (3.5%) (Table). At home therapy was based mainly on: AT2 receptor antagonists (28.5%), calcium-antagonists (28.5%), beta-blockers (17.8%), diuretics (14.2%) (Table). In ED median [minimum-maximum] systolic blood pressure was 210 [155-280] mmHg, and diastolic blood pressure 110 [80-190] mmHg. Patients were subjected to the following diagnostic tests: ECG (96.4%), cerebral CT scan (50%), chest X-ray (46.4%), fundus oculi in 14.2%, and echocardiogram in 10.7% of cases.

Results: We have demonstrated: acute ischemic coronary disease (5/27 subjects), acute ischemic episode (3/14), only in one patient congestion signs typical of acute heart failure, pathologic retinal conditions (hemorrhage, exudates) in 3/4 patients.

BNP (median[minimum-maximum]) values were 25 [10-250] pg/ml, and NGAL were 60 [30-150] ng/ml. In ED therapy was performed, principally, with calcium-antagonists (24.1%), adrenergics (24.1%), vasodilators (20.6%), diuretics and AT2R antagonists (both 17.2%), beta-blockers (13.7%).

Conclusions: The group number is too small to have a diagnostic and prognostic validity for the complications of hypertensive crisis, yet. But, a larger number of patients will help to evaluate this topic.

Short intensive observation role in diagnosis and treatment in chronic carbolithium overdose

G. Acquistapace¹, M. Rossi¹, A. Manelli², L. D’agostino², R. Spagliardi³, M. Bignamini², M. Buvoli², G. Ricevuti¹

¹Università Degli Studi - Scuola Di Specializzazione In Medicina D’emergenza-Urgenza, Pavia, Italy, ²Ao Lodi - Pronto Soccorso E Accettazione, Lodi, Italy, ³Ao Lodi - Servizio Psichiatrico Di Diagnosi E Cura, Codogno, Italy

Background: Lithium is used widely in the treatment of manic-depressive psychosis. The relationship between serum lithium concentration and symptoms (often absolutely non-specific or possibly correlated to the first psychiatric diagnosis) depends on the type of poisoning. Chronic poisoning is relatively common because the therapeutic index of lithium is low: it is 0.6 –1.2 mEq/L, measured 12 h after the last lithium dose.

Methods: Pt1: DG, a 40 year old man, presented himself at our ED reporting mental confusion. He reported in anamnesis a Bipolar Mood Disorder, his therapy was carbolithium (overall dose of 900 mg). A complete blood analyses reported a first carbolithium level of 1.99 mmol/L.

Pt 2: FR, a 80 year old woman, was referred by her daughter to our ED for a language slowdown. She reported in anamnesis a Bipolar Mood Disorder, his therapy was carbolithium (overall dose of 600 mg). A complete blood analyses showed carbolithium level of 1.83 mmol/L.

Results: Pt1: The patient was referred to our Short Intensive Observation, where intravenous therapy with 2500 ml of saline. Nevertheless carbolithium concentration increased again (12 hours after ED access, 1.71 mmol/L); considering arrhythmia development risk the patient was referred to the Cardiology Unit.

Pt2: The patient was referred to our Short Intensive Observation, where intravenous therapy 2500 ml of saline solution was administered. A second blood analyses, performed to 16 hours from ED, showed a decrease in carbolithium concentration (1.25 mmol/L). The patient was discharged.

Conclusions: Until now, in the Emergency Department (ED) setting, a 12-h level is impractical, and serial lithium levels are used in an attempt to establish a trend in the serum lithium concentration. Recently, the activity of our ED has been enriched by the addition of an area of Short Intensive Observation, where patients are waiting for admission or discharge, if we can solve their problem in 24 hours. Right here such poisoning may be diagnosed and the patient may be monitored at the first stage of diagnosis and a first treatment could be performed. As shown in our cases, it is clear that the possibility to act in this first 24 hours from ED access allows a better management and, if possible, after therapy and monitoring, patient discharge, reducing costs and length of in-hospital stay.

Ethical dilemma in resuscitation

F. Abou-Mrad¹

¹Lebanese University, Baabda, Lebanon

Background: Emergency medical services (EMS) providers face many ethical issues while providing necessary care. Although provider judgment plays a large role in the resolution of conflicts at the scene. This presentation describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers. The goals of CPR is to preserve life, Restore health, relieve suffering, limit disability, and reverse clinical death. CPR decisions are often made in seconds by rescuers who may not know the patient or know if an advance directive exists. As a result, administration of CPR may sometimes conflict with a patient’s desires of best interests.

Methods: A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

Results: It is important to establish protocols and policies, when possible, to address these high-risk and complex situations.

Conclusions: This presentation provide guidelines to healthcare providers for making the difficult decision to provide or withhold emergency cardiovascular care.

Research proposal: potential utility of galectin-3 and ST2 in detecting early myocardial structural and functional involvement in patients with type 2 diabetes and arterial hypertension

J. Seferovic¹, S. Di Somma³, P.M. Seferovic^2,4, M. Tesic², A.D. Ristic^2,4, K Lalic^1,4, A Jotic^1,4, V Giga^2,4, N.M. Lalic^1,4

¹Clinic Of Endocrinology, Diabetes And Metabolic Disorders, Clinical Center Of Serbia, Belgrade, Serbia, ²Clinic Of Cardiology, Clinical Center Of Serbia, Belgrade, Serbia, ³Postgraduate School Of Emergency Medicine, Department Of Medical-Surgery Sciences And Translational Medicine, La Sapienza, Roma, Italy, ⁴University Of Belgrade, School Of Medicine, Belgrade, Serbia

Background: In several studies, galectin-3 levels strongly correlated with classical cardiovascular (CV) risk factors such as diabetes, insulin resistance, hypertension (HT), lipid disorders, obesity, kidney dysfunction and N-terminal fragment B-type natriuretic peptide (NT-proBNP). Also, it was demonstrated that patients with T2D exhibit higher sST2 levels compared to healthy controls and this correlation was linked to the glycemic control. Moreover, the presence of left ventricular diastolic dysfunction (LVDD) in these patients is associated with even higher sST2 levels

The aim of our study is to determine the role of galectin-3 and ST2 in detecting early myocardial structural and functional involvement in patients with T2D and HT.

Methods: Study population should include 200 patients with T2D and/or HT. Patients with prior history or symptoms of ischemic heart disease, cerebrovascular or renal disease, microvascular diabetic complications and insulin therapy should be excluded. Study protocol would consist of demographic and clinical data, as well as biochemical measurements, anthropometric and echocardiographic evaluation.

Biochemical measurements include routine laboratory tests, and specific biomarkers [galectin-3, ST 2, glycosylated hemoglobin (HbA1c), N- terminal fragment B-type natriuretic peptide (NT-proBNP)]. Cardiological evaluation includes physical examination, transthoracic tissue Doppler echocardiography and stress echocardiography. LVDD will be assessed using the criteria defined in a consensus statement on the diagnosis of HF with normal LVEF by the Heart Failure and Echocardiography Associations of the ESC. In order to exclude ischemic heart diseases, a stress echocardiography test should be performed in all patients.

Results: The results of our previous study with the similar protocol demonstrated significantly increased levels of galectin-3, blood glucose, and HbA1c in patients with T2D and HT. NT-pro BNP, creatinine and urea were also higher in these patients than in other two investigated groups. Echocardiographicaly, LV diameters and IVS thickness were increased in this group of patients. Furthermore, in the same cohort a positive correlation between galectin-3 and NT-pro BNP, and galectin-3 and LV mass were demonstrated. In addition, a negative correlation between galectin-3 and LV end-diastolic diameter was revealed.

Conclusions: This study revealed that levels of galectin-3 were higher in patients with both T2D and HT, and correlated with LV mass. However, further studies are needed to define precisely the clinical value of galectin-3 in detecting early myocardial dysfunction in this subset of patients.

Acute intoxications by synthetic cannabinoids in the emergency system: the italian cases series

A Schicchi^1,5, Vm Petrolini¹, D Lonati¹, E Buscaglia¹, S Vecchio¹, A Giampreti¹, C Rimondo², C Seri², G Serpelloni², T Coccini³, P Papa⁴, G Ricevuti^1,5, Ca Locatelli¹

¹Poison Control Centre, National Toxicology Information Centre And Clinico-Toxicological Coordinating Centre Of The Natio, Pavia, Italy, ²National Early Warning System, Department For Antidrug Policies, Addiction Department, Ulss 20, Verona (Italy), Verona, Italy, ³Laboratory Of Clinical Toxicology, Irccs Salvatore Maugeri Foundation, Pavia (Italy), Pavia, Italy, ⁴Laboratory Of Analytical Toxicology, Clinical Chemistry Service, Irccs Policlinico San Matteo Foundation, Pavia (Italy), Pavia, Italy, ⁵Department Of Internal Medicine And Therapeutics, Postgraduate School Of Emergency Medicine, University Of Pavia, Asp-Id, Pavia, Italy

Background: Synthetic cannabinoids (SC) represents approximately 30% of new psychoactive substances (NPS) signaled in the last years. This study take into consideration the clinical manifestations of intoxicated patients by SC at Emergency Department (EDs) admission.

Methods: A prospective study (January 2010–December 2012) including cases evaluated by EDs network and followed by Pavia Poison Control Centre was performed. Symptomatic patients with referred/suspected abuse of SC and/or referred abuse of other substances psychoactive with an atypical clinical presentation were included. Demographic data, clinical course and laboratory results (biological sample/consumed substance) were collected.

Results: 40 patients (14-55 years) with acute SC intoxications were analyzed. Cases were registered on all national territory. SC were mainly assumed (90%) by smoking and product(s) have bought online in 45% of cases. Advanced laboratory investigations analysis (in order to detect the specific SC) were performed in 32/40 cases (80%). The clinical considerations and the correlation between clinical manifestations and specific SC were performed in the subgroup of patients (21/32) resulted positive for SCs in serum.

Main clinical manifestations were: tachycardia >100 bpm (13/21; 62%), mydriasis (12/21; 57%), anxiousness/agitation (9/21; 43%), gastrointestinal symptoms (5/21;24%), hypertension (4/21;19%), hallucinations (3/21;14%); seizures were observed in 5% of cases. No lethal cases were registered. SC identified in serum sample were: JWH-122 (10 cases), JWH-018 (4 cases), JWH-250/JWH-122 (3 cases), JWH-073 (1 case), MAM-2201 (1 case), JWH-018/JWH-122 (1 case), JWH-018/JWH-122/JWH-073 (1 case).

Conclusions: SC acute intoxications are an important and confirmed problem in the Italian emergency setting (1). Clinical diagnosis is difficult and usual screening performed in ED (and for THC) results negative (2). The Emergency physician plays a key role in making clinical suspicion of SC acute intoxication in order to proceed with second level analysis necessaries to confirm the abuse (3, 4). According to emerging medical reports a close monitoring for functional and toxic damages is necessary.

Clinical management of foodborne botulism poisoning in emergency setting: the Italian case series

L. Flore^1,3, D. Lonati¹, S. Vecchio¹, F. Anniballi², B. Auricchio², A. Fiore², Vm. Petrolini¹, M. Aloise¹, F. Chiara¹, A. Giampetri¹, D. De Medici², G. Ricevuti³, Ca. Locatelli¹

¹Poison Control Centre, National Toxicology Information Centre And Clinico-Toxicological Coordinating Centre Of The Natio, Pavia, Italy, ²Department Of Veterinary Public Health And Food Safety, National Reference Centre For Botulism, Istituto Superiore Di Sa, Roma, Italy, ³Department Of Internal Medicine And Therapeutics, Postgraduate School Of Emergency Medicine, University Of Pavia, Asp-Id, Pavia, Italy

Background: Evaluate clinical presentation characteristics of foodborne botulism poisoned patients admitted in Emergency Departments (EDs) to obtain clinical data useful for emergency physicians to make clinical suspicion, diagnosis and early antidotal treatment.

Methods: A retrospective analysis of cases of foodborne botulism registered at Pavia Poison Control Centre was performed. Implicated food, clinical presentation, latency between symptoms- ED admission-treatment, clinical course, response to the antidotal administration and laboratory analysis data were analyzed.

Results: 98 cases were included. Eleven patients (11,3%) weren’t able to identify the suspected food. History was positive for consumption of vegetables (77%) and fish (16%) in water or oil, or meat conserve in 88.7%. In 81 cases (93,2%) causative food were home-made produced, in 4 cases were industrial and in 2 cases were ingested at restaurant. Most common symptoms reported at ED were dysphagia (55,1%) followed by ocular manifestations (ptosis, diplopia and mydriasis). In three cases dysphagia was the unique neurological manifestation of the poisoning. Twenty-six patients (26.5%) required mechanical ventilation. Antitoxin was administered in 59 patients (60,2%), with an average of 63 hours after symptoms onset. Twenty-six percent were treated within 24 hours clinical manifestations onset instead 53.8% of patients received a later treatment. Five adverse reactions were registered. Neurological permanent sequelae was registered in 1 case; 1 lethal case occurred.

Conclusions: Botulism is a rare disease in which early correct diagnosis is difficult and may require a toxicological consultation and represents a medical challenge for the emergency physicians (1, 2). Clinical presentation at EDs could be undefined, diagnostic procedures could be problematic and patients must be monitored because of dramatic respiratory failure. So, the PCC support is essential for the diagnosis and the management of poisoned patients (e.g. specific laboratory tests, antidotic treatment), and in the identification and surveillance of possible outbreaks.

References: 1.Lonati D, Rossetto O, Fenicia L, Locatelli C. Botulism. In Ballantyne B, Marrs TC, Syversen T (eds): General and Applied Toxicology. Wiley, Chichester (UK), 3th edition, 2009, chap. 148, pp. 3555-3579; 2. Williams BT, Schlein SM, Caravati EM et al. Emergency department identification and critical care management of a Utah prison botulism outbreak. Ann Emerg Med. 2014 Jul;64(1):26-31.

Evaluation of the prognostic role of ST2: a new biomarker of cardiovascular disease

F. Orsini¹, F. Floridi¹, R. Marino¹, L. Magrini¹, G. Salerno², P. Cardelli², S. Di Somma^1-3

¹Emergency Medicine Department, Faculty Of Medicine And Psychology, Sapienza University, Sant’andrea Hospital, Roma, Italy, ²Clinical And Molecular Medicine Department, University, Sant’andrea Hospital Health Center, Rome, Italy, Roma, Italy, ³Department Of Medical-Surgery Sciences And Translational Medicine, Sapienza University, Sant’andrea Hospital, Roma, Italy

Background: Chest pain is one of the most common reasons of patients’ admission to the emergency room. ACS is distinguished in ST-Elevation (STEMI) and Non ST-Elevation/ Unstable Angina (NSTEMI/UA). Around 2.5 million hospital admissions worldwide are due to NSTEMI/UA.NSTEMI accounts for 1.5 million admissions to hospital each year. It is estimated that two-thirds of acute coronary syndromes present as NSTEMI,and the remaining one third are attributable to STEMI.

Methods: Aim of this study was first of all to evaluate the diagnostic and prognostic role of the new biomarker ST2.Our aim was to discover a direct correlation between the biomarker level (admission in ED) and the mortality of patients with ACS. We also studied the diagnostic and the prognostic role of high sensitivity troponin (HSTn) and we compared it with the results of ST2.We enrolled 157 patients presenting to ED with chest pain.Patients were divided into three different groups: STEMI,NSTEMI and patient without acute coronary syndrome.We monitored these groups of patients with a new biomarker (ST2) and a phone follow-up 30 days after hospital discharge.

Results: Follow-up calls shown an interesting trend among the ACS groups of patients. ST2 was significantly higher in patients who died within 30 days than in patients who survived to STEMI (p<0.007).Even HSTn was significantly higher in deceased patients comparing to the survived ones, but with a less significant statistical difference (p<0.04).The same trend was found in the NSTEMI group:ST2 was higher in the deceased compared to the survived (p<0.03).After setting a cut-off of 35ng/mL we observed that:6 out of 9 patients with a final diagnosis of NSTEMI and ST2> 35ng/mL died Only 1 out of 7 patients with a final diagnosis of NSTEMI and ST2< 35ng/mL died.The same trend was also found the STEMI group therefore showing that patients with a ST2> 35ng/mL have a higher mortality:10 out of 16 patients died.

Conclusions: ST2 has shown to be a good prognostic indicator in ACS patients. This was more important when compared to the prognostic values of other used indicators such us High Sensitivity Troponin I.At logistic regression,ST2 values showed to be a more significative risk factor than HSTn for death at 30 days.ST2 was more useful in evaluating the prognosis comparing to HSTn in both STEMI and NSTEMI patients.

Research proposal: use of anticholinergic medications in patients with cognitive impairment - the impact of hospital admission on anticholinergic burden

I. Weichert

The Ipswich Hospital Nhs Trust, Ipswich, United Kingdom

Background: This is a research project that we have already started locally expanding from an already established cooperation through GREAT on patients with acute delir.

Many prescription and over the counter medications have anticholinergic activity. This includes drugs for hypertension, cardiovascular and pulmonary disease. Anticholinergic effects have been associated with worsening of cognitive function and have been implied in increased mortality. The use of multiple, even mildly anticholinergic drugs, is thought to have an additive effect causing an increasing anticholinergic burden.

Despite the well established evidence clinicians have been slow to adapt and are not aware of the impact of many medications on cognition.

Methods: We are investigating the use of anticholinergic medications in patients admitted with a diagnosis of acute delirium or chronic cognitive impairment. We are recording the use of such medications that are known to have an effect on cognition, as described in the Anticholinergic Burden Scale (ACB) and of related drugs where there is published evidence of their anticholinergic activity which had not been included in the original research by Boustani MA et all.

As such we are monitoring the anticholinergic burden on admission and discharge and also if any further relevant medications have been used temporarily during the inpatient stay. We are recording demographic data, the length of stay in hospital, the concomitant use of cholinesterase inhibitors, whether there is a diagnosis of dementia (on admission or discharge) and/or acute delir (inclusion criteria), and also if the patients have died during admission. We will follow up on readmission within 30 days and mortality.

Results: Our hypothesis is that despite well established evidence, clinicians do not reduce anticholinergic burden in patients with acute or chronic cognitive impairment.

Descriptive statistics will be used for demographics. Statistical inference analysis will be conducted to investigate the anticholinergic burden before, during and after admission, and the effect on readmission and mortality.

Conclusions: This is an easily performed research project. By involving other centers through the GREAT network, a larger number of data sets will allow the group to produce more meaningful results and also to investigate possible differences between health care services.

Pnaemonia ab ingestis as fatal geriatric menercency

C. Guerini, L. Venturini, A. Apollinari, M. Gortan, F. Siccardi, E. Binda, S. Moschi, J. Forni, R. Maruccia, M. Armellini, A. Faragli, G. Ricevuti

Department Of Internal Medicine And Therapeutics, Postgraduate School Of Emergency Medicine, University Of Pavia, Asp-Id, Pavia, Italy

Background: Geriatric emergencies are events whose frequency is increasing as the average life expectancy is rising. Often these events are fatal and require specific and highly-specialized treatments. Often geriatric emergencies are events complicating the most common geriatric syndromes, which, even if they are not classified per se as a diseases, predispose the elderly to an acute event. Among these serious complications the Pneumonia ab ingestis is a common occurrence.

Methods: We report the case of a 78-year-old man who was admitted in our geriatric ward for rehabilitation related to severe Hypokinetic syndrome due to a previous admission due to complications of untreated type II diabetes such as dehydration and electrolyte imbalance. The patient was suffering from cognitive decline Alzheimer disease-type. The patient had an important metabolic, renal, cardiovascular, neurological comorbidity. During hospitalization, he presented dysphagia.

Results: The patient showed signs of cough, phlegm and moderate fever. According to the examination and the chest x-ray, a diagnosis is made of Pneumonia ab ingestis. A nasogastric tube is placed, enteral hydration therapy is started as well as antibiotics therapy. Biological and biochemical parameters are monitored. The patient showed a raised temperature with increase of leucocytes, hypotension and clinical picture of shock and evolved towards the esitus.

Conclusions: The clinical case highlights the classic evolution of geriatric syndrome which in the elderly have a “cascade” evolution towards a more serious condition and finally death. Patients suffering from dementia usually have common complications caused by dementia, which is almost always deadly. To treat these patients a “geriatric knowledge” is necessary in order to prevent complications by knowing the geriatric syndromes. On the basis of these considerations it seems appropriate thatThe Society for Academic Emergency Room Medicine (SAEM) has commissioned a Geriatric Emergency Medicine Task Force to address the need for health professions training and care of the elderly. The American Geriatric Society, in collaboration with National Council of State EMS Training Coordinators, has developed a training program, Geriatric Education for Emergency Medical Services (GEMS). This is a continuing education curriculum for prehospital professionals focusing specifically on the care of geriatric patients.

Advance data from Vital and Health Statistics. Available at: http://www.cdc.gov/nchs/about/major/nhcs/nhcs_reports.htm. Accessed May 26, 2004.

Richardson BK. Overview of geriatric emergencies. Mount Sinai J Med. 2003;70:75-84.

Metabolic comorbidity as cause of inconsciuosness

M. Gortan, C. Guerini, L. Venturini, A. Apollinari, F. Siccardi, E. Binda, R. Maruccia, E. Taratynova, L. Pagani, M. Armellini, A. Faragli, S. Moschi, G. Ricevuti

Department Of Internal Medicine And Therapeutics, Postgraduate School Of Emergency Medicine, University Of Pavia, Asp-Id, Pavia, Italy

Background: Comorbidity has been defined as the presence of two or more diseases in the same patient. The coexistence of different pathologies is a feature of the geriatric patient. Comorbidity, treatment with different drugs, difficulties in monitoring the correct assumptions of the therapy, altered metabolism make the geriatric patient particularly difficult to manage.

Methods: We report a case of a 84 hypertensive man with clinical history of diabetes mellitus II, dyslipidemia, chronic ischemic cardiopathy, chronic atrial fibrillation, tachy-brady syndrome treated with subsequent implantation of a monocameral pacemaker, chronic renal failure. The patient was taking at home the following therapy: Warfarin, Bisoprolol, Ramipril, Furosemide, Simvastatin, Olanzapine, Metformin, Ethyl esters of polyunsaturated fatty acids, Alprazolam, Rivastagmine, Bromazepam, Spironolactone, Triazolam.

Results: When the patient was admitted in our geriatric ward he was somnolent, cachectic and dehydrated. Blood tests indicated acute renal failure (creatinine 2.17), severe electrolyte imbalance characterized by hypernatremia (Na 159), severe glycometabolic imbalance (glycaemia 420), severe bleeding diathesis (INR 4.47, 6.33, 10). Chest x-ray made us suspect an inflammatory outbreak in the right lung. We decided to interrupt the therapy he was following. We administered vitamin K in order to treat the bleeding diathesis and this led to the restoration of the paraphysiological values (INR 1.2). Because of the suspect of a pulmonary infection, an antibiotic therapy was introduced. To restore the electrolyte and the glycometabolic balance, we started an hydration therapy, and an insulin therapy. A bladder catheter was inserted in order to control diuresis. Few days later, the patient appeared much less cachectic, acute kidney injury was getting better (creatinine 1.6), sodium values were in the physiological range (144), bleeding diathesis was under control (INR 1.2). Despite this improvement in the clinical conditions, we decided to transfer the patient in the emergency room, in order to better face the risk of sepsis.

Conclusions: The metabolic comorbidity seen in this patient was - beyond any reasonable doubt- iatrogenic. The case shows the importance of periodic checks and periodic adjustments in the therapy of geriatric patients with different diseases, as well as the risks that the patient face if a correct monitoring is not made, i.e. metabolic imbalances, which can create good conditions for the developing of infectious diseases, whose spread can lead to sepsis.

Gal-3 in Alzheimer’s patients with and without cormobidity

A. Apollinari, L. Venturini, M. Gortan, C. Guerini, F. Siccardi, R. Maruccia, A. Faragli, G. Ricevuti

Department Of Internal Medicine And Therapeutics, Postgraduate School Of Emergency Medicine, University Of Pavia, Asp-Id, Pavia, Italy

Background: Galectin-3 is a member of the lectin family and contains a carbohydrate-recognition-binding domain (CRD) of about 130 amino acids that enable the specific binding of BETA-galactosides. High levels of the protein have been found to be a biomarker for cancer and inflammation but especially for stroke and heart diseases involving myofibroblast proliferation, fibrogenesis, tissue repair, inflammation, and ventricular remodeling which cause heart failure. The discovery of a more recent role of Galectin-3 has been in cancer and apoptosis, and has been important in pursuing studies in a possible correlation between higher levels of Gal-3 in Alzheimer’s Disease (AD).

Methods: AD is a neurodegenerative disorder of the central nervous system which leads to dementia and eventually death, due to a variety of pathophysiological conditions. Levels of serum Galactin-3 are generally higher in AD patients compared to the control group. The difference between healthy subjects and diseased patients increases when the condition becomes more severe, while a smaller difference is seen among patients with a milder cognitive impairment.

We therefore put submit a observational project idea in which we follow patients affected by AD with and without heart failure. Galactin-3 levels will be measured in all patients in addition to other biomarkers associated with proliferation and heart failure. Moreover we will grow an Alzheimer cell line in cultures with and without Galactin-3 to assess the possible modulation of specific mRNA in the presence and absence of electromagnetic field stimuli.

Results: We look forward to assessing the results of the project and verify whether Galactin-3 is in fact significantly altered in patients with AD and therefore a useful biomarker for AD diagnosis in addition to other traditional tests. Furthermore we will also evaluate the results obtained by the cell cultures to verify whether Galactin-3 has a protective and immune function.

Conclusions: Gal-3 is also an important biomarker for assessment of the risk and progression of a wide array of illnesses and chronic diseases. In general patients who have been monitored and have been found with Gal-3 levels superior to the average population have a predisposition to developing a chronic disease.