Role of Lung Ultrasound in the Management of Patients with Suspected SARS-Cov-2 Infection in the Emergency Department (preprint)

Background: the LUS score has been proposed as an optimal scheme for the ultrasound study of the patient with suspected / confirmed COVID-19 pneumonia. The aim of our study was to evaluate the use of lung ultrasound as a diagnostic tool for diagnosing SARS-CoV-2 pneumonia, and to examine the validity of LUS score for the diagnosis of COVID-19 pneumonia, and to correlate with hospitalization rate and 30-days mortality.Material & methods: a retrospective analysis was performed on all patients who were referred to the General Emergency Department of the S. Orsola-Malpighi Hospital from April 2020 to May 2020 for symptoms suspected for SARS-CoV-2 infection. The ultrasound examination was based on a common execution scheme called LUS score, as previously described.Results & Conclusions: LUS score correlates with the degree of clinical severity and respiratory failure (P/F ratio, Delta (A-a), Delta (A-a) increase). COVID-19 patients with a LUS score > 7 require the use of oxygen support; a value > 10 is associated with an increased risk of oro-tracheal intubation. The LUS score presents higher values in hospitalized patients, increasing according to the degree of care intensity. COVID-19 died patients were characterized by a mean LUS score of 11 at presentation to the emergency department. A LUS score value > 7.5 displays a sensitivity of 83% and specificity of 89% against 30-days mortality in COVID-19 patients. Lung ultrasound seems to be an optimal first level method for pneumonia detection in patients with suspected SARS-CoV-2 infection.

Lung Ultrasound to Predict COVID-19 Pneumonia: A Multicenter Descriptive Study (preprint)

Background: The pandemic surge of Coronavirus disease 2019 (COVID-19) is posing the unprecedent challenge of rapidly identifying and isolating probable cases and diagnosing the main respiratory complications. We aimed to describe the application of a lung ultrasound (LUS)-based diagnostic approach, combining the LUS likelihood of COVID-19 pneumonia with patient’s symptoms and clinical history.Methods: This is an international multicenter prospective observational study on patients suspected for COVID-19, presenting to 22 different US and European hospitals. Patients underwent LUS and reverse transcription-polymerase chain reaction (RT-PCR) swab test. We identified 3 different clinical phenotypes based on pre-existing chronic cardiac or respiratory diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to 4 different patterns, characterized by the presence and distribution of typical and atypical LUS signs: high (HPLUS), intermediate (IPLUS), alternative (APLUS) and low (LPLUS) probability patterns. The association between the combination of patterns and phenotypes with RT-PCR results was described and analyzed.Findings: We studied 1462 patients, classified in mild (n=400), severe (n=727) and mixed (n=335) phenotypes. In the overall population, the HPLUS corresponded to a positive RT-PCR in 92.6% of cases, with similarly high percentages in all clinical phenotypes ranging from 87.5% (mild) to 90.3% (mixed) and 96.5% (severe). The IPLUS yielded a lower match with positive RT-PCR (65.7%). In patients with respiratory failure, the LPLUS predicted a negative RT-PCR in 100% of cases. In the overall population, the APLUS indicated an alternative pulmonary condition in 81.1% of patients. At multivariate analysis the HPLUS strongly predicted RT-PCR positivity (odds ratio 4.173, interquartile range 2.595-6.712, p<0.0001), independently from age, low oxygen saturation and dyspnea.Interpretation: Combining LUS patterns of probability for interstitial pneumonia with clinical phenotypes at presentation could facilitate the early diagnosis of COVID-19 or suggest an alternative pulmonary condition. This approach may be useful to rapidly guide and support patient’s allocation for a wiser use of hospital resources during a pandemic surge.Funding: None.Conflict of Interest: The authors declare no conflicts of interest. Ethical Approval: The local Ethical Committee Boards of each center approved the study, and the study was conducted following the ethical standards of the 1964 Helsinki declaration and its later amendments and with local guidelines for good clinical practice.

Role of ROX Index in the first assessment of COVID-19 patients in the Emergency Department (preprint)

Background: In Italy, since the first symptomatic cases of Coronavirus disease 2019 (COVID-19) appeared in late February 2020, 205.463 cases of Severe Acute Respiratory Syndrome 2 (SARS-CoV-2) were reported as of April 30, causing an high rate of hospital admission through the Emergency Department (ED).Objectives: The aim of the study was to evaluate the accuracy of ROX index in predicting hospitalization and mortality in patients with suspected diagnosis of COVID-19 in the ED. Secondary outcomes were to assess the number of readmissions and the variations of ROX index between first and second admission.Methods: This is an observational prospective monocentric study, conducted in the ED of Policlinico Sant’Orsola-Malpighi in Bologna. We enrolled 1371 consecutive patients with suspected COVID-19 and ROX index was calculated in 554 patients. Patients were followed until hospital discharge or death. Results: ROX index value < 25.7 was associated with hospitalization (AUC=0.737, 95%CI 0.696–0.779, p<0.001). ROX index < 22.3 is statistically related with higher 30-days mortality (AUC= 0.764, 95%CI 0.708-0.820, p<0.001). 8 patients were discharged and returned in the ED within the following 7 days, their mean ROX index was 30.3 (6.2; range 21.9-39.4) at the first assessment and 24.6 (5.5; 14.5-29.5) at the second assessment, (p=0.012).Conclusion: ROX index, together with laboratory, imaging and clinical findings, can help discriminate patients suspected for COVID-19 requiring hospital admission, their clinical severity and their mortality risk. Furthermore, it can be useful to better manage these patients in territorial healthcare services, especially in the hypothesis of another pandemic.

Non-COVID-19 patients in times of pandemic: decreased emergency department visits and increased out-of-hospital mortality in Northern Italy (preprint)

ObjectiveThe aim of this was to assess the short-term impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. MethodsWe conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year, using Joinpoint regression models and incidence rate ratios. ResultsNon-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of ED visits was observed in all age groups and across all severity and diagnosis groups. In the lockdown period a significant increase was found in overall out-of-hospital mortality (43.2%) and cause-specific out-of-hospital mortality related to neoplasms (76.7%), endocrine, nutritional and metabolic (79.5%) as well as cardiovascular (32.7%) diseases. ConclusionsThe pandemic caused a sudden drop of ED visits and hospitalizations of non-COVID-19 patients during the lockdown period, and a concurrent increase in out-of-hospital mortality mainly driven by deaths for neoplasms, cardiovascular and endocrine diseases. The findings of this study might be useful to understand both the population reaction and the healthcare system response at the early phases of the pandemic in terms of reduced demand of care and systems capability in intercepting it.

Alveolar-to-arterial oxygen gradient: role in the management of COVID-19 infection mild population (preprint)

COVID-19 infection is frequently associated with radiological diagnosis of interstitial pneumonia and alteration in gases exchange. We decided to test arterial blood gas assay parameters, in particular alveolar-to-arterial oxygen gradient (AaDO2), in predicting the need of hospitalization, the survival rate and in identifying pneumonia in patients with SARS-CoV-2 infection.We conducted an observational prospective study in one of the Emergency Department of our city. We included consecutive patients with symptoms likely related to SARS-CoV-2 infection, confirmed either with positive nasal pharyngeal swabs and/or with suggestive radiological findings. Areas under the curve of the receiver operator characteristic curve were computed to predict need of hospitalization and the presence of pneumonia. Survival curves were analyzed using a Log-rank test. P-value less than 0.05 were considered statistically significant.We enrolled 825 patients; the final population was composed by 530 patients. Most of them were hospitalized due to complications, the mortality was 14% but no death occured in the ED. It results that a threshold for AaDO2 of 27 could predict the need of hospitalization as well as a threshold for AaDO2 of 24 could identify the presence of pneumonia. Survival curves revealed that patients with a value of AaDO2 less than or equal to 40 had a better survival. We suggest the application of ABG parameters, in particular AaDO2, during the first assessment of COVID-19 patients in the ED, because they could be additional tools to help the emergency physician to evaluate the clinical severity of patients.The study was approved by our local ethics committee with the number 551/2020/Oss/AOUBo.

Non-COVID-19 Patients in Times of Pandemic: Decreased Emergency Department Visits and Increased Out-of-Hospital Mortality in Northern Italy (preprint)

Background: The COVID-19 pandemic forced healthcare services organization to adjust to healthcare needs of a mutating population. In this context, our aim was to assess the short-term impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of ED visits, hospitalizations and mortality.Methods: We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year, using Joinpoint regression models and incidence rate ratios.Findings: Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case hospitalized for COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously with the growth of the SARS-CoV-2 curve. The marked reduction of ED visits was observed in all age groups and across all severity codes and diagnosis groups. In the lockdown period a significant increase was found in overall out-of-hospital mortality (43·2%) and cause-specific out-of-hospital mortality related to neoplasms (76·7%), endocrine, nutritional and metabolic (79·5%) as well as cardiovascular (32·7%) diseases.Interpretation: Our main finding is a sudden drop of ED visits and hospitalizations of non-COVID-19 patients during the pandemic and the concurrent increase in out-of-hospital mortality, particularly for neoplasms, cardiovascular and endocrine diseases. As a second phase of the COVID-19 pandemic is currently underway, the scenario described in this study might be useful to understand both the population reaction and the healthcare system response at the early phases of the pandemic in terms of reduced demand of care and systems capability in intercepting it.Fundings: This study received no specific funding.Declaration of Interests: All the authors declare no conflict of interests.Ethics Approval Statement: The study was approved by the Emilia Romagna Ethical Committee on August 3rd, 2020.

Management reorganization of a Radiology ward during the Covid-19 pandemic in a University Hospital structured inpavilions. (preprint)

Objective: The aim of the recent management reorganization of the Emergency Room and Radiology ward was to face the recent Coronavirus pandemic in the most rational way possible, to preserve the essential role of these Units in the complex context of a pavillions structured Hospital. Methods: The most challenging management criticalities posed by the recent Coronavirus pandemic were individually analyzed and dealt with. The pavilions structure of our Hospital, biohazard management, shortage of personnel and shortage or temporary inadequacy of personal protective equipment were addressed as the most urgent and important problems.Results: A strategic use of the Radiology Information System and Picture Archiving And Communication System (RIS-PACS), dedicated ambulances with specific disinfection procedures, the institution of dedicated pavilions, wards, checkpoints and different paths for COVID-19 (Coronavirs Disease 2019) and non COVID-19 patients, frequent sanification procedures, serological screening for employees and emergency dedicated staff recruitment were put to place as a result of said analysis.Nevertheless, all of these goals couldn’t have been achieved without a constant sense of responsibility of the employees involved.Conclusions: A rational analysis of the most critical problems associated with a pandemic is vital to provide a fast and effective response, and represents a valuable wealth of experience in case of future pandemics.