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1.
Acad Emerg Med ; 2021 Feb 12.
Artículo en Inglés | MEDLINE | ID: covidwho-1083123

RESUMEN

OBJECTIVES: Physicians' gestalt is central in the diagnostic pipeline of suspected COVID-19, due to the absence of a single tool allowing conclusive rule in or out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID-19 in the ED, based on clinical findings or on a combination of clinical findings and bedside imaging results. METHODS: From 1st to 30th of April 2020, patients with suspected COVID-19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID-19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt, CG), and after evaluation of clinical features and results of lung ultrasound or chest x-ray (clinical and bedside imaging integrated gestalt, CBIIG). The final diagnosis was adjudicated after independent review of 30-day follow-up data. RESULTS: Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID-19. The area under the curve (AUC), sensitivity and specificity of CG and CBIIG for COVID-19 were 80.8% and 91.6% (p<0.01), 82.9% and 91.4% (p=0.01), 78.6% and 91.8% (p<0.01), respectively. CBIIG had similar AUC and sensitivity to RT-PCR for SARS-CoV-2 on the first nasopharyngeal swab per se (93.5%, p=0.24; and 87%, p=0.17, respectively). CBIIG plus RT-PCR had a sensitivity of 98.4% for COVID-19 (p<0.01 vs RT-PCR alone), as compared to 95.9% for CG plus RT-PCR (p=0.05). CONCLUSIONS: In suspected COVID-19, CG and CBIIG have fair diagnostic accuracy, in line with physicians' gestalt for other acute conditions. Negative RT-PCR plus low probability based on CBIIG can rule out COVID-19 with a relative low number of false negative cases.

2.
Epidemiol Prev ; 44(5-6 Suppl 2): 216-225, 2020.
Artículo en Inglés | MEDLINE | ID: covidwho-1068142

RESUMEN

OBJECTIVES: to explore clinical and epidemiological characteristics associated with an imaging feature of COVID-19 pneumonia at disease onset, in order to identify factors that may be evaluable by general practitioners at patient's home, and which may lead to identify a more severe disease, needing hospitalization. DESIGN: this is a retrospective/prospective observational hospital cohort. SETTING AND PARTICIPANTS: the study population includes all patients consecutively admitted to the emergency department of Città della salute e della scienza University Hospital from 01.03 to 31.05.2020 with a confirmed diagnosis of SARS-CoV-2 infection. MAIN OUTCOME MEASURES: patients were classified in two groups according to the findings of X-ray imaging, lung ultrasound and chest computer tomography, as pneumonia or not pneumonia patients. RESULTS: in multivariable analysis, factors most strongly associated with emergency department admission with pneumonia were age, oxygen saturation <90% (adj OR 4.16 ;95%CI 1.44-12.07), respiratory rate >24 breaths/min (adj OR 6.50; 95%CI 2.36-17.87), fever ≥38° (adj OR 3.05; 95%CI 1.53-6.08) and the presence of gastroenteric symptoms (vomiting and diarrhea). A delay (> 7 days) between the appearance of the initial lung symptoms (cough and dyspnea) and the admission to the emergency department was also related to a higher probability of receiving a positive imaging report (OR 4.99; 95%CI 2,02-12,34). CONCLUSIONS: in order to reorganize the management of COVID-19 patients in Italy, in view of the risk of a second wave of epidemic or of local outbreaks, it would be desirable to relocate the triage, and possibly the patient's care, from hospital to home. In this scenario it is important to identify all symptoms and signs associated with COVID-19 pneumonia that would facilitate the decision-making process of GPs leading to patients hospitalization.


Asunto(s)
/epidemiología , Pandemias , Neumonía Viral/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Comorbilidad , Diarrea/epidemiología , Diarrea/etiología , Disnea/epidemiología , Disnea/etiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitales Universitarios/estadística & datos numéricos , Humanos , Italia/epidemiología , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/etiología , Oxígeno/sangre , Neumonía Viral/sangre , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/virología , Estudios Prospectivos , Frecuencia Respiratoria , Estudios Retrospectivos , Evaluación de Síntomas , Factores de Tiempo , Vómitos/epidemiología , Vómitos/etiología
4.
Ann Emerg Med ; 2020 Oct 13.
Artículo en Inglés | MEDLINE | ID: covidwho-1037132

RESUMEN

STUDY OBJECTIVE: Accurate diagnostic testing to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical. Although highly specific, SARS-CoV-2 reverse transcriptase-polymerase chain reaction (RT-PCR) has been shown in clinical practice to be affected by a noninsignificant proportion of false-negative results. This study seeks to explore whether the integration of lung ultrasonography with clinical evaluation is associated with increased sensitivity for the diagnosis of coronavirus disease 2019 pneumonia, and therefore may facilitate the identification of false-negative SARS-CoV-2 RT-PCR results. METHODS: This prospective cohort study enrolled consecutive adult patients with symptoms potentially related to SARS-CoV-2 infection who were admitted to the emergency department (ED) of an Italian academic hospital. Immediately after the initial assessment, a lung ultrasonographic evaluation was performed and the likelihood of SARS-CoV-2 infection, based on both clinical and lung ultrasonographic findings ("integrated" assessment), was recorded. RT-PCR SARS-CoV-2 detection was subsequently performed. RESULTS: We enrolled 228 patients; 107 (46.9%) had SARS-CoV-2 infection. Sensitivity and negative predictive value of the clinical-lung ultrasonographic integrated assessment were higher than first RT-PCR result (94.4% [95% confidence interval {CI} 88.2% to 97.9%] versus 80.4% [95% CI 71.6% to 87.4%] and 95% [95% CI 89.5% to 98.2%] versus 85.2% [95% CI 78.3% to 90.6%], respectively). Among the 142 patients who initially had negative RT-PCR results, 21 tested positive at a subsequent molecular test performed within 72 hours. All these false-negative cases were correctly identified by the integrated assessment. CONCLUSION: This study suggests that, in patients presenting to the ED with symptoms commonly associated with SARS-CoV-2 infection, the integration of lung ultrasonography with clinical evaluation has high sensitivity and specificity for coronavirus disease 2019 pneumonia and it may help to identify false-negative results occurring with RT-PCR.

5.
Crit Care ; 24(1): 702, 2020 12 24.
Artículo en Inglés | MEDLINE | ID: covidwho-992527

RESUMEN

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.


Asunto(s)
/diagnóstico por imagen , Consenso , Ecocardiografía/normas , Testimonio de Experto/normas , Internacionalidad , Sistemas de Atención de Punto/normas , /terapia , Ecocardiografía/métodos , Testimonio de Experto/métodos , Humanos , Pulmón/diagnóstico por imagen , Tromboembolia/diagnóstico por imagen , Tromboembolia/terapia , Triaje/métodos , Triaje/normas , Ultrasonografía/normas
6.
Chest ; 158(3): e93-e97, 2020 09.
Artículo en Inglés | MEDLINE | ID: covidwho-728486

RESUMEN

A subset of patients with coronavirus disease 2019 (COVID-19) and lung involvement pose a disposition challenge, particularly when hospital resources are constrained. Those not in respiratory failure are sent home, often with phone monitoring and/or respiratory rate and oxygen saturation monitoring. Hypoxemia may be a late presentation and is often preceded by abnormal lung findings on ultrasound. Early identification of pulmonary progression may preempt emergency hospitalization for respiratory decompensation and facilitate more timely admission. With the goal of safely isolating infected patients while providing advanced monitoring, we present a first report of patient self-performed lung ultrasound in the home with a hand-held device under the guidance of a physician using a novel teleguidance platform.


Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/diagnóstico , Servicios de Atención de Salud a Domicilio , Pulmón/diagnóstico por imagen , Monitoreo Fisiológico/métodos , Neumonía Viral/diagnóstico , Ultrasonografía/métodos , Adulto , Femenino , Humanos , Pandemias
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