Phenotyping congestion in patients with acutely decompensated heart failure with preserved and reduced ejection fraction: The Decongestion duRing therapY for acute decOmpensated heart failure in HFpEF vs HFrEF- DRY-OFF study.

AIMS: To evaluate pulmonary and intravascular congestion at admission and repeatedly during hospitalization for acute decompensated heart failure (ADHF) in HFrEF and HFpEF patients using lung (LUS) and inferior vena cava (IVC) ultrasound. METHODS AND RESULTS: Three-hundred-fourteen patients (82±9 years; HFpEF =172; HFrEF=142) admitted to Internal Medicine wards for ADHF were enrolled in a multi-center prospective study. At admission HFrEF presented higher indexes of pulmonary and intravascular congestion (LUS-score: 0.9 ±â€¯0.4 vs 0.7 ±â€¯0.4; p<0.01; IVC end-expiratory diameter: 21.6 ±â€¯5.1 mm vs 20±5.5 mm, p<0.01; IVC collapsibility index 24.4 ±â€¯17.4% vs 30.9 ±â€¯21.1% p<0.01) and higher Nt-proBNP values (8010 vs 3900 ng/l; p<0.001). At discharge, HFrEF still presented higher B-scores (0.4 ±â€¯4 vs 0.3 ±â€¯0.4; p = 0.023), while intravascular congestion improved to a greater extent, thus IVC measurements were similar in the two groups. No differences in diuretic doses, urine output, hemoconcentration, worsening renal function were found. At 90-days follow up HF readmission/death did not differ in HFpEF and HFrEF (28% vs 31%, p = 0,48). Residual congestion was associated with HF readmission/death considering the whole population; while intravascular congestion predicted readmission/death in the HFrEF, no association between sonographic indexes and the outcome was found in HFpEF. CONCLUSIONS: Serial assessment of pulmonary and intravascular congestion revealed a higher burden of fluid overload in HFrEF and, conversely, a greater reduction in intravascular venous congestion with diuretic treatment. Although other factors beyond EF could play a role in congestion/decongestion patterns, our data may be relevant for further phenotyping HF patients, considering the importance of decongestion optimization in the clinical approach.

Predictive accuracy of triage nurses evaluation in risk stratification of syncope in the emergency department.

BACKGROUND: Syncope is a common clinical problem that accounts for 1-3% of all emergency department (ED) visits. Its prognosis is extremely variable with a 1-year mortality that may reach 30%. There are no available data about the accuracy of nursing triage in identifying high-risk syncope. The aim of our study was to evaluate the predictive accuracy of nursing triage in identifying high-risk syncope. METHODS: We conducted a retrospective study on 678 consecutive patients who presented with syncope at four EDs. For each patient, nursing triage, comorbidities, clinical features and adverse events that occurred both in the ED and at 10-day follow-up were assessed. Adverse events included death, readmission to ED, need for major therapeutic procedures, cardiopulmonary resuscitation, intensive care unit admittance, acute antiarrhythmic therapy and major causes of syncope identified during the ED evaluation. Predictive accuracy of nursing triage was evaluated. RESULTS: We observed a total of 55 (8.1%) adverse events. Eight of them (9.4%) occurred among the 85 patients who were identified as high priority by nursing triage. Sensitivity (Sn) and specificity (Sp) of urgent nursing triage in identifying adverse outcomes in the ED (19 patients) were 21% (95% CI 3% to 39%) and 88% (95% CI 85% to 90%), while the positive likelihood ratio (LR+) and negative likelihood ratio (LR-) were 1.7 and 0.9, respectively. Sn and Sp for 10-day adverse events were 15% (95% CI 5% to 24%) and 88% (95% CI 85% to 90%), respectively, with a LR+ of 1.18 and a LR- of 0.98. CONCLUSIONS: Nursing triage was characterised by a low predictive accuracy in identifying high-risk individuals.

A prototype of an adjustable advanced reciprocating gait orthosis (ARGO) for spinal cord injury (SCI).

OBJECTIVE: To develop a reciprocating gait orthosis which could be used in different sized patients. DESIGN: Clinical trial and orthotic development. SETTING: A large rehabilitation hospital in Rome, Italy PATIENTS AND METHODS: To carry out this project normal reciprocating gait orthosis parts were used. The device was modified to adjust the hip-ankle height, and the hip-hip distance. It was tested, by five patients already walking with standard ARGO, to evaluate the performances of the orthosis. The device has been tested on seven newly injured patients fulfilling specific criteria of different height and weight. MAIN OUTCOME MEASURES: Prototype suitability; patients appreciation. RESULTS: The device can be used for persons between 1.60 m and 1.85 m tall, weighing up to 100 kg. The orthosis allows an upright position without the use of the hands, and walking with a walker or with two canes. The foot orthosis cover sizes 36-40 (British 3-7) and 41-45 (British 7-11). With the exception of donning, doffing and lifting, the walking performances of the prototype and the general appreciation is comparable with those of a standard device. After a short period of training all seven patients were able to walk in the parallel bars. All of them expressed general appreciation for the device; despite this only four patients wanted the orthosis, two refused it and one has not decided yet. CONCLUSIONS: The prototype allows the same standing and walking performances of normal ARGO. It could be used in spinal cord injury patients to let them test the potential of the device and thus be useful in the effort to reduce the percentage of ARGO rejection.