Lung Ultrasound Improves Outcome Prediction over Clinical Judgment in COVID-19 Patients Evaluated in the Emergency Department.

In the Emergency Department (ED), the decision to hospitalize or discharge COVID-19 patients is challenging. We assessed the utility of lung ultrasound (LUS), alone or in association with a clinical rule/score. This was a multicenter observational prospective study involving six EDs (NCT046291831). From October 2020 to January 2021, COVID-19 outpatients discharged from the ED based on clinical judgment were subjected to LUS and followed-up at 30 days. The primary clinical outcome was a composite of hospitalization or death. Within 393 COVID-19 patients, 35 (8.9%) reached the primary outcome. For outcome prognostication, LUS had a C-index of 0.76 (95%CI 0.68−0.84) and showed good performance and calibration. LUS-based classification provided significant differences in Kaplan−Meier curves, with a positive LUS leading to a hazard ratio of 4.33 (95%CI 1.95−9.61) for the primary outcome. The sensitivity and specificity of LUS for primary outcome occurrence were 74.3% (95%CI 59.8−88.8) and 74% (95%CI 69.5−78.6), respectively. The integration of LUS with a clinical score further increased sensitivity. In patients with a negative LUS, the primary outcome occurred in nine (3.3%) patients (p < 0.001 vs. unselected). The efficiency for rule-out was 69.7%. In unvaccinated ED patients with COVID-19, LUS improves prognostic stratification over clinical judgment alone and may support standardized disposition decisions.

A 4C mortality score based dichotomic rule supports Emergency Department discharge of COVID-19 patients.

BACKGROUND: For COVID-19 patients evaluated in the Emergency Department (ED), decision on hospital admission vs. home discharge is challenging. The 4C mortality score (4CMS) is a prognostication tool integrating key demographic/clinical/biochemical data validated for COVID-19 inpatients. We sought to derive and validate a dichotomic rule based on 4CMS identifying patients with mild outcomes, suitable for safe ED discharge. METHODS: Derivation was performed in a prospective cohort of ED patients with suspected COVID-19 from two centers (April 2020). Validation was pursued in a prospective multicenter cohort of ED patients with confirmed COVID-19 from 6 centers (October 2020 to January 2021). Chest X-ray (CXR) images were independently scored. The primary composite outcome was all-cause 30-day mortality or hospital admission. Secondary outcomes were ED re-visit, oxygen therapy and ventilation. RESULTS: In a derivation cohort of 838 ED patients with suspected COVID-19, 4CMS≤8 was associated with low outpatient mortality (0.4%) and was thus selected as a feasible discharge rule. In a validation cohort of 521 COVID-19 outpatients, the mean age was 51±17 years; 97 (18.6%) patients had ≥1 CXR infiltrate. The 4CMS had an AUC of 0.82 for the primary outcome and 0.93 for mortality, outperforming other scores (CURB-65, qCSI, qSOFA, NEWS) and CXR. In 474 (91%) patients with 4CMS≤8, the mortality rate was 0.2% and the hospital admission rate was 6.8%, versus 12.8% and 36.2% for 4CMS≥9 (P<0.001). CXR did not provide additional discrimination. CONCLUSIONS: COVID-19 outpatients with 4CMS≤8 have mild outcomes and can be safely discharged from the ED. [NCT0462918].

[When medicine is respectful.] / Quando la medicina è rispettosa.

There is a relevant gap between the medicine learned on books and the clinical practice made of suffering humans facing us. Guidelines recommendations don't usually cover this aspect. The Slow Medicine movement, born in 2011, stands as a model a sober respectful and right healthcare. Everyone is entitled to express himself freely: a respectful medicine receives worths, choices and tendencies of the patient in every moment of his life. The keystone of slow decisions is to respect patient's freedom and autonomy, and to recognize his ability to make decisions even if he is elderly and frail. Listening to a patient's biography and welcoming his personal needs and expectations allows the physician to spread comfort, trust and gratification.

After the first wave and beyond lockdown: long-lasting changes in emergency department visit number, characteristics, diagnoses, and hospital admissions.

The first wave (FW) of COVID-19 led to a rapid reduction in total emergency department (ED) visits and hospital admissions for other diseases. Whether this represented a transient "lockdown and fear" phenomenon, or a more persisting trend, is unknown. We divided acute from post-wave changes in ED flows, diagnoses, and hospital admissions, in an Italian city experiencing a FW peak followed by nadir. This multicenter, retrospective, cross-sectional study involved five general EDs of a large Italian city (January-August 2020). Percent changes were calculated versus 2019, using four 14-day periods (FW peak, early/mid/late post-wave). ED visits were 147,446 in 2020, versus 214,868 in 2019. During the FW peak, visits were reduced by 66.4% (P < 0.001). The drop was maximum during daytime (69.8%) and for pediatric patients (89.4%). Critical triage codes were unchanged. Reductions were found for all non-COVID-19 diagnoses. Non-COVID-19 hospital admissions were reduced by 39.5% (P < 0.001), involving all conditions except hematologic, metabolic/endocrine, respiratory diseases, and traumas. In the early, mid, and late post-wave periods, visits were reduced by 25.4%, 25.3% and 23.5% (all P < 0.001) respectively. In the late period, reduction was greater for female (27.9%) and pediatric patients (44.6%). Most critical triage codes were unchanged. Oncological, metabolic/endocrine, and hematological diagnoses were unchanged, while other diagnoses had persistent reductions. Non-COVID-19 hospital admissions were reduced by 12.8% (P = 0.001), 6.3% (P = 0.1) and 12.2% (P = 0.001), respectively. Reductions in ED flows, led by non-critical codes, persisted throughout the summer nadir of COVID-19. Hospital admissions for non-COVID-19 diseases had transient changes.

Inaccuracy of Right Atrial Pressure Estimates Through Inferior Vena Cava Indices.

The precision of echocardiography in estimating pulmonary pressures has been debated. A value of right atrial pressure (RAP) is needed for pulmonary pressure estimation, and it could be partly responsible for the estimation error. Several schemes based on the inferior vena cava (IVC) are commonly used in clinical practice and in experimental studies for RAP estimation. However, the majority lack proper validation, and thus far, no study has compared them all. In this prospective, blinded study, a comprehensive transthoracic echocardiography was performed on 200 patients referred for right heart catheterization. The IVC was measured in different views and RAP was estimated according to 6 different schemes. One hundred ninety patients were suitable for analysis. IVC measurements were significantly but poorly associated with invasive RAP. All RAP schemes showed poor accuracy compared with invasive RAP (average accuracy 34%). None of the schemes showed a clear superiority over the others. No echocardiographic or clinical variables showed a relevant impact on the estimation error. In conclusion, RAP estimation based on the IVC is highly inaccurate irrespective of the method used and should be avoided whenever possible. Whether adding estimated RAP values affects the estimation of pulmonary pressures is yet to be determined.

Left heart morphology and function in primary aldosteronism.

Primary aldosteronism is the most frequent cause of secondary hypertension, accounting for up to 11% of cases in selected populations. Patients affected by primary aldosteronism have shown higher prevalence of cardiovascular and cerebrovascular events compared with patients with essential hypertension, despite similar blood pressure levels. Several studies have been performed over past years aiming to explain these data; many of these evaluated echocardiographic differences in hypertension-related cardiac organ damage between primary aldosteronism and essential hypertension. This article summarizes the present knowledge about structural and functional alteration of the human left heart in primary aldosteronism.

Arterial stiffness: from physiology to clinical implications.

Current European guidelines for the management of arterial hypertension introduce the assessment of arterial stiffness by pulse wave velocity (PWV) as an index of hypertension-related cardiovascular target organ damage. An increase in arterial stiffness is related to haemodynamic modifications at the level of the aorta, leading to a rise in cardiac afterload, a reduction in coronary perfusion and an overstretch of the aortic walls. An increasing number of studies have demonstrated the accuracy of PWV as an independent predictor of cardiovascular events and cardiovascular mortality in patients with different co-morbidities and cardiovascular risk. Many strategies have demonstrated their efficacy in preventing arterial stiffening; therapy of arterial hypertension is the mainstay in the management of patients with increased PWV and altered pulse wave reflection. Literature has clearly shown the specific efficacy of drugs interfering with the renin-angiotensin-aldosterone system and calcium-channel blockers in the control of central haemodynamics, particularly when compared with ß-blockers (ß-adrenoceptor antagonists). The same action has not yet been demonstrated on PWV. Further studies are needed to assess the real relative efficacy of different drug classes on the management of arterial stiffness and the clinical and prognostic relevance of these therapies.