[Statistical evaluation of potential mistakes and malpractice in a Chest Pain Unit]. / Valutazione statististica riguardante i possibili errori dimalpractice in una unità del dolore toracico.

AIMS: The Chest Pain Unit (CPU) of Policlinico Umberto I, established in 2008, is charged with the management of patients with non-traumatic chest pain transferred from the Emergency Department and aims at: a) an early recognition of patients at high risk of acute coronary syndrome (ACS), in order to perform a primary PCI within 90 minutes; b) an early diagnosis of patients at low risk of ACS in order to discharge them in a short time, and c) the diagnostic performance of clinical tests in patients at intermediate risk of ACS in order to identify those who require either a new PCI or a coronary artery bypass graft (CABG). The purpose is to avoid malpractice which could even imply the risk of legal conflicts. MATERIALS AND METHODS: We evaluated the total number of admissions to the Emergency Department of Policlinico Umberto I in the period 2010-2011 and selected the patients with non-traumatic chest pain and acute coronary syndrome. In the Chest Pain Unit, patients with non-traumatic chest pain or ACS were recruited through a) the use of the Chest Pain Score to define the typicality or atypicality of chest pain; b) the stratification of the risk of ACS using the modified Braunwald Score; and c) the stratification of patients at intermediate or high risk of ACS using the GRACE ACS Model in order to perform a PCI. RESULTS: In the period 2010-2011, 603 patients were admitted to the CPU with non-traumatic chest pain. Of them, 15.75% (95) were diagnosed with atypical chest pain; 27.03% (163) with chronic stable angina pectoris; 9.3% (56) received a diagnosis of chronic heart failure and 47.92% (289) suffered from non ischemic cardiovascular disease. Other 124 subjects were admitted to the CPU with a diagnosis of ACS, but only in 91.93% of the cases such diagnosis was confirmed, whereas for the remaining 8.06% was discarded. On the whole, 54.2% (394) of the 727 patients admitted to the CPU with non-traumatic chest pain and acute coronary syndrome showed a low cardiovascular risk; 30.12% (219) were at intermediate risk and 15.68% (144) at high risk. DISCUSSION: The aim of the CPU is to accomplish a selection of the subjects at high risk of ACS, to drastically reduce the time of diagnosis and treatment to 24-36 hours and to avoid possible mistakes or adverse events by using both unsophisticated diagnostic tests and a personalized management of diagnosis and treatment.

[An unusual cause of chest pain in]. / Una causa insolita di dolore toracico in Chest Pain Unit: un caso di miocardite.

Myocarditis seems to be mostly caused by a viral infection or more rarely by a pharmacological hypersensitivity or by radiations exposure. Nevertheless, it is not so easy to know the ethiopathogenesis of the myocarditis, because mostly it is impossible to determine the infectious agent that causes the pathology even if it is isolated. The diagnosis could often remain uncertain, so a suspect of myocarditis has to be opportunely confirmed by specific serological and diagnostic investigations, in order to avoid the appearance of a dilated cardiomyopathy which is one of its principal sequences.

[A prompt diagnosis of Steinert's dystrophy in emergency unit]. / Una pronta diagnosi di distrofia miotonica di Steinert in Pronto Soccorso.

Atrial fibrillation is frequently observed in Fist Aid. A rare cause is myotonic dystrophy There are two forms: Steinert's dystrophy caused by a defect of a gene myotoninaprotein kinase and Promm secondary to a defect of a Zinc Finger Protein Gene Clinical manifestations are localized in skeletal and face muscles, vitreous body, sexual glands, endocrine system, smooth muscle, central nervous system and myocardium. Sometimes, in mild and unrecognized forms of this rare disease there are arrhythmias as atrial fibrillation. We report the clinical case of a 52 year-old man, with a suspect diagnosis of Steinert's dystrophy, admitted to the emergency room for a persistent atrial fibrillation. The patient begins oral anticoagulation therapy. The patient perform a transesophageal echocardiogram before the electrical cardioversion with reset to sinus rhythm. In conclusion, with improving the screening methods of patients with primary and secondary myopathies, it has been seen an increase of cases in which a cardiac involvement occurred before or after the onset of the neuromuscular disorders. One of the most frequent alterations is represented by atrial fibrillation, responsible for an increased risk of cerebral embolism, with absolute indication for oral anticoagulation therapy. The myopathy more frequently associated with atrial fibrillation, is myotonic dystrophy, although the risk of cerebral embolism in these patients does not appear to be higher than the general population. The present case report is a spur to perform the diagnosis of Steinert disease in cases admitted to an Emergency Room because of arrhytmias, because of the possibility to perform fast and reliable specific genetic tests. A similar praxis confers to these Units an even more diagnostic clinical role.

[High digoxin serum levels in an elderly patient for the endogenous digoxin-like immunoreactive substances. A case report]. / Elevati livelli di digossinemia in una paziente anziana per ifattori endogeni immunoreattivi digossino-simili. Caso clinico.

UNLABELLED: Digoxin is typically prescribed in the treatment of heart failure. Its limited therapeutic range requires systematic monitoring of plasmatic concentration through immunoreactive tests. Laboratory results, however, can be altered by the presence of digoxin-like immunoreactive factors (DLIF) which are released in all clinical conditions involving volemic expansion. CASE REPORT: An 86-year-old woman arrived in emergency with severe dyspnoea, atrial flutter and a medical history of ischemic cardiopathy. The patient was treated with ACE inhibitor, furosemide, spironolactone and digoxin. The first lab test for digoxin showed levels of digoxin of 7.05 ng/ml. Although the patient did not show any clinical evidence of digital intoxication nor was she treated with drugs which might interfere with digoxin kinetics and even if she had markers of renal function within clinical limits, digoxin was suspended and a treatment was initiated with 0.9% NaCl solution and furosemide. The second lab test showed levels of digoxin of 8.38 ng/ml. A possible interference of DLIF with immunoreactive tests was therefore assumed. MATERIALS AND METHODS: The patient's serum was ultrafiltered and centrifugated to remove possible DLIF; subsequently, the measurement of digoxin levels was repeated. As a result, the digoxin level decreased to 0.25 ng/ml. CONCLUSIONS: DLIF increase in several diseases, including heart failure, end-stage renal disease, pre-eclampsy and acromegaly. High digoxin levels in a patient who does not show any symptoms of digital intoxication should lead to suspect the presence of these factors and to preventively determine DLIF in serum so as not to incur the risk of suspending an important treatment like digoxin in heart failure.

[The use of cardiac markers bed test in acute coronary syndrome in emergency department]. / Utilizzo dei biomarcatori cardiaci bed-test nella sindrome coronarica acuta nel Dipartimento di Emergenza.

AIMS: The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission. MATERIALS AND METHODS: In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage. RESULTS: Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature. DISCUSSION: The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

[Management model of chest pain in Medical Emergency Room and Chest Pain Unit of Policlinico Umberto I of Rome]. / Modello di gestione del dolore toracico in Pronto Soccorso Medico e nella Chest Pain Unit dell'Azienda Policlinico Umberto I di Roma.

In Italy one of the most common cause of access to the Emergency Departments is not traumatic chest pain, representing from the 6% to 10% of all the diagnoses. Admissions to the Emergency Department (DEA) of Policlinico Umberto I of Rome for non-traumatic chest pain, occurred between 2000 and 2008, were analyzed in this study. Out of 26,8910 admissions to the medical emergency room (PS), 21,088 (7.84%) were due to non-traumatic or precordial chest pain. Of these, 2881 (14%) patients had a diagnosis of myocardial infarction STEMI, NSTEMI and IA and 18,207 (86%) had a diagnosis of atypical chest pain, representing respectively 1.07% and 6.77% of all admissions to PS. About 27.62% of patients with atypical chest pain were discharged from the PS, 33.27% were hospitalized, 36.73% refused hospitalization, 1.68% were transferred elsewhere, and 0.7% did not uptake the visit. 85% of patients with myocardial infarction STEMI, NSTEMI and IA were hospitalized, 3.75% refused hospitalization, 8.82% were transferred elsewhere, and 1.71% died in the PS. Hospitalizations resulted often in unjustified and protracted length of hospital stays for clinical investigations, with negative repercussions for patients and costs. In the last years, the number of inappropriate hospitalizations progressively increased, partly as consequence of recourse to the court aiming at defining legal responsibility of the health board.Since avoiding inappropriate hospital admissions is an essential requirement for containing healthcare costs and improving the health service, Chest Pain Unit has been established. Its responsibility is to recognize and promptly treat patients with chest pain and acute coronary syndrome. As well, it is responsible to quickly discharge patients with chest pain at low and intermediate risk of acute coronary insufficiency, after careful clinical assessment lasting 24-36 hours.

[Therapy optimization of heart failure through the evaluation of the plasma concentration variation of B-type natriuretic peptide]. / Ottimizzazione della terapia dello scompenso cardiaco attraverso il monitoraggio delle variazioni delle concentrazioni plasmatiche del peptide natriuretico di tipo B.

AIM: Our research was based over the critical evaluation of the plasmatic concentration variation of B-type Natriuretic Peptide in emergency in patients with heart failure during therapy with diuretics, anti-aldosterone, ACE-inhibitors, beta-blockers and nitroderivates. MATERIALS AND METHOD: We selected 108 patients: 30 control subjects (average 58.40 +/- SD13.32 for 20 M, and 65 +/- SD 14.74 for 10 W), and 78 subjects (average 75.90 +/- SD 9.60 for 41 M, and 77.89 +/- SD 8.62 for 37 W) arrived to the emergency and reception department for dyspnea and/or precordialgia and/or palpitations with heart failure diagnosis according to NYHA Classification. The variation of BNP concentration was evaluated in these subjects at the admission, after 1 week, and 1 month from the beginning of the therapy. RESULTS: Patients with heart failure had a BNP concentration high during all measurements. The values were high during admission, but after 1 week and after 1 month, they reduced reaching the balance. CONCLUSIONS: BNP evaluation is a good indicator for the diagnosis of heart failure and for improving the therapy. The main limit of BNP diagnostic role is the need of knowing in advance the specific values for each patient.

[The Moschkowitz syndrome in emergency department. Case report]. / La sindrome di Moschkowitz nel Dipartimento di Emergenza. Case report.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening multisystem disorder of unknown etiology, first described by Moschkowitz in 1924. TTP is a thrombotic microangiopathy characterized by microvascular lesions with platelet aggregation. TTP is more common in adults and is associated with pregnancy; diseases such as HIV, cancer, bacterial infection, and vasculitis; bone marrow transplantation; and drugs TTP is a hematologic emergency. It is a multisystem disease that can cause rapid deterioration of the patient's neurologic, renal, and hematologic status. TTP is an uncommon disease with a high fatality rate if untreated or misdiagnosed. Rapid diagnosis and aggressive treatment by therapeutic plasma exchange are necessary to reduce the risk of a fatal outcome. Current clinical criteria for initiating therapy are: thrombocytopenia, and absence of other disease entities that could explain the thrombocytopenia. Early recognition and management are essential for patient survival. TTP is difficult to diagnose because the patient's presentation can be nonspecific and the characteristic pentad of symptoms may not occur together. Other disease entities can have some of the same symptoms. We discuss a case report of Moschkowitz syndrome in Emergency Department.

[Drug-induced toxic hepatitis]. / Epatite tossica da farmaci.

The case is described of a woman with drug hepatotoxicity, who was a psychiatric patient. The case is reported because the diagnosis occurred by a "praecoxfeeling", in fact physician's intuition is a personal structure which is born from same external incitements instead of other. The diagnosis was confirmed by clinical tests and by subsequent clinical research.