[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.

[The syncope in Emergency Department: usual management vs guidelines]. / La sincope nel Dipartimento di Emergenza: tra applicazionedelle linee guida e impatto con la realtà dell'urgenza.

INTRODUCTION: The syncope is a common cause of admission to Emergency Departments, representing around 1-3% of all admissions to the service. However, elderly age and important comorbidities often hinder a definite etiologic diagnosis, with increasing requests for diagnostic tests and longer periods of hospitalization. MATERIALS AND METHODS: We analyzed the management of 1,204 patients admitted to our Emergency Department for transient loss of consciousness in the period between 1 June 2009 and 1 June 2010, evaluating the following parameters: average age, gender, triage color code at admittance, performed diagnostic tests, diagnosis at discharge from ED and destination ward. We also studied a subgroup of 93 patients admitted to emergency medicine units evaluating their OESIL score at admittance, comorbidities, performed diagnostic tests and diagnosis at discharge from the ward. RESULTS: In the Emergency Department, 45% of patients were discharged with a diagnosis of syncope of unknown origin; in 21% of patients syncope was excluded; 19% of patients received a diagnosis of cardiogenic syncope; 11% were diagnosed with a presyncope; 3% with orthostatic hypotension and 1% with vasovagal syncope. In emergency medicine units, 51% of patients were discharged with a diagnosis of cardiogenic syncope, 11% were diagnosed with vasovagal syncope, 11% with presyncope, 11% with TIA, 8% with loss of consciousness non-syncope and 8% with syncope of unknown origin. CONCLUSIONS: Management of patients with syncope, elderly people with important comorbidities in particular, is still a serious problem for the emergency physician. The creation of specialized units for the management of syncope, the so-called syncope units, through the implementation of a shared diagnostic and therapeutic protocol, aims at reducing inappropriate hospitalization and average length of stay.

[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.