In the emergency field, many biomarkers are evaluated for clinical management of several acute diseases in clinical practice, to precise diagnosis, risk stratification or response to specific treatment. The protein ST2 is involved in inflammatory conditions, fibroproliferative diseases, autoimmune diseases, trauma, sepsis, and most recently in pulmonary and cardiovascular diseases. Higher levels of serum ST2 (sST2) are associated with inflammatory responses in several conditions. Whereas pro-BNP is considered the gold standard marker for the diagnosis of acute heart failure (HF), several studies observed that sST2 shows additional diagnostic and prognostic value; for example, this biomarker has stronger power to predict fatal events in HF in preserved or reduced ejection fraction, especially with values ≥35 ng/mL. Moreover, sST2 is useful to identify the degree of coronary artery stenosis and to predict the development of adverse events 1-year after coronary revascularization due to acute coronary syndrome (ACS). In fact, levels of sST2>35 ng/mL are associated with higher Gensini scores, multivessel disease and higher rate of major cardiovascular and cerebrovascular events. Recently, during acute COVID-19 infection, higher levels of sST2 showed role as an inflammation marker, associated with worse outcomes (i.e., ICU admission, mechanical ventilation, or in-hospital death). Although the role as prognostic marker is well highlighted in cardiovascular diseases and heart failure, sST2 can be evaluated in different conditions characterized by considerable impact in the field of emergency, giving useful information in terms of greater diagnostic accuracy, risk stratification, and prognosis.

BACKGROUND: The objective of this prospective observational study was to assess the adherence to the ACLS protocol of teams of MEU trainees, exposed in a simulated environment to clinical scenarios. Secondly, the different performances obtained by the teams belonging to the different years were evaluated.METHODS: Five clinical scenarios were proposed to the participants with the aid of a high-fidelity simulator, and the environment of an Emergency Room was reproduced. Through a dedicated check-list, derived from the AHA form, the performance of the individual teams, relating to 19 items with binary response, were then evaluated.RESULTS: No group managed to perform the resuscitation perfectly, obtaining the score of 19 correct items. The best result was 18 items obtained by a single team in the third year while the lowest number of correct items was four items corrected out of 19, score made by one of the teams in the first year. Of the total 285 items evaluated, 165 items were correctly carried out at 58%. The percentage of corrected items broken down by year is 41% for the first year, 60% for the second and 73% for the third year.CONCLUSIONS: Training trough simulation can bridge the gap between theory and practice in complete safety for both operator and patient. It allows the standardization of the minimum caseload variety of each doctor and allows the university to evaluate the clinical and relational skills of the learner in a standardized way at different levels of education. This method has a positive impact on students, trainees, teachers and healthcare companies as it makes it possible to focus not only on increasing the capacity of individuals and teams of healthcare professionals but also on protecting patients.

The importance of cardiovascular biomarkers in clinical practice increased dramatically in the last years, and the interest extends from the diagnosis purpose to prognostic applications and response to specific treatment. Acute heart failure, ischemic heart failure, and COVID-19 infection represent different clinical settings that are challenging in terms of the proper prognostic establishment. The aim of the present review is to establish the useful role of sST2, the soluble form of the interleukin-1 receptor superfamily (ST2), physiologically involved in the signaling of interleukin-33 (IL-33)-ST2 axis, in the clinical setting of acute heart failure (HF), ischemic heart disease, and SARS-CoV-2 acute infection. Molecular mechanisms associated with the IL33/ST2 signaling pathways are discussed in view of the clinical usefulness of biomarkers to early diagnosis, evaluation therapy to response, and prediction of adverse outcomes in cardiovascular diseases.

Objectives. Atrial fibrillation (AF) is a clinically relevant supra-ventricular arrhythmia which represents an independent risk factor for development of heart failure and ischemic stroke. The present study aims at the investigation of the possible clinical role of the soluble sST2 biomarker to evaluate the fibrosis in a group of patients with first diagnosed or permanent AF. The possible association with the left atrium size is also studied. Materials and Methods. The serum concentrations of the biomarker have been measured in a group of 58 patients (mean age 83.6 ± 6.0 years) and 40 individuals, assumed healthy and without AF, constituted the control group. The analysis is carried out by means of a high-sensitivity enzyme-linked immunosorbent assay. Results. The mean concentration of sST2 is 26.1 (22.7-30.5) ng/mL in the AF group, while in the control is 17.3 (15.7-18.9) ng/mL. Remarkable differences have been obtained for the two subsets with first diagnosed (23 (21.2-24) ng/mL) and permanent AF (30.5 (28.6-32) ng/mL). The analysis has been completed with a trans thoracic echocardiographic exam to evaluate the left atrium size and the left ventricular ejection fraction. Conclusions. The sST2 serum concentrations are found to be higher in the permanent AF with respect to the cases where the AF is of new onset or follow a paroxysmal pattern. The results support the adoption of the marker to evaluate the degree of fibrosis related to the left atrium of fibrillating patients. A positive association has been proved between the left atrium size and the sST2 concentrations.

ABSTRACT Objectives. Atrial fibrillation (AF) is a clinically relevant supra-ventricular arrhythmia which represents an independent risk factor for development of heart failure and ischemic stroke. The present study aims at the investigation of the possible clinical role of the soluble sST2 biomarker to evaluate the fibrosis in a group of patients with first diagnosed or permanent AF. The possible association with the left atrium size is also studied. Materials and Methods. The serum concentrations of the biomarker have been measured in a group of 58 patients (mean age 83.6 ± 6.0 years) and 40 individuals, assumed healthy and without AF, constituted the control group. The analysis is carried out by means of a high-sensitivity enzyme-linked immunosorbent assay. Results. The mean concentration of sST2 is 26.1 (22.7-30.5) ng/mL in the AF group, while in the control is 17.3 (15.7-18.9) ng/mL. Remarkable differences have been obtained for the two subsets with first diagnosed (23 (21.2-24) ng/mL) and permanent AF (30.5 (28.6-32) ng/mL). The analysis has been completed with a trans thoracic echocardiographic exam to evaluate the left atrium size and the left ventricular ejection fraction. Conclusions. The sST2 serum concentrations are found to be higher in the permanent AF with respect to the cases where the AF is of new onset or follow a paroxysmal pattern. The results support the adoption of the marker to evaluate the degree of fibrosis related to the left atrium of fibrillating patients. A positive association has been proved between the left atrium size and the sST2 concentrations.

The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre-coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and in-hospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled-up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co-infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB-65. All intra-ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB-65 score >= 2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one-third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests.

BACKGROUND:Patients with coronavirus disease 2019 (COVID-19) are often treated at home given the limited healthcare resources. Many patients may have sudden clinical worsening and may be already compromised at hospitalisation. We investigated the burden of lung involvement according to the time to hospitalisation. METHODS:In this observational cohort study, 55 consecutive COVID-19-related pneumonia patients were admitted to the Emergency Medicine Unit. Groups of lung involvement at computed tomography were classified as follows: 0 (<5%), 1 (5%-25%), 2 (26%-50%), 3 (51%-75%) and 4 (>75%). We also investigated in-hospital death and the predictive value of Yan-XGBoost model and PREDI-CO scores for death. RESULTS:The median age was 74 years and 34 were men. Time to admission increased from 2 days in group 0 to 8.5-9 days in groups 3 and 4. A progressive increase in LDH, CRP and d-dimer was found across groups, while a decrease of lymphocytes paO2 /FiO2 ratio and SpO2 was found. Ten (18.2%) patients died during the in-hospital staying. Patients who died were older, with a trend to lower lymphocytes, a higher d-dimer, creatine phosphokinase and troponin T. The Yan-XGBoost model did not accurately predict in-hospital death with an AUC of 0.57 (95% confidence interval [CI] 0.37-0.76), which improved after the addition of the lung involvement groups (AUC 0.68, 95%CI 0.45-0.90). Conversely, a good predictive value was found for the original PREDI-CO score with an AUC of 0.76 (95% CI 0.58-0.93) which remained similar after the addition of the lung involvement (AUC 0.76, 95% CI 0.57-0.94). CONCLUSION:We found that delayed hospital admission is associated with higher lung involvement. Hence, our data suggest that patients at risk for more severe disease, such as those with high LDH, CRP and d-dimer, should be promptly referred to hospital care.

Through stern social restraint measures, Italy has recently overcome the epidemic peak of COVID-19 (Coronavirus Disease-19) respiratory syndrome induced by SARS-CoV-2 and the attention is progressively moving toward its sequelae, especially on pulmonary fibrosis and the associated pulmonary functional decline [1-3].

Since the end of September 2020, the COVID-19 pandemic in Italy has registered a new increase in infections, uniform among all regions, defining the beginning of the second wave. The contagion curve began to rise after summer with the easing of the restrictions and the reopening of the social system. Then, in the last days of November 2020 it reached a peak in patients tested positive for Sars-Cov-2. This article compares the data of adult patients (>18 years old) who have been evaluated at the Emergency Department of the Umberto I Polyclinic Hospital in Rome, Italy, in March 2020 (first pandemic wave) with those of October 2020 (second pandemic wave). The study design follows the previous one in March. The typical patient who presented to the Emergency Department for COVID-19 has not changed from March to October: it is a sixty-year-old male. The main symptoms have partly changed (in the second wave, fever is less frequent 74% vs. 91% and dyspnea is more frequent 53% vs. 41%) and some secondary symptoms have appeared increasing in percentage (fatigue and diarrhea). Regarding pre-existing conditions, there are no differences. Patients are no longer hypoxic at the entrance to the Emergency Department but have more frequently undergone oxygen therapy before entering the hospital. A better organization of the hospital made it possible to hospitalize them early and carry out CPAP or NIV directly in the ward and not in the ED. At 14 days follow-up, the number of discharged patients significantly decreased in October compared to March, and the number of deaths also decreased. Between the first and second pandemic waves, the hospital response was changed according to the new assistance needs of the Roman population: the availability of COVID-19 beds increased; there was a faster transfer of the patient to the appropriate ward; there has been a modification in the therapies that followed the developments of the world scientific literature. Local medicine has also worked in "different" ways: the possibility for patients to be tested for Sars-Cov-2 has been extended and home therapies started earlier and according to global guidelines. Consequently, the patient arrived at the hospital earlier and was discharged under a higher protection regime. This whole organization has had a positive effect on the outcomes of the disease in general, but not on the mortality rate. The information gathered leads us to believe that the public is more aware of the danger of the SARS-Cov-2 virus, and that the hospital is more prepared to face this pandemic.

BACKGROUND:Although preclinical studies highlighted the potential role of NADPH oxidase (NOX) in sepsis, only few studies evaluated the oxidative stress in patients with sepsis and septic shock. The objective of the study is to appraise the oxidative stress status and platelet function in patients with sepsis and septic shock compared to healthy controls.METHODS AND RESULTS:Patients with sepsis or septic shock admitted to the hospital Policlinico Umberto I (Sapienza University, Rome) underwent a blood sample collection within 1 hour from admission. Platelet aggregation, serum thromboxane B2 (TxB2), soluble NOX2-derived peptides (sNox2-dp), and hydrogen peroxide breakdown activity (HBA) were measured and compared to those of healthy volunteers. Overall, 33 patients were enrolled; of these, 20 (60.6%) had sepsis and 13 (39.4%) septic shock. Compared to healthy controls (n = 10, age 67.8 ± 3.2, male 50%), patients with sepsis and septic shock had higher platelet aggregation (49% (IQR 45-55), 60% (55.75-67.25), and 73% (IQR 69-80), respectively, p < 0.001), higher serum TxB2 (77.5 (56.5-86.25), 122.5 (114-131.5), and 210 (195-230) pmol/L, respectively, p < 0.001), higher sNox2-dp (10 (7.75-12), 19.5 (17.25-21), and 33 (29.5-39) pg/mL, respectively, p < 0.001), and lower HBA (75% (67.25-81.5), 50% (45-54.75), and 27% (21.5-32.5), respectively, p < 0.001). Although not statistically significant, a trend in higher levels of serum TxB2 and sNox2-dp in patients who died was observed.CONCLUSIONS:Patients with septic shock exhibit higher Nox2 activity and platelet activation than patients with sepsis. These insights joined to better knowledge of these mechanisms could guide the identification of future prognostic biomarkers and new therapeutic strategies in the scenario of septic shock.

Objective: Atrial fibrillation (AF) is a common and clinically relevant supra-ventricular arrhythmia which represents an independent risk factor for development of heart failure as well as for ischemic stroke. Clinical management of this pathology can be still challenging in many patients, in particular the older ones and/or those which present comorbidity. The interest in biomarkers for diagnosis and management of the AF becomes more evident in recent years. We studied the possible role of the soluble sST2 and the GDF15 as biomarkers to stratify the risk of patients with persistent or permanent AF. Method: The serum concentrations of these biomarkers have been measured in a group of 58 patients (mean age 83.6  6.0 years) and in a control set of 40 individuals. Results: The mean serum concentration of sST2 is 22.6 (18.85-25.35) ng/mL in the AF group, while in the control is 17.25 (15.7-18.9) ng/mL (p<0.05). The corresponding data for the GDF15 are 1579 (975-3213) pg/mL and 850 (438-1234) pg/mL, respectively. Remarkable differences have been obtained for the two subsets of patients with persistent and permanent AF (sST2: (23 (21.2-24) ng/mL vs 30 (28.6-32) ng/mL, GDF15: 1347 (837-3320) vs 1931 (1238-3178)). The analysis has been completed with a trans thoracic echocardiographic exam to evaluate the left atrium size and the left ventricular ejection fraction. The results have been discussed to enhance the correlation between the instrumental and laboratory results. Conclusions:The present study suggests a possible clinical valuable role of the two biomarkers considered to refine the stratification risk in patients as the cohort here studied. A comparison between the two biomarkers is presented and discussed. The main pathological conditions that could increase the biomarkers are evaluated.

Background Quick Sequential Organ Failure Assessment (qSOFA) score is a bedside prognostic tool for patients with suspected infection outside the intensive care unit (ICU), which is particularly useful when laboratory analyses are not readily available. However, its performance in potentially septic patients with community-acquired pneumonia (CAP) needs to be examined further, especially in relation to early outcomes affecting acute management. Objective First, to compare the performance of qSOFA and CURB-65 in the prediction of mortality in the emergency department in patients presenting with CAP. Second, to study patients who required critical care support (CCS) and ICU admission. Methods Between January and December 2017, a 1-year retrospective observational study was carried out of adult (≥18 years old) patients presenting to the emergency department (ED) of our hospital (Rome, Italy) with CAP. The accuracy of qSOFA, qSOFA-65 and CURB-65 was compared in predicting mortality in the ED, CCS requirement and ICU admission. The concordance among scores ≥2 was then assessed for 30-day estimated mortality prediction. Results 505 patients with CAP were enrolled. Median age was 71.0 years and mortality rate in the ED was 4.7%. The areas under the curve (AUCs) of qSOFA-65, CURB-65 and qSOFA in predicting mortality rate in the ED were 0.949 (95% CI 0.873 to 0.976), 0.923 (0.867 to 0.980) and 0.909 (0.847 to 0.971), respectively. The likelihood ratio of a patient having a qSOFA score ≥2 points was higher than for qSOFA-65 or CURB-65 (11 vs 7 vs 6.7). The AUCs of qSOFA, qSOFA-65 and CURB-65 in predicting CCS requirement were 0.862 (95% CI 0.802 to 0.923), 0.824 (0.758 to 0.890) and 0.821 (0.754 to 0.888), respectively. The AUCs of qSOFA-65, qSOFA and CURB-65 in predicting ICU admission were 0.593 (95% CI 0.511 to 0.676), 0.585 (0.503 to 0.667) and 0.570 (0.488 to 0.653), respectively. The concordance between qSOFA-65 and CURB-65 in 30-day estimated mortality prediction was 93%. Conclusion qSOFA is a valuable score for predicting mortality in the ED and for the prompt identification of patients with CAP requiring CCS. qSOFA-65 may further improve the performance of this useful score, showing also good concordance with CURB-65 in 30-day estimated mortality prediction.

Background: The novel Coronavirus Disease-19 (COVID-19) continues to have profound effect on global health. Our aim was to evaluate the prevalence and characterize specific symptoms associated with COVID-19. Methods: This retrospective study included 326 patients with confirmed SARS-CoV-2 infection evaluated at the Emergency Department of the Umberto I Polyclinic Hospital, Rome, Italy between March 6th and April 30th, 2020. In order to assess xerostomia, olfactory and gustatory dysfunctions secondary to COVID-19, a telephone-based a modified survey obtained from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 for taste and smell disorders and the Fox Questionnaire for dry mouth were administered to 111 patients (34%) after discharge between June 4th and June 12th. Results: Taste dysfunction was the most common reported symptom (59.5%; n = 66), followed by xerostomia (45.9%; n = 51) and olfactory dysfunctions (41.4%; n = 46). The most severe symptom was olfactory dysfunction with a median severity score of 8.5 (range: 5-10). Overall 74.5% (n = 38) of patients with xerostomia, 78.8% (n = 52) of patients with gustatory dysfunctions and 71.1% (n = 33) of patients with olfactory dysfunctions reported that all symptoms appeared before COVID-19 diagnosis. Overall, the majority of patients reported one symptom only (45.9%, n = 51), 37 (33.3%) reported the association of two symptoms, and 23 (20.7%) patients reported the association of three symptoms at the same time. Conclusion: Xerostomia, gustatory and olfactory dysfunctions may present as a prodromal or as the sole manifestation of COVID-19. Awareness is fundamental to identify COVID-19 patients at an early stage of the disease and limit the spread of the virus.

A critical analysis was conducted on data relating to the COVID 19 infection in Italy. Looking at the official figures in our country, regional differences make data comparison and interpretation quite challenging. Differing health policy strategies (hospital assistance vs. local health assistance, swab tests to very specific population groups vs. screening of larger groups) add another layer of complexity when comparing data. The different levels of susceptibility to the infection among Italian regions can be partially explained by analysing many factors. We have grouped such factors into two subject areas (Social policies and healthcare strategies; Climate and geography) and listed some of the causes that could have led to different levels of susceptibility to the infection. Reflection on and awareness of the mistakes made will allow us to prevent the re-occurrence of health protection inequalities.