Background: In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting. Objectives: We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of- care ultrasound (POCUS) and D-dimer (single/age-adjusted cutoff), to select patients for AAI. Methods: This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and D-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes. Results: Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0% (95% CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted D- dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff). Conclusions: The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted D-dimer maximized efficiency. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT04430400

Aim To determine the prevalence and characteristics of pulmonary embolism (PE) in patients presenting with haemoptysis. Additionally, we assessed the efficiency and failure rates of different clinical diagnostic algorithms for PE in this patient population. Methods We enrolled consecutive adult patients who presented to nine Italian emergency departments with haemoptysis as the primary complaint. PE diagnosis was ruled out in patients with a low pre-test probability in combination with a negative age-adjusted D-dimer (referred to as the " age-adjusted" D-dimer strategy), a negative computed tomography pulmonary angiography or when a clear alternative source of bleeding was identified, along with negative findings for venous thromboembolism during a 30-day follow-up. Results A total of 546 patients were included in the study. The prevalence of PE, including the 30-day follow-up, was 4.2% (95% CI 2.7-6.3%). The majority of these cases (78%) exhibited distal (segmental or subsegmental) emboli and there were no PE-related fatalities. The " age-adjusted" D-dimer strategy initially excluded PE in 24% of patients (95% CI 21-28%), with a failure rate of 0.8% (95% CI 0.0-4.1%). Retrospectively applied, the " clinical probability-adjusted" D-dimer strategies, specifically the YEARS and Pulmonary Embolism Graduated d-Dimer (PEGeD) algorithms, excluded PE in a significantly higher proportion (30% and 32%, respectively) compared with the " age-adjusted" D-dimer strategy (p<0.05 for both), with similar failure rates. Conclusions PE is infrequent among patients presenting with haemoptysis, showing segmental or subsegmental emboli distribution. The " clinical probability-adjusted" D-dimer strategies seem to have significantly higher efficiency compared with the " age-adjusted" strategy.

BACKGROUND:The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the COVID-19 pandemic and so it is crucial the right evaluation of viral infection. According to the Centers for Disease Control and Prevention (CDC), the Real-Time Reverse Transcription PCR (RT-PCR) in respiratory samples is the gold standard for confirming the disease. However, it has practical limitations as time-consuming procedures and a high rate of false-negative results. We aim to assess the accuracy of COVID-19 classifiers based on Arificial Intelligence (AI) and statistical classification methods adapted on blood tests and other information routinely collected at the Emergency Departments (EDs).METHODS:Patients admitted to the ED of Careggi Hospital from April 7th-30th 2020 with pre-specified features of suspected COVID-19 were enrolled. Physicians prospectively dichotomized them as COVID-19 likely/unlikely case, based on clinical features and bedside imaging support. Considering the limits of each method to identify a case of COVID-19, further evaluation was performed after an independent clinical review of 30-day follow-up data. Using this as a gold standard, several classifiers were implemented: Logistic Regression (LR), Quadratic Discriminant Analysis (QDA), Random Forest (RF), Support Vector Machine (SVM), Neural Networks (NN), K-nearest neighbor (K-NN), Naive Bayes (NB).RESULTS:Most of the classifiers show a ROC >0.80 on both internal and external validation samples but the best results are obtained applying RF, LR and NN. The performance from the external validation sustains the proof of concept to use such mathematical models fast, robust and efficient for a first identification of COVID-19 positive patients. These tools may constitute both a bedside support while waiting for RT-PCR results, and a tool to point to a deeper investigation, by identifying which patients are more likely to develop into positive cases within 7 days.CONCLUSIONS:Considering the obtained results and with a rapidly changing virus, we believe that data processing automated procedures may provide a valid support to the physicians facing the decision to classify a patient as a COVID-19 case or not.

BACKGROUND: The ESC 2016 and ACC-AHA 2014 updated in 2019 guidelines for atrial fibrillation (AF) management, stratify patients according to the CHA2DS2-VASc score. In patient at lower risk they suggested an accurate evaluation of the risk factors and willing of the patient before starting anticoagulation therapy. The place and timing of this evaluation vary from hospital to hospital, the approach of the emergency department (ED) of the Azienda Ospedaliera Universitaria di Careggi (AOUC) was not yet described in literature: the patient was offered a visit within three weeks, in an AF outpatient clinic managed by ED physicians. The aim of the study was to evaluate one-year thromboembolic and hemorrhagic events incidence in a cohort of low risk patients evaluate in the AF clinic.METHODS: Among patients evaluate from 2008 to 2017 those with a CHA2DS2-VASc of 0 or 1 (0 risk factors), 1 and 2 in women (1 risk factors) were selected and underwent a structured phone interview and hospital records search to identify thromboembolic and hemorrhagic events within one year. Our results were compared with those present in literature.RESULTS: The patients in anticoagulation therapy in our cohort was 12% among patients with 0 risk factors and 27% in patients with one risk factor. In the first group there were no thromboembolic and hemorrhagic events while in the second group thromboembolic and hemorrhagic events incidence were 0.9% and 1.4% respectively. Four patients died, non for ischemic or hemorrhagic causes. Sex, thromboembolic risk factors, age, HASBLED Score of our cohort was similar to other cohort reported in literature. Anticoagulated patients were higher in other cohorts (~50% in 0 risk factors and ~65% in 1 risk factor group) while thromboembolic events were similar or lower (~0.5% in 0 risk factors and ~1.8% in 0 risk factors group) compared with our cohort.CONCLUSIONS: The conservative approach of the AF clinic of the AOUC (with lower rate of anticoagulation) seems to be appropriate, considering similar or lower thromboembolic events incidence compare to other cohorts.

Objectives: To assess concurrent validity of the Dynamic Silver Code (DSC), a tool based on administrative data that predicts prognosis in older adults accessing the emergency department (ED), in terms of association with markers of poor functional and cognitive status. Design: Cross-sectional. Setting and Participants: Data were obtained in the AIDEA study, which enrolled a cohort of >= 75-year-old patients, accessing the ED of 2 hospitals in Florence, Italy. Methods: The DSC score and classes (I to IV, corresponding to an increasing risk of death) were obtained from administrative data. Information on health and functional status prior to ED access were collected from face-to-face, direct, or proxy interviews. The 4AT test was administered to screen for possible delirium. Bivariate comparisons of the prevalence of each functional and cognitive marker across 4 DSC classes were performed. Multinomial logistic regression was used to assess the multivariable risk of being in II, III, or IV DSC class vs I. Results: Among 3358 participants (mean age 83 years, men 44%), 32.9%, 30.3%, 19.5%, and 17.2% were in DSC class I, II, III, and IV. Preadmission abnormal functional and cognitive conditions, and delirium in the ED, were increasingly more common from DSC class I through IV (P <.001). In particular, the prevalence of total inability to walk increased from 2.9% (class I) to 23.4% (class IV). In multivariable analyses, this was the strongest predictor of being in progressively worse DSC classes, whereas feeling of exhaustion, reporting of serious falls, weight loss, and severe memory loss or diagnosis of dementia gave some contribution. Conclusions and Implications: The ability of the DSC to predict survival in older persons appears to rely on its prevailing association with markers of functional impairment. These results may support clinical use of the tool. (C) 2021 The Authors. Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Background: Acute brain injury (ABI) can cause out of hospital cardiac arrest (OHCA). The aim of this study was to compare clinical features, mortality and potential for organ donation in patients with OHCA due to ABI vs other causes. Methods: From January 2017 to December 2018, all adult patients presenting to ED for OHCA were considered for the study. Two physicians established the definitive cause of OHCA, according to clinical, laboratory, diagnostic imaging and autoptic findings. Clinical features in patients with OHCA due to ABI or other causes were compared. Results: 280 patients were included in the analysis. ABI was the third most frequent cause of OHCA (21, 7.5%); ABIs were 8 subarachnoid hemorrhage, 8 intracerebral hemorrhage, 2 ischemic stroke, 2 traumatic spinal cord injury and 1 status epilepticus respectively. Neurological prodromes such as seizure, headache and focal neurological signs were significantly more frequent in patients with OHCA due to ABI (OR 5.34, p = 0.03; OR 12.90, p = 0.02; and OR 66.53, p < 0.01 respectively) while among non-neurological prodromes chest pain and dyspnea were significantly more frequent in patients with OHCA due to other causes (OR 14.5, p < 0.01; and OR 10.4, p = 0.02 respectively). Anisocoria was present in 19% of patients with OHCA due to ABI vs 2.7% due to other causes (OR 8.47, p < 0.01). In 90.5% of patients with ABI and in 53.1% of patients with other causes the first cardiac rhythm was non shockable (OR 8.1; p = 0.05). Multivariate logistic regression analysis revealed that older age, active smoking, post traumatic OHCA, neurological prodromes, anisocoria at pupillary examination were independently associated with OHCA due to ABI. Patients with ABI showed a higher mortality compared with the other causes group (19 pts., 90.5% versus 167 pts., 64.5%; p = 0.015). Potential organ donors were more frequent among ABI than other causes group (10 pts., 47.6% vs 75 pts., 28.9%) however the difference did not reach the statistical significance (p = 0.07). Conclusions: ABI is the third cause of OHCA. Neurological prodromes, absence of chest pain and dyspnea before cardiac arrest, anisocoria and initial non-shockable rhythm might suggest a neurological etiology of the cardiac arrest. Patients with OHCA due to ABI has an unfavorable outcome, however, they could be candidate to organ donation. (c) 2021 Elsevier Inc. All rights reserved.

Abstract Background Lung ultrasound (LUS) has a role in the diagnosis of pulmonary embolism (PE) mainly based on the visualization of pulmonary infarctions. However, examining the whole chest to detect small peripheral infarctions by LUS may be challenging. Pleuritic pain, a frequent presenting symptom in patients with PE, is usually localized in a restricted chest area identified by the patient itself. Our hypothesis is that sensitivity of LUS for PE in patients with pleuritic chest pain may be higher due to the possibility of focusing the examination in the painful area. We combined data from three prospective studies on LUS in patients suspected of PE and extracted data regarding patients with and without pleuritic pain at presentation to compare the performances of LUS. Results Out of 872 patients suspected of PE, 217 (24.9%) presented with pleuritic pain and 279 patients (32%) were diagnosed with PE. Pooled sensitivity of LUS for PE in patients with and without pleuritic chest pain was 81.5% (95% CI 70–90.1%) and 49.5% (95% CI 42.7–56.4%) (p < 0.001), respectively. Specificity of LUS was similar in the two groups, respectively 95.4% (95% CI 90.7–98.1%) and 94.8% (95% CI 92.3–97.7%) (p = 0.86). In patients with pleuritic pain, a diagnostic strategy combining Wells score with LUS performed better both in terms of sensitivity (93%, 95% CI 80.9–98.5% vs 90.7%, 95% CI 77.9–97.4%) and negative predictive value (96.2%, 95% CI 89.6–98.7% vs 93.3%, 95% CI 84.4–97.3%). Efficiency of Wells score + LUS outperformed the conventional strategy based on Wells score + d-dimer (56.7%, 95% CI 48.5–65% vs 42.5%, 95% CI 34.3–51.2%, p = 0.02). Conclusions In a population of patients suspected of PE, LUS showed better sensitivity for the diagnosis of PE when applied to the subgroup with pleuritic chest pain. In these patients, a diagnostic strategy based on Wells score and LUS performed better to exclude PE than the conventional strategy combining Wells score and d-dimer.

Background: In the emergency department (ED) definitive diagnosis of SARS-COV-2 pneumonia is challenging as nasopharyngeal swab (NPS) can give false negative results. Strategies to reduce false negative rate of NPS have limitations. Serial NPSs (24-48 h from one another) are time-consuming, sputum can not be collected in the majority of patients, and bronchoalveolar lavage (BAL), the most sensitive test, requires specific expertise. Laryngotracheal aspiration (LTA) is easy to perform and showed a similar accuracy to BAL for diagnosis of other pulmonary diseases, however it was not studied to diagnose SARS-COV-2 pneumonia. Objective: An observational cross-sectional study was performed to evaluate the negative predictive value of LTA in patients with suspected SARS-COV-2 pneumonia despite a negative NPS. Methods: In the EDs of two university hospitals, consecutive patients with suspected SARS-COV-2 pneumonia despite a negative NPS underwent LTA performed with a nasotracheal tube connected to a vacuum system. Final diagnosis based on all respiratory specimen tests (NPS, LTA and BAL) and hospital data was established by two reviewers and in case of discordance by a third reviewer. Results: 117 patients were enrolled. LTA was feasible in all patients and no patients experienced adverse events. Fifteen (12.7%) patients were diagnosed with community-acquired SARS-COV-2 pneumonia: 13 LTA positive and only 2 (1.7%) LTA negative. The negative predictive value of NPS and LTA was 87.3% (79.9% - 92.7%) and 98.1% (93.3%99.8%) respectively. Conclusions: LTA resulted feasible, safe and reduced false negative rate in patients with suspected SARS-COV-2 pneumonia despite a negative NPS.

PURPOSE:The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients' outcome. MATERIALS AND METHODS:We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients' outcome. RESULTS:CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients' outcome. CONCLUSION:In our study, admission CXR showed a fair specificity and a good correlation with patients' outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Background When acute aortic syndromes (AASs) are suspected, pretest clinical probability assessment and d‐dimer (DD) testing are diagnostic options allowing standardized care. Guidelines suggest use of a 12‐item/3‐category score (aortic dissection detection) and a DD cutoff of 500 ng/mL. However, a simplified assessment tool and a more specific DD cutoff could be advantageous. Methods and Results In a prospective derivation cohort (n=1848), 6 items identified by logistic regression (thoracic aortic aneurysm, severe pain, sudden pain, pulse deficit, neurologic deficit, hypotension), composed a simplified score (AORTAs) assigning 2 points to hypotension and 1 to the other items. AORTAs≤1 and ≥2 defined low and high clinical probability, respectively. Age‐adjusted DD was calculated as years/age × 10 ng/mL (minimum 500). The AORTAs score and AORTAs≤1/age‐adjusted DD rule were validated in 2 patient cohorts: a high‐prevalence retrospective cohort (n=1035; 22% AASs) and a low‐prevalence prospective cohort (n=447; 11% AASs) subjected to 30‐day follow‐up. The AUC of the AORTAs score was 0.729 versus 0.697 of the aortic dissection detection score (P=0.005). AORTAs score assessment reclassified 16.6% to 25.1% of patients, with significant net reclassification improvement of 10.3% to 32.7% for AASs and −8.6 to −17% for alternative diagnoses. In both cohorts, AORTAs≥2 had superior sensitivity and slightly lower specificity than aortic dissection detection ≥2. In the prospective validation cohort, AORTAs≤1/age‐adjusted DD had a sensitivity of 100%, a specificity of 48.6%, and an efficiency of 43.3%. Conclusions AORTAs is a simplified score with increased sensitivity, improved AAS classification, and minor trade‐off in specificity, amenable to integration with age‐adjusted DD for diagnostic rule‐out.

In patients with suspected acute aortic syndrome (AAS), standardized clinical risk assessment following the American Heart Association (AHA) and European Society of Cardiology (ESC) recommendations is based on 12 risk markers summarized in the aortic dissection detection (ADD) risk score.1, 2 However, additional risk factors and conditions have been associated with AASs. These include autoimmune diseases, immunosuppressive or glucocorticoid treatment, and use of fluoroquinolones.3-5 The latter association has even led to official prescription warnings from the Food and Drug Administration and other agencies. The underlying evidence, however, has been obtained in retrospective population studies, case series, and anecdotal reports not involving acute patients or the emergency department (ED).3-5 We use the data from the Aortic Dissection Detection Risk Score Plus D-dimer in Suspected Acute Aortic Dissection (ADvISED) prospective multicenter study to evaluate whether these risk factors are associated with diagnoses of AASs in ED patients with an operator-defined clinical suspicion and pertinent symptoms.6 We explored whether routine evaluation of these additional variables may provide any potential diagnostic advantage to physicians when approaching patients with potential AAS symptoms. The characteristics of the ADvISED study methods and cohort have been described elsewhere.6 The present subanalysis was conducted on patients from one of participating EDs (Careggi University Hospital, Florence, Italy). For all patients, ED and hospital charts were retrospectively reviewed for the following variables: (1) use of a fluoroquinolone drug in the past 90 days (at least 5 days of treatment), (2) use of any systemic nonsteroidal immunosuppressive drug or any glucocorticoid drug (defined by an equivalent dose of ≥0.25 mg/kg per day of methylprednisolone) for at least 14 days in the past 90 days, and (3) known systemic autoimmune disease such as connectivities (e.g., rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis) or vasculitis (e.g., giant cell arteritis, ANCA-associated vasculitis). Sections of medical charts reporting recent and past medical history by the treating physicians were obtained from the ED and hospital database and were evaluated by two independent reviewers, who were blinded to both diagnostic results and final diagnosis. Any discrepancy was adjudicated by discussion between reviewers. Statistical analysis included binomial logistic regression, adjusted with stratification on the main effect of known risk factors. We analyzed data from 657 patients with suspected AASs. The mean ± SD age was 63.4 ± 17 years, and 431 (65.6%) patients were male. Seventy-seven (11.7%) patients had a final diagnosis of AAS: 42 (6.4%) had a type A acute aortic dissection (AD), 17 (2.6%) had a type B AD, 10 (1.5%) had an intramural aortic hematoma, seven (1.1%) had a spontaneous aortic rupture, and one (0.1%) had a penetrating aortic ulcer. In patients with AAS, four had used fluoroquinolone drugs in the past 90 days, five were taking oral glucocorticoids, one was taking oral glucocorticoids plus rituximab, and two had a systemic vasculitis (giant cell arteritis and p-ANCA–associated vasculitis). The prevalence of the analyzed variables and the associated odd ratios (ORs) for diagnosis of AASs are shown in Table 1. None were associated with the diagnosis of AASs, in both univariate and multivariate analysis including the 12 ADD risk markers. Among the subgroup (543 patients) with low likelihood of AAS according with ESC guidelines, those ultimately not diagnosed with AASs (504 patients) were more likely to have a history of fluroquinolone, NSAID, or glucocorticoid use or known autoimmune disease (10.7% vs. 7.7%; p < 0.01). Limits of this study are its retrospective nature, potentially leading to underreporting of study variables, and insufficient power to detect exceedingly small increases in risk. We cannot exclude with certainty some degree of differential suspicion and reporting biases, but both were expected to skew findings toward a positive association between analyzed variables and AASs. In conclusion, in ED patients evaluated for suspected AASs, use of fluoroquinolones, use of immunosuppressive or glucocorticoid drugs, systemic autoimmune diseases, or any of them was not associated with final diagnosis of AASs. Hence, evaluation of these variables, despite potentially relevant in pathophysiologic terms, is unlikely to meaningfully impact on ED diagnostic reasoning.

BACKGROUND: The diagnosis of acute infection of COVID-19 remains an important challenge for clinicians. Serology has been used as population screening tool and it was introduced also in some EDs even if its sensitivity in this context was not well known. The aims of the study were to evaluate the accuracy of serology for the diagnosis of COVID-19 in the Emergency Department (ED) and to evaluate if the sensitivity of the physicians' gestalt and the sensitivity of the first nasopharingeal swab are increased by serology.METHODS: Patients were prospectively enrolled from April 7 to April 30, 2020. A blood sample for the titration of immunoglobulins IgM and IgG for SARS-Cov-2 was performed in all patients at the same of the nasopharyngeal swab. Physicians, based on clinical features and bedside diagnostic imaging tests, blinded to nasopharyngeal swab and serology results, established if COVID-19 was likely or unlikely (physicians' gestalt). Final diagnosis was independently established by two experts after review of 30-day follow-up data.RESULTS: A total of 923 patients was enrolled. 111 (12.4%) had a final diagnosis of COVID-19. Accuracy of IgM and IgG tests for COVID-19 diagnosis were similar (P=0.74). Both sensitivity and specificity of IgM and IgG were similar (P=1 and P= 0.64 respectively). The accuracy of physicians' gestalt alone (88.1%, CI 95% 84.4-91.9) was similar to the accuracy of physicians' gestalt plus serology (87.9% CI 95% 84.4-91.3) (P=0.85). Sensitivity of physicians' gestalt was 80.2% (CI 95% 71.5-87.1) and was only slightly increased by serology (85.6%, CI 95% 77.7-91.5) (P=0.03). The sensitivity of a diagnostic strategy integrating the first nasopharingeal swab with serology to rule out COVID-19 was not significantly different from the sensitivity of nasopharingeal swab alone (91% CI95% 84.1-95.6 vs. 92.8%, CI95% 86.3-96.8) (P=0.5).CONCLUSIONS: Serology is not accurate for COVID-19 diagnosis in ED and it cannot be used to safely rule out COVID-19 in association with physician's gestalt or in association with the first nasopharyngeal swab.

To investigate the effects of the dramatic reduction in presentations to Italian Emergency Departments (EDs) on the main indicators of ED performance during the SARS-CoV-2 pandemic. From February to June 2020 we retrospectively measured the number of daily presentations normalized for the number of emergency physicians on duty (presentations/physician ratio), door-to-physician and door-to-final disposition (length-of-stay) times of seven EDs in the central area of Tuscany. Using the multivariate regression analysis we investigated the relationship between the aforesaid variables and patient-level (triage codes, age, admissions) or hospital-level factors (number of physician on duty, working surface area, academic vs. community hospital). We analyzed data from 105,271 patients. Over ten consecutive 14-day periods, the number of presentations dropped from 18,239 to 6132 (- 67%) and the proportion of patients visited in less than 60 min rose from 56 to 86%. The proportion of patients with a length-of-stay under 4 h decreased from 59 to 52%. The presentations/physician ratio was inversely related to the proportion of patients with a door-to-physician time under 60 min (slope - 2.91, 95% CI - 4.23 to - 1.59, R2 = 0.39). The proportion of patients with high-priority codes but not the presentations/physician ratio, was inversely related to the proportion of patients with a length-of-stay under 4 h (slope - 0.40, 95% CI - 0.24 to - 0.27, R2 = 0.36). The variability of door-to-physician time and global length-of-stay are predicted by different factors. For appropriate benchmarking among EDs, the use of performance indicators should consider specific, hospital-level and patient-level factors.

Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results.

BACKGROUND AND PURPOSE:In patients with acute ischemic stroke treated with reperfusion therapy we aimed to evaluate whether pretreatment blood-brain barrier (BBB) leakage is associated with subsequent hemorrhagic transformation (HT).METHODS:We prospectively screened patients with acute ischemic stroke treated with intravenous thrombolysis and/or endovascular treatment. Before treatment, each patient received computed tomography (CT), CT angiography, and CT perfusion. We assessed pretreatment BBB leakage within the ischemic area using the volume transfer constant (Ktrans ) value. Our primary outcome was relevant HT, defined as hemorrhagic infarction type 2 or parenchymal hemorrhage type 1 or 2. We evaluated independent associations between BBB leakage and HT using logistic regression, adjusting for age, sex, baseline stroke severity, Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6, treatment type, and onset-to-treatment time.RESULTS:We enrolled 171 patients with available assessment of BBB leakage. The patients' mean (±SD) age was 75.5 (±11.8) years, 86 (50%) were men, and the median (interquartile range) National Institutes of Health Stroke Scale score was 18 (12-23). A total of 32 patients (18%) received intravenous thrombolysis, 102 (60%) underwent direct endovascular treatment, and 37 (22%) underwent both. Patients with relevant HT (N = 31;18%) had greater mean BBB leakage (Ktrans 0.77 vs. 0.60; p = 0.027). After adjustment in the logistic regression model, we found that BBB leakage was associated both with a more than twofold risk of relevant HT (odds ratio [OR] 2.50; 95% confidence interval [CI] 1.03-6.03 per Ktrans point increase; OR 2.34; 95% CI 1.06-5.17 for Ktrans values > 0.63 [mean BBB leakage value]) and with symptomatic intracerebral hemorrhage (OR 4.30; 95% CI 1.13-13.77 per Ktrans point increase).CONCLUSION:Pretreatment BBB leakage before reperfusion therapy was associated with HT, and may help to identify patients at risk of HT.

BACKGROUND:During the initial assessment of trauma patients, the severity of injury is very often not immediately recognizable. In trauma centers, a total body CT (TBCT) scan is routinely used to evaluate this kind of patients, even if it is burdened with health risk, economical costs, and logistical difficulties.AIM:We investigated the use of a clinical guide to establish a safe alternative to this routine practice.METHODS:We enrolled retrospectively 438 patients referring to the Emergency Department of Careggi University Hospital in Florence (Italy) over a 1-year period from 2014 to 2015, with the evidence of trauma and high-priority triage codes and then subjected to TBCT. We created a tool called VIBS ("Valutazione Integrata Bed Side") (from the Italian translation of "Bed Side Integrated Evaluation") which included all clinical, laboratory, and diagnostic data acquired bedside during the primary survey. Every VIBS profile was dichotomized in negative or positive if there was at least one altered item. We performed an analysis of correlation between VIBS and TBCT to determine sensibility, specificity, positive, and negative predictive value and likelihood ratio of VIBS.RESULTS:Sensibility of VIBS in the prediction of positive CT scan was 100% and specificity was 31.7%. Positive and negative predictive value (95% C.I.) was 44.3 (38.8-49.5) and 100 (94.0-99.9). Positive and negative likelihood ratios were 1.464 and 0. Failure rate resulted in 0% and efficiency was 20.54%.CONCLUSIONS:VIBS can safely rule out severe thoracic or abdominal injuries. This approach could limit the use of TBCT in one-fifth of suspected major trauma patients.

Background Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest. Objective To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre. Methods Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period. Results The average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX. Conclusions EPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).