Older adults account for a substantial proportion of emergency department (ED) visits, yet standard care models often fail to address their complex needs. We describe the organization and short-term outcomes of the GIROT-ED model (Gruppo Intervento Rapido Ospedale Territorio), an ED-integrated geriatric service in Florence, Italy. A retrospective observational study was conducted, including older ED patients with disability and/or moderate-to-severe dementia evaluated by the GIROT-ED service in three EDs (January 2023–December 2024) and considered for admission. Available individualized care pathways included home discharge with hospital-at-home (HaH), intermediate care, or hospital admission. Process indicators (time to first medical evaluation, ED length of stay, and 24- and 72-h revisits) and 72-h mortality were described; multivariable logistic regression identified predictors of home discharge. Among 8113 patients (median age 88 years; 62

Older adults account for a substantial proportion of emergency department (ED) visits, yet standard care models often fail to address their complex needs. We describe the organization and short-term outcomes of the GIROT-ED model (Gruppo Intervento Rapido Ospedale Territorio), an ED-integrated geriatric service in Florence, Italy. A retrospective observational study was conducted, including older ED patients with disability and/or moderate-to-severe dementia evaluated by the GIROT-ED service in three EDs (January 2023–December 2024) and considered for admission. Available individualized care pathways included home discharge with hospital-at-home (HaH), intermediate care, or hospital admission. Process indicators (time to first medical evaluation, ED length of stay, and 24- and 72-h revisits) and 72-h mortality were described; multivariable logistic regression identified predictors of home discharge. Among 8113 patients (median age 88 years; 62

BACKGROUND:Hemoptysis is a potentially life-threatening symptom that often prompts emergency department (ED) evaluation and hospitalization. Reliable prognostic tools to guide clinical decision-making and optimize resource use are currently lacking. OBJECTIVE:To prospectively validate the Florence Hemoptysis Assessment Score (FLHASc) in patients presenting with hemoptysis to the ED, and to eventually derive and validate an improved version of the score (FLHASc2). METHODS:We analyzed data from the POPEIHE study (NCT06067997), a multicenter prospective cohort of 546 consecutive adult patients presenting with hemoptysis to 9 Italian EDs. The primary outcome was a composite of in-hospital death, need for ventilatory support, intensive care unit (ICU) admission, blood transfusion, or invasive hemostatic procedures. We evaluated the prognostic performance of the original FLHASc, then derived a new model (FLHASc2) using multivariate logistic regression in a randomly selected derivation cohort (n = 321) and validated it in the remaining cohort (n = 225). A simplified version of the score was also tested. RESULTS:The original FLHASc demonstrated moderate discriminatory ability (AUC 0.71; 95% CI: 0.65-0.76) and suboptimal calibration. The FLHASc2 showed improved performance (AUC 0.79, 95% CI: 0.73-0.87 in derivation and 0.81, 95% CI: 0.73-0.88, in validation cohorts; Brier score < 0.10 in both). The simplified FLHASc2 (sFLHASc2), assigning one point per variable, maintained comparable accuracy (AUC 0.80, 95% CI: 0.72-0.87) and identified 47.8% of patients as low risk (2.7% event rate). When combined with a negative chest X-ray, the observed event rate in this subgroup dropped to 0.87%, with a negative predictive value of 99.1% (CI 95%, 96.5-100%). CONCLUSIONS:The FLHASc2 and its simplified version are accurate prognostic tools for identifying hemoptysis patients at low risk of short-term adverse outcomes. Use of the sFLHASc2 combined with chest X-ray may allow safe ED discharge in nearly half of cases. A prospective management trial is warranted to confirm its clinical impact. TRIAL REGISTRATION NUMBER:NCT06067997.

Background This study aimed to evaluate the diagnostic accuracy of the STANDING algorithm for central vertigo across different emergency departments (EDs). Secondary outcomes compared STANDING with usual care in terms of diagnostic accuracy, resource utilisation and length of stay (LOS). Methods We prospectively enrolled adult patients presenting with vertigo at one ‘hub’ and three ‘spoke’ EDs in Tuscany. Patients were assessed using either STANDING or ‘usual care’, depending on the availability of a trained emergency physician. Imaging tests, consultations and dispositions were made independently of the study. The final diagnosis of central vertigo was determined by an expert panel, based on clinical data, along with a 30-day follow-up. Results A total of 456 patients were included, with 242 (53%) assessed by STANDING. There were no statistically significant differences in age, gender or cardiovascular risk factors between the STANDING and usual care groups. The prevalence of central vertigo was 8.6%, with ischaemic stroke (4.2%) as the leading cause, with no differences between groups. The STANDING algorithm had a sensitivity of 88.2%, specificity of 91.6%, positive predictive value of 44.1%, and negative predictive value of 99%. Usual care showed lower specificity and positive predictive value (36.5% and 14.7%, respectively, p<0.05). Additionally, the STANDING group had both fewer non-contrast head CT (NCCT) requests (48.3% vs 66.8%) and a shorter LOS (median 271 vs 339 min) (p<0.05). Conclusions The STANDING algorithm demonstrated high diagnostic accuracy and a very high negative predictive value for central vertigo across EDs and appears to be associated with improved specificity, reduced use of NCCT and shorter LOS compared with ‘usual care’.

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an emerging technique in trauma care for managing severe hemorrhage when conventional resuscitation is inadequate. Methods: We report a case involving a 45 yo female patient who sustained multiple traumatic injuries—including thoracic, pelvic, and aortic damage—after a fall from approximately 5 meters. The timely insertion of a REBOA device provided critical hemodynamic support, allowing for temporary stabilization in the emergency department according to the principles of Damage Control Resuscitation. Results: This intervention facilitated her subsequent transfer to a Level 1 Trauma Center for definitive surgical intervention.Although the patient's prognosis remained poor due to the severity of her injuries, the use of REBOA illustrated its potential utility in improving hemodynamic stability in critically injured patients. Conclusions: Our findings suggest that REBOA can be a valuable adjunct in trauma management, offering a life-saving option in critical hemorrhagic cases where traditional methods are insufficient. Further research is warranted to refine REBOA application, particularly concerning optimal balloon positioning and integration with imaging techniques.

Procedural sedation and analgesia (PSA) in the emergency department (ED) presents a crucial aspect of emergency medicine, enabling the execution of painful or distressing procedures with minimal patient discomfort. This narrative review delineates the pharmacological framework, methodologies, and clinical considerations integral to optimizing PSA, with a particular focus on pediatric and geriatric populations. Through a comprehensive review and analysis of current practices, this work evaluates the pharmacokinetics and pharmacodynamics of widely utilized sedatives and analgesics, including propofol, ketamine, dexmedetomidine, fentanyl, midazolam, etomidate, nitrous oxide, and remimazolam. Special attention is dedicated to the selection criteria based on patient-specific risk factors, procedural requirements, and the management of potential adverse effects. The manuscript also explores innovative sedation techniques and the integration of new pharmacological agents, emphasizing evidence-based approaches to enhance patient safety and outcome. The results underscore the significance of tailored sedation strategies, especially for vulnerable groups such as pediatric and geriatric patients, highlighting the need for meticulous pre-procedural assessment and monitoring to mitigate risks. The conclusions drawn advocate for a nuanced application of PSA, guided by current evidence and clinical guidelines, to improve the quality of care in emergency settings. This research reinforces the imperative for ongoing education, skill development, and the adaptation of new evidence into clinical practice to advance procedural sedation and analgesia in the ED.

Introduction: Non-compressible torso hemorrhage (NCTH) is a major cause of preventable mortality in trauma, particularly when immediate surgical intervention is not available. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a promising technique to control severe hemorrhaging and stabilize patients until definitive surgical care can be performed. Case Presentation: We report the case of a 45-year-old woman who sustained multiple traumatic injuries—including thoracic, pelvic, and aortic damage—after a fall from approximately 5 m in an apparent suicide attempt. She arrived at a secondary-level trauma center in profound hemorrhagic shock, unresponsive to standard resuscitation. Interventions: As the patient’s condition deteriorated to cardiac arrest, an emergent REBOA procedure was performed by emergency physicians. This intervention rapidly restored hemodynamic stability, enabling damage control resuscitation and safe transfer to a Level 1 Trauma Center for definitive surgical management, including thoracic endovascular aortic repair and splenectomy. Outcomes: After prolonged intensive care, the patient recovered sufficiently to be discharged for rehabilitation. This case illustrates the life-saving potential of early REBOA deployment in a non-surgical, resource-limited setting to bridge patients to definitive care. Conclusions: This case supports integrating REBOA into emergency trauma protocols, particularly in centers without immediate surgical capabilities. Further research is warranted to refine REBOA deployment strategies, balloon positioning, patient selection, and the role of imaging guidance.

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.

Aim. To evaluate the diagnostic accuracy of the STANDING algorithm across different emergency departments (ED)s. As secondary outcomes we compared the STANDING and the local usual care (LUC), in term of accuracy, use of diagnostic resources and length of stay (LOS). Methods. We prospectively enrolled adult patients presenting with vertigo/dizziness at one 'hub' and three 'spoke' EDs in Tuscany, evaluated using either STANDING or LUC depending on the availability of a trained emergency physician (EP). Imaging tests, consultations and discharge/admission decisions were made independently of the study. The reference standard was a diffusion-weighted MRI of the brain and 30-days follow-up. Results. We included 456 patients, 242 (53%) assessed by STANDING. No difference in age, gender and prevalence of cardiovascular risk factors were present between STANDING and LUC groups. The prevalence of central vertigo was 8.6%, with ischemic stroke (4.2%) as the leading cause, without differences between the two groups. The sensitivity, specificity, positive and negative predictive values (95% CI) of STANDING for central disease were 88.2% (63.6-98.5), 91.6% (87.1-94.8), 44.1% (33.2-55.7), 99% (96.5-99.7), without differences between the ?hub? and the ?spoke? centres and when only ischemic stroke was considered. STANDING demonstrated higher specificity and positive predictive values than that of LUC (36.5% and 14.7%, p<0.05 for both). Additionally, requests for head CT were lower (48.3% vs. 66.8%) and LOS shorter (289 vs. 351 minutes) in the STANDING group (p<0.05 for both). Conclusions. The STANDING algorithm showed a good accuracy and a very high negative predictive value for excluding central disease and stroke, across different EDs. Compared to LUC, STANDING showed increased specificity, reduced utilisation of head CT and a shorter LOS. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement I declare that this study has not benefited from any external funding. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Comitato per l'etica nella clinica Azienda USL Toscana centro I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Dear Editor, all data analyzed during this study are included in the manuscript. Additional datasets supporting the findings of this study are available from the corresponding author upon reasonable request. Sincerely, Dr Mattia Ronchetti

This review explores the role of precision medicine in the management of bleeding disorders and anticoagulation therapy, with a focus on the use of visco-elastic tests such as Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM). These tests provide real-time, dynamic insight into a patient's coagulation status, guiding the choice between three-factor prothrombin complex concentrate (PCC3) and four-factor PCC (PCC4), as well as the use of activated four-factor PCC (FEIBA). The specific ROTEM tests, INTEM and EXTEM, further enhance our understanding of the intrinsic and extrinsic coagulation pathways. Moreover, the use of tranexamic acid (TXA) and fibrinogen, guided by these visco-elastic tests, has shown promise in trauma patients. TXA has been associated with survival benefit when administered immediately or within 3 hours of injury. Fibrinogen, a key factor in clot formation, can be monitored and supplemented as needed to optimize hemostasis. In conclusion, the practice of precision medicine, with the aid of TEG and ROTEM, offers the potential to enhance the safety and efficacy of PCC therapy, TXA administration, and fibrinogen supplementation. These tools are invaluable in tailoring therapy to the specific needs of each patient, potentially optimizing patient outcomes and minimizing the risk of adverse events.

The Authors report an accidental gas exposure of Chlorine gas in a worker. This accident is very uncommon and can lead to important life-threatening conditions, such as Reactive Airway Disfunction Syndrome (RADS) and Acute Respiratory Distress Syndrome (ARDS) with important pulmonary disfunctions and even death. This syndrome results are reversible when a quick and appropriate intensive treatment is performed.

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.

We present the first Italian reported case of an invasive meningococcal disease with rifampicin-resistance (Rif-R)secondary to chemoprophylaxis. The case is entered in a cluster of two IMDs registered in Tuscany, Italy, in November 2019 caused by two non-differentiable group-C Neisseria meningitidis belonging to ST-11 clonal-complex. The contact case, differently from the index, harbored H552Y mutation on rpoB gene which is known to confer Rif-R putting a high-cost fee on bacterial fitness. The extremely mild clinical presentation in the contact can constitute an in vivo demonstration of the virulence attenuation observed in vitro for H552Ymutants. Clinicians should be aware of the possibility of secondary cases with induced Rif-R and keep a high level of suspicion on contacts who received rifampicin-chemoprophylaxis. Molecular characterization of Rif-R should be performed routinely directly on biological samples and not only on isolates, in order to rapidly detect rare cases of resistance and consequently modify chemoprophylaxis for contacts.

Purpose Diverticulitis is a common cause of abdominal pain and CT scan is commonly used for its diagnosis in the emergency department (ED). The diagnostic performance of point-of-care ultrasound (POCUS) integrated into a clinical exam for diverticulitis is still not established. We evaluate the accuracy of clinical-sonographic assessment for the diagnosis of diverticulitis and whether POCUS could improve the selection of patients needing CT scan for complicated diverticulitis. Materials and Methods This is a multicentric observational study involving adult patients suspected of having diverticulitis presenting at 4 EDs. 21 sonographer physicians were asked to diagnose diverticulitis and complicated diverticulitis based on clinical-sonographic assessment. The final diagnosis was established by two reviewers, blinded to POCUS, based on data collected during the one-month follow-up comprehensive CT scan. Results Among 393 enrolled patients, 218 (55.5 %) were diagnosed with diverticulitis and 33 (8 %) had complicated diverticulitis. The time to diagnosis by the sonographer physicians was shorter compared to standard care (97 +/- 102 vs. 330 +/- 319 minutes, p < 0.001). Clinical-sonographic assessment showed optimal sensitivity (92.7 %) and specificity (90.9 %) for diverticulitis. However, the sensitivity (50 %) for complicated diverticulitis was low. The sonographer physician would have proceeded to CT scan in 194 (49.4 %) patients and the CT scan request compared to the final diagnosis of complicated diverticulitis demonstrated 94 % sensitivity. Conclusion Clinical-sonographic assessment is rapid and accurate for the diagnosis of diverticulitis. Even if POCUS has low sensitivity for complicated diverticulitis, it can be used to safely select patients needing CT.

A patient presenting an ST-segment elevation could represent a life-threatening condition in Emergency Department (ED). This case shows how sometimes, a chronic, and more often, an acute abuse of alcohol is related to important harmful effects on myocardial contractility. The authors present a case of a 19-year-old male of oriental-Asiatic origin admitted unconscious to ED with alcoholic fetor: on electrocardiogram a significant and widespread STsegment elevation was observed. A bedside echocardiography showed no abnormalities in segmental kinetics; therefore electrocardiogram- alterations could be related to a coronary spasm. The literature is poor about this effect induced by acute alcohol ingestion: the pathophysiological mechanism at the base of the abnormal muscle contractility, seems to be related to an impairment in cyclic guanosine monophosphate production, although a second and less probable hypothesis could be an altered intracellular concentration of calcium levels.

Nazerian, Peimana; Lazzeretti, Deliaa; Vanni, Simonea; Donnarumma, Emiliaa; Magazzini, Simoneb; Ruggiano, Germanac; Giannasi, Gianfrancod; Grifoni, Stefanoa; Zaccara, Gaetanoe Author Information

To analyze the clinical characteristics of acute meningitis and their relationship with age in adult patients presenting to the emergency department. We retrospectively investigated consecutive adult patients admitted with a diagnosis of bacterial or viral meningitis from 2002 to 2006. Data about patient’s history, symptoms and signs at presentation, etiology and clinical course were collected. To investigate the relationship of clinical presentation with age, we divided patients in four age quartiles (<30 years, between 30 and 36 years, between 37 and 56 years, >56 years). Among the 202 patients considered in the study (mean age 42.8 ± 18.7 years, range 14–90), 162 (80.2%) patients had viral and 40 (19.8%) bacterial meningitis. Specific signs, such as neck stiffness or Kernig or Brudzinski signs, were more common in the first than in the fourth quartile (73.1 vs. 45.7% P = 0.041). Conversely, altered consciousness expressed as Glasgow Coma Scale (GCS) <15 was more frequent in the fourth (80.4%) than in the first (9.6%) quartile ( P < 0.001). The linear regression analysis confirmed a significant decrease of GCS with the increasing of patient’s age ( r = −0.69, P < 0.001). At multivariate analysis, aging was associated with altered level of consciousness (OR 16.7, P < 0.001) independent of viral or bacterial etiology of the presence of comorbidities and of clinical severity (presence of severe sepsis or septic shock). Meningitis presentation largely differs with aging in adult patients. Level of consciousness is frequently altered in the older patients, when other specific signs become more rare, independent of etiology, comorbidities and clinical severity.

Background: Head injury represents one of the most important and frequent traumatic pathology in the emergency department. Among the different risk factors, preinjury use of warfarin has received considerable attention in trauma literature. The aim of this study was to identify further risk indicators of intracranial hemorrhage (ICH) to improve risk stratification of warfarinized patients with minor head injuries. Methods: Medical records of 1,554 adult patients with minor head injuries evaluated by the Emergency Department of Azienda Ospedaliera, Universitaria Careggi from January 2007 to February 2008 were analyzed retrospectively. All the patients included in the study were subjected to blood tests. The international normalized ratio (INR) measured on admission was correlated with the results of head computed tomography scan. Results: Of the 1,410 patients included in the study, 75 (5.2%) were warfarin anticoagulated at the time of trauma. The INR measured on admission was 2.37 ± 1.04 (mean ± standard deviation), and this value was significantly associated with occurrence of ICH after head trauma (r = 0.37; p < 0.005). For 12 (of 75) patients of this group, the findings of the computed tomography scans were positive. The receiver operating characteristic curve show that the most effective INR cutoff value was 2.43, with a sensitivity of 92%, a specificity of 66%, and positive and negative predictive values of 33% and 97%, respectively. Conclusions: This study highlights the strong relationship between INR values and the probability of ICH, as shown in previous studies. The high negative predictive value of the identified cutoff, if confirmed, could be used to exclude ICH.

Objective: To derive and validate a prediction rule in patients with acute chest pain (CP) without existing known coronary disease.Methods: Cohort study including 2233 patients with CP. Based on clinical judgment, 1435 were discharged as very low risk and the remaining 798 underwent exercise tolerance test (ETT). End point: 6-month composite of cardiovascular death, nonfatal myocardial infarction, and revascularization. The prediction rule was derived from a randomly selected test cohort (n = 1106) summing factors of variables selected by multivariate regression analysis: CP score higher than 6 (factor of 3), male gender, age older than 50 years, metabolic syndrome, and diabetes mellitus (factor of 1, for each). The prediction rule was validated in the remaining cohort (n = 1127). All patients with CP were categorized into 3 groups: group A (prediction rule 0-1), B (2-4), or C (5-6). Outcomes and prognostic yield of ETT were compared among each group.Results: In the test cohort, 55 patients (5%) reached the composite end point. Event rate increased as the prediction rule increased: 1% for group A, 6% for B, and 25% for C (P<.001). This pattern was confirmed in the validation cohort (P<.001). A normal ETT did not significantly improve the high (99%) negative predictive value in group A and did not succeed in excluding the composite end point (17%) in group C.Conclusions: In patients with acute CP without existing coronary disease, a prediction rule based on clinical characteristics provided a useful method for prognostication with possible implication in decision making. (C) 2010 Elsevier Inc. All rights reserved.

Bambi, Stefano; Magazzini, Simone; Pepe, Giuseppe; Ruggeri, Marco; Tramontana, Stefania; Maestri, Elena; Lumini, Enrico; Becattini, Giovanni Author Information