Fabrizio Giostra - Academia.edu (original) (raw)

Papers by Fabrizio Giostra

Journal of Clinical Medicine

COVID-19 patients may manifest thrombocytopenia and some of these patients succumb to infection d... more COVID-19 patients may manifest thrombocytopenia and some of these patients succumb to infection due to coagulopathy. The aim of our study was to examine platelet count values in patients infected with SARS-CoV-2, comparing them to a control group consisting of non-COVID-19 patients. Moreover, we evaluated the correlation between the platelet value and the respiratory alteration parameters and the outcome (hospitalization and mortality) in COVID-19 patients. The mean platelet values (×109/L) differed between patients with positive or negative SARS-CoV-2 swabs (242.1 ± 92.1 in SARS-CoV-2 negative vs. 215.2 ± 82.8 in COVID-19 patients, p < 0.001). In COVID-19 patients, the platelet count correlated with the A-aO2 gradient (p = 0.001, rho = −0.149), with its increase over the expected (p = 0.013; rho = −0.115), with the PaO2 values (p = 0.036; rho = 0.093), with the PCO2 values (p = 0.003; rho = 0.134) and with the pH values (p = 0.016; rho = −0.108). In COVID-19 negative patients, t...

The credit earned from the Quick Credit TM test accompanying this article may be applied to the a... more The credit earned from the Quick Credit TM test accompanying this article may be applied to the asset resource management (AR), operations management (OR), and communications and information management (CI) domains.

European Journal of Case Reports in Internal Medicine, 2020

Thromboembolic disease is strongly associated with, or even an integral part of, COVID-19 pneumon... more Thromboembolic disease is strongly associated with, or even an integral part of, COVID-19 pneumonia. Indeed, endothelial/microvascular damage to pulmonary capillaries seems to be the main trigger of the pneumonia. Here we report a case of pulmonary embolism in a COVID-19 patient with an atypical clinical presentation. Blood gas analysis and lung ultrasound allowed the correct diagnosis to be reached.

Emergency Care Journal, 2021

In Northern Italy the coronavirus infection has spread since February 2020: the increase in admis... more In Northern Italy the coronavirus infection has spread since February 2020: the increase in admissions of COVID-19 patients corresponded to a drastic decrease in admissions of regular patients to the Emergency Room (ER). This retrospective study was conducted by Academy of Emergency Medicine and Care (AcEMC). During the lockdown period the accesses were reduced by more than 50%, and in the following months of May and June 2020, there was a recovery clearly below (70%) previous year’s numbers. We have observed a drastic reduction in white and green codes, a fair reduction in yellow codes, while red codes remained stable. The decrease in access to the ER mainly concerned patients with low priority color codes, but also the reduction in the number of accesses of yellow and red codes, insignificant at a superficial glance, is notable. If we consider that yellow and red codes during the months of the lockdown included many patients with COVIDrelated respiratory insufficiency, it is evide...

Emergency Care Journal, 2020

SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with ... more SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with few symptoms to severe respiratory failures. Chest Computed Tomography (CT) is currently the gold-standard imaging method, although burdened by the risk of exposure to ionizing radiation and management / organizational concerns. In particular, the critical patient undergoing ventilation (invasive or not) seems to be difficult to monitor by repeated CT scan over time. We report the case of a 55-year-old male patient subjected to Continuous Positive Airway Pressure (CPAP) and prone positioning, in which the use of ultrasound monitoring allowed to verify the effectiveness of the pressure support used in recruiting previously atelectasis lung areas. Lung ultrasound can guide pulmonary recruitment and pronation maneuvers in patients undergoing non-invasive ventilation. Ultrasound can identify atelectatic lung areas, which demonstrate an alveolar re-expansion following the setting of high PEEP...

COVID-19 infection is frequently associated with radiological diagnosis of interstitial pneumonia... more COVID-19 infection is frequently associated with radiological diagnosis of interstitial pneumonia and alteration in gases exchange. We decided to test arterial blood gas assay parameters, in particular alveolar-to-arterial oxygen gradient (AaDO2), in predicting the need of hospitalization, the survival rate and in identifying pneumonia in patients with SARS-CoV-2 infection.We conducted an observational prospective study in one of the Emergency Department of our city. We included consecutive patients with symptoms likely related to SARS-CoV-2 infection, confirmed either with positive nasal pharyngeal swabs and/or with suggestive radiological findings. Areas under the curve of the receiver operator characteristic curve were computed to predict need of hospitalization and the presence of pneumonia. Survival curves were analyzed using a Log-rank test. P-value less than 0.05 were considered statistically significant.We enrolled 825 patients; the final population was composed by 530 patie...

Emergency Care Journal, 2020

Treatment of de novo acute hypoxic respiratory failure is not recommended by current Non-Invasive... more Treatment of de novo acute hypoxic respiratory failure is not recommended by current Non-Invasive Ventilation (NIV) guidelines as it does not seem to improve patients outcome. Many cases of acute hypoxic respiratory failure associated with Sars-Cov2 infection (SARI) have been observed during Sars-Cov2 pandemic. So far, data are missing regarding the use of NIV, but a correct identification of subgroups of patients based on different clinical, patho-physiological and radiological features, might be helpful for stratifying patients and choosing the correct respiratory support (invasive versus non-invasive). In case of NIV appliance, risk of environmental virus dispersion is particularly elevated; therefore, extreme attention by operators is required.

Objective: The aim of the recent management reorganization of the Emergency Room and Radiology wa... more Objective: The aim of the recent management reorganization of the Emergency Room and Radiology ward was to face the recent Coronavirus pandemic in the most rational way possible, to preserve the essential role of these Units in the complex context of a pavillions structured Hospital. Methods: The most challenging management criticalities posed by the recent Coronavirus pandemic were individually analyzed and dealt with. The pavilions structure of our Hospital, biohazard management, shortage of personnel and shortage or temporary inadequacy of personal protective equipment were addressed as the most urgent and important problems.Results: A strategic use of the Radiology Information System and Picture Archiving And Communication System (RIS-PACS), dedicated ambulances with specific disinfection procedures, the institution of dedicated pavilions, wards, checkpoints and different paths for COVID-19 (Coronavirs Disease 2019) and non COVID-19 patients, frequent sanification procedures, se...

Cureus, 2021

Introduction and aim: As first receivers of suspected coronavirus disease 2019 (COVID-19) patient... more Introduction and aim: As first receivers of suspected coronavirus disease 2019 (COVID-19) patients, clinicians of the Emergency Department (ED) have to rapidly perform the first clinical assessment evaluating the intensity of care needed. So far, clear management guidelines still lack. We identified variables associated with hospitalization in order to give a quick tool to assist clinicians in stratifying cases based on the severity at their arrival at the ED and in predicting the need for hospital care. Methods: This is a monocentric observational prospective study enrolling COVID-19 patients. A score for hospitalization prediction (CovHos Score) was created using variables associated with hospitalization at multivariate analysis and then validated on an internal subsequent cohort. Results: A total of 667 patients were included; 465 (69.7%) were hospitalized and 108 (16.2%) died at 30-days follow-up. In a multivariate analysis, male sex, age>65, alveolar-to-arterial oxygen gradient percentage increase compared to that expected for age, neutrophils/lymphocytes ratio and C-reactive protein levels were significantly associated with a higher rate of hospital admission. A CovHos score cutoff of 12 points predicted hospitalization with 85% sensitivity and 82.4 % specificity (area under a receiver operating characteristic curve [AUROC] = 0.909, 95% CI 0.884-0.935). Similar results were obtained in the validation court. A cutoff of 22 has 79% sensitivity and 77% specificity in predicting mortality (AUROC = 0.824; 95% CI 0.782-0.866); sensitivity and specificity were respectively 71.4% and 71.3% in the validation group. Conclusions: Although medical judgment still remains crucial, the CovHos score is an effective tool to assist emergency clinicians in predicting the need for hospitalization or to optimize allocation in a shortage of hospital resources.

Emergency Care Journal, 2017

Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically ... more Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically useful for diagnosing and monitoring sepsis. Eight members of AcEMC (Academy of Emergency Medicine and Care) and eight members of SIBioC (Italian Society of Clinical Biochemistry and Laboratory Medicine) were identified by the two scientific societies for producing a consensus document aimed to define practical recommendations about the use of biomarkers for diagnosing of sepsis and managing antibiotic therapy in the emergency department (ED). The cumulative opinions allowed defining three grade A recommendations (i.e., highly recommended indications), entailing ordering modality (biomarkers always available on prescription), practical use (results should be interpreted according to clinical information) and test ordering defined according to biomarker kinetics. Additional grade B recommendations (i.e., potentially valuable indications) entailed general agreement that biomarkers assessme...

The American Journal of Emergency Medicine, 2021

BACKGROUND Evidence is lacking about the impact of subsequent COVID-19 pandemic waves on Emergenc... more BACKGROUND Evidence is lacking about the impact of subsequent COVID-19 pandemic waves on Emergency Departments (ED). We analyzed the differences in patterns of ED visits in Italy during the two pandemic waves, focusing on changes in accesses for acute and chronic diseases. METHODS We conducted a retrospective study using data from a metropolitan area in northern Italy that includes twelve ED. We analyzed weekly trends in non-COVID-19 ED visits during the first (FW) and second wave (SW) of the pandemic. Incidence rate ratios (IRRs) of triage codes, patient destination, and cause-specific ED visits in the FW and SW of the year 2020 vs. 2019 were estimated using Poisson regression models. MAIN FINDINGS We found a significant decrease of ED visits by triage code, which was more marked for low priority codes and during the FW. We found an increased share of hospitalizations compared to home discharges both in the FW and in the SW. ED visits for acute and chronic conditions decreased during the FW, ranging, from -70% for injuries (IRR = 0.2862, p < 0.001) to -50% and - 60% for ischemic heart disease and heart failure. CONCLUSIONS The two pandemic waves led to a selection of patients with higher and more urgent needs of acute hospital care. These findings should lead to investigate how to improve systems' capacity to manage changes in population needs.

PLOS ONE, 2021

The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare ne... more The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare needs. Not exhaustive data are available on the consequences of this on non-COVID-19 patients. The aim of this study was to assess the impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants’ area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year. Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of E...

Intensive Care Medicine, 2021

To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspe... more To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history. Methods: This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. Results: We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients

Internal and Emergency Medicine, 2021

During the first outbreak of Coronavirus disease 2019 (COVID-19) Emergency Departments (EDs) were... more During the first outbreak of Coronavirus disease 2019 (COVID-19) Emergency Departments (EDs) were overcrowded. Hence, the need for a rapid and simple tool to support clinical decisions, such as the ROX index (Respiratory rate-OXygenation), defined as the ratio of peripheral oxygen saturation and fraction of inspired oxygen, to respiratory rate. The aim of the study was to evaluate the accuracy of the ROX index in predicting hospitalization and mortality in patients with a diagnosis of COVID-19 in the ED. The secondary outcomes were to assess the number of readmissions and the variations in the ROX index between the first and the second admission. This was an observational prospective monocentric study, carried out in the ED of Sant'Orsola-Malpighi Hospital in Bologna, Italy. Five hundred and fifty-four consecutive patients with COVID-19 were enrolled and the ROX index was calculated. Patients were followed until hospital discharge or death. A ROX index value < 25.7 was associated with hospitalization (area under the curve [AUC] = 0.737, 95% CI 0.696-0.779, p < 0.001). The ROX index < 22.3 was statistically related to higher 30-day mortality (AUC = 0.764, 95% CI 0.708-0.820, p < 0.001). Eight patients were discharged and returned to the ED within the subsequent 7 days, their mean ROX index was 30.3 (6.2; range 21.9-39.4) at the first assessment and 24.6 (5.5; 14.5-29.5) at the second assessment, (p = 0.012). The ROX index, together with laboratory, imaging and clinical findings, correlated with the need for hospital admission, mechanical ventilation and mortality risk in COVID-19 patients.

Background: the LUS score has been proposed as an optimal scheme for the ultrasound study of the ... more Background: the LUS score has been proposed as an optimal scheme for the ultrasound study of the patient with suspected / confirmed COVID-19 pneumonia. The aim of our study was to evaluate the use of lung ultrasound as a diagnostic tool for diagnosing SARS-CoV-2 pneumonia, and to examine the validity of LUS score for the diagnosis of COVID-19 pneumonia, and to correlate with hospitalization rate and 30-days mortality.Material & methods: a retrospective analysis was performed on all patients who were referred to the General Emergency Department of the S. Orsola-Malpighi Hospital from April 2020 to May 2020 for symptoms suspected for SARS-CoV-2 infection. The ultrasound examination was based on a common execution scheme called LUS score, as previously described.Results & Conclusions: LUS score correlates with the degree of clinical severity and respiratory failure (P/F ratio, Delta (A-a), Delta (A-a) increase). COVID-19 patients with a LUS score > 7 require the use of oxygen suppor...

Acta bio-medica : Atenei Parmensis, Jan 16, 2018

Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of mor... more Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. Aim of the work and Methods: To critically analyze pneumonia "rebound" cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome. 249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission....

European journal of internal medicine, May 20, 2018

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients ... more Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients with COPD to access the emergency department and have a negative impact on the course of the disease. The objectives of our study were: 1) describing the socio-demographic and clinical characteristics, and the clinical management, of patients with AECOPD, when they present to the emergency department; and 2) estimating the costs related to the management of these patients. We conducted a retrospective cohort study in Italy, collecting data on 4396 patients, from 34 centres. Patients had a mean (SD) age of 76,6 (10.6) years, and 61.2% of them where males. >70% of the patients had a moderate to very high comorbidity burden, and heart failure was present in 26.4% of the cohort. The 64.6% of patients were admitted to hospital wards, with a mean (SD) length of stay of 10.8 (9.8) days. The estimated cost per patient was 2617 €. Patients attending the ED for an AECOPD are old and present imp...

Emergency Care Journal, 2017

Emergency departments (EDs) are increasingly used for patients at the end of life stage of their ... more Emergency departments (EDs) are increasingly used for patients at the end of life stage of their diseases worldwide, even if they do not have acute and potentially treatable conditions. Moreover, an increasingly shortage of hospital beds, in spite of the wellrecognized ageing of the population, has led to a progressive prolongation of the average length of stay (LOS) time in the vast majority of Italians EDs. Therefore, the aim of this study was to describe the trend of ED non-traumatic deaths in 11 Italians EDs, and to correlate these deaths with the medium length of stay in the same EDs. All cases classified as “died during ambulance transfer or while in the ED” have been retrieved from the hospital database of the 11 participating EDs, from January 1st 2007 to December 31st 2016, with the exclusion of traumatic events. The average LOS in minutes of the seven hospitals that could provide this information was then calculated. A continuously increasing number of ED deaths was observ...

European Respiratory Journal, Sep 1, 2011

Introduction: Emergency physicians (EP) face the challenge of predicting short-term outcomes for ... more Introduction: Emergency physicians (EP) face the challenge of predicting short-term outcomes for patients with acute respiratory failure (ARF) in the emergency department. (ED) Objectives: To identify early objective clinical parameters and biomarkers for severity assessment and predicting outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) requiring noninvasive mechanical ventilation (NIV). Methods: Three-months observational prospective study in the acute setting of the ED of a university teaching hospital, including consecutive nonselected patients emergently admitted for ARF due to AECOPD treated by NIV according to EP9s indication referring to an institutional protocol. Treatment failure was defined as hospital mortality or need for invasive mechanical ventilation at any time. Results: 124 patients (media 1.38/day). Failure (23 cases, 18.5%) and success (101; 81.5%) patients were different in: neurologic status score (Kelly-Matthay scale), urea, creatinin, AST, ALT, CPK, CPK-MB, troponin T, LDH, PCR, pH, and arterial blood gas analysis parameters after 1 hour of NIV (PaO 2 , pH, PaCO 2 , HCO 3 - , SaO 2 , PaO 2 /FIO 2 ). Conclusions: NIV is a cost effective intervention even outside intensive care units for the treatment of ARF caused by AECOPD. We were able to identify in the ED early predictors of outcome (mainly about more severe clinical conditions and the response to treatment). An unresolved question in the ED is about selection criteria and early choices for patients with ARF having preset therapeutic-prognostic limits and acutely reversible processes for which NIV should be considered as ceiling treatment.

European Respiratory Journal, Sep 1, 2011

Background: The incidence and complexity of asthma acute exacerbations (AA) are widely increasing... more Background: The incidence and complexity of asthma acute exacerbations (AA) are widely increasing. The emergency physician (EP) plays a key role in AA: emergency management; medical treatment; diagnosis; prevention; maintenance; follow up; education about self-management. Aims: To define the epidemiological and clinical impact of AA at presentation to the emergency department (ED) and the role of the EP. Methods: Six months observational prospective clinical study including every consecutive AA patient who presented to the ED of a university teaching hospital Results: Patients: 209 (1.15/day). Rates%: females 63.5; Italian 70.2; practitioner9s request 6.0; current therapy for asthma 83.1; known risk factors 63.5; previous physician9s visit 15.9; ED therapy 79.5; ED mechanical ventilation 2.9; hospitalization 18.2; discharge therapy 77.9; discharge follow up 65.9; ED rebounds 4.3. Media: age 41 years; ED waiting time 48 minutes; ED time for evaluation and treatment 104 minutes; ED total time 153 minutes; systolic blood pressure 127 mmHg; diastolic 78 mmHg; pulse rate 94 bpm; pulsoxymetry 97%; body temperature 36.9°C; symptoms debut before ED 7 days; time between second and first ED visit 50 days. Conclusions: The majority of asthma exacerbations has a window of opportunity in which deterioration can be recognized and reverted; severe asthma attacks can be prevented by currently available strategies. Of concern was the dependence of most patients on ED for initial care, and the small number of cases in which patients visited a physician before presenting to the hospital. Nowadays the EP must be involved in approaching all typical most frequent and relevant causes of inadequate asthma control.

Journal of Clinical Medicine

COVID-19 patients may manifest thrombocytopenia and some of these patients succumb to infection d... more COVID-19 patients may manifest thrombocytopenia and some of these patients succumb to infection due to coagulopathy. The aim of our study was to examine platelet count values in patients infected with SARS-CoV-2, comparing them to a control group consisting of non-COVID-19 patients. Moreover, we evaluated the correlation between the platelet value and the respiratory alteration parameters and the outcome (hospitalization and mortality) in COVID-19 patients. The mean platelet values (×109/L) differed between patients with positive or negative SARS-CoV-2 swabs (242.1 ± 92.1 in SARS-CoV-2 negative vs. 215.2 ± 82.8 in COVID-19 patients, p < 0.001). In COVID-19 patients, the platelet count correlated with the A-aO2 gradient (p = 0.001, rho = −0.149), with its increase over the expected (p = 0.013; rho = −0.115), with the PaO2 values (p = 0.036; rho = 0.093), with the PCO2 values (p = 0.003; rho = 0.134) and with the pH values (p = 0.016; rho = −0.108). In COVID-19 negative patients, t...

The credit earned from the Quick Credit TM test accompanying this article may be applied to the a... more The credit earned from the Quick Credit TM test accompanying this article may be applied to the asset resource management (AR), operations management (OR), and communications and information management (CI) domains.

European Journal of Case Reports in Internal Medicine, 2020

Thromboembolic disease is strongly associated with, or even an integral part of, COVID-19 pneumon... more Thromboembolic disease is strongly associated with, or even an integral part of, COVID-19 pneumonia. Indeed, endothelial/microvascular damage to pulmonary capillaries seems to be the main trigger of the pneumonia. Here we report a case of pulmonary embolism in a COVID-19 patient with an atypical clinical presentation. Blood gas analysis and lung ultrasound allowed the correct diagnosis to be reached.

Emergency Care Journal, 2021

In Northern Italy the coronavirus infection has spread since February 2020: the increase in admis... more In Northern Italy the coronavirus infection has spread since February 2020: the increase in admissions of COVID-19 patients corresponded to a drastic decrease in admissions of regular patients to the Emergency Room (ER). This retrospective study was conducted by Academy of Emergency Medicine and Care (AcEMC). During the lockdown period the accesses were reduced by more than 50%, and in the following months of May and June 2020, there was a recovery clearly below (70%) previous year’s numbers. We have observed a drastic reduction in white and green codes, a fair reduction in yellow codes, while red codes remained stable. The decrease in access to the ER mainly concerned patients with low priority color codes, but also the reduction in the number of accesses of yellow and red codes, insignificant at a superficial glance, is notable. If we consider that yellow and red codes during the months of the lockdown included many patients with COVIDrelated respiratory insufficiency, it is evide...

Emergency Care Journal, 2020

SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with ... more SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with few symptoms to severe respiratory failures. Chest Computed Tomography (CT) is currently the gold-standard imaging method, although burdened by the risk of exposure to ionizing radiation and management / organizational concerns. In particular, the critical patient undergoing ventilation (invasive or not) seems to be difficult to monitor by repeated CT scan over time. We report the case of a 55-year-old male patient subjected to Continuous Positive Airway Pressure (CPAP) and prone positioning, in which the use of ultrasound monitoring allowed to verify the effectiveness of the pressure support used in recruiting previously atelectasis lung areas. Lung ultrasound can guide pulmonary recruitment and pronation maneuvers in patients undergoing non-invasive ventilation. Ultrasound can identify atelectatic lung areas, which demonstrate an alveolar re-expansion following the setting of high PEEP...

COVID-19 infection is frequently associated with radiological diagnosis of interstitial pneumonia... more COVID-19 infection is frequently associated with radiological diagnosis of interstitial pneumonia and alteration in gases exchange. We decided to test arterial blood gas assay parameters, in particular alveolar-to-arterial oxygen gradient (AaDO2), in predicting the need of hospitalization, the survival rate and in identifying pneumonia in patients with SARS-CoV-2 infection.We conducted an observational prospective study in one of the Emergency Department of our city. We included consecutive patients with symptoms likely related to SARS-CoV-2 infection, confirmed either with positive nasal pharyngeal swabs and/or with suggestive radiological findings. Areas under the curve of the receiver operator characteristic curve were computed to predict need of hospitalization and the presence of pneumonia. Survival curves were analyzed using a Log-rank test. P-value less than 0.05 were considered statistically significant.We enrolled 825 patients; the final population was composed by 530 patie...

Emergency Care Journal, 2020

Treatment of de novo acute hypoxic respiratory failure is not recommended by current Non-Invasive... more Treatment of de novo acute hypoxic respiratory failure is not recommended by current Non-Invasive Ventilation (NIV) guidelines as it does not seem to improve patients outcome. Many cases of acute hypoxic respiratory failure associated with Sars-Cov2 infection (SARI) have been observed during Sars-Cov2 pandemic. So far, data are missing regarding the use of NIV, but a correct identification of subgroups of patients based on different clinical, patho-physiological and radiological features, might be helpful for stratifying patients and choosing the correct respiratory support (invasive versus non-invasive). In case of NIV appliance, risk of environmental virus dispersion is particularly elevated; therefore, extreme attention by operators is required.

Objective: The aim of the recent management reorganization of the Emergency Room and Radiology wa... more Objective: The aim of the recent management reorganization of the Emergency Room and Radiology ward was to face the recent Coronavirus pandemic in the most rational way possible, to preserve the essential role of these Units in the complex context of a pavillions structured Hospital. Methods: The most challenging management criticalities posed by the recent Coronavirus pandemic were individually analyzed and dealt with. The pavilions structure of our Hospital, biohazard management, shortage of personnel and shortage or temporary inadequacy of personal protective equipment were addressed as the most urgent and important problems.Results: A strategic use of the Radiology Information System and Picture Archiving And Communication System (RIS-PACS), dedicated ambulances with specific disinfection procedures, the institution of dedicated pavilions, wards, checkpoints and different paths for COVID-19 (Coronavirs Disease 2019) and non COVID-19 patients, frequent sanification procedures, se...

Cureus, 2021

Introduction and aim: As first receivers of suspected coronavirus disease 2019 (COVID-19) patient... more Introduction and aim: As first receivers of suspected coronavirus disease 2019 (COVID-19) patients, clinicians of the Emergency Department (ED) have to rapidly perform the first clinical assessment evaluating the intensity of care needed. So far, clear management guidelines still lack. We identified variables associated with hospitalization in order to give a quick tool to assist clinicians in stratifying cases based on the severity at their arrival at the ED and in predicting the need for hospital care. Methods: This is a monocentric observational prospective study enrolling COVID-19 patients. A score for hospitalization prediction (CovHos Score) was created using variables associated with hospitalization at multivariate analysis and then validated on an internal subsequent cohort. Results: A total of 667 patients were included; 465 (69.7%) were hospitalized and 108 (16.2%) died at 30-days follow-up. In a multivariate analysis, male sex, age>65, alveolar-to-arterial oxygen gradient percentage increase compared to that expected for age, neutrophils/lymphocytes ratio and C-reactive protein levels were significantly associated with a higher rate of hospital admission. A CovHos score cutoff of 12 points predicted hospitalization with 85% sensitivity and 82.4 % specificity (area under a receiver operating characteristic curve [AUROC] = 0.909, 95% CI 0.884-0.935). Similar results were obtained in the validation court. A cutoff of 22 has 79% sensitivity and 77% specificity in predicting mortality (AUROC = 0.824; 95% CI 0.782-0.866); sensitivity and specificity were respectively 71.4% and 71.3% in the validation group. Conclusions: Although medical judgment still remains crucial, the CovHos score is an effective tool to assist emergency clinicians in predicting the need for hospitalization or to optimize allocation in a shortage of hospital resources.

Emergency Care Journal, 2017

Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically ... more Increasing evidence is emerging that the measurement of circulating biomarkers may be clinically useful for diagnosing and monitoring sepsis. Eight members of AcEMC (Academy of Emergency Medicine and Care) and eight members of SIBioC (Italian Society of Clinical Biochemistry and Laboratory Medicine) were identified by the two scientific societies for producing a consensus document aimed to define practical recommendations about the use of biomarkers for diagnosing of sepsis and managing antibiotic therapy in the emergency department (ED). The cumulative opinions allowed defining three grade A recommendations (i.e., highly recommended indications), entailing ordering modality (biomarkers always available on prescription), practical use (results should be interpreted according to clinical information) and test ordering defined according to biomarker kinetics. Additional grade B recommendations (i.e., potentially valuable indications) entailed general agreement that biomarkers assessme...

The American Journal of Emergency Medicine, 2021

BACKGROUND Evidence is lacking about the impact of subsequent COVID-19 pandemic waves on Emergenc... more BACKGROUND Evidence is lacking about the impact of subsequent COVID-19 pandemic waves on Emergency Departments (ED). We analyzed the differences in patterns of ED visits in Italy during the two pandemic waves, focusing on changes in accesses for acute and chronic diseases. METHODS We conducted a retrospective study using data from a metropolitan area in northern Italy that includes twelve ED. We analyzed weekly trends in non-COVID-19 ED visits during the first (FW) and second wave (SW) of the pandemic. Incidence rate ratios (IRRs) of triage codes, patient destination, and cause-specific ED visits in the FW and SW of the year 2020 vs. 2019 were estimated using Poisson regression models. MAIN FINDINGS We found a significant decrease of ED visits by triage code, which was more marked for low priority codes and during the FW. We found an increased share of hospitalizations compared to home discharges both in the FW and in the SW. ED visits for acute and chronic conditions decreased during the FW, ranging, from -70% for injuries (IRR = 0.2862, p < 0.001) to -50% and - 60% for ischemic heart disease and heart failure. CONCLUSIONS The two pandemic waves led to a selection of patients with higher and more urgent needs of acute hospital care. These findings should lead to investigate how to improve systems' capacity to manage changes in population needs.

PLOS ONE, 2021

The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare ne... more The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare needs. Not exhaustive data are available on the consequences of this on non-COVID-19 patients. The aim of this study was to assess the impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants’ area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year. Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of E...

Intensive Care Medicine, 2021

To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspe... more To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient's symptoms and clinical history. Methods: This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. Results: We studied 1462 patients, classified in mild (n = 400), severe (n = 727), and mixed (n = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23-91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients

Internal and Emergency Medicine, 2021

During the first outbreak of Coronavirus disease 2019 (COVID-19) Emergency Departments (EDs) were... more During the first outbreak of Coronavirus disease 2019 (COVID-19) Emergency Departments (EDs) were overcrowded. Hence, the need for a rapid and simple tool to support clinical decisions, such as the ROX index (Respiratory rate-OXygenation), defined as the ratio of peripheral oxygen saturation and fraction of inspired oxygen, to respiratory rate. The aim of the study was to evaluate the accuracy of the ROX index in predicting hospitalization and mortality in patients with a diagnosis of COVID-19 in the ED. The secondary outcomes were to assess the number of readmissions and the variations in the ROX index between the first and the second admission. This was an observational prospective monocentric study, carried out in the ED of Sant'Orsola-Malpighi Hospital in Bologna, Italy. Five hundred and fifty-four consecutive patients with COVID-19 were enrolled and the ROX index was calculated. Patients were followed until hospital discharge or death. A ROX index value < 25.7 was associated with hospitalization (area under the curve [AUC] = 0.737, 95% CI 0.696-0.779, p < 0.001). The ROX index < 22.3 was statistically related to higher 30-day mortality (AUC = 0.764, 95% CI 0.708-0.820, p < 0.001). Eight patients were discharged and returned to the ED within the subsequent 7 days, their mean ROX index was 30.3 (6.2; range 21.9-39.4) at the first assessment and 24.6 (5.5; 14.5-29.5) at the second assessment, (p = 0.012). The ROX index, together with laboratory, imaging and clinical findings, correlated with the need for hospital admission, mechanical ventilation and mortality risk in COVID-19 patients.

Background: the LUS score has been proposed as an optimal scheme for the ultrasound study of the ... more Background: the LUS score has been proposed as an optimal scheme for the ultrasound study of the patient with suspected / confirmed COVID-19 pneumonia. The aim of our study was to evaluate the use of lung ultrasound as a diagnostic tool for diagnosing SARS-CoV-2 pneumonia, and to examine the validity of LUS score for the diagnosis of COVID-19 pneumonia, and to correlate with hospitalization rate and 30-days mortality.Material & methods: a retrospective analysis was performed on all patients who were referred to the General Emergency Department of the S. Orsola-Malpighi Hospital from April 2020 to May 2020 for symptoms suspected for SARS-CoV-2 infection. The ultrasound examination was based on a common execution scheme called LUS score, as previously described.Results & Conclusions: LUS score correlates with the degree of clinical severity and respiratory failure (P/F ratio, Delta (A-a), Delta (A-a) increase). COVID-19 patients with a LUS score > 7 require the use of oxygen suppor...

Acta bio-medica : Atenei Parmensis, Jan 16, 2018

Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of mor... more Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. Aim of the work and Methods: To critically analyze pneumonia "rebound" cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome. 249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission....

European journal of internal medicine, May 20, 2018

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients ... more Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients with COPD to access the emergency department and have a negative impact on the course of the disease. The objectives of our study were: 1) describing the socio-demographic and clinical characteristics, and the clinical management, of patients with AECOPD, when they present to the emergency department; and 2) estimating the costs related to the management of these patients. We conducted a retrospective cohort study in Italy, collecting data on 4396 patients, from 34 centres. Patients had a mean (SD) age of 76,6 (10.6) years, and 61.2% of them where males. >70% of the patients had a moderate to very high comorbidity burden, and heart failure was present in 26.4% of the cohort. The 64.6% of patients were admitted to hospital wards, with a mean (SD) length of stay of 10.8 (9.8) days. The estimated cost per patient was 2617 €. Patients attending the ED for an AECOPD are old and present imp...

Emergency Care Journal, 2017

Emergency departments (EDs) are increasingly used for patients at the end of life stage of their ... more Emergency departments (EDs) are increasingly used for patients at the end of life stage of their diseases worldwide, even if they do not have acute and potentially treatable conditions. Moreover, an increasingly shortage of hospital beds, in spite of the wellrecognized ageing of the population, has led to a progressive prolongation of the average length of stay (LOS) time in the vast majority of Italians EDs. Therefore, the aim of this study was to describe the trend of ED non-traumatic deaths in 11 Italians EDs, and to correlate these deaths with the medium length of stay in the same EDs. All cases classified as “died during ambulance transfer or while in the ED” have been retrieved from the hospital database of the 11 participating EDs, from January 1st 2007 to December 31st 2016, with the exclusion of traumatic events. The average LOS in minutes of the seven hospitals that could provide this information was then calculated. A continuously increasing number of ED deaths was observ...

European Respiratory Journal, Sep 1, 2011

Introduction: Emergency physicians (EP) face the challenge of predicting short-term outcomes for ... more Introduction: Emergency physicians (EP) face the challenge of predicting short-term outcomes for patients with acute respiratory failure (ARF) in the emergency department. (ED) Objectives: To identify early objective clinical parameters and biomarkers for severity assessment and predicting outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) requiring noninvasive mechanical ventilation (NIV). Methods: Three-months observational prospective study in the acute setting of the ED of a university teaching hospital, including consecutive nonselected patients emergently admitted for ARF due to AECOPD treated by NIV according to EP9s indication referring to an institutional protocol. Treatment failure was defined as hospital mortality or need for invasive mechanical ventilation at any time. Results: 124 patients (media 1.38/day). Failure (23 cases, 18.5%) and success (101; 81.5%) patients were different in: neurologic status score (Kelly-Matthay scale), urea, creatinin, AST, ALT, CPK, CPK-MB, troponin T, LDH, PCR, pH, and arterial blood gas analysis parameters after 1 hour of NIV (PaO 2 , pH, PaCO 2 , HCO 3 - , SaO 2 , PaO 2 /FIO 2 ). Conclusions: NIV is a cost effective intervention even outside intensive care units for the treatment of ARF caused by AECOPD. We were able to identify in the ED early predictors of outcome (mainly about more severe clinical conditions and the response to treatment). An unresolved question in the ED is about selection criteria and early choices for patients with ARF having preset therapeutic-prognostic limits and acutely reversible processes for which NIV should be considered as ceiling treatment.

European Respiratory Journal, Sep 1, 2011

Background: The incidence and complexity of asthma acute exacerbations (AA) are widely increasing... more Background: The incidence and complexity of asthma acute exacerbations (AA) are widely increasing. The emergency physician (EP) plays a key role in AA: emergency management; medical treatment; diagnosis; prevention; maintenance; follow up; education about self-management. Aims: To define the epidemiological and clinical impact of AA at presentation to the emergency department (ED) and the role of the EP. Methods: Six months observational prospective clinical study including every consecutive AA patient who presented to the ED of a university teaching hospital Results: Patients: 209 (1.15/day). Rates%: females 63.5; Italian 70.2; practitioner9s request 6.0; current therapy for asthma 83.1; known risk factors 63.5; previous physician9s visit 15.9; ED therapy 79.5; ED mechanical ventilation 2.9; hospitalization 18.2; discharge therapy 77.9; discharge follow up 65.9; ED rebounds 4.3. Media: age 41 years; ED waiting time 48 minutes; ED time for evaluation and treatment 104 minutes; ED total time 153 minutes; systolic blood pressure 127 mmHg; diastolic 78 mmHg; pulse rate 94 bpm; pulsoxymetry 97%; body temperature 36.9°C; symptoms debut before ED 7 days; time between second and first ED visit 50 days. Conclusions: The majority of asthma exacerbations has a window of opportunity in which deterioration can be recognized and reverted; severe asthma attacks can be prevented by currently available strategies. Of concern was the dependence of most patients on ED for initial care, and the small number of cases in which patients visited a physician before presenting to the hospital. Nowadays the EP must be involved in approaching all typical most frequent and relevant causes of inadequate asthma control.