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Cosentini R.,Gruppo NIV | Brambilla A.M.,Gruppo NIV | Aliberti S.,University of Milan | Bignamini A.,University of Milan | And 5 more authors.
Chest | Year: 2010

Objective: Our objective was to evaluate the efficacy of noninvasive continuous positive airway pressure(CPAP) delivered by helmet in improving oxygenation in comparison with oxygen therapy in community-acquired pneumonia(CAP). Methods: This was a multicenter, randomized, controlled trial enrolling patients with CAP admitted to an ED with moderate hypoxemic acute respiratory failure(ARF)(PaO2/FIO2 ratio ≥ 210 and ≤285). Patients were randomized to helmet CPAP or standard oxygen therapy(control group). The primary end point was the time to reach a PaO 2 /FIO2 ratio >315. After reaching this value, patients randomized to CPAP were switched to oxygen, and the proportion of subjects who could maintain a PaO2/FIO2 ratio >315 at 1 h was recorded. Results: Forty-seven patients were recruited: 20 randomized to CPAP and 27 to controls. Patients randomized to CPAP reached the end point in a median of 1.5 h, whereas controls reached the end point in 48 h(P<.001). The proportion of patients who reached the primary end point was 95%(19/20) among the CPAP group and 30%(8/27) among controls(P<.001). One hour after reaching the primary end point, 2/14 patients in the CPAP group maintained a PaO 2 /FIO2 value >315. Conclusions: CPAP delivered by helmet rapidly improves oxygenation in patients with CAP suffering from a moderate hypoxemic ARF. This trial represents a proof-of-concept evaluation of the potential usefulness of CPAP in patients with CAP. Trial registration: clinicaltrials.gov; Identifier: NCT00603564. © 2010 American College of Chest Physicians.


PubMed | General Medicine Unit and, University of Adelaide, Emergency Medicine Unit, Clinical Epidemiology Unit and Flinders University
Type: Journal Article | Journal: Internal medicine journal | Year: 2015

Streaming occurs in emergency department (ED) to reduce crowding, but misallocation of patients may impact patients outcome.The study aims to determine the outcomes of patients misallocated by the ED process of streaming into likely admission or discharge.This is a retrospective cohort study, at an Australian, urban, tertiary referral hospitals ED between January 2010 and March 2012, using propensity score matching for comparison. Total and partitioned ED lengths of stay, inpatient length of stay, in-hospital mortality and 7- and 28-day unplanned readmission rate were compared between patients who were streamed to be admitted against those streamed to be discharged.Total ED length of stay did not differ significantly for admitted patients if allocated to the wrong stream (median 7.6h, interquartile range 5.7-10.6, cf. 7.5h, 5.3-11.2; P = 0.34). The median inpatient length of stay was shorter for those initially misallocated to the discharge stream (1.8days, 1.1-3.0, cf. 2.4days, 1.4-3.9; P < 0.001). In-hospital mortality and 7- and 28-day readmission rates were not adversely affected by misallocation. When considering patients eventually discharged from the ED, those allocated to the wrong stream stayed in the ED longer than those appropriately allocated (5.2h, 3.7-7.3, cf. 4.6h, 3.3-6.4; P < 0.001).There were no significant adverse consequences for an admitted patient initially misallocated by an ED admission/discharge streaming process. Patients discharge from the ED was slower if they had been allocated to the admission stream. Streaming carries few risks for patients misallocated by such a process.


Castelli R.,University of Milan | Bucciarelli P.,anchi Bonomi Hemophilia And Thrombosis Center | Porro F.,Emergency Medicine Unit | Depetri F.,University of Milan | Cugno M.,University of Milan
Thrombosis Research | Year: 2014

Background Pulmonary embolism (PE) is associated with high short-term mortality in elderly patients, even when hemodynamically stable. Methods One hundred and seventy hemodynamically stable patients with confirmed PE (41 < 65 years and 129 ≥ 65 years) were prospectively followed for one month in order to assess whether comorbidities can predict short-term mortality in elderly patients. Upon admission, patients' clinical characteristics (including instrumental and laboratory parameters) were evaluated, and two clinical scores were calculated: the Cumulative Illness Rating Scale (CIRS), commonly used to evaluate comorbidities in elderly patients, and the Pulmonary Embolism Severity Index (PESI). Results Fifteen patients (all elderly) died within one month from their PE diagnosis (mortality rate = 8.8%; 95%CI:4.6-13.1%). In these non survivors, arterial partial oxygen pressure (p < 0.0001) and saturation (p < 0.0001), pH (p = 0.001) and systolic blood pressure (p = 0.017) at admission were significantly lower than in survivors, whereas their respiratory rate (p < 0.0001), white blood cells (p < 0.0001), lactate dehydrogenase (p < 0.0001), troponin T (p = 0.001) and D-dimer (p = 0.023) were significantly higher. CIRS correlated with PESI (rho = 0.54, p < 0.0001), and was higher in non-survivors (p = 0.002). The age- and sex-adjusted odds ratio of 1-month mortality was 1.91 (95%CI:1.24-2.95) for every 1-point increase in CIRS. The AUC was 0.78 (95%CI:0.67-0.89) for the logistic model containing CIRS, and 0.88 (95%CI:0.79-0.96) for that containing PESI (p = 0.059). Conclusions In elderly patients with PE, CIRS demonstrated a fairly good performance in predicting short-term mortality. Its easiness and suitability for use in common clinical practice make CIRS a potentially useful prognostic score for short-term mortality in these patients. © 2014 Elsevier Ltd.


PubMed | Emergency Medicine Unit, anchi Bonomi Hemophilia And Thrombosis Center and University of Milan
Type: Journal Article | Journal: Thrombosis research | Year: 2014

Pulmonary embolism (PE) is associated with high short-term mortality in elderly patients, even when hemodynamically stable.One hundred and seventy hemodynamically stable patients with confirmed PE (41<65years and 12965years) were prospectively followed for one month in order to assess whether comorbidities can predict short-term mortality in elderly patients. Upon admission, patients clinical characteristics (including instrumental and laboratory parameters) were evaluated, and two clinical scores were calculated: the Cumulative Illness Rating Scale (CIRS), commonly used to evaluate comorbidities in elderly patients, and the Pulmonary Embolism Severity Index (PESI).Fifteen patients (all elderly) died within one month from their PE diagnosis (mortality rate=8.8%; 95%CI:4.6-13.1%). In these non survivors, arterial partial oxygen pressure (p<0.0001) and saturation (p<0.0001), pH (p=0.001) and systolic blood pressure (p=0.017) at admission were significantly lower than in survivors, whereas their respiratory rate (p<0.0001), white blood cells (p<0.0001), lactate dehydrogenase (p<0.0001), troponin T (p=0.001) and D-dimer (p=0.023) were significantly higher. CIRS correlated with PESI (rho=0.54, p<0.0001), and was higher in non-survivors (p=0.002). The age- and sex-adjusted odds ratio of 1-month mortality was 1.91 (95%CI:1.24-2.95) for every 1-point increase in CIRS. The AUC was 0.78 (95%CI:0.67-0.89) for the logistic model containing CIRS, and 0.88 (95%CI:0.79-0.96) for that containing PESI (p=0.059).In elderly patients with PE, CIRS demonstrated a fairly good performance in predicting short-term mortality. Its easiness and suitability for use in common clinical practice make CIRS a potentially useful prognostic score for short-term mortality in these patients.


Nicolini A.,Respiratory Diseases Unit | Ferraioli G.,Emergency Medicine Unit | Ferrari-Bravo M.,Public Health Unit | Barlascini C.,Forensic Medicine | And 2 more authors.
Clinical Respiratory Journal | Year: 2016

Background and Aims: Severe community-acquired pneumonia (sCAP) have been as defined pneumonia requiring admission to the intensive care unit or carrying a high risk of death. Currently, the treatment of sCAP consists of antibiotic therapy and ventilator support. The use of invasive ventilation causes several complications as does admission to ICU. For this reason, non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation. However, few studies have currently assessed the usefulness of NIV in sCAP. Methods: We prospectively assessed 127 patients with sCAP and severe acute respiratory failure [oxygen arterial pressure/oxygen inspiratory fraction ratio (PaO2/FiO2) <250]. We defined successful NIV as avoidance of intubation and the achievement of PaO2/FiO2 >250 with spontaneous breathing. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses. Results: NIV failed in 32 patients (25.1%). Higher chest X-ray score at admission, chest X-ray worsening, and a lower PaO2/FiO2 and higher alveolar-arteriolar gradient (A-aDO2) after 1h of NIV all independently predicted NIV failure. Higher lactate dehydrogenase and confusion, elevated blood urea, respiratory rate, blood pressure plus age ≥65 years at admission, higher A-aDO2, respiratory rate and lower PaO2/FiO2 after 1h of NIV and intubation rate were directly related to hospital mortality. Conclusions: Successful treatment is strongly related to less severe illness as well as to a good initial and sustained response to medical therapy and NIV treatment. Constant monitoring of these patients is mandatory. © 2016 John Wiley & Sons Ltd.


PubMed | Emergency Medicine Unit, Respiratory Diseases Unit, Public Health Unit, Villa Scassi Hospital and 2 more.
Type: Journal Article | Journal: The clinical respiratory journal | Year: 2016

Severe community-acquired pneumonia (sCAP) have been as defined pneumonia requiring admission to the intensive care unit or carrying a high risk of death. Currently, the treatment of sCAP consists of antibiotic therapy and ventilator support. The use of invasive ventilation causes several complications as does admission to ICU. For this reason, non-invasive ventilation (NIV) has been used for acute respiratory failure to avoid endotracheal intubation. However, few studies have currently assessed the usefulness of NIV in sCAP.We prospectively assessed 127 patients with sCAP and severe acute respiratory failure [oxygen arterial pressure/oxygen inspiratory fraction ratio (PaO2/FiO2) <250]. We defined successful NIV as avoidance of intubation and the achievement of PaO2/FiO2 >250 with spontaneous breathing. We assessed predictors of NIV failure and hospital mortality using univariate and multivariate analyses.NIV failed in 32 patients (25.1%). Higher chest X-ray score at admission, chest X-ray worsening, and a lower PaO2/FiO2 and higher alveolar-arteriolar gradient (A-aDO2) after 1h of NIV all independently predicted NIV failure. Higher lactate dehydrogenase and confusion, elevated blood urea, respiratory rate, blood pressure plus age 65 years at admission, higher A-aDO2, respiratory rate and lower PaO2/FiO2 after 1h of NIV and intubation rate were directly related to hospital mortality.Successful treatment is strongly related to less severe illness as well as to a good initial and sustained response to medical therapy and NIV treatment. Constant monitoring of these patients is mandatory.


Cibinel G.A.,Emergency Medicine Unit | Casoli G.,Emergency Medicine Unit | Elia F.,Emergency Medicine Unit | Padoan M.,Emergency Medicine Unit | And 3 more authors.
Internal and Emergency Medicine | Year: 2012

Dyspnea is a common symptom in patients admitted to the Emergency Department (ED), and discriminating between cardiogenic and non-cardiogenic dyspnea is often a clinical dilemma. The initial diagnostic work-up may be inaccurate in defining the etiology and the underlying pathophysiology. The aim of this study was to evaluate the diagnostic accuracy and reproducibility of pleural and lung ultrasound (PLUS), performed by emergency physicians at the time of a patient's initial evaluation in the ED, in identifying cardiac causes of acute dyspnea. Between February and July 2007, 56 patients presenting to the ED with acute dyspnea were prospectively enrolled in this study. In all patients, PLUS was performed by emergency physicians with the purpose of identifying the presence of diffuse alveolar-interstitial syndrome (AIS) or pleural effusion. All scans were later reviewed by two other emergency physicians, expert in PLUS and blinded to clinical parameters, who were the ultimate judges of positivity for diffuse AIS and pleural effusion. A random set of 80 recorded scannings were also reviewed by two inexperienced observers to assess inter-observer variability. The entire medical record was independently reviewed by two expert physicians (an emergency medicine physician and a cardiologist) blinded to the ultrasound (US) results, in order to determine whether, for each patient, dyspnea was due to heart failure, or not. Sensitivity, specificity, and positive/negative predictive values were obtained; likelihood ratio (LR) test was used. Cohen's kappa was used to assess inter-observer agreement. The presence of diffuse AIS was highly predictive for cardiogenic dyspnea (sensitivity 93.6%, specificity 84%, positive predictive value 87.9%, negative predictive value 91.3%). On the contrary, US detection of pleural effusion was not helpful in the differential diagnosis (sensitivity 83.9%, specificity 52%, positive predictive value 68.4%, negative predictive value 72.2%). Finally, the coexistence of diffuse AIS and pleural effusion is less accurate than diffuse AIS alone for cardiogenic dyspnea (sensitivity 81.5%, specificity 82. 8%, positive predictive value 81.5%, negative predictive value 82.8%). The positive LR was 5.8 for AIS [95% confidence interval (CI) 4.8-7.1] and 1.7 (95% CI 1. 2-2.6) for pleural effusion, negative LR resulted 0.1 (95% CI 0.0-0.4) for AIS and 0.3 (95% CI 0.1-0.8) for pleural effusion. Agreement between experienced and inexperienced operators was 92. 2% (p <0.01) and 95% (p <0.01) for diagnosis of AIS and pleural effusion, respectively. In early evaluation of patients presenting to the ED with dyspnea, PLUS, performed with the purpose of identifying diffuse AIS, may represent an accurate and reproducible bedside tool in discriminating between cardiogenic and non-cardiogenic dyspnea. On the contrary, US detection of pleural effusions does not allow reliable discrimination between different causes of acute dyspnea in unselected ED patients. © 2011 SIMI.


PubMed | Emergency Medicine Unit, University of Louisville, University of Milan Bicocca, IRCCS Humanitas Research Hospital and 4 more.
Type: Journal Article | Journal: ERJ open research | Year: 2016

The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI)


Zawaideh C.,Cardiology Unit | Aste M.,Cardiology Unit | Cutuli O.,Emergency Medicine Unit | Budaj I.,Radiology Unit | And 4 more authors.
American Journal of Emergency Medicine | Year: 2014

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of "apical stomach ballooning." Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment. Left ventricular apical ballooning syndrome (Tako-Tsubo) is an acute stress-induced cardiomyopathy characterized by transient left ventricular dysfunction [1]. Although Tako-Tsubo mimics an acute coronary syndrome, generally there is no evidence of obstructive coronary artry disease. Tako-Tsubo is estimated to represent 1% to 2 % of hos tal admissions for ST-segment elevation myocardial infarction [2,3]. The prognosis is good, if complications of the acute phase are promptly recognized and treated [4,5]. A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. She was hypertensive in medical therapy with associated paraneoplastic syndrome caused by renal cell carcinoma and previous left nephrectomy; in January 2013, she started medical therapy with pazopanib. At admission, she seemed restless and diaphoretic with unremarkable physical examination. Blood pressure was 130/80 mm Hg, pulse rate was 82 beats/min, and oxygen saturation was 98%. The abdomen was treatable but widely tender. Her chest x-ray showed an elevation of left dome of diaphragm. A nasogastric tubewas successfully positionedwith a drainage of 200 cc of gastric content with clinical benefit. Routinely, electrocardiogram showed ST-segment elevation in anterior-lateral leads. ST-segment elevation myocardial infarction was h pothesized. Urgent coronary angiography was performed, and there was no evidence of obstructive coronary artery disease. Left ventricular angiography revealed the typical apical ballooning with preserved basal systolic function (Fig. 1). Ultrasensitive troponin I peak was 16.00 μg/L. Transthoracic echocardiography confirmed wallmotion abnormalities and severe systolic left ventricle dysfunction (ejection fraction, 25%), identified alterated diastolic function (increased E/e' ratio), and excluded dynamic left ventricle outflow tract obstruction and right ventricular involvement. During the following observation, seriated transthoracic echocardiography controls and electrocardiograms showed a gradual recovery of left ventricular contractility and resolution of ST-segment elevation, but the patient complained about persistent abdominal pain and nausea. Hemodynamic parameters were stable, and no increased troponin I was detected. During the visit, therewere no signs of peritonitis, but the nasogastric tube draine more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan was performed and showed type IV giant diaphragmatic hernia with a hole in the left dome of diaphragm posteriorly through which more than one-half of the stomach was herniated and presented a sort of "apical stomach ballooning" (Fig. 2). Computed tomography scan also revealed a mural oval-shaped thrombus in the apex of the left ventricle. Despite the potential thromboembolic complications and the incomplete recovery of global systolic function, considered the emergency setting because of diaphragmatic hernia [6-8], through minimally invasive laparoscopic techniques, the hole was repaired with reduction of the stomach and gastropexy was done with clinical improvement. The herniated part of the stomachwas congested andwith thickenedwall as a recent organ-axial volvulus caused by rotation along the longitudinal cardiopyloric axis. Although heparin was continued, probably because of improvement in left ventricular function an d recovery of apical wall motion abnormalities, the apical thrombus assumed a floating morphology protruding in the left ventricle (Fig. 3, video clips 1-2),warfarin was added in the treatment.We performed as recommended a cardiac magnetic resonance [9], which confirmed the full recovery of the left ventricular contractility and excluded any thrombus in the left or right ventricle. The examination also showed soft edema/inflammation at the apical segments of the anterior wall of the left ventricle, of the septum, and of the apex because of the recent consequence of Tako-Tsubo (Fig. 4, video clip 3). This is an unusual case of apical ballooning syndrome complicated by left ventricular thrombosis associated to a physical stressful event: an apical stomach ballooning caused by a giant diaphragmatic hernia (figure presented). © 2013 Elsevier Inc.


PubMed | Cardiology Unit, Radiology Unit and Emergency Medicine Unit
Type: Case Reports | Journal: The American journal of emergency medicine | Year: 2013

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of apical stomach ballooning. Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.

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