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To reinforce the proposed association between viral findings on nasopharyngeal swab and AM, none of the patients with acute cardiac disorders other than AM tested positive for a virus. Acute myocarditis (AM) is an acute-onset inflammatory heart disease with heterogeneous clinical presentation, varying from chest pain to cardiogenic shock.1 Viral infections are believed to be associated with AM and indeed typical prodromic symptoms/signs (i.e. fever, flu-like symptoms, sore throat) are frequently reported in AM patients.1,2 Respiratory viruses, such as influenza and corona viruses, identified by real-time polymerase chain reaction (RT-PCR) from nasopharyngeal swabs, have been increasingly recognized as AM triggers.3,4 Nevertheless, no systematic study ever investigated the presence of respiratory viruses in the upper respiratory airways in AM patients. Coherently with the presence of respiratory viruses in the nasopharyngeal mucosa, patients with positive nasopharyngeal swab had a higher prevalence of prodromal respiratory symptoms/signs compared with patients with negative nasopharyngeal swab (88.9% vs. 36.6%, I P i = 0.008). [Extracted from the article]

Fulminant myocarditis (FM) is a form of acute myocardial inflammation leading to rapid-onset hemodynamic instability due to cardiogenic shock or life-threatening arrhythmias. As highlighted by recent registries, FM is associated with high rates of death and heart transplantation, regardless of the underlying histology. Because of a paucity of evidence-based management strategies exists for this disease, an International workshop on FM was held in Wuhan, China, in October 2019, in order to share knowledge on the disease and identify areas of consensus. The present report highlights both agreements and controversies in FM management across the world, focusing the attention on areas of opportunity, FM definition, the use of endomyocardial biopsy and viral identification on heart specimens, treatment algorithms including immunosuppression and the timing of circulatory support escalation. This report incorporates the most recent recommendations from national and international professional societies. Main areas of interest and aims of future prospective observational registries and randomized controlled trials were finally identified and suggested. • FM is a form of acute myocardial inflammation leading to rapid-onset clinical presentation requiring circulatory support. • Although FM is associated with poor outcomes, a paucity of evidence-based management strategies exists for this disease. • The present report highlights both agreements and controversies in FM management across the world. • International efforts should be made to launch prospective interventional studies specifically oriented to FM patients. [ABSTRACT FROM AUTHOR]

Objective: We investigated the association between the publication of the Consolidated Standards of Reporting Trials extension for abstracts (CONSORT-EA) and other variables of interest on the quality of reporting of abstracts of randomised controlled trials (RCTs) published in emergency medicine (EM) journals.Methods: We performed a survey of the literature, comparing the quality of reporting before (2005-2007) with after (2014-2015) the publication of the dedicated CONSORT-EA in 2008. The quality of reporting was measured as the sum of items of the CONSORT-EA checklist reported in each abstract, ranging from 0 to 15. The main explanatory variable was the period of publication: pre-CONSORT-EA versus post-CONSORT-EA public. Other explanatory variables were journal's endorsement of the CONSORT statement, number of centres participating in the study, study's sample size, type of intervention, significance of results, source of funding and study setting. We analysed the data using generalised estimation equations, performing a univariate and a multivariable analysis.Results: We retrieved 844 articles, and randomly selected 60 per period for review, after stratifying for journal. The mean (SD) number of items reported was 6.4 (1.9) in the period before and 6.9 (1.8) in the period after the publication of the CONSORT-EA, with an adjusted mean difference (aMD) of 0.47 (95% CI -0.13 to 1.06). Abstracts of trials of pharmacological interventions had a significantly larger mean number of reported items than those of trials of non-pharmacological interventions (aMD 1.59; 95% CI 0.94 to 2.24).Conclusions: The quality of reporting in abstracts of RCTs published in EM journals is low and was not significantly impacted by the publication of a dedicated CONSORT-EA. [ABSTRACT FROM AUTHOR]

Abstract Exacerbations of chronic obstructive pulmonary disease (COPDE) frequently require hospitalizations, may necessitate of invasive mechanical ventilation (IMV), and are associated with a remarkable in-hospital mortality. The BAP-65 score is a risk assessment model (RAM) based on simple variables, that has been proposed for the prediction of these adverse outcomes in patients with COPDE. If showed to be accurate, the BAP-65 RAM might be used to guide the patients management, in terms of destination and treatment. We conducted a retrospective, multicentre, chart-review study, on patients attending the ED for a COPDE during 2014. The aim of the study was the validation of the BAP-65 RAM for the prediction of in-hospital death or use of IMV (composite primary outcome). We assessed the discrimination and the prognostic performance of the BAP-65 RAM. We enrolled 2908 patients from 20 centres across Italy. The mean (standard deviation) age was 76 (11) years, and 38% of patients were female. The composite outcome occurred in 5.3% of patients. The AUROC of BAP-65 for the composite outcome was 0.64 (95%CI 0.59–0.68). The sensitivity of BAP-65 score ≥ 4 to predict in-hospital mortality was 44% (95% CI 34%–55%), the specificity was 84% (95% CI 82%–85%), the positive predictive value was 9% (95% CI 6%–12%), and the negative predictive value was 98% (95% CI 97%–98%). Conclusions In patients attending Italian EDs with a COPDE, we found that the BAP-65 score did not have sufficient accuracy to stratify patients upon their risk of severe in-hospital outcomes. Highlights • Patients with COPDE are at risk of adverse short-term clinical outcome. • The BAP-65 score has been proposed for the prediction of mortality and use of IMV. • We validated the prognostic performance of the score in the ED setting. • The BAP-65 tool is not sufficiently accurate for risk prediction in ED patients with COPDE. [ABSTRACT FROM AUTHOR]

Abstract: Background: Pneumocystis jirovecii pneumonia (PJP) outbreaks are described in solid organ transplant recipients. Few reports suggest interhuman transmission with important infection control implications. We described a large PJP outbreak in heart transplant (HTx) recipients. Methods: Six cases of PJP occurred in HTx recipients within 10 months in our hospital. Demographics, clinical characteristics, treatment and outcomes were described. To identify contacts among individuals a review of all dates of out‐patient visits and patient hospitalizations was performed. Cross exposure was also investigated using genotyping on PJ isolates. Results: At the time of PJP‐related hospitalization, patients' mean age was 49 ± standard deviation 4 years, median time from HTx was 8 (25%‐75% interquartile range [Q1‐Q3] 5‐12) months and none of the cases were on prophylaxis. At PJP‐related admission, 5 patients had CMV reactivation, of whom 4 were on antiviral preemptive treatment. Median in‐hospital stay was 30 (Q1‐Q3, 28‐48) days; and 2 cases required intensive care unit admission. All patients survived beyond 2 years. Transmission map analysis suggested interhuman transmission in all cases (presumed incubation period, median 90 [Q1‐Q3, 64‐91] days). Genotyping was performed in 4 cases, demonstrating the same PJ strain in 3 cases. Conclusions: We described a large PJP cluster among HTx recipients, supporting the nosocomial acquisition of PJP through interhuman transmission. Based on this experience, extended prophylaxis for more than 6 months after HTx could be considered in specific settings. Further work is required to understand its optimal duration and timing based on individual risk factor profiles and to define standardized countermeasures to prevent and limit PJP outbreaks. [ABSTRACT FROM AUTHOR]

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 €. Conclusions: Patients attending the ED for an AECOPD are old and present important comorbidities. The rate of admission is high, and costs are remarkable. [ABSTRACT FROM AUTHOR]

Myocarditis is an inflammatory disease of the myocardium with a broad spectrum of clinical presentations, ranging from mild symptoms to severe heart failure. The course of patients with myocarditis is heterogeneous, varying from partial or full clinical recovery in few days to advanced low cardiac output syndrome requiring mechanical circulatory support or heart transplantation. Fulminant myocarditis (FM) is a peculiar clinical condition and is an acute form of myocarditis, whose main characteristic is a rapidly progressive clinical course with the need for hemodynamic support. Despite the common medical belief of the past decades, recent comprehensive data, including a recent registry that compared FM with acute non-FM, highlighted that FM has a poor inhospital outcome, often requires advanced hemodynamic support, and may result in residual left ventricular dysfunction in survivors. This review aimed to provide an updated practical definition of FM, including essentials in the diagnosis and management of the disease. Finally, the outcome of FM was critically revised according to the current published registries focusing on the topic. [ABSTRACT FROM AUTHOR]

Smart cities face the challenge of combining sustainable national welfare with high living standards. In the last decades, life expectancy increased globally, leading to various age-related issues in almost all developed countries. Frailty affects elderly who are experiencing daily life limitations due to cognitive and functional impairments and represents a remarkable burden for national health systems. In this paper, we proposed two different predictive models for frailty by exploiting 12 socioclinical databases. Emergency hospitalization or all-cause mortality within a year were used as surrogates of frailty. The first model was able to assign a frailty risk score to each subject older than 65 years old, identifying five different classes for tailor made interventions. The second prediction model assigned a worsening risk score to each subject in the first nonfrail class, namely the probability to move in a higher frailty class within the year. We conducted a retrospective cohort study based on the whole elderly population of the Municipality of Bologna, Italy. We created a baseline cohort of 95 368 subjects for the frailty risk model and a baseline cohort of 58 789 subjects for the worsening risk model, respectively. To evaluate the predictive ability of our models through calibration and discrimination estimates, we used, respectively, a six-year and a four-year observation period. Good discriminatory power and calibration were obtained, demonstrating a good predictive ability of the models. [ABSTRACT FROM PUBLISHER]

Introduction The quality of reporting of abstracts of randomised controlled trials (RCTs) in major general medical journals and in some category-specific journals was shown to be poor before the publication of the ConsolidatedStandards of ReportingTrials (CONSORT) extension for abstracts in 2008, and an improvement in the quality of reporting of abstracts was observed after its publication. The effect of the publication of the CONSORT extension for abstracts on the quality of reporting of RCTs in emergency medicine journals has not been studied. In this paper, we present the protocol of a systematic survey of the literature, aimed at assessing the quality of reporting in abstracts of RCTs published in emergency medicine journals and at evaluating the effect of the publication of the CONSORT extension for abstracts on the quality of reporting. Methods and analysis: The Medline database will be searched for RCTs published in the years 2005-2007 and 2014-2015 in the top 10 emergency medicine journals, according to their impact factor. Candidate studies will be screened for inclusion in the review. Exclusion criteria will be the following: the abstract is not available, they are published only as abstracts, still recruiting, or duplicate publications. The study outcomes will be the overall quality of reporting (number of items reported) according to the CONSORT extension and the compliance with its individual items. Two independent reviewers will screen each article for inclusion and will extract data on the CONSORT items and on other variables, which can possibly affect the quality of reporting. Ethics and dissemination: This is a library-based study and therefore exempt from research ethics board review. The review results will be disseminated through abstract submission to conferences and publication in a peerreviewed biomedical journal. [ABSTRACT FROM AUTHOR]

Background:Electrocardiogram (ECG) interpretation is widely performed by emergency physicians. We aimed to determine the accuracy of interpretation of potential ST-segment elevation myocardial infarction (STEMI) ECGs by emergency physicians.Methods:Thirty-six ECGs resulted in putative STEMI diagnoses were selected. Participants were asked to focus on whether or not the ECG in question met the diagnostic criteria for an acutely blocked coronary artery causing a STEMI. Based on the coronary angiogram, a binary outcome of accurate versus inaccurate ECG interpretation was defined. We computed the overall sensitivity, specificity, accuracy and 95% confidence intervals (95%CIs) for ECG interpretation. Data on participant training level, working experience and place were collected.Results:135 participants interpreted 4603 ECGs. Overall sensitivity to identify ‘true’ STEMI ECGs was 64.5% (95%CI: 62.8–66.3); specificity in determining ‘false’ ECGs was 78% (95%CI: 76–80.1). Overall accuracy was modest (69.1, 95%CI: 67.8–70.4). Higher accuracy in ECG interpretation was observed for attending physicians, participants working in tertiary care hospitals and those more experienced.Conclusion:The accuracy of interpretation of potential STEMI ECGs was modest among emergency physicians. The study supports the notion that ECG interpretation for establishing a STEMI diagnosis lacks the necessary sensitivity and specificity to be considered a reliable ‘stand-alone’ diagnostic test. [ABSTRACT FROM PUBLISHER]

The concept of left ventricular unloading has its foundation in heart physiology. In fact, the left ventricular mechanics and energetics represent the cornerstone of this approach. The novel sophisticated therapies for acute heart failure, particularly mechanical circulatory supports, strongly impact on the mechanical functioning and energy consuption of the heart, ultimately affecting left ventricle loading. Notably, extracorporeal circulatory life support which is implemented for life-threatening conditions, may even overload the left heart, requiring additional unloading strategies. As a consequence, the understanding of ventricular overload, and the associated potential unloading strategies, founds its utility in several aspects of day-by-day clinical practice. Emerging clinical and pre-clinical research on left ventricular unloading and its benefits in heart failure and recovery has been conducted, providing meaningful insights for therapeutical interventions. Here, we review the current knowledge on left ventricular unloading, from physiology and molecular biology to its application in heart failure and recovery. [ABSTRACT FROM AUTHOR]

Geographic variations in management and outcomes of individuals supported by continuous-flow left ventricular assist devices (CF-LVAD) between the United States (US) and Europe (EU) is largely unknown. We created a retrospective, multinational registry of 524 patients who received a CF-LVAD (either HVAD or Heartmate II) between January 2008 and April 2017. Follow up spanned from date of CF-LVAD implant to post-HTx period with a median follow up of 44.8 months. The cohort included 299 (57.1%) EU and 225 (42.9%) US patients. Although the US cohort was significantly older with a higher prevalence of comorbidities, survival was similar between the cohorts (US 63.1%, EU 68.4% at 5 years, unadjusted log-rank test p = 0.43).Multivariate analyses suggested that older age, higher body mass index, elevated creatinine, use of temporary mechanical circulatory support prior CF-LVAD, and implantation of HVAD were associated with increased mortality. Among CF-LVAD patients undergoing HTx, the median time on CF-LVAD support was shorter in the US, meanwhile US donors were younger. Finally, the pattern of adverse events (stroke, gastrointestinal bleedings, late right ventricular failure, and driveline infection) during support differed significantly between US and EU. Although waitlisted patients in the US on CF-LVAD have higher risk comorbid conditions, the overall outcome is similar in US and EU. Geographic variations with regards to donor characteristics, duration of CF-LVAD support prior to transplant, and adverse events on support can explain the disparity in the utilization of mechanical bridge to transplant strategy between US and EU. • Waitlisted patients in the US on CF-LVAD have higher risk comorbid conditions. • Overall outcome of waitlisted patients in the US on CF-LVAD is similar. • There are geographic variations with regards to donor characteristics and duration of CF-LVAD support prior to transplant. • Older age, use of temporary MCS, implantation of HVAD, higher BMI and creatinine are associated with increased mortality. [ABSTRACT FROM AUTHOR]

Although Coronavirus Disease 2019 (COVID-19) presents primarily as a respiratory condition, a growing body of evidence shows it is a systemic disease. Recently, many authors have described myocardial damage in COVID-19, suggesting various pathophysiological mechanisms. In this issue, Cao et al. demonstrate the prognostic value of cardiac troponin I in patients with COVID-19, showing how even minor elevations in this molecule carry a great impact on patient mortality. In a situation such as the worldwide COVID-19 pandemic, where healthcare resources are placed under enormous stress, readily available tests such as this play an important role in helping clinicians identify patients at greater risk of developing severe forms of the disease, and should be included in the initial triage panel., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Objective: We investigated the association between the publication of the Consolidated Standards of Reporting Trials extension for abstracts (CONSORT-EA) and other variables of interest on the quality of reporting of abstracts of randomised controlled trials (RCTs) published in emergency medicine (EM) journals., Methods: We performed a survey of the literature, comparing the quality of reporting before (2005-2007) with after (2014-2015) the publication of the dedicated CONSORT-EA in 2008. The quality of reporting was measured as the sum of items of the CONSORT-EA checklist reported in each abstract, ranging from 0 to 15. The main explanatory variable was the period of publication: pre-CONSORT-EA versus post-CONSORT-EA public. Other explanatory variables were journal's endorsement of the CONSORT statement, number of centres participating in the study, study's sample size, type of intervention, significance of results, source of funding and study setting. We analysed the data using generalised estimation equations, performing a univariate and a multivariable analysis., Results: We retrieved 844 articles, and randomly selected 60 per period for review, after stratifying for journal. The mean (SD) number of items reported was 6.4 (1.9) in the period before and 6.9 (1.8) in the period after the publication of the CONSORT-EA, with an adjusted mean difference (aMD) of 0.47 (95% CI -0.13 to 1.06). Abstracts of trials of pharmacological interventions had a significantly larger mean number of reported items than those of trials of non-pharmacological interventions (aMD 1.59; 95% CI 0.94 to 2.24)., Conclusions: The quality of reporting in abstracts of RCTs published in EM journals is low and was not significantly impacted by the publication of a dedicated CONSORT-EA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

The primary objective of this study was to estimate 1) the annual risk of undergoing a severe hypoglycemic event in Italian patients with diabetes and 2) the risk of hospitalization following such event. From the HYPOTHESIS database, powered by 46 emergency departments covering a 12-million-odd population, data were extracted of 1,922 hypoglycemic events occurring in patients with diabetes in 2011. The mean age was 71.5 (standard deviation 16.8) years, 50.1% were men, and blood glucose at the time of the event was 44.2 (26.5) mg/dL. Patients were being treated with insulin alone (55%) or in combination with oral hypoglycemic agents (OHA, 15%), or with OHA alone, either in monotherapy (14%) or in multiple therapy (16%). Comorbidities were recorded in 71.8% of the patients. Based on the rates of glucose-lowering drug use in Italian patients with diabetes, the annual risk of undergoing a serious hypoglycemic event was estimated at 1.27% for subjects treated with insulin alone, the highest ( p <0.00001) as compared with insulin + OHA (0.41%) or OHA alone, either in monotherapy or in multiple therapy (0.1% and 0.17%, respectively). The risk of being hospitalized following the hypoglycemic event was the least (27.6%) for subjects treated with insulin alone ( p <0.0083). Subjects treated with insulin + OHA showed a lower risk (34.2%) as compared with that for subjects treated with OHA ( p <0.02). Death occurs in 7% of hospitalized patients. Older age ( p <0.0001) and comorbidities ( p <0.0001) were risk factors for hypoglycemia-related hospitalization. Treatments with insulin alone ( p <0.005) or in combination ( p <0.049) were negatively associated with hospital admission. Severe hypoglycemic events associated with the use of oral glucose-lowering agents carry the highest risk of hospital treatment. As such, they are also likely to generate higher tangible and intangible costs., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Colorectal cancer (CRC) is the third most common cancer in the world. A significant survival rate is achieved if it is detected at an early stage. A whole blood screening test, without any attempt to isolate blood fractions, could be an important tool to improve early detection of colorectal cancer. We searched for candidate markers with a novel approach based on the Transcriptome Mapper (TRAM), aimed at identifying specific RNAs with the highest differential expression ratio between colorectal cancer tissue and normal blood samples. This tool permits a large-scale systematic meta-analysis of all available data obtained by microarray experiments. The targeting of RNA took into consideration that tumour phenotypic variation is associated with changes in the mRNA levels of genes regulating or affecting this variation.A real time quantitative reverse transcription polymerase chain reaction (qRT- PCR) was applied to the validation of candidate markers in the blood of 67 patients and 67 healthy controls. The expression of genes: TSPAN8, LGALS4, COL1A2 and CEACAM6 resulted as being statistically different.In particular ROC curves attested for TSPAN8 an AUC of 0.751 with a sensitivity of 83.6% and a specificity of 58.2% at a cut off of 10.85, while the panel of the two best genes showed an AUC of 0.861 and a sensitivity of 92.5% with a specificity of 67.2%.Our preliminary study on a total of 134 subjects showed promising results for a blood screening test to be validated in a larger cohort with the staging stratification and in patients with other gastrointestinal diseases., Competing Interests: Authors declare no competing interest. All authors have read the journal's authorship agreement and the manuscript has been reviewed and approved by all named authors.

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.