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Study objective Accurate diagnostic testing to identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is critical. Although highly specific, SARS-CoV-2 reverse transcriptase–polymerase chain reaction (RT-PCR) has been shown in clinical practice to be affected by a noninsignificant proportion of false-negative results. This study seeks to explore whether the integration of lung ultrasonography with clinical evaluation is associated with increased sensitivity for the diagnosis of coronavirus disease 2019 pneumonia, and therefore may facilitate the identification of false-negative SARS-CoV-2 RT-PCR results. Methods This prospective cohort study enrolled consecutive adult patients with symptoms potentially related to SARS-CoV-2 infection who were admitted to the emergency department (ED) of an Italian academic hospital. Immediately after the initial assessment, a lung ultrasonographic evaluation was performed and the likelihood of SARS-CoV-2 infection, based on both clinical and lung ultrasonographic findings (“integrated” assessment), was recorded. RT-PCR SARS-CoV-2 detection was subsequently performed. Results We enrolled 228 patients; 107 (46.9%) had SARS-CoV-2 infection. Sensitivity and negative predictive value of the clinical–lung ultrasonographic integrated assessment were higher than first RT-PCR result (94.4% [95% confidence interval {CI} 88.2% to 97.9%] versus 80.4% [95% CI 71.6% to 87.4%] and 95% [95% CI 89.5% to 98.2%] versus 85.2% [95% CI 78.3% to 90.6%], respectively). Among the 142 patients who initially had negative RT-PCR results, 21 tested positive at a subsequent molecular test performed within 72 hours. All these false-negative cases were correctly identified by the integrated assessment. Conclusion This study suggests that, in patients presenting to the ED with symptoms commonly associated with SARS-CoV-2 infection, the integration of lung ultrasonography with clinical evaluation has high sensitivity and specificity for coronavirus disease 2019 pneumonia and it may help to identify false-negative results occurring with RT-PCR.

Acute aortic syndromes (AAS) are cardiovascular emergencies with unmet diagnostic needs. Copeptin is released upon stress conditions and is approved for rule-out of myocardial infarction (MI). As MI and AAS share presenting symptoms, stress mechanisms and necessity for rapid diagnosis, copeptin appears as an attractive biomarker also for AAS. We thus performed a diagnostic and observational study in Emergency Department (ED) outpatients. Inclusion criteria were chest/abdominal/back pain, syncope and/or perfusion deficit, plus AAS in differential diagnosis. Blood samples were obtained in the ED. 313 patients were analyzed and 105 (33.5%) were diagnosed with AAS. Median copeptin was 38.91 pmol/L (interquartile range, IQR, 16.33–173.4) in AAS and 7.51 pmol/L (IQR 3.58–15.08) in alternative diagnoses (P

Pre-test probability assessment is key in the approach to suspected acute aortic syndromes (AASs). However, most patients with AAS-compatible symptoms are classified at low probability, warranting further evaluation for decision on aortic imaging. White blood cell count, platelet count and fibrinogen explore pathophysiological pathways mobilized in AASs and are routinely assayed in the workup of AASs. However, the diagnostic performance of these variables for AASs, alone and as a bundle, is unknown. We tested the hypothesis that white blood cell count, platelet count and/or fibrinogen at presentation may be applied as additional tools to standard clinical evaluation for pre-test risk assessment in patients at low probability of AAS.This was a retrospective observational study conducted on consecutive patients managed in our Emergency Department from 2009 to 2014 for suspected AAS. White blood cell count, platelet count and fibrinogen were assayed during evaluation in the Emergency Department. The final diagnosis was obtained by computed tomography angiography. The pre-test probability of AAS was defined according to guidelines. Of 1210 patients with suspected AAS, 1006 (83.1%) were classified at low probability, and 271 (22.4%) were diagnosed with AAS. Within patients at low probability, presence of at least one alteration among white blood cell count9*10In addition to standard clinical evaluation, white blood cell count and platelet count may be used in patients at low pre-test probability to fine-tune risk assessment of AAS.

The aortic dissection detection (ADD) risk score has been proposed by guidelines to standardise the approach to patients with suspected acute aortic dissection (AD). However, the ADD risk score has not been validated so far.Patients with suspected AD from two clinical centres were prospectively enrolled in a registry from 2008 to 2012. The ADD risk score was calculated retrospectively by review of medical charts, according to the number of risk categories where patients met criteria. Of 1328 patients, 291 (21.9%) were diagnosed with AD. The ADD risk score was=0 in 439 (33.1%) patients, =1 in 646 (48.6%) patients and1 in 243 (18.3%) patients. The incidence of AD was 5.9%, 27.3% and 39.1% respectively in patient groups identified by ADD risk score=0, =1 and1. ADD risk score0 had a sensitivity of 91.1% (95% confidence interval (CI) 87.2-94.1%) and a specificity of 39.8% (95% CI 36.8-42.9%) for the diagnosis of AD, while ADD risk score1 had a sensitivity of 32.7% (95% CI 27.3-38.4%) and a specificity of 85.7% (95% CI 83.5-87.8%). Among patients with ADD risk score=0, mediastinum widening on chest X-ray had a sensitivity of 16.7% (95% CI 3.6-41.4%) and a specificity of 86.3% (95% CI 81.9-90.0%).The ADD risk score stratifies patients for the risk of AD. ADD risk score0 is highly sensitive and poorly specific for the diagnosis in AD. The presence of ADD risk score=0 per se does not accurately exclude AD. In patients with ADD risk score=0, chest X-ray provides limited diagnostic information.

Purpose: The diagnosis of acute aortic dissection (AoD) constitutes a major challenge. To assist physicians, the American Heart Association (AHA) has proposed a detection risk score based on high-risk predisposing conditions, pain features and physical examination. Such score identifies patients at low, intermediate and high risk of AoD. In the low-risk group, absence of a widened mediastinum on chest X-ray has been suggested as a mean to safely rule out AoD without further aortic imaging. However, the AHA risk score and derived diagnostic algorithm is awaiting validation. The aim of our study was to evaluate the diagnostic performance of the AoD AHA risk score in the emergency department (ED). Methods: Consecutive adult patients suspected of AoD from 2 EDs were included in a prospective registry from January 2008 to December 2012. Patients were classified according to the AHA risk score and the prevalence of AoD was calculated in each risk group. Furthermore, we estimated the prevalence of AoD in low-risk patients with a not-widened mediastinum on chest X-ray (CXR). The final diagnosis of AoD was obtained with computed tomography, angiography, surgery or autopsy. Results: Among the 1279 patients (mean age 68 years) included in the study, 236 (18.4%) were diagnosed with AoD; 365 (28.5%) patients presented at least one predisposing high-risk condition, 358 (27.9%) a high-risk pain feature and 342 (26.7%) a high-risk physical examination finding. 461 (36%) patients were classified as low-risk, 595 (46.5%) as intermediate-risk and 223 (17.4%) as high-risk. The respective prevalence of AoD was 10.1%, 18.9% and 34% in the 3 groups. Among the 420 (91%) low-risk patients with available CXR, the mediastinum was not-widened in 28 (60%) of 47 patients with AoD. Hence, 6.6% of low-risk patients with a not-widened mediastinum on CXR had AoD. Conclusion: The AHA risk score correctly stratifies patients for AoD prevalence in the ED. However AoD can not safely be rule out in the low risk patients even if a not-widened mediastinum is detected at CXR.

Introduction Matrix metalloproteinases (MMPs) are involved in aortic pathophysiology. Preliminary studies have detected increased plasma levels of MMP8 and MMP9 in patients with acute aortic dissection (AAD). However, the performance of plasma MMP8 and MMP9 for the diagnosis of AAD in the emergency department is at present unknown. Methods The levels of MMP8 and MMP9 were measured by ELISA on plasma samples obtained from 126 consecutive patients evaluated in the emergency department for suspected AAD. All patients were subjected to urgent computed tomography (CT) scan for final diagnosis. Results In the study cohort (N = 126), AAD was diagnosed in 52 patients and ruled out in 74 patients. Median plasma MMP8 levels were 36.4 (interquartile range 24.8 to 69.3) ng/ml in patients with AAD and 13.2 (8.1 to 31.8) ng/ml in patients receiving an alternative final diagnosis (P