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Chest trauma is the leading cause of death in people under 40. It is estimated to cause around 140,000 deaths each year. The key aims are to reduce mortality and the impact of associated complications to expedite recovery and to restore patient’s conditions. The recognition of lesions through appropriate imaging and early treatment already in the emergency department are fundamental. The majority can be managed in a non-surgical way, but especially after traumatic cardiac arrest, a surgical approach is required. One of the most important surgical procedures is the Emergency Department Thoracotomy (EDT). The aim of this review is to provide a comprehensive synthesis about the management of thoracic trauma, the surgical procedures, accepted indications, and technical details adopted during the most important surgical procedures for different thoracic trauma injuries. Literature from 1990 to 2023 was retrieved from multiple databases and reviewed. It is also important to emphasize the medico-legal implications of this type of trauma, both from the point of view of collaboration with the judicial authority and in the prevention of any litigation.

This retrospective analysis at a major Italian university hospital (January 2018–September 2022) assessed the prognostic significance of fever in patients with bloodstream infections (BSIs). Of the 1299 patients with positive blood cultures, a comparison between febrile and afebrile patients at emergency department admission was conducted. This study particularly focused on the mortality rates associated with these two groups. Notably, afebrile patients exhibited a higher mortality rate. The odds ratio for mortality in afebrile patients was significantly higher compared to febrile patients. This suggests that the absence of fever might be an indicator of increased mortality risk, highlighting the complexity of diagnosing bloodstream infections based on fever presence. This study contributes to the understanding of fever as a diagnostic marker in emergency settings.

Chest pain is one of the most prevalent causes of Emergency Department (ED) admission and could be a presenting symptom of Acute Coronary Syndrome (ACS). The aim of this review was to provide an overview of the research about troponin and its limitations and new biomarkers used in patients with cardiovascular diseases, with a special focus on soluble Suppression of Tumorigenicity 2 (sST2) and Soluble Urokinase Plasminogen Activator Receptor (suPAR). In January 2024, a PubMed and Reviews in Cardiovascular Medicine (RCM) search was carried out to identify all relevant papers in the past five years. 80 articles were included in the final review. ssT2 and suPAR are involved in both acute and chronic cardiovascular disease and can predict the risk of adverse events. sST2 and suPAR are promising biomarkers that, in combination with troponin, could help in the management of patients with chest pain in the ED. Further studies are needed to validate their role in management of ACS in this specific setting.

Coffee is one of the most widely consumed beverages in the world, which has important repercussions on the health of the individual, mainly because of certain compounds it contains. Coffee consumption exerts significant influences on the entire body, including the gastrointestinal tract, where a central role is played by the gut microbiota. Dysbiosis in the gut microbiota is implicated in the occurrence of numerous diseases, and knowledge of the microbiota has proven to be of fundamental importance for the development of new therapeutic strategies. In this narrative review, we thoroughly investigated the link between coffee consumption and its effects on the gut microbiota and the ensuing consequences on human health. We have selected the most significant articles published on this very interesting link, with the aim of elucidating the latest evidence about the relationship between coffee consumption, its repercussions on the composition of the gut microbiota, and human health. Based on the various studies carried out in both humans and animal models, it has emerged that coffee consumption is associated with changes in the gut microbiota, although further research is needed to understand more about this link and the repercussions for the whole organism.

Background: COVID-19 caused by SARS-CoV-2 virus is characterized by respiratory compromise and immune system involvement, even leading to serious disorders, such as cytokine storm. Methods: We then conducted a literature review on the topic of sepsis and covid-19, and in parallel conducted an experimental study on the histological finding of patients who died from SARS-Covid 19 infection and a control group. Results: Sepsis associated with covid-19 infection has some similarities and differences from that from other causes. Conclusion: In this paper the complex interplay between the 2 disorders was discussed, focusing on the similarities and on the effect that one could have on the other. A preliminary experimental section that demonstrates the multisystemic involvement in subjects who die from SARS-CoV-2 is also proposed.

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient’s admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981–April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

The human gastrointestinal tract hosts a complex and dynamic population of commensal bacterial species, which have coevolved with the host, generating a symbiotic relationship. Some compounds present in foods, such as polyols, prebiotic fibers, or phenolic compounds, are poorly metabolized and absorbed by the host before the transformation guided by the colonic microbiota. By influencing gut microbiota, diet plays a fundamental role in understanding the beneficial effects of the gut microbiota on the host, including its long-term metabolism. The idea that probiotics can act not only by influencing the colonizing microbiota opens the door to a wider range of probiotic possibilities, encouraging innovation in the field. Furthermore, it has been shown both that some probiotics increase phagocytosis or the activity of natural killer cells. Current prebiotics are mainly based on carbohydrates, but other substances, such as polyphenols and polyunsaturated fatty acids, could exert prebiotic effects. A prebiotic substance has been defined as ‘a substrate that is selectively used by host microorganisms that confer a health benefit’, and so can interact with the gut microbiota through competition for nutrients, antagonism, cross-feeding, and support for microbiota stability. Influencing its composition in terms of richness and diversity, food components have a key impact on the intestinal microbiota. Eating habits can strongly influence the composition of the intestinal microbiota. A healthy intestinal microbiota is essential for maintaining general health, and diet is one of the major modulators of this fascinating world of microorganisms. This must give us one more reason to adopt a healthy lifestyle.

Fibrosis, sustained by the transformation of intestinal epithelial cells into fibroblasts (epithelial-to-mesenchymal transition, EMT), has been extensively studied in recent decades, with the molecular basis well-documented in various diseases, including inflammatory bowel diseases (IBDs). However, the factors influencing these pathways remain unclear. In recent years, the role of the gut microbiota in health and disease has garnered significant attention. Evidence suggests that an imbalanced or dysregulated microbiota, along with environmental and genetic factors, may contribute to the development of IBDs. Notably, microbes produce various metabolites that interact with host receptors and associated signaling pathways, influencing physiological and pathological changes. This review aims to present recent evidence highlighting the emerging role of the most studied metabolites as potential modulators of molecular pathways implicated in intestinal fibrosis and EMT in IBDs. These studies provide a deeper understanding of intestinal inflammation and fibrosis, elucidating the molecular basis of the microbiota role in IBDs, paving the way for future treatments.

Severe bleeding is the leading cause of death in patients with major trauma admitted to the emergency department. It is estimated that about 50% of deaths happen within a few minutes of the traumatic event due to massive hemorrhage; 30% of deaths are related to neurological dysfunction and typically happen within two days of trauma; and approximately 20% of patients died of multiorgan failure and sepsis within days to weeks of the traumatic event. Over the past ten years, there has been an increased understanding of the underlying mechanisms and pathophysiology associated with traumatic bleeding leading to improved management measures. Traumatic events cause significant tissue damage, with the potential for severe blood loss and the release of cytokines and hormones. They are responsible for systemic inflammation, activation of fibrinolysis pathways, and consumption of coagulation factors. As the final results of this (more complex in real life) cascade, patients can develop tissue hypoxia, acidosis, hypothermia, and severe coagulopathy, resulting in a rapid deterioration of general conditions with a high risk of mortality. Prompt and appropriate management of massive bleeding and coagulopathy in patients with trauma remains a significant challenge for emergency physicians in their daily clinical practice. Our review aims to explore literature studies providing evidence on the treatment of hemorrhage with blood support in patients with trauma admitted to the Emergency Department with a high risk of death. Advances in blood transfusion protocols, along with improvements in other resuscitation strategies, have become one of the most important issues to face and a key topic of recent clinical research in this field.

Point-of-Care Ultrasound (POCUS) is a rapid and valuable diagnostic tool available in emergency and intensive care units. In the context of cardiac arrest, POCUS application can help assess cardiac activity, identify causes of arrest that could be reversible (such as pericardial effusion or pneumothorax), guide interventions like central line placement or pericardiocentesis, and provide real-time feedback on the effectiveness of resuscitation efforts, among other critical applications. Its use, in addition to cardiovascular life support maneuvers, is advocated by all resuscitation guidelines. The purpose of this narrative review is to summarize the key applications of POCUS in cardiac arrest, highlighting, among others, its prognostic, diagnostic, and forensic potential. We conducted an extensive literature review utilizing PubMed by employing key search terms regarding ultrasound and its use in cardiac arrest. Apart from its numerous advantages, its limitations and challenges such as the potential for interruption of chest compressions during image acquisition and operator proficiency should be considered as well and are discussed herein.

Background: The COVID-19 pandemic seemed to mainly involve the respiratory system, but it was realized that it could affect any organ, including the CNS. The pandemic has followed a wave-like trend, with its peaks being due to the COVID-19 different variants and the introduction of the vaccine, which led to an apparent reduction in hospitalizations but also brought about perplexities related to its adverse effects. The aim of this study was to analyze the changes in the use of head CT/contrast CT and their impacts on the onset of cerebrovascular disease in our emergency department during the COVID-19 period and the vaccine rollout. Methods: Patients ≥ 18 years old admitted to our emergency department from January 2018 to September 2021 were enrolled. The patients were divided into three groups. The COVID-19 period included patients who visited our emergency department from 1 March 2020 to 31 January 2021; the vaccine period was considered to range from 1 February 2021 to 30 September 2021. The patients who visited the emergency department from 1 January 2018 to 31 January 2020 were considered the controls. Results: We found an increase in head CT/contrast CT requests during the COVID-19 period and increase in head contrast CT during the vaccine period, without an increase in the incidence of cerebrovascular disease. Conclusions: The uncertainty regarding the possible thrombotic events associated with COVID-19 and its vaccine increased the relative use of head CT/contrast CT by about 20% compared to the control period

Waterhouse-Friderichsen syndrome is a rare disease characterized by bleeding into the adrenal glands, and its symptoms may vary from non-specific abdominal pain to multi-organ failure. Commonly related to a variety of infectious diseases among which sepsis from Neisseria meningitidis is the most frequent, many other etiologies have been described, and in some rare cases, even no apparent cause can be identified. We report a rare case of an idiopathic bilateral adrenal hemorrhage in a 70-year-old male who presented to our emergency department with non-specific abdominal pain. Ultrasonography Scan (US) and Computed Tomography (CT) findings were crucial for making an early diagnosis, which resulted in a short hospitalization time and, eventually, a complete recovery of the adrenal function. After discharge, Magnetic Resonance Imaging (MRI) was also performed, providing a more complete ensemble of multimodality imaging findings that can be associated with this rare syndrome.

Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy‐to‐use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56–81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849–0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848–0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort (P=0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.

Treatment of inflammatory bowel disease (IBD) remains one of the most critical public health issues, mostly due to its wide global prevalence and dramatic impact on patients’ quality of life. One of the many mechanisms implicated in the pathogenesis of this disease appears to be attributable to gut microbiota dysbiosis. For this reason, similar to what happened for Clostridium difficile, fecal microbiota transplantation is making its way as a possible new therapeutic weapon in the treatment of this disease. In this article, we will discuss the strengths of this promising treatment, while also discussing the controversial aspects and concerns regarding one of the most innovative therapies of recent times.

Patients suffering from eating disorders represent a highly vulnerable and fragile population. The recent SARS-Co-2 pandemic and its impact on public health and behavioral habits created the conditions for an overall increase in most types of mental disturbances, thus including eating disorders. The combined effects of the psychological stress (deriving from confinement and forced cohabitation, loneliness, sadness, fear, anxiety, and concerns about the uncertainty of life) had deeply increased the psychological discomfort of these patients, with possibly a significant impact on their mental status.

Background: This study aims to evaluate the prognostic role of serum PCT in older patients with suspect sepsis or infective diagnosis in the Emergency Department (ED) with a particular focus on the clinical consequences and characteristics due to frailty status. Methods: This is a observational retrospective study conducted in the ED of a teaching hospital. We identified all consecutive patients aged ≥ 80 years admitted to the ED and subsequently hospitalized for clinical suspicion of infection. Inclusion criteria were: age ≥ 80 years and clinical suspicion of infection; availability of a PCT determination obtained < 24 h since ED access; and Clinical Frailty Scale (CFS) determination. Study endpoints were the diagnostic accuracy of PCT for all-cause in-hospital death, infective diagnosis at discharge, and bloodstream infection. Diagnostic accuracy was calculated via ROC analysis and compared in the patients with severe frailty, measured by CFS > 6, and patients with low or moderate frailty (CFS 1–6). A multivariate analysis was performed to calculate the adjusted odds of raised PCT values for the study endpoints. Results: In total, 1459 adults ≥ 80 years with a clinical suspicion of infection were included in the study cohort. The median age of the sample was 85 years (82–89), with 718 (49.2%) males. The multivariate models revealed that, after adjusting for significant covariates, the PCT values at ED admission were significantly associated with higher odds of infective diagnosis only in the fit/moderately frail group (Odds Ratio [95% CI] 1.04 [1.01–1.08], p 0.009) and not in very frail patients (Odds Ratio [95% CI] 1.02 [0.99–1.06], p 0.130). Similarly, PCT values were significantly associated with higher odds of in-hospital death in the fit/moderately frail group (Odds Ratio [95% CI] 1.01 [1.00–1.02], p 0.047), but not in the very frail ones (Odds Ratio [95% CI] 1.00 [0.98–1.02], p 0.948). Conversely, the PCT values were confirmed to be a good independent predictor of bloodstream infection in both the fit/moderately frail group (Odds Ratio [95% CI] 1.06 [1.04–1.08], p < 0.001) and the very frail group (Odds Ratio [95% CI] 1.05 [1.03–1.07], p < 0.001). Conclusions: The PCT values at ED admission do not predict infective diagnosis, nor are associated with higher odds of in-hospital death. Still, in frail older adults, the PCT values in ED could be a useful predictor of bloodstream infection.

Introduction: Emergency Department (ED) overcrowding is a health, political, and economic problem of concern worldwide. The causes of overcrowding are an aging population, an increase in chronic diseases, a lack of access to primary care, and a lack of resources in communities. Overcrowding has been associated with an increased risk of mortality. The establishment of a Short Stay Unit (SSU) for conditions that cannot be treated at home but require treatment and hospitalization for up to 72 h may be a solution. SSU can significantly reduce hospital length of stay (LOS) for certain conditions but does not appear to be useful for other diseases. Currently, there are no studies addressing the efficacy of SSU in the treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). Our study aims to evaluate the efficacy of SSU in reducing the need for hospitalization, LOS, hospital readmission, and mortality in patients with NVUGIB compared with admission to the regular ward. Materials and Methods: This was a retrospective, single-center observational study. Medical records of patients presenting with NVUGIB to ED between 1 April 2021, and 30 September 2022, were analyzed. We included patients aged >18 years who presented to ED with acute upper gastrointestinal tract blood loss. The test population was divided into two groups: Patients admitted to a normal inpatient ward (control) and patients treated at SSU (intervention). Clinical and medical history data were collected for both groups. The hospital LOS was the primary outcome. Secondary outcomes were time to endoscopy, number of blood units transfused, readmission to the hospital at 30 days, and in-hospital mortality. Results: The analysis included 120 patients with a mean age of 70 years, 54% of whom were men. Sixty patients were admitted to SSU. Patients admitted to the medical ward had a higher mean age. The Glasgow-Blatchford score, used to assess bleeding risk, mortality, and hospital readmission were similar in the study groups. Multivariate analysis after adjustment for confounders found that the only factor independently associated with shorter LOS was admission to SSU (p < 0.0001). Admission to SSU was also independently and significantly associated with a shorter time to endoscopy (p < 0.001). The only other factor associated with a shorter time to EGDS was creatinine level (p = 0.05), while home treatment with PPI was associated with a longer time to endoscopy. LOS, time to endoscopy, number of patients requiring transfusion, and number of units of blood transfused were significantly lower in patients admitted to SSU than in the control group. Conclusions: The results of the study show that treatment of NVUGIB in SSU can significantly reduce the time required for endoscopy, the hospital LOS, and the number of transfused blood units without increasing mortality and hospital readmission. Treatment of NVUGIB at SSU may therefore help to reduce ED overcrowding but multicenter randomized controlled trials are needed to confirm these data

Introduction The SARS CoV-2 pandemic still generates a very high number of affected patients and a significant mortality rate. It is essential to establish objective criteria to stratify COVID-19 death risk. Frailty has been identified as a potential determinant of increased vulnerability in older adults affected by COVID-19, because it may suggest alterations of physical performance and functional autonomy. Methods We have conducted a narrative review of the literature on the evidences regarding COVID-19 and the frailty condition. Thirteen observational studies were included. Conclusion Data emerging from the studies indicate that older COVID-19 patients with a frailty condition have an increased risk of mortality compared with non-frail patients, and this association is independent of other clinical and demographic factors. A frailty evaluation is required to help clinicians to better stratify the overall risk of death for older patients with COVID-19.

Cigarette smoke is a classic risk factor for many diseases. The microbiota has been recently indicated as a new, major player in human health. Its deregulation—dysbiosis—is considered a new risk factor for several illnesses. Some studies highlight a cross-interaction between these two risk factors—smoke and dysbiosis—that may explain the pathogenesis of some diseases. We searched the keywords “smoking OR smoke AND microbiota” in the title of articles on PubMed®, UptoDate®, and Cochrane®. We included articles published in English over the last 25 years. We collected approximately 70 articles, grouped into four topics: oral cavity, airways, gut, and other organs. Smoke may impair microbiota homeostasis through the same harmful mechanisms exerted on the host cells. Surprisingly, dysbiosis and its consequences affect not only those organs that are in direct contact with the smoke, such as the oral cavity or the airways, but also involve distant organs, such as the gut, heart, vessels, and genitourinary tract. These observations yield a deeper insight into the mechanisms implicated in the pathogenesis of smoke-related diseases, suggesting a role of dysbiosis. We speculate that modulation of the microbiota may help prevent and treat some of these illnesses.

Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.

Familial hypercholesterolemia is a common genetic disorder with a propensity towards early onset of atherosclerotic cardiovascular disease (CVD). The main goal of therapy is to reduce the LDL cholesterol and the current treatment generally consists of statin, ezetimibe and PCSK9 inhibitors. Unfortunately, lowering LDL cholesterol may be difficult for many reasons such as the variation of response to statin therapy among the population or the high cost of some therapies (i.e., PCSK9 inhibitors). In addition to conventional therapy, additional strategies may be used. The gut microbiota has been recently considered to play a part in chronic systemic inflammation and hence in CVD. Several studies, though they are still preliminary, consider dysbiosis a risk factor for various CVDs through several mechanisms. In this review, we provide an update of the current literature about the intricate relation between the gut microbiota and the familial hypercholesterolemia.

There is much evidence confirming the crucial role played by the gut microbiota in modulating the immune system in the onset of autoimmune diseases. In this article, we focus on the relationship between alterations in the microbiome and the onset of diabetes mellitus type 1 and LADA, in light of the latest evidence. We will then look at both how the role of the gut microbiota appears to be increasingly crucial in the pathogenesis of these disorders and how this aspect may be instrumental in the development of new potential therapeutic strategies that modulate the gut microbiota, such as probiotics, prebiotics, and fecal microbiota transplantation.

Pancreatic cancer (PC) is an aggressive malignancy and the fourth leading cause of cancer death in the United States and Europe. It is estimated that PC will be the second leading cause of cancer death by 2030. In addition to late diagnosis, treatment resistance is a major cause of shortened survival in pancreatic cancer. In this context, there is growing evidence that microbes play a regulatory role, particularly in therapy resistance and in creating a microenvironment in the tumor, that favors cancer progression. The presence of certain bacteria belonging to the gamma-proteobacteria or mycoplasmas appears to be associated with both pharmacokinetic and pharmacodynamic changes. Recent evidence suggests that the microbiota may also play a role in resistance mechanisms to immunotherapy and radiotherapy. However, the interactions between microbiota and therapy are bilateral and modulate therapy tolerance. Future perspectives are increasingly focused on elucidating the role of the microbiota in tumorigenesis and processes of therapy resistance, and a better understanding of these mechanisms may provide important opportunities to improve survival in these patients.

Innate and adaptive immune system cells play a critical role in the host response to sepsis. Sepsis is a life-threatening disease characterized by apoptosis-induced depletion of immune cells and immunodepression, which contribute to morbidity and mortality. Many alterations in the expression of surface markers of neutrophils and monocytes have been described in septic patients. The aim of this study was to inspect the recently published literature to inform the clinician about the most up-to-date techniques for the study of circulating leukocytes. The impact on cell phenotypes and on the function of leukocytes of extracorporeal and non-blood purification treatments proposed for sepsis were also analyzed. We conducted a systematic review using Pubmed/Medline, Ovid/Willey, the Cochrane Library, the Cochrane Controlled Trials Register, and EMBASE, combining key terms related to immunological function in sepsis and selected the most relevant clinical trials and review articles (excluding case reports) published in the last 50 years. The most important alteration in neutrophils during sepsis is that they activate an anti-apoptotic survival program. In septic monocytes, a reduced characteristic expression of HLA-DR is observed, but their role does not seem to be significantly altered in sepsis. As regards adaptive immunity, sepsis leads to lymphopenia and immunosuppression in patients with septic shock; this process involves all types of T cells (CD4, CD8 and Natural Killer), except for regulatory T cells, which retain their function. Several promising therapies that target the host immune response are currently under evaluation. During the worldwide pandemic caused by SARS-CoV-2, it was useful to study the “cytokine storm” to find additional treatments, such as the oXiris® filter. This therapy can decrease the concentration of inflammatory markers that affect the severity of the disease.

Lactic acidosis represents one of the most common conditions that can compromise the health of intensive care unit (ICU) patients, increasing the mortality of patients with high levels of Lactate who do not receive a proper treatment within the first 6 h of hospitalization. There are two enantiomers of lactic acid: L-lactic acid (when the concentration increases, it can lead to a state of severe acidemia risking cardiovascular collapse, causing an increase in mortality in ICU patients) and D lactic acid (produced in the human organism by microbiota and its production increases during some pathological status). Generally, increased levels of serum lactic acid could be due to numerous factors, including hypoxia (caused for example by septic/cardiogenic/hypovolemic or obstructive shock), specific pathologies (e.g., liver disease), use of some drugs (e.g., metformin), presence of toxins, and trauma. Since the underlying cause could be fatal for the ICU patient, it is important to understand the root of this clinical status with a view to correct it and prevent the risk of a poor clinical outcome. Prevention and early treatment are the keys to control the negative clinical consequences. The aim of this review is to revise the scientific literature for further confirmation about the importance of early identification of acidotic statuses and to underline how an early diagnosis can prevent the worst clinical outcome, especially for ICU patients who are more fragile compared to the general population.

Fecal calprotectin (FC) is a very sensitive marker of inflammation of the gastrointestinal tract. Its clinical utility can be appreciated in both intestinal and extraintestinal diseases. Recent evidence suggests a link between intestinal inflammation and dermatological, rheumatic and neurological diseases. This review focuses on the role of FC in non-gastrointestinal disease, such as rheumatic, dermatologic, neurologic and last but not least SARS-CoV-2 infection.

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

Background and Objectives: The COVID-19 pandemic has been shaking lives around the world for nearly two years. The discovery of highly effective vaccines has not been able to stop the transmission of the virus. SARS-CoV-2 shows completely different clinical manifestations. A large percentage (about 40%) of admitted patients require treatment in an intensive care unit (ICU). This study investigates the factors associated with admission of COVID-19 patients to the ICU and whether it is possible to obtain a score that can help the emergency physician to select the hospital ward. Materials and Methods: We retrospectively recorded 313 consecutive patients who were presented to the emergency department (ED) of our hospital and had a diagnosis of COVID-19 confirmed by polymerase chain reaction (PCR) on an oropharyngeal swab. We used multiple logistic regression to evaluate demographic, clinical, and laboratory data statistically associated with ICU admission. These variables were used to create a prognostic score for ICU admission. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operating characteristic curve (ROC) of the score for predicting ICU admission during hospitalization were calculated. Results: Of the variables evaluated, only blood type A (p = 0.003), PaO2/FiO2 (p = 0.002), LDH (p = 0.004), lactate (p = 0.03), dyspnea (p = 0.03) and SpO2 (p = 0.0228) were significantly associated with ICU admission after adjusting for sex, age and comorbidity using multiple logistic regression analysis. We used these variables to create a prognostic score called GOL2DS (group A, PaO2/FiO2, LDH, lactate and dyspnea, and SpO2), which had high accuracy in predicting ICU admission (AUROC 0.830 [95% CI, 0.791–0.892). Conclusions: In our single-center experience, the GOL2DS score could be useful in identifying patients at high risk for ICU admission.

Myopericarditis is an inflammatory heart condition involving the pericardium and myocardium. It can lead to heart failure, dilated cardiomyopathy, arrhythmia and sudden death. Its pathogenesis is mainly mediated by viral infections but also can be induced by bacterial infections, toxic substances and immune mediated disorders. All these conditions can produce severe inflammation and myocardial injury, often associated with a poor prognosis. The specific roles of these different pathogens (in particular viruses), the interaction with the host, the interplay with gut microbiota, and the immune system responses to them are still not completely clear and under investigation. Interestingly, some research has demonstrated the contribution of the gut microbiota, and its related metabolites (some of which can mimic the cardiac myosin), in cardiac inflammation and in the progression of this disease. They can stimulate a continuous and inadequate immune response, with a subsequent myocardial inflammatory damage. The aim of our review is to investigate the role of gut microbiota in myopericarditis, especially for the cardiovascular implications of COVID-19 viral infection, based on the idea that the modulation of gut microbiota can be a new frontier in the cardiological field to prevent or treat inflammatory cardiomyopathies.

Sepsis and septic shock represent a leading cause of mortality in the Emergency Department (ED) and in the Intensive Care Unit (ICU). For these life-threating conditions, different diagnostic and prognostic biomarkers have been studied. Proadrenomedullin (MR-proADM) is a biomarker that can predict organ damage and the risk of imminent death in patients with septic shock, as shown by a large amount of data in the literature. The aim of our narrative review is to evaluate the role of MR-proADM in the context of Emergency Medicine and to summarize the current knowledge of MR-proADM as a serum indicator that is useful in the Emergency Department (ED) to determine an early diagnosis and to predict the long-term mortality of patients with sepsis and septic shock. We performed an electronic literature review to investigate the role of MR-proADM in sepsis and septic shock in the context of ED. We searched papers on PubMed®, Cochrane®, UptoDate®, and Web of Science® that had been published in the last 10 years. Data extracted from this literature review are not conclusive, but they show that MR-proADM may be helpful as a prognostic biomarker to stratify the mortality risk in cases of sepsis and septic shock with different degrees of organ damage, guiding emergency physicians in the diagnosis and the succeeding therapeutic workup. Sepsis and septic shock are conditions of high complexity and have a high risk of mortality. In the ED, early diagnosis is crucial in order to provide an early treatment and to improve patient survival. Diagnosis and prognosis are often the result of a combination of several tests. In our opinion, testing for MR-proADM directly in the ED could contribute to improving the prognostic assessment of patients, facilitating the subsequent clinical management and intensive treatment by the emergency physicians, but more studies are needed to confirm these results.

The microbiota is the set of commensal microorganisms, residing in the organism, helping proper functioning of organs and systems. The role that the microbiota plays in maintaining the health of vertebrates is widely accepted, particularly in the gastrointestinal system, where it is fundamental for immunity, development, and conversion of nutrients. Dysbiosis is an alteration of the microbiota which refers to a disturbed balance, which can cause a number of pathologies. Probiotics have proven to be effective in modulating the microbiota of the gastrointestinal system and, therefore, in promoting the health of the individual. In particular, Lactobacilli are a group of Gram-positive bacteria, which are able to produce lactic acid through glucose metabolism. They are present in different microenvironments, ranging from the vagina, to the mouth, to different tracts of the small intestine. In the present review, we will discuss the use of Limosilactobacillus in human health in general and more specifically in diverticulitis. In particular we analyze the role of Limosilactobacillus reuteri and its anti-inflammatory action. For this review, articles were identified using the electronic PubMed database through a comprehensive search, conducted by combining key terms such as “diverticulitis”, “Limosilactobacillus reuteri”, “human health and disease”, “probiotics”. We selected all the articles published in the last 10 years and screened 1017 papers. Articles referenced in the screened papers were evaluated if considered interesting for our topic. Probiotics have proven to be effective in modulating the microbiota of the gastrointestinal system and, therefore, in promoting the health of the individual. The importance of probiotics in treating diverticular disease and acute diverticulitis can be further understood if taking into consideration some pathophysiological aspects, associated to the microbiota. L. reuteri plays an important role in human health and disease. The effectiveness of L. reuteri in stimulating a correct bowl motility partly explains its effectiveness in treating diverticulitis. The most important action of L. reuteri is probably its immunomodulating activity. Levels of IL-6, IL-8, and Tumor necrosis factor (TNF-alpha) are reduced after supplementation with different strands of Lactobacilli, while T-regulatory cells increase in number and activity. Anyway, new mechanisms of action of probiotics come to light from the many investigations currently taking place in numerous centres around the world and to improve how exactly probiotic administration could make the difference in the management of diverticular disease and acute diverticulitis.

Since the end of 2019, the medical-scientific community has been facing a terrible pandemic caused by a new airborne viral agent known as SARS-CoV2. Already in the early stages of the pandemic, following the discovery that the virus uses the ACE2 cell receptor as a molecular target to infect the cells of our body, it was hypothesized that the renin-angiotensin-aldosterone system was involved in the pathogenesis of the disease. Since then, numerous studies have been published on the subject, but the exact role of the renin-angiotensin-aldosterone system in the pathogenesis of COVID-19 is still a matter of debate. RAAS represents an important protagonist in the pathogenesis of COVID-19, providing the virus with the receptor of entry into host cells and determining its organotropism. Furthermore, following infection, the virus is able to cause an increase in plasma ACE2 activity, compromising the normal function of the RAAS. This dysfunction could contribute to the establishment of the thrombo-inflammatory state characteristic of severe forms of COVID-19. Drugs targeting RAAS represent promising therapeutic options for COVID-19 sufferers.

The diagnosis and treatment of sepsis have always been a challenge for the physician, especially in critical care setting such as emergency department (ED), and currently sepsis remains one of the major causes of mortality. Although the traditional definition of sepsis based on systemic inflammatory response syndrome (SIRS) criteria changed in 2016, replaced by the new criteria of SEPSIS-3 based on organ failure evaluation, early identification and consequent early appropriated therapy remain the primary goal of sepsis treatment. Unfortunately, currently there is a lack of a foolproof system for making early sepsis diagnosis because conventional diagnostic tools like cultures take a long time and are often burdened with false negatives, while molecular techniques require specific equipment and have high costs. In this context, biomarkers, such as C-Reactive Protein (CRP) and Procalcitonin (PCT), are very useful tools to distinguish between normal and pathological conditions, graduate the disease severity, guide treatment, monitor therapeutic responses and predict prognosis. Among the new emerging biomarkers of sepsis, Presepsin (P-SEP) appears to be the most promising. Several studies have shown that P-SEP plasma levels increase during bacterial sepsis and decline in response to appropriate therapy, with sensitivity and specificity values comparable to those of PCT. In neonatal sepsis, P-SEP compared to PCT has been shown to be more effective in diagnosing and guiding therapy. Since in sepsis the P-SEP plasma levels increase before those of PCT and since the current methods available allow measurement of P-SEP plasma levels within 17 min, P-SEP appears a sepsis biomarker particularly suited to the emergency department and critical care.

The use of probiotics in critically ill adult and children patients has been growing exponentially over the last 20 years. Numerous factors in pediatriac intensive care unit (PICU) patients may contribute to intestinal dysbiosis, which subsequently promotes the pathobiota’s growth. Currently, lactobacillus and bifidobacterium species are mainly used to prevent the development of systemic diseases due to the subverted microbiome, followed by streptococcus, enterococcus, propionibacterium, bacillus and Escherichia coli, Lactobacillus rhamnosus GG, and Lactobacillus reuteri DSM 17938. The aim of this article is to review the scientific literature for further confirmation of the importance of the usage of probiotics in intensive care unit (ICU) patients, especially in the pediatric population. A progressive increase in nosocomial infections, especially nosocomial bloodstream infections, has been observed over the last 30 years. The World Health Organization (WHO) reported that the incidence of nosocomial infections in PICUs was still high and ranged between 5% and 10%. Petrof et al. was one of the first to demonstrate the efficacy of probiotics for preventing systemic diseases in ICU patients. Recently, however, the use of probiotics with different lactobacillus spp. has been shown to cause a decrease of pro-inflammatory cytokines and an increase in anti-inflammatory cytokines. In addition, in some studies, the use of probiotics, in particular the mix of Lactobacillus and Bifidobacterium reduces the incidence of ventilator-associated pneumonia (VAP) in PICU patients requiring mechanical ventilation. In abdominal infections, there is no doubt at all about the usefulness of using Lactobacillus spp probiotics, which help to treat ICU-acquired diarrhoea episodes as well as in positive blood culture for candida spp. Despite the importance of using probiotics being supported by various studies, their use is not yet part of the standard protocols to which all doctors must adhere. In the meantime, while waiting for protocols to be drawn up as soon as possible for use in PICUs, routine use could certainly stimulate the intestine’s immune defences. Though it is still too early to say, they could be considered the drugs of the future.

Background and Objectives. Fever is one of the most common presenting complaints in the Emergency Department (ED). This study aimed at evaluating the prognostic role of serum Procalcitonin (PCT) measurement among adult patients admitted to the ED with fever. Materials and Methods. This is a retrospective cross-sectional study including all consecutive patients admitted to ED with fever and subsequently hospitalized in a period of six-year (January 2014 to December 2019). Inclusion criteria were age > 18 years, fever (T ≥ 38 °C) or chills within 24 h from presentation to the ED as the main symptom, and availability of a PCT determination obtained Results. Overall, 6595 patients were included in the study cohort (3734 males, 55.6%), with a median age of 71 [58–81] years. Among these, based on clinical findings and quick sequential organ failure assessment (qSOFA), 422 were considered septic (36.2% deceased), and 6173 patients non-septic (16.2% deceased). After correction for baseline covariates, a PCT > 0.5 ng/mL was an independent risk factor for all-cause in-hospital death in both groups (HR 1.77 [1.27–2.48], and 1.80 [1.59–2.59], respectively). Conclusions. Among adult patients admitted with fever, the PCT assessment in ED could have reduced prognostic power for patients with a high suspicion of sepsis. On the other hand, it could be useful for sepsis rule-out for patients at low risk. In these latter patients, the prognostic role of PCT is higher for those with a final diagnosis of bloodstream infection.

Systemic or localized lympho-adenomegaly is a common cause of access to the emergency department (ED), and differential diagnosis is often complicated. The combination of anamnesis, physical examination, laboratory tests, and instrumental diagnosis are extremely important to orientate toward a rapid and correct therapy, even if a prompt discrimination of the etiology of this lymphadenomegaly is not often possible. Our aim with this review is to improve the management of a differential diagnosis between hematological and infective diseases as leishmaniasis in ED and suggest quick diagnostic techniques that might be useful for early identification. Together in the review, we describe a case report of a young man affected from visceral leishmaniasis who presented to our ED and was incorrectly addressed to the wrong ward for the study of his condition. Subsequently, we focus on the clinical presentation of visceral leishmaniasis and compare it to the most common differential diagnoses that are usually taken into account in the management of such patients.

The purpose of this study is to assess thrombotic risk in CoViD-19/pneumonia patients with acute respiratory failure and to compare populations treated with three different antithrombotic prophylaxis protocols. The primary outcome is to analyze the prevalence of thrombotic events in hospitalized patients, while the secondary outcome is to analyze the correlation between different anticoagulation targets with thrombotic events. All patients referred to our hospital for acute respiratory failure due to COVID-19 pneumonia between 18 and 31 May 2020 were included. Seventy-four patients were enrolled (44 men and 30 women, average age 68.6). Diagnosis of venous thromboembolism was made in 21 cases (28.4%) and thrombotic events were associated with positive pressure ventilation support (p = 0.024) and hospitalization in ICU (p < 0.0001). These patients presented higher levels of D-dimer (p < 0.0001) and their hospital length of stay was >16 days longer. Forty-seven out of 74 patients (63.5%) received intermediate or therapeutic dose of anticoagulation, while twenty-seven patients (34.5%) received standard antithrombotic prophylaxis. The analysis showed that an intermediate or therapeutic dose of anticoagulation did not decrease the prevalence of thrombotic events. On the other hand, six patients reported severe hemorrhagic complications. Despite intermediate or therapeutic-dose of anticoagulation, a high number of patients with acute respiratory failure secondary to COVID-19 developed thrombotic complications.