Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit

Background: Limited data are available on the clinical course of patients with history of atrial fibrillation (AF) when admitted in an intensive care environment. We aimed to describe the occurrence of major adverse events in AF patients admitted to a stepdown care unit (SDU) and to analyse clinical factors associated with outcomes, impact of dicumarolic oral anticoagulant (OAC) therapy impact and performance of clinical risk scores in this setting. Materials and methods: Single-centre, observational retrospective analysis on a population of subjects with AF history admitted to a SDU. Therapeutic failure (composite of transfer to ICU or death) was considered the main study outcome. Occurrence of stroke and major bleeding (MH) was considered as secondary outcomes. The performance of clinical risk scores was evaluated. Results: A total of 1430 consecutive patients were enrolled. 194 (13.6%) reported the main outcome. Using multivariate logistic regression, age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05), acute coronary syndrome (OR:3.10, 95% CI: 1.88-5.12), cardiogenic shock (OR:10.06, 95% CI: 5.37-18.84), septic shock (OR:5.19,95%CI:3.29-18.84), acute respiratory failure (OR:2.49, 95% CI: 1.67-3.64) and OAC use (OR: 1.61, 95% CI: 1.02-2.55) were independently associated with main outcome. OAC prescription was associated with stroke risk reduction and to both MH and main outcome risk increase. CHA2 DS2 -VASc (c-index: 0.545, P = .117 for stroke) and HAS-BLED (c-index:0.503, P = .900 for MH) did not significantly predict events occurrence. Conclusions: In critically ill AF patients admitted to a SDU, adverse outcomes are highly prevalent. OAC use is associated to an increased risk of therapeutic failure, clinical scores seem unhelpful in predicting stroke and MH, suggesting a highly individualized approach in AF management in this setting

Stable isotopic reconstruction of dietary changes across Late Antiquity and the Middle Ages in Tuscany

The transition from Late Antiquity to the Medieval period is considered one of the greatest periods of social, political, and economic upheaval in Europe, and has left its mark on the historical consciousness of people in this part of the world. Nevertheless, there remains considerable debate as to the degree to which the diets and economic status of different sections of society were impacted by this transition, with these so-called ‘Dark Ages’ often being uniformly considered as static and impoverished, particularly for populations along the Mediterranean rim. Such questions are especially important in central Italy, with its position at the former core of the Roman Empire leaving it most vulnerable to the major social and political shifts of the first millennium AD. However, direct insights into the diets of individuals in this region, across this key period, have been scarce, particularly in diachronic perspective. Here, we apply stable carbon (δ13C) and nitrogen (δ15N) analysis to bone collagen (n = 76), and stable carbon (δ13C) and oxygen (δ18O) isotope analysis to tooth enamel (n = 34), to human, and associated faunal, individuals dated to Late Antiquity (3rd–5th centuries AD) and the Medieval period (mid 6th–mid 13th centuries AD) in Tuscany. δ13C measurements of both tooth enamel bioapatite and bone collagen suggest that a predominantly C3 diet during Late Antiquity was gradually supplemented by increased C4 consumption during the Medieval period. We interpret this as a shift from an agricultural focus on wheat following the Roman agrarian tradition towards the inclusion of millet as a reliable fallback food. We argue that this was part of a growing local and regional resilience amongst communities in the Medieval period, with more diverse agricultural systems and cultural preferences following a transition from the Roman classical civilization toward a Germanic tradition whose economy was based on the diverse cultivation of “minor crops” and close integration of pastoral husbandry livestock

Stable isotopic reconstruction of dietary changes across Late Antiquity and the Middle Ages in Tuscany

The transition from Late Antiquity to the Medieval period is considered one of the greatest periods of social, political, and economic upheaval in Europe, and has left its mark on the historical consciousness of people in this part of the world. Nevertheless, there remains considerable debate as to the degree to which the diets and economic status of different sections of society were impacted by this transition, with these so-called ‘Dark Ages’ often being uniformly considered as static and impoverished, particularly for populations along the Mediterranean rim. Such questions are especially important in central Italy, with its position at the former core of the Roman Empire leaving it most vulnerable to the major social and political shifts of the first millennium AD. However, direct insights into the diets of individuals in this region, across this key period, have been scarce, particularly in diachronic perspective. Here, we apply stable carbon (δ13C) and nitrogen (δ15N) analysis to bone collagen (n = 76), and stable carbon (δ13C) and oxygen (δ18O) isotope analysis to tooth enamel (n = 34), to human, and associated faunal, individuals dated to Late Antiquity (3rd–5th centuries AD) and the Medieval period (mid 6th–mid 13th centuries AD) in Tuscany. δ13C measurements of both tooth enamel bioapatite and bone collagen suggest that a predominantly C3 diet during Late Antiquity was gradually supplemented by increased C4 consumption during the Medieval period. We interpret this as a shift from an agricultural focus on wheat following the Roman agrarian tradition towards the inclusion of millet as a reliable fallback food. We argue that this was part of a growing local and regional resilience amongst communities in the Medieval period, with more diverse agricultural systems and cultural preferences following a transition from the Roman classical civilization toward a Germanic tradition whose economy was based on the diverse cultivation of “minor crops” and close integration of pastoral husbandry livestock.1. Introduction 1.1. Historical background 1.2. Stable isotope analysis background 2. Materials and methods 2.1. Sites 2.2. Late antique urban necropolis of (VM) 2.3. Medieval rural cemetery of (SG) 2.4. Samples 2.5. Stable isotope measurement 2.6. Statistical analysis 3. Results 3.1. δ13C and δ15N animal bone collagen in the Late Antique urban necropolis of VM 3.2. δ13C and δ15N of animal bone collagen in the Medieval rural cemetery of SG 3.3. δ13C and δ15N human bone collagen in the Late Antique urban necropolis of VM 3.4. δ13C and δ15N of human bone collagen in the Medieval rural cemetery of SG 3.5. Comparison of δ13C and δ15N of animal bone collagen between the Late Antique urban necropolis of VM and the Medieval rural cemetery of SG 3.6. Comparison of δ13C and δ15N of human bone collagen between the Late Antique urban necropolis of VM and the Medieval rural cemetery of SG 3.7. δ13C and δ18O of animal tooth enamel in the Late Antique urban necropolis of VM 3.8. δ13C and δ18O of animal tooth enamel in Medieval rural site of SG 3.9. δ13C and δ18O of human tooth enamel in the Late Antique urban necropolis of VM 3.10. δ13C and δ18O of human tooth enamel in Medieval rural site of SG 3.11. Comparison of δ13C and δ18O of human tooth enamel between Late Antique urban necropolis of VM and the Medieval rural cemetery of SG 4. Discussion 5. Conclusion

A catastrophic case of fever of unknown origin

Background: Pancytopenia is a feature of many life-threateningconditions, ranging from drug-induced bone marrow hypoplasia,infection disease to severe hematologic disorders.Clinical case: 38-year-old woman was referred to the clinic forfever associated with epigastric pain and vomiting. She had ahistory of three months intermittent fever. In the Emergency de-partment: pancytopenia, impaired hepatic function and increaseof D-dimer. In our clinic at subsequent laboratory tests: hapto-globin consumed, hyperferritinemia, hypertriglyceridemia, hy-pofibrinogenemia, high IL6 values, beta2-microglobulin,EBV-DNA positivity, peripheral blood lymphocyte typing sugges-tive for chronic lymphoproliferative disorder T. Total body CTshowed bilateral pleural effusion, diffuse lymphadenopathy,marked hepato-splenomegaly. It was decided to perform BME(aspects of hemophagocytosis and peripheral T-cell lymphomanos) and to start immediately supportive and HLH specific ther-apy. During the 5th night, progressive respiratory failure so shewas intubated and transferred to the ICU, where she died theday after.Conclusions: Hemophagocytic lymphoistiocytosis (HLH) is a rarecondition characterized by a poor prognosis. Most common causesof secondary HLH are malignancies. As no single clinical manifes-tation is diagnostic for HLH, the diagnosis require high index ofsuspicion. The early recognition and treatment of this clinical con-dition are essential elements in the management of this pathology,although burdened by a high mortality rat

Primary care management strategies and COVID-19 related hospitalization: a population- based study

Background: Due to SARS-CoV-2 rapid mutations, the ending of the pandemic is still proceeding at a slow pace and there is the need to strengthen and invest in health systems that avoid hospital overload and its consequences on patients’ health. Most symptomatic infections have mild to moderate respiratory symptoms and patients are managed in the context of primary care. In Italy, literature on COVID-19 outpatients management by general practitioners (GPs) is scarce. This study explores the effect of GP active care and monitoring on COVID-19-related hospitalization in patients in the province of Modena (Italy) and investigates the possible determinants of GP’s management. Methods: This is a retrospective cohort study of SARS-CoV-2 infected adult outpatients managed by their GPs from March 2020 to April 2021 in the province of Modena (Italy). Data on GPs’ characteristics, management strategies (visits and remote monitoring), patients’ socio-demographic characteristics, and hospitalization were extracted from the GP’s electronic medical records and were analyzed using descriptive statistics and multiple logistic regression. Results: 46 GPs agreed to participate, and 5340 patients were included in the analyses. 3014 (56%) patients received active daily remote monitoring and 840 (16%) were visited at home. Remote monitoring and home visits were both associated with a reduction of the probability of hospitalization rate of approximately 50% (respectively OR:0.52, 95%CI:0.33, 0.80 and OR:0.50, 95%CI;0.33, 0.78). Preliminary analysis of determinants showed that GPs’ patient load, setting, age, and sex were significantly associated with management strategies. Conclusions: Active monitoring performed by GPs was effective in reducing the probability of hospitalization. Primary and hospital care integration can be effective for COVID-19 management. Studies on GPs’ characteristics and patient load and their effect on their ability to care for patients are neede

Vergleichende Methoden zur quantitativ immunologischen Bestimmung und Ermittlung von Normbereichen der Immunglobuline G, A, M, des Haptoglobins und Transferrins mit Hilfe der automatisierten Immunpräzipitatreaktion

Peer Reviewe

A case of fever in emergency medicine: the importance of clinical evaluation

A 38-years-old woman was referred to our subintensive medicine department for persistent fever associated to epigastric pain, nausea and vomiting. At the arrival, blood exams showed severe pancytopenia and increase of AST. Her clinical history did not reveal any significant associated pathology, but she complained of a recent history of three months of persistent fever, relapsing despite different antibiotic treatments and oral steroid treatment given by her general practitioner. Physical examination showed a marked increase of haepatic and splenic volume, signs of bilateral pleural effusion and the presence of continuous fever. Our first diagnostic hypotheses ranged between a subacute viral infection to a severe haematologic disorder. In the second day, blood examinations showed EBV-DNA positivity. Serum antibodies were not suggestive for autoimmunity. Despite this finding, we also observed markedly increased ferritin (> 500 ng/ml) and trygliceride levels (> 1000 mg/dl), a positive beta2-microglobilin and a markedly reduced serum haptoglobin and fibrinogen levels. A total body CT-scan showed diffuse lymphadenopathy and confirmed the bilateral pleural effusion and the marked hepato-splenomegaly observed clinically at the admission. For this reason, we proceeded with a peripheral blood cell immunophenotypization, which resulted suggestive for a chronic lymphoproliferative T-cell disorder. At this point, we felt confident in restricting our diagnostic hypotheses: particularly, the presence of a markedly increased serum ferritin and trygliceride levels and hypofibrinogenemia were strongly suggestive for lymphoma-associated haemophagocytic syndrome. For this reason, we evaluated serum IL-6 levels, which resulted markedly raised, and performed a bone marrow biopsy, showing "aspects of haemophagocytosis in perypheral T-cell lymphoma", confirming the diagnosis of haemophagocytic syndrome complicating a T-cell lymphoma. We started immediately both specific and supportive therapy for haemophagocytic syndrome, starting with high-dose metilprednisolone (1000 mg/die) and continuous haemodiafiltration to reduce rapidly serum cytokine levels. However, after an initial improvement in her clinical conditions, in the fifth day she developed acute respiratory failure and was urgently transferred to the intensive care unit, where she died the day after for multi-organ failure. Haemophagocytic lymphoistiocytosis, or haemofagocytic syndrome, is a rare group of pathologies commonly associated to several conditions, ranging from infections to autoimmunity and malignancies, characterized by a poor prognosis. Early recognition and aggressive treatment of this syndrome are essential to increase the survival probabilities, which still remain very low despite optimal medical treatment

Minor head injury in anticoagulated patients: Outcomes and analysis of clinical predictors. A prospective study

Background: The optimal management of patients taking oral anticoagulants who experience minor head injury (MHI) is unclear. The availability of validated protocols and reliable predictors of prognosis would be of great benefit. We investigated clinical factors as predictors of clinical outcomes and intracranial injury (ICI). Methods: We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The primary outcome was the occurrence of MHI-related death or re-admission to ED at day +30. The secondary outcome was the rate of delayed ICI (dICI), defined as second positive CT scan after a first negative CT scan. We assessed some clinical predictors derived from guidelines and clinical prediction rules as potential risk factors for the outcomes. Results: 450 patients with a negative first CT scan who underwent a second CT scan composed our 'study population'. The rate of the primary outcome was 4%. The rate of the secondary outcome was 4.7%. Upon univariate and multivariate analysis no statistically significant predictors for the outcomes were found. Conclusions: Previous retrospective studies showed a lot of negative predictive factors for anticoagulated patients suffering a minor head injury. In our prospective study no clinical factors emerged as predictors of poor clinical outcomes and dICI. So, even if we confirmed a low rate of adverse outcomes, the best management of these patients in ED remains not so clear and future trials are needed

Association of atrial fibrillation and acute heart failure in emergency medicine: determinants of in-hospital death

Background: the presence of atrial fibrillation (AF) and acute heart failure (AHF) is associated to a significantly increased risk of death, especially in elderly patients. Patients and Methods: we retrospectively enrolled all the consecutive patients admitted for AF in our subintensive medicine department in the period 2002- 2007. Among these, we selected those affected by AHF. In this group, we evaluated the prevalence of both concomitant acute disorders and chronic comorbidities. Particularly, we investigated, among the acute events complicating the admission: acute coronary syndromes (ACS), cardiogenic shock (CS), septic shock (SS), acute respiratory insufficiency (ARI), acute kidney injury (AKI), infections (INF), thromboembolic complications (THR) and major haemorrhages (MH). We also assessed the presence of chronic heart failure (CHF), chronic kidney disease (CKD), active cancer (AC), COPD, coronary artery disease (CAD), peripheral artery disease (PAD), type 2 diabetes mellitus (T2DM), cerebrovascular disease (CVD), chronic anaemia (CA), chronic hepatic diseases (CH) and hypertension (HYP). We adopted in-hospital death as main outcome and age, sex, concomitant acute and chronic events as predictors in a binary logistic multivariate model. Prevalence of each disease and the risk of in-hospital death were drawn in a solar-system graph, called \u201ccomorbidome\u201d, already adopted in other studies (Figure 1). Results: we obtained a final sample of 776 AF/AHF coaffected patients (age:80. 32\ub18. 32; males:46. 3%) with 78 (10. 0%) deaths. Increasing age (OR:1. 08;95%CI:1. 04-1. 13), but none of the chronic comorbidities were significantly associated to higher risk of in-hospital death. Among the acute conditions complicating the admission, ACS (OR:2. 12;95%CI:1. 00-4. 49), CS (OR:37. 47;95%CI:12. 16-115. 49), HS (OR:42. 31; 95%CI:5. 74-311. 77), SS (OR:9. 72; 95%CI:4. 47-21. 14), ARI (OR:4. 05;95%CI:1. 99-8. 23) and THR (OR:1. 410;95%CI:1. 04-1. 91) were significantly connected to an increased risk of in-hospital death. Discussion: chronic pathologies are common among elderly patients admitted for AF/AHF, however age seems to be the most important determinant of prognosis. Some acute events, by complicating the clinical course, can significantly increase the risk of death in this specific group