The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department

The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice

A Case of Severe Acute Kidney Injury by Near-Drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis

GESTIONE CLINICA E FOLLOW-UP DEI PAZIENTI IN TERAPIA ANTICOAGULANTE ORALE VITTIME DI TRAUMA CRANICO LIEVE

Background: La terapia anticoagulante orale (OAT) con Antagonisti della Vitamina K (VKAs) o con Anticoagulanti Orali Diretti (DOACs), il cui uso è in costante aumento nella popolazione, rappresenta un importante fattore di rischio di complicanze emorragiche associate al trauma cranico (TBI). Quale sia l’impatto clinico di questa terapia nel trauma cranico lieve (MTBI), in termini di emorragie intracraniche (ICH) immediate e tardive, e quale sia il percorso diagnostico-terapeutico ottimale nei pazienti in OAT vittime di MTBI senza complicanze acute, sono a tutt’oggi questioni aperte oggetto di studio. Obiettivi: Valutazione della prevalenza delle emorragie intracraniche (ICH) acute e tardive conseguenti a TBI lieve (MTBI) nella popolazione in OAT. Valutazione di eventuali differenze fra i due sottogruppi in terapia con VKAs e con DOACs. Valutazione dell’efficacia e della sicurezza di un protocollo diagnostico-terapeutico nel Dipartimento di Emergenza-Accettazione (DEA) basato sull’osservazione clinica. Metodi: In questo studio osservazionale prospettico, in un periodo di 28 mesi (01/2016-04/2018) sono stati valutati i 448 pazienti vittime di MTBI che si sono presentati al DEA dell’Azienda Ospedaliera Universitaria Pisana. Di questi, ne sono stati reclutati i 423 (M=183, F=240, età media 81.24±8.89) che rispondevano ai seguenti criteri di inclusione: trauma cranico lieve (GCS compreso tra 13 e 15) in pz. in OAT; effettivo stato di anticoagulazione [INR ≥ 1.5 nei pazienti in terapia con VKAs, assunzione del farmaco < 24h prima del TBI se in terapia con DOACs]. All'accesso in PS tutti i pazienti inclusi nello studio venivano sottoposti a TC cranio senza mezzo di contrasto (TCsmc) e, se questa risultava negativa, venivano trattenuti in regime di Osservazione Breve Intensiva (OBI) per 24h, senza sospensione della OAT. Se neurologicamente stabili e asintomatici, venivano infine dimessi con modulo informativo. A distanza di almeno 30 giorni venivano contattati e interrogati sull'eventuale comparsa di complicanze post-traumatiche tardive. Risultati: dei 423 pazienti reclutati, 43 (10.2%; 95% CI 7.3%-13.1%) sono risultati positivi per ICH alla TCsmc all'accesso, perciò esclusi dal follow-up a lungo termine; tra questi, 3 pazienti (0.7%) sono deceduti per complicanze legate all’ICH, e 2 (0.5%) hanno necessitato di intervento neurochirurgico, per una prevalenza complessiva di important outcomes dell’1.2% (95% CI 0.2%-2.2%). La prevalenza di emorragia intracranica acuta osservata nei pazienti con MTBI è risultata statisticamente maggiore (p<0.01) nei pazienti trattati con antagonisti della vitamina K (14.4%; 95% CI 9.6%-19.2%) rispetto ai pazienti in trattamento con anticoagulanti orali diretti (6%; 95% CI 2.9%-9.1%). 11 pazienti (2.9%) venivano persi dallo studio durante il follow-up; per tale motivo 369 pazienti hanno completato i 30 giorni di osservazione. Di questi, 5 pazienti (1.4%; 95% CI 0.2% - 2.6%; 1 paziente in trattamento con warfarin e 4 pazienti con DOACs) sono risultati positivi per emorragia intracranica tardiva: solo uno di essi (0.3%; 95% CI 0%-0.9%) è incorso in sequele importanti. Conclusioni: I risultati di questo studio suggeriscono che i DOACs sono più sicuri dei VKAs anche nel setting del MTBI. Inoltre, i pazienti in terapia anticoagulante orale vittime di trauma cranico lieve, con riscontro di una prima TCsmc negativa per sanguinamento, sottoposti a stretto monitoraggio clinico senza manifestazioni di deterioramento neurologico, possono essere dimessi dopo un breve periodo di osservazione (massimo 24 ore) senza effettuare una seconda TCsmc al termine dell’osservazione, con un bassissimo rischio di complicanze emorragiche tardive. Complicanze emorragiche tardive sono state osservate in un piccolissimo numero di casi, nella maggioranza dei quali non hanno avuto un impatto clinico significativo

The relationship between cardiac injury, inflammation and coagulation in predicting COVID-19 outcome

High sensitivity troponin T (hsTnT) is a strong predictor of adverse outcome during SARS-CoV-2 infection. However, its determinants remain partially unknown. We aimed to assess the relationship between severity of inflammatory response/coagulation abnormalities and hsTnT in Coronavirus Disease 2019 (COVID-19). We then explored the relevance of these pathways in defining mortality and complications risk and the potential effects of the treatments to attenuate such risk. In this single-center, prospective, observational study we enrolled 266 consecutive patients hospitalized for SARS-CoV-2 pneumonia. Primary endpoint was in-hospital COVID-19 mortality. hsTnT, even after adjustment for confounders, was associated with mortality. D-dimer and CRP presented stronger associations with hsTnT than PaO2. Changes of hsTnT, D-dimer and CRP were related; but only D-dimer was associated with mortality. Moreover, low molecular weight heparin showed attenuation of the mortality in the whole population, particularly in subjects with higher hsTnT. D-dimer possessed a strong relationship with hsTnT and mortality. Anticoagulation treatment showed greater benefits with regard to mortality. These findings suggest a major role of SARS-CoV-2 coagulopathy in hsTnT elevation and its related mortality in COVID-19. A better understanding of the mechanisms related to COVID-19 might pave the way to therapy tailoring in these high-risk individuals

Hyperglycemia at hospital admission is associated with severity of the prognosis in patients hospitalized for COVID-19: The pisa COVID-19 study

OBJECTIVE To explore whether at-admission hyperglycemia is associated with worse outcomes in patients hospitalized for coronavirus disease 2019 (COVID-19). RESEARCH DESIGN AND METHODS Hospitalized COVID-19 patients (N 5 271) were subdivided based on at-admission glycemic status: 1) glucose levels &lt;7.78 mmol/L (NG) (N 5 149 [55.0%]; median glucose5.99mmol/L[range5.38–6.72]),2)known diabetesmellitus (DM)(N5 56[20.7%]; 9.18 mmol/L [7.67–12.71]), and 3) no diabetes and glucose levels ≥7.78 mmol/L (HG) (N 5 66 [24.3%]; 8.57 mmol/L [8.18–10.47]). RESULTS Neutrophils were higher and lymphocytes and PaO2/FiO2 lower in HG than in DM and NG patients.DMandHG patients hadhigherD-dimer andworseinflammatoryprofile. Mortality was greater in HG (39.4% vs. 16.8%; unadjusted hazard ratio [HR] 2.20, 95% CI1.27–3.81,P50.005)thaninNG(16.8%)andmarginallysoinDM(28.6%;1.73,0.92– 3.25, P 5 0.086) patients. Upon multiple adjustments, only HG remained an independent predictor (HR 1.80, 95% CI 1.03–3.15, P 5 0.04). After stratification by quintile of glucose levels, mortality was higher in quintile 4 (Q4) (3.57, 1.46–8.76, P 5 0.005) and marginally in Q5 (29.6%) (2.32, 0.91–5.96, P 5 0.079) vs. Q1. CONCLUSIONS Hyperglycemia is an independent factor associated with severe prognosis in people hospitalized for COVID-19

Predictors of hospital-acquired bacterial and fungal superinfections in COVID-19: a prospective observational study

Background: Bacterial and fungal superinfections may complicate the course of hospitalized patients with COVID-19. Objectives: To identify predictors of superinfections in COVID-19. Methods: Prospective, observational study including patients with COVID-19 consecutively admitted to the University Hospital of Pisa, Italy, between 4 March and 30 April 2020. Clinical data and outcomes were registered. Superinfection was defined as a bacterial or fungal infection that occurred 48 h after hospital admission. Amultivariate analysis was performed to identify factors independently associated with superinfections. Results: Overall, 315 patients with COVID-19 were hospitalized and 109 episodes of superinfections were documented in 69 (21.9%) patients. The median time from admission to superinfection was 19 days (range 11–29.75). Superinfections were caused by Enterobacterales (44.9%), non-fermenting Gram-negative bacilli (15.6%), Gram-positive bacteria (15.6%) and fungi (5.5%). Polymicrobial infections accounted for 18.3%. Predictors of superinfections were: intestinal colonization by carbapenem-resistant Enterobacterales (OR 16.03, 95% CI 6.5–39.5, P &lt; 0.001); invasive mechanical ventilation (OR 5.6, 95% CI 2.4–13.1, P &lt; 0.001); immunomodulatory agents (tocilizumab/baricitinib) (OR 5.09, 95% CI 2.2–11.8, P &lt; 0.001); C-reactive protein on admission &gt;7 mg/dl (OR 3.59, 95% CI 1.7–7.7, P = 0.001); and previous treatment with piperacillin/tazobactam (OR 2.85, 95% CI 1.1–7.2, P = 0.028). Length of hospital stay was longer in patients who developed superinfections ompared with those who did not (30 versus 11 days, P &lt; 0.001), while mortality rates were similar (18.8% versus 23.2%, P = 0.445). Conclusions: The risk of bacterial and fungal superinfections in COVID-19 is consistent. Patients who need empiric broad-spectrum antibiotics and immunomodulant drugs should be carefully selected. Infection control rules must be reinforced