Out-of-hospital versus in-hospital status epilepticus: the role of etiology and comorbidities

Background: To identify differences in clinical characteristics between patients with out-of-hospital and in-hospital status epilepticus (SE) onset, and to evaluate the influence of SE onset setting on 30-day mortality and SE cessation. Methods: We included consecutive patients with SE admitted from 2013 to 2021 at Modena Academic Hospital. A propensity score was performed with clinical variables unevenly distributed between the two groups. Results: 711 patients were included; 55.8% (397/711) with an out-of-hospital and 44.2% (314/711) with an in-hospital onset. Patients with in-hospital SE onset were older, had a higher frequency of comorbidities, acute and/or potentially fatal etiologies, impaired consciousness before treatment, and nonconvulsive or myoclonic SE. No difference was found in SE cessation between the groups. Patients with in-hospital SE had higher 30-day mortality (127/314, 62.9% versus 75/397, 37.1; p <0.001). In-hospital onset was an independent risk factor for 30-day mortality (adjusted OR of 1.720; 95% CI: 1.107-2.674; p = 0.016). In the propensity group (n = 244), no difference was found in 30-day mortality and SE cessation between out-of-hospital and in-hospital SE onset groups (36/122, 29.5% versus 34/122, 27.9%; p=0.888; and 47/122, 38.5% versus 39/122; 32%; p = 0.347, respectively). Conclusion: In-hospital SE is associated with higher 30-day mortality without difference in SE cessation. The two groups differ considerably for age, acute and possibly fatal etiologies, comorbidities, and SE semiology. The patient location at SE onset is an important prognostic predictor. However, the increased mortality is probably unrelated to the setting of SE onset and reflects intrinsic prognostic predictors

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

Not Just Arterial Damage: Increased Incidence of Venous Thromboembolic Events in Cardiovascular Patients With Elevated Plasma Levels of Apolipoprotein CIII

Background Apolipoprotein CIII (apo CIII ) is a crucial player in triglyceride-rich lipoprotein metabolism, but may also act pleiotropically, provoking inflammatory responses and stimulating coagulation. Elevated apo CIII plasma levels have been associated with increased activity of coagulation factors. Since these features of prothrombotic diathesis are linked with venous thromboembolism ( VTE ), we hypothesized that apo CIII plays a role in VTE . Methods and Results We recorded nonfatal VTE events in 1020 patients (age 63.3\ub111.4 years; 29.1% women) with or without coronary artery disease (79.1% with coronary artery disease and 20.9% without coronary artery disease) during a long follow-up. Complete plasma lipid and apolipoproteins were available for all patients. Forty-five patients (4.4%) experienced nonfatal VTE events during a median follow-up period of 144 months. Apo CIII plasma concentration at enrollment was higher in patients with VTE compared with patients without VTE (12.2 [95% CI, 11.10-13.5] mg/dL vs 10.6 [95% CI, 10.4-10.9] mg/dL, respectively; P=0.011). Patients with apo CIII levels above the median value (10.6 mg/dL) exhibited an increased risk of VTE (incidence rate, 6.0 [95% CI , 4.0-8.0] vs 1.8 [95% CI, 0.7-2.9] VTE events/1000 person-years; unadjusted hazard ratio [ HR ], 3.42 [95% CI , 1.73-6.75]; P<0.001). This association was confirmed after adjustment for sex, age, coronary artery disease diagnosis, body mass index, hypertension, and anticoagulant treatment at enrollment ( HR , 2.66; 95% CI , 1.31-5.37 [ P=0.007]), with inclusion of lipid parameters in the Cox model (HR, 3.74; 95% CI , 1.24-11.33 [ P=0.019]), and even with exclusion of patients who died at follow-up ( HR, 3.92; 95% CI , 1.68-9.14 [ P=0.002]) or patients taking anticoagulants ( HR , 3.39; 95% CI , 1.72-6.69 [ P<0.001]). Conclusions Our results suggest that high plasma apo CIII concentrations may predict an increased risk of VTE in patients with cardiovascular disease

Red Blood Cell Distribution Width Improves Reclassification of Patients Admitted to the Emergency Department with Acute Decompensated Heart Failure

Background: The usual history of chronic heart failure (HF) is characterized by frequent episodes of acute decompensation (ADHF), needing urgent management in the emergency department (ED). Since the diagnostic accuracy of routine laboratory tests remains quite limited for predicting short-term mortality in ADHF, this retrospective study investigated the potential significance of combining red blood cell distribution width (RDW) with other conventional tests for prognosticating ADHF upon ED admission. Methods: We conducted a retrospective study including visits for episodes of ADHF recorded in the ED of the Uni versity Hospital of Verona throughout a 4-year period. Demo - graphic and clinical features were recorded upon patient presentation. All patients were subjected to standard Chest X-ray, electrocardiogram (ECG) and laboratory testing in - cluding creatinine, blood urea nitrogen, B-type natriuretic peptide (BNP), complete blood cell count (CBC), sodium, chloride, potassium and RDW. The 30-day overall mortality after ED presentation was defined as primary endpoint. Results: The values of sodium, creatinine, BNP and RDW were higher in patients who died than in those who survived, whilst hypochloremia was more frequent in patients who died than in those who survived. The multivariate model, incorporating these parameters, displayed a modest efficiency for predicting 30-day mortality after ED admission (AUC, 0.701; 95% CI, 0.662-0.738; p=0.001). Notably, the inclusion of RDW in the model significantly enhanced prediction efficiency, with an AUC of 0.723 (95% CI, 0.693-0.763; p<0.001). These results were confirmed with net reclassification improvement (NRI) analysis, showing that combination of RDW with conventional laboratory tests resulted in a much better prediction performance (net reclassification index, 0.222; p=0.001). Conclusions: The results of our study show that prognostic assessment of ADHF patients in the ED can be significantly improved by combining RDW with other conventional laboratory tests

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy

Performance of the Manchester Triage System in patients with dyspnoea: A retrospective observational study

Between 1% and 7.5% of patients admitted to the emergency department (ED) suffer from dyspnoea. The Manchester Triage System is one of Europe's most used triage systems considering five levels to prioritize patients in the ED: level 1 (red), immediate; level 2 (orange), very urgent; level 3 (yellow), urgent; level 4 (green), standard; level 5 (blue), non-urgent. With this study we aimed to evaluate the performance of the Manchester Triage System in patients with dyspnoea.; With this retrospective, observational study we analysed data from 4'076 patients with dyspnoea accessing the ED in one Italian hospital between January 1, 2017 and June 30, 2019. To determine the sensitivity and specificity we computed the area under the curve (AUC) of the receiver operating characteristics (ROC) comparing the sensitivity and specificity for each of the five priority codes and seven-day mortality.; A total of 3.6% (n = 145) of the patients died within seven days after access to the ED. From the patients dying within seven days, 6.2% (9/145) had a blue or green priority code, 17.9% (26/145) had a yellow priority code and 75.9% had an orange or red priority code. A high priority code (orange or red) had a sensitivity of 75.9%, a specificity of 66.1%, a PPV of 7.6% and a NPV of 98.7%. The AUC was 0.734 (CI 95% 0.695-0.773, p < 0.001).; The Manchester Triage System showed acceptable sensitivity and negative predictive value in patients with dyspnoea, yet a low specificity related to the risk of death. The system is safe, resulting in a low under-triage rate for death. Improving the clinical assessment during nurses' triage (e.g. considering clinical history and auscultation of lungs) and prospective validation studies with surrogate endpoints is needed in this population

La strana caduta a terra di Teresa: caso clinico

Si tratta di una caso clinico di rabdomiolisi da farmac

Epoxy Coatings Containing Clays And Organoclays: Effect Of The FillerAnd Water Content On The Uv-Curing Process

UV-cured coatings were prepared by photoinitiated cationic ring-opening polymerisation of epoxides in the presence of natural montmorillonite and different organically modified clays (5 wt%). The curing was monitored by FTIR in real time while irradiating the formulations by UV light. Significant changes of both the rate of curing and the final conversion were found. Only in the presence of a suitable montmorillonite and after a suitable pre-treatment, the process showed the same polymerisation rate, guaranteed a higher conversion than the neat epoxide and the formation of intercalated nanostructured coatings