Cause Of Access Research Articles

A rare cause of recurrent syncope: chemodectoma of left carotid

Syncope is a frequent cause of access to emergency departments. Recurrent syncope may be associated with a transient lock of consciousness. When neurological or cardiological common causes of syncope are excluded, rare causes of syncope, such as solid carotid tumors, should be considered. In this study, we report a rare case of left carotid chemodectoma in a patient with frequent access to the emergency room for syncope in which a thorough differential diagnosis has been performed.

P453 RECURRENT SYNCOPAL EPISODES IN A YOUNG PATIENT: TO IMPLANT THE PM OR NOT TO IMPLANT THE PM, ALWAYS A DIFFICULT DECISION!

Abstract Introduction Syncope represents one of the main causes of access to the Emergency Department and outpatient visits, accounting for up to 13% of hospital admissions. Although usually benign, syncopal episodes are a source of considerable distress for the patient and family members, particularly when dealing with otherwise healthy young patients. We report the case of a young patient who presented with recurrent syncopal episodes with important psychological and professional implications. Case Report A 33–year–old man comes to our Syncope Unit with a long history of repeated syncopal episodes preceded by fleeting warning signs, sometimes with minor trauma, occurring during daily activities, in conjunction with minor injuries or post–voiding but never during exertion. The patient began to limit his activities for fear of syncope and was inhibited from driving work vehicles and performing tasks at height. The various cardiological examinations performed over the years were normal. The study of syncope evoked a syncope with a 13 sec pause on carotid sinus massage while the Head–up Tilt Test was negative. A Loop Recorder (ILR) was then implanted to correlate the syncopal episodes with any slowing or pathological pauses in the heart rhythm. At remote monitoring of the ILR, an asystole of about 16 seconds symptomatic for syncope was documented. In relation to the recurring syncopal episodes, the important professional limitations imposed on the patient, as well as at the explicit request of the patient himself, despite the lacking scientific evidences availables, we proceeded to implant a dual–chamber pacemaker with a frequency response algorithm. In the 4 years after the implant there were no syncopal recurrences and the patient resumed his normal daily and professional activities with a marked improvement also in his psychological setting. After 2.5 years, however, the ventricular lead broke and required its extraction and reimplantation. Conclusions The decision to implant the device was not easy, precisely in relation to the possible complications over the years, but this allowed the patient to resume a normal private and professional life. However, an accurate risk–benefit assessment is required, sharing the "weight" of the decision with the patient and his family.

MO144: Behind the Scenes: A Year in an Onco-Nephrology Outpatient Clinic in Italy

Abstract BACKGROUND AND AIMS The progressive increasing awareness of the need for a multidisciplinary management of cancer patients, the rapid development of new anti-cancer therapies, the prolongation of oncological patients’ survival and the increased incidence of chronic kidney disease (CKD) over the years have created a breeding ground for the affirmation of onconephrology. This subspeciality of nephrology aims to fully deal with the complex and bidirectional relationship between cancer and the kidneys: on one hand, the tumour presence or its treatment can cause renal damage; on the other hand, a kidney disease can alter the bioavailability and therefore the effectiveness of the treatment itself. Well-defined multidisciplinary management of cancer patients with kidney disease can thus ensure that the highest quality of care could be administered by a dedicated team with experience in these complex issues. The objective of our study was to describe patients who were referred to our onconephrology clinic during 2021, in order to offer an analysis of their main characteristics, with the overall aim of providing experience-based considerations that will initiate further discussion on this growing subspecialty area. METHOD We performed a retrospective data collection of naive patients attending our onconephrology outpatient clinic over a 1-year period. We collected data regarding epidemiological characteristics, renal function, primary tumour, cancer therapy and reason why they were referred for a nephrological evaluation. Main characteristics of the patients are summarized in Table 1. RESULTS A cohort of 323 consecutive visits was analysed; 175 new cases; 110 males and 65 females, with an average age of 70 years. eGFR by CKD-EPI was 43 mL/min/1.73 m2 (5% CKD stage I, 12% stage II, 19% stage IIIA, 39% stage IIIB, 21% stage IV, and 4% stage V—FIG 1A). Primary tumours of the patients are summarized in Figure 1B. A total of 37 first and 81 subsequent consultations were performed for clinical evaluation, 30 versus 7 for worsening CKD, 23 versus 10 for a pre-contrast enhanced computed tomography, 19 versus 16 for renal toxicity from cancer treatment, 15 versus 5 for electrolyte disturbances, 13 versus 9 in light of the possible initiation of an oncological therapy, 12 versus 9 for acute kidney injury, as summarized in Figure 1C. Overall, 93 patients (53%) were not on active oncological therapy, while, among the others, 18 received cytotoxic chemotherapy, 25 molecularly targeted agents, 22 immunotherapy, 8 hormone therapy and 9 combination of agents of multiple classes (Figure 1D). CONCLUSION The above retrospective results shed light on the main causes of access to an onco-nephrology outpatient clinic, once again confirming both the relevance of onconephrological issues and the increasing necessity to address them in a dedicated setting. Since onconephrology is presently more experience-based than evidence-based, and since only with a thorough knowledge of the issues of onco-nephrology, together with a tight interspecialty collaboration, we can provide these patients better treatment and management, the representative set of patients we presented can be useful to understand their commonest needs and to increase the awareness on these issues, still too often underrecognized and undermanaged, due to a certain nihilistic attitude towards cancer pts with kidney issues. Finally, preliminary efficacy results (not reported here) suggest a clinically relevant benefit in terms of nephrological outcome.

Thoracic non-traumatic cardiovascular diseases: current perspective and multi-detectors Computed Tomography protocols optimization in the emergency setting.

Cardiovascular diseases (CVDs) are among the most common causes of access to the Emergency Department and among the leading causes of death worldwide. Accurate diagnostic algorithms are mandatory to ensure a rapid life-saving treatment. However, non-specific clinical presentation and unnecessary referrals to other subspecialties may lead to misinterpretation of the diagnosis and delays. In recent years, the development of imaging technologies has allowed Computed Tomography (CT) to play a prominent role in the concepts of CVD rule-in and rule-out. An optimization strategy for CT protocols is needed to reduce variability and improve image quality. A correct diagnostic suspicion is crucial, as different districts (i.e., heart, aorta and pulmonary circulation) may require different investigation techniques. Additionally, the CVD pre-test probability assessment is highly correlated with CT accuracy. The purpose of this narrative review is to analyze the current role of CT in the approach to the CVDs in the ED, and to analyze the main strategies of CT optimization.

Il sintomo febbre: l'interpretazione e la corretta gestione

In paediatric age, fever represents one of the main reasons for parental concern and the main cause of access to the emergency room. Against "fever phobia", it is essential that the paediatrician spends some time explaining to parents that fever is a defence mechanism against infection and that it should be treated rationally, with the objective of making the child feel better and not making them heal faster. Furthermore, it is useful to provide parents with indications on how to measure body temperature and advice on clinical signs to pay attention to, besides fever. Indeed, in addition to temperature, there are other parameters to evaluate in a febrile child, some clearly measurable, others for which it is necessary for the doctor to evaluate the child "face to face". It is on this issue that the main guidelines on the management of febrile children are based, whose objective is to help the paediatrician to identify those few children who have a severe disease and therefore deserve prompt treatment and investigations. The article shows current evidence on the role of fever, the most correct methods for its measurement, the reasonable use of drugs for the symptomatic control of fever and the approach to be followed in the management of fever in the child aged less than 5 years.

Adolescents' Utilization of a Tertiary-Level Pediatric Emergency Department in Italy.

AimDescribe the use of the emergency department of a tertiary-level children's hospital in Italy by adolescents.MethodsThis retrospective study was based on the medical records of patients aged 13 to 17 years, who accessed the emergency department of the Institute for Maternal and Child Health of Trieste, from 1 January to 31 December 2018. The primary outcome was to describe the leading causes of access, diagnoses, rate of hospitalization, and ward of destination among adolescent patients.ResultsDuring the study period, 24,599 patients accessed the department. Among them, 3,062 were adolescents, for a total of 3,895 unscheduled visits. The principal causes of access were trauma (45.3%) and organic diseases (38.8%). Two hundred and forty nine adolescents (6.4%) had mental health problems. One hundred and forty two adolescents (3.6%) Were Admitted to the Hospital, 54 of Whom (38%) to the Neuropsychiatric Ward, for Mental Health Problems.ConclusionsAmong adolescents seen in this Italian tertiary-level children's hospital, mental health problems represented a small proportion of emergency department visits but were the leading cause of urgent hospitalization.

Foreign Body Ingestion in Children: Epidemiological, Clinical Features and Outcome in a Third Level Emergency Department.

Ingestion of foreign bodies is a frequent pediatric cause of access to the Emergency Department (ED). The aim of this study was to determine the epidemiological and clinical features of pediatric patients with a diagnosis of foreign body ingestion and to identify the factors associated with an urgent invasive procedure or hospitalization. This is a retrospective study conducted on a population of 286 pediatric patients (0–17 years) evaluated for foreign body ingestion at the Pediatric ED of “Fondazione Policlinico Universitario A. Gemelli, IRCSS” between October 2014 and June 2019. Data concerning age and gender, underlying diseases, type of foreign body, symptoms and signs, instrumental tests, specialist visits, treatment and outcome were analyzed. The majority of foreign bodies were coins (23%). Symptoms recurred in 50% of the foreign bodies with esophageal localization and between the 92 (32%) patients with symptoms the most common was vomiting (7%). X-rays was performed in 61% of patients. Among all patients, 253 patients (88.8%) had been discharged, 21 (7%) had been hospitalized, and four (1.4%) were sent to an outpatient facility. Besides, 17 (5.9%) patients had been transferred to the Observation Unit. Of the hospitalized patients (21 (7.3%)), clinical observation was performed for 57% and endoscopic procedure for 45%. Our data confirm that the ESPGHAN-ESGE guidelines application prevents interventions that are not necessary, avoiding diagnostic and therapeutic delays.

Lesão do Nervo Tibial Provocada por Meias de Compressão Abaixo do Joelho

Introduction : Peripheral mononeuropathies are one of the leading causes of access to health care. Case Report : A 70-year-old woman felt non-specific pain in the popliteal region. After the exams, it was thought to be a radiculopathy. Therefore, the patient was medicated with muscle relaxants and anti-inflammatories without improvement of complaints, though. On examination, she had apparent pain during palpation of the semitendinosus and semimembranosus tendons. This way, it was decided to make an ultrasound scan of the popliteal region, being verified that the tibial nerve had an increased dimension in comparison to the contralateral one. The patient reported that, for the past two months, she had been using elastic stockings up to the knee region. A nerve block was performed with lidocaine, which led to a successful regression of the symptomatology. Discussion : Tibial nerve lesions tend to be uncommon as opposed to peroneal nerve lesions, since it is found in a relatively deep region. Conclusion : This case report highlights the importance of having a good clinical history combined with a detailed physical examination and the valuable details given by the ultrasound analysis at the time of the evaluation, in order to complement the data collected. Keywords: Peripheral Nerve Injuries/diagnostic imaging; Peripheral Nerve Injuries/therapy; Stockings, Compression; Tibial Nerve/injuries.

HYPERTENSIVE EMERGENCIES AND URGENCIES IN EMERGENCY DEPARTMENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: The prevalence of hypertensive emergencies (HEs) and urgencies (HUs) and of acute hypertension-mediated organ damage (aHMOD) in emergency departments (EDs) is unknown. Moreover, the predictive value of symptoms, blood pressure (BP) levels and cardiovascular risk factors to suspect the presence of aHMOD is still unclear. The aim of this study was to investigate the prevalence of HEs and HUs in EDs and of the relative frequency of subtypes of aHMOD, as well as to assess the clinical variables associated with aHMOD. Design and method: We conducted a systematic literature search on Pubmed, OVID and Web of Science from their inception to August 22, 2019. Two independent investigators extracted study-level data for a random-effects meta-analysis. Results: Eight studies were analysed, including 1970 HEs and 4983 HUs. The prevalence of HEs and HUs was 0.3% and 0.9%, respectively (O.R.for HUs vs HEs:2.5 (1.4–4.3)). Pulmonary oedema/heart failure was the most frequent subtype of aHMOD (32%), followed by ischemic stroke (29%), acute coronary syndrome (18%), haemorragic stroke (11%), acute aortic syndrome (2%) and hypertensive encephalopathy (2%). No clinically meaningful difference was found for BP levels at presentations. HU patients were younger than HE patients by 5.4 years and more often complained of non-specific symptoms and/or headache, while specific symptoms were more frequent among HE patients. Conclusions: HEs and HUs are a frequent cause of access to EDs, with HUs being significantly more common. BP levels alone do not reliably predict the presence of aHMOD, which should be suspected according to the presenting signs and symptoms.

Acute obstructive jaundice management in emergency: Management, clinical and patient’s safety considerations regarding the use of the short observation unit

Introduction: Obstructive jaundice is a frequent cause of access to the Emergency Department (ED) and requires rapid hospitalization in order to perform an endoscopic retrograde cholangiopancreatography (ERCP). To reduce overcrowding, Brief Observation Units (BOU) were set up in EDs throughout Italy where patients receive treatment for 48-72 hours, significantly decreasing hospitalizations. The objective of this study is to evaluate the cost-effectiveness of a new model for managing obstructive acute jaundice in BOUs and provide indications regarding the possibility of systematic implementation thereof within EDs. Materials and methods: From 1 January 2019 to 31 December 2019, we evaluated 213 patients (100 M/113F, mean age 65±16.8 years) who presented at the ED with acute obstructive jaundice and were subsequently admitted to the BOU. Each patient underwent blood tests, an ECG, and an ultrasound or CT scan to confirm the diagnosis. In addition, each patient presented with ERCP indications. We analyzed the introduction of the BOU from a clinical, economic and discharge time perspective and made some recommendations regarding the organizational opportunities. Results: Clinical management in BOUs has produced excellent results, but it is not cost-effective. It does, however, produce excellent performance in terms of discharge times. Conclusion: This study shows both good clinical performance in the procedures carried out in the BOU and the opportunity to avoid patient hospitalization, thus optimizing the use of available hospital beds. From an economic perspective, BOUs prove more costly and receive lower reimbursements from the Diagnosis Related Groups (DRG) system. However, despite its inefficacy in terms of costs, it may be used with certain objective advantages, especially in view of the need to liberate as many hospital beds as possible and avoid unnecessary hospitalizations during the current pandemic. Furthermore, BOUs may also improve clinical results and patient safety. Management of obstructive jaundice in BOUs may be seen as an alternative care setting to the traditional methods of admission, although with economic limitations. © 2021 A. CARBONE Editore. All rights reserved.

Analysis of the Skew Deviation to Evaluate the Period of Onset of a Canalolithiasis After Macular Damage.

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end-organ disease, and it is one of the first causes of access to the emergency room. The moment of migration of the otoconial debris in a semicircular canal does not necessarily coincide with the moment of detachment of the debris themselves. Consequently, the paroxysmal positional vertigo could arise with a variable delay with respect to the mechanical damage suffered by the macula. The aim of this work is to try to identify objective criteria to establish whether a canalolithiasis is synchronous or diachronic to the damage. The analysis of skew deviation in the context of ocular tilt reaction in patients with canalolithiasis could provide useful information to understand if macular damage occurred at the origin of the disease and when the damage may have occurred. In this study, 38 patients with BPPV were analyzed based on the type of skew deviation that was presented. We found that if the eye on the side of the canalolithiasis is hypotropic the damage of the utriculus is likely recent (last 10 days), if it is hypertropic the damage is not recent (20 days before) and finally if the eyes are at the same height it could be an utricular damage in compensation (occurring the last 10–20 days) or a secondary labyrinth canalolithiasis, without associated utricular damage. Our results show that the evaluation of skew deviation in patients suffering from BPPV could be useful to evaluate: (a) if a positional paroxysmal nystagmus can be related to an previous relevant injury event (for example a head injury that occurred days before the crisis); (b) if it is a BPPV of recent onset or a re-entry of the debris into the canal.

Rapid Clinical Management of Leishmaniasis in Emergency Department: A Case Report with Clinical Review of Recent Literature.

Simple SummaryIn this article, we have briefly described the various forms of leishmania infection occur in emergency settings as well as the principal differential diagnoses, and we propose a decision algorithm to facilitate its early recognition in the emergency department (ED). Regarding the last point, the costs and validity of the most common modern diagnostic technologies have been examined, with particular attention to their sensibility and specificity; particularly, rk39-based RTD has been examined. To reinforce the importance of a quick diagnosis performed in the emergency room, we introduce a rather paradigmatic case report of a 19-year-old patient presenting with suspected lymphoproliferative disease and subsequently addressed to the incorrect hospital ward. As often happens, signs and symptoms tended toward the diagnosis of a hematologic disease rather than an infectious one: therefore, it is crucial to include a variety of diagnostic possibilities when a patient presents with fever and associated lympho-adenomegaly with minor symptoms: Leishmaniasis always needs to be considered among them.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.

Disk Battery Ingestion: A Simple User-Guide.

Disk Battery Ingestion (DBI) is a cause of access to the emergency department (ED), especially in pediatric age. This problem, if not well managed, may lead to serious injuries, with several complications involving the gastrointestinal and respiratory tract. The aim of this review is to analyze the literature of the last 25 years to make a decisional flow-chart that may help the emergency physician. For this review, 36 articles have been analyzed (8 articles and 28 case reports), from 1995 to 2019. Data considered from each study included year of publication, type of study, population studied, type of battery, timing of ingestion, treatment, outcomes, complications. A decisional flow-chart has been configured. X-ray should be performed as the first step in every stable patient, meanwhile CT scan should be performed in unstable patients. When the battery is still localized in the esophagus, endoscopy should be performed as soon as possible, meanwhile, when the battery is beyond the esophagus, its diameter should be noted before taking a decision. The use of the flow-chart proposed may reduce the risk of worse consequences and severe injuries for the patients, helping the emergency physician in his decisional process.

Hypertensive emergencies and urgencies in emergency departments: a systematic review and meta-analysis.

The prevalence of hypertensive emergencies and urgencies and of acute hypertension-mediated organ damage (aHMOD) in emergency departments is unknown. Moreover, the predictive value of symptoms, blood pressure (BP) levels and cardiovascular risk factors to suspect the presence of aHMOD is still unclear. The aim of this study was to investigate the prevalence of hypertensive emergencies and hypertensive urgencies in emergency departments and of the relative frequency of subtypes of aHMOD, as well as to assess the clinical variables associated with aHMOD. We conducted a systematic literature search on PubMed, OVID, and Web of Science from their inception to 22 August 2019. Two independent investigators extracted study-level data for a random-effects meta-analysis. Eight studies were analysed, including 1970 hypertensive emergencies and 4983 hypertensive urgencies. The prevalence of hypertensive emergencies and hypertensive urgencies was 0.3 and 0.9%, respectively [odds ratio for hypertensive urgencies vs. hypertensive emergencies 2.5 (1.4-4.3)]. Pulmonary oedema/heart failure was the most frequent subtype of aHMOD (32%), followed by ischemic stroke (29%), acute coronary syndrome (18%), haemorrhagic stroke (11%), acute aortic syndrome (2%) and hypertensive encephalopathy (2%). No clinically meaningful difference was found for BP levels at presentations. Hypertensive urgency patients were younger than hypertensive emergency patients by 5.4 years and more often complained of nonspecific symptoms and/or headache, whereas specific symptoms were more frequent among hypertensive emergency patients. Hypertensive emergencies and hypertensive urgencies are a frequent cause of access to emergency departments, with hypertensive urgencies being significantly more common. BP levels alone do not reliably predict the presence of aHMOD, which should be suspected according to the presenting signs and symptoms.

Access to emergency care units by socially vulnerable patients: a qualitative research

Abstract Background The increasing prevalence of chronic diseases, the decline in medical demography, the ramp up of new information and diagnosis technologies, together with the growing health social inequalities urge decision makers to rethink the access to emergency care units (ECU) and reduce the rate of multiple admissions, especially for people living in vulnerable conditions. Beyond the medical causes of access to ECU, it is crucial to understand the psychosocial representations of patients and health professionals. Methods 23 socially vulnerable patients who have already been admitted within the last 3 months and ECU health/social professionals were interviewed face-to-face by a psychosocial scientist using a semi-directed approach, in 3 hospitals. The thematic content of data was analyzed in order to identify salient social representations of access to ECU. Results 27 themes emerged to understand the issue of the access to ECU, joining into 5 main categories: perceived needs for access to ECU, perception of precariousness, the relationship of patients and professionals with the healthcare system, the shared experience of aggressiveness in ECU, expectations in post-emergency support. As regards the needs for access to ICU, several issues were identified: exemption from making upfront payments, needs for listening, support, reinsurance, privacy and consideration of emergency professionals, referral by general practitioners (GP), difficult access to GP, needs for immediacy and timely healthcare services, permanent opening of ECU. As regards the experience of ECU professionals: ambivalent emotions towards socially vulnerable patients, a recurrence of passages leading to a reduced medical attention, a feeling of failure to care for vulnerable patients, coping strategies in caring for these patients. Conclusions Our results bring several leads to improve the organization and the management of healthcare in ECU and in primary care for socially vulnerable patients. Key messages To identify the psychosocial rationales of access to emergency care units provides several leads to build a more efficient healthcare policy and reduce the burden of overloaded services. To reduce the overburden of emergency services can only be achieved by a global approach of the access to both emergency and primary care and a better support after emergency discharge.

Pilot study to explore the prophylactic efficacy of oral probiotic Streptococcus salivarius K12 in preventing recurrent pharyngo-tonsillar episodes in pediatric patients.

Background: In the pediatric population, acute pharyngo-tonsillitis represents one of the most frequent causes of access to outpatient treatment and use of antibiotics. In frequent tonsillitis, the pharmacological approach is no longer effective, and, therefore, surgery becomes the treatment of choice.Methods: This study compares the prophylactic efficacy of Streptococcus salivarius K12 (Bactoblis®) in children with recurrent pharyngo-tonsillitis treated vs untreated, with a 12 -month follow-up. The primary objectives are: The incidence of recurrence of pharyngo-tonsillar episodes and the concomitant use of other drugs. Secondary objectives are: tolerability of the treatment, the effectiveness in terms of clinical improvement, days of absence from school, reduction of the use of standard therapies, and cancellation from the surgical planning list.Results: Patients belonging to group A (treated with K12 for 90 days) were 24 males and 26 females, mean age 6.6 years (SD=1.57), those belonging to group B (untreated) were 23 males and 27 females, average age 6.8 years (SD=1.72). In the follow-up, group A reported 26 inflammatory pharyngo-tonsillary episodes in the first trimester, unlike group B, who reported 72 in the second trimester. This has shown a lower incidence (3.38%) of the disease compared to group B (6.66%), for a total of 169 inflammatory pharyngo-tonsillary episodes in group A against 333 in group B. A reduction in days of school absence of 429 days in group A and 927 days in the control group (P<0.01) was also noted. Finally, 14 children of group A (28%) underwent adenotonsillectomy, against the whole group B. No adverse events were reported.Conclusion: The efficacy of K12 on the prevention of pharyngo-tonsillar infections, the decrease in the use of antibiotics and the improvement of the overall quality-of-life was confirmed, with a decreased number of absences from school and fewer patients undergoing surgery.

Cardiac imaging in patients with dyspnea.

Acute dyspnea is a frequent cause of access to the Emergency Department. Differentiation between cardiogenic and respiratory causes does not always seem simple and certain, causing a delay in initiating targeted therapies and prolonging the patient's stay in the emergency department. The basic elements for the diagnosis remain the history and the objective examination, supplemented by the execution of an electrocardiogram, a determination of blood parameters and the execution of a chest X-ray. The limits of radiological semeiotics, related to a low sensitivity to high specificity, promote other methods available to the first aid physician. Specifically, the determination of the natriuretic B-type peptide and transthoracic ultrasound is proposed as a method, recognized and validated by the recent letter on the patient bed, relatively easy to execute, fast learning, fast execution and non-invasive (referring to "ultrasound"). The sensitivity and specificity of both methods are high (86.7% and 93%, respectively) in the diagnosis of alveolus-interstitial syndrome, simplifying and accelerating the differential diagnosis of acute dyspnea.

Reasons for visits to an emergency center and hemostatic alterations in patients with recurrent spontaneous subconjunctival hemorrhage.

To evaluate causes of visits to the Eye Emergency Department, determine the prevalence of subconjunctival hemorrhage (SCH), and assess the role of hemostatic abnormalities among patients with spontaneous recurrent SCH (SRSCH). In a prospective study conducted over 2 years, hemostatic function was studied in a subgroup of 105 consecutive patients (39 male) with SRSCH free of systemic risk factors and in 53 age- and sex-matched healthy controls (HC) (24 male). A total of 10,090 patients (mean age 57.2 ± 16.7 years, range 0-94, median 58.4) were evaluated. A total of 39.3% had ocular trauma, 34.9% inflammatory ocular surface disorder, 5.7% floaters, 3.3% visual symptoms of neurologic origin, 1.6% uveitis, 1.5% ocular hypertension, 0.8% retinal tear or detachment, 0.7% retinal vascular disease, and 0.5% other causes. A total of 1.6% of the patients were hospitalized. A total of 11.7% of patients had SCH: in 86.7% it was spontaneous, in 13.3% consequent to trauma or to ocular surface disorders. A total of 105 patients had SRSCH, and the prevalence of hemostatic abnormalities among them was not different from HC. Type I von Willebrand disease was diagnosed in 1 patient with SCH and in none of the HC (χ² = 0.13, p = 0.72). Most patients had ocular infection or trauma and were treated on an outpatient basis; SCH was the third cause of access. The large majority of SCH were unprovoked, and the prevalence of hemostatic alterations in patients with SRSCH and no systemic causes was not different from the general population. Hemostatic screening or second level blood clotting tests were of no use in these patients.

O019. Headache as an emergency in children and adolescents.

Pediatric and adolescence headache is one of the most common causes of access in Emergency Departments (ED). We reviewed the literature and we found that headache in ED is generally a benign condition that tends to be self-limited or resolves after an appropriate drug treatment. Causes of non-traumatic headache in ED include more frequently primary headaches (21.8-66.3%) and secondary benign headaches (35.4-63.2%), while secondary life-threatening headaches are less frequent (2-15.3%) (Table ​(Table1).1). The most frequent worrying conditions include ventricoloperitoneal shunt malfunction, central nervous system infections, brain tumors, hydrocephalus, pseudotumor cerebri and hemorrhage. In a pediatric ED, the primary objective is to recognize the serious life-threatening conditions requiring immediate medical care among the wide spectrum of headache diagnoses. The diagnostic approach starts with a thorough history followed by a complete physical and neurologic examination. The temporal features may be useful to classify headaches into four temporal patterns (acute, recurrent acute, chronic progressive, chronic non-progressive) that aid in reaching the etiological diagnosis. A normal neurological examination has been demonstrated to highly correlate with the absence of relevant intracranial processes in several pediatric studies. Neuroimaging should be considered in patients with recent-onset severe headache or change in the type of headache or with associated signs or symptoms suggestive for intracranial diseases. The therapeutic management of headache in ED depends on general clinical conditions of the patients and the presumable etiology of headache [1]. Table 1 Comparison of the studies about etiology of headache in ED * only patients with focal neurological signs at admission to ED.

Secondary headache in emergency.

Headache is one of the most common causes of access to Emergency Departments (ED). Primary headaches and headaches secondary to benign conditions (e.g headache attributed to acute sinusitis) represent the majority of cases, while secondary life-threatening headaches are less frequent. The primary objective in the ED setting is to decide whether the headache is primary or secondary and recognize serious life-threatening conditions presenting with headache and requiring prompt medical diagnosis and care, such as subarachnoid hemorrhage (SAH), intracerebral hemorrhage, cerebral venous sinus thrombosis (CVST), cervical artery dissection (CAD), brain tumors, pituitary apoplexy, spontaneous intracranial hypotension, or intracranial infections. Careful history taking and physical examination remain the most important part of the assessment of the headache patient[1]. A thorough history should investigate the onset of headache, quality, location and irradiation of pain, associated symptoms experienced before and during the headache, concomitant medical conditions, medication use, recent trauma or interventions. The examination should then target areas identified as abnormal during the headache history; funduscopy evaluation should be performed when symptoms may suggest an increased intracranial pressure; in addition, a complete neurological assessment including level of consciousness, cranial nerve testing, pupillary responses, motor strength and sensorial testing, and signs of meningeal irritation is essential[2]. Based on historical and physical findings “red flags” for secondary headache disorders are sudden onset, onset after 50 years of age, increased frequency, severity or significant change in the usual headache pattern, new onset with an underlying medical condition (such as cancer or immunodepression), concomitant signs of systemic illness (such as fever, neck stiffness, rash), focal neurologic signs or symptoms, papilledema, and head trauma[2]. In headache patients with one or more “red flags” a diagnostic workup is indicated including blood tests, neuroimaging studies, and cerebrospinal fluid (CSF) examinations, which are selected depending on the patient's history and findings. Blood testing and dosage of inflammation indexes (erythrocyte sedimentation rate, C-reactive protein) should be performed in all headache patients especially when an infective or inflammatory condition is suspected. In the ED, non-contrast computed tomography (CT) is the preferred imaging study and is used to rule out hemorrhage, while most patients should perform a magnetic resonance imaging (MRI) brain scan followed by CT/MRI angiography if brain vessel disease is suspected (such as, CAD, aneurysms, and CVST). Lumbar puncture with CSF analysis may help to diagnose SAH, infection, tumor and disorders related to CSF hypertension or hypotension[3, 4]. Treatment and prognosis depend on the etiology of the headache. Prompt recognition and early treatment of secondary headache are essential to avoid some preventable complications.