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  1. Article: High-Dose Insulin for Toxin Induced Cardiogenic Shock: Experience at a New High and Overview of the Evidence.

    Chad, Thomas / Ulla, Marco / Garnelo Rey, Vanesa / Gómez, Carlos

    The Journal of emergency medicine

    2019  Volume 58, Issue 2, Page(s) 317–323

    Abstract: Background: High-dose insulin therapy is an effective treatment for cardiogenic shock caused by the overdose of particular medications. Other treatment options are usually of limited benefit. Consensus suggests that early initiation improves efficacy. ... ...

    Abstract Background: High-dose insulin therapy is an effective treatment for cardiogenic shock caused by the overdose of particular medications. Other treatment options are usually of limited benefit. Consensus suggests that early initiation improves efficacy. No ceiling effect has been established at doses in the general range of 0.5-10 units/kg/hour.
    Case report: A 79-year-old man presented in cardiogenic shock after an intentional overdose of numerous cardioactive medications 10 days after experiencing myocardial infarction. A high-dose insulin infusion was commenced. This was titrated up to a maximum of 20 units/kg/hour (1600 units/hour) and sustained for 32 h (61,334 units total). Minimal adverse events were seen despite this exceptional infusion rate (3 episodes of hypoglycemia and 2 episodes of hypokalemia). Concurrent catecholamine support was used, and cardiovascular function was maintained until all support was withdrawn 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are pivotal to the successful initiation/up-titration of high-dose insulin therapy. They must balance the potential for treatment failure with other treatment options, mitigate against adverse events in the initial phase of therapy, and coordinate care between other hospital specialties. This case shows that the relative safety and efficacy was extended to an infusion rate of 20 units/kg/hour, the highest recorded in the published literature. This information may help guide treatment of similar cases in the future.
    MeSH term(s) Aged ; Emergency Service, Hospital ; Humans ; Hypoglycemic Agents/administration & dosage ; Infusions, Intravenous ; Insulin/administration & dosage ; Male ; Shock, Cardiogenic/chemically induced ; Shock, Cardiogenic/drug therapy
    Chemical Substances Hypoglycemic Agents ; Insulin
    Language English
    Publishing date 2019-11-22
    Publishing country United States
    Document type Case Reports ; Journal Article
    ZDB-ID 605559-x
    ISSN 0736-4679
    ISSN 0736-4679
    DOI 10.1016/j.jemermed.2019.10.018
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  2. Article: Holy Shroud Exhibition 2010: health services during a 40-day mass-gathering event.

    Bortolin, Michelangelo / Ulla, Marco / Bono, Alessia / Ferreri, Enrico / Tomatis, Mariano / Sgambetterra, Sergio

    Prehospital and disaster medicine

    2013  Volume 28, Issue 3, Page(s) 239–244

    Abstract: Introduction: Mass-gathering events require varying types and amounts of medical resources to deal with patient presentations as well as careful planning for environmental health management. The Holy Shroud Exhibition was hosted in Torino, Italy, ... ...

    Abstract Introduction: Mass-gathering events require varying types and amounts of medical resources to deal with patient presentations as well as careful planning for environmental health management. The Holy Shroud Exhibition was hosted in Torino, Italy, between April and May 2010. The venue was a unique mass-gathering event which lasted several weeks. It was held in a limited area in the center of the city and it was attended by a large and heterogeneous population. A dedicated Health Care Service was created for the event.
    Methods: This study is a retrospective analysis of clinical presentations of patients who were managed by the Medical Services during the event. The main study outcomes included Patient Presentation Rate (PPR), type of injuries and illnesses, and the Transport to Hospital Rate (TTHR).
    Results: The PPR and TTHR were both low (0.27 and 0.039 respectively). The majority of patients presented with low severity codes and no sudden cardiac death (SCD) or cardiac arrest occurred. Cardiac and trauma emergencies were most frequent categories of presentation. A number of pediatric patients (19.37%) were treated by the event Medical Service. Approximately two million persons participated in the 40-day event.
    Conclusion: The experience for this 40-day event supported having an on-site, organized, dedicated Medical Service that decreased overcrowding of the local Emergency Medical System and hospitals. It is recommended that, for such events, there be recruitment of emergency physicians with experience in mass-gathering events, recruitment of pediatricians, and training for professionals during the planning process.
    MeSH term(s) Adolescent ; Adult ; Aged ; Ambulatory Care/organization & administration ; Ambulatory Care Facilities/organization & administration ; Anniversaries and Special Events ; Child ; Child, Preschool ; Christianity ; Female ; Humans ; Italy ; Male ; Middle Aged ; Retrospective Studies ; Young Adult
    Language English
    Publishing date 2013-06
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1025975-2
    ISSN 1945-1938 ; 1049-023X
    ISSN (online) 1945-1938
    ISSN 1049-023X
    DOI 10.1017/S1049023X13000216
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  3. Article ; Online: Role of presepsin for the evaluation of sepsis in the emergency department.

    Pizzolato, Elisa / Ulla, Marco / Galluzzo, Claudia / Lucchiari, Manuela / Manetta, Tilde / Lupia, Enrico / Mengozzi, Giulio / Battista, Stefania

    Clinical chemistry and laboratory medicine

    2014  Volume 52, Issue 10, Page(s) 1395–1400

    Abstract: Sepsis, severe sepsis and septic shock are among the most common conditions handled in the emergency department (ED). According to new Sepsis Guidelines, early diagnosis and treatment are the keys to improve survival. Plasma C-reactive protein (CRP) and ... ...

    Abstract Sepsis, severe sepsis and septic shock are among the most common conditions handled in the emergency department (ED). According to new Sepsis Guidelines, early diagnosis and treatment are the keys to improve survival. Plasma C-reactive protein (CRP) and procalcitonin (PCT) levels, when associated with documented or suspected infection, are now part of the definitions of sepsis. Blood culture is the gold standard method for detecting microorganisms but it requires too much time for results to be known. Sensitive biomarkers are required for early diagnosis and as indexes of prognosis sepsis. CRP is one of the acute phase proteins synthesized by the liver: it has a great sensitivity but a very poor specificity for bacterial infections. Moreover, the evolution of sepsis does not correlate with CRP plasma changes. In recent years PCT has been widely used for sepsis differential diagnosis, because of its close correlation with infections, but it still retains some limitations and false positivity (such as in multiple trauma and burns). Soluble CD14 subtype (sCD14-ST), also known as presepsin, is a novel and promising biomarker that has been shown to increase significantly in patients with sepsis, in comparison to the healthy population. Studies pointed out the capability of this biomarker for diagnosing sepsis, assessing the severity of the disease and providing a prognostic evaluation of patient outcome. In this mini review we mainly focused on presepsin: we evaluate its diagnostic and prognostic roles in patients presenting to the ED with systemic inflammatory response syndrome (SIRS), suspected sepsis or septic shock.
    MeSH term(s) Emergency Service, Hospital ; Humans ; Lipopolysaccharide Receptors/blood ; Neonatology ; Peptide Fragments/blood ; Prognosis ; Sensitivity and Specificity ; Sepsis/blood ; Sepsis/diagnosis
    Chemical Substances Lipopolysaccharide Receptors ; Peptide Fragments ; presepsin protein, human
    Language English
    Publishing date 2014-10
    Publishing country Germany
    Document type Journal Article ; Review
    ZDB-ID 1418007-8
    ISSN 1437-4331 ; 1434-6621 ; 1437-8523
    ISSN (online) 1437-4331
    ISSN 1434-6621 ; 1437-8523
    DOI 10.1515/cclm-2014-0199
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  4. Article ; Online: Assessment of Diagnostic and Prognostic Role of Copeptin in the Clinical Setting of Sepsis.

    Battista, Stefania / Audisio, Umberto / Galluzzo, Claudia / Maggiorotto, Matteo / Masoero, Monica / Forno, Daniela / Pizzolato, Elisa / Ulla, Marco / Lucchiari, Manuela / Vitale, Annarita / Moiraghi, Corrado / Lupia, Enrico / Settanni, Fabio / Mengozzi, Giulio

    BioMed research international

    2016  Volume 2016, Page(s) 3624730

    Abstract: The diagnostic and prognostic usefulness of copeptin were evaluated in septic patients, as compared to procalcitonin assessment. In this single centre and observational study 105 patients were enrolled: 24 with sepsis, 25 with severe sepsis, 15 with ... ...

    Abstract The diagnostic and prognostic usefulness of copeptin were evaluated in septic patients, as compared to procalcitonin assessment. In this single centre and observational study 105 patients were enrolled: 24 with sepsis, 25 with severe sepsis, 15 with septic shock, and 41 controls, divided in two subgroups (15 patients with gastrointestinal bleeding and 26 with suspected SIRS secondary to trauma, acute coronary syndrome, and pulmonary embolism). Biomarkers were determined at the first medical evaluation and thereafter 24, 48, and 72 hours after admission. Definitive diagnosis and in-hospital survival rates at 30 days were obtained through analysis of medical records. At entry, copeptin proved to be able to distinguish cases from controls and also sepsis group from septic shock group, while procalcitonin could distinguish also severe sepsis from septic shock group. Areas under the ROC curve for copeptin and procalcitonin were 0.845 and 0.861, respectively. Noteworthy, patients with copeptin concentrations higher than the threshold value (23.2 pmol/L), calculated from the ROC curve, at admission presented higher 30-day mortality. No significant differences were found in copeptin temporal profile among different subgroups. Copeptin showed promising diagnostic and prognostic role in the management of sepsis, together with its possible role in monitoring the response to treatment.
    MeSH term(s) Adolescent ; Adult ; Aged ; Aged, 80 and over ; Biomarkers/blood ; Female ; Gastrointestinal Hemorrhage ; Glycopeptides/blood ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Prognosis ; ROC Curve ; Sepsis/blood ; Sepsis/diagnosis ; Sepsis/mortality ; Young Adult
    Chemical Substances Biomarkers ; Glycopeptides ; copeptins
    Language English
    Publishing date 2016
    Publishing country United States
    Document type Journal Article ; Observational Study
    ZDB-ID 2698540-8
    ISSN 2314-6141 ; 2314-6133
    ISSN (online) 2314-6141
    ISSN 2314-6133
    DOI 10.1155/2016/3624730
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  5. Article ; Online: Diagnostic and prognostic value of presepsin in the management of sepsis in the emergency department: a multicenter prospective study.

    Ulla, Marco / Pizzolato, Elisa / Lucchiari, Manuela / Loiacono, Maria / Soardo, Flavia / Forno, Daniela / Morello, Fulvio / Lupia, Enrico / Moiraghi, Corrado / Mengozzi, Giulio / Battista, Stefania

    Critical care (London, England)

    2013  Volume 17, Issue 4, Page(s) R168

    Abstract: Introduction: Sepsis, severe sepsis and septic shock are common conditions with high mortality. Their early diagnosis in the Emergency Department (ED) is one of the keys to improving survival. Procalcitonin (PCT) has been used as a biomarker in septic ... ...

    Abstract Introduction: Sepsis, severe sepsis and septic shock are common conditions with high mortality. Their early diagnosis in the Emergency Department (ED) is one of the keys to improving survival. Procalcitonin (PCT) has been used as a biomarker in septic patients but has limited specificity and can be elevated in other scenarios of systemic inflammatory response syndrome (SIRS). Soluble CD14 (sCD14) or presepsin is the free fragment of a glycoprotein expressed on monocytes and macrophages. Preliminary reports suggest that levels of presepsin are significantly higher in septic patients than in healthy individuals. The aim of this study is to investigate the diagnostic and prognostic value of presepsin compared to PCT in people presenting at the ED with SIRS and suspected sepsis or septic shock.
    Methods: This study was conducted in two major hospitals in Turin, Italy. One hundred six patients presenting to the EDs with suspected sepsis or septic shock were included, and another eighty-three patients affected by SIRS, but with no clinical evidence of infection, were recruited as controls. Blood samples were collected at first medical evaluation and for some patients after 24 and 72 h. The samples were analyzed using the PATHFAST Presepsin assay for sCD14, and commercial kits were used for other determinations (for example, PCT). Definitive diagnosis and survival rates were obtained afterward by analysis of digital medical records.
    Results: Elevated concentrations of presepsin at presentation were observed in septic patients compared to control patients. The same trend was observed for mean values of PCT. Higher values of presepsin were observed in septic patients at presentation (time 0). The diagnostic accuracy of PCT was generally higher, and areas under the curve (AUCs) were 0.875 for PCT and 0.701 for presepsin. Mean presepsin values were significantly higher in nonsurvivor septic patients (60-day mortality) than in survivors. No significant correlation was noted between PCT and survival.
    Conclusions: In our experience, presepsin was useful in the early diagnosis of infection in a complex population of patients with SIRS, sepsis, severe sepsis and septic shock who presented to the ED. Presepsin showed a significant prognostic value, and initial values were significantly correlated with in-hospital mortality of patients affected by sepsis, severe sepsis or septic shock.
    MeSH term(s) Adult ; Aged ; Aged, 80 and over ; Biomarkers/blood ; Disease Management ; Emergency Service, Hospital ; Female ; Humans ; Lipopolysaccharide Receptors/blood ; Male ; Middle Aged ; Peptide Fragments/blood ; Prognosis ; Prospective Studies ; Sepsis/blood ; Sepsis/diagnosis ; Sepsis/therapy ; Young Adult
    Chemical Substances Biomarkers ; Lipopolysaccharide Receptors ; Peptide Fragments ; presepsin protein, human
    Language English
    Publishing date 2013-07-30
    Publishing country England
    Document type Journal Article ; Multicenter Study
    ZDB-ID 2041406-7
    ISSN 1466-609X ; 1364-8535
    ISSN (online) 1466-609X
    ISSN 1364-8535
    DOI 10.1186/cc12847
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  6. Article ; Online: Consistent bone marrow-derived cell mobilization following repeated short courses of granulocyte-colony-stimulating factor in patients with amyotrophic lateral sclerosis: results from a multicenter prospective trial.

    Tarella, Corrado / Rutella, Sergio / Gualandi, Francesca / Melazzini, Mario / Scimè, Rosanna / Petrini, Mario / Moglia, Cristina / Ulla, Marco / Omedé, Paola / Bella, Vincenzo La / Corbo, Massimo / Silani, Vincenzo / Siciliano, Gabriele / Mora, Gabriele / Caponnetto, Claudia / Sabatelli, Mario / Chiò, Adriano

    Cytotherapy

    2010  Volume 12, Issue 1, Page(s) 50–59

    Abstract: Background and aims: The aim of this study was to evaluate and characterize the feasibility and safety of bone marrow-derived cell (BMC) mobilization following repeated courses of granulocyte-colony stimulating factor (G-CSF) in patients with ... ...

    Abstract Background and aims: The aim of this study was to evaluate and characterize the feasibility and safety of bone marrow-derived cell (BMC) mobilization following repeated courses of granulocyte-colony stimulating factor (G-CSF) in patients with amyotrophic lateral sclerosis (ALS).
    Methods: Between January 2006 and March 2007, 26 ALS patients entered a multicenter trial that included four courses of BMC mobilization at 3-month intervals. In each course, G-CSF (5 microg/kg b.i.d.) was administered for four consecutive days; 18% mannitol was also given. Mobilization was monitored by flow cytometry analysis of circulating CD34(+) cells and by in vitro colony assay for clonogenic progenitors. Co-expression by CD34(+) cells of CD133, CD90, CD184, CD117 and CD31 was also assessed.
    Results: Twenty patients completed the four-course schedule. One patient died and one refused to continue the program before starting the mobilization courses; four discontinued the study protocol because of disease progression. Overall, 89 G-CSF courses were delivered. There were two severe adverse events: one prolactinoma and one deep vein thrombosis. There were no discontinuations as a result of toxic complications. Circulating CD34(+) cells were monitored during 85 G-CSF courses and were always markedly increased; the range of median peak values was 41-57/microL, with no significant differences among the four G-CSF courses. Circulating clonogenic progenitor levels paralleled CD34(+) cell levels. Most mobilized CD34(+) cells co-expressed stem cell markers, with a significant increase in CD133 co-expression.
    Conclusions: It is feasible to deliver repeated courses of G-CSF to mobilize a substantial number of CD34(+) cells in patients with ALS; mobilized BMC include immature cells with potential clinical usefulness.
    MeSH term(s) Adult ; Amyotrophic Lateral Sclerosis/drug therapy ; Amyotrophic Lateral Sclerosis/physiopathology ; Antigens, CD34/metabolism ; Biomarkers/metabolism ; Bone Marrow Cells/drug effects ; Bone Marrow Cells/physiology ; Cell Differentiation/drug effects ; Cell Differentiation/physiology ; Cell Lineage/drug effects ; Cell Lineage/physiology ; Cell Movement/drug effects ; Cell Movement/physiology ; Colony-Forming Units Assay ; Drug Administration Schedule ; Female ; Granulocyte-Macrophage Colony-Stimulating Factor/administration & dosage ; Hematopoietic Stem Cell Mobilization ; Hematopoietic Stem Cells/drug effects ; Hematopoietic Stem Cells/physiology ; Humans ; Male ; Middle Aged ; Nerve Regeneration/drug effects ; Nerve Regeneration/physiology ; Neuroglia/cytology ; Neuroglia/physiology ; Neurons/cytology ; Neurons/physiology ; Prospective Studies ; Stem Cells/drug effects ; Stem Cells/physiology ; Treatment Outcome
    Chemical Substances Antigens, CD34 ; Biomarkers ; Granulocyte-Macrophage Colony-Stimulating Factor (83869-56-1)
    Language English
    Publishing date 2010
    Publishing country England
    Document type Clinical Trial ; Journal Article ; Multicenter Study ; Research Support, Non-U.S. Gov't
    ZDB-ID 2039821-9
    ISSN 1477-2566 ; 1465-3249
    ISSN (online) 1477-2566
    ISSN 1465-3249
    DOI 10.3109/14653240903300682
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  7. Article ; Online: Lung Ultrasound-Implemented Diagnosis of Acute Decompensated Heart Failure in the ED: A SIMEU Multicenter Study.

    Pivetta, Emanuele / Goffi, Alberto / Lupia, Enrico / Tizzani, Maria / Porrino, Giulio / Ferreri, Enrico / Volpicelli, Giovanni / Balzaretti, Paolo / Banderali, Alessandra / Iacobucci, Antonello / Locatelli, Stefania / Casoli, Giovanna / Stone, Michael B / Maule, Milena M / Baldi, Ileana / Merletti, Franco / Cibinel, Gian Alfonso / Baron, Paolo / Battista, Stefania /
    Buonafede, Giuseppina / Busso, Valeria / Conterno, Andrea / Del Rizzo, Paola / Ferrera, Patrizia / Pecetto, Paolo Fascio / Moiraghi, Corrado / Morello, Fulvio / Steri, Fabio / Ciccone, Giovannino / Calasso, Cosimo / Caserta, Mimma A / Civita, Marina / Condo', Carmen / D'Alessandro, Vittorio / Del Colle, Sara / Ferrero, Stefania / Griot, Giulietta / Laurita, Emanuela / Lazzero, Alberto / Lo Curto, Francesca / Michelazzo, Marianna / Nicosia, Vincenza / Palmari, Nicola / Ricchiardi, Alberto / Rolfo, Andrea / Rostagno, Roberto / Bar, Fabrizio / Boero, Enrico / Frascisco, Mauro / Micossi, Ilaria / Mussa, Alessandro / Stefanone, Valerio / Agricola, Renzo / Cordero, Gabriele / Corradi, Federica / Runzo, Cristina / Soragna, Aldo / Sciullo, Daniela / Vercillo, Domenico / Allione, Attilio / Artana, Nicoletta / Corsini, Fabrizio / Dutto, Luca / Lauria, Giuseppe / Morgillo, Teresa / Tartaglino, Bruno / Bergandi, Daniela / Cassetta, Ilaria / Masera, Clotilde / Garrone, Mario / Ghiselli, Gianluca / Ausiello, Livia / Barutta, Letizia / Bernardi, Emanuele / Bono, Alessia / Forno, Daniela / Lamorte, Alessandro / Lison, Davide / Lorenzati, Bartolomeo / Maggio, Elena / Masi, Ilaria / Maggiorotto, Matteo / Novelli, Giulia / Panero, Francesco / Perotto, Massimo / Ravazzoli, Marco / Saglio, Elisa / Soardo, Flavia / Tizzani, Alessandra / Tizzani, Pietro / Tullio, Mattia / Ulla, Marco / Romagnoli, Elisa

    Chest

    2015  Volume 148, Issue 1, Page(s) 202–210

    Abstract: Background: Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the ... ...

    Abstract Background: Lung ultrasonography (LUS) has emerged as a noninvasive tool for the differential diagnosis of pulmonary diseases. However, its use for the diagnosis of acute decompensated heart failure (ADHF) still raises some concerns. We tested the hypothesis that an integrated approach implementing LUS with clinical assessment would have higher diagnostic accuracy than a standard workup in differentiating ADHF from noncardiogenic dyspnea in the ED.
    Methods: We conducted a multicenter, prospective cohort study in seven Italian EDs. For patients presenting with acute dyspnea, the emergency physician was asked to categorize the diagnosis as ADHF or noncardiogenic dyspnea after (1) the initial clinical assessment and (2) after performing LUS ("LUS-implemented" diagnosis). All patients also underwent chest radiography. After discharge, the cause of each patient's dyspnea was determined by independent review of the entire medical record. The diagnostic accuracy of the different approaches was then compared.
    Results: The study enrolled 1,005 patients. The LUS-implemented approach had a significantly higher accuracy (sensitivity, 97% [95% CI, 95%-98.3%]; specificity, 97.4% [95% CI, 95.7%-98.6%]) in differentiating ADHF from noncardiac causes of acute dyspnea than the initial clinical workup (sensitivity, 85.3% [95% CI, 81.8%-88.4%]; specificity, 90% [95% CI, 87.2%-92.4%]), chest radiography alone (sensitivity, 69.5% [95% CI, 65.1%-73.7%]; specificity, 82.1% [95% CI, 78.6%-85.2%]), and natriuretic peptides (sensitivity, 85% [95% CI, 80.3%-89%]; specificity, 61.7% [95% CI, 54.6%-68.3%]; n = 486). Net reclassification index of the LUS-implemented approach compared with standard workup was 19.1%.
    Conclusions: The implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.
    Trial registry: Clinicaltrials.gov; No.: NCT01287429; URL: www.clinicaltrials.gov.
    MeSH term(s) Aged ; Aged, 80 and over ; Clinical Protocols ; Cohort Studies ; Dyspnea/diagnostic imaging ; Dyspnea/etiology ; Emergency Service, Hospital ; Female ; Heart Failure/complications ; Heart Failure/diagnosis ; Humans ; Italy ; Lung Diseases/complications ; Lung Diseases/diagnostic imaging ; Male ; Middle Aged ; Predictive Value of Tests ; Ultrasonography
    Language English
    Publishing date 2015-07
    Publishing country United States
    Document type Journal Article ; Multicenter Study ; Observational Study
    ZDB-ID 1032552-9
    ISSN 1931-3543 ; 0012-3692
    ISSN (online) 1931-3543
    ISSN 0012-3692
    DOI 10.1378/chest.14-2608
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