This cohort study examines the rate of SARS-CoV-2 reinfection among people in Lombardy, Italy, who previously recovered from COVID-19.

We have confirmed that the MEWS, even when calculated once on admission, is a simple but highly useful tool to predict a worse in-hospital outcome.

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BACKGROUND Patients with suspected deep vein thrombosis (DVT) of the lower limb represent a diagnostic dilemma for general practitioners. Compression ultrasonography (US) is universally recognized as the best test of choice. We assessed the diagnostic accuracy of compression US performed by general practitioners given short training in the management of symptomatic proximal DVT.METHODS From May 2014 to May 2016, we evaluated in a multicenter, prospective cohort study all consecutive outpatients with suspected DVT; bilateral proximal lower limb compression US was performed by general practitioners and by physicians expert in vascular US, each group blinded to the other's findings. In all examinations with a negative or nondiagnostic result, compression US was repeated by the same operator after 5 to 7 days. Inter-observer agreement and accuracy were calculated. RESULTSWe enrolled a total of 1,107 patients. The expert physicians diagnosed DVT in 200 patients, corresponding to an overall prevalence of 18.1% (95% CI, 15.8%-20.3%). The agreement between the trained general practitioners and the experts was excellent (Cohen κ = 0.86; 95% CI, 0.84-0.88). Compression US performed by general practitioners had a sensitivity of 90.0% (95% CI, 88.2%-91.8%) and a specificity of 97.1% (95% CI, 96.2%-98.1%) with a diagnostic accuracy for DVT of 95.8% (95% CI, 94.7%-97.0%).CONCLUSIONS Our results suggest that, even in hands of physicians not expert in vascular US, compression US can be a reliable tool in the diagnosis of DVT. We found that the sensitivity achieved by general practitioners appeared suboptimal, however, so future studies should evaluate the implementation of proper training strategies to maximize skill. 2017;15:535-539. https://doi.org/10.1370/afm.2109. Ann Fam Med INTRODUCTIONP atients with clinical signs and symptoms of deep vein thrombosis (DVT) of the lower limbs represent a diagnostic dilemma for general practitioners.1 Reliance on clinical findings alone can lead to misdiagnosis, unnecessary exposure to anticoagulant therapy, and high associated costs. Rapid and accurate diagnosis of DVT is therefore needed to start prompt anticoagulation therapy and reduce the risk of potentially fatal pulmonary embolism.2,3 For these reasons, in general practice, the optimal diagnostic strategy for DVT has long been debated: the Wells score is not accurate enough for use in primary care, 4 but strategies that require d-dimer testing 5 are not always accessible. Compression ultrasonography (US) is considered the more widespread method of choice for confirming or ruling out the diagnosis of DVT, and its use has been validated in several prospective studies 3,[6][7][8] 536by hospitalists, radiologists, emergency physicians, or trained nurses.9-11 A more rapid diagnosis, directly obtained by general practitioners in primary care, could likely improve appropriate management of DVT, avoiding in-hospital evaluations and any pretest scores or laboratory evaluations. We undertook a prospective, multicenter cohort study to...

Although myocarditis can be a severe cardiac complication of COVID-19 patients, few data are available in the literature about the incidence and clinical significance in patients affected by SARS-CoV-2. This study aims to describe the prevalence and the clinical features of suspected myocarditis in 3 cohorts of patients hospitalized for COVID-19. We retrospectively evaluated all the consecutive patients admitted for COVID-19 without exclusion criteria. Suspect myocarditis was defined according to current guidelines. Age, sex, in-hospital death, length of stay, comorbidities, serum cardiac markers, interleukin-6, electrocardiogram, echocardiogram, and therapy were recorded. Between March 4 to May 20, 2020, 1169 patients with COVID-19 were admitted in 3 Italian Medicine wards. 12 patients (1%) had suspected acute myocarditis; 5 (41.7%) were men, mean age was 76 (SD 11.34; median 78.5 years); length of stay was 38 days on average (SD 8, median value 37.5); 3 (25%) patients died. 8 (66.7%) had a history of cardiac disease; 7 (58.33%) patients had other comorbidities like diabetes, chronic obstructive pulmonary disease, or renal insufficiency. Myocarditis patients had no difference in sex prevalence, rate of death, comorbidities, elevations in serum cardiac markers as compared with patients without myocardial involvement. Otherwise, there was a significantly higher need for oxygen-support and a higher prevalence of cardiac disease in the myocarditis group. Patients with suspected myocarditis were older, had a higher frequency of previous cardiac disease, and significantly more prolonged hospitalization and a lower value of interleukin-6 than other COVID-19 patients. Further studies, specifically designed on this issue, are warranted.

Doppler sonography has gained considerable recognition as a noninvasive method of detecting carotid artery disease, and power Doppler sonography achieves good color-filling of all the examined vessels. Dolichoarterial disease of the internal carotid artery occurs in 10-25% of the population; these alterations are characterized by atypical elongation of the vessel, which predisposes it to tortuosity, coiling, and kinking, which is the most frequent morphologic anomaly and is characterized by sharp angulation (single and double Z-shaped). A patient with double Z-shaped angulation (kinking) of the left internal carotid artery was incidentally diagnosed in an asymptomatic state because of the broad use of these noninvasive investigations.

Coronavirus disease 2019 caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is an ongoing global health emergency. 1 The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic infection to critical illness and death. In COVID-19 disease coagulopathy is frequently reported, being more prevalent in critically ills patients; indeed, SARS-CoV-2 may predispose patients to thrombotic disease, both in the venous and arterial circulation, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis. 2 Increased prevalence of antiphospholipid antibodies was also reported. 3 Elevated D-dimer values correlate with a poor prognosis, 4 with the development of acute respiratory distress syndrome (ARDS), and with the risk for admission to intensive care unit. 5 The increase in the value of D-dimer is the most sensitive change in coagulation parameters in COVID-19 and indicate a greater risk for the development of thrombosis; nevertheless, D-dimer is a marker of fibrinolysis, and only a proxy for ongoing thrombosis, and it is already known that its specificity for venous thromboembolism is low. Moreover, since the Ddimer is known to be a mixture of fragments of different weight, and tests may report results in terms of weight for units of volume or as fibrinogen equivalent units (FEU). So, it may be not correct to compare results between different tests. 6 In arterial thromboembolism D-dimer has a marginal role, if any. Therefore, the use of heparin in the treatment of COVID-19 disease, should play a fundamental role, and prophylactic doses of low molecular weight heparin (LMWH) or unfractionated heparin (UFH) were associated with a reduced 28-day mortality in more severe COVID-19 patients. 7 Consequently, the International Society of Thrombosis and Haemostasis (ISTH) recommended systematic pharmacological thromboprophylaxis in all patients who require hospital admission for COVID-19 disease. 8 Also in a position paper from Italian Society on Thrombosis and Haemostasis (SISET), the use of LMWH, UFH, or fondaparinux at doses indicated for prophylaxis of venous thromboembolism (VTE) was strongly