Liver damage worsens the prognosis of coronavirus 19 disease (COVID-19). However, the best strategy to stratify mortality risk according to liver damage has not been established. The aim of this study is to test the predictive value of the validated Fibrosis-4 (FIB-4) Index and compared it to liver transaminases and to the AST-to-Platelet ratio index (APRI). Multicenter cohort study including 992 consecutive COVID-19 patients admitted to the Emergency Department. FIB-4 > 3.25 and APRI > 0.7 were used to define liver damage. Multivariable Cox regression and ROC curve analysis for mortality were performed. Secondary endpoints were (1) need for high-flow oxygen and (2) mechanical ventilation. 240 (24.2%) patients had a FIB-4 > 3.25. FIB-4 > 3.25 associated with an increased mortality (n = 119, log-rank test p < 0.001 and adjusted hazard ratio (HR) 1.72 (95% confidence interval [95%CI] 1.14–2.59, p = 0.010). ROC analysis for mortality showed that FIB-4 (AUC 0.734, 95% CI 0.705–0.761) had a higher predictive value than AST (p = 0.0018) and ALT (p < 0.0001). FIB-4 > 3.25 was also superior to APRI > 0.7 (AUC 0.58, 95% CI 0.553–0.615, p = 0.0008). Using an optimized cut-off > 2.76 (AUC 0.689, 95% CI 0.659–0.718, p < 0.0001), FIB-4 was superior to FIB-4 > 3.25 (p = 0.0302), APRI > 0.7 (p < 0.0001), AST > 51 (p = 0.0119) and ALT > 42 (p < 0.0001). FIB-4 was also associated with high-flow oxygen use (n = 255, HR 1.69, 95% CI 1.25–2.28, p = 0.001) and mechanical ventilation (n = 39, HR 2.07, 95% CI 1.03–4.19, p = 0.043). FIB-4 score predicts mortality better than liver transaminases and APRI score. FIB-4 score may be an easy tool to identify COVID-19 patients at worse prognosis in the emergency department.

Dear Editor, As part of the board of CoSMEU – the Italian association of Emergency Medicine (EM) residents – we are looking with great concern at the current situation of the Emergency Departments (ED) and EM in our country,1 and we would like to share our point of view and experience. [...]

Background Simulation is an educational tool widely used worldwide and simulation-based education is an important training strategy in Emergency Medicine (EM) training programs. Objective In the first part of the project SIMinMEU of CosMEU and SIMMED, an electronic survey open to the Italian EM residents’ representatives was created with the aim to assess their awareness about simulation in their programs. Results Out of 33 EM residencies, 30 representatives answered the survey. Only 15 schools offer simulation, with a median of 16,27 (range 0–46) annual simulation training, with 53% of representatives indicating that the time dedicated to it met their needs. 15 do skill lab activities (50 %), 14 do High fidelity simulation (46.66%), one does serious games (3,33%) and one does virtual reality (3,33%). In situ simulations aren’t provided. Crisis resource management (CRM) and soft skills are topics covered in seven (23,3%). In 5 residencies (16,6%) there are certified facilitators. The annual exams aren’t carried out using simulation. Only in five (16,6%) residencies research in simulation is carried out. Residents’ satisfaction for simulation activities is lower than good in 73% of cases. Most residents stated lack of simulation standards and poor quality of simulation activities. The main requests are that simulation must be part of the teaching program, increased in number and better structured. Conclusions Considering the increasing interest of residents in simulation emerged by this survey, CoSMEU and SIMMED will commit to improving the quality, facilitating the spreading and guaranteeing the standardization of simulation in every EM Italian school.

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