The latest medical research on Radiology

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Imaging of ureter: a primer for the emergency radiologist.

Emergency Radiology

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most...

Fetal hydrops and the Incremental yield of Next generation sequencing over standard prenatal Diagnostic testing (FIND) study: prospective cohort study and meta-analysis.

Ultrasound in Obstetrics and Gynecology

Determine the incremental yield of next generation sequencing (predominantly exome sequencing (ES)) over quantitative fluorescence-polymerase chain reaction (QF-PCR) and chromosome microarray analysis (CMA)/karyotyping in; (i) all cases of prenatally diagnosed non-immune hydrops fetalis (NIHF); (ii) isolated NIHF; (iii) NIHF associated with additional structural anomalies and; (iv) NIHF according to severity (i.e., two cavities versus three or more cavities affected).

A prospective cohort study (from an extended group of the Prenatal Assessment of Genomes and Exomes (PAGE) study) of n=28 cases of prenatally diagnosed NIHF undergoing trio ES following a negative QFPCR and CMA/karyotype was combined with a systematic review of the literature. Electronic searches of relevant citations from MEDLINE, EMBASE and CINAHL and (January 2000 - October 2020) databases was performed. Studies included were those with: (i) ≥ n=2 cases of NIHF undergoing sequencing; (ii) testing initiated based on prenatal ultrasound-based phenotype and; (iii) a negative CMA/karyotype. PROSPERO Registration No. CRD42020221427.

The PAGE cohort study noted the additional diagnostic yield of ES was 25.0% (n=7/28) for all NIHF, 21.4% (n=3/14) for isolated NIHF and 28.6% (n=4/14) for non-isolated NIHF. From the meta-analysis, the pooled incremental yields from n=21 studies (n=306 cases) were 29% (95% CI 24-34%, I2 =0%, p<0.00001) in all NIHF, 24% (95% CI 16-33%, I2 =0%, p<0.00001) in isolated NIHF and; 38% (95% CI 28%-48%, I2 =6%, p<0.00001) in NIHF associated with additional anomalies. In the latter, congenital limb contractures were the most prevalent additional structural anomaly at 17.3% (n=19/110). Incremental yield did not differ significantly based upon hydrops severity. The commonest genetic disorders identified were RASopathies in 30.3% (n=27/89), most commonly due to PTPN11 variants in 44.4% (n=12) and the predominant inheritance pattern was autosomal dominant in monoallelic disease genes 57.3% (n=51/89), of which most were de novo 86.3% (n=44).

Use of prenatal next generation sequencing in both isolated and non-isolated NIHF should be considered in developing clinical pathways. Given the wide range of potential syndromic diagnoses and heterogeneity in prenatal phenotypes of NIHF, exome or whole genome sequencing may prove to be a more appropriate testing approach than a targeted gene panel testing strategy. This article is protected by copyright. All rights reserved.

Fusion imaging in the preoperative assessment of the extension of disease in patients with advanced ovarian cancer: feasibility and agreement with laparoscopic findings.

Ultrasound in Obstetrics and Gynecology

Fusion imaging is an emerging technique that can fuse real time ultrasound examination with other imaging modalities such as computed tomography (CT), magnetic resonance, and positron emission tomography. The primary aim of the study was to evaluate the Fusion imaging feasibility in patients with advanced ovarian cancer. The secondary aims were: 1) to compare agreement laparoscopic findings with Fusion, CT scan alone and ultrasound alone in assessing the extension of intra-abdominal disease; 2) to evaluate the time required by the Fusion technique.

patients with clinical and/or radiographic suspicion of advanced ovarian or peritoneal cancer and candidate to surgery were prospectively enrolled between December 2019 and September 2020. All patients underwent CT scan, ultrasound and Fusion examination in order to evaluate the presence/absence of the following abdominal cancer features according to the laparoscopy-based scoring model (PIV: Predictive Index Value): supracolic omentum disease, visceral carcinomatosis on the liver, lesser omental carcinomatosis and/or visceral carcinomatosis on the lesser curvature of stomach and/or on the spleen, parietal peritoneal involvement of paracolic gutter/-s and/or anterior abdominal wall, parietal peritoneal involvement of diaphragm and visceral carcinomatosis on small and large bowel (except rectosigmoid). Feasibility of the Fusion examination was evaluated. Agreement between each imaging method (ultrasound, CT scan and Fusion) and laparoscopy (considered as reference standard) was calculated using Cohen's kappa coefficient.

52 patients were enrolled in the study. Fusion examination was feasible in 51/52 (98%) patients (in one patient the CD was not working). Two other patients were excluded because laparoscopy was not performed. 49 women were considered for final analysis. Kappa values between CT, ultrasound, Fusion and laparoscopy in assessing the PIV parameters were respectively: 0.781, 0.845 and 0.896 for great omentum; 0.329, 0.608 and 0.847 for liver surface, 0.472, 0.549 and 0.756 for lesser omentum and/or stomach and/or spleen; 0.385, 0.588 and 0.795 for parietal peritoneum; 0.385, 0.497 and 0.657 for diaphragm; 0.336, 0.410 and 0.469 for bowel. The median time needed to perform Fusion examination was 20 (range 10-40) minutes.

Fusion of CT and ultrasound images is feasible in patients with advanced ovarian cancer and improves the agreement with the surgical findings when compared with the single imaging methods (ultrasound or CT scan). This article is protected by copyright. All rights reserved.

The position of the choroid plexus of the fourth ventricle in the first- and second-trimester fetuses: an early different approach to diagnostic imaging of cystic posterior fossa anomalies.

Ultrasound in Obstetrics and Gynecology

The aim of this study was to describe the sonographic appearance and position of the choroid plexus of the fourth ventricle (4thVCP) between 12 and 21 weeks' gestation in normal fetuses and in fetuses with posterior fossa anomalies.

Two-dimensional ultrasound (US) images of the midsagittal and coronal views of the brain through the posterior fontanelle and three-dimensional volumes datasets were obtained between 12 and 21 weeks prospectively from 90 normal singletons and retrospectively from 41 fetuses identified as having an abnormal posterior brain on first-trimester ultrasound examination. In all cases the diagnosis was confirmed at MRI, prenatally and/or postnatally, and/or at postmortem examination.

During the study period, 41 fetuses, with apparently isolated cystic posterior fossa anomaly based on first trimester ultrasound assessment of intracranial spaces, were reviewed in the second trimester and were found to have Dandy Walker Malformation (DWM) in 8 cases, Blake's Pouch Cyst (BPC) in 29 and they were normal in 4 patients. The position of 4thVCP was different in DWM, BPC and normal cases either at first and at second trimester examination. In particular, in normal fetuses no cyst was present, and on median and coronal planes of posterior fossa the choroid plexus appeared as an echogenic and oval shaped structure located inside the 4th ventricle apparently attached to the cerebellar vermis. In fetuses with DWM, on median view of posterior fossa, it was not possible to visualize the CP. It was infero-laterally dislocated due to the presence of a cyst which displaced the 4thVCP and could be visualized only on a coronal plane of the posterior brain. In all DWM cases the CP was positioned outside the cyst. In BPC, the 4VthCP was always located inside the cyst, on its superior part, near the vermis and was visualized on median and coronal planes.

Our study demonstrated that a longitudinal ultrasound assessment of 4thVCP and its temporal changes from 12 to 21 weeks is feasible. The ability to define the position of the 4thVCP as inside or outside the cyst is a novel finding which can be assessed in the first trimester of pregnancy and it is useful to differentiate DWM from BPC, consistently with the pathophysiology of the two conditions. This article is protected by copyright. All rights reserved.

The "breech progression angle": a new feasible and reliable transperineal ultrasound parameter for the fetal breech descent in the birth canal.

Ultrasound in Obstetrics and Gynecology

The aim of the present study was to assess the feasibility and reliability of transperineal ultrasound in the assessment of breech descent in the birth canal, by measuring the "breech progression angle".

We recruited pregnant women with singleton pregnancies and fetuses in breech presentation between 34 and 41 weeks' gestation. We acquired transperineal ultrasound images in the midsagittal view for each woman twice by an operator and once by another. Each operator measured the breech progression angle after anonymization of the transperineal ultrasound images. Breech progression angle was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded from any other measurement performed for the same woman. The intra- and interobserver reproducibility were evaluated with intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using the Bland-Altman plot. Student's t-test and Levene's W0 test were used to investigate whether a number of clinical factors had an effect on systematic differences (t-test) and homogeneity (W0 test) between breech progression angle measurements.

Overall, 44 women were included in the analysis. Breech progression angle was successfully measured by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility, with an ICC of 0.88 (95% CI, 0.80 to 0.93) and 0.83 (95% CI, 0.71 to 0.90), respectively. Mean differences for intraobserver repeatability was 0.4 (95%CI, -1.4 to 2.2) and for interobserver repeatability was -0.4 (95%CI, -2.6 to 1.8). The upper limits of agreement were 12.0 (95% CI, 8.9 to 15.1) and 13.6 (95% CI, 9.9 to 17.3) for intraobserver and interobserver repeatability, respectively. The lower limits of agreement were -11.2 (95% CI, -14.3 to -8.1) and -14.4 (95% CI, -18.2 to -10.7) for intraobserver and interobserver repeatability, respectively. No systematic difference was found both in the intra- and interobserver agreement analyses. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- and interobserver reliability.

Breech progression angle represents a new feasible and highly reproducible tool for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and the success of breech vaginal delivery are needed. This article is protected by copyright. All rights reserved.

Cell-free DNA testing of maternal blood in screening for trisomies in twin pregnancy: cohort study at 10-14 weeks and updated meta-analysis.

Ultrasound in Obstetrics and Gynecology

To expand the limited knowledge on cell-free (cf)DNA analysis of maternal blood for trisomies 21, 18 and 13 in twin pregnancies by updating the data from the Fetal Medicine Foundation (FMF) on prospective first trimester screening and those arising from systematic review of the literature.

The FMF data were derived from prospective screening for trisomies 21, 18 and 13 in twin pregnancies at 10+0 -14+1 weeks' gestation using the Harmony® prenatal test of Roche/Ariosa Diagnostics, Inc. Search of Medline, Embase, CENTRAL (The Cochrane Library), and ICTRP (World Health Organization) was carried out to identify all peer-reviewed publications on clinical validation or implementation of maternal cfDNA testing for trisomies 21, 18 and 13 in twin pregnancies, irrespective of gestational age at testing, in which data on pregnancy outcome were provided for more than 85% of the study population. Meta-analysis was then performed using the FMF data and data from the studies identified by the literature search. This review was registered in PROSPERO international database for systematic reviews RESULTS: In the FMF study, cfDNA testing was carried out in 1442 twin pregnancies and a result was obtained, after first or second sampling, in 1367 (94.8%) cases. In 93.1% (1272/1367) cases there was prenatal or postnatal karyotyping or the birth of phenotypically normal babies; 95 cases were excluded from further analysis either because the pregnancies ended in termination, miscarriage or stillbirth with no known karyotype (n=56) or there was loss to follow up (n=39). In the 1272 pregnancies included in the study there were 20 cases with trisomy 21, 10 with trisomy 18, 2 with trisomy 13 and 1240 without trisomy 21, 18 or 13. The cfDNA test classified correctly 19 (95.0%) of the 20 cases of trisomy 21, 9 (90.0%) of 10 of trisomy 18, 1 (50.0%) of 2 of trisomy 13 and 1235 (99.6%) of 1240 cases without any of the three trisomies. The literature search identified 12 relevant studies, excluding our papers because their data are included in the current study. In the combined total of our study and the 12 studies identified by the literature search there were 137 trisomy 21 and 7507 non-trisomy 21 twin pregnancies; the pooled weighted detection rate (DR) and false positive rate (FPR) were 99.0% (95% CI 92.0, 99.9%) and 0.02% (95% CI 0.001, 0.43%), respectively. In the combined total of 50 cases of trisomy 18 and 6840 non-trisomy 18 pregnancies the pooled weighted DR and FPR were 92.8% (95% CI 77.6, 98.0%) and 0.01% (95% CI 0.00, 0.44%), respectively. In the combined total of 11 cases of trisomy 13 and 6290 non-trisomy 13 pregnancies the pooled weighted DR and FPR were 94.7% (95% CI 9.14, 99.97%) and 0.10% (95% CI 0.03., 0.39%), respectively.

In twin pregnancies the reported DR of trisomy 21 by cfDNA testing is high, but lower than in singleton pregnancies, whereas the FPR appears to be equally low. The number of cases of trisomy 18 and more so trisomy 13 is too small for accurate assessment of the predictive performance of the cfDNA test. This article is protected by copyright. All rights reserved.

The influence of maternal body mass index on interobserver variability of fetal ultrasound biometry and amniotic fluid assessment in late pregnancy.

Ultrasound in Obstetrics and Gynecology

Determine interobserver reproducibility of fetal ultrasound biometry and amniotic fluid assessment in the third trimester according to BMI categories.

Prospective cohort of women with singleton gestations beyond 34 weeks, recruited into 4 groups according to BMI categories: normal, overweight, obese and morbid obese. Multiple pregnancies, diabetes, growth and fetal abnormalities were excluded. Biometric and fluid measurements were obtained by two experienced physicians/sonographers, blinded for gestational age and each other's measurements. Differences between observers were expressed as gestational age-specific Z-scores. Interobserver correlation coefficient (ICC) and Cronbach's reliability coefficient (CRC) were calculated. Bland-Altman plots were constructed to assess the level of reproducibility.

110 women were prospectively enrolled (1,320 measurements obtained by 17 sonographers / physicians): 20 had normal BMI (18.2%), 30 were overweight (27.3%), 30 were obese (27.3%) and 30 were morbidly obese (27.3%). Except for MVP (CRC 0.66), all biometric parameters and AFI had high level of reproducibility (CRC 0.84 - 0.93). Among BMI groups: BPD had the highest level of reproducibility (CRC > 0.90); AC and FL reproducibility increased with increasing BMI while MVP decreased. Interobserver differences for biometry fell within the 95% limits of agreement.

Obesity does not seem to negatively impact the reproducibility of fetal biometric parameters when undertaken by experienced physicians/sonographers. This article is protected by copyright. All rights reserved.

An outcome-based comparison of two international guidelines for defining fetal growth restriction.

Ultrasound in Obstetrics and Gynecology

Predicting fetal growth restriction (FGR) is a challenge and recent international guidelines by the Society of Maternal Fetal Medicine (SMFM) and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) differ in their definitions of FGR. Our objective was to compare the prediction of small for gestational age (SGA) and a composite neonatal outcome using the SMFM and ISUOG definitions.

This was a secondary analysis using data from a prospective study of women referred for growth ultrasound examinations. SMFM and ISUOG practice guidelines were used to define the population of patients with FGR. SMFM guidelines defined FGR as EFW or AC less than 10th percentile. ISUOG guidelines included EFW or AC less than 3rd percentile with various Doppler parameters including umbilical, uterine and middle cerebral arteries. The primary outcome was the prediction of neonatal SGA and a composite of neonatal morbidity and mortality by the two guidelines. The composite of neonatal morbidity was defined as Grade 3 and 4 interventricular hemorrhage, respiratory distress syndrome, neonatal death, pH<7.1, seizure, NICU admission. Test characteristics (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive (LR+) and negative (LR-) likelihood rations) and area under the ROC curve (AUC) were determined. The association between the FGR detected by each guideline and adverse neonatal outcomes were assessed using logistic regression.

Of 1054 women meeting inclusion criteria, 137 (13.0%) and 80 (7.6%) were defined as having FGR by SMFM and ISUOG definitions, respectively. For prediction of SGA, the SMFM FGR definition had a higher sensitivity (54.7%) compared to the ISUOG FGR definition (38.1%). The ISUOG FGR definition had the highest specificity (97.1%). LR+ was highest for the ISUOG FGR definition. The SMFM and ISUOG FGR definitions were similarly poor in predicting a composite of neonatal morbidity with sensitivities of 15.1% and 11.5%, respectively.

The SMFM guideline is associated with a higher detection rate for SGA but at the cost of some reduction in specificity. Both definitions of FGR performed poorly at predicting a composite of neonatal morbidity. This article is protected by copyright. All rights reserved.

Relationship between viral load, infection-to-delivery interval and mother-to-child transfer of anti-SARS-CoV-2 antibodies.

Ultrasound in Obstetrics and Gynecology

To investigate the association between SARS-CoV-2 viral load and infection-to-delivery interval with maternal and cord sera anti-SARS-CoV-2 IgG antibody levels in pregnant women with active or recovered SARS-CoV-2 infection.

In this prospective case-series including consecutive pregnant women with laboratory-confirmed SARS-CoV-2 infection between 27 March 2020 and 24 January 2021, we have collected information regarding deep throat saliva or nasopharyngeal swab (NPS) RT-PCR results, serial cycle threshold (Ct) values at and after diagnosis, demographic, clinical and outcome data and neonatal NPS RT-PCR results. Serum antibodies against SARS-CoV-2 were analyzed. Correlation of maternal Ct values, infection-to-delivery interval, infection duration and viral load area under the curve (AUC) with gestation age (GA) at diagnosis, maternal and cord sera IgG concentrations and transfer ratio were evaluated.

Twenty consented pregnant women had delivered their babies by 31 January 2021, including 14 women having recovered from COVID-19 and six with active infection. The median GA at clinical manifestation was 32.7 weeks (range 11.9-39.4). The median infection-to-delivery interval and infection duration were 41.5 days (range 2-187) and 10.0 days (range=1-48), respectively. The median GA at delivery was 39.1 weeks (range=32.4-40.7) and the median seroconversion interval was 14 days (range=1-19). Twelve of 13 neonates born to mothers with recovered infection tested positive for IgG. All neonatal NPS samples were reported to be negative for SARS-CoV-2 and all cord sera tested negative for IgM. There was a negative correlation between IgG concentrations in cord and maternal sera with infection-to-delivery interval and a positive correlation between IgG concentrations in maternal sera with viral load AUC. There was also a significant correlation between transfer ratio with viral load AUC.

In recovered pregnant women with COVID-19, anti-SARS-CoV-2 IgG concentrations at delivery increased with viral load during infection and decreased with infection-to-delivery interval. The median transplacental transfer ratio of IgG was 1.3 and this transfer was reduced by high viral load during infection. This article is protected by copyright. All rights reserved.

Psychological impact of early miscarriage and client satisfaction with treatment: a comparison between expectant management and misoprostol treatment in a randomized controlled trial.

Ultrasound in Obstetrics and Gynecology

To compare short- and long-term emotional distress (grief, anxiety, depressive symptoms) after early miscarriage in women randomized to expectant management or misoprostol treatment, and to compare satisfaction with treatment.

This is a randomized controlled trial ( ID: NCT01033903) comparing expectant management with misoprostol treatment of early miscarriage. If the miscarriage was not complete on day 31 after inclusion surgical evacuation was recommended. Main outcome measures were grief, anxiety, depressive symptoms and client satisfaction assessed by validated psychometric self-assessment instruments, i.e. Perinatal grief scale (PGS), Spielberger State-Trait Anxiety Inventory (STAI-S Form-Y), Montgomery-åsberg Depression Rating Scale Self-report version (MADRS-S) and Client Satisfaction Questionnaire (CSQ-8). There were four assessment points: the day of randomization, the day when the miscarriage was judged to be complete, and 3 months and 14 months after complete miscarriage. Analysis was by intention to treat.

90 women were randomized to expectant management and 94 to misoprostol treatment. The psychometric and client satisfaction scores were similar in the two treatment groups at all assessment points. At inclusion, 41% (35/86) of the women managed expectantly and 37% (34/92) of those treated with misoprostol had STAI-state scores >46 ("high levels of anxiety") and 9% (8/86) and 10% (9/91) had symptoms of moderate or severe depression (MADRS-S score >20). In both treatment groups, symptom scores for anxiety and depression were significantly higher at inclusion than after treatment and remained low until 14 months after complete miscarriage. Grief reactions were mild. The median PGS score in both treatment groups was 40.0 at 3 months and 37.0 at 14 months after complete miscarriage. Four women treated with misoprostol and two women managed expectantly had PGS scores >90 (indicating deep grief) 3 months after complete miscarriage. One woman managed expectantly had PGS score >90 after 14 months. More than 85% of the participants in both groups would recommend the treatment they received to a friend.

The psychological response to and recovery after early miscarriage did not differ between women treated with misoprostol and those managed expectantly. Satisfaction with treatment was high in both treatment groups. Our findings support patient involvement when deciding on management of early miscarriage. This article is protected by copyright. All rights reserved.

Prospective evaluation of the first-trimester screening strategy for preterm pre-eclampsia and its clinical applicability in China.

Ultrasound in Obstetrics and Gynecology

To evaluate the performance of screening strategy for preterm preeclampsia using the Fetal Medicine Foundation (FMF)'s competing risk model in mainland China and to explore its clinical applicability.

A prospective multicenter study was conducted and 10,899 singleton pregnancies were included, Mean arterial pressure (MAP), uterine artery pulsatility index (UtPI), maternal serum levels of placental growth factor (PlGF) and pregnancy associated plasma protein A (PAPPA) at 11-13 weeks' gestation were measured and converted into multiples of median according to localized parameters, individualized risk stratification was calculated using FMF's algorithm. Prior risk was calculated based on maternal characteristics and obstetric history information. The efficiency of screening strategy with various biomarker combined was evaluated, and the detection performance for other placenta-associated adverse pregnancy outcomes at fixed false positive rate for preterm preeclampsia was also analyzed.

A total of 312 pregnancies developed preeclampsia, among which 117 cases were diagnosed as preterm, 386 pregnancies were complicated by severe composite placenta-associated pregnancy outcomes, including preterm preeclampsia, 146 cases severe small for gestational age (SGA<3rd percentile), 61 cases placenta abruption, and 109 cases preterm birth delivered before 34 gestational weeks. The model containing biomarker MAP, UtPI and PAPPA achieved detection rates of 65.0 %, 72.6%, and 76.1% for preterm preeclampsia, and detection rates of 35.8%, 40.4%, 45.0% for severe composite placenta-associated outcomes, at 10%, 15%, and 20% fixed false-positive rates for preterm pre-eclampsia, respectively. Replacing PAPPA with PlGF or adding PlGF cannot improve the performance. For women screened positive for preterm preeclampsia at fixed 5% false positive rate, an estimated of 30% ended up with at least one placenta-associated pregnancy outcomes, including preeclampsia, placenta abruption, SGA(<10th percentile) and preterm birth.

The results of this population study showed that the FMF's competing-risk model for preterm preeclampsia was effective in mainland China. Women who screened as positive for preterm pre-eclampsia had an increased risk for other placenta-associated pregnancy complications. This article is protected by copyright. All rights reserved.

Impact of the COVID-19 pandemic on the activity of the Radiological Emergency Department: the experience of the Maggiore della Carità Hospital in Novara.

Emergency Radiology

During the first peak of the COVID-19 pandemic, the activity of Emergency Departments worldwide changed dramatically, focusing on diagnosis and care of the Sars-Cov-2 associated disease. These major changes also involved the activity of the Emergency Radiology Department (ERD). This study aimed to analyse the impact of the COVID-19 pandemic on imaging studies, both in terms of the amount, frequency and subspecialty of different imaging modalities requested to the ERD of the Maggiore della Carità Hospital in Novara (Italy).

To this end, our observational study took into account the imaging studies requested by the emergency department during three-time spans. These were defined as phase 0 (pre-pandemic), phase 1 (pandemic peak with complete lockdown) and phase 2 (post-pandemic peak with partial lifting of restrictive measures), as derived from Italian urgent decrees by the President of the Council of Ministers (DPCM) which established the duration and entity of the lockdown measures throughout the pandemic. The dataset was processed and then compared with Pearson's chi-squared test.

During the pandemic peak, our data showed a significant drop in the total number of studies requested and a significant rise in computed tomography (CT) studies. In particular, a statistically significant increase in chest CT studies was found, probably due to the high sensitivity of this imaging method in identifying pulmonary involvement during respiratory tract infection of possible viral etiology (SARS-Cov-2). Moreover, we observed a statistically significant decrease of X-ray (XR) and ultrasound (US) studies during phase 1 compared to phase 0 and phase 2 probably due to a reduction in the numbers of ER visits for minor traumas given the mobility restrictions and people hesitancy in visiting the ER due to fear of contagion.

We can conclude that the activity of the ERD was heavily impacted by the SARS-Cov-2 pandemic. Further studies will be needed to estimate the impact of the pandemic on public health in terms of excess mortality related to delayed diagnosis and care of non-COVID diseases.