The Role of Sars-Cov-2 Vaccination-Induced Myocarditis in Unmasking Underlying Arrhythmogenic Cardiomyopathies: A Case Series Looking Beyond the Tip of the Iceberg

Background: Acute myocarditis (AM) is a heart inflammatory disease that may also rarely occur as a complication of COVID-19 vaccines. Inflammation is involved in arrhythmogenic cardiomyopathy (ACM) pathogenesis. Little is known regarding the COVID-19 vaccines influence on ACM relapses. We present two cases of vaccine related AM revealing a pre-existent (silent) ACM. Cases presentation: Table shows a summary of the patients' main clinical characteristics. Discussion(s): We presented 2 cases of arrhythmic myocarditis-like clinical presentation in patients without previous cardiovascular history, whose timing was temporally related to a dose of vaccine against COVID-19. Subsequent diagnostic workup suggested the possible presence of an underlying silent ACM. In our case series, tissue characterization provided by CMR played a fundamental role as a diagnostic tool, showing in all cases a prominent left ventricle involvement and identifying both the underlying ACM disease and the superimposed myocardial inflammation. We hypothesize that a vaccine-induced AM could have revealed the presence of a pre-existent ACM, on which an inflammatory acute phase triggered the arrhythmic manifestation. Conclusion(s): Vaccine-induced AM could reveal the presence of a pre-existent ACM. Our report suggests that a high index of suspicion and a multidisciplinary approach is required, in order to continue the diagnostic process once the acute event has been resolved, as it may have fundamental implication in the patient management. Further studies are required to verify if some of the vaccine-triggered AM represent the ACM first manifestation..

Prevalence Characteristics and Outcomes of Covid 19 Associated Acute Myocarditis

Background: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19-associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. Method(s): A total of 112 patients with suspected AM from 56963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19-associated AM. Result(s): AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19-associated pneumonia. Twenty- one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47;P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). Conclusion(s): AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.

Improving Text Clustering Using a New Technique for Selecting Trustworthy Content in Social Networks

Today’s information society has led to the emergence of a large number of applications that generate and consume digital data. Many of these applications are based on social networks, and therefore their information often comes in the form of unstructured text. This text from social media also tends to contain a high level of noise and untrustworthy content. Therefore, having systems capable of dealing with it efficiently is a very relevant issue. In order to verify the trustworthiness of the social media content, it is necessary to analyse and explore social media data by using text mining techniques. One of the most widespread techniques in the field of text mining is text clustering, that allows us to automatically group similar documents into categories. Text clustering is very sensitive to the presence of noise and so in this paper we propose a pre-processing pipeline based on word embedding that allows selecting trustworthy content and discarding noise in a way that improves clustering results. To validate the proposed pipeline, a real use case is provided on a Twitter dataset related to COVID-19. © 2022, Springer Nature Switzerland AG.

Proceedings of the VI National Meeting of the Italian Group of Paleopathology (GIPaleo)

The presence of numerous scientific contributions in the program is certainly demonstrative of the fact that research in the field of paleopathology and anthropology has not stopped since the beginning of Covid-19. Furthermore, the same emergency that we are still partially feeling, has pushed our community scientific research to question itself more intensely in connection to the epidemic relationship and measures that repeatedly led to profound transformations in the societies of the past from different points of view: demographic, economic, social and the history buried under the bioarchaeological strata is today more capable than ever to show this connection. It can do this by bringing to light the paleodemographic data that is obtained from the study of human remains. Today we will listen to many paleopathological stories and among these I am very happy to also present ours. Twenty years ago, the University of Insubria started a collaboration with the Archaeological Superintendence of Lombardy for the study of osteological remains found mostly during emergency archaeology recoveries. These experiences led us to reach those bioarchaeological sites again with the aim of extracting all those cemetery layers that remained there because they were not subjected at that time by building reclamation interventions. Returning to those sites that in the past brought to light fragmentary anthropological data means allowing oneself the possibility of obtaining new palaeodemographic and palaeopathological data which are decisive for reconstructing the demographic and epidemiological history of the populations of the past. These new interventions led us to create an operational model that immediately intended to underline the importance of an evident continuity between the archaeological recovery and the anthropological study of the finds through the setting up of physical anthropology and paleopathology laboratories directly on the sites of the finds. All this in harmony with the final design of the projects or the museumization of bioarchaeological sites in their complexity aimed at enhancing cultural tourist routes in the area. In this regard, I would like to thank the community foundation of Varese and the Cariplo foundation for supporting our current initiatives. These include the project financed by the emblematic provincial tender and which has as its final objective the enhancement of three bioarchaeological sites in Valcuvia: the medieval sites of San Biagio in Cittiglio, Sant’Agostino in Caravate, and the modern crypt of the church of the Convent of Azzio. Today, our Research Centre works in Piedmont in different sites in the province of Vercelli and Alessandria. Aware of the importance of a physical anthropological approach in the field, our young Centre goes beyond the continental borders to reach Eritrea, the ancient city of Adulis, because it is in dissecting the taphonomic events and the funeral actions that will make it possible to identify the funerary ritual adopted by the ancient populations. The operational model of paleopathological research, which gradually enriches itself thanks to the multidisciplinary nature of the interventions and thanks to the individual experiences in the field, is thus continuously transferred and adapted to other anthropological contexts that retain potential both in terms of investigative and enhancement of the bioarchaeological heritage. Through the musealization of the sites it is also possible to acquire an attractive force towards all those potentially bioarchaeological areas but which today are in conditions of neglect because they are marginal with respect to the conventionally understood cultural tourist good. And we all know how important it is to transfer the study data even outside the academic context because making this aspect of archaeology, the truly human one, usable too, cannot fail to arouse a strong awareness of our past. We also know how much more we will have to work, following in the footsteps of the professors who started this path, to ensure that the d sciplines of paleopathology and physical anthropology arrive within all those degree courses still discovered today by these teachings to heal an important lack: knowing the human past from a physical and pathological point of view allows us to understand the evolutionary path of some pathologies, especially those of infectious nature. If my title of the speech “Paleopathology and osteoarchaeology in the province of Varese” does not respond to what is being said today, it is because my feeling about paleopathology and osteoarchaeology in the province of Varese is understood as that of carrying out research, what I could feel everywhere, through the operational model, the enthusiasm for paleopathological research and of course the people I am lucky enough to work with. The Morgagni Museum of Pathological Anatomy of the University of Padua preserves a wide series of pathological specimens, mostly from the second half of the 19th century and the early 20th century. The Museum was recently renewed, as the result of an intervention of enhancement of the museum and cultural heritage of the University of Padua and its Medical School, being also testimony to the history and evolution of human pathology and past population lifestyle. In the collection of the Morgagni Museum there are several specimens affected by atherosclerotic lesions. Atherosclerosis is characterized by a chronic inflammatory disease in which different factors are involved, such as lipoproteins, immune cells and endothelial damage. The main clinical syndromes related to atherosclerosis are angina pectoris, acute myocardial infarction, transient ischemic attack, cerebral stroke, intermittent claudication, aortic aneurysm and nephro-vascular hypertension. Atherosclerosis was believed to be a modern disease, related almost exclusively to age and current lifestyle. The cases from the Morgagni Museum are therefore useful for studying the presence of the atherosclerosis in a recent past population. In the collection there were identified six atherosclerotic cases: an atherosclerotic aneurysm of the ascending aorta: the specimen highlights the left ventricular outflow tract and the aortic root. There is a severe atherosclerosis of the ascending aorta with saccular aneurysm including a large thrombus;a syphilitic aortitis complicated by atherosclerosis: the finding highlights the left ventricular outflow tract and aortic root. It is possible to note the intima of the ascending aorta with ulcer-calcific atherosclerotic plaques and “tree-bark” whitish areas;an atherosclerotic aneurysm of the abdominal aorta: abdominal aorta with saccular atherosclerotic aneurysm, proximal to the iliac bifurcation;a case of aortic atherosclerosis: aorta with severe atherosclerosis complicated by calcification and thrombosis;a case of aortic atherosclerosis: massive dissemination of atheromatous-calcific plaques;a case of aortic atherosclerosis with parietal thrombi: widespread presence of plaques along the aortic wall. Thanks to this collection, it is possible to notice the spread of pathology on an atheromatous basis in the recent past populations. Moreover, current paleopathological investigations on ancient populations mummified remains also showed traces of atherosclerotic lesions in both sexes and different ages. It is therefore possible to support a ubiquitous diffusion in space and time of this complex multifactorial pathology which has so far considered to be almost an exclusive prerogative of old age and current lifestyle. The Morgagni Museum of Pathological Anatomy of the University of Padua, founded by Lodovico Brunetti (1813-1899) in the 1860s, gathers important pathological specimens mainly from the 19th century. Among them, there is a very peculiar preparation: it consists of a dried head representing a case of argyria dating back to 1873. The specimen is preserved in a sealed jar, all the skin has a blue-gray coloration with white-blonde hair and beard. The eyes are not preserved, but since the ocular cavities remain open, it is possible to presume that origin lly there were glass eyes. Two glass sticks are inserted inside the mouth to show that also tongue and gums have the same blue-gray pigmentation as the face. The upper teeth are strongly eroded. Argyria is a rare disease caused by chronic absorption of products with a high silver content, which surpass body’s renal and hepatic excretory capacities, leading to silver granules being deposited in the skin and its appendages, mucosae and internal organs. It is characterized by blue-gray or black staining of the skin and mucous membranes. Our case was first mentioned in 1862 as a syphilitic man who was treating himself with some caustic silver nitrate, the so called “infernal stone”, since 1840s. According to him, this medicament cured the syphilis, but turned him into a “graphite man”. The patient died in 1873 of an intestinal infection, most likely related to the prolonged ingestion of the silver nitrate. This case was described as “spectacular” by Austrian dermatologist Isidor Neumann (1832-1906), who studied a sample of the tongue of the specimen sent by Brunetti. In fact, Brunetti performed the autopsy on the body of the individual and prepared also a plaster cast of the head along with the sample for Neumann. Thus, we can assume Brunetti was also the one who preserved the original head, taxidermizing it (so-called stuffed head preparation) in order to preserve the skin color, because his famous tannisation method would not maintained the original characteristics. Human taxidermy is quite rare, and it is limited to a few cases in the 19th century. Moreover, there are just a few known human stuffed heads in the world, making the Paduan specimen particularly unique both for the pathology and the technique used for the preparation.

Update 2022 dell’Expert Opinion della Società Italiana di Cardiologia su miocarditi, pericarditi e vaccini contro il COVID-19

Vaccine-associated myocarditis and pericarditis usually develop within 14 days of COVID-19 vaccination, are exceptionally rare, manifest with mild clinical pictures and are commonly characterized by a favorable evolution. Young men inoculated with two doses of an mRNA vaccine are the subgroup at higher risk. Recent epidemiological studies evaluated the incidence and risk of vaccine-associated myocarditis and pericarditis among men and women, in different ranges of age and specific types of vaccines. Long-term population analyses demonstrated that the cardiovascular risk conferred by COVID-19 extends beyond the acute phase, representing the rationale for implementing prevention strategies for SARS-CoV-2 infection, monitoring specific populations at higher risk and pursuing the completion of the vaccination campaign. This document provides an update on the most recent scientific evidence and critical interpretation of available data in constant evolution towards personalized strategies of immunization. © 2022 Il Pensiero Scientifico Editore s.r.l.. All rights reserved.

Pancarditis as the Clinical Presentation of Eosinophilic Granulomatosis with Polyangiitis: A Multimodality Approach to Diagnosis

Eosinophilic pancarditis (EP) is a rare, often unrecognized condition caused by endomyocardial infiltration of eosinophil granulocytes (referred as eosinophilic myocarditis, EM) associated with pericardial involvement. EM has a variable clinical presentation, ranging from asymptomatic cases to acute cardiogenic shock requiring mechanical circulatory support (MCS) or chronic restrictive cardiomyopathy at high risk of progression to dilated cardiomyopathy (DCM). EP is associated with high in‐hospital mortality, particularly when associated to endomyocardial thrombosis, coronary arteries vasculitis or severe left ventricular systolic dysfunction. To date, there is a lack of consensus about the optimal diagnostic algorithm and clinical management of patients with biopsy‐proven EP. The differential diagnosis includes hypersensitivity myocarditis, eosinophil granulomatosis with polyangiitis (EGPA), hypereosinophilic syndrome, parasitic infections, pregnancy‐related hypereosinophilia, malignancies, drug overdose (particularly clozapine) and Omenn syndrome (OMIM 603554). To our knowledge, we report the first case of pancarditis associated to eosinophilic granulomatosis with polyangiitis (EGPA) with negative anti‐neutrophil cytoplasmic antibodies (ANCA). Treatment with steroids and azathioprine was promptly started. Six months later, the patient developed a relapse: treatment with subcutaneous mepolizumab was added on the top of standard therapy, with prompt disease activity remission. This case highlights the role of a multimodality approach for the diagnosis of cardiac involvement associated to systemic immune disorders.

Myocarditis, pericarditis and mRNA vaccine against COVID-19. Expert opinion of the Italian Society of Cardiology

The coronavirus disease (COVID-19) pandemic has caused 2.69 million deaths and 122 million infections. Great efforts have been made worldwide to promptly develop effective vaccines and reduce morbidity and mortality rates from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Available vaccines have proven highly effective at preventing symptomatic disease in clinical trials and real-world reports and are playing an essential role in flattening the epidemiology curve and, mostly, in reducing COVID-19 hospitalizations. Some concerns have been raised after very rare cases of myocarditis and peri-carditis recently reported by the Centers for Disease Control and Prevention (CDC) as potentially associ-ated with COVID-19 mRNA vaccinations, namely the Pfizer-BioNTech mRNA vaccine (BNT162b2) and the Moderna mRNA vaccine (mRNA-1273). Therefore, the aim of this document is to explore the possible link between COVID-19 mRNA vaccination and the development of myocarditis and/or pericarditis by per-forming a critical analysis of available data and to provide indications for specific subgroups of individuals.

Position paper of the Italian Society of Cardiology SIC): Technical, instrumental and reporting requirements for resting electrocardiography, ambulatory electrocardiographic monitoring according to Holter, ambulatory blood pressure monitoring in telemedicine

The current COVID-19 pandemic has renewed interest in providing healthcare services based on the implementation of innovative technologies. Such strategy capillarizes the therapeutic opportunities for larger urban areas, mostly when people are living under extraordinarily difficult circumstances. Improving care delivery in cardiovascular diseases appears particularly feasible when telemedicine is pursued, especially with regard to baseline standard 12-lead electrocardiography, ambulatory electrocardiographic monitoring, and 24-hour ambulatory blood pressure monitoring. Nowadays, these first-line cardiovascular examinations are also available in health centers and pharmacies, and in recent months, there has been an increasing demand of such local services in the absence of specific rules and regulations regarding technical requirements and standards of interpretation that ensure a high quality clinical consultation. The purpose of this position paper is to provide critical requirements for the type/model of devices to be used, training dedicated to healthcare personnel, ensuring security of sensitive data, highlighting type of platforms to be used, as well as for maintaining high reporting quality and standards.

SARS-CoV-2 neuropathology: Evidence from a post-mortem autopsy series in Padova, Italy

Introduction: SARS-CoV-2 is a novel strain of Coronavirus that mainly targets the respiratory tract, but with important implications also for the CNS. Data deriving from autopsy studies supports the neuroinvasive potential of SARS-CoV-2, even though infection appears to be limited to sparse cells within the brainstem and was not associated with the severity of neuropathological changes. Objectives: In the following study, we assess the neuropathological changes of 14 patients who died following a diagnosis of Sars-CoV-2 infection in Padova, Italy from March 2020 to January 2021. Methods: The cerebrum, cerebellum, brainstem, cranial nerves and meninges were sampled and histopathological evaluation was performed by histochemistry and immunohistochemistry for GFAP, CD8, CD61, CD68 and HLA-DR antibodies. SARS-CoV-2 proteins and RNA were investigated through immunohistochemistry, RTPCR and in-situ hybridization. Results: Small vessel thromboses were identified in two patients, while fresh territory ischaemic lesions were identified in three patients. Astrogliosis and microglial activation were more pronounced at the level of the brainstem in all subjects. SARS-CoV-2 proteins were found within the brainstem and meninges of 4 patients. In one patient, SARS-CoV-2 proteins and RNA were identified throughout the whole rostrocaudal extent of the brainstem and basal ganglia, with prominent involvement of neurons and oligodendrocytes in the mesencephalon, rostral pons and medulla. Conclusion: Although limited by the number of our cohort, the study contributes to define the neuroinvasive potential of SARS-CoV-2 within the CNS. In line with available literature, SARS-CoV-2 invasion does not appear to correlate with the severity of neuropathological changes.

Echocardiography and Multimodality Cardiac Imaging in COVID-19 Patients

The pandemic caused by the new SARS-CoV-2, named coronavirus disease 2019 (COVID-19) disease, has challenged the health-care systems and raised new diagnostic pathways and safety issues for cardiac imagers. Myocardial injury may complicate COVID-19 infection in more than a quarter of patients and due to the wide a range of possible insults, cardiac imaging plays a crucial diagnostic and prognostic role. There is still little evidence regarding the best-imaging pathway and the echocardiographic findings. Most of the data derive from the single centers experiences and case-reports;therefore, our review reflects the recommendations mainly based on expert opinion. Moreover, knowledge is constantly evolving. The health-care system and physicians are called to reorganize the diagnostic pathways to minimize the possibility of spreading the infection. Thus a rapid, bedside, ultrasound assessment of the heart, chest, and leg veins by point-of-care ultrasound seems to be the first-line tool of the fight against the SARS-CoV-2. A second Level of cardiac imaging is appropriate when the result may guide decision-making or may be life-saving. Dedicated scanners should be used and special pathways should be reserved for these patients. The current knowledge on cardiac imaging COVID-19 patients is reviewed.

Future perspectives of Italian cardiologists in training: A nationwide survey

Background. Adequate specialist training is the basis of a health system capable of supporting the continuous expansion of the population's demand for assistance. The continuous scientific advances, technological innovations, and the recent outbreak of a pandemic lead to a reshaping of training courses in order to guarantee a high standard of quality of care. Aims. Evaluating the feedback provided by Italian cardiologists in training about the current educational program and analyzing their perspectives about the future. Methods. We performed a 23-item national survey that has been delivered to 1443 Italian Fellow in Training (FITs), registered in the database of the Italian Society of Cardiology (ISC). The survey has been available online for 33 days (from 12 of June to 15 of July 2020). The impact of COVID-19 on medical education has been the original principal topic of the questionnaire, but we took advantage of this opportunity to investigate the perception of the trainees about their future work and training. Results. 633 cardiologists in training (44% of the FITs) participated to the survey. 45% of the participants affirmed to be completely satisfied by the current training program. 24% of respondents affirmed to have a totally inadequate or inadequate expertise on treating cardiovascular emergencies. 83% claimed to be interested in a working experience abroad but only 24% would remain lifelong in another Country. We asked the future cardiologists an opinion about the possibility of an early access to the world of work, starting from the third year of residency, provided from two recent Italian decrees ("Calabria" and "Milleproroghe"). 63% of the respondents believe that this chance does not represent an overall advantage and for 83% of them the early abandonment of the Universities could jeopardize a thorough cardiological training. Sub-specializations such as interventional cardiology and echocardiography emerged as the main topics of interest for the future careers of the FITs;however, general cardiology has been indicated as the third most requested area of interest, in contrast to the increasing tendency to sub-specializations. Only a few numbers of participants (<1%) expressed their interest in dedicating their future in the research field. Conclusions. Universities and politicians should make a great effort in the organization and re-organization of the teaching programs, taking into account the opinions of the cardiologists of tomorrow.