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Objective: Coronavirus disease 2019 (COVID-19) represents a major clinical problem in terms of death and long-term sequelae. We conducted a retrospective cohort study at Montichiari Hospital (Brescia, Italy) to better understand different determinants of outcome in different COVID-19 outbreaks. Design and method: A total of 635 patients admitted from local emergency room with a confirmed diagnosis of SARS-CoV-2 infection and a moderate to severe COVID-19 were included in the present study. A group of 260 consecutive patients during SARS-CoV-2 first wave (from February to May 2020) and 375 consecutive patients during SARS-CoV-2 second/third wave (from October 2020 to May 2021) were considered. Demographic data, comorbidities, ongoing treatment and bio-humoral, respiratory and haemodynamic data were recorded and compared. Results: Main demographic data (Table 1) were not significantly different in the two considered time-lapses, except a lower prevalence of female sex during first wave. Mortality rate was significantly lower during the latter period (25% vs 11%;p < 0.001). Time from symptoms onset to hospital admission was longer during first wave (7.8 ± 5.6 vs 5.6 ± 4.3 days;p < 0.001) while hospital staying was significantly shorter (11 ± 10 vs 15 ± 12 days;p < 0.001). Other significant differences were a wider use of corticosteroids and low-molecular weight heparin (LMWH) as well less antibiotic prescription during the second wave (Table 2). Respiratory, bio-humoral and x-Ray score were significantly poorer at the time of admission in first-wave patients (Table 3). After a multivariate regression analysis, C-reactive protein and procalcitonin values, % fraction of inspired oxygen at admission, days after symptoms onset and duration of hospital staying were the strongest predictors of outcome in both periods. Concomitant anti-hypertensive treatment (including ACE-inhibitors and ARBs) did not affect outcome. Conclusions: Our preliminary data suggest that an earlier diagnosis, a timely hospital admission and a rational use of the therapeutic options allowed to reduce the rate of systemic inflammation response (of which CRP is a hallmark) and granted a better outcome during the second of the two time-lapses considered.
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Objective: Worldwide spread of SARS-CoV-2 caused a pandemic as never were seen in the last fifty years and represented a major clinical problem in Lombardy, one of the most affected Italian Regions, in terms of death toll and long-term sequelae. This is particularly true when elder people are considered;therefore, we conducted a retrospective cohort study in the General Medicine of our Hospital. Design and method: In the present study we recorded data of patients older than 65 years, admitted to a COVID-19 unit during 2020 and 2021;we compared the characteristics of in-patients admitted in the first (March-May 2020) and the second/ third pandemic waves (October 2020-May 2021) Results: A total of 407 patients 65 year-old and older were included, 185 during the first wave and 222 during second/third waves;63 (34%) of them died during the first and 36 (16%) during the second/third wave. No significant differences were found according to main comorbidities and chronic prescriptions between the two groups of patients, whereas those admitted during the second/third wave were slightly older. Number of in-hospital adverse events were similar in the two samples. Main differences between the two groups were: a lower mean number of days with symptoms before hospitalization, and a less severe laboratory, respiratory ed radiologic profile. Further, steroid treatment was highly implemented during the second/third wave. Conclusions: Older patients admitted to hospital since the beginning of the pandemic showed diverse clinical severity profile according to different waves;patient admitted during the first wave had worse respiratory, radiological and laboratory parameters than those admitted in the second/third wave;further difference was found in COVID-19 treatment during hospital stay as steroids were largely administered during the latter waves.
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Objective: SARS-CoV2 infection can lead to several clinical scenarios, named COVID-19, ranging from mild manifestations to acute respiratory distress syndrome (ARDS), coagulation alterations and endothelial dysfunction. The functional impairment of the microcirculation seems play a key role in the pathophysiology and clinical consequences of COVID-19. However, to date there is no evidence of structural microvascular damage related to COVID-19. Design and method: The aim of this study is to investigate microvascular alterations by adaptive optics and vide-ocapillaroscopy in patients recently admitted for COVID-19 and re-evaluated one year later. Methods: We enrolled 153 patients admitted between February and April 2020 at the Hospital of Montichiari (Brescia) and at the Internal Medicine Department of ASST Spedali Civili - University of Brescia for respiratory failure due to SARSCoV2- related interstitial pneumonia. Patients were evaluated two months after nalysed sation and after one year. All patients underwent a venous blood sampling for hematochemical tests, evaluation of retinal arteriolar morphology by adaptive optics, assessment of basal and total capillary density (BCD and TCD respectively) at the dorsum of the fourth finger of the non-dominant hand by videocapillaroscopy. Results: Fifty patients with completed follow-up were nalysed. An increase of internal lumen (93.8 ± 13.3 vs. 97.3 ± 14.2 micron, p < 0.001) and a reduction of wall to lumen ratio (WLR 0.30 ± 0.03 vs. 0.27 ± 0.03, p < 0.001) were observed at the follow up visit after one year (Figure). No significant differences were observed in BCD in the dorsum of the finger after one year, whereas a significant reduction in TCD was observed (p < 0.001). Microvascular changes were independent of body mass index and the presence of hypertension or diabetes mellitus. Conclusions: Preliminary data from this study show that patients with SARSCov2 infection present an improvement of microvascular structure after one year from the disease, such as a reduction in WLR of retinal arterioles. This suggests that COVID19 might induce structural alterations in the microcirculation which contribute to vascular damage. These changes do not seem to be influenced by the weight, presence of hypertension or diabetes.
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Introduction and Aim Diagnosis of SARS-CoV-2 infection is mainly based on gene detection through polymerase chain reaction analysis on nasopharyngeal swab. The Allplex TM 2019-nCoV assay targets 3 different viral genes: RNA-dependent RNA polymerase, envelope, and nucleocapside. A coding system was developed based on different number of genes expressed: a nasopharyngeal swab was considered "positive" if all 3 genes tested underwent amplification, "mildly positive" if only 2 out of 3 genes were detected, "uncertain" if only 1 gene and "negative" if none resulted amplified from the test. Our aim was to assess whether this classification correlates with clinical outcome in a cohort of COVID-19 patients. Methods This is a retrospective study including patients admitted with diagnosis of SARS-CoV-2 infection to a medical ward at the Montichiari Hospital, Brescia, Italy, from February 28 to April 30, 2020. All patients underwent the nasopharyngeal swab upon admission. Results A total of 204 patients were included in this study. Patients with full positive nasopharyngeal swab showed higher values of C-reactive protein and neutrophiles/lymphocytes ratio compared with patients with mildly positive or uncertain nasopharyngeal swab. Mortality did not differ between the 2 groups. A Cox multivariate analysis showed that age, male sex, and CRP values are independent predictors of in-hospital mortality. Conclusions Our study demonstrated that patients with a complete SARS-CoV-2 gene detection nasopharyngeal swab show a higher inflammatory profile, and this can be an indirect measurement of viral load in COVID-19 patients.
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Background: SARS-CoV2 infection has been associated to a wide range of clinical scenarios, named COVID-19, ranging from acute respiratory distress syndrome to blood coagulation abnormalities and vascular manifestations related to hyper-inflammation. Recent focus has been addressed to study of microvascular alterations which may explain COVID-19 pathophysiology. Alterations in microvascular structure, identified as increased wall to lumen ratio (WLR) of retinal arterioles, have been extensively described in patients with cardiovascular diseases, such as hypertension or diabetes mellitus. Both inflammation and immune system dysregulation seem to play a role in the pathogenesis of these morphological changes. Purpose: Aim of this study was to evaluate through Adaptive Optics microvascular differences of retinal arterioles between patients experienced COVID-19 and controls. Methods: Patients were hospitalized between 28th February and 15th April at a Internal Medicine ward in a tertiary care hospital. All patients tested positive for a SARS-CoV-2 nasopharyngeal swab at admission and showed signs of pneumonia and respiratory insufficiency. Adaptive Optics, which allows a non-invasive evaluation of retinal arteriole structure, and blood chemistry exams were performed as part of follow up visits between 2 to 3 months after hospitalization. Baseline characteristics were collected through medical records. COVID-19 patients were compared to age-and sex-matched healthy subjects referred to our center between 2018 and 2019. Results: A total of 80 patients were included in this study (of which 40 were COVID-19 patients). Apart from smoking habit, other baseline characteristics (sex, age, cardiovascular risk factors and main comorbidities) did not differ between the two groups. At follow up visit COVID-19 patients showed lower values for leukocytes (6.2 vs. 7.5x103/μL, p=0.015) and lymphocytes (1.9 vs. 2.8x103/μL, p=0.002). Creatinine values were higher in patients who suffered from COVID-19 (1.0 vs 0.8 mg/dl, p=0.004-Figure 1, panel A). Adaptive Optics showed no differences in terms of internal lumen, wall thickness and WLR of retinal arterioles. However, the wall cross-sectional area (WCSA) was found to be higher in COVID-19 patients (p=0.039-Figure 1, panel B). Hypertension significantly affected both WCSA and WLR between COVID-19 and healthy individuals, while diabetes only impacted on WLR (Figure 2). Conclusion: Previous studies described the presence of leukopenia and lymphopenia during the acute phase of SARS-CoV2 infection. Our study demonstrates that these alterations persist several weeks after symptoms onset. Adaptive Optics showed microvascular alterations occurring in these patients: in particular, higher wall cross-sectional area of retinal arterioles were observed in patients after COVID-19 hospitalization, reflecting the complex pathogenic mechanisms which may explain the wide range of symptoms and clinical severity.
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Objective: Patients affected by novel pandemic SARS-CoV-2 may develop COVID-19 related pneumonia, which is potentially fatal. To date, the role of ongoing treatments for different conditions (such as hypertension) has been clarified in terms of their impact on survival and there is no established specific therapy for the disease, although many molecules are under investigation. Aim of the present study was testing those two issues in a population of 258 consecutive patients admitted from 29 February to 30 April 2020 to General Medicine ward of the Hospital of Montichiari (Brixia). Design and method: A group of 258 patients (173 males and 85 females, aged 71 ± 14) was enrolled. Their medical record and ongoing treatment were assessed. Patients were treated according to emerging information with oxygen, anti-malarian agents, anti-viral drugs, different antibiotics (azithromycin and others), tocilizumab and low molecular weight heparin (LMWH) at different doses. As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test Results: Ongoing therapy with ACE-inhibitors at the time of admission was associated with a worse prognosis (p=0.004), while no difference in survival was observed in patients under treatment with ARBs (p=0.68). Ongoing treatment with statins (p<0.001), low-dose aspirin (p<0.001) and steroids (p<0.001) was associated with a poorer outcome as well Administration during hospitalization of LMWH (p<0.001), steroids (p<0.001), anti-viral drugs (p=0.002), anti-malarian drugs (p<0.001) and tocilizumab (p<0.001), improved prognosis, while antibiotics (azithromycin and other) didn't have any impact. Conclusions: our experience confirms most findings in ongoing trials. Surprisingly, treatment with ACE-inhibitors seems to impact negatively on survival in patients affected by SARS-CoV-2 pneumonia. A possible explanation may be that patients treated with certain drugs are more comorbid and due to this, more fragile.
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Objective: COVID-19 is a new disease caused by pandemic SARS-CoV-2, that involves multiple organs and can cause a potentially fatal respiratory distress syndrome. Accumulating evidence point out that an “endothelitis” due to a cytokines storm causes intravascular thrombosis, especially in the lungs, and is related to the poor outcome. We tested possible relationships between anticoagulant treatment and/or administration of low molecular weight heparin (LMWH) at different doses and outcome in a population of 258 COVID-19 patients admitted from February 28th to April 30th, 2020 to General Medicine ward of the Hospital of Montichiari (Brixia, Italy). Design and method: A group of 258 consecutive patients (174 males and 84 females, mean age 71 years +/-14) was included in the present study. In 168 patients, high-flow oxygen was required (Venturi mask), 6 patients needed orotracheal intubation and 20 were given continuous positive pressure oxygen therapy (CPAP). Patient were treated (unless a pulmonary embolism was detected) with different doses of prophylactic LMWH, according to emerging evidence during pandemic period. As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test. Results: LMWH at standard dose (4000 IU once daily) didn't reduce mortality compared to no treatment (p=ns), while LMWH at a higher dose than usual prophylactic dose (enoxaparin 6000 IU once daily or 4000 IU bid) was associated with better outcome (p<0.001 vs untreated and treated with standard dose). Significance was confirmed adding patients treated with oral anti-coagulant (OAC)for any reason. None of the patients treated with LMWH at higher doses or OAC died. Conclusions: The administration of subcutaneous LMWH at a higher dose than indicated for deep vein thrombosis prophylaxis is associated with a better outcome in patients with SARS-CoV-2 pneumonia, confirming some emerging evidence.
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Objective: Emerging data show that hypertension as well as other cardiovascular risk factors may have a major role on outcome in terms of death on patients with COVID-19. We analysed a population of 258 consecutive patients admitted to General Medicine ward of the Hospital of Montichiari (Brixia, Italy) from 29 February to 30 April 2020. Design and method: A group of 258 consecutive patients (173 males and 85 females, aged 71 ± 14) was enrolled. In 168 patients, high-flow oxygen was required (Venturi mask), 20 patients needed orotracheal intubation and 11 were given continuous positive pressure oxygen therapy (CPAP). Patients were treated with the best approach according to available evidence during pandemic period: anti-malaria agents, anti-viral drugs, antibiotics (azithromycin and others), tocilizumab and low molecular weight heparin (LMWH). As of June 10th, 65 deaths had been observed. Survival curves were calculated according to Kaplan-Meier method. Comparison between groups was performed with Breslow and Mantel-Cox test. Results: As shown in the table, a significant raise in mortality was observed in patients older than 65 years (p<0.001), of male sex (p<0.001), hypertensives (p<0.001) as well as in patients with heart disease (picture 1;p<0.001), COPD (picture 2;p=0.004), diabetes (p<0.001) and neoplasms (p=0.03) compared with patients with no comorbidities or different diseases, both at discharge and at standard follow-up. The number of comorbidities impacted on survival as well. Conclusions: Hypertension, heart disease and cardiovascular risk factors play a significant role as a negative prognostic factor in patients affected by SARSCoV-2 pneumonia. This confirms previous observations (Pol Arch Intern Med 2020;130(4):304-309) and outlines the importance of prevention of contagion in population with cardiovascular risk factors or established cardiovascular disease.