Incidence and impact of anticoagulation-associated abnormal menstrual bleeding in women after venous thromboembolism.

Preliminary data and clinical experience have suggested an increased risk of abnormal uterine bleeding (AUB) in women of reproductive age treated with anticoagulants, but solid data are lacking. The TEAM-VTE study was an international multicenter prospective cohort study in women aged 18 to 50 years diagnosed with acute venous thromboembolism (VTE). Menstrual blood loss was measured by pictorial blood loss assessment charts at baseline for the last menstrual cycle before VTE diagnosis and prospectively for each cycle during 3 to 6 months of follow-up. AUB was defined as an increased score on the pictorial blood loss assessment chart (>100 or >150) or self-reported AUB. AUB-related quality of life (QoL) was assessed at baseline and the end of follow-up using the Menstrual Bleeding Questionnaire. The study was terminated early because of slow recruitment attributable to the COVID-19 pandemic. Of the 98 women, 65 (66%) met at least one of the 3 definitions of AUB during follow-up (95% confidence interval [CI], 57%-75%). AUB occurred in 60% of women (36 of 60) without AUB before VTE diagnosis (new-onset AUB; 95% CI, 47%-71%). Overall, QoL decreased over time, with a mean Menstrual Bleeding Questionnaire score increase of 5.1 points (95% CI, 2.2-7.9), but this decrease in QoL was observed only among women with new-onset AUB. To conclude, 2 of every 3 women who start anticoagulation for acute VTE experience AUB, with a considerable negative impact on QoL. These findings should be a call to action to increase awareness and provide evidence-based strategies to prevent and treat AUB in this setting. This was an academic study registered at www.clinicaltrials.gov as #NCT04748393; no funding was received.

The complexity of immunology: a rare adverse event following a Pfizer-BioNTech vaccine booster shot.

OBJECTIVE: Several mRNA vaccines have been developed to tackle the global pandemic. Despite their remarkable clinical efficacy, they are not devoid of severe short- and long-term adverse events. CASE PRESENTATION: In this paper, we describe a rare delayed adverse event (arterial and venous renal thrombosis with myocardial injury) in an otherwise healthy adult female, which occurred three months after she received a booster shot of Pfizer COVID-19 vaccine.  The patient was successfully treated for subacute renal ischemia with intra-arterial urokinase, and her myocardial injury was diagnosed with imaging (contrast-enhanced thoracic CT and cardiac magnetic resonance) and percutaneous coronary intervention. Deferred post-vaccine myocarditis was diagnosed and resolved with steroid therapy. CONCLUSIONS: In this paper, we report a useful clinical case for the pharmacovigilance database. Although scientific evidence confirms that the benefits of vaccination far outweigh the risk of adverse events, we would like to point out how important watchful observation is in the medium and long term, especially when the subject belongs to a specific risk category.

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.

HIV/AIDS EM CENA: UMA ESTRATÉGIA PARA EDUCAÇÃO SOBRE INFECÇÕES SEXUALMENTE TRANSMISSÍVEIS EM LIBRAS

Introdução: Estima-se que a população surda no Brasil seja de 344.2 mil pessoas. Apesar da Língua Brasileira de Sinais (Libras) ser legalmente reconhecida no país, existem barreiras de comunicação em saúde, o que amplia as lacunas de acesso, destacando-se a infecção pelo Vírus da Imunodeficiência Humana/Síndrome da Imunodeficiência Adquirida (HIV/Aids), decorrente da falta de acesso à prevenção, ao tratamento e à educação sexual. Objetiva-se neste estudo conceber uma ferramenta educacional em Libras sobre HIV/Aids, a fim de criar uma estratégia de comunicação educacional entre jovens surdos e profissionais da saúde. Métodos: Trata-se de um estudo descritivo qualitativo a partir de uma situação problema de uma jovem surda que desconhece as Infecções Sexualmente Transmissíveis (ISTs) e procura informações a respeito. Resultados: A vídeo aula, disponibilizada no hiperlink: https://youtu.be/xL9X4qB6l7Y, permite despertar o interesse no assunto, além de ensinar os principais sinais em Libras relacionadas à temática, o que é informativo para os usuários e os profissionais da saúde. O vídeo possui 17,42 minutos, de modo bilíngue Libras/Português, contemplando os conteúdos ISTs, HIV/Aids e métodos de prevenção. Considerando-se o atual uso de máscaras pela medida de enfrentamento ao SARS-Cov2, sem a adaptação da transparência, não permitindo a leitura labial;e o diálogo pela escrita, apesar de ser uma opção, requerer o esforço prioritário do usuário surdo, em ter que expressar dúvidas sobre temas que dificilmente foram abordados previamente em Libras, a ferramenta pode se tornar grande facilitador durante a pandemia, sendo empregada como material de apoio no Programa Saúde na Escola, em salas de espera, em eventos públicos, em consultórios e para educação continuada em serviços de saúde. A simultaneidade das duas línguas permite que, mesmo que o profissional não seja fluente em Libras, possa iniciar um diálogo empático com o paciente surdo ou deficiente auditivo. Conclusão: A vídeo aula dissipa o padrão da comunicação sobre HIV e foca na inclusão de outra parcela da sociedade, a população surda. Espera-se que esta ferramenta contribua para a sociedade, promovendo conhecimento, seja um facilitador para profissionais da saúde e professores e instigue diálogos na saúde sobre educação sexual, focando na diversidade.

Dexamethasone in covid-19 patients with acute respiratory distress syndrome. experience from a cardiology department

Aims: We assessed the effectiveness of early administration of corticosteroids in patients affected by COVID-19 with moderate to severe acute respiratory distress syndrome requiring oxygen support. Methods: This is a single-center, retrospective, controlled cohort study including patients admitted to our hospital from March 13th to April 20th, 2020. Patients received an intravenous bolus of 8mg dexamethasone twice daily for 5 days or standard care only. Clinical and laboratory characteristics were abstracted by medical records. The primary endpoint was clinical improvement, defined as an increase in the arterial partial pressure of oxygen/fraction of inspired oxygen ratio ≥50%, respiratory rate <24 breaths/min, and decrease in C-reactive protein (CRP) ≥50% compared to the baseline. The secondary endpoint was weaning from any ventilatory support. Outcomes were assessed using Kaplan-Meier analysis with Log-rank test and multivariable Cox regression. Results: Thirty-seven patients (21.6% female;mean age, 63.3±11.4 years) were identified who needed non-invasive mechanical ventilation, 23 of whom received steroids and 14 standard care. Median follow-up was 20 days (range 7-52). Treatment with dexamethasone was associated with faster clinical improvement than standard care [median days, 2 vs. 6;hazard ratio (HR), 3.28;95% confidence interval (CI), 1.64-6.55;P <.0001) and earlier weaning from ventilatory support (median days, 4 vs. 7;HR, 2.24;95% CI, 1.13-4.43;P =.014). CRP decreased over time only in patients on corticosteroids (treatment effect P <.001). Conclusion: In COVID-19 patients with moderate-to-severe ARDS the early use of dexamethasone prevented disease progression, resulting from host inflammatory response, and improved clinical outcome.

Emergency department reorganisation to cope with COVID-19 outbreak in Milan university hospital: a time-sensitive challenge.

BACKGROUND: In March 2020 we faced a huge spread of the epidemic of SARS-CoV2 in northern Italy; the Emergency Departments (ED) and the Emergency Medical Services (EMS) were overwhelmed by patients requiring care. The hospitals were forced to reorganize their services, and the ED was the focal point of this challenge. As Emergency Department in a metropolitan area of the region most affected, we saw an increasing number of patients with COVID-19, and we made some structural and staff implementations according to the evolution of the epidemic. METHODS: We analysed in a narrative way the weaknesses and the point of strength of our response to COVID-19 first outbreak, focusing point by point on main challenges and minor details involved in our ED response to the pandemics. RESULTS: The main stems for our response to the pandemic were: use of clear and shared contingency plans, as long as preparedness to implement them; stockage of as much as useful material can be stocked; training of the personnel to be prepared for a fast response, trying to maintain divided pathway for COVID-19 and non-COVID-19 patients, well-done isolation is a key factor; preparedness to de-escalate as soon as needed. CONCLUSIONS: We evaluated our experience and analysed the weakness and strength of our first response to share it with the rest of the scientific community and colleagues worldwide, hoping to facilitate others who will face the same challenge or similar challenges in the future. Shared experience is the best way to learn and to avoid making the same mistakes.