The lung ultrasound in the prognosis of COVID-19 patients

Introduction: Bedside lung ultrasound (LUS) is a useful and noninvasive tool for rapid evaluation of many chest conditions. Following the onset of the COVID-19 pandemic, the use of LUS has become common practice for evaluating lung involvement and for monitoring changes in COVID-19 patients.The prognostic role of LUS in COVID-19 patients has not yet been established. Methods: We retrospectively analysed records from 448 patients (mean age 66,08) with confirmed COVID-19 by nasopharyngeal swab, admitted to our ward of COVID Medicine Unit at Ospedale del Mare in the town of Napoli between March 2020 and May 2021. We performed LUS on all patients with COVID-19 using a 14-zone method (Soldati score from 0 to 42 points) at the admission in COVID Medicine Unit within 3 days from the onset of symptoms.We evaluated the difference in LUS score between the death and survival groups. Results: The mean LUS scores were 30,93±5.01 and 21,53±7.85 in the death group compared with the survival group (weighted mean difference (WMD)=9.51,95% CI=8.20-10.82, P value <0.0001). Conclusions: The LUS score in our COVID- 19 population was associated with mortality. LUS score is important for the risk stratification in COVID-19 patients.

Pneumomediastinum and pneumothorax in CoViD-19 patients: A case series

Background: Pneumomediastinum and pneumothorax are not rarely observed during the CoViD-19 pandemic especially among mechanically ventilated patients. We present a case series of six patients with pneumothorax and pneumomediastinum in CoViD- 19 pneumonia. Presentation of the case series: All patients were males with a mean age of 59.63 years. Two patients had spontaneous pneumomediastinum and pneumothorax.One of them denied tobacco or respiratory disease, while the other patient had an history of spontaneous pneumothorax.Four of the six patients received noninvasive ventilation and the average number of days between ventilation and subsequent barotrauma was 8,5 days. Positive end expiratory pressure (PEEP) was started at 10 cmH2 and then reduced to 8 cmH2.Three of patients had not significant comorbidities, while two of them had a medical history significant for hypertension, type 2 diabetes and ischemic heart disease. Five of six patients had a extensive bilateral interstitial pneumonia and no evidence of pulmonary embolism, three of them also had secondary bacterial pneumonia. Pneumomediastinum was treated conservatively in all patients. One patient with extensive pneumothorax required drainage. The probability of pneumomediastinum and pneumothorax increase with the combination of parenchymal injury from CoViD-19 infection and inflammatory response with additional positive pressure ventilation and likely super imposed bacterial infection. Conclusions: Pneumomediastinum and pneumothorax are important CPAP/NIV therapy complications in CoViD-19 and they should be considered if patients begin to deteriorate.

Olanzapine versus haloperidol in CoViD patients

Background and Aim: Haloperidol is the most widely used drug for the prevention and treatment of delirium in the Operating Units of Internal Medicine. New generation antipsychotics are a possible alternative often with fewer side effects. The objective of this study is the evaluation of a single-center observational retrospective study to compare the efficacy and tolerability of oral olanzapine versus haloperidol for the management of delirium in CoViD-19 patients. Materials and Methods: 97 patients were enrolled. The analysis of all data is retrospective as a single-center observational study approved by the ethics committee. Two groups were identified: the first of 49 patients treated with haloperidol, 48 patients treated with olanzapine. Results:We observed lower efficacy and safety of oral haloperidol than olanzapine in the management of delirium in elderly patients with CoViD-19-related pneumonia. In particular, we observed a reduction in the number of episodes of delirium, a reduction in hospitalization and greater compliance with ventilatory therapy with fewer adverse events in the group treated with olanzapine. Conclusions: Oral olanzapine therapy may be indicated as a better alternative for the management of delirium in the fragile high-risk geriatric patient.

Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy.

OBJECTIVE: We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care. PATIENTS AND METHODS: All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed. RESULTS: One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations. CONCLUSIONS: LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.

Diagnostic dilemmas in COVID-19 patient

As the main title 'COVID-19 revolution: a new challenge for the internist' states, the global coronavirus infection disease 2019 (COVID-19) pandemic represented a new challenge for the internists. This paper is part of a series of articles written during the difficult period of the ongoing global pandemic and published all together in this fourth issue of the Italian Journal of Medicine, with the aim of sharing the direct experiences of those who were the first to face this severe emergency, expressing each point of view in the management of COVID-19 in relation to other diseases. Each article is therefore the result of many efforts and a joint collaboration between many colleagues from the Departments of Internal Medicine or Emergency Medicine of several Italian hospitals, engaged in the front line during the pandemic. These preliminary studies therefore cover diagnostic tools available to health care personnel, epidemiological reflections, possible new therapeutic approaches, discharge and reintegration procedures to daily life, the involvement of the disease not only in the lung, aspects related to various comorbidities, such as: coagulopathies, vasculitis, vitamin D deficiency, gender differences, etc.. The goal is to offer a perspective, as broad as possible, of everything that has been done to initially face the pandemic in its first phase and provide the tools for an increasingly better approach, in the hope of not arriving unprepared to a possible second wave. This paper in particular deals with the diagnosis of COVID-19.

Prevalence of comorbidities in hospitalized populationwith COVID-19: Our experience

Background and Aim: Our objective was to evaluate the prevalenceof comorbidities in our hospitalized population with COVID-19.Materials and Methods: Forty-two patients (64.29% males,25.71% females;mean age of 70.75 ±13.73 yrs), admitted toour Hospital between March and June 2020, had been identifiedas having laboratory-confirmed 2019-SARS-CoV infection. Results: On admission 83.33% of patients presented with dyspnea, 80.95% with cough and 78.75% with fever. Diarrhea was uncommon (19.05%). Patients were classified according to their BMI(kg/m2) as lean (18.5-25) or affected by grade 1 obesity (25-29.9), grade II obesity (30-34.9) and grade III obesity (= 35). Obesity was present in 50% of cases;grade I 35.71%, gradeII and grade III 11.90% and 2.38%, respectively. Hypertension waspresent in 92.86% of patients, COPD in 54.76%, chronic kidneydisease in 45.24%, ischemic heart disease in 35.71%, diabetesin 33,33%, dementia in 30,95% and atrial fibrillation in 7.14%.On admission to the hospital lymphocytopenia was a frequent laboratory finding (97.62%). The coagulation profile revealed an elevation of fibrinogen (66.67%) and D-dimer (85.71%) levelsdespite a normal PT and APTT. The elevation of the pro BNP levelswas observed in 61.90% and troponin levels were at the sametime elevated in 13.16% of COVID-19 patients. Twelve patients(28.5%) died. Coronary artery disease was found in 70% of them. Conclusions: Comorbidities are common in patients with COVID-19. Although COVID 19 has been initially associated to a respiratory disease, it may involve the cardiovascular system with adramatic impact.