THE PHON EFFECT IN THE ABANDONED MUMMIFIED

Social isolation, confinement in the domestic context up to abandonment, phenomena as serious as they are frequent in modern society, has been emphasized by the advent of the Sars-Covid19 pandemic. The authors report the case of a 39-year-old woman found lifeless and in a partial state of mummification ("hair dryer effect"), lying on her back on the bed and covered, in part, by a quilt. At the foot of the bed a hairdryer was found connected to the electrical outlet. The environmental conditions favored the initiation of special transformative putrefactive processes, such as that of mummification. Investigating a mummified body found, to determine the cause and manner of death, can be difficult for the forensic pathologist. For the definition of the time of death we generally use the degree of evolution ofpostmortal transformative phenomena which, as we move away from the moment of death, offer less and less possibilities to delimit this period within narrow time limits, especially when these phenomena are strongly affected by the environmental factors in the context of which the corpse has stayed, as occurred in the present case. A careful analysis of the places where the death occurred and the circumstantial data possibly available to the coroner can provide useful data for the proper assessment of the case. The reporting of this event must be considered an important isolated case study for the analysis of the mummification process, as well as a warning light on an increasingly widespread social problem.

Prone positioning for patients with SARS-CoV-2-related respiratory failure in non-intensive care unit (preprint)

Background Prone positioning (PP) is an established and commonly used lung recruitment method for intubated patients with severe acute respiratory distress syndrome, with potential benefits in clinical outcome. The role of PP outside the intensive care unit (ICU) setting is debated. We aimed at describing the use and potential benefits of PP in non-intubated patients with acute respiratory failure related to COronaVIrus Disease-19 (COVID-19)-pneumonia. Methods Consecutive adult patients with COVID-19-related respiratory failure were included in a prospective collaborative cohort and classified based on the severity of respiratory failure by the partial arterial oxygen pressure to fraction of inspired oxygen ratio (PaO2/FiO2) and on clinical severity by the quick Sequential Organ Failure Assessment (qSOFA) score. Primary study outcome was the composite of in-hospital death or ICU admission within 30 days from hospitalization. Results PP was used in 114 of 536 study patients (21.8%), more commonly in patients with lower PaO2/FiO2 or receiving non-invasive ventilation and less commonly in patients with known comorbidities. A primary study outcome event occurred in 163 patients (30.4%) and was in-hospital death in 129 (24.1%). PP was not associated with death or ICU admission (HR 1.15, CI 95% 0.78-1.72) and not with death (HR 1.03, CI 95% 0.62-1.69); PP was an independent predictor of ICU admission (HR 2.55, 95%CI 1.50-4.32). The severity of respiratory failure and non-invasive ventilation were independent predictors of death or ICU admission at 30 days. The lack of association between PP and death or ICU admission was confirmed at propensity score matching analysis.Conclusion PP is used in a not negligible proportion of non-intubated patients with COVID-19-related severe respiratory failure and is not associated with death but with ICU admission. The role of PP in this setting requires evaluation in randomized studies. 

Lung Ultrasound to Predict COVID-19 Pneumonia: A Multicenter Descriptive Study (preprint)

Background: The pandemic surge of Coronavirus disease 2019 (COVID-19) is posing the unprecedent challenge of rapidly identifying and isolating probable cases and diagnosing the main respiratory complications. We aimed to describe the application of a lung ultrasound (LUS)-based diagnostic approach, combining the LUS likelihood of COVID-19 pneumonia with patient’s symptoms and clinical history.Methods: This is an international multicenter prospective observational study on patients suspected for COVID-19, presenting to 22 different US and European hospitals. Patients underwent LUS and reverse transcription-polymerase chain reaction (RT-PCR) swab test. We identified 3 different clinical phenotypes based on pre-existing chronic cardiac or respiratory diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to 4 different patterns, characterized by the presence and distribution of typical and atypical LUS signs: high (HPLUS), intermediate (IPLUS), alternative (APLUS) and low (LPLUS) probability patterns. The association between the combination of patterns and phenotypes with RT-PCR results was described and analyzed.Findings: We studied 1462 patients, classified in mild (n=400), severe (n=727) and mixed (n=335) phenotypes. In the overall population, the HPLUS corresponded to a positive RT-PCR in 92.6% of cases, with similarly high percentages in all clinical phenotypes ranging from 87.5% (mild) to 90.3% (mixed) and 96.5% (severe). The IPLUS yielded a lower match with positive RT-PCR (65.7%). In patients with respiratory failure, the LPLUS predicted a negative RT-PCR in 100% of cases. In the overall population, the APLUS indicated an alternative pulmonary condition in 81.1% of patients. At multivariate analysis the HPLUS strongly predicted RT-PCR positivity (odds ratio 4.173, interquartile range 2.595-6.712, p<0.0001), independently from age, low oxygen saturation and dyspnea.Interpretation: Combining LUS patterns of probability for interstitial pneumonia with clinical phenotypes at presentation could facilitate the early diagnosis of COVID-19 or suggest an alternative pulmonary condition. This approach may be useful to rapidly guide and support patient’s allocation for a wiser use of hospital resources during a pandemic surge.Funding: None.Conflict of Interest: The authors declare no conflicts of interest. Ethical Approval: The local Ethical Committee Boards of each center approved the study, and the study was conducted following the ethical standards of the 1964 Helsinki declaration and its later amendments and with local guidelines for good clinical practice.

Role of low-molecular weight heparin in hospitalized patients with SARS-CoV-2 pneumonia: a prospective observational study

Objectives To evaluate the impact of low molecular weight heparin (LMWH) on the outcome of patients with SARS-CoV-2 pneumonia. Methods Prospective observational study including consecutive patients with laboratory confirmed SARS-CoV-2 pneumonia admitted to the University Hospital of Pisa (4th March-30th April 2020). Demographic, clinical, and outcome data were collected. The primary endpoint was 30-day mortality. The secondary endpoint was a composite of death or severe ARDS. LMWH, hydroxychloroquine, doxycycline, macrolides, antiretrovirals, remdesivir, baricitinib, tocilizumab, and steroids were evaluated as treatment exposures of interest. First, a Cox-regression analysis, in which treatments were introduced as time-dependent variables, was performed to evaluate the association of exposures and outcomes. Then, a time-dependent Propensity-score (PS) was calculated and a PS-matching performed for each treatment variable. Results Among 315 patients with SARS-CoV-2 pneumonia, 70 (22.2%) died during hospital stay. The composite endpoint was achieved by 114 (36.2%) patients. Overall, 244 (77.5%) patients received LMWH, 238 (75.5%) hydroxychloroquine, 201 (63.8%) proteases inhibitors, 150 (47.6%) doxycycline, 141 (44.8%) steroids, 42 (13.3%) macrolides, 40 (12.7%) baricitinib, 13 (4.1%) tocilizumab, and 13 (4.1%) remdesivir. At multivariate analysis, LMWH was associated with a reduced risk of 30-day mortality (HR 0.36 [95% CI 0.21-0.6], p<0.001) and composite endpoint (HR 0.61 [95% CI 0.39-0.95], p=0.029). The PS-matched cohort of 55 couples confirmed the same results for both primary and secondary endpoint. Conclusions This study suggests that LMWH might reduce the risk of in-hospital mortality and severe ARDS in Covid-19. Randomized controlled trials are warranted to confirm these preliminary findings.

Low Diaphragm Muscle Mass Predicts Adverse Outcome in Patients Hospitalized for Covid-19 Pneumonia (preprint)

Purpose: The aim of this study was to evaluate whether measurement of diaphragm thickness by ultrasonography may be a clinically useful noninvasive method for identifying patients at risk of adverse outcomes defined as need of invasive mechanical ventilation or death. Methods: We retrospectively reviewed the records of consecutive of 77 patients with laboratory-confirmed Covid-19 infection admitted to our intermediate care unit in Pisa between March 5 and March 30, 2020, with follow up until hospital discharge or death. Logistic regression was used identify variables potentially associated with adverse outcomes and those P<0.10 were entered into a multivariate logistic regression model. Cumulative probability for lack of adverse outcomes in patients with or without low baseline diaphragm muscle mass was calculated with the Kaplan–Meier product-limit estimator.Results: The main findings of this study are that 1) patients who developed adverse outcomes had thinner diaphragm than those who did not (2.0 vs 2.2 mm, p:0.001), 2) DT and lymphocyte count were independent significant predictors of adverse outcomes, with end-expiratory DT being the strongest (-708, OR: 0.492, p: 0.018).Conclusion: Diaphragmatic ultrasound may be a valid tool to evaluate the risk of respiratory failure. Evaluating the need of mechanical ventilation treatment should be based not only on PaO2/FiO2, but on a more comprehensive assessment including DT because if the lungs become less compliant a thinner diaphragm, albeit free of intrinsic abnormality, may become exhausted, thus contributing to severe respiratory failure.