Lung inhomogeneities in COVID-19 related acute respiratory distress syndrome

Introduction: In acute respiratory distress syndrome (ARDS) inhomogeneities in lung aeration can act as local multipliers of pressure during inspiration (stress risers), increasing the risk of lung damage even in presence of airway pressures considered safe [1]. In this study we aimed to describe lung inhomogeneities in COVID-19 related ARDS (C-ARDS) and to relate these to disease severity and lung morphology. Method(s): We enrolled patients with C-ARDS within 3 days from mechanical ventilation start, deeply sedated and paralyzed. Lung CT scan was obtained at PEEP of 5 cmH2O to measure lung weight compartments (non-, poorly-, well- and over-aerated). Lung inhomogeneities were computed as the gas/tissue ratio of each voxel compared to the neighboring voxels. We considered values > 1.61 as pathologic lung inhomogeneities, as previously described [1]. The fraction of total lung volume with pathologic inhomogeneities (extent) and the average severity of inhomogeneities contained in that fraction (intensity) was calculated. Respiratory system compliance and blood gas analysis were obtained at the same PEEP level of the CT scan. Some results have been presented in another publication [2]. Result(s): Forty patients were studied in the supine position 1 (0-1) days after ICU admission. The extent of pathologic lung inhomogeneities represented 18 +/- 4% of total lung volume. The intensity of pathologic lung inhomogeneities was on average 2.53 +/- 0.12. Extent was positively correlated with the amount of poorly aerated lung weight ( r2 = 0.51, p < 0.001) (Fig. 1) and negatively correlated with the amount of non-aerated lung weight ( r2 = 0.22, p = 0.002). No correlation was found between extent and intensity and PaO2/ FiO2, dead space fraction or respiratory system compliance. Conclusion(s): In C-ARDS lung inhomogeneities represent roughly 20% of total lung volume. In these regions local stress is increased with risk of secondary lung damage.

HIV/AIDS infection in Italy up to December 31, 2020

Data on new HIV diagnoses have a national coverage since 2012. Data reported in 2020 have been affected by the COVID-19 pandemic. In 2020, 1,303 new HIV diagnoses were reported, with an incidence of 2.2 per 100,000 residents. In 2020, HIV incidence in Italy was lower compared to that reported in the European Union (3.3 new diagnoses per 100,000). Since 2018, an evident decrease in the number of new HIV diagnoses is observed, with no relevant differences by transmission mode. In 2020, heterosexual transmission accounted for 42% (25% in males, 17% in females) of reported cases, sex between men accounted for 46%, and injecting drug use accounted for 3%. Data on AIDS cases are collected since 1982. In 2020, 352 AIDS cases were reported, with an incidence of 0.7 per 100,000 residents;80% of these individuals discovered being HIV-infected in the six months prior to AIDS diagnosis.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Use of remote patient monitoring in the care of COVID-positive patients in oncology

Background: Cancer patients face an increased risk of developing acute complications from COVID-19. Remote monitoring can help with the critical need for early detection of symptoms among those diagnosed with COVID-19, enabling timely symptom management that can mitigate clinical deterioration. In response to this need, Memorial Sloan Kettering Cancer Center fast-tracked a program to monitor patients with COVID-19 from home, using an electronic symptom-tracking questionnaire and digital pulse oximeter to track patients' status and alert care teams to intervene if symptoms worsened. A multi-disciplinary group composed of Oncology providers, advanced practice providers, nursing, nursing informatics and biomedical informatics formed to manage the program. Methods: Memorial Sloan Kettering launched a remote monitoring program for patients diagnosed with COVID-19 on March 25, 2020. All patients testing positive for COVID-19 were enrolled in the program and asked to complete a daily symptom tracking questionnaire accessed through their patient portal or administered verbally over the phone. A subset of high risk patients were also provided with a digital pulse oximeter linked to their patient portal and capable of transmitting readings directly to the care team. Clinicians received alerts for patients reporting symptoms or an oxygen saturation below 92%. Alerts resulted in an immediate response from the care team to determine if the patient needed additional care. We retrospectively evaluated the program usage, outcomes and learnings from March 25, 2020 to December 22, 2020. Results: In total, 1,721 patients were enrolled in the program from March 25, 2020 to December 22, 2020. Among these, 210 were deemed high risk patients who received a pulse oximeter in addition the daily symptom questionnaire. Over this period, 27% of patients triggered an alert from an electronic symptom questionnaire, and 63% of patients with a pulse oximeter triggered an alert from their device. Among patients who triggered an alert of any kind, 3% were triaged to a higher level of care. Patients reported that the program was highly valued and alleviated anxiety about their care. Iterative improvements were made to the program over time in response to the evolving knowledge about care for patients with COVID-19. Conclusions: Memorial Sloan Kettering was able to quickly implement a program to detect and triage symptoms among patients with COVID-19 and cancer. Refinements were made over time to many aspects of the program in response to learnings about care related to COVID-19, including to clinical eligibility, alert criteria, monitoring duration and workflows. The program also demonstrated value for patients who felt more comfortable with their care while being monitored remotely. This program established a successful model for remote monitoring of patients with COVID-19 with the potential to be scaled to other institutions or clinical areas.

Telehealth transformations and redefinitions of neurodevelopmental disorders rehabilitation in a child and adolescent neuropsychiatric service in Italy during COVID pandemic: Strengths and weaknesses and possible future evolutions

The authors describe the telehealth approach and the evolution of the rehabilitation activities during COVID-19 emergency in the Child and Adolescent Neuropsychiatry Unit of the "IRCCS Ca' Granda Ospedale Maggiore Policlinico" of Milan. They focus on strengths and weaknesses of telepractice during the pandemic evolution and discuss possible future evolutions. (PsycInfo Database Record (c) 2021 APA, all rights reserved) Abstract (Italian) Gli Autori descrivono l'evoluzione e la ridefinizione dei trattamenti riabilitativi in NPIA nel corso dell'emergenza COVID-19 nell'Unita Operativa di Neuropsichiatria dell'Infanzia e dell'Adolescenza della Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano. Nello specifico vengono illustrati i cambiamenti nell'attivita riabilitativa, punti di forza e di debolezza nel corso delle tre fasi che hanno contraddistinto, ad oggi, l'emergenza sanitaria e discusse le prospettive future. (PsycInfo Database Record (c) 2021 APA, all rights reserved)