Learning from the COVID-19 pandemic in Italy to advance multi-hazard disaster risk management.

COVID-19 challenged all national emergency management systems worldwide overlapping with other natural hazards. We framed a 'parallel phases' Disaster Risk Management (DRM) model to overcome the limitations of the existing models when dealing with complex multi-hazard risk conditions. We supported the limitations analysing Italian Red Cross data on past and ongoing emergencies including COVID-19 and we outlined three guidelines for advancing multi-hazard DRM: (i) exploiting the low emergency intensity of slow-onset hazards for preparedness actions; (ii) increasing the internal resources and making them available for international support; (iii) implementing multi-hazard seasonal impact-based forecasts to foster the planning of anticipatory actions.

Acute non-oliguric kidney failure and cholestatic hepatitis induced by ibuprofen and acetaminophen: a case report.

UNLABELLED: The combined use of acetaminophen with ibuprofen has long been in clinical use because the target of action of each drug is different and they do not interfere with each other. Appropriate dosing and managing of these drugs do not likely lead to organ toxicity. However, both acetaminophen and ibuprofen can induce liver problems and acute kidney failure, respectively, if administered at high doses. We report the case of a female child, in treatment with both acetaminophen and ibuprofen, administered at therapeutic antipyretic doses in condition of volume depletion, who suffered acute kidney and liver failure. CONCLUSION: The combined ibuprofen and acetaminophen treatment, even if administered at therapeutic dosages and in a reduced number of doses, may be dangerous in conditions of volume depletion.

Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study.

BACKGROUND: Under particular conditions a patent foramen ovale (PFO) can potentially give rise to ischemic stroke by means of paradoxic embolization. In obstructive sleep apnea syndrome (OSAS) right to left shunting (RLSh) can occur through PFO during periods of nocturnal apnea. Our study aimed to evaluate the prevalence of PFO diagnosed by means of transcranial Doppler (TcD) in subjects with OSAS. METHODS: Seventy-eight consecutive subjects with OSAS (mean age 53+/-12 years) and 89 normal controls (mean age 48+/-9 years) underwent TcD with intravenous application of agitated physiological saline solution. The test was performed on patients at rest and during Valsalva maneuver. RESULTS: PFO was present in 21 out of 78 patients with OSA (27%) and in 13 out of 89 control patients (15%). Seventeen out of 21 patients with OSA showed PFO only during Valsalva maneuver (85%) with respect to 12 out of 13 subjects of the control group (92%). Prevalence of PFO in OSAS was statistically different with respect to the control group (P<0.05). However, no statistically significant differences could be found for the prevalence of provocative-only shunting PFO with respect to already at rest shunting PFO in patients with OSAS with respect to the control group. CONCLUSIONS: Prevalence of PFO in subjects with OSA is significantly higher than in normal controls. The shunt is frequently present only during Valsalva maneuver.

Tilt-table test during transcranial Doppler monitoring in Parkinson's disease.

Cardiovascular autonomic dysfunction can occur in Parkinson's disease (PD) and intracranial vascular modifications following orthostatism may be relevant to diagnostic and therapeutic decision-making. We performed transcranial Doppler monitoring of right middle cerebral artery (MCA) at rest and during passive 70 degrees tilt in 19 patients with idiopathic PD and in 19 age-matched normal controls. Brachial arterial blood pressure (systolic, diastolic and mean), cardiac frequency (CF), respiratory frequency and mean velocity (MV) of the MCA were recorded after 10 min of rest in supine position, and each minute during 9 min of tilting and 5 min of restored clinostatic position. The pulsatility and cerebrovascular resistances (CVR) indexes were calculated. At rest there was no significant difference in blood pressure, CF, respiratory frequency and MCA mean velocity between patients and controls. During tilt test, PD patients showed a trend to higher pulsatility index values (p=0.09) and significant lower diastolic blood pressure (p=0.001), while there was no significant difference in CVR index. In conclusion, PD patients showed mild hypotensive response to orthostatic stress, with intracranial compensatory vasodilation. Our findings suggest a preserved intracerebral autoregulation in PD without symptoms of orthostatic intolerance.

Transcatheter closure of patent foramen ovale: a new migraine treatment?

Transcranial Doppler (TCD) is a very sensitive tool for detecting microembolic signals (MES) in the brain vessels after injection of air-mixed saline in case of right-to-left shunt (RLS). Patent foramen ovale (PFO) can be found in nearly one-half of migraineurs with aura, and, reciprocally, the prevalence of migraine in patients with stroke with PFO is exceedingly high. We aimed to monitor the passage of MES in the brain vessels during transcatheter closure of PFO and to subsequently follow-up patients for both the efficacy of the procedure and the severity of migraine. Seventeen patients suffering from migraine with aura (MA+, n = 8) or without aura (MA-, n = 9) scheduled to undergo transcatheter closure of PFO with Amplatzer PFO occluder devices for paradoxical cerebral embolism were monitored with contrast TCD (DWL, Germany) before, during, and after the procedure to estimate the magnitude of the shunt. Spontaneous embolization to the brain was also recorded. The patients were thereafter followed-up at 1, 3, and 6 months. A composite score of migraine severity, which included frequency, duration, and intensity of the attacks in the previous 3 months (range 0-10), was obtained at the time of the procedure and at the follow-up visits. Complete occlusion of PFO was achieved in all patients after 1 month in most cases. Preoperatively, the migraine score was 6.75 in MA+ and was 6 in MA--patients. After closure, the score dropped to 2.5 in MA+ and to 4.2 in MA--patients at the 6-month follow-up visit, the difference being statistically highly significant in both groups. Overall, 5 of 17 patients no longer complained of migraine, 10 of 17 were substantially improved, and two of 17 were unchanged at 6 months. Migraine aura disappeared in six of eight patients. Closure rate was very satisfactory, from a preoperative average bubble count of 42 to an average of 4 bubbles in the four patients in whom a small residual shunt was still detectable at the 6-month follow-up visit. TCD monitoring provides the most accurate assessment of RLS at the brain level. Closure of PFO with transcatheter devices results in the substantial relief of migraine in patients with stroke with large RLS.

Patent foramen ovale with paradoxical embolism: mid-term results of transcatheter closure in 256 patients.

The purpose of this study was to assess the safety and feasibility of percutaneous interventional closure of patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) in symptomatic patients. Between June 1999 and June 2002, we performed transcatheter closure of PFO in 256 consecutive symptomatic patients (female/male = 1.45; mean age 48 +/- 16 years; range 14-75): ischemic stroke (n = 101), transient ischemic attack (n = 144), peripheral and coronary arterial embolism (n = 17); multiple events (n = 23); platypnea-orthodeoxia syndrome (n = 2); refractory hypoxemia (n = 1); and migraine aura (n = 27). The implanted devices were an Amplatzer PFO Occluder (n = 248), a Gore-HELEX Septal Occluder (n = 4), and PFO STAR (n = 4). Most procedures (n = 176.69%) were done under two-dimensional intracardiac echocardiography (ICE) guidance alone; in the last 30 patients, 3D/4D ICE reconstruction (TomTec Imaging Systems) 6mbH was obtained. In 30 cases, ICE and contrast enhanced-TCD have been used simultaneously in the catheterization laboratory. The devices were placed correctly in all patients. Mean fluoroscopy time was 9.45 +/- 5 minutes (range = 2.5-35 minutes); mean procedural time was 57 +/- 21 minutes (range = 15-135 minutes). Total occlusion rate at follow-up (mean 19 months, range 1-33) was 98.1%. No significant recurrent neurological events were observed. Transcatheter closure of PFO with or without ASA is a safe and effective, minimally invasive procedure that ensures high closure rate and avoids life-long anticoagulation. Mid-term follow-up results appear favorable with respect to recurrent thromboembolic events.

Obstructive sleep apnea can be provocative for right-to-left shunting through a patent foramen ovale.

STUDY OBJECTIVES: Under particular conditions, a patent foramen ovale (PFO) can potentially give rise to ischemic stroke by means of paradoxical embolization, due to right-to-left shunt. Our study aimed to evaluate the presence of right-to-left shunt in patients with obstructive sleep apnea syndrome (OSAS) and diagnosed PFO during sleep. DESIGN AND SETTING: Assessment of provocative-only PFO and concomitant OSAS. Evaluation of right-to-left shunting during sleep by means of transcranial doppler with contrast medium injected in the cubital vein. PARTICIPANTS: 10 consecutive patients affected by PFO detectable only under Valsalva maneuver during wakefulness and affected by OSAS (mean age 52.8 +/- 10.7 years). INTERVENTIONS: Patients underwent transcranial doppler with injection of agitated saline solution mixed with air during normal breathing and during periods of apnea/hypopnea in nocturnal sleep. MEASUREMENTS AND RESULTS: Right-to-left shunt was present in 9 patients out of 10 and appeared during obstructive apneas longer than 17 seconds. In 1 out of 10 patients, only hypopneas occurred and no right-to-left shunt could be shown. The number of microembolic signals detected during periods of nocturnal apnea was positively correlated with the number detected during Valsalva maneuver in wakefulness (p<0.0001). CONCLUSIONS: In the nocturnal sleep period, right-to-left shunt can occur during single obstructive apneas in patients with OSAS and concomitant presence of PFO. This can be a risk factor for cerebrovascular diseases. This risk could probably increase proportionally to the respiratory disturbance index of these patients.