Immune disturbance leads to pulmonary embolism in COVID-19 more than classical risk factors: a clinical and histological study.

COVID-19 induces endotheliitis and one of the main complications is enhanced coagulation. The incidence of pulmonary embolism (PE) in COVID-19 (CPE) has increased and clinical features for a rigorous analysis still need to be determined. Thus, we evaluated the clinical characteristics in CPE and the immune infiltration that occurred. Between January 1 and December 31, 2021, 38 patients were affected by CPE (9 ICU, 19 males/19 females, 70.18 ± 11.24 years) out of 459 COVID-19 cases. Controls were subjects who were evaluated for PE between January 1 2015, and December 31, 2019 (92 patients, 9 ICU, 48 males/45 females, 69.55 ± 16.59 years). All patients underwent complete physical examination, pulmonary computed tomography, laboratory tests, D-dimer, and blood gas analysis. There were no differences in laboratory tests or D-dimer. In patients with CPE, pO2, alveolar-arterial oxygen difference (A-aDO2), oxygen saturation %, and the ratio between arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FiO2), P/F, were significantly increased. There were no differences in PaCO2. Platelet count was inversely correlated to P/F (r = - 0.389, p = 0.02) but directly to A-aDO2 (r = 0.699, p = 0.001) only in patients with CPE. Histology of lung biopsies (7 CPE/7 controls) of patients with CPE showed an increase in CD15+ cells, HMGB1, and extracellular MPO as a marker of NETosis, while no significant differences were found in CD3+, CD4+, CD8+, and intracellular MPO. Overall, data suggest that CPE has a different clinical setting. Reduced oxygen content and saturation described in Patients with CPE should not be considered a trustworthy sign of disease. Increased A-aDO2 may indicate that CPE involves the smallest vessels as compared to classical PE. The significant difference in NETosis may suggest the mechanism related to thrombi formation.

Evaluation of Intraoperative End-Tidal Carbon Dioxide Change Relates to Length Hospitalisation in Peridiaphragmatic Surgery: A Pilot Study.

Intraoperative evaluation is deeply changed using many new tools, both invasive and non-invasive. Peripheral oxygen saturation percentage (SpO2) is the more reliable method for a non-invasive monitoring of patient's blood oxygen concentration. Capnography (using end-tidal CO2 (EtCO2)) evaluation is an immediate and continuous non-invasive monitoring of carbon dioxide (CO2) in the breathing that provides important information on circulatory status and ventilation.Aim of this study is to perform a preliminary analysis of oxygen change during surgery exploring its possible influence on post-operative evolution. METHODS AND RESULTS: Intraoperative evaluation of SpO2 and EtCO2 was performed. Change in each parameter was categorised as 1 point for each five-point variation from baseline value (∆SpO2 as 1 point for each 5%, ∆EtCO2 as 1 point for each 5 mmHg). For each patient, the length of stay (LOS) in the intensive care unit (ICU), total hospitalisation, duration of intervention, surgical risk and complications were recorded. RESULTS: We analysed 93 consecutive patients (43 males and 40 females, aged 66.35 ± 9.79 years) that underwent peridiaphragmatic surgery. Forty patients (48.19%) presented complications after surgery. There was no statistically significant difference in age, duration of intervention and length of stay in ICU between complicated and non-complicated patients. As expected, patients with complications present an increased hospitalisation time compared to uncomplicated cases (14.69 ± 11.41 days vs 10.70 ± 6.28 days; p < 0.05). ∆EtCO2 was significantly increased (p < 0.05) in complicated compared to non-complicated. No differences were found in ∆SpO2 between the two groups. Considering the whole population, ∆EtCO2 presents a significant direct correlation to surgical risk, hospitalisation and duration of intervention. CONCLUSION: ∆EtCO2 may be related to possible complications after surgery and hospitalisation. An important comparison between SpO2 and EtCO2 and strict monitoring with an intraoperative arterial blood gas (ABG) sample during the main steps of surgery could bring some essential information to understand oxygen changes in intra- and post-operative evolution. However, a further validation analysis is needed before the approach can be used extensively in daily clinical settings.

A New Score to Assess the Perioperative Period of the Cancer Patient Undergoing Non-Palliative Elective Surgery: A Retrospective Evaluation of a Case Report by PERIDIA Score.

The complexity of cancer patients and the use of advanced and demolitive surgical techniques frequently need post-operatory ICU hospitalization. To increase safety and to select the best medical strategies for the patient, a multidisciplinary team has performed a new peri-operatory assessment, arising from evidence-based literature data. Verifying that most of the cancer patients, admitted to the intensive care unit, undergo major surgery with localizations in the supramesocolic thoraco-abdominal area, the team focused the attention on supramesocolic peridiaphragmatic cancer surgery. Some scores already in use in clinical practice were selected for the peri-operatory evaluation process. None of them evaluate parameters relating to the entire peri-operative period. In detail, only a few study models were found that concern the assessment of the intra-operative period. Therefore, we wanted to see if using a mix of validated scores, it was possible to build a single evaluation score (named PERIDIAphragmatic surgery score or PERIDIA-score) for the entire peri-operative period that could be obtained at the end of the patient's hospitalization period in post-operative ICU. The main property sought with the creation of the PERIDIA-score is the proportionality between the score and the incidence of injuries, deaths, and the length of stay in the ward. This property could organize a tailor-made therapeutic path for the patient based on pre-rehabilitation, physiotherapy, activation of social assistance services, targeted counseling, collaborations with the continuity of care network. Furthermore, if the pre-operative score is particularly high, it could suggest different or less invasive therapeutic options, and if the intra-operative score is particularly high, it could suggest a prolongation of hospitalization in ICU. The retrospective prospective study conducted on 83 patients is still ongoing. The first data would seem to prove an increase of clinical complications in patients who were assigned a one-third score with respect to the maximum (16/48) of PERIDIA-score. Moreover, patients with a 10/16 score within each phase of the evaluation (pre, peri, and post) more frequently develop injuries. In the light of these evidence, the 29-point score assigned to our patient can be considered as predictive for the subsequent critical and fatal complications the patient faced up.

Imaging Evaluation of Pulmonary and Non-Ischaemic Cardiovascular Manifestations of COVID-19.

Coronavirus Disease 2019 (COVID-19) has been a pandemic challenge for the last year. Cardiovascular disease is the most described comorbidity in COVID-19 patients, and it is related to the disease severity and progression. COVID-19 induces direct damage on cardiovascular system, leading to arrhythmias and myocarditis, and indirect damage due to endothelial dysfunction and systemic inflammation with a high inflammatory burden. Indirect damage leads to myocarditis, coagulation abnormalities and venous thromboembolism, Takotsubo cardiomyopathy, Kawasaki-like disease and multisystem inflammatory syndrome in children. Imaging can support the management, assessment and prognostic evaluation of these patients. Ultrasound is the most reliable and easy to use in emergency setting and in the ICU as a first approach. The focused approach is useful in management of these patients due its ability to obtain quick and focused results. This tool is useful to evaluate cardiovascular disease and its interplay with lungs. However, a detailed echocardiography evaluation is necessary in a complete assessment of cardiovascular involvement. Computerized tomography is highly sensitive, but it might not always be available. Cardiovascular magnetic resonance and nuclear imaging may be helpful to evaluate COVID-19-related myocardial injury, but further studies are needed. This review deals with different modalities of imaging evaluation in the management of cardiovascular non-ischaemic manifestations of COVID-19, comparing their use in emergency and in intensive care.

Long-term evolution of the electrical stimulation for cochlear implant adult patients. The role of a progressive adaptation method.

Background: In clinical experience patients who do not frequently check the cochlear implant (CI) maps have poor auditory performance and poor acceptance of map variations over time.Aims: The aim of the present study was to evaluate the effect of CI map optimization on both speech perception and subjective hearing in a group of CI patients with a long-standing map.Material and methods: 14 patients (6 females and 8 males; age range 16-77, mean age 45.86 ± 23.85 years) fitted with a unilateral CI (Cochlear Ltd, Sydney, Australia) and a map unchanged for at least 12 months were evaluated. All CIs were remapped using mapping method with progressive adaptation. The speech discrimination in noise and subjective hearing perception (SSQ questionnaire) were evaluated with old and new map.Results: The differences in electrode level with old and new map were significantly different both for T and C- Levels (p < .001). Speech discrimination in noise was significantly better (22.9%; p < .0001) after map optimization. The SSQ questionnaire showed no statistically significant difference in the overall scores, except the listening effort sub-scale.Conclusions: Longstanding MAPs are associated with poor speech discrimination. Degradation of electrical stimulation is associated with increased mental effort.