Impact of the COVID-19 pandemic on the activity of the Radiological Emergency Department: the experience of the Maggiore della Carità Hospital in Novara.

PURPOSE: During the first peak of the COVID-19 pandemic, the activity of Emergency Departments worldwide changed dramatically, focusing on diagnosis and care of the Sars-Cov-2 associated disease. These major changes also involved the activity of the Emergency Radiology Department (ERD). This study aimed to analyse the impact of the COVID-19 pandemic on imaging studies, both in terms of the amount, frequency and subspecialty of different imaging modalities requested to the ERD of the Maggiore della Carità Hospital in Novara (Italy). METHODS: To this end, our observational study took into account the imaging studies requested by the emergency department during three-time spans. These were defined as phase 0 (pre-pandemic), phase 1 (pandemic peak with complete lockdown) and phase 2 (post-pandemic peak with partial lifting of restrictive measures), as derived from Italian urgent decrees by the President of the Council of Ministers (DPCM) which established the duration and entity of the lockdown measures throughout the pandemic. The dataset was processed and then compared with Pearson's chi-squared test. RESULTS: During the pandemic peak, our data showed a significant drop in the total number of studies requested and a significant rise in computed tomography (CT) studies. In particular, a statistically significant increase in chest CT studies was found, probably due to the high sensitivity of this imaging method in identifying pulmonary involvement during respiratory tract infection of possible viral etiology (SARS-Cov-2). Moreover, we observed a statistically significant decrease of X-ray (XR) and ultrasound (US) studies during phase 1 compared to phase 0 and phase 2 probably due to a reduction in the numbers of ER visits for minor traumas given the mobility restrictions and people hesitancy in visiting the ER due to fear of contagion. CONCLUSIONS: We can conclude that the activity of the ERD was heavily impacted by the SARS-Cov-2 pandemic. Further studies will be needed to estimate the impact of the pandemic on public health in terms of excess mortality related to delayed diagnosis and care of non-COVID diseases.

Men and women affected by Sars-CoV-2 pneumonia: same CT features but different outcome.

AIM: To compare the computed tomography (CT) features of Sars-CoV-2 pneumonia between the two sexes and among different age groups. MATERIALS AND METHODS: Consecutive patients (n=331) who presented to the emergency department and underwent chest CT and reverse transcription polymerase chain reaction (RT-PCR) with a time interval <7 days, which were subsequently found to be consistent with Sars-CoV-2 infection, were enrolled retrospectively. Two experienced radiologists evaluated the images in consensus, recording the number of pulmonary lobes with ground-glass opacities and with consolidation. A CT score was subsequently calculated based on the percentage involvement of each lobe. Clinical symptoms, comorbidities, and level of required hospitalisation were noted. In-hospital mortality was recorded and analysed via the Kaplan-Meier estimator. RESULTS: Males and females had the same age distribution. No statistically significant difference was found in the analysed CT features and in the CT score (p=0.31) between the sexes. More females were affected by two or more comorbidities (17.1% versus 7.5%, p=0.024), all comorbidities except diabetes were more prevalent in females. Women had a higher probability to be discharged home and a lower probability to be admitted to the intensive care unit (ICU; p=0.008), in-hospital mortality was inferior (13.5% versus 22%). CONCLUSION: Despite more comorbidities, women had lower hospital admission and mortality, which was independent of CT findings between both sexes.

Association between red cell distribution width and response to methotrexate in rheumatoid arthritis.

Red cell distribution width (RDW) is an unconventional biomarker of inflammation. We aimed to explore its role as a predictor of treatment response in rheumatoid arthritis (RA). Eighty-two RA patients (55 females), median age [interquartile range] 63 years [52-69], were selected by scanning the medical records of a rheumatology clinic, to analyze the associations between baseline RDW, disease activity scores and inflammatory markers, as well as the relationship between RDW changes following methotrexate (MTX) and treatment response. The lower the median baseline RDW, the greater were the chances of a positive EULAR response at three months, 13.5% [13.0-14.4] being among those with good response, vs 14.0% [13.2-14.7] and 14.2% [13.5- 16.0] (p=0.009) among those with moderate and poor response, respectively. MTX treatment was followed by a significant RDW increase (p<0.0001). The increase of RDW was greater among patients with good EULAR response, becoming progressively smaller in cases with moderate and poor response (1.0% [0.4-1.4] vs. 0.7 [0.1-2.0] vs. 0.3 [-0.1-0.8]; p=0.03). RDW is a strong predictor of early response to MTX in RA. RDW significantly increases after MTX initiation in parallel to treatment response, suggesting a role as a marker of MTX effectiveness.

Non-surgical ablative therapies for inoperable benign insulinoma.

PURPOSE: Benign insulinoma is the most common functioning neuroendocrine tumor of the pancreas. The gold-standard therapeutic approach for insulinoma is surgery, which allows for tumor removal, histology and immunochemical analyses. If surgery is not feasible, minimally invasive ablative procedures performed by interventional radiology can lead to partial or complete remission of hormone hypersecretion and tumor control in insulinoma patients. METHODS: We performed a review of existing literature on non-chemotherapeutic/radioactive ablative techniques employed for the treatment of benign, otherwise inoperable, pancreatic insulinoma. For this purpose, feasibility, effectiveness and safety of ablative treatments for pancreatic insulinoma were reviewed from literature data published from 1982 to date. RESULTS: A total of 44 insulinoma cases treated with non-surgical ablative techniques were desumed, and divided as follows: 7 cases of tumor embolization, 26 ethanol ablations, 7 radiofrequency ablations, 2 high intensity focused ultrasound ablation, 1 irreversible electroporation and 1 percutaneous microwave ablation. Most cases involved single insulinoma, predominantly located in the pancreas head and body. In the majority of patients, ablation was chosen instead of surgery due to severe comorbidities. After an average follow-up of 16 months, the overall success rate of non-surgical ablative treatments of insulinoma was 84%, the recurrence/persistence rate was 16%, and transient adverse events were noted in 23% of cases. Adverse events were usually self-limiting and medically manageable. CONCLUSIONS: Non-surgical ablation is a feasible, safe and repeatable procedure in patients with pancreatic insulinoma, who are not candidate to surgery or refuse it. Partial or complete control of symptoms and tumor growth is experienced by the majority of patients.

Recovery of Arapaima sp. populations by community-based management in floodplains of the Purus River, Amazon.

In the present study a unique dataset on population abundance in various community-based management (CBM) and non-CBM areas is analysed to address the question of whether CBM can recover overexploited populations of Arapaima sp. in river-floodplain ecosystems. All non-CBM areas possessed depleted Arapaima sp. populations with a mean density of 0·01 individuals ha(-1) . Arapaima sp. population densities in all CBM areas changed over time from depleted to overexploited or well managed status, with a mean rate of increase of 77% year(-1) . Rates of Arapaima sp. population recovery in CBM areas differed, probably reflecting differences in ecosystem productivity and compliance with management regulations. These results indicate that CBM schemes can be effective tools for the recovery and conservation of fish populations with non-migratory life cycles in tropical river-floodplain ecosystems.

Assessing water-electrolyte changes of hyperglycaemic hyperosmolar coma.

AIM: We reported new methods to accurately estimate salt and water deficits during hyperglycaemic hyperosmolar coma (HC), valid under restricted boundary conditions. The accuracy of these estimates is herein verified over the unrestricted spectrum of abnormalities, to correctly evaluate any patient with just one algorithm that recognizes the boundary conditions pertaining to each abnormality, choosing the appropriate calculations. METHODS: A large number of cases of HC was simulated on computer by subtracting an exhaustive combination of water, sodium and chloride losses coupled to a large variety of gains in glucose. Altered solute concentrations were generated. From these true plasma concentrations generated by the computer, the losses of water and electrolytes were back-calculated with our new computational algorithm, by knowing in addition only the normal total body water and extra-cellular volume. The accuracy of the method was tested by comparing true to calculated values over the entire range of deranged values. In 100 patients admitted to hospital for HC these same computations were performed, where calculated data were validated by comparing them to true data obtained by balance studies performed during correction of the abnormality. RESULTS: Both in simulated and real cases of HC true and calculated data for the changes in Na and volume were significantly correlated (R (2)=0.76 and 0.50, respectively, P<0.01), while their mean values were not significantly different by paired "t" tests (P>0.05 for all). CONCLUSION: Our new computation algorithm, applicable to the bed-side, useful in accurately assessing the average water-electrolyte deficits of HC, can be used to guide correct re-infusion strategies.

Computation of Na and water deficit of iso-osmolar dehydration.

BACKGROUND AND AIMS: The presence of altered plasma Na concentration (PNa) allows calculations of changes in water and electrolyte contents, which are not feasible during normonatremic derangements. We have developed a computational algorithm whereby the changes in solute (ΔNa and ΔCl) and solvent (ΔV) contents can be computed exactly when Na is lost entirely as NaCl (or NaHCO(3)) and nearly exactly in all other circumstances, except when the losses of Na and Cl occur in the same proportions as those of the normal plasma concentration of these ions. METHODS: In computer experiments, we simulated different fluid depletions containing 140 mEq/l of Na (which is to say, ΔNa/ΔV ≈ 140), coupled with variable ratios in Na to Cl losses (variable ΔNa/ΔCl). The data were back-calculated with our algorithms from the ensuing plasma ion concentrations (PNa(1), PCl(1) and POAN(1), where subscript (0) and (1) indicate normal and deranged plasma concentration values, respectively, and OAN indicates anions other than Cl), as if they had been measured on patients, and from known normal values (TBW(0), ECV(0), Na(0)). These were compared to the true values used to build the simulations. This procedure was reproduced in 17 patients suffering from iso-osmolar dehydration, where true data were obtained by balance studies. RESULTS: True and calculated data were compared with linear regression analysis. We obtained significant correlations both in computer-simulated and real patients (R(2) = 0.83, p < 0.005 and R(2) = 0.63, p < 0.05, respectively). CONCLUSION: This new math model and its related computational method are useful in the correct evaluation and treatment of iso-osmolar dehydration.

Depression is associated with increased occurrence of left ventricle concentric geometry in older subjects independently of blood pressure levels.

BACKGROUND AND AIM: Depression is emerging as an independent risk factor for CV events, though mechanisms underlying this association are unknown. We investigated the relation between depression and LV hypertrophy (LVH) and LV structure in a group of elderly subjects. METHODS AND RESULTS: Three hundred seventy patients (mean age 79 ± 6 years) were enrolled. CV risk factors were assessed. Depression was defined as a score ≥ 6 on the 15-item Geriatric Depression Scale. On the basis of the presence of LVH and of LV relative wall thickness (RWT) 4 echocardiographic patterns of LV adaptation were defined: concentric LVH (LVH with increased RWT); eccentric LVH (LVH with normal RWT); concentric LV remodeling (no LVH with increased RWT); normal LV (no LVH with normal RWT). Prevalence of hypertension was approximately 86% and 24.7% had diabetes (n.s. depressed vs not depressed subjects). BP was comparable in these two groups (134.7 ± 1.4 vs 135.3 ± 1.8 mmHg, 77.1 ± 0.8 vs 76.3 ± 1.0 mmHg for SBP and DBP respectively). Depressed subjects (n = 165) showed a significantly higher occurrence of concentric LVH than not depressed, after adjustment for age, sex, and hypertension. Depression was associated with a 2.1 fold higher risk of showing a LV concentric, either remodeling or LVH, pattern after adjustment for age, sex, and traditional CV risk factors. CONCLUSIONS: Depression is accompanied by a higher occurrence of concentric LVH in elderly subjects, independently of BP levels.

Quantitative assessment of the abnormalities of hyperosmolar coma when glucose excess is larger than Na deficit.

Computing Na and water deficits of hyperosmolar coma (HC) is important in correcting the derangement, to avoid unwanted iatrogenic electrolyte derangements and brain oedema. This paper derives and applies formulas valid when GA (glucose accumulation) >2.DeltaNa (sodium loss), with or without DeltaV (water depletion). We built a model system and wrote the equations describing the relationships between volume and concentration of solutes within the body water compartments. HC was simulated on computer experiments by adding GA in different amounts combined with a large variety of DeltaNa and DeltaV. The ensuing concentrations in Na (PNaNone. (1)) and glucose (PG (1)) were used to identify the condition GA >2 . DeltaNa, DeltaV=0 or not equal 0, and then, with original formulas, to back calculate GA, DeltaNa and DeltaV. These same calculations were applied to 31 patients with HC. The procedure to recognize the conditions under investigation unerringly discarded all simulations except those characterized by GA >2 . DeltaNa, with or without DeltaV. When DeltaV=0, the computations yielded values identical to the true ones for GA and DeltaNa (R (2)=1.00, p<0.0001). When DeltaV was present, the correlation coefficients between calculated and true values were 0.92 (p<0.001) for GA, 0.73 (p<0.001) for DeltaNa, 0.74 (p<0.001) for DeltaV in computer experiments, while they were R (2)>0.47<0.95 (p<0.001) in patient studies. The accuracy in computing solute and water changes demonstrates the validity of our model system of HC, and of the calculation formulas, which can be used to quantitatively evaluate the deficits in Na and volume, as well as the addition of glucose, improving the effectiveness of treatment.

Methods for the quantitative assessment of electrolyte disturbances in hyperglycaemia.

AIM: While empirical calculations are presently used, exact solutions to compute volume and solute changes of hyperosmolar coma (HC) can be obtained by subdividing the patients according to well defined clinical and laboratory conditions. These are represented by PNa(G), the plasma Na concentration that would be present if there were only glucose addition (GA), that discloses prevalent Na depletion when >PNa(1), prevalent water deficit when , = or

Metabolic characteristics of glucose intolerance: the critical role of obesity.

INTRODUCTION: Obesity enhances insulin secretion and resistance. We investigated its importance in linking insulin metabolism to glucose intolerance. MATERIAL AND METHODS: We studied 700 subjects referred by general practitioners for possible metabolic abnormalities. Plasma glucose was measured before (FPG) and after (2h-PG) OGTT, together with insulin. Insulin resistance was estimated by HOMA-IR, insulin sensitivity using ISI(gly) and ISI(Stumvoll) indexes, insulin secretion by first (1stPH est) and second phase (2ndPH est) estimates. RESULTS: Sixty three subjects had impaired glucose tolerance (IGT), 132 impaired fasting glucose (IFG), 63 a mixed disorder (IFG/IGT). Insulin resistance was present only in IGT and IFG/IGT. IFG sub-jects had inappropriately low insulin secretionexclusively during fasting. In a stepwise logistic regression analysis BMI>or=27, female sex and hy-pertension were associated to an altered 2h-PG during OGTT, while hypertension and age were linked to alterations in FPG. While overweight prevalence (BMI>or=7) was higher in all glucose intolerance groups, obesity (BMI>or=30) was typical of IGT. Overweight and obesity were related to higher insulin concentration, secretion and resistance. Obese normal glucose tolerant subjects were more insulin resistant than lean IFG patients. DISCUSSION: OGTT is essential to correctly establish the metabolic derangement of glucose intolerance. Obesity is significantly connected with the impairment of insulin metabolism even in subjects with normal FPG. Considering that both obesity and insulin resistance are independently associated to an increased cardiovascular risk, all overweight subjects, even with normal FPG, should be referred for OGTT evaluation to define glucose tolerance status in order to enforce adequate preventive actions.

Trazabilidad como eje de un sistema certificado de calidad / Traceability at the core of a certified quality system

A modo de tribuna de opinión, este artículo aporta un argumento a favor del servicio de esterilización como una inversión real para un centro de salud. El principal punto de apoyo para la defensa es el aumento de la seguridad para el paciente que supone un área quirúrgica sometida a controles de calidad de esterilización rigurosos. De ahí que la trazabilidad, un buen estudio, documentación y registro de los procesos resulte crucial (AU)

As a matter of opinion, this article puts forward an argument in favors of the sterilization service as a real investment for a health centre. The main point of support in defending this idea is the increase in safety for patients in a surgical unit which is subject to rigorous sterilization quality controls. For this reason, traceability, a thorough study, documentation and recording of the procedures are crucial (AU)

Susceptibility trends of Bacteroides fragilis group isolates from Buenos Aires, Argentina.

The aim of this study was to analyze the susceptibility trends to seven antibiotics of Bacteroides fragilis group isolates based on three survey studies performed by the Committee of Anaerobic Bacteria between 1989 and 2002. Fifty three, 82 and 65 B. fragilis group isolates were collected during each period. The antimicrobial agents included were: ampicillin, ampicillin-sulbactam (2:1), cefoxitin, piperacillin, imipenem, clindamycin, and metronidazole. Minimal inhibitory concentrations (MICs) were determined according to the reference agar dilution method described by the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS). The most active antibiotics for B. fragilis and non-B. fragilis species throughout the three periods were: imipenem with 99.1 and 100% of activity, respectively, and metronidazole with 100% of activity. The susceptibility to ampicillin-sulbactam showed a decrease, from 100% to 90.3% and to 82.4 % in the last period, for both B. fragilis and non-B. fragilis species, respectively. The overall susceptibility rates for cefoxitin, piperacillin, and clindamycin were significantly different between B. fragilis and non-B. fragilis species (84.2% vs. 56.5%; 85.9% vs. 66.7% and 88.8% vs. 64.7%, respectively, p < 0.05). Cefoxitin was the antibiotic that showed more variations as regards periods and species. The susceptibility rates for clindamycin were low, about 60%, for non-B. fragilis species during the last two periods. The variations observed in the susceptibility patterns of the B. fragilis group isolates emphasize the need to continue monitoring the emergence of resistance in order to guide the election of the most appropriate antibiotic therapy scheme for anaerobic infections.

[Nonpuerperal breast abscess caused by Finegoldia magna]. / Absceso mamario no puerperal por Finegoldia magna.

Finegoldia magna is a species of strictly anaerobic gram-positive cocci, arranged in pairs, tetrads, and clusters. These organisms are components of the normal flora of the skin, gastrointestinal and genitourinary female tracts, and oral cavity. They are asaccharolytic and their major energy sources are aminoacids and peptones. The species is usually isolated in polymicrobial cultures from abscesses, soft tissue infections, bone and joints. In the case herein presented, F. magna was recovered in pure culture from a nonpuerperal breast abscess, which adds to the two reported cases in related literature. Species identification was performed by special potency disks, standard bacteriological anaerobic tests, and production of saccharolytic and proteolytic enzymes. Antimicrobial susceptibility testing was performed by using the epsilometric test. The agents assayed and MICs (microg/ml) values were: penicillin, 0.064; cephalotin, 1; metronidazole, 0.25; minocycline, < 0.016; azithromycin, 4; claritromycin, 2. We would like to highlight the importance of identifying anaerobic gram-positive cocci at species level, and of determining the antimicrobial susceptibility pattern, when they are isolated in pure culture from appropriate samples, as in the case presently reported.

A new method to distinguish the hyponatremia of electrolyte loss from that due to pure solvent changes.

Estimates of solute and solvent changes during electrolyte abnormalities are valid only when either total body water (TBW) or solute content do not change, while it cannot be established which one of these is altered. The present paper provides a method capable of distinguishing these two different conditions. When only solvent changes, the respective concentration ratios of plasma (P) solutes PCl/PNa, POAN: /PNa, PCl/POAN: (POAN: = anions other than Cl) remain unchanged. Moreover, PNa(1)/PNa(0) (the ratio of PNa during the derangement over the normal value, indicated by subfix (1) and (0), respectively) = PCl(1)/PCl(0) = POAN: (1)/POAN: (0.) When these constraints are met, the abnormality is due only to a TBW change, which is easily calculated and corrected. When they are not met, the exact change in Na content is correctly calculated assuming no variation in TBW. These calculations could still be useful even in the presence of TBW modifications, where they represent minimum estimates of electrolyte losses. The formulas were validated by computer simulations generating true electrolyte concentrations, which were then used to back calculate the changes in their contents and extra/intra-cellular volumes. Since the predicted results were significantly correlated with the true data, the method was transferred to 24 patients with electrolyte disturbances, who met the above constraints. The calculated volume changes were significantly correlated with those obtained by body weight measurements (regression coefficient = 0.94, P < 0.0001), while the quantitative estimates of Na deficit predicted the PNa values measured after corrective treatment (P < 0.0001). This new method may prove valuable in diagnosing and treating electrolyte derangements.

Poor specificity of fasting plasma glucose cut-off values in ruling out glucose intolerance: the complementary usefulness of OGTT.

INTRODUCTION: With the objective to assess the diagnostic power of the ADA criteria in detecting glucose intolerance, we studied 654 patients by performing an oral glucose tolerance test (OGTT). MATERIAL AND METHODS: The design required computing sensitivity, specificity and predictive values for different cut-off levels of fasting plasma glucose (FPG). The patients were recruited in an outpatient facility of a General Internal Medicine department affiliated to a Medical School. RESULTS: Lowering the threshold from 7.0 to 6.1, 5.6, 5.0 and 4.4 mmol/l (126 to 110, 100, 90 and 80 mg/dl) respectively, resulted in a progressive fall in specificity (99.6, 91.6, 76.0, 45.3 and 15.8%) combined to a rise in sensitivity (8.6, 30.7, 56.4, 76.4 and 92.9%). Two subjects with FPG <5.0 mmol/l were diabetic. At the lowest FPG of 4.4 mmol/l the percentage of glucose intolerant patients by OGTT was still 11% while at 6.1 mmol/l the false positive rate was 50%. DISCUSSION: The simple screening based on FPG alone, as suggested by ADA, is ineffective, not detecting an unacceptable number of subjects with glucose intolerance, and conveys the high cost of working up an excessively large number of false positives. Only the OGTT represents the effective screening procedure.

Insulin sensitivity: gender-related differences in subjects with normal glucose tolerance.

BACKGROUND AND AIMS: To verify whether age and the perimenopausal state may herald the onset of the metabolic syndrome (MS) in females as compared to age-matched males, we studied subjects with normal glucose tolerance, according to ADA definition. METHODS AND RESULTS: In 368 eligible subjects subdivided into three age groups we measured insulin sensitivity by ISI-glycaemia, resistance by HOMA-IR, computed, during OGTT, from fasting and 2-h post-load plasma insulin and glucose concentrations. The significance of differences was tested between different age groups and between males and females within corresponding age groups. Insulin sensitivity fell slightly and insulin resistance rose significantly in the perimenopausal group as compared to younger and older female patients, and compared to men of the same age. This pattern remains after excluding patients with high blood pressure, and after adjusting for WHR and BMI by multivariate analysis. HOMA-IR averaged 2.9+/-1.8 in females, 2.2+/-1.2 in men aged 45-54 years (p<0.02), while in the other age groups insulin resistance was higher in men. CONCLUSION: The onset of MS during the menopause is associated with a physiological shift in insulin resistance occurring even in normal glucose tolerant subjects, suggesting that it may depend upon critical metabolic changes occurring specifically in that age period.