Effect of intermediate/high versus low dose heparin on the thromboembolic and hemorrhagic risk of unvaccinated COVID-19 patients in the emergency department.

BACKGROUND: The optimal prophylactic dose of heparin in patients with coronavirus-associated disease 2019 (COVID-19) in the emergency department (ED) is debated. This study aimed to analyze different thromboprophylaxis approaches in unvaccinated COVID-19 patients admitted to ED without initial venous thromboembolism. METHODS: Retrospectively, the effect of intermediate/high versus low dose heparin treatment was evaluated from December 2020 to July 2021 in a tertiary Academic Hospital in northeast Italy. The primary outcome comprised arterial or venous thromboembolism or all-cause death within 30 days. Secondary outcomes comprised each single primary outcome component or major hemorrhagic event. Cox regression was used to determine predictors of the primary outcome and propensity score weights to balance the effect of heparin treatment on all outcomes. RESULTS: Data of 144 consecutive patients (age 70 ± 13, 33% females) were included in the study. High-dose prophylactic heparin was used in 69%, intermediate in 15%, and low in 17% of patients. The primary outcome occurred in 48 patients. Independent predictors of the primary outcome were COVID-19 severity (hazards ratio (HR) 1.96, 95% confidence interval (CI) 1.05-3.65, p = 0.035) and D-dimer levels (HR each log ng/dl 1.38, 95% CI 1.04-1.84, p = 0.026). Intermediate/high dose heparin did not affect the risk of the primary outcome compared with the low dose (weighted HR 1.39, 95% CI 0.75-2.56, p = 0.292). Intermediate/high heparin increased the risk of major hemorrhagic events (weighted HR 5.92, 95% CI 1.09-32, p = 0.039). CONCLUSIONS: In unvaccinated COVID-19 patients admitted to ED, prophylaxis with heparin at the intermediate/high dose did not reduce primary outcome compared with the low dose but increased the risk of major hemorrhagic events.

Retrospective analysis of patients with dizziness evaluated in Syncope Unit: a real life experience.

PURPOSE: To evaluate the characteristics of patients referred for dizziness to a Syncope Unit. METHODS: This is a retrospective study. Of 491 patients referred to the Syncope Unit of Careggi Hospital in 2015, 198 (40.3%) who experienced dizziness alone or associated with a history of transient loss of consciousness were enrolled. All the patients underwent an initial evaluation according to the European Society of Cardiology guidelines on syncope. We compared the clinical characteristics and final diagnosis of patients referred for dizziness alone (n = 64) to those of patients with dizziness and history of transient loss of consciousness (n = 134). RESULTS: The study population had a mean age of 62 ± 20 years (range 16-96 years) and 101 (51%) were female. A final diagnosis of pre-syncope was made in about the 80% of the patients without a previous history of transient loss of consciousness. In this group, other diagnoses were benign paroxysmal positional vertigo (6.3%), transient ischemic attack (4.7%) or psychogenic dizziness (7.8%). Syncope was diagnosed in the 82.7% of the patients with dizziness and history of transient loss of consciousness. CONCLUSION: Dizziness was the main reason for referral to the Syncope Unit in almost one-third of the patients, in whom pre-syncope was the most frequent final diagnosis. Otological, neurological and psychiatric disorders should be also considered as differential diagnosis, highlighting the importance of a multidisciplinary approach.

Computational fluid dynamics applied to virtually deployed drug-eluting coronary bioresorbable scaffolds: Clinical translations derived from a proof-of-concept.

BACKGROUND: Three-dimensional design simulations of coronary metallic stents utilizing mathematical and computational algorithms have emerged as important tools for understanding biomechanical stent properties, predicting the interaction of the implanted platform with the adjacent tissue, and informing stent design enhancements. Herein, we demonstrate the hemodynamic implications following virtual implantation of bioresorbable scaffolds using finite element methods and advanced computational fluid dynamics (CFD) simulations to visualize the device-flow interaction immediately after implantation and following scaffold resorption over time. METHODS AND RESULTS: CFD simulations with time averaged wall shear stress (WSS) quantification following virtual bioresorbable scaffold deployment in idealized straight and curved geometries were performed. WSS was calculated at the inflow, endoluminal surface (top surface of the strut), and outflow of each strut surface post-procedure (stage I) and at a time point when 33% of scaffold resorption has occurred (stage II). The average WSS at stage I over the inflow and outflow surfaces was 3.2 and 3.1 dynes/cm(2) respectively and 87.5 dynes/cm(2) over endoluminal strut surface in the straight vessel. From stage I to stage II, WSS increased by 100% and 142% over the inflow and outflow surfaces, respectively, and decreased by 27% over the endoluminal strut surface. In a curved vessel, WSS change became more evident in the inner curvature with an increase of 63% over the inflow and 66% over the outflow strut surfaces. Similar analysis at the proximal and distal edges demonstrated a large increase of 486% at the lateral outflow surface of the proximal scaffold edge. CONCLUSIONS: The implementation of CFD simulations over virtually deployed bioresorbable scaffolds demonstrates the transient nature of device/flow interactions as the bioresorption process progresses over time. Such hemodynamic device modeling is expected to guide future bioresorbable scaffold design.

Hyalomatrix PA in burn care practice: results from a national retrospective survey, 2005 to 2006.

Results of a national retrospective survey on Hyalomatrix PA in burn patients are reported.A total of 11 burn centers were contacted.A total of 57 patients were available. Hyalomatrix PA was used on young and adult patients, mainly in deep partial thickness and full thickness burns. In most cases, Hyalomatrix PA was applied immediately after the wound cleaning (wound debridement or escharectomy for adults, dermabrasion or debridement in young patients). After 7 days, reepithelization processes were more frequent in deep partial thickness burns. One-half of the patient population underwent grafting. After 29 days, complete closure was achieved in almost all patients. The Vancouver Scar Scale showed better values for adults, while no differences were observed for burn depth or patients undergoing grafting. No adverse reactions were recorded.Hyalomatrix PA is used in young and adults, in deep partial thickness and full thickness burns, as a temporary coverage before grafting or alone for wound healing.

Versajet hydrosurgery versus classic escharectomy for burn débridment: a prospective randomized trial.

Our purpose was to conduct a prospective randomized trial to compare the Versajet system (Smith & Nephew, London, UK) vs hand-held dermatome escharectomy for burn débridment. All patients admitted over the course of 1 year at our burn center were recruited and randomly assigned to Versajet or hand-held dermatome escharectomy. We evaluated the 1) time for complete débridment and 2) the efficacy of Versajet in reaching the correct dermal plane. Secondary end points were the assessment of postoperative pain (evaluated with the visual analog scale), adverse effects, complete healing times, and contractures rates (after 6 months). A total of 87 patients were analyzed in two homogeneous groups of 42 (Versajet) and 45 (escharectomy) patients. All of them received adequate débridment, but the Versajet procedure was faster (P < .05) and more precise in obtaining the correct plane. One Versajet patient required ligation of a large subcutaneous vessel, which inadvertently was cut during the procedure. Versajet is a feasible, simple, and safe technique that hastens surgical débridment of burns and adds more precision to the procedure.

Apoptotic death in deep partial thickness burns vs. normal skin of burned patients.

BACKGROUND: Deep partial thickness burns have an ambiguous behavior evolving either into spontaneous healing or full thickness burns. The aim of this study was to investigate these lesions for the presence of apoptosis thereby giving a possible cellular explanation to their peculiar clinical progression. METHODS: We used colocalization of DNA fragments (terminal deoxynucleotidyl transferase mediated dUTP nick end labeling) and Fas ligand CD95 antibodies to calculate the apoptotic rate of deep partial thickness burns and normal skin in 21 patients after acute thermal injuries (significant difference considered: P < 0.05). RESULTS: Deep partial thickness burns were associated with a higher apoptotic rate than normal skin (48.15% +/- 17.22% versus 18.6% +/- 7.2%; P = 0.0002). There were no apparent significant correlations of apoptotic rate with age, days from injury, total burn surface area or deep burn area except for a slight correlation with sex (r = 0.484; P = 0.02). CONCLUSIONS: A higher apoptotic rate was present in dermal cells of deep partial thickness burns if compared to that of the unburned skin. These data would suggest that deep partial thickness progression derive from apoptosis. Specific studies are required to confirm this hypothesis and to investigate its clinical and therapeutic significance.

The use of Hyalomatrix PA in the treatment of deep partial-thickness burns.

Since 2001, Hyalomatrix PA (Fidia Advanced Biopolymers, Abano Terme, Italy) has been used in our center on pediatric burned patients as a temporary dermal substitute to cover deep partial-thickness burns after dermabrasion. This "bridge" treatment was adopted to remove necrotic debris (dermabrasion) and to stimulate regeneration in a humid and protected environment (Hyalomatrix PA). We present results obtained with this approach. On the third to fifth day after admission, dermabrasion was practiced on deep burned areas, which were covered with Hyalomatrix PA. Change of dressings was performed every 7 days. On day 21, those areas still without signs of recovery were removed with classic escharectomy and covered with thin skin grafts. We treated 300 patients. Sixty-one percent needed only one dermabrasion treatment, 22.3% (67 patients) more than one, and 16.7% (50 patients) the classic escharectomy. A total of 83% of patients healed within 21 days. Our study suggests that the combination of dermabrasion with a temporary dermal substitute could be a good and feasible approach for treatment of deep partial-thickness burns. Prospective randomized studies are now necessary to compare our protocol with the gold standard treatment of topical dressings.

Apoptotic cells are present in ischemic zones of deep partial-thickness burns.

Deep partial-thickness burns exhibit ambiguous behavior, either spontaneously healing or evolving into full-thickness burns. The aim of this study was to investigate these lesions for the presence of apoptotic cells and to compare their rate with that of superficial and full-thickness burns. We used colocalization of DNA fragments (ie, terminal deoxynucleotidyl transferase Biotin-dUTP nick end labeling) and Fas ligand CD95 antibodies to calculate the apoptotic rate of superficial, deep partial-thickness and full-thickness burns in 45 patients after the thermal injury. Biopsies were collected mainly during the acute postburn phase (first week of hospitalization). Deep partial-thickness burns presented apoptotic cells, both in the dermis and in cutaneous adnexa, and showed a higher apoptotic rate than superficial and full-thickness burns (44.5% in deep partial thickness, interquartile range 6.3-90.5%; 5.6% in superficial partial thickness, interquartile range: 0-13%; 0% for full-thickness burn; P = .000243). A significant greater apoptotic rate was present in cells of deep partial-thickness burns when compared with superficial and full thickness. These data would suggest that deep burns sustain an ischemic damage that forces cells to undergo apoptosis and could represent the biologic basis for their clinical evolution into full-thickness burns. Further correlation studies are now required to confirm this hypothesis.