Cavitaciones pulmonares, complicación tardía de la COVID-19 / Pulmonary cavitations, late complication of COVID-19

La aparición de complicaciones graves, como el neumotórax o las cavitaciones pulmonares, en pacientes con infecciones recientes por el SARS-CoV-2 aumenta la morbi-mortalidad, y supone un reto diseñar la estrategia terapéutica más adecuada que permita mejorar su pronóstico. Las cavitaciones pulmonares se suelen asociar a complicaciones secundarias como la hemoptisis y el neumotórax, y confieren mal pronóstico. Se presenta el caso de dos pacientes con enfermedad COVID-19 confirmada por PCR nasofaríngea y que, tras evolución inicialmente satisfactoria, reingresaron con afectación pulmonar compatible con cavitaciones pulmonares y con insuficiencia respiratoria. Las lesiones cavitadas pulmonares en pacientes que hayan sufrido COVID-19 deben identificarse de forma precoz y realizar las determinaciones y cultivos necesarios para descartar sobreinfecciones añadidas que puedan empeorar el pronóstico.(AU)

Patients who have recently suffered from SARS-CoV-2 infections may suffer serious complications, such as pneumothorax or pulmonary cavitations that increase morbi-mortality and imply a challenge for the design of the most appropriate therapeutic strategy to improve their prognosis. Pulmonary cavities are usually associated with secondary complications such as hemoptysis and pneumothorax, and so offer a poor prognosis. We present the case of two patients with COVID-19 disease confirmed by nasopharyngeal PCR who showed satisfactory evolution before readmission with pulmonary involvement compatible with pulmonary cavitation and respiratory failure. Cavitated lesions in the lungs of patients who recently suffered COVID-19 must be identified early in order to discard additional superinfections that may worsen the prognosis.(AU)

[Pulmonary cavitations, late complication of COVID-19].

Patients who have recently suffered from SARS-CoV-2 infections may suffer serious complications, such as pneumothorax or pulmonary cavitations that increase morbi-mortality and imply a challenge for the design of the most appropriate therapeutic strategy to improve their prognosis. Pulmonary cavities are usually associated with secondary complications such as hemoptysis and pneumothorax, and so offer a poor prognosis. We present the case of two patients with COVID-19 disease confirmed by nasopharyngeal PCR who showed satisfactory evolution before readmission with pulmonary involvement compatible with pulmonary cavitation and respiratory failure. Cavitated lesions in the lungs of patients who recently suffered COVID-19 must be identified early in order to discard additional superinfections that may worsen the prognosis.

Minimal impact of lenvatinib (Lenvima®) on muscle mass in advanced hepatocellular carcinoma and implications for treatment duration. Two cases from the REFLECT study.

OBJECTIVE: Two case reports of advanced unresectable hepatocellular carcinoma (HCC) treated with lenvatinib (Lenvima®) are presented; the drug's effect on muscle loss and duration of treatment are discussed. PATIENTS AND METHODS: Between November 2014 and December 2017, at the Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy, two male patients with advanced HCC enrolled in the lenvatinib arm of the REFLECT trial received the drug over 24 cycles (almost 2 years). We reviewed the clinical charts from baseline, when lenvatinib was started, through 24 months of treatment. The changes in the skeletal mass area (SMA), as assessed by computed tomography (CT) at the third lumbar level (L3), between baseline and month 24 into treatment were recorded. RESULTS: Case 1: SMA decreased by 2.8 cm2 between baseline and month 24 (134 cm2 vs. 131.2 cm2), with a muscle loss of 2.13%. Case 2: SMA decreased by 13 cm2 between baseline and month 24 (133 cm2 vs. 120 cm2), with a muscle loss of 10.83%. CONCLUSIONS: The disease remained stable for over 2.5 years in both patients. A minimal loss of muscle mass was noted at 24 months of treatment. The minimum effect on muscle loss may be correlated with the positive clinical response and the drug's low toxicity. Our findings may help to elucidate the effect of lenvatinib on muscle mass and inform the development of the targeted nutritional support for HCC patients.

Impact of malnutrition on survival and infections among pediatric patients with cancer: a retrospective study.

OBJECTIVE: Recognizing and managing malnutrition among hospitalized children affected by cancer is a rising need. Awareness and consideration of malnutrition among clinicians are still largely insufficient. This can principally be explained by the lack of consciousness and the shortage of easy and objective tools to identify malnutrition status. The aim of this study is to explore the impact of malnutrition on survival and infections among a population of pediatric patients with cancer. PATIENTS AND METHODS: All children aged between 3 and 18 years, newly diagnosed with a malignancy between August 2013 and April 2018, were included in our study. We assessed nutritional risk at diagnosis (with STRONGkids), then we evaluated anthropometric measurements (BMI Z-scores and weight loss), data about survival and number of hospitalization for febrile neutropenia (FN) in the first year after diagnosis. Cut-off values for malnourishment were chosen as BMI Z-score ≤-2.0. RESULTS: One hundred twenty-six pediatric cancer patients were included in the study. At diagnosis 36 pediatric cancer patients (28.6%) were at high risk of malnutrition (STRONGkids 4 or 5), whereas 6 (4.7%) others were malnourished (BMI Z-score≤-2.0). The risk of mortality and the rate of infections (≥3 hospitalizations for FN episodes) were significantly increased by malnutrition and rapid weight loss in the initial phase of treatment (3-6 months after diagnosis). Multivariate analysis confirmed the independent effect of weight loss≥ 5% at 3 months on both survival and infections, and the independent impact of a high risk of malnutrition at diagnosis on infections. CONCLUSIONS: A personalized evaluation of nutritional risk at diagnosis and a close monitoring of nutritional status during the initial phase of treatment are crucial for ensuring a timely and personalized nutritional intervention, which may potentially improve tolerance to chemotherapy and survival, and prevent prolonged hospitalization for infections in childhood cancer patients.

Role of phase angle in the evaluation of effect of an immuno-enhanced formula in post-surgical cancer patients: a randomized clinical trial.

OBJECTIVE: Neoplastic disease is frequently associated with poor nutritional status or severe malnutrition. Diet and nutritional intervention are becoming increasingly important for prognosis and quality of life in cancer patients. Accessible and repeatable tools for assessing nutritional status with body composition techniques seems to be fundamental. The aim of this study was to evaluate the effects of immunonutrition on body composition parameters, inflammatory response and nutritional status in patients at stage III of head and neck squamous carcinoma (HNSCC). PATIENTS AND METHODS: In our work, 50 malnourished subjects with HNSCC staging III were recruited and treated with oral diet (OD) or enteral nutrition (EN). Patient under EN followed, for the first three days, enteral standard nutrition (ESN) and then enteral immunonutrition (EIN). Nutrition state was evaluated on days 0, 3, and 8 through body composition and biochemical analyses. RESULTS: After 8 days, the EIN treatment showed a significant improvement in phase angle, pre-albumin, retinol binding protein and transferrin compared to the OD treatment. CONCLUSIONS: Our results showed that immunonutrition treatment improves the nutritional status of neoplastic patients, supporting chemotherapy. The phase angle is not only a predictor of cancer survival, but has also proved to be useful in the surveillance of nutritional status improvement as well as biochemical indices.

Nutritional support in mitochondrial diseases: the state of the art.

Mitochondrial diseases are a group of rare multisystem disorders characterized by genetic heterogeneity and pleomorphic clinical manifestations. The clinical burden may be heavy for patients and their caregivers. There are no therapies of proven efficacy until now and a multidisciplinary supportive care is therefore necessary. Since the common pathogenic mechanism is the insufficient energy production by defective mitochondria, nutrition may play a crucial role. However, no guidelines are still available. The article reports the current evidence, highlighting nutrition both as support and as therapy. The estimate of nutritional status, energy needs and nutritional behaviors are firstly discussed. Then, we go in-depth on the scientific rationale and the clinical evidence of the use of anti-oxidants and enzyme-cofactors in the clinical practice. In particular, we analyze the role of Coenzyme Q10, Creatine monohydrate, α-lipoic acid, riboflavin, arginine and citrulline, folinic acid, carnitine, vitamin C, K, and E. Every attempt at nutritional intervention should be made knowing patient's disease and focusing on his/her energy and nutrients' requirements. For this reason, clinicians expert in mitochondrial medicine and clinical nutritionists should work together to ameliorate care in these fragile patients.

Fecal microbiota transplantation for the treatment of patients with ulcerative colitis and other gastrointestinal conditions beyond Clostridium difficile infection: an update.

Fecal microbiota transplantation (FMT) is the transplantation of microbial gut contents from a healthy individual into the gastrointestinal tract of a person with a disease, with a view to increasing the recipient's gut microbial diversity and bacterial richness and restoring microbial homeostasis. FMT has been proven to be a safe and effective treatment for Clostridium difficile infection (CDI) and it is now a recommended treatment for recurrent or refractory infection. FMT is not currently recommended for use outside of CDI due to concerns regarding outcome and safety; however, several case series and randomized controlled trials have described its use in a research environment for a few gastrointestinal conditions related to intestinal dysbiosis including ulcerative colitis (UC), Crohn's disease (CD) and irritable bowel syndrome (IBS). The most successful reports of the clinical efficacy of FMT in gastrointestinal conditions outside of CDI have been in treating UC. We summarize the current literature regarding the use of FMT in UC, including methodology, clinical efficacy and safety concerns, and identify pitfalls and areas for future development. We also describe the available evidence to date on the use of FMT in CD, IBS and other conditions related to intestinal dysbiosi.

Clinical tools to assess nutritional risk and malnutrition in hospitalized children and adolescents.

Malnutrition in children and adolescents may be underestimated during hospital stay. In western countries, children were often hospitalized for acute or chronic diseases that are not necessarily related to malnutrition. However, acute or chronic injuries may hamper nutritional status, prolonging recovery after admission and consequently length of hospital stay. Several methods and techniques are known to investigate malnutrition in children, even if their use is not widespread in clinical practice. Many of these are simple and easy to perform and could be useful to a better management of every kind of illness. In this review, we will focus on clinical tools necessary to reveal a nutritional risk at admission and to assess nutritional status in hospitalized children and adolescents.

Nutritional support in acute pancreatitis: from physiopathology to practice. An evidence-based approach.

Acute Pancreatitis (AP) is a potentially fatal syndrome, associated with a hyper-catabolic state as well as early and late complications that may lead to multi-organ failure and death. Clinical researches produced in recent years suggest that acute pancreatitis may benefit from early oral or enteral nutrition. Nevertheless, many clinicians still believe erroneously that fasting - particularly in the early phase - may reduce AP complications and mortality. The goal of our review is to demonstrate that such false belief may harm the patients and that the whole management paradigm must change, adopting a more rational, evidence-based approach. First, we will describe AP physiopathology and the clinical assessment of its severity. Then we will discuss evidence-based data supporting early oral or enteral nutrition in AP. Finally, we will offer some practice recommendations as regards nutritional support.

Nutrition and IBD: Malnutrition and/or Sarcopenia? A Practical Guide.

Malnutrition is a major complication of inflammatory bowel disease (IBD). This mini review is focusing on main determinants of malnutrition in IBD, the most important components of malnutrition, including lean mass loss and sarcopenia, as an emerging problem. Each one of these components needs to be well considered in a correct nutritional evaluation of an IBD patient in order to build a correct multidisciplinary approach. The review is then focusing on possible instrumental and clinical armamentarium for the nutritional evaluation.

Effect of lycopene and tomato products on cholesterol metabolism.

BACKGROUND/AIMS: Increased ingestion of tomato, containing lycopene, has been associated with a decreased risk for atherosclerosis, although the exact molecular mechanism is still unknown. Here we review the available evidence for a direct regulation of tomato lycopene on cholesterol metabolism using results from experimental and human studies. RESULTS: In human macrophages lycopene dose dependently reduced intracellular total cholesterol. Such an effect was associated with a decrease in cholesterol synthesis through a reduction of 3-hydroxy-3-methylglutaryl coenzyme A reductase activity and expression, a modulation of low- density lipoprotein (LDL) receptor and acyl-coenzyme A:cholesterol acyltransferase activity. An increase in cholesterol efflux through an enhancement of ABCA1 and caveolin-1 expression was also observed. In animal models of atherosclerosis, lycopene and tomato products decreased plasma total cholesterol, LDL cholesterol and increased high-density lipoprotein cholesterol. In agreement with the experimental results, most human intervention trials analyzed show that dietary supplementation with lycopene and/or tomato products reduced plasma LDL cholesterol dependently on the dose and the time of administration. CONCLUSIONS: Although lycopene and tomato products seem to possess direct hypocholesterolemic properties, more experimental studies are needed to better understand the mechanisms involved. There is also a need for more well-designed human dietary intervention studies to better clarify the role of lycopene as a hypocholesterolemic agent.

Nutritional counselling and oral nutritional supplements in head and neck cancer patients undergoing chemoradiotherapy.

BACKGROUND: The role of nutritional counselling (NC) with or without oral nutritional supplements (ONS) in patients receiving chemoradiotherapy (CRT) for head and neck cancer (HNC) still remains to be clearly defined, particularly with regard to CRT-related toxicity. METHODS: Patients undergoing CRT for HNC received NC by the dietitian within the first 4 days of radiotherapy and weekly for the course of radiotherapy (approximately 6 weeks). A weekly supply of oral nutrition supplements [1560 kJ (373 kcal) per 100 g] for up to 3 months was provided to all patients. RESULTS: Twenty-one patients completed CRT. Mucositis G3 developed in seven (33.3%) patients, whereas mucositis G4 was absent. Dysphagia was present before the start of treatment in four patients. In the remaining 17 patients, dysphagia G3 developed during/at the end of treatment in five cases. The percentage of patients interrupting anti-neoplastic treatment for was 28% for ≥6 days, 28% for 3-5 days and 44% for 0-2 days. Mucositis G3 frequency was lower in patients with a baseline body mass index (BMI, kg m(-2) ) ≥25 (two out of 12; 16.6%) than in patients with BMI <25 (five out of nine; 55.5%) (P = 0.161) and in patients with a baseline mid arm circumference >30 cm than in those with a mid arm circumference in the range 28.1-30 cm and <28 cm, and higher in patients with a greater weight loss and a greater reduction of serum albumin and mid arm circumference. CONCLUSIONS: Nutritional counselling and ONS are associated with relatively low CRT-related toxicity and with mild deterioration of nutritional parameters.

Young stroke and basal plasma and post-methionine load homocysteine and cysteine levels 1 year after the acute event: do plasma folates make the difference?

We conducted a case-control study to evaluate the relationship between ischemic stroke in young adults (<45 years of age) and plasma homocysteine (Hcy), plasma folate and vitamin B(12), after a methionine load. We studied 42 patients with a history of ischemic stroke and 29 controls with a negative clinical history of cardio- or cerebrovascular diseases, venous thrombosis and renal disease. A fasting blood sample was drawn from each participant; the second and third samples were collected, respectively, 120 and 240 min after the methionine load. Whilst there was no difference between controls and patients in basal total homocysteine (tHcy), we found a statistically significant difference in both the 120- and 240-min samples. We compared the basal and 240-min tHcy in patients and controls. We obtained a median value of 17.8 and 11.6 micromol/l in patients and controls, respectively. The difference between these two values was highly significant. The methionine loading test (MLT) reveals Hcy metabolism abnormalities that were not revealed by the basal sample. MLT may help identify and treat this new risk factor, which seems to be both atherogenic and prothrombotic, and is hypothesized to operate through various mechanisms.

[Diet and physiologic pregnancy: energy and macronutrients requirements]. / Dieta e gravidanza fisiologica: fabbisogno di energia e di macronutrienti.

This article briefly reviews the most important issues of past and present medical literature on maternal nutrition and fetal well-being, with particular attention to energy and macronutrients requirements (proteins, lipids, carbohydrates) in pregnancy. Guidelines for nutrition in pregnancy and a few examples of diets for physiological pregnancy will be presented.

Conditional risk factors in men with previous myocardial infarction: relevance of C3 and homocysteine.

OBJECTIVE: To establish which traditional and conditional risk factors were effectively treated, and which remained active, in patients with previous myocardial infarction (PMI). METHODS AND RESULTS: In 47 PMI patients recently submitted to cardiological assessment and in 42 controls (50-70 years old men), traditional risk factors (total cholesterol, high-density lipoprotein cholesterol, blood glucose, blood pressure, cigarette smoking and body mass index) and the following variables were measured: fibrinogen, plasminogen activator inhibitor-1 (PAI-1), lipoprotein(a) [Lp(a)], total homocysteine, plasma folates, vitamin B12, high sensitivity C-reactive protein and C3 complement. Most patients were taking beta-blockers, ACE inhibitors and statins. Accordingly, patients had lower blood pressure and cholesterol values than controls. Moreover, they consumed less alcohol and coffee and did not differ from controls in cigarette smoking and body mass index. Conversely, patients had higher levels of homocysteine, fibrinogen, C3 complement and Lp(a), although of these factors only C3 and homocysteine remained significantly associated with PMI in multivariate analysis. C-reactive protein, PAI-1 and especially C3 often correlated with traditional risk factors in controls, but these correlations tended to disappear or reverse in PMI patients. Fibrinogen inversely correlated with alcohol consumption. Homocysteine correlated (inversely) with plasma folates only. Lp(a) did not correlate with any variable. CONCLUSIONS: Forty-seven patients with previous myocardial infarction displayed an excellent control of traditional risk factors, but they had higher mean C3 and homocysteine levels than the control group.

Bioelectrical impedance analysis during pregnancy and neonatal birth weight.

OBJECTIVE: To generate reference ranges for bioelectrical impedance indices throughout pregnancy and to investigate whether a relationship exists between these indices and the neonatal birth weight. STUDY DESIGN: Pregnant women with a singleton gestation, gestational age lower than 12 weeks, and absence of medical diseases before pregnancy were enrolled. Patients with pregnancy complications, such as hypertensive disorders, diabetes, and antiphospholipides syndrome were excluded. Antrophometric maternal parameters and bioelectrical impedance measurements were performed during the first, second, third trimester of pregnancy, at delivery and 60 days after delivery. Height(2)/resistance (cm(2)/Omega) and height(2)/reactance (cm(2)/Omega) were utilized to estimate the total and extracellular body water amounts, respectively. Spearman rank correlations and cox proportional hazard modelling were used for statistical purposes. RESULTS: 169 patients completed all measurements. Total and extracellular water amounts significantly increase as pregnancy advances and return to the pre-pregnancy values within 60 days after delivery. After adjustment for gestational age at delivery, fetal sex, and smoking habits, height(2)/resistance at 25 weeks (hazard=1.04, 95% confidence interval (CI) 1.02-1.06, P<0.005), height(2)/resistance at 30 weeks (hazard=1.03, 95% CI 1.01-1.05, P<0.005), height(2)/reactance at 20 weeks (hazard=1.03,95% CI 1.01-1.05, P<0.005), and height(2)/reactance at 25 weeks (hazard=1.03, 95% CI 1.01-1.04, P<0.01) were found to be independent predictors of birth weight. CONCLUSION: We have provided reference ranges for bioimpedance analysis during pregnancy, an easy, fast and non invasive method to estimate the body water composition during pregnancy. Bioelectrical impedance indices during the second trimester of pregnancy are independently related to the birth weight.

High total antioxidant activity and uric acid in tracheobronchial aspirate fluid of preterm infants during oxidative stress: an adaptive response to hyperoxia?

The effect of O2 exposure, expressed by mean daily fractional inspired oxygen concentration (FiO2), was evaluated during the first 6 d of life in the tracheobronchial aspirate fluid of 16 mechanically ventilated preterm infants in terms of both antioxidant response and oxidative damage, by measuring total antioxidant activity, uric acid concentrations and protein carbonyl content. Each day linear regression analysis was performed and a positive correlation was found between total antioxidant activity and FiO2 during the study period, especially on day 2 of life (r = 0.91, p < 0.0001), but uric acid correlated only in the first 3 d, especially on the 2nd day (r = 0.83, p < 0.0001). No correlation was found between carbonyl content and FiO2. The highest values of total antioxidant activity (416 and 790 micromol l(-1)) were found in 2 babies ventilated with highest FiO2: 1 and 0.80, respectively. Total antioxidant activity was not detectable or was very low in the babies not requiring O2 therapy. The highest value of uric acid (270 micromol l(-1)) was found in the baby ventilated with 100% oxygen. Uric acid concentrations obtained in these babies were much higher then those reported in the bronchoalveolar lavage fluid of adults. Preterm babies seem to have an antioxidant response in the tracheobronchial aspirate fluid following an oxidative stress and uric acid may be physiologically important as an antioxidant of the respiratory tract, especially during the first days of life.

[Bioelectric profiles and nutritional status in pregnancy: protocol of a multicentric project to measure bioimpedance in pregnancy]. / Profili bioelettrici e stato nutrizionale materno: protocollo di un progetto multicentrico di misure di bioimpedenza in gravidanza.

This paper re-examines the criteria underlying weight increases suggested during pregnancy. The distinction is introduced between increase in the lean and fat masses in the evaluation of the total weight increase, in order to assess the real mother's needs and work out a correct diet. Since one of the main adjustment mechanisms by the increase of the circulating mass and, more in general, the increase of water in the extracellular compartment, authors propose to use impedance measurements to longitudinally monitor the changes in the mother's lean mass during pregnancy and at the moment of delivery. The operational protocol of a multicentric project is presented, which aims at thoroughly analyzing the characterization of the mother's lean mass and its possible changes during pregnancy by means of bioimpedance measurements. A sample of 800 pregnant women will undergo bioimpedance measurements, 400 of which longitudinally during the whole pregnancy and 400 immediately before and after delivery. This study will also propose food frequency questionnaires in order to better define the nutritional status of pregnant women; moreover, sideremia, transferrin and ferritin values will be collected to assess any iron deficiencies in the studied population.

Homocysteine and oxidative modification of plasma proteins.

The oxidative status of plasma proteins after incubation with elevated homocysteine levels has been examined in the presence and absence of transition metal ions. 200µM homocysteine alone does not provoke any loss of plasma thiols groups, but their oxidation significantly enhances as copper concentration increases. No plasma proteins carbonyl groups enhancement has been concurrently found.The physiological relevance of the study is discussed in relationship with the metal-catalyzed oxidation system increment connected with age and nutritional deficiences.