Predictors of in-hospital mortality of COVID-19 patients and the role of telemetry in an internal medicine ward during the third phase of the pandemic.

OBJECTIVE: The first pandemic phase of COVID-19 in Italy was characterized by high in-hospital mortality ranging from 23% to 38%. During the third pandemic phase there has been an improvement in the management and treatment of COVID-19, so mortality and predictors may have changed. A prospective study was planned to identify predictors of mortality during the third pandemic phase. PATIENTS AND METHODS: From 15 December 2020 to 15 May 2021, 208 patients were hospitalized (median age: 64 years; males: 58.6%); 83% had a median of 2 (IQR,1-4) comorbidities; pneumonia was present in 89.8%. Patients were monitored remotely for respiratory function and ECG trace for 24 hours/day. Management and treatment were done following the timing and dosage recommended by international guidelines. RESULTS: 79.2% of patients necessitated O2-therapy. ARDS was present in 46.1% of patients and 45.4% received non-invasive ventilation and 11.1% required ICU treatment. 38% developed arrhythmias which were identified early by telemetry and promptly treated. The in-hospital mortality rate was 10%. At multivariate analysis independent predictors of mortality were: older age (R-R for≥70 years: 5.44), number of comorbidities ≥3 (R-R 2.72), eGFR ≤60 ml/min (RR 2.91), high d-Dimer (R-R for≥1,000 ng/ml:7.53), and low PaO2/FiO2 (R-R for <200: 3.21). CONCLUSIONS: Management and treatment adherence to recommendations, use of telemetry, and no overcrowding appear to reduce mortality. Advanced age, number of comorbidities, severe renal failure, high d-Dimer and low P/F remain predictors of poor outcome. The data help to identify current high-risk COVID-19 patients in whom management has yet to be optimized, who require the greatest therapeutic effort, and subjects in whom vaccination is mandatory.

Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy.

OBJECTIVE: We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care. PATIENTS AND METHODS: All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed. RESULTS: One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations. CONCLUSIONS: LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.

Electrochemotherapy in the Treatment of Cutaneous Metastases from Breast Cancer: A Multicenter Cohort Analysis.

BACKGROUND: The management of breast cancer (BC) skin metastases represents a therapeutic challenge. Electrochemotherapy (ECT) combines the administration of bleomycin with temporary permeabilization induced by locally administered electric pulses. Preliminary experience with ECT in BC patients is encouraging. METHODS: A total of 125 patients with BC skin metastases who underwent ECT between 2010 and 2013 were enrolled onto a multicenter retrospective cohort study. The treatment was administered following the European Standard Operative Procedures of Electrochemotherapy. Tumor response was clinically assessed adapting the Response Evaluation Criteria in Solid Tumors, and toxicity was evaluated according to Common Terminology Criteria for Adverse Events 4.0. Cox regression analysis was used to identify predictive factors. RESULTS: Response was evaluable in 113 patients for 214 tumors (median 1 per patient, range 1-3). The overall response rate after 2 months was 90.2 %, while the complete response (CR) rate was 58.4 %. In multivariate analysis, small tumor size (P < 0.001), absence of visceral metastases (P = 0.001), estrogen receptor positivity (P = 0.016), and low Ki-67 index (P = 0.024) were significantly associated with CR. In the first 48 h, 10.4 % of patients reported severe skin pain. Dermatologic toxicity included grade 3 skin ulceration (8.0 %) and grade 2 skin hyperpigmentation (8.8 %). Tumor 1-year local progression-free survival was 86.2 % (95 % confidence interval 79.3-93.8) and 96.4 % (95 % confidence interval 91.6-100) in the subgroup of those with CR. CONCLUSIONS: In this study, small tumor size, absence of visceral metastases, estrogen receptor positivity, and low Ki-67 index were predictors of CR after ECT. Patients who experienced CR had durable local control. ECT represents a valuable skin-directed therapy for selected patients with BC.

Body composition estimated by bioimpedance analysis in Sicilian climacteric women.

AIM: The aim of this study was to evaluate the effects of menopause transition on body weight, and body composition in a Sicilian climacteric population. METHODS: Two hundred and nine (60 pre- and one 149 postmenopausal) untreated, healthy women were selected. Body composition was estimated by BIA101 of AKERN SRL. Body Mass Index (BMI), waist and hip circumferences were also measured. RESULTS: The mean BMI of the study population was 29.4+/-0.7. There was no significative difference between pre- and postmenopausal subjects regarding BMI (chi-squared=9.25; P=0.16), its class distribution, fat mass (FM), TBW and waist-to-hip ratio (WHR). The FM was significantly more represented in pre- than in postmenopausal women (47.43+/-1.33 vs 45.02+/-0.81 kg) (P<0.01). Linear regression analysis showed a positive correlation between BMI and fat free mass (FM) percentage (chi-squares=0.7045) nevertheless among the subjects aged=or>55 years, in 57% of the normo-weight the body fat (BF) percentage was undesirably high. CONCLUSION: Climacteric changes and aging process are related to changes in body weight and fat distribution; even subjects apparently ''normo-weight'' (BMI below 25) were ''over-fat'', because revealed undesirably high BF%. Further investigation in larger population is needed to define whether BMI or BF% better predicts the risk of obesity-related diseases in climacteric Sicilian women.

Outcomes of bilateral mammoplasty for early stage breast cancer.

AIM: Long-term oncological follow-up of oncoplastic breast surgery. METHODS: Sixthy-one (63 cancers) patients affected by breast cancer suitable for breast conservation, were treated with bilateral breast reductions. Tumours located in the inferior pole of the breast were treated by a superior pedicle technique; lesions in the upper pole or in the infero-lateral or infero-medial quadrants of the breast were removed with an inferior pedicle reduction. Small and medium size breast irrespective of tumour location required a periareolar, or comma-shaped approach. RESULTS: Fifty-six patients were alive at a mean follow-up of 68 months. One patient recurred locally and she is currently alive free of disease. CONCLUSION: Results from this study are in accordance with those reported by other similar papers. Oncoplastic breast surgery maximizes cosmetic results and with wider excisions provides effective local control.

Nipple sparing subcutaneous mastectomy: sixty-six months follow-up.

AIM: Validation of oncological and reconstructive efficacy of nipple sparing subcutaneous mastectomy. METHODS: We enrolled 50 patients on behalf of Humanitas Centro Catanese di Oncologia fulfilling appropriate reconstructive and oncological criteria to undergo nipple sparing subcutaneous mastectomy. We preferably selected women with medium size-small breast affected by early stage breast cancer peripherally located with intra-operative negative frozen section of the major ducts. RESULTS: fourty-six patients were alive after a mean follow-up of 5.5 years. We observed a single case of local recurrence in the nipple successfully treated with local excision. Five patients presented metastatic disease. One is currently alive, 4 died because of progressive disease. CONCLUSIONS: Our study supports other findings regarding safety and efficacy of nipple sparing subcutaneous mastectomy for selected patients.

Colposcopy vs Hybrid Capture II assay in detection of cervical human papilloma virus infection.

PURPOSE OF INVESTIGATION: Considering the relationship between high-risk human papillomavirus types and the presence or subsequent development of cervical high-grade preinvasive lesions, the aim of the study was to determine if the Hybrid Capture II test can be used to triage women with atypical colposcopic findings. METHODS: The study was carried out on 100 patients with suspicious colposcopy findings (suggestive of human papillomavirus infection) who underwent a cervical smear for human papillomavirus testing DNA Hybrid Capture II and direct biopsies for histopathological analysis. RESULTS: Sixteen patients were negative for human papillomavirus. Of the eight patients positive for high-risk HPV type, seven presented an abnormal transformation zone grade 2 (high-grade squamous intraepithelial lesion of the cervix at histopathology). There was a significant positivity of medium-high risk virus types in the cases with more abnormal colposcopy (chi2 = 7.44; p < 0.005). Histopathological findings of high-grade squamous intraepithelial lesions were registered in the patients positive for medium-high risk human papillomavirus types (chi2 = 7.66; p < 0.025). CONCLUSIONS: Based on these results it can be concluded that if a diagnosis of a high-grade squamous intraepithelial lesion has been made on the basis of colposcopic and histopathological findings, there is a high probability that the infection was due to one or more types of human papillomavirus. There are necessary further studies to interpretate both the advantages and disadvantages of intermediate triage procedures, like Hybrid Capture II testing, compared with immediate colposcopy.

Uterine pathologies in patients undergoing tamoxifen therapy for breast cancer: ultrasonographic, hysteroscopic and histological findings.

PURPOSE OF INVESTIGATION: To evaluate endometrial abnormalities by ultrasonography, hysteroscopy and biopsy in postmenopausal patients treated with tamoxifen as adjuvant therapy for breast cancer. METHODS: The study was carried out on 113 patients who underwent vaginal ultrasonography, hysteroscopy and endometrial biopsy. RESULTS: There was a significative relation between ultrasonographic and hysteroscopic features (p < 0.001); 58 polyps were diagnosed at hysteroscopy, although 35 were not found at ultrasonography. A significant relation between ultrasonographic and histological findings was also documented (p < 0.005). A significant relation between histological findings and symptomatology was found (p < 0.05), although pathologies were also present in asymptomatic women. CONCLUSIONS: These results show that long-term tamoxifen therapy in breast cancer patients is associated with a higher incidence of uterine pathology. No significant relation has been documented between duration of treatment and grade of endometrial lesion (p > 0.05). Ultrasonography alone is useful in asymptomatic patients because it selects patients with increased endometrial thickness who should undergo hysteroscopy. Hysteroscopy is more accurate in detecting polyps, hyperplastic and neoplastic changes. Asymptomatic tamoxifen treated women should be evaluated as symptomatic patients.

Tattooing in reconstruction of the nipple and areola: a new method.

In order to produce the characteristic color of the nipple-areola complex and in unilateral reconstructions to match the other side, a modified tattooing method has been introduced. The quite different requirements between reconstruction and ornamental studio tattooing can only be satisfied by different techniques. For the first time, pigment particles have been suspended in a gel rather than adsorbed on an opaque mineral. Our porcine study has shown how the pigment is distributed in the dermis without penetration of the gel particles. The first 16 of the authors' 29 patients have been reviewed with an analysis of their appearance. Using this new method, a third achieved a completely natural appearance and two-thirds were judged to be intermediate, compared with an unnatural, although sometimes acceptable, result in all the earlier conventional tattoos.

Single-stage correction of constriction ring syndrome.

The accepted method of treatment for the constricting ring syndrome of the extremities is serial excision and repair with Z-plasties. A series of 4 patients operated upon in different centers by single-stage excision of the ring and multiple Z-plasty repair is presented. In 1 patient there was absence of a major nerve trunk underneath and distal to a constriction ring. None of the patients suffered any significant circulatory embarrassment. This surgical approach is anatomically sound and clinically safe. It should be considered as an alternative method of treatment to the currently accepted procedure.

Hyperthermia after discontinuance of levodopa and bromocriptine therapy: impaired dopamine receptors a possible cause.

Hyperthermia, with no signs of any underlying infection, may occur in the course of neuroleptic malignant syndrome, fatal catatonia, heat stroke, or malignant hyperthermia. We describe hyperthermia as a complication after discontinuance of antiparkinsonian treatment with levodopa/carbidopa and bromocriptine. Impaired nigrostriatal, hypothalamic, and mesolimbic dopaminergic functions could be involved in pathogenesis.

Surgical treatment of radiation-induced scalp lesions.

The treatment of scalp lesions induced by ionising radiation in four patients is described. In each case the technique used was different. Three required several operations and a prolonged hospital stay. The fourth patient, in whom a free flap was used, underwent a single operation. In selected patients with reasonable general health free tissue transfer may provide the best solution to such difficult management problems.

[Myasthenia and sleep]. / Myasthénie et sommeil.

A Central Nervous System (CNS) acetylcholine receptors involvement in Myasthenia Gravis (MG) has been suggested but never fully demonstrated. On the other hand, although the question concerning the neurotransmitters connected to REM sleep is still unsettled, the importance of acetylcholine as a neurotransmitter involved in the maintenance of this sleep stage has been outlined. The spontaneous night sleep organization has been studied in 9 male subjects with MG and results are compared with those obtained in normal subjects matched for age and sex. Statistically significant differences have been found: 1) slow-waves sleep better represented in MG patients; 2) average REM period length shorter in MG patients; 3) instability of the EEG consisting in a tendency toward lightening of sleep. These findings may confirm the presence of a disturbance in the CNS cholinergic activity of MG patients.