Clinical and Personal Predictors of Helmet-CPAP Use and Failure in Patients Firstly Admitted to Regular Medical Wards with COVID-19-Related Acute Respiratory Distress Syndrome (hCPAP-f Study).

Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19 is substantially different from ARDS caused by other diseases and its treatment is dissimilar and challenging. As many studies showed conflicting results regarding the use of Non-invasive ventilation in COVID-19-associated ARDS, no unquestionable indications by operational guidelines were reported. The aim of this study was to estimate the use and success rate of Helmet (h) Continuous Positive Airway Pressure (CPAP) in COVID-19-associated ARDS in medical regular wards patients and describe the predictive risk factors for its use and failure. In our monocentric retrospective observational study, we included patients admitted for COVID-19 in medical regular wards. hCPAP was delivered when supplemental conventional or high-flow nasal oxygen failed to achieve respiratory targets. The primary outcomes were hCPAP use and failure rate (including the need to use Bilevel (BL) PAP or oro-tracheal intubation (OTI) and death during ventilation). The secondary outcome was the rate of in-hospital death and OTI. We computed a score derived from the factors independently associated with hCPAP failure. Out of 701 patients admitted with COVID-19 symptoms, 295 were diagnosed with ARDS caused by COVID-19 and treated with hCPAP. Factors associated with the need for hCPAP use were the PaO2/FiO2 ratio < 270, IL-6 serum levels over 46 pg/mL, AST > 33 U/L, and LDH > 570 U/L; age > 78 years and neuropsychiatric conditions were associated with lower use of hCPAP. Failure of hCPAP occurred in 125 patients and was associated with male sex, polypharmacotherapy (at least three medications), platelet count < 180 × 109/L, and PaO2/FiO2 ratio < 240. The computed hCPAP-f Score, ranging from 0 to 11.5 points, had an AUC of 0.74 in predicting hCPAP failure (significantly superior to Call Score), and 0.73 for the secondary outcome (non-inferior to IL-6 serum levels). In conclusion, hCPAP was widely used in patients with COVID-19 symptoms admitted to medical regular wards and developing ARDS, with a low OTI rate. A score computed combining male sex, multi-pharmacotherapy, low platelet count, and low PaO2/FiO2 was able to predict hCPAP failure in hospitalized patients with ARDS caused by COVID-19.

Predictive Factors for Hemorrhagic Transformation in Acute Ischemic Stroke in the REAL-World Clinical Practice.

BACKGROUND: Few data exists on predictive factors of hemorrhagic transformation (HT) in real-world acute ischemic stroke patients. The aims of this study were: (i) to identify predictive variables of HT (ii) to develop a score for predicting HT. METHODS: We retrospectively analyzed the clinical, radiographic, and laboratory data of patients with acute ischemic stroke consecutively admitted to our Stroke Unit along two years. Patients with HT were compared with those without HT. A multivariate logistic regression analysis was performed to identify independent predictors of HT on CT scan at 24 hours to develop a practical score. RESULTS: The study population consisted of 564 patients with mean age 77.5±11.8 years. Fifty-two patients (9.2%) showed HT on brain CT at 24 hours (4.9% symptomatic). NIHSS score ≥8 at Stroke Unit admission (3 points), cardioembolic etiology (2 points), acute revascularization by systemic thrombolysis and/or mechanical thrombectomy (1 point), history of previous TIA/stroke (1 point), and major vessel occlusion (1 point) were found independent risk factors of HT and were included in the score (Hemorrhagic Transformation Empoli score (HTE)). The predictive power of HTE score was good with an AUC of 0.785 (95% CI: 0.749-0.818). Compared with 5 HT predictive scores proposed in the literature (THRIVE, SPAN-100, MSS, GRASPS, SITS-SIC), the HTE score significantly better predicted HT. CONCLUSIONS: NIHSS score ≥8 at Stroke Unit admission, cardioembolism, urgent revascularization, previous TIA/stroke, and major vessel occlusion were independent predictors of HT. The HTE score has a good predictive power for HT. Prospective studies are warranted.

Age-related burden and characteristics of embolic stroke of undetermined source in the real world clinical practice.

Few data are available on age-related burden and characteristics of embolic stroke of undetermined source (ESUS) in the real world clinical practice. The aim of our study was to provide information about it. We retrospectively analyzed data of patients consecutively admitted to our Stroke Unit along 1 year (2017, November 1st-2018, October 31st). The etiology of ischemic stroke was defined at hospital discharge; ESUS was considered as a subset of cryptogenic stroke, and defined according to the 2014 international criteria. In the analyzed period, 306 patients, 52.3% females, mean age ± SD 77.9 ± 11.9 years, were discharged with diagnosis of ischemic stroke. Ischemic strokes of cardioembolic and lacunar origin were the most frequent subtypes: 30.1% and 29.4%, respectively. Cardioembolic strokes were particularly frequent in patients ≥ 75 years, and almost always associated with atrial fibrillation. Overall, in 80 patients (26.1%) the etiology of stroke was undetermined; in 25 (8.2%) it remained undefined because of death or severe comorbidity, making further diagnostic work-up not worthy. Cryptogenic stroke occurred in 55 patients (18%), and ESUS criteria were satisfied in 39 of them (12.7%). According to age, cryptogenic stroke was diagnosed in 21.1% (21.1% ESUS) of patients < 65 years, 24.2% (19.4% ESUS) of patients aged 65-74 years, 15.5% (9.2% ESUS) of patients ≥ 75 years. After diagnostic work-up, patent foramen ovale was most commonly associated with ESUS (17.9%), especially in patients < 65 years (62.5%); covert paroxysmal atrial fibrillation was detected in 10.5% of ESUS patients ≥ 75 years. In the real world clinical practice, the frequency of ischemic strokes of undetermined etiology, and of those satisfying ESUS criteria, is not negligible, especially in younger patients. A thorough diagnostic work-up, with an age-specific approach, is therefore necessary and of the utmost importance for the identification of stroke etiology, in order to optimize secondary stroke prevention strategies.

A stepwise multiple regression model to assess the odds ratio between myofascial pain and 13 occlusal features in 238 Italian women.

OBJECTIVE: To quantify the relative risk of multiple occlusal variables for muscular disorders of the stomatognathic system. METHOD AND MATERIALS: Thirteen occlusal features were clinically assessed by the same three operators: partial unilateral posterior reverse articulation, anterior open occlusal relationship, vertical anterior overlap (normal value < 4 mm), complete unilateral posterior reverse articulation, anterior overjet (normal value < 5 mm), incisor midline discrepancy (normal value < 2 mm), Angle Class I canine and molar relationship; plus dynamic occlusion features such as length and symmetry of retruded contact position-intercanine position (RCP/ICP) slides (normal value < 2 mm), occlusal guidance patterns, and mediotrusive and laterotrusive interferences. The sample consisted of 156 women with only muscular disorders according to the Group I Research Diagnostic Criteria for temporomandibular disorders and 82 healthy women (control group). A stepwise multiple logistic regression model was used to identify the significant correlation between occlusal features and disease. RESULTS: The odds ratio for myofascial pain was 2.6 for absence of canine guidance, 2.0 for laterotrusive interference, 2.3 for mediotrusive interference, and 1.9 for reverse articulation. Other occlusal variables did not reveal statistical significance. The percentage of the total log likelihood for myofascial pain explained by the significant occlusal factors was acceptable with a Nagelkerke R2 = 0.2. The final model including the significative occlusal features revealed an optimal discriminant capacity to predict patients with myofascial pain with a sensitivity of 62.2%, or healthy subjects with a specificity of 93.6%, and an accuracy of 82.8%. CONCLUSIONS: Few occlusal features show a significative predictive value for myofascial pain.

Ventriculostomy-related infections: a critical review of the literature.

OBJECTIVE: To provide a critical evaluation of the published literature describing risk factors for ventriculostomy-related infections (VRIs) and the efficacy of prophylactic catheter exchange. METHODS: A MEDLINE literature search was performed, and data were extracted from studies published from 1941 through 2001. RESULTS: Published criteria for diagnosing VRIs are highly variable. Intraventricular hemorrhage, subarachnoid hemorrhage, cranial fracture with cerebrospinal fluid leak, craniotomy, systemic infections, and catheter irrigation all predispose patients to the development of VRIs. Extended duration of catheterization is correlated with an increasing risk of cerebrospinal fluid infections during the first 10 days of catheterization. Prophylactic catheter exchange does not modify the risk of developing later VRIs in retrospective studies. CONCLUSION: Categorizing suspected cerebrospinal fluid infections as contaminants, colonization, suspected or confirmed VRIs, or ventriculitis more accurately describes the patient's clinical condition and may indicate different management strategies. A prospective, randomized clinical trial is required to further evaluate the efficacy of prophylactic catheter exchange in limiting the incidence of VRIs during prolonged catheterization. Although prophylactic catheter exchange remains a practice option, the available data suggest that this procedure is not currently justified.

Mood spectrum in patients with different painful temporomandibular disorders.

The purpose of this study was to investigate for difference in the prevalence of mood disorders between patients with different painful temporomandibular disorders (TMD). After a sample size necessary for the study was calculated, 60 patients with a painful TMD were selected and divided into the following groups: myofascial pain (n=20), temporomandibular joint (TMJ) pain (n=18), combined myofascial and TMJ pain (n=22). Two distinct comparison groups were selected: subjects with a nonpainful TMD (n=25) and TMD-free subjects (n=29). All participants filled out a self-report validated instrument (MOODS-SR) to evaluate psychopathological symptoms related to mood disturbances. A one-way analysis of variance (ANOVA) with Bonferroni's post hoc test for multiple comparisons was performed to investigate for significant differences among the groups. The three groups of patients with painful TMD scored significantly higher than comparison groups in all MOODS-SR domains investigating depression, but no difference was shown between subjects with myofascial pain and those with TMJ pain. No significant differences among the groups emerged for the presence of manic symptoms, indicating that depressive disorders associated with TMD are not an expression of a more complex manic depressive illness. The study concluded that the presence of depressive symptoms in TMD patients seems to be related to the presence of a painful condition and seems to be unrelated to the location of pain. Furthermore, depressive disturbances in painful TMD patients affect the whole spectrum of depressive psychopathology.

Quantification of the relative risk of multiple occlusal variables for muscle disorders of the stomatognathic system.

STATEMENT OF PROBLEM: There is no consensus on the association between occlusion and temporomandibular disorders (TMD). PURPOSE: The purpose of this study was to quantify the relative risk of multiple occlusal variables for muscle disorders of the stomatognathic system. MATERIAL AND METHODS: Eight occlusal features: retruded contact position (RCP) to maximum intercuspation (MI) slide length, vertical overlap, horizontal overlap, unilateral posterior reverse articulation, anterior open occlusal relationship, incisor dental midline discrepancy, mediotrusive interferences, and laterotrusive interferences, were clinically assessed by the same trained operator. The sample consisted of 81 women with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis I diagnosis of muscle disorder, for example myofascial pain, with or without limited opening, and 48 healthy women (control group). A stepwise multiple logistic regression was used to identify the significant associations between occlusal features and disease. RESULTS: A slide from the retruded contact position to maximum intercuspation > or =2 mm and mediotrusive interferences were the only 2 occlusal features significantly associated with the presence of myofascial pain according to the RDC/TMD criterion symptoms. The odds ratio for myofascial pain was 2.57 for a slide from RCP to MI > or =2 mm and 2.45 for mediotrusive interferences. The percentage of the total log likelihood for myofascial pain explained by the significant occlusal factors amounted to 10.8% (Nagelkerke's R2=0.108). The multifactorial model, including the 2 significant occlusal factors, showed an acuracy to predict disease of 66.7% (sensitivity 71.6%; specificity 58.3%). CONCLUSION: Occlusal features showed a low predictive value to detect muscle disorders of the stomatognathic system. Multifactorial complex pathologies, such as TMD, should be studied using multivariate statistical analyses, as univariate models may overestimate some resulting associations.

Prevalence of bruxism in patients with different research diagnostic criteria for temporomandibular disorders (RDC/TMD) diagnoses.

The relationship between bruxism and temporomandibular disorders is complex and is not yet clearly understood. The purpose of this study was to investigate the prevalence of clinically diagnosed bruxism in 212 patients with different Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnoses, as compared with that in 77 sex- and age-matched TMD-free subjects. A significant association between bruxism and temporomandibular disorders emerged (p < 0.05). The highest prevalence of bruxism was found in patients with the following diagnoses: combined myofascial pain and disk displacement (87.5%); combined myofascial pain, disk displacement, and other joint conditions (73.3%); and myofascial pain (68.9%). In general, it is suggested that bruxism has a stronger relationship with muscle disorders than with disk displacement and joint pathologies, and that such a relationship seems to be independent from the presence of other RDC/TMD diagnoses along with myofascial pain.

Ventriculostomy-related infections: a critical review of the literature.

OBJECTIVE: To provide a critical evaluation of the published literature describing risk factors for ventriculostomy-related infections (VRIs) and the efficacy of prophylactic catheter exchange. METHODS: A MEDLINE literature search was performed, and data were extracted from studies published from 1941 through 2001. RESULTS: Published criteria for diagnosing VRIs are highly variable. Intraventricular hemorrhage, subarachnoid hemorrhage, cranial fracture with cerebrospinal fluid leak, craniotomy, systemic infections, and catheter irrigation all predispose patients to the development of VRIs. Extended duration of catheterization is correlated with an increasing risk of cerebrospinal fluid infections during the first 10 days of catheterization. Prophylactic catheter exchange does not modify the risk of developing later VRIs in retrospective studies. CONCLUSION: Categorizing suspected cerebrospinal fluid infections as contaminants, colonization, suspected or confirmed VRIs, or ventriculitis more accurately describes the patient's clinical condition and may indicate different management strategies. A prospective, randomized clinical trial is required to further evaluate the efficacy of prophylactic catheter exchange in limiting the incidence of VRIs during prolonged catheterization. Although prophylactic catheter exchange remains a practice option, the available data suggest that this procedure is not currently justified.

Amphotericin B-resistant Aspergillus flavus infection successfully treated with caspofungin, a novel antifungal agent.

Invasive aspergillosis is uncommon in immunocompetent hosts but is the second most common opportunistic fungal infection in immunocompromised patients. There has been a dramatic increase in the incidence of life-threatening aspergillosis during the past 2 decades, and the morbidity and mortality of these infections despite antifungal therapy remain unacceptably high. We describe a patient with amphotericin B-resistant Aspergillus flavus successfully treated with caspofungin, an agent belonging to a new class of antifungal drugs. Caspofungin shows great promise in the treatment of invasive aspergillosis.

Susceptibility of Streptococcus pyogenes from throat cultures to macrolide antibiotics and influence of collection criteria.

OBJECTIVE: To assess the incidence of resistance to erythromycin and to the three other macrolide antibiotics most extensively used in Italy (azithromycin, clarithromycin and roxithromycin) among clinical strains of Streptococcus pyogenes freshly isolated from throat cultures of pediatric patients in an area of Central Italy. METHODS: Two sets of isolates were examined. The strains of the first set (n=100) were collected according to a protocol admitting only throat swabs from untreated patients with symptoms of acute pharyngotonsillitis. The second set (n=180) consisted of strains isolated from throat cultures during the routine activity of diagnostic laboratories, no particular protocol being applied. RESULTS: A trimodal distribution of strains was observed in relation to their macrolide susceptibility levels: two clusters were constituted by highly susceptible and highly resistant strains, respectively; a third, middle cluster consisted of strains displaying low-level resistance (or even intermediate susceptibility, in a minority of isolates, to clarithromycin). The distribution of individual isolates in the three modal clusters was the same with all four drugs. Both MIC ranges and MIC50s almost overlapped in the isolates of the two sets, whereas MIC90s were far higher in the strains of the second set (4 micro g/mL for clarithromycin, 8 micro g/mL for erythromycin and azythromycin, and 16 micro g/mL for roxithromycin) than in those of the first (0.125 micro g/mL for all four drugs). Resistant strains were 5% among the isolates of the first set and three times as many among those of the second. CONCLUSIONS: The lower incidence of macrolide resistance recorded in the first set is probably more reliable: the threefold incidence observed in the second set may be overestimated due to the lower frequency of strains involved in drug-responsive infections and to the increased occurrence of strains from unsuccessfully treated patients.