Long-term comprehensive cardiopulmonary phenotyping of COVID-19.

BACKGROUND: Persistent symptoms after initial COVID-19 infection are common and are frequently referred to by the umbrella terms "post-COVID syndrome" and "long COVID". The sheer number of affected patients pose an increasing challenge to healthcare systems worldwide. To date, our understanding of the pathophysiology of the post-COVID syndrome remains poor and the extent to which persistent cardiopulmonary abnormalities contribute to the symptom complex is unclear. We sought to determine the presence and impact of cardiopulmonary sequelae after COVID-19 in longitudinal assessment. METHODS: We report on 71 patients who underwent comprehensive, longitudinal testing in regular intervals for up to 12 months after their initial COVID-19 diagnosis. Testing included pulmonary function testing, cardiopulmonary exercise testing, dedicated left and right heart echocardiography, lung ultrasonography, and cardiac MRI. RESULTS: Our results demonstrate that subjective quality of life after COVID-19 (EQ-5D visual acuity scale, VAS, 67.4 for patients treated as outpatient, 79.2 for patients admitted to the general floor, 71.8 for patients treated in an ICU) is not related to the severity of the initial infection. Maximal exercise capacity is also reduced (VO2max 79% predicted, SD ± 19%); however, this is driven in large parts by patients who had initially required ICU-level of care. The degree of objective reduction in exertion did not correlate with quality of life scores. Pulmonary function testing revealed mild and persistent reduction in DLCO over the first 12 months without significant restrictive or obstructive lung disease. Left and right heart function was intact with good RV function and intact RV/PA coupling, imaging findings suggestive of myocarditis were uncommon (7% of patients). CONCLUSION: A reduction in exercise capacity after COVID-19 is common, but is most prominent in patients previously treated in the ICU and more likely related to deconditioning or fatigue than to cardiopulmonary impairment. Subjective quality of life scores are independent of the severity of initial infection and do not correlate with objective measures of cardiopulmonary function. In our cohort, persistent cardiopulmonary impairment after COVID-19 was uncommon. The post-COVID syndrome is unlikely to be the result of cardiopulmonary sequalae and may reflect a post-ICU syndrome in some. Trial registration Registered on clinicaltrials.gov (NCT04442789), Date: June 23, 2020.

Results of a Prospective Observational Study on Mountaineering Emergencies in Western Alps: Mind Your Head.

UNLABELLED: Brustia, Raffaele, Giulia Enrione, Bruna Catuzzo, Luca Cavoretto, Massimo Pesenti Compagnoni, Enrico Visetti, Emmanuel Cauchy, Stefanie Ziegler, and Guido Giardini. Results of a prospective observational study on mountaineering emergencies in Western Alps: mind your head. High Alt Med Biol. 17:116-121, 2016.- BACKGROUND: In the northern Italian district Valle d'Aosta district during winter and summer season the population can increase up to 170% of the resident population. A prospective monocentric observational registry was held to obtain a precise picture of seasonal mountain-related medical and traumatic major events. METHODS: From 1st January 2012 to 31st December 2013 all patients admitted to the Aosta Regional Hospital Emergency Room for any event occurred above 2500 m were screened: all those affected by High Altitude Illness, Acute Illness in High Altitude, Trauma, or Cold disease were prospectively included. Activity incidence rate is expressed as the occurrence of mountain-related events per 1000 hours of mountain activity. Event Incidence rate is expressed as the occurrence of new cases per 1000 hours of mountain activity. RESULTS: Two hundred two patients were included during the study period. Trauma (65.1% vs. 24.6%, p < 0.001) and head commotive injury (48.1% vs. 15.1%, p < 0.001) were more frequent during winter compared to the summer season. High altitude illness (36.9% vs. 9.3%, p < 0.001) and cold pathologies (15.1% vs. 0.1%, p < 0.001) occurred more frequently in summer than in winter. Patients (51.4%) were immediately discharged from emergency room, 8.4% after a 24-hour observation period, and 30.6% required hospitalization. During summer, the event risk is 0.013 per person and 1000 hours of mountain activity, while in winter, event risk amounts to 0.005 per person and 1000 hours of mountain activity. COMMENTS: High altitude medical events or trauma represent <1% of pathologies observed in the emergency room department of a mountain district in the western Alps. Head commotive injury is the most observed mountain-related event in high altitude, in winter and during ski practice. High altitude illness and cold injuries are observed more frequently in summer, during trekking or climbing activities.

Prophylactic use of helmet CPAP after pulmonary lobectomy: a prospective randomized controlled study.

BACKGROUND: Patients undergoing pulmonary lobectomy carry a high risk of respiratory complications after surgery. The postoperative prophylactic treatment with helmet CPAP may prevent postoperative acute respiratory failure and improve the P(aO(2))/F(IO(2)). METHODS: We randomly allocated 50 subjects to receive continuous oxygen therapy (air-entrainment mask, F(IO(2)) 0.4) or 2 cycles of helmet CPAP for 120 min, alternating with analog oxygen therapy for 4 hours. Blood gas values were collected at admission to ICU, after 1, 3, 7, 9, 24 hours, and then in the thoracic ward after 48 hours and one week after surgery. We investigated the incidence of postoperative complications, mortality, and length of hospital stay. RESULTS: At the end of the second helmet CPAP treatment, the subjects had a significantly higher P(aO(2))/F(IO(2)), compared with the control group (366 ± 106 mm Hg vs 259 ± 60 mm Hg, P = .004), but the improvement in oxygenation did not continue beyond 24 hours. The postoperative preventive helmet CPAP treatment was associated with a significantly shorter hospital stay, in comparison to standard treatment (7 ± 4 d and 8 ± 13 d, respectively, P = .042). The number of minor or major postoperative complications was similar between the 2 groups. No difference in ICU readmission or mortality was observed. CONCLUSIONS: The prophylactic use of helmet CPAP improved the P(aO(2))/F(IO(2)), but the oxygenation benefit was not lasting. In our study, helmet CPAP was a secure and well tolerated method in subjects who underwent pulmonary lobectomy. It might be safely applied whenever necessary.

Trends in treatment and outcomes of rheumatoid arthritis in Germany 1997-2007: results from the National Database of the German Collaborative Arthritis Centres.

BACKGROUND: New strategies and options for the treatment of rheumatoid arthritis (RA) have evolved during the past decade. A study was undertaken to investigate to what extent this influenced daily rheumatological care and how this translates into clinical and patient-reported outcomes. METHODS: Data from a total of 38 723 outpatients with RA enrolled in the National Database of the German Collaborative Arthritis Centres in the years 1997-2007 were analysed. The cross-sectional annual data were compared to detect time trends. RESULTS: Between 1997 and 2007 the prescription of combinations of traditional disease-modifying antirheumatic drugs (DMARDs) increased from 8% of all patients to 23%; biological agents were prescribed to 16% of patients with RA in 2007. The mean disease activity (DAS28) fell from 4.5 to 3.4 (median 4.5-3.2). The percentage of patients with low disease activity (DAS28 <3.2) increased significantly from 23% to 49%. The proportion of patients with ≥6 swollen joints fell from 43.1% in 1997 to 8.1% in 2007 and, in those with ≥6 tender joints, from 46.3% to 15.8%. There was a large decrease in the total annual number of days of sick leave due to the rheumatic condition from 27.2 to 8.8 days per gainfully employed person. This reduction is far beyond the decline in the general population. There was also a tendency to higher participation in the work force, specifically in older patients, reflecting the trend seen in the general population. CONCLUSIONS: The intensity of drug treatment in patients with RA has increased during the past 7 years. This has been accompanied by not only a decrease in disease activity but also a considerable reduction of economic losses due to sick leave and permanent work disability.

The effects of ultrasound guidance and neurostimulation on the minimum effective anesthetic volume of mepivacaine 1.5% required to block the sciatic nerve using the subgluteal approach.

BACKGROUND: We tested the hypothesis that ultrasound (US) guidance may reduce the minimum effective anesthetic volume (MEAV(50)) of 1.5% mepivacaine required to block the sciatic nerve with a subgluteal approach compared with neurostimulation (NS). METHODS: After premedication and single-injection femoral nerve block, 60 patients undergoing knee arthroscopy were randomly allocated to receive a sciatic nerve block with either NS (n = 30) or US (n = 30). In the US group, the sciatic nerve was localized between the ischial tuberosity and the greater trochanter. In the NS group, the appropriate muscular response (foot plantar flexion or inversion) was elicited (1.5 mA, 2 Hz, 0.1 ms) and maintained to

Small renal tumors: correlation of clinical and pathological features with tumor size.

PURPOSE: We analyzed the association between tumor diameter and pathological stage, histological subtype, tumor grade and the incidence of metastases in renal cell carcinoma with a diameter of up to 4 cm (clinical stage T1a). MATERIALS AND METHODS: We analyzed a consecutive series of 663 patients with renal tumors 4 cm or less who underwent surgery at our institution between 1990 and 2006. After excluding 115 patients (17.3%) with benign tumors 548 with renal cell carcinoma were included in the study. Tumor size on preoperative imaging was correlated with pathological stage, tumor grade, histological subtype and incidence of metastases at diagnosis. For data analysis tumors were stratified by tumor diameter into 3 groups, including 2 cm--99 patients with tumors up to 2 cm, 3 cm--234 with tumors between 2.1 and 3.0 cm, and 4 cm--215 with tumors between 3.1 and 4.0 cm in diameter. RESULTS: Median clinical diameter of renal cell carcinoma in the whole series was 2.93 cm (range 0.8 to 4.0). Tumor stage was pT1a, pT1b and pT3 in 84.5%, 8.0% and 7.5% of cases, respectively. Tumor grade was 1 to 3 in 24.5%, 65.0% and 10.6% of cases, respectively. The renal cell carcinoma histological subtype was clear cell carcinoma in 77.9% of patients, papillary carcinoma in 15.3% and chromophobe carcinoma in 6.8%. Advanced tumor stage (pT3) was found in 3.0%, 5.1% and 12.1% of the patients in the 2, 3 and 4 cm groups, respectively (p <0.05). Grade 3 was found in 7.1%, 9.0% and 14.0% of the patients in the 2, 3 and 4 cm groups, respectively (p <0.05). Metastases at diagnosis were found in 3.0%, 2.6% and 6.0% of the patients in the 2, 3 and 4 cm groups, respectively. CONCLUSIONS: Negative prognostic features increase with tumor diameter and they are associated with even small tumors. However, above a tumor size of 3.0 cm there is a sharp increase in the incidence of negative prognostic parameters. New diagnostic tests are warranted to better stratify patients with respect to treatment aggressiveness for small incidental renal tumors.

Endoscopic treatment of esophageal and colo-rectal fistulas with fibrin glue.

So far, the use of fibrin glue has been limited to the treatment of anal, recto-vaginal and enterocutaneous fistulae. Between 1991 and 2003 we performed the treatment of anastomotic leaks of the upper and lower gastro-intestinal tract with fibrin glue in 13 selected patients. In our experience the treatment with fibrin glue has been proved to be effective in the selected cases. If the fistulae clinically occured 7 days after surgery a higher number of endoscopic sessions were necessary than in patients with earlier appearance of anastomotic leakage. The utilization of fibrin glue for the endoscopic management of anastomotic leakages after surgery can be successful and safe if applied in selected patients.

[Rupture of the spleen in angiosarcoma: a case report and review of the literature]. / Rottura di milza in angiosarcoma: considerazioni su di un caso clinico e revisione della letteratura.

Splenic angiosarcoma is a rare neoplasm originating from endothelial cells of the blood vessels. Its incidence is about 0.14-0.25 per million. We report the case of a patient admitted in a state of hypovolaemic shock with haemoperitoneum due to rupture of the spleen. Splenectomy was performed with evacuation of the haemorrhagic effusion. The blood was aspirated and in part instilled during the operation through intraoperative blood salvage due to the large haemoperitoneum. Histological examination revealed a splenic angiosarcoma. Splenic angiosarcoma should be suspected in cases of splenomegaly with unknown anaemia and no lymphoma, leukaemia or myelofibrosis, because of its neoplastic aggressiveness and its invariably fatal outcome. It is important to perform a splenectomy before splenic rupture owing to its negative impact on long-term survival.

[The changes in the emergency surgical treatment of diverticulitis in the last thirty-years]. / Modificazioni del trattamento chirurgico della malattia diverticolare del colon in urgenza negli ultimi 30 anni.

BACKGROUND: The surgical management of diverticulitis in emergency is controversial: The primary reconstructive surgery or Hartmann's procedure? METHODS: The Authors have analyzed our experience on 409 cases of diverticulitis from January 1975 to December 2004; 101/409 were treated in emergency and divided in two groups before and after December 1994. The patients were divided on Hinchey's classification, type of surgical procedure, ASA status and complications. The Authors have analyzed all cases by t-Student and chi2 analysis. RESULTS: No difference between two groups on age, sex, concomitant diseases are observed. The hospital stay in patients treated in emergency was 10.2 days to 7.1 days in patients operated after 24 hours (p<0.05). The incidence of primary anastomosis in the second group is higher (p<0.03). The incidence of leaks in two groups was respectively 27.2% and 10.3% (p<0.005). The deaths were 12/101 (11.8%); 9 of these in III-IV stages of Hinchey's classification. DISCUSSION: In the lasts ten years the surgical approach to diverticulitis in emergency is changed. The individual risks factors, the Hinchey's stage, play an important role in decision making. The Authors have registered a major indications to primary anastomosis in emergency.

Pancreatic pseudocysts following acute pancreatitis: risk factors influencing therapeutic outcomes.

CONTEXT: The natural history of pancreatic pseudocysts has become well known in recent years, but the choice of a proper treatment still remains controversial. OBJECTIVE: This study aims at establishing whether predictive factors influencing therapeutic outcomes exist. SETTING: Patients with pancreatic pseudocysts following an episode of acute pancreatitis treated from January 1980 to December 2001 at the Department of General Surgery and Organ Transplantation of the University of Parma, Italy. PATIENTS: Seventy-four patients were studied: 12 had a spontaneous resolution, 37 patients were treated surgically, 15 were treated endoscopically and in 10, percutaneous drainage was used. MAIN OUTCOME MEASURES: Epidemiological, clinical and pathological characteristics of patients with pancreatic pseudocysts were related to morbidity, recurrence rates and hospital stay. RESULTS: At univariate logistic regression, our data reveal a significant increase in morbidity related to age (P=0.013), etiology (alcoholic vs. biliary, P=0.024), Ranson score of previous pancreatitis (P=0.006), nutritional assessment (P=0.001), residual necrosis (P<0.001) and modality of treatment (P=0.009), whereas none of these parameters has been shown to be significantly correlated to recurrence. At multivariate logistic regression, only residual necrosis was significantly related to morbidity. CONCLUSIONS: Some factors, such as epidemiological (age, etiology), clinical (severity of previous pancreatitis, malnourishment), pathological (residual necrosis), and therapeutical factors (emergency/urgency treatment) are predictive of worse outcomes for invasive treatment of pseudocysts. In particular residual necrosis appeared to be the most important factor influencing invasive treatment outcomes, confirming that this pathological aspect deserves particular attention from surgeons. No risk factors predicting pancreatic pseudocyst recurrence emerged.

Prognostic significance of nm23 gene product expression in patients with colorectal carcinoma treated with radical intent.

Reports of the relationship between the putative metastasis suppressor NM23 and metastasis and/or survival in colorectal cancer patients are conflicting. This study aimed to investigate whether nm23 immunostaining is correlated with established prognostic variables (Dukes' stage, degree of tumour differentiation, T stage and nodal involvement) in colorectal carcinomas for the patients treated with radical intent using Kruskal chi(2) analysis. The rates of survival at five years were estimated with the use of the Kaplan-Meier product-limit method with 95% confidence intervals derived by Greenwood's formula and the curves were compared with the use of the log-rank test. Cox proportional-hazard regression model was used to identify multivariate predictors and the corresponding outcome. The staining was performed on 112 paraffin-embedded surgical specimens collected between 1989-1992 using a monoclonal anti-nm23 antibody. Follow-up of patients was until time of death or for at least 5 years. There was not a significant correlation between tumour staging, degree of tumour differentiation, nodal involvement and nm23 status. Furthermore, there was no significant association with overall 5-year survival, disease recurrence, tumour site, age or sex. Although nm23 may be involved in suppressing tumour metastasis, nm23 immunohistochemistry has no prognostic value in colorectal cancer. For these reasons nm23 does not contribute further to the prognostic information provided by established prognostic variables.

Ex vivo characterization of tumor-derived melanoma antigen encoding gene-specific CD8+cells in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: Members of the melanoma antigen encoding gene family are expressed in tumors of different histological types but not in normal tissue. For this reason, they are attractive targets for cancer immunotherapy. METHODS: In the present study, we analyzed the expression of MAGE-1 and -3 genes in the hepatocellular carcinoma (HCC) tissue as well as frequency, phenotype and function of circulating and tumor infiltrating CD8+ cells specific for HLA-A1 and -A2 restricted epitopes of MAGE-1 and -3. RESULTS: Our study shows for the first time the presence of MAGE/tetramer+ CD8 cells in the tumor tissue of patients with HCC. These cells are able to recognize the MAGE-1 sequence 161-169 and the MAGE-3 sequence 271-279. In a patient with a particularly high frequency of MAGE-1 sequence 161-169-specific T cells, phenotypic and functional analysis was performed showing a phenotype of recently-primed CD8 cells (CD28+CD27+CD45RA-CCR7). CONCLUSIONS: The observation of a spontaneous in vivo priming of a MAGE-specific T cell response in patients with HCC and the high frequency of MAGE antigens expression in this tumor, makes this antigen a potential candidate for a MAGE-specific immunotherapy in hepatocellular carcinoma.

Old and new TNM in carcinoma of the gastric antrum: analysis of our personal experience.

Various tumor node metastasis (TNM) classifications have been proposed for staging of gastric carcinoma, including the fourth edition of the TNM classification and the Japanese Research Society for Gastric Cancer (JRSGC) system. In 1997 the fifth edition of TNM classification introduced the concept of the number of metastatic lymph nodes. We review our experience with staging gastric cancer in light of both the fourth and fifth editions of the TNM classification system. From January 1986 to December 1997, we performed subtotal resection in 193 patients with carcinoma of the gastric antrum. A total of 147 patients presented with criteria from the fifth TNM edition. We compared data from these patients with data from the fourth TNM edition. We analyzed 84 females and 63 males whose average age was 68.9 years. The average number of lymph nodes removed was 16.7. We used the Kaplan-Meier method to analyze survival. In accordance with the fourth TNM edition, we recorded 82 patients who were pN0, 36 who were pN1, and 29 who were pN2; according to the fifth edition, 82 patients were pN0, 33 were pN1, 17 were pN2, and 15 were pN3. Average follow-up was 26.7 months, and average survival was 56.9 months for N0 patients, 38.7 months for N1 patients, and 24.5 months for N2 patients staged according to the fourth edition. According to the fifth edition, survival was 39.3 months for N1 patients, 33.6 months for N2 patients, and 10.3 months for N3 patients. The survival curve was statistically different (P<0.001) between N0 and N1 patients according to the fourth edition; there was no significant difference between N1 and N2 patients. According to the fifth edition, the difference in survival probability was P<0.001 between N0 and N1 patients and N2 and N3 patients. The fifth TNM edition presents a greater ease of stratification in bringing together and mediating diverse cultural experiences between West and East. This staging lays the basis for a more accurate comparison between the groups.