Search

Since December 2019, the world has been facing the life-threatening disease, named Coronavirus disease-19 (COVID-19), recognized as a pandemic by the World Health Organization. The response of the Emergency Medicine network, integrating "out-of-hospital" and "hospital" activation, is crucial whenever the health system has to face a medical emergency, being caused by natural or human-derived disasters as well as by a rapidly spreading epidemic outbreak. We here report the Pavia Emergency Medicine network response to the COVID-19 outbreak. The "out-of-hospital" response was analysed in terms of calls, rescues and missions, whereas the "hospital" response was detailed as number of admitted patients and subsequent hospitalisation or discharge. The data in the first 5 weeks of the Covid-19 outbreak (February 21-March 26, 2020) were compared with a reference time window referring to the previous 5 weeks (January 17-February 20, 2020) and with the corresponding historical average data from the previous 5 years (February 21-March 26). Since February 21, 2020, a sudden and sustained increase in the calls to the AREU 112 system was noted (+ 440%). After 5 weeks, the number of calls and missions was still higher as compared to both the reference pre-Covid-19 period (+ 48% and + 10%, respectively) and the historical control (+ 53% and + 22%, respectively). Owing to the overflow from the neighbouring hospitals, which rapidly became overwhelmed and had to temporarily close patient access, the population served by the Pavia system more than doubled (from 547.251 to 1.135.977 inhabitants, + 108%). To minimize the possibility of intra-hospital spreading of the infection, a separate "Emergency Department-Infective Disease" was created, which evaluated 1241 patients with suspected infection (38% of total ED admissions). Out of these 1241 patients, 58.0% (n = 720) were admitted in general wards (n = 629) or intensive care unit (n = 91). To allow this massive number of admissions, the hospital reshaped many general ward Units, which became Covid-19 Units (up to 270 beds) and increased the intensive care unit beds from 32 to 60. In the setting of a long-standing continuing emergency like the present Covid-19 outbreak, the integration, interaction and team work of the "out-of-hospital" and "in-hospital" systems have a pivotal role. The present study reports how the rapid and coordinated reorganization of both might help in facing such a disaster. AREU-112 and the Emergency Department should be ready to finely tune their usual cooperation to respond to a sudden and overwhelming increase in the healthcare needs brought about by a pandemia like the current one. This lesson should shape and reinforce the future.

Objectives To detect possible severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA contamination of inanimate surfaces in areas at high risk of aerosol formation by patients with coronavirus disease 2019 (COVID-19). Methods Sampling was performed in the emergency unit and the sub-intensive care ward. SARS-CoV-2 RNA was extracted from swabbed surfaces and objects and subjected to real-time RT-PCR targeting RNA-dependent RNA polymerase and E genes. Virus isolation from positive samples was attempted in vitro on Vero E6 cells. Results Twenty-six samples were collected and only two were positive for low-level SARS-CoV-2 RNA, both collected on the external surface of continuous positive airway pressure helmets. All transport media were inoculated onto susceptible cells, but none induced a cytopathic effect on day 7 of culture. Conclusions Even though daily contact with inanimate surfaces and patient fomites in contaminated areas may be a medium of infection, our data obtained in real-life conditions suggest that it might be less extensive than hitherto recognized.

We describe clinical characteristics, treatments and outcomes of 44 Caucasian patients with coronavirus disease (COVID-19) at a single hospital in Pavia, Italy, from 21–28 February 2020, at the beginning of the outbreak in Europe. Seventeen patients developed severe disease, two died. After a median of 6 days, 14 patients were discharged from hospital. Predictors of lower odds of discharge were age > 65 years, antiviral treatment and for severe disease, lactate dehydrogenase > 300 mg/dL.

Objective: This study aimed to assess the role of Tocilizumab therapy (TCZ) in terms of ICU admission and mortality rate of critically ill patients with severe COVID-19 pneumonia. Design: Patients with COVID-19 pneumonia were prospectively enrolled in SMAtteo COvid19 REgistry (SMACORE). A retrospective analysis of patients treated with TCZ matched using propensity score to patients treated with Standard Of Care (SOC) was conducted. Setting: The study was conducted at IRCCS Policlinico San Matteo Hospital, Pavia, Italy, from March 14, 2020 to March 27, 2020. Participants: Patients with a confirmed diagnosis of COVID-19 hospitalized in our institution at the time of TCZ availability. Interventions: TCZ was administered to 21 patients. The first administration was 8 mg/kg (up to a maximum 800 mg per dose) of Tocilizumab intravenously, repeated after 12 h if no side effects were reported after the first dose. Main Outcomes and Measures: ICU admission and 7-day mortality rate. Secondary outcomes included clinical and laboratory data. Results: There were 112 patients evaluated (82 were male and 30 were female, with a median age of 63.55 years). Using propensity scores, the 21 patients who received TCZ were matched to 21 patients who received SOC (a combination of hydroxychloroquine, azithromycin and prophylactic dose of low weight heparin). No adverse event was detected following TCZ administration. This study found that treatment with TCZ did not significantly affect ICU admission (OR 0.11; 95% CI between 0.00 and 3.38; p = 0.22) or 7-day mortality rate (OR 0.78; 95% CI between 0.06 and 9.34; p = 0.84) when compared with SOC. Analysis of laboratory measures showed significant interactions between time and treatment regarding C-Reactive Protein (CRP), alanine aminotransferase (ALT), platelets and international normalized ratio (INR) levels. Variation in lymphocytes count was observed over time, irrespective of treatment. Conclusions: TCZ administration did not reduce ICU admission or mortality rate in a cohort of 21 patients. Additional data are needed to understand the effect(s) of TCZ in treating patients diagnosed with COVID-19.

Coronavirus disease 2019 (COVID‐19) diagnosis is based on molecular detection of SARS‐CoV‐2 in respiratory samples such as nasal swab (NS) However, the evidence that NS in patients with pneumonia was sometimes negative raises the attention to collect other clinical specimens SARS‐CoV‐2 was shown in 10 3% rectal swabs (RS), 7 7% plasma, 1% urine, and 0% feces from 143 NS‐positive patients Potential infection by fluids different from respiratory secretion is possible but unlikely [ABSTRACT FROM AUTHOR] Copyright of Pediatric Allergy & Immunology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

We report the case of a 52-year-old man who was referred to surgery because of severe mitral and tricuspid regurgitation of Barlow's disease. In particular, the tricuspid valve was a 'four-leaflet valve'due to the presence of a small accessory leaflet between the septal and the posterior leaflets. The valve insufficiency was determined by prolapse of all leaflets (in particular of the anterior and posterior ones) associated with annular dilatation. The patient underwent both mitral and tricuspid valve repair. The tricuspid regurgitation was corrected by stitching together the middle point of the free edges of the tricuspid leaflets producing a 'four-leaflet clover-shaped' valve. Surgical and echocardiographic images of the repaired valve are reported.

Obiettivo. Lo scopo del presente lavoro è decrivere la gestione anestesiologica e l’outcome della rivascolarizzazione coronarica a cuore battente.Metodi. È stato svolto uno studio prospettico, presso un ospedale universitario, su 100 pazienti adulti consecutive sottoposti a rivascolarizzazione coronarica a cuore battente. I punti salienti della gestione anestesiologica sono il mantenimento della stabilità emodinamica e del contributo diastolico atriale.Risultati. L’introduzione degli stabilizzatori meccanici ha migliorato le gestione di questi pazienti. L’incidenza di complicazioni è stata: mortalità ospedaliera 1%; infarto miocardico acuto 3%; sindrome da bassa gittata 2%; fibrillazione atriale 16%. L’incidenza di insufficienza renale acuta postoperatoria è stata limitata al 2% e in nessun caso si è reso necessario un trattamento sostitutivo renale. Non è stato registrato nessun evento neurologico. Solo il 19% dei pazienti ha ricevuto emotrasfusioni. Il 97% dei pazienti è stato estubato entro 12 h dalla fine dell’ intervento.Conclusioni. La strategia anestesiologica applicata, combinata a una buona tecnica chirurgica e all’uso di dispositivi innovativi, rende questo tipo di chirurgia sicura anche in pazienti ad alto rischio. AIM: The aim of this paper is to describe the anesthesiological management and the outcome of beating heart revascularization.METHODS: A prospective study has been performed in a tertiary teaching hospital on 100 consecutive patients undergoing off-pump coronary artery revascularization. The main features of anesthetic technique are the maintenance hemodynamic stability and atrial kick.RESULTS: Mechanical stabilisers shunts have improved the management of these patients. In hospital mortality was 1%, acute myocardial infarction 3%, low output syndrome 2%, atrial fibrillation 16%. Only 2% of patients had acute renal failure, but no patient needed renal replacement treatment. No neurologic event was noted. Only 19% of patients received blood transfusion. Ninety-seven % of patients were extubated within 12 h.CONCLUSIONS: The application of this anesthetic strategy combined with surgical skillful and new devices makes off-pump surgery safe also in high risk patients.

OBJECTIVES: This study was designed to investigate the potential of circumferential pulmonary vein (PV) ablation for atrial fibrillation (AF) to maintain sinus rhythm (SR) over time, thus reducing mortality and morbidity while enhancing quality of life (QoL).BACKGROUND: Circumferential PV ablation is safe and effective, but the long-term outcomes and its impact on QoL have not been assessed or compared with those for medical therapy.METHODS: We examined the clinical course of 1,171 consecutive patients with symptomatic AF who were referred to us between January 1998 and March 2001. The 589 ablated patients were compared with the 582 who received antiarrhythmic medications for SR control. The QoL of 109 ablated and 102 medically treated patients was measured with the SF-36 survey.RESULTS: Median follow-up was 900 days (range 161 to 1,508 days). Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically (p < 0.001), and not different from that expected for healthy persons of the same gender and calendar year of birth (p = 0.55). Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 (95% confidence interval [CI], 0.31 to 0.68; p < 0.001) for all-cause mortality, of 0.45 (95% CI, 0.31 to 0.64; p < 0.001) for morbidities mainly due to heart failure and ischemic cerebrovascular events, and of 0.30 (95% CI, 0.24 to 0.37; p < 0.001) for AF recurrence. Ablated patients' QoL, different from patients treated medically, reached normative levels at six months and remained unchanged at one year.CONCLUSIONS: Pulmonary vein ablation improves mortality, morbidity, and QoL as compared with medical therapy. Our findings pave the way for randomized trials to prospect a wider application of ablation therapy for AF.

Biochemical studies of myelin fractions were undertaken on Lewis rats during various time-points in the development of chronic-relapsing experimental allergic encephalomyelitis (CR-EAE). Lipid and protein composition of myelin fractions obtained by sucrose density gradient centrifugation at 10, 19, 24, and 66 d postinduction (pi) were determined by high-performance thin-layer chromatography (HPTLC) and sodium dodecyl sulfate-polyacrilamide gel electrophoresis (SDS PAGE), respectively. When comparing the myelin fractions of CR-EAE affected animals with those of controls, main differences were observed at 10 d pi. These changes were particularly evident in the light myelin fraction, where a decrease in the percentage of phosphatidylethanolamine and small basic protein relative to the total lipids and proteins of the fraction were observed. At 19 and 24 d pi no biochemical differences were present in both fractions. At 66 d pi, differences in the lipid composition were observed again only in the light myelin fraction. These findings suggest that the light myelin fraction is the most sensitive, particularly at the early stages of the disease, and must play a key role in demyelinating processes.

This paper aims to address the mechanisms responsible for poor perioperative cardiac performance, analyzing the pathophysiology of heart failure and the main hemodynamic parameters (contractility, preload, afterload, systemic vascular resistance, and pulmonary artery pressure) used in diagnosing patients and assessing their response to therapy. It will also discuss potential therapeutic approaches to cardiac surgery patients. With advances in monitoring and life support, our critically ill patients often become trapped in a sheer, impenetrable net of wires and tubes. Unfortunately, technology can seriously compromise patient safety if the data obtained is misinterpreted. While advanced technology has become a part of daily life in the Intensive Care Unit (ICU), there remains a crucial step that cannot be performed by computers: the link from sensors to patient status. We should always remember to look past the cables and monitors and to look at the patient. This would not only reduce the number of ever-present wires, but would also help improve patient outcome. The field of non-transplant cardiac surgery for heart failure is extremely challenging for the cardiac anesthesiologist. The high incidence of postoperative low cardiac output syndrome should mandate aggressive monitoring and therapy. Nevertheless, a comprehensive understanding of the pathophysiology of heart failure and the hemodynamic implications of surgical therapies is mandatory for optimal patient management. In particular, the presence of systolic dysfunction should not automatically rule out other potential causes of poor global cardiac performance.

Aim. A high postoperative peak of cardiac Troponin I is associated to an increased risk of morbidity and mortality after cardiac operations. The aim of this study was to investigate the release of cardiac Troponin I in different cardiac surgical procedures. Methods. This was a prospective, single-centre study performed at the IRCCS San Raffaele Hospital in Milan, Italy. The study group consisted of 194 consecutive patients undergoing cardiac surgery. For each of them creatinkinase MB and cardiac Troponin I were assayed preoperatively, at ICU arrival, 4 h and 18 h postoperatively. Results. Different cardiac surgical procedures were characterized by different release of cardiac biomarkers (P < 0.001, ANOVA test). Off-pump coronary artery bypass grafting (CABG) was associated to the smallest amount of myocardial injury while mitral valve replacement produced the largest amount of biomarkers release. Patients who suffered a postoperative cardiac event released more myocardial necrosis biomarkers; than those with an uneventful course (P=0.01). Conclusion. We showed that each type of cardiac operation has a peculiar amount of myocardial necrosis biomarkers: mitral valve replacement in particular is associated to the highest release of cardiac biomarkers.