Gemelli decision tree Algorithm to Predict the need for home monitoring or hospitalization of confirmed and unconfirmed COVID-19 patients (GAP-Covid19): preliminary results from a retrospective cohort study.

OBJECTIVE: To develop a deep learning-based decision tree for the primary care setting, to stratify adult patients with confirmed and unconfirmed coronavirus disease 2019 (COVID-19), and to predict the need for hospitalization or home monitoring. PATIENTS AND METHODS: We performed a retrospective cohort study on data from patients admitted to a COVID hospital in Rome, Italy, between 5 March 2020 and 5 June 2020. A confirmed case was defined as a patient with a positive nasopharyngeal RT-PCR test result, while an unconfirmed case had negative results on repeated swabs. Patients' medical history and clinical, laboratory and radiological findings were collected, and the dataset was used to train a predictive model for COVID-19 severity. RESULTS: Data of 198 patients were included in the study. Twenty-eight (14.14%) had mild disease, 62 (31.31%) had moderate disease, 64 (32.32%) had severe disease, and 44 (22.22%) had critical disease. The G2 value assessed the contribution of each collected value to decision tree building. On this basis, SpO2 (%) with a cut point at 92 was chosen for the optimal first split. Therefore, the decision tree was built using values maximizing G2 and LogWorth. After the tree was built, the correspondence between inputs and outcomes was validated. CONCLUSIONS: We developed a machine learning-based tool that is easy to understand and apply. It provides good discrimination in stratifying confirmed and unconfirmed COVID-19 patients with different prognoses in every context. Our tool might allow general practitioners visiting patients at home to decide whether the patient needs to be hospitalized.

Suicide of isolated inmates suffering from psychiatric disorders: when a preventive measure becomes punitive.

We performed external autopsies and examinations on two inmates who had committed suicide by hanging themselves with their underwear and using the window bars of their cells as ligature points after they had been placed in solitary confinement. In one case, the inmate had even been deprived of her clothing (with the exception to her underwear). Underwear has been rarely described as a means for self-harm and, to the best of our knowledge, no previous study has focused on cases of prison suicides committed using this garment, even though it is available to every inmate. The two cases were very similar; both inmates were young, physically aggressive and in their first week at a new facility; both had been affected by mental disorders, had been prescribed psychotropic medications and had histories of psychiatric hospitalisation. In each case, the psychiatric evaluations had highlighted significant suicidal risk. We discuss these two cases in an attempt to describe the complexity of and contradictions within the management of suicidal inmates at correctional facilities. We aim to propose new strategies and emphasise the need to introduce evidence-based standardised protocols over inhumane, ineffective and simplistic punitive measures in the management of these individuals.

Prevalence of alcohol and other drugs in injured drivers and their association with clinical outcomes.

OBJECTIVE: Driving under the influence of alcohol or drugs is a risk factor for motor vehicle accidents (MVAs). This issue has become an increasing concern for the governments of many European and North American countries, thereby encouraging the adoption of preventive policies. The aim of this study was to investigate the associations between major clinical outcomes and alcohol or drug abuse among drivers involved in MVAs who were referred to an Italian Emergency Department. PATIENTS AND METHODS: The study population consisted of consecutive injured drivers who were admitted to the Emergency Department following an MVA during a period of one year. The patients' blood alcohol concentrations (BACs) and the presence of the most common drugs of abuse [amphetamine, methamphetamine, methylenedioxymethamphetamine (MDMA), barbiturates, benzodiazepines, benzoylecgonine (cocaine main metabolite), cannabinoids, methadone, and opiates)] were determined and evaluated in association with major clinical outcomes and demographic data. RESULTS: Overall, 347 injured drivers were enrolled. Of the 347 enrolled patients, 164 (47.3%) had a positive BAC (greater than 5 mg/dL). A subgroup of 107 injured drivers was also screened for drugs of abuse. Thirty-seven of these subjects (34.5%) were positive for at least one drug. A statistically significant association was found between BAC and triage at admission (p<0.01), hospitalization (p<0.01), and lesions of internal organs (p=0.04). CONCLUSIONS: The results of this study show that a significant proportion of injured drivers had detectable levels of BAC and/or illegal drugs. Positive BACs were significantly associated with worse clinical outcomes. These findings suggest that the implementation of methods to prevent alcohol and drug abuse is of paramount importance in the effort to reduce the rates of MVAs and their dramatic consequences.

Tuberculosis: medico-legal aspects.

Tuberculosis is a diffusive infectious disease whose typical behaviour differentiates it from other infectious diseases spread by human-to-human transmission (flu, chicken pox, cholera, etc.) that follow a classic epidemic pattern. Indeed, in the presence of a known source of Koch bacilli that is capable of spreading the bacteria by air, not all exposed individuals inhale the bacteria, not all those who inhale them absorb them, not all those who absorb the bacteria are unable to eliminate them, not all who are able to eliminate them do so using delayed hypersensitivity, not all those who react with delayed hypersensitivity suffer lasting tissue damage (among other things, minor), not all who suffer tissue damage have anatomical sequelae, and not all those who have anatomical sequelae, however minimal, become carriers of bacilli in the latent period. The vast majority (90-95%) of the latter - which are in any case a portion, not the totality of those exposed - remain asymptomatic throughout their lives and never develop active tuberculosis. Based on these biological characteristics and the legal concepts of "epidemic" and "disease," it becomes highly problematic, if not impossible, to assert both that tuberculosis can cause events of sufficient magnitude to be associated with the crime of "epidemic," and that the mere diagnosis of a latent tuberculosis infection is sufficient to assume the presence of an illness legally prosecutable in criminal proceedings or a disability prosecutable in civil proceedings. Furthermore, clinically apparent tuberculosis is a temporarily-and in some cases permanently-disabling condition, and in certain work environments, even with the difficulties caused by the lack of available effective diagnostic tools and the insidious behaviour of the disease in the early stages, targeted monitoring to identify other persons who may become ill is appropriate.

Haemophagocytic syndrome associated with mucormycosis infection.

Several clinical forms of mucormycosis are recognized. The tendency of mucoraceous zygomycetes to invade the blood vessels often produces a disseminated infection. A case of disseminate mucormycosis complicated by a haemophagocytic syndrome (HS) in a 32-year-old Caucasian male is reported in this article. Few cases of infection-associated HS (IAHS), involving infections caused by fungi, have been reported. In all the recorded cases, the fungal infection coexists with malignant lymphoma, immunodeficiency and a long-term steroid therapy for renal transplant or Crohn's disease. This is the second described case of the HS due to mucormycosis.

1. Dissection of the vertebral artery during a basketball game: a case report.

Dissection of the vertebral artery represents a significant potential cause of strokes among young and middle-aged people. We present a case of dissection of the vertebral artery observed at the forensic autopsy of a professional basketball player who was suddenly taken ill during a practice game and died seven days after the event. A medico-legal autopsy was performed in order to establish an essential causal relationship between arterial dissection and basketball activity. No preceding trauma possibly contributing to the dissection was discovered. The histology of the arterial wall did not show specific alterations in the adventitia, the muscular layer, or the intima. In addition, the toxicological examination excluded any effects of drugs of abuse. We describe macroscopic and microscopic findings in the autopsy, and discuss possible mechanisms of the arterial rupture as well as the autopsy procedure in similar cases.

Basal and stress-induced release of noradrenaline in hypothalamus of spontaneously hypertensive rats at different ages.

Basal and stress-induced noradrenaline (NA) release was studied by intracerebral microdialysis in the hypothalamic paraventricular nucleus of spontaneously hypertensive rats (SHR) at different ages (9 weeks, 6, 18 and 24 months). NA was measured in 20-min dialysate samples by high performance liquid chromatography with electrochemical detection. Microdialysis sampling was done at baseline, during a 20-min immobilization stress and for the next 100 min. Basal NA levels decreased with age, showing a highly significant correlation. Immobilization stress raised NA similarly in the four age groups (respectively 281%, 235%, 243%, 251% of baseline at 9 weeks, 6, 18, 24 months), indicating that the response to stress is maintained at all these ages and is not affected by the development of hypertension or by aging.

Aging prolongs the stress-induced release of noradrenaline in rat hypothalamus.

A stress-induced increase in noradrenaline (NA) release was measured by intracerebral microdialysis in the hypothalamic paraventricular nucleus of freely moving Wistar-Kyoto rats at three different ages (6, 18 and 24 months). NA levels in 20-min dialysate samples were measured by high-performance liquid chromatography with electrochemical detection. Microdialysis sampling was done at the baseline during a 20-min immobilization stress and for the next 100 min. Basal NA release was not significantly different in the three age groups. The immobilization stress increased NA levels (247, 197 and 234% of the baseline for the 6-, 18- and 24-month animals, respectively) which was not significantly different in the three groups. In the two younger groups NA returned to the baseline in the first sample after the end of the stress (t = 40 min) whereas in the 24-month group it remained significantly higher for longer (until t = 60 min). Stress-induced release of hypothalamic NA thus appears to be prolonged in old rats.

Lack of glucocorticoids sustains the stress-induced release of noradrenaline in the anterior hypothalamus.

The release of endogenous noradrenaline in the anterior hypothalamus was studied with microdialysis perfusion in freely moving rats that were subjected to immobilization stress. Experiments were carried out in sham-adrenalectomized and adrenalectomized rats that were first given drinking water containing corticosterone for 5 days following surgery and then switched to a corticosterone-free diet the day before stress application. One group of these adrenalectomized animals was injected with dexamethasone. Basal release of noradrenaline collected in 20-min fractions was similar in the three groups of animals and averaged 24 fmol. The recovery of the probe was about 10%. In sham-adrenalectomized rats application of 20-min immobilization stress increased noradrenaline release to 310% of baseline in the sample collected during stress application. A significant increase (+ 175% of baseline) was still observed in the next 20-min sample. Subsequent values were all identical to baseline. In adrenalectomized rats lacking exogenous corticosterone the stress-induced release of noradrenaline was prolonged with noradrenaline levels remaining elevated for 2 h after the onset of stress. The total noradrenaline release during this entire period was about 2.5 times higher in adrenalectomized than in sham-operated rats. However, the maximal increase during the period of immobilization was not significantly affected. Treatment with dexamethasone prevented the prolonged increase in noradrenaline release but did not affect the increase during the period of stress. While glucocorticoids do not appear to affect the increased release of NA in the anterior hypothalamus during the period of stress, they act to limit the duration of this activation after the application of stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between electroencephalogram isoelectric time and hippocampal norepinephrine levels, measured by microdialysis, during ischemia in rats.

It is suggested that norepinephrine (NE) plays a role during transient forebrain ischemia. NE may have a protective action against neuronal cell death in the hippocampus, or it may be one of the causes of injurious ischemic effects. We used the microdialysis technique to study extracellular NE levels in the rat hippocampus before, during, and after 30 min of transient incomplete forebrain ischemia (induced by four-vessel occlusion) to describe the time course of NE in this condition. There was a maximal increase (fivefold) in extracellular NE after 10 min of reflow only when the electroencephalogram was isoelectric. NE levels returned to baseline 40 min after release of the carotid clamps and remained constant for the next 80 min. Thus there appears to be a transient NE overflow in the hippocampus during ischemia, closely related to the complete loss of brain electrical activity.