3D CT-Inclusive Deep-Learning Model to Predict Mortality, ICU Admittance, and Intubation in COVID-19 Patients.

Chest CT is a useful initial exam in patients with coronavirus disease 2019 (COVID-19) for assessing lung damage. AI-powered predictive models could be useful to better allocate resources in the midst of the pandemic. Our aim was to build a deep-learning (DL) model for COVID-19 outcome prediction inclusive of 3D chest CT images acquired at hospital admission. This retrospective multicentric study included 1051 patients (mean age 69, SD = 15) who presented to the emergency department of three different institutions between 20th March 2020 and 20th January 2021 with COVID-19 confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR). Chest CT at hospital admission were evaluated by a 3D residual neural network algorithm. Training, internal validation, and external validation groups included 608, 153, and 290 patients, respectively. Images, clinical, and laboratory data were fed into different customizations of a dense neural network to choose the best performing architecture for the prediction of mortality, intubation, and intensive care unit (ICU) admission. The AI model tested on CT and clinical features displayed accuracy, sensitivity, specificity, and ROC-AUC, respectively, of 91.7%, 90.5%, 92.4%, and 95% for the prediction of patient's mortality; 91.3%, 91.5%, 89.8%, and 95% for intubation; and 89.6%, 90.2%, 86.5%, and 94% for ICU admission (internal validation) in the testing cohort. The performance was lower in the validation cohort for mortality (71.7%, 55.6%, 74.8%, 72%), intubation (72.6%, 74.7%, 45.7%, 64%), and ICU admission (74.7%, 77%, 46%, 70%) prediction. The addition of the available laboratory data led to an increase in sensitivity for patient's mortality (66%) and specificity for intubation and ICU admission (50%, 52%, respectively), while the other metrics maintained similar performance results. We present a deep-learning model to predict mortality, ICU admittance, and intubation in COVID-19 patients. KEY POINTS: • 3D CT-based deep learning model predicted the internal validation set with high accuracy, sensibility and specificity (> 90%) mortality, ICU admittance, and intubation in COVID-19 patients. • The model slightly increased prediction results when laboratory data were added to the analysis, despite data imbalance. However, the model accuracy dropped when CT images were not considered in the analysis, implying an important role of CT in predicting outcomes.

Low back pain in a natural disaster.

UNLABELLED: Low back pain is usually self-limited. The transition from acute to chronic LBP is influenced by physical and psychological factors. Identification of all contributing factors, in a mass emergency setting, differentiating primary and secondary life-threatening forms of LBP, is the best approach for success. Aims of the present report were to estimate the prevalence of LBP in population afferent to four advanced medical presidiums (AMPs) during postseismic emergency period and to evaluate frequency of use, types of pain killers administered to patients and short-term efficacy of them. METHODS: Study was carried out in four AMPs during the first 5 weeks after the earthquake. Site, type of eventual trauma, pain intensity during LBP episode by Verbal Numerical Rating Scale (vNRS) were registered. Diagnosis of primary or secondary LBP was made on the basis of clinical features and therapeutic treatment was also analyzed. RESULTS: The prevalence of acute LBP was 4.9% (95%, IC 3.7 to 6.4), among 958 first accesses to AMP, representing 14.1% (95%, IC 10.8 to 18.3) of cases on the total of 322 patients treated for all pain conditions. Episodes of relapsed LBP in chronic pre-existing LBP represented the 40% (n = 19) of cases, while the first episode was present in 60% of patients (n = 28). Pain treatment was effective with a significant reduction in vNRS in short term evaluation. CONCLUSIONS: The emotional stress induced by natural disaster tends to heighten norepinephrine and sympathetic nervous system activity, which may further amplify nociception through peripheral or central mechanisms that result in consistent prevalence of primary NSLBP and become potential risk factor for pain chronicization.

Pain and natural disaster.

The treatment for pain in emergency medicine is a matter of increasing interest. Available data indicate that in both normal conditions and during major-emergencies, the majority of healthcare providers are culturally and professionally unprepared to adequately treat acute pain conditions. In case of natural disasters, opioid drugs are often unavailable. Moreover, no guidelines or validated protocols provide adequate indications for the treatment for pain in case of massive emergencies. Training of the medical and nursing staff, in both formal and continuing, or on-the-job education is needed to adequately face a devastating emergency. Unfortunately, there is an inadequate level of training among healthcare professionals, even in highly seismic areas, and the source of aid is frequently limited, especially in the immediate aftermath of a disaster to those already present at the scene. Pain inadequately treated may modify the characteristics of the pain itself. Pain is no longer considered just a symptom, but itself becomes an autonomous pathology heavily influencing the social life and psycho-social aspects of a person. In the disastrous situation following an earthquake, an inadequate treatment of pain was the major violation of the psycho-physical integrity of individuals and a severe violation of their rights, as human beings and patients.

Duloxetine and pregabalin for pain management in multiple rheumatic diseases associated with fibromyalgia.

The fibromyalgia syndrome (FMS) is characterized by chronic and widespread musculoskeletal pain and soreness accompanied by sleep disorders, chronic fatigue and affective disorders. FMS is often associated with other forms of immuno-rheumatic diseases. Although FMS pathophysiology is still not fully understood, a number of neuroendocrine, neurotransmission and neurosensitive disorders might generate a mechanism for the elicitation of pain by "central sensitization," which is common to many other painful conditions. The present case describes the success of a therapeutic scheme, which associates two different pharmacological classes, anticonvulsants and new-generation antidepressants, when FMS complicates a rare pathology called Cogan's syndrome. The association of two drugs might noticeably affect the molecular mechanisms of difficult pain, thus solving painful conditions of multifactorial origin.

Continuous Erector Spinae and Serratus-Intercostal Block With Ketamine-Dexmedetomidine Sedation for Quadrantectomy and Axillary Dissection in a Multimorbid Patient.

Multimorbidity is a clinical presentation that poses an increased risk of perioperative and postoperative complications. Tailored anaesthetic management could potentially minimise the risk of negative outcomes. Peripheral nerve and fasciae blocks are valid strategies for perioperative and postoperative pain management, which avoid complications related to general anaesthesia and reduce the risk of intensive care unit admission as well as the hospital length of stay. We describe the case of a 56-old patient with multimorbidity, including obesity with a BMI of 45.7, unstable angina, predicted difficult airway management and obstructive sleep apnoea syndrome (OSAS) scheduled for left mastectomy with sentinel lymph node biopsy, managed with a left continuous thoracic erector spinae plane (ESP) block plus serratus-intercostal plane block (BRanches of Intercostal nerves at the Level of Mid-Axillary line (BRILMA)), and sedation with combined ketamine-dexmedetomidine. Fascial blocks combined with opioid-free anaesthesia (OFA) proved to be effective for the multimorbid patient, ensuring successful perioperative management and a proper recovery after surgery.

Two cases of metformin-associated lactic acidosis in post-operative period in emergency department: time to be aware-case reports.

Background: Diabetic patients on metformin therapy may be vulnerable to lactic acidosis during acute illness. This is particularly true since the comorbid conditions among patients with diabetes and the frequent use of renin-angiotensin system blockers increase the risk of renal dysfunction. Case Description: We present two cases of metformin-associated lactic acidosis (MALA) occurred after abdominal surgery. A 74-year-old woman presented to emergency department (ED) for a transient loss of consciousness. She had vomiting, diarrhea, and lack of appetite in the last 3 days and she had had an abdominal adhesiolysis surgery 12 days before. A 78-year-old man, with history of right hemicolectomy performed 15 days before admission to ED. Patient presented with diffuse abdominal pain, diarrhea, nausea, and vomiting). Arterial blood gas analysis showed acidemia (pH 7.031), elevated anion gap (AG), lactate >15.5 mmol/L. Due to the patients' critical condition, vasopressor infusion and fluid resuscitation were started and an urgent continuous veno-venous hemodialysis with citrate and calcium (CVVHD-CiCa) treatment was provided. Conclusions: A promptly differential diagnosis at ED and early treatment with vital support and CVVHD-CiCa enabled the resolution of MALA, which can often be a fatal complication in diabetic patients taking metformin. Close collaboration with the surgical and endocrinological team would be necessary for the management of the postoperative period planning the reintroduction of metformin in patients undergoing major abdominal surgery, to avoid the possibility of the onset of MALA.

Fascial Plane Blocks Combination for Breast Surgery in Obese Patients With Difficult Airway Management: Insidious or a Valid Alternative.

Obesity poses several challenges for anesthetists. The several comorbidities associated with obesity can result in very complex management, which requires a multimodal and reasoned approach. The possible difficult airways are, certainly, the obstacle that most can put the anesthetist to the test. From this point of view, regional anesthesia (RA) can be a valid alternative to general anesthesia (GA) in selected patients. The possibility of performing an anesthetic block allows the fulfilment of the surgical act. We present the case of a 56-year-old woman, with a BMI of 43. In her medical history, she has obstructive sleep apnea syndrome (OSAS) on home-oxygen therapy without continuous positive airway pressure (CPAP) therapy. The patient reported probable airway difficulties in previous breast surgery, and the preoperative evaluation highlighted and confirmed the high risk. For this reason, in agreement with the surgeons and the patient, we decided to perform RA. Forty minutes before the start of the surgery, a deep anesthetic ultrasound-guided serratus anterior plane (US-SAP; branches of the intercostal nerves in the middle axillary line [BRILMA]) was performed, followed by a right ultrasound-guided erector spinae plane (US-ESP) block. Mild sedation with propofol 1 mg/kg/h was administered and SpO2 always remained above 97% with nasal oxygen at 3 l/min. The surgery was completed in 35 minutes, the patient complained of no pain, and received opioid rescue therapy during the post-operative period. This case presents clinical evidence that RA can help in avoiding some dreadful complications that can occur during GA in obese patients. In any case, the anesthetic management choice must be carefully reasoned, considering the patient's clinical conditions, surgical needs, and, not least, the skills of the anesthetist.

Anti-AT1R autoantibodies and prediction of the severity of Covid-19.

The stimulation of AT1R (Angiotensin II Receptor Type 1) by Angiotensin II has, in addition to the effects on the renin-angiotensin system, also pro-inflammatory effects through stimulation of ADAM17 and subsequent production of INF-gamma and Interleukin-6. This pro-inflammatory action stimulate the cytokine storm that characterizes the most severe forms of SARS-CoV-2 infection. We studied the effect of AT1Rab on the AT1R on 74 subjects with SARS-CoV-2 infection with respiratory symptoms requiring hospitalization. We divided the patients into 2 groups: 34 with moderate and 40 with severe symptoms that required ICU admission. Hospitalized subjects showed a 50% reduction in the frequency of AT1Rab compared to healthy reference population. Of the ICU patients, 33/40 (82.5%) were AT1Rab negative and 16/33 of them (48.5%) died. All 7 patients positive for AT1Rab survived. These preliminary data seem to indicate a protective role played by AT1R autoantibodies on inflammatory activation in SARS-CoV-2 infection pathology.

Headache prevalence in the population of L'Aquila (Italy) after the 2009 earthquake.

Stress induced by the events of daily life is considered a major factor in pathogenesis of primary tension-type headache. Little is known about the impact that could have a more stressful event, like a natural disaster, both in patients with chronic headache, both in people that do not had headache previously. The aim of the present study was to observe the prevalence of headache in the population following the devastating earthquake that affected the province of L'Aquila on April 6, 2009. The study population was conducted in four tent cities (Onna, Bazzano, Tempera-St. Biagio, Paganica). Sanitary access is recorded in the registers of medical triage, in the first 5 weeks, after the April 6, 2009. The prevalence of primary headache presentation was 5.53% (95% CI 4.2-7.1), secondary headache was 2.82% (95% CI 1.9-4.9). Pain intensity, assessed by Numerical Rating Scale score showed a mean value of 7±1.1 (range 4-10). The drugs most used were the NSAIDs (46%) and paracetamol (36%), for impossibility of finding causal drugs. This study shows how more stressful events not only have an important role in determining acute exacerbation of chronic headache, but probably also play a pathogenic role in the emergence of primary headache. Also underlines the lack of diagnostic guidelines or operating protocols to early identify and treat headache in the emergency settings.

Transdermal buprenorphine for central neuropathic pain: clinical reports.

Transdermal buprenorphine is an effective analgesic for a variety of pain conditions. Traditionally, neuropathic pain is treated with medications such as tricyclic antidepressants or anticonvulsants, with opioid medications as second or third-line agents. We present two different painful conditions of presumed neuropathic origin, with complex etiopathogenesis, which were successfully treated with buprenorphine. The results of treatment of these neuropathic pain syndromes with buprenorphine are encouraging, suggesting that it might represent a valid alternative to standard approaches for central neuropathic pain.

Assessment of Pain and Associated Comorbidities: A Survey of Real Life Experiences Among Nurses in Italy.

PURPOSE: Pain is a symptom that should be evaluated along with its comorbidities in order to plan an effective holistic treatment strategy involving specific pharmacological interventions, side effect management, psychological support, control of therapeutic effects over time, and dialogue with the patient and their relatives. In this holistic process of caring for patients with pain, nurses play a central role as they deal with suffering patients directly and continuously. The purpose of this study was to evaluate the types of pain identified by nurses in their daily clinical practice and the associated comorbidities (anamnestic history taking) by geographical region and to evaluate the pharmacological strategies used. METHODS: A cross-sectional survey was performed among 696 registered nurses in Italy. Data were collected using an online questionnaire. RESULTS: There was a significant difference between geographical regions in terms of reports of acute and chronic pain: acute pain was more frequently reported in the South (63.5%), while chronic pain was more frequent in the Central region (32.3%; p=0.0008). Additionally, chronic oncological pain was more frequent in the Northeast (29.6%), while chronic non-oncological pain was more frequently reported in the Central region (33.9%; p=0.0001). The underlying pain disorders reported were also different between geographical regions; rheumatic pain (21.8%) and neurological pain (18.6%) were more frequent in the Central region, while musculoskeletal pain was significantly more frequent in the South (43.4%; p=0.004). Anxiety, sleep disorders and somatization were found in acute pain (60.82%, 43.56% and 53.12%), while depression and mood disorders were more frequently detected in chronic pain condition (p<0.001). CONCLUSION: Our study showed differences among Italian regions in pain assessment. Specific education on pain management nursing is essential for nurses. Promotion of optimal nursing care for people affected by pain is the main focus of pain management nursing. Nowadays, nurses should focus on personalized complex care and research in order to improve the patient's quality of life.

Plates versus struts versus an extracortical rib fixation in flail chest patients: Two-center experience.

PURPOSES: Notwithstanding advances in medical and surgical management of flail chest, its morbidity and mortality rates are still high. Aim of this study is to compare three approaches for parietal thoracic stabilization by analyzing both early and long-term patient outcomes. METHODS: A retrospective study from January 2006 to January 2018 involving sixty-five surgical flail chest (25 plates,11 struts and 29 wires fixations) was conducted. A mean Abbreviated Injury Scale (AIS) was 2.38±0.82 and a mean Injury Severity Score (ISS) was 32.02±8.21. RESULTS: Struts and plates stabilizations compared with wires fixation showed an immediate restoring of the partial pressure of oxygen (90.56 mmHg vs 91.90 mmHg vs 89.23 mmHg, p = 0.021), the carbon-dioxide levels (36.00 mmHg vs 35.03 mmHg vs 38.98 mmHg, p = 0.000) and the oxygen-blood saturation (97.71% vs 98.21% vs 92.12%, p = 0.000) in the early postoperative period. Furthermore, struts and plates ensured a better recovery of daily activities up to the 3rdmonth (QoL=1.0: p<0.001 in lateral flail chest and p<0.02 in anterior and antero-lateral flail chest). At the 12thmonth no difference in QoL was found between the different approaches. CONCLUSIONS: Plate and strut fixation revealed a lower rate of postoperative morbidity and mortality. Wires stabilization was characterized for a reduction of operative time.

Pleural empyema associated with alveolar-pleural fistulas in severe acute respiratory syndrome coronavirus 2.

Surgery in COVID-19 disease complicated by APF represents the last life-saving treatment option. The choice of the therapeutic period to indicate this approach is fundamental. In fact, the clinical stability of patient is necessary in order to allow single-lung ventilation and to minimize postoperative sequelae.

Airway management in anesthesia for thoracic surgery: a "real life" observational study.

BACKGROUND: One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs. METHODS: A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway. RESULTS: Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted. CONCLUSIONS: DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.

An Analysis of Italian Nurses' Approach to Patients' Pain: A Nationwide Online Survey.

Healthcare providers play a fundamental role in evaluating pain. Several issues about how nurses are educated remain unsolved. The aim of our study was to address how Italian nurses manage patients suffering from pain in daily practice. A cross-sectional survey was administered among Italian registered nurses. Data were collected using a 34-item questionnaire that had been previously validated during a pilot study. The lowest level of participation/education/information events was observed in the South (p=0.0001). A significant difference among the four areas was found in the department affiliation of responders (p=0.0001). Pain assessment at patients' admission was most frequent in the Northeast (32.9%), whereas the lowest frequency was found in the South (15.1%) (p=0.0001). The prevalence of nurses' knowledge of pain scales and their distribution in usual applications was similar in the Northwest and -east, and Central Italy, but lower in the South (p=0.0001). This study underlines the need for change in the clinical approach to pain treatment in healthcare. Pain assessment is a fundamental step for preparing individualized therapeutic plans, and nurses play a crucial role in improving the quality of life of suffering patients.

Outcomes following primary percutaneous coronary intervention for unprotected left main-related ST-segment elevation myocardial infarction.

INTRODUCTION: Unprotected left main (ULM) related ST-segment elevation myocardial infarction (STEMI) is a severe event, often leading to circulatory failure and/or sudden cardiac death. Although high-risk ULM thrombosis populations treated by primary percutaneous coronary intervention (PPCI) have been previously described, very little is known regarding the outcomes following PPCI for ULM-related STEMI in a hospital without on-site surgical back-up. METHODS: A retrospective cohort analysis was performed on all consecutive patients who underwent PPCI for ULM-related STEMI in a single center. The primary end-point was to assess in-hospital mortality in the overall population and according to the presence/absence of cardiogenic shock at admission. RESULTS: Between October 2006 and December 2012, 1094 patients underwent PPCI for STEMI. PPCI for ULM-related STEMI was performed in 34 (3.1%) patients. Among these, 22 (64.7%) were in cardiogenic shock at admission. Baseline mean ejection fraction was lower (P = 0.008), whereas the prevalence of patients with pre-procedural cardiac arrest and Killip Class III-IV was significantly higher in the cardiogenic shock (P = 0.05 and P < 0.001, respectively) compared with non-cardiogenic shock group. Furthermore, patients with cardiogenic shock had a higher prevalence of pre-procedural thrombolysis in myocardial infarction flow 0-1 (P = 0.05) and associated other vessel chronic total occlusion (P = 0.05) compared with non-cardiogenic shock group. Procedural success rate was lower in the cardiogenic shock compared with non-cardiogenic shock group (77.3 vs. 100%, P = 0.09), whereas in-hospital mortality rate was significantly higher in the cardiogenic shock compared with non-cardiogenic shock group (36.4 vs. 0%, P = 0.02). No deaths were reported among survivors of the acute phase at mid-term follow-up, whereas target lesion revascularization rate was 7.6%. CONCLUSIONS: PPCI for ULM-related STEMI in a hospital without on-site surgical back-up was technically feasible in most of the cases. Although the procedural success and in-hospital mortality rates were influenced by cardiogenic shock at admission, an excellent mid-term outcome among patients who survived the hospitalization was reported independently by the severity of clinical presentation.