Doubts and concerns about COVID-19 uncertainties on imaging data, clinical score, and outcomes.

BACKGROUND: COVID-19 is a pandemic disease affecting predominantly the respiratory apparatus with clinical manifestations ranging from asymptomatic to respiratory failure. Chest CT is a crucial tool in diagnosing and evaluating the severity of pulmonary involvement through dedicated scoring systems. Nonetheless, many questions regarding the relationship of radiologic and clinical features of the disease have emerged in multidisciplinary meetings. The aim of this retrospective study was to explore such relationship throughout an innovative and alternative approach. MATERIALS AND METHODS: This study included 550 patients (range 25-98 years; 354 males, mean age 66.1; 196 females, mean age 70.9) hospitalized for COVID-19 with available radiological and clinical data between 1 March 2021 and 30 April 2022. Radiological data included CO-RADS, chest CT score, dominant pattern, and typical/atypical findings detected on CT examinations. Clinical data included clinical score and outcome. The relationship between such features was investigated through the development of the main four frequently asked questions summarizing the many issues arisen in multidisciplinary meetings, as follows 1) CO-RADS, chest CT score, clinical score, and outcomes; 2) the involvement of a specific lung lobe and outcomes; 3) dominant pattern/distribution and severity score for the same chest CT score; 4) additional factors and outcomes. RESULTS: 1) If CT was suggestive for COVID, a strong correlation between CT/clinical score and prognosis was found; 2) Middle lobe CT involvement was an unfavorable prognostic criterion; 3) If CT score < 50%, the pattern was not influential, whereas if CT score > 50%, crazy paving as dominant pattern leaded to a 15% increased death rate, stacked up against other patterns, thus almost doubling it; 4) Additional factors usually did not matter, but lymph-nodes and pleural effusion worsened prognosis. CONCLUSIONS: This study outlined those radiological features of COVID-19 most relevant towards disease severity and outcome with an innovative approach.

The coagulation profile as a marker for acute appendicitis in the paediatric population: Retrospective study.

INTRODUCTION: Appendicitis is the commonest and most frequently misdiagnosed acute abdominal surgical illness in the paediatric population worldwide. The aim of this study is to evaluate the role of coagulation profile in acute appendicitis (AA) in children. MATERIALS AND METHODS: we retrospectively collected data of patients submitted to appendectomy from 2011 to 2017. According to histopathology, patients were divided into three groups: not histologically confirmed AA (NAA), simple AA (SAA) and complicated AA (CAA). White blood cell (WBC) count, relative neutrophilia (Neutr%), C-reactive protein (CRP), prothrombin time ratio (PTratio), activated partial thromboplastin time ratio (APTTratio) and fibrinogen (Fib) were compared among groups. RESULTS: Three hundred and seven patients were included: 57 NAA, 184 SAA and 66 CAA. WBC was significantly different among groups: CAA (mean 16.67 × 103/ml), SAA (14.73 × 103/ml, P= 0.01) and NAA (10.85 × 103/ml, P< 0.0001). Significant differences were found for Neutr% (mean CAA 81.14 vs. SAA 77.03 P= 0.006, vs. NAA 63.86 P< 0.0001) and CRP (mean NAA 2.56, SAA 3.26, CAA 11.58, P< 0.0001). PTratio and Fib increased with the severity of AA receiver operator characteristic curves were similar for CRP (0.739), Fib (0.726), WBC (0.746) and Neutr% (0.754), while for PTratio and aPTTratio were 0.634 and 0.441, respectively. CONCLUSIONS: extrinsic coagulation pathway is altered in AA, especially in CAA. Coagulation can be useful in the diagnostic and perioperative anaesthetic management of AA in children. Fib seems to have the highest accuracy.

Key Role of Respiratory Quotient to Reduce the Occurrence of Hypoxemia During Extracorporeal Gas Exchange: A Theoretical Analysis.

OBJECTIVES: Extracorporeal respiratory support, including low blood flow systems providing mainly extracorporeal CO2 removal, are increasingly applied in clinical practice. Gas exchange physiology during extracorporeal respiratory support is complex and differs between full extracorporeal membrane oxygenation and extracorporeal CO2 removal. Aim of the present article is to review pathophysiological aspects which are relevant for the understanding of hypoxemia development during extracorporeal CO2 removal. We will describe the mathematical and physiologic background underlying changes in respiratory quotient and alveolar oxygen tension during venovenous extracorporeal gas exchange and highlight the clinical implications. DESIGN: Theoretical analysis of venovenous extracorporeal gas exchange. SETTING: Italian university research hospital. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: While the effect of extracorporeal CO2 removal on the respiratory quotient of the native lung has long been known, the role of extracorporeal oxygenation in dictating changes in the respiratory quotient has been less addressed. Indeed, both extracorporeal CO2 removal and extracorporeal oxygen delivery affect the respiratory quotient of the native lung and thus influence the alveolar PO2. Indeed, for the same amount of extracorporeal CO2 extraction, it is possible to reduce the FIO2, reduce the risk of absorption atelectasis, and maintain the same alveolar PO2, by increasing the extracorporeal oxygen delivery. CONCLUSIONS: Worsening of hypoxemia is frequent during low-flow extracorporeal CO2 removal combined with ultraprotective mechanical ventilation. In this context, increasing extracorporeal oxygen delivery, increases the respiratory quotient of the native lung and could reduce both the occurrence of alveolar hypoxia and absorption atelectasis, thus optimizing the residual lung function.

Antithrombin supplementation during extracorporeal membrane oxygenation: study protocol for a pilot randomized clinical trial.

BACKGROUND: Normal levels of plasma antithrombin (AT) activity might decrease heparin requirements to achieve an adequate level of anticoagulation during treatment with extracorporeal membrane oxygenation (ECMO). Acquired AT deficiency during ECMO is common, but formal recommendations on target, timing, and rate of AT supplementation are lacking. Thus, we conceived a pilot trial to evaluate the feasibility and safety of prolonged AT supplementation in patients requiring veno-venous ECMO for respiratory failure. METHODS: Grifols Antithrombin Research Awards (GATRA) is a prospective, randomized, single blinded, multicenter, controlled two-arm trial. Patients undergoing veno-venous ECMO will be randomized to either receive AT supplementation to maintain a functional AT level between 80 and 120% (AT supplementation group) or not (control group) for the entire ECMO course. In both study groups, anticoagulation will be provided with unfractionated heparin following a standardized protocol. The primary endpoint will be the dose of heparin required to maintain the ratio of activated partial thromboplastin time between 1.5 and 2. Secondary endpoints will be the adequacy of anticoagulation and the incidence of hemorrhagic and thrombotic complications. DISCUSSION: GATRA is a pilot trial that will test the efficacy of a protocol of AT supplementation in decreasing the heparin dose and improving anticoagulation adequacy during ECMO. If positive, it might provide the basis for a future larger trial aimed at verifying the impact of AT supplementation on a composite outcome endpoint including hemorrhagic events, transfusion requirements, and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03208270 . Registered on 5 July 2017.

Mediterranean dietary pattern adherence: associations with prediabetes, metabolic syndrome, and related microinflammation.

BACKGROUND: The adherence to the Mediterranean Diet (Med Diet) seems to reduce the incidence of metabolic syndrome. The present study aimed to explore whether the adherence to the overall Med Diet pattern and to specific Med Diet items is associated with the presence of metabolic syndrome, impaired fasting glucose (IFG), insulin resistance (IR), and microinflammation in subjects free of diabetes and cardiovascular diseases. MEASUREMENTS: Each patient underwent clinical assessment. Adherence to the Med Diet was measured by a previously validated 14-item questionnaire. Metabolic syndrome was defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria; IR was defined by homeostasis model assessment of insulin resistance (HOMA-IR); inflammation was assessed through a high-sensitivity C-reactive protein (hsCRP) assay. RESULTS: A total of 120 subjects (64.2% women, mean age 59.8±10.2 years) were enrolled at this study. Subjects with lower Med Diet pattern adherence exhibited higher occurrence of metabolic syndrome and all its components and higher HOMA-IR and hsCRP values (P for all <0.0001). Subjects with metabolic syndrome were less likely to consume olive oil (P=0.002) and vegetables (P=0.023). By multivariable analyses, the overall Med Diet score was found to be strongly and inversely associated with the presence of metabolic syndrome [B=-0.066; 95% confidence interval (CI) -0.105 to -0.028; P=0.001], IFG (B=-0.076; 95% CI -0.114 to -0.038; p<0.0001), high HOMA-IR (B=-0.071; 95% CI -0.108 to -0.034; P<0.0001) and high hsCRP (B=-0.082; 95% CI -0.125 to -0.045; P<0.0001). None of specific Med Diet items independently predicted metabolic syndrome, IFG, and high HOMA-IR. Instead, the consumption of white meat over red meat (B=-0.324; 95% CI -0.467 to -0.178; P<0.0001) was found to be inversely associated with increased hsCRP. CONCLUSIONS: The inverse associations between adherence to Med Diet and the prevalence of metabolic syndrome and prediabetes may be due more to the effects of the entire dietary pattern rather than to individual food components. Metabolic syndrome-related microinflammation may further be linked to specific Med Diet components.

Depressive symptoms in older people with metabolic syndrome: is there a relationship with inflammation?

OBJECTIVE: To investigate if there is a higher prevalence of depressive symptoms in older people with metabolic syndrome (MetS) compared with those without and whether dedpressive symptoms are independently associated to MetS and its single components and to the inflammatory markers. METHODS: Physical parameters, standard blood analytes, high sensitivity C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR) were assessed. Fifteen-item Geriatric Depression Scale and mini mental state examination (MMSE) were administered. RESULTS: One hundred thirty-three subjects were enrolled. MetS patients (57) exhibited higher prevalence of depressive symptoms (p < 0.0001), worse cognitive function (p < 0.0001), and higher levels of ESR and hsCRP were higher (p < 0.0001). The univariate analysis showed a linear strong correlation of depressive symptoms (p < 0.0001) with the MMSE score (r = -0.422), body mass index (r = 0.414), MetS (r = 0.582), number of MetS components (r = 0.663), fasting blood glucose (r = 0.565), ESR (r = 0.565), hsCRP (r = 0.745), central obesity (r = 0.269; p = 0.002), and high-density lipoprotein cholesterol (r = -0.241; p = 0.005). However, the multivariate analysis showed that only age (B = -0.093; p = 0.032), MetS (B = 1.446; p = 0.025), fasting blood glucose (B = 0.039; p = 0.005), and hsCRP (B = 7.649; p < 0.0001) were independently associated with depressive symptoms. CONCLUSIONS: MetS and inflammation are independently associated with depressive symptoms in older people. Inflammation may explain cognitive decline too. Further investigations are needed to better understand the direction of these associations and to determine whether these can be reversible.

[Predictors of liver fibrosis in patients with non-alcoholic fatty liver disease. The role of metabolic syndrome, insulin-resistance and inflammation]. / Predittori di fibrosi epatica in pazienti con steatosi epatica non-alcolica. Il ruolo della sindrome metabolica, dell'insulino-resistenza e dell'infiammazione.

INTRODUCTION: NAFLD (non-alcoholic fatty liver disease) reaches an high prevalence in the general population, and it is closely related to metabolic syndrome (MetS). The entity of metabolic abnormalities and the chronic inflammation seem to play a main role in the development of liver fibrosis. The aim of our study is to determine whether subjects with NAFLD and MetS have higher liver fibrosis degree when compared with NAFLD subjects without MetS, and to investigate the relations between fibrosis, MetS and its single components and inflammation. MATERIALS AND METHODS: We considered 24 patients with NAFLD. Those who had viral- and alcohol- related liver disease were excluded. MetS was diagnosed according to NCEP ATP III criteria; inflammatory status was determined through C-reactive protein (PCR) assay. The peripheral insulin-resistance was assessed by calculating HOMA ir. Liver fibrosis was measured by transient elastography (Fibroscan®). RESULTS: Subjects with MetS had higher HOMA ir, PCR and Fibroscan® score (log value: 0.92±0.24 KPa vs 0.73±0.2 KPa; p=0.047). The linear correlation analysis showed that Fibroscan® score was related to MetS, number of MetS components, waist circumference, HOMA ir and PCR. However the multivariate regression analysis showed that only HOMA ir (B=0.077; 95%CI: -0.002- 0.157; p=0.05) and PCR (B=0.152; 95% CI: 0.006 - 0.299; p=0.006) were independent predictors of higher Fibroscan® score. CONCLUSION: MetS is associated to higher liver fibrosis degree in subjects with NAFLD. The insulin-resistance and inflammation seem to be the main determinants.

Screening cognition in the elderly with metabolic syndrome.

BACKGROUND: Metabolic syndrome reaches its highest prevalence in the elderly, and evidence suggests that metabolic syndrome could be an independent risk factor for cognitive impairment. The aims of this study were to detect whether patients with metabolic syndrome have lower cognition and to investigate whether there is a relationship with cognition and single metabolic syndrome components. METHODS: We assessed fasting blood glucose (FBG), high-density lipoprotein cholesterol (HDL-C), triglycerides, high-sensitivity C-reactive protein (hsCRP), and anthropometric measurements. Metabolic syndrome was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. The population sample was divided into two groups according to the presence of metabolic syndrome. Cognitive function was investigated through the Mini-Mental State Examination (MMSE). RESULTS: We enrolled 159 elderly subjects (mean age, 69.8±4.8 years). Seventy had metabolic syndrome. Metabolic syndrome subjects had higher hsCRP values (P<0.0001) and lower MMSE scores (P<0.0001) than those without metabolic syndrome. MMSE scores were significantly correlated with body mass index (BMI), hsCRP, metabolic syndrome, the number of metabolic syndrome components, and each of them. However, at multivariate regression analysis, only fasting blood glucose [FBG; B=-0.046; 95% confidence interval (CI) -0.066 to -0.028; P<0.0001] and the number of metabolic syndrome components (B=-0.317; 95% CI -0.572 to -0.010; P=0.042) were found to be independent predictors of lower MMSE scores. CONCLUSION: We found that subjects with metabolic syndrome have lower MMSE scores than those without, even without symptomatic cognitive impairment, and that the number of metabolic abnormalities is independently associated to lower MMSE scores. We suggest that these patients should always undergo cognitive screening to prevent more severe outcomes.