THE STORM (acute coronary Syndrome in paTients end Of life and Risk assesMent) study.

INTRODUCTION: Elderly patients with coexisting frailty and multiple comorbidities frequently present to the emergency department (ED). Because non-cardiovascular comorbidities and declining health status may affect their life expectancy, management of these patients should start in the ED. This study evaluated the role of Gold Standards Framework (GSF) criteria for identifying patients with acute coronary syndromes (ACS) approaching end of life. METHODS: All consecutive patients admitted to the ED and hospitalised with a diagnosis of ACS between May 2012 and July 2012 were included. According to GSF criteria, patients were labelled as positive GSF status when they met at least one general criterion and two heart disease criteria; furthermore, traditional cardiovascular risk scores (the Global Registry for Acute Coronary Events (GRACE) score and the Age, Creatinine and Ejection Fraction (ACEF) score) were calculated and WHOQOL-BREF was assessed. Mortality and repeat hospitalisation due to cardiovascular and non-cardiovascular causes were evaluated at 3-month and 12-month follow-up. RESULTS: From a total of 156 patients with ACS enrolled, 22 (14%) had a positive GSF. A positive GSF was associated with higher rate of non-cardiovascular events (22.7% vs 6.7%; p=0.03) at 3 months and higher rates of both cardiovascular and non-cardiovascular events (36% vs 16.4%; p=0.04 and 27.3% vs 6.7%; p=0.009, respectively) at 12 months. In multivariate analysis, an in-hospital GRACE score was a predictor of cardiovascular events, while a positive GSF independently predicted non-cardiovascular events. CONCLUSIONS: The GSF score independently predicts non-cardiovascular events in patients presenting with ACS and may be used along with traditional cardiovascular risk scores in choosing wisely the most appropriate treatment. The present results need to be externally validated on larger samples.

Ultrasound-Guided Needle Biopsy as an Alternative to Chamberlain's Mediastinotomy and Video-Assisted Thoracoscopic Surgery (VATS) in the Diagnosis of Anterior Mediastinal Neoformations: A Retrospective Analysis.

(1) Background: The prompt diagnosis of anterior mediastinal lesions is a challenge due to their often being categorized as malignant tumours. Ultrasound-guided Transthoracic Core Needle Biopsy (US-TCNB) is an innovative technique that is arousing increasing interest in clinical practice. However, studies in this area are still scarce. This study aims to compare the diagnostic accuracy and complication rate of US-TCNB with those of traditional surgical methods-Anterior Mediastinotomy and Video Assisted Thoracoscopic Surgery (VATS)-in patients with anterior mediastinal lesions. (2) Methods: This retrospective study involved patients evaluated between January 2011 and December 2021 who had undergone US-TCNB at the Interdepartmental Unit of Internal and Interventional Ultrasound, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy. Personal data, diagnostic questions, and technical information concerning the bioptic procedure, periprocedural complications and histological reports were collected. (3) Results: Eighty-three patients were included in the analysis. Histological examination was performed in 78 cases, with an overall diagnostic accuracy of 94.0% (sensitivity 94%; specificity 100%). Only in 5 patients was a diagnosis not achieved. Complications occurred in 2 patients who were quickly identified and properly treated without need of hospitalization. The accuracy of US-TCNB was comparable to the performance of the main traditional diagnostic alternatives (95.3% for anterior mediastinotomy, and 98.4% for VATS), with a much lower complication rate (2.4% vs. 3-16%). The outpatient setting offered the additional advantage of saving resources. (4) Conclusions: a US-guided needle biopsy can be considered effective and safe, and in the near future it may become the procedure of choice for diagnosing anterior mediastinal lesions in selected patients.

A case of histological diagnosis of Toxoplasma gondii myositis in a person living with HIV.

We report the case of a 58-year-old male with a recent diagnosis of HIV infection admitted for progressive muscular weakness and psychomotor impairment. Cerebrospinal examination documented a mild hyperproteinorrachia, with normal cells count and reduced glycorrhachia. Brain gadolinium-enhanced MRI showed bilateral T2 and FLAIR hyperintensities in the nucleo-capsular region and irregular contrast-enhancement of the globi pallidi and the right putamen. The histologic analysis of a quadriceps biopsy showed several foci of inflammatory infiltrates with concomitant muscular fiber atrophy and degeneration. Scattered intracytoplasmic inclusions were observed in muscle fibers, representing the main pathological feature. A positive PCR for Toxoplasma gondii and a Toxoplasma gondii specific monoclonal antibody immunohistochemical staining confirmed the diagnosis.

Light Scattering Technology and MALDI-TOF MS in the microbiological fast-track of bloodstream infections: potential impact on antimicrobial treatment choices in a real-life setting.

Introduction. Rapid identification (ID) and antimicrobial susceptibility testing (AST) of bloodstream infections (BSI) pathogens are fundamental to switch from empirical to targeted antibiotic therapy improving patients outcome and reducing antimicrobial resistance spreading.Hypothesis. The adoption of a rapid microbiological protocol (RP) based on Matrix-Assisted Laser Desorption Ionization-Time Of Flight Mass Spectrometry (MALDI-TOF MS) and Light Scattering Technology (LST) for rapid diagnosis of BSI could positively impact on patients' antimicrobial management.Aim. The study aim was to evaluate a RP for BSI microbiological diagnosis in terms of accuracy, turnaround time (TAT) and potential therapeutic impact.Methodology. A prospective observational study was conducted: monomicrobial bacterial blood cultures of septic patients were analysed in parallel by RP and standard protocol (SP). In RP the combination of MALDI-TOF MS and LST was used for rapid ID and AST assessments, respectively. To determine the potential impact of RP on antimicrobial therapy management, clinicians were interviewed on therapeutic decisions based on RP and SP results. RP accuracy, TAT and impact were evaluated in comparison to SP results.Results. A total of 97 patients were enrolled. ID and AST concordance between RP and SP were 96.9 and 94.7 %, respectively. RP technical and real-life TAT were lower than SP (6.4 h vs. 18.4 h; 9.5 vs. 27.1 h). The agreement between RP- and SP-based therapeutic decisions was 90.7 (90 % CI 84.4-95.1). RP results could produce 24/97 correct antibiotic changes with 18/97 possible de-escalations and 25/97 prompt applications of infection control precautions.Conclusion. With the application of RP in BSI management, about one-fourth of patients may safely benefit from early targeted antibiotic therapy and infection control policies with one working day in advance in comparison to conventional methods. This protocol is feasible for clinical use in microbiology laboratories and potentially helpful for Antimicrobial Stewardship.

Impact of an empiric antimicrobial therapy manual on antimicrobial usage and multidrug resistant organism trends in a large Italian teaching hospital.

Aim: To evaluate the changes in antimicrobial consumption and multidrug-resistant microorganism trends after introducing an empiric antimicrobial therapy manual to support antimicrobial stewardship. Methods: A 4-year prospective interventional study assessed the effect of introducing an empiric antimicrobial therapy manual in medical and surgical wards during two periods: pre-intervention period (January 2015-May 2017) and post-intervention period (June 2017-December 2019). Outcomes included microorganism trends of bloodstream infections (BSI) for Klebsiella pneumoniae carbapenemase-producing bacteria (KPC), extended spectrum beta-lactamase ESBL-E. coli, meticillin-resistant Staphylococcus aureus (MRSA) and Candida albicans. Also, Clostridioides difficile infection (CDI) episodes were included. Rates were normalised per 1000 patient-days (PD). Antimicrobial consumption was assessed as defined daily dose (DDD)/1000 PD in interrupted time series analysis. Results: In medical wards, we observed a significant decrease in the consumption of piperacillin-tazobactam and a decrease in the trends of tigecycline and vancomycin consumption. In surgical wards, there was a significant decrease in consumption of fluoroquinolones and piperacillin-tazobactam. This decrease was maintained in trend for all the antimicrobials but was significant for tigecycline only. In medical wards, there was a significant reduction of MRSA and C. albicans. In surgical wards, we observed a decrease in MRSA, ESBL-E. coli, C. albicans and CDI. KPC cases decreased by 22.5% in medical wards and 74.3% in surgical wards. Conclusion: The results suggest that a persuasive educational approach to antimicrobial stewardship, with the introduction of an empiric antimicrobial manual and continuous education, resulted in reductions in both antimicrobial use and healthcare-associated BSI caused by multidrug-resistant organisms. More studies with longer follow up are needed to investigate the effect of antimicrobial stewardship on clinical outcomes.

Clinical and microbiological characteristics of bloodstream infections caused by Enterococcus spp. within internal medicine wards: a two-year single-centre experience.

Enterococcal bloodstream infections (E-BSI) constitute the second cause of Gram-positive bacterial BSI in Europe with a high rate of in-hospital mortality. Furthermore, E-BSI treatment is still challenging because of intrinsic and acquired antibiotic resistances. We conducted a retrospective, 2-year, observational, single-centre study to evaluate clinical outcome and risk factors for E-BSI mortality in internal medicine wards. 201patients with E-BSI were included in the analysis. Infection rate was 2.4/1000 days of hospital admission. Most E-BSI were hospital acquired (78.1%). The median age was 68 years. Charlson Comorbidity Index, adjusted for age, was 5 (range 4-6). Patients with E-BSI frequently had at least one invasive device, predominantly a central venous (73%) or a bladder catheter (61.7%). Enterococcus faecium accounted for 47.94% of E-BSI (resistance rate to ampicillin or vancomycin was 22.2 and 23.3%, respectively) and Enterococcus faecalis for 52.08% (resistance rate to ampicillin or vancomycin was 3.1 and 2.2%, respectively). Among all E-BSI, 25% of patients received appropriate therapy. In total, 59% of E-BSI underwent echocardiography. At the multivariate analysis, resistance to vancomycin (OR 2.09, p = 0.025), sepsis (OR 2.57, p = 0.003) and septic shock (OR 3.82, p = 0.004) was a predictor of mortality. No difference in 28-day survival was observed between appropriate or inappropriate treatment, except for endocarditis. However, E-BSI sources in clinical practices are not always properly investigated, including the rule-out of intracardiac vegetations. We did not demonstrate a difference in mortality for inappropriate therapy in the absence of endocarditis in comorbid patients with a long history of medicalization.

The Refeeding Syndrome: a neglected but potentially serious condition for inpatients. A narrative review.

The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe undernourishment. RFS derives from an abnormal electrolyte and fluid shifts leading to many organ dysfunctions. Symptoms generally appear within 2-5 days of re-feeding and may be absent/mild or severe and life threating, depending on the pre-existing degree of malnutrition and comorbidities. The lack of a standard definition and the nonspecificity of the symptoms make both incidence estimate and diagnosis difficult. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed a unifying definition for the RFS and its severity classification. The awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving the management. The objectives of this narrative review were to summarize the current knowledge and recommendations about the RFS and to provide useful tips to help physicians to recognize and prevent the syndrome.

Implementing hospital guidelines improves warfarin use in non-valvular atrial fibrillation: a before-after study.

BACKGROUND: The use of oral anticoagulant therapy (OAT) to prevent non-valvular atrial fibrillation (NVAF) related-strokes is often sub-optimal. We aimed to evaluate whether implementing guidelines on antithrombotic therapy (AT) by a multifaceted strategy may improve appropriateness of its prescription in NVAF-patients discharged from a large tertiary-care hospital. METHODS: A survey was conducted on all consecutive NVAF patients discharged before (1st January-30th June 2000, n = 313) and after (1st January-30th June 2004, n = 388) guideline development and implementation. RESULTS: When strongly recommended, OAT use increased from 56.6% (60/106 in 2000) to 81.9% (86/105 in 2004), with an absolute difference of +25.3% (95%CI: 15% 35%). In patients for whom the choice OAT/acetylsalicylic acid should be individualised, those discharged without any AT were 33.7% (34/101) in 2000 and 16.9% (21/124) in 2004 (-16.7%;95%CI: -26.2% -7.2%). In a logistic regression model, OAT prescription in 2004 was increased by 2.11 times (95%CI: 1.47 3.04), after accounting for stroke risk, presence of contraindications (OR = 0.18; 0.13 0.27), older age (OR = 0.30; 0.21 0.45), prophylaxis at admission (OR = 3.03; 2.08 4.43). OAT was positively associated with the stroke risk in the 2004 sample only. CONCLUSION: The guideline implementation has substantially improved the appropriateness of OAT at discharge, through a better evaluation at patient's individual level of the benefit-to-risk ratio.

Implementing guidelines for venous thromboembolism prophylaxis in a large Italian teaching hospital: lights and shadows.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) remains a serious complication in hospitalized patients, in spite of several published guidelines (GL) on its prevention. The objective of this study (part of the TRiPSS-2 project) was to evaluate the impact of a locally adapted GL, supported by a multifaceted implementation strategy, in improving VTE prophylaxis in a large teaching hospital. DESIGN AND METHODS: A before and after controlled study was used to evaluate the impact of the recommendations on the appropriateness of prophylaxis. We evaluated the medical charts of two random samples, each of 250 patients, discharged in the first semester of the years 2000 and 2002. The hospital incidence of VTE (1996-2004) was also monitored, through the discharge summaries. RESULTS: Among high risk patients, appropriateness of prophylaxis increased both in medical (from 25% to 41.7%, p=0.0075) and in surgical patients (from 63.7% to 97.1%, p=0.0004). A parallel sharp increase (by 6-8 times) of consumption of elastic stockings was documented. In both medical and surgical patients the incidence of VTE decreased markedly and sustainedly in 2002-2004, with an adjusted odds ratio of 0.68 (95% confidence interval: 0.62-0.75). However, the use of lower than recommended doses of heparins and the increased use of prophylaxis in low risk patients represent unsolved problems. INTERPRETATION AND CONCLUSIONS: Implementing locally adapted GL may be highly effective in improving appropriateness of prophylaxis and in reducing the incidence of VTE; however a careful evaluation of changes is recommended in order to identify unsolved problems or undesired effects.

Guidelines for preoperative assessment: impact on clinical practice and costs.

OBJECTIVE: To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented. DESIGN: We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization. MAIN MEASURES: Mean number of tests prescribed, preoperative assessment cost per patient. RESULTS: The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 69 euros to 26 euros). As regards the cost per patient for preoperative evaluation and hospital stay (115 euros considering only variable costs, 580 euros including all costs), the application of the guidelines would reduce costs by 41-52% according to different cost evaluation approaches for hospital stay. CONCLUSION: Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.