Impact of sarcopenia in SARS-CoV-2 patients during two different epidemic waves.

BACKGROUND: Sarcopenia was reported to be associated with poor clinical outcome, higher incidence of community-acquired pneumonia, increased risk of infections and reduced survival in different clinical settings. The aim of our work is to evaluate the prognostic role of sarcopenia in patients with the 2019 novel coronavirus disease (COVID-19). MATERIALS AND METHODS: 272 COVID-19 patients admitted to the University Hospital of Modena (Italy) from February 2020 to January 2021 were retrospectively studied. All included patients underwent a chest computed tomography (CT) scan to assess pneumonia during their hospitalization and showed a positive SARS-CoV-2 molecular test. Sarcopenia was defined by skeletal muscle area (SMA) evaluation at the 12th thoracic vertebra (T12). Clinical, laboratory data and adverse clinical outcome (admission to Intensive Care Unit and death) were collected for all patients. RESULTS: Prevalence of sarcopenia was high (41.5%) but significantly different in each pandemic wave (57.9% vs 21.6% p < 0.0000). At the multivariate analysis, sarcopenia during the first wave (Hazard Ratio 2.29, 95% confidence intervals 1.17 to 4.49 p = 0.0162) was the only independent prognostic factor for adverse clinical outcome. There were no significant differences in comorbidities and COVID19 severity in terms of pulmonary involvement at lung CT comparing during the first and second wave. Mixed pattern with peripheral and central involvement was found to be dominant in both groups. CONCLUSION: We highlight the prognostic impact of sarcopenia in COVID-19 patients hospitalized during the first wave. T12 SMA could represent a potential tool to identify sarcopenic patients in particular settings. Further studies are needed to better understand the association between sarcopenia and COVID-19.

A computational model to compare different investment scenarios for mini-stereotactic frame approach to deep brain stimulation surgery.

UNLABELLED: Deep brain stimulation (DBS) alleviates symptoms of many neurological disorders by applying electrical impulses to the brain by means of implanted electrodes, generally put in place using a conventional stereotactic frame. A new image guided disposable mini-stereotactic system has been designed to help shorten and simplify DBS procedures when compared to standard stereotaxy. A small number of studies have been conducted which demonstrate localization accuracies of the system similar to those achievable by the conventional frame. However no data are available to date on the economic impact of this new frame. AIM: The aim of this paper was to develop a computational model to evaluate the investment required to introduce the image guided mini-stereotactic technology for stereotactic DBS neurosurgery. METHODS: A standard DBS patient care pathway was developed and related costs were analyzed. A differential analysis was conducted to capture the impact of introducing the image guided system on the procedure workflow. The analysis was carried out in five Italian neurosurgical centers. RESULTS: A computational model was developed to estimate upfront investments and surgery costs leading to a definition of the best financial option to introduce the new frame. Investments may vary from Euro 1.900 (purchasing of Image Guided [IG] mini-stereotactic frame only) to Euro 158.000.000. Moreover the model demonstrates how the introduction of the IG mini-stereotactic frame doesn't substantially affect the DBS procedure costs.

Surgical site infections in HIV-infected patients: results from an Italian prospective multicenter observational study.

BACKGROUND: The quality of life of the HIV-infected population in developed countries has substantially improved over the years. Accordingly, the clinical limitations in the surgical treatment of the HIV-infected patients are becoming fewer, and the number of HIV-infected patients undergoing surgical interventions of all types is increasing. However, available data on the incidence and risk factors for post-surgical complications, such as surgical site infections (SSI), in HIV-infected patients are still limited and often controversial. The aim of this study was to determine the incidence and the associated risk factors for SSI in HIV-infected patients. METHODS: A 1-year observational prospective multicenter surveillance study was conducted in 11 Italian Infectious Diseases Clinical Centers from which 305 consecutive HIV-infected patients undergoing different surgical procedures were enrolled. Postdischarge surveillance was conducted within 30 days after surgery. A number of variables were included in a multivariate analysis aimed at assessing potential risk factors for SSI, including body mass index, diabetes, Hepatitis C (HCV) and hepatitis B virus infection, lipodistrophy, HIV viral load, CD4 cell count and white blood cell count, preoperative hospital stay, National Nosocomial Infection Surveillance (NNIS) risk score, and any antimicrobial prophylaxis. RESULTS: SSI occurred in 29 of 305 (9.5%) patients, of which 17 (58.6%) SSI occurred during hospital stay, and 12 (41.4%) occurred during the postdischarge period. The SSI of the 29 patients were classified as superficial (21, 72.4%), deep (four, 13.8%), organ/space (one, 3.4%), and sepsis (three, 10.3%). Nearly 50% of the superficial and 50% of the deep SSI occurred during the postdischarge period. Organ/space infection and sepsis accounted for 13.7% of all SSI and were observed during the in-hospital stay. The multivariate analysis revealed that HCV co-infection was significantly associated to SSI occurrence. Total hospital stay was longer among patients with SSI than among those without SSI (p = 0.041). CONCLUSION: Although 92.5% of our HIV-infected patients presented a NNIS score < or = 1, the SSI rate was twofold higher than that reported in Italian and European studies for the general population, with more severe clinical presentations. This is the first report of an association between HCV-HIV co-infection and SSI occurrence. Additionally, the viro-immunological status of our patients was not related to SSI occurrence, which suggests the need for further research for other potential risk factors that may be implicated in the occurrence of SSI.

Outpatient parenteral antibiotic therapy for bone and joint infections: an italian multicenter study.

In the early eighties, the advantages of outpatient parenteral antibiotic therapy (OPAT) (reduced costs, no hospitalization trauma in children, no immobilization syndrome in elderly, reduction in nosocomial infections by multiresistant organisms) were identified in the United States, and suitable therapeutic programs were established. Currently, more than 250,000 patients per year are treated according to an OPAT program. In order to understand the different ways of managing OPAT and its results, a National OPAT Registry was set up in 2003 in Italy. Analysis of data concerning osteomyelitis, septic arthritis, prosthetic joint infection and spondylodiskitis, allowed information to be acquired about 239 cases of bone and joint infections, with particular concern to demographics, therapeutic management, clinical response, and possible side effects. Combination therapy was the first-line choice in 66.9% of cases and frequently intravenous antibiotics were combined with oral ones. Teicoplanin (38%) and ceftriaxone (14.7%), whose pharmacokinetic/pharmacodynamic properties permit once-a-day administration, were the two top antibiotics chosen; fluoroquinolones (ciprofloxacin and levofloxacin) were the most frequently utilized oral drugs. Clinical success, as well as patients' and doctors' satisfaction with the OPAT regimen was high. Side-effects were mild and occurred in 11% of cases. These data confirm that the management of bone and joint infections in an outpatient setting is suitable, effective and safe.

Daily modifications of 3H-naloxone binding sites in the rat brain: a quantitative autoradiographic study.

The endogenous opioid peptides, the opiate receptors and several related behaviours, like opioid-mediated analgesia, show daily variations in different animal species including rats. The attempt to correlate the daily rhythm of opiate receptors in the central nervous system (CNS) to opiate related rhythmic phenomena requires an experimental approach with a high anatomical resolution, as the opioid distribution is very heterogeneous. In this paper we present the study of daily variations of 3H-naloxone binding sites in the different regions of the adult male rat brain, performed by means of quantitative autoradiography. Five rats are sacrificed at each investigated time of the day (0200, 0600, 1000, 1400, 1800 and 2200). The ligant is 3H-naloxone (4 nM), the quantification is performed by means of densitometric procedures (image analyzer Tesak VDC 501, computer Digital PDP 11, 3H-microscale). The statistical analysis is performed according to the single Cosinor method and the one-way analysis of variance followed by the multiple range test of Duncan. We analysed 33 different regions of the rat CNS, and the daily variations of opiate receptors are regionally selective. A circadian rhythm is found in the anterior cingulate cortex, hippocampal cortex, periventricular, medial, ventral, reticular and posterior nuclei of the thalamus, rhomboid, gelatinosus and rheuniens nuclei, lateral hypothalamus, locus coeruleus, grey substance of the pons, reticular formation of medulla oblongata, inferior olivary complex, medial part of the nucleus of the solitary tract and nucleus of the spinal tract of the trigeminal nerve. An ultradian rhythm is found in the medial and lateral preoptic areas, in the medial hypothalamus, in the medial and in the lateral nuclei of habenula. No significant variations during 24 hr according to the Cosinor analysis are found in the dorsal and lateral cerebral cortex, striatum, globus pallidus, bed nucleus of the stria terminalis, septal nuclei, lateral nucleus of the thalamus, cochlear nuclei, nucleus of the solitary tract, lateral and caudal parts, dorsal motor nucleus of the vagal nerve, XII and IX nerve nuclei. The amplitude of the daily variations observed ranges from 10 to 40%. Our results demonstrate the high anatomical selectivity of the daily modifications of 3H-naloxone binding sites in the rat CNS. They also indicate that quantitative autoradiography is a suitable and sensitive technique for these studies.

[Changes in the blood levels of adrenal hormones after prolonged physical activity]. / Modificazioni dei livelli plasmatici degli ormoni surrenalici dopo attività fisica protratta.

In order to evaluate the effect of prolonged physical activity on the adrenal cortex we have measured the plasma blood level of dehydroepiandrosterone sulphate (DHEAS), androstenedione (A) and cortisol (C) in ten moderately trained male subjects an hour before and 5-10 minutes after an hour of swimming. Mean plasma levels of DHEAS after physical activity were significantly higher respect to pre-exercise levels. The mean plasma levels of A pre- and post-exercise also demonstrated a significantly difference. Cortisol levels did not increase significantly after this kind of physical activity. These results suggest that prolonged exercise determines an independent activation of the cortical zona reticularis as to that of the zona fasciculata.

[Hyperprolactinemia in hypothyroidism: effects of L-thyroxine therapy]. / Iperprolattinemia nell'ipotiroidismo: effetti della terapia con L-tiroxina.

It is well known that the pituitary PRL secretion is modified in patients with primary hypothyroidism. The serum PRL is elevated in approximately one third of patients, the others presenting with enhanced PRL release after TRH intravenous (i.v.) administration. The objective of this study was to verify how treatment with L-thyroxine modifies the enhanced PRL response to TRH administration in a group of patients with primary hypothyroidism. Eight female patients aged 28 to 64 (mean age +/- SD = 17.2 +/- 6.0) with primary hypothyroidism were studied. Diagnosis was based on clinical features and plasma FT4 (mean +/- SD = 5.2 +/- 0.9 pmol/l; n.r. 7.7-19.3 pmol/l) and TSH (mean +/- SD = 87.3 +/- 20 mUI/l; n.r. 0.2-5 mUI/l) levels. As controls eleven normal age-matched female subjects were also studied. After an overnight fasting an indwelling catheter was inserted into an antecubital vein of the forearm and kept patient by slow infusion of normal saline solution. After 60' the basal blood sample was collected and 200 mcg of TRH was injected intravenously (0'), further blood samples were taken at 30', 60', 90', 120' and 180'. PRL determinations (n.r. 3-19 ng/ml) of the blood samples obtained were made using fluoroimmunometric assay. Hypothyroid patients underwent a second TRH test after L-thyroxine replacement therapy (100 mcg/day) had led to euthyroidism for at least three months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Exacerbation of autoimmune hypothyroidism after hemi-hypophysectomy in a patient with Cushing's disease]. / Esacerbazione di ipotiroidismo autoimmune dopo emi-ipofisectomia in una paziente con morbo di Cushing.

A 41 year old woman affected by Cushing's disease underwent hemi-hypophysectomy with removal of an ACTH secreting microadenoma. Forty days later, when normal ACTH, cortisol plasma levels and urinary cortisol levels were restored, features of primary autoimmune hypothyroidism developed. While cortisol levels were elevated serum thyroid hormone levels were normal, serum hormone TSH was at the upper limit of the normal range and serum antimicrosomal antibodies were slightly elevated. It is likely that hypothyroidism already present before surgery was not clinically evident due to the immunosuppressive effect of high cortisol levels. The need to assess thyroid function in patient with hypercortisolism is emphasized with the aim to identify the possible onset of autoimmune thyroid disease when cortisol levels are normalized.

[Acute suppurative thyroiditis in a patient with prior subacute thyroiditis]. / Tiroidite acuta suppurativa in un paziente con pregressa tiroidite subacuta.

Acute suppurative thyroiditis is an uncommon thyroid disorder usually caused by bacterial infection. The most common route of infection is a fistula that originates from the fundus of the pyriform sinus. Pre-existing thyroid disease, most commonly nodular goiter, has been reported to be present in acute suppurative thyroiditis. A 44 year old man presented a subacute thyroiditis, resolved by nonsteroidal antiinflammatory treatment. One year later, the patient abruptly complained of fever and painful swelling in the thyroid region. A relapse subacute thyroiditis was diagnosed and prednisone treatment was started. A few days later owing to a worsening of the pain and of the clinical features the patient was referred to our department. He presented dysphagia and he was feverish, the overlying skin of the neck swelling was erythematous and warm. There was a neutrophilia (83.7%). Plasma FT4, FT3 and TSH were normal. Anterior neck region ultrasonography showed an enlargement of the left thyroid lobe with poorly defined shapes and inhomogeneous parenchyma while the right lobe of the gland was normal. The 131-I thyroid scan showed a large cold area in the upper part of the left thyroid lobe and preserved radionuclide uptake in the residual parenchyma. The RAIU was normal. We diagnosed acute suppurative thyroiditis and started antibiotics treatment. The day after the patient was still feverish and he gave out from the mouth a great quantity of sero-purulent material with a swelling reduction and improvement of the neck pain. Barium swallow examination did not show any fistula in the cervical esophagus. The fistula opening was demonstrated by indirect laryngoscopy in the postero-lateral side of hypopharynx.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart rate variability in patients with Sjögren's syndrome.

Heart rate variability (HRV) gives information about sympathetic parasympathetic autonomic balance. Our purpose was to determine whether HRV is abnormal in patients with Sjögren's syndrome. In 16 patients with Sjögren's syndrome and 30 matched controls, a short time analysis of HRV was performed for both the frequency and the time domain. In the time domain, patients tended to display a slower heart rate, greater R-R variability and higher standard deviation of the mean (SDNN) than did healthy subjects, but the differences were not statistically significant. In the frequency domain the spectral measures of HRV showed a slight reduction of LF and an increase of HF; as a result, the ratio between high and low frequencies, representative of sympathovagal modulation, was significantly reduced. Our data suggest an increase in the parasympathetic control of heart rate in patients with Sjögren's syndrome. This predominance in vagal tone could exert a protective and antiarrhythmic role in patients with primary Sjögren's syndrome, and may be relevant with reference to the lower incidence of sudden death in this disorder compared to other major autoimmune diseases.

[Evaluation of dopaminergic activity of the hypothalamus in patients with polycystic ovarian syndrome]. / Valutazione del tono dopaminergico ipotalamico in pazienti con sindrome dell'ovaio policistico.

To evaluate the hypothalamic dopaminergic activity in patients with polycystic ovary syndrome (PCOS), we studied the PRL, TSH, LH and FSH responses to i.m. administration of sulpiride in five euthyroid women affected by PCOS and in five normal women. The mean basal PRL and TSH plasma levels resulted significantly higher (p less than 0.01) in PCOS subjects with respect to normal subjects. The incremental area under PRL and TSH profiles, after sulpiride administration, were significantly lower (p less than 0.05) in PCOS patients than in the control group; no significant variation of LH and FSH plasma levels resulted. Our data suggest a decrease dopaminergic activity in PCOS.

[The community-acquired pneumonia: appropriateness of the admissions, risk factors and therapy]. / Le polmoniti acquisite in comunita: appropriatezza dei ricoveri, fattori di rischio e terapia adottata.

In a clinical and epidemiological study used Fine's Pneumonia Severity Index to determine the appropriateness of the hospitalisation of patients with community acquired pneumonia in the Internal Medicine Department of a hospital in Northern Italy. Risk factors and antibiotic treatment were checked against recent international guidelines. The study shows that 20% of the admissions were to be not appropriate. The principal risk factors were old age and such the co-morbidities heart failure, chronic cerebral diseases and COPD. In the home setting macrolides are less used than the new fluoroquinolones respirators. In the hospitals arrangements, b-lactams are still highly used, perhaps because of the high percentage of elderly patients. The data currently available suggest that some new fluoroquinolones such as levofloxacin are quite effective, presenting a broad spectrum of action, high bioavailability and good tolerability. Sequential therapy with this antibiotic leads to shorter hospitalisation times.

Outpatient parenteral antibiotic therapy in the elderly: an Italian observational multicenter study.

Bacterial infections are the most frequent cause of hospitalization in elderly patients. In the early eighties, the advantages of Outpatient parenteral Antibiotic therapy (OPAT) were identified in the United States, and suitable therapeutic programs were established. In order to understand the different ways of managing OPAT, a National OPAT Registry was set up in 2003 in Italy. This study analyzes data concerning bacterial infections in 176 elderly patients including demographics, therapeutic management, clinical response, and side-effects. Bone and joint infections (48.9%) and skin and soft tissue infections (27.8%) were the most common infections treated with OPAT. Teicoplanin (28.9%) and ceftriaxone (22.1%) were the top two antibiotics chosen. OPAT was mainly performed at a hospital infusion center (52.8%). The clinical success rate was high and side-effects were low (12.6% of cases). Management of bacterial infections in the elderly with an outpatient program is effective and safe.

Effects of prolonged treatment with diltiazem on pituitary secretion of luteinizing hormone, follicle-stimulating hormone, thyrotropin and prolactin.

In previous studies it has been observed that acute administration or short-term treatment with calcium channel blockers can influence the secretion of some pituitary hormones. In this study, we have examined the effect of the long-term administration of diltiazem on luteinizing-hormone (LH), follicle-stimulating hormone (FSH), thyrotropin (TSH) and prolactin (PRL) levels under basal conditions and after gonadotropin-releasing hormone (GnRH)/thyrotropin-releasing-hormone (TRH) stimulation in 12 subjects affected by cardiovascular diseases who were treated with diltiazem (60 mg 3 times/day per os) for more than 6 months and in 12 healthy volunteers of the same age. The basal levels of the studied hormones were similar in the two groups. In both the treated patients and the control subjects, a statistically significant increase (p < 0.01) in LH, FSH, TSH and PRL levels was observed after GnRH/TRH administration. Comparing the respective areas under the LH, FSH, TSH and PRL response curves between the two groups did not present any statistically significant difference. These findings indicate that long-term therapy with diltiazem does not alter pituitary hormone secretion.

Influence of exercise on dehydroepiandrosterone sulphate and delta 4-androstenedione plasma levels in man.

To study the involvement of adrenal cortex in prolonged physical exercise, we measured plasma dehydroepiandrosterone sulphate (DHEAS), delta 4-androstenedione (delta 4-A) and cortisol (C) levels in 20 moderately trained men one hour before and 5-10 min after one-hour-swimming. Mean plasma DHEAS and delta 4-A pre-exercise levels increased significantly with respect to post-exercise levels. Cortisol levels moderately increased, but showed no significant modifications after the exercise. These results suggest that in this physical exercise there is an independent activation of the cortical zona reticularis as to that of the zona fasciculata.

Evidence of altered dopaminergic modulation of prolactin and thyrotropin secretion in patients with polycystic ovary syndrome.

In order to evaluate the functional activity of the tubero-infundibular dopaminergic system in polycystic ovary syndrome (PCOS), we analysed the prolactin (PRL) and thyrotropin (TSH) responses to the dopamine antagonist sulpiride. We studied 8 euthyroid women affected by PCOS and 7 normal women. The mean baseline PRL values were normal in both groups. After sulpiride administration the incremental area under the PRL profile in PCOS was significantly lower than in normal subjects (p less than 0.01). The mean basal plasma TSH levels were significantly higher in the PCOS than in the control group (p less than 0.01). After sulpiride administration the incremental area under the TSH profile was significantly lower in PCOS patients than in normal women (p less than 0.01). The higher basal plasma levels of TSH, the blunted response of PRL and the lack of response of TSH to sulpiride in PCOS suggest a relative decrease of the dopaminergic activity in PCOS patients.

Legionnaires' disease imported from Spain in a patient with beta-thalassaemia minor.

The Authors report a rare case of Legionnaires' disease imported from Spain in a patient with beta-thalassaemia minor. This condition as predisposing factor for Legionella pneumophila infection is discussed, with particular emphasis on the therapeutic implications.

Iron removal therapy in porphyria cutanea tarda: phlebotomy versus slow subcutaneous desferrioxamine infusion.

Twenty-five patients with overt clinical and biochemical findings of porphyria cutanea tarda took part in a study comparing intensive phlebotomy with slow subcutaneous desferrioxamine treatment. Fifteen male patients (Group A) had intensive venesection therapy. Ten patients (Group B) with associated diseases (minor thalassemia, cardiovascular impairment, pulmonary tuberculosis or severe liver cirrhosis) received 1.5 g of desferrioxamine by slow subcutaneous infusion using an automatic syringe pump 5 days a week. No patient complained of appreciable side effects. Serum iron, ferritin and uroporphyrins were normalized in all subjects by the end of treatment. The mean time necessary for complete recovery was 13.8 months (range 9-19) and 11.2 months (range 6-14) in Groups A and B, respectively. Liver function significantly improved during and after the treatments in both groups. We conclude that recovery from porphyria cutanea tarda can be achieved equally well using phlebotomy or desferrioxamine subcutaneous infusion. Phlebotomy is easily performed and remains the treatment of choice; slow subcutaneous desferrioxamine treatment, although expensive, is recommended when severe associated diseases contra-indicate venesection.

Effects of thyroid hormone status on the growth hormone responses to clonidine.

It has been shown that thyroid hormones are positive regulators of GH synthesis and secretion. The serum GH response to stimuli seems to be influenced either by sex or by spontaneous hypothalamic rhythm. The growth hormone responses to clonidine administration (4 micrograms/kg) have been therefore studied in a group of female patients with thyroid disease (seven hyperthyroid and five hypothyroid) before and after the achievement of the euthyroid state. In hyperthyroid patients both basal and clonidine-stimulated GH levels were similar to normal subjects; the achievement of euthyroidism did not modify the GH response to clonidine. Serum GH peaks after clonidine were lower in hypothyroids patients than in hyperthyroids and normal subjects; the GH response to alpha 2-agonist administration did not change during thyroid replacement therapy. The GH response to clonidine was not influenced by the GH secretory status in the preceding hour.