Predicting poor outcome in patients with suspected COVID-19 presenting to the Emergency Department (COVERED) - Development, internal and external validation of a prediction model.

BACKGROUND: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed. OBJECTIVE: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome. METHODS: In this prospective, multi-center study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort. RESULTS: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75). CONCLUSION: The COVERED risk score showed excellent discriminatory ability, also in an external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

Italian SARS-CoV-2 patients in intensive care: towards an identikit for subjects at risk?

OBJECTIVE: To investigate patient characteristics and factors that increase the risk of being admitted to intensive care and that influence survival in cases of SARS-CoV-2 pneumonia. PATIENTS AND METHODS: One-hundred and ninety-one SARS-CoV-2 patients were admitted to the "Fondazione Poliambulanza di Brescia" Hospital (Brescia, Lombardy, Italy) in the period 1st March 2020 to 11th April 2020. Data on demographics, clinical presentation at admission, co-morbidities, pharmacological treatment, admission to intensive care and death was recorded. Logistic regression and survival analysis were carried out to investigate the risk of being admitted to intensive care and the risk of death. RESULTS: The mean age of the study cohort was 64.6±9.9 years (range 20-88). Median BMI was 28.5±5 kg/m2. Fever (81%) and dyspnea (65%) were the most common symptoms on admission. Most of patients (63%) had at least one co-existing disease. The 157 (82%) patients admitted to intensive care were more likely to be of intermediate age (60-69 years; OR 3.23, 95% CI 1.32-8.38), overweight (OR 2.66, 95% CI 1.02-7.07) or obese (OR 5.63, 95% CI 1.73-21.09) and with lymphocytopenia (OR 2.75, 95% CI 1.17-6.89) than the 34 patients admitted to the ordinary ward. During intensive care, 50% of patients died and their death was associated with older age (HR 2.06, 95% CI 1.07-3.97), obesity (HR 2.23, 95% CI 1.15-4.35) and male gender (HR 1.9, 95% CI 1.02-3.57). CONCLUSIONS: We found that admission to intensive care and poor survival were associated with advanced age and higher body mass index, albeit with differences in statistical significance. Pre-existing diseases and symptoms on admission were not associated with different clinical outcomes. Interestingly, male gender was more prevalent among SARS-CoV-2 patients and was related negatively to survival, but it was not associated with more frequent admission to intensive care.

Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation.

We compared the risk of pulmonary aspiration in patients whose lungs were mechanically ventilated through a laryngeal mask airway (35 630 procedures) or tracheal tube (30 082 procedures). Three cases of pulmonary aspiration occurred with the laryngeal mask airway and seven with the tracheal tube. There were no deaths related to pulmonary aspiration. The incidence and outcome of pulmonary aspiration detected in this study were similar to those previously reported. The adjusted odds ratio (OR) for pulmonary aspiration with the laryngeal mask airway was 1.06 (95% CI 0.20-5.62). Unplanned surgery (OR 30.5, 95% CI 8.6-108.9) and male sex (OR 8.6, 95% CI 1.1-68) were associated with an increased risk of aspiration and age < 14 years with a reduced risk (OR 0.21, 95% CI 0.07-0.64). There were contraindications and exclusions to the use of the laryngeal mask airway but in this selected population the use of an laryngeal mask airway was not associated with an increased risk of pulmonary aspiration compared with a tracheal tube.

Stratton-Parker syndrome: confirmation of a new entity.

Recently, Stratton and Parker [Am J Med Genet 32:169-173, 1989] reported on a child with a previously undescribed combination of growth hormone deficiency, wormian bones, dextrocardia, brachycamptodactyly, and other midline defects. We report on another patient with similar clinical signs.

Negative pressure ventilation vs external high-frequency oscillation during rigid bronchoscopy. A controlled randomized trial.

STUDY OBJECTIVES: To compare the effectiveness of two modalities of external ventilation during rigid bronchoscopy: intermittent negative pressure ventilation (INPV) and external high-frequency oscillation (EHFO). DESIGN: Prospective, controlled, randomized, nonblinded study. SETTING: University-affiliated hospital. PATIENTS: Seventy patients undergoing interventional rigid bronchoscopy for tracheobronchial lesions were enrolled into the study. INTERVENTIONS: Mechanical ventilation was performed by INPV or EHFO. When pulse oximetry was < 90%, manually assisted ventilation was delivered. MEASUREMENTS AND RESULTS: Arterial blood gases were sampled preoperatively and intraoperatively. Most patients in both groups had normal intraoperative PaCO(2) (mean, 43. 6 +/- 11.8 mm Hg under EHFO and 37.4 +/- 8.2 mm Hg under INPV; p = 0.012), and acidemia occurred in 9 of 35 patients of EHFO group and in 2 of 35 patients of INPV group (p = 0.049). Hypercapnia (PaCO(2) > 50 mm Hg) was observed in 10 patients under EHFO and in 2 with INPV (p = 0.026). Intraoperative mean PaO(2) was similar (101.4 +/- 52.9 mm Hg with EHFO and 124.2 +/- 50.3 mm Hg with INPV; p = 0.07), but O(2) supply was different (3.5 +/- 2.3 L/min during INPV and 8.5 +/- 6.2 L/min during EHFO; p < 0.001). Intraoperative hypoxemia (PaO(2) < 60 mm Hg) occurred in five patients with EHFO and two with INPV (p = 0.426). Three EHFO patients required manually assisted ventilation (mean, 0.2 +/- 0.9), but no INPV patient did (p = 0.142). CONCLUSIONS: External negative pressure ventilation appears to be a suitable choice during rigid bronchoscopy: both EHFO and INPV ensure effective ventilation and comfortable operating conditions in the majority of patients. Some patients may receive inadequate ventilation with EHFO, developing respiratory acidosis and requiring manually assisted ventilation. In comparison with INPV, EHFO requires a higher fraction of inspired oxygen.

Breathing pattern and arterial blood gases during Nd-YAG laser photoresection of endobronchial lesions under general anesthesia: use of negative pressure ventilation: a preliminary study.

STUDY OBJECTIVE: To evaluate the efficacy of negative pressure ventilation (NPV) in avoiding or reducing apneas and related hypoxemia and respiratory acidosis during laser therapy (LT) of endobronchial lesions. DESIGN: A prospective, controlled, randomized study. SETTING: An operating theater of a respiratory endoscopy and laser therapy unit. POPULATION AND INTERVENTION: Twenty-seven consecutive patients referred to LT were entered into the study. Fourteen patients were randomly assigned to LT under general anesthesia and spontaneous assisted ventilation (control group) whereas in 13 cases, NPV by a poncho-wrap ventilator (NPV group) was added to the procedure. MEASUREMENTS AND RESULTS: The prevalence and the duration of apnea/hypopnea periods assessed by respiratory inductive plethysmography during LT were significantly reduced under NPV, compared to the control group. As compared to baseline, during LT, all control patients developed mild to severe hypercapnia (PaCO2 ranging from 55 to 76 mm Hg) and respiratory acidosis (pH from 7.33 to 7.19), whereas only three patients undergoing NPV (23%) developed hypercapnia (PaCO2 from 52 to 68 mm Hg) and related acidosis (pH from 7.29 to 7.21). Optimal oxygenation was achieved in all of the patients; nevertheless, patients under NPV needed a lower mean oxygen supply; five of them (38%) could be treated at a fraction of inspired oxygen of 0.21 for the whole procedure. CONCLUSION: NPV may be useful in reducing apneas during laser therapy under general anesthesia, thus reducing hypercapnia, related acidosis, and need of oxygen supplementation.

Occurrence of Black Dot of Potato Caused by Colletotrichum coccodes in Central Italy.

Between 1997 and 2000, black dot of potato (Solanum tuberosum L.), caused by the polyphagous soilborne fungus Colletotrichum coccodes (Wallr.) Hughes, was observed each summer in fields located in Umbria (central Italy). Disease incidence ranged from 50 to 100%, and early potato cultivars were generally more susceptible than late-maturing ones. Disease symptoms were first observed during August as a yellowing and wilting of foliage in the tops of plants, followed by rotting of the roots and stems, which led to the premature death of 50 to 70% of plants. Setose1 sclerotia (300 to 500 mm in diameter) and acervuli of the fungus were found on roots and stems of infected plants. Acervuli produced hyaline, aseptate, cylindrical conidia (16 to 22 × 2.5 to 4.5 µm) formed on unicellular cylindrical phialidic conidiophores. The fungus was isolated from diseased stems and roots on potato dextrose agar (PDA) at pH 6.5. Pathogenicity of the fungus was confirmed by fulfilling Koch's postulates using 3- to 4-week-old potato plants of a local cultivar. A superficial 5-mm vertical cut was made with a scalpel into the base of potato stems (2 cm beneath the soil surface), and 5-mm-diameter plugs of PDA alone (control plants) or PDA plus fungal growth were placed over the cuts. The wounds were sealed with wet cotton swabs that were held in place with Parafilm. Symptoms that resembled those in the field were observed on inoculated plants 6 to 8 weeks postinoculation. Symptoms did not appear on the control plants. The same fungus was reisolated from the diseased plants. Based on morphological characteristics of sclerotia, acervuli, and conidia, as well as pathogenicity tests, the fungus was identified as C. coccodes. To our knowledge, this is the first report of C. coccodes as the causal agent of black dot of potato in central Italy. We did not observe foliar outbreaks of the disease, which were reported from the United States (2). In both 1921 (1) and 1951 (3), the fungus was reported to cause severe outbreaks of the disease in northern Italy. Since then, its presence in Italy has been rarely recorded in potato (4). The occurrence of extremely dry and hot weather conditions during the summers of 1997 to 2000, which are favorable for disease development, made the disease particularly severe. We cannot exclude the possibility that the disease may have been present in central Italy before our observations, as it can be misdiagnosed and its symptoms can be masked by the symptoms of other diseases. The significance of black dot in central Italy needs to be reappraised in terms of both yield loss and tuber quality. References: (1) C. Arnaudi. Atti Ist. Bot. Univ. Pavia. Ser. 3, 1:71, 1924. (2) A. W. Barkdoll and J. R. Davis. Plant Dis. 76:131, 1992. (3) G. Goidanich. Inf. Fitopatol. 1:5, 1951. (4) S. Vitale et al. J. Plant Pathol. 80:265, 1998.

[Leydig cell tumor of the testicle. Clinical case]. / I tumori a cellule di Leydig del testicolo. Caso clinico.

The case of a young man affected by Leydig cell tumor of the right testis, without gynecomastia and feminization signs is reported. The plasmatic level of testosterone, estrogenic hormones, APF and Beta-HCG were normal. The diagnostic and therapeutical aspects are discussed and the role of the radical orchifuniculectomy in T1N0M0 stage is pointed out.

Pressure controlled versus volume controlled ventilation with laryngeal mask airway.

STUDY OBJECTIVE: To quantify the impact on peak airway pressure of pressure-controlled and volume-controlled ventilation during Laryngeal Mask Airway (LMA) use. DESIGN: Prospective, crossover clinical study. SETTING: University-affiliated hospital. PATIENTS: 32 ASA physical status I and II patients undergoing general anesthesia with the LMA. INTERVENTIONS: Patients were ventilated for three minutes both with pressure-controlled and volume-controlled ventilation, provided that tidal volume (V(T) ) and inspiratory time (It) were constant. MEASUREMENTS AND MAIN RESULTS: The monitored parameters were electrocardiography, arterial blood pressure, pulse oximetry, capnography, neuromuscular transmission, airway pressure and flow, and concentration of ventilated vapors and gases. The actually delivered V(T) was similar with both types of ventilation (volume-controlled = 0.67 +/- 0.13 lt, pressure-controlled = 0.67 +/- 0.14 lt; p = 0.688). Peak airway pressure was lower during pressure-controlled ventilation (14.6 +/- 3.5 cmH(2)O) than during volume-controlled ventilation (16 +/- 4 cmH(2)O) (p < 0.001). Furthermore, we noted that the higher the airway pressure with volume-controlled ventilation, the greater was the reduction in airway pressure during pressure-controlled ventilation. CONCLUSIONS: Pressure-controlled rather than volume-controlled ventilation can improve the effectiveness of mechanical ventilation in patients with high airway pressure.

Impact of heat and moisture exchangers on ventilatory pattern and respiratory mechanics in spontaneously breathing patients.

The upper airways warm and saturate inspired air with water vapour. In intubated or tracheotomized patients, this function is replaced either by hot water humidifiers or by heat and moisture exchangers (HMEs). The aim of this study was to quantify the modifications of ventilatory mechanics and patients' work when two different HMEs were added to spontaneously breathing patients. We studied nine consecutive patients with no previous history of chronic obstructive lung disease. All patients had been weaned from mechanical ventilation. They were breathing through devices supplying positive end-expiratory pressure and/or O2 enrichment. Two different HMEs were used: Icor Mediflux 1 and Icor Mediflux 2. These HMEs have identical chemical composition and configuration, but the Mediflux 1 is larger than the Mediflux 2. The humidification of the inspired gases was obtained alternatively by an active humidifier and the two HMEs. Data regarding ventilatory pattern and respiratory mechanics were collected by pulmonary monitor CP100 (Bicore). Tidal volume, work of breathing and pressure-time product were greater with Mediflux 1 than with Mediflux 2 or active humidifier. There were no significant differences in respiratory rate, intrinsic positive end-expiratory pressure (PEEPi), rapid shallow breathing index, arterial CO2 and O2 partial pressure. The larger HME (Mediflux 1) increased patient's effort, with no evidence of patient discomfort. However, the smaller HME (Mediflux 2) did not add a detectable load and provided adequate humidification. In conclusion, the smaller HME appears to be preferable for the management of spontaneously breathing patients.

[Late radiological aspects after vagotomy and gastric drainage]. / Aspetti radiologici tardivi dopo vagotomia e drenaggio gastrico.

Personal experience in 87 cases of vagotomy and gastric drainage is presented. Pyloroplasty according to Heinecke-Mikulicz was performed in 50 cases and drainage according to Judd in 9. Three groups were distinguished on the basis of the presence of a "gastroduodenal canal" and "pseudodiverticula". Twenty-two patients were subjected to a Finney pyloroplasty, radiologically visible is a transparent line from the large curvature of the antrum to the lesser curvature medially. Jaboulay-Alexiu gastroduodenostomy was performed in 6 cases. Here anastomosis between the large curvature and the second duodenal portion was noted, with preservation of the pylorus. Mention is made of the difficulty of recurrent ulcer diagnosis and the exact interpretation of the appearance of the antrum, pylorus and duodenum after drainage operations of this type.

[Experience in the treatment of bleeding esophageal varices]. / Esperienza nel trattamento delle varici esofagee sanguinanti.

Personal experience with respect to the diagnosis and treatment of bleeding oesophageal varices in patients with cirrhosis is described. Diagnosis is directed both to the establishment of the site of bleeding and the disease responsible and to the evaluation of risk in view of the possibliity of portal decompression. Treatment is aimed at stopping bleeding and at lowering this risk so that as many patients as possible can be operated with an acceptable degree of surgical risk.

[Indications and technics of trans-obturator by pass]. / Le indicazioni e la tecnica del bypass trans-otturatorio

Starting from a clinical case in which a trans-obturator by-pass was necessary, the most recent findings as regards the technique of this and its indications are reviewed. The procedure is to be considered a valid alternative in cases of ischaemic revascularization when the usual Scarpa triangle route cannot be used.

[Use of glucagon in the treatment of acute pancreatitis]. / Impeigo del glucagone nel trattamento della pancreatite acuta

Personal experience with glucagon in 15 cases of acute pancreatitis is reported. Complete remission of pain within 2-3 hr after infusion of the drug was noted in 85% of the series, together with normalisation of blood amylase within 48-72 hr. Glucagon inhibits pancreatic secretio&n. Vairous theories concerning its mechanism of action are examined.

[Endoscopic control of patients subjected to vagotomy and drainage for duodenal ulcer. Personal experience]. / Controllo endoscopico in pazienti operati di vagotomia e drenaggio per ulcera duodenale. Nostra esperienza.

The usefulness of endoscopic examination of patients subjected to vagotomy and drainage for duodenal ulcer is stressed, since it permits recurrences and ineffective treatment to be detected, along with the control of other parameters, such as the appearance of the mucosa, the performance of gastric drainage, the features of peristalsis and gastric tone, and the performance of the cardial sphincter. Data from a series of 43 endoscopies performed after 192 vagotomy and drainage operations carried out between 4-1973 and 5-1976 are presented.

[Cystic lymphangioma of the mesentery. A case of intestinal obstruction and a brief review of the literature]. / Linfangioma cistico del mesentere. Un caso di occlusione intestinale e breve revisione della letteratura.

Mesenteric cystic lymphangioma is a rare pathology which is not often described in the literature. Moreover, its etiopathogenesis is still uncertain. It may remain asymptomatic or it may present aspecific painful abdominal symptoms of the sub-acute type correlated with compressive phenomena or, more rarely, with acute intestinal obstruction. Surgery is the only form of treatment for both acute and sub-acute abdominal forms. The authors report a case of two mesenteric cystic lymphangiomas of the ileum which led to the onset of intestinal obstruction caused by ileal volvulus in a 45-year-old man.

[Benign tumors of the stomach]. / I tumori benigni dello stomaco.

Personal experience in cases of benign tumour of the stomach is presented. Diagnosis cannot be based on the clinical evidence alone, but must be supported by radiological examination and, more particularly, by endoscopic biopsy. Endoscopic resection and continuous follow-up examinations provide an alternative to radical surgery and gastrotomic resection.

[Embolisms of the upper extremities]. / Embolie degli arti superiori.

6 cases of upper extremity embolism observed over the past three years are reported. Fogarty embolectomy was carried out in all patients, favourable revascularization results being obtained in 5. Forearm amputations was necessary in 1 case owing to the presence of ischaemic lesions that were already advanced at admittance, further proof that results depend above all on the vitality of the extremity rather than on the duration of the arterial occlusion.

[Stenosis of the left angle of the colon caused by chronic pancreatitis]. / La stenosi dell'angolo sinistro del colon da pancreatite cronica.

Case of stenosis of the left flexure of the colon caused by pancreatitis is reported. The relevant literature is surveyed and an account is given of the pathogenesis of this forms, and the examinations required in its diagnosis, particularly coloscopy. A preference is expressed for an internal colic derivation (colon-colon anastomosis) rather than resection, on account of the smaller degree of risk involved.

[Intrahepatic bilio-jejunal anastomosis]. / Anastomosi bilio-digiunali intraepatiche.

Personal experience in intrahepatic biliojejunal anastomosis is described, along with the operative tactics and techniques now employed. Stress is laid on the importance of peroperative cholangiography in the division of patients into two groups with respect to drainage of intrahepatic bile, depending on whether or not a wide pathway exists between the two halves of the liver. The strategy to be used for each group is explained.