Acetic acid disinfection as a potential adjunctive therapy for non-severe COVID-19.

PURPOSE: SARS-CoV-2 is a new pandemic influenza caused by a coronavirus which main route of transmission is through exhaled droplets that primarily infect the nose and the nasopharynx. The aim of this paper is to evaluate the effect of acetic acid, the active component of vinegar, as a potential disinfectant agent for upper airways. METHODS: Twenty-nine patients were enrolled and divided into two groups: group 1 (14 patients) was composed of patients treated with off-label hydroxychloroquine and lopinavir/ritonavir, whereas group 2 (15 patients) was composed of patients treated with hydroxychloroquine only, combined with the inhalation of acetic acid disinfectant at a 0.34% concentration. A questionnaire-based evaluation of symptoms was performed after 15 days in both groups. RESULTS: It appears that the number of patients treated with acetic acid (group 2) that experienced improvement in individual symptoms was double that of the other group of patients (group 1), although numbers are too small for robust statistical analysis. CONCLUSIONS: Considering its potential benefits and high availability, acetic acid disinfection appears to be a promising adjunctive therapy in cases of non-severe COVID-19 and deserves further investigation.

Postoperative long-term morbidity of extended endoscopic maxillectomy for inverted papilloma.

BACKGROUND: Extended endoscopic maxillectomy (Sturmann-Canfield procedure) allows full visualization of the maxillary sinus by sectioning the lacrimal duct and removing the medial part of the anterior maxillary wall. The aim of this study is to evaluate the morbidity of Sturmann-Canfield procedure in patients treated for inverted papilloma. METHODOLOGY: The clinical records of all patients treated with a Sturmann-Canfield procedure for inverted papilloma from October 2000 to September 2015 at two teaching hospitals were reviewed. All patients were evaluated by nasal endoscopy and lacrimal system patency was assessed. Pre-maxillary cutaneous sensitivity was tested with a Semmes-Weinstein aesthesiometer and thermic stimulation. The SNOT-22 questionnaire was administered. Patients were also asked to report any other post-surgical complaints. RESULTS: Fifty-nine patients were identified. Mean follow-up after surgery was 66.3 months. Mean SNOT-22 score was 5.94 (range 0-20); the majority of patients (86%) had a SNOT-22 symptom score of 3 or lower. Mucocoele occurred in 3 (5%) cases. Lacrimal pathway obstruction was observed in 7 (12%) patients. Fourteen (24%) patients complained of paraesthesia in the malar area; hypoesthesia was present in only 5 (8%) cases. Hypoesthesia in the region innervated by the anterior superior alveolar nerve was detected in 17 (29%) patients. One patient reported a slight depression of paralateronasal soft tissues. CONCLUSIONS: Although nasal function outcomes and the results from SNOT-22 questionnaires were favourable, a high rate of neurologic and lacrimal complications was observed. Potential morbidity of the intervention, including the possibility of negative aesthetic sequelae, should be discussed during preoperative counselling.

Violence against women in Rome: An analysis of cases treated in the gynecology emergency department of the hospital Umberto I between 1999 and 2013.

BACKGROUND: The gynecological emergency department of the Policlinico Umberto I, Rome sees an average of about 30 cases of violence against females each year. It is stressed that these cases are not representative of all cases of violence against women in Rome and they cannot be used to estimate the prevalence or incidence of the phenomenon, but they may provide some insight on the victims and their aggressors, the use of drugs or alcohol, factors which may affect the decision to report the attack to the police and attacks on children. METHODS: The case records of all 458 females seen in the emergency department between 1999 and 2013 were retrieved, data were extracted and an Excel worksheet was prepared. Temporal variation in the numbers of cases, the types of aggression, the use of drugs or alcohol, reporting the attack to the police and violence against children were specifically investigated using frequency tabulations and appropriate statistical tests. RESULTS: There has been little change in the number of cases seen during the 15 year period; there is no significant seasonal effect or difference between the days of the week. Just over half of the attacks were reported to the police, but this was less likely among the older victims. About 87% of the cases involved vaginal and/or anal penetration. The use of drugs and/or alcohol was most common, 43%, among unmarried women aged 21-25. There were 32 cases of violence against children aged under 16. CONCLUSIONS: There has been little change in the number and characteristics of violent attacks on women seen at this large hospital in Rome over the years 1999-2013.These cases provide little information about the general epidemiology of violence against women, although they do imply that this great social and cultural problem continues unabated in Rome.

Cocaine induced midline destructive lesions.

PURPOSE: Review of the literature concerning cocaine induced midline destructive lesions (CIMDL). METHODS: We reviewed the English literature regarding CIMDL involving the nose and its surrounding structures. The review is based on a search of the US National Library of Medicine (PubMed) online database from January 1st, 1982 to March 31st, 2013. RESULTS: CIMDL is a pathology that mimics systemic diseases with positive anti-neutrophil cytoplasmic antibodies (ANCA). The prevalence of CIMDL is considered to be about 4.8% among cocaine users. Clinical manifestations include hyposmia, facial pain, crusting, ulcers, nasal septal perforation, palatal perforation, sinus wall destruction, orbital erosion and damage of the anterior skull base. The presence of ANCA directed against human neutrophil elastase (HNE) is the most distinguishing feature of CIMDL. Toxicological tests, indirect immunofluorescence microscopy, antigen specific solid assay testing, histopathological analysis, apoptosis assay and MRI imaging concur in the clinical identification of CIMDL. The pathogenesis of CIMDL is poorly understood and implicates inflammatory, infective, proapoptotic and autoimmune mechanisms. CONCLUSION: CIMDL must be readily recognized by clinicians to provide appropriate treatment. Immunosuppressive therapy has no role in the treatment of CIMDL. Only abstinence can interrupt the progression of the disease.

Assessment of baseline characteristics and risk factors among Emergency Department patients presenting with recent onset atrial fibrillation: a retrospective cohort study.

BACKGROUND: The Cardioversion of Atrial Fibrillation in Emergency (CAFE) study was an observational, retrospective, multicenter study focusing on patients with recent onset atrial fibrillation (AF) seen in six different Emergency Departments (ED) of Rome, Italy. AIM: The aim of this study was to present the baseline characteristics and risk factors of the patients enrolled to the CAFE study. MATERIALS AND METHODS: We retrospectively reviewed 3085 eligible patients diagnosed with recent onset AF in any of the EDs between January 2008 and December 2009. Inclusion criteria required documented ICD-9 primary discharge/admission diagnosis of AF in the ED and stable hemodynamic conditions at presentation (systolic blood pressure > 90 mmHg). Exclusion criteria were permanent AF or an ongoing acute coronary syndrome. RESULTS: Median age was 71 years (interquartile ranges, 62-78 years) and 50.8% were men. Palpitations was the most common symptom at ED presentation and was present in 73.5% of the study subjects. Hypertension was the most prevalent comorbidity, affecting 59.3% of the patients evaluated, and the presence of previous episode(s) of AF was also common (52.3%). Regarding home treatment, the drugs most prescribed were antiplatelets (31.2%) and diuretics (25.2%). A CHADS2 score of 0 was found in 814 patients (26.4%), while a CHADS2 score of 1 was reported in 1114 patients (36.1%). Finally, a CHADS2 score ≥ 2 was reported in 1157 patients (37.5%). CONCLUSIONS: The present study represents an important snapshot of demographics, comorbidities, risk factors and anticoagulation management about patients with recent onset AF. Disparities were noted in anticoagulation management, suggesting that this is still a main problem among patients with AF.

Venous thrombosis in emergency department: diagnosis, treatment, and disposition.

AIM: The Authors describe diagnosis, treatment and therapy of deep venous thrombosis in Emergency Department following the last guidelines indications. DISCUSSION: Deep venous thrombosis of the legs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep venous thrombosis and pulmonary embolism) include the post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Acute pulmonary embolism may occur rapidly and unpredictably and may be difficult to diagnose. Diagnosis and treatment can reduce the risk of death, and appropriate primary prophylaxis is usually effective. Patients treated for acute pulmonary embolism appear to be more times as likely to die of recurrent thromboembolism in the next year.

Soluble sST2 biomarker analysis for fibrosis development in atrial fibrillation. A case control study.

ABSTRACT: Objectives. Atrial fibrillation (AF) is a clinically relevant supra-ventricular arrhythmia which represents an independent risk factor for development of heart failure and ischemic stroke. The present study aims at the investigation of the possible clinical role of the soluble sST2 biomarker to evaluate the fibrosis in a group of patients with first diagnosed or permanent AF. The possible association with the left atrium size is also studied. Materials and Methods. The serum concentrations of the biomarker have been measured in a group of 58 patients (mean age 83.6 ± 6.0 years) and 40 individuals, assumed healthy and without AF, constituted the control group. The analysis is carried out by means of a high-sensitivity enzyme-linked immunosorbent assay. Results. The mean concentration of sST2 is 26.1 (22.7-30.5) ng/mL in the AF group, while in the control is 17.3 (15.7-18.9) ng/mL. Remarkable differences have been obtained for the two subsets with first diagnosed (23 (21.2-24) ng/mL) and permanent AF (30.5 (28.6-32) ng/mL). The analysis has been completed with a trans thoracic echocardiographic exam to evaluate the left atrium size and the left ventricular ejection fraction. Conclusions. The sST2 serum concentrations are found to be higher in the permanent AF with respect to the cases where the AF is of new onset or follow a paroxysmal pattern. The results support the adoption of the marker to evaluate the degree of fibrosis related to the left atrium of fibrillating patients. A positive association has been proved between the left atrium size and the sST2 concentrations.

Scant justification for interhospital transfers: a cause of reduced efficiency in the emergency department.

INTRODUCTION: Interhospital transfers are one of the critical points of the emergency system, which often cause overcrowding of the emergency department (ED) and limit its effectiveness. METHODS: A retrospective study was carried out, analyzing the clinical case files concerning the ED of the Policlinico "Umberto I" in Rome (Latium region, Italy) with the aim of establishing the reasons for the numerous unjustified transfers. RESULTS: From 1 January to 30 June 2006, 77 597 admissions to the ED occurred, and 861 patients (1.1%) were sent from other hospitals. 361 patients out of 861 (41.9%) were transferred with critical clinical conditions. The remaining 500 patients (58.1%) were transferred requiring specialised care. The need for specialised care was confirmed in 230 cases (46.0%) and therefore these transfers could be considered justified. The other 270 transfers (54.0%) were unjustified: 138 patients remained in the hospital to which they had been sent, contributing to crowding of the ED; 132 patients were returned, thereby placing them at additional risk. CONCLUSION: Unfamiliarity with the regulations governing interhospital transfers is the main cause of scantly justified transfers and the consequent reduction in efficiency of the ED in the receiving hospital.

Treatment with icatibant in the management of drug induced angioedema.

Acute, drug-induced angioedema may not respond to standard therapies, because the pathogenetic mechanism that induces the pathology is not always mediated by histamine but, in certain instances, by bradykinin. A case of angioedema is reported here, in which allergic etiology was excluded by the non-response to antihistamines. Considering the clinical history (repeated use of drugs) and the ineffectiveness of standard therapy, it was decided to administer a beta2 receptor antagonist, icatibant. After 20 minutes, the patient reported a subjective improvement. The only form of angioedema for which this type of medication is licensed is the hereditary deficiency of C1 inhibitor. The use of icatibant for the treatment of other types of angioedema (which can also be life-saving if the airway is involved) is off label. The off-label use of a drug is allowed in the absence of a viable alternative therapy, if there is scientific evidence in the literature and if the prescriber takes responsibility. The case here reported draws attention to this therapeutic problem and underlines the fact that a life-threatening emergency can justify the use of icatibant.

Effect of selective enzymatic digestions on skin biopsies from pseudoxanthoma elasticum: an ultrastructural study.

Skin biopsies from patients with pseudoxanthoma elasticum (PXE) were studied by electron microscopy either before or after selective digestions with collagenase, elastase, trypsin, hyaluronidase, chondroitinase AC and ABC, with the aim of identifying an eventual organic component associated with mineralization within the elastin fibers and the chemical nature of the enormous aggregates of filaments very often associated with, but distinct from mineralized elastin fibers. The results obtained, on both embedded thin sections and fresh tissue fragments, showed that elastin fibers, whether mineralized or not, were sensitive only to elastase, and they did not contain significant amounts of materials different from elastin that could be accounted for by ion precipitation; the aggregates of microfilaments in strict connection with altered elastin fibers were mostly sensitive to elastase and hyaluronidase, were partially removed by trypsin and chondroitinase, and were not modified by collagenase, which seems to indicate that the microfilaments consist mainly of abnormally aggregated elastin molecules together with low sulfated proteoglycans. It may be concluded that PXE is a complex genetic disorder of the connective tissue, and that mineralization of elastin is only one of the alterations of the extracellular matrix.

Delayed ANCA positivity in pulmonary-renal syndrome.

A 57-year-old man was admitted due to rapidly progressive renal failure and pulmonary edema. Chest X-ray showed a bilateral lung infiltrate, while a normal myocardial contractility was reported by echocardiography. Though initially ANCA were absent, a necrotizing vasculitis with polymorphonuclear leukocyte infiltrate was observed in a kidney biopsy specimen. Renal histology was compatible with microscopic polyangiitis because of necrotizing lesions located at small vessels and at glomeruli that were not crescentic. Corticosteroids and immunosuppressive treatment was played with significant clinical improvement. Six months later, the patient died of a gastrointestinal hemorrhage due to bowel perforation by vasculitic lesion. This time high p-ANCA positivity was detected and at renal histology crescentic glomeruli were observed.

A case of Sweet's syndrome associated with monoclonal immunoglobulin of IgG-lambada type and p-ANCA positivity.

We report a case of Sweet's syndrome associated with monoclonal gammopathy of uncertain significance (MGUS) and positivity for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). A 65-year-old man patient came to our hospital complaining of remittent-intermittent fever, weight loss, associated with papules affecting all his body and without mucosal or ocular involvement. Histology of biopsy specimens of papules allowed the diagnosis of Sweet's syndrome. This is the first case of this rare syndrome associated both with MGUS and p-ANCA positivity. The monoclonal immunoglobulin, possibly directed to neutrophils like an antibody, may cause both their fragmentation and release of antigens responsible of p-ANCA appearance.

Ultraviolet B radiation induces activation of neutral and acidic sphingomyelinases and ceramide generation in cultured normal human keratinocytes.

The sphingomyelin pathway is an ubiquitous, evolutionary conserved signaling system which transduces an extracellular signal into the cell. During the past few years increasing evidence has shown that the sphingolipid ceramide may play a role as a second messenger in intracellular signal transduction. The ceramide generation via sphingomyelinase (SMase) is followed by three major cellular responses: cell growth arrest, induction of cell differentiation and/or induction of programmed cell death or apoptosis. The aim of this study is to investigate whether activation of SMases and generation of ceramide can be induced by UVB radiation in normal human keratinocytes. The present data show that exposure to UVB radiation results in rapid generation of ceramide. The ceramide accumulation starts 15 min after UV exposure and progressively increases up to 24 h. In vitro measurement of SMase activity following exposure to UVB evidences an activation of both neutral and acidic SMases. Moreover, UVB induces apoptosis in normal human keratinocytes as shown by TUNEL technique and FACS analysis. These data indicate that UVB induced ceramide generation and activation of both neutral and acidic SMases, suggesting that sphingolipids metabolism may be involved in the UVB signaling pathway.

Telecar: an Italian telecardiology project.

The Telecar (tele-assistance cardiology) project was an example of tele-assistance between health centres of the Regione Lazio in Italy. The project was approved by the Ministry of Health, financed with 500,000,000 lire and carried out by an operative station within 'La Sapienza' University (Rome). About 40 of the health centres in Lazio that did not have cardiologists or electrocardiography (ECG) equipment were provided with telematic instruments (Cardiophone and fax). With this equipment, they were able to transmit ECG signals and receive copies of ECG reports. The 40 health centres included first-aid clinics, 'guardia medica' surgeries and community centres. The project was carried out between 1989 and 1992. During these three years the health centres transmitted a total of 4807 ECGs, 2057 (43%) of which were routine, the remaining 2750 (57%) being suspected emergencies. Of the suspected emergencies, 681 cases (25%) had a confirmed abnormality. We can confirm that telematic aids are very important for an operative station, where all kinds of emergencies must be dealt with.

[The evaluation of in-hospital precoronary times. The experience of a department of emergency medicine]. / Valutazione dei tempi precoronarici intraospedalieri. Esperienza di un dipartimento di medicina d'urgenza.

The above study was aimed at evaluating the "in-hospital precoronary times" of patients with acute myocardial infarction presenting to the Emergency Department of Policlinico Umberto I, Rome. From April to August 1993, 58 cases of acute myocardial infarction were admitted. In six of these, over 24 hrs had elapsed before admission. In 24 of the remaining cases thrombolysis was indicated. Mean time before admission to the coronary unit was 5 hrs for 52 patients. Mean in-hospital delay before starting thrombolysis was 40 +/- 20 minutes; mean delay before admission to the coronary unit was 3 h/45 min. In-hospital time before thrombolysis was one of the lowest in the literature and shows the efficient organization of the department. Delay until transfer to the coronary unit was long and is a sign of the paucity of these specialized beds. Therefore, the possibility to perform thrombolytic therapy immediately in the emergency department becomes even more essential.

[Non-traumatic rhabdomyolysis: clinical and laboratory diagnosis, assessment of renal complications]. / La rabdomiolisi non traumatica: riconoscimento clinico e di laboratorio, valutazione delle complicanze renali.

PURPOSE: Non traumatic rhabdomyolysis (RML) is an infrequent and sometimes clinically silent syndrome. RML incidence is increasing in the last few years. A prospective study was performed: 1) to value the non traumatic RML incidence in patients admitted to Emergency Room; 2) to reevaluate the clinical and laboratory criteria of diagnosis; 3) to establish complications' incidence and prognosis during the recovery. PATIENTS AND METHODS: In Emergency Medical First Aid 15.301 patients were examined. To the study were admitted only patients having CK level grater than fivefold the upper normal limits and without trauma, recent surgery, heart and cerebral disease. RESULTS: During the six months study, non traumatic RML incidence was 0.1% (16 patients of 15.301). Drugs, alcohol and substance abuse acute intoxication were the commonest causes. The Acute Renal Failure (ARF) was the more frequent complication (9 patients of 16). Four patients of nine was treated only by fluid administration, the other five by dialysis. Oligoanuric-ARF appeared only in patients affected by toxic RML. These patients had no-return to normal renal functional values at the time of hospital discharge. CONCLUSIONS: Non traumatic RML should be take into account by emergency doctor in cases of acute intoxication. To prevent the complications it's necessary the right interpretation of clinical and laboratory datas and an early and adequate therapy.

[The nurse's role in the identification and management of alcohol abuser in the Emergency Department]. / Ruolo dell'infermiere nell'identificazione e gestione del paziente con abuso alcolico nel dipartimento di emergenza.

The emergency department (ED) nurse plays a major role both in recognizing and in the management of the patients affected by alcohol related problems, such-as acute alcohol intoxication (AAI), alcohol withdrawal (AW), traumatic or spontaneous illness due to acute or chronic effects of alcohol abuse. Here are described both the clinical problems and the diagnostic instruments that nurse can use in ED to increase diagnostic sensibility. Furthermore both clinical features of AAI in relation with blood alcohol concentration (BAC), diagnostic criteria and test to evaluate AW severity are reported in this review. Even diagnostic instruments to identify alcohol abuse also in trauma are reported: the alcohol breath test, BAC and laboratory test. Even the Alcohol Use Disorders Identification Test (A.U.D.I.T.) questionnaire is reported to recognize the alcohol abuser. In conclusion acquiring a specific training, nurse can play a major role in the complex intervention net of alcoholics rehabilitation.

[Professional accreditation of emergency care services. Experience of the polyclinic "Umberto I" of Rome]. / L'accreditamento professionale dei servizi di Pronto Soccorso. Il percorso del Policlinico "Umberto 1o" di Roma.

Professional Accreditation can be seen as a Quality Improvement/Assurance Program for the delivery of Medical and Nursing Care, through organizational analysis to determine the level of compliance to specific criteria, correlated with satisfactory assistance processes. We report the experience of a professional accreditation process of an Emergency Department within a University Hospital in Rome, with high level assistance facilities. Voluntary interdisciplinary working groups were formed and working process was decomposed, as Quality Assurance Programs propose, so that critical points in each phase could be pointed out and hypothesis for improvements could be advanced for subsequent operative planning of changes. This method was used and applied to analyze the Emergency Department's "mission", clearing the goals of department, accordingly with the hospital's management mandate, and therefore permit the assessment of the level of compliance to quality indicators. Results of the different phases and critical analysis of all the steps are described.