High efficiency particulate air filters and heat & moisture exchanger filters increase positive end-expiratory pressure in helmet continuous positive airway pressure: A bench-top study.

BACKGROUND: Helmet continuous positive airway pressure (CPAP) has been widely used during the COVID-19 pandemic. Specific filters (i.e. High Efficiency Particulate Air filter: HEPA; Heat & Moisture Exchanger Filter: HMEF) were used to prevent Sars-CoV2 environmental dispersion and were connected to the CPAP helmet. However, HEPA and HMEF filters may act as resistors to expiratory gas flow and increase the levels of pressure within the hood. METHODS: In a bench-top study, we investigated the levels of airway pressure generated by different HEPA and HMEF filters connected to the CPAP helmet in the absence of a Positive End Expiratory Pressure (PEEP) valve and with two levels of PEEP (5 and 10 cmH2O). All steps were performed using 3 increasing levels of gas flow (60, 80, 100 L/min). RESULTS: The use of 8 different commercially available filters significantly increased the pressure within the hood of the CPAP helmet with or without the use of PEEP valves. On average, the increase of pressure above the set PEEP ranged from 3 cmH2O to 10 cmH2O across gas flow rates of 60 to 100 L/min. The measure of airway pressure was highly correlated between the laboratory pressure transducer and the Helmet manometer. Bias with 95% Confidence Interval of Bias between the devices was 0.7 (-2.06; 0.66) cmH2O. CONCLUSIONS: The use of HEPA and HMEF filters placed before the PEEP valve at the expiratory port of the CPAP helmet significantly increase the levels of airway pressure compared to the set level of PEEP. The manometer can detect accurately the airway pressure in the presence of HEPA and HMEF filters in the helmet CPAP and its use should considered.

Cardiac involvement in athletes infected by SARS COV-2 disease.

Objectives: The aim of the present study was to conduct a review of the current literature evaluating the available evidence to date in terms of epidemiology, pathophysiology and clinical presentation of COVID-19 in relation to cardiovascular involvement, with a special focus on the myocarditis model, in the population of athletes (professional and recreational) who are preparing to return to competitions, with the ultimate aim of guaranteeing maximum safety for resuming sports activities. News: The COVID-19 pandemic has resulted in the inevitable cancellation of most sports activities, practiced at both a professional and amateur level, in order to minimize the risk of spreading the infection. Since the number of athletes who tested positive was rather high, the potential cardiac involvement in this peculiar population of subjects contracting the disease in a mild (asymptomatic, slightly symptomatic) or moderate form, has recently raised concerns following the observation of cases of recorded myocardial damage, myocarditis, arrhythmias and a first reported case of Sudden Cardiac Death (SCD) in a 27-year-old professional basketball player. Several studies even seem to confirm the possibility of permanent impairment of the cardiorespiratory system following the infection. Medical history, biomarkers, electrocardiographical and cardiac imaging features appear to be crucial in distinguishing cardiovascular alterations related to COVID-19 infection from typical adaptations to exercise related to athletes' heart. Prospects and Projects: Clarifications and prospective data based on long-term follow-ups on larger populations of athletes are still needed to exclude the development of myocardial damage capable of negatively affecting prognosis and increasing cardiovascular risk in athletes recovered from COVID-19 in asymptomatic (simple positivity to SARS-COV-2) or in a mild form. Conclusion: From a clinical point of view extreme caution is necessary when planning the return to sport (Return To Play-RTP) of athletes recovered from a mild or asymptomatic form of COVID-19: a careful preliminary medical-sports evaluation should be carried out in order to assess the potential development of myocardial damage that would increase their cardiovascular risk.

Objectifs: Le but cette étude était de mener une revue de la littérature actuelle évaluant les différents éléments disponibles en termes d'épidémiologie, de physiopathologie et de présentation clinique de l'atteinte cardio-vasculaire du COVID-19. Une attention particulière sera donnée aux lésions myocardiques dans la population des athlètes, à la fois de niveau professionnel et amateur, qui s'apprêtent à reprendre la compétition, dans le but de garantir une sécurité maximale dans la reprise des activités sportives. Actualités: La pandémie de COVID-19 a entraîné l'annulation inévitable de la plupart des activités sportives, pratiquées à la fois à un niveau professionnel et amateur, afin de minimiser le risque de propagation de l'infection. Le nombre d'athlètes testés positifs étant plutôt élevé, les répercussions cardiaques potentielles dans cette population particulière de sujets contractant la maladie sous une forme légère (asymptomatique, légèrement symptomatique) ou modérée, a récemment soulevé des inquiétudes suite à l'observation de cas de lésions myocardiques, de myocardites, d'arythmies et d'un premier cas signalé de mort subite chez un basketteur professionnel de 27 ans. De plus, plusieurs études semblent confirmer la possibilité d'une altération permanente du système cardiorespiratoire suite à l'infection. Les antécédents médicaux, les biomarqueurs, les caractéristiques électrocardiographiques et à l'imagerie cardiaque semblent ainsi être des éléments cruciaux pour pouvoir distinguer les altérations cardiovasculaires liées à l'infection au COVID-19 des adaptations typiques à l'exercice des cœurs d'athlètes. Perspectives et projets: Des précisions et des données prospectives basées sur des suivis à long terme sur des populations plus importantes d'athlètes sont encore nécessaires pour exclure le développement de lésions myocardiques capables d'affecter négativement le pronostic et d'augmenter le risque cardiovasculaire chez les athlètes en rémission d'une infection au COVID-19 asymptomatique (positivité simple au SARS-COV-2) ou sous une forme légère. Conclusion: D'un point de vue clinique, une extrême prudence est nécessaire lors de la planification du retour au sport des athlètes en rémission d'une forme légère ou asymptomatique de COVID-19: une évaluation médico-sportive minutieuse de ces patients doit être effectuée afin d'évaluer le développement potentiel de lésions myocardiques qui augmenteraient leur risque cardiovasculaire.

Survival in HIV-infected patients with lymphoma according to the choice of antiretroviral treatment: an observational multicentre study.

OBJECTIVES: Lymphoproliferative disorders are often observed in HIV-positive patients. Combination antiretroviral treatment (cART) during antineoplastic chemotherapy is beneficial, but little is known about the clinical outcome according to different antiretroviral combinations. The aim of the study was to address this gap in current knowledge. METHODS: A retrospective study was conducted in five large Italian centres for the period from 1998 to 2015; HIV-positive patients diagnosed with lymphoma were included and demographic, clinical and therapeutic variables were recorded and associated with clinical outcomes. Bivariate and multivariate analyses were performed, including Cox proportional hazard models for survival. RESULTS: A total of 399 patients were included in the study. The most common types of lymphoma were diffuse large B-cell lymphoma (DLCLB; n = 164), Hodgkin lymphoma (HL; n = 99) and Burkitt lymphoma (BL; n = 57), followed by plasmablastic lymphoma (PBL; n = 38), T-cell lymphoma (TCL; n = 17), indolent lymphoma (n = 10) and other less common types (n = 14). cART was given to 327 (out of 387 evaluable) patients: in 216 subjects it was protease inhibitor (PI)-based, in 73 it was nonnucleoside reverse transcriptase inhibitor (NNRTI)-based and in 18 it was integrase strand transfer inhibitor (INSTI)-based (the remaining 20 individuals received other regimens). The 5-year overall survival was 57.5% (52.8% for DLCLB, 67.8% for HL, 42.3% for BL, 60.6% for PBL and 64.7% for TCL). PI-based ART compared with other compounds was associated with worse survival in non-Hodgkin lymphoma (NHL) and HL patients combined (P ≤ 0.001) and in NHL patients alone (P < 0.001); grade 3-4 haematological toxicities were more commonly observed in PI-treated individuals. Lymphoma diagnosis in recent years, better immunovirological status, lower lymphoma stage and better prognostic indexes were associated with better survival. CONCLUSIONS: PI-based cART while on chemotherapy was associated with worse overall survival and more frequent haematological complications in HIV-positive patients with lymphoma.

[Imported dengue in two tertiary Italian hospitals: Use of rapid diagnostic tests]. / Dengue importée dans deux hôpitaux tertiaires en Italie : utilisation des tests de diagnostic rapides.

Dengue fever is growing at a global level both as number of cases and as geographic area of endemicity. Italy is not in endemic area, but the competent vector Aedes albopictus is widespread in this country, so that the possibility of introduction of the infection cannot be ruled out. We retrospectively collected demographic, clinical, and laboratory data about consecutive cases diagnosed in Torino and Negrar-Verona in the period 2010-2015. One hundred thirteen cases of dengue were observed, with an increasing trend during years. The infection was imported mostly from south-east Asia, but the risk appears to be higher in Latin America. More than half of the patients were admitted to the hospital but only one case of severe dengue was observed. Many patients presented after the resolution of symptoms. Rapid diagnostic tests were done in the majority of patients and allowed a diagnosis both in the acute (NS1 antigen) and convalescent (IgMantibodies) phases of the disease. An early diagnosis is paramount to avoid the spreading of the infection.

Mobile ECMO team for inter-hospital transportation of patients with ARDS: a retrospective case series.

INTRODUCTION: Transport of patients undergoing extracorporeal membrane oxygenation is currently available in 5 referral centers in our country. METHODS: Retrospective case series of patients managed by our mobile extracorporeal membrane oxygenation team and transferred to San Gerardo University Hospital from December 2004 to December 2012. RESULTS: 42 patients were transported. The mean age was 42.11 (standard deviation ±18.11) years, with a range between 2 years and 70. 14 patients were females (33%) and 28 males (67%). The average transport distance was 121.69 km (±183.08) with a range between 9 km and 1044 Km. The mission's mean time was equal to 508 minutes (±185) with range of 120-960 minutes. 29 patients (69%) were transported with extracorporeal membrane oxygenation support, while 13 patients (31%) were transported with conventional ventilation. In 28 patients (97%) a veno-venous bypass was utilized, while in one case (3%) a Veno-Arterial cannulation was performed. 32 patients survived (76%) and have been discharged alive from hospital. No major clinical or technical issues were observed during the transport. CONCLUSIONS: According to our data, we conclude that a dedicated mobile team allowed safe ground transportation of patients with severe acute lung injury to our tertiary care institution.

Lymphogranuloma venereum: an old, forgotten re-emerging systemic disease.

Lymphogranuloma venereum (LGV) is a sexually transmitted infection endemic in parts of Africa, Asia, South America, and the Caribbean, but once was rarely observed in Western countries, where most cases were considered to be imported. However, recent outbreaks have been reported in Europe, Australia, New Zealand, the United States and Canada, mainly among HIV positive men who have sex with men, signaling LGV re-emergence. The etiological agent of LGV is Chlamydia trachomatis serotypes L1, L2 and L3, and current outbreaks are mostly sustained by L2b type. The clinical course can be classically divided into three stages: an initial papule, which may ulcerate at the site of inoculation, followed by regional lymphoadenopathy (second stage, generally unilateral). In the tertiary stage, lymphatic obstruction, with elephantiasis of genitalia, and rectal involvement can lead to the formation of strictures and fistulae that may require surgical treatment. Recent cases are observed mainly among HIV positive people, often co-infected with HCV and others STIs, engaging in high-risk sexual practices. The main clinical picture is a relative new entity characterized by progressive ulcerative proctitis, the so called anorectal syndrome. Diagnosis is often delayed, requires a high index of clinical suspicion and must rely on the use of nucleic acid amplification tests. The differential diagnosis of proctitis should include LGV infection. Gastroenterologists, coloproctologists, dermatologists and other specialists need to be aware of LGV proctitis to avoid diagnostic delay and progression of disease to the tertiary stage.

Short-term additional enfuvirtide therapy is associated with a greater immunological recovery in HIV very late presenters: a controlled pilot study.

OBJECTIVES: To evaluate whether the addition of enfuvirtide to standard highly active antiretroviral therapy (HAART) could confer immunovirological benefits in human immunodeficiency virus (HIV)-infected very late presenters. The current study is an open comparative therapeutic trial of standard protease inhibitor (PI)-based HAART ± additional enfuvirtide in treatment-naïve deeply immunologically impaired HIV-positive patients. METHODS: Very late presenters (CD4 <50/mm(3)), without tuberculosis and neoplasms, were alternatively allocated to two nucleoside reverse transcriptase inhibitors (NRTIs) and lopinavir/ritonavir without (control arm, CO) or with (ENF arm) enfuvirtide 90 mg bid. Enfuvirtide was administered until the achievement of viral load <50 copies/ml and for at least 24 weeks. The primary objective was the magnitude of CD4+ cell recovery at 6 months. HIV RNA was intensively monitored in the first month, and, thereafter, monthly, as for CD4+ cell count and percentage, clinical data, and plasma drug concentrations. RESULTS: Of 22 enrolled patients (11 per arm), 19 completed the study (10 in the ENF arm). Baseline CD4+ cell counts and % were comparable, with 20 CD4+/mm(3) (12-37) and a percentage of 3.3 (1.7-7.1) in the ENF arm, and 16 CD4+/mm(3) (9-29) and a percentage of 3.1 (2.3-3.8) in the CO arm, respectively. The baseline viral load was also comparable between the two arms, with 5.77 log10 (5.42-6) and 5.39 log10 (5.06-6) in the ENF and CO arms, respectively. Enfuvirtide recipients had higher CD4+ percentage at week 8 (7.6 vs. 3.6%, p = 0.02) and at week 24 (10.7 vs. 5.9%, p = 0.02), and a greater CD4+ increase at week 24 (207 vs. 134 cells/mm(3), p = 0.04), with 70% of enfuvirtide intakers versus 12.5% of controls who achieved a CD4+ cell count >200/mm(3) (p = 0.01). At 48 weeks, patients in the ENF arm had CD4+ cell counts higher than controls (251 vs. 153cells/mm(3), p = 0.04) and were also found to be faster in reaching a CD4 cell count over 200/mm(3): 18 (8-24) versus 48 (36-108) weeks (p = 0.01). Viral load decay at week 4 was greater in the ENF arm (-3 vs. -2.2 log, p = 0.04), while the proportion of patients with viral load <50 copies/ml at week 24 was comparable. CONCLUSIONS: In this pilot study, the addition of enfuvirtide to a lopinavir-based HAART was shown to be associated with a significantly faster and greater immunological recovery in newly discovered HIV-positive patients with very low CD4+ cell counts. Induction strategies using an enfuvirtide-based approach in such subjects warrant further investigation.

Evaluation of the effect of autologous mesenchymal stem cell injection in a large-animal model of bilateral kidney ischaemia reperfusion injury.

OBJECTIVES: Adult mesenchymal stem cells (MSC) have been proven to be of benefit to the kidney in different experimental models of renal injuries. All studies have been performed in valuable rodent models, but the relevance of these results to large mammals and ultimately, to humans remains unknown. Therefore, the aim of this study was to investigate the effect of MSC transplantation in an alternative ovine large-animal model of bilateral kidney ischaemia reperfusion injury. MATERIAL AND METHODS: Sheep were divided into three groups: one sham-operated group and two groups submitted to renal bilateral ischaemia for 60 min. Animals with ischaemia reperfusion injury were treated with injection of autologous MSCs or with vehicle medium. RESULTS: The model sheep presented with renal histological manefestations that closely resembled lesions seen in patients. Transplanted MSCs were found in glomeruli but not in tubules and did not express glomerular cell markers (podocin, von Willebrand factor), but functional evaluation showed no beneficial effect of MSC infusion. Morphological and molecular analyses corroborated the functional results. MSCs did not repair kidney parenchyma and failed to modulate cell death and proliferation or cytokine release (tumour necrosis factor-alpha, vascular endothelial growth factor alpha (VEGF-alpha), Bcl-2, caspase). CONCLUSION: In this unique autologous large-animal model, MSCs did not exhibit reparative or paracrine protective properties.

Moxifloxacin for the treatment of HIV-associated tuberculosis in patients with contraindications or intolerance to rifamycins.

Administration of rifampicin or rifabutin in the treatment of HIV-associated tuberculosis (TB) is made rather complex by the risk of drug-drug interactions with most antiretrovirals and/or for reasons of toxicity. While in selecting the appropriate concomitant regimens the priority usually goes to rifamycins with exclusion of interacting antiretrovirals, in some circumstances the former cannot be used and anti-TB rifamycin-free regimens must be administered. We describe here the clinical course of two patients with HIV-associated TB in whom the last generation fluorquinolone moxifloxacin (found to exert significant activity against Mycobacterium tuberculosis) successfully replaced rifamycins.

Human kappa opioid receptor gene (OPRK1) polymorphism is associated with opiate addiction.

Variants of the opioid receptors are the obvious candidates underlying addiction. The kappa opioid receptor (KOR) system seems to play a role in stress responsivity, opiate withdrawal and responses to psycho-stimulants, inhibiting mesolimbic dopamine. KOR gene polymorphisms have been reported to contribute to predisposition to voluntary alcohol-drinking behavior in experimental animals. In humans, the 36G > T single nucleotide polymorphism (SNP) on KOR gene, that was recently identified, has been found associate with substance dependence, with inconclusive findings. In the present study, 106 heroin addicts (West European, Caucasians) and 70 healthy control subjects matched for race and gender, with no history of substance use disorder, have been genotyped. The frequency of KOR 36G > T SNP was significantly higher among heroin-dependent individuals compared with control subjects (Fisher's exact = 0.044; Pearson chi(2) = 4.2734, P = 0.039; likelihood ratio chi(2) tests = 4.6156, P = 0.032). Although KOR silent polymorphisms may apparently have no consequences on mRNA transcription, post-transcriptional mechanisms, such as mRNA stability, translation efficiency, and regulability may impair the function of kappa receptors system, with increased risk for substance use disorders. In specific, the neurobiological changes induced by mu-kappa opioid imbalance could underlie vulnerable personality traits and risk behavior.

Effects of olanzapine on aggressiveness in heroin dependent patients.

This study compared the anti-aggressiveness effects of the atypical anti-psychotic olanzapine with that of selective serotonin reuptake inhibitors (SSRI) and benzodiazepines (BZD) among patients with heroin dependence submitted to opioid-agonists substitution treatment. Sixty-seven (67) patients who met the DSM-IV criteria for heroin dependence and showed aggressive personality traits, not affected by comorbid schizophrenia or bipolar disorder, accepted to participate in a 12-week prospective, observational trial. Patients were included into two subgroups in relationship with treatment, for the evaluation of the endpoints at week 12: group 1: substitution treatment in combination with OLA (32 patients); group 2: substitution treatment in combination with fluoxetine/paroxetine and clonazepam (35 patients). Efficacy measures were Buss Durkee Hostility Inventory (BDHI), Symptoms Check List-90 (SCL 90) anger--hostility scores, incidence rates of aggressive incidents and attacks. The rates of patients who remained in treatment at week 12 in group 1, treated with OLA, and group 2, treated with SSRI and BDZ, were not significantly different (17 = 53.1% vs 16 = 45.7%). BDHI total, direct aggressiveness, verbal aggressiveness scores, SCL 90 aggressiveness scores and aggressive incidents rates showed a significantly more consistent decrease from baseline in group 1 than in group 2 subjects, in the patients who completed the treatment (p < 0.001; p < 0.01; p < 0.05; p < 0.01; p < 0.001). Among the completers, 69.3% achieved early full substance abuse remission, while 30.7% achieved partial substance abuse remission, with no significant difference between 1 and 2 treatment subgroups. Although obtained by an observational--open clinical study, with multiple limitations, our findings suggest that OLA may be useful as an adjunctive agent in reducing aggressive/hostile behaviour in heroin addicted individuals during maintenance substitution treatment. Otherwise, atypical anti-psychotic OLA seems to be unable to improve the outcome in terms of addictive behavior and relapse risk in the addicted patients not affected by overt psychotic disorders.

[Vital signs of hemodynamic monitoring]. / I parametri vitali del monitoraggio emodinamico.

The aim of hemodynamic monitoring in intensive care is to recognize derangements in physiologic variables, which herald the progression toward organ failure. Traditionally the term "vital signs" refers to heart rate, arterial pressure, respiratory rate and body temperature monitoring. Continuous monitoring of vital signs, is advocated, since trends are more significant than single measurements, and is still a cornerstone, in the hemodynamic evaluation of a critically ill patient. Nevertheless, the spectrum of hemodynamic derangements that can arise during intensive care unit stay is very large and often additional information, beside the vital signs, are needed to evaluate correctly the individual patient.

[Ventilator associated pneumonia]. / La polmonite da ventilatore.

Ventilator associated pneumonia (VAP) is a nosocomial lower respiratory tract infection that ensues in critically ill patients undergoing mechanical ventilation. The reported incidence of VAP varies between 9% and 68% with a mortality ranging between 33% and 71%. Two key factors are implicated in the pathogenesis of VAP: bacterial colonization of the upper digestive-respiratory tract and aspiration of oral secretions into the trachea. Preventive measurements are advocated to reduce the incidence of VAP, such as selective decontamination of the digestive tract (SDD), supraglottic aspiration and positioning. Prompt recognition and treatment of established VAP has also been demostrated to affect outcome. Therefore, the knowledge of risk factors associated with the development of VAP and the implementation of strategies to prevent, diagnose and treat VAP are mainstems in the nursing of mechanically ventilated patients.

[Nursing of intubation]. / Nursing dell'intubazione.

Recent developments in noninvasive ventilation allow the intensivists to delay the time o intubation of the patient admitted to the ICU. This new possibility of a gain in time leads to the fact that those patients who are intubated in the ICLI, are patients with a very compromised hemodynamic and respiratory situation. For this reason, we developed a specific protocol regarding the intubation procedure of this kind of patients. This paper reviews our strategies for endotracheal tube positioning in critically ill patients and shows the fundamental role of the nurses during this procedure.

[Nursing of tracheostomy]. / Nursing della tracheostomia.

In this abstract we have analyzed the different techniques of tracheostomy, considering new semplified methods of this procedure and therefore the common use of it in weaning from mechanical ventilation the critical care patients. We've tried to summarize guide lines of the preoperative, operative and postoperative procedures of tracheostomy, comparing our nursing clinical experience in ICU and the latest literature. We've primarily analyzed the nursing aspects of this issue, trying to focus on the priority of the treatment of the tracheostomezed patient.

[Helmet delivered CPAP for in-patients]. / CPAP con scafandro nei reparti di degenza.

The scanty availability of intensive care beds in our hospital, compared with the needings of the area, led us to employ surgical department beds as post-intensive beds. The possibility of delivering non invasive ventilation by head helmet allowed, also in such settings, the ventilation of patients. This paper analyses the main capacities and problems that are faced by the nurse in the management of head helmet delivered CPAP. Main systems for gas delivery that can be used in the departments, PEEP application modalities and psychologic management of the patient are detailed.

Monitoring of intra-abdominal pressure.

Intra-abdominal pressure monitoring is a very important parameter in the ICU setting, since pathological alterations of this value are significant and are responsible for functional alterations involving cardio-respiratory system, kidneys and central nervous system. Responsibility of the professional nurse in the ICU is to perform a tight and adequate monitoring of those patients who are at risk for a rise in intra-abdominal pressure.