Analysis and clinical determinants of post-COVID-19 syndrome in the Lombardy region: evidence from a longitudinal cohort study.

OBJECTIVE: To define macro symptoms of long COVID and to identify predictive factors, with the aim of preventing the development of the long COVID syndrome. DESIGN: A single-centre longitudinal prospective cohort study conducted from May 2020 to October 2022. SETTING: The study was conducted at Luigi Sacco University Hospital in Milan (Italy). In May 2020, we activated the ARCOVID (Ambulatorio Rivalutazione COVID) outpatient service for the follow-up of long COVID. PARTICIPANTS: Hospitalised and non-hospitalised patients previously affected by COVID-19 were either referred by specialists or general practitioners or self-referred. INTERVENTION: During the first visit, a set of questions investigated the presence and the duration of 11 symptoms (palpitations, amnesia, headache, anxiety/panic, insomnia, loss of smell, loss of taste, dyspnoea, asthenia, myalgia and telogen effluvium). The follow-up has continued until the present time, by sending email questionnaires every 3 months to monitor symptoms and health-related quality of life. PRIMARY AND SECONDARY OUTCOME MEASURES: Measurement of synthetic scores (aggregation of symptoms based on occurrence and duration) that may reveal the presence of long COVID in different clinical macro symptoms. To this end, a mixed supervised and empirical strategy was adopted. Moreover, we aimed to identify predictive factors for post-COVID-19 macro symptoms. RESULTS: In the first and second waves of COVID-19, 575 and 793 patients (respectively) were enrolled. Three different post-COVID-19 macro symptoms (neurological, sensorial and physical) were identified. We found significant associations between post-COVID-19 symptoms and (1) the patients' comorbidities, and (2) the medications used during the COVID-19 acute phase. ACE inhibitors (OR=2.039, 95% CI: 1.095 to 3.892), inhaled steroids (OR=4.08, 95% CI: 1.17 to 19.19) and COVID therapies were associated with increased incidence of the neurological macro symptoms. Age (OR=1.02, 95% CI: 1.01 to 1.04), COVID-19 severity (OR=0.42, 95% CI: 0.21 to 0.82), number of comorbidities (OR=1.22, 95% CI: 1.01 to 1.5), metabolic (OR=2.52, 95% CI: 1.25 to 5.27), pulmonary (OR=1.87, 95% CI: 1.10 to 3.32) and autoimmune diseases (OR=4.57, 95% CI: 1.57 to 19.41) increased the risk of the physical macro symptoms. CONCLUSIONS: Being male was the unique protective factor in both waves. Other factors reflected different medical behaviours and the impact of comorbidities. Evidence of the effect of therapies adds valuable information that may drive future medical choices.

Unexpected CD4 decay, hidden adherence gaps, resilience, and the need for long-acting therapy in a single HIV outpatients' cohort.

This single-centre, single-cohort study examines hidden non-adherence to antiretroviral therapy in a setting of persistent optimal viral suppression but concordant absolute and percent CD4 decay by >10% from the previous test. After the finding of important drug holidays in two virologically suppressed patients, between January 2021 and January 2022 all PLWH who fulfilled CD4 decay criteria were asked for how long therapy was interrupted, how many days before re-testing CD4 and HIV RNA was it resumed and the reason for interruption. Of 668 HIV-infected subjects, 61 fulfilled the pre-specified criteria for significant CD4 decay and 15 (2.25% of the total, 25% of the CD4 decay group) admitted long-lasting treatment interruptions, compensated by treatment resumption before the subsequent testing. Eleven treatment interruptions exceeded 28 days, and none was shorter than 15 days. CD4 recovery was worse at 6 months in non-adherent subjects (-0.5 vs + 16/mmc, p < 0.0001) and in non adherence vs immune decay time-related with COVID-19 (0 vs + 22/mmc, p < 0.0001). Reasons for interrupting treatment were travel, psychological, poverty-related, addiction and sentimental sphere problems. Long-acting regimens, with stringent control of precision in timely administration, may protect PLWH from damaging their health status and possibly transmit HIV.

Dynamic changes in T-wave and QTc interval during tilt table testing: Innocent until proven otherwise.

A16-year-old female underwent tilt table testing, which resulted positive for reflex vasodepressive syncope. 12­lead ECG during syncope showed T-wave inversion in infero-lateral leads, along with QTc interval increase >100 msec compared to baseline. These abnormalities rapidly disappeared in supine position with resumption of consciousness. Complete cardiac evaluation excluded heart disease. T-wave changes and moderate QTc prolongation are relatively common in young (mainly female) patients undergoing tilt table testing and they appear benign in nature. However, in a minority of cases, on the basis of the clinical context and after an accurate ECG analysis, further examinations may be warranted.

Decay rate of antiS1/S2 IgG serum levels after 6 months of BNT162b2 vaccination in a cohort of COVID-19-naive and COVID-19-experienced subjects.

Vaccination toward SARS-CoV-2 reduced mortality and 'boosters' are being implemented. We offer scientific contribution about IgG production in the COVID-19 experienced population. From January 2021 to March 2021, 183 residents and staff from the Elderly Nursing Home "San Giuseppe Moscati" who had received two doses of the BNT162b2 vaccine were enrolled. The antibody response was assessed by the DiaSorin LIAISON-CLIA S1/S2® IgG solution. Cutoff levels for response (>39 BAU/mL) and neutralizing activity (>208 BAU/mL) were derived from DiaSorin official data. Serology was assessed before and after the first vaccination, and 2 weeks and 6 months after the second vaccination. Anti-S IgG in COVID-19 experienced, baseline IgG producers spiked after the first vaccination to median 5044 BAU/mL and decayed at 6 months to 2467.4 BAU/mL. Anti-S IgG in COVID-19 experienced, baseline IgG non-producers spiked after the second vaccination to median 1701.7 BAU/mL and decayed at 6 months to 904.8 BAU/mL. Anti-S IgG in COVID-19 naïve subjects spiked after the second vaccination to median 546 BAU/mL and decayed at 6 months to 319.8 BAU/mL. The differences between sequential timepoint levels in each group were statistically significant (p < .0001). Serology analysis revealed different kinetics between COVID-19 experienced subjects depending on baseline response, possibly predicting different IgG persistence in blood.

Capacitive and Resistive Electric Transfer Therapy: A Comparison of Operating Methods in Non-specific Chronic Low Back Pain.

Capacitive and resistive electric transfer (TECAR) modes of therapy use radiant energy to generate endogenous heat and are used for musculoskeletal disorders for their analgesic, decontracting, and elasticizing properties. While the capacitive mode is supposed to interact with soft tissues, the resistive mode interacts more with hard tissues. This study aims to investigate whether the successive order of the two modes during their application could make a difference concerning the outcome. The study included 40 patients affected by chronic non-specific low back pain. Patients were assessed using algometry, before and immediately after the therapeutic intervention, and thermal imaging, before, immediately after, and then 30 and 60 min after the intervention. Each patient had two TECAR interventions on different days of a total of 20 min each, with a resistive followed by capacitive mode and conversely, capacitive followed by resistive mode. The capacitive mode alternated with the resistive mode by 10 min during either intervention. Results showed that the effects consisting of temporary increases in the superficial temperature of the lower back and pressure pain threshold were alike for both interventions. We conclude that TECAR therapy reduces low back pain regardless of the operative mode adopted, with only an insignificant advantage when starting the sequence from the resistive application.

Quantum Medicine: A Role of Extremely Low-Frequency Magnetic Fields in the Management of Chronic Pain.

Extremely low-frequency electromagnetic field (ELF-MF) therapy is a promising treatment for chronic pain, given its ability to interact with body homeostasis using water-mediated transmission mechanisms typical of quantum medicine. The present study aims to assess the effects of ELF-MF therapy on chronic pain in 49 patients suffering from various musculoskeletal disorders. The therapy was applied through a Quec Phisis setup generating the electromagnetic field as the ion cyclotronic resonance. Patients underwent eight therapy sessions of 45 min each performed every other day. The bioimpedance assessment was based on the comparison of the height-adjusted body resistance (R/h) and reactance (Xc/h) measured during the first and last sessions of eight-session treatment. Pain perception was quantified using the standard visual-analog scale. We found significant increases in both R/h and Xc/h parameters of body bioimpedance after electromagnetic therapy corresponding with reductions in pain perception. We conclude that the ELF-MF therapy can restore the body's state of health and thus seems a valid therapeutic approach for the treatment of musculoskeletal-derived pain.

One-year durability of anti-spike IgG to SARS-CoV-2: Preliminary data from the anticrown prospective observational study one year durability of COVID-19 anti-spike IgG.

Data are presented of 368/503 post-COVID-19 outpatients followed within the AntiCROWN Cohort who have a one-year control and a baseline assessment of anti-S1/S2 antibodies, detected with the The LIAISON® SARS-CoV-2 S1/S2 IgG solution by DiaSorin. Loss of response occurred in 4 subjects having a baseline level below 50 AU/mL.

STELO: a new tool for family physicians for the correct identification of inherited cancer syndromes.

BACKGROUND: The hereditary cancer syndromes represent overall <10% of all cancers. These syndromes are not irrelevant for public health because all the cancers typical of these syndromes affected young people and many members of the same family and the cancers are more aggressive than the sporadic ones and need specific surgery and medical therapy. We developed a new family assessment tool: STELO designed for family physicians to identify patients could benefit from Cancer Genetic Counselling. OBJECTIVE: Test the sensitivity and specificity of a new assessment tool for the correct identification of inherited cancer syndromes. METHODS: Retrospectively we tested the new tool on a subset of patients who had already undergone genetic counselling at the Cancer Genetic Counselling Service of ASST (Azienda Socio Sanitaria Territoriale) Settelaghi Varese, to investigate sensitivity, specificity and applicability of this new tool in routine genetic screening. STELO responses were matched against the opinion of two cancer geneticists (i.e. gold standard) who blinded each other decided if the history of these patients was properly suspected as a hereditary cancer syndrome. RESULTS: The Genetic Counselling Service followed 546 subjects from 2014 to 2015. STELO tool was tested retrospectively on these clinical records and resulted positive in 418 cases, out of 546 (76.5%). STELO reported, towards the gold standard, 88.5% and 52.3% of sensitivity and specificity, respectively. CONCLUSIONS: STELO has demonstrated to have a good sensitivity. The specificity was expectedly low given that STELO has been developed for general medicine, so it needs to be simple, practical, of rapid consultation and effectively used in clinical practice.

Domestic Violence Between Childhood Incest and Re-victimization: A Study Among Anti-violence Centers in Italy.

The study focuses on a specific problem in the area of child sexual abuse (CSA), which is still under-researched: the relationship between incest and adult female re-victimization treatment within the ambit of domestic violence in Italian centers. About 112 anti-violence centers were contacted, but only 13 participated and only 16 psychologists were interviewed to reconstruct the biographies of 32 victims. The study aimed to examine if and how the service centers recognized and dealt with the problem of re-victimization among survivors based on psychologists' narrations. Findings showed that the description of perpetrators revealed not only sexual abuse was perpetrated, but also psychological and physical abuse. About half of mothers did not come to their daughters' aid and those who cooperated with the abusers had mostly suffered from CSA at a time in their life. Only three mothers did help their daughters in contacting the anti-violence centers. However, most of the service centers were not concerned with the relationship between incest and domestic re-victimization, while those who considered the problem, dealt with it only on the practitioner-patient level. In addition, despite the psychologists used professional and empathetic language, they disclosed their high emotional involvement and a genuine bewilderment. A discussion on the need to standardize the psychotherapeutic support given to these re-victimized women was presented, with a critique to the un-discriminated de-pathologization approach adopted by almost all anti-violence centers. In particular, we wanted to underline the fact that, although, this approach is useful in treating victims who were not abused during infancy, it could be insufficient for women who suffered from incest.

Factors That Negatively Affect the Prognosis of Pediatric Community-Acquired Pneumonia in District Hospital in Tanzania.

Community-acquired pneumonia (CAP) is still the most important cause of death in countries with scarce resources. All children (33 months ± 35 DS) discharged from the Pediatric Unit of Itigi Hospital, Tanzania, with a diagnosis of CAP from August 2014 to April 2015 were enrolled. Clinical data were gathered. Dried blood spot (DBS) samples for quantitative real-time polymerase chain reaction (PCR) for bacterial detection were collected in all 100 children included. Twenty-four percent of patients were identified with severe CAP and 11% died. Surprisingly, 54% of patients were admitted with a wrong diagnosis, which increased complications, the need for antibiotics and chest X-rays, and the length of hospitalization. Comorbidity, found in 32% of children, significantly increased severity, complications, deaths, need for chest X-rays, and oxygen therapy. Malnourished children (29%) required more antibiotics. Microbiologically, Streptococcus pneumonia (S. p.), Haemophilus influenza type b (Hib) and Staphylococcus aureus (S. a.) were the bacteria more frequently isolated. Seventy-five percent of patients had mono-infection. Etiology was not correlated with severity, complications, deaths, oxygen demand, or duration of hospitalization. Our study highlights that difficult diagnoses and comorbidities negatively affect clinical evolution. S. p. and Hib still play a large role; thus, implementation of current vaccine strategies is needed. DBS is a simple and efficient diagnostic method for bacterial identification in countries with scarce resources.

The management of small renal masses: what is likely to change?

The diffusion of imaging has determined an increased discovery of small renal masses (SRMs). Recent publications have been reviewed to present the state of the art in the management of SRMs and to try to foresee the next steps in this challenging condition. The role of percutaneous biopsies is expanding, since management algorithms include also active surveillance and ablative therapies. However up to 30% of biopsies fail to provide histological diagnosis and there is the risk of under-evaluating high-grade tumors. Active surveillance has been proposed in patients with reduced life expectancy and numerous comorbidities. The average growth of SRMs is slow, and metastatic progression has been observed in about 1%. Ablative therapies (cryotherapy and radiofrequency ablation) are used in patients with relevant comorbidities or advanced age and unfit for surgery, but who desire active treatment. Compared to conservative surgical treatment both techniques have increased local progression rates, while metastatic progression is relatively low.Partial nephrectomy (PN) is the recommended curative treatment for SRMs and can be performed open, laparoscopically or robotically. Open PN represents the benchmark, with similar cancer specific survival and better preservation of renal function compared to nephrectomy. Laparoscopy is comparable to open surgery in terms of oncologic results, but a long learning curve is necessary. Perioperative outcomes of robot-assisted PN appear superior to laparoscopy and the learning curve is shorter, but data for oncological results are still immature. With the increasing diffusion of robotic technology it is likely more SRMs will be managed with this approach.

Is synchronised NIPPV more effective than NIPPV and NCPAP in treating apnoea of prematurity (AOP)? A randomised cross-over trial.

BACKGROUND: Apnoea, desaturations and bradycardias are common problems in preterm infants which can be treated with nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). It is unclear whether synchronised NIPPV (SNIPPV) would be even more effective. OBJECTIVE: To assess the effects of flow-SNIPPV, NIPPV and NCPAP on the rate of desaturations and bradycardias in preterm infants and, secondarily, to evaluate their influence on pattern of breathing and gas exchange. PATIENTS AND METHODS: Nineteen infants (mean gestational age at study 30 weeks, 9 boys) with apnoeic spells were enrolled in a randomised controlled trial with a cross-over design. They received flow-SNIPPV, NIPPV and NCPAP for 4 h each. All modes were provided by a nasal conventional ventilator able to provide synchronisation by a pneumotachograph. The primary outcome was the event rate of desaturations (≤80% arterial oxygen saturation) and bradycardias (≤80 bpm) per hour, obtained from cardiorespiratory recordings. The incidence of central apnoeas (≥10 s) as well as baseline heart rate, FiO2, SpO2, transcutaneous blood gases and respiratory rate were also evaluated. RESULTS: The median event rate per hour during flow-SNIPPV, NIPPV and NCPAP was 2.9, 6.1 and 5.9, respectively (p<0.001 and 0.009, compared with flow-SNIPPV). Central apnoeas per hour were 2.4, 6.3 and 5.4, respectively (p=0.001, for both compared with flow-SNIPPV), while no differences in any other parameter studied were recorded. CONCLUSIONS: Flow-SNIPPV seems more effective than NIPPV and NCPAP in reducing the incidence of desaturations, bradycardias and central apnoea episodes in preterm infants.

Could the sling position influence the clinical outcome in male patients treated for urinary incontinence? A magnetic resonance imaging study with a 3 tesla system.

OBJECTIVE: To analyze the morphologic changes visible on magnetic resonance imaging (MRI) after sling procedure in continent patients and to compare MRI findings with the incontinent ones, to detect possible factors explaining the different clinical outcomes. METHODS: Twenty-seven male patients who were treated with Advance sling for urinary stress incontinence after prostate surgery were enrolled: 16 had clinical recovery, whereas 11 had persistent incontinence. Patients after sling were defined as continent if used 0-1 dry "security pad" or incontinent >1 pad. Magnetic Resonance examinations were performed with a 3 Tesla system and included 3-dimensional T2-weighted sequence. Three readers performed a qualitative (representation of the bulb and indentation of the sling) and a quantitative analysis (length of the bulb posterior to the sling and distance of the sling from a line bisecting the pubic symphysis). RESULTS: The sling was clearly recognizable in all 16 continent patients but only in 2 of 11 incontinent ones. The length of the bulb posterior to the sling was >10 mm (range, 10-28) in all continent patients and in 2 of the incontinent ones. The sling was coincident with a line drawn through the long axis of the pubic bone in 9 of 16 continent patients. A statistically significant association was found between MRI qualitative findings and continence status (P <.0001). CONCLUSION: On the basis of our MRI results, the position of the sling and, in particular, the length of the urethral bulb posterior to the sling seem to be correlated with continence and must be considered in case of treatment failure.

Long-term functional outcomes in patients with a W-shaped ileal orthotopic neobladder with no antireflux mechanism.

OBJECTIVE: To evaluate the long-term renal function, continence, and voiding function in 64 patients, surviving for 5 or more years after W-shaped ileal neobladder with a short afferent limb and refluxing ureterointestinal anastomoses. MATERIALS AND METHODS: Kidney morphology and function were evaluated using nuclear renography, creatinine, and glomerular filtration rate. Continence and voiding function were evaluated with a diary on frequency, voided volumes, number of pads, and with the incontinence severity index (ISI) questionnaire, the American Urological Association-Symptom Index (AUA-SI), and the American Urological Association-Symptom Problem Index. RESULTS: The renal scan showed a dilatation of the upper urinary tract in 4.8% of renoureteral units. Of the patients, 12.5% voided with intermittent or permanent catheterization. The remaining 87.5% voided spontaneously; 75% did not use pads, 12.5% used protection for safety, 7.1% 1 pad, and 5.4% more than 1 pad, during the day; during night, 55.3% did not use pads, 23.2% used protection for safety, and 12.6% and 8.9% 1 or more than 1 pad. The ISI questionnaire showed that 35.7% were fully continent, whereas 41%, 12.5%, and 10.8% had slight, moderate, and severe incontinence. The AUA-SI showed that 50% had mild, 39.3% moderate, and 10.7% severe lower urinary tract symptoms. Urinary incontinence, daytime frequency, and nocturia correlated positively with the age of patients at follow-up and negatively with voided volume. CONCLUSION: Long-term detrimental effect on renal function of orthotopic neobladder with no antireflux anastomoses is limited. Long-term continence and voiding function results are satisfactory. The ISI questionnaire might be useful to evaluate and grade incontinence in patients with orthotopic neobladder, whereas the AUA-SI has many limitations.

Results of vardenafil mediated power Doppler ultrasound, contrast enhanced ultrasound and systematic random biopsies to detect prostate cancer.

PURPOSE: We evaluated the ability of the phosphodiesterase-5 inhibitor vardenafil to increase prostate microcirculation during power Doppler ultrasound. We also evaluated the results of contrast and vardenafil enhanced targeted biopsies compared to those of standard 12-core random biopsies to detect cancer. MATERIALS AND METHODS: Between May 2008 and January 2010, 150 consecutive patients with prostate specific antigen more than 4 ng/ml at first diagnosis with negative digital rectal examination and transrectal ultrasound, and no clinical history of prostatitis underwent contrast enhanced power Doppler ultrasound (bolus injection of 2.4 ml SonoVue® contrast agent), followed by vardenafil enhanced power Doppler ultrasound (1 hour after oral administration of vardenafil 20 mg). All patients underwent standard 12-core transrectal ultrasound guided random prostate biopsy plus 1 further sampling from each suspected hypervascular lesion detected by contrast and vardenafil enhanced power Doppler ultrasound. RESULTS: Prostate cancer was detected in 44 patients (29.3%). Contrast and vardenafil enhanced power Doppler ultrasound detected suspicious, contrast enhanced and vardenafil enhanced areas in 112 (74.6%) and 110 patients (73.3%), and was diagnostic for cancer in 32 (28.5%) and 42 (38%), respectively. Analysis of standard technique, and contrast and vardenafil enhanced power Doppler ultrasound findings by biopsy core showed significantly higher detection using vardenafil vs contrast enhanced power Doppler ultrasound and standard technique (41.2% vs 22.7% and 8.1%, p <0.005 and <0.001, respectively). The detection rate of standard plus contrast or vardenafil enhanced power Doppler ultrasound was 10% and 11.7% (p not significant). CONCLUSIONS: Vardenafil enhanced power Doppler ultrasound enables excellent visualization of the microvasculature associated with cancer and can improve the detection rate compared to contrast enhanced power Doppler ultrasound and the random technique.

Treatment with intraoperative Patent Blue V dye of refractory lymphocele after inguinal lymphadenectomy for squamous cell penile carcinoma.

OBJECTIVES: To evaluate the potential curative role of the intraoperative use of a dye, the Patent Blue V, for the treatment of refractory lymphoceles by mapping the lymphatic leakage and selectively ligating the opened lymphatics. Inguinal lymphocele is a well-known complication after inguinofemoral lymph node dissection for penile cancer, and a variety of curative approaches have been reported. METHODS: From 1995 to 2007, 40 patients had undergone partial or total penectomy for squamous cell cancer. Superficial inguinal lymph node dissection with saphenous vein sparing or deep lymph node dissection was performed in 15 patients. It was unilateral in 14 and bilateral in 1 patient. When the lymphoceles were refractory to conventional therapy, ligation of the lymphatic vessels after mapping of the leakage with the Patent Blue V dye was the treatment of choice. RESULTS: Overall, 5 lymphoceles were detected in 4 patients that were continuously increasing in size after discharge and were treated conventionally. In the 2 refractory lymphoceles, we then opted for the intraoperative use of a dye, the Patent Blue V, to map the lymphatic leakage and selectively ligate the opened lymphatics. In both cases, complete resolution of the lymphoceles occurred. No complications were observed with this technique. CONCLUSIONS: The presented technique is able to cure persistent lymphoceles refractory to conventional treatment after inguinal lymph node dissection.