Severe asthma exacerbation: Changes in patient characteristics, management, and outcomes from 1997 to 2016 in 40 ICUs in the greater Paris area.

Background: Despite advances in asthma treatments, severe asthma exacerbation (SAE) remains a life-threatening condition in adults, and there is a lack of data derived from adult patients admitted to intensive care units (ICUs) for SAE. The current study investigated changes in adult patient characteristics, management, and outcomes of SAE over a 20-year period in 40 ICUs in the greater Paris area. Methods: In this retrospective observational study, admissions to 40 ICUs in the greater Paris area for SAE from January 1, 1997, to December 31, 2016 were analyzed. The primary outcome was the proportion of ICU admissions for SAE during 5-year periods. Secondary outcomes were ICU and hospital mortality, and the use of mechanical ventilation and catecholamine. Multivariate analysis was performed to assess factors associated with ICU mortality. Results: A total of 7049 admissions for SAE were recorded. For each 5-year period, the proportion decreased over time, with SAE accounting for 2.84% of total ICU admissions (n=2841) between 1997 and 2001, 1.76% (n=1717) between 2002 and 2006, 1.05% (n=965) between 2007 and 2011, and 1.05% (n=1526) between 2012 and 2016. The median age was 46 years (interquartile range [IQR]: 32-59 years), 55.41% were female, the median Simplified Acute Physiology Score II was 20 (IQR: 13-28), and 19.76% had mechanical ventilation. The use of mechanical ventilation remained infrequent throughout the 20-year period, whereas the use of catecholamine decreased. ICU and hospital mortality rates decreased. Factors associated with ICU mortality were renal replacement therapy, catecholamine, cardiac arrest, pneumothorax, acute respiratory distress syndrome, sepsis, and invasive mechanical ventilation (IMV). Non-survivors were older, had more severe symptoms, and were more likely to have received IMV. Conclusion: ICU admission for SAE remains uncommon, and the proportion of cases decreased over time. Despite a slight increase in symptom severity during a 20-year period, ICU and hospital mortality decreased. Patients requiring IMV had a higher mortality rate.

Clinical and imaging characteristics of patients with COVID-19 predicting hospital readmission after emergency department discharge: a single-centre cohort study in Italy.

OBJECTIVE: We aimed at identifying baseline predictive factors for emergency department (ED) readmission, with hospitalisation/death, in patients with COVID-19 previously discharged from the ED. We also developed a disease progression velocity index. DESIGN AND SETTING: Retrospective cohort study of prospectively collected data. The charts of consecutive patients with COVID-19 discharged from the Reggio Emilia (Italy) ED (2 March 2 to 31 March 2020) were retrospectively examined. Clinical, laboratory and CT findings at first ED admission were tested as predictive factors using multivariable logistic models. We divided CT extension by days from symptom onset to build a synthetic velocity index. PARTICIPANTS: 450 patients discharged from the ED with diagnosis of COVID-19. MAIN OUTCOME MEASURE: ED readmission within 14 days, followed by hospitalisation/death. RESULTS: Of the discharged patients, 84 (18.7%) were readmitted to the ED, 61 (13.6%) were hospitalised and 10 (2.2%) died. Age (OR=1.05; 95% CI 1.03 to 1.08), Charlson Comorbidity Index 3 versus 0 (OR=11.61; 95% CI 1.76 to 76.58), days from symptom onset (OR for 1-day increase=0.81; 95% CI 0.73 to 0.90) and CT extension (OR for 1% increase=1.03; 95% CI 1.01 to 1.06) were associated in a multivariable model for readmission with hospitalisation/death. A 2-day lag velocity index was a strong predictor (OR for unit increase=1.21, 95% CI 1.08 to 1.36); the model including this index resulted in less information loss. CONCLUSIONS: A velocity index combining CT extension and days from symptom onset predicts disease progression in patients with COVID-19. For example, a 20% CT extension 3 days after symptom onset has the same risk as does 50% after 10 days.

Characteristics and prognosis of bloodstream infection in patients with COVID-19 admitted in the ICU: an ancillary study of the COVID-ICU study.

BACKGROUND: Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring intensive care unit (ICU) have a high incidence of hospital-acquired infections; however, data regarding hospital acquired bloodstream infections (BSI) are scarce. We aimed to investigate risk factors and outcome of BSI in critically ill coronavirus infectious disease-19 (COVID-19) patients. PATIENTS AND METHODS: We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU study) that included 4010 COVID-19 ICU patients. For the present analysis, only those with data regarding primary outcome (death within 90 days from admission) or BSI status were included. Risk factors for BSI were analyzed using Fine and Gray competing risk model. Then, for outcome comparison, 537 BSI-patients were matched with 537 controls using propensity score matching. RESULTS: Among 4010 included patients, 780 (19.5%) acquired a total of 1066 BSI (10.3 BSI per 1000 patients days at risk) of whom 92% were acquired in the ICU. Higher SAPS II, male gender, longer time from hospital to ICU admission and antiviral drug before admission were independently associated with an increased risk of BSI, and interestingly, this risk decreased over time. BSI was independently associated with a shorter time to death in the overall population (adjusted hazard ratio (aHR) 1.28, 95% CI 1.05-1.56) and, in the propensity score matched data set, patients with BSI had a higher mortality rate (39% vs 33% p = 0.036). BSI accounted for 3.6% of the death of the overall population. CONCLUSION: COVID-19 ICU patients have a high risk of BSI, especially early after ICU admission, risk that increases with severity but not with corticosteroids use. BSI is associated with an increased mortality rate.

Hot moments and hotspots of cyanobacteria hyperblooms in the Curonian Lagoon (SE Baltic Sea) revealed via remote sensing-based retrospective analysis.

A temporally and spatially detailed historical (1985-2018) analysis of cyanobacteria blooms was performed in the Curonian Lagoon (Lithuania, Russia), the largest coastal lagoon in the Baltic Sea. Satellite data allowed the mapping of cyanobacteria surface accumulations, so-called "scums", and of chlorophyll-a concentration. The 34-year time series shows a tendency towards later occurrence (October-November) of the cyanobacteria scum presence, whereas the period of its onset (June-July) remains relatively constant. The periods when scums are present, "hot moments", have been consistently increasing in duration since 2008. The differences in the starting, ending and annual duration of cyanobacteria blooms have been significantly altered by hydro-meteorological conditions (river discharge, water temperature, and wind conditions) and their year-round patterns. The most important environmental factors that determined the temporal changes of the scum presence and area were the standing stock of cyanobacteria and the ambient wind conditions. The "hotspots", the areas where the blooms most likely occur, were distributed in the south-southwestern and central parts of the lagoon. The least affected areas were the northern part, which is connected to the coastal waters of the Baltic Sea, and the Nemunas River delta region. The longstanding, well-established spatial patterns of cyanobacteria blooms were linked to hydrodynamic features, namely water renewal time and current patterns, and to potential nutrient sources that included muddy sediments and the locations of colonies of piscivorous birds. Our findings confirmed that the annual and seasonal variations of cyanobacteria blooms and their regulation are a complex issue due to interactions between multiple factors over spatially and temporally broad scales. Despite great progress in the prevention and control of eutrophication and cyanobacteria blooms, the lagoon is still considered to be in a poor ecological status. This work provides a new and missing understanding on the spatial and temporal extent of cyanobacteria blooms and the factors that govern them. Such an understanding can help in planning management strategies, forecasting the magnitude and severity of blooms under changing nutrient loads and potential climate scenarios.

SAR image wave spectra to retrieve the thickness of grease-pancake sea ice using viscous wave propagation models.

Young sea ice composed of grease and pancake ice (GPI), as well as thin floes, considered to be the most common form of sea ice fringing Antarctica, is now becoming the "new normal" also in the Arctic. A study of the rheological properties of GPI is carried out by comparing the predictions of two viscous wave propagation models: the Keller model and the close-packing (CP) model, with the observed wave attenuation obtained by SAR image techniques. In order to fit observations, it is shown that describing GPI as a viscous medium requires the adoption of an ice viscosity which increases with the ice thickness. The consequences regarding the possibility of ice thickness retrieval from remote sensing data of wave attenuation are discussed. We provide examples of GPI thickness retrievals from a Sentinel-1 C band SAR image taken in the Beaufort Sea on 1 November 2015, and three CosmoSkyMed X band SAR images taken in the Weddell Sea on March 2019. The estimated GPI thicknesses are consistent with concurrent SMOS measurements and available local samplings.

Gender Differences in COVID-19 Lockdown Impact on Mental Health of Undergraduate Students.

Background: Prolonged university closures and social distancing-imposed measures due to the COVID-19 pandemic obliged students to at-home learning with online lectures and educational programs promoting potential social isolation, loneliness, hopelessness, and episodes of clinical decompensation. Methods: A web-based cross-sectional survey was carried out in a university institute in Milan, Northern Italy, to assess the COVID-19 lockdown impact on the mental health of the undergraduate students. We estimated the odds ratios (OR) and the corresponding 95% confidence intervals (CI) using adjusted logistic regression models. Results: Of the 8,177 students, 12.8% reported depressive symptoms, 25.6% anxiety, 8.7% insomnia, and 10.6% reported impulsive tracts, with higher proportions among females than males. Mental health symptoms were positively associated with caring for a person at home, a poor housing quality, and a worsening in working performance. Among males compared with females, a poor housing quality showed a stronger positive association with depressive symptoms and impulsivity, and a worsening in the working performance was positively associated with depressive and anxiety symptoms. In addition, the absence of private space was positively associated with depression and anxiety, stronger among males than females. Conclusions: To our knowledge, this is the first multidisciplinary consortium study, involving public mental health, environmental health, and architectural design. Further studies are needed to confirm or refute our findings and consequent recommendations to implement well-being interventions in pandemic conditions.

COVID-19 Lockdown: Housing Built Environment's Effects on Mental Health.

Since the World Health Organization (WHO) declared the coronavirus infectious disease 2019 (COVID-19) outbreak a pandemic on 11 March, severe lockdown measures have been adopted by the Italian Government. For over two months of stay-at-home orders, houses became the only place where people slept, ate, worked, practiced sports, and socialized. As consolidated evidence exists on housing as a determinant of health, it is of great interest to explore the impact that COVID-19 response-related lockdown measures have had on mental health and well-being. We conducted a large web-based survey on 8177 students from a university institute in Milan, Northern Italy, one of the regions most heavily hit by the pandemic in Europe. As emerged from our analysis, poor housing is associated with increased risk of depressive symptoms during lockdown. In particular, living in apartments <60 m2 with poor views and scarce indoor quality is associated with, respectively, 1.31 (95% CI: 1046-1637), 1.368 (95% CI: 1166-1605), and 2.253 (95% CI: 1918-2647) times the risk of moderate-severe and severe depressive symptoms. Subjects reporting worsened working performance from home were over four times more likely to also report depression (OR = 4.28, 95% CI: 3713-4924). Housing design strategies should focus on larger and more livable living spaces facing green areas. We argue that a strengthened multi-interdisciplinary approach, involving urban planning, public mental health, environmental health, epidemiology, and sociology, is needed to investigate the effects of the built environment on mental health, so as to inform welfare and housing policies centered on population well-being.

Covid-19 pandemic impact on mental health: a web-based cross-sectional survey on a sample of Italian general practitioners.

BACKGROUND: Since the World Health Organization declared the new 2019 coronavirus disease (Covid-19) outbreak first a Public Health Emergency of International Concern and then a pandemic, Italy held more than 195.350 cases and 26.380 deaths. Working in the frontline with suspected Covid-19 infection patients, general practitioners (GPs) are daily under both physical and psychological pressure.  Methods: A web-based cross-sectional survey was carried out on italian GPs working in Genoa (Italy), to assess the impact of Covid-19 pandemic on mental health. The survey was anonymous and a free Google Forms® software was used. RESULTS: One hundred thirty-one GPs completed the survey. Compared to GPs with absent or mild depressive symptoms (PHQ-9 < 10), GPs reporting moderate to severe depressive symptoms (N=30, 22.9%; PHQ-9 ≥ 10) reported more helplessness (96.7% vs. 79.2%, p=.025), spent more than three hours searching for COVID-19 information (43.3% vs. 19.8%, p=.024), perceived less adequate personal protective equipment (PPE) (6.7% vs. 23.8%, p=.049) and visited more COVID-19 infected patients (16.63 ± 27.30 vs. 9.52 ± 11.75, p=.041). Moreover, PHQ-9 ≥ 10 GPs reported a significant higher severity for both anxiety and insomnia (13.43 ± 4.96 vs. 4.88 ± 3.53 and 11.60 ± 5.53 vs. 4.84 ± 3.81, respectively; p<.001), and a worse quality of life in both mental (34.60 ± 7.45 vs. 46.01 ± 7.83, p<.001) and physical (43.50 ± 9.37 vs. 52.94 ± 4.78, p<.001) component summary. CONCLUSIONS: Our results give early insight into the urgent need to provide continuity of care for patients at the community-level, adequate PPE to GPs and a clear guidance from public health institutions. A precarious healthcare system both at a national and regional level might have triggered negative mental health outcomes in Italian GPs.

Serum Copeptin levels in the emergency department predict major clinical outcomes in adult trauma patients.

BACKGROUND: Early prognostication in trauma patients is challenging, but particularly important. We wanted to explore the ability of copeptin, the C-terminal fragment of arginine vasopressin, to identify major trauma, defined as Injury Severity Score (ISS) > 15, in a heterogeneous cohort of trauma patients and to compare its performances with lactate. We also evaluated copeptin performance in predicting other clinical outcomes: mortality, hospital admission, blood transfusion, emergency surgery, and Intensive Care Unit (ICU) admission. METHODS: This single center, pragmatic, prospective observational study was conducted at Arcispedale Santa Maria Nuova, a level II trauma center in Reggio Emilia, Italy. Copeptin determination was obtained on Emergency Department (ED) arrival, together with venous lactate. Different outcomes were measured including ISS, Revised Trauma Score (RTS), hospital and ICU admission, blood transfusion, emergency surgery, and mortality. RESULTS: One hundred and twenty five adult trauma patients admitted to the ED between June 2017 and March 2018. Copeptin showed a good ability to identify patients with ISS > 15 (AUC 0.819). Similar good performances were recorded also in predicting other outcomes. Copeptin was significantly superior to lactate in identifying patients with ISS > 15 (P 0.0015), and in predicting hospital admission (P 0.0002) and blood transfusion (P 0.016). Comparable results were observed in a subgroup of patients with RTS 7.84. CONCLUSIONS: In a heterogeneous group of trauma patients, a single copeptin determination at the time of ED admission proved to be an accurate biomarker, statistically superior to lactate for the identification of major trauma, hospital admission, and blood transfusion, while no statistical difference was observed for ICU admission and emergency surgery. These results, if confirmed, may support a role for copeptin during early management of trauma patients.

Bipolar subtypes and their clinical correlates in a sample of 391 bipolar individuals.

Differences between BD-I and BD-II patients with regard to specific illness characteristics are poorly understood. This study is mainly aimed to compare socio-demographic and clinical characteristics between BD-I and BD-II patients with the goal of clarifying possible predictors of clinical course. The sample of this cohort study is composed of 391 currently euthymic bipolar patients. Participants were all receiving only maintenance treatment; their psychopharmacological regimens and psychopathological conditions were stable at assessment. After univariate analyses, BD-II patients were more likely to be female, had more frequently a recent depressive episode and substance abuse/dependence relative to BD-I subjects. BD-II patients were also less likely to have a positive history of psychiatric conditions in family, psychotic symptoms at first episode, and first depressive illness episode. Moreover, BD-II were older at their illness onset and first treatment than BD-I patients. Furthermore, BD-I were more likely to have higher depressive, manic, anxiety, and symptoms severity than BD-II patients. After logistic regression analyses, being female (OR = 0.289), having psychiatric conditions in family (OR = 0.273), and higher severity of illness at CGI (OR = 0.604) were all significantly associated with BD-II. Additional studies are required to replicate these results, and facilitate the prediction of BD outcomes according to the specified profile.

Predictors of recurrence in a sample of 508 outpatients with major depressive disorder.

OBJECTIVE: Specific predictors of relapse/recurrence in major depressive disorder (MDD) have been identified but evidence across studies are inconsistent. This study aimed to identify the most relevant socio-demographic/clinical predictors of MDD recurrence in a sample of 508 outpatients. METHODS: This naturalistic cohort study included 508 currently euthymic MDD patients (mean age = 54.1 ±â€¯16.2) of which 53.9% had a single and 46.1% recurrent depressive episodes. A detailed data collection was performed and illness histories were retraced through clinical files and lifetime computerized medical records. RESULTS: Compared to patients with single episode, MDD patients with recurrent episodes significantly differ regarding current age, gender, working status, positive history of psychiatric disorders in family, first-lifetime illness episode characteristics, first-episode and current psychotic symptoms, current melancholic features and seasonality, age at first treatment, duration of untreated illness, and comorbid cardiovascular/endocrinological conditions. However, after multivariate analyses controlling for current age, gender, educational level, working status differences, psychiatric conditions in family, and age of illness episode, recurrence was associated with older age (p ≤ .001), younger age at first treatment (p ≤ .005), being treated with previous psychoactive treatments (p .001), and longer duration of untreated illness (p .001). CONCLUSIONS: The variables associated with MDD recurrence identified in the current study may aid in the stratification of patients who could benefit from more intensive maintenance treatments for MDD. However, clinicians should rapidly identify cases that are not likely to recur in order to avoid unnecessary treatments which are commonly considered as the standard of care.

Long-Acting GLP-1 Receptor Agonist Exenatide Influence on the Autonomic Cardiac Sympatho-Vagal Balance.

Long-acting glucagon-like peptide 1 receptor agonists are increasingly used to treat type 2 diabetes. An increase of heart rate (HR) has been observed with their use. To elucidate the role of the cardiac sympatho-vagal balance as a possible mediator of the reported increase in HR, we performed power spectral analysis of HR variability (HRV) in patients receiving exenatide extended-release (ER). Twenty-eight ambulatory patients with type 2 diabetes underwent evaluation at initiation of exenatide-ER and thereafter at 3 and at 6 months. To obtain spectral analyses of HRV, a computerized acquisition of 10 minutes of RR electrocardiogram intervals (mean values of ~700 RR intervals) were recorded both in lying and in standing positions. All patients showed a substantial increase of HR both in lying and in standing positions. Systolic blood pressure, body weight, and glycated hemoglobin A1c significantly decreased both at 3 and 6 months compared with basal levels. The low-frequency/high-frequency ratio varied from 3.05 ± 0.4 to 1.64 ± 0.2 (P < 0.001) after 3 months and to 1.57 ± 0.3 (P < 0.001) after 6 months in a lying position and from 4.56 ± 0.8 to 2.24 ± 0.3 (P < 0.001) after 3 months and to 2.38 ± 0.4 (P < 0.001) after 6 months in a standing position compared with basal values, respectively. HR variations, induced by exenatide-ER treatment, do not appear to be related to sympathetic autonomic tone. Of note, we observed a relative increase of vagal influence on the heart.

Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation.

BACKGROUND: Increased left ventricular afterload during peripheral venoarterial-extracorporeal membrane oxygenation (VA-ECMO) support frequently causes hydrostatic pulmonary oedema. Because physiological studies demonstrated left ventricular afterload decrease during VA-ECMO assistance combined with the intra-aortic balloon pump (IABP), we progressively changed our standard practice systematically to associate an IABP with VA-ECMO. This study aimed to evaluate IABP efficacy in preventing pulmonary oedema in VA-ECMO-assisted patients. METHODS: A retrospective single-centre study. RESULTS: Among 259 VA-ECMO patients included, 104 received IABP. Weinberg radiological score-assessed pulmonary oedema was significantly lower in IABP+ than IABP- patients at all times after ECMO implantation. This protection against pulmonary oedema persisted when death and switching to central ECMO were used as competing risks (subhazard ratio 0.49, 95% confidence interval (CI) 0.33-0.75; P<0.001). Multivariable analysis retained IABP as being independently associated with a lower risk of radiological pulmonary oedema (odds ratio (OR) 0.4, 95% CI 0.2-0.7; P=0.001) and a trend towards lower mortality (OR 0.54, 95% CI 0.29-1.01; P=0.06). Finally, the time on ECMO free from mechanical ventilation increased in IABP+ patients (2.2±4.3 vs. 0.7±2.0 days; P=0.0003). Less frequent pulmonary oedema and more days off mechanical ventilation were also confirmed in 126 highly comparable IABP+ and IABP- patients, propensity score matched for receiving an IABP. CONCLUSIONS: Associating an IABP with peripheral VA-ECMO was independently associated with a lower frequency of hydrostatic pulmonary oedema and more days off mechanical ventilation under ECMO.

Retrieval of severe acute respiratory failure patients on extracorporeal membrane oxygenation: Any impact on their outcomes?

OBJECTIVE: Mobile extracorporeal membrane oxygenation (ECMO) retrieval teams (MERTs) assure ECMO implantation and under-ECMO retrieval of patients with most severe acute respiratory failure (ARF) to experienced ECMO centers. Although described as feasible, mobile ECMO has only been poorly evaluated in comparison with on-site implantation. This study was undertaken to compare the indications, characteristics, and outcomes of MERT-implanted patients with venovenous (VV)-ECMO versus those implanted on site in our intensive care unit (ICU). METHODS: Retrospective, single-center study. RESULTS: Among 157 VV-ECMO implantations from 2008 to 2012, the MERT hooked up 118 (75%) patients with refractory ARF, as reflected by their median partial pressure of O2 in arterial blood/fraction of inspired oxygen of 58 (interquartile range, 50-73). ARF was accompanied by severe multiorgan failure, with a median Simplified Acute Physiology Score-II of 71 (61-81), median Sequential Organ Failure Assessment score of 14 (10-16), and with 82% of the patients receiving inotropes. All patients were transported by ground ambulance: median distance was 15 (6-25) km, and median transport time was 35 (25-35) minutes, during which no major ECMO system-related event occurred. For the MERT- and on-site-implanted groups, ICU mortality was comparable (46.6% vs 53.8%, respectively, P = .5), as were ECMO-related complication rates (53.4% of MERT vs 53.8% of on-site-implanted groups, P = 1.0). According to multivariable analysis, MERT ECMO implantation was not associated with ICU mortality (odds ratio, 1.1; 95% confidence interval, 0.4-2.7; P = .85). CONCLUSIONS: ICU mortality and ECMO-related complications of patients with MERT-implanted VV-ECMO who were transferred to our ECMO referral center were comparable with those implanted on site by the same team, thereby supporting this strategy to manage patients with severe ARF.

Limit regimes of ice formation in turbulent supercooled water.

A study of ice formation in stationary turbulent conditions is carried out in various limit regimes of crystal growth, supercooling, and ice entrainment at the water surface. Analytical expressions for the temperature, salinity, and ice concentration mean profiles are provided, and the role of fluctuations in ice production is numerically quantified. Lower bounds on the ratio of sensible heat flux to latent heat flux to the atmosphere are derived and their dependence on key parameters such as salt rejection in freezing and ice entrainment in the water column is elucidated.

Dispersive-to-nondispersive transition and phase-velocity transient for linear waves in plane wake and channel flows.

In this study we analyze the phase and group velocity of three-dimensional linear traveling waves in two sheared flows: the plane channel and the wake flows. This was carried out by varying the wave number over a large interval of values at a given Reynolds number inside the ranges 20-100, 1000-8000, for the wake and channel flow, respectively. Evidence is given about the possible presence of both dispersive and nondispersive effects which are associated with the long and short ranges of wavelength. We solved the Orr-Sommerfeld and Squire eigenvalue problem and observed the least stable mode. It is evident that, at low wave numbers, the least stable eigenmodes in the left branch of the spectrum behave in a dispersive manner. By contrast, if the wave number is above a specific threshold, a sharp dispersive-to-nondispersive transition can be observed. Beyond this transition, the dominant mode belongs to the right branch of the spectrum. The transient behavior of the phase velocity of small three-dimensional traveling waves was also considered. Having chosen the initial conditions, we then show that the shape of the transient highly depends on the transition wavelength threshold value. We show that the phase velocity can oscillate with a frequency which is equal to the frequency width of the eigenvalue spectrum. Furthermore, evidence of intermediate self-similarity is given for the perturbation field.

"Real life use" of troponin in the emergency department: a survey of over 3000 cases.

INTRODUCTION: The aim of this study was to identify clinical variables which may be independently associated with positivity of a cardiac troponin I (cTnI) assay in a large population of patients admitted to the emergency department (ED). MATERIALS AND METHODS: 3166 subjects, with at least two troponin I tests ordered within 6 hours in the ED, were studied. Patient data were statistically analyzed to identify clinical associations with increased values of Troponin I. RESULTS: Although patients with diagnosis of acute coronary syndrome displayed troponin I values significantly higher than those of other groups, positivity to troponin I (>40 ng/L) was also observed in patients with other clinical conditions. In multivariate analysis, age, elevated heart rate and electrocardiographic changes were independently associated with troponin I positivity at admission. In the whole study population troponin I positivity exhibited high sensitivity and negative predictive value, counterbalanced by low specificity and limited positive predictive value. CONCLUSIONS: Troponin I positivity should be combined with history and clinical evaluation and cautiously interpreted in the ED, especially in patients exhibiting factors associated with higher troponin I levels such as older age, elevated heart rate or ECG changes.

Lower levels of 25-hydroxyvitamin D3 are associated with a higher prevalence of microvascular complications in patients with type 2 diabetes.

OBJECTIVE: Low levels of serum 25-hydroxyvitamin D [25(OH)D] are commonly found in type 2 diabetes. We examined whether there is an association between circulating 25(OH)D concentrations and the presence of microvascular complications in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: We studied 715 outpatients with type 2 diabetes who regularly attended our clinic. Participants were evaluated for the presence of microvascular complications (namely retinopathy and/or nephropathy) by clinical evaluation, fundus examination, urine examination and biochemical tests. Serum 25(OH)D levels were also measured for each participant. RESULTS: Hypovitaminosis D (ie, a serum 25(OH)D level <30 ng/mL) was found in 75.4%, while deficiency (ie, a 25(OH)D level <20 ng/mL) was found in 36.6% of these patients. Serum 25(OH)D levels decreased significantly in relation to the severity of either retinopathy or nephropathy or both. In multivariate logistic regression analysis, lower 25(OH)D levels were independently associated with the presence of microvascular complications (considered as a composite end point; OR 0.758; 95% CI 0.607 to 0.947, p=0.015). Notably, this association remained significant even after excluding those with an estimated glomerular filtration rate <60 mL/min/1.73 m(2). CONCLUSIONS: We found an inverse and independent relationship between circulating 25(OH)D levels and the prevalence of microvascular complications in patients with type 2 diabetes. However, vitamin D may be simply a marker and causality cannot be implied from our cross-sectional study. Whether vitamin D supplementation in patients with type 2 diabetes may have beneficial effects on the risk of microvascular complications remains to be investigated.

Accidental digitoxin intoxication: an interplay between laboratory and clinical medicine.

INTRODUCTION: Two Italian adults arrived at the Emergency Department referring diarrhea, nausea and vomiting for 4 days; weakness, fatigue and visual hallucinations were also complained of. Patients reported the ingestion of some leaves of a plant, which they supposed to be "donkey ears", a week before. Physical examination showed hypotension and bradycardia and ECG examination disclosed sinus rhythm and repolarization abnormalities (scooping of the ST-T complex) in both patients and a 2:1 AV block in the man. MATERIALS AND METHODS: Digoxin concentration was evaluated twice for each patient (at the admission and after 4 hours) by the automated immunoassay system ADVIA Centaur. Digitoxin concentration was evaluated by liquid chromatography-mass spectrometry (LC-MS/MS). RESULTS: Despite clinical picture was suggestive of digitalis intoxication, digoxin levels were undetectable. Due to the more severe clinical picture, the male patient was treated with anti-digoxin antibodies (Digifab) achieving a good clinical improvement and remission of the AV block within two hours. Initial diagnosis was confirmed by LC-MS/MS showing high digitoxin concentrations, but digoxin was undetectable. Patients remained stable and 48 hours later were discharged from the hospital. CONCLUSION: Whereas digoxin determination frequently relies on monoclonal antibodies which do not cross-react to digitoxin, polyclonal antibodies constituting Digifab recognize a large spectrum of cardiac glycosides, including digitoxin. This report emphasizes the primary role of the clinical approach to patients in the emergency setting and how an active communication and a continuous sharing of professional experiences between Laboratory and Clinicians ensure an early and correct diagnosis.