The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak.

OBJECTIVES: The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. METHODS: Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. RESULTS: The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. CONCLUSIONS: Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.

Tele-medicine versus face-to-face consultation in Endocrine Outpatients Clinic during COVID-19 outbreak: a single-center experience during the lockdown period.

CONTEXT: The COVID-19 outbreak in Italy is the major concern of Public Health in 2020: measures of containment were progressively expanded, limiting Outpatients' visit. OBJECTIVE: We have developed and applied an emergency plan, tailored for Outpatients with endocrine diseases. DESIGN: Cross-sectional study from March to May 2020. SETTING: Referral University-Hospital center. PATIENTS: 1262 patients in 8 weeks. INTERVENTIONS: The emergency plan is based upon the endocrine triage, the stay-safe procedures and the tele-Endo. During endocrine triage every patient was contacted by phone to assess health status and define if the visit will be performed face-to-face (F2F) or by tele-Medicine (tele-Endo). In case of F2F, targeted stay-safe procedures have been adopted. Tele-Endo, performed by phone and email, is dedicated to COVID-19-infected patients, to elderly or frail people, or to those with a stable disease. MAIN OUTCOME MEASURE: To assess efficacy of the emergency plan to continue the follow-up of Outpatients. RESULTS: The number of visits cancelled after endocrine triage (9%) is lower than that cancelled independently by the patients (37%, p < 0.001); the latter reduced from 47 to 19% during the weeks of lockdown (p = 0.032). 86% of patients contacted by endocrine-triage received a clinical response (F2F and tele-Endo visits). F2F visit was offered especially to young patients; tele-Endo was applied to 63% of geriatric patients (p < 0.001), visits' outcome was similar between young and aged patients. CONCLUSIONS: The emergency plan respects the WHO recommendations to limit viral spread and is useful to continue follow-up for outpatients with endocrine diseases.

Successful treatment of Castleman's disease with HAART in two HIV-infected patients.

Castleman's disease is a heterogeneous group of lymphoproliferative disorders of unknown aetiology. Recently, human herpesvirus type 8 (HHV-8) has been associated with various diseases in individuals with HIV infection, including Kaposi's sarcoma, B cell non Hodgkin's lymphomas, and Castleman's disease. In Castleman's disease it has been hypothesized that HHV-8, encoding a number of various virokines, can be responsible for clinical manifestations of the disease.Previously, two reports have described a clinical recovery from HIV-associated Castleman's disease: by administration of a monoclonal antibody neutralizing human IL-6 in one case, and in another case by treatment with highly antiretroviral therapy and anti-herpesvirus therapy, following splenectomy. We report two cases where HAART alone led to clinical recovery from Castleman's disease. In both the cases reported here, although follow-up biopsy was not performed, it is likely that the inhibition of HHV-8 replication and of virokine release, through the restoration of immunity by HAART, was the basis for the disappearance of the clinical symptoms.

Leuconostoc species: a case-cluster hospital infection.

Leuconostoc species are members of the Streptococcacae family. They are generally regarded as non-pathogenic culture contaminants and are thought to be an uncommon cause of infection. We present a study of a case-cluster nosocomial infection due to Leuconostoc spp. Three patients were hospitalized at the time of the infection with significant underlying diseases and all had a compromised skin and mucous barriers. Two had received previous antibiotic therapy. This report highlights the importance of Leuconostoc spp. as an emerging pathogen, even though the modes of transmission and reservoirs of Leuconostoc spp. are as yet unknown.

Recovery of long-term natural protection against reactivation of CMV retinitis in AIDS patients responding to highly active antiretroviral therapy.

OBJECTIVES: To see whether in severely immunosuppressed AIDS patients (with prior Cytomegalovirus retinal disease) who have significant increases in CD4+ lymphocytes following the initiation of highly active antiretroviral therapy (HAART) anti-Cytomegalovirus (CMV) maintenance therapy can be withdrawn with no subsequent progression of CMV retinitis. METHODS: Eight patients with AIDS and one or more previous episodes of CMV retinitis interrupted anti-CMV maintenance therapy following the successful beginning of HAART. CD4 cell counts and HIV-RNA were monitored monthly while measurement of CMV antigenemia and ophthalmoscopy were carried every 2 weeks thereafter. RESULTS: The HAART recipients in whom anti-CMV maintenance therapy had been interrupted had measureable increases of CD4+ T lymphocytes, substantial control of both HIV-RNA and CMV viraemia and did not show recurrence of retinitis during a mean follow-up of 98.4 weeks (range 78-120, SD 15.2). CONCLUSIONS: Anti-CMV maintenance therapy can be interrupted with no subsequent progression of retinal damage over a long time in patients with AIDS who successfully respond to HAART with a significant increase in CD4 cell count.

[Magnetic resonance imaging in tendon and ligament injuries of the ankle. Our personal experience]. / La Risonanza Magnetica nelle lesioni tendinee e legamentose della caviglia. Esperienza personale.

While Magnetic Resonance Imaging (MRI) has become a routine diagnostic method in knee studies, little has been published about ankle injuries. This is probably due to the anatomic complexity of the bone and ligament structures of this joint. Our study was aimed at assessing the yield of MRI of the ankle with a cost-effective, compact, low-field (0.2 T) M(R) system (Artoscan, Esaote). January, 1994, to August, 1995, 148 ankle examinations were carried out in a series of patients whose age ranged 7 to 75 years. In 56.7% of cases the exam was performed because of acute joint strain and in 43.3% for pain and chronic ankle instability. In 16.2% of cases the exam was negative; in 41.2% osteochondral injuries were found (which are not considered in this paper) and in 62.1% of cases ligament and tendon injuries were demonstrated. As for the latter, 46 patients had anterior talofibular rupture, 3 associated anterior talofibular and calcaneofibular ligament injuries, 9 tenosynovitis of extensor or flexor tendons, 2 tendon rupture and 17 Achilles tendon conditions (10 chronic tendinitis, 2 bone metaplasia and 5 tendon rupture cases). Three tarsal tunnel syndromes and 3 accessory soleus muscles were also observed. Surgical correlation was available only in 17 patients; after radiography and MRI, the vast majority of patients was treated nonoperatively. Nevertheless, a good correlation was demonstrated between M(R) and intraoperative findings or clinical and US findings. The authors believe that low-field MRI can be a very useful diagnostic tool in the study of ankle tendon injuries and to assess the severity of ligament injuries, for better treatment planning.

[Ultrasonography of the shoulder: the acromioclavicular joint]. / Ecografia della spalla: l'articolazione acromio-claveare.

In 95% of the patients complaining of shoulder pain, pain is consequent to mechanical impingement of the coraco-acromial arch on the rotator cuff. Acromioclavicular joint conditions play a major role (well over 50%) in initiating the process. This study was aimed at assessing the value of acromioclavicular investigations during shoulder US studies. September 1992 to September 1993, a hundred and seventy-four patients with shoulder pain underwent US exams of both shoulders and acromioclavicular joints. In 62% of patients rotator cuff tears (from less to more severe) were demonstrated, in 48% biceps tendon conditions (effusion, tendonitis, dislocation or tear) and in 31% aspecific degenerative changes of the rotator cuff. Three acromioclavicular joint cysts, a clavicular fracture and an acromioclavicular dislocation were also observed. The patients with US patterns of acromioclavicular conditions were 105 (60%); in 38% of cases, only capsular hypertrophy due to joint degeneration was observed. In 22% of cases the latter was associated with arthrosis-like changes of the articular rim. In 63% of cases rotator cuff tears were associated and in 37% of cases there were aspecific degenerative cuff changes. The authors believe that, especially in the latter cases, acromioclavicular joint US can be a useful approach to diagnosis and treatment.