Multidisciplinary Approach to Patients With Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome.

Introduction: The morbidity associated with metastatic spinal disease is significant because of spinal cord and/or nerve root compression. The purpose of this paper is to define a diagnostic-therapeutic path for patients with vertebral metastases and from this path to build an algorithm to reduce the devastating consequences of spinal cord compression. Materials and Methods: The algorithm is born from the experience of a primary care center. A spine surgeon, an emergency room (ER) physician, a neuroradiologist, a radiation oncologist, and an oncologist form the multidisciplinary team. The ER physician or the oncologist intercept the patient with symptoms and signs of a metastatic spinal cord compression. Once the suspicion is confirmed, the following steps of the flow-chart must be triggered. The spine surgeon takes charge of the patient and, on the base of the anamnestic data and neurological examination, defines the appropriate timing for magnetic resonance imaging (MRI) in collaboration with the neuroradiologist. From the MRI outcome, the spine surgeon and the radiation oncologist consult each other to define further therapeutic alternatives. If indicated, surgical treatment should precede radiation therapy. The oncologist gets involved after surgery for systemic therapy. Results: In 2021, the Spine and Spinal Cord Surgery department evaluated 257 patients with vertebral metastasis. Fifty-three patients presented with actual or incipient spinal cord compression. Among these, 27 were admitted due to rapid progression of symptoms, neurological deficits and/or spine instability signs. The level was thoracic in 21 cases, lumbar in 4 cases, cervical in 1 case, sacral in 1 case. Fifteen were operated on, 10 of these programmed and 5 in emergency. Discussion: Patients with a history of malignancy can present to the ER or to the oncology department with symptoms that must be correctly framed in the context of a metastatic involvement. Even when there is no previous cancer history, the patient's pain characteristics and clinical signs must be interpreted to yield the correct diagnosis of vertebral metastasis with incipient or current spinal cord compression. The awareness of the alert symptoms and the application of an integrated paradigm consent to frame the patients with spinal cord compression, obtaining the benefits of a homogeneous step-by-step diagnostic and therapeutic path. Early surgical or radiation therapy treatment gives the best hope for preventing the worsening, or even improving, the deficits. Conclusions: Metastatic spinal cord compression can cause neurological deficits compromising quality of life. Treatment strategies should be planned comprehensively. A multidisciplinary approach and the application of the proposed algorithm is of paramount importance to optimize the outcomes of these patients.

Effect of intermediate/high versus low dose heparin on the thromboembolic and hemorrhagic risk of unvaccinated COVID-19 patients in the emergency department.

BACKGROUND: The optimal prophylactic dose of heparin in patients with coronavirus-associated disease 2019 (COVID-19) in the emergency department (ED) is debated. This study aimed to analyze different thromboprophylaxis approaches in unvaccinated COVID-19 patients admitted to ED without initial venous thromboembolism. METHODS: Retrospectively, the effect of intermediate/high versus low dose heparin treatment was evaluated from December 2020 to July 2021 in a tertiary Academic Hospital in northeast Italy. The primary outcome comprised arterial or venous thromboembolism or all-cause death within 30 days. Secondary outcomes comprised each single primary outcome component or major hemorrhagic event. Cox regression was used to determine predictors of the primary outcome and propensity score weights to balance the effect of heparin treatment on all outcomes. RESULTS: Data of 144 consecutive patients (age 70 ± 13, 33% females) were included in the study. High-dose prophylactic heparin was used in 69%, intermediate in 15%, and low in 17% of patients. The primary outcome occurred in 48 patients. Independent predictors of the primary outcome were COVID-19 severity (hazards ratio (HR) 1.96, 95% confidence interval (CI) 1.05-3.65, p = 0.035) and D-dimer levels (HR each log ng/dl 1.38, 95% CI 1.04-1.84, p = 0.026). Intermediate/high dose heparin did not affect the risk of the primary outcome compared with the low dose (weighted HR 1.39, 95% CI 0.75-2.56, p = 0.292). Intermediate/high heparin increased the risk of major hemorrhagic events (weighted HR 5.92, 95% CI 1.09-32, p = 0.039). CONCLUSIONS: In unvaccinated COVID-19 patients admitted to ED, prophylaxis with heparin at the intermediate/high dose did not reduce primary outcome compared with the low dose but increased the risk of major hemorrhagic events.

Approach to patients with COVID-19 disease: the procedure in Udine.

Coronavirus disease 2019 poses a serious threat to public health. The protocol developed at the Azienda Sanitaria Universitaria Friuli Centrale (Italy) is based on clinical data, laboratory tests, chest echography and HRCT. Several therapeutic options are considered, since patients vary in disease severity, evolution and co-morbidities and because so far there are no clear indications about therapeutic strategy based on randomized clinical trial. In this protocol chest echography has a central role in categorizing patient status, follow-up and decision-making.

Genetic polymorphisms of the renin-angiotensin-aldosterone system and renal insufficiency in essential hypertension.

OBJECTIVE: The renin-angiotensin-aldosterone system (RAAS) plays an important role in the control of renal function both in physiological and pathological conditions. The aim of the present study was to evaluate the relation between four genetic polymorphisms of the RAAS and renal insufficiency in a population of patients with essential hypertension living in north-east Italy. DESIGN AND METHODS: Eighty-six hypertensive patients with renal insufficiency and 172 hypertensive patients without renal damage matched for age and hypertension duration to within 2 years were evaluated. Genotyping for insertion/deletion of angiotensin-converting enzyme (ACE I/D), angiotensinogen (AGT) M235T, angiotensin II type 1 receptor (AT1R) A1166C and aldosterone synthase (CYP11B2) -344C/T polymorphisms were performed using polymerase chain reaction, with further restriction analysis when required. RESULTS: Each of the genetic polymorphisms of the RAAS genes was associated with renal failure; the adjusted odds ratios were 1.47 and 1.89 for ACE D allele, assuming a co dominant and a recessive mode of inheritance, respectively; 1.51 for AGT T235 allele assuming a co dominant, and 1.98 assuming a recessive, pattern of inheritance; 1.79 for AT1R C1166 allele considering a dominant pattern; and 3.89 for CYP11B2 -344C allele as a recessive effect. However, CYP11B2 genotypes were not in Hardy-Weinberg equilibrium among controls. The associations AGT TT-AT1R AC and CYP11B2 CC-ACE DD showed a possible positive interaction in the development of renal insufficiency among hypertensive subjects. The association AGT MM-AT1R AA and AGT MM-AT1R AA-CYP11B2 TT or TC combinations were associated with a reduced risk for renal failure. CONCLUSIONS: Our findings suggest that in patients with essential hypertension an unfavorable genetic pattern of RAAS may contribute to the increased risk for the development of renal failure.