CT Perfusion as a Predictor of the Final Infarct Volume in Patients with Tandem Occlusion.

BACKGROUND: CT perfusion (CTP) is used in patients with anterior circulation acute ischemic stroke (AIS) for predicting the final infarct volume (FIV). Tandem occlusion (TO), involving both intracranial large vessels and the ipsilateral cervical internal carotid artery could generate hemodynamic changes altering perfusion parameters. Our aim is to evaluate the accuracy of CTP in the prediction of the FIV in TOs. METHODS: consecutive patients with AIS due to middle cerebral artery occlusion, referred to a tertiary stroke center between March 2019 and January 2021, with an automated CTP and successful recanalization (mTICI = 2b - 3) after endovascular treatment were retrospectively included in the tandem group (TG) or in the control group (CG). Patients with parenchymal hematoma type 2, according to ECASS II classification of hemorrhagic transformations, were excluded in a secondary analysis. Demographic, clinical, radiological, time intervals, safety, and outcome measures were collected. RESULTS: among 319 patients analyzed, a comparison between the TG (N = 22) and CG (n = 37) revealed similar cerebral blood flow (CBF) > 30% (29.50 ± 32.33 vs. 15.76 ± 20.93 p = 0.18) and FIV (54.67 ± 65.73 vs. 55.14 ± 64.64 p = 0.875). Predicted ischemic core (PIC) and FIV correlated in both TG (tau = 0.761, p < 0.001) and CG (tau = 0.315, p = 0.029). The Bland-Altmann plot showed agreement between PIC and FIV for both groups, mainly in the secondary analysis. CONCLUSION: automated CTP could represent a good predictor of FIV in patients with AIS due to TO.

Temporal lobe atrophy as a potential predictor of functional outcome in older adults with acute ischemic stroke.

BACKGROUND: To explore whether temporal lobe atrophy predicts 3-month functional outcome in a population of patients with anterior circulation acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). METHODS: We retrospectively selected patients > 65 years from our prospective endovascular stroke registry between June 2013 and August 2018. According to 3-month modified Rankin Scale (mRS), patients were divided in two groups, named good (mRS ≤ 2) and poor (mRS > 2) outcome. Measures of temporal lobe atrophy (i.e., interuncal distance [IUD], medial temporal lobe thickness [mTLT] and radial width of temporal horn [rWTH]) were assessed on pre-treatment CT scan. Cutoff values for good outcome were obtained for IUD, mTLT and rWTH by means of non-parametric ROC curve analysis. Multivariate analysis was performed to identify predictors of outcome. Ordinal shift analysis based on cutoff values was built to evaluate differences in 3-month mRS. RESULTS: Among 340 patients, 130 (38.2%) had good and 210 (61.8%) had poor outcome. We found the following cutoff values for good outcome: < 25 mm for IUD, > 15 mm for mTLT and < 4 mm for rWTH. Lower IUD (OR 0.71; 95% CI 0.63-0.80; p < 0.0001) and rWTH (OR 0.73; 95% CI 0.61-0.87; p < 0.0001) and higher mTLT (OR 1.30; 95% CI 1.14-1.49; p < 0.0001) were independently associated with good outcome. Ordinal shift analysis based on cutoff values revealed significant differences in the rate of good outcome for rWTH (49 vs 27%; p < 0.0001), mTLT (52 vs 21%; p < 0.0001) and IUD (57 vs 17%; p < 0.0001). CONCLUSIONS: Assessment of temporal lobe atrophy may predict functional outcome in patients with AIS treated with MT.

Carotid artery stenting during endovascular thrombectomy for acute ischemic stroke with tandem occlusion: the Italian Registry of Endovascular Treatment in Acute Stroke.

PURPOSE: The management of tandem extracranial internal carotid artery and intracranial large vessel occlusion during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) has been under-investigated. We sought to investigate outcomes of AIS patients with tandem occlusion (TO) treated with carotid artery stenting (CAS) compared to those not treated with CAS (no-CAS) during EVT. METHODS: We performed a cohort study using data from AIS patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. Outcomes were 3 months' mortality, functional outcome, complete and successful recanalization, any intracranial hemorrhage, parenchymal hematoma and symptomatic intracerebral hemorrhage. RESULTS: Among 466 AIS patients with TO, CAS patients were 122 and no-CAS patients were 226 (118 excluded). After adjustment for unbalanced variables, CAS was associated with a lower rate of 3 months' mortality (OR 0.407, 95% CI 0.171-0.969, p = 0.042). After adjustment for pre-defined variables, CAS was associated with a lower rate of 3 months' mortality (aOR 0.430, 95% CI 0.187-0.989, p = 0.047) and a higher rate of complete recanalization (aOR 1.986, 95% CI 1.121-3.518, p = 0.019), successful recanalization (aOR 2.433, 95% CI 1.263-4.686, p = 0.008) and parenchymal hematoma (aOR 2.876, 95% CI 1.173-7.050, p = 0.021). CAS was associated with lower 3 months mortality (OR 0.373, 95% CI 0.141-0.982, p = 0.046) and higher rates of successful recanalization (OR 2.082, 95% CI 1.099-3.942, p = 0.024) after adjustment for variables associated with 3 months' mortality and successful recanalization, respectively. CONCLUSIONS: Among AIS patients with TO, CAS during EVT was associated with a higher rate of successful reperfusion and a lower rate of 3 months' mortality.

Acne fulminans and its multiple associated factors: a systematic review.

Acne fulminans (AF) is a severe form of acne that presents with an outburst of haemorrhagic pustules and ulcerations, which may or may not be associated with systemic symptoms and laboratory abnormalities. In the latest classification, four variants of AF are considered, but this does not include AF associated with systemic therapies and inherited genetic syndromes. To systematically review disease features and evaluate differences among AF. Related articles were searched using the terms "acne fulminans", "acne conglobata with septicaemia", "acute febrile ulcerative acne" and "pseudo acne fulminans". We searched Medline and Google Scholar from inception to 1977 to identify case reports, case series, commentaries and reviews reporting new AF cases. A total of 98 articles met our inclusion criteria. AF induced by higher levels of androgens more frequently presented nodules and cysts than erosions, crusted and haemorrhagic lesions and necrosis. In contrast, patients affected by AF without any apparent cause (referred to here as "miscellaneous AF") more frequently presented with ulcerations and erosions, and patients with AF associated with systemic treatment showed a similar frequency of lesions. Notably, AF in patients with high levels of androgens and AF induced by antibiotics rarely showed comedones. In addition, aseptic osteolytic lesions were more common in miscellaneous AF than other AF. AF may present with differences in clinical and laboratory features and associated systemic illnesses, which should be evaluated for the planning of a personalized therapeutic scheme. We propose a classification of AF, according to its association with certain factors.

A consensus-based approach on the management of patients with both psoriasis and psoriatic arthritis in the dermatological and rheumatological settings in Italy: The ADOI PSO-Amore Project.

Psoriasis is a complex disease often needing a multidisciplinary approach. In particular, the collaboration between dermatologist and rheumatologist is crucial for the management of patients suffering from both psoriasis (PSO) and psoriatic arthritis (PsA). Here we report a series of recommendations from a group of experts, as a result of a Consensus Conference, defining the circumstances in which it is preferable or even mandatory, depending on the available settings, to rely on the opinion of the two specialists, jointly or in a deferred manner. Indications are given on how to organize a 3rd level joint Dermatology- Rheumatology care unit, in connection with 1st and 2nd level clinicians of both specialties, GPs, and other specialists involved in the management of psoriasis. A potential patient journey is suggested, that can be used as a basis for future design and validation of national and/or local diagnostic therapeutic and assistance pathways.

Epstein-Barr virus reactivation after COVID-19 vaccination in a young immunocompetent man: a case report.

We present the case of a 24-year-old Caucasian man, who developed a scaly erythematous skin rash after the second dose of coronavirus disease 2019 (COVID-19) vaccination with Comirnaty (BNT162b2, BioNTech/Pfizer; Pfizer, New York, NY, USA) and proved positive for Epstein-Barr virus (EBV) reactivation. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines have been associated with an up-regulated T helper type 1-cell response, possibly favoring an immune system imbalance. Also, EBV reactivation has been postulated after COVID-19 vaccination, but only in the immunosuppressed. Noteworthy we report the first case of EBV viral reactivation associated with cutaneous manifestations in an immunocompetent patient after the COVID-19 vaccine.

Epidemiological, Clinical and Microbiological Characteristics of Patients with Bloodstream Infections Due to Carbapenem-Resistant K. Pneumoniae in Southern Italy: A Multicentre Study.

BACKGROUND: In the present study, our aim was to evaluate the clinical and microbiological characteristics of a cohort of patients with bloodstream infections (BSI) due to Carbapenem-Resistant Enterobacteriaceae (CRE) and investigate the independent predictors of mortality. METHODS: All episodes of carbapenem-resistant E. coli (CREc) or K. pneumoniae (CRKp) BSI that were subject to a mandatory notification from January to December 2020 in all acute care hospitals and long-term care facilities of the Campania region in southern Italy were enrolled. All carbapenem-resistant strains were assessed through molecular tests for the presence of five carbapenemase gene families, i.e., K. pneumoniae Carbapenemase (KPC), oxacillinase-48 (OXA-48), New Delhi Metallo-ß-lactamase (NDM), Verona integron encoded metallo-ß-lactamase (VIM) and Imipenemase (IMP). RESULTS: During the study period, a total of 154 consecutive non-repeated CRE BSI, all due to CRKp, were reported. The most frequently identified genes were KPC in 108 cases (70.1%), followed by metallo-betalactamases (MBL) (16.2%), and OXA-48 (2.6%); in 17 isolates (11%) no carbapenemase was detected. The overall mortality at 90 days was 41.9%. Using a log-rank test, patients without risk factors for CRE infections showed a significantly lower cumulative mortality (p = 0.001). After multivariate logistic regression analysis, the presence of at least one risk factor was the only predictor of mortality (OR: 1.7, 95% CI 1.2-6.1, p = 0.015). CONCLUSIONS: The study reported a non-negligible prevalence of MBL-producing organisms among CRKp isolated from blood cultures in our region. This data highlights the importance of molecular characterization of all clinical isolates of carbapenem-resistant organisms.

Diagnostic and infection control strategies for Clostridioides difficile infections in a setting of high antimicrobial resistance prevalence.

Clostridioides difficile (CD) is a major nosocomial pathogen and the leading cause of antibiotic-associated diarrhoea. In light of the strong association between antimicrobial use and CD infections (CDI), it may be hypothesised that areas at higher prevalence of antimicrobial resistance, like the region of Campania in southern Italy, could also have a higher rate of CDI. In this multicentre, region-based, prospective study, we analysed such issues, exploiting CDI incidence data collected from local hospitals. In 2016, the Italian National Centre for Disease Control supported a project involving three Italian regions: Friuli Venezia Giulia, Lazio and Campania. In Campania, a network of 49 hospitals willing to participate in the project was created. The project consisted of two phases: a survey on practice patterns concerning CDI and an epidemiological surveillance study. We identified a stringent need to improve awareness about CDI among the regional health-care community, as a widespread lack of surveillance programmes for CDI control was observed (existing in only 40% of participating facilities). Moreover, almost half of the participating hospitals (n=16, 43%) had no standardised procedures or protocols to control and prevent CDI. In the second phase of the study, we collected data of CDI cases during a six-month surveillance programme. In all, 87 CDI cases were observed, for a total of 903,334 patient bed-days and 122,988 admissions. According to the above data, CDI incidence was 0.96 cases/10000 patient bed-days, much lower than expected based on prior studies conducted elsewhere. The results of our study suggest CDI remains a rather neglected clinical issue in Campania. Despite a high burden of antimicrobial resistance and antimicrobial use in our geographic setting, we observed a very low incidence of CDI. Such a low incidence could be explained by underdiagnosis, but could also be related to actual diet, the lower patient age or the specific genetic background. However, further studies are warranted to either confirm or rebut the above hypotheses.

Mechanical Thrombectomy for Acute Intracranial Carotid Occlusion with Patent Intracranial Arteries : The Italian Registry of Endovascular Treatment in Acute Stroke.

PURPOSE: Intracranial carotid artery occlusion represents an underinvestigated cause of acute ischemic stroke as well as an indication for mechanical thrombectomy. We investigated baseline and procedural characteristics, outcomes and predictors of outcome in patients with acute ischemic stroke secondary to intracranial carotid artery occlusion. METHODS: A retrospective analysis of the Italian Registry of Endovascular Treatment in Acute Stroke was performed. Patients with intracranial carotid artery occlusion (infraclinoid and supraclinoid) with or without cervical artery occlusion but with patent intracranial arteries were included. The 3­month functional independence, mortality, successful reperfusion and symptomatic intracranial hemorrhage were evaluated. RESULTS: Intracranial carotid artery occlusion with patent intracranial arteries was diagnosed in 387 out of 4940 (7.8%) patients. The median age was 74 years and median baseline National Institute of Health Stroke Scale (NIHSS) was 18. Functional independence was achieved in 130 (34%) patients, successful reperfusion in 289 (75%) and symptomatic intracranial hemorrhage in 33 (9%), whereas mortality occurred in 111 (29%) patients. In univariate analysis functional independence was associated with lower age, lower NIHSS at presentation, higher rate of successful reperfusion and lower rate of symptomatic intracranial hemorrhage. Multivariable regression analysis found age (odds ratio, OR:1.03; P = 0.006), NIHSS at presentation (OR: 1.07; P < 0.001), diabetes (OR: 2.60; P = 0.002), successful reperfusion (OR:0.20; P < 0.001) and symptomatic intracranial hemorrhage (OR: 4.17; P < 0.001) as the best independent predictors of outcome. CONCLUSION: Our study showed a not negligible rate of intracranial carotid artery occlusion with patent intracranial arteries, presenting mostly as severe stroke, with an acceptable rate of 3­month functional independence. Age, NIHSS at presentation and successful reperfusion were the best independent predictors of outcome.

Use of Ceftazidime-Avibactam and Ceftolozane-Tazobactam After Lung Transplantation.

INTRODUCTION: After lung transplantation (LTx), infections caused by multidrug-resistant (MDR) bacteria are frequent and difficult to treat. Some new antibiotics seem to be effective in treating these infections. MATERIAL AND METHODS: We describe our experience in treatment of Klebsiella pneumoniae MDR and Pseudomonas aeruginosa MDR infections with ceftazidime-avibactam (CEF-AVI) and ceftazidime-tazobactam (CEFT-TAZ) in patients who underwent LTx. RESULTS: In 3 patients who underwent double LTx and in 4 patients who underwent single LTx, strains of K. pneumoniae and P. aeruginosa were isolated from bronchoalveolar lavage. All patients showed worsening of respiratory functions, increasing in inflammation indexes, and, in some cases, onset of pulmonary consolidation. P. aeruginosa was treated with CEFT-TAZ for 10 days average (7-15 days) and K. pneumoniae with CEF-AVI for 14 days average (4-24 days). One patient developed a septic state caused by K. pneumoniae, requiring 24 days of therapy. None had shown side effects caused by drugs administration. One patient died after 15 days from lung transplant owing to primary graft dysfunction. CONCLUSIONS: CEF-AVI and CEFT-TAZ seems to be effective in treatment of infections caused by MDR bacteria after lung transplant.

Inflammatory Myofibroblastic Tumor After Lung Transplant-A Rare and Aggressive Complication: A Case Report.

INTRODUCTION: Malignant diseases are well-known complications after lung transplantation (LT). Among these, inflammatory myofibroblastic tumor (IMT) is a rare neoplasm with a not well-known and often aggressive biological behavior. MATERIAL AND METHODS: We hereby describe 2 cases of cystic fibrosis patients who underwent bilateral sequential LT (BSLT) complicated by IMT. RESULTS: A 26-year-old man presented a right endobronchial lesion 6 months after BSLT. Two consecutive fiber bronchoscopic biopsies showed granulation tissue. For the persistent lesion growth, the patient underwent a transthoracic biopsy showing histologic diagnosis of IMT. Therefore, he underwent to right pneumonectomy that was unfortunately complicated after 6 months with a late bronchopleural fistula and empyema with exitus 6 months later. A 31-year-old woman 1 year after BSLT presented with a left voluminous pleural-parenchymal lesion; the histologic examination after biopsy revealed an IMT. She underwent a removal of the lesion with a macroscopic R0 resection. Histologic, immunophenotypic, and cytogenetic examinations showed a strong overexpression of anaplastic lymphoma kinase requiring biological adjuvant therapies; however, the patient refused it. Four years later, she presented a recurrence treated with debulking procedure and adjuvant radiotherapy. At last follow-up, the patient was alive with stable disease and optimal graft function. CONCLUSIONS: Although IMT is a rare complication after lung transplant, to obtain a careful diagnosis, an early and aggressive treatment is mandatory.

Management of a case of unacknowledged foreign body in the upper airway.

Tracheobronchial foreign body aspiration occurs rarely in adults and may go unrecognized for a long time, but early detection and immediate retrieval of the foreign body are essential to prevent major morbidity. We describe the case of an adult who unusually aspirated part of his dental prosthesis during an attempted strangulation, which was unacknowledged until 6 months later when he was hospitalized with acute respiratory failure and required an emergency surgical tracheotomy. The foreign body was successfully removed via flexible bronchoscopy.

[Critical aspects of the direct distribution of medicines to patients upon discharge at the G. Rummo hospital in Benevento (Italy)]. / Criticità del percorso di distribuzione diretta dei farmaci e possibili interventi correttivi presso l'A.O.

Delivering prescription drugs directly to patients at the moment of discharge from the hospital is a useful tool for ensuring continuity in patient drug use, improving prescriptive appropriateness, limiting pharmaceutical expenditure and analyzing pharmacoepidemiological data. A project was therefore conducted from April 2005 to January 2007, at the G. Rumino hospital in Benevento (Italy), to encourage the direct delivery of drugs to patients upon discharge. The project consisted of various phases. Firstly, the medical records of all patients discharged from the hospital during April 2005 were analysed, mainly to collect information regarding discharge prescriptions, verify whether copies of the discharge form and prescription records were present in the chart, the type of drugs prescribed and whether these were available in the hospital pharmacy list of available drugs and had been dispensed to the patient. The percentage of drugs not available and of patients who did not pick up the prescribed drugs was calculated, critical aspects of the prescription process were analysed, and corrective measures implemented. A second evaluation of medical records was then performed for patients discharged in January 2007, to evaluate the effectiveness of the corrective measures applied. Results show that most discharged patients continue not to take advantage of the direct distribution of drugs in hospital and more information and communication to physicians and patients regarding this opportunity is required.

[Sexually transmitted diseases: a public health issue]. / Le malattie sessualmente trasmesse:Un problema di sanità pubblica.

Sexually Transmitted Diseases (STDs) are a main problem in the public health policy. The importance of these diseases is not only limited to their high incidence but also to the complications they may cause and to their role in the HIV transmission. Control of STDs represents one of the main aims of the World Health Organization. For many years STDs were thought to have been almost completely eliminated; instead, recently the rates of STDs are increasing. This has prompted the search for control strategies, that, however, have shown to be difficult to implement. For this reason, prevention programs based on promotion of responsible sexual behaviour, early diagnosis and treatment, and reduction of infectiousness, have been implemented in many countries.

[New procedures for improving case sheets editing]. / Intervento di miglioramento della qualità di compilazione della Cartella Clinica.

Case sheets are very important instruments for improving health care quality in hospitals. Despite their importance, they are very seldom used and filled in the right way. The study is based on an attempt to optimise case sheets editing; it implies multiple steps: 1. Project development; implementation of a pattern for assessing markers (thoroughness, clearness, reliability and record tracking); 2. Delivery of personal research protocols; 3. Early analysis, assessment of results; detection of severity; 4. Correctional interventions; 5. Secondary analysis; assessment of interventions. Although most indicators have shown an improvement, outcomes remain unsatisfactory, given the extent of shortfalls before intervention.