Italian SARS-CoV-2 patients in intensive care: towards an identikit for subjects at risk?

OBJECTIVE: To investigate patient characteristics and factors that increase the risk of being admitted to intensive care and that influence survival in cases of SARS-CoV-2 pneumonia. PATIENTS AND METHODS: One-hundred and ninety-one SARS-CoV-2 patients were admitted to the "Fondazione Poliambulanza di Brescia" Hospital (Brescia, Lombardy, Italy) in the period 1st March 2020 to 11th April 2020. Data on demographics, clinical presentation at admission, co-morbidities, pharmacological treatment, admission to intensive care and death was recorded. Logistic regression and survival analysis were carried out to investigate the risk of being admitted to intensive care and the risk of death. RESULTS: The mean age of the study cohort was 64.6±9.9 years (range 20-88). Median BMI was 28.5±5 kg/m2. Fever (81%) and dyspnea (65%) were the most common symptoms on admission. Most of patients (63%) had at least one co-existing disease. The 157 (82%) patients admitted to intensive care were more likely to be of intermediate age (60-69 years; OR 3.23, 95% CI 1.32-8.38), overweight (OR 2.66, 95% CI 1.02-7.07) or obese (OR 5.63, 95% CI 1.73-21.09) and with lymphocytopenia (OR 2.75, 95% CI 1.17-6.89) than the 34 patients admitted to the ordinary ward. During intensive care, 50% of patients died and their death was associated with older age (HR 2.06, 95% CI 1.07-3.97), obesity (HR 2.23, 95% CI 1.15-4.35) and male gender (HR 1.9, 95% CI 1.02-3.57). CONCLUSIONS: We found that admission to intensive care and poor survival were associated with advanced age and higher body mass index, albeit with differences in statistical significance. Pre-existing diseases and symptoms on admission were not associated with different clinical outcomes. Interestingly, male gender was more prevalent among SARS-CoV-2 patients and was related negatively to survival, but it was not associated with more frequent admission to intensive care.

Prevalence of isolated left ventricular diastolic dysfunction in hypertension as assessed by combined transmitral and pulmonary vein flow Doppler study.

In a relatively large population of patients with treated systemic hypertension and normal left ventricular systolic function, prevalence of abnormalities of left ventricular diastolic function, as assessed by Doppler echocardiographic study of mitral and pulmonary vein flow, was high, with 51% of patients showing indirect signs of increased left ventricular end-diastolic pressure. Furthermore, our data documented that a "normal" mitral flow profile does not exclude the presence of an abnormality of left ventricular filling, which could be otherwise identified by combined analysis of a pulmonary vein flow profile.

Atrial fibrillation and cognitive disorders in older people.

OBJECTIVES: To find a correlation between chronic nonrheumatic atrial fibrillation (CNRAF) and cognitive impairment in a group of older, nondemented patients. SETTING: Acute Care Unit for the Elderly, Poliambulanza Hospital, Brescia (Italy). METHODS: Two hundred fifty-five hospital in-patients older than 70 years (42 with CNRAF and 213 controls with normal sinus rhythm) were assessed by complete clinical history, physical examination, ECG, serum albumin levels, APACHE II score, mental status (Mini-Mental State Exam [MMSE] and Geriatric Depression Score [GDS]), functional status (Barthel Index and instrumental activities of daily living [IADL]), number of prescribed drugs, and comorbidity (Charlson Index). RESULTS: The group of patients with CNRAF had MMSE scores significantly lower than that of the reference group with normal sinus rhythm. Chronic nonrheumatic atrial fibrillation retained an independent relation to cognitive impairment also after adjusting for those variables associated with mental decline in univariate models (GDS, IADL, and APACHE II scores). CONCLUSIONS: The results of this study support the relationship between nonrheumatic atrial fibrillation and impaired cognitive function. Independent of etiopathogenetic mechanisms (thromboembolic or hemodynamic hypotheses), prevention of cognitive impairment in older persons should take into account the treatment of atrial fibrillation and its consequences.

Primary carcinoid tumor of the ovary: report of an unusual case.

Carcinoid tumors are endocrine malignancies that are often associated with a characteristic syndrome, the malignant carcinoid syndrome, which is most common in patients with small bowel tumors and liver metastases. In the rare instances when the syndrome is present without liver metastases the primary tumor is usually localized to the bronchus or ovary and secretes hormones directly into the systemic circulation. About two thirds of patients with carcinoid syndrome have evidence of carcinoid heart disease. We report on a case of a primary ovarian carcinoid tumor with an unusual clinical presentation.

Failure of low dosage thrombolytic therapy with streptokinase to treat heparin-induced thrombocytopenic-thrombotic syndrome.

We report the case of a 58-year-old man affected by thrombocytopenic-thrombotic syndrome induced by therapy with subcutaneous unfractionated heparin for superficial phlebitis of the left inferior limb. Thrombolytic therapy with low-dosage streptokinase, reported as successful in a previous case described by other authors, was inefficacious and the patient's outcome was unfavourable. Thrombocytopenic-thrombotic syndrome may be a dreadful and often deadly consequence of heparin therapy, and its treatment needs investigation, owing to currently broadening use of anticoagulant treatment with both unfractionated and low molecular weight heparins.

Congestive heart failure due to rapid right ventricular obliteration by metastatic malignant melanoma.

We describe a 47-year-old man with a history of malignant melanoma, starting with a resection from his left thigh and followed, 4 years later, by a metastatic melanoma in the right ventricle. Within a few days, hemodynamic compromise occurred combined with evidence of an impressive intracavitary growth of the tumor causing obstruction of the right ventricular inflow and outflow tract. Echocardiography was valuable in the assessment of neoplastic cardiac involvement and was useful in detecting rapid right ventricular cavity obliteration by the expansion of the metastatic mass.

Abnormalities of left ventricular filling in valvular aortic stenosis. Usefulness of combined evaluation of pulmonary veins and mitral flow by means of transthoracic Doppler echocardiography.

It has been recently demonstrated that indexes obtained from the study of pulmonary venous flow by Doppler echocardiography are related to left ventricular (LV) pressures during diastole and may improve the assessment of LV filling derived from analysis of mitral flow velocities. In this study we evaluated the pattern of pulmonary venous flow and transmitral flow by means of transthoracic pulsed Doppler echocardiography in 31 adult patients (11 females, 20 males, mean age 72 +/- 10 years) with valvular aortic stenosis (Doppler valve area: 0.77 +/- 0.17 cm2) and in 15 age-matched normal subjects (five females, 10 males, mean age 68 +/- 6 years). Doppler indexes of mitral flow were similar between the two groups; on pulmonary venous flow, peak systolic velocity was lower (46 +/- 13 vs. 63 +/- 17 cm/s, P < 0.01) and both duration of reversal flow during atrial systole and difference between pulmonary atrial reversal flow and mitral A wave duration were longer in aortic stenosis patients compared to normals (148 +/- 21 vs. 111 +/- 16 ms and 6 +/- 27 vs. -26 +/- 21 ms, respectively, P < 0.001). Twenty-two aortic stenosis patients showed an early to late mitral flow ratio (E/A) < or = 1 and the remaining nine patients had a E/A > 1.(ABSTRACT TRUNCATED AT 250 WORDS)

Congestive heart failure in patients with valvular aortic stenosis. A clinical and echocardiographic Doppler study.

The aim of this study was to evaluate echographically anatomic and functional features of the left ventricle in adult patients with valvular aortic stenosis according to the presence or absence of congestive heart failure and the level of ventricular performance. Fifty-six adult patients with moderate-to-severe aortic stenosis underwent echocardiographic Doppler examination in order to evaluate left ventricular mass and dimensions, systolic function and filling dynamics. Twenty-seven patients had no heart failure and were symptomatic for angina (5), syncope (4) or were symptom-free (group I); the other 29 had heart failure (group II): 16 with normal left ventricular systolic performance (fractional shortening > 25%, group IIa) and 13 with systolic dysfunction (fractional shortening < or = 25%, group IIb). Despite a similar left ventricular mass, compared to group IIa, group IIb showed a significant left ventricular dilatation (end-diastolic diameter: 61 +/- 6.5 vs. 45.5 +/- 6.1 mm, p < 0.001) and mild or no increase in wall thickness (11.5 +/- 1.6 vs. 14.9 +/- 2 mm, p < 0.001). Indices of left ventricular filling on Doppler transmitral flow were also significantly different between the two groups, with a higher early-to-late filling ratio and a shorter deceleration time of early filling in group IIb (2.8 +/- 1.9 vs. 1.2 +/- 0.85, p < 0.01, and 122 +/- 66 vs. 190 +/- 87 ms, p < 0.05, respectively), both indirectly indicating higher left atrial pressure. Finally, heart failure was generally more severe in group IIb patients. In some patients with aortic stenosis, symptoms of heart failure may be present despite a normal left ventricular systolic function and seem to depend on abnormalities of diastolic function. The presence of systolic or isolated diastolic dysfunction appears to be related to a different geometric adaptation of the left ventricle to chronic pressure overload.