Prone Positioning for ARDS. still misunderstood and misused

Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by a non-cardiogenic pulmonary edema with bilateral chest X-ray opacities and hypoxemia refractory to oxygen therapy and low level of positive end-expiratory pressure (1). Recently, a large observational study reported an ARDS prevalence of 10.4% of all ICU admissions and of 23.4% of all subjects receiving mechanical ventilation (2). Despite these alarming numbers, according to the most recent literature, ARDS is still under-recognized, undertreated, and associated with a mortality rate that in the most severe forms is close to 50% (2)

Clinical Management of Critical COVID-19 Patients: Insights from the Literature and "On the Field" Experience

AbstractThe recent outbreak of the coronavirus disease (COVID-19) is a health emergency all over the world. Several health care professionals are currently putting their best efforts to deal with this situation. The aim of this review is to report insights from the literature and "on the field" experience in clinical management of critical COVID-19 patients. Respiratory support varies from high flow nasal cannula (HFNC) to noninvasive and invasive mechanical ventilation, often associated with nitric oxide, prone position, and extracorporeal membrane oxygenation (ECMO). Experienced specialists have to manage the airways minimizing any contamination and virus spread. The hemodynamic management of critical COVID-19 patients requires not only an accurate fluid strategy, but also an appropriate use of vasopressors and inotropes. Various adjuvant treatments have been proposed: antiviral drugs, immunomodulators, anticoagulants, antibiotics, and nutrition

Association between antibodies to carbamylated proteins and subclinical atherosclerosis in rheumatoid arthritis patients

BACKGROUND: Rheumatoid arthritis (RA) patients carry a high risk of cardiovascular morbidity and mortality. The excess of cardiovascular disease cannot be entirely explained by traditional risk factors and the immune system contributes to the development of atherosclerosis. Moreover, post-translational modifications such as citrullination and carbamylation have been linked to inflammation and atherosclerosis. Anti-carbamylated proteins antibodies (anti-CarP) are a new subset of autoantibodies identified in RA patients. This study aimed to investigate a possible association between anti-CarP and subclinical atherosclerosis in RA patients. METHODS: We enrolled RA patients and normal healthy controls (NHS) without known cardiovascular risk factors or heart disease. Cardiovascular risk was assessed using the Modified Systemic Coronary Risk Evaluation (mSCORE). Anti-CarP were investigated by a solid phase "home-made" ELISA. Anti-citrullinated protein antibodies (ACPA) and Rheumatoid Factor (RF) were investigated by ELISA assays. Subclinical atherosclerosis was evaluated by brachial artery Flow-Mediated Dilatation (FMD) and Carotid Intima-Media Thickness (c-IMT) while arterial stiffness by Ankle-Brachial Index (ABI) and Cardio-Ankle Vascular Index (CAVI). RESULTS: We enrolled 50 RA patients (34 F and 16 M, mean age 58.4 ± 13.1 years, mean disease duration 127 ± 96.7 months) and 30 age and sex matched NHS. According to the mSCORE, 58% of patients had a low risk, 32% a moderate and 8% a high risk for cardiovascular disease. FMD was significantly lower in RA patients than in NHS (5.6 ± 3.2 vs 10.7 ± 8.1%; p < 0.004) and CAVIs significantly higher in a RA patients compared to NHS (left CAVI 8.9 ± 1.7 vs 8.1 ± 1.5; p < 0.04 for and right CAVI 8.8 ± 1.6 vs 8.0 ± 1.4; p < 0.04 for the). ABI and c-IMT did not differ between the two populations. The multivariate regression analysis showed a significant association of anti-CarP antibodies with FMD, left and right CAVI and both c-IMT (r = 1.6 and p = 0.05; r = 1.7 and p = 0.04; r = 2.9 and p = 0.05; r = 1.5 and p = 0.03; r = 1.1 and p = 0.03 respectively). CONCLUSIONS: This study confirms that RA patients, without evidence of cardiovascular disease or traditional risk factors, have an impaired endothelial function. Moreover, we found an association with anti-CarP antibodies suggesting a possible contribution of these autoantibodies to endothelial dysfunction, the earliest stage of atherosclerosis. Besides ultrasound assessment, anti-CarP should be assessed in RA patients and considered an additional cardiovascular risk factor

Anti-carbamylated protein antibodies as a new biomarker of erosive joint damage in systemic lupus erythematosus

Background: The application of more sensitive imaging techniques, such as ultrasonography (US), changed the concept of non-erosive arthritis in systemic lupus erythematosus (SLE), underlining the need for biomarkers to identify patients developing the erosive phenotype. Anti-citrullinated peptide antibodies (ACPA), associated with erosions in inflammatory arthritis, have been identified in about 50% of patients with SLE with erosive arthritis. More recently, anti-carbamylated proteins antibodies (anti-CarP) have been associated with erosive damage in rheumatoid arthritis. We aimed to assess the association between anti-CarP and erosive damage in a large SLE cohort with joint involvement. Methods: We evaluated 152 patients (male/female patients 11/141; median age 46years, IQR 16; median disease duration 108months, IQR 168). All patients underwent blood draw to detect rheumatoid factor (RF) and ACPA (commercial enzyme-linked immunosorbent assay (ELISA) kit), and anti-CarP ("home-made" ELISA, cutoff 340aU/mL). The bone surfaces of the metacarpophalangeal and proximal interphalangeal joints were assessed by US: the presence of erosions was registered as a dichotomous value (0/1), obtaining a total score (0-20). Results: The prevalence of anti-CarP was 28.3%, similar to RF (27.6%) and significantly higher than ACPA (11.2%, p=0.003). Erosive arthritis was identified in 25.6% of patients: this phenotype was significantly associated with anti-CarP (p=0.004). Significant correlation between anti-CarP titer and US erosive score was observed (r=0.2, p=0.01). Conclusions: Significant association was identified between anti-CarP and erosive damage in SLE-related arthritis, in terms of frequency and severity, suggesting that these antibodies can represent a biomarker of severity in patients with SLE with joint involvement

The Pontine Marshes:An integrated study of the origin, history, and future of a famous coastal wetland in Central Italy

The Pontine Marshes (Central Italy) are known for their long drainage history starting early in Roman times and culminating in their reclamation (bonificaintegrale) by the Fascist’s regime under Mussolini, mostly in the 1930s of past century. The geology of this coastal wetland and causes for its drainageproblems received limited attention till recently. We reviewed results from recent studies, identified still existing knowledge gaps and performedadditional research to fill these, to produce a full description of the Holocene history and drainage of these marshes. Massive coring data that servedto map the soils and surficial geology, observations in archaeological excavations, analytical data on soil and sediment characteristics, and radiocarbondatings allowed us to distinguish several phases in this history, with a main break in the early Roman Republican period with the first systematic drainageworks. Earlier, natural processes brought about by sea level rise largely controlled its drainage. Once artificial drainage started, soil subsidence became animportant process, aggravating the drainage problems. The bonifica introduced mechanical drainage, temporarily masking the impacts of subsidence. Wequantified the historical subsidence using DTMs and developed scenarios for the impacts of sea level rise and subsidence in 2100 and 2200, assuming thatthis rise will be mitigated by a coastal defence system and enhanced capacity of the mechanical drainage. Our results demonstrate the important role ofsoil subsidence throughout the history of this wetland and need to include subsidence in scenarios for the impacts of sea level rise

Gram-negative septic thrombosis in critically ill patients: A retrospective case-control study

Background: Data on septic thrombosis caused by Gram-negative bacilli (GN-ST) in intensive care unit (ICU) patients are currently limited. Methods: The aim of this retrospective case–control study (matched 1:3) performed over a 15-month period on ICU patients with bacteraemia, associated (cases) or not (controls) with GN-ST, was to assess 30-day mortality and clinical/microbiological features of GN-ST. Results: During the study period, 16 patients with GN-ST and 48 controls were analyzed. Polytrauma was the cause of ICU admission in 12 (75%) cases and 22 (46%) controls (p = 0.019). In no case of septic thrombosis was surgical debridement performed. The site of venous thrombosis was more frequently in the lower limbs, associated with bone fracture in nine out of 12 (75%) cases. The median duration of bacteraemia (22 days vs 1 day; p 72 h was significantly associated with GN-ST (area under the curve (AUC) 0.95, sensitivity 0.996 and specificity 0.810; p < 0.001). Finally, 30-day mortality was 20% in cases and 67% in controls (p < 0.001). Conclusions: Critically ill patients with GN-ST showed specific clinical features. Despite delayed bacteraemia clearance, targeted antibiotic therapy plus anticoagulation usually provided clinical improvement and a low 30-day mortality rate

Scalp high-frequency oscillations differentiate neonates with seizures from healthy neonates

OBJECTIVE We aimed to investigate (1) whether an automated detector can capture scalp high-frequency oscillations (HFO) in neonates and (2) whether scalp HFO rates can differentiate neonates with seizures from healthy neonates. METHODS We considered 20 neonates with EEG-confirmed seizures and four healthy neonates. We applied a previously validated automated HFO detector to determine scalp HFO rates in quiet sleep. RESULTS Etiology in neonates with seizures included hypoxic-ischemic encephalopathy in 11 cases, structural vascular lesions in 6, and genetic causes in 3. The HFO rates were significantly higher in neonates with seizures (0.098 ± 0.091 HFO/min) than in healthy neonates (0.038 ± 0.025 HFO/min; P = 0.02) with a Hedge's g value of 0.68 indicating a medium effect size. The HFO rate of 0.1 HFO/min/ch yielded the highest Youden index in discriminating neonates with seizures from healthy neonates. In neonates with seizures, etiology, status epilepticus, EEG background activity, and seizure patterns did not significantly impact HFO rates. SIGNIFICANCE Neonatal scalp HFO can be detected automatically and differentiate neonates with seizures from healthy neonates. Our observations have significant implications for neuromonitoring in neonates. This is the first step in establishing neonatal HFO as a biomarker for neonatal seizures

Role of anti-cyclic citrullinated peptide antibodies in discriminating patients with rheumatoid arthritis from patients with chronic hepatitis C infection-associated polyarticular involvement

This study was performed to assess the utility of anti-cyclic citrullinated peptide (anti-CCP) antibodies in distinguishing between patients with rheumatoid arthritis (RA) and patients with polyarticular involvement associated with chronic hepatitis C virus (HCV) infection. Serum anti-CCP antibodies and rheumatoid factor (RF) were evaluated in 30 patients with RA, 8 patients with chronic HCV infection and associated articular involvement and 31 patients with chronic HCV infection without any joint involvement. In addition, we retrospectively analysed sera collected at the time of first visit in 10 patients originally presenting with symmetric polyarthritis and HCV and subsequently developing well-established RA. Anti-CCP antibodies and RF were detected by commercial second-generation anti-CCP2 enzyme-linked immunosorbent assay and immunonephelometry respectively. Anti-CCP antibodies were detected in 23 of 30 (76.6%) patients with RA but not in patients with chronic HCV infection irrespective of the presence of articular involvement. Conversely, RF was detected in 27 of 30 (90%) patients with RA, 3 of 8 (37.5%) patients with HCV-related arthropathy and 3 of 31 (9.7%) patients with HCV infection without joint involvement. Finally, anti-CCP antibodies were retrospectively detected in 6 of 10 (60%) patients with RA and HCV. This indicates that anti-CCP antibodies can be useful in discriminating patients with RA from patients with HCV-associated arthropathy

The Effect of Different Archwires on Initial Orthodontic Pain Perception: A Prospective Controlled Cohort Study

The early stages of orthodontic treatment are frequently associated with pain that can vary in intensity and duration, representing one of the main reasons for treatment discontinuation. Whilst the use of drugs is recognised as being effective to control orthodontic pain, there are no reliable data indicating the best first archwire for efficacy and minimum discomfort. A prospective controlled cohort study was conducted to compare the intensity and the characteristics of orthodontic pain during the first 15 days of treatment with 2 archwires. Fifty subjects were enrolled and divided into two groups: one received 0.012 inch stainless steel (SS) as the first archwire; the other, a 0.014 inch super-elastic nickel–titanium (Ni-Ti) archwire. Patients compiled a visual analogue scale to measure pain intensity over 15 days, a questionnaire for pain characteristics, the Somatosensory Amplification Scale and the State-Trait Anxiety Inventory to control the psychosocial component of pain. Dental casts were digitally analysed to evaluate the initial arch length discrepancy. In the first 3 days of treatment, the mean VAS values of the SS group were significantly lower than those of the Ni-Ti group (p &lt; 0.05). No significant differences emerged between the groups concerning pain characteristics. The 0.012 inch SS archwire could be used at the beginning of orthodontic treatment to minimise pain perception and improve compliance

The Effect of Bite Raise on AHI Values in Adult Patients Affected by OSA: A Systematic Review with Meta-Regression

Obstructive sleep apnea (OSA) is a highly prevalent sleep breathing disorder characterized by the collapse of the pharyngeal walls that entails recurrent episodes of cessation of breathing or decrease in airflow while sleeping. This results in sleep fragmentation, decreased oxygen saturation and an increase in the partial pressure of carbon dioxide, causing excessive daytime sleepiness, hypertension and increased prevalence of cardiovascular morbidity and mortality. Mandibular advancement devices (MAD) represent a valid alternative therapy to Continuous Positive Airway Pressure, thrusting the mandible forward, increasing the lateral diameter of the pharynx and reducing the collapsibility of the airway. Several investigations have focused on the detection of the best mandibular advancement amount in terms of effectiveness and tolerance, but few and contrasting data are available on the role of occlusal bite raise in reducing the apnea/hypopnea index (AHI). The aim of this systematic review with meta-regression analysis was to investigate the effect of the bite raise of MAD on AHI values in adult patients affected by OSA. An electronic search was performed in MEDLINE, the Cochrane Database, Scopus, Web of Science and LILACS. Randomized controlled trials (RCT) investigating the effectiveness of MAD in OSA patients were included. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the risk of bias with the Cochrane risk-of-bias tool for randomized trials (RoB2). Six RCT were included. The success rate of each study was computed: (mean baseline AHI − mean post treatment AHI)/mean baseline AHI. The GRADE scores indicated that the quality of evidence was very low. The meta-regression analysis showed that there was no correlation between the occlusal bite raise and the AHI improvement