Analisi della Gestione di un anno di Traumi Maggiori nel "Trauma Center" dell'Azienda Ospedaliera-Universitaria Pisana

Introduzione: La cura del paziente vittima di trauma rimane uno dei punti cardine della pratica della medicina d'emergenza. I medici d'emergenza giocano un ruolo vitale nelle fasi di stabilizzazione, di diagnosi della e della cura del trauma. L’intensivista affronta un’importante sfida clinica quando un paziente con trauma multiplo arriva al pronto soccoro. La gestione dei pazienti con trauma coinvolge abilità complesse, come rapide decisioni, capacità tecniche e di leaderschip. Una corretta rianimazione, mai come in questo ambito, può incrementare/ migliorare gli esiti funzionali e la prognosi quod vitam, dei pazienti feriti. Scopi: l’obiettivo principale della presente tesi è stato quello di analizzare alcuni indicatori di performance del Dipartimento Emergenza Accettazione (DEA) di II livello dell’AOU Pisana (AOUP) nella gestione del trauma maggiore. Materiali e metodi: Il presente studio è un’analisi retrospettiva dei Traumi Maggiori, giunti presso il DEA dell’AOUP, nel periodo 1° Gennaio 2014 – 31 Dicembre 2014. Di tutti i pazienti sono stati raccolti i parametri vitali, i dati di laboratorio, i referti delle indagini strumentali e tutto ciò che era connesso alla cartella clinica del paziente; sono state quindi valutate le principali dinamiche che hanno portato all’evento, le lesioni più frequenti, le metodiche di indagine più utilizzate e le concordanze diagnostiche tra queste, la mortalità e le sue principali cause e infine le prognosi di tutti i soggetti trattati. Inoltre è stata condotta, in collaborazione con l’UO. di Anestesia e Rianimazione del Pronto Soccorso dell’AOUP, una sotto-analisi, dei casi trattati in primis dal Pronto Soccorso e secondariamente trasferiti per cure di secondo livello in tale reparto. Di questi pazienti sono stati identifcati il SOFA Score (Sequential Organ Failure Assessment) e SAPS II Score (Simplified Acute Physiology Score). I dati sono stati elaborati in un software statistico da cui sono stati ricavati i risultati dello studio. Risultati: Nel periodo dello studio, sono giunti nel PS dell’AOUP, 363 traumi maggiori. secondo i criteri attribuiti al triage. Di questi ne sono stati selezionati 263, escludendo quindi dallo studio 100 pazienti, dei quali 26 perché pediatrici e 74 perché non rispondenti ai criteri di inclusione cheli identificavano come traumi maggiori. Dei 263 pazienti individuati, 172 erano uomini (65,40%) e 91 erano donne (34,60%). L’età media di tali soggetti era di 44,2 ± 17,83 anni con un range di età tra i 18 agli 87 anni. Le cause di trauma più frequenti sono stati gli incidenti con motoveicoli/biciclette (N= 95; 36,12%), seguiti da incidenti con autoveicoli (N= 88; 33,46%), cadute (N= 39; 14,83%), investimenti (N= 25; 9,51%) e infine altri generi di trauma (N= 7; 2,66%). Le sedi corporee di trauma colpite sono il cranio (N= 138; 52,47%), il torace (N=106; 40,30%), l’addome (N= 64; 24,43%), il bacino (N= 76; 28,90%), la colonna vertebrale (N= 94; 37,74%) e infine gli arti (N= 176; 66,92%). Grazie alla registrazione del Glasgow Coma Scale, della Frequenza respiratoria e della Pressione arteriosa sistolica, è stato calcolato il Revised Trauma Score (RTS) dei pazienti, che era quindi così distribuito: RTS = 12 (N= 237; 90,11%), RTS 11-9 (N= 8; 3,04%), RTS = 5-8 (N= 11; 4,18%) e RTS < 4 (N= 0; 0%). Sono stati individuati i casi in cui sono stati richiesti gli emoderivati (N= 31; 11,79%) e poi utilizzati in PS (N= 5; 16,13%), e I casi in cui è stata richiesta la valutazione angiografica (N= 14; 5,32%), alla quale è stata fatta seguire la procedura di embolizzazione (N= 9; 64,29%). Tra le indagini diagnostiche strumentali quella maggiormente eseguita è stata l’ECOFast, seguita poi dall’Rx Torace, Rx Bacino, dalla TC Cranio, TC Torace, TC Rachide Cervicale, TC Addome, l’RX Rachide cervicale e infine la TC Bacino. A queste, sono state fatte seguire le analisi della concordanza tra indagini diagnostiche diverse, effettuate sullo stesso segmento corporeo e per lo stesso quesito. I dati scaturiti da questo studio sono stati i seguenti: concordanza Rx Cervicale e TC Cervicale scarsa; concordanza Rx e TC per il rilevamento delle Fratture di Coste/ scarsa; concordanza in caso di PNX tra TC e Rx modesta; concordanza per Versamento nel Torace, tra Rx e TC scarsa; concordanza per la presenza di Contusione/Addensamento Polmonare, tra Rx e TC scarsa; concordanza tra EcoFast e TC Addome moderata; concordanza Rx bacino e TC bacino eccellente. In merito all’esito dei pazienti dello studio, sono stati divisi in deceduti in Pronto Soccorso (N= 3; 1,15%), dimessi a domicilio entro 24 h (N= 86; 32,70%), posti in Osservazione Breve Intensiva (OBI) (N= 63; 23,95%), dei quali alcuni sono stati poi dimessi nei giorni successive (N= 55; 87,30%), mentre altri sono stati ricoverati al termine dell’osservazione (N=8; 12,70%), rientrando nel computo dei pazienti ricoverati (N= 119; 45,25%). Dei pazienti ricoverati, è stato poi individuato il raparto di destinazione e dallo studio delle SDO, la prognosi finale, distinta in deceduti (N= 6; 5,04%), in dimessi a domicilio (N= 86; 72,23%), in dimesso presso Residenza Sanitaria Assistita (N= 1; 0,84%), dimessi per dimissione volontaria (N= 1; 0,84%), in trasferiti in un altro ospedale per acuti (N= 18; 15,13%) e infine in trasferiti in un altro ospedale di riabilitazione (N= 7; 5,88%). Dall’analisi statistica dei parametri vitali e indagini di laboratorio, è emerso che risultano significativi nella prognosi di questi pazienti l’Hb, l’età, l’ematocrito e l’aPTT. Non risultano significativi gli altri parametri considerati (GCS e Pressione arteriosa Sistolica (PAs)), sebbene creatininemia e INR abbiano un trend verso la significatività statistica. La principale causa di morte è stata lo Shock Emorragico (N= 5; 55,56%) seguita da morte per Lussazione Atlanto-Occipitale (N= 2; 22,22%), morte per Ematoma Sottodurale Acuto (N= 1; 11,11%) e morte per trauma da schiacciamento (N= 1; 11,11%). Nella sottoanalisi dei pazienti ricoverati in rianimazione, per la bassa numerosità del campione non è stato possibile stimare il peso statistico dei parametri misurati. Conclusioni: I dati confermano che il trauma maggiore rimane una delle principali cause di morte tra i giovani e che la determinante più frequente di tale mortalità è da imputare alle complicanze dell’emorragia scaturito da questo. L’efficienza del Trauma Team pisano sembra collocarsi ai livelli di altri traumi team di II livello con una tendenza ad un miglioramento rispetto a questi centri, specie sui dati sulla mortalità precoce. L’uso di protocolli di trattamento precoce della coagulopatia da trauma potrebbero migliorare ancora la performance del team. Da un punto di vista della gestione dei Traumi a Dinamica Maggiore, dal presente studio, è stato messo in risalto come più della metà dei casi giunti al PS, vengono gestiti e dimessi direttamente dall’UO. Di Medicina d’Urgenza Universitaria e di PS che fanno parte della stessa Unità Operativa Complessa, per un totale di 169 pazienti (64,26%) divisi in 141 (53,61%) gestiti e dimessi dal PS e Osservazione Breve Intensiva e 28 dal reparto di Medicina d’Urgenza Ospedaliera (10,65%). Lo studio inoltre conferma che la diagnostica di I livello non è sufficiente ad escludere con ragionevole sicurezza la presenza di lesioni anche pericolose per la vita e che l’uso della TC rimane necessario ed il gold-standard, sebbene l’implementazione di protocolli ecografici poit-of-care potrà ridurre l’impatto radiologico questi pazienti

Preliminary monitoring of the presence of perfluoroalkyl substances in Italian eggs from different breeding systems

Perfluoroalkylated substances (PFASs) are a wide cluster of fluorinated molecules largely engaged industrially and commercially for many purposes. Because of the strength of the fluorine-carbon bond, PFASs show a firm tenacity against thermal degradation, hydrolysis, photolysis and biodegradation. On the other hand, such chemical stability gives them persistent environmental pollutant feature. In 2012, EFSA published a scientific report on PFASs in food, mentioning their adverse effects on health. Based on observational studies evidences, EFSA has recommended a tolerable daily intake (TDI) for the two most known PFASs, i.e. PFOS 150 ng/kg b.w./day and PFOA 1500 ng/kg b.w./day. The aim of this study was to monitor, for the first time, the level of contamination of PFASs in chicken eggs laid in Northern Italy. The eggs were collected from different rearing systems, in order to search a correlation between this variable and the contamination of PFASs. In this study four PFASs [perfluoro-nnonanoic acid (PFNA), perfluoro-noctanoic- acid (PFOA), sodium perfluoro-1- hexanesulfonate (PFHxS) and sodium perfluoro- 1-octanesulfonate (PFOS)] were analyzed by liquid chromatography-tandem mass spectrometer (LC-MS/MS). 132 eggs were analyzed, split up in 11 groups according to the geographical origin and rearing system. Results accord with literature data available for chicken eggs: almost all the samples show a PFASs contamination level under the limit of quantification (LOQ) of 0.25 ng/mL. No significant difference results from the rearing system, attesting an equal distribution and a concentration of PFASs detectable under the limit of quantification

COVID-19 infection in adult patients with hematological malignancies:a European Hematology Association Survey (EPICOVIDEHA)

Background: Patients with hematological malignancies (HM) are at high risk of mortality from SARS-CoV-2 disease 2019 (COVID-19). A better understanding of risk factors for adverse outcomes may improve clinical management in these patients. We therefore studied baseline characteristics of HM patients developing COVID-19 and analyzed predictors of mortality. Methods: The survey was supported by the Scientific Working Group Infection in Hematology of the European Hematology Association (EHA). Eligible for the analysis were adult patients with HM and laboratory-confirmed COVID-19 observed between March and December 2020. Results: The study sample includes 3801 cases, represented by lymphoproliferative (mainly non-Hodgkin lymphoma n = 1084, myeloma n = 684 and chronic lymphoid leukemia n = 474) and myeloproliferative malignancies (mainly acute myeloid leukemia n = 497 and myelodysplastic syndromes n = 279). Severe/critical COVID-19 was observed in 63.8% of patients (n = 2425). Overall, 2778 (73.1%) of the patients were hospitalized, 689 (18.1%) of whom were admitted to intensive care units (ICUs). Overall, 1185 patients (31.2%) died. The primary cause of death was COVID-19 in 688 patients (58.1%), HM in 173 patients (14.6%), and a combination of both COVID-19 and progressing HM in 155 patients (13.1%). Highest mortality was observed in acute myeloid leukemia (199/497, 40%) and myelodysplastic syndromes (118/279, 42.3%). The mortality rate significantly decreased between the first COVID-19 wave (March–May 2020) and the second wave (October–December 2020) (581/1427, 40.7% vs. 439/1773, 24.8%, p value < 0.0001). In the multivariable analysis, age, active malignancy, chronic cardiac disease, liver disease, renal impairment, smoking history, and ICU stay correlated with mortality. Acute myeloid leukemia was a higher mortality risk than lymphoproliferative diseases. Conclusions: This survey confirms that COVID-19 patients with HM are at high risk of lethal complications. However, improved COVID-19 prevention has reduced mortality despite an increase in the number of reported cases

Phenotypes of adults with congenital heart disease around the globe: a cluster analysis

Objective To derive cluster analysis-based groupings for adults with congenital heart disease (ACHD) when it comes to perceived health, psychological functioning, health behaviours and quality of life (QoL). Methods This study was part of a larger worldwide multicentre study called APPROACH-IS; a cross sectional study which recruited 4028 patients (2013–2015) from 15 participating countries. A hierarchical cluster analysis was performed using Ward's method in order to group patients with similar psychological characteristics, which were defined by taking into consideration the scores of the following tests: Sense Of Coherence, Health Behavior Scale (physical exercise score), Hospital Anxiety Depression Scale, Illness Perception Questionnaire, Satisfaction with Life Scale and the Visual Analogue Scale scores of the EQ-5D perceived health scale and a linear analogue scale (0–100) measuring QoL. Results 3768 patients with complete data were divided into 3 clusters. The first and second clusters represented 89.6% of patients in the analysis who reported a good health perception, QoL, psychological functioning and the greatest amount of exercise. Patients in the third cluster reported substantially lower scores in all PROs. This cluster was characterised by a significantly higher proportion of females, a higher average age the lowest education level, more complex forms of congenital heart disease and more medical comorbidities. Conclusions This study suggests that certain demographic and clinical characteristics may be linked to less favourable health perception, quality of life, psychological functioning, and health behaviours in ACHD. This information may be used to improve psychosocial screening and the timely provision of psychosocial care

Interfacial interaction between cerium oxide and silicon surfaces

Abstract The interaction of cerium oxide films with Si substrates is investigated by means of X-ray photoelectron spectroscopy. Cerium oxide films of different thickness have been grown at room temperature by reactive deposition on different Si surfaces, namely Si(111), Si(100) and thermally oxidized Si(100). We show that cerium oxide and silicon form a silicate phase of subnanometric thickness and that the interfacial phase composition and thickness is similar on the (111) and (100) Si surfaces. The silicate phase formed at the interface contains cerium in the 3+ oxidation state, while silicon presents different oxidation states up to 4+. With a thermal annealing in O2 at 1040K the interface reaction proceeds and the silicate phase evolves in stoichiometry. We demonstrate the stability of the silicate phase towards oxidation after exposure to atomic or molecular oxygen or air. The presence of a thick thermal oxide layer on the Si surface partially limits the extent of the reaction. Highlights ► A subnanometric silicate phase forms at the interface between cerium oxide and Si. ► The silicate phase evolves in thickness and composition after thermal treatments. ► The interfacial reaction has the same extent on the (111) and (100) Si surfaces. ► The interfacial reaction is partially limited by the presence of a silicon oxide. ► The silicate phase is stable towards oxidizing treatments

Perfluoroalkyl contaminants in eggs from backyard chickens reared in Italy

Per- and poly-fluoroalkyl substances (PFASs) are persistent and bioaccumulative compounds with adverse impacts on the environment and human health. Diet is one of the main sources of exposure to PFASs. Recently, the EFSA established a tolerable weekly intake (TWI) limit (4.4ng/kg b.w.) for a mixture of the four major PFASs. Eggs and egg products can contribute to this intake, with their contamination possibly dependent on the husbandry system. Monitoring Italian eggs from backyard chickens revealed a relatively uniform PFAS contamination, with perfluoro-1-octanesulfonate being the most abundant. Contamination was detected to be significantly higher in eggs from backyard chickens than in eggs from commercial laying hens, consistent with a previous Italian study. According to the recently set TWI value, the consumption of eggs from backyard chickens could contribute significantly to dietary intake of PFASs (up to 29% of the TWI in children, considering the lower bound approach)

Nature of Ag Islands and Nanoparticles on the CeO2(111) Surface

Ag nanoparticles have been deposited on stoichiometric and or reduced thin CeO2 films grown on Pt(111). The nucleation and growth of the Ag nanoparticles has been characterized by STM and XPS (X-ray photoemission spectroscopy) measurements complemented with DFT calculations on Ag atoms, clusters, and extended layers deposited on slab models of the CeO2(111) surface. The XPS spectra clearly show a reduction of the ceria support by Ag deposition (formation of Ce3+ ions). This is accompanied by a positive shift of the Ag 3d core levels, in which final state effects related to the finite size of the Ag deposits come into play. The DFT calculations support the view of a direct electron transfer from the Ag clusters and nanoparticles to the ceria support. Other possible origins of the reduction of the ceria substrate, like the occurrence of oxygen reverse spillover on the Ag nanoparticles, are ruled out based on energy considerations

Varying molecular interactions by coverage in supramolecular surface chemistry

The possibility of modifying the intermolecular interactions of absorbed benzene-carboxylic acids from coordination to hydrogen bonding by changing their surface coverage is demonstrated through a combination of scanning tunnelling microscopy, X-ray photoemission spectroscopy and density functional theory calculations

Discrepancy of p16 immunohistochemical expression and HPV RNA in penile cancer. A multiplex in situ hybridization/immunohistochemistry approach study

BACKGROUND: The high-risk human papillomavirus (HPV) infection represents one of the main etiologic pathways of penile carcinogenesis in approximately 30-50% of cases. Several techniques for the detection of HPV are currently available including Polymerase chain reaction-based techniques, DNA and RNA in situ hybridization (ISH), p16 immunohistochemistry (IHC). The multiplex HPV RNA ISH/p16 IHC is a novel technique for the simultaneous detection of HPV E6/E7 transcripts and p16INK4a overexpression on the same slide in a single assay. The main aim of this study was to evaluate the discrepancy of p16 IHC expression relatively to HPV RNA ISH in penile cancer tissue.METHODS: We collected a series of 60 PCs. HPV has been analysed through the RNA ISH, p16 IHC and the multiplex HPV RNA ISH/p16 IHC.RESULTS: The multiplex HPV RNA ISH /p16 IHC results in the series were in complete agreement with the previous results obtained through the classic p16 IHC and HPV RNA scope carried out on two different slides. The multiplex HPV RNA ISH /p16 IHC showed that HPV positivity in our series is more frequently in usual squamous cell carcinoma than in special histotypes (19 out of 60-15%- versus 6 out of 60-10%-), in high-grade than in moderate/low grade carcinomas (6 out of 60-10%- versus 4 out of 60-6.7%-). In addition, our data revealed that in 5 out of 20 cases with p16 high intensity expression is not associated with HPV RNA ISH positivity.CONCLUSIONS: Our findings emphasize that the use of p16 as a surrogate of HPV positivity was unsuccessful in approximatively 8% of cases analysed in our series. Indeed, p16 IHC showed a sensitivity of 100% and a specificity of 71%, with a positive predictive value (PPV) of 54% and a negative predictive value of 100%; when considering high intensity, p16 IHC showed a sensitivity of 100%, a specificity of 89%, with a PPV of 75% and NPV of 100%. Since HPV positivity could represent a relevant prognostic and predictive value, the correct characterization offered by this approach appears to be of paramount importance