Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Bezold\u2019s abscess secondary to os tympanicum cholesteatoma in Goldenhar syndrome

OBJECTIVES: The diagnosis of Bezold’s abscess can be challenging especially when craniofacial malformations imply facial and cervical morphological asymmetries. In addition, craniofacial malformations might predispose to the occurrence and atypical diffusion pathways of suppurative processes originating from abnormally developed temporal bone structures. METHODS: A 30-year-old female presented with a left laterocervical swelling, worsening over time. The female was affected by Goldenhar syndrome. CT and MRI were performed. RESULTS: CT revealed a dysmorphic os tympanicum and a deep cervical abscess in continuity with its cavity. Drainage of the cervical abscess was performed but a subsequent brain MRI detected a large cholesteatoma that was removed with left lateral petrosectomy. CONCLUSIONS: Radiology has a crucial role in the diagnosis and planning of the treatment of Bezold’s abscesses, particularly in syndromic patients. MRI, in this case, helped in diagnosing the presence of the cholesteatoma and consequently appropriately approach the surgical removal

Epidemiologic, Imaging, and Clinical Issues in Bezold’s Abscess: A Systematic Review

Bezold’s abscess is a deep neck abscess related to otomastoiditis. Due to the insidious clinical presentation, diagnosis can be extremely challenging, leading to delays in treatment and possible life-threatening complications. The literature currently provides a fragmented picture, presenting only single or small number of cases. The present study aims at examining our experience and the literature findings (based on PRISMA criteria) of 97 patients with Bezold’s abscess, summarizing their epidemiology, pathogenesis, clinical presentation, imaging findings, and treatments. Bezold’s abscess is found at any age, with overt male prevalence among adults. The clinical presentation, as well as the causative pathogens, are strikingly heterogeneous. Otomastoiditis and cholesteatoma are major risk factors. A clinical history of otitis is commonly reported (43%). CT and MRI are the main diagnostic tools, proving the erosion of the mastoid tip in 53% of patients and the presence of a concomitant cholesteatoma in 40%. Intracranial vascular (24%) or infectious (9%) complications have also been reported. Diagnosis might be easily achieved when imaging (CT) is properly applied. MRI has a limited diagnostic role, but it might be crucial whenever intracranial complications or the coexistence of cholesteatoma are suspected, helping to develop proper treatment (prompt antibiotic therapy and surgery)

Epidemiologic, Imaging, and Clinical Issues in Bezold’s Abscess: A Systematic Review

Bezold’s abscess is a deep neck abscess related to otomastoiditis. Due to the insidious clinical presentation, diagnosis can be extremely challenging, leading to delays in treatment and possible life-threatening complications. The literature currently provides a fragmented picture, presenting only single or small number of cases. The present study aims at examining our experience and the literature findings (based on PRISMA criteria) of 97 patients with Bezold’s abscess, summarizing their epidemiology, pathogenesis, clinical presentation, imaging findings, and treatments. Bezold’s abscess is found at any age, with overt male prevalence among adults. The clinical presentation, as well as the causative pathogens, are strikingly heterogeneous. Otomastoiditis and cholesteatoma are major risk factors. A clinical history of otitis is commonly reported (43%). CT and MRI are the main diagnostic tools, proving the erosion of the mastoid tip in 53% of patients and the presence of a concomitant cholesteatoma in 40%. Intracranial vascular (24%) or infectious (9%) complications have also been reported. Diagnosis might be easily achieved when imaging (CT) is properly applied. MRI has a limited diagnostic role, but it might be crucial whenever intracranial complications or the coexistence of cholesteatoma are suspected, helping to develop proper treatment (prompt antibiotic therapy and surgery)

[Kidney Transplant from donors after cardiac death (DCD): monocentric experience and literature review]

Il trapianto di rene da donatore dopo morte cardiaca (DCD) rappresenta una valida opzione per incrementare il numero di organi disponibili, mantenendo standard di sopravvivenza e di funzionalit\ue0 del graft sovrapponibili ai trapianti da donatore per morte cerebrale (DBD). Il Centro di Riferimento Trapianti dell\u2019Emilia Romagna ha attivato un programma di donazione da DCD a partire da Gennaio 2016. Il presente studio \ue8 stato condotto con lo scopo di analizzare la casistica dei trapianti di rene eseguiti nei primi 30 mesi di attivit\ue0 del programma, confrontando gli outcome dei DCD con quelli dei trapianti da donatore DBD eseguiti nello stesso periodo. Sono stati inoltre indagati eventuali fattori prognostici predittivi di funzionalit\ue0 renale. Nel periodo esaminato sono stati eseguiti 16 trapianti di rene da 10 donatori DCD (5 SCD-DCD e 5 ECD-DCD). Non sono state osservate Primary Non Function(PNF). Sono state osservate 2 graft loss entro 12 mesi, entrambe conseguenti a transplantectomia per rottura dell\u2019arteria renale in corso di complicanza infettiva. Due pazienti sono deceduti in seguito a tali complicanze infettive. La DGF ha avuto un\u2019incidenza del 44%. In termini di funzionalit\ue0 del trapianto non sono state osservate differenze nei valori di creatininemia ed eGFR alla dimissione, a 12 ed a 24 mesi rispetto ai DBD. Le caratteristiche di marginalit\ue0 del donatore (ECD-DCD o KDPI >65%) correlavano con una pi\uf9 elevata incidenza di DGF e valori di funzione renale peggiori alla dimissione. Nessuno dei fattori analizzati, tra cui lo Score di Karpinsky, ha mostrato correlazione con i valori di creatiniemia e filtrato glomerulare a 12 e 24 mesi.Kidney transplant from donor after circulatory death (DCD) represents a valid choice to increase the incidence of renal transplantation, presenting recipients' and grafts' survival rates comparable to those from brain dead donors (DBD). In January 2016, the Transplant Referral Center in the Emilia Romagna region has started a DCD program. In the present study we report on the first 30 months of the program as far as our own Center in Bologna is concerned, and we provide a comparison with DBD transplants performed over the same period. From January 2016 to September 2018, 16 kidney transplants from 10 DCD donors (5 SCD-DCD and 5 ECD-DCD) have been performed, with two graft-loss at 12 months of follow-up, both due to renal artery rupture caused by infectious arteritis with consequent transplantectomy. Two patients died due to sepsis. Seven (44%) delay graft function (DGF) have been reported. No differences have been found between DCD and DBD in terms of kidney function (serum creatinine and eGFR evaluated at discharge, 12 and 24 months of follow-up). Kidney from marginal donors (ECD-DCD or KDPI >65%) were associated with a higher rate of DGF and worst graft function at discharge. All the predicting factors that have been analysed, including Karpinsky Score, failed to show an association with serum creatinine and eGFR at 12 and 24 months of follow up

Challenges and Opportunities of Mass Vaccination Centers in COVID-19 Times:A Rapid Review of Literature

A mass vaccination center is a location, normally used for nonhealthcare activities, set up for high-volume and high-speed vaccinations during infectious disease emergencies. The high contagiousness and mortality of COVID-19 and the complete lack of population immunity posed an extraordinary threat for global health. The aim of our research was to collect and review previous experiences on mass vaccination centers. On 4 April 2021, we developed a rapid review searching four electronic databases: PubMed/Medline, Scopus, EMBASE, Google Scholar and medRxiv. From a total of 2312 papers, 15 of them were included in the current review. Among them, only one article described a COVID-19 vaccination center; all of the others referred to other vaccinations, in particular influenza. The majority were conducted in the United States, and were simulations or single-day experiences to practice a mass vaccination after bioterrorist attacks. Indeed, all of them were published after September 11 attacks. Regarding staff, timing and performance, the data were highly heterogenous. Several studies used as a model the Center for Disease Control and Prevention guidelines. Results highlighted the differences around the definition, layout and management of a mass vaccination center, but some aspects can be considered as a core aspect. In light of this, we suggested a potential definition. The current review answers to the urgency of organizing a mass vaccination center during the COVID-19 pandemic, highlighting the most important organizational aspects that should be considered in the planning

COVID-19 vaccination surveillance: a public health commitment

none9noopenGiacomo Pietro Vigezzi , Vincenza Gianfredi , Alessandra Lume , Massimo Minerva , Paola Nizzero , Anna Biancardi , Anna Odone , Carlo Signorelli , Matteo MoroVigezzi, GIACOMO PIETRO; Gianfredi, Vincenza; Lume, Alessandra; Minerva, Massimo; Nizzero, Paola; Biancardi, Anna; Odone, Anna; Signorelli, Carlo; Moro, Matte