32 research outputs found
Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases
Background: In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine. Methods: Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published. Results: The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm. Conclusions: We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research
Sindrome di Ehlers-Danlos: un raro caso di ischemia intestinale e renale
Caso clinico:Un uomo di 52 anni giunge alla nostra osservazioneper dolore epigastrico irradiato ai fianchi ed alvo chiuso a feci egas da alcuni giorni; ipertrofia prostatica all\u2019anamnesi patologicaremota. Obiettivamente addome trattabile, non dolorabile,peristalsi vivace; PA 180/100 mmhg. Gli esami ematochimicimostravano leucocitosi neutrofila (WBC 17,95), incremento ditroponina I (0,108 ng/ml), D-dimero 1207 (ng/ml), LDH (513U/l), CPK (1102 U/l), AST (96 U/l) e ALT (120 U/l) ed elevatiindici biologici di flogosi (PCR 18,9 mg/dl). La TC addomeevidenziava ectasie, dissezione e microaneurismi di tronco celiaco,aa mesenteriche, arcata pancreatico-duodenale ed ileocolica consegni di ischemia intestinale diffusa e lesioni infartuali renalibilaterali per dissezione di vari tratti delle arterie renali. Presenteinoltre dissezione dell\u2019arteria carotide interna destra extracranicaalla TC vasi epicranici. Negativa risultava la sierologia immunitaria;la ricerca genetica per malattia del collagene confermava ladiagnosi di sindrome di Ehlers-Danlos di tipo IV. Il paziente \ue8 stato trattato con eparina ev, antiipertensivi ev con buona rispostaclinica e laboratoristica. Dimesso e seguito in regimeambulatoriale con discrete condizioni cliniche, decedevaimprovvisamente a sette mesi dalla diagnosiConclusioni:La S. di Ehlers-Danlos \ue8 una malattia ereditariadovuta ad alterazioni del collagene e del tessuto connettivo conquadri clinici eterogenei. La forma vascolare (tipo IV) \ue8 la pi\uf9 gravepotendo determinare rottura di grossi vasi e perforazioni visceralifino all\u2019exitus
CHA2DS2-VASC and HAS-BLED scores in the prediction of NVAF-related events in a population of critically ill patients
Background: non-valvular atrial fibrillation (NVAF) is the most common
arrhythmia in clinical practice. Its risk increases with age and the presence
of comorbidities. NVAF-related morbility is associated to thromboembolic
events and, among patients undergoing to anticoagulant therapy, to haemorrhagic
complications. Guidelines suggest stratifying the thrombotic risk
with CHA2DS2-VASc score and the haemorrhagic risk with HAS-BLED
score before initiating any anticoagulant treatment. These two scores share
several items, and it is common to observe patients with both an increased
thrombotic and haemorrhagic risk. This area represents a \u201cgrey zone\u201d where
guidelines are not able to suggest any evidence-based approach.
Patients and Methods: we enrolled 519 consecutive, critically-ill subjects
affected by permanent NVAF admitted to our Subintensive Medicine
department. CHA2DS2-VASc score and HAS-BLED score were calculated
at admission. For each patient, we evaluated age, sex, admission diagnosis,
comorbidities, thromboembolic and haemorrhagic events.
Results: mean age was 75.61(\ub111.92) years; males represented 50.3% of the
sample; patients had a median of 2(0-6) comorbidities. We observed 38 haemorrhagic
events and 80 thromboembolic events; HAS-BLED had a median
of 2(0-5), CHA2-DS2-VASc score had a median of 3(0-6); CHA2DS2-VASc
had an AUC of 0.56;95%CI:0.50-0:63(p=0.06); HAS-BLED had an AUC of
0.53;95%CI:0.44-0:62(p=0.53). Discussion: in this population of elderly patients admitted for critical
illnesses, CHA2DS2-VASc and HAS-BLED scores have a limited predictive
value for both thromboembolic and haemorrhagic events. Newer approaches
based on machine learning and topological data analysis could better
discriminate the risk factors of NVAF-related complications and give a more
reliable prediction of thrombotic or haemorrhagic events
The role of procalcitonin in emergency medicine
evaluate
its efficacy. Informations regarding the diagnostic and prognostic role
of PCT in the critically ill subject are lacking. Aim of this study was to evaluate
the value of PCT in the diagnosis of bacterial infections and its prognostic
weight in the unstable patient.
Methods: we enrolled 1063 consecutive, critically ill subjects admitted to
our Internal Subintensive Medicine Department in the period 2008-2010,
evaluating age, sex, haemodynamic parameters, blood exams, PCT and
blood cultures. In particular we collected the absolute number of peripheral
white blood cells, troponin I (TnI) and serum creatinine. Among hemodynamic
parameters, we evaluated the presence of shock (defined as systolic
blood pressure < 90 mmHg, low urine output, < 0.5 ml/kg/h and reduced cutaneous perfusion). The degree of severity of the pathology was assessed
with the SAPS-II score. We\u2019ve set as outcomes mortality or intensive therapy
transfer, overall survival and length of hospital admission.
Results: We observed positive cultures in 375 subjects, whose mean PCT
levels were significantly higher than in patients without positive cultures
(0,84 ng/ml versus 0,20 ng/ml; p<0,0001). ROC curve analysis, however,
underlined a sub-optimal role of PCT in predicting bacterial isolation
(AUC:0,58;95% CI: 0,54-0,62). 172 patients died, and their mean PCT
values were significantly higher than survivors (2,62 ng/ml versus 0,17 ng/
ml; p<0,05). Calculating an optimal cutoff of 0,50 ng/ml, mean time without
events among subjects with lower PCT was 44 days compared with 26 days
observed in patient with high PCT. The prognostic weight of PCT was superior
than TnI, and PCT was correlated with prognosis independently from
bacterial infection. A model including SAPS2, troponin I and PCT had a
good AUC (0,734; 95%CI: 0,667-0,775) in predicting in-hospital events,
such as death or transfer to intensive-care unit.
Discussion: Procalcitonin is now a widely used marker of bacterial infection,
despite several papers confirmed its low diagnostic yeld. In our population,
we confirmed this observation by showing a low correlation between increased
PCT and positive bacterial isolates (blood, sputum or urine cultures).
However, an increased PCT value was associated, independently from the
presence of sepsis or infection, to an increased rate of adverse events and a
lower event-free survival. When combined in a model including clinical and
serologic markers of severity, such as SAPS2 and troponin I, PCT showed
a good prognostic value for in-hospital death or complications by increasing
the AUC of the model. This derived model was able to predict adverse
event in all the critically ill patients enrolled, independently from the cause
of admission.
Conclusion: Among critically ill patients PCT has a low diagnostic yeld,
with a poor predictive value for positive bacterial cultures. PCT, however,
maintains a good prognostic significance in predicting both event-free
survival and adverse events during the hospitalization. In particular, PCT
increases the prognostic value of commonly used scores, such as SAPS2,
and well-recognised prognostic markers, as troponin I. A model including
SAPS2, troponin I and PCT is highly predictive for in-hospital adverse
events among critically ill patients, and could be used to predict the risk
of in-hospital mortality and the probability of transfer to intensive therapy
unit
CHA2DS2-VASc and HAS-BLED scores do not predict NVAF-related events in a population of critically ill patients
Background: Non-valvular atrial fibrillation(NVAF) is commonamong critically-ill subjects and is associated to worseoutcomes.NVAF-related morbility is associated to thromboembolicand haemorragic complications.Guidelines suggest stratifying thethrombotic risk with CHA2DS2-VASc and the haemorrhagic risk withHAS-BLED. These scores are not validated for the critically-ill, andguidelines are not able to suggest any evidence-based approach.Patients and Methods: Single-cohort, perspective study enrollingall the consecutive patients admitted to our department for a crit-ical illness and affected by NVAF. We excluded patients admittedfor trauma or surgical pathologies. Embolic outcome(TE) was de-fined as the occurrence of embolic manifestations at the admis-sion or during the hospitalization. Haemorragic outcome(MH) wasdefined as the occurrence of major haemorrhage according toISTH criteria during the hospitalization or at the 12-months follow-up. For each patient, we evaluated age, sex, admission diagnosis,comorbidities, CHA2DS2-VASc, HAS-BLED, TE and MH. Results: 519 subjects[age:75.6(\ub111.9);males:50.3%;comorbidi-ties:2(0-6)].38 MH(7,3%),80 TE(15,4%).HAS-BLED: median of2(0-5),CHA2-DS2-VASc:median of 3(0-6);among MH, HAS-BLED:median of 3(1-4), CHA2-DS2-VASc:median of 2(1-3);amongTE,HAS-BLED: median of 2(1-3), CHA2-DS2-VASc:median of 3(1-4);CHA2DS2-VASc had an AUC of 0.56[95%CI:0.50-0:63(p=0.06)] for TE;HAS-BLED had an AUC of 0.53 [95%CI:0.44-0:62(p=0.53)] for MH. Discussion: In this population, CHA2DS2-VASc and HAS-BLEDhad limited predictive value for TE and MH
Thalidomide-dexamethasone plus pegylated liposomal doxorubicin vs. thalidomide-dexamethasone: a case-matched study in advanced multiple myeloma
A case of fever in emergency medicine: the importance of clinical evaluation
A 38-years-old woman was referred to our subintensive medicine department
for persistent fever associated to epigastric pain, nausea and vomiting.
At the arrival, blood exams showed severe pancytopenia and increase of
AST. Her clinical history did not reveal any significant associated pathology,
but she complained of a recent history of three months of persistent
fever, relapsing despite different antibiotic treatments and oral steroid treatment
given by her general practitioner. Physical examination showed a
marked increase of haepatic and splenic volume, signs of bilateral pleural
effusion and the presence of continuous fever. Our first diagnostic hypotheses
ranged between a subacute viral infection to a severe haematologic
disorder. In the second day, blood examinations showed EBV-DNA positivity.
Serum antibodies were not suggestive for autoimmunity. Despite
this finding, we also observed markedly increased ferritin (> 500 ng/ml)
and trygliceride levels (> 1000 mg/dl), a positive beta2-microglobilin and
a markedly reduced serum haptoglobin and fibrinogen levels. A total body
CT-scan showed diffuse lymphadenopathy and confirmed the bilateral
pleural effusion and the marked hepato-splenomegaly observed clinically
at the admission. For this reason, we proceeded with a peripheral blood cell
immunophenotypization, which resulted suggestive for a chronic lymphoproliferative
T-cell disorder. At this point, we felt confident in restricting our
diagnostic hypotheses: particularly, the presence of a markedly increased
serum ferritin and trygliceride levels and hypofibrinogenemia were strongly
suggestive for lymphoma-associated haemophagocytic syndrome. For this
reason, we evaluated serum IL-6 levels, which resulted markedly raised, and
performed a bone marrow biopsy, showing "aspects of haemophagocytosis
in perypheral T-cell lymphoma", confirming the diagnosis of haemophagocytic
syndrome complicating a T-cell lymphoma. We started immediately
both specific and supportive therapy for haemophagocytic syndrome, starting
with high-dose metilprednisolone (1000 mg/die) and continuous haemodiafiltration
to reduce rapidly serum cytokine levels. However, after an
initial improvement in her clinical conditions, in the fifth day she developed
acute respiratory failure and was urgently transferred to the intensive care
unit, where she died the day after for multi-organ failure. Haemophagocytic
lymphoistiocytosis, or haemofagocytic syndrome, is a rare group of pathologies
commonly associated to several conditions, ranging from infections
to autoimmunity and malignancies, characterized by a poor prognosis.
Early recognition and aggressive treatment of this syndrome are essential
to increase the survival probabilities, which still remain very low despite
optimal medical treatment