Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Studio ultrasonografico muscolare nelle miopatie infiammatorie idiopatiche

Le miopatie infiammatorie idiopatiche, comunemente conosciute con il termine miositi, sono un gruppo eterogeneo di patologie autoimmuni e acquisite che condividono l’infiammazione della muscolatura scheletrica e che si manifestano con debolezza e fatica muscolare progressive. La valutazione della funzione muscolare nelle miositi è certamente un parametro importante da considerare nel monitoraggio di questi pazienti. Nella pratica clinica vengono utilizzati test muscolari manuali standardizzati per la misura della forza muscolare (MMT), dati laboratoristici (dosaggio degli indici di necrosi muscolare) e tecniche di imaging per valutare l’attività di malattia e il danno muscolare. Tradizionalmente la tecnica di imaging più utilizzata per lo studio dell’infiammazione e del danno muscolare è risonanza magnetica che tuttavia è un esame costoso e non sempre facilmente accessibile. L'ecografia è al contrario una tecnica diagnostica priva di controindicazioni, meno costosa e facilmente disponibile, per questi motivi la valutazione ecografica muscolare nei pazienti con miosite ha suscitato notevole interesse negli ultimi anni e recentemente sta avendo le prime applicazioni in ambito clinico. Lo scopo principale di questo lavoro è valutare il ruolo dell'ecografia muscolare nella diagnosi e follow up dei pazienti con miopatia infiammatoria idiopatica miopatia e confrontare i dati dei pazienti con quelli di un gruppo di soggetti sani

Dermatomiosite classica e clinacamente amiopatica: aspetti clinici e sierologici

Negli ultimi due decenni accanto alla dermatomiosite classica è stata riconosciuta dalla letteratura internazionale la dermatomiosite clinicamente amiopatica. Quest'ultima presenta le tipiche lesioni cutanee della dermatomiosite, ma nessuna evidenza clinica di interessamento muscolare. Questo lavoro ha lo scopo di confrontare, da un punto di vista clinico e sierologico, i diversi gruppi di malattia. Lo studio, retrospettivo e monocentrico, è stato effettuato su un totale di 103 pazienti (95 dermatomiosite classica e 8 clinicamente amiopatica),di ognuno sono state studiate le caratteristiche cliniche e sierologiche dall'esordio fino al termine del follow up, evidenziando eventuali analogie o differenze presenti nei due gruppi di pazienti

One year in review: systemic vasculitis

Systemic vasculitis are complex and heterogenous disorders. During the past months great efforts have been made aimed at clarifying disease pathogenesis and at improving patient management and treatment. In this review we summarise the most important scientific contributions on vasculitis pathogenesis, diagnostic tools and treatment published in 2015

The Clinical Efficacy of Radium-223 for Bone Metastasis in Patients with Castration-Resistant Prostate Cancer: An Italian Clinical Experience

Background/Aim: Prostate cancer frequently causes bone metastases and skeletal events that impair quality of life (QoL) and survival. The alpha emitter radium-223 is a new drug that improves treatment in men with castration-resistant prostate cancer (CRPC) and bone metastases. Our aim was to evaluate the effectiveness of radium-223. Subjects and Methods: In this retrospective study we enrolled 48 subjects. Pain reduction, alkaline phosphatase (ALP), time to first symptomatic skeletal event, and QoL were the variables we evaluated. Results: Radium-223 was well tolerated, with a manageable toxicity profile and a modest objective response rate. A considerable difference in serum ALP levels before and after treatment was observed, with a significant correlation between pain relief and QoL, which showed a value of R2 to 0.44 with a slope of 1.50 (p = 0.0021). Conclusions: Radium-223 showed a clinical benefit, with a reduction in pain symptoms in 58% of patients. Radium-223 was shown to be an effective and well-tolerated therapeutic option in patients with metastatic CRPC progressing after docetaxel plus prednisone treatment

Muscular vasculitis confined to lower limbs: description of two case reports and a review of the literature

Muscular involvement is common during systemic vasculitides, such as polyarteritis nodosa. However, in rare cases, muscular involvement can be the only clinically evident feature of the disease. The clinical pattern of isolated muscular vasculitis may mimic several other inflammatory muscle disorders, such as idiopathic inflammatory myositis, and may represent a challenge in differential diagnosis. Herewith, we present two clinical cases as examples of peculiar clinical and histopathological characteristics of isolated muscular vasculitis. Our patients were successfully treated with steroids and immunosuppressive agents. Moreover, we provide a review of the recent existing medical literature. Our cases suggest the importance of performing muscle biopsy in patients with muscular symptoms to guide the diagnosis and the treatment

Can radium 223 be a conservative non-surgical management of medication-related osteonecrosis of the jaw?

Osteonecrosis of the jaw (ONJ) is a rare and severe necrotic bone disease reflecting a compromise in the body's osseous healing mechanisms and unique to the craniofacial region. Radium 223 dichloride (Ra223) is the only targeted alpha therapy able to extend survival in patients with bone metastases from prostate cancer. Mechanism of action and data currently available focused mainly on osteoblastic metastases from prostate cancer. In 2018, a Caucasian 54-year-old woman presented to our institution for a breast cancer with bone metastases. Since the patient refused any treatment and taking into account the bone disease, our multidisciplinary team evaluated a supplementary strategy with radium 223. A total of six treatments were planned with a dose of 50 KBq/kg every 4 weeks according to Phase 2 data. Four days after the second cycle administration, the patient presented for examination with a self-extracted necrotic bone fragment. Oroantral communication remained in the absence of algic symptomatology or suppuration. The multidisciplinary approach between oncologists, nuclear physicians, and dental health teams is crucial throughout the treatment process to avoid unnecessary suffering in patients at risk. More prospective studies are needed; however, considering the limitation of the present case, radio 223 may play an adjuvant role in the medical treatment of cancer patients with active ONJ

Hematologic toxicity of radium-223 in elderly patients with metastatic Castration Resistant Prostate Cancer: a real-life experience

Background: Treatment with radium-223 has been shown to increase survival and to delay skeletal events related to bone metastases of patients with metastatic Castration Resistant Prostate Cancer (mCRPC). This treatment has also proved to be well tolerated, and hematological toxicity, in particular anemia, represents the most represented adverse event. Materials and methods: We evaluated the hematologic toxicity of Ra-223 treatment in a real-life experience of 38 patients from two Italian cancer centers, with bone metastases from mCRPC. The main endpoint of the study was the evaluation of the efficacy and tolerability of treatment with radium-223, with greater reference to hematological toxicity (especially anemia) as the cause of interruption of treatment, specifically in the elderly patient. Results: From August 2016 to October 2017, a total of 38 consecutive nonselected patients, 20 of them aged >75 years, with mCRPC symptomatic bone metastases, were enrolled for radium-223 at standard doses. Hematologic adverse events were recorded more frequently (72.4% with AE), and 36.8% had anemia. The most frequent cause of treatment discontinuation due to AEs was anemia [8/10 patients (80%)], followed by thrombocytopenia (2 patients) and neutropenia (1 patient). Hematologic AEs were more represented in elderly patients with greater disease burden and previously treated with docetaxel. Conclusions: Anemia is the most represented AE related to radium-223 treatment in elderly patients with greater disease burden and previously treated with docetaxel, besides representing the main reason for interruption of treatment. Correct patient selection, appropriate timing, and adequate supportive care are elements that could facilitate successful treatment with radium-223, preventing premature interruption of the same. The results of this experience support the opportunity to propose treatment with radium-223 mostly in patients in the earliest stages. Keywords: Cancer, Older, Prostate, Ra-223, Toxicit