Prevalence and Epidemiological and Clinical Features of Bacterial Infections in a Large Cohort of Patients Hospitalized for COVID-19 in Southern Italy: A Multicenter Study

BACKGROUND

The aim of this study was to evaluate the prevalence of bacterial infections and antimicrobial prescriptions in a large cohort of COVID-19 patients and to identify the independent predictors of infection and antibiotic prescription.

METHODS

All consecutive patients hospitalized for COVID-19 from March 2020 to May 2021 at 1 of the 17 centers participating in the study were included. All subjects showing a clinical presentation consistent with a bacterial infection with microbiological confirmation (documented infection), and/or a procalcitonin value >1 ng/mL (suspected infection) were considered as having a coinfection (if present at admission) or a superinfection (if acquired after at least 48 h of hospital stay).

RESULTS

During the study period, of the 1993 patients, 42 (2.1%) presented with a microbiologically documented infection, including 17 coinfections and 25 superinfections, and 267 (13.2%) a suspected infection. A total of 478 subjects (24.5%) received an antibacterial treatment other than macrolides. No independent predictors of confirmed or suspected bacterial infection were identified. On the contrary, being hospitalized during the second wave of the pandemic (OR 1.35, 95% CI 1.18-1.97, p = 0.001), having a SOFA score ≥3 (OR 2.05, 95% CI 1.53-2.75, p < 0.001), a severe or critical disease (OR 1.66, 95% CI 1.24-2.23, p < 0.001), and a high white blood cell count (OR 1.03, 95% CI 1.004-1.06, p = 0.023) were all independently related to having received an antimicrobial prescription.

CONCLUSIONS

Our study reported a high rate of antimicrobial prescriptions despite a limited number of documented or suspected bacterial infections among the large cohort of hospitalized COVID-19 patients.

IPOM plus versus IPOM standard in incisional hernia repair: results of a prospective multicenter trial

PURPOSE

Laparoscopic ventral hernia repair is a well-established technique with satisfying outcomes even at long term for the treatment of incisional and ventral hernia. However, the literature debate is still ongoing regarding the preferred surgical technique. Nowadays, two approaches are commonly adopted: the intraperitoneal onlay mesh repair (sIPOM) and the intraperitoneal onlay mesh reinforcement with defect closure before mesh placement (pIPOM). The aim of this prospective analysis is to compare the postoperative outcomes of patients treated for incisional hernia (IH) with sIPOM and pIPOM after 36 months follow-up in terms of recurrence, quality of life and wound events.

METHODS

Patients receiving pIPOM and sIPOM for IH were actively followed up for 36 months. At the outpatient clinic, hernia recurrence (HR), mesh bulging (MB), quality of life with the Gastrointestinal Quality of Life Index (GIQLI) and wound events were assessed.

RESULTS

Between January 2015 and January 2019, 98 patients underwent a pIPOM and 89 underwent an sIPOM. At 36 months, nine patients (4 in pIPOM and 5 in sIPOM) experienced an HR, while MB was recorded in four patients in pIPOM and nine in sIPOM. No statistically significant difference could be identified also in terms of final GIQLI score and wound events.

CONCLUSIONS

LVHR with or without fascial closure, also in our study, provides satisfactory results in terms of safety and efficacy. The discordant results in the literature are probably related to independent variables such as the type of mesh, the type of suture and closure technique. Therefore, was the funeral of sIPOM done too early? STUDY DATASET IS AVAILABLE ON CLINICALTRIALS.

GOV ID

NCT05712213.

Is absorbable mesh useful in preventing parastomal hernia after emergency surgery? The PARTHENOPE study

PURPOSE

Colostomy is a frequent event in oncological or inflammatory bowel diseases. Its related morbidity includes retraction, infection and parastomal hernia (PH), which is a quite common late complication. Several surgical options are available for PH repair, the majority including mesh. However, results are often disappointing with relevant recurrence rates, up to 33%. The study aim was to assess the feasibility and effectiveness of prophylactic biosynthetic mesh (BIO-A^®, polyglycolide-trimethylene carbonate copolymer) placed during colostomy fashioning, in reducing PH. A prospective randomized controlled double-blind trial was conducted from January 2014 to December 2019 to compare conventional end-colostomy with end-colostomy reinforced with BIO-A mesh in ante-rectus position in patients undergoing colon diversion in emergency surgery.

METHODS

Patients were clinically followed up at 3, 6, and 12 months and received a CT scan at 6 and 12 months. The postoperative morbidity and wound events were also evaluated.

RESULTS

55 patients receiving conventional colostomy considered as Control Group and 55 patients receiving BIO-A mesh supported colostomy (Mesh Group) were included in the study. At 12 months, the incidence of PH was 9 (12.7%) and 24 (43.6%) in the Mesh Group and Control Group, respectively (p < 0.05). Postoperative morbidity was similar between Mesh Group and Control Group (7 [12.7%] vs 4 [7.3%], respectively; p = 0.340). The multivariable analysis showed that not using a mesh (p = 0.042), age > 70 years (p = 0.041), diabetes (p < 0.001), colon dilation > 7 cm (p < 0.0001) and COPD (p = 0.009) were all related with postoperative PH.

CONCLUSIONS

The prophylactic BIO-A mesh positioning during colostomy is an effective procedure reducing PH incidence at a 1 years follow-up guaranteeing low postoperative morbidity. STUDY DATASET IS AVAILABLE ON CLINICALTRIALS.

GOV ID

NCT04436887.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

BACKGROUND

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined.

METHODS

This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations.

RESULTS

From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P  < 0.001). One patient in the mesh group required mesh removal because of deep infection.

CONCLUSION

Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

GRAPHICAL ABSTRACT

An RCT was conducted to compare the widely recommended midline laparotomy closure using a slowly absorbable running suture with closure using a sublay mesh (Parietex ProGrip™), in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Patients were followed up for 24 months with clinical and ultrasonographic evaluation during outpatient visits. Prophylactic reinforcement of the midline abdominal wall, using a ProGrip™ Parietex mesh in the retromuscular position, at the time of urgent laparotomy in clean-contaminated wounds was safe and effective in reducing the incidence of incisional hernia, although larger studies with longer follow-up are required.

Biliopancreatic Limb Length in One Anastomosis Gastric Bypass: Which Is the Best?

BACKGROUND

The use of one anastomosis gastric bypass (OAGB) is rapidly spreading. Concerns about biliary reflux and malabsorption with consequent nutritional deficits exist, so studies on biliopancreatic limb (BPL) adequate length in OAGB are required to balance excess weight loss in percentage (% EWL), resolution of comorbidities, and nutritional deficit. The purpose was to evaluate, at 2 years after OAGB, the effects of BPL length on weight loss, resolution of comorbidity, and nutritional deficiencies in patients.

METHODS

From January 2015 to January 2017, 180 patients were collected into three groups based BPL length: group A, 150 cm; group B, 180 cm; and group C, 200 cm. Aims were to compare %EWL, co-morbidity resolution rates, nutritional parameters, and morbidity/mortality in the three groups.

RESULTS

The total number of patients was 180: 60 for each group. One hundred seventy-two (95%) patients attended the 1-year follow-up (group A = 58; group B = 58, group C = 56). One hundred fifty-seven (87%) patients attended the 2-year follow-up (group A = 52 (87%); group B = 53 (88%); group C = 52 (87%)). There was no statistically significant difference in %EWL, %TWL, T2DM, and hypertension resolution rates among the groups. About vitamin deficiency, differences were not statistically significant. Iron and ferritin deficiency rate were statistically significant only between A and C groups.

CONCLUSIONS

According to our evidence, standardization of BPL length shorter than 200 cm is suggested, potentially minimizing malnutrition-related outcomes. Our study seems to show that a BPL of 150-180 cm is safe and effective in terms of EWL and comorbidity improvement with low malnutrition effects even in BMI > 50.

Dysregulation of lipid metabolism and pathological inflammation in patients with COVID-19

In recent months, Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread throughout the world. COVID-19 patients show mild, moderate or severe symptoms with the latter ones requiring access to specialized intensive care. SARS-CoV-2 infections, pathogenesis and progression have not been clearly elucidated yet, thus forcing the development of many complementary approaches to identify candidate cellular pathways involved in disease progression. Host lipids play a critical role in the virus life, being the double-membrane vesicles a key factor in coronavirus replication. Moreover, lipid biogenesis pathways affect receptor-mediated virus entry at the endosomal cell surface and modulate virus propagation. In this study, targeted lipidomic analysis coupled with proinflammatory cytokines and alarmins measurement were carried out in serum of COVID-19 patients characterized by different severity degree. Serum IL-26, a cytokine involved in IL-17 pathway, TSLP and adiponectin were measured and correlated to lipid COVID-19 patient profiles. These results could be important for the classification of the COVID-19 disease and the identification of therapeutic targets.

Postoperative Clinical-Endoscopic Follow-up for GERD and Gastritis After One Anastomosis Gastric Bypass for Morbid Obesity: How, When, and Why

INTRODUCTION

The one anastomosis gastric bypass (OAGB) is a widely diffused surgical procedure for morbid obesity. Several studies considered OAGB at risk for biliary reflux and anastomotic ulcers. The aim of the study was to evaluate gastro-esophageal reflux disease (GERD) and esophagitis/gastritis rate after OAGB diagnosed by upper endoscopy (UE), comparing the results with GERD-Health-Related Quality of Life (HRQL) score.

METHODS

From July 2014 to February 2019, patients underwent OAGB with at least 12-month follow-up were retrospectively evaluated. Clinical evaluation was associated with GERD-HRQL scoring. UE with a mucosal biopsy was also performed. A comparison among clinical scores and endoscopic findings was performed.

RESULTS

Two hundred forty-one patients were analyzed in the study. Anthropometric features (BMI, %Excess weight loss, %Total weight loss) were significantly improved. Only 30% of patients with GERD-HQRL>30 showed esophagitis at UE: 11/181 (6.1%) showed grade A erosive esophagitis, 2/181 (1.1%) grade B esophagitis, whereas no patient resulted in grade C/D. Fifty-two patients (28.7%) showed endoscopic remnant gastritis of at least grade 1, with histological gastritis of at least mild grade in 70/181 patients (38.7%).

CONCLUSION

OAGB is a feasible and effective procedure in terms of weight reduction and comorbidities control, but controversies remain about the long-term onset of GERD and bile reflux. The incidence of esophagitis was increased after OAGB. However, the severity and incidence were lower compared to sleeve gastrectomy. Conversely, the incidence of gastritis, ileo-gastric anastomotic inflammation, and HP positivity were not negligible, suggesting the potential benefits of endoscopic surveillance after OAGB.

Primary Malignant Fibrous Histiocytoma of Storiform-Pleomorphic Type: A Case Report of an Ano-Rectal Localization

Among the various localizations of primary malignant histiocytoma, the ano-rectal one is exceedingly rare. In this paper we report a case characterized by a storiform-pleomorphic pattern of the tumor and a rapid fatal course of the disease with metastasis in the lungs. The prognostic value of the histologic features is briefly discussed.

Hepatitis A virus strains circulating during 1997-2015 in Campania, a Southern Italy region with periodic outbreaks

In Italy, the incidence of hepatitis A has progressively declined over the last 30 years, though not homogeneously throughout the country. In Campania, Southern Italy, high annual incidence rates have been reported and several periodic outbreaks have occurred. To investigate the phylogenetic and epidemiologic relationships among HAV strains circulating in Campania over the period 1997-2015, 87 hepatitis A cases were investigated. The most frequent risk factor was the consumption of raw/undercooked shellfish (75/87, 86.2%). During 1997-2002 most viral strains were subtype IA (16/23, 70%); the phylogenetic pattern suggests that the incidence peaks observed in 2000-2001 had likely been caused by multiple strains. During a large 2004 outbreak, almost all viral variants were subtype IB (38/41, 93%); most of them (22/38, 58%) were recognized to be one of two main strains (differing for just a single nucleotide), the remaining sequences were strictly related variants. In 2014/2015, only IA strains were observed; two phylogenetically related but distinct strains were responsible, respectively, for a small cluster in 2014 and an outbreak in 2015. In each outbreak, several strains unrelated to those responsible for most cases were detected in a minority of patients, documenting a background of sporadic cases occurring even in the course of outbreaks; some of them proved to be identical to strains detected 11-14 years previously. Overall, the data suggest that several related and unrelated HAV strains have endemically circulated over the last 15 years in Campania, with some strains gaining epidemic transmission likely because of a local combination of multiple factors, including inadequate waste water purification and dietary habits.

The current spectrum and prevalence of intestinal parasitosis in Campania (region of southern Italy) and their relationship with migration from endemic countries

BACKGROUND

In Italy, the current clinical-epidemiological features of intestinal parasitosis and the impact of recent massive migration flows from endemic areas on their distribution are not very well known.

METHODS

An analysis was carried out involving 1766 patients (720 natives and 1046 immigrants) observed during the period 2009-2010 (the 'current group') and 771 native patients observed during the period 1996-1997 (the 'historical group'), a time at which immigration in the area was minimal. Patients were analyzed for intestinal parasitosis at four healthcare centres in Campania.

RESULTS

A wide variety of intestinal parasites was detected in the study subjects. Immigrants had a significantly higher prevalence of parasitosis and multiple simultaneous infections than natives in both groups. In both study groups of natives, the detection of at least one parasite was significantly associated with a history of travel to endemic areas. Among immigrants, we found an inverse correlation between the frequency of parasite detection and the amount of time spent in Italy. No circulation of parasites was found among contacts of parasitized patients.

CONCLUSIONS

Intestinal parasites are still a cause of intestinal infection in Campania. Although immigrants have a significantly higher prevalence of parasitosis than natives, this does not increase the risk of infection for that population. This is likely due to the lack of suitable biological conditions in our area.

Clinical case of seroconversion for syphilis following a needlestick injury: why not take a prophylaxis?

A 47-year-old woman was pricked accidentally with a needle previously used for a neurosyphilitic man. At day 0 she had no positive laboratory results for the infection, while the source, at day 1, had TPHA positive, but no post-exposure prophylaxis (PEP) against syphilis was prescribed. The subject missed the day 30 follow-up, and underwent our visit at day 90, when she showed no clinical signs, but she seroconverted (VDRL = positive 1/2; TPHA = positive 1/320; FTA-Abs IgG and IgM = present). She started antibiotic therapy, and currently her serological status is VDRL = positive 1/2, TPHA = positive 1/160, FTA-Abs IgM = negative.

[Effect of anti-retroviral therapy on body composition changes: a literature review]

Protein-energetic malnutrition, characterized by both lean mass and fat depletion, was common in the pre-HAART era, and was associated with shortened survival and diminished quality of life. The pathogenesis of protein-energy malnutrition was multifactorial, and nutritional treatments were largely ineffective in the absence of disease stabilization. The introduction of HAART brought markedly improved outcomes, including a decrease in the incidence of malnutrition. However, other nutritional and metabolic alterations were noticed, and included changes in body shape, both lipoatrophy and lipohypertrophy, as well as changes in metabolism, notably hyperlipidemia and insulin resistance. These conditions, though sometimes occurring together, may occur independently, suggesting a complex, multifactorial cause. Several mechanisms have been hypothesized, including impairment to adipocyte differentiation and adipokine regulation, production of proinflammatory cytokines and mitochondrial toxicity. The role of the single drug class is still unclear, because both PI and NRTI have been associated with the syndrome, and the therapeutic protocols include both groups. Most of the medical therapies proposed for lipodystrophy are ineffective, and even if surgery remains an alternative, it is not associated with long lasting outcomes.

[Anatomicosurgical research on isolating the retrohepatic segment of the vena cava inferior]

The retrohepatic segment of the inferior vena cava is considered of major importance in the surgical management of both thoracoabdominal trauma and neoplasms involving the venous wall. Twenty autopsies and 10 anatomical specimens were employed to examine the patterns of the avascular inter-hepato-caval median space. For the isolation and ligation of the hepatic veins a rubber snare was inserted into the avascular plane assuring a right tension of the vasculo-parenchymal lamina which attracts the liver to the vena cava. The number and the course of the hepatic veins were clearly identified. Authors' experience, coupled with a critical review of the literature, confirms that successful isolation of the believed surgically inaccessible retrohepatic vena cava and hepatic veins may represent a suitable approach for major injuries or neoplasias of these structures.

[Anatomicosurgical study of the superior mesenteric vein]

Results of an autoptic study of the superior mesenteric vein in thirty cadavers are reported. The anatomo-surgical patterns of the venous axis are emphasized. In fact, a better knowledge of this vessel allows an easier and safer surgical approach during pancreatic resections.

[Anatomo-surgical notes on transhiatal access in esophagectomy]

The Authors through an anatomic study on 20 cadavers specify the surgical procedure for transhiatal esophagectomy and describe the anatomical structures involved. The proper manoeuvres and artifices to avoid intraoperative accidents are suggested. Finally, the indications for this peculiar operation are discussed.