Effectiveness and safety of a new helmet CPAP configuration allowing tidal volume monitoring in patients with COVID-19

BACKGROUND

High generated tidal volumes (Vt) have been correlated with higher risk of self-induced lung injury and worse clinical outcome. This study aimed to evaluate the effectiveness and safety of a new helmet continuous positive airway pressure delivered (h-CPAP) configuration allowing Vt monitoring in patients affected by COVID-19.

METHODS

This prospective observational study was performed in the respiratory intermediate care unit of University Hospital in Turin, Italy, between March 24th, and June 15th, 2020. Included patients were treated with CPAP via a single-limb intentional leak configuration by a turbine-driven ventilator, provided with a dedicated patch. Effectiveness and safety of the configuration and healthcare workers safety were the outcomes of the study.

MAIN FINDINGS

Thirty-five patients were included in this study. Median age was 67 years (IQR 57-76 years), and 30 patients (85.7%) were men. Median value of overall leaks (intentional plus unintentional) was 68 L/min (IQR 63-75). Reliability of Vt measurements was 100%. An out of scale of Vt (above 50% compared to the previous values) was never recorded. Six patients (17.1%) needed more than two helmet replacements, due to leak test >10 l/min. Arm oedema and skin breakdowns were reported in sixteen (45.7%) and seven (20%) patients respectively. Among the 63 healthcare workers involved in the care of COVID-19 patients during the study only one was positive at RT-PCR nasopharyngeal swab testing.

CONCLUSIONS

The use of h-CPAP for treating COVID-19 in this configuration allowed for reliable Vt monitoring. Further studies evaluating this configuration in larger patients' cohorts are needed.

Effects of hyperoxemia in patients with sepsis - A post-hoc analysis of a multicentre randomized clinical trial

BACKGROUND

Administration of supplemental oxygen is a life-saving treatment in critically ill patients. Still, optimal dosing remains unclear during sepsis. The aim of this post-hoc analysis was to assess the association between hyperoxemia and 90-day mortality in a large cohort of septic patients.

METHODS

This is a post-hoc analysis of the Albumin Italian Outcome Sepsis (ALBIOS) randomized controlled trial (RCT). Patients with sepsis who survived the first 48 h since randomization were included and stratified into two groups according to their average PaO₂ levels during the first 48 h (PaO_{2 0-48 h}). The cut-off value was established at 100 mmHg (average PaO_{2 0-48 h} >100 mmHg: hyperoxemia group; PaO_{2 0-48h}≤100: normoxemia group). The primary outcome was 90-day mortality.

RESULTS

1632 patients were included in this analysis (661 patients in the hyperoxemia group, 971 patients in the normoxemia group). Concerning the primary outcome, 344 (35.4%) patients in the hyperoxemia group vs. 236 (35.7%) in the normoxemia group had died within 90 days from randomization (p = 0.909). No association was found after adjusting for confounders (HR 0.87; CI [95%] 0.736-1.028, p = 0.102) or after excluding patients with hypoxemia at enrollment, patients with lung infection or including post-surgical patients only. Conversely, we found an association between lower risk of 90-day mortality and hyperoxemia in the subgroup including patients who had the lung as primary site of infection (HR 0.72; CI [95%] 0.565-0.918). Mortality at 28 days, ICU mortality, incidence of acute kidney injury, use of renal replacement therapy, days to suspension of vasopressor or inotropic agents, and resolution of primary and secondary infections did not differ significantly. Duration of mechanical ventilation and length of stay in ICU were significantly longer in patients with hyperoxemia.

CONCLUSIONS

In a post-hoc analysis of a RCT enrolling septic patients, hyperoxemia as average PaO₂>100 mmHg during the first 48 h was not associated with patients' survival.

Improved Survival and Quality of Life Through an Integrative, Multidisciplinary Oncological Approach: Pathophysiological Analysis of Four Clinical Cancer Cases and Review of the Literature

Objectives: According to the National Cancer Institute, the integrative medicine (IM) approach to medical care combines standard medicine with complementary and alternative medicine practices that have proved safe and effective.

Methods: We describe the clinical cases of four patients with malignant pleural mesothelioma (MPM), diffuse malignant peritoneal mesothelioma (DMPM), intrahepatic cholangiocarcinoma, and breast cancer (BC) who received supportive treatment (ST) according to an IM approach after the failure of standard cancer treatments or the appearance of serious adverse events caused by antiblastic chemotherapy. The critical role of complementary drugs in reducing the side effects of cancer treatments and normalizing the white cell count is especially apparent in the case of the patient with metastatic BC, who experienced prolonged neutropenia.

Results: The IM approach was well-tolerated and had no adverse side effects. It improved the quality of life (QoL) of all patients and in two cases extended overall survival.

Conclusion: The extended clinical and instrumental response to IM of the patients with malignant mesothelioma and the improved health-related QoL and good tolerance of the ST demonstrated in all cases support the value of this approach in patients whose cancer therapies have failed but who show a good performance status. Our data require confirmation in a well-designed prospective clinical trial.

Rationale and evidence on the use of tocilizumab in COVID-19: a systematic review

BACKGROUND

Tocilizumab is an IL-6 receptor-blocking agent proposed for the treatment of severe COVID-19. The aim of this systematic review was to describe the rationale for the use of tocilizumab for the treatment of COVID-19 and to summarize the available evidence regarding its efficacy and safety.

METHODS

MEDLINE, PubMed, EMBASE, pre-print repositories (bioRxiv and medRxiv) and two trial Registries were searched for studies on the use of tocilizumab in COVID-19 or SARS-CoV-2 infection, viral pneumonia, and/or sepsis until 20th June 2020.

RESULTS

We identified 3 indirect pre-clinical studies and 28 clinical studies including 5776 patients with COVID-19 (13 with a comparison group, 15 single-arm). To date, no randomized trials have been published. We retrieved no studies at low risk of bias. Forty-five ongoing studies were retrieved from trial registries.

CONCLUSIONS

There is insufficient evidence regarding the clinical efficacy and safety of tocilizumab in patients with COVID-19. Its use should be considered experimental, requiring ethical approval and clinical trial oversight.

Abnormal F-18 Fluorodeoxyglucose Uptake of the Lung in Immunocompromised Lymphoma Patients in Complete Remission: Report of Two Cases and Revision of Literature

Limited data suggest that F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) may have a role in diagnosing infection. Here we present two cases of lymphoma patients in complete response (CR) who presented during follow-up dry cough and fever. Physical examination and serum evaluations were negative for lymphoma while whole body FDG-PET showed lung uptake which posed a differential diagnosis between relapse of lymphoma and an atypical pneumonia due to persistent lymphopenia. In both cases, cytology examination of sputum suggested Pneumocystis Jiroveci pneumonia (PJP). After appropriate antibiotic treatment, the follow-up examination showed complete resolution of the lung changes revealed by FDG-PET. False-positive results on FDG-PET were supposed to be due to the high uptake of FDG in non-neoplastic inflammatory cellular elements such as macrophages and lymphocytes. Our findings suggest that in cases of FDG-PET positive images in immunocompromised patients with previous hematologic disease, caution must be used, and differential diagnosis might include infections such as PJP in addition to relapse of disease.

Molecular modeling approaches in the discovery of new drugs for anti-cancer therapy: the investigation of p53-MDM2 interaction and its inhibition by small molecules

The mdm2 oncogene product, MDM2, is an ubiquitin protein ligase that inhibits the transcriptional activity of the tumor suppressor p53 and promotes its degradation. About 50% of all human cancers present mutations or deletions in the TP53 gene. In the remaining half of all human neoplasias that express the wild-type protein, aberrations of p53 regulators, such as MDM2, account for p53 inhibition. For this reason, designing small-molecule inhibitors of the p53-MDM2 protein-protein interaction is a promising strategy for the treatment of cancers retaining wild-type p53. The development of inhibitors has been challenging. Although many small-molecule MDM2 inhibitors have shown potent in vitro activity, only a limited number of compounds have demonstrated to possess acceptable pharmacokinetic properties for in vivo evaluation. To date, the most studied chemotypes have been cis-imidazolines (such as nutlins), benzodiazepines, and spiro-oxindoles. The cis-imidazolines were the first discovered potent and selective small-molecule inhibitors of the p53-MDM2 interaction and they continue to show therapeutic potential. This review will focus on recent molecular modeling approaches (molecular dynamics, pharmacophore-based, molecular docking, structure-based design) used with the aim to better understand the behavior of these proteins and to discover new small-molecule inhibitors of the p53-MDM2 protein-protein interaction for the treatment of cancer.

Usefulness of 18FDG-positron emission tomography (FDG-PET) for early prediction of erlotinib (Eb) treatment outcome in non-small cell lung cancer (NSCLC) patients: Results of a pilot study

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Background: FDG-PET could be useful for early evaluation of tumor response to tyrosine kinase inhibitors (TKI). Glucose metabolic activity seems to closely reflect response to epidermal growth factor receptor (EGFR) TKI in vivo and in vitro (Su H et al, Clin Cancer Res 2006;12:5659–67). Thus, we attempted to assess the clinical value of FDG-PET for early prediction of tumor response to Eb an EGFR-TKI. Methods: Pts with NSCLC stage IV in progression after at least one line of chemotherapy and PS 0–1 were treated with Eb (150 mg orally once daily). FDG-PET was performed on days 0 and 2, after administration of 3 daily doses. FDG uptake was evaluated as the maximum standardized uptake value in the tumor (SUVmax). SUVmax was divided by SUV of the background region (liver) to produce the tumor:nontumor ratio (TNT). FDG-PET responses were evaluated by quantitative changes on TNT and classified according to the EORTC PET study group. PET response were compared with radiographic tumor response (RECIST criteria) assessment based on CT scan at baseline and on day 45. Results: From May 2007, 27 pts were enrolled and 23 were evaluable (4 not-evaluable: 2 BAC PET negative, 2 violations). FDG-PET revealed a metabolic partial response (PR) in 8 pts; subsequent CT scan assessment evidenced 4 PR and 4 long lasting stable disease (SD), respectively. Seven pts had metabolic progressive disease (PD) at PET scan and 8 had SD, all of them presented PD at CT scan. Metabolic PR was associated with a longer median progression-free survival (152 vs 45 days, p = < 0.0001) and longer overall survival (323 vs 128 days p=0.15). For radiological PD pts who presented metabolic SD or PD, survival time was respectively 220 and 117 days. EGFR gene mutation, gene copy number and protein expression are ongoing. Conclusions: FDG-PET using changes on TNT can very early predict (already 2 days after initiation) Eb treatment outcome. Particularly, pts with early metabolic PD are unlikely to benefit from Eb. Therefore, evaluation of the early metabolic response holds promise for assessment of pts selection. The two different behavior of FDG-PET observed on refractory pts, deserve biomolecular analysis for understanding mechanism of resistance.

No significant financial relationships to disclose.

[Chronic osteomyelitis: one-step treatment]

PURPOSE

Chronic osteomyelitis is a surgical disease that require significant dedication from surgeons to eradicate. Osteomyelitis can result from a variety of etiologies but most often is a consequence of trauma (open fractures) to a long bone. This type includes osteomyelitis secondary to a contiguous focus of infection (after trauma and its surgical treatment: osteosynthesis). Here we are reporting one case of post-traumatic chronic osteomyelitis of the humerus.

PATIENTS AND METHODS

A 34-years-old man presented with a post-traumatic chronic osteomyelitis due to an open fractur of the diaphysis humerus. We proposed a one-step surgical treatment, including fistulectomy, sequestrectomy, opening of the proximal and distal intramedullary canal. Antimicrobial therapy should be followed by close observation and treatment with appropriate antibiotics.

RESULTS

A clinical control at 30 days from the intervention revealed that: no secretion; negative cultured exam; second-intention healing of the skin.

CONCLUSIONS

Treatment requires isolation of the pathogens, significant debridement for removal of all infective and necrotic material, both of bone origin and soft-tissue one. Is is necessary not to close the foci: in this way we leave an external drainage, which is able to provide a tissues sterilization by secretion drainage and by the effects of the systemic antimicrobial therapy. Our results indicate that this long-term problem can be solved by a one-stage procedure that provide spontaneous second- healing of the skin defects, excluding the bony and soft tissue reconstruction.

[Current trends and future perspectives in the therapy of the osteoporosis]

Osteoporosis is a pathology of considerable social impact for its high frequency in the elderly and for serious complications of the fragility fracture. Osteoporosis prevention requires high bone mass peak during growth age, adult and elder people must limit the bone loss by taking specific daily behavior and nutritional measures. The pharmacological treatment is based on drugs which are able to change bone metabolism, among which the bisphosphonates result to have a good efficacy with few collateral effects, the last generation (Alendronate and Risedronate) may be taken once a week. Promising for the next future is the Recombinante Parathormon, recently approved from the Food and Drug Administration for osteoporosis treatment. Leptin and l'Osteoprogerin are new experimental molecules under study able to act on the mechanism of central and local regulation of bone remodeling.

High fat fed hamster, a unique animal model for treatment of diabetic dyslipidemia with peroxisome proliferator activated receptor alpha selective agonists

Dyslipidemia, a major risk factor for cardiovascular disease, may be directly linked to diabetic hyperglycemia and insulin resistance. An appropriate dyslipidemic animal model that has diabetes would provide an important tool for research on the treatment of diabetic dyslipidemia. Ten days of high fat feeding in golden Syrian hamsters resulted in a significant increase in insulin resistance and baseline serum lipid levels accompanied by a pronounced dyslipidemia. Thirteen days of treatment with fenofibrate, a peroxisome proliferator-activated receptor alpha (PPARalpha) selective agonist, produced a dose-dependent decrease in serum lipid levels. The pattern observed was characterized by lowered very-low-density lipoprotein (VLDL) and low-density lipoprotein (LDL) and raised high-density lipoprotein (HDL) cholesterol in a fashion similar to that seen in man. Diabetic conditions were also significantly improved by fenofibrate with a normalization of impaired glucose tolerance and an improvement of insulin sensitivity during an oral glucose tolerance test. These data suggest that fenofibrate may correct not only the dyslipidemia but also the insulin resistance caused by a high fat diet, and the high fat fed hamster may be a good animal model for research on the treatment of diabetic dyslipidemia with PPARalpha selective agonists.

PPARalpha agonists reduce 11beta-hydroxysteroid dehydrogenase type 1 in the liver

11beta-hydroxysteroid dehydrogenase type 1 (11betaHSD1) is an enzyme that converts cortisone to the active glucocorticoid, cortisol. Cortisol-cortisone interconversion plays a key role in the regulation of glucose metabolism, since mice deficient in 11betaHSD1 are resistant to diet-induced hyperglycemia. Peroxisome proliferator activator receptors (PPAR) are key regulators of glucose and lipid homeostasis. We observed a striking downregulation of murine hepatic 11betaHSD1 expression and activity after chronic treatment of wild-type mice with PPARalpha agonists, while 11betaHSD1 in the livers of PPARalpha knockout mice, or in mice treated for only 7 h with PPARalpha agonists, was unaltered. Our results are the first to show PPARalpha agonists can affect glucocorticoid metabolism in the liver by altering 11betaHSD1 expression after chronic treatment. Regulation of active glucocorticoid levels in the liver by PPARalpha agonists may in turn affect glucose metabolism, consistent with reports of their antidiabetic effects.

Lack of prognostic value of 99mTc MIBI rest, 18F FDG and 201TL rest/redistribution on PTCA outcome of patients with moderate left ventricle dysfunction

BACKGROUND

The clinical work-out of patients undergoing coronary revascularization includes the assessment of myocardial viability. This approach has to be defined in the different classes of patients. The aim of this study was to evaluate the predictive prognostic value of different techniques on outcome following PTCA in patients with moderate left ventricle dysfunction (left ventricle EF > or = 40%).

METHODS

Seventeen patients with EF > or = 40% and undergoing PTCA were studied by 201Tl rest/redistribution, 18F-FDG and 99mTc-MIBI rest. Regional kinesis was scored by echo, dividing left ventricle in 11 segments. The echo evaluation was repeated at 1 and 6 months after revascularization.

RESULTS

Global EF was 52.5 +/- 7% and 69 segments had abnormal kinesis. Patients underwent stress/rest 99mTc-MIBI SPET, rest/redistribution 201Tl SPET and rest 18F-FDG PET. Among the 11 segments defined on echo-matched tomographic images, the one with the highest activity at stress was assumed as reference (activity = 100%). If > 50% of reference segment, 18F-FDG and 201Tl uptakes were considered significant. After PTCA, the echo-follow-up did not demonstrated significant improvement of left ventricle function at 30 days after PTCA (EF 56 +/- 6%) as well as at 6 months (EF 56 +/- 9%). The positive predictive value under these conditions resulted: 46.5% with 99mTc-MIBI rest, 47.4% with 201Tl rest-redistribution and 45.7% with 18F-FDG.

CONCLUSIONS

In summary, in the class of patients with moderately compromised function, considering as reference the improved regional kinesis after PTCA, 99mTc-MIBI at rest, 201Tl rest/redistribution and 18F-FDG do not exhibit a clear predictive value; patient population is then a highly relevant point to establish the accuracy of these diagnostic procedures.

[Correction measured by attenuation in tomographic heart studies with single photon emission with thallium 201. Comparison with positron- emission tomographic studies with ammonium marked with nitrogen]

PURPOSE

We investigated 201Tl myocardial uptake with(out) nonuniform attenuation compensation in ischemic myocardiopathy patients. The segmental patterns of the two types of SPECT images were compared with PET [13N]NH3 studies performed in the same patient. PET images were taken as reference and the diagnostic accuracy of SPECT with(out) attenuation correction was evaluated.

MATERIAL AND METHODS

During the SPECT study transmission and emission data were simultaneously recorded by a triple head gamma camera equipped with fan beam collimators and a 99mTc transmission line source (740MBq). SPECT and PET images, the former reconstructed with(out) attenuation correction, were corecorded and reoriented along the short axis. The left ventricular wall was divided into 11 segments and segmental activity normalized to maximum in each study.

RESULTS

Statistically significant differences were found between PET/(un)corrected SPECT ratios in posterior and septal segments. In these myocardial regions, attenuation correction compensates for attenuation artifacts, by correcting the underestimation of radioactivity concentration caused by radiation absorption. A statistically significant difference was also found in midventricular anterior and apical segments (p < .05). However, in these regions attenuation correction results in a decrease in corrected relative to uncorrected SPECT activity. The agreement rate with PET data is higher for corrected SPECT (mean differences were 3.12 +/- 11.51 and 2.19 +/- 8.63 for uncorrected versus corrected SPET). We had 50% positive and 77% negative predictive value without attenuation correction, versus up to 69% and 90%, respectively, with attenuation correction.

CONCLUSIONS

The attenuation correction procedure with simultaneous transmission-emission effectively reduces attenuation artifacts in SPECT myocardial imaging. While diagnostic accuracy increases in posterior and septal myocardial regions, anterior and apical data need careful interpretation because a relative decrease in radioactivity concentration can be observed after attenuation correction.

Long-term treatment of malignant gliomas with intramuscularly administered polyinosinic-polycytidylic acid stabilized with polylysine and carboxymethylcellulose: an open pilot study

Polyinosinic-polycytidylic acid stabilized with polylysine and carboxymethylcellulose (poly-ICLC) (10-50 mcg/kg, administered intramuscularly one to three times weekly) was given for < or = 56 months to 38 patients with malignant gliomas. There was minimal or no toxicity. Twenty of 30 patients (66%) receiving at least twice weekly poly-ICLC showed regression or stabilization of gadolinium-enhancing tumor, as revealed by magnetic resonance imaging (median = 65% volume decrease). All but one patient with anaplastic astrocytomas who received continuous poly-ICLC remain alive, with a median progression-free survival of 54 months from diagnosis. Median Kaplan-Meier survival is 19 months for patients with glioblastomas who receive at least twice weekly poly-ICLC treatments. Tumor response was associated with 2',5' -oligoadenylate synthetase activation (P = 0.03) but not with serum interferon. We hypothesize clinical activation by poly-ICLC of a basic host tumor suppressor system. Prolonged, quality survival with tumor stabilization or regression confirmed by magnetic resonance imaging for most patients with anaplastic astrocytomas and glioblastomas suggests that more extensive laboratory and controlled clinical studies are warranted. The concept of long-term, broad spectrum stimulation of host defenses with nontoxic, inexpensive double-stranded ribonucleic acids, such as low-dose poly-ICLC, may be applicable to the treatment of other malignancies.

[Fetal megalosomia: clinical and prognostic value of main risk factors]

Fetal megalosomia associates with an increased risk of maternal and perinatal pathology. However it is right to make a clear distinction between "physiologic" megalosomia, expression of a high genetic potential of growth from the fetus, and megalosomia referable to any maternal pathology. While the first one entails problems of obstetric management at the most, the second one compels to take measures in order to reduce its incidence. A sample of 45 fetuses with megalosomia was studied retrospectively and compared with a standard sample, randomly selected among the fetuses, term delivered, who in the same period considered (January 1990-January 1994) weighed less than 4 kg at birth. This was done in order to verify which of the risk factors of fetal megalosomia reported in the medical literature affects the most the people who address our Institute. Important risk factors resulted, besides maternal height and postdatism, pre-gestational overweight and obesity. The prognostic significance of the factors, such as advanced maternal age, multiparity, male sex of the unborn child, excessive maternal weight gain during pregnancy, previous megalosomia, was of more difficult interpretation. In our experience, gestational diabetes didn't play the role, universally recognized to it, of the most important risk factor of fetal megalosomia.

[Autologous blood collection in pregnancy. Prospective study]

Autologous blood predonation during pregnancy, with the aim of autotransfusion after delivery, has gained increasing consensus over the last few years. However, there are still some controversial aspects. In particular, the cost/benefit ratio of institutionalizing the above mentioned practice would appear altogether unfavourable (too many women would be really in need of transfusion after delivery). The aim of the present study is to assess the results of our experience using autotransfusion in obstetrics. This longitudinal and prospective study was carried out on a sample of 29 pregnant women who donated 1 unit of blood during the last month of their pregnancy. Phlebotomy was preceded by a verification of the permitting conditions (Hb > or = 11 g/dl; Ht > or = 33%). Before, during and after phlebotomy, the patients underwent cardiotocographic monitoring and periodic observation of vital parameters. The hematologic parameters registered during the various test (before predeposit, before delivery, in puerpery) were statistically analysed. The hemochromo values appeared satisfactory in all cases at the time of admittance for labour. As a consequence of a hematic loss higher than usual at the moment of delivery, in many cases the hemoglobin values during puerpery did not enable us to exclude a priori the advisability of a transfusion. From the study we see how the cost/benefit ratio of the predeposit practice in obstetrics is less unfavourable than commonly thought.

[Autologous transfusion in obstetrics and fetal safety]

It is common knowledge that for modern medicine transfusion therapy represents a precious resource and an often mandatory option. It is equally known that autohemotransfusion (or autologous transfusion) provides further advantages: certainty of blood availability when necessary, absence of transfusion reactions, elimination of the risk of infections that is still associated with the traditional homologous transfusions. In its most widespread application, autotransfusion provides for the donation of one or more units of autologous blood, mostly before elective surgery. Even in obstetrics the practice of autologous blood donation with the aim of autotransfusion is finding increasing employment. However, there are still controversial aspects and the need is pointed out for more authoritative verifications as refers to the alleged innocuity to the fetus of acute maternal blood loss. The present study was performed to contribute personal experience to a better definition of the possible interactions between autologous blood donation during pregnancy and unborn child welfare. To this end, 80 term pregnant women underwent fetal heart rate electronic monitoring before, during and after the donation of one unit of autologous blood. Both during and after the phlebotomy there were no cardiotocographic signs of fetal hypo-oxygenation. Even the non stress tests performed at a distance of 24 hours and those that were periodically repeated afterwards were normal, confirming the safety of autologous predonation during pregnancy. However, the authors think that in obstetrics it is still premature to consider the experimental phase of autotransfusion as definitively exhausted.