Physiologic Range of Myocardial Mechano-Energetic Efficiency among Healthy Subjects: Impact of Gender and Age

BACKGROUND

Myocardial mechano-energetic efficiency (MEE) is the capability of the left ventricle (LV) to convert the chemical energy obtained from the cardiac oxidative metabolism into mechanical work. The aim of present study was to establish normal non-invasive MEE and MEEi reference values.

METHODS

In total, 1168 healthy subjects underwent physical examinations, clinical assessment, and standardized transthoracic echocardiographic (TTE) examination. MEE was obtained by TTE as the ratio between stroke volume (SV) and heart rate (HR): MEE = SV/HR [HR expressed in seconds (HR/60)]. Because MEE is highly related to left ventricular mass (LVM), MEE was then divided by LVM with the purpose of obtaining an estimate of energetic expenditure per unit of myocardial mass (i.e., indexed MEE, MEEi, mL/s/g).

RESULTS

The mean values of MEE and MEEi in the overall population were 61.09 ± 18.19 mL/s; 0.45 ± 0.14, respectively. In a multivariable analysis, gender, body surface area (BSA), diastolic blood pressure, left atrial volume indexed to BSA, E/e' and tricuspid annular plane systolic excursion (TAPSE) were the independent variables associated with MEE, while age, gender, BSA and TAPSE were the independent variables associated with MEEi.

CONCLUSIONS

The knowledge of age- and gender-based MEE and MEEi normal values may improve the global assessment of LV cardiac mechanics and serve as a reference to identify phenotypes at high risk of cardiovascular events.

Pharmacotherapy Based on ACE2 Targeting and COVID-19 Infection

The new SARS-CoV-2 coronavirus is responsible for the COVID-19 pandemic. A massive vaccination campaign, which is still ongoing, has averted most serious consequences worldwide; however, lines of research are continuing to identify the best drug therapies to treat COVID-19 infection. SARS-CoV-2 penetrates the cells of the host organism through ACE2. The ACE2 protein plays a key role in the renin–angiotensin system (RAS) and undergoes changes in expression during different stages of COVID-19 infection. It appears that an unregulated RAS is responsible for the severe lung damage that occurs in some cases of COVID-19. Pharmacologically modifying the expression of ACE2 could be an interesting line of research to follow in order to avoid the severe complications of COVID-19.

Pregnancy and COVID-19, focus on vaccine and pharmacological treatment

The global pandemic of COVID-19 is currently ongoing. Clinical evidence shows that specific population groups such as the elderly, individuals with comorbidities, and pregnant women may be at increased risk for infection and serious complications. In particular, physiologic changes during pregnancy may be significant on the immune and respiratory systems and progression of COVID-19 disease. Pregnant women are routinely excluded from pre-registration clinical trials, this potentially limits their access to therapies through off-label or compassionate use. Vaccination remains an important pillar of the response to COVID-19, particularly as variants of the virus continue to spread across countries. Growing evidence indicates that COVID-19 mRNA vaccines do not cause pregnancy complications for expectant mothers and their infants. In this brief review, we explore current knowledge about COVID-19 in pregnancy by highlighting current recommendations for vaccination and drug treatments.

Lichen sclerosus in pediatric age: A new disease or unknown pathology? Experience of single centre and state of art in literature

Lichen Sclerosus (LS) is a chronic inflammatory skin disease with unknown etiology. In pediatric age the main disease "lichenlinked" is the phimosis in male. This is a retrospective study that reports the experience of our clinic and review of the literature. We included all patients affected by pathological phimosis, treated by circumcision between January 2015 and May 2020, older than 6 years old and with an histopathological diagnosis of lichen sclerosus. The aim was to identify prognostic factors based on histological report to plan the clinical management of patients. Statistical analysis was done. We included 207 patients. The mean age of children was 9,78 years (5-18 years, DS±3.29). Based on the histological features we divided patients in 2 groups: early lesions (70/207, 34%) and advanced (137/207, 66%). In term of complications lichen linked we considered meatal stenosis that needed of urethral dilatations. We included 7 patients (7/207, 3,4%). We report P value Statistical Significance in many aspects. An early diagnosis of LS and surgical treatment of foreskin are essential to prevent early and late complications in children. The size of sample is a limit of the study but results encourage our management.

[A retrospective pharmacovigilance analysis: could decreased reporting of suspected adverse reactions generate future safety concerns?]

BACKGROUND

The collection and management of spontaneous reports of suspected adverse drug reactions represents a passive pharmacovigilance method for post-marketing drug safety surveillance, as it is a practical and rapid way to detect a potential warning sign. We performed an in-depth retrospective analysis of suspected adverse reaction reports in the National Pharmacovigilance Network (RNF) for the first eight months of 2019 (pre-pandemic period), 2020 (global pandemic covid-19 onset), 2021 (first post-pandemic period due to vaccine phase).

METHODS

The reports of suspected adverse drug reactions were extrapolated from the National Network of Pharmacovigilance. Data from Italy, the Campania Region, and the Local Health Unit Naples 3 South were compared. A retrospective qualitative analysis of demographics data, clinical status, suspected drugs, adverse drug reactions (ADRs) description and its degree of seriousness were collected.

RESULTS

We observed 1071 ADRs, of which 281 were serious; of these, 39 led to hospitalization, 779 were not serious, and 2 caused death. In the pre-pandemic period, chemotherapy drugs most frequently induced ADRs. The year 2020, in the midst of the covid-19 pandemic, saw a clear reduction in the number of drug reports, compared to 2019 and 2021, both at national and regional level, and at ASL Napoli 3 Sud. A reduction in 2020 that ranges from -40.75% to -72.56% at the national and regional level, respectively; reaching as much as -88.13% at the local level in the health authority under analysis. In 2021, on the other hand, there is a clear increase in the number of reports, which numerically exceed even those in 2019 by +194.71% in Italy, +15.25% in the Campania Region, and +90.68% in the Local Health Unit Naples 3 South.

CONCLUSIONS

The covid-19 pandemic has affected the trend in the number of reports of suspected adverse drug reactions. This is for several reasons: first, frontline exposed health care workers have been able to devote less time to pharmacovigilance activities to cope with the health emergency, second, since the start of the covid-19 vaccination campaign, health care workers have been more focused on reporting suspected adverse reactions to vaccines. Clinicians should beware of these adverse effects and monitor early warning signs carefully.

Phenotyping congestion in patients with acutely decompensated heart failure with preserved and reduced ejection fraction: The Decongestion duRing therapY for acute decOmpensated heart failure in HFpEF vs HFrEF- DRY-OFF study

AIMS

To evaluate pulmonary and intravascular congestion at admission and repeatedly during hospitalization for acute decompensated heart failure (ADHF) in HFrEF and HFpEF patients using lung (LUS) and inferior vena cava (IVC) ultrasound.

METHODS AND RESULTS

Three-hundred-fourteen patients (82±9 years; HFpEF =172; HFrEF=142) admitted to Internal Medicine wards for ADHF were enrolled in a multi-center prospective study. At admission HFrEF presented higher indexes of pulmonary and intravascular congestion (LUS-score: 0.9 ± 0.4 vs 0.7 ± 0.4; p<0.01; IVC end-expiratory diameter: 21.6 ± 5.1 mm vs 20±5.5 mm, p<0.01; IVC collapsibility index 24.4 ± 17.4% vs 30.9 ± 21.1% p<0.01) and higher Nt-proBNP values (8010 vs 3900 ng/l; p<0.001). At discharge, HFrEF still presented higher B-scores (0.4 ± 4 vs 0.3 ± 0.4; p = 0.023), while intravascular congestion improved to a greater extent, thus IVC measurements were similar in the two groups. No differences in diuretic doses, urine output, hemoconcentration, worsening renal function were found. At 90-days follow up HF readmission/death did not differ in HFpEF and HFrEF (28% vs 31%, p = 0,48). Residual congestion was associated with HF readmission/death considering the whole population; while intravascular congestion predicted readmission/death in the HFrEF, no association between sonographic indexes and the outcome was found in HFpEF.

CONCLUSIONS

Serial assessment of pulmonary and intravascular congestion revealed a higher burden of fluid overload in HFrEF and, conversely, a greater reduction in intravascular venous congestion with diuretic treatment. Although other factors beyond EF could play a role in congestion/decongestion patterns, our data may be relevant for further phenotyping HF patients, considering the importance of decongestion optimization in the clinical approach.

A short focus, azithromycin in the treatment of respiratory viral infection COVID-19: efficacy or inefficacy?

Azithromycin is a macrolide antibiotic. Recent evidence has demonstrated in vitro activity against a wide variety of respiratory tract viruses, including SARS-CoV-2 responsible for the current global pandemic COVID-19. A mechanism of action acting on different phases of the viral cycle is assumed. In addition to its in vitro antiviral properties, some evidence also suggests immunomodulatory and antifibrotic activity. These properties of azithromycin could be useful in the treatment of viral respiratory tract infections such as COVID-19. However, clinical data on the antiviral efficacy of azithromycin in the treatment of respiratory tract infections are inconsistent, both when used as monotherapy and in polypharmacological combination. In addition, cases of azithromycin-induced QT long and malignant arrhythmias are reported. In this short review, we attempt to determine the role of azithromycin in the treatment of viral respiratory tract infections such as COVID-19, therapeutic efficacy, or inefficacy?

Right Heart Pulmonary Circulation Unit Response to Exercise in Patients with Controlled Systemic Arterial Hypertension: Insights from the RIGHT Heart International NETwork (RIGHT-NET)

Background. Systemic arterial hypertension (HTN) is the main risk factor for the development of heart failure with preserved ejection fraction (HFpEF). The aim of the study was was to assess the trends in PASP, E/E’ and TAPSE during exercise Doppler echocardiography (EDE) in hypertensive (HTN) patients vs. healthy subjects stratified by age. Methods. EDE was performed in 155 hypertensive patients and in 145 healthy subjects (mean age 62 ± 12.0 vs. 54 ± 14.9 years respectively, p < 0.0001). EDE was undertaken on a semi-recumbent cycle ergometer with load increasing by 25 watts every 2 min. Left ventricular (LV) and right ventricular (RV) dimensions, function and hemodynamics were evaluated. Results. Echo-Doppler parameters of LV and RV function were lower, both at rest and at peak exercise in hypertensives, while pulmonary hemodynamics were higher as compared to healthy subjects. The entire cohort was then divided into tertiles of age: at rest, no significant differences were recorded for each age group between hypertensives and normotensives except for E/E’ that was higher in hypertensives. At peak exercise, hypertensives had higher pulmonary artery systolic pressure (PASP) and E/E’ but lower tricuspid annular plane systolic excursion (TAPSE) as age increased, compared to normotensives. Differences in E/E’ and TAPSE between the 2 groups at peak exercise were explained by the interaction between HTN and age even after adjustment for baseline values (p < 0.001 for E/E’, p = 0.011 for TAPSE). At peak exercise, the oldest group of hypertensive patients had a mean E/E’ of 13.0, suggesting a significant increase in LV diastolic pressure combined with increased PASP. Conclusion. Age and HTN have a synergic negative effect on E/E’ and TAPSE at peak exercise in hypertensive subjects.

Gilteritinib as treatment for extra-medullary relapse of FLT3-ITD acute myeloid leukemia FLT3-ITD, after allogeneic haematopoietic stem cell transplantation

Case of a patient with acute myeloid leukemia (AML) positive for mutations in both genes NPM1 and FLT3-ITD who underwent two allogeneic haematopoietic stem cell transplants (HSCT); the second allograft one was followed by extramedullary relapse (granulocytic sarcoma of right breast), with blast cells positive for FLT3-ITDmutation.  Treatment with Gilteritinib, a second generation selective oral type I FLT3 inhibitor, was started after the second HSCT with complete regression of breast granulocytic sarcoma in absence of hematological and extra hematologic toxicity. We conclude that Gilteritinib can represent an effective therapy for extra hematologic relapse, with acceptable toxicity and outpatient management.

Left-sided acute appendicitis in a patient with situs viscerum inversus totalis: A case report

Introduction and importance

Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as situs viscerum inversus (SVI) and midgut malrotation (MM). Preoperative diagnosis of LSAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of LSAA.

Case presentation

A 67-year-old Caucasian male with presented to the Emergency Department with a two-day history of left lower quadrant (LLQ) abdominal pain, nausea, vomiting, diarrhea and fever. Physical examination revealed LLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a LSAA with intraluminal appendicoliths, fat infiltration and pericecal fluid collection in a patient with SVI. The patient underwent laparoscopic appendectomy: a gangrenous and perforated appendicitis was sectioned and removed with drainage of pericecal abscess. The postoperative course of the patient was uneventful.

Clinical discussion

LSAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of LSAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming SVIT or MM. Laparoscopic appendectomy represents the correct treatment of LSAA.

Conclusion

LSAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with LLQ abdominal pain. Preoperative diagnosis of LSAA needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of LSAA.

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Left-sided acute appendicitis (LSAA) is a very rare cause of acute abdomen.

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LSAA develops in association with situs viscerum inversus or midgut malrotation.

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Diagnosis of LSAA is a challenge because of the absence of specific clinical presentation.

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Laparoscopic appendectomy is the standard treatment of LSAA.

Perspectives of association Baricitinib/Remdesivir for adults with Covid-19 infection

Background

The global COVID-19 pandemic is currently underway. A massive worldwide vaccination campaign is still underway, representing the most promising weapon available to stop the pandemic.

Methods and Results

However, research continues to investigate the most effective drug treatments to reduce and avoid the most serious complications caused by COVID-19 infection. Recently, new evidence of good therapeutic efficacy against COVID-19 has emerged for the antiviral Remdesivir and the immunomodulatory Baricitinib, also in combination. The first one showed SARS-CoV-2 antireplicative activity, the second one useful to reduce the hyperinflammatory state caused by cytokine storm in the most severe phases of the infection.

Conclusions

In this short communication we describe the molecular pharmacological mechanisms and the latest evidence for the use of these therapeutic agents in the treatment of COVID-19 infection.

P076 DIFFERENT SURGICAL APPROACH IN DIASTASIS RECTI REPAIR: IMPORTANCE OF AN OVERALL VIEW OF THE DISEASE

Aim

Diastasis Recti (DR) is characterized by a defect of the linea alba sometimes associated with midline hernias, and frequent lipocutaneous excess. We present our experience in the treatment of diastasis recti with Inter Recti Distance (IRD) &gt; 50mm -with or without umbilical hernia- by 3 different approaches.

Material and Methods

From January 2018 to February 2020, 104 patients were referred to our unit for clinical and radiological diagnosis of DR with IRD &gt; 50 mm. Three different surgical approaches were used, based on presence of lipocoutaneous excess: laparoabdominoplasty, laparominiabdominoplasty and minimally-invasive/endoscopic with Totally Sublay Anterior Repair (TESAR) approach.

Results

We performed 28 TESAR (29.8%), 44 laparoabdominoplasties (42.3%) and 32 laparominiabdominoplasties (30.8%). Overall complication rate was 26% (27 patients). In 3 (2.9%) cases major surgical complications (Clavien-Dindo 3-4) occurred, all for open operations. Minor complications (Clavien-Dindo 1-2) included: 13 cutaneous ischemia, 10 small muscular hematomas and 1 subcutaneous seroma. The overall median post-operative stay was 3 days (range 2 – 14 days), and 3, 4 and 3 days for TESAR, laparoabdominoplasty and laparominiabdominoplasty groups, respectively. No recurrence registered to date.

Conclusions

Our experience shows the importance of an overall view of the functional and cosmetic impairment created by the DR. The surgeon must obtain an optimal functional outcome also aiming for the best cosmetic result. Therefore different approaches have to be considered, tailored to the clinical, instrumental and psychological aspects of the disease. The complication rate, while in line with the literature, emphasize how in this type of operation the critical issues of functional as well as morphological surgery coexist.

Risk of drug-induced cardiac arrhythmia during COVID-19 therapeutic treatment

Therapeutic treatment of severe COVID-19 infection involves the administration of multiple pharmacologic agents to reduce the risk of serious complications; this may result in drug interactions and possible adverse reactions and induced cardiotoxicity. The risk-benefit ratio associated with the use of medications to treat COVID-19 should be carefully monitored. In addition, the severe COVID-19 patient may experience cardiac damage, and alteration of normal cardiac electrophysiology function. Severe COVID-19 with cardiac involvement and the risk of drug-induced adverse reactions may cause cardiac arrhythmias, including long qt syndrome, which in some cases may lead to sudden death. In this short review we briefly review the pharmacological agents used to treat severe COVID-19 with increased risk of causing long qt forms.

The risks of liver injury in COVID-19 patients and pharmacological management to reduce or prevent the damage induced

Background

The global pandemic COVID-19 caused by the new coronavirus SARS-CoV-2 has already caused about 1.4 million deaths, and to date, there are no effective or direct antiviral vaccines. Some vaccines are in the last stages of testing. Overall mortality rates vary between countries, for example, from a minimum of 0.05% in Singapore to a maximum of 9.75 in Mexico; however, mortality and severity of COVID-19 are higher in the elderly and in those with comorbidities already present such as diabetes, hypertension, and heart disease.

Main text

Recent evidence has shown that an underlying liver disease can also be a risk factor, and SARS-CoV-2 itself can cause direct or indirect damage to liver tissue through multisystem inflammation generated especially in the more severe stages. In the current pandemic, liver dysfunction has been observed in 14–53% of patients with severe COVID-19. In addition, drugs administered during infection may be an additional factor of liver damage. The mechanism of cellular penetration of the virus that occurs by viral entry is through the receptors of the angiotensin 2 conversion enzyme (ACE-2) host that are abundantly present in type II pneumocytes, heart cells, but also liver cholangiocytes.

Conclusion

In this manuscript, we describe the clinical management aimed at preserving the liver or reducing the damage caused by COVID-19 and anti-COVID-19 drug treatments.

Association and pharmacological synergism of the triple drug therapy baricitinib/remdesivir/rhACE2 for the management of COVID-19 infection

A massive vaccination campaign against the global COVID-19 pandemic caused by SARS-CoV-2 virus began worldwide in January 2021. However, studies continue to investigate the most effective and safe drug therapies to manage the various stages of viral infection. It is critical in the therapeutic management of the patient, with ongoing COVID-19 infection, to reduce viral load and replication, and to regulate the generalized hyperinflammatory state caused by the cytokine storm that occurs in the most severe phases. Probably the right drug therapy is represented by the use of different drugs acting in different modalities and on different targets, to avoid also viral drug resistance. In this article, we describe an interesting scientific pharmacological hypothesis arising from the evidence in the literature; we believe that the association of baricitinib/remdesivir/rhACE2, administered at the right time and dose, represents an important pharmacological synergism that can be therapeutically more effective for the treatment of COVID-19 infection than the single administration of drugs and avoid the phenomenon of drug resistance caused by the virus.

A new perspective on SARS-CoV-2 management

Baricitinib/remdesivir/rhACE2 may have an effective synergism of action

Avoiding viral drug resistance is of paramount importance

Beyond liquid biopsy: Toward non-invasive assays for distanced cancer diagnostics in pandemics

Liquid biopsy technologies have seen a significant improvement in the last decade, offering the possibility of reliable analysis and diagnosis from several biological fluids. The use of these technologies can overcome the limits of standard clinical methods, related to invasiveness and poor patient compliance. Along with this there are now mature examples of lab-on-chips (LOC) which are available and could be an emerging and breakthrough technology for the present and near-future clinical demands that provide sample treatment, reagent addition and analysis in a sample-in/answer-out approach. The possibility of combining non-invasive liquid biopsy and LOC technologies could greatly assist in the current need for minimizing exposure and transmission risks. The recent and ongoing pandemic outbreak of SARS-CoV-2, indeed, has heavily influenced all aspects of life worldwide. Ordinary tasks have been forced to switch from “in presence” to “distanced”, limiting the possibilities for a large number of activities in all fields of life outside of the home. Unfortunately, one of the settings in which physical distancing has assumed noteworthy consequences is the screening, diagnosis and follow-up of diseases.

In this review, we analyse biological fluids that are easily collected without the intervention of specialized personnel and the possibility that they may be used -or not-for innovative diagnostic assays. We consider their advantages and limitations, mainly due to stability and storage and their integration into Point-of-Care diagnostics, demonstrating that technologies in some cases are mature enough to meet current clinical needs.

Logistics management provides greater efficiency, governance and compliance

During the 2020 Congress of the Italian Society of Hospital Pharmacy (Sifo 2020), there was a heated debate about whether it is more convenient to dispense healthcare directly in hospitals and public facilities, or indirectly, through the use of external private pharmacies. The former solution is called "direct dispensing" (DD), while the latter is called "dispensing on commission" (DPC). The strengths and advantages of DD over DPC are many: greater therapeutic appropriateness due to direct control of treatment plans, cost savings from external commissions, and greater clinical sharing of treatment by all healthcare personnel. The main weakness is the organization of a complex warehouse. As the number of chronic patients and advanced therapies increases, direct care requires a new structure and logistics system to manage large administrative, accounting, and information flows. The purpose of this article is to compare the two logistic models implemented in Italy in order to structure a computerized model that can increase the efficiency of the National Health System (NHS).

Physiopathology and prospectives for therapeutic treatment of pulmonary fibrotic state in COVID-19 patients

The COVID-19 global pandemic has caused about 4,30 Mln deaths. Recently the first vaccines have been licensed, representing the most powerful weapon available to stop the pandemic. The COVID-19 viral infection in the most severe cases can cause severe lung lesions with the presence of fibrotic tissue. Even among cured individuals, the presence of pulmonary fibrotic tissue may be the major cause of long-term complications of COVID-19 requiring antifibrotic therapeutic treatment even in the post-COVID-19 infection phase to accelerate the healing process and fully recover lung function. This article reviews the fibrogenic mechanism of SARS-CoV-2-induced viral damage and the antifibrotic treatments indicated to treat sequelae post COVID-19 infection.

Clinical Pharmacology Aspects in Patients Treated with TNF Inhibitors During SARS-Cov-2 Pandemic

In this period of global pandemic caused by SARS-Cov-2, it is of paramount importance to recognize all risk factors that may increase the likelihood of infection. In addition to the risk factors known as pre-existing diseases and old age, risk factors could be drug treatments for chronic diseases, such as immunomodulating drugs that can alter immune defences and response to infectious agents. Antibodies that inhibit tumor necrosis factor (TNF) such as adalimumab infliximab etanercept and golimumab have been used for over 20 years in severe cases of autoimmune diseases such as rheumatoid arthritis, inflammatory bowel disease or ankylosing spondylitis. Due to their mechanism of action they reduce inflammation and can stop the progression of the disease by inhibiting a key factor of inflammation such as TNF. In this article we want to examine the possible correlation between therapy with TNF inhibitors and the increased risk of SARS-CoV-2 infection, and the possible paradoxical therapeutic efficacy in patients with ongoing infection, especially in phase two and three. We express our opinion on this very complex and sensitive topic which is the subject of discussion among physicians and experts, based on current knowledge of the literature.