Enoxaparin for thromboprophylaxis in hospitalized COVID-19 patients: The X-COVID-19 Randomized Trial

BACKGROUND

It is uncertain whether higher doses of anticoagulants than recommended for thromboprophylaxis are necessary in COVID-19 patients hospitalized in general wards METHODS: This is a multicentre, open-label, randomized trial performed in 9 Italian centres, comparing 40 mg b.i.d. versus 40 mg o.d. enoxaparin in COVID-19 patients, between April 30 2020 and April 25 2021. Primary efficacy outcome was in-hospital incidence of venous thromboembolism (VTE): asymptomatic or symptomatic proximal deep vein thrombosis (DVT) diagnosed by serial compression ultrasonography (CUS), and/or symptomatic pulmonary embolism (PE) diagnosed by computed tomography angiography (CTA). Secondary endpoints included each individual component of the primary efficacy outcome and a composite of death, VTE, mechanical ventilation, stroke, myocardial infarction, admission to ICU. Safety outcomes included major bleeding.

RESULTS

The study was interrupted prematurely due to slow recruitment. We included 183 (96%) of the 189 enrolled patients in the primary analysis (91 in b.i.d., 92 in o.d.). Primary efficacy outcome occurred in 6 patients (6.5%, 0 DVT, 6 PE) in the o.d. group and 0 in the b.id. group (ARR 6.5, 95% CI: 1.5-11.6). The absence of concomitant DVT and imaging characteristics suggests that most pulmonary artery occlusions were actually caused by local thrombi rather than PE. Statistically nonsignificant differences in secondary and safety endpoints were observed, with two major bleeding events in each arm.

CONCLUSIONS

No DVT developed in COVID-19 patients hospitalized in general wards, independently of enoxaparin dosing used for thromboprophylaxis. Pulmonary artery occlusions developed only in the o.d. group. Our trial is underpowered and with few events.

Impact of implementing a Choosing Wisely educational intervention into clinical practice: The CW-SIMI study (a multicenter-controlled study)

OBJECTIVES

To evaluate the impact of an educational intervention based on the Italian Society of Internal Medicine Choosing Wisely (CW-SIMI) recommendations.

DESIGN

Multicenter, interventional, controlled study.

SETTING

Twenty-three acute-care hospital wards in Italy.

PARTICIPANTS

303 Physicians working in internal medicine wards.

INTERVENTION

An online educational course.

MAIN OUTCOMES

The rate of proton pump inhibitor (PPI) prescriptions, the number of days of central venous catheter (CVC) usage, and the duration of intravenous (IV) antibiotic prescriptions evaluated at one month (T1) and at six months (T2) after course completion. Patients admitted and discharged during a 30-day period before the educational intervention (T0, one year before T2) were considered the comparison group.

RESULTS

A total of 232 physicians completed the course, while 71 did not attend the course. Data from 608, 662, and 555 patients were analyzed at T0, T1, and T2, respectively. The rate of PPI prescriptions declined at one month (RR: 0.67, 95% CI: 0.52-0.87, p = 0.0005) and at six months (RR: 0.62, 95% CI: 0.46-0.84, p = 0.003), and the number of days of CVC usage was reduced at six months (9.13 days at T0 vs. 5.52 days at T2, p = 0.007). The duration of IV antibiotic prescriptions displayed a decreasing trend (7.94 days at T0 vs. 7.42 days at T2, p = 0.081).

CONCLUSIONS

A simple online educational intervention based on the CW-SIMI recommendations was associated with a clinically relevant reduction in the usage of PPIs and CVCs. Further studies are needed to confirm these findings and a possible benefit on patients' outcomes.

Effects of laser photobiomodulation in the management of oral lichen planus: a literature review

Objectives

This review aims to understand whether Photobio-modulation (PBM) therapy is a valid aid in the management of Oral Lichen Planus (OLP) and its symptoms. Moreover, an analysis to determine whether it is a valid replacement for conventional therapies and whether standardized protocols can be used in PBM sessions or whether these should be changed depending on the type of injury has been made. Finally, an evaluation to determine whether PBM may induce transformation of dysplastic oral keratinocytes into squamous cell carcinoma has been made.

Materials and Methods

Searches were conducted on two search databases for relevant publications released between 1992 and 2019. The databases used were: Pubmed "Medline", and Google Scholar. Forty-four articles complied with the inclusion criteria and were included for quality assessment and data extraction.

Results

All the studies reported positive effects of PBM; how-ever, there was wide heterogeneity in the laser parameters used in the management of the OLP. The effective dose ranges from 2 to 3 J/cm2, in order to see the desired biological effects.

Conclusions

PBM is useful in controlling algal sensation and can be used in cases of OLP lesions that are not responsive to conventional therapies or when corticosteroid doses are too high for the patient, resulting in possible side effects. Standardized biostimulation protocols with further scientific insights are therefore required.

Report of a 'consensus' on the lines of therapy for primary immune thrombocytopenia in adults, promoted by the Italian Gruppo di Studio delle Piastrine

Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1. classification of four 'lines of therapy'; 2. acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3_I . practicability of splenectomy; 3_Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4_a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.

Postnatal Phencyclidine (PCP) as a Neurodevelopmental Animal Model of Schizophrenia Pathophysiology and Symptomatology: A Review

Cognitive dysfunction and negative symptoms of schizophrenia remain an unmet clinical need. Therefore, it is essential that new treatments and approaches are developed to recover the cognitive and social impairments that are seen in patients with schizophrenia. These may only be discovered through the use of carefully validated, aetiologically relevant and translational animal models. With recent renewed interest in the neurodevelopmental hypothesis of schizophrenia, postnatal administration of N-methyl-D-aspartate receptor (NMDAR) antagonists such as phencyclidine (PCP) has been proposed as a model that can mimic aspects of schizophrenia pathophysiology. The purpose of the current review is to examine the validity of this model and compare it with the adult subchronic PCP model. We review the ability of postnatal PCP administration to produce behaviours (specifically cognitive deficits) and neuropathology of relevance to schizophrenia and their subsequent reversal by pharmacological treatments. We review studies investigating effects of postnatal PCP on cognitive domains in schizophrenia in rats. Morris water maze and delayed spontaneous alternation tasks have been used for working memory, attentional set-shifting for executive function, social novelty discrimination for selective attention and prepulse inhibition of acoustic startle for sensorimotor gating. In addition, we review studies on locomotor activity and neuropathology. We also include two studies using dual hit models incorporating postnatal PCP and two studies on social behaviour deficits following postnatal PCP. Overall, the evidence we provide supports the use of postnatal PCP to model cognitive and neuropathological disturbances of relevance to schizophrenia. To date, there is a lack of evidence to support a significant advantage of postnatal PCP over the adult subchronic PCP model and full advantage has not been taken of its neurodevelopmental component. When thoroughly characterised, it is likely that it will provide a useful neurodevelopmental model to complement other models such as maternal immune activation, particularly when combined with other manipulations to produce dual or triple hit models. However, the developmental trajectory of behavioural and neuropathological changes induced by postnatal PCP and their relevance to schizophrenia must be carefully mapped out. Overall, we support further development of dual (or triple) hit models incorporating genetic, neurodevelopmental and appropriate environmental elements in the search for more aetiologically valid animal models of schizophrenia and neurodevelopmental disorders (NDDs).

Longitudinal analysis of heart and liver iron in thalassemia major patients according to chelation treatment

Iron chelators and nuclear magnetic resonance imaging (MRI) techniques for assessing iron loading in liver and heart have greatly improved survival of thalassemic patients suffering iron overload-associated cardiomyopathy. However, the correlation between liver iron concentration and myocardial siderosis is ambiguous. Using an objective metric of time delay, scientists have demonstrated a lag in the loading and unloading of cardiac iron with respect to that of the liver. In the present study, we further tested this hypothesis with different chelation treatments. We analyzed the effect of three chelating treatment approaches on liver and cardiac iron content in 24 highly compliant patients who underwent 3 or more MRIs under each chelation treatment. Of the 84 MRIs considered, 32 were performed on deferoxamine (DFO - 8 patients), 24 on deferiprone (DFP - 7 patients), and 28 on combined therapy (DFO+DFP - 9 patients). In patients treated with DFO, changes in cardiac iron significantly lagged changes in liver iron but the opposite pattern was observed in patients treated with DFP (p=0.005), while combined therapy showed a pattern in-between DFO and DFP. We conclude that the temporality of changes of cardiac and liver iron is chelator-dependent, so that chelation therapy can be tailored to balance iron elimination from the liver and the heart.

Analysis of red cell parameters on the Sysmex XE 2100 and ADVIA 120 in iron deficiency and in uraemic chronic disease

OBJECTIVE

The percentage measurement of hypochromic red cells (HYPO) and reticulocyte haemoglobin content (CHr) using the ADVIA system has recently been validated as a useful tool in indicating iron deficiency, also in cases of chronic diseases such as renal failure. The aim of this study was to evaluate the extent to which the red cell parameters, RBC-Y and RET-Y, provided by Sysmex XE 2100, correlate with HYPO and CHr.

MATERIAL AND METHODS

The laboratory markers of iron status were evaluated together with HYPO, CHr, RBC-Y and RET-Y in 92 healthy subjects (C), 42 iron-deficient patients (ID) and 88 uraemic patients receiving regular dialysis treatment (RDT).

RESULTS

In ID patients, increased HYPO and decreased RBC-Y, CHr and RET-Y values, with no overlapping with reference values, were found and a significant correlation was present between ADVIA 120 and Sysmex indices (p<0.001 for each correlation). In RDT patients, HYPO median values were increased with a wide distribution of values (95 % reference range = 0.7-27.5 % and 0.7-22.6 % in men and women, respectively). In contrast, RBC-Y was normal/increased (95 % reference range = 169.4-191.1 and 168.7-190.5 in men and women, respectively), even though there was a significant correlation between them (p<0.001). CHr and RET-Y values were within the reference range; moreover, in these patients mean cell volume of red cells and of reticulocytes (MCV and MCVr) median values were increased.

CONCLUSIONS

This study confirmed the validity of RBC-Y in the management of ID, but not in RDT, where the diagnostic power of RBC-Y as an index of cell hypochromia is limited owing to high MCV values.

[Percutaneous neurolysis of the celiac plexus under CT guidance in the invasive treatment of visceral pain caused by cancer]

To verify the effectiveness and the incidence of complication in the transcutaneal celiac plexus block with CT-guided in the patient with intractable upper abdominal cancer, using alcoholic solutions to different concentrations (50% and 96%), previous insertion of the peridural catheter. From December 1997 to June 2002, studies were carried out on 24 patients with CT-guided percutaneous coeliac plexus neurolysis including 17 men and 7 women with inoperable abdominal malignancy and two with chronic pancreatitis. The patients were affected by very intense pain controllable only with high doses of analgesic narcotics. Before the procedure a catheter was installed in the peridurale space between L1-T12. To avoid general anesthesia, 40 mL of marcaine 0.5% was injected to relieve the back pain sometimes reported after the neurolysis, caused by the diffusion of alcohol in the coeliac plexus. This technique requires a posterior percutaneous procedural transaortic approach CT scan guided, to determine the correct position of the needle tips and the spread of neurolytic solution (40 mL of 96% + 3 mL of contrast medium) around the origin of the coeliac trunk's anatomical center of the plexus. The first 10 patients have received 40 mL of 50% ethyl alcohol + 3 mL of contrast medium. To evaluate the rate of the analgesia relief, a visual analogue pain score (VAS) was used before and 48 hours after the neurolysis. The percutaneous neurolysis of the celiac plexus is useful to relieve the pain in patients affected by cancer developing in upper abdomen. The CT-scan guide of the needle allows an omogeneous distribution of the contrast medium. The insertion of the peridural catheter made a complete analgesia and reduced the incidence of complications. Our method provided an excellent control of the pain in all patients. In our experience the pain relief was almost complete in patients treated with 96% ethyl alcohol solution (VAS from 8 before the treatment to 1, 48 hours after the treatment). The alcohol administered in elevated concentrations (96%), does not increase the incidence of complications.

Electrospray ionisation tandem mass spectrometry in the characterisation of isomeric benzofurocoumarins

A set of aminoalkoxy-substituted, differently annullated furocoumarins, differing in the position of the aminoalkoxy chain and in the unsaturation level of the fused ring, has been subjected to electron impact and electrospray ionisation (ESI) experiments. In order to achieve a distinct characterisation of isomeric compounds, which partially failed under electron impact conditions, collision-induced dissociation experiments were performed on protonated molecules. The breakdown curves obtained by varying the tickle voltage on an ion trap ESI instrument led to the desired characterisation.

Vesicle formation from hexasubstituted cyclophosphazenic derivatives

Hexakis[butoxytris(ethoxy)]cyclophosphazene (3a), hexakis[dodecyloxytetrakis (ethoxy)]cyclophosphazene (3b) and hexakis[hexadecyloxyeicosanekis(ethoxy)]cyclophosphazene+ ++ (3c) were synthesised and their ability to form niosomes was studied. All synthesised compounds in the presence of cholesterol were shown to form vesicles, which aggregated strongly. To prevent aggregation, dicetylphosphate was used. The capacity of the sonicated and unsonicated niosomes to encapsulate hydrophile and lipophile molecules was also studied using carboxyfluorescein and diphenylhexatriene.

Implant periapical lesions: clinical, histologic, and histochemical aspects. A case report

A new entity, the "implant periapical lesion," has recently been described. The etiology of this condition could be attributed to overheating of the bone, overloading of the implant, presence of a pre-existing infection or of residual root particles and foreign bodies in the bone, implant contamination during production or during insertion, or placement of the implant in an infected maxillary sinus. In this report, a titanium plasma-sprayed implant had been inserted into the mandible of a 53-year-old patient; after 5 months a fistula developed and periapical radiography showed a large radiolucent image around the apical portion of the implant. The implant was removed, and histologic examination showed necrotic bone and an inflammatory infiltrate inside the hollow portion of the implant. The etiology of the implant failure in this instance could be related to a fracture and vascular impairment of the bone inside the implant during insertion, to external contamination of the implant, or to the poor bone quality of the implant site.

Matrix-assisted laser desorption/ionization mass spectrometry in the dairy industry. 2. The protein fingerprint of ewe cheese and its application to detection of adulteration by bovine milk

Ewe milk and ewe cheese samples were analysed by matrix-assisted laser desorption/ionization mass spectrometry and their protein profiles were compared with those obtained from bovine milk and bovine cheeses. Various mixtures of bovine and ewe cheeses in different weight ratios were analysed, leading to a reproducible calibration curve, which has been successfully employed in determining the percentage of bovine milk fraudulently added to ewe milk in the production of marketed ewe cheese.

Clinical and histological results in alveolar ridge enlargement using coralline calcium carbonate

A very important parameter during the insertion of dental implants is the amount of bone present in a site. A regenerative procedure to increase the width and the height of bone is proposed with the use of occlusive barrier membranes and biomaterials. The authors used, in six patients with deficient alveolar ridges, prior to implant insertion, Biocoral gel particles in connection with expanded polytetrafluoroethylene membranes. After 6 months it was observed that a tissue similar to mature bone had regenerated under the membrane and microscopically it was observed that the Biocoral particles were still present and almost all were completely surrounded by mature bone.

Synthesis and mass spectrometric behavior of some new nucleosides as potential anti-HIV agents

The electron-impact (EI) mass spectrometric behaviour of a series of 8-aza-purines derivatized with hydroxymethylcyclopentane and exhibiting cis-trans isomerization in the cyclopentane ring has been studied in detail with the aid of metastable-ion data. Specific fragmentation processes, present in both EI and mass analysed ion kinetic energy spectra of molecular species, allow characterization of the different pairs of stereoisomers. Contrary to what is observed in the case of purine analogs, the presence of a nitrogen atom in position 8 strongly inhibits fragmentation processes related to the heterocycle.

Histological evaluation of bone reactions to aluminium oxide dental implants in man: a case report

Alumina implants have been shown to possess high biocompatibility. The authors present the case of an aluminium oxide ceramic implant removed because of fracture of the abutment after a 30-month loading period. It was possible to observe microscopically that the implant was covered by highly mineralized mature compact lamellar bone; no connective tissue or inflammatory cells were present at the interface. Osteocytes were observed very close to the bone-implant interface. These features indicate the good biocompatibility of the implant.

Macrocyclic polyesters. I. A novel class of 1,3-butandiol derivatives as potential antimicrobial agents

This paper reports the synthesis of a novel class of macrocyclic tetraesters containing 1,3-butandiol sub-units by reacting the stannolan derivative of the diol with diacyl chloride. The structure of the possible isomers was assigned by spectroscopic data and comparison with samples otherwise prepared. Preliminary screening revealed that these compounds have low antimicrobial activity, although it is higher than that of the starting diol.

Deferoxamine-induced growth retardation in patients with thalassemia major

In the retrospective study reported here, we compared the longitudinal growth in three groups of children with thalassemia major who received a similar transfusion program but different schedules of chelation treatment. In those patients who initiated deferoxamine (DF) administration by daily subcutaneous infusion (50 to 80 mg/kg/day) simultaneously with the beginning of transfusion (at 8 +/- 6 months), mean height at 2 to 6 years of age was significantly reduced in comparison (1) with those patients who initiated DF subcutaneous treatment after 3 years at similar doses and (2) with those who were treated intramuscularly with small doses. In the patients treated at an early stage, those with more marked stunted growth had a clinical and radiologic ricketslike syndrome associated with joint stiffness. Mineral metabolism studies in these patients showed a reduction of hair and leukocyte zinc levels and leukocyte alkaline phosphatase activity. Our findings indicate that DF administration at high doses by continuous infusion before iron overload has been established adversely affects longitudinal growth. By contrast, after 3 years of age, even large doses (in the order of 100/mg/kg/day) did not result in growth retardation. The growth retardation observed may be related to chelation of other trace elements, including zinc, in the presence of low iron burden, to the direct toxic effect of unchelated DF by interference with critical iron-dependent enzymes, or both. These results indicate that in patients with thalassemia major, DF administration should be initiated only after iron accumulation is established, namely, around 3 years of age, after 20 to 30 transfusions, which are usually associated with ferritin levels in the range of 800 to 1000 ng/ml. At this age, deferoxamine doses should be established on the basis of iron balance studies and dose response curves. Doses higher than 50 to 60 mg/kg do not adversely affect growth but produce toxic side effects on acoustic and visual pathways and therefore should not be used. Longitudinal growth monitoring of DF-treated patients is warranted.