Association between respiratory distress time and invasive mechanical ventilation in COVID-19 patients: A multicentre regional cohort study

AIM

To determine whether the duration of respiratory distress symptoms in severe COVID-19 pneumonia affects the need for invasive mechanical ventilation and clinical outcomes.

MATERIALS AND METHODS

An observational multicentre cohort study of patients hospitalised in five COVID-19-designated ICUs of the University Hospitals of Emilia-Romagna Region. Patients included were adults with pneumonia due to SARS-CoV-2 with PaO₂/FiO₂ ratio <300 mmHg, respiratory distress symptoms, and need for mechanical ventilation (invasive or non-invasive). Exclusion criteria were an uncertain time of respiratory distress, end-of-life decision, and mechanical respiratory support before hospital admission.

MEASUREMENTS AND MAIN RESULTS

We analysed 171 patients stratified into tertiles according to respiratory distress duration (distress time, DT) before application of mechanical ventilation support. The rate of patients requiring invasive mechanical ventilation was significantly different (p < 0.001) among the tertiles: 17/57 patients in the shortest duration, 29/57 in the intermediate duration, and 40/57 in the longest duration. The respiratory distress time significantly increased the risk of invasive ventilation in the univariate analysis (OR 5.5 [CI 2.48-12.35], p = 0.003). Multivariable regression analysis confirmed this association (OR 10.7 [CI 2.89-39.41], p < 0.001). Clinical outcomes (mortality and hospital stay) did not show significant differences between DT tertiles.

DISCUSSION

Albeit preliminary and retrospective, our data raised the hypothesis that the duration of respiratory distress symptoms may play a role in COVID-19 patients' need for invasive mechanical ventilation. Furthermore, our observations suggested that specific strategies may be directed towards identifying and managing early symptoms of respiratory distress, regardless of the levels of hypoxemia and the severity of the dyspnoea itself.

The role of snow in scavenging aerosol particles: A physical-chemical characterization

The below cloud scavenging of aerosols by snow has been analysed in León (NW Spain). Six snow events were registered over the course of one year of study. Ultrafine and accumulation aerosol particles were measured using a scanning mobility particle sizer spectrometer, while hydrometeors were characterized using a disdrometer. Furthermore, the chemical composition of the melted snow-water samples (soluble and insoluble fractions) was analysed. The scavenging coefficient (λ) showed a great variability among events. An effective washing of particles was observed during the first 30 min of snowfall. The mean change in the scavenging efficiency (%ΔC) of particle number concentration (PNC) and λ coefficient during this time interval were: i) nucleation mode: 36.3 % and 3.02 · 10-4 s-1; ii) Aitken mode: 30.4 % and 2.37 · 10-4 s-1 and iii) accumulation mode: 22.4 % and 1.77 · 10-4 s-1. The range of particle sizes that is less efficiently scavenged by snowfall was observed between 400 and 600 nm. When analyzing the whole snow event, an increase of PNC was observed. Two possible explanations underlie this behaviour: it could be caused by changes in air masses or by the resuspension of aerosol particles scavenged by snowflakes upon reaching the ground. A clear relationship was observed between Ca2+, SO42- and NO3- concentrations of aerosol particles before the snow event and the concentrations registered in the melted snow-water. The largest and smallest changes in aerosol number concentrations were caused by snowflakes of 3 and 6 mm in diameter, respectively. The particle size distributions (PSD) were fitted to log-normal distributions and the parameters were compared before and after snowfall.

Feasibility and efficacy of a multidisciplinary palliative approach in patients with advanced interstitial lung disease. A pilot randomised controlled trial

INTRODUCTION AND OBJECTIVES

Interstitial lung diseases (ILDs) encompass a heterogeneous group of parenchymal lung disorders which have a significant burden on quality of life and exercise. The primary purpose of this randomised pilot trial performed in advanced ILD was to determine the feasibility and efficacy of a multidisciplinary palliative care approach (including physiotherapist, psychologist, pulmonologists, and palliative care doctors) to relieve patients' symptoms of dyspnoea, depression measured with the Center for Epidemiological Studies-Depression (CES-D) scale and quality-of-life (QoL) at 6 and 12 months.

MATHERIALS AND METHODS

Fifty patients with confirmed interstitial lung disease at computed tomography (CT) scan and advanced disease were enrolled at our clinic. Patients were randomised to usual care group vs intervention group; in the intervention group, patients were scheduled to meet a physiotherapist, a psychologist, a palliative care doctor, and a pulmonologist specialized in ILD care. Data on dyspnoea, cough, quality of life and depression were recorded; patients in the intervention group were also tested to assess lower body flexibility and strength.

RESULTS

Both groups showed a worsening in dyspnoea during the time course of the trial, but the Borg scale was less in the intervention group at 6 and 12 months. A similar trend was observed also for the CES-D scale. No differences were observed for the other scales.

CONCLUSIONS

A multi-disciplinary palliative care intervention in patients with advanced fibrosing interstitial lung disease is feasible and effective.

TRIAL REGISTRATION

NCT02929966 on ClinGovTrial.

Magnetic and elemental characterization of the particulate matter deposited on leaves of urban trees in Santiago, Chile

Airborne particulate matter is a serious threat to human health, especially in fast-growing cities. In this study, we carried out a magnetic and elemental study on tree leaves used as passive captors and urban dust from various sites in the city of Santiago, Chile, to assess the reliability of magnetic and elemental measurements to characterize particulate matter pollution from vehicular origin. We found that the magnetic susceptibility and saturation isothermal remanent magnetization measured on urban tree leaves is a good proxy for tracing anthropogenic metallic particles and allow controlling the exposure time for particulate matter collection, in agreement with other studies carried out in large cities. Similar measurements on urban soil can be influenced by particles of detritic (natural) origin, and therefore, magnetic measurements on tree leaves can help to identify hotspots where fine particles are more abundant. Elemental particle-induced X-ray emission analysis of tree leaves showed the presence of a number of elements associated with vehicular emissions, in particular Cu, Zn, Fe, K and S which are present at every site, and As, Se, V, Ni, Sr, Zr, Mo and Pb identified at some sites. We observed a correlation between magnetic parameters and the concentrations of S and Br as well as Cu to a smaller extent. Moreover, this study shows the importance of selecting carefully the tree species as well as the location of trees in order to optimize phytoremediation.

Time course of ischemic and bleeding burden in consecutive patients undergoing transcatheter aortic valve replacement (FOCUS-ONE registry)

BACKGROUND AND AIMS

Ischemic or bleeding events might occur after transcatheter aortic valve replacement (TAVR), with the potential to hamper clinical outcomes. This study aimed to characterize the average daily ischemic risks (ADIRs) and the average daily bleeding risks (ADBRs) over 1-year in all consecutive patients undergoing TAVR.

METHODS

ADBR included all bleeding events according to VARC-2 definition, and ADIR included cardiovascular deaths, myocardial infarction and ischemic stroke. ADIRs and ADBRs were assessed within different timeframes post TAVR: acute (0-30 days), late (31-180 days), and very late (>181 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparison of ADIRs and ADBRs. Our analysis was performed in the overall cohort and according to antithrombotic strategy (LT-OAC vs No LT-OAC).

RESULTS

Ischemic burden was higher than bleeding burden, independently from the indication to LT-OAC, and in all timeframes examined. In the overall population, ADIRs were three-fold ADBRs (0.0467 [95% CI, 0.0431-0.0506] vs 0.0179 [95% CI, 0.0174-0.0185]; p < 0.001*). While ADIR was significantly higher in the acute phase, ADBR was relatively stable in all timeframes analysed. Of note, in LT-OAC population, OAC + SAPT group showed lower ischemic risk and higher bleeding events compared with OAC alone (ADIR: 0.0447 [95% CI: 0.0417-0.0477] vs 0.0642 [95% CI: 0.0557-0.0728]; p < 0.001*, ADBR 0.0395 [95% CI: 0.0381-0.0409] vs 0.0147 [95% CI: 0.0138-0.0156]; p < 0.001*).

CONCLUSIONS

In patients undergoing TAVR Average daily risk fluctuates over time. However, ADIRs overcome ADBRs in all timeframes, especially in the acute phase and regardless of antithrombotic strategy adopted.

COVID-19 and acute heart failure among patients with cancer

Background

Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for death. However, detailed information on causes of death and the contribution of pre-existing health conditions to death yet is missing.

Purpose

This study focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer by assessing the relation between cancer and de novo acute heart failure (AHF) with in-hospital mortality.

Methods

The initial population consisted of 3968 patients included in the ISACS COVID-19 registry between March 2020 and February 2022. Of these, 546 patients with chronic HF were excluded, leaving a final population of 3422. Patients were divided in two groups according to the presence or absence of a cancer diagnosis at the time of hospitalization for COVID-19. Primary outcomes were incidence of in-hospital mortality or AHF during hospitalization. Association between cancer and outcomes was estimated using multivariable logistic regression analyses. Subsidiary analysis was conducted to evaluate differences between patients with prior vs active cancer.

Results

Of the 3422 patients included in the study, 468 patients had cancer (8.2% active, 5.5% past cancer). Cancer patients were older (68.9±13.4 vs 63.3±15.6, p-value &lt;0.001) and more likely to be female (50.4% vs 39.1%, p-value &lt;0.001). They presented more frequently with a history of chronic obstructive pulmonary disease (12.3% vs 7.6%, p-value = 0.001). When considering outcomes, cancer patients had a significantly higher incidence of in-hospital mortality (27.7% vs 19.2%; p-value &lt;0.001). This despite the presence of a numerically higher mean PiO2/FiO2 (281±108.8 vs 267.05±122.5, p-value = 0.11) on admission and a lower rate of X-ray findings of interstitial pneumonia (60% vs 70.5%, p-value &lt;0.001) than their non-oncological counterparts, as well as similar use of mechanical ventilation (30.6% vs 35.0%, p value=0.14). The association between cancer and death persisted when adjusting for demographic, laboratory findings and in-hospital treatment (OR: 1.46; 95% CI: 1.11–1.94; p value=0.01). Cancer patients also had higher rates of AHF (9.6% vs 4.7%, p-value &lt;0.001) during hospitalization. This association was independent from presence of cardiovascular risk factors or comorbidities (OR: 1.61; 95% CI: 1.07–2.43; p value=0.02). When restricting the analysis to the cancer population, AHF appeared to be significantly associated with death (OR: 2.41; 95% CI 1.18–4.95; p-value = 0.01), but this correlation persisted only in patients affected by active cancer in age and sex adjusted analyses (OR: 4.27; 95% CI: 1.51–12.07; p value=0.01 vs 1.20; 95% CI: 0.38–3.76; p-value = 0.75).

Conclusions

The incidence of AHF in cancer patients with COVID-19 is high. Patients with active cancer are also at high risk for mortality. This has implications for cardiac monitoring and chemotherapy administration during COVID-19.

Funding Acknowledgement

Type of funding sources: None.

Detection of Neorickettsia sp. in Oligoryzomys flavescens rodent from a protected urban area in Buenos Aires City (Argentina)

Rodents play an important role in vector-borne pathogens cycle. To detect Anaplasma, Ehrlichia, Neorickettsia, Rickettsia and Borrelia species in rodents from a protected urban area in Buenos Aires City (Argentina) were analyzed 203 organ pools of Mus musculus, Oligoryzomys flavescens, Rattus norvegicus, Deltamys kempi and Scapteromys aquaticus by PCR. Only one O. flavescens (1.2%) was positive by PCR for 16S rRNA fragment for the Anaplasmataceae family and the sequence had 99.7% identity with Neorickettsia risticii. Plus, the sequence obtained for a fragment of the p51 gene for the genus Neorickettsia from positive sample had 95.3-96.1% identity with N. risticii found previously in bats Tadarida brasiliensis from Buenos Aires City. Our study presents the first finding of Neorickettsia in rodents from natural environment, but further studies are necessary about these vector-borne bacteria and the rol of rodents in its epidemiology.

Ablation in patients with Ebstein Anomaly and Wolff Parkinson White Syndrome

Funding Acknowledgements

Type of funding sources: None.

Background - Introduction: Ablation in patients with Ebstein Anomaly (EA) and Wolff Parkinson White syndrome (WPW) is challenging due to the complex anatomy and the presence of multiple accessory pathways (AP).

Objectives

Report the results of our recent experience of ablation in patients with EA and WPW syndrome.

Methods

We conducted a retrospective review of the cases of EA and WPW syndrome, which were taken to ablation in our center between 2015 and 2020.

Results

We found that in the indicated period 30 electrophysiological studies and ablations had been performed in 26 patients, 53.8% were males and the mean age at the time of the study was 20.6 ± 9.1 years, the mean tricuspid septal valve attachment was 44.5 ± 17.7%.

Regarding the procedures, 15 were conventional studies (50%) and 15 (50%) were performed with electroanatomical mapping. We used intracardiac echocardiogram (ICE) in 10 cases (33.3%). The acute success rate was 85.7% and in the follow-up 3 patients (10%) presented recurrence. Only one patient presented a major complication, which was a complete AV block. There was a tendency to improve the acute success with the use of electroanatomical mapping in comparation with conventional studies (93.3% vs 66.6%, p = 0.068), and with the use of ICE acute success was significantly improved (100% vs 70%, p = 0.04).

Seven patients presented multiple accessory pathways (26.9%). The most frequent location was the right posterolateral with 61.53%, followed by the right posteroseptal with 26.9% and the right lateral with 19.2%.

Conclusions

The ablation in patients with EA and WPW syndrome constitutes a challenge, we found that the use of electroanatomical mapping and the use of ICE could improve the acute success rate. New studies are needed to demonstrate the usefulness of these techniques to improve the acute success rate and to reduce the recurrence rate. ProceduresProcedures (N = 30)N%Conventional procedures1550.0Electroanatomical mapping1550.0Intracardiac echocardiogram1033.3Acute success2485.7Recurrence310.0Major complication13.3Descriptive table of our experience in ablation of patients with ED and WPW syndrome.Abstract Figure. Location of the accessory pathways

Impact of the COVID-19 pandemic on electrophysiological procedures at a national referral center

Funding Acknowledgements

Type of funding sources: None.

Background - Introduction: The COVID-19 pandemic has generated serious repercussions on the health system, reducing the number of all cardiology procedures worldwide.

Objectives

Describe the impact of the COVID-19 pandemic on the procedures performed by the electrophysiology department in a national referral center. 

Methods

We made a retrospective review of our data base and we compared procedures made in the last 3 years since 2017 to 2019 with the procedures made in the 2020. We divide the procedures into two large groups: Cardiac Implantable Electronic Devices (CIED) related procedures (which included implants, revisions, changes, upgrades and extractions) and electrophysiological studies and ablations (which included conventional and complex procedures). Other types of procedures were no included.

Results

There was a significant reduction in all procedures, the average of procedures performed in the last 3 previous years was 467 (there were 479 in 2017, 411 in 2018 and 511 in 2019), while in 2020 we performed only 319 (p = 0.01); this represents a reduction of 33.4% in the total number of procedures performed in our center. There was no statistical difference regarding the CIED related procedures, the average of procedures of the last 3 previous years was 174 (there were 186 in 2017, 148 in 2018 and 188 in 2019), and in 2020 we performed 189 procedures, this value is near to the average of the last 3 previous years and very close to the value of the 2019 (p = 0.46).

Regarding the electrophysiological studies and ablations, the average of procedures of the last 3 previous years was 293 (there were 293 in 2017, 263 in 2018 and 323 in 2019), while in 2020 we performed only 129 procedures, considerably decreasing compared to the previous years (p &lt; 0.01). The reduction in the electrophysiological studies and ablations was 55.97%. The most affected months were April, May and June.

Conclusions

The COVID-19 pandemic considerably affected the number of electrophysiological procedures in our center, reducing it by 33.4% compared to the previous years. The reduction of procedures fundamentally affected the electrophysiological studies and ablations, reducing them by 55.97%. The number of CIED related procedures were no affected. Electrophysiological procedures Procedures2017201820192017-2019 average2020CIED related procedures186148188174189Electrophysiological studies and ablations293263323293129Total479411511467319Comparative table of the electrophysiological procedures performed in our center in recent years.Abstract Figure. Comparison of the procedures.

LABEC, the INFN ion beam laboratory of nuclear techniques for environment and cultural heritage

The LABEC laboratory, the INFN ion beam laboratory of nuclear techniques for environment and cultural heritage, located in the Scientific and Technological Campus of the University of Florence in Sesto Fiorentino, started its operational activities in 2004, after INFN decided in 2001 to provide our applied nuclear physics group with a large laboratory dedicated to applications of accelerator-related analytical techniques, based on a new 3 MV Tandetron accelerator. The new accelerator greatly improved the performance of existing Ion Beam Analysis (IBA) applications (for which we were using since the 1980s an old single-ended Van de Graaff accelerator) and in addition allowed to start a novel activity of Accelerator Mass Spectrometry (AMS), in particular for ¹⁴C dating. Switching between IBA and AMS operation became very easy and fast, which allowed us high flexibility in programming the activities, mainly focused on studies of cultural heritage and atmospheric aerosol composition, but including also applications to biology, geology, material science and forensics, ion implantation, tests of radiation damage to components, detector performance tests and low-energy nuclear physics. This paper describes the facilities presently available in the LABEC laboratory, their technical features and some success stories of recent applications.

KCNQ1 V141M and Short QT Syndrome: are we dealing with a different entity?

 

Short QT Syndrome (SQTS) is a highly malignant inherited primary electrical disease that is associated with ventricular arrhythmias and sudden cardiac death (SCD); despite this, some patients may present a different arrhythmic phenotype with supraventricular affection. One particular presentation can be notably separated from others. The V141M variant from the KCNQ1 gene frequently presents with fetal bradycardia, atrial fibrillation, sinus, and AV node dysfunction, but without a single reported event of ventricular arrhythmia.

To perform a literature review and pool analysis of SQTS cases, and compare patients with the V141M mutation in KCNQ1 to other SQTS cases to determine if we are dealing with a different electrical disorder.

We conducted a search in the Varsome, Mastermind, MEDLINE, PubMed, and ClinVar databases to identify SQTS patients and conduct a pooled analysis. Their age, gender, clinical presentation, ECG findings, genetic analysis, and follow-up assessment were collected for analysis. If the duration of the QT interval was not described, it was determined by direct measurements in published ECG. For the comparison between groups, SQTS patients, we separated into two main groups: Non-KCNQ1 V141M patients (Group 1) and positive KCNQ1 V141M mutation (Group 2). Categorical variables are expressed as percentages. The categorical variables were analyzed using chi-square or Fisher exact test when necessary.

We gathered 56 patients with a diagnosis of SQTS from 27 previous publications combined with one other case followed by the authors. A total of 13 (23.2%) patients presented with the V141M KCNQ1 mutation, the majority of KCNQ1 V141M patients were female (10 [77%]). Patients from group 1 had a significantly higher rate of familiar SCD (53.4% vs. 18.1%; P=0.04). Patients from the latter group have a significant history of SND when compared to the control group (36.3% vs. 0; P=0.001). The presence of SCD showed no significant difference between the two groups; nevertheless, the difference regarding ventricular arrhythmias is well represented (41.8% vs. 0; P=0.01). Both sinus and AV node dysfunction were present in almost all V141M patients when compared to the control group; a statistical significance was found (P = &gt;0.001 for both instances). On the same regard, almost all patients from de V141M group presented SVA (84.6% vs 28.5%; P=0.001), specifically atrial fibrillation was present in all but 2 patients from the V141M group, which was significant (84.6% vs 24.3%; P = &gt;0.001). Finally, fetal bradycardia was present in most of the members of this group, in contrast with the control group, with no patients with this characteristic (P = &gt;0.001).

SQTS is a phenotypically heterogeneous disease with many genetic subtypes; we propose a differentiation between the common known presentations of this syndrome and the more defined phenotype of the KCNQ1 V141M mutation.

First Mexican patient with SQTS

Funding Acknowledgement

Type of funding source: None

Chemical composition of rainwater under two events of aerosol transport: A Saharan dust outbreak and wildfires

A one-year campaign of joint sampling of aerosols and precipitation, carried out in León, Spain, allowed to study the impact of two special events that affected the air quality in the north of the country, on rainfall in the city: a period with wildfires and a Saharan dust intrusion. The wildfires that occurred in northern Portugal and northwestern Spain in August 2016 affected the chemistry of rainfall on 15 August 2016, causing an increase in concentrations of NH₄⁺, Na⁺, Cl^-, K⁺, Mg²⁺, Ca²⁺, SO₄^2- and NO₃^- and in the concentrations of organic acids, which was reflected in the levels of soluble and insoluble organic carbon. This led to acidification of rainwater (pH = 4.8). The second precipitation event was registered between 11 and 14 February 2017, during which the rainwater was collected in four daily fractions (P₁, P₂, P₃ and P₄). The rain sample of 12 February (P₂) coincided with a Saharan dust intrusion that reached northern Iberia that day. The chemical composition of P₂ showed an increase in the Ca²⁺ (>800%), Mg²⁺ (71%), Cl^- (62%), and SO₄^2- (33%) concentrations, with respect to P₁. The input of crustal elements to the atmosphere helped to neutralize the P₂ rainwater, causing pH values higher than 6.5. Once the dust intrusion left the north of the Peninsula, the composition of rainwater P₃ and P₄ revealed a mixture of marine contribution with local anthropogenic emissions, as well as a decrease in ion concentrations and conductivity, and an increase in pH values.

Management strategies to minimize the use of synthetic chemical acaricides in the control of the cattle tick Rhipicephalus (Boophilus) microplus (Canestrini, 1888) in an area highly favourable for its development in Argentina

The aim of this work was to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Canestrini, 1888) (Ixodida: Ixodidae) in an area highly favourable for its development in Argentina. Control schemes using three or four annual applications of synthetic acaricides were evaluated. Furthermore, the dynamics of the non-parasitic phases of R. microplus were analysed to provide a framework for the application of pasture spelling as a tool for tick control. The treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in abundance of this tick in autumn. A significant overall effect against R. microplus can be achieved when the control strategies tested in this study are applied within the area most ecologically favourable for this tick in Argentina. Analysis of the dynamics of the non-parasitic phase of R. microplus indicates that the spelling period required to achieve a significant reduction of larvae in pastures fluctuates between 12 and 17 weeks if spelling is initiated in spring or early summer, but between 20 and 28 weeks if spelling is started in late summer, autumn or winter.

Unusual winter Saharan dust intrusions at Northwest Spain: Air quality, radiative and health impacts

Saharan air masses can transport high amounts of mineral dust particles and biological material to the Iberian Peninsula. During winter, this kind of events is not very frequent and usually does not reach the northwest of the Peninsula. However, between 21 and 22 February 2016 and between 22 and 23 February 2017, two exceptional events were registered in León (Spain), which severely affected air quality. An integrative approach including: i) typical synoptic conditions; ii) aerosol chemical composition; iii) particle size distributions; iv) pollen concentration; v) aerosol optical depth (AOD); vi) radiative forcing and vii) estimation of the impact of aerosols in the respiratory tract, was carried out. In the global characterization of these events, the exceedance of the PM₁₀ daily limit value, an increase in the coarse mode and a rise in the iron concentration were observed. On the 2016 event, an AOD and extinction-related Ångström exponent clearly characteristic of desert aerosol (1.1 and 0.05, respectively) were registered. Furthermore, pollen grains not typical of flowering plants in this period were identified. The chemical analysis of the aerosol from the 2017 event allowed us to confirm the presence of the main elements associated with mineral sources (aluminum, calcium, and silica concentrations). An increase in the SO₄^2-, NO₃^- and Cl^- concentrations during the Saharan dust intrusion was also noted. However, in this event, there was no presence of atypical pollen types. The estimated dust radiative forcing traduced a cooling effect for surface and atmosphere during both events, corroborated by trends of radiative flux measurements. The estimated impact on the respiratory tract regions of the high levels of particulate matter during both Saharan dust intrusions showed high levels for the respirable fraction.

Efficacy of winter-spring strategic control against Rhipicephalus (Boophilus) microplus infestations on cattle in an area with ecological conditions highly favourable for the tick in northeast Argentina

This work was performed to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Ixodida: Ixodidae) infestations on cattle in the area ecologically most favourable for the development of this tick in Argentina. Two control schemes using three and four annual applications of acaricides, respectively, were evaluated. Animals in Group 1 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, and fipronil on day 85. Animals in Group 2 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, flumethrin on day 85, and fipronil on day 114. Animals in Group 3 represented the control group. Both treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in the frequency of this tick in autumn. The two treatment schemes were similar in terms of efficacy and thus the addition of a fourth treatment does not seem to confer any further advantage. The results of this work indicate that these strategic control methods provide appropriate levels of control against R. microplus.

Combined use of daily and hourly data sets for the source apportionment of particulate matter near a waste incinerator plant

A particulate matter (PM) source apportionment study was carried out in one of the most polluted districts of Tuscany (Italy), close to an old waste incinerator plant. Due to the high PM10 levels, an extensive field campaign was supported by the Regional Government to identify the main PM sources and quantify their contributions. PM10 daily samples were collected for one year and analysed by different techniques to obtain a complete chemical characterisation (elements, ions and carbon fractions). Hourly fine (<2.5 μm) and coarse (2.5-10 μm) aerosol samples were collected by a Streaker sampler for a shorter period and hourly elemental concentrations were obtained by PIXE. Positive Matrix Factorization (PMF) analysis of daily and hourly data allowed the identification of 10 main sources: six anthropogenic (Biomass Burning, Traffic, Secondary Nitrates, Secondary Sulphates, Incinerator, Heavy Oil combustion), two natural (Saharan Dust and Fresh Sea Salt) and two mixed sources (Local Dust and Aged Sea Salt). Biomass burning turned out to be the main source of PM, accounting for 30% of the PM10 mass as annual average, followed by Traffic (18%) and Secondary Nitrates (14%). Emissions from the Incinerator turned out to be only 2% of PM10 mass on average. PM10 composition and source apportionment have been assessed in a polluted area near a waste incinerator, by PMF analysis on daily and hourly compositional data sets.

Ecological characterization of a tick community across a landscape gradient exhibiting differential anthropogenic disturbance in the Atlantic Forest ecoregion in Argentina

An ecological analysis of a tick (Ixodida: Ixodidae) community across a landscape gradient presenting differential anthropogenic disturbance in the Atlantic Forest ecoregion in Argentina was performed. Ticks were collected from vegetation and hosts between September 2014 and August 2016. A total of 12 697 free-living ticks and 3347 specimens from hosts were collected, including 317 ticks infesting humans. The values obtained show considerable species diversity in the forest environment accompanied by low equitability. The similarity index derived from a comparison of forest and agricultural environments was higher than that calculated by comparing forest and urban environments. The data suggest that although a cycle of one generation per year is apparent in some species, more than one cohort may co-exist within the populations of some of these species. Well-marked patterns of the seasonal distribution of free-living tick species emerged in environments with no anthropic modification. The results indicate that forest environments are more suitable habitats than agricultural and urban environments for many species of native tick, but are unsuitable for exotic species that have successfully established in environments that have been modified by man.

Neoadjuvant Chemotherapy to Radiation and Concurrent Chemoradiation for Locally Advanced Squamous Cell Carcinoma of the Cervix: A Review of the Recent Literature

Radiotherapy is the standard treatment for locally advanced cervical cancer; nevertheless it fails to control disease progression within the irradiation fields in more than 40% of cases, particularly in patients with bulky tumor. Distant metastases are not infrequent in more advanced cases. Chemotherapy has been integrated with radiotherapy to improve local control and treat distant subclinical metastases. Schedules of combined treatment more frequently represented by neoadjuvant chemotherapy followed by radiation (NACT) and by concomitant chemotherapy and radiation (CT-RT). A review of the recent literature is presented. The role of NACT is controversial: high response rates are reported but doubtful advantages in terms of survival or local control have been shown. In randomized trials, hydroxyurea concomitant to radiation improves local control and survival, particularly in stage IIIB and IVA. Several randomized trials of concurrent chemoradiation with 5FU, cisplatin and mitomycin C are underway, but few have been published: no significative differences are reported in term of local control or survival. Acute toxicity is higher than in radiation alone, but usually manageable. For the analysis of late morbidity a longer follow-up is required. Large randomized trials of adequate radiotherapy versus concomitant chemoradiation are necessary to refine our understanding of the benefits of this integrated treatment.

Concurrent Carboplatin/5Fu and Radiotherapy Compared to Radiotherapy Alone in Locally Advanced Cervical Carcinoma: A Case-Control Study

Aims and background

Despite the introduction of innovative techniques in radiotherapy (RT) delivery, no significant improvement in survival has been achieved in the last decades. Concurrent chemoradiation therapy (CRT) is one of the several avenues being explored to improve the results.

Methods and study design

Twenty-eight women with locally advanced squamous cell carcinoma of the uterine cervix were treated with CRT comprising a combination of external and intracavitary RT, along with 3 cycles of 5-fluorouracil (5-FU) and carboplatin. Toxicity, pelvic control rate and disease-free survival achieved in this group of patients were compared in a case-control study with those of a group of 28 patients with similar clinicopathologic characteristics treated with radical RT alone at our institution.

Results

CRT was well tolerated, with 97% of the patients completing the protocol as planned. Acute toxicity, primarily hematologic, was significantly (P=0.05) higher in the cases than in the controls (25% vs 3%). One treatment-related death occurred in a stage III patient in the CRT group. The median follow-up was 55 months (range, 20–156) in the RT group and 20 months (range, 14–46) in the CRT group. Pelvic control rate, disease-free survival and overall survival were not significantly different in the two groups. Estimated 5-year survival rate was 70% and 66% respectively for the RT and CRT group.

Conclusions

Concomitant carboplatin/5-FU and radiotherapy is a safe and tolerable means of treatment for locally advanced cervical cancer. In our study, however, concurrent CRT did not result in a significant improvement in pelvic control rate or survival compared to standard conventional radiotherapy.

The Role of Radiotherapy in the Treatment of Stage III Non-Small Cell Lung Cancer: A Survey of Clinical Practices in Lombardy, Italy, by the Airo-Lombardia Cooperative Group

Aims and background

The role of radiotherapy in the treatment of stage III non-small cell lung cancer is controversial. The aim of this survey was to investigate the use of this modality in current clinical practice in Lombardy, a highly industrialized region of northern Italy.

Methods

A questionnaire was sent to all 13 radiotherapy centers in Lombardy, covering statistical, clinical, technical and strategical aspects, and the responses were analyzed.

Results

A wide range of attitudes was observed among participating radiation oncologists; the percentage of cases treated with curative intent varied largely between centers (4-100%), as did the proportion of patients given to radiation only rather than combined modality treatment (5-100% vs 0-90%).

Conclusions

An urgent need exists for better cooperation between all clinicians involved in lung cancer treatment, pursuing the goals of a more uniform clinical practice and a more aggressive clinical research attitude.

Role of cardiovascular magnetic resonance in suspected cardiac amyloidosis: late gadolinium enhancement pattern as mortality predictor

BACKGROUND

Cardiac magnetic resonance (CMR) has gained a central role in the diagnosis of cardiac amyloidosis (CA). While the diagnostic role of a typical late gadolinium enhancement (LGE) pattern (global subendocardial enhancement coupled with accelerated contrast washout) has been identified, evidence is still conflicting regarding the prognostic role of such examination.

METHODS AND RESULTS

We retrospectively analysed all patients referring for CMR at Niguarda Hospital (Milan, Italy) from January 2006 to January 2015 for suspected CA. Primary outcome was all-cause mortality. We identified 42 patients and divided them into 2 groups, according to the presence (Group A) or absence (Group B) of a typical amyloidosis LGE pattern. At the end of the follow-up (median 37 months, interquartile range 10-50 months), 31 patients (74%) had died. The hazard ratio for all-cause death was 3.2 (95% confidence interval [CI] 1.5-6.4, p < 0.01) for Group A versus Group B. Median survival time was 17 months (95% CI 7-42 months) for Group A and 70 months (95% CI 49-94 months) for Group B (p < 0.01). Multivariate analysis did not find any adjunctive predictive role for biventricular volumes and ejection fraction, indexed left ventricular mass, transmitral E/e' at echocardiography, age at diagnosis or serum creatinine.

CONCLUSION

In our population, a typical LGE pattern was significantly associated with higher mortality. Moreover, patients with a typical LGE pattern showed a globally worse prognosis. Our data suggest that the LGE pattern may play a central role in prognostic stratification of patients with suspected CA, thus prompting further diagnostic and therapeutic measures.

Population dynamics of the cattle tick Rhipicephalus (Boophilus) microplus in a subtropical subhumid region of Argentina for use in the design of control strategies

The population dynamics of Rhipicephalus microplus (Ixodida: Ixodidae) in northwest Argentina was analysed to support the design of strategic methods for its control. Both parasitic and non-parasitic phases were studied. The seasonal activity of R. microplus in its parasitic phase was characterized by three peaks in abundance: the first in mid-late spring; the second in summer, and the third in autumn. The non-parasitic phase of R. microplus was characterized by a long total non-parasitic period observed after exposures of females from mid-summer to early autumn, a short total non-parasitic period observed after exposures of females from late winter to late spring, a short period of larval longevity in early and mid-summer, and no hatch of the eggs produced by females exposed in mid- and late autumn and winter. Treatments of cattle administered during the period from late winter to late spring will act on small cohorts of R. microplus, preventing the emergence of larger generations in summer and autumn. A 17-week spelling period starting in late spring and early summer will be necessary to achieve optimal control of R. microplus free-living larvae. If spelling begins in mid- or late summer or in autumn, the required period will be 26-27 weeks.

Vectorial competence of Amblyomma tonelliae to transmit Rickettsia rickettsii

The aim of this work was to test the vectorial competence of Amblyomma tonelliae (Ixodida: Ixodidae) to transmit Rickettsia rickettsii (Rickettsiales: Rickettsiaceae), the agent of Rocky Mountain spotted fever (RMSF). All parasitic stages of A. tonelliae were exposed to R. rickettsii by allowing each stage to feed on hosts inoculated with this pathogen. Thereafter, ticks were fed on uninfected hosts. All stages of A. tonelliae were able to acquire the R. rickettsii infection and maintain it by transstadial and transovarial transmission. When infected ticks fed on uninfected hosts, the hosts developed rickettsiosis disease. This study demonstrates the vectorial competence of A. tonelliae to transmit R. rickettsii. These results have epidemiological relevance because A. tonelliae is one of the tick species most likely to infest humans in Argentina, including in areas in which RMSF has been reported.

Dynamics of Exposure to Rickettsia parkeri in Cattle in the Paraná River Delta, Argentina

Several cases of human rickettsiosis caused by Rickettsia parkeri were recently documented in the Paraná River delta of Argentina, where the tick vector is Amblyomma triste Koch. As cattle suffer recurrent A. triste infestations, they are at risk of becoming infected with R. parkeri Herein we investigated the dynamics of R. parkeri and its A. triste vector in a herd of beef cattle. Cattle were followed for 18 mo and samples were analyzed for the presence of antibodies against four Rickettsia species (R. parkeri, Rickettsia bellii, Rickettsia amblyommii, and Rickettsia felis) and also for the presence of rickettsial DNA. Additionally, cattle were examined for attached ticks and questing adult ticks were collected. All ticks were analyzed for the presence of rickettsial DNA. No evidence of rickettsemia was found in any cow, but the high R. parkeri infection rate documented in A. triste both questing in the study area (13.9%) and feeding on cattle (19.8%) and the identification of antibodies against R. parkeri antigen in 90% of cattle are evidence that infection is taking place. Altogether, our data suggest that A. triste ticks are capable of naturally exposing cattle to R. parkeri However, the progress of R. parkeri infection and its impact on bovine health and production remain to be established.

Efficacy of non-invasive mechanical ventilation in the general ward in patients with chronic obstructive pulmonary disease admitted for hypercapnic acute respiratory failure and pH < 7.35: a feasibility pilot study

AIM

To date non-invasive (NIV) mechanical ventilation use is not recommended in chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure (ARF) and pH < 7.30 outside a 'protected environment'. We assessed NIV efficacy and feasibility in improving arterial blood gases (ABG) and in-hospital outcome in patients with ARF and severe respiratory acidosis (RA) admitted to an experienced rural medical ward.

METHODS

This paper is a prospective pilot cohort study conducted in the General Medicine Ward of Budrio's District Hospital. Two hundred and seventy-two patients with ARF were admitted to our Department, 112, meeting predefined inclusion criteria (pH < 7.35, PaCO2 > 45 mmHg). Patients were divided according to the severity of acidosis into: group A (pH < 7.26), group B (7.26 ≤ pH < 7.30) and group C (7.30 ≤ pH < 7.35). ABG were assessed at admission, at 2-6 h, 24 h, 48 h and at discharge.

RESULTS

Group A included 55 patients (24 men, mean age: 80.8 ± 8.3 years), group B 31 (12 men, mean age: 80.3 ± 9.4 years) and group C 26 (15 men, mean age: 78.6 ± 9.9 years). ABG improved within the first hours in 92/112 (82%) patients, who were all successfully discharged. Eighteen percent (20/112) of the patients died during the hospital stay, no significant difference emerged in mortality rate (MR) within the groups (23%, 16% and 8%, for groups A, B and C, respectively) and between patients with or without pneumonia: 8/29 (27%) versus 12/83 (14%). On multivariable analysis, only age and Glasgow Coma Scale had an impact on the clinical outcome.

CONCLUSION

In a non-'highly protected' environment such as an experienced medical ward of a rural hospital, NIV is effective not only in patients with mild, but also with severe forms of RA. MR did not vary according to the level of initial pH.

Implementing constrained multi-time approach with bootstrap analysis in ME-2: An application to PM2.5 data from Florence (Italy)

Advanced receptor models have been recently developed and tested in order to improve the resolution of apportionment problems reducing rotational ambiguity of results and aiming at identifying a larger number of sources. In particular, multi-time model is a factor analysis method able to compute source profiles and contributions using aerosol compositional data with different time resolutions. Unlike traditional factor analysis, each measured value can be inserted into multi-time model with its original time schedule, thus all temporal information can be effectively used in the modelling process. In this work, multi-time model was expanded in order to impose constraints on modelled factors aiming at improving the source identification. Moreover, as far as we know for the first time, a suitable bootstrap technique was implemented in the multi-time scheme to estimate the uncertainty of the final constrained solutions. These implemented approaches were tested on a PM2.5 (particulate matter with aerodynamic diameter <2.5 μm) dataset composed of 24-h samples collected during one year and hourly data sampled in parallel for two shorter periods in Florence (Italy). The daily samples were chemically characterised for elements, ions and carbonaceous components while elemental concentrations only were available for high-time resolved samples. The application of the advanced model revealed the major contribution from traffic (accounting for 37% of PM2.5 as annual average) and allowed an accurate characterisation of involved emission processes. In particular, exhaust and non-exhaust emissions were identified. The constraints imposed in the continuation run led to a better description of the factor associated to nitrates and also of biomass burning profile and the bootstrap results gave useful information to assess the reliability of source apportionment solutions. Finally, the comparison with the results computed by ME-2 base model applied to daily and hourly compositional data separately demonstrated the advantages provided by the multi-time approach.

Ecology and genetic variation of Amblyomma tonelliae in Argentina

The ecology of Amblyomma tonelliae (Ixodida: Ixodidae), including its seasonal distribution and the development periods of each stage, was investigated during a study carried out over two consecutive years in northwestern Argentina. In addition, the genetic variation of this tick was studied through analyses of 16S rDNA sequences. Amblyomma tonelliae has a 1-year lifecycle characterized by a long pre-moult period in larvae with no development of morphogenetic diapause. Larvae peak in abundance during late autumn and early winter; nymphs peak in abundance in spring, and adults do so from late spring to early summer. Amblyomma tonelliae shows a marked ecological preference for the driest areas of the Chaco ecoregion. In analyses of 16S rDNA sequences in genes from different populations of A. tonelliae, values for nucleotide diversity and the average number of nucleotide differences showed genetic diversity within this species to be low. No significant differences were found in comparisons among populations.

Biomass burning contributions estimated by synergistic coupling of daily and hourly aerosol composition records

Biomass burning (BB) is a significant source of particulate matter (PM) in many parts of the world. Whereas numerous studies demonstrate the relevance of BB emissions in central and northern Europe, the quantification of this source has been assessed only in few cities in southern European countries. In this work, the application of Positive Matrix Factorisation (PMF) allowed a clear identification and quantification of an unexpected very high biomass burning contribution in Tuscany (central Italy), in the most polluted site of the PATOS project. In this urban background site, BB accounted for 37% of the mass of PM10 (particulate matter with aerodynamic diameter<10 μm) as annual average, and more than 50% during winter, being the main cause of all the PM10 limit exceedances. Due to the chemical complexity of BB emissions, an accurate assessment of this source contribution is not always easily achievable using just a single tracer. The present work takes advantage of the combination of a long-term daily data-set, characterized by an extended chemical speciation, with a short-term high time resolution (1-hour) and size-segregated data-set, obtained by PIXE analyses of streaker samples. The hourly time pattern of the BB source, characterised by a periodic behaviour with peaks starting at about 6 p.m. and lasting all the evening-night, and its strong seasonality, with higher values in the winter period, clearly confirmed the hypothesis of a domestic heating source (also excluding important contributions from wildfires and agricultural wastes burning).

Changes of swallowing function after tracheostomy: a videofluoroscopy study

BACKGROUND

Patients after tracheostomy often present swallowing dysfunctions but little is known about the mechanism underlying dysphagia and its reversibility. The aims of this study were: 1) to characterize swallowing dysfunctions in patients with dysphagia and tracheostomy; 2) to evaluate the reversibility of these changes; 3) to evaluate the possible influence of the underlying disease.

METHODS

Prospective, observational, single-center study enrolling patients with tracheostomy admitted to a rehabilitation center over a period of 36 months. All patients who were found to be dysphagic underwent a swallowing study with videofluoroscopy (VF) at the beginning of hospital stay and a second VF study was repeated after approximately 4 weeks.

RESULTS

A total of 557 patients with tracheostomy were admitted to the rehabilitation center during the considered period. 187 patients fulfilled the enrolling criteria and were studied with VF soon after admission. They had been tracheostomized for respiratory failure secondary to cerebrovascular accident (N.=106) or to acute-on chronic respiratory failure (N.=81). Incomplete backward epiglottis folding, pharyngeal retention, penetration and aspiration were the most frequent swallowing dysfunctions, observed with a frequency of 48%, 32%, 33% and 28%, respectively. Eighty-one patients underwent a second VF study, where these four swallowing phases again turned out to be the most compromised, with a frequency of 41%, 19%, 27% and 17%, respectively. The improvement was less evident in patients with chronic respiratory disease.

CONCLUSION

The swallowing function is impaired in patients with dysphagia and tracheostomy, but most swallowing abnormalities appear to be partially reversible. Patients with chronic respiratory disease exhibit a worse swallowing function.

Sigmodontinae rodents as hosts for larvae and nymphs ofIxodes loricatusNeumann, 1899 (Acari: Ixodidae)

Larvae and nymphs of Ixodes loricatus Neumann, 1899 ticks (confirmed by morphological characters and by comparison of 16S mitochondrial rDNA sequences) were collected from Sigmodontinae Wagner, rodents in central and northern Argentina and Uruguay. A total of 100 larvae and 38 nymphs of I. loricatus were collected on the genera Akodon Meyen (n = 36 individuals), Calomys Waterhouse (n = 2), Oligoryzomys Bang in = 12), Oxymycterus Waterhouse (n = 9), and Scapteromys Waterhouse (n = 13). 72 larvae and 18 nymphs were collected on Akodon. Adults of I. loricatus were found in central Argentina and Uruguay on Didelphimorphia of the genera Didelphis Linnaeus and Lutreolina Thomas. Ixodes loricatus has been considered a species with strict total specificity to Didelphimorphia. Our results show that this statement may not be justified. Sigmodontinae rodents are sympatric and share habitats with the phylogenetically distant Didelphimorphia; infestation with I. loricatus seems to be its consequence. We tentatively consider I. loricatus moderately specific to Didelphimorphia.

Receptor modelling of airborne particulate matter in the vicinity of a major steelworks site

In this study, the Multilinear Engine (ME-2) receptor model was applied to speciated particulate matter concentration data collected with two different measuring instruments upwind and downwind of a steelworks complex in Port Talbot, South Wales, United Kingdom. Hourly and daily PM samples were collected with Streaker and Partisol samplers, respectively, during a one month sampling campaign between April 18 and May 16, 2012. Daily samples (PM10, PM2.5, PM2.5-10) were analysed for trace metals and water-soluble ions using standard procedures. Hourly samples (PM2.5 and PM2.5-10) were assayed for 22 elements by Particle Induced X-ray Emission (PIXE). PM10 data analysis using ME-2 resolved 6 factors from both datasets identifying different steel processing units including emissions from the blast furnaces (BF), the basic oxygen furnace steelmaking plant (BOS), the coke-making plant, and the sinter plant. Steelworks emissions were the main contributors to PM10 accounting for 45% of the mass when including also secondary aerosol. The blast furnaces were the largest emitter of primary PM10 in the study area, explaining about one-fifth of the mass. Other source contributions to PM10 were from marine aerosol (28%), traffic (16%), and background aerosol (11%). ME-2 analysis was also performed on daily PM2.5 and PM2.5-10 data resolving 7 and 6 factors, respectively. The largest contributions to PM2.5-10 were from marine aerosol (30%) and blast furnace emissions (28%). Secondary components explained one-half of PM2.5 mass. The influence of steelworks sources on ambient particulate matter at Port Talbot was distinguishable for several separate processing sections within the steelworks in all PM fractions.

A meta-analysis of host specificity in Neotropical hard ticks (Acari: Ixodidae)

Host specificity of Neotropical hard ticks (Acari: Ixodidae) was analyzed by using the number of hosts species for each tick species and the index of host specificity S(TD)*, which integrates phylogenetic and ecological information. The analyses were based on 4172 records of hard ticks collected from wild and domestic tetrapods. Most tick species included in this study were associated with three to 20 host species. No tick species has been associated either with a single species or with a single genus of host. It was found that the number of host species is sensitive to sampling effort, but not the S(TD)*. The most frequent values of S(TD)* were between 2.5 and 3.5, which shows that the host species more frequently used by Neotropical hard tick species belong to different families or different orders. Immature stages tend to use a broader taxonomic range of hosts than adults, and the interpretation of both measures of host specificity used in this study led to the conclusion that the impact of non-endemic hosts does not alter the patterns of host specificity in Neotropical hard ticks. The index S(TD)* showed that a high proportion of tick species has phylogenetically unrelated species as principal hosts. The conclusion reached in this work indicates that strict host specificity is not common among Neotropical hard ticks and suggests that the influence of tick ecology and evolution of habitat specificity, tick generation time, phenology, time spent off the host and the type of life-cycle could be more important than hosts species.

Effectiveness and predictors of success of noninvasive ventilation during H1N1 pandemics: a multicenter study

BACKGROUND

The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure.

METHODS

In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2<300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV.

RESULTS

Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P<0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P<0.001. According to logistic regression model, a SAPS II>29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI.

CONCLUSION

The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.