Ozone as adjuvant support in the treatment of COVID-19: A preliminary report of probiozovid trial

The evaluation of new therapeutic resources against coronavirus disease 2019 (COVID-19) represents a priority in clinical research considering the minimal options currently available. To evaluate the adjuvant use of systemic oxygen-ozone administration in the early control of disease progression in patients with COVID-19 pneumonia. PROBIOZOVID is an ongoing, interventional, randomized, prospective, and double-arm trial enrolling patient with COVID-19 pneumonia. From a total of 85 patients screened, 28 were recruited. Patients were randomly divided into ozone-autohemotherapy group (14) and control group (14). The procedure consisted in a daily double-treatment with systemic Oxygen-ozone administration for 7 days. All patients were treated with ad interim best available therapy. The primary outcome was delta in the number of patients requiring orotracheal-intubation despite treatment. Secondary outcome was the difference of mortality between the two groups. Moreover, hematological parameters were compared before and after treatment. No differences in the characteristics between groups were observed at baseline. As a preliminary report we have observed that one patient for each group needed intubation and was transferred to ITU. No deaths were observed at 7-14 days of follow up. Thirty-day mortality was 8.3% for ozone group and 10% for controls. Ozone therapy did not significantly influence inflammation markers, hematology profile, and lymphocyte subpopulations of patients treated. Ozone therapy had an impact on the need for the ventilatory support, although did not reach statistical significance. Finally, no adverse events related to the use of ozone-autohemotherapy were reported. Preliminary results, although not showing statistically significant benefits of ozone on COVID-19, did not report any toxicity.

Role of computed tomography in predicting critical disease in patients with covid-19 pneumonia: A retrospective study using a semiautomatic quantitative method

Background

So far, only a few studies evaluated the correlation between CT features and clinical outcome in patients with COVID-19 pneumonia.

Purpose

To evaluate CT ability in differentiating critically ill patients requiring invasive ventilation from patients with less severe disease.

Methods

We retrospectively collected data from patients admitted to our institution for COVID-19 pneumonia between March 5th-24th. Patients were considered critically ill or non-critically ill, depending on the need for mechanical ventilation. CT images from both groups were analyzed for the assessment of qualitative features and disease extension, using a quantitative semiautomatic method. We evaluated the differences between the two groups for clinical, laboratory and CT data. Analyses were conducted on a per-protocol basis.

Results

189 patients were analyzed. PaO₂/FIO₂ ratio and oxygen saturation (SaO₂) were decreased in critically ill patients. At CT, mixed pattern (ground glass opacities (GGO) and consolidation) and GGO alone were more frequent respectively in critically ill and in non-critically ill patients (p < 0.05). Lung volume involvement was significantly higher in critically ill patients (38.5 % vs. 5.8 %, p < 0.05). A cut-off of 23.0 % of lung involvement showed 96 % sensitivity and 96 % specificity in distinguishing critically ill patients from patients with less severe disease. The fraction of involved lung was related to lactate dehydrogenase (LDH) levels, PaO₂/FIO₂ ratio and SaO₂ (p < 0.05).

Conclusion

Lung disease extension, assessed using quantitative CT, has a significant relationship with clinical severity and may predict the need for invasive ventilation in patients with COVID-19.

Clinical Management of Critical COVID-19 Patients: Insights from the Literature and “On the Field” Experience

The recent outbreak of the coronavirus disease (COVID-19) is a health emergency all over the world. Several health care professionals are currently putting their best efforts to deal with this situation. The aim of this review is to report insights from the literature and “on the field” experience in clinical management of critical COVID-19 patients. Respiratory support varies from high flow nasal cannula (HFNC) to noninvasive and invasive mechanical ventilation, often associated with nitric oxide, prone position, and extracorporeal membrane oxygenation (ECMO). Experienced specialists have to manage the airways minimizing any contamination and virus spread. The hemodynamic management of critical COVID-19 patients requires not only an accurate fluid strategy, but also an appropriate use of vasopressors and inotropes. Various adjuvant treatments have been proposed: antiviral drugs, immunomodulators, anticoagulants, antibiotics, and nutrition.

Intracranial pressure monitoring during percutaneous tracheostomy "percutwist" in critically ill neurosurgery patients

BACKGROUND

Tracheostomy is commonly required as part of the management of patients with severe brain damage. Percutaneous dilation tracheostomy is increasingly used in intensive care unit as an alternative to standard surgical tracheostomy. However, this procedure carries the risk of neurological complications, particularly in patients with intracranial hypertension. In this study, we sought to quantify the effects of Percutwist(R) tracheostomy (Rusch-Teleflex Medical) on intracranial pressure (ICP), cerebral perfusion pressure (CPP), arterial CO(2) tension (Paco(2)), and arterial O(2) tension (Pao(2)), in 65 consecutive critically ill patients admitted to the neurosurgical intensive care unit, undergoing bedside percutaneous tracheostomy.

METHODS

Sixty-five patients (29 men, 36 women, mean age 43 yr, 7 +/- 10.6) Glasgow Coma Scale <or=8, requiring long-term ventilatory support with a stable ICP <or=20 mm Hg were included. Elective percutaneous tracheostomies were performed at the bedside under endoscopic fiberoptic control. Intraoperative monitoring included continuous: electrocardiogram, Spo(2), invasive arterial blood pressure, ICP, CPP = mean arterial blood pressure-ICP). Episodes of ICP increment above 20 mm Hg or CPP decrease below 60 mm Hg (lasting more than 3 min) were recorded; hypoxia was defined as Pao(2) below 90 mm Hg, hypercarbia as Paco(2) more than 40 mm Hg.

RESULTS

Eighteen episodes of intracranial hypertension were recorded in 11 patients. No statistically significant modification of monitored variables was recorded, although the transient ICP increase was very close to statistical significance (P = 0.051). No episodes of CPP reduction below 60 mm Hg occurred. Six percent of patients developed hypercarbia.

CONCLUSIONS

Percutwist tracheostomy is a single-step method which allows for effective ventilation during the procedure, thus reducing the risk of hypercarbia and development of intracranial hypertension. The technique did not cause secondary pathophysiological insult and could be considered safe in a selected population of brain-injured patients.

Early postoperative complications after intracranial surgery: comparison between total intravenous and balanced anesthesia

This prospective study was performed to compare the incidence of complications occurring after neurosurgical procedures in patients anesthetized with either sevoflurane-fentanyl or propofol-remifentanil anesthesia. We enrolled 162 American Society of Anesthesiologists (ASA) I to III patients (82 females and 80 males, Glasgow 15) undergoing elective neurosurgical procedures. Anesthesia was conducted using either propofol-remifentanil (T group; n=80 patients) or sevoflurane-fentanyl (S group; n=82 patients). All patients were monitored in the postanesthesia care unit for 6 hours after extubation. We analyzed and compared in both groups the incidence of high severity complications such as respiratory events (PaO2 <90 mm Hg; PaCO2 >45 mm Hg) and neurologic events (seizures, new motor or sensory deficit, unexpected delay of awakening) and the incidence of low severity complications such as hypertension (mean arterial pressure increase above 30% of baseline), hypotension (mean arterial pressure decrease below 30% of baseline), pain, shivering, nausea, and vomiting. A total of 162 complications occurred in 92 patients (57%) with 50 patients (31%) having had 1, 26 patients (16%) having had 2, and 16 patients (10%) having had 3 or more events. The most frequent complication was respiratory impairment (28%) which was frequently reported only in the first postoperative hour. Out of the total number of complicating events, 77 (48 %) were found in group S, and 85 (52%) in group T (P=ns). Severe complications were rarely reported and evenly distributed in the 2 anesthetic groups. Similarly, no difference could be demonstrated in the composite incidence of less serious complications between the 2 anesthetic regimens tested in this study. This study confirms that the recovery period after neurosurgical procedures remains a time of great potential danger to patients given the high incidence of postoperative complicating events independently from the anesthetic strategy.

No difference in emergence time and early cognitive function between sevoflurane-fentanyl and propofol-remifentanil in patients undergoing craniotomy for supratentorial intracranial surgery

Balanced anesthesia with sevoflurane-fentanyl has been widely accepted as anesthetic management for neurosurgery. Propofol-remifentanil regimen has been successfully used in various surgical settings, but a comprehensive comparison of sevoflurane-fentanyl and propofol-remifentanil anesthesia in patients undergoing craniotomy for supratentorial intracranial surgery has not yet been done. The aim of this prospective, randomized, open-label clinical trial was to compare clinical properties of sevoflurane-fentanyl with propofol-remifentanil anesthesia in patients undergoing supratentorial intracranial surgery. The primary endpoint was to compare early postoperative recovery and cognitive functions within the two groups; we also evaluated hemodynamic events, vomiting, shivering, and pain. One hundred twenty patients (64 males; age 15-75 years) were randomized to either total intravenous anesthesia (group T) or sevoflurane anesthesia (group S). Emergence and extubation times and cognitive function (Short Orientation Memory Concentration Test [SOMCT]) were compared in the two groups. Brain swelling, incidence of hypotensive and hypertensive episodes, postoperative vomiting, shivering, and pain were also analyzed. The mean emergence time (12.2 +/- 4.9 minutes for group S versus 12.3 +/- 6.1 minutes for group T; P = 0.92) and extubation time (18.2 +/- 2.3 minutes for group S versus 18.3 +/- 2.1 minutes for group T; P = 0.80) were similar in the two groups. Average SOMCT scores, both 15 minutes after extubation (25.6 +/- 4.9 in group S versus 23.9 +/- 7.5 in group T; P = 0.14) and 45 minutes after extubation (27.3 +/- 2.2 in group S versus 26.0 +/- 5.1 in group T; P = 0.07) were also comparable. Brain swelling was present in seven and five patients in groups S and T, respectively (P = 0.76). Hypotension was present in 12% (group S) and 28% (group T) of patients (P = 0.02). Hypertension was present in 17% of patients in group S and 40% of patients in group T (P = 0.0046). Shivering was present in 18% and 25% of patients in groups T and S (P = 0.37). Our study demonstrates that there is no patient benefit of using total intravenous anesthesia with an ultra-short-acting opioid over the conventional balanced volatile technique in terms of recovery and cognitive functions.

Do GOLD stages of COPD severity really correspond to differences in health status?

The purpose of this study was to assess whether different stages of chronic obstructive pulmonary disease (COPD) severity defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria correlate with meaningful differences in health status. A total of 381 COPD patients, aged 73+/-6 yrs, were classified in the five GOLD stages. Disease-specific (St George Respiratory Questionnaire (SGRQ)) and generic indexes of health status were measured in all patients. Multivariate analysis of covariance or Kruskal Wallis tests were used to compare health status indexes across the spectrum of GOLD stages of COPD severity. GOLD stages of COPD severity significantly differed in SGRQ components and Barthel's index, but not in the indexes assessing cognitive and affective status and quality of sleep. The largest variation in health status was observed at the transition from stage IIa to stage IIb, while there were no other significant differences between consecutive stages. Both female sex and comorbidity were associated with a greater impact of COPD on the health status. In conclusion, the upper limit of stage IIb (forced expiratory volume in one second of 49%) marks a threshold for dramatic worsening of health status. Progression of chronic obstructive pulmonary disease severity from stage 0 to stage IIa does not correspond to any meaningful difference in health status.

Reversible bronchial obstruction and disease-related health status in COPD

We aimed to assess whether partially reversible and fixed airway obstructions are associated with different health status profiles of chronic obstructive pulmonary disease (COPD) patients. We characterized health status profiles of outpatients over 64 years suffering from COPD with fixed (n = 181) or partially reversible obstruction (n = 95) and from chronic bronchitis with forced expiratory volume in the first second (FEV1) > 69% of that predicted (n = 109) on the basis of the Saint George Respiratory Questionnaire (SGRQ) and indexes assessing cognitive (Mini Mental State), affective (15-item Geriatric Depression Scale) and physical status (Index of Barthel, six-minute walking test) and quality of sleep (Index of disturbed sleep). The degree of group-specificity of health status profiles was assessed by discriminant analysis. The 54.1% of COPD patients with partially reversible obstruction were recognized to have a distinctive health status profile characterized by a moderate to severe impairment of all components ('Symptoms', 'Activity', 'Impacts') of the SGRQ and of select indexes of performance. According to logistic regression analysis, this health status profile was associated with FEV < 46% of that predicted (odds ratio (OR): 1.6, 95% confidence interval (CI): 1.07-2.38), the use of at least three respiratory drugs (OR: 2.28, CI: 1.46-3.57) and living alone (OR: 2.01, 95% CI: 1.3-2.29). COPD patients with fixed obstruction had a very heterogeneous health status. Research is needed to verify whether the unfavorable health status profile typical of a subset of COPD patients is associated with a distinctive prognosis and can be improved by dedicated therapeutic interventions.

Evaluation of health outcomes in elderly patients with asthma and COPD using disease-specific and generic instruments: the Salute Respiratoria nell'Anziano (Sa.R.A.) Study

OBJECTIVES

To compare the effects of asthma and COPD on health status (HS) in elderly patients, and to assess the correlation between disease-specific and generic instruments assessing HS.

DESIGN

Multicenter, cross-sectional, observational study.

SETTING

The Salute Respiratoria nell'Anziano (respiratory health in the elderly) Study network of outpatient departments.

PATIENTS

One hundred ninety-eight asthma patients and 230 COPD patients > or = 65 years old.

MEASUREMENTS

HS was assessed by the Saint George's Respiratory Questionnaire (SGRQ) and five generic outcomes: Barthel's index, 6-min walk test, mini mental state examination, geriatric depression scale (GDS), and quality-of-sleep index. Independent correlates of SGRQ scores were assessed by logistic regression. Patients were considered to have a "good" HS or "poor" HS according to whether they did or did not perform worse than 75% of the corresponding population of asthma or COPD patients, on at least two of the five generic outcomes.

RESULTS

On average, COPD patients had poorer HS than asthma patients on the SGRQ. Only polypharmacy (more than three respiratory drugs) and diagnosis of COPD qualified as independent correlates of the SGRQ score. The SGRQ "Activity" and "Impacts" scores shared the following independent correlates: polypharmacy, Barthel's index < 92, and GDS > 6. Further correlates were waist/hip ratio > 1 for the Activity score, and age and occiput-wall distance > 9 cm for the Impacts score. All sections of the SGRQ except for the Symptoms score could significantly distinguish patients with good HS and poor HS.

CONCLUSIONS

Individual dimensions of HS recognize different determinants. COPD outweighs asthma as a cause of distressing respiratory symptoms. A high degree of concordance exists between SGRQ and generic health outcomes, except for the Symptoms dimension in COPD patients.

A real-time, multichannel scaler-analyzer system for clinical investigations

The design of a fast, versatile multichannel scaler-analyzer system is described here. This system is especially suitable for clinical measurements in real time from multichannel nuclear sources characterized by single or multiple isotopes. The instrumentation characteristics are as follows: 1) The system is programmable and modular, with 16 channels maximum per module. The active channels can be selected. The channel scanning time depends upon the selected system configuration. 2) The true acquisition phase is autonomous. The acquired data are transferred from the instrumentation to the master computer under interrupt control. 3) The system is constructed from commercially available components. Their high integration and speed have led to powerful, compact, flexible instrumentation while containing cost.

A microprogrammed data acquisition system for renography

The purpose of this project was to design an efficient, low cost, and portable system for renography suitable for clinical use. The principles involved in the renographic test, and the procedures and calculations which act on the design of our system, are given. The system consists of an Apple II Plus computer equipped with 48K memory, two disk drives with diskettes of 143K each, a thermal printer with graphic capability, the Microsoft Z80 card, and an interface which is specifically designed for renographic data acquisition.