European Multicenter Study of ET-COVID-19

BACKGROUND AND PURPOSE

Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19.

METHODS

Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality.

SECONDARY OUTCOMES

early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage.

RESULTS

We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH).

CONCLUSIONS

The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.

Thromboxane and prostacyclin biosynthesis in heart failure of ischemic origin: effects of disease severity and aspirin treatment

SUMMARY BACKGROUND

Thromboembolism is a relatively common complication of chronic heart failure (HF) and the place of antiplatelet therapy is uncertain.

OBJECTIVES

We characterized the rate of thromboxane and prostacyclin biosynthesis in chronic HF of ischemic origin, with the aim of separating the influence of HF on platelet activation from that of the underlying ischemic heart disease (IHD).

PATIENTS AND METHODS

We compared urinary 11-dehydro-thromboxane (TX)B(2), 2,3 dinor 6-keto-PGF(1alpha,) 8-iso-prostaglandin (PG)F(2alpha), and plasma N-terminal pro-brain natriuretic peptide (NT-pro-BNP), asymmetric dimethylarginine (ADMA), and soluble CD40 ligand (sCD40L), in 84 patients with HF secondary to IHD, 61 patients with IHD without HF and 42 healthy subjects.

RESULTS

HF patients not on aspirin had significantly higher urinary 11-dehydro-TXB(2) as compared with healthy subjects (P < 0.0001) and IHD patients not on aspirin (P = 0.028). They also showed significantly higher 8-iso-PGF(2alpha) (P = 0.018), NT-pro-BNP (P = 0.021) and ADMA (P < 0.0001) than IHD patients not on aspirin. HF patients on low-dose aspirin had significantly lower 11-dehydro-TXB(2) (P < 0.0001), sCD40L (P = 0.007) and 2,3-dinor-6-keto-PGF(1alpha) (P = 0.005) than HF patients not treated with aspirin. HF patients in NYHA classes III and IV had significantly higher urinary 11-dehydro-TXB(2) than patients in classes I and II, independently of aspirin treatment (P < 0.05). On multiple linear regression analysis, higher NT-pro-BNP levels, lack of aspirin therapy and sCD40L, predicted 11-dehydro-TXB(2) excretion rate in HF patients (R(2) = 0.771).

CONCLUSIONS

Persistent platelet activation characterizes HF patients. This phenomenon is related to disease severity and is largely suppressable by low-dose aspirin. The homeostatic increase in prostacyclin biosynthesis is impaired, possibly contributing to enhanced thrombotic risk in this setting.

Recombinant activated factor VII therapy in acquired hemophilia of the elderly

Acquired hemophilia is a life-threatening condition associated with a high mortality, occurring mainly in elderly patients. We report on a 92-year-old male, administered two courses of 90 microg kg(-1) of recombinant activated factor VII (rFVIIa) due to failure of human factor VIII (FVIII) therapy, without side effects nor evidence of thrombotic complications. Despite the bleeding being completely under control, the patient died on day 11 of acute respiratory failure due to pneumonia. This case confirms previous reports on the complexity and severity of this disorder, showing that rFVIIa is an effective and safe agent for achieving hemostasis even in elderly patients with a FVIII inhibitor.

Factors related to the length of in-hospital stay of geriatric patients

The aim of this study was to evaluate factors predicting length of stay in hospital of geriatric patients. Study participants were 402 patients (183 males and 219 females) consecutively admitted to four geriatric wards located in Chieti, Perugia, Pescara and Prato, Italy. Information on potential predictors of length of stay was collected; in particular, we assessed the presence and severity of specific chronic medical conditions, level of physical function, cognitive status, and depressive symptoms. Moreover, information on family and social support was obtained. In general, participants were old, often cognitively impaired and physically disabled. Average length of stay ranged from 9.4 +/- 3.3 days (Perugia) to 14.1 +/- 7.2 days (Chieti), and was statistically different across centers (p < 0.001). None of the specific medical diagnoses was associated with different length of stay. However, higher comorbidity score (p < 0.001), living alone (p < 0.01), lower MMSE score (p = 0.03), and poor functional status (p = 0.05) were all associated with longer length of stay. When these variables were included in a multivariate model predicting length of stay, differences between centers were no longer statistically significant. Findings of this study show that specific medical diagnoses are not adequate instruments to estimate length of stay in geriatric units. Other assessment systems based on extension of the social network, comorbidity, and the cognitive as well as the functional level need to be developed.

Characteristics of geriatric patients related to early and late readmissions to hospital

The aim of the study was to evaluate which characteristics of geriatric patients account for readmission to hospital, 6 months after discharge. All patients (203 females, 176 males) consecutively admitted over a two-month period to four acute geriatric care units, located in the cities of Chieti, Perugia, Pescara and Prato, participated in the study. Data that could potentially explain early and late readmissions were collected for each patient. Prevalence of diseases and comorbidity were assessed with the Cumulative Illness Rating Scale (CIRS); physical function by self-report (ADL, IADL) and objective (Stand and Walking Speed) measures; cognitive level by MMSE; and depressive symptoms by the Geriatric Depression Scale (GDS). Information on family and social support were also obtained. After discharge, data on hospital readmissions were collected for six months. For each readmitted patient (cases), medical records were reviewed, and supplementary information was obtained from families and general practitioners. Readmissions were classified as "early" (within the first three months), "late" (within the third and sixth month), and "multiple" (2 or more readmissions irrespective of the period). Patients not readmitted (alive at home) were considered as controls. Systematic differences between centers and between periods of readmissions were evaluated using one-way analyses of variance, and Pearson's chi 2 test. Factors related to early, late, and multiple readmission were identified in multivariate logistic regression models. On univariate analysis, patients readmitted over the first three-month period were sicker than controls (CIRS classes 3-4: 52.1% vs 34.1%), had more social problems or behavioral symptoms, and were more functionally impaired (ADL dependencies 3.3 +/- 0.4 vs 2.1 +/- 0.2). Patients who were readmitted between the third and the sixth month after discharge had a significantly higher CIRS total score (p = 0.006). Patients with multiple readmissions had more severe diseases, and more social problems. On multivariate analysis, early readmission was associated with unsatisfactory social conditions, living alone, severity of diseases and cognitive impairment, while late readmission was associated with comorbidity only. Multiple readmissions were related only to social factors, and to hospital admission before the baseline evaluation. The findings of this study suggest that interventions aimed at improving unfavorable social conditions may reduce the rate of rehospitalization in geriatric patients.

Surgical treatment of intracranial aneurysms in patients aged over 70: 25 years of experience

Many references and communications regarding neurosurgical topics in elderly patients underline the interest of our Unit for this subject. We already presented in 1978 a series of 75 patients over 60 years of age operated on for intracranial aneurysms; we reported a 90% of success in all the cases operated with clinical grade 1 or 2 according to Botterel grading system on admission. In 1986, during the XXXV Congress of the Italian Neurosurgical Society, we presented other 15 cases operated for intracranial aneurysm over 70 years of age. We present an upgrading of our casistic.

[Controlled multicenter study on the therapeutic effectiveness of mesoglycan in patients with cerebrovascular disease]

One hundred and forty-five elderly patients affected by cerebrovascular diseases were included in the study. Patients were divided into two age-, sex- and clinically matched groups: the first group included 103 patients who were treated for six months with mesoglycan (100 mg/day), whereas the second group, which numbered 42 patients, received standard anti-platelet treatment over the same period. The results of the study confirm the clinical efficacy of mesoglycan compared to standard treatment with antiplatelet drugs in terms of ischemic events and the "quality of life" of cerebrovasculopathic patients.

Impact of endoscopic ultrasonography on diagnosis and treatment of primary gastric lymphoma

Endoscopic ultrasonography (EUS) allows a visualization in vivo of the gastric wall. Five ultrasonic layers of different echogenicities are displayed; each corresponds to a precise anatomic structure. In gastric diseases this layering evidently changes. In 10 patients with suspected primary gastric lymphoma, EUS showed a characteristic thickening of the second, the second and third layers, or a diffuse, transmural thickening of the entire wall. A precise correlation between the longitudinal and depth infiltration observed at EUS and the surgical finding was seen in all patients. In three cases in which the preoperative bioptic diagnosis was erroneous (two gastritis and one carcinoma) EUS showed a characteristic echographic pattern for lymphoma, which was confirmed at surgery. There was agreement also, in EUS and surgical findings in all patients, about involvement of neighbor organs. It seems possible that in the future EUS could play an important role in detecting, staging, and planning treatment of lymphoma and other gastric tumors.

Gastric carcinoid: a clinical and endoscopic assessment of four cases

We have established a pre-operative diagnosis in four cases of non-secretory gastric carcinoid of the body and fundus presenting as multiple polyps in three patients, and a single polyp mass in the fourth patient. Clinical and endoscopic findings are not specific, and the pre-operative diagnosis was established by means of biopsy or polypectomy. We observed biochemical and histological differences between multiple and single carcinoids, which might indicate different mechanisms of carcinoid pathogenesis.

[Pseudotumor cerebri: 19 cases in childhood]

Nineteen patients affected by Pseudotumor Cerebri and treated in the Neurosurgical Department of U.S.L. 10/D of Florence, are considered by Authors. Patients age varied from 4 to 14 years and their selection was made following Boddie, Banna and Bradley criteria published in 1974. Plain X Ray of the Skull was positive in 5 cases while ventriculography (when executed) were always normal. Quite normal were Angiography and CT scan. There were no pathological findings in CSF. The series of patients is considered analyzing somatic features, sex and possible aetiologic noxae. An interesting data is the presence of fever (39 degrees C) from 7 to 20 days before the onset of cranial hypertension. The possibility of blood-brain barrier alteration following infectious disease which causes an interstitial edema is considered and proposed by authors as a starting point for future research.

Follow up and surgical considerations on a series of patients operated on for non tumoral aqueductal stenosis

A series of 90 patients operated on between 1966 and 1983 in the Neurosurgical Division of USL 10/D (Florence) for non tumoral aqueductal stenosis is presented. The Authors discuss the different of shunts used and the follow up which is favourable in patients operated on with an early diagnosis.

Detection of portal hypertension and esophageal varices by means of endoscopic ultrasonography

Endoscopic ultrasonography (EUT) enables not only the visualization of the portal system and of the esophageal varices, as obtained by transabdominal ultrasonography and fiberoptic endoscopy, but also the visualization of intramural and periesophageal collateral veins. Fifteen cirrhotic patients were examined by EUT without complications. When present, esophageal or gastric varices were always detected. In all cases enlarged extrinsic periesophageal veins were visualized, and in 14 of 15 their caliber was correlated with the size of esophageal varices. In three patients examined after sclerotherapy the submucosal veins had disappeared, but extrinsic collateral vessels were patent. EUT will probably become a fundamental technique in the study of portal hypertension and esophageal varices, before and after therapy.

Endoscopic electromyography and manometry of the human sphincter of Oddi

The myoelectric and manometric activities of the sphincter of Oddi were recorded in 8 patients using an original probe passed through the papilla of Vater during duodenoscopy. The sphincter of Oddi's myoelectric activity showed rhythmic bursts of action potentials which appeared in correspondence with the ascending phase of the phasic pressure waves. On the basis of these results, we believe that electromyography could in some cases replace manometry for studying sphincter of Oddi motility, since it avoids pressure perfusion of the bilio-pancreatic tract, with its concomitant risks, and provides sufficient information for motor studies.

Acute operation in cases of middle cerebral artery occlusion

The authors describe their personal experience with middle cerebral artery embolectomy performed in four patients within 6 hours after the start of clinical symptoms. The work is of a preliminary nature. No conclusion can be drawn as to the ultimate value of this treatment, and further clinical trials seem justified.

Endoscopic manometry in the diagnosis of the postcholecystectomy pain syndrome

A manometric study of the distal biliary tract was carried out by means of a side-hole perfused catheter passed through the papilla Vateri during duodenoscopy in patients with postcholecystectomy biliary pain not due to stones or inflammation of the biliary tree. The sphincter of Oddi showed in these cases a significantly higher basal tone than in controls with superimposed phasic pressure waves of high amplitude. The basal pressure of the common bile duct was also higher than in controls. These manometric findings may help differentiate the functional papillary stenosis from other causes of the postcholecystectomy pain syndrome and may be useful in settling the question of performing sphincterotomy in these patients.

[Effect of 2 mercaptopropionylglycine on the cytotoxic activity of lymphocytes from patients with chronic active hepatitis against rabbit hepatocytes isolated and cultured in vitro]

"In vivo" and "in vitro" action of 2 MPG on lymphocytotoxic activity was evaluated in 22 patients with CAH, 14 were HBsAg positive and 8 were negative. The test was performed with and without 2 MPG in the colture medium, and before and after treatment. HBsAg+ patients received 2 MPG treatment, while HBsAg- ones received immunosoppressive therapy and 4 of these were on 2 MPG treatment as well. Cytotoxic Index was reduced non-significantly by addition of 2 MPG in colture medium in both groups. 2 MPG treatment does not modify cytotoxic activity which is reduced by immunosoppressive therapy. These findings suggest a positive effect of 2 MPG on liver-cell metabolism with an increased resistence of the epatocyte to the "in vitro" lymphocytes aggression. Hence it may be suggested an association treatment with immunosoppressive agents and 2 MPG.