Risk Stratification in COVID-19 Pneumonia - Determining the Role of Lung Ultrasound

LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings.

MATERIALS AND METHODS

 An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2^nd to April 3^rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER).

RESULTS

 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967.

CONCLUSION

 The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.

A video-based training to effectively teach CPR with long-term retention: the ScuolaSalvaVita.it ("SchoolSavesLives.it") project

Enhancing CPR knowledge in schools is the key to improving bystander CPR rate and survival after an out-of-hospital cardiac arrest, but the best method to do so in a whole area is unknown. We wanted to assess if a province-based project, which involves the Secondary Schools of a whole Province, is effective in teaching schoolchildren CPR, and how well the skills are retained. We trained 100 teachers from the 21 Secondary Schools of the Province of Pavia with a BLS/AED course and we supplied each school with 10 low-budget manikins and four educational videos. These videos, about 2 min each, consist of a motivational part, an instructive part, a demonstrative part and a practice-while-watching part. We explained to the teachers how to use manikins and videos in a 2-h course. We carried out both a theoretical and a practical test in 21 classes, randomly selected between the classes trained by the teachers, 3 months and 6 months after the training. In the first 5 months of the project, 5146 schoolchildren aged 14-19, in the 21 Secondary Schools of our Province, were trained by their teachers. We tested 304 students 3 months after the course and 318 students 6 months after the course, with good results both in theoretical and practical skills. Our study demonstrates that the ScuolaSalvaVita project is able to effectively teach CPR through teachers using a video-based training in the Secondary Schools of a whole Province obtaining good long-term memory of CPR skills.

Protocol of a Multicenter International Randomized Controlled Manikin Study on Different Protocols of Cardiopulmonary Resuscitation for laypeople (MANI-CPR)

INTRODUCTION

Out-of-hospital cardiac arrest is one of the leading causes of death in industrialised countries. Survival depends on prompt identification of cardiac arrest and on the quality and timing of cardiopulmonary resuscitation (CPR) and defibrillation. For laypeople, there has been a growing interest on hands-only CPR, meaning continuous chest compression without interruption to perform ventilations. It has been demonstrated that intentional interruptions in hands-only CPR can increase its quality. The aim of this randomised trial is to compare three CPR protocols performed with different intentional interruptions with hands-only CPR.

METHODS AND ANALYSIS

This is a prospective randomised trial performed in eight training centres. Laypeople who passed a basic life support course will be randomised to one of the four CPR protocols in an 8 min simulated cardiac arrest scenario on a manikin: (1) 30 compressions and 2 s pause; (2) 50 compressions and 5 s pause; (3) 100 compressions and 10 s pause; (4) hands-only. The calculated sample size is 552 people. The primary outcome is the percentage of chest compression performed with correct depth evaluated by a computerised feedback system (Laerdal QCPR). ETHICS AND DISSEMINATION: . Due to the nature of the study, we obtained a waiver from the Ethics Committee (IRCCS Policlinico San Matteo, Pavia, Italy). All participants will sign an informed consent form before randomisation. The results of this study will be published in peer-reviewed journal. The data collected will also be made available in a public data repository.

TRIAL REGISTRATION NUMBER

NCT02632500.

Short versus long course antibiotic therapy for acute pyelonephritis in adults: a systematic review and meta-analysis

Acute pyelonephritis (aPN) is defined as a severe form of urinary tract infection. Despite its severity and the high incidence in the community setting, there is no consensus on the optimal duration of treatment. The aim was to compare effectiveness and tolerability of short- versus long-course treatment with the same antibiotic agent in patients with aPN. We searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2016 for randomized controlled trials (RCTs). Three pairs of authors independently extracted data and appraised risk of bias. We included 4 RCTs (439 participants). Short antibiotic treatment lasted from 4 to 14 days and long treatment from 7 to 42 days but was at least 2 days longer than the corresponding short-course. At the end of treatment, we did not find any significant differences in clinical success [risk ratio (RR) 1.01; 95% confidence interval (CI), 0.96-1.07, moderate quality evidence] as well as in microbiological success (RR 0.99; 95% CI, 0.92-1.07, very low-quality evidence). At 4-6 weeks after the end of treatment there were no significant differences in clinical relapses (RR 1.20, 95% CI 0.43-3.30, very low-quality evidence) and re-infection of other germs (RR 2.40; 95% CI, 0.68-8.49, very low-quality evidence), even if short-term therapy seemed to have more risk of recurrences (RR 2.39, 95% CI 1.19-4.83, very low quality of evidence). The incidence of any adverse effect seemed to be lower with the short-term therapy, though the results are not statistically significant (RR 0.63, 95% CI 0.39-1.02, low quality evidence). Short-term treatment for aPN seems to be equivalent to long-term treatment in terms of clinical and microbiological success at the end of treatment or tolerability. The only relevant difference is the frequency of recurrence of the same biological germ up to 4-6 weeks after the end of treatment, which is significantly higher with the short-term therapy.

Complete chest recoil during laypersons' CPR: Is it a matter of weight?

INTRODUCTION

Chest compressions depth and complete chest recoil are both important for high-quality Cardio-Pulmonary Resuscitation (CPR). It has been demonstrated that anthropometric variables affect chest compression depth, but there are no data about they could influence chest recoil. The aim of this study was to verify whether physical attributes influences chest recoil in lay rescuers.

METHODS

We evaluated 1 minute of compression-only CPR performed by 333 laypersons immediately after a Basic Life Support and Automated External Defibrillation (BLS/AED) course. The primary endpoint was to verify whether anthropometric variables influence the achievement a complete chest recoil. Secondary endpoint was to verify the influence of anthropometric variables on chest compression depth.

RESULTS

We found a statistically significant association between weight and percentage of compressions with correct release (p≤0.001) and this association was found also for height, BMI and sex. People who are heavier, who are taller, who have a greater BMI and who are male are less likely to achieve a complete chest recoil. Regarding chest compressions depth, we confirm that the more a person weighs, the more likely the correct depth of chest compressions will be reached.

CONCLUSIONS

Anthropometric variables affect not only chest compression depth, but also complete chest recoil. CPR instructors should tailor their attention during training on different aspect of chest compression depending on the physical characteristics of the attendee.

Decreased platelet responsiveness to clopidogrel correlates with CYP2C19 and PON1 polymorphisms in atherosclerotic patients

Clopidogrel and aspirin are the most commonly used medications worldwide for dual antiplatelet therapy after percutaneous coronary intervention. However, clopidogrel hyporesponsiveness related to gene polymorphisms is a concern. Populations with higher degrees of genetic admixture may have increased prevalence of clopidogrel hyporesponsiveness. To assess this, we genotyped CYP2C19, ABCB1, and PON1 in 187 patients who underwent percutaneous coronary intervention. Race was self-defined by patients. We also performed light transmission aggregometry with adenosine diphosphate (ADP) and arachidonic acid during dual antiplatelet therapy. We found a significant difference for presence of the CYP2C19*2 polymorphism between white and non-white patients. Although 7% of patients had platelet resistance to clopidogrel, this did not correlate with any of the tested genetic polymorphisms. We did not find platelet resistance to aspirin in this cohort. Multivariate analysis showed that patients with PON1 and CYP2C19 polymorphisms had higher light transmission after ADP aggregometry than patients with native alleles. There was no preponderance of any race in patients with higher light transmission aggregometry. In brief, PON1 and CYP2C19 polymorphisms were associated with lower clopidogrel responsiveness in this sample. Despite differences in CYP2C19 polymorphisms across white and non-white patients, genetic admixture by itself was not able to identify clopidogrel hyporesponsiveness.

Gender medicine: an up-date

Women get sick more, use more health services, take more drugs, and have a higher frequency of serious adverse reactions. Despite this, the drugs we use are little studied in women: both clinical studies and pre-clinical experiments are carried out predominantly in males and the young. Before 1990, no more than 26-30% of women were usually enrolled in a trial, so we lacked the statistical power of showing the efficacy and safety of the drugs being studied in the whole population. The gender blindness (transposition of the male studies in female populations) resulted in a lack of awareness of the differences between males and females, and this prevented both genders from receiving the best possible care. This gender bias also, to a lower degree, hurts men: depression, migraines, osteoporosis have not been studied properly in males. Although the process is slow, the scientific community has begun to pay more attention to direct and indirect influences that gender exercise on biological mechanisms, and this includes both internal and external cultural and environmental factors. Therefore, the differences between the old, the young, children, and pregnant women (considered the third gender group) will become increasingly more important as care becomes more personalized. The first course of gender medicine was established only in 2002 at Columbia University, New York, USA. The World Health Organization has incorporated gender medicine into the Equity Act. This implies that the treatment given must be the most appropriate and best suited the individual patient’s gender. The Committee on Women’s Health of the Ministry of Health in Italy was established in 2007. Institutions now pay great attention to the importance of this clinical perspective and are sensitive to the need for change. This review focuses on specific open questions regarding gender: pharmacology, clinical trial recruitment, cardiovascular prevention, stroke, osteoporosis, chronic obstructive pulmonary disease, depression, and discusses presentations made to the 1st course of gender medicine organized as part of the 18th National Congress of the Federation of Associations of Hospital Doctors on Internal Medicine (FADOI), 2012.