Alexithymia Increases Pericranial and Cervical Muscle Tenderness in Women with Migraine

Background/Objectives: Alexithymia is characterized by a deficit in identifying and communicating feelings. Emerging evidence suggests that alexithymia is highly prevalent in migraine, in a complex interplay with psychiatric comorbidity. Pericranial/cervical muscle tenderness is a remarkable clinical feature in a large proportion of migraine patients. This pilot study aimed at investigating the relationship between alexithymia and pericranial/cervical muscle tenderness in female migraineurs. Methods: A total of 42 female patients fulfilling the diagnostic criteria for migraine were enrolled into this pilot, observational, cross-sectional study after informed consent was obtained. Each patient underwent a psychological assessment to identify any alexithymia by means of TAS-20, anxiety/mood comorbidity (by means of STAI-Y1 STAI-Y2, BDI-II), and migraine-related disability (by means of HIT-6), and a physical cranial/cervical musculoskeletal examination. Palpation of pericranial and cervical muscles was carried out in the standardized manner. A Cumulative Muscle Tenderness (CUM) score (0-6) was calculated for each patient. A multivariate analysis was performed to investigate any association amongst the TAS-20 score, the CUM score, and the following covariates: BDI-II, STAI-Y1, STAI-Y2, and HIT-6 scores, age, disease duration, monthly migraine days, and average head pain intensity in the previous three months. Results: Overall, 35.6% of the sample had alexithymia. The multivariate analysis detected a linear and independent relationship between the TAS-20 and CUM scores, with a statistically significant (p = 0.017) association. Conclusions: This pilot study suggests that alexithymia plays a role in increasing pericranial/cervical muscle tenderness in migraine, independently from psychiatric comorbidity. A novel therapeutical approach, targeting alexithymia, may well reduce muscular tenderness in female migraineurs.

Predicting amyloid-PET status in a memory clinic: The role of the novel antero-posterior index and visual rating scales

INTRODUCTION

Visual rating scales are increasingly utilized in clinical practice to assess atrophy in crucial brain regions among patients with cognitive disorders. However, their capacity to predict Alzheimer's disease (AD)-related pathology remains unexplored, particularly within a heterogeneous memory clinic population. This study aims to assess the accuracy of a novel visual rating assessment, the antero-posterior index (API) scale, in predicting amyloid-PET status. Furthermore, the study seeks to determine the optimal cohort-based cutoffs for the medial temporal atrophy (MTA) and parietal atrophy (PA) scales and to integrate the main visual rating scores into a predictive model.

METHODS

We conducted a retrospective analysis of brain MRI and high-resolution TC scans from 153 patients with cognitive disorders who had undergone amyloid-PET assessments due to suspected AD pathology in a real-world memory clinic setting.

RESULTS

The API scale (cutoff ≥1) exhibited the highest accuracy (AUC = 0.721) among the visual rating scales. The combination of the cohort-based MTA and PA threshold with the API yielded favorable accuracy (AUC = 0.787). Analyzing a cohort of MCI/Mild dementia patients below 75 years of age, the API scale and the predictive model improved their accuracy (AUC = 0.741 and 0.813, respectively), achieving excellent results in the early-onset population (AUC = 0.857 and 0.949, respectively).

CONCLUSION

Our study emphasizes the significance of visual rating scales in predicting amyloid-PET positivity within a real-world memory clinic. Implementing the novel API scale, alongside our cohort-based MTA and PA thresholds, has the potential to substantially enhance diagnostic accuracy.

Association between Mortality and Lung Low Attenuation Areas in NSCLC Treated by Surgery

BACKGROUND

to test the association with overall survival (OS) of low attenuation areas (LAAs) quantified by staging computed tomography (CT) of patients who underwent radical surgery for nonsmall-cell lung cancer (NSCLC).

METHODS

patients who underwent radical surgery for NSCLC at our institution between 1 January 2017 and 30 November 2021 were retrospectively evaluated. Patients who performed staging or follow-up CTs in other institutions, who received lung radiotherapy or chemotherapy, and who underwent previous lung surgery were excluded. At staging and 12-months follow-up CT, LAAs defined as voxels <-950 Hounsfield units, were extracted by software. The percent of LAAs relative to whole-lung volume (%LAAs) and the ratio between LAAs in the lobe to resect and whole-lung LAAs (%LAAs lobe ratio) were calculated. Cox proportional hazards regression analysis was used to test the association between OS and LAAs.

RESULTS

the final sample included 75 patients (median age 70 years, IQR 63-75 years; females 29/75, 39%). It identified a significant association with OS for pathological stage III (HR, 6.50; 95%CI, 1.11-37.92; p = 0.038), staging CT %LAAs ≥ 5% (HR, 7.27; 95%CI, 1.60-32.96; p = 0.010), and staging CT %LAA lobe ratio > 10% (HR, 0.24; 95%CI 0.05-0.94; p = 0.046).

CONCLUSIONS

in patients with NSCLC who underwent radical surgery, a %LAAs ≥ 5% and a %LAA lobe ratio > 10% at staging CT are predictors, respectively, of shorter and longer OS. The LAA ratio to the whole lung at staging CT could be a critical factor to predict the overall survival of the NSCLC patients treated by surgery.

Acute Budd-Chiari Syndrome with Complete Portal Vein Thrombosis Complicated by Hepato-Renal Syndrome Treated Successfully by Emergent TIPS with Rheolytic Thrombectomy

We described a case of a 73-year-old female admitted to the emergency department with acute hepatic and renal failure (hepato-renal syndrome, HRS) due to acute Budd-Chiari syndrome associated with complete portal vein thrombosis (BCS-PVT) for an unknown cause. Despite the initial therapy with anticoagulants, a sudden impairment of the renal function requiring hemodialysis was observed. The hepatic transplant was excluded for patient age and clinical conditions. Thus, the patient was successfully treated by emergent transjugular intrahepatic portosystemic shunt (TIPS) previous rheolytic thrombectomy of the PVT with AngioJet Ultra PE Thrombectomy System (Boston Scientific, Marlborough, MA, USA). After the procedure, the sudden resolution of the HRS was observed, and the patient is alive 13 months after hospital dismission with no TIPS dysfunction. In conclusion, emergent extended TIPS with the usage of rheolytic thrombectomy device in patient with acute BCS-PVT complicated by HRS is feasible by experienced operators and provide resolution of the HRS.

Are Interstitial Lung Abnormalities a Prognostic Factor of Worse Outcome in COVID-19 Pneumonia?

PURPOSE

To assess the association between interstitial lung abnormalities (ILAs) and worse outcome in patients affected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19)-related pneumonia.

MATERIALS AND METHODS

The study included patients older than 18 years, who were admitted at the emergency department between February 29 and April 30, 2020 with findings of COVID-19 pneumonia at chest computed tomography (CT), with positive reverse-transcription polymerase chain reaction nasal-pharyngeal swab for SARS-CoV-2, and with the availability of prepandemic chest CT. Prepandemic CTs were reviewed for the presence of ILAs, categorized as fibrotic in cases with associated architectural distortion, bronchiectasis, or honeycombing. Worse outcome was defined as intensive care unit (ICU) admission or death. Cox proportional hazards regression analysis was used to test the association between ICU admission/death and preexisting ILAs.

RESULTS

The study included 147 patients (median age 73 y old; 95% CIs: 71-76-y old; 29% females). On prepandemic CTs, ILA were identified in 33/147 (22%) of the patients, 63% of which were fibrotic ILAs. Fibrotic ILAs were associated with higher risk of ICU admission or death in patients with COVID-19 pneumonia (hazard ratios: 2.73, 95% CIs: 1.50-4.97, P =0.001).

CONCLUSIONS

In patients affected by COVID-19 pneumonia, preexisting fibrotic ILAs were an independent predictor of worse prognosis, with a 2.7 times increased risk of ICU admission or death. Chest CT scans obtained before the diagnosis of COVID-19 pneumonia should be carefully reviewed for the presence and characterization of ILAs.

CT perfusion extended window ischemic core estimation: Bayesian algorithm versus oscillation index singular value decomposition

BACKGROUND AND PURPOSE

Ischemic core estimation by CT perfusion (CTp) is a diagnostic challenge, mainly because of the intrinsic noise associated with perfusion data. However, an accurate and reliable quantification of the ischemic core is critical in the selection of patients for reperfusion therapies. Our study aimed at assessing the diagnostic accuracy of two different CTp postprocessing algorithms, that is, the Bayesian Method and the oscillation index singular value decomposition (oSVD).

METHODS

All the consecutive stroke patients studied in the extended time window (>4.5 hours from stroke onset) by CTp and diffusion-weighted imaging (DWI), between October 2019 and December 2021, were enrolled. The agreement between both algorithms and DWI was assessed by the Bland-Altman plot, Wilcoxon signed-rank test, Spearman's rank correlation coefficient, and the intraclass correlation coefficient (ICC).

RESULTS

Twenty-four patients were enrolled (average age: 72 ± 15 years). The average National Institutes of Health Stroke Scale was 14.42 ± 6.75, the median Alberta Stroke Program Early CT score was 8.50 (interquartile range [IQR] = 7.75-9), and median time from stroke onset to neuroimaging was 7.5 hours (IQR = 6.5-8). There was an excellent correlation between DWI and oSVD (ρ = .87, p-value < .001) and DWI and Bayesian algorithm (ρ = .94, p-value < .001). There was a stronger ICC between DWI and Bayesian algorithm (.97, 95% confidence interval [CI]: .92-.99, p-value < .001) than between DWI and oSVD (.59, 95% CI: .26-.8, p-value < .001).

DISCUSSION

The agreement between Bayesian algorithm and DWI was greater than between oSVD and DWI in the extended window. The more accurate estimation of the ischemic core offered by the Bayesian algorithm may well play a critical role in the accurate selection of patients for reperfusion therapies.

Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report

Thoracic duct (TD) is the largest lymphatic vessel in the body and drains the lymph at the junction between the left subclavian and jugular veins. Chylothorax (CTX) represents an accumulation of lymphatic fluid in the pleural space. We present a case of a 65 years-old man with an histologically diagnosed mediastinal type B non-Hodgkin Lymphoma, treated with chemo-immunotherapy. CT scan during follow up showed significant left side pleural effusion, amounting to 2.8 litres after drainage. Conservative treatment with low fat parenteral nutrition was started without reduction of drainage output, then lymphangiography (LP) with Lipiodol was performed demonstrating a leak in the distal TD. CTX increased in the following days, and a further LP was performed. Using transvenous retrograde access we catheterized TD at the left subclavian jugular veins using a microcatheter. The leak was treated with multiple conventional and controlled delivery microcroils and cyanoacrylate, obtaining complete embolization without residual leak.

The Impact of Highly Effective Treatment in Pediatric-Onset Multiple Sclerosis: A Case Series

Introduction: Pediatric-onset multiple sclerosis (POMS) is characterized by high inflammatory disease activity. Our aim was to describe the treatment sequencing and report the impact highly effective disease-modifying treatment (HET) had on disease activity. Materials and Methods: Five consecutive patients with POMS were administered HET following lower efficacy drug or as initial therapy. Data on treatment sequencing, relapses and MRIs were collected during the follow-up. Results: Our patients had an average age of 13.8 years (range 9–17) at diagnosis and 13.4 years (range 9–16) at disease onset, and 2/5 (40%) POMS were female. The pre-treatment average annualized relapse rate was 1.6 (range 0.8–2.8), and the average follow-up length was 5 years (range 3–7). A total of 2/5 (40%) patients were stable on HET at initial therapy, and 3/5 (60%) required an escalation to more aggressive treatment, even if two of them had been put on HET as initial treatment. Four out of five patients (80%) had No Evidence of Disease Activity-3 status (NEDA-3) at an average follow-up of 3 years (range 2–5). Conclusion: It has been observed that in a recent time period all the cases had prompt diagnosis, early HET or escalation to HET with a good outcome in 80% of the cases.

A “Post-mortem” of COVID-19-Asscoiated Stroke: a Case-control Study

Objectives

To assess whether COVID-19 could be a concurrent factor in the genesis and/or worsening of stroke and to provide data on COVID-19 –associated stroke patients during the first pandemic wave and comparative data on COVID-19 negative stroke patients in the same period.

Materials and Methods

This is a retrospective, observational, case-control, single centre study, carried out in a General Hospital in northern Italy. Sixty-three consecutive stroke patients were included, COVID-19-associated stroke was classified as cases and non COVID-19-associated stroke as controls.

Results

A total of 19/63 (28.8%) had a COVID-19-associated stroke, 11 /63 (17.5%) were haemorrhagic and 52/63 (82.5%) ischaemic. COVID-19-associated strokes were more severe (p-value 0.019) and had a higher risk of severe disability and/or death (OR 3.79, CI 95%: 1.21-11.93, p-value 0.19). The COVID-19-associated stroke patients with onset during hospitalization for COVID-19 had a more severe stroke than patients with COVID-19 onset during hospitalization for stroke (p-value 0.019).

Conclusion

Although no relationship was observed between the stroke aetiology and COVID-19, intriguingly, COVID-associated stroke turned out to be more severe and disabling. Hopefully, further studies will provide more data and help in the management of this emerging population.

Patients with Parkinson's disease and a history of falls have decreased cerebellar grey matter volumes in the cognitive cerebellum

The objective of this study was to determine if cerebellar gray matter (GM) structure differs between fallers and non-fallers with Parkinson's disease (PD) and their respective association to cognitive function. A total of 48 fallers and 63 non-fallers with PD were identified from the Parkinson's Progression Markers Initiative database. Fallers were categorized as those who self-reported a fall within the past year. Unified Parkinson's Disease Rating Scale-III (UPDRS-III), Montreal Cognitive Assessment (MoCA), Trail Making Test parts A (TMT-A) and B (TMT-B) scores were collected for each patient. Cerebellar GM volumes were derived from magnetic resonance imaging data. Analyses of covariance were used to compare group differences. Partial Pearson's correlations were used to assess the relationship between cerebellar GM volumes to UPDRS-III and cognitive outcomes. Significance was set at P ≤ 0.01. Fallers had significantly decreased GM volumes in lobules V, Crus-1, Crus-2, and VIIb (P<0.01). Cerebellar GM volumes in non-fallers demonstrated little-to-no relationship with UPDRS-III, MoCA, and TMT-B (P>0.01). However, TMT-A performance demonstrated significant, fair association to GM volumes in lobules I-IV, V, VI, Crus-1, and Crus-2 (r=-0.44 - -0.34, P<0.01) in non-fallers. Patients with PD and a history of falls have significantly decreased GM volumes in cerebellar lobules associated with cognitive functions. However, these lobule volumes become disassociated with cognitive function compared to non-fallers.

Change in the second exteroceptive suppression period of the temporalis muscle during erenumab treatment

Comparative studies on the second exteroceptive suppression period (ES2) of the masseter or temporalis muscle in migraineurs and controls have provided conflicting results. As the interneurons responsible for ES2 are probably close to the trigeminal nucleus caudalis and receive afferents also from the anti-nociceptive system, the study of ES2 could provide information on neural circuits involved in migraine pathophysiology. The aim of this observational, pilot study was to assess whether erenumab treatment may affect the exteroceptive suppression reflex of the temporalis muscle activity in migraineurs. The exteroceptive suppression reflex of the temporalis muscle activity was previously studied in a small case series of three chronic female migraineurs and after 4 months of beneficial erenumab treatment, administered according to current clinical indications. There was a statistically significant decrease in ES2 latency (p-value 0.039) and duration (p-value 0.030) after treatment. The change observed in the temporalis ES2 during erenumab treatment indicates that ES2 may play some kind of role as a neurophysiological marker and that this monoclonal antibody can modulate the brainstem circuits involved in migraine pathophysiology, at least indirectly. Further studies are required to confirm this intriguing hypothesis.

Multiple Sclerosis Treatment in the COVID-19 Era: A Risk-Benefit Approach

The COVID-19 pandemic poses an ongoing global challenge, and several risk factors make people with multiple sclerosis (pwMS) particularly susceptible to running a severe disease course. Although the literature does report numerous articles on the risk factors for severe COVID-19 and vaccination response in pwMS, there is a scarcity of reviews integrating both these aspects into strategies aimed at minimizing risks. The aim of this review is to describe the risk of vulnerable pwMS exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the issues related to the SARS-CoV-2 vaccine and to evidence possible future strategies in the clinical management of pwMS. The authors searched for papers on severe COVID-19 risk factors, SARS-CoV-2 vaccination and people with multiple sclerosis in support of this narrative literature review. We propose a multilevel strategy aimed at: the evaluation of risk factors for severe COVID-19 in people with multiple sclerosis, identifying the most appropriate vaccination schedule that is safe for people on disease-modifying drugs (DMDs) and a strict follow-up of high-risk people with multiple sclerosis to allow for the prompt administration of monoclonal antibodies to manage COVID-19 risks in this patient population.

A sabbath in the emergency room or a case of anticholinergic toxicity?

We report the case of a 32-year-old Italian man admitted to our emergency room for visual disturbances with blurred vision, anisocoria and temporal headache suddenly occurred in absence of other neurological symptoms. A diagnosis of Datura stramoniuminduced anticholinergic toxicity was done. With our work, we want to highlight the importance of a meticulous clinical examination, including papillary diameter and reflexes, combined with a detailed history of the patient in the emergency room. Anticholinergic toxicity is a medical emergency. The diagnosis is always clinical, and it can represent a challenge for the emergency clinicians because it can mimic several neurological diseases, including acute stroke and seizures, but early diagnosis is crucial to avoid severe complications and management errors.

Spyglass percutaneous transhepatic lithotripsy of symptomatic recurrent lithiasis of the intrahepatic bile duct with distal stenosis

In patients with symptomatic intrahepatic biliary lithiasis, the treatment is usually discussed by a multidisciplinary team. Although hepatectomy is considered as definitive treatment, when lobar atrophy is absent, endoscopic procedures are frequently proposed as first-line treatment due the low invasiveness and for sparing liver parenchyma. Percutaneous route is used in case of peroral approach failure. We present a case of recurrent symptomatic intrahepatic biliary lithiasis of the right posterior hepatic duct, sustained by downstream biliary stenosis. Peroral cholangioscopy failed to visualize the stone for the accompanying stenosis. Thus, the patient was successfully treated with percutaneous transhepatic lithotripsy performed with Spyglass direct visualization system II (Boston Scientific Inc., Natick, Massachusetts, USA). During the procedure, the biopsy of the biliary stenosis revealed fibrosis, which was treated by cholangioplasty with cutting balloon. After 15 months, the patient is asymptomatic, with moderate residual stenosis in absence of calculi at follow-up magnetic resonance cholangiography.

Predictors of the multiwire technique use in carotid artery stenting

OBJECTIVES

The multiwire technique (MWT) in carotid artery stenting (CAS), characterized by the use of more than one guidewire to support guiding catheter in patients with hostile neck anatomy, increases procedural time, enhancing the risk of periprocedural stroke. The aim of the present study was to identify which factors are predictors of the MWT use in CAS, in order to stratify patients with longer procedure at potential higher risk of periprocedural stroke.

METHODS

The study retrospectively included patients who underwent CAS for stenotic plaque between January 2015 and December 2019. Exclusion criteria was incomplete clinical data. For each patients were registered clinical data, main aortic arch and supra-aortic vessel anatomical features, carotid plaque characteristics, and procedural details. The sample was divided in two group on the basis of the number of guides used during the stenting procedure: one guide (standard technique, ST) or more than one guidewire (MWT) to support the guiding catheter. Differences between groups were tested by Chi-square text or Fisher's exact test and Mann-Whitney U test. Logistic regression analysis was used to identify predictors for the use of the MWT. The area under the ROC (AUC) curve was used to assess performance of the model to predict the use of the multiwire technique.

RESULTS

The final sample included 146 of the 204 (71%) patients who underwent CAS during the study period. The median age of the patients was 79 years (IQR 71-83 years) with 47/146 (32%) females. CAS was performed with MWT in 17/146 (12%) of the cases. MWT was used more likely in patients with aortic arch type II or III as compared to ST (71% vs 37%, P = 0.02) while plaques with heavy concentric calcifications were more frequent in ST as compared to MWT (38% vs 12%, P = 0.03). At multivariable analysis aortic arch type II or III (OR 5.08, 95% CI 1.48-17.93, P < 0.01), plaque stenosis > 79% (OR 4.13, 95% CI 1.03-16.61, P = 0.04), and plaque heavy concentric calcifications (OR 0.19, 95% CI 0.04-0.94, P = 0.04) were independent predictors of MWT use. The model showed an AUC of 0.827 (95% CI 0.756-0.884) for the prediction of the MWT use during CAS.

CONCLUSIONS

Aortic arch type II or III, carotid plaque with stenosis higher than 79% of the lumen or without heavy concentric calcifications were predictors for the use of the MWT during CAS. These features should be considered during planning of CAS as hallmark of vascular stiffness and therefore of higher procedure complexity.

Not all is COVID19: a case of eclampsia and posterior reversible encephalopathy syndrome in the emergency room

In the so called COVID19 era, headache, fever and gastrointestinal symptoms are highly suggestive for SARS-CoV-2 infection, but in all the cases presenting to the emergency room, clinicians should always keep in mind alternative diagnoses, particularly if the patient is pregnant.  Life-threatening diseases, such as eclampsia and posterior reversible encephalopathy syndrome (PRES), should be promptly recognized and treated. Eclampsia is defined as a seizure occurring in association with pre-eclampsia, and it represents one of the major and serious obstetric disorders associated with significant maternal and perinatal morbidity and mortality. PRES is a distinctive clinical and imaging syndrome characterized by acute headaches, visual impairment, seizures, and altered sensorium, that can be associated with severe eclampsia. Emergency clinicians should always consider eclampsia in the differential diagnosis of headache in pregnant women. The prompt and accurate diagnosis of eclampsia/PRES is crucial to prevent adverse maternal and perinatal outcomes. Here we describe the case of a young pregnant woman admitted to our emergency department for fever, dyspnea, headache, nausea and vomiting, who developed generalized tonic clonic seizures and a subsequent status epilepticus due to eclampsia and PRES.

Applying Theory of Change to strategy articulation cycles in design projects: Potentials and shortcomings through the Designscapes case study

Since the 1990s, the framework of Theory of Change has been used to address complex contexts of intervention especially in relation to planning and evaluating social practice. Theory of Change can be defined as the systematic and cumulative study of the links between the activities, outcomes, and context of an intervention. The aim of this paper is to explore through a case study whether Theory of Change can support more strategic approaches in design. In particular, the paper examines how Theory of Change was applied to DESIGNSCAPES - a project oriented, among other things, toward offering a supporting service for all those city actors interested in using design to develop urban innovation initiatives that tackle complex issues of broad concern.

Iatrogenic Hypoglycemia Induced by Valproic Acid in an Adult Patient

Literature on antiepileptic induced iatrogenic hypoglycemia is scanty. Due to its broad spectrum of activity and mechanisms of action, valproic acid (VPA), a fatty acid, is the most widely prescribed epilepsy treatment worldwide.Herein, we describe an adult epileptic patient, where persistent, otherwise unexplained hypoglycemia, was most likely induced by VPA, as suggested by the VPA time course and glucose blood levels. Indeed, no further hypoglycemic episodes occurred after VPA discontinuation and the diagnostic work-up ruled out other possible causes of hypoglycemia.This case supports the hypothesis that VPA may induce hypoglycemia, due to still not well-defined metabolic mechanisms of action. Moreover, it emphasizes the fact that an iatrogenic pathogenesis should be considered if an apparently unexplained hypoglycemia occurs in a patient on chronic therapy with antiepileptics, even at a therapeutical dosage.

Two-year follow-up during fingolimod treatment in a pediatric multiple sclerosis patient still active on first-line treatment

Treatment of pediatric multiple sclerosis (MS) has been increasingly debated in the last few years due to limited knowledge of treatment strategies and therapeutic options. When MS develops at a young age, it usually has a very inflammatory disease course, with many relapses and disease activity as seen in magnetic resonance imaging (MRI). Therefore, treatment with immunomodulatory drugs may be beneficial in these patients. However, limited data are available to date on the treatment of pediatric MS. Although observational, prospective, and retrospective studies provide some information on its treatment course, only one clinical trial in pediatric patients has been published, the PARADIGMS trial, which showed an 82% reduction in relapse rate with fingolimod (0.5 mg/day) versus interferon β-1a (30 μg once weekly intramuscularly). Here, we present the case of a pediatric patient with MS (age of onset, 13 years), who was initially treated with interferon β-1a for 2 years and subsequently switched to fingolimod, owing to clinical and radiological activity despite treatment with interferon β-1a.

Beyond This Book

Some concluding notes originate from the view proposed by the previous chapters. This particular view is like a picture that captures a portion of a landscape in a specific frame, time and logical context. This chapter clarifies this frame and suggests ways to extend this view beyond the logical, professional and time limitations that a book could possibly present.

Screening for Fabry disease in unknown origin axonal polyneuropathy: to do or not to do, this is the question!

Fabry disease (FD) is a systemic X-linked lysosomal disorder. A ‘peripheral nerve variant’ of FD has been hypothesized in subjects with neuropathy, without the early manifestations of the classic phenotype. A cohort of undiagnosed neuropathy patients with chronic polyneuropathy of undetermined aetiology and demyelinating neuropathy, unresponsive to immunomodulating treatment, were screened for FD. A total of 103 patients (64% males), were enrolled. No typical pathogenetic mutations for FD were identified. We are aware that the study sample was very small, but only a large, unfeasible theoretical sample size could demonstrate a statistically significant increased prevalence of FD in neuropathy patients, as peripheral neuropathy of undetermined cause is uncommon and there is a low prevalence of FD in the general population. Therefore, we are of the opinion that including tailored FD screening in the neuropathy diagnostic work-up, particularly when there are additional clinical characteristics, should be considered.

Qualitative and quantitative chest CT parameters as predictors of specific mortality in COVID-19 patients

PURPOSE

To test the association between death and both qualitative and quantitative CT parameters obtained visually and by software in coronavirus disease (COVID-19) early outbreak.

METHODS

The study analyzed retrospectively patients underwent chest CT at hospital admission for COVID-19 pneumonia suspicion, between February 21 and March 6, 2020. CT was performed in case of hypoxemia or moderate-to-severe dyspnea. CT scans were analyzed for quantitative and qualitative features obtained visually and by software. Cox proportional hazards regression analysis examined the association between variables and overall survival (OS). Three models were built for stratification of mortality risk: clinical, clinical/visual CT evaluation, and clinical/software-based CT assessment. AUC for each model was used to assess performance in predicting death.

RESULTS

The study included 248 patients (70% males, median age 68 years). Death occurred in 78/248 (32%) patients. Visual pneumonia extent > 40% (HR 2.15, 95% CI 1.2-3.85, P = 0.01), %high attenuation area - 700 HU > 35% (HR 2.17, 95% CI 1.2-3.94, P = 0.01), exudative consolidations (HR 2.85-2.93, 95% CI 1.61-5.05/1.66-5.16, P < 0.001), visual CAC score > 1 (HR 2.76-3.32, 95% CI 1.4-5.45/1.71-6.46, P < 0.01/P < 0.001), and CT classified as COVID-19 and other disease (HR 1.92-2.03, 95% CI 1.01-3.67/1.06-3.9, P = 0.04/P = 0.03) were significantly associated with shorter OS. Models including CT parameters (AUC 0.911-0.913, 95% CI 0.873-0.95/0.875-0.952) were better predictors of death as compared to clinical model (AUC 0.869, 95% CI 0.816-0.922; P = 0.04 for both models).

CONCLUSIONS

In COVID-19 patients, qualitative and quantitative chest CT parameters obtained visually or by software are predictors of mortality. Predictive models including CT metrics were better predictors of death in comparison to clinical model.

Comparison of admission chest computed tomography and lung ultrasound performance for diagnosis of COVID-19 pneumonia in populations with different disease prevalence

PURPOSE

Chest computed tomography (CT) is considered a reliable imaging tool for COVID-19 pneumonia diagnosis, while lung ultrasound (LUS) has emerged as a potential alternative to characterize lung involvement. The aim of the study was to compare diagnostic performance of admission chest CT and LUS for the diagnosis of COVID-19.

METHODS

We included patients admitted to emergency department between February 21-March 6, 2020 (high prevalence group, HP) and between March 30-April 13, 2020 (moderate prevalence group, MP) undergoing LUS and chest CT within 12 h. Chest CT was considered positive in case of "indeterminate"/"typical" pattern for COVID-19 by RSNA classification system. At LUS, thickened pleural line with ≥ three B-lines at least in one zone of the 12 explored was considered positive. Sensitivity, specificity, PPV, NPV, and AUC were calculated for CT and LUS against real-time reverse transcriptase polymerase chain reaction (RT-PCR) and serology as reference standard.

RESULTS

The study included 486 patients (males 61 %; median age, 70 years): 247 patients in HP (COVID-19 prevalence 94 %) and 239 patients in MP (COVID-19 prevalence 45 %). In HP and MP respectively, sensitivity, specificity, PPV, and NPV were 90-95 %, 43-69 %, 96-72 %, 20-95 % for CT and 94-93 %, 7-31 %, 94-52 %, 7-83 % for LUS. CT demonstrated better performance than LUS in diagnosis of COVID-19, both in HP (AUC 0.75 vs 0.51; P < 0.001) and MP (AUC 0.85 vs 0.62; P < 0.001).

CONCLUSIONS

Admission chest CT shows better performance than LUS for COVID-19 diagnosis, at varying disease prevalence. LUS is highly sensitive, but not specific for COVID-19.

COVID-19 outbreak in Italy: Clinical-radiological presentation and outcome in three oncologic patients

We present three patients affected by pulmonary squamous cell carcinoma, metastatic esophageal cancer and advanced non-Hodgkin lymphoma, who incurred in coronavirus 2019 (COVID-19) infection during the early phase of epidemic wave in Italy. All patients presented with fever. Social contact with subject positive for COVID-19 was declared in only one of the three cases. In all cases, laboratory findings showed lymphopenia and elevated C-reactive protein (CRP). Chest x-ray and computed tomography showed bilateral ground-glass opacities, shadowing, interstitial abnormalities, and “crazy paving” pattern which evolved with superimposition of consolidations in one patient. All patients received antiviral therapy based on ritonavir and lopinavir, associated with hydroxychloroquine. Despite treatment, two patients with advanced cancers died after 39 and 17 days of hospitalization, while the patient with lung cancer was dismissed at home, in good conditions.

SosCaregivers: piloting of a psycho-social service for family caregiver in a hard-to-reach setting

Background

”Ageing-in-place” may improve elderly citizens' quality of life and the sustainability of welfare systems. In this process engaging family caregivers is crucial.

Methods

A community-based participatory research in the remote area of Vallecamonica was enacted. First, we surveyed unmet needs of family caregivers. Then, a scoping literature review on existing interventions for engaging family caregivers was performed. Third, 4 co-design workshops were conducted to co-generate a new service. Finally, the service was piloted for a period of 6 months and evaluated.

Results

51 caregivers participated in the survey: they were mainly females, mean 60 y.o and with medium-low level of education. The scoping review resulted in only 14 interventions targeted to elderly's caregivers in remote areas. The workshops involved 27 caregivers and co-designed a new psycho-social service (SOSCargivers) articulated into: 1) a structured informative platform to facilitate health literacy and information seeking; 2) a tailored educational program focused on medical and practical aspects related to elderly care; 3) a set of peer-to-peer meetings for experience sharing and mutual support; 4) a “caregivers board” was created to lead the service. In the piloting 5 training sessions, 5 peer-to-peer meetings, 3 meeting with the “citizens board” were enabled.

Conclusions

The service was positively received by caregivers, although participation wasn't high. Co-designing the service with its expected users facilitates the depth understanding of local people's needs and expectations. SOSCaregivers may support family caregivers of elderly citizens in hard to reach areas by both delivering more value and giving them an active role in the social-care network.

Key messages

Family caregivers’ engagement is crucial for integrated and sustainable services in hard to reach communities. Co-designing the service with its expected users facilitates the Department understanding of local people’s needs and expectations.

Well-aerated Lung on Admitting Chest CT to Predict Adverse Outcome in COVID-19 Pneumonia

Background CT of patients with severe acute respiratory syndrome coronavirus 2 disease depicts the extent of lung involvement in coronavirus disease 2019 (COVID-19) pneumonia. Purpose To determine the value of quantification of the well-aerated lung (WAL) obtained at admission chest CT to determine prognosis in patients with COVID-19 pneumonia. Materials and Methods Imaging of patients admitted at the emergency department between February 17 and March 10, 2020 who underwent chest CT were retrospectively analyzed. Patients with negative results of reverse-transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 at nasal-pharyngeal swabbing, negative chest CT findings, and incomplete clinical data were excluded. CT images were analyzed for quantification of WAL visually (%V-WAL), with open-source software (%S-WAL), and with absolute volume (VOL-WAL). Clinical parameters included patient characteristics, comorbidities, symptom type and duration, oxygen saturation, and laboratory values. Logistic regression was used to evaluate the relationship between clinical parameters and CT metrics versus patient outcome (intensive care unit [ICU] admission or death vs no ICU admission or death). The area under the receiver operating characteristic curve (AUC) was calculated to determine model performance. Results The study included 236 patients (59 of 123 [25%] were female; median age, 68 years). A %V-WAL less than 73% (odds ratio [OR], 5.4; 95% confidence interval [CI]: 2.7, 10.8; P < .001), %S-WAL less than 71% (OR, 3.8; 95% CI: 1.9, 7.5; P < .001), and VOL-WAL less than 2.9 L (OR, 2.6; 95% CI: 1.2, 5.8; P < .01) were predictors of ICU admission or death. In comparison with clinical models containing only clinical parameters (AUC = 0.83), all three quantitative models showed better diagnostic performance (AUC = 0.86 for all models). The models containing %V-WAL less than 73% and VOL-WAL less than 2.9 L were superior in terms of performance as compared with the models containing only clinical parameters (P = .04 for both models). Conclusion In patients with confirmed coronavirus disease 2019 pneumonia, visual or software quantification of the extent of CT lung abnormality were predictors of intensive care unit admission or death. ©  RSNA, 2020 Online supplemental material is available for this article.

A-25 The Effect of Cognitive Dual-Tasks on Dynamic Postural Sway During Sub-Maximal Gait on a Treadmill

Objective

To investigate the effect of a cognitive task on postural control during treadmill walking. We hypothesized that postural sway acceleration would decrease during dual-task compared to single-task gait.

Method

Ten (5 females, 5 males) physically active, healthy young adults (Age: 22.50 ± 3.01) with no history of cognitive deficits or head injury were recruited from a University campus for this cross-sectional study. Participants reported to a biomechanics laboratory for a single testing session and completed two, 5-minute walking trials on a treadmill at 90% of maximal gait-speed under single and dual-task conditions while instrumented with a single inertial measurement unit (IMU) on the lower-back. During dual-task gait, participants concurrently performed a Stroop Test displayed on a mounted screen in front of the treadmill during the entire trial. Root mean square (RMS) of acceleration was analyzed in the medial-lateral, anterior-posterior, superior-inferior, and resultant planes during the dual-task trial. Paired t-tests and effect sizes (ES) were calculated for each sway plane between single and dual-tasks.

Results

No differences were identified between single and dual-task RMS acceleration in the medial-lateral (p = 0.98, ES = 0.01), anterior-posterior (p = 0.49, ES = 0.23) or superior-inferior (p = 0.98, ES = 0.01) planes. However, the RMS acceleration in the resultant plane was lower in the dual-task condition (Mean Difference: 0.031 ± 0.037; p = 0.02, ES = 0.85).

Conclusions

This novel dual-task gait paradigm utilized constant sub-maximal gait speed to investigate the influence of a sustained cognitive dual-task on postural sway using a single IMU. These preliminary results indicate that this dual-task gait paradigm may affect gross postural sway in healthy adults.

The Incremental Diagnostic Value of [18F]Florbetaben PET and the Pivotal Role of the Neuropsychological Assessment in Clinical Practice

BACKGROUND

Amyloid pathology is a key feature of Alzheimer's disease (AD) and can be assessed in vivo with amyloid positron emission tomography (PET) imaging.

OBJECTIVE

The objective of this study was to evaluate the incremental value of a PET scan with [18F]florbetaben, in terms of changes of diagnosis, diagnostic confidence, and treatment plan when added to a standardized diagnostic workup for cognitive disorders, with particular focus on the role of the neuropsychological assessment, including the Free and Cued Selective Reminding Test (FCSRT).

METHODS

A total of 104 patients (69 mild cognitive impairment, 35 dementia), with diagnostic uncertainty after diagnostic workup, were recruited from our memory clinic. [18F]florbetaben PET scans were interpreted as amyloid negative or positive on the basis of a semi-quantitative visual rating. Clinical diagnosis and diagnostic confidence for AD or non-AD dementia were rated before and after PET result disclosure, as was the impact of PET on the patient management plan.

RESULTS

There were 69/104 (66%) [18F]florbetaben positive scans, 51/62 (82%) patients were suspected as having AD before the PET scan and 18/42 (43%) were not. Overall, the data obtained at PET changed 18/104 diagnoses (17%) and increased diagnostic confidence from 69.1±8.1% to 83.5±9.1 (p < 0.001), with the greatest impact on diagnosis and confidence in PET negative patients with an initial diagnosis of AD (p < 0.01) and in early-onset patients (p = 0.01).

CONCLUSION

Amyloid PET represents a source of added value in dementia diagnosis, with a significant effect on diagnosis and diagnostic confidence. However, the use of a complete neuropsychological assessment has an add-on value on limiting the amyloid PET influence on change of diagnosis, and the real impact of amyloid PET should always be weighed up together with an accurate standardized diagnostic workup.

The management of patients with acute ischemic stroke while on direct oral anticoagulants (DOACs): data from an Italian cohort and a proposed algorithm

Approximately 1-2% of patients with non-valvular atrial fibrillation have an acute ischemic stroke (AIS) while on direct oral anticoagulant (DOAC) treatment every year. However, current evidence on stroke subtypes, pathophysiology and factors leading to the failure of DOAC preventive therapy in a "real world" setting is still scanty. This study aimed at investigating whether there is any relationship between DOAC plasma levels and the stroke occurrence, on the basis of the phenotypic classification and pathophysiology of the stroke, in a cohort of DOAC-treated patients admitted to our hospital for AIS over 1-year period. A total of 28 patients had DOAC plasma levels determined in emergency and were included in the study, nine patients receiving dabigatran, 11 rivaroxaban and 8 apixaban. The DOAC levels were low in 8/28 patients (28.6% of the sample), intermediate in 4 (14.3%) and high in 16 (57.1%). The most prevalent stroke subtype was the small vessel disease, according to the A-S-C-O phenotypic classification, in 53.6% of our sample. The most common clinical presentation was "minor stroke" in 71.4% of the cases. There was a significantly higher proportion of patients with high DOAC levels in the small vessel group, compared to the cardioembolic group without other phenotypes. The question arises as to the most suitable clinical management of AIS in these patients on DOACs. In the current absence of clear evidence, taking into account the DOAC levels (low/intermediate/high) and the underlying stroke pathophysiology, we present a flowchart of our proposed clinical management of ischemic stroke in patients while on DOAC.

CSF biomarkers and amyloid PET: concordance and diagnostic accuracy in a MCI cohort

Brain amyloid deposition is one of the main hallmarks of Alzheimer's disease (AD) and two approaches are available for assessing amyloid pathology in vivo: cerebrospinal fluid (CSF) biomarkers levels and amyloid load visualized by amyloid beta positron emission tomography imaging (Amy-PET) probes. We aimed to investigate the concordance between CSF biomarkers and Amy-PET in a memory clinic cohort. Moreover, using a proper clinical follow-up, we wanted to assess the diagnostic accuracy of CSF and PET biomarkers in predicting the progression of patients with mild cognitive impairment (MCI) to AD dementia. We included 31 MCI patients who underwent [18F]florbetaben PET and CSF sampling (Aβ1-42, t-Tau, p-Tau). A semiquantitative visual scan assessment was used to quantify amyloid deposition in 5 brain regions, rating from 1 (negative), to 2 and 3 (positive). CSF biomarkers were considered abnormal if: Aβ1-42 < 600 pg/ml, p-Tau/Aβ1-42 > 0.08 and t-Tau/Aβ1-42 > 0.52. We also applied less lenient cutoffs of 550 pg/ml and 450 pg/ml for Aβ1-42. The concordance rate was 77% between Amy-PET and CSF Aβ1-42 levels, and 89% between Amy-PET and p-Tau/Aβ1-42 and t-Tau/Aβ1-42. According to the clinical follow-up, Amy-PET (sensitivity [SE] 93.7%, specificity [SP] 80%) exhibited the best diagnostic accuracy in discriminating AD from non-AD, followed by p-Tau/Aβ1-42 ratio and t-Tau/Aβ1-42 ratio (SE 93.7%, SP 66.6%), and Aβ1-42 levels (SE 81%, SP 60%). The regional uptake of [18F]florbetaben PET in the precuneus and the striatum showed the best SP (86.6%). In discordant cases, the clinical diagnosis was most often in agreement with PET results. In general, concordance between CSF biomarkers and Amy-PET was good, especially when the ratios between CSF amyloid and Tau biomarkers were used. However, Amy-PET proved to be superior to CSF Aβ1-42 in terms of diagnostic accuracy for AD, with the possibility to further increase its specificity by focusing the analysis in specific areas such as the precuneus/posterior cingulate cortex and the striatum.

A Case of Recurrent Secondary Aortoenteric Fistula 4 Months after Surgery Treated by Endovascular Coiling of the Aortic Stump and Bilateral Chimney Stent Grafts to Renal Arteries

The treatment of recurrent aortoenteric fistula (AEF) previously repaired by surgery is challenging, with a high mortality rate. Open repair is often limited by "hostile abdomen," while endovascular treatment is difficult when the distance between the aortic stump and the origin of the renal arteries is short, with high risk of their occlusion. We describe a recurrent AEF repaired by surgery 4 months earlier, treated by endovascular coiling of the aortic stump after deployment of 2 renal artery stent grafts with the chimney technique.