Publications by authors named "Francesco Pugliese"

169 Publications

Outcome of a Modified Sympathicotomy for Cardiac Neuromodulation of Untreatable Ventricular Tachycardia.

JACC Clin Electrophysiol 2021 Apr 28;7(4):442-449. Epub 2020 Oct 28.

Thoracic Unit, Policlinico Umberto I, Sapienza University, Rome, Italy.

Objectives: This study aimed to describe the preliminary results of a modified sympathicotomy for cardiac sympathetic denervation (CSD), which may reduce the predictive risk and intraoperative surgical time of the procedure.

Background: CSD, in patients with refractory ventricular tachycardia (VT), is comprehensively recognized as an important treatment option for patients with structural heart disease as well as congenital inherited arrhythmia syndrome.

Methods: We consecutively enrolled 5 patients with refractory VT. Baseline demographic, medical, and surgical data as well as arrhythmia outcomes and procedural complications were evaluated.

Results: A total of 5 patients (mean age: 67.4 years) were enrolled for the treatment of refractory VT with a modified CSD technique. In 3 of 5 patients, an overall reduction in VT burden (ranging from 75% to 100%) and VT number was observed after the CSD despite an in-hospital early recurrence.

Conclusions: A modified CSD (sympathicotomy T2-T5) with stellate ganglion sparing and the use of unipolar radiofrequency is feasible, effective, and safe in the setting of untreatable VT.
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http://dx.doi.org/10.1016/j.jacep.2020.08.022DOI Listing
April 2021

Postoperative delirium in kidney transplant patients.

Transpl Int 2021 Apr 21. Epub 2021 Apr 21.

Department of Anesthesiology and Critical Care, Sapienza University of Rome, Rome, Italy.

Delirium, also known as acute brain failure, is a medical condition characterized by recent onset of confusion, fluctuating awareness, disorganized thought, with memory and attention impairment. Post-operative delirium (POD) generally arises 1 to 3 days after surgery, in 25-37% of the hospitalized patients and in > 65% of those admitted to intensive care unit [1].
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http://dx.doi.org/10.1111/tri.13890DOI Listing
April 2021

Prior Antibiotic Therapy and the Onset of Healthcare-Associated Infections Sustained by Multidrug-Resistant in Intensive Care Unit Patients: A Nested Case-Control Study.

Antibiotics (Basel) 2021 Mar 15;10(3). Epub 2021 Mar 15.

Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy.

Epidemiological research has demonstrated direct relationships between antibiotic consumption and the emergence of multidrug-resistant (MDR) bacteria. In this nested case-control study, we assessed whether prior exposure to antibiotic therapy and its duration affect the onset of healthcare-associated infections (HAIs) sustained by MDR (MDR-Kp) in intensive care unit patients. Cases were defined as patients who developed an MDR-Kp HAI. Controls matched on sex and the length of intensive care unit (ICU) stay were randomly selected from the at-risk population. Any antibiotic agent received in systemic administration before the onset of infection was considered as antibiotic exposure. Multivariable conditional logistic regression analyses were performed to estimate the effect of prior exposure to each antibiotic class (Model 1) or its duration (Model 2) on the onset of HAIs sustained by MDR-Kp. Overall, 87 cases and 261 gender-matched controls were compared. In Model 1, aminoglycosides and linezolid independently increased the likelihood of developing an MDR-Kp HAI, whereas exposure to both linezolid and penicillins reduced the effect of linezolid alone. In Model 2, cumulative exposure to aminoglycosides increased the likelihood of the outcome, as well as cumulative exposures to penicillins and colistin, while a previous exposure to both penicillins and colistin reduced the influence of the two antibiotic classes alone. Our study confirms that aminoglycosides, penicillins, linezolid, and colistin may play a role in favoring the infections sustained by MDR-Kp. However, several double exposures in the time window before HAI onset seemed to hinder the selective pressure exerted by individual agents.
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http://dx.doi.org/10.3390/antibiotics10030302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8000440PMC
March 2021

Prevalence and outcome of silent hypoxemia in COVID-19.

Minerva Anestesiol 2021 03;87(3):325-333

Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany.

Background: In the early stages of COVID-19 pneumonia, hypoxemia has been described in absence of dyspnea ("silent" or "happy" hypoxemia). Our aim was to report its prevalence and outcome in a series of hypoxemic patients upon Emergency Department admission.

Methods: In this retrospective observational cohort study we enrolled a study population consisting of 213 COVID-19 patients with PaO2/FiO2 ratio <300 mmHg at hospital admission. Two groups (silent and dyspneic hypoxemia) were defined. Symptoms, blood gas analysis, chest X-ray (CXR) severity, need for intensive care and outcome were recorded.

Results: Silent hypoxemic patients (68-31.9%) compared to the dyspneic hypoxemic patients (145-68.1%) showed greater frequency of extra respiratory symptoms (myalgia, diarrhea and nausea) and lower plasmatic LDH. PaO2/FiO2 ratio was 225±68 mmHg and 192±78 mmHg in silent and dyspneic hypoxemia respectively (P=0.002). Eighteen percent of the patients with PaO2/FiO2 from 50 to 150 mmHg presented silent hypoxemia. Silent and dyspneic hypoxemic patients had similar PaCO2 (34.2±6.8 mmHg vs. 33.5±5.7 mmHg, P=0.47) but different respiratory rates (24.6±5.9 bpm vs. 28.6±11.3 bpm respectively, P=0.002). Even when CXR was severely abnormal, 25% of the population was silent hypoxemic. Twenty-six point five percent and 38.6% of silent and dyspneic patients were admitted to the ICU respectively (P=0.082). Mortality rate was 17.6% and 29.7% (log-rank P=0.083) in silent and dyspneic patients.

Conclusions: Silent hypoxemia is remarkably present in COVID-19. The presence of dyspnea is associated with a more severe clinical condition.
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http://dx.doi.org/10.23736/S0375-9393.21.15245-9DOI Listing
March 2021

The role of teicoplanin in the treatment of SARS-CoV-2 infection: A retrospective study in critically ill COVID-19 patients (Tei-COVID study).

J Med Virol 2021 Mar 6. Epub 2021 Mar 6.

Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy.

Teicoplanin has a potential antiviral activity expressed against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was suggested as a complementary option to treat coronavirus disease 2019 (COVID-19) patients. In this multicentric, retrospective, observational research the aim was to evaluate the impact of teicoplanin on the course of COVID-19 in critically ill patients. Fifty-five patients with severe COVID-19, hospitalized in the intensive care units (ICUs) and treated with best available therapy were retrospectively analysed. Among them 34 patients were also treated with teicoplanin (Tei-COVID group), while 21 without teicoplanin (control group). Crude in-hospital Day-30 mortality was lower in Tei-COVID group (35.2%) than in control group (42.8%), however not reaching statistical significance (p = .654). No statistically significant differences in length of stay in the ICU were observed between Tei-COVID group and control group (p = .248). On Day 14 from the ICU hospitalization, viral clearance was achieved in 64.7% patients of Tei-COVID group and 57.1% of control group, without statistical difference. Serum C-reactive protein level was significantly reduced in Tei-COVID group compared to control group, but not other biochemical parameters. Finally, Gram-positive were the causative pathogens for 25% of BSIs in Tei-COVID group and for 70.6% in controls. No side effects related to teicoplanin use were observed. Despite several limitations require further research, in this study the use of teicoplanin is not associated with a significant improvement in outcomes analysed. The antiviral activity of teicoplanin against SARS-CoV-2, previously documented, is probably more effective at early clinical stages.
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http://dx.doi.org/10.1002/jmv.26925DOI Listing
March 2021

Endoscopic 'suction room' to treat complex enteral stump leaks after upper gastrointestinal surgery.

Endosc Int Open 2021 Mar 19;9(3):E371-E377. Epub 2021 Feb 19.

Digestive Endoscopy Unit, ASST Niguarda, Milan, Italy.

Leaks/dehiscence of the enteral stump associated with infected peri-enteric collections after upper gastrointestinal surgery are a life-threatening adverse event, not usually endoscopically treatable. We describe a new endoscopic approach to treat complex entero-cutaneous fistulas (CECF) by creating a "suction room" through placement of multiple stents (enteral, biliary and/or pancreatic) and a large nose-enteral suction tube inside the enteral stent maintained on a continuous negative aspiration suction. Between January 2016 and December 2019, six consecutive patients referred to our unit with CECF of the enteral stump after failed redo surgeries underwent creation of a "suction room." In five patients, enteral, biliary and pancreatic stents were positioned before a nose-to-stent or nose-to-collection large 18 Fr tube placement. In one patient, a pancreatic stent was not placed. Technical and clinical success were achieved in all patients. Mean and median times of aspiration were 49 and 27 days, respectively, with a mean hospital stay of 56 days after the endoscopic procedure. Stents were successfully removed. Mean post-procedural follow-up was 17.3 months. Endoscopic creation of the "suction room" offers the unique possibility of treating complex entero-cutaneous fistulas in surgically altered sites, which are difficult to manage with standard endoscopic methods.
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http://dx.doi.org/10.1055/a-1336-2922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895649PMC
March 2021

The first "exclusive COVID-19" endoscopy project.

Endoscopy 2021 04 23;53(4):453-454. Epub 2021 Feb 23.

Digestive and Interventional Endoscopy Unit, ASST Niguarda, Milan, Italy.

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http://dx.doi.org/10.1055/a-1341-1039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044597PMC
April 2021

Malaria in an asylum seeker paediatric liver transplant recipient: diagnostic challenges for migrant population.

J Infect Dev Ctries 2021 Jan 31;15(1):172-178. Epub 2021 Jan 31.

Migrant and global Health Research Organization (Mi-HeRO) Rome, Italy.

Transplanted patients are particularly exposed to a major risk of infectious diseases due to prolonged immunosuppressive treatment. Over the last decade, the growing migration flows and the transplant tourism have led to increasing infections caused by geographically restricted organisms. Malaria is an unusual event in organ transplant recipients than can be acquired primarily or reactivation following immunosuppression, by transfusion of blood products or through the transplanted organ. We report a rare case of Plasmodium falciparum infection in a liver transplanted two years-old African boy who presented to one Italian Asylum Seeker Center on May 2019. We outlined hereby diagnostic challenges, possible aetiologies of post-transplantation malaria and finally we summarized potential drug interactions between immunosuppressive agents and antimalarials. This report aims to increase the attention to newly arrived migrants, carefully evaluating patients coming from tropical areas and taking into consideration also rare tropical infections not endemic in final destination countries.
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http://dx.doi.org/10.3855/jidc.12541DOI Listing
January 2021

Oral Bacteriotherapy in Patients With COVID-19: A Retrospective Cohort Study.

Front Nutr 2020 11;7:613928. Epub 2021 Jan 11.

Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy.

Mounting evidence suggests SARS-CoV-2 may impact on host microbiota and gut inflammation, infecting intestinal epithelial cells. This possible link and its implications can be investigated by observing the effects of modulation of the microbial flora in patients with COVID-19. The aim of this study was to compare the rate of mortality, the need of ICU hospitalization and the length of hospitalization in patients with severe COVID-19 pneumonia who received the best available therapy (BAT) vs. patients treated with BAT and supplemented with oral bacteriotherapy. This retrospective, observational cohort study included 200 adults with severe COVID-19 pneumonia. All patients received therapeutic regimens including low molecular weight heparin plus one or more between hydroxychloroquine, azithromycin, antivirals, and Tocilizumab. Oral bacteriotherapy was used as complementary treatment. Out of the 200 patients, 112 received BAT without oral bacteriotherapy, and 88 BAT with oral bacteriotherapy. Crude mortality was 22%. Eleven percent died in the group of patients treated with BAT plus oral bacteriotherapy vs. 30% subjects in the group of patients managed only with BAT ( < 0.001). By multivariate analysis, the age >65 years, CRP >41.8 mg/L, Platelets <150.000 mmc, and cardiovascular events were associated with the increased risk of mortality. Oral bacteriotherapy was an independent variable associated with a reduced risk for death. Despite large prospective trials are needed, this study highlights a possible role for oral bacteriotherapy in the management of patients hospitalized for COVID-19 pneumonia.
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http://dx.doi.org/10.3389/fnut.2020.613928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829198PMC
January 2021

Neuroinflammation, neuronal damage or cognitive impairment associated with mechanical ventilation: A systematic review of evidence from animal studies.

J Crit Care 2021 Apr 25;62:246-255. Epub 2020 Dec 25.

Department of Anaesthesia and Intensive Care, Sapienza University of Rome, Roma, Italy.

Purpose: Long-term cognitive impairment is a complication of critical illness survivors. Beside its lifesaving role, mechanical ventilation has potential complications. The aim of this study is to systematically review the evidence collected in animal studies that correlate mechanical ventilation with neuroinflammation, neuronal damage and cognitive impairment.

Methods: We searched MEDLINE and EMBASE databases for studies published from inception until August 31st, 2020, that enrolled mechanically ventilated animals and reported on neuroinflammation or neuronal damage markers changes or cognitive-behavioural impairment.

Results: Of 5583 studies, 11 met inclusion criteria. Mice, rats, pigs were used. Impact of MV: 4 out of 7 studies reported higher neuroinflammation markers in MV-treated animals and 3 studies reported no differences; 7 out of 8 studies reported a higher neuronal damage and 1 reported no differences; 2 out of 2 studies reported cognitive decline up to 3 days after MV. Higher Tidal volumes are associated with higher changes in brain or serum markers.

Conclusion: Preclinical evidence suggests that MV induces neuroinflammation, neuronal damage and cognitive impairment and these are worsened if sub-optimal MV settings are applied. Future studies, with appropriate methodology, are necessary to evaluate for serum monitoring strategies.

Trial Registration Number: CRD42019148935.
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http://dx.doi.org/10.1016/j.jcrc.2020.12.017DOI Listing
April 2021

In Response.

Anesth Analg 2021 05;132(5):e92-e93

Department of Thoracic Surgery and Lung Transplantation, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy,

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http://dx.doi.org/10.1213/ANE.0000000000005420DOI Listing
May 2021

Differential induction of type I and III interferon genes in the upper respiratory tract of patients with coronavirus disease 2019 (COVID-19).

Virus Res 2021 04 5;295:198283. Epub 2021 Jan 5.

Laboratory of Virology, Department of Molecular Medicine, Sapienza University, Affiliated to Istituto Pasteur Italia, Rome 00185, Italy; Microbiology and Virology Unit, Hospital "Policlinico Umberto I", Sapienza University, Rome 00185, Italy.

The natural course of type I and III interferon (IFN) response in the respiratory tract of COVID-19 patients needs to be better defined. We showed that type I/III IFNs, IFN-regulatory factor 7 (IRF7), and IFN stimulated genes (ISGs), are highly expressed in the oropharyngeal cells of SARS-CoV-2 positive patients compared to healthy controls. Notably, the subgroup of critically-ill patients that required invasive mechanical ventilation had a general decrease in expression of IFN/ISG genes. Heterogeneous patterns of IFN-I/III response in the respiratory tract of COVID-19 patients may be associated to COVID-19 severity.
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http://dx.doi.org/10.1016/j.virusres.2020.198283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834390PMC
April 2021

Acute Kidney Injury and COVID-19: A Picture from an Intensive Care Unit.

Blood Purif 2021 Jan 7:1-5. Epub 2021 Jan 7.

Department of General and Specialist Surgery "Paride Stefanini", "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy.

Introduction: Acute kidney injury (AKI) is a frequent complication in coronavirus disease 2019 (COVID-19) patients admitted to intensive care unit (ICU) for severe respiratory failure. The aim is to evaluate the rate of AKI, defined according to Kidney Disease: Improving Global Outcome guidelines, in a series of critical COVID-19 patients admitted to the ICU of a single tertiary teaching hospital.

Methods: From April to May 2020, all consecutive critically ill COVID-19 patients admitted to the ICU who did not meet exclusion criteria (length of ICU stay <48 h, ESRD requiring dialysis, and patients still hospitalized in ICU at the time of data analysis) were enrolled in this study. Patients were stratified according to the highest AKI stage attained during ICU stay.

Results: Sixty-one patients were included in the analysis. AKI was observed in 35/61 patients (57.4%): 25/35 episodes (71.4%) were observed within the first 7 days. AKI was classified as follows: 17.1% stage 1, 25.7% stage 2, and 57.2% stage 3. Fourteen out of 20 stage-3 patients required continuous renal replacement therapy (CRRT), mostly related to persistent oliguria. The overall ICU mortality was 68.9%, and it was higher in patients developing AKI if compared to no-AKI patients (p = 0.006). Renal function recovery of any grade was observed in 14 out of 35 AKI patients (40%). Among patients undergoing CRRT, 13 patients were still dialysis dependent at the time of death.

Conclusion: In critical COVID-19 patients, ICU mortality is particularly high, especially in patients developing AKI. An accurate monitoring of renal function in early phases of respiratory failure should be ensured in order to timely apply any strategy aimed at limiting renal complications during ICU stay.
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http://dx.doi.org/10.1159/000513153DOI Listing
January 2021

Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience.

Surg Endosc 2021 Apr 5;35(4):1908-1914. Epub 2021 Jan 5.

Digestive and Interventional Endoscopy Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy.

Background And Aim: Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions.

Methods: It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted.

Results: We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2-10). During the follow-up interval, no leak recurrences were observed.

Conclusions: Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.
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http://dx.doi.org/10.1007/s00464-020-08199-8DOI Listing
April 2021

Thulium laser to endoscopically manage a rectal erosion and intraluminal mesh migration after ventral rectopexy.

BMJ Case Rep 2021 Jan 4;14(1). Epub 2021 Jan 4.

Digestive and Interventional Endoscopy Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milano, Italy.

Rectal erosions after ventral rectopexy (VR) is an uncommon but challenging adverse event and can be associated with partial migration of the mesh into the intestinal cavity. Re-do surgery is difficult and often provides colostomy and/or anterior rectal resections. However, no alternative solutions are described in the available literature. An 82-year-old woman presented to our hospital for rectal erosion and intraluminal migration of the mesh placed at a 1-year laparoscopic VR. We performed an innovative totally endoscopic approach, using thulium laser and two endoscopes, that led to a successful removal of the mesh. The described mini-invasive technique can be an effective alternative to surgery in tertiary referral centres.
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http://dx.doi.org/10.1136/bcr-2020-235807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783476PMC
January 2021

Von Willebrand factor with increased binding capacity is associated with reduced platelet aggregation but enhanced agglutination in COVID-19 patients: another COVID-19 paradox?

J Thromb Thrombolysis 2021 Jan 2. Epub 2021 Jan 2.

Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.

Patients with Coronavirus-associated disease-2019 (COVID-19) display alterations of the hemostatic system and the presence of a prothrombotic status frequently leading to vascular complications. However, the impact of COVID-19 on platelet activity, aggregation and agglutination still needs to be clarified. We measured total levels of von Willebrand factor (vWF) and vWF binding to the platelet glycoprotein (Gp) complex (GPIb-IX-V), in a cohort of COVID-19 patients admitted to the intensive care unit of our Institution. Moreover, we evaluated platelet aggregation in response to agonists (ADP, collagen, arachidonic acid) and platelet agglutination in response to ristocetin. We found that levels of vWF antigen and the active form of vWF binding to platelets (vWF:RCo), were markedly increased in these patients. These results were associated with higher agglutination rates induced by ristocetin, thereby indirectly indicating an increased capability of vWF to bind to platelets. Conversely, we found that platelet aggregation in response to both ADP and collagen was lower in COVID-19 patients compared to healthy volunteers. This study shows that COVID-19 is associated with increased vWF-induced platelet agglutination but reduced platelet responsivity to aggregation stimuli. Our findings have translational relevance since platelet adhesion to vWF may represent a marker to predict possible complications and better delineate therapeutic strategies in COVID-19 patients.
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http://dx.doi.org/10.1007/s11239-020-02339-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778414PMC
January 2021

EUS-guided enteroenteral bypass for transenteric ERCP: building on prior knowledge.

Gastrointest Endosc 2021 Jan;93(1):279

Digestive and Interventional Endoscopy Unit, Grande Ospedale Metropolitano Niguarda, Milan, Italy.

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http://dx.doi.org/10.1016/j.gie.2020.07.046DOI Listing
January 2021

In Response.

Anesth Analg 2021 04;132(4):e58-e59

Department of Thoracic Surgery and Lung Transplantation, University of Rome Sapienza, Policlinico Umberto I, Rome, Italy,

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http://dx.doi.org/10.1213/ANE.0000000000005377DOI Listing
April 2021

Preoperative Versus Postoperative Scalp Block Combined With Incision Line Infiltration for Pain Control After Supratentorial Craniotomy.

Clin J Pain 2021 Mar;37(3):194-198

Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy.

Objective: Postoperative pain after craniotomy is a significant clinical problem that is sometimes underestimated, although moderate or severe pain in early postoperative period complicates up to 60% of cases. The purpose of this prospective randomized multicenter trial was to determine the optimal timing for selective scalp block in patients undergoing general anesthesia for supratentorial craniotomy.

Materials And Methods: After ethics committee approval and informed consent, 56 adult patients were enrolled, and randomly assigned to receive a selective scalp block combined with incision line infiltration preoperatively or postoperatively.

Results: Postoperative pain at 24 hours after the procedure was recorded in all 56 enrolled patients. In patients assigned to receive a scalp block preoperatively, median VAS score at 24 hours after surgery was 0 (0 to 2), and in patients assigned to receive a scalp block postoperatively it was 0 (0 to 3) (P>0.05). There was no difference in severity of pain at 24, 12, 6, and 2 hours after surgery between the 2 study groups, but the amount of fentanyl administered intraoperatively was lower in patients assigned to the preoperative scalp block group (1.6±0.7 vs. 2.4±0.7 mkg/kg/h, P=0.01).

Discussion: This study confirms and extends available clinical evidence on the safety and efficacy of selective scalp blocks for the prevention of postoperative pain. Recorded data suggest that there is no difference in terms of occurrence and severity of postoperative pain regardless of whether the scalp block is performed preoperatively (after general anesthesia induction) or postoperatively (before extubation). Patients assigned to receive a scalp block combined with incision line infiltration preoperatively needed less intraoperative opioids than those assigned to postoperative scalp block.
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http://dx.doi.org/10.1097/AJP.0000000000000905DOI Listing
March 2021

Fatal Takotsubo syndrome in critical COVID-19 related pneumonia.

Cardiovasc Pathol 2021 Mar-Apr;51:107314. Epub 2020 Nov 28.

Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Rome, Italy.

COVID-19 can involve several organs and systems, often with indirect and poorly clarified mechanisms. Different presentations of myocardial injury have been reported, with variable degrees of severity, often impacting on the prognosis of COVID-19 patients. The pathogenic mechanisms underlying cardiac damage in SARS-CoV-2 infection are under active investigation. We report the clinical and autopsy findings of a fatal case of Takotsubo Syndrome occurring in an 83-year-old patient with COVID-19 pneumonia. The patient was admitted to Emergency Department with dyspnea, fever and diarrhea. A naso-pharyngeal swab test for SARS-CoV-2 was positive. In the following week his conditions worsened, requiring intubation and deep sedation. While in the ICU, the patient suddenly showed ST segment elevation. Left ventricular angiography showed decreased with hypercontractile ventricular bases and mid-apical ballooning, consistent with diagnosis of Takotsubo syndrome. Shortly after the patient was pulseless. After extensive resuscitation maneuvers, the patient was declared dead. Autopsy revealed a subepicardial hematoma, in absence of myocardial rupture. On histology, the myocardium showed diffuse edema, multiple foci of contraction band necrosis in both ventricles and occasional coagulative necrosis of single cardiac myocytes. Abundant macrophages CD68+ were detected in the myocardial interstitium. The finding of diffuse contraction band necrosis supports the pathogenic role of increased catecholamine levels; the presence of a significant interstitial inflammatory infiltrate, made up by macrophages, remains of uncertain significance.
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http://dx.doi.org/10.1016/j.carpath.2020.107314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699026PMC
February 2021

Splenic Hematoma as a Rare Complication of Colonoscopy; a Case Report.

Arch Acad Emerg Med 2020 25;8(1):e84. Epub 2020 Oct 25.

Emergency Department, Sandro Pertini Hospital, Rome, Italy.

Splenic injuries after colonoscopy are an uncommon complication, which can lead to potentially unfortunate outcomes. Their management depends on the type of the splenic damage (hematomas, lacerations, rupture). We describe the case of a woman who visited the Emergency Department due to abdominal pain and pre-syncopal condition, which had occurred 12 hours after she underwent a colonoscopy. An abdominal computed tomography scan showed a splenic hematoma and a hemoperitoneum. An emergency splenectomy was performed successfully. Emergency physicians, who are at the forefront of diagnosing and treating patients, should consider this post-endoscopic complication in order to implement a prompt treatment.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7682628PMC
October 2020

Antibiotic Prophylaxis for Percutaneous Endoscopic Gastrostomy in Children: A Randomised Controlled Trial.

J Pediatr Gastroenterol Nutr 2021 03;72(3):366-371

NESMOS Department, Sapienza University of Rome, Sant'Andrea University Hospital.

Objectives: Paediatric studies on the role of antibiotic prophylaxis in the prevention of postoperative infections in children undergoing percutaneous endoscopic gastrostomy (PEG) are lacking. The aim of this study was to assess if a single dose of co-amoxiclav before PEG can decrease the rate of peristomal wound and systemic infection in children.

Methods: In this prospective, randomised, double-blind, multicentre trial, children undergoing PEG were randomized to antibiotic prophylaxis with co-amoxiclav versus placebo and the rate of local and systemic infections were assessed.

Results: Of the 106 patients considered for inclusion, 49 patients were randomized. In the per-protocol analysis, the occurrence of wound infection was 5% (1/20) in the antibiotic group and 21% (4/19) in the placebo group (P = 0.13, 16% difference in proportions, odds ratio [OR] 0.19, 95% confidence interval [CI] 0.02-1.9). The occurrence of systemic infection was 9% (2/22) in the antibiotic group and 27.2% (6/25) in the placebo group [P = 0.17, 18% difference in proportions, OR 0.32, 95% CI 0.06%-1.80%]. Similar results were obtained in intention-to-treat analysis. Interestingly, the overall infection rate was significantly higher in the placebo group as compared with the antibiotic group (40% vs 13.6%; P = 0.04) and the duration of hospital stay was significantly longer in the placebo group as compared with the antibiotic group (4.4 ± 1.6 vs 3.5 ± 1.05; P = 0.02). The number-needed-to-treat (NTT) to prevent 1 peristomal infection on average are 6.7 patients.

Conclusions: A preoperative dose of co-amoxiclav reduces the overall infection rate and the duration of hospital stay. Our data suggest that antibiotic prophylaxis should be recommended in every children undergoing PEG placement.
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http://dx.doi.org/10.1097/MPG.0000000000002981DOI Listing
March 2021

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

J Med Virol 2021 04 10;93(4):2210-2220. Epub 2020 Nov 10.

Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Rome, Italy.

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.
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http://dx.doi.org/10.1002/jmv.26636DOI Listing
April 2021