Objectives
Evidences from either small series or spontaneous reporting are accumulating that SARS-CoV-2 involves the Nervous Systems. The aim of this study is to provide an extensive overview on the ...major neurological complications in a large cohort of COVID-19 patients.
Methods
Retrospective, observational analysis on all COVID-19 patients admitted from February 23rd to April 30th, 2020 to ASST Papa Giovanni XXIII, Bergamo, Italy for whom a neurological consultation/neurophysiological assessment/neuroradiologic investigation was requested. Each identified neurologic complication was then classified into main neurologic categories.
Results
Of 1760 COVID-19 patients, 137 presented neurologic manifestations that manifested after COVID-19 symptoms in 98 pts and was the presenting symptom in 39. Neurological manifestations were classified as: (a) cerebrovascular disease 53 pts (38.7%) including 37 ischemic and 11 haemorrhagic strokes, 4 transient ischemic attacks, 1 cerebral venous thrombosis; (b) peripheral nervous system diseases 31 (22.6%) including 17 Guillain–Barrè syndromes; (c) altered mental status 49 (35.8%) including one necrotizing encephalitis and 2 cases with RT-PCR detection of SARS-Cov-2 RNA in CSF; (d) miscellaneous disorders, among whom 2 patients with myelopathy associated with Ab anti-SARS-CoV-2 in CSF. Patients with peripheral nervous system involvement had more frequently severe ARDS compared to patients with cerebrovascular disease (87.1% vs 42%; difference = 45.1% 95% CI 42.0–48.2;
χ
2
= 14.306;
p
< 0.0002) and with altered mental status (87.1% vs 55.6%; difference = 31.5% 95% CI 27.5–37.5%;
χ
2
= 7.055;
p
< 0.01).
Conclusion
This study confirms that involvement of nervous system is common in SARS-CoV-2 infection and offers clinicians useful information for prevention and prompt identification in order to set the adequate therapeutic strategies.
Background
The assessment of human and diagnostic resources is a prerequisite to improving the management of emergency neurology.
Objective
To provide a landscape on the organization of the Lombardy ...Region hospitals for emergency neurological care management.
Methods
We designed an anonymized questionnaire including 6 sections with 21 questions on facilities, human and diagnostic resources, and intra- and between-hospital connections. The time needed to fill the questionnaire was estimated not to exceed 6 min.
Results
The questionnaire was returned by 33/41 (80.5%) hospitals, 22 classified as level 1 (spoke), and 11 as level 2 (hub). Five of 33 (15%) did not have a neurology unit. The mean annual rate of neurological consultations accounted for 5–6% of all admissions (range 2–8%) and did not differ between levels 1 and 2 hospitals. Neurologists were 24-h available in 21/33 (64%) hospitals, 12-h and on call at night in 6 (18%), less than 12 h without nocturnal availability in 5 (15%), and neither present nor available in 1 (3%). Brain CT and CSF examinations were 24-h universally available, whereas EEG and neurosonology were not in most hospitals. Despite angio-CT was 24-h available in more than 75% of the hospitals, only 45% of them had 24-h availability of diffusion/perfusion imaging, and 43% were not available at any time. Only 12% of the hospitals had 24-h availability of neuroradiologists and 6% of interventional neuroradiologists.
Conclusion
Our data, while emphasizing current critical issues, offer clues for identifying priorities and improving the management of emergency and time-dependent neurological diseases.
Purpose
To provide a comprehensive evidence-based assessment of the anatomical characteristics of the pyramidalis muscle (PM).
Materials and methods
A thorough systematic search of the literature ...through August 31st 2020 was conducted on major electronic databases PubMed, Scopus and Web of Science (WOS) to identify studies eligible for inclusion. Data were extracted and pooled into a meta-analysis using MetaFor package in R and MetaXL. A random-effects model was applied. The primary outcome of interest was the prevalence of PM. The secondary outcomes were the dimensions (length and width) of the PM.
Results
A total of 11 studies (
n
= 787 patients; 1548 sides) were included in the meta-analysis. The multinomial pooled prevalence estimate (PPE) for a bilateral absence of the PM was 11.3% (95% CI 7.2%, 16.2%, 82.3% (95% CI 76.2%, 87.6%) for a bilateral presence, and 6.3% (95% CI 3.3%, 10.2%) for a unilateral presence. Of four studies (
n
= 37 patients) that reported the side of a unilateral presence, the PPE of a unilateral right-side presence was 42.2% (95% CI 23.0%, 62.3%) compared to 57.8% for a unilateral left-side presence (95% CI 37.7%, 77.0%). The mean length of the PM displayed high levels of heterogeneity, ranging from 3.12 to 12.50 cm.
Conclusion
The pyramidalis muscle is a rather constant anatomical structure being present in approximately 90% of individuals.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that is responsible for coronavirus disease 2019 (COVID-19), which has rapidly spread across the world, becoming a pandemic. ...The "cytokine storm" (CS) in COVID-19 leads to the worst stage of illness, and its timely control through immunomodulators, corticosteroids, and cytokine antagonists may be the key to reducing mortality. After reviewing published studies, we proposed a Cytokine Storm Score (CSs) to identify patients who were in this hyperinflammation state, and at risk of progression and poorer outcomes. We retrospectively analyzed 31 patients admitted to Infectious Disease Department in "St. Maria" Hospital in Terni with confirmed SARS-CoV-2 infections, and analyzed the "CS score" (CSs) and the severity of COVID-19. Then we conducted a prospective study of COVID-19 patients admitted after the definition of the CSscore. This is the first study that proposes and applies a new score to quickly identify COVID-19 patients who are in a hyperinflammation stage, to rapidly treat them in order to reduce the risk of intubation. CSs can accurately identify COVID-19 patients in the early stages of a CS, to conduct timely, safe, and effect administration of immunomodulators, corticosteroids, and cytokine antagonists, to prevent progression and reduce mortality.
Dying in a head-down position is a not so common occurrence, and the cause of death may not be immediately clear by the results of the autopsy. The authors describe a case of a six-months-old baby, ...previously healthy and asymptomatic, found in a head-down position, stuck between the bed and the wall. Despite the efforts to revive the baby, he was declared dead at the arrival of the ambulance. After the autopsy was carried out it was deemed that the cause of death was a cardio-respiratory failure caused by upside-down position of the baby, bilateral interstitial pneumonia and the immobilization of the thorax. This case shows how important it is, for the forensic pathologists, to take into account both autoptical, histological, toxicological results and the report of the scene, especially in the absence of decisive findings.
Background and purpose
Real‐world data on alemtuzumab are limited and do not provide evidence of its effectiveness after various disease‐modifying therapies (DMTs). Our aim was to provide real‐world ...data on the impact of clinical variables and previous DMTs on clinical response to alemtuzumab.
Methods
Sixteen Italian multiple sclerosis centers retrospectively included patients who started alemtuzumab from January 2015 to December 2018, and recorded demographics, previous therapies, washout duration, relapses, Expanded Disability Status Scale (EDSS) score, and magnetic resonance imaging data. Negative binomial regression models were used to assess the effect of factors on annualized relapse (ARR) after alemtuzumab initiation.
Results
We studied 322 patients (mean age 36.8 years, median EDSS score 3, median follow‐up 1.94 years). Previous treatments were: fingolimod (106), natalizumab (80), first‐line oral agents (56), first‐line injectables (interferon/glatiramer acetate; 30), and other drugs (15). Thirty‐five patients were treatment‐naïve. The pre‐alemtuzumab ARR was 0.99 and decreased to 0.13 during alemtuzumab treatment (p < 0.001). The number of previous‐year relapses was associated with alemtuzumab ARR (adjusted risk ratio RR 1.38, p = 0.009). Progression‐free survival was 94.5% after 1 year, and 89.2% after 2 years of alemtuzumab treatment. EDSS score improvement occurred in 13.5% after 1 year, and 20.6% after 2 years. Re‐baselining patients after 6 months of alemtuzumab treatment, led to no evidence of disease activity status in 71.6% after 1 year and 58.9% after 2 years.
Conclusions
Alemtuzumab decreases ARR independent of previous therapy, including patients with disease activity during natalizumab treatment. Overall, 90% of patients showed no disease progression, and 20% an improvement after 2 years of alemtuzumab.
Alemtuzumab decreases annualized relapse independent of previous therapy, including in patients with disease activity during natalizumab treatment. Overall, 90% of patients show no disease progression, and 20% an improvement after 2 years of alemtuzumab. Re‐baselining patients after 6 months, led to no evidence of disease activity status in 71.6% after 1 year and 58.9% after 2 years.
The common hepatic artery (CHA) is the main arterial supply to the liver. Common classifications of the anatomical variations of the celiac trunk have only marginally described the CHA. Currently, ...the only classification addressing anatomical variants in cases of CHA absence from the celiac trunk is that reported by Huang et al. In this systematic review, the prevalence of these variations, according to Huang's classification, have been analyzed.
The review was registered in PROSPERO (CRD 42018096679). The risk of bias was assessed using the AQUA tool.
Fifty-four articles were included in the review (26,250 participants). The overall pooled prevalence estimate (PPE) of an absent CHA was 3.1%. Of those participants who underwent preoperative radiological evaluation, the overall PPE of an absent CHA was 3.8% for subjects who were evaluated via angiography and 3.0% for participants who underwent angio-CT evaluation. The overall PPE of an absent CHA was 3.9% in cadavers and 3.2% in participants evaluated surgically. Type I or Type II aberrations were the most common; in participants with CHA aberrations, 65.4% of those participants had either Type I or Type II aberrations.
The overall PPE of an absent CHA was 3.1%, a result representing a significant, common anatomical variation. Our study revealed that an absence of a CHA was associated with a replaced CHA. The most common arterial variant was a replaced CHA originating from the Superior Mesenteric Artery and running across the anterior or posterior side of the pancreas (i.e., Types I and II).
•Variations of common hepatic artery strongly affect gastrointestinal surgery.•Overall common hepatic artery is absent in 3.1% of patients•The absence of the Common Hepatic Artery is associated with a replaced artery•The most of the replaced arteries originate from the Superior Mesenteric Artery.•A thorough preoperative evaluation is mandatory for the assessment of the surgical anatomy.
Background
A high reactivation of multiple sclerosis (MS) was reported in patients treated with alemtuzumab after fingolimod. We aimed to understand whether this shift enhanced the risk for ...reactivation in a real-life cohort.
Methods
Subjects with relapsing MS, shifting from fingolimod to alemtuzumab were enrolled. We collected the following data: age, sex, disease duration, relapses after fingolimod withdrawal, new T2/gadolinium (Gd)-enhancing lesions in the last magnetic resonance imaging (MRI) during fingolimod and in the first, while on alemtuzumab, lymphocyte counts at alemtuzumab start, and Expanded Disability Status Scale (EDSS) before and after alemtuzumab.
Results
We enrolled 77 patients (women 61 (79%); mean age 36.2 years (SD 9.6), and disease duration 12.3 years (SD 6.8) at fingolimod discontinuation; median washout 1.8 months). The annualised relapse rate was 0.89 during fingolimod, 1.32 during washout, and 0.15 after alemtuzumab (
p
= 0.001). The EDSS changed from a median of 3 (IQR 2–4) at the end of fingolimod to 2.5 after alemtuzumab (IQR 1.5–4) (
p
= 0.013). The washout length and the lymphocyte count before alemtuzumab were not associated with EDSS change after alemtuzumab (
p
= 0.59 and
p
= 0.33, respectively). MRI activity decreased after alemtuzumab compared to that during fingolimod (
p
= 0.001). At alemtuzumab start, lymphocyte counts were < 0.8 × 10
3
/mL in 21 patients.
Conclusions
In our cohort, alemtuzumab reduced relapse, new T2/Gd-enhancing lesions, and EDSS score, as compared to the previous periods (fingolimod/washout). These results were not related to washout length or lymphocyte counts. Therefore, a rapid initiation of alemtuzumab after fingolimod does not seem to be a risk factor for MS reactivation.
NSTI (Necrotizing Soft Tissue Infection) is an infection of any layer within the soft tissue compartment that is rapidly progressive and often fatal. The authors describe a case of a 67-year-old man ...who developed a spontaneous NSTI and died of septic shock approximately 36 h after he was first admitted to the emergency room. The infection started from the chest as a result of a minimum muscle strain, in the absence of any cutaneous lesions or important risk factors such as immunosuppression. The infection was caused by Streptococcus pyogenes.
The described case has many peculiarities that make it almost unique.
Background Patients with wake-up stroke (WUS) are excluded from thrombolysis because of unknown time of symptom onset. Previous studies have reported similar stroke severity and early ischemic ...changes (EICs) in patients with WUS and stroke of known onset. These studies, however, included patients within a large timeframe to imaging or did not quantify EICs. The aim of our study was to quantify EICs of patients with WUS presenting within 3 hours of symptom recognition compared to standard 3-hours recombinant tissue plasminogen activator (rt-PA)–treated patients and assess the extent of ischemic lesion and functional independence at follow-up. Methods Patients were selected from our prospectively collected stroke database. Baseline and follow-up computed tomographic scans were graded with Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Clinical outcome measures were modified Rankin Scale score, mortality, and symptomatic intracerebral hemorrhage. Results Demographic features, risk factors, stroke severity, and baseline ASPECTS were similar in both groups. WUS and rt-PA–treated patients had similar tissue outcome (median ASPECTS 7.0 vs 7.5; P = .202). Functional outcome was more favorable in rt-PA–treated patients (61.6% vs 43.1%; odds ratio OR 2.12; 95% confidence interval CI 1.05-4.28; P = .037). After adjusting for age, stroke severity, treatment, and EICs in less than one-third of middle cerebral artery territory, rt-PA and National Institutes of Health Stroke Scale scores remained the only significant predictors of outcome (OR 7.76; 95% CI 2.40-25.05; P = .001 and OR 0.74; 95% CI 0.67-0.82; P < .001, respectively). Conclusions Within 3 hours of symptom recognition, patients with WUS have EICs similar to rt-PA–treated patients. It is reasonable to expect that selected WUS patients might benefit from thrombolysis within 3 hours of symptom awareness.
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