The results of the 4th National Report for the Italian flora under the 92/43/EEC 'Habitats' Directive are presented. The outcomes showed a general negative conservation status for plant species, with ...the worst situation being in the Mediterranean bioregion. At the National level, significant monitoring and conservation activities are required.
•Chest CT patterns in COVID-19 may be divided into three main phenotypes with different characteristics o In phenotype 1, respiratory mechanics are consistent with high pulmonary compliance and ...severe hypoxemia.•In phenotype 2, moderate to high PEEP as well as lateral and/or prone positioning may help recruit collapsed areas.•Phenotype 3 resembles typical ARDS and should be managed as such.•Attention should be paid to the risk of pulmonary embolism, regardless of phenotype.
Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure requiring mechanical ventilation. The abnormalities observed on chest computed tomography (CT) and the clinical presentation of COVID-19 patients are not always like those of typical acute respiratory distress syndrome (ARDS) and can change over time. This manuscript aimed to provide brief guidance for respiratory management of COVID-19 patients before, during, and after mechanical ventilation, based on the recent literature and on our direct experience with this population. We identify that chest CT patterns in COVID-19 may be divided into three main phenotypes: 1) multiple, focal, possibly overperfused ground-glass opacities; 2) inhomogeneously distributed atelectasis; and 3) a patchy, ARDS-like pattern. Each phenotype can benefit from different treatments and ventilator settings. Also, peripheral macro- and microemboli are common, and attention should be paid to the risk of pulmonary embolism. We suggest use of personalized mechanical ventilation strategies based on respiratory mechanics and chest CT patterns. Further research is warranted to confirm our hypothesis.
There is a paucity of data concerning the optimal ventilator management in patients with COVID-19 pneumonia; particularly, the optimal levels of positive-end expiratory pressure (PEEP) are unknown. ...We aimed to investigate the effects of two levels of PEEP on alveolar recruitment in critically ill patients with severe COVID-19 pneumonia.
A single-center cohort study was conducted in a 39-bed intensive care unit at a university-affiliated hospital in Genoa, Italy. Chest computed tomography (CT) was performed to quantify aeration at 8 and 16 cmH
O PEEP. The primary endpoint was the amount of alveolar recruitment, defined as the change in the non-aerated compartment at the two PEEP levels on CT scan.
Forty-two patients were included in this analysis. Alveolar recruitment was median interquartile range 2.7 0.7-4.5 % of lung weight and was not associated with excess lung weight, PaO
/FiO
ratio, respiratory system compliance, inflammatory and thrombophilia markers. Patients in the upper quartile of recruitment (recruiters), compared to non-recruiters, had comparable clinical characteristics, lung weight and gas volume. Alveolar recruitment was not different in patients with lower versus higher respiratory system compliance. In a subgroup of 20 patients with available gas exchange data, increasing PEEP decreased respiratory system compliance (median difference, MD - 9 ml/cmH
O, 95% CI from - 12 to - 6 ml/cmH
O, p < 0.001) and the ventilatory ratio (MD - 0.1, 95% CI from - 0.3 to - 0.1, p = 0.003), increased PaO
with FiO
= 0.5 (MD 24 mmHg, 95% CI from 12 to 51 mmHg, p < 0.001), but did not change PaO
with FiO
= 1.0 (MD 7 mmHg, 95% CI from - 12 to 49 mmHg, p = 0.313). Moreover, alveolar recruitment was not correlated with improvement of oxygenation or venous admixture.
In patients with severe COVID-19 pneumonia, higher PEEP resulted in limited alveolar recruitment. These findings suggest limiting PEEP strictly to the values necessary to maintain oxygenation, thus avoiding the use of higher PEEP levels.
Purpose
Clinical data on patients with intra-abdominal candidiasis (IAC) is still scarce.
Methods
We collected data from 13 hospitals in Italy, Spain, Brazil, and Greece over a 3-year period ...(2011–2013) including patients from ICU, medical, and surgical wards.
Results
A total of 481 patients were included in the study. Of these, 27 % were hospitalized in ICU. Mean age was 63 years and 57 % of patients were male. IAC mainly consisted of secondary peritonitis (41 %) and abdominal abscesses (30 %); 68 (14 %) cases were also candidemic and 331 (69 %) had concomitant bacterial infections. The most commonly isolated
Candida
species were
C. albicans
(
n
= 308 isolates, 64 %) and
C. glabrata
(
n
= 76, 16 %). Antifungal treatment included echinocandins (64 %), azoles (32 %), and amphotericin B (4 %). Septic shock was documented in 40.5 % of patients. Overall 30-day hospital mortality was 27 % with 38.9 % mortality in ICU. Multivariate logistic regression showed that age (OR 1.05, 95 % CI 1.03–1.07,
P
< 0.001), increments in 1-point APACHE II scores (OR 1.05, 95 % CI 1.01–1.08,
P
= 0.028), secondary peritonitis (OR 1.72, 95 % CI 1.02–2.89,
P
= 0.019), septic shock (OR 3.29, 95 % CI 1.88–5.86,
P
< 0.001), and absence of adequate abdominal source control (OR 3.35, 95 % CI 2.01–5.63,
P
< 0.001) were associated with mortality. In patients with septic shock, absence of source control correlated with mortality rates above 60 % irrespective of administration of an adequate antifungal therapy.
Conclusions
Low percentages of concomitant candidemia and high mortality rates are documented in IAC. In patients presenting with septic shock, source control is fundamental.
Critically ill COVID-19 patients have pathophysiological lung features characterized by perfusion abnormalities. However, to date no study has evaluated whether the changes in the distribution of ...pulmonary gas and blood volume are associated with the severity of gas-exchange impairment and the type of respiratory support (non-invasive versus invasive) in patients with severe COVID-19 pneumonia.
This was a single-center, retrospective cohort study conducted in a tertiary care hospital in Northern Italy during the first pandemic wave. Pulmonary gas and blood distribution was assessed using a technique for quantitative analysis of dual-energy computed tomography. Lung aeration loss (reflected by percentage of normally aerated lung tissue) and the extent of gas:blood volume mismatch (percentage of non-aerated, perfused lung tissue-shunt; aerated, non-perfused dead space; and non-aerated/non-perfused regions) were evaluated in critically ill COVID-19 patients with different clinical severity as reflected by the need for non-invasive or invasive respiratory support.
Thirty-five patients admitted to the intensive care unit between February 29th and May 30th, 2020 were included. Patients requiring invasive versus non-invasive mechanical ventilation had both a lower percentage of normally aerated lung tissue (median interquartile range 33% 24-49% vs. 63% 44-68%, p < 0.001); and a larger extent of gas:blood volume mismatch (43% 30-49% vs. 25% 14-28%, p = 0.001), due to higher shunt (23% 15-32% vs. 5% 2-16%, p = 0.001) and non-aerated/non perfused regions (5% 3-10% vs. 1% 0-2%, p = 0.001). The PaO
/FiO
ratio correlated positively with normally aerated tissue (ρ = 0.730, p < 0.001) and negatively with the extent of gas-blood volume mismatch (ρ = - 0.633, p < 0.001).
In critically ill patients with severe COVID-19 pneumonia, the need for invasive mechanical ventilation and oxygenation impairment were associated with loss of aeration and the extent of gas:blood volume mismatch.
•Physiotherapy may help prevent or mitigate sequelae related to bed rest, thus improving physical function and outcomes and reducing length of stay by increasing ventilator free-days.•Before starting ...chest physiotherapy, we recommend the use of adequate personal protective equipment, limiting healthcare workers in the room to one physician and one physiotherapist, as well as choosing a negative-pressure chamber if available.•Chest physiotherapy should be tailored to the specific phenotype of COVID-19 patients.•Patients who might be eligible for a spontaneous breathing trial should receive chest physiotehrapy before and after extubation.•NIV, CPAP, and HFNO should also be considered for short periods after extubation, until complete respiratory autonomy is reached.
In late 2019, an outbreak of a novel human coronavirus causing respiratory disease was identified in Wuhan, China. The virus spread rapidly worldwide, reaching pandemic status. Chest computed tomography scans of patients with coronavirus disease-2019 (COVID-19) have revealed different stages of respiratory involvement, with extremely variable lung presentations, which require individualized ventilatory strategies in those who become critically ill. Chest physiotherapy has proven to be effective for improving long-term respiratory physical function among ICU survivors. The ARIR recently reported the role of chest physiotherapy in the acute phase of COVID-19, pointing out limitation of some procedures due to the limited experience with this disease in the ICU setting. Evidence on the efficacy of chest physiotherapy in COVID-19 is still lacking. In this line, the current review discusses the important role of chest physiotherapy in critically ill mechanically ventilated patients with COVID-19, around the weaning process, and how it can be safely applied with careful organization, including the training of healthcare staff and the appropriate use of personal protective equipment to minimize the risk of viral exposure.
The primary objective of the study is to describe the cellular characteristics of bronchoalveolar lavage fluid (BALF) of COVID-19 patients requiring invasive mechanical ventilation; the secondary ...outcome is to describe BALF findings between survivors vs non-survivors.
Patients positive for SARS-CoV-2 RT PCR, admitted to ICU between March and April 2020 were enrolled. At ICU admission, BALF were analyzed by flow cytometry. Univariate, multivariate and Spearman correlation analyses were performed.
Sixty-four patients were enrolled, median age of 64 years (IQR 58-69). The majority cells in the BALF were neutrophils (70%, IQR 37.5-90.5) and macrophages (27%, IQR 7-49) while a minority were lymphocytes, 1%, TCD3+ 92% (IQR 82-95). The ICU mortality was 32.8%. Non-survivors had a significantly older age (p = 0.033) and peripheral lymphocytes (p = 0.012) were lower compared to the survivors. At multivariate analysis the percentage of macrophages in the BALF correlated with poor outcome (OR 1.336, CI95% 1.014-1.759, p = 0.039).
In critically ill patients, BALF cellularity is mainly composed of neutrophils and macrophages. The macrophages percentage in the BALF at ICU admittance correlated with higher ICU mortality. The lack of lymphocytes in BALF could partly explain a reduced anti-viral response.
The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe.
A multinational, multicenter, retrospective study was ...conducted in 23 ICUs in 9 European countries, representing the first phase of the candidemia/intra-abdominal candidiasis in European ICU project (EUCANDICU).
During the study period, 570 episodes of ICU-acquired IC were observed, with a cumulative incidence of 7.07 episodes per 1000 ICU admissions, with important between-center variability. Separated, non-mutually exclusive cumulative incidences of candidemia and IAC were 5.52 and 1.84 episodes per 1000 ICU admissions, respectively. Crude 30-day mortality was 42%. Age (odds ratio OR 1.04 per year, 95% CI 1.02-1.06, p < 0.001), severe hepatic failure (OR 3.25, 95% 1.31-8.08, p 0.011), SOFA score at the onset of IC (OR 1.11 per point, 95% CI 1.04-1.17, p 0.001), and septic shock (OR 2.12, 95% CI 1.24-3.63, p 0.006) were associated with increased 30-day mortality in a secondary, exploratory analysis.
The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.
Polycyclic aromatic hydrocarbons (PAH) are ubiquitous in the environment. We hypothesized that early life exposure to PAHs
may have particular importance in the etiology of breast cancer. We ...conducted a population-based, case-control study of ambient
exposure to PAHs in early life in relation to the risk of breast cancer. Total suspended particulates (TSP), a measure of
ambient air pollution, was used as a proxy for PAHs exposure. Cases ( n = 1,166) were women with histologically confirmed, primary, incident breast cancer. Controls ( n = 2,105) were frequency matched by age, race, and county of residence to cases. Annual average TSP concentrations (1959-1997)
by location were obtained from the New York State Department of Environmental Conservation for Erie and Niagara Counties.
Based on the monitor readings, prediction maps of TSP concentrations were generated with ArcGIS 8.0 (ESRI, Inc., Redlands,
CA) using inverse distance squared weighted interpolation. Unconditional logistic regression was used to estimate odds ratios
and 95% confidence intervals. In postmenopausal women, exposure to high concentrations of TSP (>140 μg/m 3 ) at birth was associated with an adjusted odds ratio of 2.42 (95% confidence interval, 0.97-6.09) compared with exposure
to low concentrations (<84 μg/m 3 ). However, in premenopausal women, where exposures were generally lower, the results were inconsistent with our hypothesis
and in some instances were suggestive of a reduction in the risk of breast cancer. Our study suggests that exposure in early
life to high levels of PAHs may increase the risk of postmenopausal breast cancer; however, other confounders related to geography
cannot be ruled out.
Background:
Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on ...the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients.
Methods:
Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE when clinically indicated to maintain adequate mean arterial pressure (MAP) on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rS
o
2
), and non-invasive intracranial pressure (nICP).
Results:
Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57–68.5 years), and 78% were male. PLR test led to a low CA index 58% (44–76.3%). FC and NE administration resulted in a CA index of 90.8% (74.2–100%) and 100% (100–100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased 18.6 (17.7–19.6) vs. 19.3 (18.2–19.8) mm Hg,
p
= 0.009, and 12.9 (8.5–18) vs. 15 (10.5–19.7) mm Hg,
p
= 0.001, respectively. PLR test, FC, and NE resulted in a significant increase in MAP and rS
o
2
.
Conclusions:
In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.
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