Medicina, Volume 57, Issue 6 (June 2021) – 128 articles

Background and Objectives: The objective of this study was to evaluate the association between periodontal disease and obstructive sleep apnea syndrome (OSAS). Materials and Methods: Electronic search using PubMed, Scopus, LILACS, and Cochrane library was carried out for randomized controlled trials, cohort, case-control, longitudinal and epidemiological studies on humans published from January 2009 until September 2020. The participants had to be male and female adults who were diagnosed with OSAS either by overnight polysomnography (carried out at a sleep laboratory or at home) or by a home sleep testing monitor (Apnea Risk Evaluation System). Methodological quality assessment was carried out using the Newcastle-Ottawa Quality Assessment Scale (NOS) for case-control studies while an adapted form of NOS was used for cross-sectional studies. Results: Ten studies fulfilled the inclusion criteria of our review, 5 were case-control studies, and 5 cross-sectional. Sample size ranged from 50 to 29,284 subjects, for a total of 43,122 subjects, 56% of them were male, their age ranged from 18 to 85 years old. The heterogeneity among the studies regarding the classification of periodontal disease, and the different methods for OSAS severity assessment, complicated the comparison among the studies. Conclusions: There is low evidence of a possible association between OSAS and periodontitis. The pathophysiological mechanism, cause-effect, or dose-response relationship are still unclear. Further studies are needed and should use a precise classification of OSAS subjects, while the new classification of periodontitis from the World Workshop of Chicago 2017 should be used for the periodontal assessment. Full article

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed. Full article

Background: Neutropenic enterocolitis (NE), which in the past was also known as typhlitis or ileocecal syndrome for the segment of the gastrointestinal tract most affected, is a nosological entity that is difficult to diagnose and whose pathogenesis is not fully known to date. Initially described in pediatric patients with leukemic diseases, it has been gradually reported in adults with hematological malignancies and non-hematological conditions, such as leukemia, lymphoma, multiple myeloma, aplastic anemia, and also myelodysplastic syndromes, as well as being associated with other immunosuppressive causes such as AIDS treatment, therapy for solid tumors, and organ transplantation. Therefore, it is associated with high mortality due to the rapid evolution in worse clinical pictures: rapid progression to ischemia, necrosis, hemorrhage, perforation, multisystem organ failure, and sepsis. Case report: A case report is included to exemplify the clinical profile of patients with NE who develop sepsis. Literature Review: To identify a specific profile of subjects affected by neutropenic enterocolitis and the entity of the clinical condition most frequently associated with septic evolution, a systematic review of the literature was conducted. The inclusion criteria were as follows: English language, full-text availability, human subjects, and adult subjects. Finally, the papers were selected after the evaluation of the title and abstract to evaluate their congruity with the subject of this manuscript. Following these procedures, 19 eligible empirical studies were included in the present review. Conclusions: Despite the recent interest and the growing number of publications targeting sepsis and intending to identify biomarkers useful for its diagnosis, prognosis, and for the understanding of its pathogenesis, and especially for multi-organ dysfunction, and despite the extensive research period of the literature review, the number of publications on the topic “neutropenic enterocolitis and sepsis” appears to be very small. In any case, the extrapolated data allowed us to conclude that the integration of medical history, clinical and laboratory data, radiological imaging, and macroscopic and histological investigations can allow us to identify a specific pathological profile. Full article

Background and Objectives: This study aimed to investigate whether mild fetal tricuspid regurgitation (TR) at 11^+ 0 to 13^+ 6 weeks of gestation affects perinatal outcomes. Since fetal right ventricular load is associated with placental resistance, we hypothesized that fetal mild TR would be associated with perinatal outcomes as a consequence of abnormal placentation. Materials and Methods: We retrospectively evaluated 435 women with first-trimester scan data. Blood flow across the tricuspid valve was examined in singleton pregnancies between 11^+ 0 and 13^+ 6 weeks of gestation. Women were categorized according to the presence or absence of fetal mild TR, and the maternal and pregnancy characteristics and perinatal outcomes were compared. Multiple linear and logistic regression analyses were conducted to identify independent predictors of perinatal outcome. Results: In the group with mild TR, there were more cases of borderline amniotic fluid index, including oligohydramnios (p = 0.031), and gestational age- and sex-specific birth weights were lower (p = 0.012). There were no significant differences in other perinatal outcomes, including preeclampsia, gestational hypertension and small for gestational age. Gestational diabetes (adjusted odds ratio (OR) 0.514, 95% confidence interval (CI) 0.312–0.947) and fetal mild TR (adjusted OR 1.602, 95% CI 1.080–2.384) were identified as factors associated with below borderline amniotic fluid index before birth. The factors that affected gestational age and sex-specific birth weight were also gestational diabetes (adjusted beta coefficient 9.673, p = 0.008) and the presence of fetal mild TR (adjusted beta coefficient −6.593, p = 0.007). Conclusions: Mild fetal TR observed in the first trimester is negatively associated with fetal growth and the amniotic fluid index at term but not with other adverse pregnancy or perinatal outcomes due to abnormal placentation. Full article

Tumor chemosensitivity assays (TCAs), also known as drug response assays or individualized tumor response tests, have been gaining attention over the past few decades. Although there have been strong positive correlations between the results of these assays and clinical outcomes, they are still not considered routine tests in the care of cancer patients. The correlations between the assays’ results (drug sensitivity or resistance) and the clinical evaluations (e.g., response to treatment, progression-free survival) are highly promising. However, there is still a need to design randomized controlled prospective studies to secure the place of these assays in routine use. One of the best ideas to increase the value of these assays could be the combination of the assay results with the omics technologies (e.g., pharmacogenetics that gives an idea of the possible side effects of the drugs). In the near future, the importance of personalized chemotherapy is expected to dictate the use of these omics technologies. The omics relies on the macromolecules (Deoxyribonucleic acid -DNA-, ribonucleic acid -RNA-) and proteins (meaning the structure) while TCAs operate on living cell populations (meaning the function). Therefore, wise combinations of TCAs and omics could be a highly promising novel landscape in the modern care of cancer patients. Full article

Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN’s mean MCSD was 2.10 mm (SD 0.13), and the C7 root’s CSA was 10.78 mm² (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN. Full article

Lithium salts are the first-line prophylaxis treatment for bipolar disorder in most guidelines. The majority of bipolar women are treated with mood stabilizers at the time they wish to get pregnant. One reason for this is the rising average age at first childbirth, at least in the high-income countries, which increases in general the likelihood of a medication with psychotropic drugs. Previously, lithium exposition during pregnancy was thought to strongly increase the risk of severe cardiac malformation. However, recent studies only point to a low teratogenic risk, so nowadays an increasing number of women are getting pregnant with ongoing lithium treatment. Regarding lithium medication during breastfeeding, there is evidence that lithium transfers to the breastmilk and can also be detected in the infants’ serum. The influence on the infant is still a largely understudied topic. Regular monitoring of the infants’ renal clearance, thyroid function, and lithium levels is warranted when breastfeeding under lithium exposure. In this case series, we present three case reports of bipolar mothers who were treated with lithium during pregnancy and breastfeeding to add to the scarce literature on this important topic. In short, we strengthen the importance of therapeutic drug monitoring due to fluctuating plasma levels during pregnancy and after birth, and we can report the birth and development of three healthy infants despite lithium medication during pregnancy and breastfeeding. Full article

Background: The association of coronavirus disease 2019 (COVID-19) with hypertension has been one of the frequently discussed topics in current studies since hypertension was identified as a risk factor for coronavirus disease. However, no studies seem to be focused on the BP (blood pressure) in patients with hypertension after COVID-19. Report: This report presents the cases of five frail geriatric patients (avg. age 78.3 (±6.4) years) with sarcopenia and controlled hypertension (office BP < 140 mmHg) who were diagnosed with SARS-CoV-2. Findings: Control ABPM performed after COVID-19 showed that these hypertensive patients were hypotensive and that the previously well-established therapy was suddenly too intensive for them. Conclusions: These findings suggest that BP control after COVID-19 is needed and that ABPM is, particularly in frail geriatric patients, by no means a luxury but a necessity. Full article

Background and Objectives: A hospital-based stroke registry is a useful tool for systematic analyses of the epidemiology, clinical characteristics, and natural course of stroke. Analyses of stroke registry data can provide information that can be used by health services to improve the quality of care for patients with this disease. Materials and Methods: Data were collected from the Riga East University Hospital (REUH) Stroke Registry in order to evaluate the etiology, risk factors, clinical manifestations, treatment, functional outcomes, and other relevant data for acute stroke during the period 2016–2020. Results: During a five-year period, 4915 patients (3039 females and 1876 males) with acute stroke were registered in the REUH Stroke Registry. The causative factors of stroke were cardioembolism (45.7%), atherosclerosis (29.9%), lacunar stroke (5.3%), stroke of undetermined etiology (1.2%), and stroke of other determined causes (1.2%). The most frequent localizations of intracerebral hemorrhage were subcortical (40.0%), lobar (18.9%), and brainstem (9.3%). The most prevalent risk factors for stroke were hypertension (88.8%), congestive heart failure (71.2%), dyslipidemia (46.7%), and atrial fibrillation (44.2%). In addition, 1018 (20.7%) patients were receiving antiplatelet drugs, 574 (11.7%) were taking statins, and 382 (7.7%) were taking anticoagulants. At discharge, 35.5% of the patients were completely independent (mRS (modified Rankin Scale) score: 0–2), while 49.5% required some form of assistance (mRS score: 3–5). The intrahospital mortality rate was 13.7%, although it was higher in the hemorrhage group (30.9%). Conclusions: Our stroke registry data are comparable to those of other major registries. Analysis of stroke registry data is important for improving stroke care and obtaining additional information for stroke studies. Full article

Background and Objectives: Urinary levels of dickkopf-3 (DKK-3) are associated with poor renal survival in patients with non-dialytic chronic kidney disease. However, it remains unknown whether urinary DKK-3 levels can predict residual renal function (RRF) decline in patients undergoing peritoneal dialysis (PD). Therefore, we investigated the correlation between urinary levels of DKK-3 and the subsequent rate of RRF decline in PD patients. Materials and Methods: This study included 36 PD patients who underwent multiple peritoneal equivalent tests during 2011–2021. The relationship between baseline clinical characteristics and the subsequent annual rate of Kt/V decline was investigated. Results: The annual rate of renal Kt/V decline was 0.29 (range: 0.05–0.48), which correlated with renal Kt/V (r = 0.55, p = 0.0005) and 24 h urinary DKK-3 excretion (r = 0.61, p < 0.0001). Similarly, 24 h urinary DKK-3 excretion (β = 0.44, p = 0.0015) and renal Kt/V (β = 0.38, p = 0.0059) were independently associated with the annual rate of renal Kt/V decline in multivariate analyses. Conclusions: Urinary DKK-3 assessment may help identify PD patients at a high risk of RRF decline. Full article

Background and Objectives: The aim of this study was to assess the effects of physiotherapy with aerobic exercise together with temporomandibular joint range of motion exercises (supervised) and physiotherapy with aerobic exercise only (unsupervised), also to review the correlations between neck movements, pain, temporomandibular joint range of motion movements and quality of life in individuals with migraine. Methods: The flexion, extension and lateral flexion of the cervical spine were measured in degrees with a mechanical goniometer and pressure pain thresholds with algometer. Quality of life was assessed with the SF-36 questionnaire and temporomandibular joint range of motion with a centimeter. Results: The study showed statistically significant cervical flexion results in both groups (p < 0.05), masticatory muscle results and temporomandibular joint range of motion between the groups (p < 0.05). A correlation between left upper trapezius muscle pain and cervical lateral flexion was observed in the intervention group. Physical activity correlated with cervical extension, activity limitation due to physical ailments and general health. A correlation between temporomandibular joint and right-side masticatory muscles pain was found. A correlation between upper trapezius muscle pain and left- as well as right-side temporalis muscles were found in the control group. Strong correlations were found between pain and activity limitation due to physical ailments and emotional state. The temporomandibular joint range of motion strongly correlated with activity limitation due to physical ailments. Conclusions: Physiotherapy based on aerobic exercises together with temporomandibular joint exercises was more effective than physiotherapy based on aerobic exercise for decreasing pain, increasing pressure pain thresholds and cervical range of motion. Full article

Background and Objectives: The aim of this study was to investigate parameters that can be used to predict mortality in patients diagnosed with COVID-19 in the emergency department (ED). Materials and Methods: Patients diagnosed with COVID-19 in the ED were included in this prospective study. The patients were divided into two groups. The surviving patients were included in Group 1 (survivors), and the patients who died were included in Group 2 (non-survivors). The electrocardiogram (ECG), laboratory results and chest computerized tomography (CCT) findings of the two groups were compared. The CCT images were classified according to the findings as normal, mild, moderate and severe. Results: Of the 419 patients included in the study, 347 (83%) survived (survivor) and 72 (17%) died (non-survivor). The heart rate and respiratory rate were found to be higher, and the peripheral oxygen saturation (SpO₂) and diastolic blood pressure (DBP) were found to be lower in the non-survivor patients. QRS and corrected QT interval (QTc) were measured as longer in the non-survivor patients. In the CCT images, 79.2% of the non-survivor patients had severe findings, while 11.5% of the survivor patients had severe findings. WBC, neutrophil, NLR, lactate, D-dimer, fibrinogen, C- Reactive Protein (CRP), urea, creatinine, creatine kinase-MB (CK-MB) and hs-Troponin I levels were found to be higher and partial pressure of carbon dioxide (PCO₂₎, base excess (BE), bicarbonate (HCO₃₎, lymphocyte eosinophil levels were found to be lower in non-survivor patients. The highest AUC was calculated at the SpO₂ level and the eosinophil level. Conclusions: COVID-19 is a fatal disease whose mortality risk can be estimated when the clinical, laboratory and imaging studies of the patients are evaluated together in the ED. SpO₂ that is measured before starting oxygen therapy, the eosinophil levels and the CT findings are all important predictors of mortality risk. Full article

Background and Objectives: to investigate the current state of art in the study of personality disorders in central serous chorioretinopathy (CSC), also taking into account the dimensional approach. Materials and Methods: this systematic review was conducted according to PRISMA guidelines. We included articles written in English or Italian, published in peer reviewed journals from 1 January 2010 to 31 December 2020. Results: after the screening, 10 studies were included. The results suggest that CSC patients are not characterized by the prevalence of a formal personality disorder, but they are better explained by typical personality traits that may alter their relationship with others. CSC patients seems to be characterized by high levels of aggressiveness and anxiety traits along with low sociability. We propose a model of disease where stress exacerbates prior specific traits in a vicious circle where some traits might be involved in disease progression and manifestation. Conclusions: maladaptive personality traits might be an essential feature of the disease and may represent a possible link between psychiatric symptoms, such as insomnia, anxiety, and depression, and endocrinological patterns. Further research should use a specific assessment scale evaluating both the level of interpersonal functioning and specific maladaptive traits. Full article

Background and Objectives: Emotional dysfunction is considered a key component in personality disorders; however, only few studies have examined the relationship between the two. In this study, emotional dysfunction was operationalized through the Affect Integration Inventory, and the aim was to examine the relationships between the level of affect integration and the levels of symptom distress, interpersonal problems, and personality functioning in patients diagnosed with personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Materials and Methods: Within a hospital-based psychiatric outpatient setting, 87 patients with personality disorder referred for treatment were identified for assessment with the Affect Integration Inventory and other measures (e.g., the Symptom Checklist-90, Revised, the Inventory of Interpersonal Problems 64 circumplex version, and the Severity Indices of Personality Problems). Results: The analyses revealed that problems with affect integration were strongly and statistically significantly correlated with high levels of symptom distress, interpersonal problems, and maladaptive personality functioning. Additionally, low scores on the Affect Integration Inventory regarding discrete affects were associated with distinct and differentiated patterns of interpersonal problems. Conclusion: Taken together, emotional dysfunction, as measured by the Affect Integration Inventory, appeared to be a central component of the pathological self-organization associated with personality disorder. These findings have several implications for the understanding and psychotherapeutic treatment of personality pathology. Furthermore, they highlight the importance of considering the integration of discrete affects and their specific contributions in the conceptualization and treatment of emotional dysfunction in patients with personality disorders. Full article

Oro-antral communication (OAC) acts as a pathway for bacteria between the maxillary sinus and oral cavity, and is a common complication after the removal of a dental implant or extraction of a tooth from the maxillary posterior area. In the case of an untreated OAC, oro-antral fistula develops and becomes epithelialized. We aimed to introduce a treatment for OAC closure via a sinus bone grafting procedure using bone tacks and a collagen membrane with an allograft. The procedure was performed by applying an absorbable membrane made in pouch form. This membrane acted as a barrier for closing the large sinus membrane perforation. Bone tacks were used to fix the membranes. Subsequently, the maxillary sinus was filled with the allograft, and the absorbable membrane was reapplied. Primary closure was achieved by performing a periosteum-releasing incision for a tension-free suture. After 6 months, sufficient bone dimensions were gained without any occurrence of maxillary sinusitis or recurrence of OAC. Additional bone grafts and implantation could be performed to rehabilitate the maxillary posterior area. We conclude that this technique might be a useful treatment for reconstructing the maxillary posterior area with simultaneous sinus bone graft and OAC closure. Full article

Background and Objectives: GISTs (Gastrointestinal stromal tumors) are the most common mesenchymal gastrointestinal tract tumours and are mainly located in the stomach. Their malignant potential depends on size, location, and type. Endoscopic techniques are a less invasive modality for patients not eligible for surgery. ESD (endoscopic submucosal dissection) is mainly used for the removal of smaller GISTs, with intraluminal growth and a more superficial location. Thus, R0 resection capability in some cases may be not sufficient, limited by tumour size, location in the gastric wall, and its connection level with the muscularis propria. In such cases, an endoscopic full-thickness resection can become a new alternative. In this retrospective pilot study, we evaluated ESD and hybrid resection techniques in terms of safety, efficacy, and disease recurrence for selected types of gastric GISTs. Materials and Methods: A retrospective comparison was conducted in a group of patients who underwent ESD or a hybrid technique combining endoscopic resection with endoscopic suturing using the OverStitch system (HT) for type II or III gastric GISTs. A total of 21 patients aged 70 ± 8 years underwent endoscopic resection. Seventeen lesions were treated with ESD and four with the HT. Results: R0 resection was achieved in all patients treated using HT (type III lesions) and in 53% of those treated with ESD (p = 0.08). None of the type III lesions treated with ESD were excised with R0. Lesions treated with R0 ESD resections were significantly smaller (1.76 ± 0.35 cm) than those with R1 ESD resections (2.39 ± 0.40 cm) (p < 0.01). The mean lesion size treated with the HT was 2.88 ± 0.85 cm. Conclusions: HT may be a new resection modality for large gastric GISTs with high muscularis propria connection grades. Further studies are required to evaluate its safety and efficacy and to form precise inclusion criteria for endoscopic resection techniques. Full article

Background and Objectives: Unstable mixed episodes or rapid switching between opposite affective poles within the scope of short cycles was first characterized in 1967 by S. Mentzos as complex polymorphous states with chaotic overlap of manic and depressive symptoms. Well-known examples include antidepressant-induced mania/hypomania and rapid/ultra-rapid/ultradian cycling, when clinicians observe an almost continuous mixed state with a constant change of preponderance of manic or depressive symptoms. Achieving stable remission in these cases is challenging with almost no data on evidence-based treatment. When mood stabilizers are ineffective, electroconvulsive therapy (ECT) has been suggested. Objectives: After reviewing the evidence from available literature, this article presents our own clinical experience of ECT efficacy and tolerability in patients with ultra-rapid cycling bipolar disorder (BD) and unstable mixed states. Materials and Methods: We conducted an open, one-year observational prospective study with a “mirror image” design, including 30 patients with rapid and ultra-rapid cycling BD on long-term mood stabilizer treatment (18 received lithium carbonate, 6 on valproate and 6 on carbamazepine) with limited effectiveness. A bilateral ECT course (5–10 sessions) was prescribed for regaining mood stability. Results: ECT was very effective in 12 patients (40%) with a history of ineffective mood stabilizer treatment who achieved and maintained remission; all of them received lithium except for 1 patient who received carbamazepine and 2 with valproate. Nine patients (30%) showed partial response (one on carbamazepine and two on valproate) and nine patients (30%) had no improvement at all (four on carbamazepine and two on valproate). For the whole sample, the duration of affective episodes was significantly reduced from 36.05 ± 4.32 weeks in the year prior to ECT to 21.74 ± 12.14 weeks in the year post-ECT (p < 0.001). Depressive episodes with mixed and/or catatonic features according to DSM-5 specifiers were associated with a better acute ECT response and/or long-term mood stabilizer treatment outcome after ECT. Conclusions: ECT could be considered as a useful option for getting mood instability under control in rapid and ultra-rapid cycling bipolar patients. Further randomized trials are needed to confirm these results. Full article

Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person. Full article

Background and Objectives: Neutrophil-to-lymphocyte ratio (NLR), a very low cost, widely available marker of systemic inflammation, has been proposed as a potential predictor of short-term outcome in patients with intracerebral hemorrhage (ICH). Methods: Patients with ICH admitted to the Neurology Department during a two-year period were screened for inclusion. Based on eligibility criteria, 201 patients were included in the present analysis. Clinical, imaging, and laboratory characteristics were collected in a prespecified manner. Logistic regression models and receiver operating characteristics (ROC) curves were used to assess the performance of NLR assessed at admission (admission NLR) and 72 h later (three-day NLR) in predicting in-hospital death. Results: The median age of the study population was 70 years (IQR: 61–79), median admission NIHSS was 16 (IQR: 6–24), and median hematoma volume was 13.7 mL (IQR: 4.6–35.2 mL). Ninety patients (44.8%) died during hospitalization, and for 35 patients (17.4%) death occurred during the first three days. Several common predictors were significantly associated with in-hospital mortality in univariate analysis, including NLR assessed at admission (OR: 1.11; 95% CI: 1.04–1.18; p = 0.002). However, in multivariate analysis admission, NLR was not an independent predictor of in-hospital mortality (OR: 1.04; 95% CI: 0.9–1.1; p = 0.3). The subgroup analysis of 112 patients who survived the first 72 h of hospitalization showed that three-day NLR (OR: 1.2; 95% CI: 1.09–1.4; p < 0.001) and age (OR: 1.05; 95% CI: 1.02–1.08; p = 0.02) were the only independent predictors of in-hospital mortality. ROC curve analysis yielded an optimal cut-off value of three-day NLR for the prediction of in-hospital mortality of ≥6.3 (AUC = 0.819; 95% CI: 0.735–0.885; p < 0.0001) and Kaplan–Meier analysis proved that ICH patients with three-day NLR ≥6.3 had significantly higher odds of in-hospital death (HR: 7.37; 95% CI: 3.62–15; log-rank test; p < 0.0001). Conclusion: NLR assessed 72 h after admission is an independent predictor of in-hospital mortality in ICH patients and could be widely used in clinical practice to identify the patients at high risk of in-hospital death. Further studies to confirm this finding are needed. Full article

Transforming growth factor beta (TGF-β), as a master regulator of immune response, is deeply implicated in the complex pathophysiology and development of autoimmune thyroid diseases. Based on the close interplay between thyroid autoimmunity and TGF-β, scientific interest was shifted to the understanding of the possible role of this molecule regarding the diagnosis, prognosis, and therapy of these diseases. The main aim of this review is to present research data about possible treatment options based on the role of TGF-β in thyroid autoimmunity. Suggested TGF-β-mediated therapeutic strategies regarding autoimmune thyroid diseases include either the enhancement of its immunosuppressive role or inhibition of its facilitatory role in thyroid autoimmunity. For example, the application of hr-TGF-β can be used to bolster the inhibitory role of TGF-β regarding the development of thyroid diseases, whereas anti-TGF-β antibodies and similar molecules could impede its immune-promoting effects by blocking different levels of TGF-β biosynthesis and activation pathways. In conclusion, TGF-β could evolve to a promising, novel therapeutic tool for thyroid autoimmunity. Full article

The aim of this paper is to share our experience in managing a patient with Klebsiella pneumoniae mycotic abdominal aortic aneurysm who was also infected with COVID-19. A 69-year-old male was transferred to our hospital for the management of an infra-renal mycotic abdominal aortic aneurysm. During his hospital course, the patient contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was intubated due to respiratory distress. Over a short period, his mycotic aneurysm increased in size from 2.5 cm to 3.9 cm. An emergency repair of his expanding aneurysm was achieved using our previously described protocol of coating endovascular stents with rifampin. The patient was managed with a rifampin-coated endovascular stent graft without any major complications. Postoperatively, the patient did not demonstrate any neurological deficits nor any vascular compromise. He remained afebrile during his postoperative course and was extubated sometime thereafter. He was then transferred to the ward for additional monitoring prior to his discharge to a rehab hospital while being on long-term antibiotics. During his hospital stay, he was monitored with serial ultrasounds to ensure the absence of abscess formation, aortic aneurysm growth or graft endoleak. At 6 weeks after stent graft placement, he underwent a CT scan, which showed a patent stent graft, with a residual sac size of 2.5 cm without any evidence of abscess or endoleak. Over a follow-up period of 180 days, the patient remained asymptomatic while remaining on long-term antibiotics. Thus, in patients whose surgical risk is prohibitive, endovascular stent grafts can be used as a bridge to definitive surgical management. Full article

Background and Objectives: Evaporative dry eye disease is frequently associated with meibomian gland dysfunction. Patients are often unhappy because of daily drops, care burden, and suboptimal conventional treatments. In this study, we assessed the efficacy of a novel device, the Eye-light^®, a combination of intense pulsed light therapy and low-level light therapy, as a novel treatment for meibomian gland dysfunction and dry eye disease. Materials and Methods: This was a retrospective, single-center study carried out over a 6-week period, in which 22 eyes from 11 patients were included. Each patient received four combined light therapy treatment sessions, once weekly over 4 weeks. Patients underwent a clinical examination and filled out a standardized questionnaire to evaluate symptoms one week prior to treatment, and one week after the fourth session. Results: Combined light therapy improved several ocular surface outcome measures in our patients. This study demonstrates that this adjunctive treatment significantly improves the ocular surface and quality of life of patients with dry eye disease and meibomian gland dysfunction. Conclusions: Combined light therapy may be included in meibomian gland dysfunction treatment protocols as an adjunctive rescue treatment. Full article

Background and Objectives: Direct current cardioversion (DCCV) is a safe and useful treatment for atrial tachyarrhythmias. In the past, the energy delivered in DCCV was decided upon empirically, based only on the type of tachyarrhythmia. This conventional method does not consider individual factors and may lead to unnecessary electrical damage. Materials and Methods: We performed DCCV in patients with atrial tachyarrhythmias. The impedance and electrical current at the moment of shock were measured. The human thoracic impedance between both defibrillator patches and the electric current that was used were measured. Results: A total of 683 DCCVs were performed on 466 atrial tachyarrhythmia patients. The average impedance was 64 ± 11 Ω and the average successful current was 23 ± 6 mA. The magnitude of the electrical current that was successful depended upon the human impedance (linear regression, B = −0.266, p < 0.001) and the left atrial diameter (B = 0.092, p < 0.001). Impedance was directly proportional to body mass index (BMI) (B = 1.598, p < 0.001) and was higher in females than in males (77 ± 15 Ω vs. 63 ± 11 Ω, p < 0.001). Notably, the high-impedance (>70 Ω) group had a higher BMI (27 ± 4 kg/m² vs. 25 ± 3 kg/m², p < 0.001) and a higher proportion of females (37% vs. 9%, p < 0.001) than the low-impedance group (<70 Ω). However, thoracic impedance was not an independent predictor for successful DCCV. Conclusions: Human thoracic impedance was one of the factors that impacted the level of electrical current required for successful DCCV in patients with atrial arrhythmias. In the future, it will be helpful to consider individual predictors, such as BMI and gender, to minimize electrical damage during DCCV. Full article

Background and Objectives: The aim of this study was twofold: (i) to analyze the relationships between fitness status (repeated-sprint ability (RSA), aerobic performance, vertical height jump, and hip adductor and abductor strength) and match running performance in adult women soccer players and (ii) to explain variations in standardized total distance, HSR, and sprinting distances based on players’ fitness status. Materials and Methods: The study followed a cohort design. Twenty-two Portuguese women soccer players competing at the first-league level were monitored for 22 weeks. These players were tested three times during the cohort period. The measured parameters included isometric strength (hip adductor and abductor), vertical jump (squat and countermovement jump), linear sprint (10 and 30 m), change-of-direction (COD), repeated sprints (6 × 35 m), and intermittent endurance (Yo-Yo intermittent recovery test level 1). Data were also collected for several match running performance indicators (total distance covered and distance at different speed zones, accelerations/decelerations, maximum sprinting speed, and number of sprints) in 10 matches during the cohort. Results: Maximal linear sprint bouts presented large to very large correlations with explosive match-play actions (accelerations, decelerations, and sprint occurrences; r = −0.80 to −0.61). In addition, jump modalities and COD ability significantly predicted, respectively, in-game high-intensity accelerations (r = 0.69 to 0.75; R² = 25%) and decelerations (r = −0.78 to −0.50; R² = 23–24%). Furthermore, COD had significant explanatory power related to match running performance variance regardless of whether the testing and match performance outcomes were computed a few or several days apart. Conclusion: The present investigation can help conditioning professionals working with senior women soccer players to prescribe effective fitness tests to improve their forecasts of locomotor performance. Full article

Background and Objectives: The efficacy of hydroxy methyl glutaryl-coenzyme A reductase inhibitors (statins) in reducing the incidence of cardiovascular events pushed the target LDL-cholesterol (LDL-C) levels lower and lower in successive guidelines despite signals regarding potential cognitive side effects. We evaluated the relationship between cognitive impairment and LDL-C levels in elderly ischemic stroke patients. Materials and Methods: 29 ischemic stroke patients aged 65 and above with LDL-C levels ≤70 mg/dL, classified according to the TOAST criteria, underwent detailed neuropsychological testing comprising the MMSE test, Montreal Cognitive Assessment (MoCA) and Addenbrooke’s Cognitive Evaluation (ACE-III) test. Their performances were compared to those of 29 age-matched ischemic stroke patients with LDL-Cl levels >71 mg/dL. Results: The MMSE test failed to detect significant cognitive differences between the two groups. The MoCA and ACE-III tests detected impairments in visuo-spatial/executive function, attention, and recall/memory in patients with low LDL-C. A stepwise linear regression model of the ACE-III total scores revealed that LDL-cholesterol levels could contribute to 13.8% of the detected cognitive dysfunction, second in importance only to age, which contributed to 38.8% of the detected impairment. Conclusions: Physicians should be cautious when prescribing statins to elderly people. Hydrophilic ones may be preferred in cognitively impaired patients. Full article

The COVID-19 health emergency has thrown the health systems of most European countries into a deep crisis, forcing them to call off and postpone all interventions deemed not essential or life-saving in order to focus most resources on the treatment of COVID-19 patients. To facilitate women who are experiencing difficulties in terminating their pregnancies in Italy, the Ministry of Health has adapted to the regulations in force in most European countries and issued new guidelines that allow medical abortion up to 63 days, i.e., 9 weeks of gestational age, without mandatory hospitalization. This decision was met with some controversy, based on the assumption that the abortion pill could “incentivize” women to resort to abortion more easily. In fact, statistical data show that in countries that have been using medical abortion for some time, the number of abortions has not increased. The authors expect that even in Italy, as is the case in other European countries, the use of telemedicine is likely to gradually increase as a safe and valuable option in the third phase of the health emergency. The authors argue that there is a need to favor pharmacological abortion by setting up adequately equipped counseling centers, as is the case in other European countries, limiting hospitalization to only a few particularly complex cases. Full article

(1) Background: Halitosis is a frequent condition that affects a large part of the population. It is considered a “social stigma”, as it can determine a number of psychological and relationship consequences that affect people’s lives. The purpose of this review is to examine the role of psychological factors in the condition of self-perceived halitosis in adolescent subjects and adulthood. (2) Type of studies reviewed: We conducted, by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines, systematic research of the literature on PubMed and Scholar. The key terms used were halitosis, halitosis self-perception, psychological factors, breath odor and two terms related to socio-relational consequences (“Halitosis and Social Relationship” OR “Social Issue of Halitosis”). Initial research identified 3008 articles. As a result of the inclusion and exclusion criteria, the number of publications was reduced to 38. (3) Results: According to the literature examined, halitosis is a condition that is rarely self-perceived. In general, women have a greater ability to recognize it than men. Several factors can affect the perception of the dental condition, such as socioeconomic status, emotional state and body image. (4) Conclusion and practical implication: Self-perceived halitosis could have a significant impact on the patient’s quality of life. Among the most frequent consequences are found anxiety, reduced levels of self-esteem, misinterpretation of other people’s attitudes and embarrassment and relational discomfort that often result in social isolation. Full article

Background and Objectives: Maternal brain tumors diagnosed during pregnancy are very rare, and their clinical course remains incompletely understood. We recently experienced a case of a brain tumor diagnosed at 30 weeks of gestation, and the treatment was initiated after delivery at 32 weeks of gestation. In this study, we reviewed case reports of brain tumors diagnosed during pregnancy, focusing on whether the brain tumor was treated during pregnancy or after termination of pregnancy and on the timing of therapeutic intervention. Materials and Methods: We searched PubMed and Ichushi-Web for articles published after January 2000 that reported cases of maternal brain tumors diagnosed during pregnancy. The patients were divided into two groups according to whether the tumor was treated during pregnancy (Group A) or after termination of pregnancy (Group B). Results: In total, 42 patients were included in the study (13 (31%) in Group A and 29 (69%) in Group B). The most common symptoms before diagnosis were those caused by increased intracranial pressure (57.1%). The diagnosis was made at 18 ± 6 weeks of gestation in Group A and 26 ± 9 weeks of gestation in Group B (p = 0.007). In all cases diagnosed after 34 weeks of gestation, termination of pregnancy was followed by treatment. Treatment was initiated within two weeks of diagnosis in 50% of patients in Group A and 30% in Group B. Conclusions: When severe symptoms caused by increased intracranial pressure last for several weeks, imaging tests should be considered. Termination of pregnancy is a good option for a brain tumor diagnosed after 34 weeks of gestation, while comprehensive treatment decisions should be made based on the severity of symptoms and the course of pregnancy in other cases. Full article

Background and Objectives: Chances of surviving sepsis increase markedly upon prompt diagnosis and treatment. As most sepsis cases initially show-up in the Emergency Department (ED), early recognition of a septic patient has a pivotal role in sepsis management, despite the lack of precise guidelines. The aim of this study was to identify the most accurate predictors of in-hospital mortality outcome in septic patients admitted to the ED. Materials and Methods: We compared 651 patients admitted to ED for sepsis (cases) with 363 controls (non-septic patients). A Bayesian mean multivariate logistic regression model was performed in order to identify the most accurate predictors of in-hospital mortality outcomes in septic patients. Results: Septic shock and positive qSOFA were identified as risk factors for in-hospital mortality among septic patients admitted to the ED. Hyperthermia was a protective factor for in-hospital mortality. Conclusions: Physicians should bear in mind that fever is not a criterium for defining sepsis; according to our results, absence of fever upon presentation might be indicative of greater severity and diagnosis of sepsis should not be delayed. Full article

Background and Objectives The greatest challenge vaccines face is that of acceptance from the general population. Healthcare professionals’ (HCPs) recommendations have significant influence on general public vaccination behavior. The aim of this study was to assess the willingness of HCPs to get vaccinated against COVID-19, two weeks before initiation of vaccinations. Materials and Methods: We conducted an anonymous online survey from 11–15 December 2020 among HCPs by emails delivered from the local medical and nursing stuff associations. Results: The 71.1% of 656 HCPs intended to accept vaccination, 5.9% did not and 23% were still undecided. The acceptance rate was higher in physicians (76.5%) and significantly lower in nurses (48.3%). Most of the responders who intended to accept vaccination were males (p = 0.01), physicians (p = 0.001), older (p = 0.02), married (p = 0.054) with children (p = 0.001), and had treated patients with COVID-19 (p < 0.001). In the multivariate logistic regression, the predictors of HCPs willingness to get vaccinated were parenthood (OR = 4.19, p = 0.003), being a physician (OR = 2.79, p = 0.04), and treating confirmed/suspected COVID-19 patients (OR = 2.87, p = 0.036). Conclusions: Low vaccination acceptance rate was found especially in nurses, and as this may have a negative impact in the vaccination compliance of the general public, interventional educational programs to enhance vaccination are crucial. Full article