Minerva medica
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Angiotensin converting enzyme 2 (ACE2) receptor sites for severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2), responsible for the disease called COVID-19 are present in the liver, especially in correspondence with cholangiocytes. Liver damage during SARS-CoV-2 infection can be due to several mechanism including direct cytopathic effect, synergy of intestinal damage/liver damage (lipopolysaccharides/Kupfer and other cells interaction), uncontrolled immune reaction (lymphopenia and significant increase in C reactive protein, ferritin, lactate dehydrogenase, D-dimer, interleukin (IL)-6, IL- 10, IL-2, interferon-gamma, etc.), sepsis, drug-induced liver injury, hypoxia and thromboembolic events. An increase in aspartate aminotransferase (AST) from 14 to 58% and alanine transaminase (ALT) from 21 to 76% has been reported. ⋯ The consumption of alcohol reduces both innate and acquired immune activity and it has been hypothesized that this habit is correlated with liver increase of ACE2 receptors. Furthermore, nonalcoholic and alcoholic steatosis/steatohepatitis is a breeding ground for the development of oxidative stress. In this context, any encounter with SARS-CoV-2 infection can support and aggravate the systemic cytokine tsunami.
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According to 2018 ESC Guidelines for syncope, the first aim in ED evaluation is to identify patients with underlying acute diseases, at higher risk of short-term adverse events; in the meantime, emergency physicians should also identify cases of hypotensive syncope elicited by non-severe concurrent conditions, as they mostly do not require hospitalization. After excluding these cases, ESC GL state that patients should be managed with initial evaluation and risk stratification, providing several tables and flow-charts to do it. To optimize ED management, we propose to combine these two phases, as in the clinical practice they occur at the same, with the following simplified paths: patients with only clinical features suggestive of reflex syncope should be discharged, with a fast-track to an outpatient Syncope Unit only in case of severe syncope; patients with orthostatic syncope could be discharged with measures to prevent recurrences or be managed in an ED Observation Unit (EDOU) in case of fluid loss or other causes of volume depletion; patients with major clinical or ECG criteria suggestive of cardiogenic syncope should be admitted, for diagnostic or therapeutic purposes; patients with undetermined syncope or minor clinical or ECG criteria suggestive of cardiogenic syncope should be managed in an EDOU. ESC GL give focus to this novel care pathway, but they do not provide clear details on the organizational aspects; accordingly, this document proposes resources and protocols for managing patients in EDOU, as a first part of the functional path of the outpatient Syncope Unit.
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The efficacy and safety of continuous positive airway pressure and respiratory physiotherapy outside the Intensive Care Unit during a pandemic. ⋯ Continuous positive airway pressure with patient mobilization (including pronation) was effective and safe in patients with ARDS due to COVID-19 managed outside the Intensive Care Unit setting during the pandemic.