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Background Noninvasive respiratory support (NIRS) has been diffusely employed outside the intensive care unit (ICU) to face the high request of ventilatory support due to the massive influx of patients with acute respiratory failure (ARF) caused by coronavirus-19 disease (COVID-19). We sought to summarize the evidence on clinically relevant outcomes in COVID-19 patients supported by NIV outside the ICU. Methods We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials register, along with medRxiv and bioRxiv repositories for pre-prints, for observational studies and randomized controlled trials, from inception to the end of February 2021. Two authors independently selected the investigations according to the following criteria: (1) observational study or randomized clinical trials enrolling ≥ 50 hospitalized patients undergoing NIRS outside the ICU, (2) laboratory-confirmed COVID-19, and (3) at least the intra-hospital mortality reported. Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines were followed. Data extraction was independently performed by two authors to assess: investigation features, demographics and clinical characteristics, treatments employed, NIRS regulations, and clinical outcomes. Methodological index for nonrandomized studies tool was applied to determine the quality of the enrolled studies. The primary outcome was to assess the overall intra-hospital mortality of patients under NIRS outside the ICU. The secondary outcomes included the proportions intra-hospital mortalities of patients who underwent invasive mechanical ventilation following NIRS failure and of those with ‘do-not-intubate’ (DNI) orders. Results Seventeen investigations (14 peer-reviewed and 3 pre-prints) were included with a low risk of bias and a high heterogeneity, for a total of 3377 patients. The overall intra-hospital mortality of patients receiving NIRS outside the ICU was 36% [30–41%]. 26% [21–30%] of the patients failed NIRS and required intubation, with an intra-hospital mortality rising to 45% [36–54%]. 23% [15–32%] of the patients received DNI orders with an intra-hospital mortality of 72% [65–78%]. Oxygenation on admission was the main source of between-study heterogeneity. Conclusions During COVID-19 outbreak, delivering NIRS outside the ICU revealed as a feasible strategy to cope with the massive demand of ventilatory assistance. Registration PROSPERO, https://www.crd.york.ac.uk/prospero/ , CRD42020224788, December 11, 2020.

An ongoing outbreak of pneumonia associated with severe acute respiratory coronavirus 2 (SARS-CoV-2) occurred at the end of February 2020 in Lombardy, Italy. We analyzed data from a retrospective, single-center case series of 310 consecutive patients, with confirmed SARS-CoV-2 infection, admitted to the emergency room. We aimed to describe the clinical course, treatment and outcome of a cohort of patients with COVID-19 pneumonia, with special attention to oxygen delivery and ventilator support. Throughout the study period, 310 consecutive patients, with confirmed SARS-CoV-2 infection, attended the Emergency Room (ER), of these, 34 were discharged home directly from the ER. Of the remaining 276 patients, the overall mortality was 30.4%: 7 patients died in the ER and 77 during hospitalization. With respect to oxygen delivery: 22 patients did not need any oxygen support (8.0%), 151 patients were treated with oxygen only (54.7%), and 49 (17.8%) were intubated. 90 patients (32.6%) were treated with CPAP (Continuous Positive Airway Pressure) or NIV (Non Invasive Ventilation); in this group, 27 patients had a Do Not Intubate (DNI) order and were treated with CPAP/NIV as an upper threshold therapy, showing high mortality rate (88.9%). Among the 63 patients treated with CPAP/NIV without DNI, NIV failure occurred in 36 patients (57.1%), with mortality rate of 47.2%. Twenty-seven (27) patients were treated with CPAP/NIV without needing mechanical ventilation and 26 were discharged alive (96.3%). The study documents the poor prognosis of patients with severe respiratory failure, although a considerable minority of patients treated with CPAP/NIV had a positive outcome.

Background Triage is essential for optimising resource allocation in emergency care, particularly in low- and middle-income countries. Some triage tools, such as the Interagency Integrated Triage Tool (IITT), have been developed specifically for resource-limited settings, but their implementation and evaluation remain challenging due to shortages of staff, limited training opportunities, and infrastructure constraints. This study aimed to evaluate the impact of implementing a structured triage system adapted from the IITT on the identification of urgent/emergency cases and wait times compared with unstructured nursing assessment alone in a rural general hospital in Uganda. Methods A prospective quality improvement study was conducted in the outpatient department (OPD) of Dr Ambrosoli Memorial Hospital in Kalongo, Uganda. Data were collected on all patients attending the OPD for 7 consecutive days before and after IITT implementation. Outcomes included changes in emergency/urgent cases identification, proportion of undertriage/overtriage using hospital admission as the gold standard for assessing triage accuracy, OPD wait times and total OPD length of stay. Multivariable regression was used to adjust for confounders. Results A total of 304 patients in the pre-implementation period and 246 patients in the post-implementation period were included in the analysis. After implementation of the IITT, the proportion of emergency/urgent cases increased from 16.4% to 22.8%, but there was no significant association between IITT implementation and identification of emergency/urgent cases, overtriage and undertriage after adjustment for confounders. IITT implementation was associated with a 23-minute reduction in time to provider (95% CI -35.49 to -12.03, p  < 0.001) and a 35-minute reduction in total OPD length of stay (95% CI -57.41 to -12.76, p  = 0.002). Conclusions A structured triage system adapted from the IITT showed similar proportions of overtriage and undertriage compared with unstructured nursing assessment alone, but improved patient flow by significantly reducing wait times and length of stay in the OPD of a resource-limited rural hospital in Uganda. These findings suggest that structured triage can be feasibly implemented without additional resources in similar low-resource hospitals; however, further studies are needed to fully assess the impact of IITT in this and similar settings.

Platypnea-orthodeoxia syndrome (POS) is an unusual cause of hypoxia characterized by enormous variation in oxygen saturation during postural changes. We describe here the clinical presentation, the diagnostic challenge of POS and discuss the main pathophysiological etiologies of the disease in a 75-year-old woman who was admitted because shortness of breath. After ruling out the most important causes of dyspnea we observed that the symptoms improved when the patient was lying flat. The diagnostic workup with computed tomography scan and air bubble saline echocardiography lead us to a correct diagnosis.

Acute abdominal pain represents a challenge for the physician because it can hide a serious intra-abdominal pathology necessitating emergency intervention. A 65-year-old man presented to Emergency Department with sudden-onset abdominal pain. He underwent liver transplantation four years before. He complained tenderness on abdominal palpation. Blood chemistry and abdominal x-ray were normal. Contrast-enhanced computed tomography showed acute renal artery thrombosis. The patient underwent renal arterial thrombectomy and stent placement in less than two hours. Organ transplantation is a condition that makes patients at greater risk of life-threatening conditions. Renal artery thrombosis is a rare, severe and misdiagnosed condition which can benefit from a prompt cooperation among emergency physician, surgeon, and interventional radiologist. Transplant patients with acute abdominal pain should be considered at high risk of medical emergency. Acute renal artery thrombosis is a time dependent medical emergency in those patients with chronic drug-induced nephrotoxicity.

The loss of one of the two copies of the 9 bp tandem repeat sequence (CCCCCTCTA) located in the small non-coding region between the cytochrome oxidase II (COII) and the lysine tRNA genes in human mtDNA has been reported to be polymorphic in Asian, Oceanian and Sub-Saharan African populations, but it has rarely been observed in Europe. In this study, we will evaluate the possible association between the MIC9D polymorphism and cognitive disorders. A genetic analysis of unrelated Sicilian patients with cognitive deficits was performed to identify the 9 bp deletion MIC9D polymorphism. The MIC9D polymorphism was found in six patients, whereas this variant was absent in control individuals without cognitive deficits. The patients with the MIC9D polymorphism exhibited more complex clinical presentations; in particular, all had neuromuscular disorders and five also presented with behavioral disorders. The present study suggests a potential association between the MIC9D polymorphism and cognitive impairment with concurrent neuromuscular and behavioral involvement.

Forest bathing is gaining attention for its health and well-being benefits, leading to growing interest among academics, policymakers, and practitioners. While most studies have focused on its physiological and psychological effects, less is known about how different stakeholders perceive the characteristics that make forest bathing effective and meaningful. This study explored expert and non-expert perspectives on forest bathing in Italy through the Q-methodology, aiming to identify shared and divergent views on key aspects such as site features, accessibility, and perceived benefits. The results highlighted four distinct viewpoints: a scientific-health-oriented perspective emphasising medical efficacy (mainly experts); a preference for more naturalness and ecological integrity (mainly non-experts); a possible socio-economic opportunity (mainly non-experts); and a preference for a more managed forest environment with supporting structures (mainly experts). Despite differences, consensus emerged on several points, including the cultural and physical relevance of forest bathing and the importance of inclusive accessibility while preserving low-impact environments. The findings highlighted the potential of Q-methodology to capture the plurality of stakeholder voices, offering a basis for more inclusive planning and policy development in the context of nature-based well-being initiatives.

Deep-Seated Gravitational Slope Deformations (DSGSDs) are common in many geological environments, and due to their common limited displacement rate, they can remain unrecognized for a long time. Among the most significant events in Sicily is the Mt. San Calogero DSGSD. To contribute to a better understanding of its characteristics, including the geologic setting promoting its development, ongoing kinematics, and mechanism, a specific analysis was completed. In this paper, the results of this analysis, based on a three-folded strategy, are provided and interpreted in the context of DSGSD predisposing conditions and controlling factors. Especially, field observations associated to visual interpretation of aerial imagery were used for the identification and mapping of main geological features and landforms, high-resolution X-Band DInSAR data enabled researchers to fully characterize the deformational behavior of the slope, while a reduced complexity slope stability analysis allowed them to reconstruct the deep geometry of the DSGSD. Results from the analysis indicate that the DSGSD of Mt. San Calogero is composed of three blocks corresponding to fault-bounded tectonic elements and characterized by a specific kinematics and sensitivity to external forcing (i.e., rainfall), multiple landslides are associated to the DSGSD in the area and the deep geometry of the DSGSD is concave upward and resemble the characteristics of a rotational slide. The interpretation of the results suggests that the formation and the deformation of the Mt. San Calogero DSGSD are linked with the local and regional fault systems related to the Sicilian orogen, while shallow landslides are triggered, in clayey terrains, mostly by rainfalls. In addition, the integrated approach reveals that active tectonics and rainfalls in the San Calogero massive relief are the main driving forces of its different deformation behavior.

In the recent years, both the prescriptions of serum 25(OH)D levels assay, and vitamin D supplementation are constantly increasing, as well as the costs to be incurred relating to these specific aspects. As in many other countries, the risk of vitamin D deficiency is particularly high in Italy, as recently confirmed by cohort studies in the general population as well as in patients with metabolic bone disorder. Results confirmed the North-South gradient of vitamin D levels described among European countries, despite the wide use of supplements. Although vitamin D supplementation is also recommended by the Italian Medicine Agency for patients at risk for fragility fracture or for initiating osteoporotic medication, the therapeutic gap for osteoporosis in Italy is very high. There is a consistent proportion of osteoporotic patients not receiving specific therapy for osteoporosis following a fragility fracture, with a poor adherence to the recommendations provided by national guidelines and position paper documents. The failure or inadequate supplementation with vitamin D in patients on antiresorptive or anabolic treatment for osteoporosis is thought to further amplify the problem and exposes patients to a high risk of re-fracture and mortality. Therefore, it is important that attention to its possible clinical consequences must be given. Thus, in light of new evidence from the literature, the SIOMMMS board felt the need to revise and update, by a GRADE/PICO system approach, its previous original recommendations about the definition, prevention, and treatment of vitamin D deficiency in adults, released in 2011. Several key points have been here addressed, such as the definition of the vitamin D status: normality values and optimal values; who are the subjects considered at risk of hypovitaminosis D; opportunity or not of performing the biochemical assessment of serum 25(OH)D levels in general population and in subjects at risk of hypovitaminosis D; the need or not to evaluate baseline serum 25(OH)D in candidate subjects for pharmacological treatment for osteoporosis; how and whether to supplement vitamin D subjects with hypovitaminosis D or candidates for pharmacological treatment with bone active agents, and the general population; how and whether to supplement vitamin D in chronic kidney disease and/or chronic liver diseases or under treatment with drugs interfering with hepatic metabolism; and finally, if vitamin D may have toxic effects in the subject in need of supplementation.

Aromatic L-amino acid decarboxylase deficiency (AADCd) is a rare autosomal recessive neurometabolic disorder caused by AADC deficiency, an enzyme encoded by the DDC gene. Since the enzyme is involved in the biosynthesis of serotonin and dopamine, its deficiency determines the lack of these neurotransmitters, but also of norepinephrine and epinephrine. Onset is early and the key signs are hypotonia, movement disorders (oculogyric crises, dystonia and hypokinesia), developmental delay and autonomic dysfunction. Taiwan is the site of a potential founder variant (IVS6+4A>T) with a predicted incidence of 1/32,000 births, while only 261 patients with this deficit have been described worldwide. Actually, the number of affected persons could be greater, given that the spectrum of clinical manifestations is broad and still little known. In our study we selected 350 unrelated patients presenting with different neurological disorders including heterogeneous neuromuscular disorders, cognitive deficit, behavioral disorders and autism spectrum disorder, for which the underlying etiology had not yet been identified. Molecular investigation of the DDC gene was carried out with the aim of identifying affected patients and/or carriers. Our study shows a high frequency of carriers (2.57%) in Sicilian subjects with neurological deficits, with a higher concentration in northern and eastern Sicily. Assuming these data as representative of the general Sicilian population, the risk may be comparable to some rare diseases included in the newborn screening programs such as spinal muscular atrophy, cystic fibrosis and phenylketonuria.