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Purpose To analyze the application of a lung ultrasound (LUS)-based diagnostic approach to patients suspected of COVID-19, combining the LUS likelihood of COVID-19 pneumonia with patient’s symptoms and clinical history. Methods This is an international multicenter observational study in 20 US and European hospitals. Patients suspected of COVID-19 were tested with reverse transcription-polymerase chain reaction (RT-PCR) swab test and had an LUS examination. We identified three clinical phenotypes based on pre-existing chronic diseases (mixed phenotype), and on the presence (severe phenotype) or absence (mild phenotype) of signs and/or symptoms of respiratory failure at presentation. We defined the LUS likelihood of COVID-19 pneumonia according to four different patterns: high (HighLUS), intermediate (IntLUS), alternative (AltLUS), and low (LowLUS) probability. The combination of patterns and phenotypes with RT-PCR results was described and analyzed. Results We studied 1462 patients, classified in mild ( n  = 400), severe ( n  = 727), and mixed ( n  = 335) phenotypes. HighLUS and IntLUS showed an overall sensitivity of 90.2% (95% CI 88.23–91.97%) in identifying patients with positive RT-PCR, with higher values in the mixed (94.7%) and severe phenotype (97.1%), and even higher in those patients with objective respiratory failure (99.3%). The HighLUS showed a specificity of 88.8% (CI 85.55–91.65%) that was higher in the mild phenotype (94.4%; CI 90.0–97.0%). At multivariate analysis, the HighLUS was a strong independent predictor of RT-PCR positivity (odds ratio 4.2, confidence interval 2.6–6.7, p  < 0.0001). Conclusion Combining LUS patterns of probability with clinical phenotypes at presentation can rapidly identify those patients with or without COVID-19 pneumonia at bedside. This approach could support and expedite patients’ management during a pandemic surge.

•The response to Td is not influenced by co-administration of other vaccines.•Tetanus and diphtheria antibody titres above 0.1 IU/ml persist for decades.•Vaccine booster may be delayed beyond the current recommended10-year interval.•Polyclonal B-cell stimulation is not involved in preserving Td antibody levels.•HLA-DRB1∗01 allele marks subjects with a defective response to re-vaccination. Cellular and humoral immune responses to tetanus-diphtheria vaccine (Td) were assessed in human leukocyte antigen (HLA)-typed Italian military personnel who received multiple concomitant vaccines. Td-specific antibodies and T-lymphocytes were measured in individuals with one (group-1) and more than one (group-2) Td boosters. A third group (group-3), who received several vaccines, but not Td, was studied to verify the hypothesis of the polyclonal B-cell activation as mechanism for antibody persistence. The antibody response to Td toxoids was higher in group-1, who showed lower baseline antibody levels, than in group-2 subjects. The antibody response to tetanus was higher than to diphtheria toxoid in both groups. No correlation between antibody and cellular response, and no interference in the response to Td by co-administration of different vaccines were observed. HLA-DRB1∗01 allele was detected at significant higher frequency in subjects unable to double the baseline anti-diphtheria antibody levels after the vaccination. Anti-tetanus and diphtheria antibodies half-lives were assessed and the long-lasting persistence above the threshold for protection (0.1 IU/ml) was estimated in over 65 and 20 years, respectively. No significant increase of anti-diphtheria antibodies was observed in consequence of polyclonal B-cell activation. This study emphasizes the duration of Td vaccination-induced seroprotection, suggesting that re-vaccination should probably be performed at intervals longer than 10 years. No reciprocal interference by concomitantly administered vaccines has been observed. HLA-DRB1∗01 allele was significantly associated with anti-diphtheria defective response. Finally, this study does not confirm that anti-diphtheria antibody levels are maintained by polyclonal B-cell activation. Clinical trial registry: The study was registered with NCT01807780.

We evaluated the effectiveness of a training program with high-fidelity simulation (HFS) to improve technical (TS) and non-technical skills (NTS) of residents in Emergency Medicine. We conducted a 2-year training program for the management of a critical patient based on HFS (6 sessions for every year, four teams who performed 4 scenarios per session). At the beginning of the training program, all participants received a presentation of Crisis Resource Management (CRM) principles. Each session covered a different topic in Emergency Medicine Curriculum. TSs were measured as the proportion of completed tasks in the following areas: airway, breathing, circulation, disability and exposure (ABCDE) assessment and management, completion of anamnesis based on AMPLE (allergy, medications, previous illness, last meal and event) scheme, diagnostic and therapeutic assessment. NTSs were rated by the Clinical Teamwork Scale (CTS). Scores’ values and the percentage of correctly performed actions were presented as median with interquartile range. Friedmann non-parametric test was employed to evaluate the trend of TS and NTS over the following sessions. Among the TS, the assessment and management of ABCDE and completion of therapeutic tasks improved (all p < 0.05). The completion of diagnostic tasks (p = 0.050) tended toward significant improvement. The overall CTS score (first session 61 ± 17, last session 84 ± 16, p < 0.001) as well as Communication (first 13.7 ± 3.6, last 18.7 ± 3.5, p < 0.001), Situational Awareness (first 5.3 ± 1.8, last 6.4 ± 1.4, p = 0.012) and Role Responsibility subscores (first 9.7 ± 2.8, last 12.1 ± 3.7, p < 0.001) increased through the following sessions. Therefore, HFS has proven to be an effective instrument to improve TS and NTS among Emergency Medicine residents.

To analyze the prognostic value of lactate levels for day-7 and in-hospital mortality, in septic patients with and without shock. In the period November 2011–December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis of sepsis. Lactate dosage was performed at ED-HDU admission (T0), after 2 h (T2), 6 h (T6) and 24 h (T24); lactate clearance was calculated at T2 and T6 [T2: ((LAC T0—LAC T2/LAC T0)*100)]; T6: [(LAC T0—LAC T6/LAC T0)*100]. The end-points were day-7 and in-hospital mortality. At every evaluation, the lactate level was higher in patients with shock than in those without (T0 3.8 ± 3.8 vs 2.4 ± 2.1; T6 2.9 ± 3.2 vs 1.6 ± 1.1; T24 3.0 ± 4.4 vs 1.4 ± 0.9 meq/L, all p < 0.001). Among patients with shock, an analysis for repeated measures confirmed a more marked lactate level reduction in survivors compared with non-survivors, both by day-7 and in-hospital mortality (p = 0.057 and p = 0.006). A Kaplan–MeIer analysis confirmed a significantly better day-7 survival in patients with T6 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) and T24 (with shock 86% vs 70%; without shock 93% vs 82, all p < 0.05) lactate ≤ 2 meq/L, compared with patients with higher levels. A T6 lactate clearance > 10% was more frequent among in-hospital survivors in the whole study population (57% vs 39%) and in patients with shock (74% vs 46%, all p < 0.05). Higher lactate levels and decreased clearance were associated with an increased short-term and intermediate-term mortality regardless of the presence of shock.

To evaluate if the assessment of coagulation abnormalities at ED admission could improve prognostic assessment of septic patients. This report utilizes a portion of the data collected in a prospective study, with the aim to identify reliable biomarkers for an early sepsis diagnosis. In the period November 2011–December 2016, we enrolled 268 patients, admitted to our High-Dependency Unit with a diagnosis severe sepsis/septic shock. Study-related blood samplings were performed at ED-HDU admission (T0), after 6 h (T6) and 24 h (T24): D-dimer, thrombin–antithrombin complex (TAT) and prothrombin fragment F1 + 2 levels were analyzed. The primary end-points were day-7 and in-hospital mortality. Day-7 mortality rate was 16%. D-dimer (T0: 4661 ± 4562 µg/ml vs 3190 ± 7188 µg/ml; T6: 4498 ± 4931 µg/ml vs 2822 ± 5623 µg/ml; T24 2905 ± 2823 µg/ml vs 2465 ± 4988 µg/ml, all p < 0.05) and TAT levels (T0 29 ± 45 vs 22 ± 83; T6 21 ± 22 vs 15 ± 35; T24 16 ± 19 vs 13 ± 30, all p < 0.05) were higher among non-survivors compared to survivors. We defined an abnormal coagulation activation (COAG+) as D-dimer > 500 µg/ml and TAT > 8 ng/ml (for both, twice the upper normal value). Compared to COAG−, COAG+ patients showed higher lactate levels at the earliest evaluations (T0: 3.3 ± 2.7 vs 2.5 ± 2.3, p = 0.041; T6: 2.8 ± 3.4 vs 1.8 ± 1.6, p = 0.015); SOFA score was higher after 24 h (T24: 6.7 ± 3.1 vs 5.4 ± 2.9, p = 0.008). At T0, COAG+ patients showed a higher day-7 mortality rate (HR 2.64; 95% CI 1.14–6.11, p = 0.023), after adjustment for SOFA score and lactate level. Presence of abnormal coagulation at ED admission shows an independent association with an increased short-term mortality rate.

This collection of seven papers studies important aspects of the syntax of Albanian, Bulgarian, Greek, and Romanian from a comparative perspective based on current linguistic frameworks, including the Minimalist Program. Topics addressed include control, raising, and obviation, negation, noun phrase structure, clitic pronouns, and verb movement.

Background and Objectives: Several treatments are available for sudden sensorineural hearing loss (SSNHL), but no studies have compared the different treatments based on the delay from the onset of the disease. Our study aims to compare the effect of hyperbaric oxygen therapy (HBOT), oral steroids (OS) and combination of both therapies (HBOT + OS) for treating SSNHL. Materials and Methods: This randomized study analyzed 171 patients with SSNHL. Patients were evaluated by pure tone audiometry test (PTA) at baseline (T0) and 20 days after treatment (T1). Three groups were available HBOT-A-, OS-B- and HBOT + OS-C-. After baseline PTA, patients were randomly assigned to each group. Statistical analysis was performed by one-way ANOVA and Chi-square. Results: Patients in the HBOT + OS and HBOT groups improved their auditory function (p < 0.05). HBOT was the best choice for treatment when started by 7 days from SSNHL onset, while HBOT + OS in case of late treatment. Profound SNHL recovered equally by HBOT and HBOT + OS (p < 0.05). Upsloping SNHL obtained better auditory results by HBOT compared to HBOT + OS (p < 0.05). Downsloping and flat SSNHL had the most improvement with HBOT + OS compared to HBOT only (p < 0.05). Conclusions: Combination of HBOT and OS is a valid treatment for SSNHL both in case of early and late treatment. Combination of HBOT and OS was the choice with the best results in case of treatment started >14 days from symptom onset.

Introduction: The number of people with migrant status living in Europe is proliferating. Most of the refugees in Italy come from war zones, and many of them denounce having been victims of persecutory acts in their country of origin. Highly cultured migrant populations have shown better results and oral health behaviour than those who were poorly cultured. The PROTECT project aimed to build a network for the early management of head and neck pathologies among refugees and migrants, promoting the dissemination of correct information about the prevention and treatment of these pathologies. Materials and methods: A national cross-sectional study among the refugees and migrant population in the Lazio region, Italy, from February 2018 to September 2021 was performed. The oral health of 3023 participants was investigated within a network of 56 reception centres and cultural associations. Data collected via an oral health survey questionnaire gathered information on participants’ demographic factors, migration status and dental behaviours and clinical examinations of the participants with the help of mouth mirrors, periodontal probes and artificial light. Results: The mean age was 31.6 ± 13.1, and among all the subjects, 2058 were male (68.1%) and 965 were women (41.9%). Most participants were born in Nigeria, followed by Bangladesh, Pakistan, Somalia, Mali and Senegal. The overall oral pain prevalence was 48.2%. The prevalence of patients claiming poor oral hygiene was 32.4%; 36.2% of the subjects consumed high amounts of sugar; and 26.7% saw their dentist for a check-up in the last year. At the clinical examination, 68.9% of patients had caries experience (considering decay of deciduous teeth, and caries of permanent teeth and teeth with fillings), with 32.2% showing pulpal involvement. Low levels of oral hygiene were also found at the clinical examination, with 46.5% of patients presenting plaque and calculus. The trend of the DMFT index was found to be 5.41. Good periodontal health (CPI = 0) was present in approximately 33.5% of patients. The CPI = 1 index reported bleeding from gingivitis in 37% of patients; tartar was found in 27% of patients (CPI = 2). The percentage of patients with CPI = 3 was 3.6%. Just over half (52.2%) of the migrants examined had malocclusion, and only 0.7% had a malocclusion in treatment. Conclusions: The goal to be achieved is to develop education and prevention programs for head–neck diseases, and perhaps even more. The first step towards this goal can be removing the obstacles migrants encounter in accessing health care.

This volume grew out of the workshop on the syntax of Balkan languages, organized by Angela Ralli and Irene Philippaki-Warburton, held in Athens in 1996 in connection with the Glow Colloquium The idea behind this workshop which featured Brian D. Joseph and María Luisa Rivero as invited speakers, was to provide a forum where comparative work related to the syntax of Balkan languages could be presented. This is also the basic goal of the present collection. The volume brings together seven papers on syntactic topics in which leading and new researchers in Balkan syntax examine aspects of the grammar of mainly Albanian, Bulgarian, Greek, and Romanian.

With an article on general issues concerning the Balkan isoglosses, three contributions on sentential structure, two on the nominal domain and one on verb movement, it constitutes a good first effort to bring together relatively current theoretical work in comparative syntax while also familiarizing the reader with distinctive characteristics of the Balkan sprachbund. The author presents a number of fascinating Balkan areal features, but expresses concern as to whether studies of the latter type are useful for current syntactic theory (mainly because of the relatively recent contact situation that gave rise to the various constructions), and he seems to believe that they do not necessarily contribute much to detecting distinctive properties and the genesis of a sprachbund either (probably true to a large extent, given their orientation).