Defining the Impact of Adjuvant Treatment on the Prognosis of Patients with Inoperable Glioblastoma Undergoing Biopsy-only: Does the Survival Benefit Outweigh the Treatment Effort?

Purpose: Patients with inoperable glioblastoma (GBM) usually experience worse prognosis compared to those in whom gross total resection (GTR) is achievable. Considering the treatment duration and its side effects identification of patients with survival benefit from treatment is essential to guarantee the best achievable quality of life. The aim of this study was to evaluate the survival benefit from radio-chemotherapy and to identify clinical, molecular, and imaging parameters associated with better outcome in patients with biopsied GBMs. Methods: Consecutive patients with inoperable GBM, who underwent tumor biopsy at our department from 2005 to 2019 were retrospectively analyzed. All patients had histologically confirmed GBM and were followed up until death. The overall survival (OS) was calculated from date of diagnosis to date of death. Clinical, radiological and molecular predictors of OS were evaluated. Results: A total of 95 patients with biopsied primary GBM were enrolled in the study. The mean age was 64.3±13.2 years, 56.8 % (54/95) were male and 43.2 % (41/95) female. Mean OS in the entire cohort was 9 months. After stratification for adjuvant treatment a higher median OS was found in the group with adjuvant treatment (7 months, range 2-88) compared to the group without treatment (1 month, range 1-5) Log-rank test, p<0.0001.Conclusion: Patients with inoperable GBM undergoing biopsy indeed experience a very limited OS. Adjuvant treatment is associated with significantly longer OS compared to patients not receiving treatment and should be considered, especially in younger patients with good clinical condition at presentation.

Dynamics of the Third Wave of COVID-19 from the Perspective of the Emergency Department in a Large Regional Hospital—Single Center Observational Study

Background: The outbreak of the Coronavirus Disease 2019 (COVID-19) pandemic has caused many significant social and economic changes. The consecutive waves of the epidemic in various countries have had dissimilar courses depending on the methods used to combat it. The aim of this study was to determine the dynamics of the third wave of COVID-19 from the perspective of emergency departments (ED). Methods: This was a retrospective review of medical records from ED. The authors have identified the most frequent symptoms. Prognostic factors have been chosen—prognostic scales, length of stay (LOS)—and a number of resources required have been calculated. Results: As the time passed, there were fewer patients and they presented mild symptoms. A statistically significant difference was observed in the median of blood oxygenation measurement (p = 0.00009), CRP level (p = 0.0016), and admission rate. Patients admitted to the hospital required more resources at ED. LOS was shorter in patients discharged home (p < 0.0001). Conclusions: The blood oxygen saturation (SPO2) and CPR levels can be helpful in decision-making regarding medical treatment. The fast-track for patients in good clinical condition may shorten the duration of stay in ED, and reduce the number of required resources.

739 Atypical presentation of Takotsubo syndrome early after pacemaker implantation

Aims Takotsubo syndrome (TTS) is an acute stress-induced cardiomyopathy showing left ventricular (LV) dysfunction without obstructive coronary arteries disease. A sudden massive surge of circulatory catecholamines from an intense physical or emotional stress may play a central role in the pathogenesis of TTS. We report the case of an 87 years-old woman who developed TTS with uncommon presentation after permanent pacemaker (PM) implantation. Methods and results The patient was referred to our hospital for PM implantation because of advanced atrio-ventricular block (3:1). She suffered by rheumatoid arthritis (RA), arterial hypertension, and chronic kidney disease. Echocardiogram, performed before PM implantation, showed normal LV kinesis and normal ejection fraction (EF 60%). She was initially administered with infusion of Isoprenaline 2 mcg/min. The subsequent day, she underwent permanent dual-chamber pacemaker implantation without any complications. After 3 days, the patient complained severe asthenia and fever, together with increase of white blood cells and C reactive protein. Blood cultures were negative. We started antibiotic therapy and, suspecting a reactivation of RA, steroid therapy with infusion of methylprednisolone 40 mg/die. Electrocardiogram showed normal sinus rhythm and paced ventricular rhythm. PM interrogation showed normal function. Surprisingly, echocardiogram showed LV dysfunction with apical and medium segments akinesia, and severe EF reduction (35%). Coronary angiography documented absence of coronary obstructive lesions, assessing diagnosis of TTS. The patient was discharged 1 week after admission in good clinical condition. One week later, an echocardiogram showed apical akinesia, partial recovery of medium segments motility, and slight increase of EF (40%). The excess of catecholamines could lead to decreased cardiac muscular function and to spasm of coronary arteries: these events can lead to acute heart failure and decrease of LVEF. Furthermore, about 90% of patients with TTS are women, especially in postmenopausal period. Peculiarities of this case were the atypical symptoms of TTS and the combination of different predisposing stressors factors: female sex in postmenopausal period, anamnesis of chronic inflammatory disease, use of stress-inducing drugs (methylprednisolone and isoprenaline, the last associated with TTS after PM-implantation), atrio-ventricular block itself, and PM implantation procedure. Our findings remark that even a low-risk procedure could be a possible cause of TTS in patient with such risk factors. In our opinion, in this subset of patients, conscious sedation could be useful to reduce the stress load, together with an early procedure and consequently the minimal use of exogenous stress drugs like Isoprenaline, even if the patient is in a good clinical condition. Conclusions This case highlights TTS as a potential complication after PM implantation, especially in post-menopausal women with high pre-existing stress load.

Should Comorbidities be Considered in the Decision to Discharge COVID-19 Patients From Hospital? A Case Series

An outbreak of COVID-19 started in December 2019 in the city of Wuhan and is now rapidly spreading across the world. We report two cases of confirmed COVID-19 with pre-existing comorbidities who were discharged from the hospital with a good clinical condition and in concordance with interim discharge protocols. However, they were readmitted and died on the discharge day. Here we discuss the importance of patient demographics in clinical management vs. the resolution of the pulmonary disease alone and raise a question about the impact of comorbidities on discharge protocols.

Electrochemotherapy as a Trigger to Overcome Primary Resistance to Anti-PD-1 Treatment: A Case Report of Melanoma of the Scalp

BackgroundImmunotherapy with immune checkpoint inhibitors is one of the main therapies for advanced melanoma. Nevertheless, albeit remarkable, immunotherapy results are still unsatisfactory as more than half of patients progress, and resistance to treatment still has a dramatic impact on clinical outcomes. Local treatments such as radiotherapy or electrochemotherapy (ECT), in addition to local control with palliative intent, have been shown to release tumoral neoantigens that can stimulate a robust systemic antitumor immune response.Case PresentationWe report the case of a patient with multiple nodular melanoma lesions of the scalp initially treated with local ECT. Soon after the procedure, multiple new lesions appeared close to the treated ones, therefore the patient started a systemic treatment with the anti-PD-1 nivolumab. The lesions of the scalp did not respond to immunotherapy, presenting a loco-regional spreading. To control the bleeding and painful lesions, we performed a second ECT, while continuing systemic immunotherapy. The treated lesions responded to the second procedure, while the other lesions continued progressing in number and dimension. Unexpectedly, after 2 months from the second ECT, the patient presented a progressive shrinkage of both treated and untreated lesions until complete remission. Concomitantly, he developed immune-related adverse events including grade 4 thyroid toxicity, grade 2 vitiligo-like depigmentation and grade 2 pemphigoid. At present, after 18 months from the first ECT and 14 months from the starting of anti-PD-1 immunotherapy, the patient is in good clinical condition and complete remission of disease still persists.ConclusionThis case highlights the potential role of ECT in increasing tumor immunogenicity and consequently in inducing a powerful immune response overcoming primary resistance to checkpoint inhibitor immunotherapy.

A rare case of mobile ball-like mass in right atrium associated with dilated cardiomyopathy

Mobile thrombus in the Right Atrium (RA) is a rare condition. Here, we described a case of a 59-year-old male who presented in emergency room with complaints of progressively worsening dyspnea for 7 years. He was normotensive, had elevated jugular venous pressure and clear lungs. ECG revealed ventricular tachycardia. After successfully electrical defibrillation, an urgent 2D echocardiogram was obtained and revealed the enlargement of all heart chambers and a ball-like, mobile mass in the right atrium. An emergent CT scan revealed no sign of pulmonary embolism. Based on morphological features on echocardiogram, we highly suspected it as RA thrombus. The patient was treated with anticoagulant therapy comprising of low molecular heparin and warfarin since he rejected surgical treatment. Repeat echocardiogram was performed 7 days after anticoagulant therapy and showed disappearance of the RA mass. He was subsequently maintained on warfarin (INR=2.4- 3.0) and other medications for heart failure. The patient was followed up as outpatient and kept in good clinical condition. We concluded that early recognition of this rare situation and prompt management can help in preventing life-threatening complications, and anticoagulant therapy was a therapeutic option for RA thrombus.

Litrre’s hernia: partially reduced inguinal hernia in a 3-year-old boy

This report examines the case of a 3-year-old child presenting with a 1-month history of swelling in the right groin. The boy had no associated nausea or vomiting, was afebrile and had had normal bowel movements. Attempts to reduce the swelling were only partially successful. Ultrasonography indicated the presence of turbid hydrocele and a hernia sac containing an intestinal loop. Accordingly, the patient underwent an urgent herniotomy. Exposing the hernia sac revealed 5 cm Meckel’s diverticulum, and the base of the diverticulum was resected from the inside of the hernia sac. The boy was discharged 4 days after the operation in good clinical condition. The presented case highlights the need to consider Littre’s hernia when dealing with partially reduced inguinal hernias in children with no general signs or evidence of intestinal obstruction.

A CASE REPORT RESPIRATORY MANIFESTATIONS OF COVID-19 STARTING WITH A GASTROINTESTINAL COMPLAINT: A COINCIDENCE OR A CORRELATION?

Background: SARS COV-2 is the cause of the current outbreak of COVID-19. The infection of SARS COV-2 causes changes in the gut- lung axis and the intestinal microbiota pro-inflammatory cytokines interaction which leads to the injury of the gastrointestinal tract. One of the symptoms of COVID-19 outside the respiratory system is a complaint in the GIT. Materials and Methods: We present a COVID-19 case report that begins with a complaint of abdominal pain. Results: There was no previous suspicion of COVID-19, but after a radiological examination and SARS-COV2 positive PCR result, the patient was proven to be suffering from COVID-19. Conclusion: After hospitalization in the ICU for about 14 days, a recovery occurred and the patient was able to go home in a very good clinical condition.

Laparoscopic Lavage in Complicated Diverticulitis with Colonic Perforation, Always Be Closing?

Laparoscopic lavage is seen as an acceptable alternative to colonic resection in selected patients with acute diverticulitis with purulent peritonitis. There is no consensus on what surgical technique should be used when performing this procedure. This case series describes the disease course of 3 patients with acute diverticulitis with purulent peritonitis treated with laparoscopic lavage and direct suturing of a colonic perforation. All patients (38- and 71-year-old males and a 44-year-old female) were seen in the emergency department due to acute lower abdominal pain. Clinical examination and laboratory and imaging studies were suggestive of perforated diverticular disease. Laparoscopic lavage with placement of drain(s) and direct suturing of a colonic perforation was performed. Postoperative treatment with intravenous antibiotics was continued for a variable term. Postoperative courses were uneventful. Patients were discharged on postoperative days 5, 5, and 7. At almost 1-year follow-up, all patients are in good clinical condition and have not had a recurrent episode of diverticulitis<i>.</i> Therefore, this case series shows promising results of laparoscopic lavage with direct suturing of colonic perforation in patients with diverticulitis with perforation and purulent peritonitis.

Long-term survival of an adolescent glioblastoma patient under treatment with vinblastine and valproic acid illustrates importance of methylation profiling

Glioblastoma (GBM) is an exceptionally aggressive brain tumor with a dismal prognosis, demanding fast and precise classification as a base for patient-specific treatment strategies. Here, we report on an adolescent patient with a histologically bona fide GBM that shows a molecular methylation profile suggesting a low-grade glioma-like subgroup. Despite an early relapse, intolerance of temozolomide, and change of treatment strategy to vinblastine and valproic acid (VPA), the patient is now in good clinical condition after more than 5 years since initial diagnosis. This case stresses the merit of methylation array data for clinical prognosis and treatment planning.