Long-term physical impairments in survivors of COVID-19-associated ARDS compared with classic ARDS: A two-center study.

PURPOSE: This work aimed to compare physical impairment in survivors of classic ARDS compared with COVID-19-associated ARDS (CARDS) survivors. MATERIAL AND METHODS: This is a prospective observational cohort study on 248 patients with CARDS and compared them with a historical cohort of 48 patients with classic ARDS. Physical performance was evaluated at 6 and 12 months after ICU discharge, using the Medical Research Council Scale (MRCss), 6-min walk test (6MWT), handgrip dynamometry (HGD), and fatigue severity score (FSS). We also assessed activities of daily living (ADLs) using the Barthel index. RESULTS: At 6 months, patients with classic ARDS had lower HGD (estimated difference [ED]: 11.71 kg, p < 0.001; ED 31.9% of predicted value, p < 0.001), 6MWT distance (ED: 89.11 m, p < 0.001; ED 12.96% of predicted value, p = 0.032), and more frequent significant fatigue (OR 0.35, p = 0.046). At 12 months, patients with classic ARDS had lower HGD (ED: 9.08 kg, p = 0.0014; ED 25.9% of predicted value, p < 0.001) and no difference in terms of 6MWT and fatigue. At 12 months, patients with classic ARDS improved their MRCss (ED 2.50, p = 0.006) and HGD (ED: 4.13 kg, p = 0.002; ED 9.45% of predicted value, p = 0.005), while those with CARDS did not. Most patients in both groups regained independence in ADLs at 6 months. COVID-19 diagnosis was a significant independent predictor of better HGD (p < 0.0001) and 6MWT performance (p = 0.001), and lower prevalence of fatigue (p = 0.018). CONCLUSIONS: Both classic ARDS and CARDS survivors experienced long-term impairments in physical functioning, confirming that post-intensive care syndrome remains a major legacy of critical illness. Surprisingly, however, persisting disability was more common in survivors of classic ARDS than in CARDS survivors. In fact, muscle strength measured with HGD was reduced in survivors of classic ARDS compared to CARDS patients at both 6 and 12 months. The 6MWT was reduced and fatigue was more common in classic ARDS compared to CARDS at 6 months but differences were no longer significant at 12 months. Most patients in both groups regained independent function in ADLs at 6 months.

Are Football Players More Prone to Muscle Injury after COVID-19 Infection? The "Italian Injury Study" during the Serie a Championship.

INTRODUCTION: Football was the first sport to resume competitions after the coronavirus disease 2019 (COVID-19) lockdown and promptly the hypothesis was raised of a potential relationship between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and musculoskeletal injuries in athletes. This study aimed to confirm the association between SARS-CoV-2 infection and muscle strain injury in a large population of elite football players and to investigate if the COVID-19 severity level could affect the risk of injury. METHODS: A retrospective cohort study involving 15 Italian professional male football teams was performed during the Italian Serie A 2020-2021 season. Injuries and SARS-CoV-2 positivity data were collected by team doctors through an online database. RESULTS: Of the 433 included players, we observed 173 SARS-CoV-2 infections and 332 indirect muscle strains. COVID-19 episodes mostly belonged to severity level I and II. The injury risk significantly increased after a COVID-19 event, by 36% (HR = 1.36, CI95% 1.05; 1.77, p-value = 0.02). The injury burden demonstrated an 86% increase (ratio = 1.86, CI95% 1.21; 2.86, p-value = 0.005) in the COVID-19 severity level II/III versus players without a previous SARS-CoV-2 infection, while level I (asymptomatic) patients showed a similar average burden (ratio = 0.92, CI95% 0.54; 1.58, p-value = 0.77). A significantly higher proportion of muscle-tendon junction injuries (40.6% vs. 27.1%, difference = 13.5%, CI95% 0.002%; 26.9%, p-value = 0.047) was found when comparing level II/III versus Non-COVID-19. CONCLUSIONS: This study confirms the correlation between SARS-CoV-2 infection and indirect muscle injuries and highlights how the severity of the infection would represent an additional risk factor.

Impact of COVID-19-Related Social Isolation on Behavioral Outcomes in Young Adults Residing in Northern Italy.

Social isolation affects our emotions, behavior and interactions. Worldwide, individuals experienced prolonged periods of isolation during the first wave of the COVID-19 pandemic when authorities-imposed restrictions to reduce the spread of the virus. In this study, we investigated the effects of social isolation on emotional and behavioral outcomes in young adults from Lombardy, Italy, a global hotspot of COVID-19. We leveraged baseline (pre-social isolation) and follow-up (mid- or post-isolation) data collected from young adults enrolled in the ongoing, longitudinal Public Health Impact of Metals Exposure (PHIME) study. At baseline, 167 participants completed the ASEBA questionnaires (ASR/YSR) by web link or in person; 65 completed the ASR 12-18 weeks after the onset of restrictions. Using the sign test and multiple linear regression models, we examined differences in ASR scores between baseline and follow-up adjusting for sex, age, pre-pandemic IQ and time with social restrictions (weeks). Further, we examined interactions between sex and time in social isolation. Participants completed the ASR after spending an average of 14 weeks in social isolation (range 12-18 weeks). Thought problems increased between baseline and follow-up (median difference 1.0; 1st, 3rd quartile: -1.0, 4.0; p = 0.049). Among males, a longer time in social isolation (≥14 weeks) was associated with increased rule-breaking behaviors of 2.8 points. These results suggest the social isolation related to COVID-19 adversely impacted mental health. In particular, males seem to externalize their condition. These findings might help future interventions and treatment to minimize the consequences of social isolation experience in young adults.

Predictive markers for clinical outcomes in a cohort of diabetic patients hospitalized for COVID-19.

INTRODUCTION: The role of glycemic control, both prior and during hospitalization, on mortality from COVID-19 in diabetic patients is debated. Furthermore, it is not clear whether hyperglycemia has a direct effect or requires inflammatory mechanisms. OBJECTIVE: To identify predictors of clinical outcomes (in-hospital mortality, length of hospitalization, respiratory failure, need for intensive care), considering hyperglycemia, inflammation markers and clinical history. METHODS: Retrospective observational study of 291 diabetic patients hospitalized with COVID-19 in the Spedali Civili di Brescia from February 1th 2020 to March 31th 2021, with also outpatient electronic records. Glucose, inflammatory parameters, creatinine were collected within 24 h after admission to the hospital. A causal mediation analysis allowed the estimation of the direct and indirect effects of hyperglycemia on mortality. RESULTS: Glucose at admission ≥ 165 mg/dL and reduced renal function were associated with an increased risk of in-hospital mortality and length of hospitalization (all p < 0.001), while an increase in inflammatory parameters was significantly associated with an increased risk of all outcomes. High basophil count was associated with reduced mortality (p < 0.001). Hyperglycemia had a direct effect on mortality (p < 0.001); the indirect, through inflammatory markers, was significant only for absolute neutrophil count, C-Reactive protein and procalcitonin (p = 0.007, p = 0.029, p = 0.042). Patients with microvascular complications and with chronic kidney disease showed higher mortality (p = 0.03, p = 0.01). CONCLUSIONS: Hyperglycemia at admission, renal function and inflammatory parameters were found to be predictors of in-hospital mortality, while an increased basophil count was protective. Hyperglycemia had a direct effect on mortality, the indirect effect was only through few markers and markedly lower than the direct one.

COVID-19 Aftermath: Exploring the Mental Health Emergency among Students at a Northern Italian University.

In this study, we investigated the symptoms of physical and mental health associated with lifestyle changes due to a lockdown among the students of a university in Northern Italy, one of the most affected areas in Europe during the first wave of COVID-19. We examined the psychopathological variations in relation to mental health problems in a young population. The goal was to develop interventions to resolve these new psychosocial problems. From June to July 2020, students participated in an anonymous survey asking about habits and symptoms that emerged during the lockdown and the COVID-19 pandemic. Five health outcomes were assessed: digestive disorders; headaches; fear of COVID-19; panic and anxiety crises; and depression/sadness. The conditions and duration of the social isolation, lifestyle, SARS-CoV-2 infection in the household, financial situation, and productivity were considered in the analysis. A total of 3533 students completed the survey. The participants experienced headaches, depression and sadness, digestive disorders, a fear of COVID-19, and anxiety/panic crises. The duration of isolation was associated with an increased risk of digestive disorders, headaches, and COVID-19 fear. The female gender, medium-intense telephone usage, sleep quality, memory difficulties, and performance reduction were associated with an increased risk of the health outcomes. Future interventions should focus on promoting and implementing different habits with the support of health and university organizations.

Psychological and Emotional Impact of COVID-19 Pandemic on People Living with Chronic Disease: HIV and Cancer.

People living with chronic disease (PLWCD) are the frailest category, both for the risk of severe COVID-19 illness and for the impact on the care continuum. Aim of this study was to analyze coping strategies and resilience in people living with HIV (PLWH) compared to people living with oncological diseases (PLWOD) during COVID-19 pandemic. We administrated an anonymous questionnaire, which explored the emotional experience, the demographic factors linked to a COVID-19-related stress syndrome, the patient's perception about the adequacy of clinical undertaking from the hospital and the resilience. We analyzed 324 questionnaires. There were no significant differences in prevalence of psychological distress among the whole cohort; however, PLWOD were calmer, less troubled, and more serene than PLWH. Moreover, PLWH smoked more, ate more, and gained more weight than PLWOD. Most patients didn't feel lonely and continued to take pleasure from their activities. No differences in resilience were found between the groups. In the whole cohort lower levels of resilience were found in patients that were unemployed, with history of psychological disorders and in those who experienced more feelings of anger, anxiety and concern. In our study, patients seemed to preserve their well-being, and to activate adaptive coping during the pandemic.

Psychological Distress in Healthcare Workers between the First and Second COVID-19 Waves: The Role of Personality Traits, Attachment Style, and Metacognitive Functioning as Protective and Vulnerability Factors.

The COVID-19 pandemic has impacted the mental health of healthcare workers (HCWs) since its outbreak, but little attention has been paid to person-level vulnerability and protective factors. This study aims to determine the prevalence of both general and pandemic-related psychological distress among HCWs between the first and second COVID-19 waves in Italy and analyze associations between psychological distress and personality traits, attachment style, and metacognitive functioning. Between June and October 2020, 235 Italian HCWs completed questionnaires concerning psychological stress, personality traits, attachment style, and metacognitive functioning; 26.5% of respondents presented with moderate to extremely severe levels of general psychological distress and 13.8% with moderate to extremely severe levels of pandemic-related psychological distress. After controlling for demographic and occupational variables, significant associations emerged among high emotional stability as a personality trait and both general (aOR: 0.58, 95% CI: 0.41-0.79) and pandemic-related psychological stress (aOR: 0.62, 95% CI: 0.41-0.90). Additionally, higher scores regarding one's ability to understand others' emotional states were associated with lower odds of developing psychological distress (aOR: 0.78, 95% CI: 0.63-0.93). Lastly, when comparing those with fearful attachment styles to those with secure attachments, the aOR for psychological distress was 4.73 (95% CI: 1.45-17.04). These results highlight the importance of conducting baseline assessments of HCWs' person-level factors and providing regular screenings of psychological distress.

Aneurismal subarachnoid hemorrhage during the COVID-19 outbreak in a Hub and Spoke system: observational multicenter cohort study in Lombardy, Italy.

BACKGROUND: Lombardy was the most affected Italian region by the first phase of the COVID-19 pandemic and underwent urgent reorganization for the management of emergencies, including subarachnoid hemorrhage from a ruptured cerebral aneurysm (aSAH). The aim of the study was to define demographics, clinical, and therapeutic features of aSAH during the COVID-19 outbreak and compare these with a historical cohort. METHODS: In this observational multicenter cohort study, patients aged 18 years or older, who were diagnosed with aSAH at the participating centers in Lombardy from March 9 to May 10, 2020, were included (COVID-19 group). In order to minimize bias related to possible SAH seasonality, the control group was composed of patients diagnosed with aSAH from March 9 to May 10 of the three previous years, 2017-2018-2019 (pre-pandemic group). Twenty-three demographic, clinical, and therapeutic features were collected. Statistical analysis was performed. RESULTS: Seventy-two patients during the COVID-19 period and 179 in the control group were enrolled at 14 centers. Only 4 patients were positive for SARS-CoV-2. The "diagnostic delay" was significantly increased (+ 68%) in the COVID-19 group vs. pre-pandemic (1.06 vs. 0.63 days, respectively, p-value = 0.030), while "therapeutic delay" did not differ significantly between the two periods (0.89 vs. 0.74 days, p-value = 0.183). Patients with poor outcome (GOS at discharge from 1 to 3) were higher during the COVID-19 period (54.2%) compared to pre-pandemic (40.2%, p = 0.044). In logistic regression analysis, in which outcome was the dichotomized Glasgow Outcome Scale (GOS), five variables showed p-values < 0.05: age at admission, WFNS grade, treatment (none), days in ICU, and ischemia. CONCLUSIONS: We documented a significantly increased "diagnostic delay" for subarachnoid hemorrhages during the first COVID-19 outbreak in Lombardy. However, despite the dramatic situation that the healthcare system was experiencing, the Lombardy regional reorganization model, which allowed centralization of neurosurgical emergencies such as SAHs, avoided a "therapeutic delay" and led to results overall comparable to the control period.

Early prediction of in-hospital death of COVID-19 patients: a machine-learning model based on age, blood analyses, and chest x-ray score.

An early-warning model to predict in-hospital mortality on admission of COVID-19 patients at an emergency department (ED) was developed and validated using a machine-learning model. In total, 2782 patients were enrolled between March 2020 and December 2020, including 2106 patients (first wave) and 676 patients (second wave) in the COVID-19 outbreak in Italy. The first-wave patients were divided into two groups with 1474 patients used to train the model, and 632 to validate it. The 676 patients in the second wave were used to test the model. Age, 17 blood analytes, and Brescia chest X-ray score were the variables processed using a random forests classification algorithm to build and validate the model. Receiver operating characteristic (ROC) analysis was used to assess the model performances. A web-based death-risk calculator was implemented and integrated within the Laboratory Information System of the hospital. The final score was constructed by age (the most powerful predictor), blood analytes (the strongest predictors were lactate dehydrogenase, D-dimer, neutrophil/lymphocyte ratio, C-reactive protein, lymphocyte %, ferritin std, and monocyte %), and Brescia chest X-ray score (https://bdbiomed.shinyapps.io/covid19score/). The areas under the ROC curve obtained for the three groups (training, validating, and testing) were 0.98, 0.83, and 0.78, respectively. The model predicts in-hospital mortality on the basis of data that can be obtained in a short time, directly at the ED on admission. It functions as a web-based calculator, providing a risk score which is easy to interpret. It can be used in the triage process to support the decision on patient allocation.

Physical, cognitive and mental health outcomes in 1-year survivors of COVID-19-associated ARDS.

We report on the outcome of 114 COVID-19-associated acute respiratory distress syndrome (ARDS) survivors evaluated at 3, 6 and 12 months after intensive care unit discharge with assessment of physical, mental and cognitive impairments. Critical illness polyneuromyopathy was diagnosed in 23 patients (39%). Handgrip dynamometry was 70% predicted at 3 months and significantly improved over time, whereas the 6 min walk test (80% predicted) and severe fatigue (27% of patients) did not. Independence in activities of daily living (ADL) was achieved by 98% at 3 months. Cognitive impairment (28% at 3 months) improved over time, whereas depression, anxiety and post-traumatic stress disorder symptoms, present in 9%, 10% and 4% at 3 months, did not. Normalised health-related quality of life was good. COVID-19-associated ARDS leads to persisting impairment in performance-based measures of physical function, while ADL, cognitive and mental health status, and health-related quality of life may be less impaired. Trial registration number NCT04608994.

Estimating the Impact of the COVID-19 Pandemic on Maternal and Perinatal Health Care Services in Italy: Results of a Self-Administered Survey.

The coronavirus disease 2019 (COVID-19) pandemic is strongly changing the way most people live their lives, and disrupting specialist healthcare systems. Such public health disruptions have resulted in significant collateral damage with particular implications for vulnerable populations, including the perinatal population. This Study aims to estimate the impact of the COVID-19 pandemic on Italian maternal and perinatal health care services. A questionnaire was designed to evaluate the COVID-19 impact on Italian maternal and perinatal healthcare facilities and their activities and provision of services from March to May 2020. The survey was completed by hospital-based and community-based Italian maternal and perinatal healthcare facilities. Most of these were located in Lombardy or Veneto (the most affected Italian regions). 70% of all facilities reported that the first wave of the COVID-19 pandemic negatively influenced the functioning of one or more aspects of the perinatal service; only 28.4% of facilities all over the country continued to provide outpatient routine visits and examinations as usual; 23.4% of facilities became understaffed during the index period due to various reasons such as ward transfer and sick leave. This is the first Italian study, and among very few international studies that describe the effects of the COVID-19 pandemic on antenatal and postnatal healthcare facilities and their provision of activities and services. Our findings confirm that healthcare systems even in high-income countries were not entirely prepared to handle such a global health emergency; indeed, specialized maternal and perinatal healthcare services have been disrupted by this global health emergency.

Rapid Point-Of-Care Serology and Clinical History Assessment Increase Protection Provided by RT-PCR Screening: A Pilot Study Involving Three Nursing Homes in Brescia, a Hotspot of Lombardy.

Background: COVID-19 outbursts have been registered worldwide within care homes with asymptomatic transmission combined with shortage/inaccuracy of diagnostic tests undermining the efforts at containment of the disease. Nursing facilities in Lombardy (Italy) were left with no, or limited, access to testing for 8 weeks after the outbreak of COVID-19. Methods: This study includes 246 residents and 286 workers of three different nursing homes in Brescia-Lombardy. Clinical questionnaires and rapid serology tests were devised to integrate the data of the first available RT-PCR screening. Follow-up serology after 60-days was performed on 67 of 86 workers with positive serology or clinically suspicious. Findings: Thirty-seven residents and 18 workers had previous positive RT-PCR. Thorough screening disclosed two additional RT-PCR-positive workers. Serology screening revealed antibodies in 59 residents and 48 workers, including 32/37 residents and all workers previously positive at RT-PCR. Follow up serology disclosed antibodies in two additional workers with recent symptoms at the time of screening. The professionals in close contact with residents had more infections (47/226-20.79% vs. 1/60-1.66%; p = 0.00013 Fisher exact-test). A suspicious clinical score was present in 44/64 residents and in 41/50 workers who tested positive with either method with totally asymptomatic disease more frequent among residents 28.1 vs. 10.0% (p = 0.019 Fisher exact-test). Interpretation: Based on the available RT-PCR ± results at the time of symptoms/contacts, our integrated clinical and serological screening demonstrated sensitivity 89% and specificity 87%. This multimodal assessment proved extremely useful in understanding the viral spread in nursing homes, in defining its stage and in implementing protective measures. Rapid serology tests demonstrated efficient and particularly suited for older people less able to move/cooperate.

Mental Health States Experienced by Perinatal Healthcare Workers during COVID-19 Pandemic in Italy.

BACKGROUND: The ongoing COVID-19 pandemic has had an impact on mental health status in a variety of populations. METHODS: An online non-probability sample survey was used to assess psychological distress symptoms and burnout among perinatal healthcare professionals (PHPs) during the pandemic in Italy. The questionnaire included the Depression, Anxiety, and Stress Scale-21 (DASS-21) and the Maslach Burnout Inventory (MBI). Demographic and occupational factors associated with stress, anxiety, and depression symptoms were analyzed. RESULTS: The sample size was 195. The estimated self-reported rates of moderate to severe anxiety symptoms, depression symptoms, and perceived stress levels were 18.7, 18.7, and 21.5%, respectively. Furthermore, 6.2% of respondents reported burnout. One factor associated with all three self-reported psychological distress issues was suffering from trauma unrelated to the pandemic (aOR: 7.34, 95% CI: 2.73-20.28 for depression; aOR: 6.13, 95% CI: 2.28-16.73 for anxiety; aOR: 3.20, 95% CI: 1.14-8.88 for stress). Compared to physicians, psychologists had lower odds of developing clinically significant depressive symptoms (aOR: 0.21, 95% CI: 0.04-0.94) and high stress levels (aOR: 0.19, 95% CI: 0.04-0.80). CONCLUSIONS: High rates of self-reported symptoms of depression and anxiety, as well as perceived stress, among PHPs were reported during the COVID-19 pandemic. Health authorities should implement and integrate timely and regular evidence-based assessment of psychological distress targeting PHPs in their work plans.

Epidemiological and Clinical Characterization of Superinfections in Critically Ill Coronavirus Disease 2019 Patients.

To describe the epidemiology of superinfections (occurring > 48 hr after hospital admission) and their impact on the ICU and 28-day mortality in patients with coronavirus disease 2019 with acute respiratory distress syndrome, requiring mechanical ventilation. DESIGN: Retrospective analysis of prospectively collected observational data. SETTING: University-affiliated adult ICU. PATIENTS: Ninety-two coronavirus disease 2019 patients admitted to the ICU from February 21, 2020, to May 6, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prevalence of superinfection at ICU admission was 21.7%, and 53 patients (57.6%) had at least one superinfection during ICU stay, with a total of 75 (82%) ventilator-associated pneumonia and 57 (62%) systemic infections. The most common pathogens responsible for ventilator-associated pneumonia were Pseudomonas aeruginosa (n = 26, 34.7%) and Stenotrophomonas maltophilia (n = 14, 18.7%). Bloodstream infection occurred in 16 cases, including methicillin-resistant Staphylococcus epidermidis (n = 8, 14.0%), Enterococcus species (n = 6, 10.5%), and Streptococcus species (n = 2, 3.5%). Fungal infections occurred in 41 cases, including 36 probable (30 by Candida albicans, six by C. nonalbicans) and five proven invasive candidiasis (three C. albicans, two C. nonalbicans). Presence of bacterial infections (odds ratio, 10.53; 95% CI, 2.31-63.42; p = 0.005), age (odds ratio, 1.17; 95% CI, 1.07-1.31; p = 0.001), and the highest Sequential Organ Failure Assessment score (odds ratio, 1.27; 95% CI, 1.06-1.63; p = 0.032) were independently associated with ICU or 28-day mortality. CONCLUSIONS: Prevalence of superinfections in coronavirus disease 2019 patients requiring mechanical ventilation was high in this series, and bacterial superinfections were independently associated with ICU or 28-day mortality (whichever comes first).

COVID-19 incidence and mortality in Lombardy, Italy: An ecological study on the role of air pollution, meteorological factors, demographic and socioeconomic variables.

Lombardy, the most populated and industrialized Italian region, was the epicentre of the first wave (March and April 2020) of COVID-19 in Italy and it is among the most air polluted areas of Europe. We carried out an ecological study to assess the association between long-term exposure to particulate matter (PM) and nitrogen dioxide (NO2) on COVID-19 incidence and all-cause mortality after accounting for demographic, socioeconomic and meteorological variables. The study was based on publicly available data. Multivariable negative binomial mixed regression models were fitted, and results were reported in terms of incidence rate ratios (IRRs) and standardized mortality ratios (SMR). The effect of winter temperature and humidity was modelled through restricted cubic spline. Data from 1439 municipalities out of 1507 (95%) were included in the analyses, leading to a total of 61,377 COVID-19 cases and 40,401 deaths from all-causes collected from February 20th to April 16th and from March 1st to April 30th, 2020, respectively. Several demographic and socioeconomic variables resulted significantly associated with COVID-19 incidence and all-cause mortality in a multivariable fashion. An increase in average winter temperature was associated with a nonlinear decrease in COVID-19 incidence and all-cause mortality, while an opposite trend emerged for the absolute humidity. An increase of 10 µg/m3 in the mean annual concentrations of PM2.5 and PM10 over the previous years was associated with a 58% and 34% increase in COVID-19 incidence rate, respectively. Similarly, a 10 µg/m3 increase of annual mean PM2.5 concentration was associated with a 23% increase in all-cause mortality. An inverse association was found between NO2 levels and COVID-19 incidence and all-cause mortality. Our ecological study showed that exposure to PM was significantly associated with the COVID-19 incidence and excess mortality during the first wave of the outbreak in Lombardy, Italy.

Anxiety in neurosurgical patients undergoing nonurgent surgery during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic has forced many countries into lockdown and has led to the postponement of nonurgent neurosurgical procedures. Although stress has been investigated during this pandemic, there are no reports on anxiety in neurosurgical patients undergoing nonurgent surgical procedures. METHODS: Neurosurgical patients admitted to hospitals in eastern Lombardy for nonurgent surgery after the lockdown prospectively completed a pre- and postoperative structured questionnaire. Recorded data included demographics, pathology, time on surgical waiting list, anxiety related to COVID-19, primary pathology and surgery, safety perception during hospital admission before and after surgery, and surgical outcomes. Anxiety was measured with the State-Trait Anxiety Inventory. Descriptive statistics were computed on the different variables and data were stratified according to pathology (oncological vs nononcological). Three different models were used to investigate which variables had the greatest impact on anxiety, oncological patients, and safety perception, respectively. Because the variables (Xs) were of a different nature (qualitative and quantitative), mostly asymmetrical, and related to outcome (Y) by nonlinear relationships, a machine learning approach composed of three steps (1, random forest growing; 2, relative variable importance measure; and 3, partial dependence plots) was chosen. RESULTS: One hundred twenty-three patients from 10 different hospitals were included in the study. None of the patients developed COVID-19 after surgery. State and trait anxiety were reported by 30.3% and 18.9% of patients, respectively. Higher values of state anxiety were documented in oncological compared to nononcological patients (46.7% vs 25%; p = 0.055). Anxiety was strongly associated with worry about primary pathology, surgery, disease worsening, and with stress during waiting time, as expected. Worry about positivity to SARS-CoV-2, however, was the strongest factor associated with anxiety, even though none of the patients were infected. Neuro-oncological disease was associated with state anxiety and with worry about surgery and COVID-19. Increased bed distance and availability of hand sanitizer were associated with a feeling of safety. CONCLUSIONS: These data underline the importance of psychological support, especially for neuro-oncological patients, during a pandemic.

Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy.

Importance: There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery. Objective: To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties. Design, Setting, and Participants: This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score. Exposures: Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase-polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations. Main Outcomes and Measures: The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors. Results: Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-∞). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications. Conclusions and Relevance: In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.