Chilblain-like lesions (COVID-19 toes) have the same impact on family members than psoriasis systemically treated: insights from a case-control study targeting the pediatric population.

OBJECTIVE: COVID-19 toes represent the main dermatological COVID-19 cutaneous manifestation in pediatric patients. Its diagnosis exposes the whole family to social stigma and this aspect was not previously evaluated. PATIENTS AND METHODS: This was a multicenter, case-control, observational study that compared the family impact of COVID-19 toes vs. psoriasis (PsO). We enrolled 46 pediatric patients (23 with psoriasis and 23 with COVID-19 toes, age and gender matched) and their parents/caregivers that had to fill the Dermatitis Family Impact (DFI) questionnaire. RESULTS: DFI index did not differ significantly between both subgroups (p=0.48), and in psoriatic patients did not correlate with both Psoriasis Area Severity Index (PASI) (p=0.59) and itch-VAS (p=0.16). CONCLUSIONS: COVID-19 toes, a transitory dermatosis, exerted a similar impact/perturbation on family dynamics than PsO, a well-known stigmatizing, chronic inflammatory dermatosis.

Inhibitory potential of anticoagulant and antiplatelet agents on COVID-19- induced NETs release

Background: Neutrophil extracellular traps (NETs) release is the one of the main mechanisms behind hypercoagulability and disease severity in severe acute respiratory syndromes. The identification of drugs capable of inhibiting this pathological mechanism is mandatory. Aim(s): Neutrophil extracellular traps (NETs) release is the one of the main mechanisms behind hypercoagulability and disease severity in severe acute respiratory syndromes. The identification of drugs capable of inhibiting this pathological mechanism is mandatory. Method(s): Healthy neutrophils (20 x 103/well) were stimulated with phorbol myristate acetate (PMA) or sera from severe COVID-19 patients (n = 16) in the presence or absence of dipyridamole (10 muM), aspirin (1 mM) and heparin (50 mug/mL). Neutrophils nuclei were stained with nuclear red and incubated with a medium containing the non-permeable cell membrane marker Sytox Green. Cell images were obtained using IncuCyte ZOOM and the number of cells that suffered netosis was monitored over time. NETs release was determined after 1 h of incubation and the percentage of NETs was calculated dividing the number of green cells by the total number of cells per well. Result(s): COVID-19 induced NETs was lower in neutrophils pretreated with heparin (median 2.6%, IQR 2.6-2.9) than in non-treated neutrophils (median 3.6%, IQR 3.2-4.0, p < 0.0001). Pretreatment with dipyridamole and aspirin did not change the effect of COVID-19 sera in inducing NETs. A similar pattern of inhibition was observed with PMA stimulation, in which heparin decreased NETs by 3 times (NETs after PMA 43.2% and NETs after PMA and heparin 14.8%) while dipyridamole and aspirin did not significantly affect the release of PMA-induced NETs (Figure 1). Figure 2 illustrates the identification of NETs. Conclusion(s): Heparin was capable of inhibiting in vitro NETs release induced by COVID-19, while dipyridamole and aspirin had no significant effect on this process. Such findings are in line with evidence that heparin use can improve COVID-19 prognosis. (Figure Presented).

Flu shot in the era of COVID-19 vaccination: findings from a research hospital of Rome : Domenico Pascucci

Influenza represents a major burden for public health. Healthcare workers (HCWs) are a priority target group for flu vaccination. During the COVID-19 pandemic, when SARS-CoV-2 vaccines were not yet available, susceptibility to influenza vaccination especially by HCWs increased. The aim of this study is to analyze the flu vaccination coverage among HCWs and to study which factors affected their adherence given the concomitant COVID-19 vaccination. The retrospective study was conducted in an Italian research hospital from October 2021 to January 2022. A total of 7,048 individuals was included. Age class, gender and job category variables were analyzed. Statistically significant differences among groups were tested through χ2 test. Univariate and multivariate analyses (p < 0,005) were performed to assess differences towards vaccination attitude. The flu vaccination coverage rate was 24.6%. Among the selected job categories, 29.8% of physicians, 19.9% of nurses and 19.7% of other HCWs were vaccinated with a statistically significant decrease (p < 0.001) across all categories respect with the last campaign. The findings of the logistic regression depicted that the 40-59 years old age class, compared with the youngest age class (OR 1.30, 95% CI 1.12-1.43) as well as being physician (OR 2.79, 95% CI 1.87-3.41) with the respect to being nurses, had a higher adherence to vaccination. Interestingly, being male, is associated with a statistically significant reduction (OR 0.71, 95% CI 0.59-0.87) in vaccination uptake. Study findings showed a several decline in the flu vaccination coverage comparing with previous campaigns, probably due to the concomitant administration of the booster dose against SARS-CoV-2. This alarm should not be underestimated and requires timely and innovative organizational approaches (i.e., combined vaccine). Further studies are needed to analyze the reasons for this poor adhesion and the strategies to be adopted to increase the awareness of the HCWs. Key messages • Reaching high coverage rates and restore a positive trend for the future campaign for flu vaccination it is essential strategy to protect HCWs themselves, their patients and the hospital community. • Decision-makers should implement consistent communication strategies to lessen vaccine hesitancy among HCWs.

Ukrainian refugee crisis: the experience of the Roman Local Health Authority “ASL Roma 1” : Andriy Melnyk

Problem On February 24th, 2022, Ukraine was invaded by Russian forces, forcing many Ukrainians to flee from their homes as refugees. More than 55,000 Ukrainians have since arrived on Italian territory. In response to the humanitarian crisis, the Roman Local Health Authority “ASL Roma 1” provided socio-sanitary assistance through first reception centers to more than 7700 refugees, prioritizing people with high social vulnerability. Ukraine’s vaccine hesitancy and different epidemiological landscape represented a major hurdle to be overcome. Practice ASL Roma 1’s practice served to ensure infectious diseases prevention and control, as well as continuity of care for non-communicable diseases and mental health issues. It consisted of repurposing resources, such as COVID-19 Hubs and their personnel, stipulating Public-Private Partnerships and collaborations with the local Ukrainian community, massive training, creating a centralized multidisciplinary team (with Ukrainian members) and a dedicated database/IT system. Results ASL Roma 1 empowered local Ukrainian communities by providing equipment, medical and administrative staff and socio-sanitary assistance. Ukrainian volunteers helped bridge the cultural gap for essential service provision, such as COVID-19 screening, enrolment in the NHS, health and social orientation, vaccinations and a tailored care pathway. Thus, more than 7700 refugees were assisted, with 1830 COVID-19 vaccinations administered and 170 in critical conditions promptly receiving specialized care. Lessons The multidisciplinary and cross-cultural interaction between doctors, nurses, cultural mediators, social workers, and other key actors was essential in ensuring a holistic care pathway. Services catered to Ukrainian refugees need complete integration between primary and centralized care. Flexibility and resilience are fundamental to foster an ecosystem of innovation and optimization of healthcare provision on all levels, from local to supranational. Key messages • The multidisciplinary and cross-cultural interaction between all medical and non-medical key actors is essential in ensuring a holistic care pathway and complete social integration of asylum seekers. • Health system flexibility, resilience and an ecosystem of innovation and optimization of healthcare provision on all levels are fundamental components of preparedness for future refugee crises.

Introducing Community Houses in Italy: a scoping review of the international literature : Ambrogio Cerri

Background The SARS-CoV-2 pandemic put under pressure all the world's health systems, to the point that it was a severe threat to their stability. At the same time, this scenario confirmed the importance of primary health care to guarantee effective care for patients who suffer from complex and chronic diseases. From these considerations and in the light of the funding provided by the European Union for enhancing the health care system in Italy, our working group has decided to analyse various organisational models of Primary Health Care founded around the world to set up innovative Primary care community Centers in Italy, called Community Houses. Methods A scoping review of the international literature was conducted on Pubmed, searching for primary care models based on integration and co-location of services. Each organisational model was then evaluated using different levels of multidimensional integration inspired by the taxonomy work of P. P. Valentijn, such as clinical, professional, organisational, system, functional and normative integration levels. Results The search produced 2053 results, initially screened by title and and, subsequently, by full-text, finally obtaining 116 articles. When a model is characterised by integrating services with external stakeholders, it also presents more integration levels than the others. In particular, these models are, on average, about 20% more likely to have an organisational, functional and normative integration in the model. Moreover, by stratifying for population complexity, we can find an increase in integration levels for populations suffering from chronic diseases with a higher degree of complexity, such as diabetes or cancer. Conclusions From these preliminary results, we can conclude that it is necessary to prefer primary care models with more integration levels to deliver better healthcare for people with complex or chronic diseases, improving the performance of the Health Care System, especially in Italy. Key messages Our work has allowed us to advise the policymakers on a correct reorganisation of the National Health System in Italy employing the European Union funds. The results of this study will be used to organised Primary care community Centers in Italy, called Community Houses, which aim to facilitate the integration and co-location of services.

Incremental net benefit of wearable devices for home monitoring of chronically ill patients : Gerardo Altamura

Background Hospital overcrowding is a growing problem worldwide. Studies demonstrated that up to 40% to 67% of hospitalizations of residents in nursing homes may be avoidable, causing health and economic damages. Furthermore, research shows that for non-critical patients there are arguably no differences between home and hospital recovery in terms of health outcomes, with a preference for home settings in most patients. During COVID-19 pandemic, telemedicine and homecare increased its range of possible intervention, allowing efficient and cost-effective processes of care. Transdermal sensors are indeed a cheap and easy to use alternative to conventional instruments, allowing a continuously operative and ready-to-use tool to care providers. This systematic review aims to map the application fields of these technologies, demonstrating their accuracy and assessing their cost-effectiveness in chronically ill home-assisted patients. Methods Articles were retrieved from Scopus, Web of Science, and PubMed. The dominance ranking matrix (DRM) tool was applied to allow a qualitative synthesis of the studies. Incremental net benefits (INBs) were estimated and meta-analysis was implemented to pool INBs across studies. A comparison between wearables and conventional tools accuracy was simultaneously carried out through a literature review. Results The database search identified 1156 publications of which six articles were considered eligible for the meta-analysis. According to DRM, 80% of evaluated studies showed the cost-effectiveness of wearable devices. The pooled INB of wearables over conventional measurement was estimated at US$1280 (95% CI US$952 - US$2849). In 85% of evaluated wearables the accuracy resulted comparable to conventional measurement tools. Conclusions Wearables performances resulted as accurate as conventional methods and their application cost-effective. A continuous measurement of parameters may relate to a better process of care for chronically ill outpatients. Key messages • Wearables are a cheap and accurate alternative to conventional life parameters measurement tools. • Technology evolution might soon reduce the pressure on hospitals, changing the care process of chronically ill outpatients allowing continuous evaluation of their health status.

Hospital networks in Italy: state of the art and future pespectives. Insights from a qualitative research study.

Background Hospitals have undergone important that changes that have led, in recent decades at the international level, to the need for greater integration between hospitals and local healthcare services. The main institutional networks that have been developed in Italy are, as commended by the institutional levels, of 4 main types: the Emergency-Urgency Network, the Time-Dependent Networks, the Oncological Networks, and the Networks with primary care settings. It was important to assess the state of the art and analyze it in relation to possible future developments. Objective The aim of the study was to collect insights from both evidence-based knowledge and personal experience gained by experts in the field regarding the current condition and possible future developments of hospital networks. Material and methods A qualitative research methodology was chosen. Four mini-focus group meetings were organized among participants with proven expertise on the subject. Discussions were guided by four open-ended questions corresponding to the four areas of interest. Directed content analysis was chosen as the methodology for data analysis and final reporting of results. Results Four main categories were explored: "hospital networks and complexity", "hospital networks complexity and the need for integration", "levers for hospital networks governance" and "the COVID-19 challenge and future developments for hospital networks". In particular, the participants found that it is important to understand healthcare systems as complex systems and, therefore, to study the properties of complex systems. In this way it is possible to achieve value-based healthcare in complex contexts. It is also necessary to keep in mind that complexity represents a challenge for coordination/ integration in hospital networks. Mintzberg identified specific mechanisms to achieve it. Of them, mutual adaptation is the key to self-organization. Valentijn showed the organizational levels on which coordination/integration has to be obtained. Hospital network governance should include both hierarchy and self-determination logic to achieve integration in each of the four levels. The participants identified three key levers for governing complex organizations: "education", which consists of multi-professional and multi-level training in governance in complex systems; "information" consisting in considering the data registering as an integral part of the clinical care process to informative value; "leadership", which consists in convincing actors, directed towards personal gains, to achieve valuable goals. Finally, the challenge that COVID-19 served as an incentive for future developments of hospital networks. Discussion Various common points between the definitions of network and complex systems can be found. It is important to study the properties of complex systems in order to achieve value-based healthcare in the hospital networks context. The insights gained should be useful for all professionals from and across all levels of healthcare organizational responsibility, being able to orient roles and actions to achieve coordination/integration inside hospital networks. Conclusions Complexity literature can help understand how to achieve coordination/integration in healthcare settings and find levers for effective governance. It is important to study the current situation to anticipate and, possibly govern, future developments. In conclusion, governance of hospital networks should be interpreted as coordination/integration inside and across multiple organizational levels of co-responsibility.

Management of atypical Hemolytic-Uremic Syndrome in gravida with SARS-COVID-2 infection

Background. Coronavirus disease is a highly contagious infection that can be deadly and is caused by the severe acute respiratory syndrome SARS-CoV-2.The current literature indicates that pregnancy may worsen the course of COVID-19 infection compared to non pregnant women at the same age. Atypical hemolytic uremic syndrome (aHUS) is a complement-mediated disorder, characterized by microangiopathic hemolysis, thrombocytopenia, and renal failure. Case presentation. A case of a gravida at 20 weeks of gestation with worsening clinical conditions due to aHUS, and SARS-COV-2 infection was managed. Continuous renal replacement therapies with transfusion of plasma was started. Diagnosis comprised atypical HELLP presentation with progressive reduction of PLT levels versus other thrombotic microangiopathy. Conclusions. The lack of anti-ADAMTS 13 antibodies allowed to make the diagnosis of Hemolytic-Uremic Syndrome (HUS). The patient started therapy with Eculizumab 900 mg that was administered one time every 7 days. The patient resumed spontaneous urination after one day of therapy. Renal failure persisted after 5 days with creatinine levels at 7.9 mg/dL and azotemia at 126 mg/dL. It is challenging to predict the impact of immune-mediated therapies on pregnant women. Furthermore, additional data about the immunomodulatory changes in COVID-19 patients during pregnancy may reveal pathophysiological events behind this deadly disease.

TIME COURSE OF THE DEVELOPMENT OF IMMUNOTHROMBOSIS DURING COVID-19 HOSPITALIZATION

Introduction: Hypercoagulability in COVID-19 has been attributed to immunothrombosis, a process that involves the formation of neutrophils extracellular traps (NETs). The moment of the COVID-19 evolution in which immunothrombosis mechanisms are triggered is not established. Aim: To describe the kinetics of NETs release during COVID-19 hospitalization associating with thrombosis and death. Methods: We quantified citrullinated H3 and inflammatory cytokines (TNF-α, IL-6), markers of NETs release, on 4 time points during COVID-19 hospitalization (admission, day 4, day 8 and last day) between May and July 2020. The association between changes in these markers levels and clinical outcomes was determined. Results: 101 patients were included, the median days in-hospital were 15, 62% were men, 27% were obese, 43% were diabetic, 54% were hypertensive, 59% were critically ill, 11% had a thrombotic event and 21% died. IL-6 levels were high on admission in survivors (median 25.32, IQR 24.19-28.15) and non-survivors (median 24.19, IQR 12.51-27.19), but gradually decreased on day 4 (median 12.07, IQR 6.32-17.81), day 8 (median 9.34, IQR 5.18-17.59) and last day (median 8.64, IQR 4.81-14.89) in survivors. TNF-α levels remained 2 times higher in non-survivors: admission (median 1.60, IQR 0.64-2.26), day 4 (median 1.78, IQR 1.02-2.60), day 8 (median 1.65, IQR 0.93-2.5), last day (median 2.41, IQR 1.31-4.06);than in survivors: admission (median 0.81, IQR 0.52-1.26), day 4 (median 0.84, IQR 0.44-1.16), day 8 (median 0.72, IQR 0.44-1.24), last day (median 0.69, IQR 0.4-1.14). CitH3 levels were similar between non-survivors at the beginning of hospitalization: admission (median 1.03, IQR 0.43-4.34), day 4 (median 1.1, IQR 0.65-3.45);as for survivors: admission (median 1.20, IQR 0.45-2.60), day 4 (median 1.27, IQR 0.64-3.29). On day 8, citH3 increased by 3-fold (median 3.80, IQR 1.98-10.15) in non-survivors and 2-fold (median 2.60, IQR 1.22-5.01) in survivors. While IL-6 and TNF-α levels were similar between patients with and without thrombosis, citH3 levels increased shortly on day 4, before the occurrence of a thrombotic event: admission (median 1.64, IQR 0.44-4.14), day 4 (median 3.21, IQR 2.57-9.31);but it didn't change on non-thrombotic event patients: admission (median 1.05, IQR 0.44-2.50), day 4 (median 1.06, IQR 0.58-2.95). Conclusion: Markers of inflammation and immunothrombosis were associated with poor outcomes in COVID-19;however, these disorders were detected in different moments during COVID-19 course. While an increased inflammatory response was observed since the beginning of hospitalization, markers of immunothrombosis arose latter during the course of the disease. Acknowledgment of the time-course of immunothrombosis development in COVID-19 is important for planning therapeutic strategies against this pathological process.

NEUTROPHIL EXTRACELLULAR TRAPS E COVID-19

Introdução: A participação de NETs (neutrophil extracellular traps- NETs- redes extracelulares de neutrófilos) na fisiopatogenia da COVID19 já foi descrita, especialmente nos casos graves de infecção por SARSCoV2, em que se destacam a inflamação sistêmica e imunotrombose culminando com injúria tecidual e insuficiência respiratória. Sabe-se que o estado protrombótico já nas fases iniciais da COVID19 deve-se em parte à formação de NETs em resposta à inflamação sistêmica desencadeada pela infecção viral Avaliamos 55 casos de pacientes com diagnóstico de pneumonia grave por COVID19 e mensuramos marcadores de NETose à admissão hospitalar e alta, a fim de identificar associações entre NETs e melhora clínica. Materiais e métodos: Avaliamos marcadores de NETs (H3 citrulinado por ELISA (clone 11D3, ELISA, Cayman e DNA livre pela técnica de PicoGreen (dsDNAAssay Kit (ThermoFisherScientific, EUA) no D0 (admissão no protocolo),D5 e alta em 55 pacientes com diagnóstico de pneumonia grave por SARSCoV2 (de acordo com os critérios da Organização Mundial de Saúde, definida por saturação em ar ambiente < ou igual a 93%, e/ou frequência respiratória igual ou superior a 30), admitidos à Unidade de Terapia Intensiva (UTI) em um hospital terciário em São Paulo, SP. O acompanhamento desses pacientes foi feito desde a admissão até a alta, a fim de correlacionar NETs no D0 (dia de inclusão no protocolo) e melhora clínica (definida por redução de 2 ou mais pontos na escala ordinal de gravidade da Organização Mundial de Saúde) desde a admissão até o D14 de internação hospitalar. Para as análises simples, foram realizados testes de MannWhitney e t de student e para as análises múltiplas, foram realizadas regressões logísticas. Resultados: Observamos que os níveis de H3 citrulinado sofrem uma ascensão do D0 para o D5, com posterior queda no momento alta, de maneira estatisticamente significativa (p = 0,025);evidenciando que a formação de NETs e sua queda acompanham o curso clínico da COVID19. Nas análises univariadas, observou-se associação significativa entre níveis de H3 citrulinado no D0 e melhora clínica (p=0.03), sendo que pacientes com melhora clínica têm níveis mais baixos de H3 citrulinado do que pacientes sem melhora clínica. Outras variáveis preditoras de melhora clínica nesta análise foram idade (p = 0.014) e escore SOFA (Sequential Organ Failure Assessment) no D0 (p < 0.001). Entretanto, nas análises múltiplas, apenas o score de SOFA (OR = 0,2, IC95%:0,05-0,84, p = 0.028) manteve esta associação. Discussão e conclusão: A associação entre NETs e fisiopatologia da COVID19 já foi descrita em alguns cenários, bem como correlacionados os marcadores de NETose à gravidade da doença. Os achados do presente estudo sugerem que a formação de NETs acompanha o curso clínico da COVID19. A intensidade da NETose no início da doença parece ser um parâmetro preditor de melhora clínica, porém, são necessários mais estudos para afirmar esta hipótese.

DIAGNÓSTICO DA COVID-19 E SEU IMPACTO SOBRE O RISCO TROMBÓTICO EM UMA COORTE DE PACIENTES SIMULTANEAMENTE HOSPITALIZADOS POR SÍNDROME RESPIRATÓRIA AGUDA GRAVE

Objetivos: Evidências prévias sugerem que o risco trombótico é maior na COVID-19 do que em outros tipos de síndrome respiratória aguda grave (SRAG). Contudo, tal comparação se baseou principalmente em coortes históricas. O objetivo deste estudo foi avaliar a incidência de eventos tromboembólicos em pacientes com COVID-19 e outras SRAG internados em um mesmo período de tempo. Material e métodos: Foram selecionados pacientes internados entre março e junho de 2020 no Hospital de Clínicas - UNICAMP que atendiam aos critérios clínicos de SRAG segundo o Ministério da Saúde e a Definição de Berlim, e que apresentavam ao menos 2 resultados de RT-PCR ou ELISA confirmando ou excluindo o diagnóstico de COVID-19. Dos 253 indivíduos internados por SRAG nesse período, foram incluídos 101 pacientes COVID-19 e 102 pacientes não-COVID-19. Os demais foram excluídos por prontuário médico incompleto (n = 16) ou falta de exame laboratorial para COVID-19 (n = 34). Análise descritiva, testes de qui-quadrado, testes-t e regressão logística binária foram usados para comparar os pacientes COVID-19 e não COVID-19. Resultados: Pertenciam ao sexo masculino 62% e 48% dos pacientes COVID-19 e não-COVID-19, respectivamente (P = 0.07). A mediana de idade, em anos, foi 55.77 (IQR 42.31 a 66.68) no grupo COVID-19 e 59.04 (IQR 45.13 a 69.73, P = 0.39) no grupo não-COVID-19. Ambos os grupos apresentaram um escore de Pádua (COVID-19: 3 IQR 2 a 4;não-COVID-19: 3 IQR 2 a 5, P = 0.47) e uma saturação de oxigênio (COVID-19: 92% IQR 90% a 96%;não-COVID-19: 94% IQR 91% a 97%, P = 0.44) semelhantes à admissão. Contudo, a necessidade de suporte de oxigenação invasiva (37.6% vs. 14.7%, P = 0.0002), de drogas vasoativas (44.6% vs. 21.6%, P=0.0006) e de internação em UTI (55.4% vs. 40.2%, P = 0.04) foi maior entre aqueles infectados por SARS-CoV-2. Em conformidade, esses mesmos pacientes permaneceram internados por mais tempo (15 dias IQR 6 a 30.5 vs. 7 dias IQR 3 a 16.3, P < 0.0001) e vieram a óbito com mais frequência (27.7% vs. 14.7%, P = 0.03). Em relação a marcadores de coagulação, não houve diferença estatisticamente relevante entre os grupos quanto a tempo de protrombina, fibrinogênio e D-dímero (COVID-19: 1488 ng/mL IQR 726.5 a 3476;não COVID-19: 1773 ng/mL IQR 807.5 a 4153.8, P = 0.57). Apesar do uso de tromboprofilaxia ter sido mais comum entre pacientes COVID-19 (76.2% vs. 41.2%, P < 0.0001), a incidência de eventos tromboembólicos confirmados por exame de imagem se mostrou similar entre os grupos, mesmo após ajuste para múltiplos fatores (idade, sexo, tromboprofilaxia, hipertensão arterial, diabetes mellitus, escore de Pádua, internação em UTI, tempo de internação total): houve 7 eventos em 7 pacientes não COVID-19 e 13 eventos em 9 pacientes COVID-19 (OR ajustado 0.91, 95% IC 0.28-2.95, P = 0.87). Os eventos mais recorrentes no grupo COVID-19 foram embolismo pulmonar (53.8%) e trombose venosa profunda (23.1%), que representaram 57.1% (P = 0.37) e 14.3% (P = 0.37) dos eventos não-COVID-19, respectivamente. Discussão: Ao analisar pacientes internados em um mesmo período de tempo, constatamos que, embora elevado, o risco tromboembólico na COVID-19 é semelhante ao de outros tipos de SRAG, indicando que um estado de hipercoagulabilidade é inerente à SRAG em geral. Além disso, os resultados obtidos revelam que o uso de tromboprofilaxia foi significativamente maior no grupo COVID-19, e que não houve diferença estatisticamente relevante entre os níveis de D-dímero dos pacientes COVID-19 e não COVID-19. Conclusão: Tais achados fornecem uma melhor compreensão sobre o risco tromboembólico associado à infecção por SARS-CoV-2, e sugerem que evidências prévias de taxas de trombose mais elevadas na COVID-19 sofreram viés pelo uso de coortes históricas.

COVID-19 Diagnosis and Its Impact on Thrombotic Risk in a Cohort of Patients Simultaneously Hospitalized Due to Acute Respiratory Distress Syndrome

Previous evidence suggests that the thromboembolic risk is greater among patients with COVID-19 than among those affected by other types of acute respiratory distress syndrome (ARDS). However, such comparison has been primarily based on historical cohorts. In order to reduce the possible influence of such selection bias, the main goal of this study was to evaluate thromboembolic events in patients with COVID-19 and other ARDS hospitalized in the same time period. For this reason, we have selected patients admitted from March to June, 2020 at the UNICAMP Clinical Hospital who met the ARDS clinical criteria established by the Brazilian Ministry of Health and the Berlin Definition by presenting two or more flu-like symptoms and at least one ARDS-specific manifestation (dyspnea, persistent chest pressure, oxygen saturation lower than 95% at hospital admission, or lip/face cyanosis). Symptom onset or worsening occurred 30 days before hospital admission at the latest, and COVID-19 diagnosis was confirmed or excluded by at least 2 real time polymerase chain reactions or enzyme-linked immunosorbent assays. Descriptive analysis, chi-square and t-tests, as well as binary logistic regression, were used to compare COVID-19 and non-COVID-19 patients. Of the 253 patients hospitalized due to ARDS during this period, 101 COVID-19 and 102 non-COVID-19 patients were included in this study. The remaining patients were excluded due to incomplete medical records (n=16) or absence of COVID-19 testing results (n=34). Table 1 demonstrates the included patients' demographic and clinical baseline features. Both COVID-19 and non-COVID-19 groups showed similar baseline risk of hospital-associated thrombosis (assessed by reduced mobility within the past 3 days or more, previous thromboembolism event, recognized “thrombophilia”, and infarction, stroke, trauma or surgery within the past 4 weeks) and oxygen saturation at admission (COVID-19: 92% IQR 90% to 96%;non-COVID-19: 94% IQR 91% to 97%, P=0.44). However, the need for invasive oxygenation support (37.6% vs. 14.7%, P=0.0002) and vasoactive drugs (44.6% vs. 21.6%, P=0.0006) was greater in COVID-19 than in non-COVID-19 patients. Accordingly, those infected by SARS-CoV-2 were more frequently admitted in ICU (55.4% vs. 40.2%, P=0.04) and for a longer period of time (13 days IQR 6 to 22 vs. 3 days IQR 2 to 8.3, P=0.02) than those affected by other types of ARDS. In comparison to the non-COVID-19 group, the COVID-19 group's median total hospital stay was more lasting (15 days IQR 6 to 30.5 vs. 7 days IQR 3 to 16.3, P<0.0001), and its death rate, higher (27.7% vs. 14.7%, P=0.03), as shown in Table 2. With respect to coagulation markers (Table 3), activated partial thromboplastin time and C-reactive protein levels were greater in COVID-19 than in non-COVID-19 patients, while the latter presented higher median platelet counts. There was no statistically significant difference between both study groups in regards to prothrombin time, fibrinogen, and D-dimer levels (COVID-19: 1488 ng/mL IQR 726.5 to 3476;non-COVID-19: 1773 ng/mL IQR 807.5 to 4153.8, P=0.57). Although thromboprophylaxis was more commonly administered to COVID-19 (76.2%) than non-COVID-19 patients (41.2%, P<0.0001), the incidence of thromboembolic events confirmed by imaging examination was similar between groups even after adjusting for multiple factors (age, sex, thromboprophylaxis use, arterial hypertension, and cancer): there were 7 confirmed events in 7 non-COVID-19 patients, and 13 confirmed events in 9 COVID-19 patients (adjusted OR 0.74, 95% CI 0.24-2.25, P=0.59). Table 4 demonstrates the characteristics of such thrombotic manifestations. By analyzing patients hospitalized in the same time period, we have found that although high, the thromboembolic risk in COVID-19 is similar to that in other types of ARDS, indicating that a hypercoagulable state is inherent to ARDS in general. Additionally, the obtained results show that the use of thromboprophylaxis was significantly higher among COVID-19 patients, and that there was no tatistically relevant difference between COVID-19 and non-COVID-19 patients' D-dimer levels, a commonly used coagulation marker. Such findings provide a better understanding of the thromboembolic risk associated with SARS-CoV-2 infection, and suggest that previous evidence of higher thrombosis rates in COVID-19 suffered bias from the use of historical cohorts. [Formula presented] Disclosures: No relevant conflicts of interest to declare.

From infections to preventive actions monitoring in health facilities: an experience on MDROs

Healthcare-Associated Infections (HAIs) and Antimicrobial Resistance (AMR) involve high costs both in health and economic terms for patients and health systems. Implementing Infection Prevention and Control (IPC) programs is critical to decrease infectious agents' transmission in healthcare settings. The aim of this study is to assess if the monitoring of Contact Precautions could decrease the incidence of Multi-Drug Resistant Organisms (MRDOs) infections. This pilot study was conducted in a teaching hospital in Rome. A checklist of 16 items was developed to assess the compliance to Contact Precautions in 11 hospital wards in which MRDOs were detected between November and December 2020. It was administered on-site both interviewing healthcare professionals and through direct observation. A paired t-test with α = 5% was used to compare the number of alert organisms in the first quarter of 2020 respect to the first quarter of 2021 before and after implementing the surveillance checklist. A total of 30 checklists were analyzed. The rate of compliance to Contact Precautions was high for the proper use of personal protective equipment (100%), the intensified room cleaning (100%) and the presence of isolation mark (100%), while it was low for the active screening of contacts (53%). Mean MDROs infections rate decreased from 4.94 to 4.37 for every 1000 hospitalization day, with an average decrease of 0.57. However, the paired t-test showed that there was no statistically significant difference between the mean number of MDROs infections before and after the implementation of the checklist (p > 0.05). Despite the good adherence to IPC program, the low infection rate decrease, is probably due to the impact of COVID-19 on the HAIs surveillance and prevention practices. Even if the check-list administration could be a useful tool to reduce MDROs infections, it should be associated to other prevention strategies during the COVID-19 pandemic in order to achieve a successful outcome. Key messages Preventing Healthcare-Associated Infections represents a priority public health challenge in order to improve patient safety and health system economic sustainability. The COVID-19 pandemic has shown that healthcare facilities should enhance efforts in their IPC programs to reduce Healthcare-Associated Infections.