The Challenge of Mass Casualty Incident Response Simulation Exercise Design and Creation: A Modified Delphi Study.

BACKGROUND: A Mass Casualty Incident response (MCI) full scale exercise (FSEx) assures MCI first responder (FR) competencies. Simulation and serious gaming platforms (Simulation) have been considered to achieve and maintain FR competencies. The translational science (TS) T0 question was asked: how can FRs achieve similar MCI competencies as a FSEx through the use of MCI simulation exercises? METHODS: T1 stage (Scoping Review): PRISMA-ScR was conducted to develop statements for the T2 stage modified Delphi (mD) study. 1320 reference titles and abstracts were reviewed with 215 full articles progressing for full review leading to 97 undergoing data extraction.T2 stage (mD study): Selected experts were presented with 27 statements derived from T1 data with instruction to rank each statement on a 7-point linear numeric scale, where 1 = disagree and 7 = agree. Consensus amongst experts was defined as a standard deviation ≤ 1.0. RESULTS: After 3 mD rounds, 19 statements attained consensus and 8 did not attain consensus. CONCLUSIONS: MCI simulation exercises can be developed to achieve similar competencies as FSEx by incorporating the 19 statements that attained consensus through the TS stages of a scoping review (T1) and mD study (T2), and continuing to T3 implementation, and then T4 evaluation stages.

Effect of Lactoferrin on Clinical Outcomes of Hospitalized Patients with COVID-19: The LAC Randomized Clinical Trial

As lactoferrin is a nutritional supplement with proven antiviral and immunomodulatory abilities, it may be used to improve the clinical course of COVID-19. The clinical efficacy and safety of bovine lactoferrin were evaluated in the LAC randomized double-blind placebo-controlled trial. A total of 218 hospitalized adult patients with moderate-to-severe COVID-19 were randomized to receive 800 mg/die oral bovine lactoferrin (n = 113) or placebo (n = 105), both given in combination with standard COVID-19 therapy. No differences in lactoferrin vs. placebo were observed in the primary outcomes: the proportion of death or intensive care unit admission (risk ratio of 1.06 (95% CI 0.63–1.79)) or proportion of discharge or National Early Warning Score 2 (NEWS2) ≤ 2 within 14 days from enrollment (RR of 0.85 (95% CI 0.70–1.04)). Lactoferrin showed an excellent safety and tolerability profile. Even though bovine lactoferrin is safe and tolerable, our results do not support its use in hospitalized patients with moderate-to-severe COVID-19.

Relationship between intensive care surge capacity and hospital factors: an extensive experience.

As a prolonged surge scenario, the COVID-19 pandemic has offered an unparalleled opportunity to improve hospital surge capacity (SC) understanding and the ability to manage it. In this study, the authors report the experience of a large hospital network and evaluate potential relationships between Intensive Care Units SC (ICU-SC) and some hospital-related variables: bed occupancy, emergency department admissions, ward admission from ED, and elective surgery procedures. Pearson's partial correlation coefficient (r) has been used to define the relationship between SC and the daily values of the above variables, collected through a dedicated digital platform that also ensured a regular quality check of the data. The observation has concerned several levels of analysis, namely two different types of SC calculation (SC base-SCb and SC actual-SCa), hospital category level and multi-hospital level, and two consecutive pandemic waves. Among the 16 hospitals observed, the correlation was shown to be moderate-positive with non-ICU bed occupancy (r/ = 0.62, r/ = 0.54), strong/moderate with ICU bed occupancy (r/ = 0.72, r/ = 0.54), and moderate with ward admissions from ED (r/ = 0.50, r/ = 0.51) On the contrary, the correlation proved to be moderate-negative with ED admissions (r/ = - 0.69, r/ = - 0.62) and low with the number of elective surgery procedures (r/ = - 0.10, r/ = - 0.16). This study identified a positive correlation between SC and three variables monitored: ICU bed occupancy, non-ICU bed occupancy, and ward admissions from ED. On the contrary, the correlation was negative for ED admission and the number of elective surgery procedures. The results have been confirmed across all levels of analysis adopted.

Effect of Lactoferrin on Clinical Outcomes of Hospitalized Patients with COVID-19: The LAC Randomized Clinical Trial.

As lactoferrin is a nutritional supplement with proven antiviral and immunomodulatory abilities, it may be used to improve the clinical course of COVID-19. The clinical efficacy and safety of bovine lactoferrin were evaluated in the LAC randomized double-blind placebo-controlled trial. A total of 218 hospitalized adult patients with moderate-to-severe COVID-19 were randomized to receive 800 mg/die oral bovine lactoferrin (n = 113) or placebo (n = 105), both given in combination with standard COVID-19 therapy. No differences in lactoferrin vs. placebo were observed in the primary outcomes: the proportion of death or intensive care unit admission (risk ratio of 1.06 (95% CI 0.63-1.79)) or proportion of discharge or National Early Warning Score 2 (NEWS2) ≤ 2 within 14 days from enrollment (RR of 0.85 (95% CI 0.70-1.04)). Lactoferrin showed an excellent safety and tolerability profile. Even though bovine lactoferrin is safe and tolerable, our results do not support its use in hospitalized patients with moderate-to-severe COVID-19.

Health Emergency and Disaster Risk Management Workforce Development Strategies: Delphi Consensus Study.

INTRODUCTION: Health workforce development is essential for achieving the goals of an effective health system, as well as establishing national Health Emergency and Disaster Risk Management (Health EDRM). STUDY OBJECTIVE: The objective of this Delphi consensus study was to identify strategic recommendations for strengthening the workforce for Health EDRM in low- and middle-income countries (LMIC) and high-income countries (HIC). METHODS: A total of 31 international experts were asked to rate the level of importance (one being strongly unimportant to seven being strongly important) for 46 statements that contain recommendations for strengthening the workforce for Health EDRM. The experts were divided into a LMIC group and an HIC group. There were three rounds of rating, and statements that did not reach consensus (SD ≥ 1.0) proceeded to the next round for further ranking. RESULTS: In total, 44 statements from the LMIC group and 34 statements from the HIC group attained consensus and achieved high mean scores for importance (higher than five out of seven). The components of the World Health Organization (WHO) Health EDRM Framework with the highest number of recommendations were "Human Resources" (n = 15), "Planning and Coordination" (n = 7), and "Community Capacities for Health EDRM" (n = 6) in the LMIC group. "Policies, Strategies, and Legislation" (n = 7) and "Human Resources" (n = 7) were the components with the most recommendations for the HIC group. CONCLUSION: The expert panel provided a comprehensive list of important and actionable strategic recommendations on workforce development for Health EDRM.

The COVID-19 pandemic response and its impact on post-corona health emergency and disaster risk management in Italy.

Background: The COVID-19 pandemic has profoundly impacted societies, influencing countries' Health Emergency and Disaster Risk Management (H-EDRM) systems. By taking Italy as a case study, this research aimed to investigate the response to the COVID-19 pandemic, focusing on the changes made to the existing H-EDRM system, with an emphasis on human resources, health service delivery, and logistics and the forward-looking strategies for the next health emergencies and disasters. Methods: We performed a retrospective observational case study using qualitative methodology. Data was collected via semi-structured interviews and analyzed considering the World Health Organization (WHO) H-EDRM framework. Multiple interviewees were selected to obtain a holistic perspective on the Italian response to COVID-19. Stakeholders from five different sectors (policy-making, hospital, primary care, third sector, lay community) from three of the most impacted Italian regions (Piemonte, Lombardia, and Veneto) were interviewed, for a total of 15 respondents. Results: Results on human resources revolved around the following main themes: personnel, training, occupational health, and multidisciplinary work; results on health service delivery encompassed the following main themes: public health, hospital, and primary care systems; results on logistics dealt with the following themes: infrastructures, supplies, transports, and communication channels. Lessons learned stressed on the importance of considering pragmatic disaster preparedness strategies and the need for cultural and structural reforms. Stakeholders mentioned several implications for the post-pandemic H-EDRM system in Italy. Conclusions: Findings highlight that the interconnection of sectors is key in overcoming pandemic-related challenges and for future disaster preparedness. The implications for the Italian H-EDRM system can inform advancements in disaster management in Italy and beyond.

Dynamic assessment of surge capacity in a large hospital network during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has provided an unprecedented scenario to deepen knowledge of surge capacity (SC), assessment of which remains a challenge. This study reports a large-scale experience of a multi-hospital network, with the aim of evaluating the characteristics of different hospitals involved in the response and of measuring a real-time SC based on two complementary modalities (actual, base) referring to the intensive care units (ICU). METHODS: Data analysis referred to two consecutive pandemic waves (March-December 2020). Regarding SC, two different levels of analysis are considered: single hospital category (referring to a six-level categorization based on the number of hospital beds) and multi-hospital wide (referring to the response of the entire hospital network). RESULTS: During the period of 114 days, the analysis revealed a key role of the biggest hospitals (>Category-4) in terms of involvement in the pandemic response. In terms of SC, Category-4 hospitals showed the highest mean SC values, irrespective of the calculation method and level of analysis. At the multi-hospital level, the analysis revealed an overall ICU-SC (base) of 84.4% and an ICU-SC (actual) of 106.5%. CONCLUSIONS: The results provide benchmarks to better understand ICU hospital response capacity, highlighting the need for a more flexible approach to SC definition.

The Involvement of the European Master in Disaster Medicine (EMDM) Alumni in the COVID-19 Pandemic Response: An Example of the Perceived Relevance of Disaster Medicine Education during Disasters.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has revealed a gap in disaster preparedness of health workers globally. Disaster medicine education is a key element to fill this gap. OBJECTIVES: This study evaluated the involvement of the European Master in Disaster Medicine (EMDM) Alumni in the current COVID-19 pandemic response and their self-perceived value of the EMDM educational program in accomplishing their tasks during the disaster. METHODS: An online survey targeting the EMDM Alumni was conducted from January through March 2021. Quantitative data were described using percentages or means, as appropriate, while qualitative data were categorized using deductive thematic analysis. RESULTS: In total, 259 Alumni completed the survey. Most of the Alumni (88.03%; standard error of the proportion [SEp] = 0.02) participated directly in the COVID-19 pandemic response - nationally or internationally - with different roles and responsibilities at different levels and sectors. Around 25% of the Alumni reported an increase in their tasks and responsibilities due to COVID-19 response, but few worked beyond their main specialization (5.26%) or expertise (2.19%). Moreover, Alumni shifted their role from clinical practice to managerial, public health, education and training, and policymaking roles during COVID-19 (P <.001). Participants believed that the EMDM study program and the competencies acquired during the course were relevant and useful to perform their tasks during the COVID-19 pandemic response (mean = 5.26; 5.17 standard error of the mean [SEM] = 0.108, 0.107), respectively. Around 36% (SEp = 0.03) of the participants deemed that some contents were not sufficient for COVID-19 response. CONCLUSION: Most of the EMDM Alumni were involved in the COVID-19 pandemic response, playing diverse roles with an increased level of responsibility compared to those played before the pandemic. Moreover, the Alumni perceived the EMDM curriculum as relevant for accomplishing their tasks. However, they also reported gaps within the curriculum, especially topics related to outbreak and pandemic response. The findings of the study stress the value of investing in disaster medicine education world-wide and of pushing to update and standardize post-graduate disaster medicine curricula.

The Burden of Carbapenem-Resistant Acinetobacter baumannii in ICU COVID-19 Patients: A Regional Experience.

Since the beginning of the COVID-19 pandemic, the impact of superinfections in intensive care units (ICUs) has progressively increased, especially carbapenem-resistant Acinetobacter baumannii (CR-Ab). This observational, multicenter, retrospective study was designed to investigate the characteristics of COVID-19 ICU patients developing CR-Ab colonization/infection during an ICU stay and evaluate mortality risk factors in a regional ICU network. A total of 913 COVID-19 patients were admitted to the participating ICUs; 19% became positive for CR-Ab, either colonization or infection (n = 176). The ICU mortality rate in CR-Ab patients was 64.7%. On average, patients developed colonization or infection within 10 ± 8.4 days from ICU admission. Scores of SAPS II and SOFA were significantly higher in the deceased patients (43.8 ± 13.5, p = 0.006 and 9.5 ± 3.6, p < 0.001, respectively). The mortality rate was significantly higher in patients with extracorporeal membrane oxygenation (12; 7%, p = 0.03), septic shock (61; 35%, p < 0.001), and in elders (66 ± 10, p < 0.001). Among the 176 patients, 129 (73%) had invasive infection with CR-Ab: 105 (60.7%) Ventilator-Associated Pneumonia (VAP), and 46 (26.6%) Bloodstream Infections (BSIs). In 22 cases (6.5%), VAP was associated with concomitant BSI. Colonization was reported in 165 patients (93.7%). Mortality was significantly higher in patients with VAP (p = 0.009). Colonized patients who did not develop invasive infections had a higher survival rate (p < 0.001). Being colonized by CR-Ab was associated with a higher risk of developing invasive infections (p < 0.001). In a multivariate analysis, risk factors significantly associated with mortality were age (OR = 1.070; 95% CI (1.028-1.115) p = 0.001) and CR-Ab colonization (OR = 5.463 IC95% 1.572-18.988, p = 0.008). Constant infection-control measures are necessary to stop the spread of A. baumannii in the hospital environment, especially at this time of the SARS-CoV-2 pandemic, with active surveillance cultures and the efficient performance of a multidisciplinary team.

A Review of COVID-19 Response Challenges in Ethiopia.

BACKGROUND: The COVID-19 pandemic has positioned fragile healthcare systems in low-income countries under pressure, leading to critical gaps in service delivery. The pandemic response demands the healthcare system to be resilient and continue provision of healthcare services. This review is aimed at describing the healthcare response challenges during the pandemic in Ethiopia. METHODOLOGY: Eligible studies dealing with challenges of the healthcare system in response to the COVID-19 pandemic in Ethiopia were included. The six World Health Organization (WHO) healthcare system building blocks were used to categorize healthcare challenges. PubMed ProQuest, databases were searched, and results were summarized using systematic review synthesis. RESULTS: Financial constraints led to a shortage of mechanical ventilators. Furthermore, the pandemic hindered the capacity to avail full packages of personal protective equipment in health facilities and intensive care capacity. The pandemic also affected the delivery of maternal, child and new-born services, prevention, and treatment of childhood illness, including immunization services. CONCLUSIONS: The COVID-19 pandemic posed various challenges to the performance of the healthcare system in Ethiopia. It is recommended that policy makers and stakeholders enhance pandemic preparedness and strengthen response capacity by considering the six WHO healthcare system building blocks.

Mental Health Impact and Burnout in Critical Care Staff During Coronavirus Disease 2019 Outbreak.

OBJECTIVE: The coronavirus disease 2019 outbreak exposed intensive care unit health care workers to a psychological burden. The aim of the study was to assess burnout, depression, anxiety, and post-traumatic stress symptoms in the intensive care unit staff during the pandemic period and to focus on the factors that contributed to psychological discomfort by using validated psychometric tools. METHODS: This was a monocentric study developed at the end of the first emergency crisis period (May 2020). We used a custom-designed survey using SurveyMonkey. The first part of the online survey included 27 general questions (sociodemographic information, the professional role, and possible changes assigned in job tasks and duties), the second part included validated psychometric tools: Maslach Burnout Inventory, General Health Questionnaire-12 Items, Impact of Event Scale, Beck Anxiety Inventory, and Beck Depression Inventory-II. Factors indepen- dently associated with reported symptoms of mental health disorders were identified. RESULTS: The response rate was 88%, with 95 respondents. Depressive and mild-moderate anxiety symptoms were reported in 20% and in 12% of health care workers, respectively, and half of the sample experienced moderate or severe post-traumatic stress symptoms. In total, 64% of health care workers reported high levels of burnout. General mental health problems were more frequently reported by women (P =.3), by those who were tested negative for the coronavirus disease 2019 buffer (P < .02), and by those who changed their family habits (P =.02) as a consequence of the pandemic. Being single or divorced (P = .04) was associated with the presence of depressive symptoms; vice versa, cohabiting with a partner or being married was associated with lower levels of depression. Anxious symptoms were reported in health care workers with no previous working experience in the intensive care unit. CONCLUSIONS: Health care workers experience high levels of psychological burden during the coronavirus disease 2019 pandemic. Knowing the risk factors can aid to develop strategies of observation and prevention and also strengthen the ability to be resilient to stressful situations.

Clinical Outcomes in Patients Aged 80 Years or Older Receiving Non-Invasive Respiratory Support for Hypoxemic Acute Respiratory Failure Consequent to COVID-19.

As the clinical outcome of octogenarian patients hospitalised for COVID-19 is very poor, here we assessed the clinical characteristics and outcomes of patients aged 80 year or older hospitalised for COVID-19 receiving non-invasive respiratory support (NIRS). A multicentre, retrospective, observational study was conducted in seven hospitals in Northern Italy. All patients aged ≥80 years with COVID-19 associated hypoxemic acute respiratory failure (hARF) undergoing NIRS between 24 February 2020, and 31 March 2021, were included. Out of 252 study participants, 156 (61.9%) and 163 (64.6%) died during hospital stay and within 90 days from hospital admission, respectively. In this case, 228 (90.5%) patients only received NIRS (NIRS group), while 24 (9.5%) were treated with invasive mechanical ventilation (IMV) after NIRS failure (NIRS+IMV group). In-hospital mortality did not significantly differ between NIRS and NIRS+IMV group (61.0% vs. 70.8%, respectively; p = 0.507), while survival probability at 90 days was significantly higher for NIRS compared to NIRS+IMV patients (0.379 vs. 0.147; p = 0.0025). The outcome of octogenarian patients with COVID-19 receiving NIRS is quite poor. Caution should be used when considering transition from NIRS to IMV after NIRS failure.

Longitudinal survey on the Psychological Impact of the COVID-19 Pandemic in Healthcare Workers (PsyCOVer) in France: study protocol.

INTRODUCTION: In the pandemic, healthcare professionals face even higher levels of stress. It is therefore a priority to estimate the impact of the pandemic on mental health and to propose targeted strategies to improve resilience. The aims of the study were to (1) assess the mental health of healthcare professionals working with patients with COVID-19 and identify social determinants that may increase the risk of negative outcomes; and (2) test the effectiveness of an intervention to improve the resilience of healthcare professionals in France. METHODS AND ANALYSIS: To evaluate the first objective, a national longitudinal study will be carried out among healthcare professionals working with patients with COVID-19. Participants will be recruited via an internet link that will be widely disseminated on social media, mailing lists, medical boards and French medical journals. Primary outcomes are mental health distress/symptoms and resilience. Secondary outcomes are burnout, social and occupational supports and substance use. To meet the second objective, an interventional study will be conducted. The main outcome is the effectiveness of the PsySTART-Responder and the Anticipate.Plan.Deter program. Qualitative analyses will be conducted to understand the strategies used to cope with the pandemic. ETHICS AND DISSEMINATION: The study protocol was approved by the Sorbonne Université Ethical Committee (No 2020-CER-2020-27) and was declared to French Commission on Information Technology and Liberties, CNIL (N°2222413, 20-05-2021). The results of this study will provide a better understanding of mental health and social inequalities in mental health among healthcare professionals working in the pandemic; data about the effectiveness of the PsySTART-Responder and the Anticipate.Plan.Deter interventional program in France.

Health Workforce Development in Health Emergency and Disaster Risk Management: The Need for Evidence-Based Recommendations.

The Sendai Framework for Disaster Risk Reduction 2015-2030 placed human health at the centre of disaster risk reduction, calling for the global community to enhance local and national health emergency and disaster risk management (Health EDRM). The Health EDRM Framework, published in 2019, describes the functions required for comprehensive disaster risk management across prevention, preparedness, readiness, response, and recovery to improve the resilience and health security of communities, countries, and health systems. Evidence-based Health EDRM workforce development is vital. However, there are still significant gaps in the evidence identifying common competencies for training and education programmes, and the clarification of strategies for workforce retention, motivation, deployment, and coordination. Initiated in June 2020, this project includes literature reviews, case studies, and an expert consensus (modified Delphi) study. Literature reviews in English, Japanese, and Chinese aim to identify research gaps and explore core competencies for Health EDRM workforce training. Thirteen Health EDRM related case studies from six WHO regions will illustrate best practices (and pitfalls) and inform the consensus study. Consensus will be sought from global experts in emergency and disaster medicine, nursing, public health and related disciplines. Recommendations for developing effective health workforce strategies for low- and middle-income countries and high-income countries will then be disseminated.

Simple Parameters from Complete Blood Count Predict In-Hospital Mortality in COVID-19.

INTRODUCTION: The clinical course of Coronavirus Disease 2019 (COVID-19) is highly heterogenous, ranging from asymptomatic to fatal forms. The identification of clinical and laboratory predictors of poor prognosis may assist clinicians in monitoring strategies and therapeutic decisions. MATERIALS AND METHODS: In this study, we retrospectively assessed the prognostic value of a simple tool, the complete blood count, on a cohort of 664 patients (F 260; 39%, median age 70 (56-81) years) hospitalized for COVID-19 in Northern Italy. We collected demographic data along with complete blood cell count; moreover, the outcome of the hospital in-stay was recorded. RESULTS: At data cut-off, 221/664 patients (33.3%) had died and 453/664 (66.7%) had been discharged. Red cell distribution width (RDW) (χ 2 10.4; p < 0.001), neutrophil-to-lymphocyte (NL) ratio (χ 2 7.6; p = 0.006), and platelet count (χ 2 5.39; p = 0.02), along with age (χ 2 87.6; p < 0.001) and gender (χ 2 17.3; p < 0.001), accurately predicted in-hospital mortality. Hemoglobin levels were not associated with mortality. We also identified the best cut-off for mortality prediction: a NL ratio > 4.68 was characterized by an odds ratio for in-hospital mortality (OR) = 3.40 (2.40-4.82), while the OR for a RDW > 13.7% was 4.09 (2.87-5.83); a platelet count > 166,000/µL was, conversely, protective (OR: 0.45 (0.32-0.63)). CONCLUSION: Our findings arise the opportunity of stratifying COVID-19 severity according to simple lab parameters, which may drive clinical decisions about monitoring and treatment.

Just-in-Time Training in a Tertiary Referral Hospital During the COVID-19 Pandemic in Italy.

The COVID-19 pandemic is threatening health systems worldwide, requiring extraordinary efforts to contain the virus and prepare health care systems for unprecedented situations. In this context, the entire health care workforce must be properly trained to guarantee an effective response. Just-in-time training has been an efficient solution for rapidly equipping health care workers with new knowledge, skills, and attitudes during emergencies; thus, it could also be an effective training technique in the context of the response to the COVID-19 pandemic. Because of the unexpected magnitude of this health crisis, the health care workforce must be trained in 2 areas: (1) basic infection prevention and control, including public health skills that are the core of population-based health management and (2) disaster medicine principles, such as surge capacity, allocation of scarce resources, triage, and the ethical dilemmas of rationing medical care. This Perspective reports how just-in-time training concepts and methods were applied in a tertiary referral hospital in March 2020, during the COVID-19 pandemic in Northern Italy, one of the hardest hit places in the world. The COVID-19 just-in-time training was designed to provide hospital staff with the competencies they need to work proficiently and safely inside the hospital, including an understanding of the working principles and standard operating procedures in place and the correct use of personal protective equipment. Moreover, this training was intended to address the basic principles of disaster medicine applied to the COVID-19 pandemic. Such training was essential in enabling staff to rapidly attain competencies that most of them lacked because disaster medicine and global health are not included in the curricula of Italian medical and nursing schools. Although a formal evaluation was not performed, this is a useful example of how to create just-in-time training in a large hospital during a crisis of an unprecedented scale.

The National Emergency Medical Service Role During the COVID-19 Pandemic in Sierra Leone.

This report describes the main adaptive and transformative changes adopted by the brand-new National Emergency Medical Service (NEMS) to face the novel coronavirus disease 2019 (COVID-19) in Sierra Leone, including ambulance re-distribution, improvements in communication flow, implementation of ad-hoc procedures and trainings, and budget re-allocation. In a time-span of four months, 1,170 COVID-19 cases have been handled by the NEMS through a parallel referral system, while efforts have been made to manage the routine emergencies of the country, causing a substantial intensification of daily activities.

Outcomes of COVID-19 patients treated with continuous positive airway pressure outside the intensive care unit.

AIM: We aimed to characterise a large population of coronavirus disease 2019 (COVID-19) patients with moderate-to-severe hypoxaemic acute respiratory failure (ARF) receiving continuous positive airway pressure (CPAP) outside the intensive care unit (ICU), and to ascertain whether the duration of CPAP application increased the risk of mortality for patients requiring intubation. METHODS: In this retrospective, multicentre cohort study, we included adult COVID-19 patients, treated with CPAP outside ICU for hypoxaemic ARF from 1 March to 15 April, 2020. We collected demographic and clinical data, including CPAP therapeutic goal, hospital length of stay and 60-day in-hospital mortality. RESULTS: The study included 537 patients with a median (interquartile range (IQR) age of 69 (60-76) years. 391 (73%) were male. According to the pre-defined CPAP therapeutic goal, 397 (74%) patients were included in the full treatment subgroup, and 140 (26%) in the do not intubate (DNI) subgroup. Median (IQR) CPAP duration was 4 (1-8) days, while hospital length of stay was 16 (9-27) days. 60-day in-hospital mortality was 34% (95% CI 0.304-0.384%) overall, and 21% (95% CI 0.169-0.249%) and 73% (95% CI 0.648-0.787%) for full treatment and DNI subgroups, respectively. In the full treatment subgroup, in-hospital mortality was 42% (95% CI 0.345-0.488%) for 180 (45%) CPAP failures requiring intubation, and 2% (95% CI 0.008-0.035%) for the remaining 217 (55%) patients who succeeded. Delaying intubation was associated with increased mortality (hazard ratio 1.093, 95% CI 1.010-1.184). CONCLUSIONS: We described a large population of COVID-19 patients treated with CPAP outside ICU. Intubation delay represents a risk factor for mortality. Further investigation is needed for early identification of CPAP failures.

Infective endocarditis complicating COVID-19 pneumonia: a case report.

BACKGROUND: During the COVID-19 outbreak, cardiovascular imaging, especially transoesophageal echocardiography (TOE), may expose healthcare personnel to virus contamination and should be performed only if strictly necessary. On the other hand, transthoracic echocardiography (TTE) and TOE represent the first-line imaging exams for the diagnosis of infective endocarditis (IE). To date, this is the first case of COVID-19 complicated by IE. CASE SUMMARY: We present the case of a 57-year-old man with severe COVID-19 pneumonia requiring mechanical ventilation. During the intensive care unit (ICU) stay, he developed fever and positive haemocoltures for methicillin-resistant Staphylococcus aureus infection. TTE did not identify endocardial vegetations. TOE was then performed and outlined IE of the aortic valve on the non-coronary cusp. Antibiotic therapy was given with progressive resolution of the septic state and improvement of inflammatory signs. After 30 days of ICU stay, the patient was transferred to the Sub-ICU and then to a rehabilitation hospital. A close follow-up has been scheduled: after full recovery, a new echocardiography will be performed (TTE and TOE, if the former is non-conclusive) to consider surgical valve repair in the case of persistence/progression of the valvular lesion or deterioration of the valve function. DISCUSSION: In COVID-19 patients, echocardiography remains the leading imaging exam for the diagnosis of IE. If the suspicion of IE is high, even in this setting of patients, TTE or TOE (if TTE is non-conclusive) are mandatory. A high degree of attention must be paid and appropriate preventive measures taken to avoid contamination of healthcare personnel.

COVID-19 Pandemic: Perspective From Italian Pediatric Emergency Physicians.

OBJECTIVES: To document the lived experience of Italian pediatric emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We developed a structured interview to collect the lived experience of the staff of the pediatric emergency department (PED) of a tertiary referral university hospital in Northern Italy. The open-ended questions were draft according to the suggestions of Canadian colleagues and administered by 1 interviewer, who was part of the PED staff, at the end of March 2020. All the PED staff was interviewed, on a voluntary basis, using purposive sampling. RESULTS: Most respondents declared to be afraid of becoming infected and of infecting their families. The number of patients seen in the PED has decreased, and the cases tend to be more severe. A shift in the clinical approach to the ill child has occurred, the physical examination is problem-oriented, aiming to avoid un-necessary maneuvers and to minimize the number of practitioners involved. The most challenging aspects reported are: (1) performing a physical examination in personal protective equipment (PPE), (2) being updated with rapidly evolving guidelines, and (3) staying focused on the possible COVID-19 clinical presentation without failing in differential diagnosis. CONCLUSIONS: During the COVID-19 pandemic, it seems that pediatric emergency physicians are radically changing their clinical practice, aiming at prioritizing essential interventions and maneuvers and self-protection.