Six-month multidisciplinary follow-up in multisystem inflammatory syndrome in children: An Italian single-center experience.

Background: A severe multisystem inflammatory syndrome in children (MIS-C) related to SARS-CoV-2 has been described after infection. A limited number of reports have analyzed the long-term complications related to pro-inflammatory status in MIS-C. We evaluated multiorgan impairment at the 6-month follow-up in MIS-C. Methods: We enrolled 33 pediatric patients consecutively hospitalized for MIS-C and monitored for almost 6 months. The inter-relationship of patient's features and disease severity at admission with long term complications was studied by multivariate analysis. Results: Endo-metabolic derangement, cardiac injury, respiratory, renal and gastrointestinal manifestations and neurological involvement are part of the initial presentation. The most abnormalities appear to resolve within the first few weeks, without significant long term dysfunction at the 6-months follow-up, except for endocrine (non-thyroidal illness syndrome in 12.1%, insulin resistance in 21.2%) and neurological system (27.3% cognitive or psychological, behavioral, adaptive difficulties). Endocrine and heart involvement at admission represent a significant factor on the long term sequelae; however no association between severity score and long-term outcome was noted. Conclusions: The severity of initial clinical presentation may be associated to organ domain, however it is not related to long term sequelae. The prevalent organ restoration supports a predominant indirect immune-mediated injury triggered by a systemic inflammatory response; however a direct damage due to the viral entry could be not excluded. Eventhought our preliminary results seem to suggest that MIS-C is not a long-term risk condition for children health, a longer follow-up is mandatory to confirm this hypothesis.

Health Technology Assessment to assess value of biomarkers in the decision-making process.

Clinical practice guidelines (CPGs) on screening, surveillance, and treatment of several diseases recommend the selective use of biomarkers with central role in clinical decision-making and move towards including patients in this process. To this aim we will clarify the multidisciplinary interactions required to properly measure the cost-effectiveness of biomarkers with regard to the risk-benefit of the patients and how Health Technology Assessment (HTA) approach may assess value of biomarkers integrated within the decision-making process. HTA through the interaction of different skills provides high-quality research information on the effectiveness, costs, and impact of health technologies, including biomarkers. The biostatistical methodology is relevant to HTA but only meta-analysis is covered in depth, whereas proper approaches are needed to estimate the benefit-risk balance ratio. Several biomarkers underwent HTA evaluation and the final reports have pragmatically addressed: 1) a redesign of the screening based on biomarker; 2) a de-implementation/replacement of the test in clinical practice; 3) a selection of biomarkers with potential predictive ability and prognostic value; and 4) a stronger monitoring of the appropriateness of test request. The COVID-19 pandemic has disclosed the need to create a robust and sustainable system to urgently deal with global health concerns and the HTA methodology enables rapid cost-effective implementation of diagnostic tests allowing healthcare providers to make critical patient-management decisions.

Association between indoor-outdoor green features and psychological health during the COVID-19 lockdown in Italy: A cross-sectional nationwide study.

Exposure to public green spaces was shown to be associated with psychological health. Nonetheless, evidence is lacking on the role of different green features within and/or surrounding the home environment when public green spaces are inaccessible or not usable. The overarching goal of this study is to shed light on the associations between the presence of greenness within the home and in the surrounding environment and the detrimental effects of quarantine on psychological health during the COVID-19 pandemic lockdown in Italy. A cross-sectional nationwide study involving an online survey was conducted of an Italian population-based sample of 3886 respondents on the association of indoor and outdoor green features (i.e., presence of plant pots, sunlight, green view and accessibility of private green space and natural outdoor environment) with self-reported increases in anxiety, anger, fear, confusion, moodiness, boredom, irritability, recurrent thoughts and/or dreams, poor concentration and sleep disturbance during the COVID-19 lockdown. Single-exposure regression models were performed to estimate associations between single green features and each psychological health outcome adjusted for relevant covariates. In the adjusted models, the presence of plant pots at home was associated with a lower self-reported increase in anxiety, anger, fear, irritability, and sleep disturbance. A greater amount of sunlight in the home was associated with a lower increase in anger, fear, confusion, moodiness, boredom, irritability, poor concentration, and sleep disturbance. A greater amount of green view and access to private green spaces were both associated with a lower increase in each of the psychological health outcomes except for green view and recurrent thought and/or dreams. Natural outdoor environment was associated with anxiety, fear, boredom, irritability, and sleep disturbance. Significant associations remained robust when adjusted for number of confirmed COVID-19 cases. Insights on future investigations are provided.

Diagnosis of SARS-CoV-2 in children: accuracy of nasopharyngeal swab compared to nasopharyngeal aspirate. (preprint)

The tests currently used for the direct identification of SARS-CoV-2 include specimens taken from upper and lower respiratory tract; recommendations from Word Health Organization prioritise nasopharyngeal swab (NS). In literature there are not available paediatric studies about the identification of SARS-CoV-2 through nasopharyngeal aspirate (NPA), but the use of NPA is deemed to be better than NS to identify respiratory viruses in children. The aim of our study is to evaluate diagnostic performances of NS compared to NPA for the detection of SARS-CoV-2 in children. We collected 300 paired samples (NS and NPA) from children hospitalized and followed up in our paediatric unit. We calculated the sensitivity and specificity of NS referred to NPA of the whole sample and then, considering both the age ([≥] and < 6 years old) and the period of collection (March vs follow up) as covariates in different analysis. The NS has a low sensitivity in detecting SARS-CoV-2 in children when referred to NPA; whereas its specificity results high. In children under 6 years of age, our results suggest to prefer the collection of NS, whenever possible. Though statistically not significant, the sensitivity of NS becomes higher if it is performed before NPA.

In a Time of Need: A Grassroots Initiative in Response to PPE Shortage in the COVID-19 Pandemic.

SETTING: Primary care is the first line of defence in healthcare, particularly during the coronavirus disease 2019 (COVID-19) pandemic. In the London-Middlesex region of Ontario, a critical shortage of personal protective equipment (PPE) was identified among primary care physicians (PCPs). INTERVENTION: With the help of the London-Middlesex Primary Care Alliance, volunteer administrators, physicians and medical students coordinated the acquisition and redistribution of community-donated PPE to PCPs across London-Middlesex. Our scope evolved to include PPE reusability and stewardship and PCP wellness. OUTCOME: Beginning on March 16, 2020, our initial four-week operation provided PPE to over 200 PCPs. We received 60 donations, including over 118,000 gloves, 13,700 masks, 700 wellness kits and reusable cloth masks and gowns. Each delivery included educational pamphlets, and our online PPE stewardship session was attended by over 30 physicians. IMPLICATIONS: In response to the PPE shortage in COVID-19, our efforts evolved into a complex adaptive system, supported by an organizational body with a pre-existing communication infrastructure, to great success. Our scope extended beyond simple PPE provision to PCPs. Furthermore, our initiative established a framework for a centralized response to PPE shortage in Ontario Health West.

Seroprevalence of SARS-CoV-2 IgG significantly varies with age: results from a mass population screening (SARS-2-SCREEN-CdA). (preprint)

ObjectivesCastiglione DAdda is one of the municipalities more precociously and severely affected by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) epidemic in Lombardy. With our study we aimed to understand the diffusion of the infection by mass seroprevalence screening. MethodsWe searched for SARS-CoV-2 IgGs in the entire voluntary population using lateral flow immune-cromatographic tests on capillary blood (rapid tests). We then performed chemioluminescent serological assays (CLIA) and naso-pharyngeal swabs in a randomized representative sample of 562 subjects and in every subject with a positive rapid test. ResultsBased on CLIA serologies on the representative random sample (509 subjects), we estimated a 23% IgG seroprevalence. We also found a strong correlation between age and prevalence, with the elderly showing the highest probability of a positive serological test. ConclusionsIn an area of unrestricted viral circulation less than one-fourth of the population tested positive for SARS-CoV-2 IgG. Seroprevalence increased with increasing age, possibly suggesting differences in susceptibility to the infection.

Are health indicators able to describe the ability to cope of Health Systems with COVID-19 epidemic? (preprint)

The Coronavirus Disease 19 epidemic is an infectious disease which was declared as a pandemic and hit all the Countries, all over the world, from the beginning of the year 2020. Despite the emergency vigilance plans, in all the Countries, Health Systems experienced a different ratio of lethality, admissions to intensive care units and managing quarantine of positive patients. The aim of this study is to investigate if some health indicators might have been useful to understand the capacity of Italian National Health Service to manage the COVID 19 epidemic. We will compare data in two different Italian regions in the Northern part of Italy (Lombardy and Veneto) with the national data to understand if different health strategies might be significant to explain different patterns of COVID 19 epidemic in Italy. The two regions have two different health policies to face CoViD-2019 epidemic. To face epidemic like this one the answer should be outside hospitals but this means to have general practitioners well-trained and enough healthcare personnel working outside hospitals.

Dynamics of the SARS-CoV-2 epidemic in the earliest-affected areas in Italy: 1 Mass screening for SARS-CoV-2 serological positivity (SARS-2-SCREEN). (preprint)

Background Several municipalities in the Lombardy Region have been affected by the SARS-CoV-2 infection since the earliest stages of the epidemic. To date, 89442 confirmed cases have been diagnosed in Lombardy, and mortality in several municipalities has already surpassed that of the past decade. Currently, the true extent of the SARS-CoV-2 infection remains unknown as several affected subjects may have been asymptomatic or have presented mild disease, thus not resulting in the identified COVID-19 cases. Methods This cross-sectional study aims to define the spread of infection within the population by determining the seroprevalence of IgG antibodies directed against SARS-CoV-2 by rapid immunochromatographic testing and subsequent confirmation by serology on venous blood by liquid phase immunochemical testing, also allowing to compare the two methods. Testing will be performed on adults and minors residing, domiciled or working in several municipalities of the Lombardy Region, involved in the initial stages of the epidemic. The study will include rapid finger-prick testing and venous sampling for antibodies against SARS-CoV-2, and nasopharyngeal swabbing (NPS). Concurrent notification of test results will occur via the regional healthcare information system (SISS). Discussion This study was developed with the desire to understand the seroprevalence of SARS-CoV-2 infection and the epidemiological transmission characteristics of this virus. Understanding the spread and severity of the disease could help in the implementation of effective infection surveillance containment and countermeasures facilitating the identification of cases that have been exposed to the virus and the traceability of contacts. This study has been approved by the Ethics Committee of the University of Milan (35/2020).