The Ethical Triage Dilemma: Who Should Receive Medical Care First, Is This the Right Question?

In 2020, with the outbreak of the COVID-19 pandemic, academics and scientists began to question the triage criteria for allocating insufficient healthcare resources, trying to ethically justify the answer to the question, Who should receive medical care first? In this article, I will argue that even if we apply triage criteria, we won't be able to avoid the violation of human dignity or of the right to life and to health care. I will then suggest that, maybe, the real ethical triage dilemma lies not in the question, Who should receive medical care first? but in the question, How are we to decide who should receive medical care first?. © 2023 The Author. Ratio Juris published by University of Bologna and John Wiley & Sons Ltd.

Inverse correlation between central hypogonadism and circulating IL-10 levels in males with severe COVID-19

Introduction & Objectives: After the early and dramatic induction of inflammatory cytokines, IL-6 emerged to be associated with severe outcomes in patients with COVID-19. Likewise, high IL-10 plasma levels have been reported, and central hypogonadism has been recently observed in male patients with severe clinical outcomes (i.e., Intensive Care Unit (ICU) admission or death) of COVID-19. We aimed to investigate the role of IL-10 over the pathophysiology of COVID-19 and its relationship with hypogonadism in males. Materials & Methods: Plasma from 281 voluntary healthy males (HC) and 258 laboratory-confirmed COVID-19 males (i.e., asymptomatic (n=24);symptomatic (n=155);ICU patients (n=48);and, deceased (n=31)) was collected to measure levels of total testosterone (TT), IL-10 and the nonclassical MHC class I HLA-G (HLA-G) molecule - associated to IL-10 and involved in immune escape after viral infection - by specific enzyme-linked immunosorbent assay. Results: An inverse correlation between TT and IL-10 levels was identified, with TT levels progressively decreasing from HC (median (IQR) 10.4 (8.1-13.4) nmol/L) to asymptomatic COVID-19 (3.9 (3.1-5.3) nmol/L), to symptomatic COVID-19 (3.0 (1.8-5.7) nmol/L), ICU (1.0 (0.5-1.8) nml/L) and deceased (0.7 (0.3-2.3) nmol/L) patients, respectively (p<0.0001). Conversely, IL-10 levels progressively decreased from deceased COVID-19 patients (11.3 (4.5-37.7) pg/ml), to ICU (8.0 (2.6-16.7) pg/mL), symptomatic (6.0 (3.0-10.9) pg/mL), asymptomatic COVID-19 patients (6.0 (1.6-6.0) pg/mL), and HC (3.0 (1.3-3.0) pg/mL), respectively (p<0.0001). Similarly, HLA-G levels, progressively increased from HC to COVID-19 patients with most severe clinical outcomes. Conclusions: These data indicate that circulating TT is inversely associated to both IL-10 and HLA-G levels in men with COVID-19, where lower TT and higher IL-10 levels are associated with the most severe clinical outcomes. Further investigations are required to better define whether TT and IL-10 might be early effective biomarkers of clinical severity in males with COVID-19 and to exploit if TT is involved in promoting IL-10 and HLA-G induction.

Severely low testosterone in men with COVID-19: A case-control study

Introduction & Objectives: In patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) reasons for sex disparity in disease severity are still unclear and circulating androgens could play a role. We investigated circulating sex steroids levels in a cohort of symptomatic patients with COVID-19 compared to a cohort of healthy men. Materials & Methods: Data of 286 patients with COVID-19 admitted to a single academic centre were compared to 305 voluntaryhealthy blood donors. Patients were further categorized according to disease severity as: Group 1: mildly symptomatic and discharge home;Group 2: admitted in the internal medicine unit;Group 3: admitted to intensive care unit (ICU);and, Group 4: deceased because of COVID-19. Healthy controls were subdivided in SARS-CoV-2 negative and asymptomatic unaware SARS-CoV-2 positive. Health-related comorbidities were scored with the Charlson Comorbidity Index (CCI). Moreover, a validated composite risk score (Liang et al, 2020) was calculated to estimate the risk of developing critical illness in men with COVID-19. Hypogonadism was defined as a total testosterone (TT) level < 9.2 nmol/l. Logistic regression analysis tested the association between TT level and the risk of death due to COVID-19. Results: Overall, men with COVID-19 showed a higher burden of comorbidities than healthy controls and asymptomatic positive controls (CCI³2 in 66/286 (24%) vs. 0/281 (0%) vs. 0/24 (0%);p<0.0001). TT levels were significantly lower in patients with COVID-19 vs. asymptomatic vs. healthy controls (mean (IQR) 2.5 (1-4.7) nmol/L) vs. 11.8 (8.4-14.4) vs. 10.4 (8.1-13.4) nmol/L, respectively;p<0.0001). Of all, hypogonadism was observed in 257 (89.8%) patients, 9 (33%) asymptomatic and 42 (14.9%) healthy controls at hospital admission (p<0.0001). In as many as 243 (85%) patients, hypogonadism was secondary. Of patients, in Group 1 were 24 (4.5%), in Group 2: 155 (29%), in Group 3: 48 (8.9%), and in Group 4: 31 (5.8%). Both Group 3 and 4 patients had significantly lower TT (1.0 (0.5,1.8) and 0.7 (0.3,2.3) nmol/L, respectively) compared to Group 2 (3.0 (1.8,5.7)) and Group 1 (3.9 (3.1,5.3) nmol/L) patients (p<0.0001). At logistic regression, a lower TT level was associated with a higher risk of death (OR: 0.66;95%CI 0.45, 0.98) after accounting for the critical illness score. Of note, the lower the TT, the higher the risk of death for the same Critical-Ill COVID-19 score (Figure 1).(Figure Presented) Conclusions: We unveiled an independent association between SARS-CoV-2 infection status and hypogonadism already at hospital admission, with lower testosterone levels predicting the most severe clinical outcomes.

Considerazioni per un'Etica del Triage Dall'analisi dei casi di Brasile, Stati Uniti e Italia alla giustificazione dell'utilitarismo

Over the past year, due to the Covid-19 pandemic, most medical associations and ethics committees around the world have issued a series of triage guidelines and recommendations that seek to ethically justify the allocation of scarce medical resources. In my article, starting from the analysis of the triage approach adopted in Brazil, the United States and Italy, I will try to verify whether the applied criteria can fit into a utilitarian vision. I will later provide an ethical justification for the utilitarian approach based on the self-preservation theory and on the «veil of ignorance» suggested by J. Rawls. I will also support the thesis that human beings have the right to live all stages of their life, and that, in triage, age should be taken into account. In conclusion, I will suggest the application of some principles that could limit the violation of fundamental human rights in the allocation of scarce medical resources, pursuing the goal of saving as many lives as possible. © 2021. All Rights Reserved.

Impact of societal changes during the COVID-19 pandemic on children's screen time

Background: The COVID-19 pandemic led to dramatic societal changes including widespread school closures that resulted in many parents working from home while caring for their children. These changes may lead to increases in screen time among children, potentially impacting health risks including obesity. We evaluated the changes in children's screen time from pre-pandemic to during the pandemic. Methods: Participants are children ages 4-5 years (n = 100) and their mothers enrolled in a pediatric cohort from Northern California participating in the Environmental influences of Child Health Outcomes (ECHO) Program. Data collection is ongoing for 3 other study sites. Parent reported child screen time was assessed pre-pandemic from Oct 2019-Feb 2020 and during the pandemic from Feb-Mar 2021. We used a multivariate general linear mixed model that adjusted for baseline screen time, child sex, age, race/ethnicity and mother's education. Results: From pre-pandemic to during the pandemic total screen time increased 112.6 minutes/day (95% CI 67.3-157.8) in the multivariate adjusted model. The biggest increase in screen time was related to doing homework on a computer or tablet 60.6 minutes/day (95% CI 45.4, 74.9). Excluding homework, the total increase in screen time was 61.4 minutes/day (95% CI 20.6, 102.2). The most common increases in non-educational screen time were in playing games or using apps on a smartphone or tablet 22.9 minutes/day (95% CI 6.75,39.0) and playing video games 15.31 minutes/day (95% CI 6.56, 24.1). Conclusions: Screen time increased during the COVID-19 pandemic among young children. Over 50% of this increase was education related. It will be important to determine the long-term impact of increased screen time during the COVID-19 pandemic on child's health risk.

Considerations about the Ethic of Triage. From the analysis of the cases of Brazil, The United States and Italy to the Justification of utilitarianism

Over the past year, due to the Covid-19 pandemic, most medical associations and ethics committees around the world have issued a series of triage guidelines and recommendations that seek to ethically justify the allocation of scarce medical resources. In my article, starting from the analysis of the triage approach adopted in Brazil, the United States and Italy, I will try to verify whether the applied criteria can fit into a utilitarian vision. I will later provide an ethical justification for the utilitarian approach based on the self-preservation theory and on the "veil of ignorance" suggested by J. Rawls. I will also support the thesis that human beings have the right to live all stages of their life, and that, in triage, age should be taken into account. In conclusion, I will suggest the application of some principles that could limit the violation of fundamental human rights in the allocation of scarce medical resources, pursuing the goal of saving as many lives as possible.

Overcoming Disruption in Special Collections Public Services

Special collections and archives workers have unique experiences in providing service to their patron base while also working to overcome disruption and physical displacement. The disruption may take the form of a major renovation, a closure due to natural disaster, being forced out of a library space, budget cuts, or other operational issues. This article captures the experiences of twenty-eight staff members providing access services to their subset of users, in the form of interviews, in order to reflect upon how our profession connects with, provides services to, and places value on the relationships we cultivate with the public. We sought to gain insight from those who have experienced disruptions to their services in the past in order to apply this knowledge to the pandemic situation of 2020 and 2021, as well as those experiencing major disruptions in the future. The interview responses are a general representation of what staff may endure when embarking on a project that is a major disruption to service delivery. The experiences of the participants revealed a cyclical interconnectedness between the themes, indicating the complex nature of work involving human beings. The responses provide tangible recommendations to those planning for, beginning, or experiencing a disruption. © 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.

Relationships matter. new paths for tourism beyond COVID-19 pandemic. an exploratory research from Italy

This chapter aims to understand how and to what extent relational tourism, heavily related to the direct contact among guests, hosts and local communities, can be pursued in the post-COVID-19 scenario and which role could be played by new technologies. According to the multidimensional model of relational tourism (Ruggieri 2007) and the network relationality framework (Marques and Gondim Matos 2020), this research analyses the experience of an online gastronomic “relay race”, the Staffetta della Cucina Ciocheciò, organised during the COVID-19 lockdown. The role played by technology in maintaining existing relations, creating new ones and promoting relational tourism has been analysed through semi-structured interviews and a questionnaire. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021.

Eculizumab treatment in patients with COVID-19: preliminary results from real life ASL Napoli 2 Nord experience.

OBJECTIVE: SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2)-related pneumonia, referred to as COVID-19 (Coronavirus Disease 19), is a public health emergency as it carries high morbidity, mortality, and has no approved specific pharmacological treatments. In this case series, we aimed to report preliminary data obtained with anti-complement C5 therapy with eculizumab in COVID-19 patients admitted to intensive care unit (ICU) of ASL Napoli 2 Nord. PATIENTS AND METHODS: This is a case series of patients with a confirmed diagnosis of SARS-CoV2 infection and severe pneumonia or ARDS who were treated with up to 4 infusions of eculizumab as an off-label agent. Patients were also treated with anticoagulant therapy with Enoxaparin 4000 IU/day via subcutaneous injection, antiviral therapy with Lopinavir 800 mg/day + Ritonavir 200 mg/day, hydroxychloroquine 400 mg/day, ceftriaxone 2 g/day IV, vitamine C 6 g/day for 4 days, and were on Non-Invasive Ventilation (NIV). RESULTS: We treated four COVID-19 patients admitted to the intensive care unit because of severe pneumonia or ARDS. All patients successfully recovered after treatment with eculizumab. Eculizumab induced a drop in inflammatory markers. Mean C Reactive Protein levels dropped from 14.6 mg/dl to 3.5 mg/dl and the mean duration of the disease was 12.8 days. CONCLUSIONS: Eculizumab has the potential to be a key player in treatment of severe cases of COVID-19. Our results support eculizumab use as an off-label treatment of COVID-19, pending confirmation from the ongoing SOLID-C19 trial.