Outpatient treatment of abdominal wall hernia. A strategy to reduce the impact of the COVID-19 pandemic

Outpatient treatment of the abdominal wall hernia. A strategy to reduce the impact of the Covid-19 AIM: The aim of this study is to demonstrate the feasibility and efficacy of the treatment of abdominal wall hernias in ambulatory setting in selected patients to break down long waiting lists due to the COVID 19 pandemic.METHODS: From February to June 2021, we performed 120 hernia repair operations with local anesthesia in ambulatory settings without anesthetists. (105 inguinal hernia, 6 femoral hernia and 9 umbilical hernia). All patients were selected from our waiting lists first through a telephone interview through an adequate collection of the anamnesis and then clinically (LEE index and ASA score) and based on the characteristics of the hernia.RESULTS: For all patients, the operation was performed under local anesthesia with lidocaine and naropine. Lichtenstein tension-free mesh repair were performed for all patients with inguinal hernia;polypropylene mesh-plug was the technique used to repair the crural hernias while a direct plastic was performed for the treatment of umbilical hernias.. The mean age was 58 years. We did not observe any intraoperative complications and patients were discharged after 4 hours of operation. There was no case of readmission. Only 3 (2.5%) patients developed scrotal bruising. We did not observe any other complications or recurrence at 30 days and 6 months. Most patients (97.5%) expressed satisfaction for local anesthesia and for the path created.CONCLUSION: Hernia pathologies could be treated in ambulatory setting with good results in selected patients and could represent an alternative to face the limitations imposed by the COVID pandemic on daily surgical activities.

The Challenges and Value of Undergraduate Oral Exams in the Physical Chemistry Classroom: A Useful Tool in the Assessment Toolbox

The COVID-19 pandemic illuminated challenges with assessment, especially in online environments that threaten academic integrity. In the wake of the pandemic, faculty in higher education were seeking alternative assessments that meet the assessment goal(s) of their classroom. Even though the COVID-based disruptions are diminishing, higher education continues to experience ongoing upheaval related to new technology, such as ChatGPT, requiring ongoing reevaluation of our assessment practices. Upon reflecting on our assessment goals, we explored oral exams as a potentially valuable tool in the assessment toolbox in Physical Chemistry I and II courses at two institutions. In analyzing the course evaluation data at both institutions, we found consistent themes in student-perceived challenges, student-perceived value, and instructor-perceived value. Students had an overwhelmingly positive response to the oral exam experience and recommended their continued use in spite of their perceived challenges. Students found the oral exams challenging due to the stress and anxiety of verbal presentation and the depth of understanding required to answer questions verbally. In response to these challenges, students adjusted their study habits to incorporate studying in groups, verbally speaking out loud, utilizing spaced practice methods, and focusing on understanding concepts and equations instead of relying on memorization of material. Considering the challenges and required adjustment in study habits, students still overwhelmingly recommend using oral exams because they recognize the value of communication and teamwork in their future careers. In addition to student value, the instructors found value in oral assessments, despite the challenges with time commitments, validity, reliability, and fairness. We believe oral assessments in undergraduate chemistry curricula warrant further investigation as a useful tool in the assessment toolbox. © 2023 American Chemical Society and Division of Chemical Education, Inc.

The role of skin tests with polyethylene glycol and polysorbate 80 in the vaccination campaign for COVID-19: results from an Italian multicenter survey.

Summary: Background. International guidelines suggested skin tests with Polyethylene-glycol (PEG) and polysorbate 80 (PS-80), to investigate a possible hypersensitivity to these excipients either to identify subjects at risk of developing allergic reactions to Covid-19 vaccines, or in patients with suspected IgE mediated hypersensitivity reactions (HR) to the Covid-19 vaccine. The main purpose of this study was to investigate the prevalence of PEG and PS sensitization in patients with a clinical history of HR to drugs containing PEG/PS and in patients with a suspected Covid-19 vaccine immediate HR. Methods. This was a multicenter retrospective study conducted by allergists belonging to 20 Italian medical centers. Skin testing was performed in 531 patients with either a clinical history of suspected hypersensitivity reaction (HR) to drugs containing PEG and/or PS-80 (group 1:362 patient) or a suspected HR to Covid-19 vaccines (group 2: 169 patient), as suggested by the AAIITO/SIAAIC guidelines for the "management of patients at risk of allergic reactions to Covid-19 vaccines" [1]. Results. 10/362 (0.02%) had positive skin test to one or both excipients in group 1, 12/169 (7.1%) in group 2 (p less than 0.01). In group 2 HRs to Covid-19 vaccines were immediate in 10/12 of cases and anaphylaxis occurred in 4/12 of patients. Conclusions. The positivity of skin test with PEG and or PS before vaccination is extremely rare and mostly replaceable by an accurate clinical history. Sensitization to PEG and PS has to be investigated in patients with a previous immediate HR to a Covid-19 vaccine, in particular in patients with anaphylaxis.

The ALIGHIERI survey: An Italian overview of global impact of the COVID-19 pandemic on general surgery practice

Background: The present survey aimed to provide a comprehensive overview of the Italian scenario concerning general surgery during the first wave coronavirus disease 2019 (COVID-19) outbreak and evaluate the experiences, trends, attitudes, and possible educational outcomes that this emergency brought to light. Methods: A 31-item survey was designed and edited by the scientific board of the Associazione Chirurghi Ospedalieri Italiani (ACOI), addressing the impact of the pandemic outbreak on surgical staff and activity during the period from 9 March to 30 May 2020 (phase 1, lockdown period) and addressing the status of surgical activity, staff, and surgery resumption in the period from 1 June to 30 September 2020 (phase 3, restart). The survey was distributed via email and social media to Italian general surgeon working both in COVID-19 and non-COVID-19 hospitals. Results: One thousand two hundred and three valid answers were collected for section 1, and 583 for section 2. Fifty percent of the surgery units involved in the study reported that the pandemic had negatively affected their ability to provide surgical assistance. Elective procedures were suppressed for nononcological diseases in 75% of the cases. Seventy-five percent of respondents prioritized oncological surgery over other procedures. During the restart period, the overall surgical activity was resumed entirely only in the 21% of the involved hospital. Conclusion: It will be crucial to organize a "recovery plan" t for all the surgical procedures postponed following a spoke-hub model. When "normal circumstances" will be re-established and a clear need for an organization on a national basis to face the subsequent pandemic outbreaks maintaining surgical activity as steady as possible. © 2022 CIC Edizioni Internazionali s.r.l.. All rights reserved.

A Year with COVID19 - Experience from the Front Line in a Large Infectious Disease (ID) Clinical Practice

Background. ID Care (IDC) is a large, 43 physician, 74 provider, practice that treats patients in 16 acute care hospitals (ACH) and 120 skilled nursing facilities (SNF) in NJ. March 4, 2021 was the first day a patient with COVID19 seen by IDC. Over the subsequent year IDC evaluated, treated, and tested over 23,000 persons for COVID19. Patients were seen in 2 distinct times - wave 1 (W1) March 5-August 31 and wave 2 (W2) September 1 to March 4. We compare the experience of these 2 waves and report on the year of COVID19 at IDC. Methods. The administrative data base for IDC was queried for demographic, visit and testing information. A survey of providers was performed to capture incidence of COVID19 and vaccination rates. Daily census logs were used to create epi curves. Comparisons between waves were performed using student T Test or X2. Results. Table 1 provides the comparisons between waves. More patients were seen in W2, however, the number of visits per patient was less, consistent with a shorter length of stay. Fewer patients were seen in SNF in W2 compared to W1. The age and sex distribution between the waves were the same. A total of 8741 molecular tests were performed. Test positivity peaked the week of December 31 at 6.99% and dropped to 0% by May 1 consistent with vaccination and the NJ epidemic curve. During the year of COVID19, 6/74 (8%) clinicians were infected with SARSCoV2. All recovered. Infections in providers were not clearly work-related exposures. 73/74 clinicians were vaccinated. Conclusion. The year of COVID19 occurred in 2 distinct waves. W1 was short and intense. The age and gender distributions were the same between the waves. Even though wave 2 was numerically greater, the cases in SNF were statistically less than the first wave likely from improved IP practice initiated in W1. The numbers of visits per patient, a surrogate for LOS, was statistically less in W2. The decline in test positivity paralleled deployment of vaccination. Despite an intensity of exposure of 158 patients/provider or 1198 visits/provider to SARSCoV2 infected persons only 8% of the clinician staff were infected. ID clinical practice can use electronic databases to help describe regional outbreaks of transmissible disease giving additional perspective across the care continuum. A more usable standard tool would enhance this capacity.

Serological Response Following BNT162b2 Anti-Sars-Cov-2 mRNA Vaccination in Hematopoietic Stem Cell Transplantation Patients

Patients with hematological malignancies (HM) undergoing hematopoietic stem cell transplantation (HSCT) have an increased vulnerability to SARS-Cov-2 (Sharma et al, Lancet Haematology 2020;Ljungman et al, Leukemia 2021), the reason why international guidelines strongly support the need for a protective vaccination for these subjects. The most relevant data currently available on the response to a complete anti-SARS-Cov-2 vaccination cycle in HM patients after HSCT refer to 314 patients reported in a Lithuanian national survey (Maneikis et al, Lancet Haematol 2021). In this study, the median titers of antibodies against SARS-Cov-2, determined 7-21 days after the second vaccination, were comparable to that of healthy controls (HC) in both autologous and allogeneic groups, with no patient found below the protective threshold of 50 arbitrary units (AU)/ml. Notably, the large majority of patients had received the transplant more than 1 year before vaccination. In a prospective, cohort study, we compared 114 patients, who had received an autologous or allogeneic HSCT at least three months before the first dose of vaccination, to 107 HC, matched for age and sex. Study population and HC received two doses of BNT162b2 anti-SARS-Cov-2 mRNA vaccine on days 1 and 21, between April and May 2021. Serological tests were performed by a commercially available immunoassay for the quantitative determination of anti-spike IgG antibodies to SARS-Cov-2. The cut-off for defining responders was 50 or greater AU/ml. Patients and HC samples were collected four weeks after the second dose of the vaccine. Table 1 reports the main clinical characteristics of patients and HC. Eighteen of 114 patients (16%) did not respond (24% in the allogeneic group, 6% in autologous recipients). Overall, median antibodies titers did not differ between HC and the entire cohort of transplanted patients, recipients of allogeneic HSCT, all patients responding to the vaccine or responders in the autologous subgroup (Figure 1A). All autologous HSCT recipients had significantly lower titers of antibodies than HC, while higher levels were found in responders who had received allogeneic HSCT (Figure 1A). Responders in the allogeneic subgroup showed antibodies titers significantly higher than responders in the autologous subgroup (Figure 1B). We further stratified patients in three groups, according to the time elapsed from transplant to vaccination: G1:<1 year;G2:1-5 years;G3:>5 years. Higher antibodies titers were observed in HC compared to all transplanted patients in G1 (Figure 1C), including both allogeneic (Figure 1D) and autologous (Figure 1E) HSCT recipients. No differences emerged in G2 between HC and all patients (Figure 1C), allogeneic (Figure 1D) or autologous (Figure 1E) HSCT recipients. Finally, no differences were found in G3 when comparing HC with all patients (Figure 1C) or allogeneic recipients (Figure 1D), whereas patients in the autologous subgroup showed significantly lower titers than HC (Figure 1E). Myeloma patients with controlled disease showed higher titers than patients with active disease (Figure 1F). According to median age, autologous HSCT recipients older than 57 years had significantly lower antibody levels than younger patients (Figure 1G). Autologous vs allogeneic HSCT, age of all patients and of allogeneic HSCT recipients, sex, type of allogeneic HSCT, conditioning regimen, age and sex of donor, occurrence of GVHD, disease type and single vs double autologous HSCT did not significantly impact on antibody levels (data not shown). No relevant side effects were recorded after vaccination. With a median follow up of 12 weeks, no case of COVID19 occurred among vaccinated patients. In our single center study, patients with a previous history of HSCT tolerated well BNT162b2 vaccine and mounted a potentially protective immune response in the majority of cases one month after two doses of vaccine. However, lack of response was not rare, especially in the allogeneic setting. The main factor associated with the quality of response was the tim from HSCT, with lower responses within the first year from transplant and differences between autologous and allogeneic groups transplanted more than five years before vaccination. Here, a consolidated, complete immune reconstitution in allogeneic HSCT recipients, as well as age and a still active disease in the autologous setting, could have played opposite pivotal roles. [Formula presented] Disclosures: Delia: Gilead: Consultancy;Amgen: Consultancy;abbvie: Consultancy;Jazz pharmaceuticals: Consultancy.

Construction of a resource for advance care planning in multiple sclerosis (concure-SM): Results of cognitive debriefing with users

Background: ConCure-SM is a mixed-methods research project for developing and testing an advance care planning (ACP) intervention for people with progressive multiple sclerosis (pwPMS) in Italy. It consists of a booklet to be used during the ACP conversation (the focus of this presentation) and a training program for neurologists and other MS healthcare professionals (HPs). Aims: To assess the acceptability and comprehensibility of the ConCure-SM booklet. Methods: An inter-disciplinary panel translated and adapted to the Italian legislation and to the MS context a booklet developed by the National ACP programme for New Zealand. The booklet was then probed via individual cognitive interviews with pwPMS and caregivers, and a focus group meeting (FGM) with MS HPs. Two weeks before the interview/ FGM, held on digital platform due to the COVID-19 pandemic, participants received the booklet and were invited to browse it. Results: Between September-January 2021 we conducted 13 interviews which lasted between 36 and 80 minutes. Participants were 10 pwPMS and 3 caregivers (2 spouse, one daughter);8 were men, median age was 54 years. Data saturation was achieved after 11 interviews were analyzed. Twelve HPs participated in the FGM (7 neurologists, 3 psychologists, one nurse and one physiotherapist), which lasted 1.45 min. Thematic analysis (performed by LDP, SV, and LG) identified 4 overarching themes: comprehensibility and clarity;content acceptability and emotional impact;images and layout;suggestions for improvement. Interviews revealed that the booklet was useful and informative, though pwPMS found it emotionally taxing. The FGM was well participated;few experiential data on ACP emerged, lack of training and time constraint emerging as major reasons. Conclusions: Cognitive debriefing was key to refine the ConCure-SM booklet. Interview and FGM results corroborated use of the booklet within the ACP conversation, and the challenge of appraisal as a standalone tool.

Treatment of cll relapsed/refractory patients in covid-19 pandemic: A real-life experience with venetoclax-rituximab combination in southern Italy

Background: Given the multifactorial immune defect characterizing chronic lymphocytic leukemia (CLL), it appears conceivable that these patients have risk factors that increase their likelihood of complications and death from COVID-19. Aims: To evaluate incidence and severity of COVID-19 cases in a well-defined cohort of patients with CLL receiving venetoclax-based combinations. Methods: We administered a survey to a cohort of CLL treating hematologists from hematological centers in southern Italy. Participants were asked: a) to indicate whether they had offered a test for detection of COVID-19 infection (mainly nasopharyngeal swabs) only to CLL patients who reported symptoms or universally;b) to provide information on the incidence of COVID-19 infection and its severity;c) to specify reasons of possible treatment modifications. The survey was restricted to relapsed-refractory (R/R) CLL patients treated from Feb 1st to Dec 31th 2020 with time-limited venetoclax/rituximab (VR) combination as recommended by MURANO protocol (venetoclax for up to 2 years plus rituximab for the first 6 months), within their clinical practice. Results: A specific questionnaire was sent to 30 CLL hematologists, but only 26 responded to all questions. We considered suitable for the present analysis the 24 questionnaires compiled by hematologists who declared to have treated at least one patient with VR combination in the observation period. Of those, 20.8% worked in academic hospitals. Overall, the survey allowed to collect data on 124 patients who were treated with VR combination. The median number of patients treated in each center was 5 (range,1-15).COVID-19 surveillance tests consisted of viral RNA reverse transcriptase PCR (RT-PCR) on nasopharyngeal swabs. Generally, a policy of universal SARS-CoV-2 testing to be performed on patients at different time-points of therapy was used. Most patients (83/124, 66.9%) were tested before beginning the ramp-up with venetoclax;moreover 66/124 (53.2%) were regularly tested before each rituximab infusion (Fig 1).Reasons for potential change of the schedule of treatment were also investigated. The survey revealed that adherence to treatment was relatively high (70.8%). Only 29.1% physicians modified the therapeutic program mainly because of grade 3 neutropenia. Changes consisted of transient interruption of venetoclax, reduction of doses, and delay of rituximab infusion.Only 2/124 patients (1.6%) had a symptomatic RT-PCR proven diagnosis of COVID-19 infection and required hospitalization. Both patients needed oxygen therapy and admission into an intensive care unit. Of those, 1 patient who was receiving VR combination at the time of COVID infection, eventually died. The second patient developed COVID-19 infection while receiving venetoclax monotherapy (after the VR combination period). He recovered from COVID-19 infection and after 21 days of treatment interruption, he was able to restart venetoclax. Summary/Conclusion: Results of the present survey provide information, thus far lacking, on the use in real-world clinical practice of VR combination during the COVID19 pandemic in 2020. Current literature on the prevalence of COVID-19 infection in CLL, has some limitations (i.e., small size sample, heterogeneity of treatment, restriction to only the first pandemic wave);this survey, performed on a large number of CLL patients treated with VR combination only seems to provide additional information on safe management of CLL treatment during the COVID19 pandemic.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) after COVID-19

Background and aims: SARS-CoV-2 infection is now known to be associated with a wide spectrum of neurological autoimmune syndromes, in some cases responding to immunotherapies, arising during or after the infection. Whether molecular mimicry or other immune stimulation may induce an aberrant delayed autoimmune response is still to be established. Methods: Case report. Results: A 71 year-old man with no previous medical history apart from mild COVID-19 pneumonia three month earlier, sought medical attention for a subacute onset of diplopia in left gaze, general malaise and fatigue. MRI was characterized by bilateral FLAIR hyperintensities with punctate, perivascular and confluent post-gadolinium enhancement in the pons, mesencephalon, hypothalamus, internal capsules and right hippocampus. Repeated cerebrospinal fluid analysis were normal (2 cells/μL), with no evidence of oligoclonal bands or atypical cells. Screening panel for autoimmune and infectious aetiologies was negative. Whole-body contrast-enhanced CT was unremarkable. Stereotactic temporal lobe brain biopsy showed aspecific chronic lymphocytic perivascular inflammation. Partial spontaneous remission of symptoms occurred within few weeks. He was then treated with intravenous high-dose methylprednisolone with almost complete enhancement regression on MRI. Collected data were suggestive of CLIPPERS with diffuse bilateral sovratentorial involvement. The patient started daily oral steroid tapering and monthly cycles of intravenous cyclophosphamide with persistent clinical and neuroradiological stability. Conclusion: CLIPPERS is a rare diagnosis and to the best of our knowledge, this is the first time it was reported after COVID-19 disease. Even though a case report is not enough to suggest a causal link, future reports could support this possibility. (Figure Presented).

Anton syndrome in posterior reversible encephalopathy syndrome followed by Guillain-Barré syndrome: A case report

Background and aims: Anton-Babinski syndrome is a rare condition due to occipital injury by different mechanisms, such as vasogenic edema in posterior reversible encephalopathy syndrome (PRES) resulting from bood-brain barrier (BBB) disruption. PRES has been rarely associated with Guillain-Barré syndrome (GBS). It has hypothesized that autonomic dysfunction in GBS might lead to BBB damage with consequent PRES before motor symptom onset. Another possibility is that BBB injury in PRES might trigger immune-mediated reaction leading to GBS. Methods: An 80-year-old woman was admitted to our emergency room (ER) after she developed two partial seizures, successfully treated with 5mg of intravenous midazolam. Her medical history was unremarkable except for previous SARS-CoV-2 disease. Results: After one hour from midazolam administration, the patient was still markedly confused. Examination revealed binocular blindness, without signs of optic neuropathy;despite being obviously blind, she denied any vision disturbance, a phenomenon known as visual anosognosia. Her blood pressure was 180/90mmHg. Brain MRI showed posterior alterations compatible with PRES. She was treated with antihypertensive and vision recovered after 24 hours. On day 3, she developed areflexia and proximal symmetrical weakness to both upper and lower limbs. Electromyography suggested recent motor poliradiculoneuropathy. Clinical picture was compatible with GBS and intravenous immunoglobulins were started, with gradual recovery. A 8-day follow-up MRI showed nearly complete normalization of posterior lesions. Figure 1 Conclusion: Anton syndrome is a possible rare presentation of PRES. Occurrence of unexplained weakness after PRES should raise suspicion of GBS in consideration of their pathophysiologic connection.

How School Has Changed for 3–14-year-Old Students: An Italian Case Study

This chapter summarizes the actions implemented by the Comprehensive Institute ‘Cuneo Oltrestura’ during the COVID-19 emergency. This Italian school includes kindergarten, primary, and secondary schools. The Institute had already in place a variety of technological tools well integrated into the daily lessons. This has favoured the mandatory shift from a face to face methodology to a distance learning that the lockdown situation has forced. The characteristics of the new learning environment for each school type are summarized as well as, the experience of “adopting schools” to support other schools in implementing distance learning. © 2021, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.