Digital Health Literacy during COVID-19: gender differences from a Florentine University experience : Veronica Gallinoro

Gender appears to be a strong predictor of online health information-seeking behaviour (OHISB). Gender differences in OHISB have been studied in different countries with different results, but no studies investigated gender-specific behaviour among University students during the COVID-19 pandemic, which has brought with it a consequential infodemic. We sought to investigate any gender differences in OHISB in the period between the first and the second wave of the COVID-19 pandemic. A questionnaire promoted by the COVID-HL network was administered to 2996 students of all the courses at the University of Florence. It included existing validated scales adapted to the COVID-19 pandemic and newly developed scales. Gender differences were tested using the χ2 test or the Mann-Whitney U test, where appropriate. Male students reported a higher score in DHL than females (p < 0.001). However, female students reported using more often different sources for online information seeking (p < 0.05, except for YouTube), searching more corona-related topics (p < 0.05, except for economic and social consequences) and considering ‘‘very important'’ each item in the ‘‘Importance of internet information search'’ section (p < 0.05). Furthermore, female students are more likely to be ‘‘often dissatisfied'’ or ‘‘partly satisfied'’ with information about COVID-19 (p < 0.001) and to search more often for information for themselves and other people. Our study confirmed that gender could affect the way students search for health information on the Internet. Since students, in particular females, have been affected by stress and anxiety during the pandemic, these findings could help institutions to promote gender-specific education programmes to improve students’ DHL and their mental health outcomes, as well as to provide health information that fit specific gender needs. Key messages • Gender influences how university students search on the Internet for health information. • This should guide institutions to better address educational programmes to improve their Digital Health Literacy.

Evaluation of COVID-19 impact on DELAYing diagnostic-therapeutic pathways of lung cancer patients in Italy (COVID-DELAY study): fewer cases and higher stages from a real-world scenario.

INTRODUCTION: COVID-19 has disrupted the global health care system since March 2020. Lung cancer (LC) patients (pts) represent a vulnerable population highly affected by the pandemic. This multicenter Italian study aimed to evaluate whether the COVID-19 outbreak had an impact on access to cancer diagnosis and treatment of LC pts compared with pre-pandemic time. METHODS: Consecutive newly diagnosed LC pts referred to 25 Italian Oncology Departments between March and December 2020 were included. Access rate and temporal intervals between date of symptoms onset and diagnostic and therapeutic services were compared with the same period in 2019. Differences between the 2 years were analyzed using the chi-square test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS: A slight reduction (-6.9%) in newly diagnosed LC cases was observed in 2020 compared with 2019 (1523 versus 1637, P = 0.09). Newly diagnosed LC pts in 2020 were more likely to be diagnosed with stage IV disease (P < 0.01) and to be current smokers (someone who has smoked more than 100 cigarettes, including hand-rolled cigarettes, cigars, cigarillos, in their lifetime and has smoked in the last 28 days) (P < 0.01). The drop in terms of new diagnoses was greater in the lockdown period (percentage drop -12% versus -3.2%) compared with the other months included. More LC pts were referred to a low/medium volume hospital in 2020 compared with 2019 (P = 0.01). No differences emerged in terms of interval between symptoms onset and radiological diagnosis (P = 0.94), symptoms onset and cytohistological diagnosis (P = 0.92), symptoms onset and treatment start (P = 0.40), and treatment start and first radiological revaluation (P = 0.36). CONCLUSIONS: Our study pointed out a reduction of new diagnoses with a shift towards higher stage at diagnosis for LC pts in 2020. Despite this, the measures adopted by Italian Oncology Departments ensured the maintenance of the diagnostic-therapeutic pathways of LC pts.

Prevalence and impact of COVID-19 sequelae on treatment pathways and survival of cancer patients who recovered from SARS-Cov-2 infection

Background: The long-term impact of COVID-19 in cancer patients (pts) is undefined. Methods: Among 2795 consecutive pts with COVID-19 and cancer registered to OnCovid between 01/2020 and 02/2021, we examined clinical outcomes of pts reassessed post COVID-19 recovery. Results: Among 1557 COVID-19 survivors, 234 (15%) reported sequelae including respiratory symptoms (49.6%), fatigue (41%) and cognitive/psychological dysfunction (4.3%). Persisting COVID-19 sequelae were more likely found in males (p=0.0407) aged ≥65 years (p=0.0489) with ≥2 comorbidities (p=0.0006) and positive smoking history (p=0.0004). Sequelae were associated with history of prior hospitalisation (p<0.0001), complicated disease (p<0.0001) and COVID-19 therapy (p=0.0002). With a median post-COVID-19 follow up of 128 days (95%CI 113-148), multivariable analysis of survival revealed COVID-19 sequelae to be associated with an increased risk of death (HR 1.76, 95%CI 1.16-2.66) after adjusting for sex, age, comorbidities, tumour characteristics, anticancer therapy and COVID-19 severity. Out of 473 patients who were on systemic anticancer therapy (SACT) at COVID-19 diagnosis;62 (13.1%) permanently discontinued therapy and 75 (15.8%) received SACT adjustments, respectively. Discontinuations were due to worsening performance status (45.1%), disease progression (16.1%) and residual organ disfunction (6.3%). SACT adjustments were pursued to avoid hospital attendance (40%), prevent immunosuppression (57.3%) or adverse events (20.3%). Multivariable analyses showed permanent discontinuation to be associated with an increased risk of death (HR 4.2, 95%CI: 1.62-10.7), whereas SACT adjustments did not adversely affect survival. Conclusions: Sequelae post-COVID-19 affect up to 15% of patients with cancer and adversely influence survival and oncological outcomes after recovery. SACT adjustments can be safely pursued to preserve oncological outcomes in patients who remain eligible to treatment.

Pneumomediastinum and pneumothorax in CoViD-19 patients: A case series

Background: Pneumomediastinum and pneumothorax are not rarely observed during the CoViD-19 pandemic especially among mechanically ventilated patients. We present a case series of six patients with pneumothorax and pneumomediastinum in CoViD- 19 pneumonia. Presentation of the case series: All patients were males with a mean age of 59.63 years. Two patients had spontaneous pneumomediastinum and pneumothorax.One of them denied tobacco or respiratory disease, while the other patient had an history of spontaneous pneumothorax.Four of the six patients received noninvasive ventilation and the average number of days between ventilation and subsequent barotrauma was 8,5 days. Positive end expiratory pressure (PEEP) was started at 10 cmH2 and then reduced to 8 cmH2.Three of patients had not significant comorbidities, while two of them had a medical history significant for hypertension, type 2 diabetes and ischemic heart disease. Five of six patients had a extensive bilateral interstitial pneumonia and no evidence of pulmonary embolism, three of them also had secondary bacterial pneumonia. Pneumomediastinum was treated conservatively in all patients. One patient with extensive pneumothorax required drainage. The probability of pneumomediastinum and pneumothorax increase with the combination of parenchymal injury from CoViD-19 infection and inflammatory response with additional positive pressure ventilation and likely super imposed bacterial infection. Conclusions: Pneumomediastinum and pneumothorax are important CPAP/NIV therapy complications in CoViD-19 and they should be considered if patients begin to deteriorate.

Prevalence and impact of COVID-19 sequelae on treatment pathways and survival of cancer patients who recovered from SARS-CoV-2 infection

Background: The long-term impact of COVID-19 in cancer patients (pts) is undefined. Methods: Among 2795 consecutive pts with COVID-19 and cancer registered to OnCovid between 01/2020 and 02/2021, we examined clinical outcomes of pts reassessed post COVID-19 recovery. Results: Among 1557 COVID-19 survivors, 234 (15%) reported sequelae including respiratory symptoms (49.6%), fatigue (41%) and cognitive/psychological dysfunction (4.3%). Persisting COVID-19 sequelae were more likely found in males (p=0.0407) aged ≥65 years (p=0.0489) with ≥2 comorbidities (p=0.0006) and positive smoking history (p=0.0004). Sequelae were associated with history of prior hospitalisation (p<0.0001), complicated disease (p<0.0001) and COVID-19 therapy (p=0.0002). With a median post-COVID-19 follow up of 128 days (95%CI 113-148), multivariable analysis of survival revealed COVID-19 sequelae to be associated with an increased risk of death (HR 1.76, 95%CI 1.16-2.66) after adjusting for sex, age, comorbidities, tumour characteristics, anticancer therapy and COVID-19 severity. Out of 473 patients who were on systemic anticancer therapy (SACT) at COVID-19 diagnosis;62 (13.1%) permanently discontinued therapy and 75 (15.8%) received SACT adjustments, respectively. Discontinuations were due to worsening performance status (45.1%), disease progression (16.1%) and residual organ disfunction (6.3%). SACT adjustments were pursued to avoid hospital attendance (40%), prevent immunosuppression (57.3%) or adverse events (20.3%). Multivariable analyses showed permanent discontinuation to be associated with an increased risk of death (HR 4.2, 95%CI: 1.62-10.7), whereas SACT adjustments did not adversely affect survival. Conclusions: Sequelae post-COVID-19 affect up to 15% of patients with cancer and adversely influence survival and oncological outcomes after recovery. SACT adjustments can be safely pursued to preserve oncological outcomes in patients who remain eligible to treatment. Clinical trial identification: NCT04393974. Legal entity responsible for the study: Imperial College London. Funding: Has not received any funding. Disclosure: A. Cortellini: Financial Interests, Personal, Advisory Board: MSD;Financial Interests, Personal, Advisory Board: BMS;Financial Interests, Personal, Advisory Board: Roche;Financial Interests, Personal, Invited Speaker: Novartis;Financial Interests, Personal, Invited Speaker: AstraZeneca;Financial Interests, Personal, Invited Speaker: Astellas;Financial Interests, Personal, Advisory Board: Sun Pharma. D.J. Pinato: Financial Interests, Personal, Advisory Board: ViiV Healthcare;Financial Interests, Personal, Invited Speaker: Bayer;Financial Interests, Personal, Advisory Board: Eisai;Financial Interests, Personal, Invited Speaker: Roche;Financial Interests, Personal, Invited Speaker: AstraZeneca. All other authors have declared no conflicts of interest.

Thyroid axis and COVID 19

Introduction: Non-thyroidal illness syndrome (NTIS) is also known as low T3 syndrome. NTIS is characterized by low plasma T3, low or normal T4, or elevated reverse T3 (rT3), with normal or slightly decreased TSH. NTIS is a strong predictor of poor prognosis in critically ill hospitalized patients. Different thyroid hormone profiles were defined during critical illness. High fT4 with a low fT3 level in patients with coronary heart disease were significantly related to mortality. If NTIS is a physiologic response to a systemic inflammation or a maladaptation status is controversial. NTIS with low fT3 and a lower fT3/fT4 ratio was referred in patients with COVID-19. Furthermore, angiotensin-converting enzyme (ACE) 2, an receptor in the pathogenesis of COVID-19, was demonstrated to be expressed in the thyroid gland. SARS-CoV-2- related thyroiditis is recognized. The effects of COVID-19 on the thyroid axis remain uncertain. Objectives: We aimed to study the characteristics of thyroid hormone levels in inpatients with COVID-19. Methods: Prospective study: 57 covid-19 patients (29/57 ♂) with criteria for admission to a medical clinic from August to November 2020. Median age was 56 years (range(R) : 21-89). 3,6% was asymptomatic, 14,3% mild, 28,6% moderate and 53,6% severe. fT4, TT3, TSH, TgAb and TPOAb were analysed in addition to studies due to their underlying pathology. Data are expressed as median and R or mean ± SD and % Results: The median of TSH was 1.77 uUI/ml (R: 0.02-64.9), the X ± SD of fT4 and TT3 was 1.22 ± 0.3 ng/ml and 72.3 ± 23.04 ng/dl respectively. Forty two/ 57 patients presented low T3. The profiles observed in this group are described in table 1. Two patients with positive TPOAb had high TSH, low T3 and normal fT4 and 3 only low T3. Image: Conclusion: 1-In this population of COVID-19 patients upon admission to hospitalization and excluding one clinical hypothyroid patient 73, 7% presented low T3. 2- In the patient with clinical hypothyroidism and negative antibodies as well as those with altered TSH, low TT3 and normal or high fT4 we cannot exclude destructive or autoinmune thyroiditis until the evolution is known. 3-Classic NTI with low T3, low o normal fT4 and nomal TSH was observed in 42, 1% patients. 4- It should be noted the high prevalence of patients with low TT3, high fT4 and normal TSH. We consider that is another face of NTI in COVID-19 as it was referred in patients with coronary disease.To our knowledge, this is the first descriptive report of different faces of NTI in COVID 19 patients.

Correlation between inflammatory parameters and thyroid hormones in patients with COVID-19

Introduction: Non-thyroidal illness syndrome (NTI), (decreased T3 and/or T4 without increased TSH), has been reported in COVID-19 infection. In patients admitted with COVID-19 we found classic NTI presentation and a high prevalence of low T3, high freeT4 (FT4) and normal TSH, which could represent a different presentation of NTI. Low T3 and high FT4 have been associated with mortality1. Objectives: 1-To evaluate correlation of thyroid hormones with biochemical markers of inflammation and association with disease outcome in hospitalized patients with COVID-19. 2-To evaluate these parameters in the two profiles of NTI. Methods: Prospective single- center study that included 55 consecutively patients with COVID-19 hospitalized from August to November 2020. 28/55 (50 %) were male, median age 56y (21-89). Clinical presentation: asymptomatic 3,6% (n=2), mild 14,3% (n=8), moderate 28,6% (n=16), severe 53,6% (n=30). 74,1% had pneumonia, 3.6% (n=2) died and 79,3% had favorable evolution. Thyroid hormones (T4, T3, FT4, FT3) and their ratios (T3/T4, FT3/FT4) were correlated with inflammatory parameters (albumin, ferritin, fibrinogen, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], lactate dehydrogenase [LDH], D-dimer). Comparison between hormone levels, clinical presentation and outcome was performed. Statistical analysis: Spearman correlation, Mann Whitney test and Kruskal-Wallis test. Results: We found correlation between thyroid hormones and their ratios with inflammatory parameters (Table). T3/T4 ratio was lower in severe vs mild/moderate disease [7.5 (4.5-15.5) vs 9.2 (5.8-18.1);p=0.04] and in patients who died vs those discharged [5 (4.53-5.6) vs 8.1 (4.7-18.1);p=0.03]. High FT4 NTI had lower albumin [3.4 (3-4) vs 3.7 (3-4);p=0.03], higher ferritin [1202 (930-7127) vs 435 (101-2232);p<0.05] and tendency to higher fibrinogen [681(583-798) vs 508 (307- 807);p=0.06] than normal/low FT4 NTI. No patient with mild disease at onset had high FT4. Image: Conclusion: In this cohort, both thyroid hormones correlated with inflammation parameters and worse clinical outcome. In NTI group with high FT4, inflammatory parameters were more marked and presentation of the disease more severe.

Surgical management protocol during the COVID-19 pandemic in an Italian non-referral center

BACKGROUND: In the surgical scenario, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion worldwide entails on one end the need to continue to perform surgery at least in case of emergency or oncologic surgery, in patients with or without COrona Virus Disease 2019 (COVID-19), and on the other hand, to avoid the pandemic diffusion both between patients and medical and nursing team. Aim is to report our surgical management protocol during the COVID-19 pandemic in an Italian non-referral center. METHODS: Data retrieved during the outbreak for the COVID-19 pandemic, from March 8 to May 4, 2020 (study period) were analyzed and compared to data obtained during the same period in 2019 (control period). RESULTS: During the study period 41 surgical procedures (24 electives, 17 emergency surgical procedures) underwent surgery in comparison to 99 procedures in the control period. Stratified procedures in elective and emergency surgery, and based on the indication for surgery, the only statistically significant difference was observed in the elective surgery regarding the abdominal wall surgery (0 vs. 13 procedures, p=0.0339). Statistically significant differences were not observed regarding the colorectal and the breast oncologic surgery. All stuff members were COVID-19 free. CONCLUSIONS: The present protocol proved to be safe and useful to prevent SARS-CoV-2 infection before and after surgery for both patients and stuff. The pandemic was responsible for the reduction in number of procedures performed, anyway for the oncologic surgery a statistically significant volume reduction in comparison to 2019 was not observed.