Definition of Indicators for Multi-Criteria Decision Analysis of COVID-19 Emergency Response and Health System Resilience in Italy

The 30 January 2020 the World Health Organization declared the beginning of a global pandemic emergency. Italy was among the first European Countries to be severely impacted by the COVID-19 virus. This short communication describes the organisation of a project investigating different responses to the pandemics, studying the assessment of local and national Health Systems resilience to a biologic hazard such is a Coronavirus. Preliminary results highlighted a fragmented response to the epidemics across the Italian territory probably connected to different public health policies or local emergency management models. The implementation of a Multi-Criteria Decision Analysis is provided to study which are the main important indicators to be considered in the pandemic management. The analysis highlights the successful and effective measures for pandemic planning considering different systems: health, economic, political, socio-psychological, demographic, and emergency.

Applying Intelligent Reflector Surfaces for Detecting Violent Expiratory Aerosol Cloud using Terahertz Signals

The recent COVID-19 pandemic has driven researchers from different spectrum to develop novel solutions that can improve detection and understanding of SARS-CoV- 2 virus. In this article we propose the use of Intelligent Reflector Surface (IRS) and terahertz communication systems to detect violent expiratory aerosol cloud that are secreted from people. Our proposed approach makes use of future IRS infrastructure to extend beyond communication functionality by adding environmental scanning for aerosol clouds. Simulations have also been conducted to analyze the accuracy of aerosol cloud detection based on a signal scanning and path optimization algorithm. Utilizing IRS for detecting violent expiratory aerosol cloud can lead to new added value of telecommunication infrastructures for sensor monitoring data that can be used for public health. IEEE

Evolving Intelligent Reflector Surface Toward 6G for Public Health: Application in Airborne Virus Detection

While metasurface-based intelligent reflecting surfaces (IRS) are an important emerging technology for future generations of wireless connectivity in its own right, plans for the mass deployment of these surfaces motivate the question of their integration with other new and emerging technologies that would require such widespread deployment. This question of integration and the vision of future communication systems as an invaluable component for public health motivated our new concept of Intelligent Reflector-Viral Detectors (IR-VD). In this novel scheme, we propose deployment of intelligent reflectors with strips of receptor-based viral detectors placed between the reflective surface tiles. Our proposed approach encodes information of the presence of the virus by flicking the angle of the reflected beams, using time variations between the beam deviations to represent the messages. This information includes the presence of the virus, its location and load size. The article presents simulations to demonstrate the encoding process that represents the number of virus particles that have bound to the IR-VD. IEEE

SARS-CoV-2-Related Gene Expression in Alveolar Type II Cells in Aging and Emphysema

RATIONALE: The alveolar epithelium is the barrier between inhaled air and the underlying tissue. Alveolar type II (ATII) cells produce and secrete pulmonary surfactant and restore the injured epithelium. It has been reported that SARS-CoV-2 infection causes diffused alveolar damage in the lung. However, host factors facilitating virus infection and COVID-19 pathogenesis are not well known. METHODS: We isolated ATII cells from young and elderly non-smoker, smoker, and ex-smoker organ donors. Also, cells were obtained from lung transplants of emphysema patients. Gene and protein expression related to SARS-CoV-2 infection were analyzed using RT-PCR and Western blotting, respectively. RESULTS: ACE2 was identified as a receptor mediating infection. We found that its levels were significantly increased in ATII cells isolated from elderly smokers compared to non-smokers as detected by Western blotting. ACE2 expression was also higher in ATII cells obtained from emphysema patients compared to non-smokers. ACE2 mRNA levels were increased in elderly non-smokers and smokers compared to young organ donors regardless of smoking status. The viral entry depends on TMPRSS2 protease activity. We detected its increased levels in elderly smokers than young non-smokers by Western blotting. Both ACE2 and TMPRSS2 mRNA levels were higher in emphysema in comparison with non-smokers. Moreover, we found increased CD209L gene and protein levels in young smokers and emphysema patients compared to non-smokers. Furthermore, GRP78, an endoplasmic reticulum chaperone, is an important host factor for viral infection. We detected its increased expression in ATII cells isolated from young and elderly smokers compared to non-smokers by Western blotting. Also, its higher levels were observed in emphysema patients than in non-smokers. CONCLUSION: Our results suggest dysregulation of SARS-CoV-2 infection-related genes and proteins especially in elderly smokers and emphysema patients, which may provide insight into the pathogenesis of COVID-19.

Outcomes with high flow nasal therapy vs invasive mechanical ventilation in COVID-19 patients with hypoxemic respiratory failure

Rationale: Coronavirus disease 2019 (COVID-19) has provoked an unprecedented global pandemic. Invasive mechanical ventilation (IMV) rates in COVID-19 have been reported to be from 2.3% to 33%. The wide range in reported intubation rates is attributed in part to diverging institutional practices for the care of patients presenting with hypoxemic respiratory failure. The role of high flow nasal therapy (HFNT) in the treatment of COVID-19 has been controversial and underreported. Objectives: To report a retrospective analysis comparing the outcomes of patients treated with HFNT and IMV for hypoxemic respiratory failure secondary to COVID-19. Methods: This was an analysis of consecutive patients admitted to Temple University Hospital between March 10, 2020, and May 17, 2020, for moderate to severe hypoxemic respiratory failure from COVID-19 pneumonia. Patients were divided into three groups: IMV group-not placed on HFNT prior to intubation. HFNT group-received only HFNT. HFNT to intubation group-received HFNT prior to intubation. Comparisons were made between demographics, baseline laboratory values, and outcomes. Results: 1396 patients admitted to Temple University Hospital between March 10, 2020, and May 17, 2020 with suspected COVID-19 infection were retrospectively screened for this study. 837 patients tested positive for COVID-19 by nasopharyngeal RT-PCR or deemed positive based on clinical features. There were no statistically significant differences in terms of demographics between all three groups. However, the intubation and HFNT to intubation groups had a higher incidence of malignancy compared to the HFNT only group. There was a higher incidence of smoking in the intubation group (59.2%) and HFNT to intubation group (53.7%) compared to HFNT only group (29.2%). Laboratory data were similar between all three groups besides admission BUN/creatinine. In terms of therapies, high-dose steroids were administered more frequently to patients in the HFNT (84.3%) and HFNT to intubation (90.2%) groups compared to the intubated group (56.5%). Overall, 49 (28.1%) were intubated, 84 (48.2%) were treated with HFNT only, and 41 (23.5%) progressed from HFNT to intubation. The mortality was 36.7% in the intubation group, 6% in the HFNT only group, and 43.9% in the HFNT to intubation group. Overall mortality was 25.7%. Conclusion: Our institutional decision to utilize HFNT as the primary treatment for moderate to severe hypoxemic respiratory failure led to a low intubation rate thus reducing overall morbidity and mortality. In the appropriate clinical context HFNT should be the considered the oxygen modality of choice in moderate to severe hypoxemic respiratory failure secondary to COVID-19 pneumonia.

Rox index predicts intubation in patients with COVID-19 pneumonia and moderate to severe hypoxemic respiratory failure receiving high flow nasal therapy

Introduction Use of high flow nasal therapy (HFNT) to treat COVID-19 pneumonia has been greatly debated around the world due to concern for increased healthcare worker transmission and delays in invasive mechanical Ventilation (IMV). Herein we analyze the utility of the ROX index to predict the need and timing for IMV in a retrospective analysis of patients with COVID-19 with moderate to severe hypoxemic respiratory failure treated with HFNT. Methods This was a retrospective analysis of 129 consecutive patients with COVID-19 admitted to Temple University Hospital in Philadelphia, Pennsylvania, from March 10, 2020, to May 17, 2020 with moderate to severe hypoxemic respiratory failure treated with High Flow nasal therapy (HFNT). HFNT patients were divided into two groups: HFNT only and HFNT progressed to IMV. The primary outcome was the ability of the ROX index to predict the need of IMV. Secondary outcomes were mortality, rates of intubation, length of stay (LOS) and rates of nosocomial infections in our cohort treated with HFNT were also reported. Results 837 patients with COVID-19 were screened, 129 met inclusion criteria. The mean age was 60.8(+13.6) years, BMI 32.6(+8), 58(45 %) were female, 72(55.8%) were African American, 40 (31%) Hispanic. 48 (37.2%) were smokers. Of the 129, 89 were HFNT only group whereas 40 in the HFNT progressed to IMV group. Mean time to intubation was 2.5 days(+ 3.3). The 89 HFNT only patients had a significant improvement in ROX from initiation of HFNT at all recorded time points. In contrast, the ROX in HFNT progressed to IMV patients remained unchanged or decreased over time. ROX index of less than 5 at HFNT initiation was predictive of progression to IMV (OR = 2.137, p = 0,052). Any decrease in ROX index after HFNT initiation was predictive of intubation (OR= 14.67, p <0.0001). In multivariate analysis, ΔROX (<=0 versus >0), peak D-dimer >4000 and admission GFR < 60 ml/min were very strongly predictive of need for IMV (ROC = 0.86, p=0.001). Mortality was 11.2% in HFNT only group versus 47.5% in the HFNT progressed to IMV group (p = 0.0001). Mortality and need for pulmonary vasodilators were higher in the HNFT progressed to IMV group. Conclusion ROX index is a valuable, noninvasive tool to evaluate patients with moderate to severe hypoxemic respiratory failure in COVID-19 treated with HFNT. ROX helps predicts need for IMV and thus limiting morbidity and mortality associated with IMV.

Obesity outcomes in acute respiratory distress syndrome due to COVID-19: A retrospective single center experience

Introduction: The “obesity paradox” has been reported in critically ill patients with acute respiratory distress syndrome (ARDS). Obese patients with ARDS were shown to have more ventilator free days and lower mortality compared to non-obese patients. One proposed explanation was increased levels of pro-inflammatory cytokines creating a protective environment from acute inflammation. In COVID-19, BMI ≥ 30 increases risk of illness severity, need for critical care, respiratory failure requiring use of invasive mechanical ventilation (IMV), and mortality. It is unknown if the “obesity paradox” applies to patients with SARS-CoV2 who require IMV. We examined a cohort of patients with respiratory failure due to COVID-19 who required IMV and compared outcomes between obese and non-obese patients. Methods: Data was collected from patients treated in the COVID Intensive Care Unit (ICU) from March to June 2020. A total of 85 patients were identified. All patients were COVID nasopharyngeal swab positive. Results: There were 38 (44.7%) patients with BMI < 30, and 47 (55.3%) with BMI ≥ 30. The median BMI was 25.5 in the BMI < 30 group, and 37.5 in the BMI ≥ 30 group. In the BMI < 30 group, median age was 67 years, majority male (65.8%) and African American (50%). The BMI ≥ 30 group had a median age of 63.5, majority male (53.2%) and African American (63.8%). Median Sequential Organ Failure Assessment score on admission was higher in the BMI ≥ 30 group at 3 (1.5-4.5) vs. 2 (1.0-4.0). There was elevated creatinine on admission with higher percentage of diabetes, heart failure, and renal disease in the BMI ≥ 30 group. Inflammatory markers, such as CRP and IL-6 were lower in the higher BMI group at presentation. There was higher in-hospital mortality in the BMI ≥ 30 group at 57.5%, with longer ICU length of stay (12.35 vs. 7.6 days), longer days on ventilator (10.2 vs. 4 days), and lower PaO2/FiO2 ratio after intubation (146 vs 348). The higher BMI group had higher rates of prone ventilation, paralytic use, and extracorporeal membrane oxygenation support. Discussion: From our data, obesity did not appear to have better outcomes in ARDS due to COVID-19 infection. Higher BMI was associated with higher disease severity, severe respiratory failure, longer ventilator days, longer ICU length of stay, and higher mortality. Interestingly, inflammatory markers were initially lower in obese patients, suggesting a possible adaptive physiologic response to inflammation, but without effect on overall outcomes.

Utility of remote monitoring and telemedicine in lung transplant recipients during COVID19 pandemic restrictions

Introduction: COVID19 pandemic has led to a significant increase in telemedicine utilization due to risk of healthcare acquired infection. Lung transplant recipients are high risk for infection and have extraordinary health care needs. The HGE remote symptom monitoring has been shown to be beneficial in COPD patients to decrease exacerbations and time to treatment1-8. During peak pandemic restrictions we transitioned to a telemedicine only system and patients were encouraged to enroll in the “HGE COVIDCare” for reporting daily symptoms suspicious for COVID19. With a combination of remote symptom monitoring and telemedicine, we aimed to provide early intervention and necessary care, while decreasing the risk of infection. This study assesses the feasibility and short-term outcomes of using this combination in lung transplant recipients. Methods: Single center, retrospective study of lung transplant recipients of who were enrolled in the HGE COVIDCare symptoms tracker program in March 2020. Pre-pandemic data was collected prior to March 15 and post pandemic restriction data was collected after July 15th, 2020. Patients were asked to report daily symptoms via HGE-COVID website, which was triaged by transplant nurses. We recorded self-reported symptoms from the symptom tracker, details of tele medicine visits and hospitalizations, and changes in pulmonary function tests. Results: The first 50 lung transplant recipients enrolled were included in this short-term analysis with most patients within one-year post transplant (66%). During the four-month pandemic restriction, 6 patients (12%) had “symptom events” reported via the tracker. None of the symptoms were due to COVID19. Etiologies included pneumonia, bronchial stenosis, diarrhea due to C diff and medication or symptoms self-resolving prior to team outreach. 8 patients (16%) were admitted to the hospital for non COVID indications and 2 patients died during this period due to sepsis. Post pandemic limitation PFTs were available for 35 (70%) patients. None of the patients had a decline in PFTs, compared to the “pre pandemic” values. The incidence of hospitalization or acute rejection was similar in the months preceding the pandemic compared to the 4-month pandemic restriction period. Conclusions: In lung transplant recipients, a combination of telemedicine and remote symptom monitoring is feasible and safe. It did not lead to increased rate of hospitalization, acute rejection or worsening lung function in this short term follow up. This model could be potentially followed to help decrease risk of healthcare acquired infections, patient visits and health care costs without impacting outcomes. .