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BACKGROUND AND AIM: Sars-CoV-2 infection can lead to severe pulmonary impairment at all ages, however, the best therapy in children is not established. Our objective is to discuss a severe pulmonary case in a pediatric oncology patient who presented good clinical evolution and the therapeutic measures chosen in its management. METHOD(S): Case report and literature review. RESULT(S): A 2-year-old girl undergoing chemotherapy for acute lymphocytic leukemia had received cytarabine and methotrexate one week before being admitted to the ward for febrile neutropenia, identified with Sars-Cov-2 infection by RT-PCR. Referred to pediatric intensive care on day 3 of symptoms when she was prostrate and antibiotics switched to a broader spectrum. On day 8 of symptoms she rapidly developed respiratory failure and required mechanical ventilation at high parameters, CT scan showed lesions in ground glass in 75% of the lung parenchyma. On day 9, she was still feverish and showed altered inflammatory tests, such as ferritin 4492 mcg/L D-dimer 5909 ng/dL CRP 28 mg/ dL. Cardiac, hepatic and renal functions remained stable. At that moment, the patient received gammaglobulin 2g/kg in a single dose and methylprednisolone 2mg/kg/day for 5 days. Substantial improvement was observed 48 hours after the introduction of anti-inflammatory therapy, allowing for weaning and extubation after 7 days of mechanical ventilation. 72 hours after extubation, she was discharged home, breathing normally on room air. CONCLUSION(S): Severe Sars-Cov-2 lung infection in a pediatric oncology patient with markedly high inflammatory tests was treated with anti-inflammatory therapies such as steroids and gammaglobulin, with rapid and favorable recovery (Figure Presented).
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Background: Detection and surveillance of SARS-CoV-2 is of eminent importance, particularly due to the rapid emergence of variants of concern (VOCs). Since September 2020, the TaqPath COVID-19 assay (Thermo Fisher Scientific, Waltham, MA, USA) has been used to identify viral strains of the new lineage B.1.1.7, since it previously failed to detect the S-gene 69/70 deletion. Rapid detection of these variants of concern can help to contain them and prevent widely spreading throughout the population. This study evaluated S-gene mutations screening with a commercially available qualitative real-time PCR (RT-PCR) assay to detect likely variant of SARS-CoV-2 by the S gene amplification curve non-sigmoidal fluorescence profile. Method(s): The viral RNA of the samples was extracted using the Seegene STARlet automated system combined with StarMag 96x4 Viral DNA/RNA 200C. All samples were subjected to Real Time RT-PCR with the AllplexTM SARS-CoV-2 Assay kit (Seegene Inc, Seul, South Korea) for the qualitative detection of four target genes: E, N, RdRp, and S genes. PCR has been performed by a CFX-96 real-time thermocycler (Bio-Rad Laboratories Inc, Hercules, CA, USA) and Ct values were acquired from the fluorescence channels by the fluorophores FAM (E gene), Quasar 670 (N gene), Cal Red 610 (RdRp and S genes), and HEX (internal control). Gene target amplification curve analysis was performed using Seegene Viewer ver 3.24 (Seegene). The samples tested positive for SARS-CoV-2 viral genome, which presented abnormalities in the fluorescence profile of the amplification curve of the RdRP/S genes, were further subjected to the amplification protocol by the GSD NovaTYpe SARS-CoV-2 amplification kit (Nova Tec Immunodiagnostica, Dietzenbach, Hessen, Germany), and to definitively confirm the presence of the English variant (lineage B.1.1.7), subsequently subjected to Next Generation Sequencing (NGS). Result(s): Thirty respiratory samples subjected to amplification using the AllplexTM SARS-CoV-2 Assay in early January 2021, showed a reduction in amplification efficiency on the fluorescence profile of RdRP/S genes with slope and inflection point variations. The profile of the SARS-CoV-2 English variant (lineage B.1.1.7) for the 30 samples, was performed first by qualitative test in RT-PCR, GSD Nova TYpe SARS-CoV-2, and subsequently confirmed by NGS technology (analysis performed in an external laboratory). Both analytical methodologies identified all 30 samples with the B.1.1.7. lineage of SARS-CoV-2. This last diagnostic proof pushed our working group to evaluate the presence and degree of spread of the English variant in the area of the Napoli 3 Sud ASL, testing the viral genome of 900 samples to RT-PCR using the Allplex TM SARS-Cov-2 kit, alterations in the fluorescence profile of the amplification curves related to the S gene were observed and confirmed using the GSD NovaTYpe SARS-CoV-2 kit. Conclusion(s): Since late 2020, several variants of SARS-CoV-2 have emerged around the world. The gold standard molecular method to detect a specific variant consists in the total or partial sequencing of the virus genome, but today the latter remains expensive and time-consuming, limiting its implementation in all diagnostic samples. PCR-based screening approaches are relatively cheaper, and results can be verified in a few hours. The indirect approach in RT-PCR, on SARS-Cov-2 diagnostic tests of positive samples, of the non-sigmoidal fluorescence profile of the S gene using AllplexTM SARS-CoV-2 PCR assay allows a quick and cheaper prediction of the lineage B.1.1.7. Therefore, using Allplex SARS-COV 2 can be used as an early and first-line screening, before eventually using the sequencing of the viral genome. Copyright © 2022 EDIZIONI MINERVA MEDICA.
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Introduction: The COVID-19 pandemic has caused mental health consequences. Preadolescents and adolescents are particularly vulnerable to stress exposure and social isolation. We focused on the impact of restrictions on youth with type 1 diabetes (T1D). Objective(s): The aim of this study was to observe glycemic control and psychological adjustment trajectories after 1 year of the COVID-19 pandemic. Method(s): We followed a cohort of youth with T1D of Pediatric Diabetes Unit at the University Hospital of Padova. Inclusion criteria were: age between 12 and 20 years, T1D duration >1 year. We used a mixed method approach. We analyzed mean glucose, Coefficient of Variance (CV), Time In Range (TIR), Time Above Range (TAR), Time Below Range (TBR) and Glucose Management Indicator (GMI). Test of Anxiety and Depression for Children and Adolescents (TAD) was used to evaluate psychological symptoms. Glucose metrics and psychological data were collected at different COVID-19 time points: 1 year before, during the first lockdown, and during the second wave. Further, during the diabetes summer camp, 24 participants joined group meetings to explore their COVID-19 lockdown experiences. Data were analyzed using thematic analysis. Result(s): Our data showed that 1 year post-pandemic, the improvement in glycemic control appears time stable, while depression and anxiety symptoms get worse in preadolescents (p < 0.05). Common identified themes were: changes in interpersonal relationships and health-related behaviors, lifestyle modifications and emotion regulation. Qualitative data suggest that some participants experienced psychosocial distress during lockdowns, while others spent time selfcaring and discovering new aspects of themselves. Conclusion(s): Repeated exposure to stress and potentially traumatic events increases risk of psychological morbidity in people with higher vulnerability, such as adolescents with T1D. Patients' cognitive appraisal influenced wellbeing and psychological adjustment to the pandemic.
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Background To face the second COVID-19 wave, Italy implemented a tiered restriction system with different risk levels (yellow=low;orange=medium, red=high). It is unknown whether the effect of the tiers was equal among provinces with varying levels of socioeconomic deprivation (SED). At each restriction level, we analyzed the impact of the province's SED on the SARS-CoV-2 daily reproduction number (Rt). Methods We considered the Rt (Nov 2020-May 2021) as the dependent variable and the SED as the independent variable. The Rt was estimated using daily incidence data from the Civil Protection Department as the instantaneous Rt. The province SED was measured using the percentage of individuals whose yearly income was less than 10,000€ (2019 data from the Ministry of Economy and Finance). We used multilevel linear regression models with random intercepts stratified by restriction level to estimate the effect of the SED on Rt (β) and its Standard Error (SE). Our analyses adjusted the estimates for the number of days into the tier first and then for other covariates. Results We found different levels and trends of Rt by SED in every restriction. Days-adjusted models found a containing effect for the red and the orange tier, while the Rt had an increasing trend in yellow. Higher SED was associated with higher Rt: β was positive and significant in red (β = 0.004 SE = 0.001) and orange (β = 0.002 SE = 0.001) but not in the lowest tier (β = 0.001 SE = 0.001). We found a significant interaction between the number of days into the restriction and the SED in the complete models. Compared to less deprived, more deprived provinces had slower Rt reduction in the highest tier. However, they had steeper Rt reductions in orange and slower increasing trends in yellow. Conclusions The highest restriction had milder effects in more deprived provinces, while lower tiers were more effective. These results underline the importance of accounting for SED when implementing public health measures. Key messages • Area-level deprivation can modify the effects of public health measures. • Socioeconomic characteristics of the areas should be considered when implementing policies aimed to prevent the spread of epidemics.
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Aim: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to the potential risk of virus transmission by laparoscopy and controversial recommendations on this issue in the literature. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Method(s): From 1 August to 30 September 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study by email. The questionnaire included questions on Personal protective equipment (PPE), local policies and screening for SARS-CoV- 2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Result(s): 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% pavs 37.4%) with PCR alone as the preferred test (57.1 % vs 15.8 %). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a decline in the use of NOM. Conclusion(s): Management of acute appendicitis seem to have improved in the last waves of pandemic. Increased evidence regarding SARS-COV- 2 infection along with a better organization of healthcare systems has been translated into tailored attitudes and a better care of patients affected by AA worldwide.
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Background: The impact of the severe acute respiratory syndrome Coronavirus 2 disease (COVID-19) pandemic on people with systemic autoimmune rheumatic diseases (SARDs) remains to be fully established. It is unclear whether SARDs are an independent risk factor for COVID-19 infection and poor outcome. Objectives: The aim of our study is to assess the incidence and prognosis of test-proven SARS-CoV-2 infection during the frst COVID-19 wave in a large population of SARD patients of the Lazio Italian region. Methods: We retrospectively evaluated in a cohort of 4.716.119 subjects aged over 18 years and affiliated to the health system of the Lazio Italian Region, the incidence and 30-day outcomes of COVID-19 infection in 40.490 SARD pts and compared to the affiliated population as incidence rate ratio adjusted for demographics and comorbidities (adjIRR). SARD diagnosis and comorbidities were derived from medical administrative records using the Chronic Related Group classifcation system. Data on COVID-19 infection were derived from a dedicated regional digital network. Results: The risk of COVID-19 infection was increased in patients with Psoriatic Arthritis (adjIRR=1.21, 95% CI 1.10-1.33) and Undifferentiated Connective Tissue Disease (adjIRR=1.26, 95% CI 1.03-1.54). The risk of hospitalisation was higher in patients with Axial Spondylarthritis (adjIRR=2.16, 95% CI 1.45-3.22), and Systemic Vasculitis (adjIRR=1.81, 95% CI 1.07-3.06) while the risk of Intensive care unit admission was higher in Systemic Erythematous Lupus (adjIRR=3.67, 95% CI 1.52-8.83) and primary Sjögren Syndrome (adjIRR=4.13, 95% CI 1.71-9.96) patients. An increased COVID-19 mortality was reported in patients with Rheumatoid Arthritis (adjIRR=1.50, 95% CI 1.04-2.17), Systemic Erythematous Lupus (adjIRR=2.67, 95% CI 1.10-6.44), primary Sjögren Syndrome (adjIRR=2.51, 95% CI 1.12-5.62), and Scleroderma (adjIRR=4.60, 95% CI 2.06-10.29). Conclusion: The incidence of severe COVID-19 is not increased in the same percentage in SARDs. Each SARD presents a peculiar pattern in terms of increased risk of COVID-19 incidence, hospitalisation, intensive care unit admission and death, that is not linked to the immunosuppressive behaviour of the disease.
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COVID-19 , Eosinophilia , Erythema Multiforme , BNT162 Vaccine , COVID-19 Vaccines , Erythema Multiforme/chemically induced , Humans , RNA, Messenger , SARS-CoV-2ABSTRACT
According to UN-Habitat, in 2020 there were 1,934 metropolises around the world, representing approximately 60 per cent of the world’s urban population. In 2020, 2.5bn people lived in metropolises, which is equivalent to one-third of the global population. Due to their structure and function, this typology of city has become central in tackling key urban challenges in recent years. Thanks to information communications technology (ICT), artificial intelligence (AI), quantum computing and big data analysis, they have demonstrated great flexibility in policymaking and innovation, rethinking their functions and spaces, and enhancing resilience and sustainability in order to provide better services in more efficient ways. Fifteen-minute cities, investment in algorithms for public mobility, conversion of abandoned areas into green spaces, are only some of the solutions adopted around the world in both developed and developing countries. The COVID-19 pandemic has accelerated digital processes, allowing for a reconsideration of urban environments, movement, and existence through the employment of new technologies and solutions. Therefore, the major goals of this research are to: 1) review the literature on the influence of ICTs on urban areas;2) analyse the research on the impact of the COVID-19 pandemic on cities;and 3) analyse new policies and resolutions on urban and city planning. © Henry Stewart Publications.
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Objectives: In order to contain Covid 19 pandemic, a lockdown was established in several countries, including Italy, with a great impact on the daily routine of children and teenagers. As a consequence, healthcare professionals were encouraged to follow patients through telemedicine. Our center, in line with ISPAD recommendations, continued to follow patients and families through a telehomecare program which included video interviews, analysis of diabetes data through CGM metrics, psychological and nutritional assessments. The aim of our study was understanding how Covid-19 pandemic can impact on glycemic control in youths with type 1 diabetes. Methods: 117 subjects (F/M = 52/65) with T1DM were recruited from 8 to 24 April 2020. The mean age was 15.9 ± 2.3 years, mean duration of T1DM was 7.9 ± 4.6 years and mean BMI was 22.18 ± 3.6. The majority of participants were treated with MDI (87%), the others with CSII (13%). The mean A1c level was 7.6 ± 1.2%. We analyzed standardized CGM metrics: mean glucose, glycemic variability, TIR, time below range and GMI of two weeks during the lockdown, comparing data with those reported in the same weeks of the previous year. The psychological wellbeing was evaluated using TAD (Test of Anxiety and Depression). Results: In our population, during the lockdown, there was an increase of TIR compared to the same period of the previous year (P = 0.02). As regards psychological evaluation, 5% reached a score for anxiety and 12% for depression. However no significant correlation was identified between TIR and TAD scores. Conclusions: This study provides pointers to the impact of quarantine on diabetes management in a pediatric population. Adolescents with T1DM improved their glycemic control during the restrictions due to COVID-19 pandemic. One of the hypotheses could be related to a more regular daily routine and nutritional pattern.
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The COVID-19 pandemic has challenged our abilities to provide timely surgical care for patients, including women with gynecologic cancer. In March 2020, the American College of Surgeons, The US Surgeon General, and many medical and surgical academic societies recommended postponing elective surgical interventions. Recognizing that the pandemic may occur in waves, special considerations should be made for appropriate indications for surgical intervention in the setting of strained resources and personnel to meet surgical demand and prioritize excellent patient care. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to hesitate, and reintegrate surgery. Regarding prioritization, patients should be counseled on risks of surgical delay versus in-hospital or community-acquired COVID-19 exposure in the perioperative setting. Patients should be informed that surgical prioritization is based on (1) local projected resources, (2) disease prevalence, (3) patient and tumor characteristics, and (4) expected outcomes from delays. Several prioritization algorithms have been developed that take into account disease characteristics, patient comorbidities, available personal protective equipment, length of hospital stay, local COVID-10 prevalence, and more. Most oncological procedures have been classified as semiurgent, with a high priority tier 3 designation (second to emergent cases and trauma). Published literature demonstrates that most women with newly diagnosed gynecologic cancer are unlikely to be impacted by a few weeks surgical delay. Those with malignancies with a propensity for metastasis or advanced stage ovarian and uterine malignancies that require interval cytoreduction should be prioritized when possible. For mitigation of complications before, during, and after surgery, patients should be educated on recommendations for social distancing, hand hygiene, and personal protective equipment such as face masks. Providers should abide by similar recommendations and use eye protection in the ambulatory and inpatient settings. N95 respirators or powered air-purifying respirators are recommended in the care of suspected or known COVID-19 patients. Clinical screening should be done at multiple points, COVID-19 testing should be done preoperatively, and a positive test result should delay surgery until asymptomatic formore than 14 days. Safety protocols are critical during procedural intubation and extubation, as this is themost hazardous aspect of surgery in a COVID-19-positive/unknown patient. Open surgery should not be considered safer than minimally invasive surgery. Practitioners for whom the risk of severe disease and death is highest should avoid participating in the surgical care of known COVID-19-positive patients, if possible. Telemedicine should be incorporated to limit provider and patient exposure in the postoperative setting. Virtual platforms have also demonstrated efficacy in virtual rounding as well as patient care settings to involve family members in treatment planning and discussions around diagnosis. Platforms emphasizing enhanced recovery time and same-day discharge should be prioritized, and measures should be taken to reduce delirium risk given lack of patient visitors. Reintegration efforts should focus on systematically prioritizing the nonurgent cases that were initially delayed. Surgical restrictions are likely to continue for some time, and institutional and departmental leadership will be paramount to optimize surgical manpower, support operative personnel, and use hospital resources equitably and responsibly.
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Starting from 1st case in Italy, on February 20th, 2020, CO-rona VI-rus D-isease 2019 (COVID-19) pandemic spread to whole Italian territory, with different regional distribution. Tuscany has been classified as medium diffusion area (40-100 cases/100000 inhabitants). In this context, all healthcare structures reviewed their organization to meet new needs. Our study's objectives were description of organizational model outlined to safely manage Emergency Department (ED) and analysis of patients' flows within Hospital of Pisa during pandemic. The ED has been reorganized with dedicated areas for examination and waiting for tests results. A similar reduction (-62%) of ED accesses comparing to the same period of 2019 and the previous months of 2020 was observed. Hospital Task Force arranged for progressive activation of Units by modules, according to territorial needs. From the beginning of March to the end of April 2020, 315 COVID-19 patients were hospitalized. Overall, a 45% reduction in hospital admissions compared to the same period of 2019 was observed, with increased mortality (4% versus 2%). The University Hospital of Pisa efficiently managed COVID-19 emergency with a logistical reorganization of ED.
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BACKGROUND: High flow nasal cannula (HFNC) showed better oxygenation than standard oxygen therapy delivered through a face mask in acute respiratory failure for all causes. HFNC may offer an alternative in patients with acute hypoxemia and potentially reduce mortality. It was widely applied in China during the COVID-19 emergency. However, no data have been published about settings and protocols. The purpose of this paper was to report a single center experience on effectiveness and safety of HFNC in weaning of COVID-19 associated respiratory failure. METHODS: We retrospectively analyzed patient records from Sub-intensive Care Unit (Cotugno Hospital, Naples, Italy). Four patients (3F;age: 60±9.23 years;BMI: 27.5±5.2) were de-escalated from ventilation (3 Helmet CPAP, 1 invasive mechanical ventilation) to HFNC oxygen therapy. All patients were admitted for severe acute respiratory failure and pneumonia due to SARS-COV-2 (PaO2/Fio2 at baseline: 104±42.3 mmHg) and showed a typical progressive stage at chest imaging. Weaning was initiated following a stable period of ventilation (PaO2/Fio2 in last days of first respiratory support: 377±60.2 mmHg). HFNC was set on 34 °C, with flow ranging from 50 to 60 L/min and FiO2 from 40 to 60%. RESULTS: Right after initiation of HFNC (day 1), the mean PaO2/Fio2 was 238 mmHg (±65), without clinical signs of respiratory distress. No difference was observed on lactate. After 3 days of therapy mean PaO2/Fio2 increased to 377 mmHg (±106.3). All patients recovered from respiratory failure (PaO2>60 mmHg in room air) after 7 days (±3.2). CONCLUSIONS: HFNC might be helpful in weaning severe respiratory distress. Clinical effectiveness and comfort should be assessed within 3 days. The correct timing should be ruled by PaO2/Fio2 during ventilation and clinical signs of distress. Further evidence is required for firm conclusions.
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PURPOSE: COVID-19 is a novel threat to patients with adrenal insufficiency (AI), whose life expectancy and quality (QoL) are impaired by an increased risk of infections and stress-triggered adrenal crises (AC). If infected, AI patients require prompt replacement tailoring. We assessed, in a cohort of AI patients: prevalence and clinical presentation of COVID-19; prevalence of AC and association with intercurrent COVID-19 or pandemic-related psychophysical stress; lockdown-induced emotional burden, and health-related QoL. METHODS: In this monocentric (Ancona University Hospital, Italy), cross-sectional study covering February-April 2020, 121 (40 primary, 81 secondary) AI patients (59 males, 55 ± 17 years) completed telematically three questionnaires: the purpose-built "CORTI-COVID", assessing medical history and concern for COVID-19-related global health, AI-specific personal health, occupational, economic, and social consequences; the AddiQoL-30; the Short-Form-36 (SF-36) Health Survey. RESULTS: COVID-19 occurred in one (0·8% prevalence) 48-year-old woman with primary AI, who promptly tailored her replacement. Dyspnea lasted three days, without requiring hospitalization. Secondary AI patients were not involved. No AC were experienced, but pandemic-related stress accounted for 6/14 glucocorticoid up-titrations. Mean CORTI-COVID was similar between groups, mainly depending on "personal health" in primary AI (ρ = 0.888, p < 0.0001) and "economy" in secondary AI (ρ = 0.854, p < 0.0001). Working restrictions increased occupational concern. CORTI-COVID correlated inversely with QoL. AddiQoL-30 and SF-36 correlated strongly. Comorbidities worsened patients' QoL. CONCLUSION: If educational efforts are made in preventing acute events, AI patients seem not particularly susceptible to COVID-19. The novel "CORTI-COVID" questionnaire reliably assesses the pandemic-related emotional burden in AI. Even under unconventional stress, educated AI patients preserve a good QoL.