ABSTRACT
Introduction: Diagnosis of ventilator-associated pneumonia (VAP) in COVID-19 patients remains challenging. Also, the lack of gold standard for microbiological sampling undermines clinical judgement and management. We studied incidences of microbiologically-confirmed VAP comparing endotracheal aspirate (ETA) and bronchoalveolar lavage (BAL) in COVID-19 patients. Etiological agreement between ETA and BAL was then assessed. Method(s): Single-center prospective cohort study (NCT04766983). Patients were enrolled within 48 h from intubation;surveillance ETA ( ETASURV) was performed twice weekly. ETA ( ETACX) and BAL ( BALCX) samples were collected upon VAP suspicion (Johanson's criteria). CDC definitions were used for microbiological confirmation. ETA-BAL agreement (interrater reliability and Cohen's kappa) and clinical/microbiological data were assessed for the first episodes of suspected VAP per patients. Result(s): Ninety intensive care (ICU) patients enrolled from 01/2021 to 05 06/2022, of which 26 females (28.9%);median age was 60 [52-66] years. In-ICU mortality was 30/90 (33.3%), median length of stay in survivors 19 (10-32) days. Fifty-three patients (58.9%) had >= 1 episode of suspected VAP after 6 [5;10] days from ICU admission. ETASURV were available in 52 cases, 2 [1;3] days before VAP suspect, and tested positive in 28 (53.8%). ETACX and BALCX resulted positive in 35 (66.0%) and 29 (54.7%) of episodes. Main microbiological results are displayed in Fig. 1, panel A. Etiological agreement between techniques is shown in Fig. 1, panel B. Incidence rate of VAP suspicions per 1000 ventilator-days was 60.2 (95% CI 43.9-76.4), while incidence rates of microbiologically-confirmed VAP were 27.4 (18.3-36.5) with ETACXand 18.9 (95% CI 12.0-25.8) with BALCX, respectively. Conclusion(s): We observed different incidence of VAP in COVID-19 ICU patients depending on sampling method. Etiological agreement between techniques yielded limited interrater reliability. The potential clinical impact needs further studies.
ABSTRACT
Introduction Randomized controlled trials showed efficacy of vaccines against coronavirus disease 19 (COVID-19). There is the need to quantify vaccine effectiveness in real-word contexts, including people at high risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), such as health care workers (HCWs). Objectives To evaluate vaccine effectiveness among hospital HCWs. Methods We performed a cohort study among HCWs of a large University hospital in Milan, Lombardy, Italy by merging routinely collected data on demographics, COVID-19 vaccination, and polymerase chain-reaction (PCR) tests performed on nasopharyngeal swabs. Follow-up started on December 27, 2020 (start of vaccination campaign). We included HCWs never PCR-positive before the start date and with at least a PCR test afterwards. Vaccination was treated as a time-dependent variable by calculating person-years (PY) at risk before and after vaccine doses. Subjects contributed PY until first positive PCR test (cases) or last test for never positive HCWs (to avoid immortal time bias). We calculated infection rates (cases per 1000 PY), rate ratios (RR, with a Poisson regression model adjusted for gender, age, occupation and 30-day periods), vaccine effectiveness (VE = (1-RR)x100) and 95% confidence intervals (CI) taking never vaccinated HCWs as reference. Results As of May 10, there were 3,152 vaccinated (97% with BNT162b2, 140 with one dose, 2,679 with two doses) and 333 non-vaccinated. We counted 29 infected cases (rate 385) among non-vaccinated, 6 (rate 65) from day 14 after the first dose (VE 79%, CI 49-92%), and 24 (rate 65) from day 7 after the second dose (VE 89%, CI 80-94%). Most cases after vaccination were asymptomatic or mildly symptomatic. Conclusion In these preliminary analysis we found high effectiveness of COVID-19 vaccine in HCWs in our hospital. Further work is needed to assess long-term effectiveness and to better plan future preventive strategies among this high-risk occupational group.
ABSTRACT
Background and aim: Gastrointestinal infections represent a risk factor for functional gastrointestinal and somatoform extraintesti-nal disorders. We investigated the prevalence and relative risk (RR) of gastrointestinal and somatoform symptoms five months after SARS-CoV-2 infection compared with a control cohort. Materials and methods: 378 subjects, age range 18-60 years, were stu-died. 177 SARS-CoV-2 infected patients and 201 controls responded to an online questionnaire about symptoms and signs during the acute phase of the infection and after 4.8±0.3 months. 13 and 18 patients were respectively excluded because of a previous gastrointestinal dise-ase. Presence and severity of gastrointestinal symptoms, somatization, anxiety and depression were recorded with a structured standardized questionnaire, including the Structured Assessment of Gastrointestinal Symptoms (SAGIS) questionnaire, the Symptom Check List (SCL)-12 for somatization and the Hospital Anxiety and Depression Scale (HADS). Stool form through Bristol Stool scale and a yes/no question summari-zing the Rome IV criteria for Irritable Bowel Syndrome (IBS) were also recorded. Any association between exposure to infection and symp-toms was evaluated by calculating crude and adjusted RR values and score differences with 95% confidence intervals (CI). Results: Fever, dyspnea, loss of smell/taste/weight, diarrhea, myal-gia, arthralgia and asthenia were reported by more than 40% of patients during the acute phase. Abdominal pain/discomfort, diar-rhea/incontinence and gastroesophageal reflux disease/regurgita-tion symptoms persisted after SARS-CoV-2 infection, but with very low severity;the relative increase on the mean score of each domain was minimal (score difference up to +0.16). Compared with con-trols, adjusted RRs for loose stools, chronic fatigue and somatization were increased after infection: 1.88 (95% CI 0.99–3.54), 2.24 (95% CI 1.48–3.37), 3.62 (95% CI 1.01–6.23) respectively. The prevalence of IBS and HADS scores tended to be greater in patients than in con-trols. Gastrointestinal sequelae were greater in patients with diar-rhea during the acute phase. Conclusions: Mild gastroenterological symptoms persist five months after SARS-CoV-2 infection, in particular in patients report-ing diarrhea in the acute phase. Infected patients are at increased risk of chronic fatigue and somatoform disorders, thus supporting the hypothesis that both functional gastrointestinal and somato-form disorders may have a common biological orig
ABSTRACT
Patients with Covid-19 frequently develop atypical thyroiditis coexisting with non-thyroidal illness syndrome (Muller et al LancetD& E 2020). We analysed thyroid dysfunction: 1) in relation to Covid-19 disease severity;2) observing its evolution over time. Baseline assessment of 179 patients hospitalised in sub-intensive care units for Covid-19 disease, without known history of thyroid dysfunction or amiodarone therapy, with thyroid function and inflammatory markers measured at hospital admission. Thyroidultrasound (thyroid-US) and thyroid autoantibodies measurement were performed in 65 patients after they became SARS-CoV-2 negative, of whom 14 were also studied with radioisotope thyroiduptake (99mTc or I123) since showing focal-hypoechoic-areas. 46 patients were re-evaluated at 6 months of follow-up. Patients on steroid treatment started before hospitalization (N = 62) were excluded due to its lowering effect on TSH. At baseline 11/117 patients (9.4%) had thyrotoxicosis (low TSH and/or high FT4);23/117 (19.7%) had low TSH and required a more intensive oxygen support during hospitalization (P = 0.02). TSH positively correlated with lymphocyte count (P < 0.01). FT3 correlated negatively with length of hospitalization (P = 0.04) and death rate (P = 0.03). Only 7.7% patients had detectable TgAb/TPOAb and none TRAb. Thyroid-US showed focal-hypoechoic-areas in 28% patients, of whom thyroid-uptake was focally-reduced in 57%, diffusely-reduced in 14% and normal in 28%. Importantly, focalhypoechoic-areas were more frequent among patients with baseline low TSH compared with normal TSH (P = 0.03). Furthermore, patients with focal-hypoechoic-areas had higher baseline FT4 (P = 0.02) and IL-6 (P = 0.02) than those without. Thyroid function and inflammatory markers had normalized at 3 months and remained normal thereafter. At 6 months focalhypoechoic-areas persisted in the majority of patients, often reduced in size;thyroid-uptake was repeated in 8 patients and resulted increased in 7 (87.5%). Thyroid dysfunction during moderate-to-severe Covid-19 disease was mild and transient and correlated with increased death rate and length of hospitalization;low TSH correlated with lymphopenia and was associated with increased need of oxygen support during hospitalization. Focal-hypoechoic-areas at thyroid-US persisted up to 6 months in nearly 1/3 of patients and correlated with thyroid and inflammatory parameters at hospital admission, confirming a key role of thyroiditis in Covid-19 related thyroid dysfunction;long-term effects are unknown.
ABSTRACT
Background and aims: Although COVID-19 infection predominantly manifests with respiratory symptoms, recent studies have also reported the occurrence of neurological involvement in the acute phase as well as in the follow-up of recovered subjects Methods: Our study focuses on assessing the prevalence of neurological sequelae in COVID-19 patients hospitalized at Ospedale Maggiore Policlinico in Milan. Seventy-five COVID-19 recovered subjects followed a general follow-up protocol including pneumological, infectious and cardiovascular assessment 5-10 months after the onset of SARS-CoV2 infection;among them, a subset of 53 patients was evaluated through a self-administered 18-item questionnaire developed ad-hoc addressing sensory, motor and cognitive neurological symptoms. Results: Collected data has shown that 77.4% patients developed at least one neurological sequela, and 46.3% presented with more than three symptoms. Among symptomatic patients, the most prevalent manifestations were insomnia (65.9%) and daytime sleepiness (46.3%), followed by walking difficulties (31.7%). Other less frequent symptoms were headache (15.1%), hyposmia and hypogeusia (15.1%), and tremor (9.4%). Prevalence of symptoms 18-item questionnare showing the distribution of neurological manifestations Conclusion: Post-COVID-19 manifestations are reported in about 90% of recovered patients. This preliminary study suggests that neurological findings represent a significant part of such manifestations. We are currently expanding the questionnaire to a larger cohort of patients and correlating our findings with patients' demographical and clinical features, as well as with the severity of the previous SARSCoV2 infection. Currently, the same questionnaire is also being validated and administered to age-and sex-matched healthy controls who have not developed symptoms suggestive of Covid-19, and a cohort of non-COVID-19 hospitalized patients.
ABSTRACT
Purpose The respiratory system, and namely the lung, is undoubtedly the preferential target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical pictures are extremely various, up to the intensive care unit (ICU) admission for acute respiratory distress syndrome (ARDS). Lung transplantation (LT) is a consolidate therapeutic option for end-stage chronic respiratory diseases. Its role in an acute setting is questionable, particularly due to lack of experiences, donor shortage, and the difficulty to fully evaluate the potential recipient. We report our preliminary experience with the first two cases of LT for SARS-CoV-2 related ARDS, trying to provide some food for thought. Methods We retrospectively analysed our first two cases of bilateral LT for ARDS after COVID-19. We recorded data on pre-transplantation clinical course, transplantation management and outcomes. Results The two patients had a similar clinical evolution of COVID-19. Transplantations were successful in both cases;the first patient is alive and in good condition 5 months after transplantation, while the second died 62 days after surgery. Table 1 shows clinical details and relevant time-points. Conclusion Our experience showed that LT for COVID-19 is feasible. Importantly, observing a dedicated protocol made the procedure safe for the healthcare staff involved. On the other hand, our second unsuccessful case poses relevant questions: first of all, lung transplantation should be reserved to highly selected patient, after careful clinical, infective as well as psychiatric evaluation. The ethical aspects should also be considered in this situation, with regard to the centre rate mortality on waiting list. Anyway, the potential role of LT in the acute and sub-acute/chronic settings suggests the need for maintaining LT centre active during pandemic. Finally, COVID-19, once more, imposes to share clinical experiences.
ABSTRACT
OBJECTIVES: The management of healthcare workers (HCWs) exposed to confirmed cases of coronavirus disease 2019 (COVID-19) is still a matter of debate. We aimed to assess in this group the attack rate of asymptomatic carriers and the symptoms most frequently associated with infection. METHODS: Occupational and clinical characteristics of HCWs who underwent nasopharyngeal swab testing for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a university hospital from 24 February 2020 to 31 March 2020 were collected. For those who tested positive and for those who tested positive but who were asymptomatic, we checked the laboratory and clinical data as of 22 May to calculate the time necessary for HCWs to then test negative and to verify whether symptoms developed thereafter. Frequencies of positive tests were compared according to selected variables using multivariable logistic regression models. RESULTS: There were 139 positive tests (8.8%) among 1573 HCWs (95% confidence interval, 7.5-10.3), with a marked difference between symptomatic (122/503, 24.2%) and asymptomatic (17/1070, 1.6%) workers (p < 0.001). Physicians were the group with the highest frequency of positive tests (61/582, 10.5%), whereas clerical workers and technicians had the lowest frequency (5/137, 3.6%). The likelihood of testing positive for COVID-19 increased with the number of reported symptoms; the strongest predictors of test positivity were taste and smell alterations (odds ratio = 76.9) and fever (odds ratio = 9.12). The median time from first positive test to a negative test was 27 days (95% confidence interval, 24-30). CONCLUSIONS: HCWs can be infected with SARS-CoV-2 without displaying any symptoms. Among symptomatic HCWs, the key symptoms to guide diagnosis are taste and smell alterations and fever. A median of almost 4 weeks is necessary before nasopharyngeal swab test results are negative.