The midwife's experience in mantaining the psychoneuroendocrine balance of women in labour during the COVID-19 pandemic: a phenomenological study

Objective. Neurohormonal processes control both the physiological aspects of labor and childbirth, and contribute to the subjective psychological experiences of birth. This concept has always been underestimated in clinical practice and this became even more glaring during the COVID-19 pandemic. The aim of the study was to analyze through the experience of midwives, how they, during the pandemic, have contributed to influence and maintain the balance of the psycho-neuro-endocrine axis (PNEI). Materials and Methods. A qualitative research study, based on the phenomenological method of Cohen on a sample of midwives from the A.O.U.I Policlinico of Bari, interviewed in September 2021. Results. Four main themes emerged from the analysis of the interviews and field notes: ''Woman Care'', ''Loneliness and Fear'', ''Mask and DPI'', and finally ''COVID and Contagion''. In addition, eleven subthemes were derived from these as can be seen in the table (Table 1). The results of the analysis showed how midwives, who have always been the main reference figures for women, newborns and couples, have worked tirelessly to ensure that women received the best possible care, covid positive or not, aware of the influence that the psycho-physical component has on the hormonal release that guides the course of the birth event. Conclusions. As the pandemic continues, there is an urgent need to improve the care and promote a physiological birth since it is known that giving birth physiologically is a psychologically powerful experience. From this emerges the need for health care providers to become aware of the importance of maintaining the psychoneuroendocrine balance to allow women to have the most positive birth experience possible.

Hypoxia promotes metabolic and functional platelet exhaustion in critically ill COVID-19 patients

Background: Severe Coronavirus disease 2019 (COVID-19) has been associated with a dysregulated cytokine production, lymphocyte and monocyte exhaustion, and immunothrombotic complications that reduce gas exchange in the lungs and contribute to multiorgan failure. Aim(s): The objective of this study was to characterize the interplay between platelets and the dysregulated immune phenotype that drives disease severity. Method(s): To achieve this goal, we performed a high-throughput flow cytometric profiling of the phenotype and interactions of platelets circulating in the blood of Sars-COV2-positive subjects upon hospitalization. Patients were stratified into non-ICU (n = 35) and critically ill ICU (n = 25) patients and compared to sex-and age-matched Sars-COV2-negative patients (n = 15) and healthy volunteers (n = 20). All participants gave written informed consent. The study was approved by the Ethics Committee of our institution. Result(s): Platelets from ICU patients had dysfunctional mitochondria and a non-adhesive phenotype. Displayed significantly less glycoprotein (GP)Ibalpha and GPVI on the surface and failed to present active integrin alphaIIbbeta3 and P-selectin on the plasma membrane in response to exogenous stimuli. Platelet hypo-responsiveness positively correlated with the Horowitz index (PaO2/FiO2 ratio), a measure of lung function, and with the D-dimer concentration, a surrogate marker of ongoing thrombosis. Exposure of platelets from healthy volunteers to acute hypoxic conditions (1% O2) recapitulated this phenotype in vitro. Despite the low adhesiveness, platelets of ICU patients bound avidly to innate immune cells. Interactions with monocytes and NK cells increased with severity, even though these leukocytes subpopulations were reduced in the circulation of ICU patients. Platelet-T cell aggregates were doubled in non-ICU patients compared to controls but were not detectable among the ICU patients. Conclusion(s): In summary, platelets from COVID-19 patients who have reduced lung function present features of metabolic and functional exhaustion and bind primarily innate but not adaptive immune cells, thus promoting the dysregulated immune response that drives COVID19 severity.

Toll-like receptor 4-dependent and Independent platelet-dependent thrombosis in SARS-CoV-2 infection

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with an increased risk of venous and arterial thrombosis but the underlying mechanism if still unclear. Aim(s): The study would identify a mechanism implicated in platelet activation and thrombus growth during SARS-CoV-2 infection. Method(s): We performed a cross-sectional analysis of platelet function in 30 SARS-CoV-2 and 20 healthy subjects (HS) by measuring Nox2-derived oxidative stress and thromboxane (Tx) B2 and investigated if administration of monoclonal antibodies against the Spike(S) protein of SARS-CoV-2 affects platelet activation. Furthermore, we investigated in vitro if the Spike(S) protein of SARS-CoV-2 or plasma from SARS-CoV-2 enhanced platelet activation. Result(s): Ex vivo studies showed enhanced platelet Nox2-derived oxidative stress and TxB2 biosynthesis and under laminar flow platelet-dependent thrombus growth in SARS-CoV-2 compared to controls;both effects were lowered by Nox2 and Toll-like receptor 4(TLR4) inhibitors. Two hours after administration of monoclonal antibodies a significant inhibition of platelet activation was observed in SARS-CoV-2 patients compared to untreated ones. In vitro study showed that S protein functionally interacts with platelet TLR4, and a docking simulation analysis suggested that TLR4 binds to S protein via three receptor-binding domains;furthermore, in platelets from SARS-CoV-2 S protein co-immunoprecipitated with TLR4. Plasma from SARS-CoV-2 patients incubated with normal platelets enhanced platelet activation and Nox2-related oxidative stress, an effect blunted by TNF-alpha inhibitor;this effect was recapitulated by an in vitro study documenting that TNF-alpha alone promoted platelet activation and amplified the platelet response to S protein via p47phox up-regulation. Conclusion(s): The study identifies two TLR4-dependent and independent pathways promoting platelet-dependent thrombus growth and suggests inhibition of TLR4 or p47phox as a tool to counteract thrombosis in SARS-CoV-2.

Lessons for Remote Post-earthquake Reconnaissance from the 14 August 2021 Haiti Earthquake

On 14th August 2021, a magnitude 7.2 earthquake struck the Tiburon Peninsula in the Caribbean nation of Haiti, approximately 150 km west of the capital Port-au-Prince. Aftershocks up to moment magnitude 5.7 followed and over 1,000 landslides were triggered. These events led to over 2,000 fatalities, 15,000 injuries and more than 137,000 structural failures. The economic impact is of the order of US$1.6 billion. The on-going Covid pandemic and a complex political and security situation in Haiti meant that deploying earthquake engineers from the UK to assess structural damage and identify lessons for future building construction was impractical. Instead, the Earthquake Engineering Field Investigation Team (EEFIT) carried out a hybrid mission, modelled on the previous EEFIT Aegean Mission of 2020. The objectives were: to use open-source information, particularly remote sensing data such as InSAR and Optical/Multispectral imagery, to characterise the earthquake and associated hazards;to understand the observed strong ground motions and compare these to existing seismic codes;to undertake remote structural damage assessments, and to evaluate the applicability of the techniques used for future post-disaster assessments. Remote structural damage assessments were conducted in collaboration with the Structural Extreme Events Reconnaissance (StEER) team, who mobilised a group of local non-experts to rapidly record building damage. The EEFIT team undertook damage assessment for over 2,000 buildings comprising schools, hospitals, churches and housing to investigate the impact of the earthquake on building typologies in Haiti. This paper summarises the mission setup and findings, and discusses the benefits, and difficulties, encountered during this hybrid reconnaissance mission.

The neutrophil/lymphocyte ratio as a prognostic factor in COVID-19 patients: a case-control study.

OBJECTIVE: SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) has been identified in China as responsible for viral pneumonia, now called COVID-19 (Coronavirus Disease 2019). Patients infected can develop common symptoms like cough and sore throat, and, in severe cases, acute respiratory syndrome and even death. To optimize the available resources, it is necessary to identify in advance the subjects that will develop a more serious illness, therefore requiring intensive care.The neutrophil / lymphocyte ratio (NLR) parameter, resulting from the blood count, could be a significant marker for the diagnosis and management of risk stratification. PATIENTS AND METHODS: A retrospective, single-center case-control observational study was conducted. The differential cell count of leukocytes, the NLR and the clinical course of patients hospitalized in intensive care with COVID-19 were analyzed, comparing them with other patients (COVID-19 and non-COVID-19) and healthy individuals selected among workers of the Teaching Hospital Policlinico Umberto I in Rome. RESULTS: 370 patients (145 cases and 225 controls) were included in the case-control study, 211 males (57%) and 159 females (43%). The average age of the population was 63 years (SD 16.35). In the group of cases, out of 145 patients, 57 deaths and 88 survivors were recorded, with a lethality rate of 39.3%. The group of cases has an NLR of 7.83 (SD = 8.07), a much higher value than the control group where an NLR of 2.58 was recorded (SD = 1.93) (p <0.001). The Neutrophils / Lymphocytes ratio may prove to be a diagnostic factor for COVID-19, an NLR> 3.68 revealed an OR 10.84 (95% CI = 6.47 - 18.13) (p <0.005). CONCLUSIONS: The value of NLR considered together with the age variable allows a risk stratification and allows the development of diagnostic and treatment protocols for patients affected by COVID-19. A high neutrophil to lymphocyte ratio suggests worse survival. Risk stratification and management help alleviate the shortage of medical resources and reduce the mortality of critically ill patients.

A case of chronic systemic capillary leak syndrome (SCLS) exacerbated during SARS-CoV2 infection.

Systemic capillary leak syndrome (SCLS) is a very rare and lethal disease characterized by hemoconcentration and hypoalbuminemia caused by reversible plasma extravasation. The underlying cause for SCLS remains largely unknown and acute treatment has remained mainly supportive. Prophylaxis with intravenous immunoglobulin (IVIG) has been shown to successfully prevent further episodes in affected patients. We reported a case of SCLS in a patient who presented to our hospital with COVID-19 and developed profound shock.

The impact of the COVID-19 pandemic on healthcare-associated infections in intensive care unit patients: a retrospective cohort study.

BACKGROUND: During the intensive care units' (ICUs) reorganization that was forced by the COVID-19 emergency, attention to traditional infection control measures may have been reduced. Nevertheless, evidence on the effect of the COVID-19 pandemic on healthcare-associated infections (HAIs) is still limited and mixed. In this study, we estimated the pandemic impact on HAI incidence and investigated the HAI type occurring in COVID-19 patients. METHODS: Patients admitted to the main ICU of the Umberto I teaching hospital of Rome from March 1st and April 4th 2020 were compared with patients hospitalized in 2019. We assessed the association of risk factors and time-to-first event through multivariable Fine and Grey's regression models, that consider the competitive risk of death on the development of HAI (Model 1) or device related-HAI (dr-HAI, Model 2) and provide estimates of the sub-distribution hazard ratio (SHR) and its associated confidence interval (CI). A subgroup analysis was performed on the 2020 cohort. RESULTS: Data from 104 patients were retrieved. Overall, 59 HAIs were recorded, 32 of which occurred in the COVID-19 group. Patients admitted in 2020 were found to be positively associated with both HAI and dr-HAI onset (SHR: 2.66, 95% CI 1.31-5.38, and SHR: 10.0, 95% CI 1.84-54.41, respectively). Despite being not confirmed at the multivariable analysis, a greater proportion of dr-HAIs seemed to occur in COVID-19 patients, especially ventilator-associated pneumonia, and catheter-related urinary tract infections. CONCLUSIONS: We observed an increase in the incidence of patients with HAIs, especially dr-HAIs, mainly sustained by COVID-19 patients. A greater susceptibility of these patients to device-related infections was hypothesized, but further studies are needed.

Comparison of clinical features and outcomes in COVID-19 and influenza pneumonia patients requiring intensive care unit admission.

BACKGROUND: Little is known in distinguishing clinical features and outcomes between coronavirus disease-19 (COVID-19) and influenza (FLU). MATERIALS/METHODS: Retrospective, single-centre study including patients with COVID-19 or FLU pneumonia admitted to the Intensive care Unit (ICU) of Policlinico Umberto I (Rome). Aims were: (1) to assess clinical features and differences of patients with COVID-19 and FLU, (2) to identify clinical and/or laboratory factors associated with FLU or COVID-19 and (3) to evaluate 30-day mortality, bacterial superinfections, thrombotic events and invasive pulmonary aspergillosis (IPA) in patients with FLU versus COVID-19. RESULTS: Overall, 74 patients were included (19, 25.7%, FLU and 55, 74.3%, COVID-19), median age 67 years (58-76). COVID-19 patients were more male (p = 0.013), with a lower percentage of COPD (Chronic Obstructive Pulmonary Disease) and chronic kidney disease (CKD) (p = 0.001 and p = 0.037, respectively) than FLU. SOFA score was higher (p = 0.020) and lymphocytes were significantly lower in FLU than in COVID-19 [395.5 vs 770.0 cells/mmc, p = 0.005]. At multivariable analysis, male sex (OR 6.1, p < 0.002), age > 65 years (OR 2.4, p = 0.024) and lymphocyte count > 725 cells/mmc at ICU admission (OR 5.1, p = 0.024) were significantly associated with COVID-19, whereas CKD and COPD were associated with FLU (OR 0.1 and OR 0.16, p = 0.020 and p < 0.001, respectively). No differences in mortality, bacterial superinfections and thrombotic events were observed, whereas IPA was mostly associated with FLU (31.5% vs 3.6%, p = 0.0029). CONCLUSIONS: In critically ill patients, male sex, age > 65 years and lymphocytes > 725 cells/mmc are related to COVID-19. FLU is associated with a significantly higher risk of IPA than COVID-19.

Does lung ultrasound score correlate with severityof CoViD-19 pneumonia assessed by CT scan?

Background: The Lung Ultrasound Score (LUS), is a semiquantitative score to measure the lung aeration loss and represents thesum of the scores of different pulmonary regions. LUS has beenpreviously employed in evaluation of patients with CoViD-19.Theaim of our analysis was to compare the severity of LUS findingswith computed tomography (CT) scan, when available, and its distribution in pulmonary areas.Methods: We analysed the patients with confirmed CoViD-19pneumonia admitted in the High Intensity Internal Medicine Unit,Santa Maria del Carmine Hospital (Rovereto -TN), between 7thMarch and 18th April 2020. 32 patients were enrolled, and in asubgroup of 12 patients it was performed CT scan, within 36 hoursfrom admission.Results: LUS score was directly related with CT score (r 0.71,p=0.006). The LUS score was not uniformly distributed in the pulmonary regions. The score increases from anterior-superior regionsto posterior-inferior with a p <0.001 and from anterior to lateralregions with a p<0.05. Right vs left scores were similar.Conclusions: our study demonstrates that lung ultrasound scorecorrelates with severity of CoViD-19 pneumonia assessed by CTscan. LUS might help the risk stratification of the disease, especially in settings where CT scan is not available;certainly otherstudies will be needed in order to confirm our results.