Hemoperfusion with CytoSorb as Adjuvant Therapy in Critically Ill Patients with SARS-CoV2 Pneumonia

Background: Several pro- and anti-inflammatory cytokines involved in COVID-19 and it is reasonable to speculate that their removal from blood might limit organ damage. Hemoperfusion with CytoSorb is a technique developed to adsorb molecules in the middle molecular weight range (up to 55 kDa). Studies in vitro and in vivo have shown that HP is highly effective in clearing blood from a number of cytokines. Method(s): We report a case series of 9 consecutive COVID-patients admitted to our COVID Intensive Care Unit (ICU). Five of them were treated with HP using CytoSorb (T), due to the heavy emergency overload it was impossible to deliver blood purification in the other 4 patients (C), who were also considered as potential candidates by the attending medical team. All patients had pneumonia and respiratory failure requiring continuous positive airway pressure. Different antibacterial prophylaxes, antiviral, and anti-inflammatory therapies including steroids were delivered. Result(s): Our results show a better clinical course of T compared to control patients (C), in fact all T except 1 survived, and only 2 of them were intubated, while all C required intubation and died. CRP decreased in both groups, but to a greater extent after HP. Lymphocytopenia worsened in control patient but not in treated patient after HP. Procalcitonin increased in 2 of the not treated patients. In all survived patients (n = 4) HP reduced pro-inflammatory cytokines, as IL-6, TNF-alpha, and IL-8. Notably, a striking effect was observed on IL-6 levels that at the end of the second session were decreased by a 40% than before the first treatment. Serum levels of IL-8 and TNF-alpha were lowered within normal range. In all patients the treatment was safe and there were no complications. Conclusion(s): Our study suggests a potential efficacy of HP in an early phase of viral infection not only for improving survival in the treated patients but also by the remodeling treatment-associated cytokine levels.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study Manejo de las vías respiratorias en la insuficiencia respiratoria aguda SARS-COV-2: un estudio observacional prospectivo multicéntrico

Graphical Objective Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. Setting Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. Patients Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. Interventions Endotracheal Intubation Adverse Events. Main variables of interests The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%;hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure;cardiac arrest. Results Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. Conclusion In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. Clinical Trial registration www.clinicaltrials.gov identifier: NCT04909476

Calibration and Application of the Integrated Assessment Tool RIAT+ for Air Quality Planning in the Po Valley

Aim of this work is to explore the uncertainty generated by using different source-receptor (S/R) functions in the air quality (AQ) planning, in terms of selecting the most cost-effective measures to improve AQ and reduce population exposure. Both technical and non-technical measures have been evaluated through the regional integrated assessment tool RIAT+. Applications of RIAT+ provides valuable information for drafting the local AQ plans. In Friuli-Venezia Giulia in order to reduce the population exposure to PM10 exceedances, priority should be given to measures concerning domestic heating, livestock, maritime and road traffic. Moreover, RIAT+ has been applied in the Po Valley to assess the impact on AQ of the COVID-19 lockdown. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study.

Objective: Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. Setting: Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. Patients: Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. Interventions: Endotracheal Intubation Adverse Events. Main variables of interests: The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. Results: Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. Conclusion: In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. Clinical Trial registration: www.clinicaltrials.gov identifier: NCT04909476.

Objetivo: Pocos estudios han informado las implicaciones y los eventos adversos de realizar una intubación endotraqueal para pacientes críticos con COVID-19 ingresados ​​en unidades de cuidados intensivos. El objetivo del presente estudio fue determinar los eventos adversos relacionados con la intubación traqueal en pacientes con COVID-19, definidos como la aparición de inestabilidad hemodinámica, hipoxemia severa y paro cardíaco. Ámbito: Hospitales médicos de atención terciaria, estudio de doble centro realizado en el norte de Italia desde noviembre de 2020 hasta mayo de 2021. Pacientes: Pacientes adultos con prueba PCR SARS-CoV-2 positiva, ingresados por insuficiencia respiratoria y necesidad de manejo avanzado de vías aéreas invasivas. Intervenciones: Eventos adversos de la intubación endotraqueal. Principales variables de interés: El punto final primario fue determinar la ocurrencia de al menos 1 de los siguientes eventos dentro de los 30 minutos posteriores al inicio del procedimiento de intubación y describir los tipos de eventos adversos periintubación mayores. : hipoxemia severa definida como una saturación de oxígeno medida por pulsioximetría <80%; inestabilidad hemodinámica definida como PAS 65 mmHg registrada al menos una vez o PAS < 90 mmHg durante 30 minutos, nuevo requerimiento o aumento de vasopresores, bolo de líquidos > 15 mL/kg para mantener la presión arterial objetivo; paro cardiaco. Resultados: Entre 142 pacientes, el 73,94% experimentó al menos un evento periintubación adverso importante. El evento predominante fue la inestabilidad cardiovascular, observada en el 65,49% de todos los pacientes sometidos a intubación de urgencia, seguido de la hipoxemia severa (43,54%). El 2,82% de los pacientes tuvo un paro cardíaco. Conclusión: En este estudio de prácticas de intubación en pacientes críticos con COVID-19, los eventos adversos periintubación mayores fueron frecuentes. Registro de ensayos clínicos: www.clinicaltrials.gov identificador: NCT04909476.

Reduced circulating FABP2 in patients with moderate to severe COVID-19 may indicate enterocyte functional change rather than cell death.

The gut is of importance in the pathology of COVID-19 both as a route of infection, and gut dysfunction influencing the severity of disease. Systemic changes caused by SARS-CoV-2 gut infection include alterations in circulating levels of metabolites, nutrients and microbial products which alter immune and inflammatory responses. Circulating plasma markers for gut inflammation and damage such as zonulin, lipopolysaccharide and ß-glycan increase in plasma along with severity of disease. However, Intestinal Fatty Acid Binding Protein / Fatty Acid Binding Protein 2 (I-FABP/FABP2), a widely used biomarker for gut cell death, has paradoxically been shown to be reduced in moderate to severe COVID-19. We also found this pattern in a pilot cohort of mild (n = 18) and moderately severe (n = 19) COVID-19 patients in Milan from March to June 2020. These patients were part of the first phase of COVID-19 in Europe and were therefore all unvaccinated. After exclusion of outliers, patients with more severe vs milder disease showed reduced FABP2 levels (median [IQR]) (124 [368] vs. 274 [558] pg/mL, P < 0.01). A reduction in NMR measured plasma relative lipid-CH3 levels approached significance (median [IQR]) (0.081 [0.011] vs. 0.073 [0.024], P = 0.06). Changes in circulating lipid levels are another feature commonly observed in severe COVID-19 and a weak positive correlation was observed in the more severe group between reduced FABP2 and reduced relative lipid-CH3 and lipid-CH2 levels. FABP2 is a key regulator of enterocyte lipid import, a process which is inhibited by gut SARS-CoV-2 infection. We propose that the reduced circulating FABP2 in moderate to severe COVID-19 is a marker of infected enterocyte functional change rather than gut damage, which could also contribute to the development of hypolipidemia in patients with more severe disease.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study.

OBJECTIVE: Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. SETTING: Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. PATIENTS: Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. INTERVENTIONS: Endotracheal Intubation Adverse Events. MAIN VARIABLES OF INTERESTS: The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. RESULTS: Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. CONCLUSION: In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov identifier: NCT04909476.

Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study Manejo de las vías respiratorias en la insuficiencia respiratoria aguda SARS-COV-2: un estudio observacional prospectivo multicéntrico

Graphical Objective Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. Setting Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. Patients Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. Interventions Endotracheal Intubation Adverse Events. Main variables of interests The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%;hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure;cardiac arrest. Results Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. Conclusion In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. Clinical Trial registration www.clinicaltrials.gov identifier: NCT04909476

Humoral SARS-CoV-2 response in asymptomatic precursor plasma cell dyscrasia patients: IMPACT study results

Introduction: Patients with hematologic malignancies, including multiple myeloma (MM), experience worse SARS-CoV-2 infection outcomes and sub-optimal vaccine responses. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) precede MM and affect ∼5% of individuals age >=50. We previously showed that individuals with MGUS and SMM exhibit immune dysregulation. Here, we investigate the immune response to SARS-CoV-2 vaccination in these asymptomatic but potentially immunocompromised individuals. Methods: The IMPACT study (IRB #20-332) is a prospective study at Dana-Farber Cancer Institute in collaboration with MMRF, which enrolled individuals nationwide with a diagnosed plasma cell dyscrasia and healthy individuals. As of October 2021, 3,005 individuals completed a questionnaire regarding prior infection or vaccination. We obtained 1,350 blood samples from 628 participants and analyzed anti-SARS-CoV-2 IgG antibody titer by ELISA. Results: 2,771 (92%) participants were fully vaccinated (2 doses BNT162b2 or mRNA-1273;1 dose Ad26.COV2.s), 269 (9%) had received a 3rd mRNA vaccine dose, and 234 (8%) were unvaccinated. 1,387 (46%) and 1,093 (36%) participants received mRNA vaccines (BNT162b2 and mRNA-1273), and 139 (5%) participants received an adenovirus vector vaccine (Ad26.COV2.S). 34 (1%) individuals reported SARS-CoV-2 infection after full vaccination. We measured antibody titers in 201 MGUS, 223 SMM, 40 smoldering Waldenstrom macroglobulinemia (SWM), 64 MM, and 100 healthy controls. Multiple linear regression model estimated the association between various clinical variables and post-vaccination antibody titers. As previously reported, having MM was associated with low antibody titer (p < 0.001). Of note, having SMM, regardless of risk stratification by 2/20/20 criteria, was also associated with low antibody titers, indicating that even low-risk SMM patients have a poor response to vaccination. MGUS and SWM diagnoses were not significantly associated with antibody titers. Additionally, male sex (p < 0.010), elapsed time after vaccination (p < 0.001), and BNT162b2 vaccine (p < 0.001) were associated with low antibody titers. SARS-CoV-2 infection prior to vaccination was associated with high antibody titers. We identified 25 patients (6 MGUS, 10 SMM, 2 SWM, 7 MM) who submitted blood samples after both the 2nd and 3rd dose. In these patients we observed a significant increase in antibody titer after a 3rd dose (p = 0.002). We also observed that antibody titers of patients after a 3rd dose (13 MGUS, 12 SMM, 2 SWM, 31 MM) were comparable to that of healthy individuals after a 2nd dose (p = 0.833). Conclusion: Our data indicates that suboptimal response to SARS-CoV-2 does not only occur with MM and cancer patients receiving therapy but also in precursor asymptomatic patients including low-risk SMM.

Planning to restart: tourism in Barcelona in the post-COVID era

Tourist flows are not uniformly distributed in the city, but tend to polarize around the symbolic and nodal places of it. This situation can have two outcomes: on the one hand, the urban regeneration and the creation of places shared among residents and visitors;on the other hand, the construction of enclavic places which lead to crowding out of the resident population. The pandemic may perhaps be considered a reset and restart phase for a rethinking and reconstruction of the urban tourism system, involving all agents (tourists, enterprises, local communities, public authorities, etc.) within an innovative, dynamic and sustainable planning. In recent years, Barcelona, the leading city in European tourism, has seen the rise of phenomena such as: overtourism and the overcoming of the carrying capacity;touristification;tourist gentrification;and tourism-phobia. Barcelona intends to reconcile the needs of city and tourism, also addressing the current pandemic situation, through studied plans and strategies, promoting culture and the offer diversification, the redistribution of tourists, sustainability, the participation and cooperation of stakeholders.

Airways management in SARS-CoV-2 related respiratory failure: a prospective observational multi-center study

Introduction: Emergency intubation of COVID-19 patients is a highrisk procedure and a challenge to intensivists [1,2]. The aim was to determine major adverse events related to tracheal intubation in COVID-19 patients: severe hypoxemia, hemodynamic instability and cardiac arrest. Methods: This is a prospective, observational, dual-center study of COVID-19 patients undergoing advanced airway management for respiratory failure and admitted in ICU from November 2020 to May 2021. We reported data about demographics, comorbidities and parameters related to the intubation and expertise. Within 30 min from the intubation, we recorded the occurrence of severe hypoxia, cardiac arrest, hemodynamic instability. We collected data about difficult airways, the need of front of neck airways position, death within 30 min from the intubation, arrhythmia, esophageal intubation, pneumomediastinum and pneumothorax recognized within 6 h from the intubation. Results: Within 142 patients considered for our analysis, 73.94% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability in 65.49% of patients, followed by severe hypoxemia (43.54%) and cardiac arrest (2.82%). First-pass success was achieved for 90.84% of patients. The rate of major adverse events was significantly lower with first-pass intubation success than for 2 attempts. No difference was found in ICU LOS between patients with a major adverse periintubation event and patients without events. Conclusions: In this observational study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were observed frequently.

What breast radiologists have learned from the COVID-19 pandemic

The impact of COVID-19 on the world of breast cancer care has been unprecedented, with worrisome short- and long-term consequences, and there remains a long road ahead to recover and unbury the breast imaging departments from their current backlog. Radiologists have to consider what the new normal will be going forward. At present time, because of widescale COVID-19 vaccination, benign vaccine-related reactive lymphadenopathy is likely to be encountered in oncologic patients and we need data-driven guidelines to manage unilateral lymphadenopathy and avoid unnecessary biopsies. In the next years, some procedures like wearing masks and maintaining social distancing will probably remain in use, as radiologists show patients that they are concerned about patient safety. Accordingly, odds are it will incorporate novel protocols for patient safety, innovative technologies (such as telemedicine and Artificial Intelligence algorithms), and changes in radiology workflow to create an environment that feels safe to both patients and radiologists, preventing backlogs (preventive service must not to be declined anymore) and burnouts (we need to take medical staff’s mental health seriously). However, there is hope on the horizon with new lessons learned from this pandemic that can help clear the backlog and improve the working in breast imaging departments to achieve what is most important: saving lives in the fight against breast cancer. © 2022 AME Publishing Company. All Rights Reserved.

Medical-health recommendations for the Serie A League

Given the most recent epidemiological data and in view of the increasing spread of the Sars-CoV-2 virus in society as a whole and the world of sport in particular, the following medical and health recommendations are proposed to implement the FIGC regulations, approved by the CTS and already in place for professional soccer and the LEGA Serie A, in order to: 1) protect the health of individual players and the team group and reduce the risk of contracting the Sars-CoV-2 virus for all members and employees of Serie A Clubs by means of periodic and preventive monitoring;2) reduce the spread of the virus from within the group to the general public, by taking social responsibility;and 3) standardize management of the testing, transport, analysis and reporting process of the system. In order to pursue these objectives and optimize the recommendations set out below, it is necessary: 1) to identify a single company/ central laboratory to contact in order to guarantee a consistent method in the management of the testing, transport, analysis and reporting processes of molecular swabs (PCR). All Serie A clubs shall refer to this company/central laboratory, recognizing its exclusive status for the execution of such processes;2) to identify a contact authority available 24h (with dedicated email and telephone) within Serie A for the coordination and management of every need and/or emergency;3) for the Ministry of Health to activate a contact figure to coordinate and oversee each local ATS/ASL so as to guarantee that clubs receive uniform indications and provisions and to act as interface for the entire professional system. This central figure will delegate the management of everyday business to the various local ATS/ASLs, receiving constant, up-to-date feedback;and 4) to urge the Ministry of Health to adopt uniform procedures within the National Health System (local ATS/ASLs) in matters of management of players who test positive a second time after announcing their recovery and management of players who, in contact quarantine, are called up to the national team or who return from it. The FMSI may also make its DCOs available, as an opportunity to be agreed with the FIGC and the AIA, to perform rapid antigen tests on the refereeing group 2 hours before a game. The following recommendations are subject to review considering new scientific and epidemiological evidence. Copyright © 2020 Edizioni Minerva Medica.

Analysis of physical therapy education in Brazil during the COVID-19 pandemic

Introduction: The COVID-19 pandemic brought the need for social distancing as a strategy to control the disease, prompting most countries to te., mporarily suspend educational activities at all levels. Objective: To analyze the status of physical therapy education in Brazilian public and private institutions during the COVID-19 pandemic. Methods: A cross-sectional study with professors from physical therapy courses in Brazil. The study was conducted using an electronic form distributed via a social media application, containing questions on the characteristics of the professor, educational institution and work process. Associations were analyzed by the chi-squared test at 5% significance. Results: A total of 313 professors from 22 Brazilian states participated, with 62.94% from private institutions and 73.80% reporting that activities were conducted via emergency remote teaching (ERT). Among the professors who shifted to ERT, 63.20% did so with no prior planning and 28.13% had received no training for this this teaching format. An association was observed between the type of institution (public or private) and professors' age (p < 0.001), sex (p < 0.001), teaching experience (p < 0.001) and adopting ERT (p < 0.001). Conclusion: In Brazil, the COVID-19 pandemic prompted most institutions to switch to ERT, more prevalent at private facilities, with no prior planning for the transition from in-person to remote teaching. © 2021. All Rights Reserved.