Assessing the heterogeneity of the impact of COVID-19 incidence on all-cause excess mortality among healthcare districts in Lombardy, Italy, to evaluate the local response to the pandemic: an ecological study.

OBJECTIVES: The fragmentation of the response to the COVID-19 pandemic at national, regional and local levels is a possible source of variability in the impact of the pandemic on society. This study aims to assess how much of this variability affected the burden of COVID-19, measured in terms of all-cause 2020 excess mortality. DESIGN: Ecological retrospective study. SETTING: Lombardy region of Italy, 2015-2020. OUTCOME MEASURES: We evaluated the relationship between the intensity of the epidemics and excess mortality, assessing the heterogeneity of this relationship across the 91 districts after adjusting for relevant confounders. RESULTS: The epidemic intensity was quantified as the COVID-19 hospitalisations per 1000 inhabitants. Five confounders were identified through a directed acyclic graph: age distribution, population density, pro-capita gross domestic product, restriction policy and population mobility.Analyses were based on a negative binomial regression model with district-specific random effects. We found a strong, positive association between COVID-19 hospitalisations and 2020 excess mortality (p<0.001), estimating that an increase of one hospitalised COVID-19 patient per 1000 inhabitants resulted in a 15.5% increase in excess mortality. After adjusting for confounders, no district differed in terms of COVID-19-unrelated excess mortality from the average district. Minimal heterogeneity emerged in the district-specific relationships between COVID-19 hospitalisations and excess mortality (6 confidence intervals out of 91 did not cover the null value). CONCLUSIONS: The homogeneous effect of the COVID-19 spread on the excess mortality in the Lombardy districts suggests that, despite the unprecedented conditions, the pandemic reactions did not result in health disparities in the region.

Strategies to convert hospital beds for COVID-19 patients to minimize emergency department overcrowding.

Background: The shortage of hospital beds for COVID-19 patients has been one critical cause of Emergency Department (ED) overcrowding. Purpose: We aimed at elaborating a strategy of conversion of hospital beds, from non-COVID-19 to COVID-19 care, minimizing both ED overcrowding and the number of beds eventually converted. Research Design: Observational retrospective study. Study Sample: We considered the centralized database of all ED admissions in the Lombardy region of Italy during the second "COVID-19 wave" (October to December 2020). Data collection and Analysis: We analyzed all admissions to 82 EDs. We devised a family of Monte Carlo simulations to evaluate the performance of hospital beds' conversion strategies triggered by ED crowding of COVID-19 patients, determining a critical number of beds to be converted when passing an ED-specific crowding threshold. Results: Our results suggest that the maximum number of patients waiting for hospitalization could have been decreased by 70% with the proposed strategy. Such a reduction would have been achieved by converting 30% more hospital beds than the total number converted in the region. Conclusions: The disproportion between reduction in ED crowding and additionally converted beds suggests that a wide margin to improve the efficiency of the conversions exists. The proposed simulation apparatus can be easily generalized to study management policies synchronizing ED output and in-hospital bed availability.

Preliminary results on an autochthonous dengue outbreak in Lombardy Region, Italy, August 2023.

In August 2023, six locally acquired dengue virus 1 infections were detected in Lodi province, Lombardy Region, in northern Italy, where the vector Aedes albopictus is present. Four cases were hospitalised, none died. The viruses clustered with Peruvian and Brazilian strains collected between 2021 and 2023. This preliminary report highlights the importance of continued integrated surveillance of imported vector-borne virus infections and the potential for tropical disease outbreaks in highly populated regions of northern Italy where competent vectors are present.

Prognostic value of respiratory parameters for COVID-19 patients in the emergency department: results from the EC-COVID study.

While several studies have evaluated the prognostic weight of respiratory parameters in patients with COVID-19, few have focused on patients' clinical conditions at the first emergency department (ED) assessment. We analyzed a large cohort of ED patients recruited within the EC-COVID study over the year 2020, and assessed the association between key bedside respiratory parameters measured in room air (pO2, pCO2, pH, and respiratory rate [RR]) and hospital mortality, after adjusting for key confounding factors. Analyses were based on a multivariable logistic Generalized Additive Model (GAM). After excluding patients who did not perform a blood gas analysis (BGA) test in room air or with incomplete BGA results, a total of 2458 patients were considered in the analyses. Most patients were hospitalized on ED discharge (72.0%); hospital mortality was 14.3%. Strong, negative associations with hospital mortality emerged for pO2, pCO2 and pH (p-values: < 0.001, < 0.001 and 0.014), while a significant, positive association was observed for RR (p-value < 0.001). Associations were quantified with nonlinear functions, learned from the data. No cross-parameter interaction was significant (all p-values were larger than 0.10), suggesting a progressive, independent effect on the outcome as the value of each parameter departed from normality. Our results collide with the hypothesized existence of patterns of breathing parameters with specific prognostic weight in the early stages of the disease.

On-demand use of peripheral arterial catheters outside the Intensive Care Unit: Development and retrospective evaluation of an internal protocol for insertion and management.

BACKGROUND: COVID-19 patients require frequent arterial blood gas analysis for the assessment of oxygenation status. OBJECTIVE: The main objective of this research is to describe a dedicated protocol developed to standardize the insertion and management of peripheral Arterial Catheters (AC) for on-demand use, in the Emergency Department of "Maggiore" Hospital (Lodi, Italy).This strategy represents a valid alternative to repeated arterial punctures outside the intensive care unit. METHODS: The crucial points of the protocol were defined: vessel selection criteria, device used, technique of insertion, choice of securement and dressing device, and procedures had been created for correct management. RESULTS: During April and December 2020, 50 AC were inserted, two dislocations and one malfunction were observed. No major complications (Catheter Related Bloodstream Infection, thrombosis, bleeding, pseudoaneurysms, hematoma, artery occlusion - even temporary - and skin irritation) were observed. CONCLUSIONS: To the authors knowledge, this is the first article describing the insertion and management of ACs for on-demand utilization outside the intensive care unit. The safe and effective use of this technique could be clinically relevant in patients requiring multiple ABG without need of invasive monitoring; it also allows the reduction of both artery sticks and workload of health care providers. However, clinical studies are needed to confirm the validity of the proposed treatment, especially the use of the most appropriate securement system and the most effective solution for locking catheters.

Ultrasound Detection of Portomesenteric Venous Gas Is an Early Sign of Bowel Ischaemia in Non-Traumatic Abdominal Pain: Old Dogs, New Tricks-Four Cases Report.

Acute bowel ischemia is a severe disease often with a poor outcome. Early diagnosis can improve outcome, but atypical clinical manifestations and nonspecific laboratory and instrumental diagnostic findings may delay computed tomographic angiography (CTA). Portomesenteric venous gas (PVG), indirect sign of pneumatosis intestinalis, is considered a late finding with poor prognosis. We report four cases where PVG, easily identified through point-of-care ultrasonography (POCUS), was an early sign of bowel ischemia leading to a precocious diagnosis confirmed at CTA. In acute non-traumatic abdominal pain, an evidence of PVG could be an early ultrasonographic finding of bowel ischemia in the emergency department.

The First Italian Telemedicine Program for Non-Critical COVID-19 Patients: Experience from Lodi (Italy).

Italy was the first Western country to face a massive SARS-CoV-2 outbreak. The limited information initially available on the natural course of the disease required caution in the discharge of patients accessing health facilities. This resulted in overcrowded health facilities and emergency services. In this context, improvements of other forms of hospital care assistance were needed. This study shows the results of the first Italian remote monitoring program for COVID-19 patients. The program was implemented by the Azienda Socio Sanitaria (ASST) Lodi (Italy) by using the innovative Zcare software®. Data generated during patient recruitment, monitoring, and discharge were extracted from the Zcare software and statistically analysed. Data refer to a sample of 1196 patients enrolled in the remote monitoring program in 2020. Patients reported symptoms mainly during the first week. The most frequently reported symptoms were general fatigue, cough, and loss of taste and smell (dysosmia). More than 80% of patients reported a saturation level below 96% at least once, and more than 70% had a temperature above 37 °C. Active monitoring of reported symptoms provided valuable insights into the disease's natural history during its less severe acute phase. Only 109 individuals visited the emergency department at least once in the first 100 days of monitoring. Of these, 101 had COVID-19 infection, 69 of whom were hospitalized following a first clinical assessment at the emergency department. The ASST Lodi's telemedicine strategy for COVID patients appears to be a viable alternative to hospitalization. This strategy enables the provision of proper care while making resources available for more critically ill patients, and enhances the availability of resources available for more critically ill patients.

Tunneling technique of PICCs and Midline catheters.

BACKGROUND: The tunneling technique is currently widely used for placement of CVC. Recently, some clinicians have used this technique for peripherally inserted central catheters (PICC), or Midline catheters (MCs). OBJECTIVE: To describe a safe antegrade tunneling technique for PICCs and MCs insertion with a blunt tunneler. METHODS: This retrospective monocentric survey collected ASST Lodi hospital data from January 1st to December 31st, 2019. The indication for PICCs and MCs tunneled implant was to respect the correct vein/catheter ratio or special clinical situation (children, burns, wounds, and wider catheter 5/6 fr). Contraindications included the operator's low skills and severe risk of bleeding (INR > 3; Platelet count <50'000). RESULTS: About 390 PICCs (327 4 fr and 63 5 fr) and 183 MCs were placed. One hundred and sixty-five PICCs (42%) and 110 MCs (60%) were tunneled. Five fr PICCs were more present among tunneled catheters (54/165 [32.7%] vs 9/225 [4%] p < 0.0001). In the majority tunneling was necessary to respect the correct catheter/vein ratio. The exit site was shifted only for four special clinical situations: skin infections (one PICC and two MCs); burns (one MC). No early complication (intraprocedural, major bleeding), catheter related thrombosis, or device fractures occurred. Two catheter-related bloodstream infections (one PICC, one MC), nine dislocations (four PICCs, five MCs), one MC occlusion were recorded. CONCLUSIONS: The antegrade tunneling technique with blunt tunneler of PICCs and MCs is simple, rapid and is regarded as a safe maneuver. More in-depth and future prospective studies are needed to evaluate the impact of tunneling on early and late complications.

Risk Stratification in COVID-19 Pneumonia - Determining the Role of Lung Ultrasound.

LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings. MATERIALS AND METHODS: An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2nd to April 3rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER). RESULTS: 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967. CONCLUSION: The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.

Retrospective survey from vascular access team Lombardy net in COVID-19 era.

BACKGROUND: Venous Access Devices (VADs) are the most used devices in COVID-19 patients. OBJECTIVE: Identify VADs implanted, catheter related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and accidental remove of VADs in both COVID-19 positive and COVID-19 free patients. Successive analysis was conducted comparing COVID-19 positive patients with COVID-19 free with inverse probability propensity score weights using simple regression to account for these two confounders (peripheral tip as central/peripheral and hospitalization as no/yes). METHODS: This multicenter, retrospective cohort study collected data from seven hospitals in Lombardy during the pandemic period from February 21st to May 31st 2020. RESULTS: A total of 2206 VADs were evaluated, 1107 (50.2%) of which were inserted in COVID-19 patients. In COVID-19 cohort the first choice was Long Peripheral Cannula in 388 patients (35.1%) followed by Midline Catheter in 385 (34.8%). The number of "central tip" VADs inserted in COVID-free inpatients and COVID-19 positive were similar (307 vs 334). We recorded 42 (1.9%) CRT; 32 (79.2%) were observed in COVID-19 patients. A total of 19 CRBSI were diagnosed; 15 (78.95%) were observed in COVID-19. Accidental removals were the more represented complication with 123 cases, 85 (69.1%) of them were in COVID-19. COVID-19 significantly predicted occurrence of CRT (OR = 2.00(1.85-5.03); p < 0.001), CRSB (OR = 3.82(1.82-8.97); p < 0.001), and Accidental Removal (OR = 2.39(1.80-3.20); p < 0.001) in our propensity score weighted models. CONCLUSIONS: CRT, CRBSI, and accidental removal are significantly more frequent in COVID-19 patients. Accidental removals are the principal complication, for this reason, the use of subcutaneously anchored securement is recommended for a shorter period than usual.

Bergamo and Covid-19: How the Dark Can Turn to Light.

The novel coronavirus, SARS-CoV-2, continues to spread rapidly. Here we discuss the dramatic situation created by COVID-19 in Italy, particularly in the province of Bergamo (the most severely affected in the first wave), as an example of how, in the face of an unprecedented tragedy, acting (albeit belatedly)-including imposing a very strict lockdown-can largely resolve the situation within approximately 2 months. The measures taken here ensured that Bergamo hospital, which was confronted with rapidly rising numbers of severely ill COVID-19 patients requiring hospitalization, was able to meet the initial challenges of the pandemic. We also report that local organization and, more important, the large natural immunity against SARS-CoV-2 of the Bergamo population developed during the first wave of the epidemic, can explain the limited number of new COVID-19 cases during the more recent second wave compared to the numbers in other areas of Lombardy. Furthermore, we highlight the importance of coordinating the easing of containment measures to avoid what is currently observed in other countries, especially in the United States, Latin American and India, where this approach has not been adopted, and a dramatic resurgence of COVID-19 cases and an increase in the number of hospitalisations and deaths have been reported.

COVID-19 Epidemic in the Middle Province of Northern Italy: Impact, Logistics, and Strategy in the First Line Hospital.

The novel coronavirus (COVID-19) began in China in early December 2019 and rapidly has spread to many countries around the globe, with the number of confirmed cases increasing every day. An epidemic has been recorded since February 20 in a middle province in Northern Italy (Lodi province, in the low Po Valley). The first line hospital had to redesign its logistical and departmental structure to respond to the influx of COVID-19-positive patients who needed hospitalization. Logistical and structural strategies were guided by the crisis unit, managing in 8 days from the beginning of the epidemic to prepare the hospital to be ready to welcome more than 200 COVID-19-positive patients with different ventilatory requirements, keeping clean emergency access lines, and restoring surgical interventions and deferred urgent, routine activity.

Contrast enhanced ultrasound vs chest x-ray to determine correct central venous catheter position.

PURPOSES: We aimed to analyze the diagnostic accuracy of contrast enhanced ultrasonography (CEUS), compared with chest x-ray (CXR), in the detection of correct central venous line (CVL) placement. Our hypothesis was to verify whether CEUS could substitute CXR as a reference standard for correct placement of CVL or function as a triage test to limit the execution of CXR only for selected patients. BASIC PROCEDURES: CEUS was carried out in 71 non consecutive patients to verify the correct positioning of a central venous line. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios of CEUS compared to CXR, with their respective 95% confidence interval (CI), were calculated. MAIN FINDINGS: CXR identified 6 CVL misplacements (8,4%, CI 95% 3,2%-18%). Four of these were intravascular and 2 in the right atrium. CEUS identified only 3 misplacements, of which 1 was intravascular and 2 intracardiac. Using CXR as a reference standard, and considering intravascular and intracardiac malpositioning altogether, the sensitivity, specificity, and positive and negative likelihood ratio of CEUS were 33% (95% CI, 0%-71%), 98% (95% CI, 95%-100%), 21%, 7%, 0%, and 68%, respectively. The negative and positive predictive values were 94% (95% CI, 89%-100%) and 67% (95% CI, 13%-100%). PRINCIPAL CONCLUSIONS: CEUS can't substitute CXR, or become a triage test in selected patients, in evaluating the correct tip position after CVL placement.

Atrial fibrillation in emergency department: prevalence of sinus rhythm 1 week after discharge.

BACKGROUND: Current guidelines do not provide definitive indications about the treatment in emergency departments (ED) of patients with recent-onset atrial fibrillation (AF). METHODS: A multicentre observational study involving four general hospitals of the same metropolitan area was conducted. All consecutive adult patients admitted to the ED with recent symptoms of AF (<48 h duration) and discharged home were considered. Patients who underwent ED early cardioversion were enrolled in group A. Patients managed with ventricular rate control were enrolled in group B. RESULTS: On the 24 h Holter recordings at 1-week follow-up, stable sinus rhythm was detected in 46/58 (79.3%; 95% CI 68.9 to 89.7) patients in group A and 8/33 (24.2%; 95% CI 9.6 to 38.9) patients in group B (p<0.01). CONCLUSION: According to the study results, rhythm at the time of ED discharge is a poor indicator of the short-term evolution of AF.