Awake prone positioning for patients with COVID-19-related respiratory failure: a systematic review and meta-analysis.

The role of awake prone positioning (aPP) in patients with acute hypoxemic respiratory failure is debated. We performed a systematic review and meta-analysis to evaluate the role of aPP in acute respiratory failure related to COronaVIrus Disease-19 (COVID-19). Studies reporting on the clinical course of patients with acute respiratory failure related to COVID-19 treated or not treated by aPP were included in the systematic review and meta-analysis (ProsperoID: CRD42022333211). The primary study outcome was the composite of in-hospital death or orotracheal intubation; the individual components of the primary outcome were secondary study outcomes. The composite of in-hospital death or orotracheal intubation was available for 6 studies (1884 patients), five randomized and one prospective; a significant reduction in the risk of this outcome was observed in patients treated vs. not treated by aPP (33.5% vs. 39.8%; OR 0.73, 95% CI 0.60-0.89; I2 0%). In-hospital death was reported in 34 studies (6808 patients) and occurred in 17.4% vs. 23.5% of patients treated or not treated with aPP (random effect OR 0.60, 95% CI 0.46-0.79; I2 59%); orotracheal intubation was observed in 25.8% vs. 32.7% of patients treated or not treated with aPP (27 studies, 5369 patients; random effect OR 0.85, 95% CI 0.56-1.27; I2 84%). aPP reduces the risk for death or orotracheal intubation in patients with acute respiratory failure related to COVID-19. Further studies should be conducted to confirm the clinical benefit of aPP outside the ICU.Registration Prospero ID: CRD42022333211.

Dealing with dehydration in hospitalized oldest persons: accuracy of the calculated serum osmolarity.

BACKGROUND:  Assessment of hydration status is complex and difficult to detect in older persons. Different methods have been developed to determine hydration status in clinical settings, but their diagnostic accuracy remains questionable. AIMS: The aim of this study was to determine and compare the diagnostic accuracy of all methods routinely used in acute settings to detect dehydration in a cohort of hospitalized oldest-old persons, using as primary reference standard blood urea nitrogen (BUN) to creatinine ratio. METHODS:  This retrospective study was conducted on 59 oldest-old subjects at hospital admission in an acute setting, with complete physical, biochemical, bioelectrical impedance analysis (BIA) and ultrasound assessment, including inferior vena cava diameters. RESULTS: Fifty-nine (45 women/14 men) subjects, with a mean age of 87.4 ± 5.9 years, were studied. Based on the value of the BUN/creatinine ratio, the whole population was divided into hyperhydrated (n = 10), normohydrated (n = 42), and dehydrated (n = 7) groups. Among parameters indicating the hydration status, serum sodium levels (p < 0.0001), serum chloride levels (p = 0.010), calculated plasma osmolarity (p < 0.0001), and fat mass (FM) (p = 0.030) differed significantly among groups. A ROC analysis showed that the highest and most significant value for dehydration detection was the calculated plasma osmolarity (AUC: 0.820, p = 0.013), which significantly correlated with clinical parameters including heart rate (r = 0.300; p = 0.021), capillary refill (r = 0.379; p = 0.013) and systolic blood pressure (r = - 0.261; p = 0.046). DISCUSSION: The measurement of calculated serum osmolarity is simple and inexpensive and may quickly provide high sensitivity and specificity indication of dehydration in hospitalized oldest-old persons.

Modelling the SARS-CoV-2 vaccination campaign in Italy: the fundamental role of unreported cases.

In Italy and around the world, the year 2021 was dedicated to vaccination campaigns against the COVID-19 epidemic arising after the outbreak of SARS-CoV-2 in China in 2019. In December 2020, we proposed a model prediction for the effects of vaccination, and now, after more than 9 months of the vaccination campaign, a comparison of those predictions with the actual data is mandatory. Surprising evidences emerge suggesting new strategies to consider regarding the spread of the virus and to protect frail people. After several months of the immunization campaign in Italy, it is estimated that approximately 20 000 deaths were avoided during the year 2021.

Modelling SARS-CoV-2 unreported cases in Italy: Analysis of serological survey and vaccination scenarios.

OBJECTIVES: Aim of the present paper is the study of the large unreported component, characterizing the SARS-CoV-2 epidemic event in Italy, taking advantage of the Istat survey. Particular attention is devoted to the sensitivity and specificity of the serological test and their effects. METHODS: The model satisfactory reproduces the data of the Italian survey showing a relevant predictive power and relegating in a secondary position models which do not include, in the simulation, the presence of asymptomatic groups. The corrections due to the serological test sensitivity (in particular those ones depending on the symptoms onset) are crucial for a realistic analysis of the unreported (and asymptomatic) components. RESULTS: The relevant presence of an unreported component during the second pandemic wave in Italy is confirmed and the ratio of reported to unreported cases is predicted to be roughly 1:4 in the last months of year 2020. A method to correct the serological data on the basis of the antibody sensitivity is suggested and systematically applied. The asymptomatic component is also studied in some detail and its amount quantified. A model analyses of the vaccination scenarios is performed confirming the relevance of a massive campaign (at least 80000 immunized per day) during the first six months of the year 2021, to obtain important immunization effects within August/September 2021.

A study of SARS-CoV-2 epidemiology in Italy: from early days to secondary effects after social distancing.

BACKGROUND: The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to 101,739 confirmed cases, in Italy, as of March 30th, 2020. While the analogous event in China appears to be under control at the moment, the outbreaks in western countries are still at an early stage of development. Italy, at present, is playing a major role in understanding the transmission dynamics of these new infections and evaluating the effectiveness of control measures in a western social context. METHODS: We combined a quarantined model with early-stage development data in Italy (during the period February 20th-March 30th) to predict longer-term progression (from March 30th, till June 25th, 2020 in a long-term view) with different control measures. Due to significant variations in the control strategies, which have been changing over time, and thanks to the introduction of detection technologies leading to faster confirmation of the SARS-CoV-2 infections, we made use of time-dependent contact and diagnosis rates to estimate when the effective daily reproduction ratio can fall below 1. Within the same framework, we analyze the possible secondary infection event after relaxing the isolation measures. OUTCOMES AND INTERPRETATION: We study two simplified scenarios compatible with the observation data and the effects of two stringent measures on the evolution of the epidemic. On one side, the contact rate must be kept as low as possible, but it is also clear that, in a modern developed country, it cannot fall under certain minimum levels and for a long time. The complementary parameter tuned is the transition rate of the symptomatic infected individuals to the quarantined class, a parameter δI I connected with the time tI = 1/δI  needed to perform diagnostic tests. Within the conditions of the outbreak in Italy, this time must fall under 12-8 h in order to make the reproduction number less than 1 to minimize the case numbers. Moreover, we show how the same parameter plays an even more important role in mitigating the effects of a possible secondary infection event.

Prediction of major bleeding in patients receiving DOACs for venous thromboembolism: A prospective cohort study.

BACKGROUND: In the direct oral anticoagulants (DOACs) era, extended anticoagulation is an attractive strategy after venous thromboembolism (VTE). The role of currently available bleeding risk scores for VTE patients treated with DOACs in clinical practice is undefined. METHODS: Consecutive patients with VTE were included in a prospective multicenter cohort at the initiation of treatment with DOACs. The role of ATRIA, HAS-BLED, Kuijer, ORBIT, RIETE and VTE-BLEED scores in predicting major bleeding (ISTH definition) while on DOAC treatment was assessed. RESULTS: Overall, 1034 patients were included and followed for one year or until the end of treatment or the occurrence of major bleeding. During study period, 26 major bleedings occurred in 25 patients (2.8% patient-year). Anemia, bleeding history and creatinine clearance <60 ml/min were significant predictors of major bleedings. The predictive value of bleeding risk scores was modest. In the 12-month study period, ORBIT (HR intermediate-high vs. low risk patients 3.62, 95% CI 1.65-7.94 and c-statistics 0.645, 95% CI 0.523-0.767) and VTE-BLEED (HR high vs. low 16.11, 95% CI 2.18-119.09 and c-statistics 0.674, 95% CI 0.593-0.755) score significantly predicted major bleeding. The lowest incidence of major bleeding (0.3%) was observed in the low-risk category of VTE-BLEED, while the highest (7.1%) in the high-risk category of ORBIT. CONCLUSIONS: In a real-life cohort of patients with VTE treated with DOACs, the predictive value of currently available bleeding risk scores was modest and not statistically different. Whether these scores can be used for decision making on anticoagulation should be assessed in management studies.

Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism: results from the Italian Pulmonary Embolism Registry.

The exact prevalence of mobile right heart thromboemboli (RHTh) in patients with pulmonary embolism (PE) is unknown, depending upon PE severity and the use of early echocardiography. Similarly, the mortality rate is variable, though RHTh detection appears to substantially increase the risk of death in patients with PE. The aim of this study was to assess the prevalence of RHTh in different risk categories in a wide series of patients with PE, and to analyse the effect of RHTh on in-hospital mortality. Among 1,716 patients enrolled in the Italian Pulmonary Embolism Registry, 1,275 (13.3% at high risk, 59.3% at intermediate risk and 27.4% at low risk) had echocardiography within 48 hours from hospital admission and entered the study. Overall, RHTh were detected in 57 patients (4.5%, at admission echocardiography in 88%): in 27/169 (16%) high-risk, in 29/756 (3.8%) intermediate-risk and 1/350 (0.3%) low-risk patients, respectively. At multivariate analysis, only advanced age (odds ratio [OR] 1.61, 95% confidence [CI] 1.27-2.03, p<0.0001), high-risk category (OR vs low-risk category 37.82, 95% CI 11.26-127.06, p<0.0001) and recurrent PE (OR 45.92, 95%CI 15.19-139.96, p<0.0001) showed a statistically significant effect on mortality. The presence of RHTh significantly increased the risk of dying (OR 3.89, 95%CI 1.98-7.67, p=0.0001) at univariate analysis, but this result was not mantained in the multivariate model (OR 1.64, 95%CI 0.75-3.60, p=0.216). In conclusion, though patients with RHTh had a more severe presentation of PE, this study did not detect an association between RHTh and prognosis.