The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy

Extended access to general practice services during weekends in the first wave of the COVID-19 pandemic

OBJECTIVE

The incidence, symptoms, and trajectories of COVID-19 in the community were unknown in the early phase of the pandemic. Consequently, organizing a primary health care response was challenging. The aim of this study was to investigate whether reorganizing general practice services with extended weekend access for patients was feasible, and to assess the extent to which patients used this service.

DESIGN

Observational study with registration after a simple intervention.

SETTING

General practice services in the second half of March 2020 when the first wave of the COVID-19 pandemic hit Bergen, the second largest city in Norway.

SUBJECTS

All general practices in Bergen were asked to be available during weekends for their patients with respiratory tract infections (RTIs), by telephone, video-, or e-consultation.

MAIN OUTCOME MEASURES

Number of practices participating, patients connected to these practices, and consultations for RTIs and suspected COVID-19.

RESULTS

During the first weekend, 33 of 71 practices (45%) covering 51% of the population participated. The following weekend this increased to 39 practices (53%) covering 64% of the population. The first weekend 25 practices reported a total of 336 consultations for RTIs, eight of which were for confirmed and 113 were for suspected COVID-19. The corresponding numbers reported from 23 practices the second weekend were 158 RTI consultations, four for confirmed and 41 for suspected COVID-19.

CONCLUSIONS

On short notice about half the practices in Bergen were made accessible during weekends for their patients with RTIs. The number of consultations per practice was small, but combined this amounted to a substantial improvement in the emergency services.

Changing the stroke network during pandemic scenarios does not affect the management of patients with a positive Cincinnati prehospital stroke scale

INTRODUCTION

Time plays a crucial role in the management of stroke, and changing the prehospital emergency network, altering the HUB and spoke relationship in pandemic scenarios, might have an impact on time to fibrinolysis or thrombectomy. The aim of this study was to evaluate the time-dependent stroke emergency network in Lombardy region (Italy) by comparing 2019 with 2020 and early 2021. Three parameters were investigated: (i) time of arrival of the first vehicle at the scene, (ii) overall duration of missions, and (iii) number of patients transported by emergency vehicles.

METHODS

Data analysis process conducted using the SAS-AREU portal (SAS Institute, USA).

RESULTS

The number of patients with a positive CPSS was similar among the different pandemic waves. Mission duration increased from a mean time (SD) of 52.9 (16.1) min in 2019 to 64.1 (19.7) in 2020 and 55.0 (16.8) in 2021. Time to first vehicle on scene increased to 15.7 (8.4) min in 2020 and 16.0 (7.0) in 2021 compared to 2019, 13.6 (7.2) (P < 0.05). The number of hospital with available stroke units decreased from 46 in 2019 to 10 during the first pandemic wave.

CONCLUSIONS

The pandemic forced changes in the clinical mission of many hospitals by reducing the number of stroke units. Despite this, the organization of the emergency system allowed to identify strategic hospitals and thus avoid excessive transport time. The result was an adequate time for fibrinolysis/thrombectomy, in agreement with the guidelines. Coordinated management in emergency situations makes it possible to maintain service quality standards, despite the unfavorable scenario.

Biosafety Issues in Patient Transport during COVID-19: A Case Study on the Portuguese Emergency Services

During the COVID-19 pandemic, first responders faced significant biosafety challenges, especially while handling patient transport, potentially exposing them to infection. The PANDEM-2 (European project on pandemic preparedness and response) project, funded by the Horizon 2020 program, sought to investigate the challenges confronting Emergency Medical Systems throughout the EU. First responders from Portugal's National Institute of Medical Emergency (INEM) were considered as a representative operational model of the national first responder agencies of European member states because they played a critical role during the COVID-19 pandemic. As a result, they were asked to complete an online survey about their COVID-19 pandemic-related professional activities. The survey focused on their perspectives on current biosafety guidelines and their operational practices. It covered opinions on existing protocols, technical concerns during patient transport, and issues after the patients arrived at the hospital. The key findings revealed concerns about risk assessment, the inadequacy of guidelines, and disparities in equipment access. This survey emphasizes the importance of developing streamlined, adaptable biosafety protocols, better coordination between prehospital and in-hospital services, and the development of scalable, cost-effective biosafety solutions. Based on our findings, we propose improvements to national and European biosafety directives and advocate for streamlined adaptation during pandemics.

Outcome of emergency patients transported by ambulance during the COVID-19 pandemic in Osaka Prefecture, Japan: a population-based descriptive study

Background

The novel corona virus (COVID-19) pandemic occurred worldwide. Although an excessive burden was placed on emergency medical institutions treating urgent and severe patients, its impact on patient outcome remains unknown. This study aimed to assess the impact of the COVID-19 pandemic in 2021 on the emergency medical services (EMS) system and patient outcomes in Osaka Prefecture, Japan.

Methods

This was a retrospective descriptive study with a study period from January 1, 2019 to December 31, 2021. We included patients who were transported by ambulance and had cleaned data that was recorded in the ORION system. The study endpoints were the number of patients transported by ambulance and the number of deaths among these patients in each month. To assess the impact of the COVID-19 pandemic on the EMS system, the incidence rate ratio (IRR) and 95% confidence interval (CI) were calculated using 2019 as the reference year. Mortalities were evaluated based on deaths in the emergency department and deaths at 21 days after hospitalization.

Results

The numbers of patients transported by ambulance were 500,194 in 2019, 443,321 in 2020 (IRR: 0.88, 95% CI: 0.87-0.88), and 448,054 in 2021 (IRR: 0.90, 95% CI: 0.89-0.90). In 2019, the number of patients transported by ambulance and who died in the emergency departments was 4,980, compared to 5,485 in 2020 (IRR: 1.10, 95% CI; 1.06-1.44) and 5,925 in 2021 (IRR: 1.19, 95% CI: 1.15-1.24). In 2019, the number of patients who died within 21 days after hospitalization was 11,931, compared to 11,913 in 2020 (IRR; 1.00, 95% CI; 0.98-1.03) and 13,376 in 2021 (IRR; 1.12, 95% CI; 1.09-1.15).

Conclusion

The COVID-19 pandemic decreased the number of ambulance requests and worsened mortality of patients transported by ambulance in Osaka Prefecture during 2021.

Social isolation during the COVID-19 pandemic is associated with the decline in cognitive functioning in young adults

Coronaviruses have caused widespread disease and death worldwide, leading to the implementation of lockdown measures and the closure of educational institutions in various countries. This research aims to investigate the impact of social isolation on the cognitive functioning of young students. The study included 84 subjects, with 48 being socially isolated and 36 non-isolated individuals. The participants' mental health was assessed using the Mini-Mental State Examination (MMSE), while cognitive functions were evaluated through attention-switching tasks (AST), pattern recognition memory (PRM), and choice reaction time (CRT) tests utilizing the Cambridge Neuropsychological Automated Battery (CANTAB) software. The socially isolated group had an average age of 21.3 ± 1.1 years, whereas the non-isolated group had an average age of 22.8 ± 2.0 years. The MMSE scores were 25.8 ± 1.6 for the socially isolated group and 28.6 ± 1.3 for the non-isolated group. In terms of cognitive functioning, there were significant differences (p = 0.000) observed in the values of AST correct latency for non-switching blocks (blocks 3 and 5) between the socially isolated group (608.1 ± 139.2) and the non-isolated group (499.5 ± 67.8). Similarly, the AST mean correct latency for switching blocks (block 7) was significantly different (p = 0.012) between the socially isolated group (784.4 ± 212.5) and the non-isolated group (671.8 ± 175.6). The socially isolated group exhibited significantly higher values in AST correct mean latency, AST congruent mean latency, AST incongruent mean latency, and AST percent mean correct trials compared to the non-isolated group. Additionally, the PRM mean percent correct significantly differed (p = 0.000) between the isolated group (81.3 ± 12.0) and the non-isolated group (91.9 ± 9.2). The isolated group also showed a higher CRT correct mean latency (482.4 ± 128.9) than the non-isolated group (451.0 ± 59.0), however the difference was not significant. In conclusion, social isolation during the COVID-19 pandemic has resulted in a decline in the cognitive functioning of young students.

A long trend of sexually transmitted diseases before and after the COVID-19 pandemic in China (2010-21)

BACKGROUND

The longer ongoing benefits of coronavirus disease 2019 (COVID-19) non-pharmaceutical interventions (NPIs) for sexually transmitted diseases (STDs) in China are still unclear. We aimed to explore the changes in five STDs (AIDS, hepatitis B, hepatitis C, gonorrhoea, and syphilis) before, during, and after the COVID-19 pandemic in mainland China, from 2010 to 2021.

METHODS

The number of the monthly reported cases of the five STDs were extracted from the website to construct the Joinpoint regression and autoregressive integrated moving average (ARIMA) models. Eight indicators reflecting NPIs were chosen from the COVID-19 Government Response Tracker system. The STDs and eight indicators were used to establish the Multivariable generalised linear model (GLM) to calculate the incidence rate ratios (IRRs).

RESULTS

With the exception of hepatitis B, the other four STDs (AIDS, hepatitis C, gonorrhoea, and syphilis) had a positive average annual percent change over the past 12years. All the ARIMA models had passed the Ljung-Box test, and the predicted data fit well with the data from 2010 to 2019. All five STDs were significantly reduced in 2020 compared with 2019, with significant estimated IRRs ranging from 0.88 to 0.92. In the GLM, using data for the years 2020 (February-December) and 2021, the IRRs were not significant after adjusting for the eight indicators in multivariate analysis.

CONCLUSION

Our study demonstrated that the incidence of the five STDs decreased rapidly during the COVID-19 pandemic in 2020. A recovery of STDs in 2021 was found to occur compared with that in 2020, but the rising trend disappeared after adjusting for the NPIs. Our study demonstrated that NPIs have an effect on STDs, but the relaxation of NPI usage might lead to a resurgence.

Detection of patients with COVID-19 by the emergency medical services in Lombardy through an operator-based interview and machine learning models

BACKGROUND

The regional emergency medical service (EMS) in Lombardy (Italy) developed clinical algorithms based on operator-based interviews to detect patients with COVID-19 and refer them to the most appropriate hospitals. Machine learning (ML)-based models using additional clinical and geospatial epidemiological data may improve the identification of infected patients and guide EMS in detecting COVID-19 cases before confirmation with SARS-CoV-2 reverse transcriptase PCR (rtPCR).

METHODS

This was an observational, retrospective cohort study using data from October 2020 to July 2021 (training set) and October 2021 to December 2021 (validation set) from patients who underwent a SARS-CoV-2 rtPCR test within 7 days of an EMS call. The performance of an operator-based interview using close contact history and signs/symptoms of COVID-19 was assessed in the training set for its ability to determine which patients had an rtPCR in the 7 days before or after the call. The interview accuracy was compared with four supervised ML models to predict positivity for SARS-CoV-2 within 7 days using readily available prehospital data retrieved from both training and validation sets.

RESULTS

The training set includes 264 976 patients, median age 74 (IQR 55-84). Test characteristics for the detection of COVID-19-positive patients of the operator-based interview were: sensitivity 85.5%, specificity 58.7%, positive predictive value (PPV) 37.5% and negative predictive value (NPV) 93.3%. Contact history, fever and cough showed the highest association with SARS-CoV-2 infection. In the validation set (103 336 patients, median age 73 (IQR 50-84)), the best-performing ML model had an AUC of 0.85 (95% CI 0.84 to 0.86), sensitivity 91.4% (95 CI% 0.91 to 0.92), specificity 44.2% (95% CI 0.44 to 0.45) and accuracy 85% (95% CI 0.84 to 0.85). PPV and NPV were 13.3% (95% CI 0.13 to 0.14) and 98.2% (95% CI 0.98 to 0.98), respectively. Contact history, fever, call geographical distribution and cough were the most important variables in determining the outcome.

CONCLUSION

ML-based models might help EMS identify patients with SARS-CoV-2 infection, and in guiding EMS allocation of hospital resources based on prespecified criteria.

Risk of SARS-CoV-2 transmission in the close contacts in a small rural area in the Veneto Region (NE-Italy): past evidence for future scenarios

Background

During the first pandemic phase of COVID-19, an epidemiological study, named First survey, was conducted on the population of a small rural area in northern Italy. In spring 2020, the results showed how a prolonged lockdown slowed down the spread of the virus.

Methods

After contacting positive First Survey subjects and their families, those who decided to join voluntarily underwent a blood test to assess the presence of qualitative lgG about 2 months after the previous one. This was to determine if IgG persisted in individuals who tested positive in the First Survey as well as to assess the antibody status of their close family members, to determine if they were unintentionally infected.

Results

Based on serological analysis, 35.1% of the samples contained blood IgG. In subjects who tested positive during the First Survey, 62.5% remained IgG positive more than 2 months later. Among family members who were exposed to a positive relative, 23.7% were infected. Linear regression analysis showed that the presence of an infected person within a household resulted in the infection spreading to the others, but not excessively. Induced isolation extinguished the infection regardless of the extent of the contagion (intra-family or extra-family). Micro-outbreaks of SARS-Cov-2 infection which arose in the same household from extra-familial infections played a decisive role on the statistical significance of IgG-positive subjects (p < 0.001).

Discussion

The study reveal 52.6% of the IgG-positive subjects in the Second Survey came from the First Survey and 47.4% were family members previously in contact with positive subjects. Data suggest that there have been undiagnosed patients feeding the spread of the virus since the beginning of the pandemic. In conclusion, for future pandemics, it will be necessary: i) to ensure the rapid isolation of symptomatic patients and the early identification of their close contacts, ii) to carry out the maximum number of tests in the shortest possible time, both on symptomatic and asymptomatic subjects, and iii) to implement information campaigns to make people aware of their risks, and implement clear, non-conflicting communication.

Severe Acute Respiratory Syndrome Coronavirus 2 and Medical Evacuation in Lombardy: Lessons Learned from an Unprecedented Pandemic

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging infectious disease pandemic developed in Lombardy (northern Italy) during the last week of February 2020 with a progressive increase of patients presenting with serious clinical findings. Despite the efforts of the Central Italian Government, regional resources were rapidly at capacity. The solution was to plan the medical evacuation (MEDEVAC) of 119 critically ill patients (median age 61 years) to in-patient intensive care units in other Italian regions (77) and Germany (42). Once surviving patients were deemed suitable, the repatriation process concluded the assignment. The aim of this report is to underline the importance of a rapid organization and coordination process between different nodes of an effective national and international network during an emerging infectious disease outbreak and draw lessons learned from similar published reports.

Close contact behaviors of university and school students in 10 indoor environments

Close contact routes, including short-range airborne and large-droplet routes, play an important role in the transmission of SARS-CoV-2 in indoor environments. However, the exposure risk of such routes is difficult to quantify due to the lack of data on the close contact behavior of individuals. In this study, a digital wearable device, based on semi-supervised learning, was developed to automatically record human close contact behavior. We collected 337,056 s of indoor close contact of school and university students from 194.5 h of depth video recordings in 10 types of indoor environments. The correlation between aerosol exposure and close contact behaviors was then evaluated. Individuals in restaurants had the highest close contact ratio (64%), as well as the highest probability of face-to-face pattern (78%) during close contact. Accordingly, university students showed greater exposure potential in dormitories than school students in homes, however, a lower exposure was observed in classrooms and postgraduate student offices in comparison with school students in classrooms. In addition, restaurants had the highest aerosol exposure volume for both short-range inhalation and direct deposition on the facial mucosa. Thus, the classroom was established as the primary indoor environment where school students are exposed to aerosols.

Does the use of a diving mask adapted for non-invasive ventilation in hypoxemic acute respiratory failure in individuals with and without COVID-19 increase the ratio of arterial oxygen partial pressure to fractional inspired oxygen? A randomized clinical trial

Non-invasive ventilation (NIV) can be used in acute hypoxemic respiratory failure (AHRF); however, verifying the best interface for its use needs to be evaluated in the COVID-19 pandemic scenario. The objective of this study was to evaluate the behavior of the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio) in patients with AHRF with and without COVID-19 undergoing NIV with the conventional orofacial mask and the adapted diving mask. This is a randomized clinical trial in which patients were allocated into four groups: i) group 1: COVID-19 + adapted mask (n=12); ii) group 2: COVID-19 + conventional orofacial mask (n=12); iii) group 3: non-COVID-19 + adapted mask (n=2); iv) group 4: non-COVID-19 + conventional orofacial mask (n=12). The PaO2/FiO2 ratio was obtained 1, 24, and 48 hours after starting NIV, and the success of NIV was evaluated. This study followed the norms of the Consolidated Standards of Reporting Trials statement and was registered in the Brazilian Registry of Clinical Trials under registration RBR-7xmbgsz. Both the adapted diving mask and the conventional orofacial mask increased the PaO2/FiO2 ratio. The interfaces differed in terms of the PaO2/FiO2 ratio in the first hour [309.66 (11.48) and 275.71 (11.48), respectively] (p=0.042) and 48 hours [365.81 (16.85) and 308.79 (18.86), respectively] (p=0.021). NIV success was 91.7% in groups 1, 2, and 3, and 83.3% in group 4. No adverse effects related to interfaces or NIV were observed. NIV through the conventional orofacial mask interfaces and the adapted diving mask was effective in improving the PaO2/FiO2 ratio; however, the adapted mask presented a better PaO2/FiO2 ratio during use. There was no significant difference between interfaces regarding NIV failure.

Extended Multicriteria Group Decision Making with a Novel Aggregation Operator for Emergency Material Supplier Selection

How to ensure the normal production of industries in an uncertain emergency environment has aroused a lot of concern in society. Selecting the best emergency material suppliers using the multicriteria group decision making (MCGDM) method will ensure the normal production of industries in this environment. However, there are few studies in emergency environments that consider the impact of the decision order of decision makers (DMs) on the decision results. Therefore, in order to fill the research gap, we propose an extended MCGDM method, whose main steps include the following: Firstly, the DMs give their assessment of all alternatives. Secondly, we take the AHP method and entropy weight method to weight the criteria and the DMs. Thirdly, we take the intuitionistic fuzzy hybrid priority weight average (IFHPWA) operator we proposed to aggregate evaluation information and take the TOPSIS method to rank all the alternatives. Finally, the proposed method is applied in a case to prove its practicability and effectiveness. The proposed method considers the influence of the decision order of the DMs on the decision results, which improves the accuracy and efficiency of decision-making results.

Increased Prehospital Emergency Medical Service Time Interval and Nontransport Rate of Patients With Fever Using Emergency Medical Services Before and After COVID-19 in Busan, Korea

BACKGROUND

In Korea, patients with fever have been preemptively isolated to isolation beds in the emergency department (ED) since the coronavirus disease 2019 (COVID-19) pandemic began. However, isolation beds were not always available, and transport delays or failure (nontransport), especially for infants, were reported in the media. Few studies have focused on delays and failure in transporting fever patients to the ED. Therefore, this study aimed to examine and compare the emergency medical service (EMS) time interval and nontransport rate of patients with fever using EMSs before and after COVID-19.

METHODS

This retrospective observational study analyzed the prehospital EMS time interval and nontransport rate of fever patients who contacted EMSs in Busan, South Korea, from March 1, 2019 to February 28, 2022, using emergency dispatch reports. All fever patients (≥ 37.5°C) who contacted EMSs during this study were included. The EMS time interval was defined as the time between the patient's EMS call and ED arrival time. Nontransport was defined as a case recorded as not being transported in the emergency dispatch reports. The study population of 2019 was compared to the population of 2020 and 2021 with the independent t-test, Mann-Whitney U test, and χ² test. As a subgroup, the EMS time intervals and nontransport rates of infants with fever were compared before and after COVID-19.

RESULTS

A total of 554,186 patients accessed the EMS during the study period, and 46,253 patients with fever were included. The EMS time interval (mean ± standard deviation, minutes) of fever patients was 30.9 ± 29.9 in 2019, 46.8 ± 127.8 in 2020 (P < 0.001) and 45.9 ± 34.0 in 2021 (P < 0.001). The nontransport rate (%) was 4.4 in 2019, 20.6 in 2020 (P < 0.001), and 19.5 in 2021 (P < 0.001). For infants with fever, the EMS time interval was 27.6 ± 10.8 in 2019, 35.1 ± 15.4 in 2020 (P < 0.001), and 42.3 ± 20.5 in 2021 (P < 0.001), and the nontransport rate (%) was 2.6 in 2019, 25.0 in 2020, and 19.7 in 2021.

CONCLUSION

After the emergence of COVID-19, in Busan, the EMS time interval of fever patients was delayed, and approximately 20% of fever patients were not transported. However, infants with fever had shorter EMS time intervals and higher nontransport rates than the overall study population. A comprehensive approach, including prehospital and hospital ED flow improvements, is required beyond increasing the number of isolation beds.

“We are Tired but Do Not Give Up” the Dilemma and Challenges of Primary Nurses Facing the Omicron Variant: Qualitative Research

Background

Everyone becomes aware due to the epidemic, especially primary department nurses. The significance of their experiences teaches nurses how to take care of themselves and be successful in their caregiving.

Objective

The purpose of this study was to investigate the perceptions of nurses working in primary care settings in rural regions during the omicron variant pandemic.

Methods

On the basis of the Nvivo 12 analytic approach, extensive semi-structured interviews were used to perform this qualitative study. 20 interviews later, data saturation had been reached. Data collecting was place from February to March 2022 for a month. The following participant characteristics were discovered through semi-structured interviews with 20 nurse participants. Ages of the participants, who were split between eight men and twelve women, varied from 28 to 43 years (average age 36.4 years). The majority (75% of them) had a vocational education, and their years of experience ranged from five to fifteen (average 11 years).

Results

4 topics and 7 sub-themes' results. The results' fundamental message is: The Nursing Clinical Practice Dilemma, school district, virus type uncertainty Indigenous peoples do not adhere to the concept of the afterlife. Must Be Excited and Alert; School Cluster; Virus Type Confusion; Non-Belief in Covid; and the Dilemma of Nursing in Clinical Practice are the Overarching Themes of This Study.

Conclusion

Making innovations to increase motivation thereby reducing mental and physical fatigue are the implications of the results of this study. Further exploration of the readiness of nurses to treat patients in the main department is believed to be beneficial for the results of this study.

Implementation of a digital early warning score (NEWS2) in a cardiac specialist and general hospital settings in the COVID-19 pandemic: a qualitative study

OBJECTIVES

To evaluate implementation of digital National Early Warning Score 2 (NEWS2) in a cardiac care setting and a general hospital setting in the COVID-19 pandemic.

DESIGN

Thematic analysis of qualitative semistructured interviews using the non-adoption, abandonment, scale-up, spread, sustainability framework with purposefully sampled nurses and managers, as well as online surveys from March to December 2021.

SETTINGS

Specialist cardiac hospital (St Bartholomew's Hospital) and general teaching hospital (University College London Hospital, UCLH).

PARTICIPANTS

Eleven nurses and managers from cardiology, cardiac surgery, oncology and intensive care wards (St Bartholomew's) and medical, haematology and intensive care wards (UCLH) were interviewed and 67 were surveyed online.

RESULTS

Three main themes emerged: (1) implementing NEWS2 challenges and supports; (2) value of NEWS2 to alarm, escalate and during the pandemic; and (3) digitalisation: electronic health record (EHR) integration and automation. The value of NEWS2 was partly positive in escalation, yet there were concerns by nurses who undervalued NEWS2 particularly in cardiac care. Challenges, like clinicians' behaviours, lack of resources and training and the perception of NEWS2 value, limit the success of this implementation. Changes in guidelines in the pandemic have led to overlooking NEWS2. EHR integration and automated monitoring are improvement solutions that are not fully employed yet.

CONCLUSION

Whether in specialist or general medical settings, the health professionals implementing early warning score in healthcare face cultural and system-related challenges to adopting NEWS2 and digital solutions. The validity of NEWS2 in specialised settings and complex conditions is not yet apparent and requires comprehensive validation. EHR integration and automation are powerful tools to facilitate NEWS2 if its principles are reviewed and rectified, and resources and training are accessible. Further examination of implementation from the cultural and automation domains is needed.

Trends in respiratory diseases before and after the COVID-19 pandemic in China from 2010 to 2021

BACKGROUND

The ongoing benefits of coronavirus disease 2019 (COVID-19) nonpharmaceutical interventions (NPIs) for respiratory infectious diseases in China are still unclear. We aimed to explore the changes in seven respiratory infectious diseases before, during, and after COVID-19 in China from 2010 to 2021.

METHODS

The monthly case numbers of seven respiratory infectious diseases were extracted to construct autoregressive integrated moving average (ARIMA) models. Eight indicators of NPIs were chosen from the COVID-19 Government Response Tracker system. The monthly case numbers of the respiratory diseases and the eight indicators were used to establish the Multivariable generalized linear model (GLM) to calculate the incidence rate ratios (IRRs).

RESULTS

Compared with the year 2019, the percentage changes in 2020 and 2021 were all below 100% ranging from 3.81 to 84.71%. Pertussis and Scarlet fever started to increase in 2021 compared with 2020, with a percentage change of 183.46 and 171.49%. The ARIMA model showed a good fit, and the predicted data fitted well with the actual data from 2010 to 2019, but the predicted data was bigger than the actual number in 2020 and 2021. All eight indicators could negatively affect the incidence of respiratory diseases. The seven respiratory diseases were significantly reduced during the COVID-19 pandemic in 2020 and 2021 compared with 2019, with significant estimated IRRs ranging from 0.06 to 0.85. In the GLM using data for the year 2020 and 2021, the IRRs were not significant after adjusting for the eight indicators in multivariate analysis.

CONCLUSION

Our study demonstrated the incidence of the seven respiratory diseases decreased rapidly during the COVID-19 pandemic in 2020 and 2021. At the end of 2021, we did see a rising trend for the seven respiratory diseases compared to the year 2020 when the NPIs relaxed in China, but the rising trend was not significant after adjusting for the NPIs indicators. Our study showed that NPIs have an effect on respiratory diseases, but Relaxation of NPIs might lead to the resurgence of respiratory diseases.

Temporal dynamic characteristics of human monkeypox epidemic in 2022 around the world under the COVID-19 pandemic background

Background

The reemergence of the monkeypox epidemic has aroused great concern internationally. Concurrently, the COVID-19 epidemic is still ongoing. It is essential to understand the temporal dynamics of the monkeypox epidemic in 2022 and its relationship with the dynamics of the COVID-19 epidemic. In this study, we aimed to explore the temporal dynamic characteristics of the human monkeypox epidemic in 2022 and its relationship with those of the COVID-19 epidemic.

Methods

We used publicly available data of cumulative monkeypox cases and COVID-19 in 2022 and COVID-19 at the beginning of 2020 for model validation and further analyses. The time series data were fitted with a descriptive model using the sigmoid function. Two important indices (logistic growth rate and semi-saturation period) could be obtained from the model to evaluate the temporal characteristics of the epidemic.

Results

As for the monkeypox epidemic, the growth rate of infection and semi-saturation period showed a negative correlation (r = 0.47, p = 0.034). The growth rate also showed a significant relationship with the locations of the country in which it occurs [latitude (r = -0.45, p = 0.038)]. The development of the monkeypox epidemic did not show significant correlation compared with the that of COVID-19 in 2020 and 2022. When comparing the COVID-19 epidemic with that of monkeypox, a significantly longer semi-saturation period was observed for monkeypox, while a significant larger growth rate was found in COVID-19 in 2020.

Conclusions

This novel study investigates the temporal dynamics of the human monkeypox epidemic and its relationship with the ongoing COVID-19 epidemic, which could provide more appropriate guidance for local governments to plan and implement further fit-for-purpose epidemic prevention policies.

An impact of content delivery, equity, support and self-efficacy on student's learning during the COVID-19

Due to the outbreak of Covid-19, the colleges and universities across the world have shifted to online classes in place of face-to-face classes. In the wake of this outbreak, the present study focuses on analyzing the impact of sudden shift to online classes, on the undergraduate and postgraduate student's overall learning. The PLS-SEM results concluded that the content delivery has been the most significant construct to impact both self-efficacy and overall learning. The self-efficacy partially mediates the support and equity relationship with the overall learning. The student with greater self-efficacy will have better overall learning from this e-synchronous teaching methodology. However, content delivery has a stronger role in impacting the overall learning even if there is absence of self-efficacy, thus concluding no mediation.

Etiologic reclassification of cryptogenic stroke after implantable cardiac monitoring and computed tomography angiography re-assessment

INTRODUCTION

Different mechanisms may underlie cryptogenic stroke, including subclinical atrial fibrillation (AF), nonstenotic carotid plaques (NCP), and aortic arch atherosclerosis (AAA). In a cohort of cryptogenic stroke patients, we aimed to: (1) evaluate the prevalence of subclinical AF, NCP, and AAA, and reclassify the etiology accordingly; (2) compare the clinical features of patients with reclassified etiology with those with confirmed cryptogenic stroke.

METHODS

Data of patients hospitalized for cryptogenic stroke between January 2018 and February 2021 were retrospectively analyzed. Patients were included if they received implantable cardiac monitoring (ICM) to detect subclinical AF. Baseline computed tomography angiography (CTA) was re-evaluated to assess NCP and AAA. Since aortic plaques with ulceration/intraluminal thrombus were considered pathogenetic during the initial workup, only patients with milder AAA were included. Stroke etiology was reclassified as "cardioembolic", "atherosclerotic", or "mixed" based on the detection of AF and NCP/AAA. Patients with "true cryptogenic" stroke (no AF, ipsilateral NCP, or AAA detected) were compared with those with reclassified etiology.

RESULTS

Among 63 patients included, 21 (33%) were diagnosed with AF (median follow-up time of 15 months), 12 (19%) had ipsilateral NCP, and 6 (10%) had AAA. Stroke etiology was reclassified in 30 patients (48%): cardioembolic in 14 (22%), atherosclerotic in 9 (14%), and mixed in 7 (11%). Patients with true cryptogenic stroke were younger compared to those with reclassified etiology (p = 0.001).

DISCUSSION

One or more potential covert stroke sources can be recognized in half of the patients with a cryptogenic stroke through long-term cardiac monitoring and focused CTA re-assessment.

Incidence and outcome of patients with difficulty in hospital acceptance during COVID-19 pandemic in Osaka Prefecture, Japan: A population-based descriptive study

Aim

The impact of the coronavirus disease (COVID-19) pandemic on the emergency medical service system in Japan has not been fully revealed. The purpose of this study was to determine the impact of the COVID-19 pandemic in 2021 on the difficulty in hospital acceptance of patients and patient outcome in Osaka Prefecture.

Methods

This study was a descriptive epidemiological study with a 3-year study period from January 2019 to December 2021. We included patients who were transported by ambulance and had registered in the Osaka Emergency Information Research Intelligent Operation Network (ORION) system. The primary end-point of this study was the difficulty in hospital acceptance by month, and the secondary outcome was the mortality of patients who experience difficulty in hospital acceptance in each year.

Results

We included 1,302,646 cases in this study. The proportion of cases with difficulty in hospital acceptance was 2.74% (12,829/468,709) in 2019, 3.74% (15,527/414,987) in 2020, and 5.09% (21,311/418,950) in 2021. The crude odds ratio for 2020 was 1.38 (95% confidence interval, 1.35-1.41) and for 2021 was 1.90 (95% confidence interval, 1.86-1.95). In 2019, 218 patients with difficulty in hospital acceptance had died by 21 days after hospitalization, whereas the number increased to 405 in 2020 and 750 in 2021.

Conclusion

The number of patients experiencing difficulty in hospital acceptance during the COVID-19 pandemic in Osaka Prefecture increased, and patient outcomes were worse than before the pandemic.

Psychological factors in adherence to COVID-19 public health restrictions in Italy: A path model testing depressed mood, anxiety, and co-rumination via cellphone

During the COVID-19 pandemic, the success of major non-pharmaceutical interventions, such as quarantine orders, has depended upon robust rates of citizens' adherence to protocols. Thus, it is critical to public health for research to illuminate factors that affect compliance with contagion-mitigating practices. Previous research has examined sociodemographic factors and aspects of psychological distress as correlates of adherence to public health guidelines. The current study expanded this research to investigate the psychosocial process of co-rumination, which has been identified in previous research as a maladaptive type of social interaction that is associated with elevated levels of anxiety and depression. Data were collected from 932 Italian adults during the initial stages of the highly stressful COVID-19 pandemic and lockdown. A path model was tested to examine multivariate relationships among sociodemographic characteristics, symptoms of psychological distress (i.e., depression and anxiety), co-rumination via cellphone, and self-reported adherence to COVID-19-related public health restrictions. Results revealed that higher rates of co-rumination via cellphone were associated with lower levels of adherence to public health restrictions. Symptoms of depression and anxiety were differentially related to co-rumination processes and adherence to public health restrictions. Higher levels of depression symptoms were directly associated with poorer adherence to public health restrictions, and this path was mediated through higher levels of co-rumination via cellphone. On the contrary, higher levels of state anxiety were directly associated with greater adherence to public health guidelines. This path was also mediated through co-rumination via cellphone. Higher levels of anxiety were correlated with lower levels of co-rumination, which in turn were correlated with lower levels of adherence. These results suggest fruitful directions for future research examining co-rumination as a maladaptive coping behavior that may be addressed within public health interventions.

Natural language processing analysis applied to COVID-19 open-text opinions using a distilBERT model for sentiment categorization

COVID-19 is a disease that affects the quality of life in all aspects. However, the government policy applied in 2020 impacted the lifestyle of the whole world. In this sense, the study of sentiments of people in different countries is a very important task to face future challenges related to lockdown caused by a virus. To contribute to this objective, we have proposed a natural language processing model with the aim to detect positive and negative feelings in open-text answers obtained from a survey in pandemic times. We have proposed a distilBERT transformer model to carry out this task. We have used three approaches to perform a comparison, obtaining for our best model the following average metrics: Accuracy: 0.823, Precision: 0.826, Recall: 0.793 and F1 Score: 0.803.

Psychological impact of COVID-19 after hospital discharge: A follow-up study on Italian recovered patients

BACKGROUND

Since COVID-19 outbreak, clinical experience on its management during the acute phase has rapidly grown, including potential effects on the psychopathological dimension. However, still few data are available regarding the impact on survivors' mental health over the long-term.

METHODS

A sample of 1457 COVID-19 patients underwent a multidisciplinary follow-up protocol, approximately 3 months after hospital discharge, including a psychological evaluation. The primary outcomes were anxiety, depression, resilience, post-traumatic symptoms, and health-related quality of life. Furthermore, we examined the potential role of hospitalization and delay in the follow-up assessment on the increased burden of illness.

RESULTS

Although a general high level of resilience emerged, suggesting most patients relied on their individual and interpersonal resources to face difficulties related to the pandemic, almost one third of the sample reported signs of psychological distress over time, especially post-traumatic symptoms, with anxiety being more represented than depression. Furthermore, hospitalization - regardless of the setting of care - and promptness in follow-up evaluation were found to play a protective role on patients' recovery and mental wellbeing.

LIMITATIONS

Selection bias of patients exclusively admitted to the hospital; absence of a control group; psychological assessment relying on self-reported instruments.

CONCLUSIONS

The current crisis demands resilience and adjustment resources, either in the acute and post-acute phase. Thus, the clinical effort should aim at relieving the traumatic impact of such condition through timely interventions. Further investigation may address potential predictors of developing a traumatic stress response, in order to identify and promptly treat at-risk subpopulations.

Maternal and infant NR3C1 and SLC6A4 epigenetic signatures of the COVID-19 pandemic lockdown: when timing matters

Stress exposure during pregnancy is critically linked with maternal mental health and child development. The effects might involve altered patterns of DNA methylation in specific stress-related genes (i.e., glucocorticoid receptor gene, NR3C1, and serotonin transporter gene, SLC6A4) and might be moderated by the gestational timing of stress exposure. In this study, we report on NR3C1 and SLC6A4 methylation status in Italian mothers and infants who were exposed to the COVID-19 pandemic lockdown during different trimesters of pregnancy. From May 2020 to February 2021, 283 mother-infant dyads were enrolled at delivery. Within 24 h from delivery, buccal cells were collected to assess NR3C1 (44 CpG sites) and SLC6A4 (13 CpG sites) methylation status. Principal component (PC) analyses were used to reduce methylation data dimension to one PC per maternal and infant gene methylation. Mother-infant dyads were split into three groups based on the pregnancy trimester (first, second, third), during which they were exposed to the COVID-19 lockdown. Mothers and infants who were exposed to the lockdown during the first trimester of pregnancy had lower NR3C1 and SLC6A4 methylation when compared to counterparts exposed during the second or third trimesters. The effect remained significant after controlling for confounders. Women who were pregnant during the pandemic and their infants might present altered epigenetic biomarkers of stress-related genes. As these epigenetic marks have been previously linked with a heightened risk of maternal psychiatric problems and less-than-optimal child development, mothers and infants should be adequately monitored for psychological health during and after the pandemic.

Determining the Factors That Influence Stunting during Pandemic in Rural Indonesia: A Mixed Method

OBJECTIVE

Pandemic causes an increase in the poverty rate. The consequences will be many, including the birth of stunting babies. The COVID-19 pandemic has had an impact on stunting. Analyzing the factors that cause stunting during a pandemic will provide suggestions for effective stunting prevention strategies at the national, regional, community, and household levels. This study aims to determine the factors that influence stunting during the pandemic.

METHOD

We use mixed methods. The respondents of this study were 152 mothers of the Maternal and Child Nutrition Security project, and the sampling technique is Cluster Sampling. Quantitatively using a baseline survey whose analysis uses multiple logistic regression to determine the unadjusted and adjusted odds ratio. The qualitative data used focus group discussions which were analyzed using Nvivo 12 with a questionnaire, and anthropometric measurements of children from surveyed households.

RESULTS

This study summarizes the multivariate analysis of stunting determinants in the pandemic era, revealing statistically significant interactions between household sanitation facilities and household water treatment. Significant risk factors for severe stunting during the pandemic were male gender, older child age, coming from a low socioeconomic quintile, not participating in prenatal care at a health facility, and mother's involvement in choices about what to prepare for Community House. The FGDs identified misinformation about childcare and consumption of sweetened condensed milk as significant contributors to child malnutrition.

CONCLUSIONS

Lack of sanitation facilities and untreated water are contributing factors. Water, sanitation, and hygiene initiatives must be included into Indonesian policies and programs to combat child stunting during a pandemic. The need for further research related to government assistance for improving toddler nutrition, as well as the relationship between WASH and linear development in early infancy should be explored.

Posttraumatic Stress Disorder among Registered Nurses and Nursing Students in Italy during the COVID-19 Pandemic: A Cross-Sectional Study

(1) Background: Posttraumatic stress disorder (PTSD) is a mental health disorder characterized by a range of syndromal responses to extreme stressors. The present study aimed to explore any differences in PTSD between registered nurses and nursing students, according to sex and nursing experience, during the COVID-19 pandemic. (2): Methods: An observational descriptive study was conducted among Italian nurses and nursing students during the first wave of the COVID-19 pandemic. An online questionnaire was distributed in an anonymous form through the Google function of Google Modules to some social pages and nursing groups. (3) Results: In total, 576 participants were enrolled in this study. Of these, 291 (50.50%) were registered nurses and 285 (49.50%) were nursing students. By considering the Impact of Event Scale—Revised values in nurses and in nursing students according to sex, a significant difference was reported in the avoidance sub-dimension (p = 0.024), as female nurses recorded higher levels than nursing students. No further significant differences were suggested by considering both sex and nursing experience, respectively. (4) Conclusion: PTSD could be a serious consequence for both nurses and nursing students during the COVID-19 pandemic.

Hospitals early challenges and interventions combatting COVID-19 in the Eastern Mediterranean Region

Background

During rapidly evolving outbreaks, health services and essential medical care are interrupted as facilities have become overwhelmed responding to COVID-19. In the Eastern Mediterranean Region (EMR), more than half of countries are affected by emergencies, hospitals face complex challenges as they respond to humanitarian crises, maintain essential services, and fight the pandemic. While hospitals in the EMR have adapted to combat COVID-19, evidence-based and context-specific recommendations are needed to guide policymakers and hospital managers on best practices to strengthen hospitals’ readiness, limit the impact of the pandemic, and create lasting hospital sector improvements towards recovery and resilience.

Aim

Guided by the WHO/EMR’s “Hospital readiness checklist for COVID-19”, this study presents the experiences of EMR hospitals in combatting COVID-19 across the 22 EMR countries, including their challenges and interventions across the checklist domains, to inform improvements to pandemic preparedness, response, policy, and practice.

Methods

To collect in-depth and comprehensive information on hospital experiences, qualitative and descriptive quantitative data was collected between May-October 2020. To increase breadth of responses, this comprehensive qualitative study triangulated findings from a regional literature review with the findings of an open-ended online survey (n = 139), and virtual in-depth key informant interviews with 46 policymakers and hospital managers from 18 out of 22 EMR countries. Purposeful sampling supported by snowballing was used and continued until reaching data saturation, measures were taken to increase the trustworthiness of the results. Led by the checklist domains, qualitative data was thematically analyzed using MAXQDA.

Findings

Hospitals faced continuously changing challenges and needed to adapt to maintain operations and provide essential services. This thematic analysis revealed major themes for the challenges and interventions utilized by hospitals for each of hospital readiness domains: Preparedness, Leadership, Operational support, logistics, supply management, Communications and Information, Human Resources, Continuity of Essential Services and Surge Capacity, Rapid Identification and Diagnosis, Isolation and Case Management, and Infection, Prevention and Control.

Conclusion

Hospitals are the backbone of COVID-19 response, and their resilience is essential for achieving universal health coverage. Multi-pronged (across each of the hospitals readiness domains) and multi-level policies are required to strengthen hospitals resilience and prepare health systems for future outbreaks and shocks.

Changes in temporal properties for epidemics of notifiable infectious diseases in China during the COVID-19 epidemic: population-based surveillance study

BACKGROUND

The COVID-19 was first reported in 2019, and the Chinese government immediately carried out stringent and effective control measures in response to the epidemics.

OBJECTIVE

These non-pharmaceutical interventions may have impacted incidences of other infectious diseases as well. Potential explanations underlying this reduction, however, are not clear. Hence, in this study, we aimed to study the influence of the COVID-19 prevention policies on other infectious diseases (mainly class B infectious diseases) in China.

METHODS

The time-series datasets between 2017 and 2021 for 23 notifiable infectious diseases were extracted from public datasets from the National Health Commission of China. Several indices (peak and trough amplitude, infection selectivity, preferred time to outbreak, oscillatory strength) of each infectious disease were calculated before and after the COVID-19 outbreak.

RESULTS

We found that the prevention and control policies for COVID-19 had a strong significant reduction effect on outbreaks of other infectious diseases. A clear event-related trough (ERT) was observed after the outbreak of COVID-19 under the strict control policies, and its decreasing amplitude is related to the infection selectivity and preferred outbreak time of the disease before the COVID-19. We also calculated the oscillatory strength before and after the COVID-19 outbreak and found that it is significantly stronger before the COVID-19 outbreak, and does not correlate with the trough amplitude.

CONCLUSIONS

Our results directly demonstrate that prevention policies for the COVID-19 have immediate additional benefits for controlling most class B infectious diseases, and several factors (infection selectivity, preferred outbreak time) may have contributed to the reduction of outbreaks. This study may guide the implementation of non-pharmaceutical interventions to control a wider range of infectious diseases.

CLINICALTRIAL

Inflammation, underweight, malignancy and a marked catabolic state as predictors for worse outcomes in COVID-19 patients with moderate-to-severe disease admitted to Internal Medicine Unit

Introduction

During COVID-19 pandemic, Internal Medicine Units (IMUs) accounted for about 70% of patients hospitalized. Although a large body of data has been published regarding the so-called first wave of the pandemic, little is known about the characteristics and predictors of worse outcomes of patients managed in IMUs during the second wave.

Methods

We prospectively assessed demographics, comorbidities, treatment and outcomes, including ventilation support (VS) and death, in patients admitted to our IMU for SARS-CoV-2 between October 13th, 2020 and January 21st, 2021. Clinical evolution and biochemical testing 1, 7 and 14 days after COVID-19 diagnosis were recorded.

Results

We studied 120 patients (M/F 56/64, age 71±14.5 years) admitted to our IMU. Most of them had at least one comorbidity (80%). Patients who died were older, more frequently underweight, affected by malignant neoplasms and on statin therapy compared to patients eventually discharged. Both worse outcome groups (VS and death) presented higher neutrophils, ferritin, IL-6 and lower total proteins levels than controls. Age was significantly associated with mortality but not with VS need. The multivariate analysis showed age and gender independent association of mortality with underweight, malignancy and antibiotics use at the admission. With regard to biochemical parameters, both unfavourable outcomes were positively associated with high WBC count, neutrophils, blood urea nitrogen and low serum total proteins.

Conclusions

Our study identified inflammation, underweight, malignancy and a marked catabolic state as the main predictors for worse outcomes in COVID-19 patients admitted to IMU during the so-called second wave of the pandemic.

Psychological Distress and Resilience among Italian Healthcare Workers of Geriatric Services during the COVID-19 Pandemic

The COVID-19 pandemic exposed healthcare workers (HW) to heavy workload and psychological distress. This study was aimed to investigate distress levels among Italian physicians, nurses, rehabilitation professionals and healthcare assistants working in geriatric and long-term care services, and to explore the potential role of resilience as a protective resource. The General Health Questionnaire-12, the Connor-Davidson Resilience Scale, and a demographic survey were completed by 708 Italian HWs. Distress and resilience levels were compared between professionals through ANOVA; the contribution of sex, age, professional role, and resilience to distress was explored through regression analyses. Physicians reported significantly higher resilience and distress levels than rehabilitation professionals and healthcare assistants respectively. Women, HWs aged above 45, physicians, and participants reporting low resilience levels were at higher risk for distress. Findings suggest the importance of supporting HW's resilience to counterbalance the pandemic related distress.

Emergency Department Management of COVID-19 Suspected Patients. An International Perspective

Objectives: In December 2019, an invasive viral outbreak, the Corona Virus Disease 19 spread to the whole world. An international cross-sectional study was conducted to evaluate how healthcare workers in Emergency departments dealt with this pandemic.

Methods: A questionnaire was sent to 180 healthcare workers around the world during May and June of the year 2020.

Results: A total of 134 HCW from 23 countries responded with a majority of Emergency physicians (36.8%). The PCR testing is available in 72.9% of the hospitals. Different architectural strategies were used to isolate suspected cases in the Emergency department (ED). Half of the institutions would not allow visitors, while the other half, restricted visiting hours and the number of visitors. Triage for suspected patients relied in 82.8% on symptoms. Almost 98% of HCW used a combination of mask, gloves, gown and face shield. Around 65% of the HCW have a tendency to discharge more patients from the ED than what they were used to.

Conclusion: The COVID-19 pandemic made a major change within the emergency departments worldwide.

Concerns about Wearing Masks to Avoid COVID-19 Infection in China: Assessment of an Internet-based Cross-sectional Study

BACKGROUND

The novel coronavirus disease of 2019 (COVID-19) is likely to spread from person to person in close contact settings. The Chinese Center for Disease Control and Prevention has released a handbook on COVID-19 which introduced health information to the public, specifically related to wearing masks correctly and adopting preventive measures to avoid the COVID-19 infection.

OBJECTIVE

The current study aimed to assess the level of mask knowledge, behavior related to mask usage, and major information channels in China.

METHODS

An Internet-based survey was conducted primarily using the DingXiang Doctor WeChat public accounts. The data about mask knowledge and behavior were recollected and analyzed. Besides descriptive statistical analysis, logistic regression was used to analyze significant risk factor.

RESULTS

There were a total of 10,304 respondents to the survey, more than half were under 30 years old, and nearly three-quarters were women. Over 80% of participants had a bachelor's degree or higher, as well as the largest amounts of respondents were business/service workers (40.80%). Over half of the study participants got married (51.46%). The findings revealed that 67.49% of the participants practiced protective mask behavior, 97.93% believed that wearing masks is effective against COVID-19, 96.85% chose the mask that has two or more layers of washable, breathable fabric, 70.57% wore masks correctly. Gender, age, occupation, and education level had significant effects on behavior, while marital and infection status of family members were not significant. In addition, it was found that WeChat public accounts (89.55%) were the most prominent source of health information for Chinese netizens after the break of COVID-19.

CONCLUSIONS

This study elucidated that the Chinese netizens' protective mask behavior was far lower than mask knowledge. Improved information channels and adequate information on wearing masks are necessary to improve the public's protective mask behavior, particularly among the males, elderly, and people with less education.

CLINICALTRIAL

Idiopathic pulmonary fibrosis telemedicine management during COVID-19 outbreak

The present report investigates the impact of a Telemedicine Service (TMS) on the management of Idiopathic Pulmonary Fibrosis (IPF) during coronavirus disease of 2019 (COVID-19) outbreak in Italy. The TMS comprised 3 phone numbers, active 12 h per day, and an email address, monitored every 4 h by trained physicians; chat- and videoconference-services were also offered. At the end of the study period, our staff contacted all patients, to get information about the final outcome (i.e. composite hospitalisations/all causes of death). Outcomes were compared with a cohort of patients who attended our unit in the same period of the previous year (when no TMS was available). 189 patients participated in the present study. From 11th March to 4th May 2020, 61% of patients made at least one TMS access, mostly by emails (53%), followed by phone calls (33%). With regard to the primary outcome, TMS patients experienced a significant lower rate of events of the 182 patients of the no-TMS cohort (p < 0.001). Specifically, a significant difference was observed for IPF hospitalisation (p < 0.001) whereas no differences were observed with regard to deaths (p = 0.64). TMS permits patients to be followed up even during COVID-19 lockdown, with an encouraging impact on outcomes.

A Region-Wide All-Hazard Training Program for Prehospital Mass Casualty Incident Management: A Real-World Case Study

OBJECTIVE

We report the development, implementation, and results of a sustainable region-wide mass-casualty management prehospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy.

METHODS

The educational program learning objectives are: (1) command and control, communications, and resource management; (2) mass casualty triage and the START triage protocol; (3) on-scene management; (4) Regione Lombardia and AREU Mass Casualty standard operating procedures; and (5) inter-agency communications and relations. For each course edition data on participants' summative assessment, participants' feedback and costs were collected.

RESULTS

Between June 26, 2013, and December 31, 2020, a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers; 1239 (93%) passed the summative assessment and were qualified as being operationally "ready." Regarding participant feedback, the overall program was rated 4.4 ± 0.7 out of 5. The overall cost of running the provider program during the study period was €321 510 (circa US $382 000). The average cost per edition was €3828 and €242 per participant.

CONCLUSIONS

We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction, and contained costs to systematically train emergency medical service personnel.

[The different phases of molecular and antigenic evolution of SARS-CoV-2 viruses during the 20 months following its emergence]

From its emergence in December 2019 and until the end of the fourth pandemic wave in October 2021, SARS-CoV-2 circulation has been associated with significant molecular evolutions of the virus. These were linked to mutations that have led to new virus linages with replication advantages as a result of increased transmission, or partial immune escape in the context of progressively increasing global immunisation. The pandemic context with large scale epidemics massive outbreaks observed in highly populated areas has favoured this emergence of "variants". During the 20 months period, at least three evolutionary phases have been observed, leading to the situation observed in October 2021. For the first time, an unprecedented worldwide surveillance effort has been conducted to monitor the circulation of the emerging virus, with rapid data sharing. This molecular surveillance system has provided an accurate description of the circulating viruses, and their evolution. The implementation of these tools and skills able to provide SARS-CoV-2 molecular epidemiological data has upgraded the global capacity for surveillance worldwide, and may allow us to be better prepared for a future pandemic episode.

Coronavirus outbreak from early career psychiatrists' viewpoint: What we have learned so far

PURPOSE

Since the World Health Organization declared the coronavirus outbreak a global pandemic several million cases and more than three million deaths have been already confirmed worldwide due to COVID-19.

DESIGN AND METHODS

Early Career Psychiatrists from all over the world present an overview of what happened in their own countries and what they have learned so far by this experience in everyday clinical practice.

PRACTICE IMPLICATION

We tried to take a real time picture of this unexpected situation, drawing useful hints for now and the future.

Supporting Decision Making in Intensive Care: Ethical Principles for Managing Access to Care During the COVID-19 Pandemic

The pandemic from COVID-19 causes a health threat for many countries and requires an internationally coordinated response due to the high spread of the infection. The current local and international situation gives rise to logistical and ethical considerations regarding the imbalance between needs for assistance and availability of health resources in the continuation of the emergency. A shortage condition will require healthcare professionals to choose between patients who will have access to respiratory support and those who will have to continue without. The sharing of criteria for the introduction of patients to the different therapeutic paths is fundamental to prevent the onset of ethical issues. The present paper analyzes the critical issues related to the scarcity of healthcare resources and the limitation of access to intensive care with the aim of proposing ethically sustainable principles for the management of the current pandemic situation.

"We Are at The Forefront of Rural Areas" Emergency Nurse's Experience During Pandemic: A Qualitative Study

Purpose: The pandemic makes everyone alert, including nurses who are in emergency rooms at community health centers, the importance of their experiences is a lesson for nurses to maintain themselves and be effectivein providing services. This study aimed to explore the experience of nurses who are in emergency rooms at rural area during the coronavirus disease pandemic. Methods: This qualitative research was conducted based on the Nvivo 12 analysis method using in-depth semistructured interviews. Data saturation was reached after 20 interviews were completed. Data collection lasted for 1 month from February to March 2020. Results: Semistructured interviews with 20 nurse participants obtained the following participant characteristics. Eight participants were males and 12 were females with an age ranged from 28 to 43 years (average age 36.4 years). The majority had vocational education (75%), with long experience that ranged from 5 to 15 years (average 11 years). The findings of four themes and seven subthemes. The theme of the findings is Expressions of care, Compliance increases using Personal Protective Equipment (PPE), Focus to refer to, Triage at the forefront. Conclusion: This research reveals that Expressions of care, Compliance increases using PPE, Focus to refer to, Triage at the forefront is the main theme identified in this study. Further investigation of the readiness of nurses in handling patients in the emergency room is considered to be of benefit to the results of this study.

Predicting Covid-19 emergency medical service incidents from daily hospitalisation trends

INTRODUCTION

The aim of our retrospective study was to quantify the impact of Covid-19 on the temporal distribution of emergency medical services (EMS) demand in Travis County, Austin, Texas and propose a robust model to forecast Covid-19 EMS incidents.

METHODS

We analysed the temporal distribution of EMS calls in the Austin-Travis County area between 1 January 2019 and 31 December 2020. Change point detection was performed to identify the critical dates marking changes in EMS call distributions, and time series regression was applied for forecasting Covid-19 EMS incidents.

RESULTS

Two critical dates marked the impact of Covid-19 on the distribution of EMS calls: March 17th, when the daily number of non-pandemic EMS incidents dropped significantly, and 13 May, by which the daily number of EMS calls climbed back to 75% of the number in pre-Covid-19 time. The new daily count of the hospitalisation of Covid-19 patients alone proves a powerful predictor of the number of pandemic EMS calls, with an r² value equal to 0.85. In particular, for every 2.5 cases, where EMS takes a Covid-19 patient to a hospital, one person is admitted.

CONCLUSION

The mean daily number of non-pandemic EMS demand was significantly less than the period before the Covid-19 pandemic. The number of EMS calls for Covid-19 symptoms can be predicted from the daily new hospitalisation of Covid-19 patients. These findings may be of interest to EMS departments as they plan for future pandemics, including the ability to predict pandemic-related calls in an effort to adjust a targeted response.

Tracheostomy in Mechanically Ventilated Patients With SARS-CoV-2-ARDS: Focus on Tracheomalacia

BACKGROUND

The SARS-CoV-2 pandemic increased the number of patients needing invasive mechanical ventilation, either through an endotracheal tube or through a tracheostomy. Tracheomalacia is a rare but potentially severe complication of mechanical ventilation, which can significantly complicate the weaning process. The aim of this study was to describe the strategies of airway management in mechanically ventilated patients with respiratory failure due to SARS-CoV-2, the incidence of severe tracheomalacia, and investigate the factors associated with its occurrence.

METHODS

This retrospective, single-center study was performed in an Italian teaching hospital. All adult subjects admitted to the ICU between February 24, 2020, and June 30, 2020, treated with invasive mechanical ventilation for respiratory failure caused by SARS-CoV-2 were included. Clinical data were collected on the day of ICU admission, whereas information regarding airway management was collected daily.

RESULTS

A total of 151 subjects were included in the study. On admission, ARDS severity was mild in 21%, moderate in 62%, and severe in 17% of the cases, with an overall mortality of 40%. A tracheostomy was performed in 73 (48%), open surgical technique in 54 (74%), and percutaneous Ciaglia technique in 19 (26%). Subjects who had a tracheostomy performed had, compared to the other subjects, a longer duration of mechanical ventilation and longer ICU and hospital stay. Tracheomalacia was diagnosed in 8 (5%). The factors associated with tracheomalacia were female sex, obesity, and tracheostomy.

CONCLUSIONS

In our population, approximately 50% of subjects with ARDS due to SARS-CoV-2 were tracheostomized. Tracheostomized subjects had a longer ICU and hospital stay. In our population, 5% were diagnosed with tracheomalacia. This percentage is 10 times higher than what is reported in available literature, and the underlying mechanisms are not fully understood.

Perceptions and stress factors among physicians in pre-graduate and post-graduate training in Morocco: COVID-19 pandemic context

Context: On 30 January, 2020, WHO stated that the global COVID-19 epidemic is a public health emergency. Facing this critical situation, health-care workers were at risk of developing psychological distress and other mental health problems. Aims: This study seeks to explore the feelings, attitudes and perceptions of the COVID-19 pandemic among physicians in pre-graduate and post-graduate training from Marrakesh University Hospital Centre. Methods and Material:We conducted a cross-sectional study with internal and resident-physicians in May 2020. Data collection was based on a self-administered electronic questionnaire. The sociodemographic informations, pandemic impact on the occupational and social fields and stress factors were evaluated. Statistical significance was set at p < 0.05. Results: The number of participants was 74. The sex ratio was 1.4 with an average age of 26.1 ± 3.6 years. Two-thirds were directly involved in the management of patients with SARS-CoV2. The majority reported that their work puts them at high-risk of exposure to SARS-CoV2 and 66% felt stressed at work, female physicians were more stressed than men (p = 0.028). Not knowing when the pandemic will be under control and the risk of developing an infection with SARS-CoV2 were the main sources of stress. About motivators for similar situations, respondents emphasized family support (91.9%) and recognition by management and supervisors for the additional efforts they provide (83.8%). Conclusions: The protection of health-care workers is an important component of public health measures to combat this pandemic. Special interventions to promote health-care workers mental well-being must be implemented immediately.

A Statewide EMS Viral Syndrome Pandemic Triage Protocol: 24 Hour Outcomes

Background: Early during the COVID-19 pandemic, Emergency Medical Services (EMS) systems encountered many challenges that prompted crisis-level strategies. Maryland's statewide EMS system implemented the Viral Syndrome Pandemic Triage Protocol which contained a decision tool to help identify patients potentially safe for self-care at home. Objectives: This study assessed the effects of the Maryland Viral Syndrome Pandemic Triage Protocol and the safety of referring patients for self-care at home. Methods: This is a retrospective statewide analysis of EMS patients from March 19 thru September 4, 2020, who were not transported and had documentation of the Viral Syndrome Pandemic Triage Protocol's decision support tool completed, as well as a random sample of 150 patients who were not transported and did not have documentation of the decision tool. Descriptive statistics were performed as well as a two-stage multivariable logistic regression model for the outcomes of ED presentation within 24 hours and subsequent hospitalization. Results: 301 EMS patients were documented as triaged to home using the protocol and outcomes data were available for 282 (94%). 41(14.5%) patients presented to an ED within 24 hours and 14 (5% of 282) required inpatient hospitalization. Nine (3.2%) patients were subsequently hospitalized with a diagnosis of COVID-19 illness. Of those patients for whom the decision tool was not documented, 35 (23%) had an ED visit within 24 hours and 15 (10%) were hospitalized (p = 0.075). Multivariate logistic regression model results (N = 432) suggest that those with documentation of triage protocol use had some advantage over those patients without documentation. The 95% CIs of the estimated effect of Triage/No Triage protocol documented were wide and crossed the 1.0 limit but overall, all effects Odds Ratios and Adjust Odds Ratios were consistently over 1.0 with the lowest value of 1.3 and the highest value of 2.1. Conclusion: Most patients (95%) who were triaged to self-care at home with home documented decision support tool use did not require hospitalization within 24 hours following EMS encounter and this appears to be safe. Future opportunity exists to incorporate such tools into comprehensive pandemic preparedness strategies along with appropriate follow up and quality improvement mechanisms.

The Influence of the COVID-19 Pandemic on ICU Organization, Care Processes, and Frontline Clinician Experiences: A Qualitative Study

BACKGROUND

The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally.

RESEARCH QUESTIONS

Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists?

STUDY DESIGN AND METHODS

Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system.

RESULTS

Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians' anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff.

INTERPRETATION

We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

High class filtering facepiece (FFP) are fundamental and effective in protection of emergency health care workers: an observational cohort study in a German community

Background

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly contagious airborne virus inducing pandemic coronavirus disease 2019 (COVID-19). This is most relevant for medical staff working under harmful conditions in emergencies often dealing with patients and an undefined SARS-CoV-2 status. We aimed to measure the effect of high-class filtering facepieces (FFP) in emergency medical service (EMS) staff by analyzing seroprevalence and history of positive polymerase chain reaction (PCR) for SARS-CoV-2.

Method

This observational cohort study included workers in EMS, who were compared with hospital staff (HS) and staff, which was not directly involved in patient care (NPC). All direct patient contacts of EMS workers were protected by FFP2/N95 (filtering face piece protection class 2/non-oil-based particulates filter efficiency 95%) masks, whereas HS was protected by FFP2/N95 exclusively when a patient had a proven or suspected SARS-CoV-2 infection. NPC was not protected by higher FFP. The seroprevalence of SARS-CoV-2 antibodies was analyzed by immunoassay by end of 12/2020 together with the history of a positive PCR. In addition, a self-assessment was performed regarding the quantity of SARS-CoV-2 positive contacts, about flu symptoms and personal belief of previous COVID-19 infections.

Results

The period in which contact to SARS-CoV-2 positive patients has been possible was 10 months (March to December 2020)—with 54,681 patient contacts documented for EMS—either emergencies (n = 33,241) or transportation services (n = 21,440). Seven hundred-thirty (n = 730) participants were included into the study (n = EMS: 325, HS: 322 and NPC: 83). The analysis of the survey showed that the exposure to patients with an unknown and consecutive positive SARS-CoV-2 result was significantly higher for EMS when compared to HS (EMS 55% vs. HS 30%, p = 0.01). The incidence of a SARS-CoV-2 infection in our cohort was 1.2% (EMS), 2.2% (HS) and 2.4% (NPC) within the three groups (ns) and lowest in EMS. Furthermore, the belief of previous COVID-19 was significant higher in EMS (19% vs. 10%),

Conclusion

The consistent use of FFP2/N95 in EMS is able to prevent work-related SARS-CoV-2 infections in emergency situations. The significance of physical airway protection in exposed medical staff is still relevant especially under the aspect of new viral variants and unclear effectiveness of new vaccines.

Graphical Abstract

Review of Emergency Medical Services Vulnerability to High Consequence Infectious Disease in the United States

Purpose: Emergency medical services (EMS) responders are a group of medically skilled professionals who perform a wide range of essential medical services within a community including emergency response, patient transport, and mobile integrated healthcare. The proper functioning of the EMS system is paramount to the well-being of the medical system and public health. The intent of this paper is to review current EMS standards and practice to determine the danger a high consequence infectious disease (HCID) may pose to these healthcare workers and the community.

Areas Addressed: Through the review of EMS practice several areas were identified as vulnerabilities to the EMS network. These vulnerabilities consisted of the lack of standardized licensing practice, inconsistent medical direction, and the inability to properly implement the use of personal protective equipment (PPE). The compounding of these vulnerabilities allows for HCIDs to pose a serious threat to EMS personnel with the possibility of devastating and crippling the EMS infrastructure within the US.

Discussion: The vulnerabilities identified must be addressed both to protect EMS providers and to enhance the resilience of the US healthcare system. Ways to address the identified vulnerabilities should focus on improving the EMS curriculum and increasing minimum levels of education for first responders. Targeting minimum education and training standards could be the most effect method of reducing the dangers of HCIDs to EMS systems.

The Experience of Child Neuropsychiatry Residents who Volunteered in Italian COVID-19-Designated Hospitals

OBJECTIVE

During the first months of 2020, the coronavirus disease of 2019 (COVID-19) spread rapidly and soon reached a pandemic level. With the increasing number of hospitalizations, medical and nursing personnel resources were soon inadequate. As a consequence, medical volunteers became a key human resource and young medical residents in any specialty were hired on a voluntary basis to contribute to take care of patients with COVID-19. This study reports on the lived experience of residents in child neuropsychiatry who volunteered in Italian hotspot COVID-19-designated hospitals during the epidemic outbreak.

METHODS

A phenomenological, qualitative approach using semi-structured interviews with open-ended questions was used to obtain in-depth narratives of the experience of residents in child neuropsychiatry volunteering in North Italy COVID-19-designated hospitals. All residents (n = 8) participated in the study. Interviews were conducted by an expert researcher trained in qualitative methods. Data analysis was performed by independent coders.

RESULTS

Five core themes could be identified from the interviews: acting as mediators on two fronts, facing the shock of COVID-19 reality, capitalizing from specialty education, growing as persons and professionals, and humanizing medical care.

CONCLUSIONS

This study is unique in providing an in-depth understanding of the experience of young residents in child neuropsychiatry volunteering in general hospitals during the COVID-19 pandemic in Northern Italy. The findings suggest that this experience may be highly beneficial for both the residents and the hospital quality of care. Insights for an accurate planning of residents' engagement in future healthcare emergencies are provided.

Different Approaches to Confronting the Biological Epidemic; Prevention Tools with an Emphasis on COVID-19: A Systematized Study

BACKGROUND

The World Health Organization has identified COVID-19 as a public health emergency and is urging governments to stop the virus transmission by adopting appropriate policies. In this regard, authorities have taken different approaches to cutting the chain or controlling the spread of the disease. The aim of this study was to determine the approaches to biological epidemics and related prevention tools with emphasis on COVID-19 disease.

METHODS

The present study was a systematize study of publications related to the prevention strategies for Covid-19 disease. The study was carried out based on the PRISMA guidelines, CASP and AACODS. The data resources included ISI/WOS, PubMed, Scopus, science direct, Ovid and ProQuest. WHO website, published reports of countries, as well as the Worldometer website were evaluated. The time-frame of the study was from 1 December 2019 to 30 May 2020.

RESULTS

The study findings showed that in order to confronting the COVID-19 epidemic, in general, there are three approaches of "mitigation", "active control", and "suppression" and four strategies of "quarantine", "isolation", "social distance", and "lockdown" in both individual and social dimensions to deal with epidemics. Selection and implementation of each approach requires specific strategies and has different effects when it comes to controlling and inhibiting the disease.

CONCLUSION

One possible approach to control the disease is to change individual behavior and lifestyle. In addition to prevention strategies, use of masks, observance of personal hygiene principles such as regular hand washing and non-contact of contaminated hands with the face, as well as observance of public health principles such as sneezing and coughing etiquettes, safe extermination of personal protective equipment must be strictly observed. The use of the previous experiences in the world, along with the current experiences of countries, can be very helpful in choosing the accurate approach for each country in accordance with the characteristics of that country and lead to the reduction of possible costs at the national and international levels.

The emergence and transmission of COVID-19 in European countries, 2019-2020: a comprehensive review of timelines, cases and containment

When it emerged in late 2019, COVID-19 was carried via travelers to Germany, France and Italy, where freedom of movement accelerated its transmission throughout Europe. However, effective non-pharmaceutical interventions introduced by European governments led to containment of the rapid increase in cases within European nations. Electronic searches were performed to obtain the number of confirmed cases, incident rates and non-pharmaceutical government measures for each European country. The spread and impact of non-pharmaceutical interventions throughout Europe were assessed and visualized. Specifically, heatmaps were used to represent the number of confirmed cases and incident rates for each of the countries over time. In addition, maps were created showing the number of confirmed cases and incident rates in Europe on three different dates (15 March, 15 April and 15 May 2020), which allowed us to assess the geographic and temporal patterns of the disease.

Longitudinal evaluation for COVID-19 chest CT disease progression based on Tchebichef moments

Blur is a key property in the perception of COVID-19 computed tomography (CT) image manifestations. Typically, blur causes edge extension, which brings shape changes in infection regions. Tchebichef moments (TM) have been verified efficiently in shape representation. Intuitively, disease progression of same patient over time during the treatment is represented as different blur degrees of infection regions, since different blur degrees cause the magnitudes change of TM on infection regions image, blur of infection regions can be captured by TM. With the above observation, a longitudinal objective quantitative evaluation method for COVID-19 disease progression based on TM is proposed. COVID-19 disease progression CT image database (COVID-19 DPID) is built to employ radiologist subjective ratings and manual contouring, which can test and compare disease progression on the CT images acquired from the same patient over time. Then the images are preprocessed, including lung automatic segmentation, longitudinal registration, slice fusion, and a fused slice image with region of interest (ROI) is obtained. Next, the gradient of a fused ROI image is calculated to represent the shape. The gradient image of fused ROI is separated into same size blocks, a block energy is calculated as quadratic sum of non-direct current moment values. Finally, the objective assessment score is obtained by TM energy-normalized applying block variances. We have conducted experiment on COVID-19 DPID and the experiment results indicate that our proposed metric supplies a satisfactory correlation with subjective evaluation scores, demonstrating effectiveness in the quantitative evaluation for COVID-19 disease progression.