Pilot Study for a Model for the Collection of Waiting Lists Data.

The analysis of data on waiting lists in Italy is regulated by the PNGLA (National Plan for the Governance of Waiting Lists). However, the Plan does not specify the characteristics of the data to be returned by the Regions for the purposes of monitoring, with the result that it is frequently either in aggregate form, unreadable, or incomplete, and therefore cannot be analysed in any meaningful way. Fondazione the Bridge and AGENAS, with the University of Genoa and the University of Pavia, conducted a pilot study on a methodological model for the collection of waiting lists data. The model proved to be effective and replicable, also providing a more valuable opportunity to analyse waiting lists data.

Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study.

Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.

Vaccination strategies for high-risk and fragile populations in Lombardy (Italy): a region-wide assessment of hospital-based models and best practices.

Background: Subjects with selected underlying medical conditions are at higher risk of infection and severe outcomes from vaccines preventable diseases. While most countries adopt life-course approaches to vaccination, high-risk group immunization programmes could maximize individual protection, while contributing to population health. The COVID-19 pandemic stimulated the planning and implementation of successful hospital-based high-risk groups' immunization models. However, in Italy, high-risk subjects' vaccine coverage is not actively monitored at the national or regional level, nor shared guidelines exist yet on hospital-based immunization programmes. Study Design: The study reports findings from a region-wide assessment of the availability, characteristics, and setting-specific features of hospital-based immunization programmes for high-risk subjects in the Lombardy region. Methods: Fondazione The Bridge a not-for-profit organization based in Milan, in collaboration with the Prevention Unit of the Lombardy Region Directorate for Welfare, and the University of Pavia coordinated a project aimed at bringing together regional health institutions, key stakeholders, academic experts, scientific societies and patients' associations to assess high-risk subjects' barriers to vaccine uptake and inform preventive programmes and policies. In this context, we designed and implemented a survey to systematically map the existence and characteristics of hospital-based immunization programmes targeting high-risk subjects. The survey was proposed to all 115 hospital medical directions of the Lombardy region. Results: We collected data from 97 hospital medical directions, with a response rate of 85%. Among respondents, 24% were publi-cly managed hospitals, 17% were Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) and 59% accredited private hospitals. Overall, 51.5% facilities in the Lombardy Region reported to actively administer vaccines to high-risk subjects in hospital settings, the prevalence being 89.6% in public hospitals. Among hospitals where vaccines are actively administered, 46% reported to have centralized vaccines ambulatory clinics, while 54% reported to administer vaccines in the context of inpa-tient care, within clinical wards. In 14% of hospitals vaccination counselling is carried out at the hospital level, while patients are referred to community services for the vaccine administration, 58% have established clinical pathways and formalized internal procedures to integrate vaccine prevention within the clinical care. Conclusions: Half of hospital facilities in the Lombardy Region administer vaccines to high-risk patients. Hospital-based im-munization models vary widely by vaccines programmes, organizational aspects, vaccines procurement and workforce involved. Identifying best practices and effective models can help tackle current challenges and improve immunization coverage for at-risk groups.

Trends (2020-2022) toward Reduced Prevalence of Postcoronavirus Disease Syndrome and Improved Quality of Life for Hospitalized Coronavirus Disease 2019 Patients with Severe Infection and Venous Thromboembolism.

The coronavirus disease 2019 (COVID-19) pandemic seems to be at its end. During the first outbreak, alfa was the dominant variant, and in the two following years, delta was the dominant variant. Questions remain about the prevalence and severity of post-COVID syndrome (PCS). We compared the medium-term outcomes of a selected group of patients considered at high risk for PCS: hospitalized patients with severe COVID-19 infection who presented clinical evidence of the acute onset of venous thromboembolism. Weighted Cox regression was used to estimate the adjusted hazard ratios for the risk of early and medium-term complications and quality of life (QoL) in COVID-19 patients developing acute venous thrombo-embolism according to the period of admission to the hospital. The primary outcome was the modification of QoL at a median follow-up of 24 months in patients hospitalized for COVID-19. The secondary outcome was the modification of QoL related to COVID-19 severity. The absolute risk of mortality for hospitalized COVID-19 patients was higher during the first outbreak (risk difference, 19% [95% confidence interval [CI], 16-22%]). Patients with acute onset of thromboembolism during the first outbreak had increased mortality, hospital stay, and need for intensive care unit treatment (p < 0.01). In patients who suffered from severe COVID-19 infection and thromboembolism in the following 2 years, symptoms during follow-up were less common and milder (risk difference 45% [95% CI, 40-52%]. In total, 19 patients were alive at 24 months follow-up: 12 patients (63%) reported important physical symptoms and 10 patients (52%) relevant emotional/mental symptoms. All patients reported reduced QoL in comparison with the preinfection time; in 15 patients (79%), the reduced QoL limited significantly their social and work activities. All patients reported permanent worsening of QoL after discharge from the hospital. Comparing the three different February to April interval years (2020, 2021, and 2022), patients reported a somewhat worse perception of health condition in comparison with the preinfection time, respectively, in 100, 79, and 56% respectively. The findings of our study show reduced prevalence and severity of PCS in the last 2 years. Less virulent variants, herd immunity, and vaccination may played a significant role.

A Radiomic-Based Machine Learning System to Diagnose Age-Related Macular Degeneration from Ultra-Widefield Fundus Retinography.

The present study was conducted to investigate the potential of radiomics to develop an explainable AI-based system to be applied to ultra-widefield fundus retinographies (UWF-FRTs) with the objective of predicting the presence of the early signs of Age-related Macular Degeneration (AMD) and stratifying subjects with low- versus high-risk of AMD. The ultimate aim was to provide clinicians with an automatic classifier and a signature of objective quantitative image biomarkers of AMD. The use of Machine Learning (ML) and radiomics was based on intensity and texture analysis in the macular region, detected by a Deep Learning (DL)-based macular detector. Two-hundred and twenty six UWF-FRTs were retrospectively collected from two centres and manually annotated to train and test the algorithms. Notably, the combination of the ML-based radiomics model and the DL-based macular detector reported 93% sensitivity and 74% specificity when applied to the data of the centre used for external testing, capturing explainable features associated with drusen or pigmentary abnormalities. In comparison to the human operator's annotations, the system yielded a 0.79 Cohen κ, demonstrating substantial concordance. To our knowledge, these results are the first provided by a radiomic approach for AMD supporting the suitability of an explainable feature extraction method combined with ML for UWF-FRT.

Decentralization of Clinical Trials: Opportunities, Risks and Development Paths.

The pandemic period represented, from many points of view, an opportunity for the updating of research processes, simplifying paths and highlighting the need to reflect on new ways of designing and organizing clinical trials. Starting from a literature analysis, a multidisciplinary working group composed of clinicians, patient representatives, university professors, researchers and experts in the field of health policy, ethics applied to health, digital health, logistics confronted with respect to the positive aspects, critical issues and risks that decentralization and digitalization can imply for the different target groups. The working group proposed feasibility guidelines of decentralized protocols for Italy, developing reflections that may be relevant also for other European countries.

Standardization Proposal for the Transmission of Waiting List Data in Italy.

Each Italian region is required to manage and disclose data relating to waiting times for healthcare services which are provided by both public and private hospitals and local health units accredited to the Sistema Sanitario Nazionale (SSN - in English, National Healthcare System). The current law governing data relating to waiting times and their sharing is the Piano Nazionale di Governo delle Liste di Attesa (PNGLA - in English National Government Plan for Waiting Lists). However, this plan does not propose a standard to monitor such data, but only provides a few guidelines that the Italian regions are required to follow. The lack of a specific technical standard for managing sharing of waiting list data and the lack of precise and binding information in the PNGLA make the management and transmission of such data problematic, reducing the interoperability necessary to have an effective and efficient monitoring of the phenomenon. The proposal for a new standard for the transmission of waiting list data derives from these shortcomings. This proposed standard promotes greater interoperability, is easy to create with an implementation guide, and has sufficient degrees of freedom to assist the document author.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey.

BACKGROUND: Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons. METHODS: Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile. RESULTS: A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly. DISCUSSION: Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey.

BACKGROUND: Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes. METHODS: An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile. RESULTS: 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. DISCUSSION: The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI.

Healthcare Insights: Evaluating the Access to the Italian Healthcare System.

The Italian health system is organised on a regional basis and services are provided by both public and private operators, affecting the planning of services, access to services by citizens and their health rights. The creation of an observatory monitoring the methods and times of access to healthcare services has been pursued. The preliminary phase of the project is presented, which will lead to the comparison of the data obtained from 2019, with an eye on the Covid-19 pandemic impact.

Timely adaptation of a Pediatric Unit to COVID-19 emergency in Northern Italy: the experience of Fondazione IRCCS Policlinico San Matteo in Pavia.

Italy is one of the most exposed countries worldwide to COVID-19, and Lombardy is the most affected region in Italy. In this context, Fondazione IRCCS Policlinico San Matteo in Pavia, one of the largest University hospitals in the region, has been involved in the management of the outbreak since its inception. Immediately after the communication of the first Italian COVID-19+ patient, the Pediatric Unit has been completely reorganized to face the approaching outbreak. The optimization of the Pediatric Unit resources for COVID-19 emergency is reported as an example to safely preserve health activity during the pandemic.

Clinical and immunological relevance of anti-neuronal antibodies in celiac disease with neurological manifestations.

AIM: To assess anti-neuronal antibodies (NA) prevalence and their correlation with neurological disorders and bowel habits in celiac disease (CD) patients. BACKGROUND: Neurological manifestations are estimated to occur in about 10% of celiac disease patients and NA to central nervous system (CNS) and enteric nervous system (ENS) are found in a significant proportion of them. Little is known about the clinical and immunological features in CD patients with neurological manifestations. PATIENTS AND METHODS: NA to CNS and ENS were investigated in 106 CD patients and in 60 controls with autoimmune disorders by indirect immunofluorescence on rat / primate cerebellar cortex and intestinal (small and large bowel) sections. RESULTS: IgG NA to CNS (titer 1:50 - 1:400) were positive in 23 celiacs (21%), being more frequently detected in those with neurological disorders that in those without neurological dysfunction (49% vs. 8%, P< 0.0001). Of the 26 celiacs (24%) with IgG NA to ENS, 11 out of 12 with an antibody titer > 1:200 had severe constipation. Only one patient with cerebellar ataxia and intestinal sub-occlusion was positive for NA to CNS and ENS. NA to CNS and ENS were found in 7% and 5% of controls, respectively. CONCLUSION: In CD the positivity of NA to CNS can be regarded as a marker of neurological manifestations. High titer NA to ENS are associated with severe constipation. The demonstration of NA to CNS and ENS suggests an immune-mediated pathogenesis leading to central neural impairment as well as gut dysfunction (hence constipation), respectively.

Cardioversion of acute atrial fibrillation in the short observation unit: comparison of a protocol focused on electrical cardioversion with simple antiarrhythmic treatment.

BACKGROUND: Direct current cardioversion (DCC) has been shown to be effective for the management of atrial fibrillation (AF) in the emergency department (ED). Pharmacological cardioversion was compared with a strategy including DCC on patients with uncomplicated, recent-onset (<48 h) AF managed in a short observation unit (SOU). METHODS: A prospective observational study was undertaken over a period of 13 months in two institutions. A DCC-centred protocol was applied to 171 AF cases in a hospital (DCC-cohort) and pharmacological cardioversion to 151 AF cases in another hospital (P-cohort). Patients remaining in AF after 24 h were admitted. The outcomes were rate of discharge in sinus rhythm, length of stay in the ED-SOU, rate of hospitalisation and complications of treatment. Data collected were analysed according to Student t test and χ(2) statistics. RESULTS: Discharge in sinus rhythm was achieved in 159/171 cases in the DCC-cohort and 77/151 cases in the P-cohort (93% vs 51%; number needed to treat (NNT) 2.4; 95% CI 2.0 to 3.1, p<0.001), whereas mean length of stay was 7+7 h in the DCC-cohort and 9+6 h in the P-cohort (p=0.43). Eleven cases from the DCC-cohort and 67 from the P-cohort were admitted (admission rate 6% vs 44%; NNT 2.6; 95% CI 2.2 to 3.5, p<0.001). Three short-term complications occurred in the DCC-cohort and five in the P-cohort (2% vs 3%, p=0.59). Two strokes were registered in the DCC-cohort during 6-month follow-up (p undefined). CONCLUSIONS: Electrical cardioversion of recent-onset AF in the SOU is safe, effective and reduces hospitalisations. Further studies are needed to identify the most cost-effective strategy for the management of AF patients in emergency settings.

Obturator mononeuropathy caused by lipomatosis of the nerve: a case report.

We report a patient who presented with the clinical features of obturator mononeuropathy. Abdomino-pelvic computed tomography revealed a fusiform mass in the right perivesical space; magnetic resonance imaging (MRI) showed characteristic "coaxial-cable-like" appearance in cross-section and "spaghetti-like" appearance in longitudinal section, pathognomonic of lipomatosis of the nerve. Nerve lipomatosis as the cause of obturator neuropathy has not been previously reported. MRI provides definite and graphic proof of the diagnosis.

Motor cortex excitability changes following a lesion in the posterior columns of the cervical spinal cord.

We used transcranial magnetic stimulation (TMS) to explore if an impairment of central sensory function produced by an isolated lesion in the cervical posterior white columns would change motor cortex excitability. Cortical silent period duration was prolonged when compared with the control subjects, while central motor conduction and motor thresholds were in the normal limits. We first demonstrate that the involvement of the ascending proprioceptive sensory pathways in spinal cord diseases may have direct consequences on the activity of intracortical inhibitory interneuronal circuits. These findings further elucidate the role of afferent inputs in motor cortex reorganisation.

Cortical silent period following TMS in a patient with supplementary sensorimotor area seizures.

The cortical silent period (CSP) following transcranial magnetic stimulation (TMS) was evaluated in a patient with a dysembrioplastic neuroepithelial tumor (DNET) in the lateral portion of the right superior frontal gyrus (SFG) who suffered from supplementary sensorimotor area (SSMA) seizures. CSP duration was shortened on the affected side. Ipsilateral alterations of motor cortex excitability with TMS in epileptogenic DNET located outside the PMA argue in favour of cortico-cortical connections to primary motor cortex from SSMA. This functional connectivity should be taken into consideration to better understand the pathophysiology of ictal motor manifestations.