The wounding potential of assault rifles: analysis of the dimensions of entrance and exit wounds and comparison with conventional handguns. A multicentric study.

The appearance of a gunshot wound (GSW) is greatly influenced by the velocity of the projectile, where high-velocity projectiles (HVPs) are defined as ballistic agents reaching a muzzle velocity of > 600 m/s fired from assault rifles. The aim of the study is to present and explain the differences in the dimensions of entrance and exit wounds between the most used handguns and assault rifles and to propose a predictor of HVP, i.e., the ratio of exit and entrance wounds (EX/ENR). The surface area of entrance and exit GSWs and the EX/ENR were calculated. 66 perforating GSWs produced by NATO FMJ 7.62 × 52 mm and 5.56 × 42 mm fired from assault rifles were assigned to the HVP, while 64 lesions produced by conventional projectiles fired from revolvers and semi-automatic pistols were assigned to the low-velocity projectile (LVP) group. The dimensions of the exit wounds of the HVP group were significantly higher when compared to the LVP group (95% CI 0.9886-2.423, p < 0.05). The HVP group showed significantly higher values for the EX/ENR when compared to the LVP group (95% CI 2.617-7.173, p < 0.05). The evaluation of the EX/ENR can be considered an adequate tool to assess the type of weapon involved and to roughly estimate the associated wounding mechanisms, which can guide both the physician in the management and treatment of the patients affected by GSW, and the forensic pathologist in crime investigation.

Lethal nitrous oxide (N2O) intoxication during surgery: the contribution of immunohistochemistry in identifying the cause of death: a case report.

BACKGROUND: Nitrous oxide (N2O) is a gas used in medicine for its analgesic, anxiolytic and amnesic properties. It is a drug considered safe if adequately administered. In the literature, accidental N2O-related deaths are rare. They are mostly related to inhalation of this substance for recreational and autoerotic purposes; rarely are reported deaths due to incorrect administration of medical gas in anesthesia. The diagnosis of death from acute N2O intoxication is complex and is generally an exclusion diagnosis: the macroscopic and microscopic post-mortem signs are entirely nonspecific. Furthermore, the circumstantial data are not always supportive and can even be confusing, mainly if the death occurred inside a hospital. CASE PRESENTATION: We describe a particular case of death from acute nitrous oxide poisoning in a hospital environment, of a Caucasian male of 72-years-old. The intoxication occurred during a minimally invasive vascular surgery due to an incorrect assembly of the supply lines of medical gases (O2 and N2O). The identification of the cause of death resulted from the analysis of circumstantial data, macroscopic and microscopic autoptic findings, and immunohistochemical investigations based on the search for antibodies anti E-selectin, P-selectin, and HIF 1-α. CONCLUSION: Although not pathognomonic of asphyxiation by N2O, the latter molecules are a valid and early marker of hypoxic insult. Therefore, in concert with all other findings, it may constitute valid support for the forensic pathologist to ascertain the cause of death in case of suspected intoxication by N2O.

Oxidative Stress Markers in Human Brain and Placenta May Reveal the Timing of Hypoxic-Ischemic Injury: Evidence from an Immunohistochemical Study.

During pregnancy, reactive oxygen species (ROS) serve as crucial signaling molecules for fetoplacental circulatory physiology. Oxidative stress is thought to sustain the pathogenesis and progression of hypoxic-ischemic encephalopathy (HIE). A retrospective study was performed on the brains and placentas of fetuses and newborns between 36-42 weeks of gestation (Group_1: Fetal intrauterine deaths, Group_2: Intrapartum deaths, Group_3: Post-partum deaths, Control group sudden neonatal death); all groups were further divided into two subgroups (Subgroup_B [brain] and Subgroup_P [placenta]), and the study was conducted through the immunohistochemical investigations of markers of oxidative stress (NOX2, 8-OHdG, NT, iNOS), IL-6, and only on the brain samples, AQP4. The results for the brain samples suggest that NOX2, 8-OHdG, NT, iNOS, and IL-6 were statistically significantly expressed above the controls. iNOS was more expressed in the fetal intrauterine death (Group_1) and less expressed in post-partum death (Group_3), while in intrapartum death (Group_2), the immunoreactivity was very low. IL-6 showed the highest expression in the brain cortex of the fetal intrauterine death (Group_1), while intrapartum death (Group_2) and post-partum death (Group_3) showed weak immunoreactivity. Post-partum death (Group_3) placentas showed the highest immunoreactivity to NOX2, which was almost double that of the fetal intrauterine death (Group_1) and intrapartum death (Group_2) placentas. Placental tissues of fetal intrauterine death (Group_1) and intrapartum death (Group_2) showed higher expression of iNOS than post-partum death (Group_3), while the IL-6 expression was higher in the fetal intrauterine death (Group_1) than the post-partum death (Group_3). The AQP4 was discarded as a possible marker because the immunohistochemical reaction in the three groups of cases and the control group was negative. The goal of this study, from the point of view of forensic pathology, is to provide scientific evidence in cases of medical liability in the Obstetric field to support the clinical data of the timing of HIE.

Trends for Percutaneous Tracheostomy in Italian Acute Care Setting over a 5-Year Period.

Background: Tracheostomy is a widespread procedure usually performed with a percutaneous approach for prolonged mechanical ventilation. Little is known about the population-based trends for percutaneous tracheostomies (PT). The aim of this study was to evaluate the order to analyze the characteristics, rates, and costs of PTs performed in Italy from 2009 to 2014. Methods: We analyzed 102,646 PTs performed in Italy between 2009 and 2014. We obtained the data of patients from the section of the discharge report of the Italian Ministry of Health (National Archive for Hospital Discharge Form, Ministry of Health) about age, gender, length of stay (LOS), hospital types, and hospital region for code 541 and 542 for the years 2009, 2010, 2011, 2012, 2013 and 2014. Our additional source of data was the Annual Discharge Reports of the Italian Ministry of Health. Results: In this study, including 102,646 PTs performed from 2009 to 2014, we found that (1) the rates of PTs significantly decreased over time; (2) PTs were mostly performed in patients aged less than 65 years and hospitalized in ICUs for less than 40 days; and (3) the costs of PTs severely decreased over time, with a breakpoint between 2011 and 2012. Conclusions: Percutaneous tracheostomy is still a procedure frequently performed in the setting of acute care. Although percutaneous tracheostomy still results in high medical care reimbursement, it is a safe and cost-saving procedure.

Psychological Distress of Healthcare Workers in 4 Hospitals Compared to General Population During the First Italian Wave of COVID-19 Pandemic.

COVID-19 caused important consequences on public health, economy, physical, and mental health of people. The aim of this study was to evaluate the impact of COVID-19 on frontline workers, comparing them with their colleagues who had no contact with the patients and with the general population, by administering an online questionnaire based on the Distress Questionnaire-5 (DQ5). The study was carried out during the first Italian wave of COVID-19 pandemic from 1st to 30th of April. Participants were divided in 3 groups: group 1 is general population group that includes the general population which are quarantined but not isolated, group health care staff not working in COVID-19 hospitals, and group 3 healthcare staff group working in COVID-19 hospitals. The survey was carried with the Distress Questionnaire-5 (DQ5) as a tool to detect the psychological distress and mental health problems. A total of 2983 people participated in this survey. Seven hundred and twenty four out of 1123 (64%) were employers of the 4 hospitals included in this study. Particularly among the respondents, 2259 (75.7%) were general population, 502 (16.8%) were health care staff not working in COVID-19 hospitals, while 222 (7.4%) were health care staff working in covid-19 hospitals. Health care personnel working in COVID-19 hospitals (DQ-5 = 13, 10-16) had less psychological distress compared with health care staff not working in COVID-19 hospitals (DQ-5 = 14, 11-16) and general population (DQ-5 = 14, 11-17; P = .04). The regression model showed that people aged 26 to 35 (OR: 2.06, 95% CI: 1.21-3.48) and female (OR: 2.35, 95% CI: 1.95-2.83) were significantly at risk to develop a DQ-5 ≥ 11. During the first Italian wave of COVID-19 pandemic, healthcare personnel working in COVID-19 hospitals had less psychological distress compared with health care staff not working in COVID-19 hospitals and general population, probably because they were prepared to face situations like outbreak or emergencies.

Telemedicine in Cancer Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Telemedicine is defined as the delivery of medical services through a variety of telecommunication tools. This novel approach can fit the needs of cancer patients who cannot often reach clinics due to their disabling symptoms. In this population of patients, pain is undoubtedly the most important symptom which dramatically affects the quality of life. Our work aimed to investigate the effectiveness of telemedicine in the management of cancer pain in order to assess the feasibility of a combination between telemedicine and traditional in-person visits; we also propose a model of integration of these two approaches. METHODS: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework to conduct our study. Quality assessment and risk of bias were performed according Cochrane criteria. Results were reported as mean differences and summarized using forest plots. We performed a trial sequential analysis (TSA) to assess the conclusiveness of our results. RESULTS: Pain severity score and pain interference were lower for patients treated with telemedicine compared to those undergoing classical management (mean difference: -0.408; P =< .001 and -0.492; P = .004, respectively). TSA confirmed that our results were statistically significant and pointed out the need of other studies to reach the required sample size. PROSPERO registration: CRD42022333260. CONCLUSIONS: Telemedicine can be effectively used to manage cancer pain. This novel approach will certainly have a revolutionary economic and organizational impact on health care systems in the next future. Furthermore, the model herein proposed could help set up an algorithm to safely and efficiently implement telemedicine.

Forensic Diagnosis of Freshwater or Saltwater Drowning Using the Marker Aquaporin 5: An Immunohistochemical Study.

Background and Objectives: Aquaporins are a family of water channel proteins. In this study, the renal and intrapulmonary expression of aquaporin-5 (AQP5) was examined in forensic autopsy cases to evaluate it as a drowning marker and to differentiate between freshwater drowning and saltwater drowning. Materials and Methods: Cases were classified into three groups: freshwater drowning (FWD), saltwater drowning (SWD), and controls (CTR). Samples were obtained from forensic autopsies at less than 72 h postmortem (15 FWD cases, 15 SWD cases, and 17 other cases) and were subjected to histological and immunohistochemical investigations. Results: In FWD group, intrapulmonary AQP5 expression was significantly suppressed compared with SWD and CTR; there was no significant difference in AQP5 expression among the other two groups. The same differences in expression were also observed in the kidney. Conclusions: These observations suggest that AQP5 expression in alveolar cells was suppressed by hypotonic water to prevent hemodilution. Moreover, it is possible to hypothesize that in the kidney, with the appearance of hypo-osmotic plasma, AQP5 is hypo-expressed, as a vital reaction, to regulate the renal reabsorption of water. In conclusion, the analysis of renal and intrapulmonary AQP5 expression would be forensically useful for differentiation between FWD and SWD, or between FWD and death due to other causes.

The other side of the crisis: organizational flexibility in balancing Covid-19 and non-Covid-19 health-care services.

BACKGROUND: Many healthcare systems have been unable to deal with Covid-19 without influencing non-Covid-19 patients with pre-existing conditions, risking a paralysis in the medium term. This study explores the effects of organizational flexibility on hospital efficiency in terms of the capacity to deliver healthcare services for both Covid-19 and non-Covid-19 patients. METHOD: Focusing on Italian health system, a two-step strategy is adopted. First, Data Envelope Analysis is used to assess the capacity of hospitals to address the needs of Covid-19 and non-Covid-19 patients relying on internal resource flexibility. Second, two panel regressions are performed to assess external organizational flexibility, with the involvement in demand management of external operators in the health-care service, examining the impact on efficiency in hospital capacity management. RESULTS: The overall response of the hospitals in the study was not fully effective in balancing the needs of the two categories of patients (the efficiency score is 0.87 and 0.58, respectively, for Covid-19 and non-Covid-19 patients), though responses improved over time. Furthermore, among the measures providing complementary services in the community, home hospitalization and territorial medicine were found to be positively associated with hospital efficiency (0.1290, p < 0.05 and 0.2985, p < 0.01, respectively, for non-Covid-19 and Covid-19 patients; 0.0026, p < 0.05 and 0.0069, p < 0.01, respectively, for non-Covid-19 and Covid-19). In contrast, hospital networks are negatively related to efficiency in Covid-19 patients (-0.1037, p < 0.05), while the relationship is not significant in non-Covid-19 patients. CONCLUSIONS: Managing the needs of Covid-19 patients while also caring for other patients requires a response from the entire healthcare system. Our findings could have two important implications for effectively managing health-care demand during and after the Covid-19 pandemic. First, as a result of a naturally progressive learning process, the resource balance between Covid-19 and non-Covid-19 patients improves over time. Second, it appears that demand management to control the flow of patients necessitates targeted interventions that combine agile structures with decentralization. Finally, untested integration models risk slowing down the response, giving rise to significant costs without producing effective results.

Implementations and strategies of telehealth during COVID-19 outbreak: a systematic review.

BACKGROUND: Telehealth is an effective option to fight the outbreak of COVID-19. This review aims to systematically characterize the utilization and applications of telehealth during the COVID-19 pandemic focusing mainly on technology implementations. METHODS: This study was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The literature search was conducted in Science Direct, IEEE XPLORE, Scopus, and Web of Science databases from January 2020 until July 2021, with an English language restriction. A quality assessment was based on the Critical Appraisal Skills Programs checklist. RESULTS: The included studies focused on the implementation of technology for telehealth, multidisciplinary approach, service satisfaction, guidelines, and medical training. They provided illustrative insight into the strategy of telehealth in different medical specialties, such as pediatric gastroenterology, oncology, ophthalmology, and laryngology. Nonsurgical specialties had the greatest number of telehealth visits. Clinicians showed positive attitudes toward the implementation of video telehealth visits; patients report high levels of satisfaction with this care and strong interest in continuing this modality as a significant portion of clinical practice. CONCLUSIONS: This systematic review provided an illustrative insight into the strategy of telehealth for different purposes. According to our findings, telehealth may be used in different medical area with a clear strategy of intervention according to patients' and doctors' needs.

Binge-eating episode as a direct cause of death in a young individual without eating disorder.

Binge eating is characterised by the ingestion of large quantities of food in a short time. Cases in the literature deal exclusively with gastric perforation in people with a history of anorexia nervosa, binge eating disorder or bulimia nervosa.We report the case of a young woman with no previous diagnosis of mental illness and a history of only two binge-eating episodes that occurred a few years earlier. She died suddenly during a binge-eating episode from stomach rupture resulting from a single perforation of the stomach with leakage of food material within the abdominal cavity. There was no sign of gastric necrosis or peritonitis. The deceased died quickly.Our case, which appears unique in the literature, shows that there is a risk of death even in people with no diagnosis of eating disorders and a history of only few and isolated binge-eating episodes. Physicians should carefully investigate a patient's history to assess any risks.

Cervical Spine Manipulations: Role of Diagnostic Procedures, Effectiveness, and Safety from a Rehabilitation and Forensic Medicine Perspective: A Systematic Review.

BACKGROUND: Cervical spine manipulations (CSM) have been performed for centuries and are a widely practiced intervention to manage cervical spine musculoskeletal disorders. We aimed to perform an overview of the literature concerning the effects and the adverse events of CSM in the Physical and Rehabilitation Medicine (PRM) field with a forensic medicine perspective. METHODS: A search in the scientific literature (PubMed, Google Scholar, PEDro and Cochrane) was carried out from inception until October 2020. RESULTS: Fourteen articles were included in this narrative summary. The possible development of side effects requires a careful mandatory balance of benefits and risks even when there is an indication for this approach. Moreover, a qualified professional is essential to perform CSM-a non-invasive therapeutic procedure that can be potentially harmful. CONCLUSIONS: In conclusion, it is essential to perform the diagnosis, to treat, and to manage complications within the PRM field, both for the reduction of malpractice claims and, most importantly, for the safety of the patient.

Ketamine in Acute Brain Injury: Current Opinion Following Cerebral Circulation and Electrical Activity.

The use of ketamine in patients with TBI has often been argued due to its possible deleterious effects on cerebral circulation and perfusion. Early studies suggested that ketamine could increase intracranial pressure, decreasing cerebral perfusion pressure and thereby reducing oxygen supply to the damaged cerebral cortex. Some recent studies have refuted these conclusions relating to the role of ketamine, especially in patients with TBI, showing that ketamine should be the first-choice drug in this type of patient at induction. Our narrative review collects evidence on ketamine's use in patients with TBI. Databases were examined for studies in which ketamine had been used in acute traumatic brain injury (TBI). The outcomes considered in this narrative review were: mortality of patients with TBI; impact on intracranial pressure and cerebral perfusion pressure; blood pressure and heart rate values; depolarization rate; and preserved neurological functions. 11 recent studies passed inclusion and exclusion criteria and were included in this review. Despite all the benefits reported in the literature, the use of ketamine in patients with brain injury still appears to be limited. A slight increase in intracranial pressure was found in only two studies, while two smaller studies showed a reduction in intracranial pressure after ketamine administration. There was no evidence of harm from the ketamine's use in patients with TBI.

Penetrating cardiac injuries: literature review and analysis of the forensic approach.

Penetrating cardiac injuries represent an increasingly frequent type of trauma in clinical and autopsy practice. The present study aims to review the specialist literature of the last decade (2010-2020) to assess whether the main features of these lesions have changed compared to previous years. The following characteristics were considered: sex, age, cardiac structure involved, execution or not of surgery and postoperative survival, hemodynamic stability, circumstances and mechanism of production, injury and cause of death. Furthermore, the authors propose a practical appraisal of penetrating heart injury in which death was due to a delay in rescue. In line with the data obtained from the practical case, the review showed that compared to the past, the differences concern especially the mortality rate. This paper highlights that the forensic pathologist who approaches a case of transcardiac injury must consider that the circumstances of death are not always attributable to accidental events, attacks or suicides, but may also be due to clinical malpractice or failure to rescue.

Accidental identification of peritoneal encapsulation during an autopsy after a car accident.

Peritoneal encapsulation is a rare congenital pathological condition. Typical of this pathology is the presence of an accessory peritoneal flap that encloses the entire mass of the small intestine. Subjects with this condition often do not show symptoms and, in most cases, finding of it is accidental. We report a case of peritoneal encapsulation, not previously identified and found during an autopsy; the deceased, positive for HIV and affected by a Kaposi's sarcoma, died following a road accident. Unlike other cases in the literature, the peritoneum encapsulated all abdominal organs and not only small intestines. Notwithstanding, there were no signs of intestinal ischaemia or intestinal obstruction.

Suicide and Neurotrophin Factors: A Systematic Review of the Correlation between BDNF and GDNF and Self-Killing.

According to WHO data, suicide is a public health priority. In particular, suicide is the fourth-leading cause of death in young people. Many risk factors of suicide are described, including individual-, relationship-, community-, and societal-linked ones. The leading factor is the diagnosis of mental illness. Nevertheless, not all people who attempt suicide are psychiatric patients; these characteristics help define high-risk populations. There are currently no useful biomarkers to indicate the risk of suicide. In recent years, neurotrophic factors have increasingly become of scientific interest. This review aims to summarize the current scientific knowledge on the correlation between BDNF and GDNF and suicide, to theorize whether neurotrophins could be a reliable marker for an early diagnosis of suicidal risk. The authors conducted a systematic review following PRISMA criteria. They found eight research papers in agreement with the inclusion criteria. According to the results of these studies, there may be a connection between BDNF brain levels and complete suicide, although there are discrepancies. A lack of interest in GDNF may suggest less involvement in the suicidal dynamic. Further studies may provide helpful information to researchers.

Lean approach to the management of patients undergoing intravitreal injections during COVID-19 pandemic.

BACKGROUND: To introduce Lean approach principles in the management of patients undergoing intravitreal injections (IVIs) for wet age-related macular degeneration. METHODS: Retrospective single-centre cohort study. Services location, IVIs scheduling, utilization of staff, data recording methods, ophthalmic examination and surgical procedures were analysed; a new Intravitreal Injection Centre (IVIC) was developed according to Lean principles. Mean number of daily IVIs performed, mean time between registration and discharge, mean turnover time in between patients, percentages of performed IVIs on the monthly scheduled IVIs and of patients rating their experience ⩾8/10 via standardized feedback questionnaires were retrospectively analysed. RESULTS: The mean IVIs number per day increased from 20 ± 4.08 to 50 ± 7.07, and the mean time between registration and discharge of a patient decreased from 240 ± 14.14 to 60 ± 8.16 min (p = 0.00057 and p < 0.00001, respectively). Mean turnover time in between patients decreased from 10 ± 1.41 to 8 ± 2 min (p = 0.055). The percentage of monthly IVIs performed on the total of scheduled IVIs increased from 60% to 100%, and the percentage of satisfied patients who rated IVIC ⩾8/10 increased from 45% to 95% (p = 0.0177 and p < 0.00105, respectively). CONCLUSION: The IVIC improved the quality, efficiency, speed of the overall procedures and clinical capacity of the IVI service through a fast one-way route for patients, limiting time wasted and total distance travelled. This model facilitates the creation of a one-stop clinic through the just-in-time management principle and may be relevant to other ophthalmology services.

The Role of miRNAs as New Molecular Biomarkers for Dating the Age of Wound Production: A Systematic Review.

BACKGROUND: The timing of wounds production is a significant issue in forensic pathology. Although various methods have been evaluated, obtaining an accurate dating of lesions is still a challenge. The pathologist uses many parameters to value wound age, such as histological and immunohistochemical. In recent years, there have been many studies regarding the use of miRNAs in wound-age estimation; indeed, miRNAs have multiple potential uses in forensic pathology. SCOPE: This review aims to verify the efficacy and feasibility of miRNAs as a tool for determining the timing of lesions. MATERIALS AND METHODS: The authors conducted the systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed was used as a search engine to find articles published between January, 1st 2016 and October, 1st 2021, to evaluate the current state of the art regarding wound-age estimation. RESULTS: A total of 256 articles were collected; after screening according to PRISMA guidelines, the systematic review included 8 articles. The studies included in this review were all Original articles evaluating the use of biomarkers for wound-age determination. DISCUSSION AND CONCLUSION: The literature review showed that analysis of miRNA is an innovative field of study with significant potentiality in forensic pathology. There are few studies, and almost all of them are at an early stage. The challenge is to understand how to standardize the samples' selection to obtain reliable experimental data. This observation represents a necessary prerequisite to planning further clinical trials.

Wound Vitality in Decomposed Bodies: New Frontiers Through Immunohistochemistry.

Background: The question about wound vitality and the estimation of wound age of production are two of the classic investigation fields of forensic sciences. To answer this, the techniques most frequently used in research studies are immunohistochemistry (IHC), molecular biology, and biochemistry. Despite the great data on the literature about the usefulness of IHC in forensic pathology, there is always a request for further studies, especially on tissues altered by putrefactive phenomena. In fact, the degradation of the tissues is intended as the main limiting factor to the use of this technique. Scope: The aim of this pilot study was to evaluate the immunohistochemical behavior of samples collected from decomposed bodies (in different putrefaction phases) and to relate these findings to wound vitality and postmortem interval. Materials and Methods: Samples of skin and soft tissues were collected during autopsies, which were executed on decomposed bodies, whose cause of death was concluded to be traumatic. An immunohistochemical study was performed using antibodies against CD15, CD45, IL-15, tryptase, and glycophorin-A MMPs (endopeptidases involved in degrading extracellular matrix proteins: MMP-9 and MMP-2). An immunohistochemistry (IHC) reaction was evaluated according to a qualitative method as the following legend: (0): not expressed, (+): isolated and disseminated expression, (++): expression in groups or widespread foci, and (+++): widespread expression. Results: Most of the tested markers (tryptase, glycophorin, IL15, CD 15, CD 45, and MMP9) showed to be highly expressed in the tissue of putrefied skin for 15 days. Discussion and Conclusion: Although certainly inconclusive, this experimental application demonstrated that a nonexclusive but combined use of multiple antibodies is appropriate to verify wound vitality in decomposed bodies. Among them, GPA exhibited major reliability.

Organizational strategies to reduce physician burnout: a systematic review and meta-analysis.

BACKGROUND: The growing "process" of burnout impair performance and quality of professional services, with consequences for physicians, healthcare care organization, and patient's outcomes. AIMS: We aim to evaluate which strategy of intervention, individual or organization directed, is more effective to reduce physician burnout and to provide management suggestions in terms of actual organizational strategies and intensity leading to reductions in physician burnout. METHODS: The meta analysis was conducted according to the PRISMA guidelines. We included physicians of any specialty in the primary, secondary, or intensive care setting, including residents and fellows. Eligible interventions were any intervention designed to relieve stress and/or improve the performance of physicians and reported burnout outcomes, including physician-directed interventions and organization-directed interventions. The electronic search strategy applied standard filters for identification of the different studies. Databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (from inception to September 2018), and EMBASE (from beginning to September 2018). Meta analysis was performed with mixed random effect using DerSimonian and Laird method. The standardized mean difference (SMD) and 95% CI for each outcome were separately calculated for each trial pooling data when needed, according to an intention-to-treat principle. RESULTS: Pooled interventions were associated with small significant reductions in burnout (SMD = - 0.289; 95% CI, - 0.419 to - 0.159; I2 = 29%) (Fig. 2). Organization-directed interventions were associated with a medium reduction in burnout score (SMD = - 0.446; 95% CI, - 0.619 to - 0.274; I2 = 8%) while physician-directed interventions were associated with a moderate reduction in burnout score (SMD = - 0.178; 95% CI, - 0.322 to - 0.035; I2 = 11%). DISCUSSION: This systematic review and meta-analysis showed that (1) organization-directed interventions were associated with moderate reduction in burnout score, (2) physician-directed interventions were associated with small reduction in burnout score, (3) organization-directed interventions reduced more the depersonalization than physician-directed interventions, (4) organization-directed interventions were related to a more improvement of the personal accomplishment than physician-directed interventions. CONCLUSIONS: This meta analysis found that physicians could gain important benefits from interventions to reduce burnout, especially from organizational strategies, by viewing burnout rooted in issues related to the working environment and organizational culture.

Post-Acute COVID-19 Rehabilitation Network Proposal: From Intensive to Extensive and Home-Based IT Supported Services.

Management of COVID-19 post-acute syndrome is an emerging health issue in rehabilitation. This article aims to present a proposal, based on the principles of clinical governance, health management and information technology (IT), and to respond to the need for a structured organization model for post-acute COVID-19 rehabilitation. The authors present a regional-based model of a network of clinicians and healthcare managers using a dedicated IT platform to achieve both effectiveness and efficiency objectives, to ensure coordination of the available resources and the most appropriate rehabilitative treatment for patients. The proposed post-acute COVID-19 rehabilitation network has been designed according to the model of a clinical management project within the Italian national healthcare system, and its context is an easily adjustable model for the European healthcare systems. The authors base the project on current laws and scientific guidelines in rehabilitation in Italy and in Europe and use the SWOT analysis technique to assess the proposal feasibility. The primary aims of the project are: (1) standardizing the minimum assessment tools of post-COVID-19 patients with disabilities; (2) ensuring an individual rehabilitation project for each patient with international classification of functioning, disability and health (ICF) coding and (3) reporting the activity performance with appropriate indicators. The secondary aims are: (1) developing educational programs for patients and care givers also aimed at acquiring better empowerment and positive behavior; (2) creating a regional database for data collection and (3) improving IT, and specifically tele-rehabilitation, as a suitable approach during the COVID-19 emergency and also in the future. Expected results are: continuum of care; effectiveness, efficacy and appropriateness in the delivery of rehabilitation treatments through a standardized minimum assessment and the wording of the individual rehabilitation project and a precise reporting of performance indicators to measure the effectiveness of clinical activities and the satisfaction of patients and caregivers. The assessment of results will be analyzed at three and six months to implement corrective actions according to the concept of continuous improvement of the Deming cycle. The IT remote approach allows the patient to meet the needs of proximity of care and empowerment, and, at the same time, to contain the spread of infection. This project could have a significant healthcare impact ensuring a more efficient and effective management of the demand of rehabilitation post-acute COVID-19, expanding the professional skills of the rehabilitation team members, improving both clinical and process data, in addition to optimal allocation of available economic resources.