Dating Business Cycles in France : A Reference Chronology

This paper proposes a reference quarterly chronology for periods of expansion and recession in France since 1970, carried out by the Dating Committee of the French Economic Association. The methodology is based on two pillars: 1) econometric estimations from various key data to identify candidate periods, and 2) a narrative approach that describes the economic background that prevailed at that time to finalize the dating chronology. Starting from 1970, the Committee has identified four economic recession periods: the two oil shocks 1974-1975 and 1980, the investment cycle of 1992-1993, and the Great Recession 2008-2009. For the Covid recession, the peak is dated in the last quarter of 2019 and the trough in the second quarter of 2020.

A VIRTUOUS IMPLEMENTATION of TELEMEDICINE SERVICES in RHEUMATOLOGY: DESCRIPTION of CHANGE MANAGEMENT PRACTICES ADOPTED by the NIGUARDA HOSPITAL

Background: Over the past few decades there have been an increasing debate around the use of telemedicine. Despite this, there is still a slow rate of adoption of telemedicine services. According to a recent scoping review this may be due to a piecemeal approach to the change process, and a lack of understanding of how to plan, manage and reinforce change when implementing telemedicine service1. A virtuous example of implementation of telemedicine services can be found within the rheumatology unit of Niguarda Hospital in Milan (Italy), where the whole staff has been involved in experimenting with new multichannel interactions to communicate with patients for more than a decade. Developed in 2011 with the introduction of the iAr Plus app for the collection of Patient Reported Outcomes (PROs), the project was first targeted to patients with Rheumatoid arthritis, Pso-riatic arthritis and Spondylarthritis. In 2019 the project consolidated and added the home delivery of biological drugs for the stable patients. During spring 2020, this experience was further enhanced and extended to all patients treated with biological drugs to facilitate patient interaction during Covid-19 and was characterized by three elements: remote monitoring, triage through phone calls and home delivery of medication. What contextual factors and mechanisms adopted to plan, manage, and reinforce change where more successful? Objectives: This study aimed to highlight what were the distinctive and successful elements of this implementation experience, what we could learn from it, and which managerial implications we could derive for future implementations. Methods: We adopted a realist evaluation approach2 to identify the underlying generative mechanisms that explain 'how' the outcomes were caused and the influence of context. Thus, we deepened how the change management process has been managed by conducting semi-structured interviews with the unit director, and the staff members involved in the phases of the project (i.e., clinicians, nurses, and administrative staff). The interviews were recorded and analyzed through an ad-hoc framework1 for the analysis of change management practices. This framework identifes 10 change steps divided into 13 strategic practices and 6 operational practices that are important during the preparatory phase of the change process, for managing the change, and to sustain and reinforce longterm change. Results: Our study identifed the most relevant actions put in place by the rheumatology unit during the three major steps of preparing for change (e.g., developed telemedicine App, assigned coordinating role, identifed champions), managing change (e.g., developed and articulated a clear vision, provided training, developed ownership), and reinforcing change (e.g., continued to engage partners). The analysis highlighted four main lessons learned: frst the characteristics of the context and a strong managerial structure were a prerequisite for success. The generative mechanisms that explain how these successful outcomes were caused are: a leadership role able to defne a clear vision and a clear specialization of tasks and roles;the involvement of all team members;regular meetings and interactions. Second, patients should be involved as central actors in the defnition of the care pathway. The fnal decision on the kind of services to be used was made by the patient. Third, the relevant stakeholders should be involved since the co-design of the app. Finally, change should be incremental. The Rheumatic unit introduced one change at a time, and this brought to constant improvements. Conclusion: The framework adopted can be used either to retrospectively analyze the experiences developed but may also act as a tool to guide future tele-medicine service implementation and research. As well as the lessons learned can guide the implementation of future telemedicine experiences.

JOINING TELEMEDICINE SERVICES in RHEUMATOLOGY: The ROLE PLAYED by PERSONALIZED EXPERIENCE from PATIENTS' PERSPECTIVE

Background: With the beginning of the Covid-19 pandemic, many hospital departments worldwide, including rheumatology ones, were forced to implement telemedicine strategies. Telemedicine revealed to be an umbrella term, with various practical implementations and different degrees of pre-paredness1. Some practitioners were already familiar with telemedicine, as in the case of the Rheumatology Unit of ASST Niguarda Hospital in Milan (Italy), where telemedicine projects have been implemented for more than a decade with structured design and organized processes. Moreover, patients in Niguarda have experimented telemedicine with personalized mixes of channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. This represents a paradigmatic case study that enables us to deepen essential questions on the success of telemedicine. Objectives: Given that the last decision on joining telemedicine rests with patients2, we decided to adopt their perspective. We deepened three main aspects: i) the benefits perceived, ii) the willingness to enrol in future projects, iii) the preference on the service-mix, i.e., on-distance contacts rather than in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the type of personalized experience had. Methods: We conducted a survey from November 2021 to January 2022, enrolling randomly outpatients who attended the rheumatology unit for any reason. The survey originated from well-known surveys, such as the Tele-Health Usability Questionnaire3 and the Intention to use telehealth services4. However, we decided to overcome the usual separation that makes surveys addressed either to users or no users of telemedicine. Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telemedicine, which explored the three areas mentioned: benefits, adherence, preferences on service-mix. For this part, questions were the same for all patients apart from the tense used, being conditional tense for no-users and past tense for users. All the answers were analysed with descriptive statistics and regression models. Results: A complete response was given by 400 patients: 71% were female, 59% were 40-64 years old, 53% of them declared to work, and the diseases most represented were Rheumatoid Arthritis (36%) and Osteoporosis/arthrosis (21%). The descriptive statistics revealed interesting differences between users and no users, e.g., the desire to participate in future projects was stated by 95% of users, 81% of no users. These results were confrmed by multivariate logistic regression models that controlled for the influencing patients' characteristics (such as being old or a frequent hospital attender). It emerged that no-users imagined wide-ranging benefits. As for the willingness to participate to future telehealth projects, even if personal characteristics showed an impact (e.g., being a worker increased the probability to adhere), other things being equal, having had a more intense experience of telemedicine increased the odds of accepting by 3.1 times (95% C.I. 1.04-9.25), compared to no users. Furthermore, the more telemedicine was experienced, the higher the willingness to substitute in-person with online contacts. Conclusion: Our study contributes to enlighten the crucial role played by the telemedicine experience in determining patients' preferences. On one side, users appeared more aware of the realistic benefts to be expected from telemedicine. On the other side, it seemed that the more telemedicine was experienced, the higher the willingness to adhere to future projects and to increase on-distance contacts.

Survey on the efficacy of telephone-based communication with relatives of hospitalized cancer patients in COVID-19 era in Italy

Background: Physical distancing and no-visitor policies adopted to prevent COVID-19 spread in hospital wards have deeply impacted communication with patients and their relatives. Whereas in pre-COVID-19 era family-clinician meetings were held in person, during the SARSCoV- 2 pandemic interactions often take place over the phone. The frequently unilateral direction of the communication might cause feelings of uncertainty and distress to those who are at home. Until now little data about this topic have been collected, and most of them refer to COVID-19 patients. Literature about hospital communication with non-COVID-19 patients and their relatives during the pandemic is lacking. Material and methods: After no-visitor policy was adopted in the Onco-Hematological Unit of Modena, inpatients' relatives were contacted daily for clinical updates. After discharge, a telephone satisfaction survey was administered to all relatives of patients consecutive admitted between December 2020 and January 2021 (n=97). Mean score of response and potential statistically significative differences depending on respondents' characteristics were assessed. Suggestions were collected. Results: Most relatives were satisfied with the communication received, with a mean score over all items of 4.69 on a 5-point Likert scale (standard deviation: 0.60). Results showed high satisfaction rate with both the informative (mean?}SD: 4.66?}0.64) and emotional (mean?}SD: 4.66?}0.58) content, with no significant difference depending on respondents' demographic characteristics (p>0.05). Among suggestions, 13% found it useful to organize more video calls;12% would have preferred to have always talked to the same clinician;4% suggested the first meeting be held in person and 2% would have liked to have seen the patient before discharge, especially after a long hospital stay. Conclusions: Our findings show that a structured telephone- based interaction might help overcome communication barriers imposed by pandemic-related restrictions. We believe that these findings could stimulate other clinicians to think about ways to involve relatives in continuous care of their loved ones when personal contact is impossible and might lead to other studies with a higher number of participants. In our view, anything that can help with the identification of relational and communication strategies that have worked during the pandemic will contribute to the creation of a precious know-how in view of future crises.

Severe thrombocytopenia in patient with SARS-CoV-2 infection

Background: SARS-CoV-2 disease (CoViD-19) is an important pandemic respiratory disease that emerged in China on December 2019 and quickly spread around the world. Many studies on SARSCoV- 2 infection demonstrate its association with an increased incidence of coagulopathy. In this case-report we describe a serious thrombocytopenia as an early manifestation of CoViD-19. Description of the case: A 59-year-old male with moderate dyspnea and rare petechiae spread to the trunk arrived at the DEA. He reported infection with SARS-CoV-2 from a week with the appearance of petechiae 24 hours before the discovery of positivity. He also reported COPD history and hypertension. At the entrance the patient was lucid, oriented and cooperative. The B.P. was 110/75 with sinus rhythm with pulse of 110 bpm, apyretic, SpO2 85% in A.A. To DEA showed examinations: thrombocytopenia (8,000), leukocytosis (15,560), D-Dimer 11727, VES 74, PCR 10.53, ferritin 1592, LDH 365. The EGA (Reservoir 90%) detected pO2 70.0 mmHg, pCO2 36.5 mmHg, pH7.44, SpO2 94% and P/F 78. The X-ray chest showed multiple thickening at the lower lobar seat bilaterally and moderately spread interstitial thickening. He was admitted to the CPAP cycle (FiO2 90% PEEP 7.5 cm H2O) and therapy based on dexamethasone, fluid therapy, cholecalciferol, antibiotics and multiple platelet transfusions. After 12 days the patient died. Conclusions: In many CoViD-19 studies the incidence of thrombocytopenia is about 36%. The peculiarity of this case-report is given by the serious thrombocytopenia as an initial manifestation in the absence of clinical bleeding.

Isth registry on pregnancy and COVID-19 associated coagulopathy (COVPREG-COAG)-first report

Background: Increased susceptibility to severe illnesses has been reported in pregnancy, following infection with SARS-CoV-2 resulting in COVID-19, in part evoked by pregnancy-related physiologic and immunologic changes. In the non-pregnant population, COVID-19 associated coagulopathy (CAC) with a thrombotic phenotype has been described in those with severe illness. Pregnancy is an inherently prothrombotic state, yet data on CAC in pregnancy remains scarce. The ISTH SSC for Women's Health Issues in Thrombosis and Haemostasis developed the international registry (COV-PREG-COAG) addressing CAC in pregnancy. Aims: To examine the occurrence of CAC during pregnancy, its characteristics, association with disease severity, and effects on maternal and fetal outcomes. Methods: Physicians worldwide were invited to participate. The ISTH REDCap online platform, which utilizes robust data confidentiality and security protocols for data capture, was adopted. Data included: pregnancy demographics, disease state, comorbidities, haemostatic parameters, details of coagulopathy and its treatment, as well as fetal and maternal outcomes. As of March 8, 2021, 340 COVID-19 affected pregnancies were reported to COV-PREG-COAG. Results: Table 1 summarizes relevant findings. Over 80% of COVID-19 occurred in the third trimester and 55% of women were asymptomatic. Most common symptoms included cough (47%), fever (39%), shortness of breath (25%) and anosmia (17%). Comorbid pathologies were reported as follows: obesity (66%), respiratory illnesses (7.6%) and diabetes (2.4%). Among 336 women with complete information, 5% were hospitalized, 3.3% had severe disease, and 1.3% required ICU admission. Two patients with CAC required ECMO/mechanical ventilation. CAC features included: prolonged PT/APTT (9.1%), thrombocytopenia (4.9%), elevated D-dimer (4.6%), hyper-fibrinogenemia (5%). Non of the patients developed hypofibrinogenemia. Sixty-six percent of women received postpartum thromboprophylaxis. There was one venous thromboembolic event and no maternal deaths. Conclusions: This early report from the ISTH registry demonstrates that CAC and thrombotic events are infrequent in COVID-19 affected pregnancies. Further data is required before drawing definite conclusions.

Il doppio binario delle cure primarie. Alcune scelte di fondo per i sistemi di tutela della salute

What role did primary care and general practice play in the different phases of Covid-19 epidemic? What can we learn from the emergency to innovate the health system and the role of primary care in our country? The article addresses these questions by presenting the happenings that directly involved primary care and general practitioners (especially on topics concerning USCA, personal safety and protection, and new care models) and by making some considerations on the immediate future. The role of general practice is discussed from a double perspective, where the epidemic situation coexists with the ordinary care management, especially of chronic patients. The management of the pandemic forces us to reflect on i) the coordination of territorial actors, ii) the management of territorial services network operations, iii) the consequences of challenging the traditional care model, and iv) the hypothesis of a new mix of person-centred services and community centred-services. Copyright © FrancoAngeli.