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.

Effects of Different Teaching Approaches on Proxy Measures of Physical Fitness of Italian Kindergarten Children.

Developing physical fitness (PF) behaviors early in life enhances physical development and facilitates sustained participation in physical activity and sports across childhood. This study addressed the effect of different teaching approaches on precursors of PF in kindergarten children. A total of 178 children (5.45 ± 0.40 years, female = 92) from 11 classes were organized into three groups. Group 1 (structured activity + free play) and Group 2 (only free play) attended the same playground (PrimoSport0246) for one hour/week for 10 weeks. Group 3 (structured activity + free play in kindergarten) followed their standard physical education curriculum at school. PF tests (standing long jump, medicine ball throw, and 20 m running speed) were administered pre- and post-intervention. Factorial ANOVA was implemented using a percentage change in PF performance (PFC) as the dependent variable, and teaching approaches, gender, and age as factors. Group 1 demonstrated significant improvements in fitness performance compared with Groups 2 and 3. Moderate to large effect sizes (Cohen's d range: 0.68-1.40) were noted in both males and females. Six-year-old demonstrated the greatest improvement in composite PFC compared to Groups 2 and 3. A structured teaching plan, even with a limited dose of once per week, supported the development of PF attributes in kindergarteners.

Interaction between Geographical Areas and Family Environment of Dietary Habits, Physical Activity, Nutritional Knowledge and Obesity of Adolescents.

There are marked differences in the regional distribution of childhood obesity in Italy. This study sought to investigate the interaction between geographical areas and family environment of dietary habits, physical activity, nutritional knowledge and obesity of adolescents. A cross-sectional study was conducted on 426 school-aged children and 298 parents residing in Central Italy (Florence, Tuscany) and Southern Italy (Corigliano, Calabria), in 2021. Survey questionnaire investigated anthropometry, eating behavior, nutritional knowledge and physical activity. BMI was determined and compared with reference percentile charts for adolescents. Multivariate regression analyses showed that: (1) an adolescent's BMI was directly influenced by their parents' BMI independently of parental nutritional knowledge and dietary or physical activity habits; (2) parents transmitted eating or physical activity habits to their children; (3) the geographic region of residence is not in itself an independent determinant of children's BMI. The clear message is that prevention of childhood obesity should consider family-based approaches. Parental obesity can be the point of convergence of the complex interactions between a parent's and child's habits and should be one of the most important factors to look for.

Effects of Free Play and Partly Structured Playground Activity on Motor Competence in Preschool Children: A Pragmatic Comparison Trial.

Both the indoor and the outdoor environments and their organization exert pronounced influence upon physical activity behavior and motor development of preschool children. The aim of this study was to explore whether partly structured activity or free play in a specific playground had different impacts on motor competence development in 4-6-year-old preschoolers. The study had a pretest-post-test design, with two intervention groups and one control. Sixty-two children were included in a partly structured activity group and forty-three children in a free-play group. Both groups participated in playground activities consisting of 10 sessions (once a week), each lasting 1 h, in a specific playground setting. For the partly structured activity group, activities in each session consisted of a combination of both structured and free activity while the free-play group were engaged in unstructured play only. The control group did not attend the playground activities (N = 36). To assess levels of motor skills, each child completed pre- and post-tests using the Movement Assessment Battery for children (MABC-2), the Test of Motor Competence (TMC) and two playground-specific tests. A 3 (study group) and X 2 (gender) ANCOVAs were conducted on post-test scores on each of the test items from TMC, MABC-II and playground tests, with pre-test scores as covariates. Post hoc pairwise multiple comparisons were conducted with the alpha Bonferroni corrected, and the partial eta-squared (η2p) was applied as a measure of effect size. The results indicate no significant differences in motor competence measured by the TMC or the MABC-2 between groups. On the contrary, a significant improvement in performance in the playground-specific tests was observed in the partly structured activity group compared to the free-play and control groups.

Cardiopulmonary resuscitation missed by bystanders: Collateral damage of coronavirus disease 2019.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic changed the time-dependent cardiac arrest network. This study aims to understand whether the rescue standards of cardiopulmonary resuscitation (CPR) and out-of-hospital cardiac arrest (OHCA) were handled differently during pandemic compared to the previous year. METHODS: Data for the years 2019 and 2020 were provided by the records of the Lombardy office of the Regional Agency for Emergency and Urgency. We analysed where the cardiac arrest occurred, when CPR started and whether the bystanders used public access to defibrillation (PAD). RESULTS: During 2020, there was a reduction in CPRs performed by bystanders (odds ratio [OR] = 0.936 [95% confidence interval (CI95% ) 0.882-0.993], p = .029) and in the return of spontaneous circulation (ROSC) (OR = 0.621 [CI95% 0.563-0.685], p < .0001), while there was no significant reduction in the use of PAD. Analysing only March, the period of the first wave in Lombardy, the comparison shows a reduction in bystanders CPRs (OR = 0.727 [CI95% 0.602-0.877], p = .0008), use of PAD (OR = 0.441 [CI95% 0.272-0.716], p = .0009) and in ROSC (OR = 0.179 [CI95% 0.124-0.257], p < .0001). These phenomena could be influenced by the different settings in which the OHCAs occurred; in fact, those that occurred in public places with a mandatory PAD were strongly reduced (OR = 0.49 [CI95% , 0.44-0.55], p < .0001). CONCLUSIONS: COVID-19 had a profound impact on the time-dependant OHCA network. During the first pandemic wave, CPR and PAD used by bystanders decreased. The different contexts in which OHCAs occurred may partially explain these differences.

Missed training, collateral damage from COVID 19?

BACKGROUND: during the COVID-19 pandemic a total lockdown was enforced all over Italy starting on March 9th. This resulted in the shrinking of economic activities. In addition, all formal occupational security-training courses were halted, among them the 81/08 law lectures and Basic Life Support-Defibrillation (BLS-D) laymen training courses. The aim of the study was to evaluate the impact of the pandemic on BLS-D laymen training courses in the Lombardy region. METHODS: BLS-D training courses records for the Lombardy region were analysed. The analysis was conducted from 2016 to 2020 as part of the Hippo project. RESULTS: between 2017 and 2019 BLS-D trained laymen kept increasing, moving from 53,500 trained individuals up to 74,700. In 2020 a stark reduction was observed with only 22,160 individuals trained. Formal courses were not halted completely during 2020. Still, in the months available for training, the number of individuals enrolled showed a sharp 50% reduction. CONCLUSIONS: laymen training courses for emergency management are a fundamental component of primary prevention practice. The 81/08 and 158/12 Italian laws have decreed this practice mandatory on the workplace. Following the enforcement of the lockdown and the subsequent interruption of emergency management courses, efforts will be necessary to re-establish and guarantee the high quality training of the pre-pandemic period.

Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma.

INTRODUCTION: Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation. MATERIALS AND METHODS: This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital. RESULTS: The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites. CONCLUSIONS: Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.

OHCA survey in Lombardy: comparison between years 2014 and 2019 (pre COVID-19).

BACKGROUND AND AIM: The incidence of Out of Hospital Cardiac Arrest (OHCA) is estimated at 1/1000 persons/year. In the pre-Covid-19 era world, OHCA survival rate in Europe was 7-6%. The main objective is to analyze OHCA survival in the Lombardy region by highlighting the factors related to both the victims' characteristics and the chain of survival. METHODS: All OHCAs were grouped into four pre-established periods in 2019 (14-23 January; 15-24 April; 15-24 July; 14-23 October). Following the Utstein method, we selected witnessed OHCAs with presumed cardiac etiology. The outcome of each case was collected in four moments in time: Return of spontaneous circulation (ROSC), Emergency Department (ED), 24 hours and 30 days. The neurological outcome 30 days after OHCA was also investigated and stratified with the Cerebral Performance Category Score (CPC). RESULTS: We selected 456 cases of OHCA with witnessed cardiac etiology. ROSC was achieved in 121 cases (26.5%), survival in the Emergency Departments in 110 patients (24.1%), after 24 hours in 86 (18.86%) and after 30 days in 72 (15.8%). Male sex was shown to improve OHCA survival. A shockable presentation rhythm, Cardiopulmonary Resuscitation (CPR) performed by bystanders and the activation of Public Access Defibrillation (PAD) positively influenced OHCA outcome. CONCLUSIONS: Males are more predisposed to incur an OHCA event than females, but they have greater chances of survival. Factors most related to survival are: shockable rhythm, bystanders CPR and the activation of a PAD. (www.actabiomedica.it).

Flexible SAW Microfluidic Devices as Wearable pH Sensors Based on ZnO Nanoparticles.

In this work, a new flexible and biocompatible microfluidic pH sensor based on surface acoustic waves (SAWs) is presented. The device consists of polyethylene naphthalate (PEN) as a flexible substrate on which aluminum nitride (AlN) has been deposited as a piezoelectric material. The fabrication of suitable interdigitated transducers (IDTs) generates Lamb waves (L-SAW) with a center frequency ≈500 MHz traveling in the active region. A SU-8 microfluidics employing ZnO nanoparticles (NPs) functionalization as a pH-sensitive layer is fabricated between the IDTs, causing a shift in the L-SAW resonance frequency as a function of the change in pH values. The obtained sensitivity of ≈30 kHz/pH from pH 7 to pH 2 demonstrates the high potential of flexible SAW devices to be used in the measurement of pH in fluids and biosensing.

Conformable AlN Piezoelectric Sensors as a Non-invasive Approach for Swallowing Disorder Assessment.

Deglutition disorders (dysphagia) are common symptoms of a large number of diseases and can lead to severe deterioration of the patient's quality of life. The clinical evaluation of this problem involves an invasive screening, whose results are subjective and do not provide a precise and quantitative assessment. To overcome these issues, alternative possibilities based on wearable technologies have been proposed. We explore the use of ultrathin, compliant, and flexible piezoelectric patches that are able to convert the laryngeal movement into a well-defined electrical signal, with extremely low anatomical obstruction and high strain resolution. The sensor is based on an aluminum nitride thin film, grown on a soft Kapton substrate, integrated with an electrical charge amplifier and low-power, wireless connection to a smartphone. An ad-hoc designed laryngeal motion simulator (LMS), which is able to mimic the motions of the laryngeal prominence, was used to evaluate its performances. The physiological deglutition waveforms were then extrapolated on a healthy volunteer and compared with the sEMG (surface electromyography) of the submental muscles. Finally, different tests were conducted to assess the ability of the sensor to provide clinically relevant information. The reliability of these features permits an unbiased evaluation of the swallowing ability, paving the way to the creation of a system that is able to provide a point-of-care automatic, unobtrusive, and real-time extrapolation of the patient's swallowing quality even during normal behavior.

Direct Scaling of Measure on Vortex Shedding through a Flapping Flag Device in the Open Channel around a Cylinder at Re∼103: Taylor's Law Approach.

The problem of vortex shedding, which occurs when an obstacle is placed in a regular flow, is governed by Reynolds and Strouhal numbers, known by dimensional analysis. The present work aims to propose a thin films-based device, consisting of an elastic piezoelectric flapping flag clamped at one end, in order to determine the frequency of vortex shedding downstream an obstacle for a flow field at Reynolds number Re∼103 in the open channel. For these values, Strouhal number obtained in such way is in accordance with the results known in literature. Moreover, the development of the voltage over time, generated by the flapping flag under the load due to flow field, shows a highly fluctuating behavior and satisfies Taylor's law, observed in several complex systems. This provided useful information about the flow field through the constitutive law of the device.

The Lombardy Emergency Medical System Faced with COVID-19: The Impact of Out-of-Hospital Outbreak.

OBJECTIVE: The Lombardy region was among the areas most affected by COVID-19 infection worldwide; the Lombardy Emergency Medical System (EMS) responded immediately to this emergency. We analyzed several critical aspects to understand what occurred in that region. METHODS: This retrospective study compares the events managed by the dispatch center and the characteristics of the patients transported to the hospital -age, sex, SpO2, deaths- managed by the EMS in Brescia and Bergamo provinces between March-April 2020 and March-April 2019. Ambulances' waiting time at the hospitals before discharging patients and the patients' severity at emergency department admission were also analyzed. RESULTS: EMS managed 37,340 events in March-April 2020, +51.5% versus 2019. "Breathing" or "Infective" events reported to the dispatch center increased more than ten-fold (OR 25.1, p < 0.0001) in March 2020 and two-fold in April 2020 compared to 2019 (OR 3, p < 0.0001). Deaths increased +246% (OR 1.7, p < 0.0001), and patients not transported to hospital +481% (OR 2.9, p < 0.0001) in March 2020 compared to 2019. In some hospitals, ambulances waited more than one hour before discharging the patients, and the emergency departments doubled the admission of critically ill patients. Transported patients for "Breathing" or "Infective" events were primarily males (OR 1.5, p < 0.0001). The patients had lower SpO2 in 2020 than in 2019 and they were younger. CONCLUSIONS: The Lombardy region experienced an unexpected outbreak in an extremely short timeframe and in a limited area. The EMS coped with this pandemic, covering an extremely higher number of requests, with a ten-fold increase in the number of events managed.

Emergency treatment in Lombardy: a new methodology for the pre-Hospital Drugs management on Advanced Rescue Vehicles.

BACKGROUND AND AIM OF THE WORK: The main objectives of our work were the regional harmonization and standardization of pharmaceutical supplies on MSA in Lombardy. METHODS: The retrospective investigation was articulated in 2 phases: the first was the collection of data in every area of the Region (2012), the second was the analysis and elaboration of the information retrieved. RESULTS: Beginning with 24 common drugs used by 8 AATs out of 12 an evaluation of the chemical-therapeutic characteristics was performed. The temporary list, including over 80 drugs classified in more than 25 therapeutic groups, was finally reduced to provide bags that were easier to handle but at the same time complete. Between October and November 2014, the proposed supply, including 71 formulations and approved by the Technical Board of AREU, officially entered into force. At the same time, the working group followed the same procedure to define the standard equipment for the Region's helicopters, with only 58 formulations for relatively reduced weight allowed on board. CONCLUSIONS: In conclusion, we can state that, thanks to the support of experts, of the literature review, and thanks to the practical experience of the members of the AREU working groups and thanks to the documents coming from AIFA and EMA, the first operative regional project of unified pharmacological supply for MSA was delivered.

Piezoelectricity and Biocompatibility of Flexible ScxAl(1-x)N Thin Films for Compliant MEMS Transducers.

There is huge research activity in the development of flexible and biocompatible piezoelectric materials for next-generation compliant micro electro-mechanical systems (MEMS) transducers to be exploited in wearable devices and implants. This work reports for the first time on the development of flexible ScxAl(1-x)N films deposited by sputtering technique onto polyimide substrates, assessing their piezoelectricity and biocompatibility. Flexible ScxAl(1-x)N films have been analyzed in terms of morphological, structural, and piezoelectric properties. ScxAl(1-x)N layer exhibits a good surface roughness of 4.40 nm and moderate piezoelectricity with an extracted effective piezoelectric coefficient (d33eff) value of 1.87 ± 0.06 pm/V, in good agreement with the diffraction pattern analysis results. Cell viability assay, performed to study the interaction of the ScxAl(1-x)N films with human cell lines, shows that this material does not have significant effects on tested cells. Furthermore, the ScxAl(1-x)N layer, integrated onto a flexible device and analyzed by bending/unbending measurements, shows a peak-to-peak open-circuit voltage (VOC) of 0.32 V and a short-circuit current (ISC) of 0.27 µA, with a generated power of 19.28 nW under optimal resistive load, thus demonstrating the potential of flexible ScxAl(1-x)N films as active layers for next-generation wearable/implantable piezoelectrics.

Reliability of Protective Coatings for Flexible Piezoelectric Transducers in Aqueous Environments.

Electronic devices used for marine applications suffer from several issues that can compromise their performance. In particular, water absorption and permeation can lead to the corrosion of metal parts or short-circuits. The added mass due to the absorbed water affects the inertia and durability of the devices, especially for flexible and very thin micro-systems. Furthermore, the employment of such delicate devices underwater is unavoidably subjected to the adhesion of microorganisms and formation of biofilms that limit their reliability. Thus, the demand of waterproofing solutions has increased in recent years, focusing on more conformal, flexible and insulating coatings. This work introduces an evaluation of different polymeric coatings (parylene-C, poly-dimethyl siloxane (PDMS), poly-methyl methacrylate (PMMA), and poly-(vinylidene fluoride) (PVDF)) aimed at increasing the reliability of piezoelectric flexible microdevices used for sensing water motions or for scavenging wave energy. Absorption and corrosion tests showed that Parylene-C, while susceptible to micro-cracking during prolonged oscillating cycles, exhibits the best anti-corrosive behavior. Parylene-C was then treated with oxygen plasma and UV/ozone for modifying the surface morphology in order to evaluate the biofilm formation with different surface conditions. A preliminary characterization through a laser Doppler vibrometer allowed us to detect a reduction in the biofilm mass surface density after 35 days of exposure to seawater.

Out-of-hospital cardiac arrest (OHCA) Survey in Lombardy: data analysis through prospective short time period assessment.

BACKGROUND AND AIM OF THE WORK: The results of out-of-hospital cardiac arrests (OHCA) are usually reported through data collected collected via "ad hoc"  registries, but in large populations, samples of short time periods can be used to apply the results to the entire population. We would like to describe the situation of Lombardy to provide evidence on successful procedures, which may be carried out in a larger context. METHODS: Observational, prospective, analytical, single cohort study in Lombardy population. Data of OHCA of cardiac aetiology, according to "Utstein Style", with resuscitation attempts started by the Emergency Medical Service (EMS), were collected for 40 days subdivided in 10-day-periods in all seasons 2014-15 via Operating System "Emergency Management" (EmMa). RESULTS: Of 1219 cases, 536 events of witnessed OHCA of presumed cardiac etiology were analyzed. Outcomes were: sustained Return Of Spontaneous Circulation ROSC (25.6%), Survival Event in Emergency Department (22.8%), Survival after 24 hours (21.2%) and Survival after hospital discharge at home 30 days after (11.2%). Statistically significant results were found in age, rhythm of presentation, and resuscitation by bystanders. Sex, seasonality and rescue timing did not differ statistically. CONCLUSIONS: Overall the thirty-day survival rate was similar to studies with larger databases. Our data are consistent with the concept that all emergency service should provide CPR instructions for every citizen who activate the EMS in the suspect of a SCA; further investigation should clarify how long interval could be useful for ROSC and sustained ROSC in patients resuscitated by lay people using CPR instructions.

Comparing Free Play and Partly Structured Play in 4-5-Years-Old Children in an Outdoor Playground.

The aim of this study was to compare how the organization of a movement session as partly structured play or free play influenced the physical activity engagement in 4-5 years old pre-schoolers. The partly structured playgroup consisted of 46 children and the free playgroup consisted of 33 children. The playground activities consisted of 10 sessions each lasting 1 h, executed once per week in the period Mars to May 2017 at a specific playground setting. The partly structured playgroup conducted a movement activity session that included a combination of both structured- and free play activities. The free playgroup engaged in unstructured play, only. To detect the intensity of the physical activity each child carried an accelerometer 1 h the first week and last week of the intervention. Results indicate a significant difference in physical activity level between the two groups for the 5-year-old in the favor of the partly structured playgroup. There was a significant difference between the four-and 5-year-old in relation to physical activity level. No significant difference between the activity in March and May for the whole group was found.