A COVID-19 nosocomial cluster in a university hospital in southern Italy: a social network analysis.

Introduction: Healthcare workers on duty at the hospital are at high risk of COVID-19 infection. However, despite the introduction of risk-lowering practices in the hospital setting, there have been many cases of SARS-COV-2 infection among Health Care Workers. Fast and efficient contact tracing and Sars-CoV-2 PCR-based testing of the close contacts of Health Care Workers with confirmed infections are essential steps to limit nosocomial outbreaks. Methods: This cross-sectional study was conducted at Bari Policlinico General University-Hospital (Apulia, Italy) and describes the management of a cluster of SARS-COV-2 infections in three Operative Units. The contact tracing activities and the measures implemented to control the outbreak are described. Results: Among the 186 Health Care Workers active in the cluster setting, there were 9 (4.8%) confirmed cases, including the index case. Due to the outbreak, three Operative Units were closed to limit virus circulation. Health Care Workers with confirmed infections tested negative after a mean of 28.0±6.6 days (range: 13-37) and none required hospitalization. Conclusions: Protection of the health of Health Care Workers during the COVID-19 pandemic should be a public health priority. However, despite recent recommendations and the implementation of protective measures, SARS-COV-2 infections of Health Care Workers remain at a high rate, indicative of the continued high risk of cluster onset in the nosocomial setting.

A new paradigm of hospital care for SARS-COV-2 patients in the post-emergency phase in Italy.

Abstract: In Italy, at the beginning of the SARS-CoV-2 pandemic, the main organizational model of hospital care was represented by the physical or functional division of hospitals and wards into COVID and non-COVID areas, in order to separate SARS-CoV-2-infected patients from the others. Now that the emergency phase has reached its long-awaited end, it is necessary to develop a new hospital care paradigm that may deal with SARS-CoV-2-positive patients discriminating between those who are hospitalized because of COVID-19 and those who are diagnosed with SARS-CoV-2 infection immediately before or after the first access to healthcare facilities.

Bamlanivimab and Etesevimab administered in an outpatient setting for SARS-CoV-2 infection.

The early administration of anti-SARS-CoV-2 monoclonal antibodies (mAb) could decrease the risk of severe disease and the need of inpatients care. Herein, our clinical experience with Bamlanivimab/Etesevimab for the treatment of early SARS-CoV-2 infection through an outpatient service was described. Patients with confirmed COVID-19 were selected by General Practitioners (GPs) if eligible to mAb administration, according to manufacturer and AIFA (Agenzia-Italiana-del-Farmaco) criteria. If suitability was confirmed by the Multidisciplinary Team, the patient was evaluated within the next 48-72 hours. Then, all patients underwent a medical evaluation, followed by mAb infusion or hospitalization if the medical condition had worsened. Overall, from March 29th to June 4th, 2021, 106 patients with confirmed COVID-19 were identified by GPs; 26 were considered not eligible and then excluded, while 9 refused treatment. Among the 71 remaining, 6 were not treated because of worsening of symptoms soon after selection. Finally, 65 received mAb therapy. All treated patients survived. However, 2/65 developed adverse events (allergic reaction and atrial fibrillation, respectively) and 6/65 needed hospitalization. By performing univariate logistic regression analysis, diabetes was the only risk factor for hospitalization after mAb administration [aOR = 9.34, 95%CI = 1.31-66.49, p= .026]. Importantly, subjects who worsened awaiting mAb were more frequently obese (OR = 16.66, 95%CI = 1.80-153.9, p= .013) and received home corticosteroid therapy for COVID-19 (OR = 14.11, 95%CI = 1.53-129.6, p= .019). Establishing a network among GPs and COVID units could be an effective strategy to provide mAb treatment to patients with early SARS-CoV-2 infection to reduce hospitalizations and pressure on healthcare systems.

Prevention and protection measures of healthcare workers exposed to SARS-CoV-2 in a university hospital in Bari, Apulia, Southern Italy.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-related infection has a major impact on public health, and healthcare workers (HCWs) are exposed to high biological risk. This paper describes the prevention procedures introduced at the University Hospital of Bari, Italy to reduce the risk to HCWs, consisting of enhanced preventive measures and activation of a report system to collect HCWs' contacts. Twenty-three confirmed cases of infection (0.4% of all HCWs) were reported in the 30-day observation period following implementation of the protocol. This shows that correct management of HCWs' contacts is essential to avoid nosocomial clusters.

Bilateral Striatal Necrosis after Sydenham's Chorea in a 7-Year-Old Boy: A 2-Year Follow-Up.

Child bilateral striatal necrosis (BSN) is a rare and etiologically heterogeneous condition. An association with group A streptococcus (GAS) infection was previously reported in two cases of BSN in infancy and early childhood. We here report on a 7-year-old boy who developed chorea and dystonia 20 days after symptomatic recovery from Sydenham's chorea. Repeated brain magnetic resonance imaging scans, obtained before, soon after the onset of the post-Sydenham symptoms, and 1 year later were consistent with an evolution from bilateral striatal microbleeding to necrosis, and consequently reduced basal ganglia volume and enlargement of the frontal horns. No support was found for other possible autoimmune, infectious, metabolic, toxic or genetic etiologies for BSN. Prednisone treatment was instituted and continued for 1 year. Two years after the onset of the post-Sydenham symptoms, the child, although much improved, still has generalized dystonic-choreic movements. This case confirms and extends into school age, the link between GAS and BSN.

Primary HPV test screening in cervical cancer: a two-year experience of a single screening center in Latina (Italy).

OBJECTIVE: The aim of this study was to evaluate the effect and performance of the new algorithm in cervical cancer screening program in two years' experience of Latina (Italy). MATERIALS AND MTHODS: The female population was divided into two groups, the first group was referred to PAP test and the second one to hr-HPV test according to national guidelines. RESULTS: In two years the participation mean rate increased among women aged 35-64 compared to women aged 25-34. The primary PAP test positive rate and hr-HPV test positive rate were 4.0% and 5.2%, respectively. The PAP test positive rate among hr-HPV+ women decreased from 2012 to 2013. Women with hr-HPV+/PAP+ were referred immediately to colposcopy and this rate was 1.2%. The predictive positive value for CIN2+ to colposcopy was 10.9% in 2012 and 9.1% in 2013, while the detection rate for CIN2+ was 1.6% in 2012 and 1.4% in 2013. CONCLUSION: The stratification of the female population leads to a decreased inappropriate therapeutic path while the combination of hr-HPV test with PAP test in woman aged 35-64 lets obtain high levels specificity and sensitivity results.

The 16, 18, and 45 HPV infection in high grade squamous cervical lesions in primary hr-HPV test screening program.

Infection with high-risk human papillomavirus (hr-HPV) 16, 18, and 45 causes 94% of cervical carcinoma. In the present screening center the authors perform the hr-HPV test followed by Pap test to women aged 35-64 years if they result hr-HPV+. The authors' aimed to provide data regarding the genotyping test and eventually to propose this test as alternative to triage cytology. They used a genotyping test to identify HPV 16, 18, and 45 in 22 women with histological diagnosis of CIN2+, 22 women with histological diagnosis of CIN1 and 22 women hr-HPV+/Pap-. The group of CIN2+ showed the higher positivity to the test and the higher positivity to HPV 16 than other groups. Analyzing the clinical performance of the genotyping test the authors observed that the specificity was 64%. From these data they concluded that the identification of HPV 16 is predictive for high-grade lesions but this test could not be used alternatively to triage cytology.

The "one-out, all-out" principle entails the risk of imposing unnecessary restoration costs: a study case in two Mediterranean coastal lakes.

The Water Framework Directive uses the "one-out, all-out" principle in assessing water bodies (i.e., the worst status of the elements used in the assessment determines the final status of the water body). In this study, we assessed the ecological status of two coastal lakes in Italy. Indices for all biological quality elements used in transitional waters from the Italian legislation and other European countries were employed and compared. Based on our analyses, the two lakes require restoration, despite the lush harbor seagrass beds, articulated macrobenthic communities and rich fish fauna. The "one-out, all-out" principle tends to inflate Type I errors, i.e., concludes that a water body is below the "good" status even if the water body actually has a "good" status. This may cause additional restoration costs where they are not necessarily needed. The results from this study strongly support the need for alternative approaches to the "one-out, all-out" principle.

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females.

AIM: Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. METHOD: Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. RESULTS: Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. CONCLUSION: Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.

Use of fibrin glue in the treatment of pilonidal sinus disease: a pilot study.

BACKGROUND: Pilonidal sinus (PS) disease of the sacrococcigeal region is an acquired condition resulting from penetration of shed hair shafts through the skin. Different types of operations have been described in the letterature. More recently fibrin glue has been used with succesfull. Aim of this study was to assess the effectiveness of fibrin glue for the treatment of pilonidal sinus. PATIENTS AND METHODS: Eight patients age ranged 21,8 +/- 6,5 affected by PS disease of sacrococcigeal region were included in this study. All patients undergoing surgical operation under local anaesthesia. Following administration of 1% methylene blue through the main opening, a small vertical elliptical incision is maked including the entire sinus opening and an excision of PS was performed without entering the sinus cavity, removing a minimal amount of subcutaneous tissue. Afterwards the highly concentrated fibrin glue, containing 1,000 U/ml of thrombin was applied to cover the wound. Post-operative pain, analgesic consumption, duration of hospital stay, failure healing, the rate and time of recurrence, time to healing, time to return to work and post-operative complications were recordered. RESULTS: All patients expressed satisfaction with the procedure. Mean hospital stay was 5.4 +/- 2.1 hours. Healing was achieved after 25.8 +/- 13.2 days. The post-operative pain mean score was 3.8 +/- 2.1 in first day, 2,9 +/- 1,8 in third day and 1,3 +/- 0,8 in the seventh day. The mean analgesic consumption per week was 5,6 +/- 3,2 medications. Mean time to return to work was 5,3 +/- 2,1 days. CONCLUSION: The minimal excision of PS and application of fibrin glue is a non-invasive effective treatment, easy and simple to performe and not associated to recurrences. For these reasons this procedure in our opinion as the first line treatment for pilonidal sinus disease.

Factors predicting the persistence of genital human papillomavirus infections and PAP smear abnormality in HIV-positive and HIV-negative women during prospective follow-up.

As part of an extensive multi-institutional DIANAIDS study focused on assessing the risk factors, natural history, diagnosis and follow-up of genital human papillomavirus (HPV) infections in HIV-infected women, the present communication reports a sub-cohort of 142 women (89 HIV+ and 48 HIV-), followed-up for a mean of 14.07 (+/-10.84) months to analyse the factors predicting the persistence and clearance of HPV infections (polymerase chain reaction [PCR] and sequencing) and cervical Papanicolaou (PAP) smear abnormalities, using both univariate (Kaplan-Meier) and multivariate (Cox) survival analysis. The appearance of new HPV infections during the follow-up was significantly more frequent in HIV-positive than in HIV-negative women, odds ratio (OR) 8.800 (95% confidence interval [CI]: 1.199-64.611), and also the clearance rate was significantly less frequent in HIV-positive than in HIV-negative women, 69.2% vs 22.8%, respectively (OR 0.330; 95% CI: 0.163-0.670). These two groups were also markedly different with respect to the clinical course of the cervical lesions, in the frequency of progressive disease (determined by PAP smear) was higher in HIV-positive group (12/89) than in HIV-negative women (2/52) (OR 3.506; 95% CI 0.816-15.055) (P = 0.055), in whom the disease regressed more frequently than in HIV-positive women (13.5% vs 7.9%) (OR 0.584; 95% CI 0.217-1.573). Using (1) HPV-positivity, (2) oncogenic HPV-type and (3) significant PAP smear abnormality at the end of follow-up as outcome measures, (1) was significantly (P < 0.001) predicted by the following variables in univariate analysis: age, mode of contraception, CD4 count, and HIV-positivity. The significant predictors of (2) were age and mode of contraception. The outcome measure (3) was significantly predicted by CD4 count, PAP smear abnormality and PCR status at entry. In the multivariate analysis, the significant independent predictive factors for HPV-positivity proved to be only the HIV status (P < 0.001), and PCR status at entry, p53 polymorphism at aa-72, oncogenic HPV type and significant PAP smear at entry remained independent predictors, with the significance level of P < 0.05. None of the significant predictors of oncogenic HPV type in univariate analysis retained their independent value in multivariate analysis. Oncogenic HPV type at entry proved to be an independent predictor of significant PAP smear (P < 0.05). The present results indicate that HIV-infected women, even on highly active antiretroviral therapy, demonstrate a more aggressive clinical course of cervical HPV infections, and fail to eradicate the disease more frequently than HIV-negative women. This persistence of HPV-positivity, oncogenic HPV type and significant PAP smear abnormality can be predicted by the results of PAP test and HPV typing in univariate analyses, and partly retain their independent predictive value also in multivariate analysis. Clearly, in addition to regular monitoring by PAP smear, HPV testing for the oncogenic HPV types seems to provide additional prognostic information in the management of cervical lesions in HIV-infected women.

Papnet-assisted cytological diagnosis intensifies the already marked variability among cytological laboratories.

OBJECTIVE: The main objective was to assess the sensitivity, specificity and reliability of PAPNET-assisted diagnosis in comparison with conventional screening. SETTING: Seven Italian and one English University or Research Institutes, and a random sample of an other 20 Italian Laboratories of the Italian National Health Service (INHS) provided the cervical smears. METHODS: During the training phase every center examined in rotation four sets of slides for a total of 300 representative slides. Afterwards, 900 "positive" slides were added to the 3,100 slides which were collected consecutively without any selection or exclusion. The eight main centers were divided into four couples and each couple of centers examined 775 slides with the PAPNET system, "blindly" to the original diagnosis. An expert cytopathologist (M.A.) of the National Institute of Health (NIH) reassessed 40% of the slides with an original negative diagnosis to evaluate the false negative rate. Two expert NIH cytopathologists (M.A., G.M.) re-examined all slides where a disagreement had been observed between the original and one or both of the study diagnoses. The main analyses concerned the following three main categories: WNL and unsatisfactory for evaluation; ASCUS, AGUS and LSIL; HSIL and carcinoma. A special algorithm was devised to define the reference diagnosis for sensitivity and specificity assessment. RESULTS: Laboratories, even belonging to the same couple, classified as "no review" a very different proportion of slides ranging from 35% to 74%. The index of kappa agreement between the members of couples examining the same sets of slides was low or very low, ranging from 0.30 to 0.03. The sensitivity of the review classification was particularly low in some laboratories. Surprisingly, only a small correlation was observed between the sensitivity of the review classification and the proportion of slides classified as "review". The "tentative" diagnosis on PAPNET tiles of the "review" slides was almost as reliable as the microscopic diagnosis. In the overall performance, there were many significant differences among the eight laboratories. The best laboratory had a sensitivity of 95% and a specificity of 96%. At least three laboratories displayed unacceptably low sensitivity and one a very low specificity. CONCLUSION: Altogether these results seem to confirm that there are wide differences among cytological laboratories per se, and that these differences are intensified by the use of an instrument like PAPNET. The huge variation in performance may be explained by differences in basic skills and by different training, but it is difficult to understand exactly what could have been done to reduce it.

Performance of cytology and colposcopy in diagnosis of cervical intraepithelial neoplasia (CIN) in HIV-positive and HIV-negative women.

As part of an extensive multi-institutional DIANAIDS-HIV-HPV-SIL project run in Italy (co-ordinated by ISS), the present study compares the performance (sensitivity, specificity, agreement) of routine cervical smear cytology with that of colposcopy in the detection of histologically-confirmed CIN lesions in 37 HIV-positive and 21 HIV-negative women, belonging to the DIANAIDS cohort of 459 women. All women were subjected to a cervical smear, colposcopy and biopsy, making possible the pairwise comparison of these techniques. In the whole series of HIV-positive and HIV-negative women, cytology had a sensitivity of 86.9% and specificity of 83.3%, the sensitivity of grade 2 abnormality on colposcopy against histology being 82.6% and specificity, 33.3%. No statistically significant difference was observed in the performance of Pap smears between the HIV-positive and HIV-negative women. The sensitivity of cytology was 89.7% vs 82.4% and the specificity, 75% vs 100%. For colposcopy, the sensitivity was 79.3% vs 88.2% and the specificity, 75% vs 50%. These data suggest that cervical Pap smear cytology is a highly sensitive and specific diagnostic tool in the clinical monitoring of lower genital tract pathology in HIV-positive women. Colposcopy, on the other hand, proved to be a somewhat less accurate diagnostic tool in these women.

[The STF Project: Female Tumor Screening]. / Il progetto STF--Screening Tumori Femminili.

A pilot study has been carried out to evaluate women's compliance to a screening program for cervical cancer. The study, initiated in 1994, was performed in conjunction with the ACRO project of the CNR by the Italian National Health Institute, in collaboration with La Sapienza University of Rome and the National Institute for Cancer Research in Genoa. A preliminary telephone survey was carried out on a sample of 400 women (200 in Rome and 200 in Genoa) to assess, among other factors, their attitude towards the screening program. Afterwards, an ad hoc advertising campaign was launched and 21,827 women, randomly chosen from the register office's lists, were sent a personal invitation to participate in the screening. Most women showed interest in attending the screening program at the interview, but the percentages of participation were low (25.7% in Genoa and 27.3% in Rome). On the other hand, a high percentage of women who participated in the screening had already had a Pap test in the previous three years (Genoa, 73%; Rome, 76%). The recruiting techniques that were used in this study, and that are commonly used, do not seem to reach the core of the target population for cervical screening, i.e. women who have never had a Pap test or who had a Pap test more than 5 years earlier. New methods of recruiting aimed at categories at risk and based more on direct contacts need to be developed.

Variation in the assessment of adequacy in cervical smears.

OBJECTIVE: To assess the interobserver reproducibility of the diagnosis of 'adequacy' of cervical smears according to the Bethesda System criteria in cervical smears. STUDY DESIGN: 358 cervical smears were obtained from three Italian cytopathological centres in 1998-99. All centres provided consecutively collected smears. The cervical smears were independently and blindly assessed by four cytologists. The screening was performed using a 10x objective and an additional evaluation of the percentage of cellularity was performed using a 4x objective. RESULTS: The proportion of smears assessed by the four cytologists as 'adequate' ranged from 60% to 70%, the proportion of 'satisfactory for evaluation but limited by' ranged from 27% to 38%, and the proportion of 'inadequate smears' ranged from 2% to 4%. Full agreement in the assessment of smear adequacy was observed in 311 slides and disagreement was observed only in 47. The category 'inadequate smear' was less reliable than the other two; however, the kappa value observed was acceptable. CONCLUSION: The present study shows that it is possible to achieve a high reproducibility in the assessment of smear adequacy, at least among expert cytologists who follow the Bethesda System criteria strictly.

Using the number of koilocytes to predict HIV serostatus in women with HPV-associated SIL.

OBJECTIVE: To investigate the relationship between specific cytopathologic changes, koilocyte counts and human papillomavirus (HPV) types in HIV-positive and -negative women. STUDY DESIGN: A cohort of 459 women (266 HIV+ and 193 HIV-), were examined in a multicentric study (Early Diagnosis of Neoplasia in AIDS) involving 14 gynecologic centers. Altogether, 97 women had cervical smears consistent with squamous intraepithelial lesions (SIL). Koilocytes were found in 60/97 SIL slides, subjected to quantitative counting in 30 predetermined fields. HPV genotype was determined by polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analysis. RESULTS: SIL lesions were four times more frequent (29%) in HIV-positive women than in HIV-negative women (10%) (odds ratio = 3.80). HPV DNA was equally frequent in both groups. There was a strong association between the number of koilocytes and HIV serostatus in both high grade and low grade SIL diagnoses. The presence of eight or more koilocytes had a specificity of 93% and sensitivity of 76% toward the diagnosis of HIV-positive status. No HIV-negative woman had a count > 8 koilocytes. No association was shown between koilocyte count and HPV genotype. CONCLUSION: An elevated number of koilocytes could suggest the possibility of HIV infection. Pap smear examination might give the first clue to HIV positivity in otherwise-unsuspected cases.