Multidrug-Resistant Bacterial Colonization and Infections in Large Retrospective Cohort of Mechanically Ventilated COVID-19 Patients1.

Few data are available on incidence of multidrug-resistant organism (MDRO) colonization and infections in mechanically ventilated patients, particularly during the COVID-19 pandemic. We retrospectively evaluated all patients admitted to the COVID-19 intensive care unit (ICU) of Hub Hospital in Milan, Italy, during October 2020‒May 2021. Microbiologic surveillance was standardized with active screening at admission and weekly during ICU stay. Of 435 patients, 88 (20.2%) had MDROs isolated ≤48 h after admission. Of the remaining patients, MDRO colonization was diagnosed in 173 (51.2%), MDRO infections in 95 (28.1%), and non-MDRO infections in 212 (62.7%). Non-MDRO infections occurred earlier than MDRO infections (6 days vs. 10 days; p<0.001). Previous exposure to antimicrobial drugs within the ICU was higher in MDRO patients than in non-MDRO patients (116/197 [58.9%] vs. 18/140 [12.9%]; p<0.001). Our findings might serve as warnings for future respiratory viral pandemics and call for increased measures of antimicrobial stewardship and infection control.

Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey.

BACKGROUND: During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions. METHODS: A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave. RESULTS: Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic. CONCLUSIONS: Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.

Prone position in intubated, mechanically ventilated patients with COVID-19: a multi-centric study of more than 1000 patients.

BACKGROUND: Limited data are available on the use of prone position in intubated, invasively ventilated patients with Coronavirus disease-19 (COVID-19). Aim of this study is to investigate the use and effect of prone position in this population during the first 2020 pandemic wave. METHODS: Retrospective, multicentre, national cohort study conducted between February 24 and June 14, 2020, in 24 Italian Intensive Care Units (ICU) on adult patients needing invasive mechanical ventilation for respiratory failure caused by COVID-19. Clinical data were collected on the day of ICU admission. Information regarding the use of prone position was collected daily. Follow-up for patient outcomes was performed on July 15, 2020. The respiratory effects of the first prone position were studied in a subset of 78 patients. Patients were classified as Oxygen Responders if the PaO2/FiO2 ratio increased ≥ 20 mmHg during prone position and as Carbon Dioxide Responders if the ventilatory ratio was reduced during prone position. RESULTS: Of 1057 included patients, mild, moderate and severe ARDS was present in 15, 50 and 35% of patients, respectively, and had a resulting mortality of 25, 33 and 41%. Prone position was applied in 61% of the patients. Patients placed prone had a more severe disease and died significantly more (45% vs. 33%, p < 0.001). Overall, prone position induced a significant increase in PaO2/FiO2 ratio, while no change in respiratory system compliance or ventilatory ratio was observed. Seventy-eight % of the subset of 78 patients were Oxygen Responders. Non-Responders had a more severe respiratory failure and died more often in the ICU (65% vs. 38%, p = 0.047). Forty-seven % of patients were defined as Carbon Dioxide Responders. These patients were older and had more comorbidities; however, no difference in terms of ICU mortality was observed (51% vs. 37%, p = 0.189 for Carbon Dioxide Responders and Non-Responders, respectively). CONCLUSIONS: During the COVID-19 pandemic, prone position has been widely adopted to treat mechanically ventilated patients with respiratory failure. The majority of patients improved their oxygenation during prone position, most likely due to a better ventilation perfusion matching. TRIAL REGISTRATION: clinicaltrials.gov number: NCT04388670.

Endosonographic evaluation of the mediastinum through the i-gel O2 supraglottic airway device.

INTRODUCTION: Endobronchial ultrasound (EBUS) is an endoscopic diagnostic procedure combining flexible fibrobronchoscopy with ultrasound techniques; it allows transbronchial needle aspiration biopsy for the diagnosis and staging of mediastinal masses. We present our preliminary experience with the use of the i-gel O2 supraglottic airway device for management of EBUS procedures. METHODS: An observational study on 39 patients who underwent EBUS under general anesthesia was performed. Airways were managed with i-gel O2 by anesthesiologists unfamiliar with it. Data collected included patient characteristics, i-gel O2 positioning, mechanical ventilation, procedure, and complications occurring during and after the EBUS. RESULTS: The i-gel airway was successfully positioned during the first attempt in 34/39 cases (87.2%). No failed positioning was recorded. The EBUS scope easily passed through the i-gel in all patients and in 14 (35.6%) cases it was also inserted through the esophagus allowing the examination or fine needle aspiration of paraesophageal lymph nodes. In one case, during the EBUS procedure, the i-gel was dislocated but easily put in place again. During EBUS, air leakages were significant in 2 cases (5.1%) and minimal in 14 cases (35.9%). A brief self-solved laryngospasm and a bronchospasm during bronchoscopy were recorded. After recovery, no patients had dysphagia; mild odynophagia and pharyngodinia were referred by 2 (5.1%) and 12 (30.1%) patients, respectively. CONCLUSIONS: The i-gel O2 airway is easy to position and manage even for anesthesiologists unfamiliar with it. This supraglottic airway device is suitable for a complete endosonographic evaluation of the mediastinum.

Malnutrition and Perioperative Nutritional Support in Retroperitoneal Sarcoma Patients: Results from a Prospective Study.

INTRODUCTION: Retroperitoneal soft tissue sarcomas (RPSs) are mesenchymal neoplasms. The prevalence of protein energetic malnutrition (PEM) and its impact in RPS patients who were candidates for surgery is unknown. MATERIALS AND METHODS: A prospective feasibility study enrolled 35 patients with primary RPS who were candidates for extended multivisceral resection. PEM was screened at enrollment. Preoperative high protein ß-hydroxy-ß-methyl butyrate oral nutritional support (ONS) was provided according to the degree of PEM. After surgery, nutritional support followed standard practice, targeting at least 1 g/kg/day protein and 20 kcal/kg/day caloric intake within the third postoperative day (POD). PEM was re-evaluated before surgery on POD 10, and at 4 and 12 months after surgery. Primary outcomes were the patient's compliance to preoperative ONS and the physician's compliance to postoperative nutritional targets. RESULTS: PEM was documented in 46% of patients at baseline; ONS met a 91% adherence (overall well tolerated). After ONS, PEM reduced to 38% (p = 0.45). The postoperative caloric target was reached on day 4.1 (standard error ± 2.7), with a protocol adherence rate of 52%. On POD 10, 91% of patients experienced PEM, the worsening of which was greater after resection of four or more organs (p = 0.06). At 4 and 12 months after surgery, almost all patients had fully recovered. A significant correlation between PEM at surgery and postoperative complications was found (p = 0.04). CONCLUSIONS: Relevant PEM prevalence in RPS is documented for the first time. PEM correlates with greater morbidity. In this setting, preoperative ONS was feasible and well-tolerated. Disease-related factors for PEM and the ideal perioperative caloric target in the context of extended multivisceral resection need to be further investigated. Nutritional support should be included in enhanced recovery after surgery programs for RPS. TRIAL REGISTRY: ClinicalTrials.gov identifier: NCT03877588.

What makes a word so attractive? Disclosing the urge to read while bisecting.

Expert readers have been repeatedly reported to misperceive the centre of visual stimuli, shifting systematically to the left the bisection of any lines (pseudoneglect) while showing a cross-over effect while bisecting different types of orthographic strings (Arduino et al., 2010, Neuropsychologia, 48, 2140). This difference has been attributed to asymmetrical allocation of attention that visuo-verbal material receives when lexical access occurs (e.g., Fischer, 2004, Cognitive Brain Research, 4, 163). The aim of this study was to further examine which visual features guide recognition of potentially orthographic materials. To disentangle the role of orthography, heterogeneity, and visuo-perceptual discreteness, we presented Italian unimpaired adults with four experiments exploiting the bisection paradigm. The results showed that a cross-over effect emerges in most discrete strings, especially when their internal structure, that is being composed of heterogeneous elements, is suggestive of orthographically relevant material. Interestingly, the cross-over effect systematically characterized the processing of letter strings (Experiment 2) and words (Experiments 3 and 4), whether visually discrete or not. Overall, this pattern of results suggests that neither discreteness nor heterogeneity per se are responsible for activating visual scanning mechanisms implied in text exploration, although both contribute to increasing the chance of a visual stimulus undergoing a perceptual analysis dedicated to pre-lexical processing.

The impact of verbal working memory on number-space associations.

Spatial-numerical associations are observed when participants perform number categorization tasks. One such observation is the spatial numerical associations of response codes (SNARC) effect, showing an association between small numbers and the left-hand side and between large numbers and the right-hand side. It has long been argued that this spatial association is automatically activated by the long-term representation underlying numbers processing. Instead, van Dijck and Fias (2011) argued that this association is a short-term representation that is constructed during task execution. This argument was based on the observation of an association between the ordinal position of an item in working memory and response side (e.g., the ordinal position effect). Four different experiments were set up to systematically investigate this assumption. Our results indicate that the activation of the canonical order of numbers in working memory (e.g., 1, 2, 3, etc.) is indeed necessary to observe the SNARC effect. The activation of the standard sequence of numbers (e.g., from 1 to 9) can be overruled when a new random sequence is memorized. However, this is only observed when retrieval of the memorized sequence is required during the numbers classification task.

Nature or nurture in finger counting: a review on the determinants of the direction of number-finger mapping.

The spontaneous use of finger counting has been for long recognized as critical to the acquisition of number skills. Recently, the great interest on space-number associations shifted attention to the practice of finger counting itself, and specifically, to its spatial components. Besides general cross-cultural differences in mapping numbers onto fingers, contrasting results have been reported with regard to the directional features of this mapping. The key issue we address is to what extent directionality is culturally mediated, i.e., linked to the conventional reading-writing system direction, and/or biologically determined, i.e., linked to hand dominance. Although the preferred starting-hand for counting seems to depend on the surveyed population, even within the same population high inter-individual variability minimizes the role of cultural factors. Even if so far largely overlooked, handedness represents a sound candidate for shaping finger counting direction. Here we discuss adults and developmental evidence in support of this view and we reconsider the plausibility of multiple and coexistent number-space mapping in physical and representational space.

The centre is not in the middle: evidence from line and word bisection.

English and German readers have been shown to mark a position to the left of the true centre as the subjective midpoint in word bisection. This effect resembles a well-known phenomenon observed with the bisection of solid lines (pseudoneglect), although this behavioural similarity does not imply a common origin. The purpose of the present study was twofold: on the one hand, to investigate the perceptual and lexical features that influence the bisection of Italian orthographic strings and, on the other hand, to investigate whether identical or partially independent processing mediate bisection of line and orthographic stimuli. Five experiments were carried out to explore to what extent stimulus type (lines, words, pseudowords, consonant strings, symbols), stimulus length (from 3 to 13 characters), list context (pure and mixed), and written word frequency (high and low) affected the bisection performance. The results showed that list context modulated the processing similarities across different materials and that word frequency failed to influence the magnitude of the bisection bias. More critically, across all five experiments, the results showed different effects for solid lines versus orthographic material. Lines were always bisected to the left, independent of length and list context. By contrast, a crossover effect emerged with orthographic material; for long stimuli (above five letters) the bias was consistently to the left, while short stimuli showed a consistent rightward bias. The results indicate that manual bisection involved partly different cognitive mechanisms during word and line perception and that this may depend on the characteristics of the stimuli (words/discrete vs. lines/continuous).

Placing order in space: the SNARC effect in serial learning.

The SNARC effect, consisting of a systematic association between numbers and lateralized response, reflects the mental representation of magnitude along a left-to-right mental number line (Dehaene et al. in J Exp Psychol 122:371-396, 1993). Critically, this effect has been reported in the classification of overlearned non-numerical sequences such as letters, days and months (Gevers et al. in Cognition 87:B87-B95, 2003 and Cortex 40:171-172, 2004) suggesting that ordinal, rather than magnitude information, is critical for spatial coding. This study tests the hypothesis of an oriented spatial representation as the privileged way of mentally organizing serial information, by looking for stimulus-response compatibility effects in the processing of a newly acquired arbitrary sequence. Here we report an association between ordinal position of the items and spatial response preference for both order-relevant and order-irrelevant tasks. These results suggest that any ordered information, even when order is not intrinsically relevant to it, is spontaneously mapped in the representational space. This spatial representation is likely to acquire a left-to-right orientation, at least in western cultures.