Teachers' emotional well-being during the SARS-CoV-2 pandemic with long school closures: a large-scale cross-sectional survey in Northern Italy.

OBJECTIVES: This study aimed to evaluate the magnitude of emotional burden on teaching staff during the SARS-CoV-2 pandemic in a significantly impacted region. In addition, the correlates of emotional burden were analysed to enable the design of targeted interventions. STUDY DESIGN: This study was a cross-sectional survey. METHODS: An electronic survey was administered to the teaching staff at public schools and kindergartens in a specific geographical area. Cross-sectional assessments of pandemic-specific variables were performed using the Pandemic Fatigue Scale, the Depression Anxiety Stress Scale (DASS)-21, the Satisfaction with Life Scale, and the Resilient Coping Scale. DASS-21 results were compared with results from a parallel survey that was representative of the local general population. RESULTS: In total, 3251 teaching staff members participated in the survey. Teachers showed a higher emotional burden for depression, anxiety and stress than the general population during the pandemic. According to a linear regression model, this burden is correlated with the language in which the questionnaires were answered, mistrust towards institutions, specific SARS-CoV-2 anxiety, past infection with SARS-CoV-2, avoidance of information about the pandemic and pandemic fatigue; emotional burden was negatively correlated with measures for life satisfaction, resilience and team atmosphere. Some independent variables were shown to contribute differentially to the variance of depression, anxiety or stress. CONCLUSIONS: Emotional distress during the pandemic among teachers is higher than in the general population and correlates with variables that could, at least in principle, be targeted for specific interventions.

Weekend effects on health outcomes and operational efficiency in emergency admissions to general medicine services of the Central Hospital of the Autonomous Province of Bolzano, Italy.

The possibility of higher death rates after admission to hospital during the weekend has been intensively investigated in North America and Northern Europe, while data are almost absent from Southern Europe and other WHOV regions. Increased death rates have not been uniformly confirmed. Differences in hospital care on weekends can vary depending on the reason for hospital admission, place and time. The aim was to verify whether weekend admission from the emergency department to internal medicine services is associated with parameters of operational efficiency in a Northern Italian hospital. A retrospective analysis was performed using hospital administration data of 3,594 admissions in 2016. A total of 287 patients (8.0%) had intensive care unit/IMCU transfers and 218 patients (6.1%) deceased in the hospital. Patients admitted on the weekend were similar to patients admitted during the week across age and gender, while weekend patients were more likely to be admitted on a "bad" day, defined as a day with a median number of admitted patients per day of >10 during the week and >9 on weekend. When adjusting for age and gender, patients admitted on weekend had significantly shorter length of stay compared to patients admitted during the week. In conclusion, emergency weekend admission to an internal medicine service was not associated with worse hospitalization-relevant outcomes in a regional hospital in Italy. Lower length-of-stay when emergency admission was on weekend is suggestive of lower disease severity of patients admitted to internal medicine services than on weekdays. If this represents higher risk of inappropriate hospital admission on weekends requires further study.

Antithrombin concentrate use in disseminated intravascular coagulation of sepsis: meta-analyses revisited.

Recently, two meta-analyses examined the effect of antithrombin on mortality in patients with sepsis and disseminated intravascular coagulation (DIC) with diverging results. In the meta-analysis observing no significant survival effect of antithrombin, the results of a large trial were included under the assumption that all 2314 participants of the trial had sepsis and DIC, which according to post hoc analyses was not the case. To the other meta-analysis reporting beneficial effect, the same trial contributed only those 229 patients that had confirmed sepsis-induced DIC. Replacing the mixed sepsis patient group with and without DIC with the group of sepsis patients with confirmed DIC provides evidence for a beneficial intervention effect of antithrombin also in the meta-analysis that reported no beneficial effect of antithrombin on mortality. This revised result does not change the overall conclusion that the quantity and quality of evidence supporting the use of antithrombin in sepsis patients with DIC is low.

[Adjuvant treatment of sepsis: what is known?]. / Adjuvante Therapie der Sepsis : Was ist gesichert?

BACKGROUND: Recent decades have been characterized by a large number of trials for registration of new drugs or indication approvals in the field of sepsis. Modern anti-inflammatory drugs or interventions are intended to correct the overwhelming dysregulation of inflammatory and coagulation pathways seen particularly in the early phase of sepsis. Immunostimulatory therapies are also being studied in order to correct immunoparalysis, which develops later in the course of sepsis as a compensatory mechanism. CURRENT STUDY RESULTS: Recombinant activated protein C, drotrecogin α, was conditionally approved and later withdrawn from the market by the producer because the initially observed beneficial effect could not be confirmed. The efficacy and safety of antithrombin, which, like drotrecogin α, also modulates inflammation and coagulation as an endogenous anticoagulant could not be confirmed when used for treating sepsis. As sepsis leads to disseminated intravascular coagulation which may be counteracted by antithrombin, new guidelines recommend antithrombin as a treatment option in this subgroup of sepsis patients. Intravenous administration of immunoglobulin, enteral administration of immunomodulating substances as immunonutrition, and the substitution of selenium, all showed some effectiveness in small heterogeneous studies, but their efficacy was not confirmed in large high-quality trials. Intensive glycemic control, which was temporarily recommended for acutely ill patients, increased the risk for adverse hypoglycemia in several clinical trials so that blood glucose target levels have been redefined and guidelines now no longer ask for normalization of blood glucose values with insulin. CONCLUSION AND OUTLOOK: None of the new drugs, however, has successfully become established as a new standard of care. In the future, studies of novel sepsis therapies may succeed better if suitable biomarkers allow for patient selection, reflecting key pathophysiologic mechanisms that are targeted by the innovative drugs.

High-volume hemofiltration in critically ill patients: a systematic review and meta-analysis.

BACKGROUND: High volume hemofiltration (HVHF) has been proposed as method for blood purification, especially under the condition of systemic inflammatory syndromes. Our goal was to evaluate the effects of HVHF in critically ill patients. METHODS: A systematic review and meta-analysis was conducted of randomized controlled trials containing original data comparing HVHF defined by a dose of >50 mL/kg/h versus standard volume hemofiltration in critically ill patients. The primary outcome assessed was mortality. Additional endpoints assessed were renal recovery, vasopressor dependency, cytokine reduction and adverse events. RESULTS: Four studies investigating continuous HVHF and three studies examining pulse high volume hemofiltration (PHVHF) using prescribed doses between 62 and 85 mL/kg/h met the criteria for this systematic review and provided data eligible for meta-analysis on a total of 558 patients. Meta-analyses did not show an effect of continuous HVHF (odds ratio, OR: 0.85; 95% confidence interval [CI]: 0.50-1.45; 4 trials; N.=473) or PHVHF (OR: 0.62; 95% CI: 0.22-1.74; 3 trials; N.=85) on mortality (both combined: OR: 0.85; 95% CI: 0.60-1.22; 7 trials; N.=558). Continuous HVHF had no significant beneficial effect on renal recovery of survivors (OR: 0.62; 95% CI: 0.17-1.97; 3 trials; N.=445). Inconsistent reports of a more rapid hemodynamic stabilization or improved cytokine clearance were mainly restricted to PHVHF. CONCLUSION: No clear overall beneficial effect of HVHF or PHVHF compared to standard volume hemofiltration can be detected.

[Volume replacement therapy options for critically ill patients]. / Volumentherapeutische Möglichkeiten bei kritisch kranken Patienten.

For critically ill patients with hypovolemia, volume replacement therapy is important to maintain sufficient tissue perfusion and oxygenation. Nearly all patients receive crystalloids and often additionally colloids. The advantages of the former are low costs, immediate availability, the ability to fill both the intravascular and extravascular fluid spaces and a non-allergenic potential. Administration of excessive fluid with extravasation can, however, be a problem with crystalloids and promotes the formation of tissue edema, particularly with large volumes. Colloids are more efficient volume expanders and tissue edema can be avoided. The disadvantages compared to crystalloids are the higher costs and the risk of rare but potentially severe anaphylactic reactions. Artificial colloids (hydroxyethyl starch) are cheaper than the natural colloid albumin but the safety profile is less favorable.

Contrast media-induced nephropathy in patients undergoing angiography prior to or during vascular surgery: a systematic review.

Nephropathy induced after administration of contrast medium is an acute and severe complication that is of particular concern in vascular surgery. While patients undergoing coronary procedures have been extensively studied, there is a paucity of data on pre- and intraoperative prevention of contrast-induced nephropathy in vascular surgery patients. There is lack of a robust analysis exploring the additive effect of pre- or intraoperative administration of drugs such as N-acetylcysteine, dopamine and sodium bicarbonate in addition to adequate hydration in patients undergoing angiography prior to or after completion of vascular surgery. A systematic review of contrast-induced nephropathy after angiography in patients undergoing vascular surgery was carried out. Eligible trials were sought by multiple methods, and the pooled odds ratios for contrast-induced nephropathy were computed under a random effects model. Twenty-one publications were identified for screening and 6 studies were included for systematic review. All 6 studies investigated preoperative angiography-related contrast-induced nephropathy; one study also investigated completion angiography. The overall frequency of contrast-induced nephropathy in patients undergoing vascular surgery was 9.2% (79/862). Risk factors for contrast-induced nephropathy identified were age >70 years, high contrast volume, pre-existing renal disease and antihypertensive medication. Two studies found that administration of N-acetylcysteine prior to angiography does not provide added benefit in preventing contrast-induced nephropathy. Advanced age and pre-existing renal and vascular risk factors such as arterial hypertension expose vascular surgery patients to increased risk of contrast-induced nephropathy. Those undergoing completion angiography appear to be at even higher risk, particularly if severely azotemic. Further randomized clinical trials analyzing strategies for preventing contrast-induced nephropathy are needed.

Nosocomial diarrhoea in adult medical patients: the role of Clostridium difficile in a North Italian acute care teaching hospital.

BACKGROUND: The number of patients with severe Clostridium difficile-associated diarrhoea (CDAD) increases. Health care facilities are requested to establish rates of nosocomially acquired CDAD (N-CDAD) to understand the impact of control or prevention measures, and the burden of N-CDAD on health care resources. OBJECTIVE: Aim of the single-center surveillance project was to establish local prevalence rates of N-CDAD in adult acute care medical patients. METHODS: For a period of at least one year, all diarrhoeal stools from inpatients of a general internal medicine ward were tested for Clostridium difficile toxin A. Case record files were retrospectively analysed and questionnaires were completed for patients with positive stool assays who met the case definitions. RESULTS AND DISCUSSION: During the surveillance period, 2,610 medical patients had been acutely hospitalized. Stools had been submitted to the hospital laboratory from 163 patients (6.2%) because of diarrhoea and were screened for Clostridium difficile cytotoxin. Complete data sets were available for analysis from 150 patients. Of 137 identified potential cases, 77 (56.2%) met the case definitions for nosocomial diarrhoea. Thirteen of the patients with nosocomial diarrhoea (16.9%) were detected positive by the Clostridium difficile toxin A assay. The overall prevalence of N-CDAD among inpatients was 8.7 cases/100 diarrhoeal stools. The mean number ofN-CDAD cases was 62.3 cases/100,000 patient days and 5 cases/1,000 patient admissions. The mean age of N-CDAD patients was 79.4 years (range 71 to 92). All patients were given broad-spectrum antibiotics before acute diarrhoea developed. Four patients died for reasons not directly related to N-CDAD which confirms increased disease severity as an important risk factor. CONCLUSIONS: This single-center surveillance project, which established N-CDAD rates at frequencies currently reported from international surveys, is useful as benchmark and will help in understanding patterns and impact of N-CDAD at the regional level.

Reduced watery diarrhea during pregnancy in a psoriasis patient with lymphocytic colitis.

Lymphocytic colitis which is more common in women than in men has been associated with autoimmune conditions, and hormones are thought to play a role. The effect of pregnancy on the clinical course of women with lymphocytic colitis has not yet been reported. We describe a case of chronic watery diarrhea in a woman with psoriasis and lymphocytic colitis that has relapsed after successful treatment with budesonide had been stopped before undergoing modern assisted reproductive care. Elevated stool frequencies diminished after in vitro fertilization and remained normal throughout pregnancy when no systemic immunosuppressive therapy was administered and plaque psoriasis slightly worsened under local symptomatic treatment. After preterm birth and early breastfeeding cessation, chronic watery diarrhea, however, recurred. This clinical observation suggests that pregnancy influences the overall course of chronic watery diarrhea of autoimmune-associated microscopic colitis.

[Scoring of disseminated intravascular coagulation (DIC) in intensive care medicine]. / Il punteggio per la diagnosi della coagulazione intravascolare disseminata (CID) in terapia intensiva.

A close association between disseminated intravascular coagulation (DIC) and increased morbidity and mortality of the critically ill has been uncovered in the ongoing validation of newly developed scoring systems of DIC. DIC scoring aims at quantifying and standardizing pathological activation of coagulation in these patients. Because of the high predictive power of DIC scoring for morbidity and mortality, early identification of DIC may play an important role in the management of critical illness by widening of the therapeutic window before development of irreversible organ failure. Therapeutic intervention in DIC is not well studied. Promising data on targeted modification of DIC by administration of antithrombin has been reported in the past, however, randomized controlled trials on the use of antithrombin for the treatment of DIC are still few. Early detection of DIC by application of novel scores could play a particular role in future DIC trials by defining patient populations most likely to benefit from targeted intervention in their clotting disturbance of critical illness.

[Endogenous anticoagulant therapy for sepsis. Success and failure]. / Gerinnungsaktive Substanzen als Sepsistherapeutika. Erfolg und Misserfolg.

Whereas antithrombin and tifacogin failed to improve clinical outcome in cases of severe sepsis, drotrecogin alfa (activated) increased the chances of survival of patients with this condition. Concerns about efficacy and safety of drotrecogin alfa have been raised because of internal and external validity and internal consistency problems found in the PROWESS study, and because of the drug's single positive pivotal phase III documentation that led to restricted marketing authorisations for only a subgroup of studied patients whose randomisation had not been stratified. Concerns intensified with data from ADDRESS, the PROWESS follow-up, and paediatric studies. It is difficult to make rational and safe recommendations for drotrecogin alfa use on the available evidence. Further trials have been suggested. The relevant bodies should review product approval in light of their own guidelines for marketing authorisations on the basis of single pivotal trials and request the further study required to prevent the possibility of patients receiving a non-efficacious and potentially lethal drug.

Two cases of foodborne botulism with home-preserved asparagus.

Botulism is a rare but potentially fatal disease caused by toxins produced by Clostridium botulinum. We report botulism in two adult females, one of them just tasting from "bad" asparagus and the other eating the full portion. Both patients survived after intermittent mechanical ventilation and trivalent antitoxin administration. The diagnosis was confirmed by detection of botulinum toxin. Acute onset of bilateral cranial neuropathies associated with symmetric descending weakness as well as some key features of the botulism syndrome including absence of fever, symmetric neurologic deficits, the patients remaining responsive and no sensory deficits, with the exception of blurred vision, led to the clinical diagnosis in the first presenting case which was then easily made in the second. Despite the fact that amount of toxin ingested, time-to-symptom development, and time-to-recovery markedly differed in the two patients, their maximal disease severity was similar.

Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation.

BACKGROUND: Disseminated intravascular coagulation (DIC) is a serious complication of sepsis that is associated with a high mortality. OBJECTIVES: Using the adapted International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring algorithm for DIC, we evaluated the treatment effects of high-dose antithrombin (AT) in patients with severe sepsis with or without DIC. PATIENTS AND METHODS: From the phase III clinical trial in severe sepsis (KyberSept), 563 patients were identified (placebo, 277; AT, 286) who did not receive concomitant heparin and had sufficient data for DIC determination. RESULTS: At baseline, 40.7% of patients (229 of 563) had DIC. DIC in the placebo-treated patients was associated with an excess risk of mortality (28-day mortality: 40.0% vs. 22.2%, P < 0.01). AT-treated patients with DIC had an absolute reduction in 28-day mortality of 14.6% compared with placebo (P = 0.02) whereas in patients without DIC no effect on 28-day mortality was seen (0.1% reduction in mortality; P = 1.0). Bleeding complications in AT-treated patients with and without DIC were higher compared with placebo (major bleeding rates: 7.0% vs. 5.2% for patients with DIC, P = 0.6; 9.8% vs. 3.1% for patients without DIC, P = 0.02). CONCLUSIONS: High-dose AT without concomitant heparin in septic patients with DIC may result in a significant mortality reduction. The adapted ISTH DIC score may identify patients with severe sepsis who potentially benefit from high-dose AT treatment.