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AIMS: In this work, the survival and mortality data of 54 consecutive patients admitted to the Intensive Care Unit (ICU) and suffering from severe respiratory insufficiency imputable to viral SARS - CoV - 2 infection were analyzed and shared, after a critical review of the evidence in order to optimize the most dedicated clinical and treatment strategy, for a future 'targeted' management in the care of the possible return flu outbreak. METHODS: At our Emergency Department of the Crema Hospital, from the beginning of the pandemic until the end of June 2020, 54 consecutive patients admitted to ICU suffering from severe acute respiratory infection (SARI) and severe respiratory distress (ARDS) attributable to viral SARS - CoV - 2 infection were recruited. The recruitment criterion was based on refractory hypoxia, general condition and clinical impairment, comorbidities and CT images. The incoming parameters of the blood chemistry and radiology investigations and the timing of the gold - tracheal intubation were compared. Medical therapy was based on the application of shared protocols. RESULTS: The onset of symptoms was varyng, i.e. within the range of 1-14 days. The average time from the admission to the emergency room to the admission to intensive care was approximately 120 h. The average number of days of hospitalization in the ICU was 28 days. With a majority of male patients, the most significant age group was between 60 and 69 years. There were 21 deaths and, compared to the survivors, the deceased ones were older at an average age of about 67 years (vs an average age of the survivors of about 59 years). From the available data entering the ICU, the surviving patients presented average better values of oximetry and blood gas analysis, with a lower average dosage of D-Dimer than the deceased. Ones with a presence of bilateral pneumonia in all patients, the worsening of the ARDS occurred in 31 patients. 9 out of 25 patients early intubated died, while 12 out of 23 patients died when intubation was performed after 24 h of non-invasive ventilation. The presence of multiple comorbidities was shown in 17 of 28 patients and revealed an additional adverse prognostic factor. Also, more than one complication in the same patient were detected; after respiratory worsening, renal failure was more frequently found in 16 patients. Some particular complications such as lesions induced by ventilation with barotrauma mechanism (VILI), ischemic heart disease and the appearance of central and peripheral neurological events were detected too. CONSIDERATIONS: SARS - CoV - 2 disease is caused by a new coronavirus that has its main route of transmission through respiratory droplets and close contact, resulting in a sudden onset of the clinical syndrome with acute respiratory infection (SARI) and severe respiratory distress (ARDS). But it can also appear with other symptoms such as gastrointestinal or neurological events, as to be considered as a disease with multisystem phenotype. This pathology evolves towards a serious form of systemic disease from an acute lung damage to venous and arterial thromboembolic complications and multi-organ failure, mostly associated with high mortality. All patients received empirical or targeted antibiotic therapy for prevention and control of infections of potential pathogens, together with low molecular weight heparin therapy. The majority of patients was subjected to the off - label protocol with antivirals and hydroxychloroquine therapy, we used cortisone support therapy under surveillance and in 3 cases the protocol with anti - IL6 monoclonal antibody (Tolicizumab). In a simplified classification of the tomographic examination of the chest, mostly 3D and 2C lesions were found in the deceased patients with a prevalence of severe and moderate forms, whilst in the survivors the distribution appears with a prevalence of medium and moderate forms. Among the intubated patients, 21 patients, all suffering from worsening ARDS, died whilst there was no mortality in patients subjected to non-invasive ventilation it so. The heterogeneity of the respiratory syndromes and the presence of multiple comorbidities represent an unfortunate prognostic factor. Among the complications, besides the respiratory worsening, renal failure, liver failure and the state of sepsis were most frequently found; less frequent complications were lesions induced by ventilation with a barotrauma mechanism, ischemic heart disease, the appearance of central neurological events of sensory alterations, meningo - encephalitis and cerebral hemorrhage, and peripheral neurological events with polyneuro - myopathies. Mechanical ventilation can adversely affect the prognosis due to lung damage induced, protective ventilation remains the necessary treatment during severe hypoxia in patients with SARS - CoV - 2. The essential prerequisite remains the search for optimal 'customized' values since conditions can vary from patient to patient and, in the same patient, during different times of ventilation. CONCLUSIONS: In these extraordinary circumstances, our reality was among the most affected and was able to hold the impact thanks to the immediate great response set in place by the operators, although it costed us an effort especially the one to try to guarantee a high quality level of assistance and care compared to the huge wave of patients in seriously bad conditions. Further research on this heterogeneous pathology and data sharing could help identify a more dedicated clinical decision-making and treatment pathway that, together with a resource planning, would allow us to better face any new disease outbreak.
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COVID-19/terapia , Cuidados Críticos/métodos , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva , Pandemias , Respiração Artificial/métodos , SARS-CoV-2 , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Betacoronavirus , Infecções por Coronavirus , Pandemias , Pneumonia Viral , COVID-19 , Humanos , Itália , SARS-CoV-2RESUMO
BACKGROUND: the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists. METHODS: all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years. RESULTS: 2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001. CONCLUSIONS: over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.
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Child maltreatment (CM) has been enormously studied. However, a preventive practice still requires comprehensive and effective instruments to assess the risks for CM in a family context. The aim of this study is to describe the development process of an evidence-based CM risk assessment instrument (Family Needs Checklist, FNC) for primary prevention online utilization. This article reports the development process of the checklist and its mobile application, consisting of a systematic literature review, identification of known risk factors using the content analysis method, and generation of the checklist, including a multidisciplinary group in the design and feedback. As a result, a comprehensive and compact checklist was developed to be used by parents or caregivers as a self-referral instrument with an option to be used with professionals as a basis for joint conversations. The FNC consists of parental, family-, and child-related risk factors. Based on the international evidence, the online application consists of knowledge about different CM types, information about risk factors and protective factors as well as recommendations and guidance to support services. The FNC is based on robust evidence on known risk factors causing CM in families. It can be used for primary prevention utilization in the general population.
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Maus-Tratos Infantis , Aplicativos Móveis , Lista de Checagem , Criança , Maus-Tratos Infantis/prevenção & controle , Família , Humanos , Fatores de RiscoRESUMO
The responsiveness of professionals working with children and families is of key importance for child maltreatment early identification. However, this might be undermined when multifaceted circumstances, such as the COVID-19 pandemic, reduce interdisciplinary educational activities. Thanks to technological developments, digital platforms seem promising in dealing with new challenges for professionals' training. We examined a digital approach to child maltreatment training through the ERICA project experience (Stopping Child Maltreatment through Pan-European Multiprofessional Training Programme). ERICA has been piloted during the pandemic in seven European centers involving interconnected sectors of professionals working with children and families. The training consisted of interactive modules embedded in a digital learning framework. Different aspects (technology, interaction, and organization) were evaluated and trainers' feedback on digital features was sought. Technical issues were the main barrier, however, these did not significantly disrupt the training. The trainers perceived reduced interaction between participants, although distinct factors were uncovered as potential favorable mediators. Based on participants' subjective experiences and perspectives, digital learning frameworks for professionals working with children and families (such as the ERICA model nested in its indispensable adaptation to an e-learning mode) can represent a novel interactive approach to empower trainers and trainees to tackle child maltreatment during critical times such as a pandemic, and as an alternative to more traditional learning frameworks.
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COVID-19 , Maus-Tratos Infantis , Criança , Maus-Tratos Infantis/prevenção & controle , Humanos , Pandemias , SARS-CoV-2 , Inquéritos e QuestionáriosRESUMO
We report onset, course, correlations with comorbidities, and diagnostic accuracy of nasopharyngeal swab in 539 individuals suspected to carry SARS-COV-2 admitted to the hospital of Crema, Italy. All individuals underwent clinical and laboratory exams, SARS-COV-2 reverse transcriptase-polymerase chain reaction on nasopharyngeal swab, and chest X-ray and/or computed tomography (CT). Data on onset, course, comorbidities, number of drugs including angiotensin converting enzyme (ACE) inhibitors and angiotensin-II-receptor antagonists (sartans), follow-up swab, pharmacological treatments, non-invasive respiratory support, ICU admission, and deaths were recorded. Among 411 SARS-COV-2 patients (67.7% males) median age was 70.8 years (range 5-99). Chest CT was performed in 317 (77.2%) and showed interstitial pneumonia in 304 (96%). Fatality rate was 17.5% (74% males), with 6.6% in 60-69 years old, 21.1% in 70-79 years old, 38.8% in 80-89 years old, and 83.3% above 90 years. No death occurred below 60 years. Non-invasive respiratory support rate was 27.2% and ICU admission 6.8%. Charlson comorbidity index and high C-reactive protein at admission were significantly associated with death. Use of ACE inhibitors or sartans was not associated with outcomes. Among 128 swab negative patients at admission (63.3% males) median age was 67.7 years (range 1-98). Chest CT was performed in 87 (68%) and showed interstitial pneumonia in 76 (87.3%). Follow-up swab turned positive in 13 of 32 patients. Using chest CT at admission as gold standard on the entire study population of 539 patients, nasopharyngeal swab had 80% accuracy. Comorbidity network analysis revealed a more homogenous distribution 60-40 aged SARS-COV-2 patients across diseases and a crucial different interplay of diseases in the networks of deceased and survived patients. SARS-CoV-2 caused high mortality among patients older than 60 years and correlated with pre-existing multiorgan impairment.
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COVID-19/patologia , Comorbidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Proteína C-Reativa/análise , COVID-19/mortalidade , COVID-19/virologia , Criança , Pré-Escolar , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Fatores de Risco , SARS-CoV-2/isolamento & purificação , Resultado do Tratamento , Adulto Jovem , Tratamento Farmacológico da COVID-19RESUMO
Infection of novel Coronavirus has been declared pandemic by the WHO and now is a world public health crisis. Laboratory activity becames essential for the timely diagnosis. Few parameters, such Lymphocytes count, SaO2 and CRP serum level can be used to assess the severity of COVID-19 in emergency room.
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Biomarcadores/sangue , Infecções por Coronavirus/diagnóstico , Contagem de Linfócitos , Oxigênio/sangue , Pneumonia Viral/diagnóstico , Betacoronavirus , Proteína C-Reativa/análise , COVID-19 , Infecções por Coronavirus/sangue , Serviço Hospitalar de Emergência , Humanos , Neutrófilos , Pandemias , Pneumonia Viral/sangue , Saúde Pública , SARS-CoV-2RESUMO
After December 2019 outbreak in China, the novel Coronavirus infection (COVID-19) has very quickly overflowed worldwide. Infection causes a clinical syndrome encompassing a wide range of clinical features, from asymptomatic or oligosymptomatic course to acute respiratory distress and death. In a very recent work we preliminarily observed that several laboratory tests have been shown as characteristically altered in COVID-19. We aimed to use the Corona score, a validated point-based algorithm to predict the likelihood of COVID-19 infection in patients presenting at the Emergency rooms. This approach combines chest images-relative score and several laboratory parameters to classify emergency room patients. Corona score accuracy was satisfactory, increasing the detection of positive patients' rate.
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Betacoronavirus/isolamento & purificação , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Serviço Hospitalar de Emergência , Pneumonia Viral/diagnóstico , Reação em Cadeia da Polimerase Via Transcriptase Reversa/métodos , Biomarcadores/metabolismo , COVID-19 , Teste para COVID-19 , Estudos de Coortes , Infecções por Coronavirus/diagnóstico por imagem , Infecções por Coronavirus/metabolismo , Serviço Hospitalar de Emergência/normas , Reações Falso-Negativas , Humanos , Resultados Negativos , Pandemias , Pneumonia Viral/diagnóstico por imagem , Pneumonia Viral/metabolismo , Reprodutibilidade dos Testes , Reação em Cadeia da Polimerase Via Transcriptase Reversa/normas , SARS-CoV-2 , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/normasRESUMO
We describe clinical and laboratory findings in 35 patients tested positive for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction on nasopharyngeal swab experiencing one or multiple syncope at disease onset. Clinical neurologic and cardiologic examination, and electrocardiographic findings were normal. Chest computed tomography showed findings consistent with interstitial pneumonia. Arterial blood gas analysis showed low pO2, pCO2, and ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) indicating hypocapnic hypoxemia. Patients who presented with syncope showed significantly lower heart rate as compared to 68 SARS-CoV-2 positive that did not. Such poorer than expected compensatory heart rate increase may have led to syncope based on individual susceptibility. We speculate that SARS-CoV-2 could have caused angiotensin-converting enzyme-2 (ACE2) receptor internalization in the nucleus of the solitary tract and other midbrain nuclei, impairing baroreflex and chemoreceptor response, and inhibiting the compensatory tachycardia during acute hypocapnic hypoxemia.
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COVID-19/complicações , Síncope/virologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Frequência Cardíaca/fisiologia , Humanos , Hipocapnia/virologia , Hipóxia/virologia , Masculino , Pessoa de Meia-Idade , SARS-CoV-2RESUMO
A training package (pre-tested in a pilot phase) about supporting children who have parents with a mental illness and/or with substance misuse (COPMI) was developed and delivered to 131 different professionals from six different European Countries. A questionnaire about importance, awareness and competence on the issue (8 items on knowledge and 15 items on skills) was developed and completed by participants before and after the training. The training was evaluated by participants as generally very successful in terms of improving the importance, awareness and competence of their knowledge and skills, with a statistically significant difference in the pre-/post-analyses (no decreases occurred). Different professional groups performed differently in the pre-training self-rating scores. The participants in some countries were mainly drawn from one professional group (i.e. teachers in Finland, social workers in Germany and psychologists in Poland). It was found that stigma was considered an extremely important concern even before the training, whilst country-specific legal issues were not taken into proper account in the training. Some possibilities for further refinement of the training programme are suggested.
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Proteção da Criança , Filho de Pais com Deficiência/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Transtornos Mentais , Sistemas de Apoio Psicossocial , Transtornos Relacionados ao Uso de Substâncias , Criança , Humanos , Estigma Social , Apoio Social , Inquéritos e QuestionáriosRESUMO
The lack of pan-European guidelines for empowering children of parents with mental illness led to the EU project CAMILLE - Empowerment of Children and Adolescents of Mentally Ill Parents through Training of Professionals working with children and adolescents. The aim of this initial task in the project was to analyse needs, expectations and consequences for children with respect to living with a parent with mental illness from the perspective of professionals and family members. This qualitative research was conducted in England, Finland, Germany, Italy, Norway, Poland and Scotland with 96 professionals, parents with mental illness, adult children and partners of parents with mental illness. A framework analysis method was used. Results of the study highlighted that the main consequences described for children of parental mental illness were role reversal; emotional and behavioural problems; lack of parent's attention and stigma. The main needs of these children were described as emotional support, security and multidisciplinary help. Implications for practice are that professionals working with parents with mental illness should be aware of the specific consequences for the children and encourage parents in their parental role; multi-agency collaboration is necessary; schools should provide counselling and prevent stigma.
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Filho de Pais com Deficiência/psicologia , Necessidades e Demandas de Serviços de Saúde , Transtornos Mentais/psicologia , Adolescente , Adulto , Criança , Europa (Continente) , Grupos Focais , Humanos , Entrevistas como Assunto , Relações Pais-Filho , Papel (figurativo) , EstereotipagemRESUMO
The aim of this contribution is to draw considerations on the first year of activity of a cath lab on call 24/24 h for primary coronary angioplasty (PTCA) (April 2007-April 2008) of a small hospital without surgical backup. We performed 152 primary PTCA in 156 patients presenting to the emergency room with ST-elevation myocardial infarction. The mean time from arrival to the emergency room to the insertion of the arterial introducer was 48 min. Patient management included a 12-lead ECG and family history, the telephone call to the hospital cardiologist and then to the cath lab operator and nurse. Procedural success was obtained in 97% of cases. Mortality was 6%. Other complications occurred in 4% of patients. The no-reflow phenomenon occurred in 4% of patients. We used 1.9 stents/patient. Direct stenting was performed in 43% of cases. In 14% of lesions, the procedure was concluded with only balloon angioplasty. The radial access was used in 15% of patients, whereas the femoral access was used in the remainder. Drug-eluting stents were implanted in 1% only of patients with acute myocardial infarction. Glycoprotein IIb/IIIa inhibitors and clopidogrel were extensively used prior to the procedure. Our data, although obtained in a smaller population sample and referring to a relatively short period of time, are similar to those of the American registry on PTCA. In conclusion, the results obtained in our center with the invasive management of acute myocardial infarction appear consistent with those of other centers and encourage us to continue along our chosen path.