Nosocomial outbreak by NDM-1-producing Klebsiella pneumoniae highly resistant to cefiderocol, Florence, Italy, August 2021 to June 2022.

A nosocomial outbreak by cefiderocol (FDC)-resistant NDM-1-producing Klebsiella pneumoniae (NDM-Kp) occurred in a large tertiary care hospital from August 2021-June 2022 in Florence, Italy, an area where NDM-Kp strains have become endemic. Retrospective analysis of NDM-Kp from cases observed in January 2021-June 2022 revealed that 21/52 were FDC-resistant. The outbreak was mostly sustained by clonal expansion of a mutant with inactivated cirA siderophore receptor gene, which exhibited high-level resistance to FDC (MIC ≥ 32 mg/L) and spread independently of FDC exposure.

Large Nosocomial Outbreak of Colistin-Resistant, Carbapenemase-Producing Klebsiella pneumoniae Traced to Clonal Expansion of an mgrB Deletion Mutant.

We describe a large hospital outbreak (93 bloodstream infections) of colistin-resistant Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae isolates which was mirrored by increased colistin consumption. The outbreak was mostly traced to the clonal expansion of an mgrB deletion mutant of an ST512 strain that produced KPC-3.

Physical Impact of SARS-CoV-2 Infection in a Population of Italian Healthcare Workers.

SARS-CoV-2 infection often causes symptoms and illness that can last for months after the acute phase, i.e., so-called "Long COVID" or Post-acute COVID-19. Due to the high prevalence of SARS-CoV-2 infection among Healthcare Workers (HCWs), post-COVID-19 symptoms can be common and threaten workers' occupational health and healthcare systems' functioning. The aim of this cross-sectional, observational study was to present data related to post-COVID-19 outcomes in a population of HCWs infected by COVID-19 from October 2020 to April 2021, and to identify possible factors associated with the persistence of illness, such as gender, age, previous medical conditions, and features of acute illness. A total of 318 HCWs who had become infected by COVID-19 were examined and interviewed approximately two months after their recovery from the infection. The clinical examinations were performed by Occupational Physicians in accordance with a specific protocol at the Occupational Medicine Unit of a tertiary hospital in Italy. The mean age of the participants was 45 years old, and 66.7% of the workers were women while 33.3% were men; the sample mainly consisted of nurses (44.7%). During the medical examination, more than half of the workers mentioned that they had experienced multiple residual bouts of illness after the acute phase of infection. Men and women were similarly affected. The most reported symptom was fatigue (32.1%), followed by musculoskeletal pain (13.6%) and dyspnea (13.2%). In the multivariate analysis, dyspnea (p < 0.001) and fatigue (p < 0.001) during the acute stage of illness and the presence of any limitation in working activities, in the context of fitness for a work evaluation performed while the occupational medicine surveillance program was being conducted (p = 0.025), were independently associated with any post-COVID-19 symptoms, which were considered final outcomes. The main post-COVID-19 symptoms-dyspnea, fatigue, and musculoskeletal pain-showed significant associations with dyspnea, fatigue, and musculoskeletal pain experienced during the acute stage of infection, with the presence of limitations in working activities, and pre-existing pneumological diseases. A normal weight according to body mass index was a protective factor. The identification of vulnerable workers as those with limitations in working activities, pneumological diseases, a high BMI, and of an older age and the implementation of preventive measures are key factors for preserving Occupational Health. Fitness-to-work evaluations performed by Occupational Physicians can be considered a complex index of overall health and functionality that can identify workers who may suffer from relevant post-COVID-19 symptoms.

Return to Work of Healthcare Workers after SARS-CoV-2 Infection: Determinants of Physical and Mental Health.

Introduction. The SARS-CoV-2 pandemic has involved healthcare workers (HCWs) both as caregivers and as patients. This study is a retrospective cross-sectional analysis of the HCWs working in a third-level hospital in Central Italy who were infected with COVID-19 from March 2020 to April 2021. This research aims at identifying the physical and mental health outcomes of HCWs infected with COVID-19 who returned to work after the infection, the determinants of those outcomes, such as age and sex, and the identification of possible vulnerable professional groups. Methods. A questionnaire about the acute illness, the experience of returning to work, and health perceptions after the disease was administered to 427 healthcare workers 3 months after recovering from the SARS-CoV-2 infection. Results. The majority interviewed (84.5%) reported symptoms at the time of the positive test, with no significant differences regarding age or sex, while a significant difference in the mean age was found regarding hospitalization (p < 0.001). At 3 months after the infection, females (p = 0.001), older workers (p < 0.001), and healthcare assistants (p < 0.001) were more likely to report persistent symptoms. Sex (p = 0.02) and age (p = 0.006) influenced the quality of sleep after the infection. At work, the nurses group reported increase in workload (p = 0.03) and worse relationships (p = 0.028). At 3 months after the infection, female workers perceived worse physical (p = 0.002) and mental (p < 0.001) health status according to the SF-12. A negative correlation was found between age and PCS score (p < 0.001) but not MCS score (p = 0.86). A significant difference in PCS score was found between nurses and physicians (p = 0.04) and between residents and all other groups (p < 0.001). Finally, the group of workers reporting sleep alterations showed lower PCS and MCS scores (p < 0.001) and working relationships had an impact on MCS scores (p < 0.001). Conclusions. Age, sex, and type of job had an impact on physical and mental outcomes. Organizing specific interventions, also tailored to professional sub-groups, should be a target for healthcare systems to protect and boost the physical and mental health of their workers.

Need to take special care of non-responders to hepatitis B vaccination among health-care workers, students and chronic patients.

Both our research and that published by Sticchi et al. on immunological memory against hepatitis B virus (HBV) in health-care workers (HCWs) vaccinated as infants or adolescents confirm that in those testing negative after the primary course, one additional (fourth) booster dose is able to elicit an anti-HBs response in >85% subjects. The fifth and the sixth doses further contribute substantially to a high overall response rate. The rate of subjects showing an anamnestic response after the booster dose was almost six-fold higher in HCWs compared to chronic patients. Since universal vaccination in Italy resulted in a significant decrease in HBV infections, special attention and testing should be addressed to those affected by chronic diseases.

Utility of Healthcare System-Based Interventions in Improving the Uptake of Influenza Vaccination in Healthcare Workers at Long-Term Care Facilities: A Systematic Review.

Healthcare workers (HCWs) in long-term care facilities (LTCFs) can represent a source of influenza infection for the elderly. While flu vaccination coverage (VC) is satisfactory in the elderly, HCWs are less likely to be vaccinated. There is no definitive evidence on which types of healthcare system-based interventions at LTCFs would be more useful in improving the vaccination uptake among HCWs. We performed a systematic review in different databases (Pubmed, Cochrane Database of Systematic Reviews, Health Evidence, Web of Science, Cinahl) to provide a synthesis of the available studies on this topic. Among the 1177 articles screened by their titles and abstracts, 27 were included in this review. Most of the studies reported multiple interventions addressed to improve access to vaccination, eliminate individual barriers, or introduce policy interventions. As expected, mandatory vaccinations seem to be the most useful intervention to increase the vaccination uptake in HCWs. However, our study suggests that better results in the vaccination uptake in HCWs were obtained by combining interventions in different areas. Educational campaigns alone could not have an impact on vaccination coverage. LTCFs represent an ideal setting to perform preventive multi-approach interventions for the epidemiological transition toward aging and chronicity.

Health Literacy, Vaccine Confidence and Influenza Vaccination Uptake among Nursing Home Staff: A Cross-Sectional Study Conducted in Tuscany.

The aim of this cross-sectional study is to address whether health literacy (HL) and vaccine confidence are related with influenza vaccination uptake among staff of nursing homes (NHs). It was conducted in Tuscany (Italy) in autumn 2018, including the staff of 28 NHs. A questionnaire was used to collect individual data regarding influenza vaccination in 2016-2017 and 2017-2018 seasons; the intention to be vaccinated in 2018-2019; as well as demographic, educational, and health information. It included also the Italian Medical Term Recognition (IMETER) test to measure HL and eight Likert-type statements to calculate a Vaccine Confidence Index (VCI). The number of employees that fulfilled the questionnaire was 710. The percentage of influenza vaccination uptake was low: only 9.6% got vaccinated in 2016-2017 and 2017-2018 and intended to vaccinate in 2018-2019. The VCI score and the IMETER-adjusted scores were weakly correlated (Rho = 0.156). At the multinomial logistic regression analysis, the VCI was a positive predictor of vaccination uptake. In conclusion, vaccine confidence is the strongest predictor of influenza vaccination uptake among the staff of NHs. The development of an adequate vaccine literacy measurement tool could be useful to understand whether skills could be related to vaccine confidence.

High chance to overcome the non-responder status to hepatitis B vaccine after a further full vaccination course: results from the extended study on healthcare students and workers in Florence, Italy.

Healthcare workers (HCWs) are considered high-risk subjects for Hepatitis B Virus (HBV) infection due to occupational exposure to blood and body fluids. Vaccination represents the core strategy for HBV infection prevention. Following our previous publication on this topic, we aimed to assess the effectiveness of booster vaccine doses in eliciting the immunological response in seronegative (<10 mIU/mL) HCWs and students of Careggi Teaching Hospital, Florence (Italy). All subjects received primary vaccination course, and they were tested for serum anti-HBs antibodies. In seronegative subjects, a challenge dose of vaccine was administered and the test was repeated 1 month later. Six hundred and ninety-eight (87.8%) of 795 HCWs and students tested responded to the challenge dose. After this challenge dose, males more often had negative anti-HBs titer compared with females (15.9% vs 10.2%; p < .05). The completion of the second vaccination course was offered to subjects with persistently negative anti-HBs titer. 76.2% (32) of those who accepted the fifth dose, and 3 of the 5 who accepted the sixth dose seroconverted. This report shows the importance to convey a strong message to negative subjects at the initial anti-HBs dosage: accepting all the three additional vaccine doses allows the vast majority of them to obtain protection.

Childhood vaccination coverage in Europe: impact of different public health policies.

Introduction: Vaccination is a crucial tool for the primary prevention of infectious diseases. Thanks to widespread vaccination, in the last century smallpox has been eradicated, and the Americas and Europe have become polio-free. Areas covered: The aim of our study was to assess vaccination coverage in childhood up to booster preschool age in order to update the analysis on European trends of immunization coverage in the last nine years (2009-2017) and to assess the impact of different national policies on vaccine uptake. Expert opinion: Despite the good results, several EU countries are going through unprecedented outbreaks of vaccine-preventable diseases due to insufficient coverage. The increase of vaccine hesitancy has made it difficult to reach and maintain high rates of vaccination coverage. Enforcing mandatory vaccinations is one of the strategies adopted by some countries, like Italy and France, to increase coverage. However, each country should find the most suitable way to keep up with vaccination coverages according to own cultural and organizational background.

Assessing Vaccine Hesitancy among Healthcare Workers: A Cross-Sectional Study at an Italian Paediatric Hospital and the Development of a Healthcare Worker's Vaccination Compliance Index.

Healthcare workers (HCWs) in paediatric hospitals are an important source of advice on vaccinations, but vaccine hesitancy can affect even these professionals. The aim of this study is to assess this phenomenon, measuring it by means of a scoring system. A survey was conducted in five departments of an Italian paediatric university hospital of national interest. Vaccination against influenza was considered a behavioral indicator of vaccination uptake. Using the collected data, the healthcare worker's vaccination compliance index (HVCI) was computed. The results demonstrate statistically significant differences between departments and professional profiles. Nearly 80% of the sample was not immunized against seasonal influenza. According to the HVCI scores, the most hesitant departments are the intensive care unit, emergency room, and oncohematology department, while the most hesitant professional profiles are nurses and auxiliary staff. The score of the unvaccinated is significantly lower than that of the vaccinated, and the same difference was found between those who self-perceive to be skilled versus unskilled. The HVCI score was statistically verified as a predictive parameter to assess vaccination against seasonal influenza. By means of strategic training policies, both HVCI and perceived skills could be improved, suggesting that hospital management should draw a complex intervention program to fight against hesitancy.

Older People Living in Nursing Homes: An Oral Health Screening Survey in Florence, Italy.

The oral health state plays an important role in the concept of 'elderly frailty', since institutionalized older people are prone to suffering from bad oral conditions. The aim of this study is to assess the state of oral health in the older residents of nursing homes and to measure its potential association with the cognitive state, the degree of functional autonomy, and the malnutrition risk. Methods: We enrolled 176 subjects from 292 residents in five nursing homes in Florence. For each subject, we performed the Malnutrition Universal Screening Tool, the Pfeiffer test, the Minimum Data Set-Long Form, a dental examination, and the Geriatric Oral Health Assessment Index questionnaire. The results show that the oral condition was poor in 43.8% of cases, medium in 38.1%, and good in 18.2%. A worse oral health state was significantly associated (p < 0.05) with a worse cognitive state and with a higher dependency in daily living activities. The malnutrition score among the older people was unrelated to the oral health condition (p = 0.128). It can be concluded that the oral health condition in older institutionalized subjects is an open challenge for the public healthcare system, since the maintenance of adequate good oral health is an essential element of good physical as well as cognitive and psychological health.

Models for governing relationships in healthcare organizations: Some empirical evidence.

Recently, most European countries have undergone integration processes through mergers and strategic alliances between healthcare organizations. The present paper examined three cases within the Italian National Health Service in order to determine how different organizations, within differing institutional contexts, govern an healthcare integration process. Furthermore, we explored the possibility that the governance mode, usually seen as alternatives (i.e., merger or alliance), could be considered as a separate step in the development of a more suitable integration process. Multiple case studies were used to compare different integration approaches. Specifically, three cases were considered, of which two were characterized by collaborative processes and the other by a merger. Semi-structured interviews were conducted with managers involved in the processes. Each case presents different governing modes, structures, and mechanisms for achieving integration. The role played by the institutional context also led to different results with unique advantages and disadvantages. Three main conclusions are discussed: (a) Alliances and mergers can be interpreted as different steps in a path leading to a better integration; (b) The alignment between institutional/political time horizon and the time needed for the organizations to achieve an integration process lead to a better integration;

Is hepatitis B vaccination performed at infant and adolescent age able to provide long-term immunological memory? An observational study on healthcare students and workers in Florence, Italy.

Universal vaccination programmes against Hepatitis B Virus (HBV) have significantly reduced the burden of the disease; nevertheless, HBV infection remains a relevant issue for high-risk subjects, such as healthcare workers (HCWs), who may potentially be exposed to blood or body fluids. Our study evaluates the long-term duration of the immunological memory of HBV vaccination 11-23 years after primary immunization by examining the response to booster doses in HCWs and students of health disciplines at Careggi Teaching Hospital in Florence (Italy). All participants (n = 2,203) had received a complete HBV immunization course in infancy or adolescence. Blood samples were collected to measure antibody levels against the HBV surface antigen (anti-HBs); an anti-HBs titre <10 mIU/mL was considered as negative. The administration of the vaccination course during infancy induced lower long-term anti-HBs titres compared to those in case of vaccination performed during adolescence (titre <10 mIU/mL: 51.1% and 12.2% respectively; p < 0.001), also considering that an equal number of years has elapsed since vaccination. A booster dose administered to subjects vaccinated in infancy is able to induce anamnestic immunological response in a higher percentage of vaccinated people (p < 0.001). Few subjects (n. = 4) accepted a fifth dose of vaccine in the case of persistent anti-HBs negative titres; this aspect requires further investigation. The total absence of acute hepatitis B among vaccinated subjects suggests that the long incubation period of the disease allows the activation of immunologic memory mechanisms, which is also true in case of low anti-HBs level. In conclusion HCWs still represent a high-risk category; it is therefore, necessary to increase efforts to protect and vaccinate these subjects.

[The interplay of diagnostic and antimicrobial stewardship for the management of septic patients: the Tuscan model.] / L'integrazione tra stewardship diagnostica e antimicrobica nella gestione del paziente settico in Toscana.

Antimicrobial resistance is a global threat caused by the rapid spread of multiresistant microorganisms. Antimicrobial stewardship (AS) is a coordinated intervention designed to improve the appropriate use of antimicrobials by promoting the selection of the optimal drug regimen, dose, duration of therapy and route of administration. AS programs have proved effective in reducing antimicrobial resistance, inappropriate antimicrobial use and in improving patient outcomes. Recently developed rapid diagnostic technologies in microbiology (RDTM) allows a faster and etiological diagnosis of infection and a reduction in the use of unnecessary empirical therapies. This may result in important advancement in time-critical care pathways for septic patients. Nevertheless, RDTM are costly and if not rationally positioned may consume resources and hinder the efficacy of AS programs. In this regard, Tuscany Region is engaged in designing, through a systemic approach, an effective high-quality clinical microbiological service grid. In order to develop a sustainable and equitable model for integrating diagnostic and antimicrobial stewardship we conducted a survey in the regional network of 14 microbiological laboratories. The results shows that in order to develop a sustainable service we need to improve the communication at the interface between laboratories and care unit, harmonize the time windows for processing samples and to devise a robust score for stratifying patient with suspected sepsis.

Assessment of Health Literacy and validation of single-item literacy screener (SILS) in a sample of Italian people.

BACKGROUND: Health literacy (HL) is a complex concept with multiple components; it involves the ability to effectively use and interpret texts, documents, and numbers. THE AIMS OF OUR STUDY WERE: to measure HL levels among a sample of adult Italian patients; to develop and validate the Italian version of the single-item literacy screener (SILS); to assess the diagnostic accuracy of the SILS as an indicator of limited reading ability regarding health documents, compared to the newest vital sign (NVS). METHODS: The subjects were enrolled in emergency departments, primary care settings, and specialist departments. The Italian versions of the NVS and of the SILS were administered to the patients, as well as a questionnaire aimed in collected socio-demographic information. RESULTS: Overall, 174 patients completed the interview (compliance: 87%). Considering the NVS, 24.1% of the subjects presented high likelihood of limited HL, 13.2% a possibility of limited HL, and 62.6% adequate HL. SILS has shown a good concurrent validity compared to NVS (Spearman's rho r = -0.679; p < 0.001). The diagnostic accuracy of the SILS was high. The best performance parameters in assessing the diagnostic accuracy of SILS are found to be for threshold value of 2 in in identifying subjects with high likelihood of limited HL at the NVS (sensitivity: 83.3%; specificity: 82.6%; accuracy: 82.8%; positive predicted value: 60.3%; negative predicted value: 94%; Cohen's kappa: 0.6). CONCLUSION: The Italian version of SILS - as an indicator of limited reading and understanding ability regarding health information - is a good tool to measure HL in comparison to more complex measurement instruments of functional HL, like NVS.

Health literacy in Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample, and to validate health literacy measures in the Italian language.

INTRODUCTION: Health literacy (HL) concerns the knowledge and competences necessary for people to meet complex health demands. The aims of this study are to assess the level of HL in a sample using the Italian version of the Newest Vital Sign and the association of HL and selected antecedents with health outcomes, and to develop and validate the Italian version of the three Brief Health Literacy Screeners, two subjective numeracy items and the short form and the short-short form of the European Health Literacy Survey Questionnaire. METHODS AND ANALYSIS: The study adopts a cross-sectional design and is being conducted in Florence, with information collected through telephone interviews. The population-based sample has been randomly selected using the registries of eight general practitioners (GPs). Based on a power calculation, 480 subjects will be included. Participants have been randomly offered two different questionnaires, each containing different HL measures. Data on sociodemographics and important antecedents and consequences of HL will be collected and the distribution of HL levels calculated. The mediating role of HL will be assessed using Preacher and Hayes' model. To assess the concurrent validity of the HL scales, correlation and receiver operating characteristic analyses will be performed. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of the Area Vasta Centro. Results will be disseminated via scientific journals and conference presentations, and individual data made available to the GPs.

Recommended vaccinations for asplenic and hyposplenic adult patients.

Asplenic or hyposplenic (AH) individuals are particularly vulnerable to invasive infections caused by encapsulated bacteria. Such infections have often a sudden onset and a fulminant course. Infectious diseases (IDs) incidence in AH subjects can be reduced by preventive measures such as vaccination. The aim of our work is to provide updated recommendations on prevention of infectious diseases in AH adult patients, and to supply a useful and practical tool to healthcare workers for the management of these subjects, in hospital setting and in outpatients consultation. A systematic literature review on evidence based measures for the prevention of IDs in adult AH patients was performed in 2015. Updated recommendations on available vaccines were consequently provided. Vaccinations against S. pneumoniae, N. meningitidis, H. influenzae type b and influenza virus are strongly recommended and should be administered at least 2 weeks before surgery in elective cases or at least 2 weeks after the surgical intervention in emergency cases. In subjects without evidence of immunity, 2 doses of live attenuated vaccines against measles-mumps-rubella and varicella should be administered 4-8 weeks apart from each other; a booster dose of tetanus, diphtheria and pertussis vaccine should be administered also to subjects fully vaccinated, and a 3-dose primary vaccination series is recommended in AH subjects with unknown or incomplete vaccination series (as in healthy people). Evidence based prevention data support the above recommendations to reduce the risk of infection in AH individuals.

Misdiagnosis of vertebral fractures on local radiographic readings of the multicentre POINT (Prevalence of Osteoporosis in INTernal medicine) study.

BACKGROUND: Osteoporotic vertebral fractures (VFs) are often misdiagnosed because asymptomatic and occurring in the absence of specific trauma. Further, diagnostic assessment of VFs may be suboptimal. AIM OF THE STUDY: To assess the misdiagnosis of vertebral fractures on local radiographic readings in the cohort of patients enrolled in the POINT study. METHODS: We enrolled hospitalised patients, admitted for any cause to the Internal Medicine Units of 37 hospitals participating to the cross-sectional previously published POINT study. The assessment of VFs was performed both by local radiologists and by two expert skeletal radiologists, by using semiquantitative method (SQ). To better evaluate mild vertebral deformities, the two central radiologists also used the algorithm-based qualitative assessment (ABQ). RESULTS: The radiographs of 661 patients (401 females; mean age 75.8±8.0) were evaluated. The inter-reader percent agreement between two central expert radiologists per-vertebra assessment was excellent (99.78%; k=0.984; 95% CI, 0.977-0.991). Central reading identified 318/661 (48.1%) patients with at least one VF. Local and central readings agreed in 502/661 (75.9%) patients, resulting in a fair reproducibility (k=0.52; 95% confidence interval 0.44-0.59). Diagnostic performance parameters of local readings were: sensitivity 76.1%; specificity 75.8%; PPV 74.46%; NPV 77.38%). By examining 9254 vertebrae, central and local readers diagnosed 665 (7.2%) and 562 (6.1%) VFs respectively. Misdiagnosis (102 false positives and 205 false negatives) mainly occurred for mild VFs. Local readings identified correctly 460 out 665 VFs diagnosed by central readings, resulting in sensitivity of 69.2% and PPV of 81.8%. CONCLUSIONS: Following a standardized protocol of acquisition techniques and of interpretation criteria, an excellent agreement between local and central readings for moderate and severe vertebral fractures resulted. However a significant amount of mild vertebral fractures, that are the most of VFs, were misdiagnosed by local radiologists. In order to improve VFs assessment, the radiologists should be trained and sensitized in relation to the relevant clinical significance of osteoporotic VFs identification.

Thromboembolic burden, prognostic assessment and outcomes of females compared to males in acute pulmonary embolism.

BACKGROUND: Literature lacks on sex differences in acute pulmonary embolism (PE). Therefore, the aim of our study was to provide information about sex difference in thromboembolic burden, prognostic assessment and outcomes of PE. MATERIALS AND METHODS: We analyzed and compared differences between females and males retrieving data of a multicenter, observational, retrospective, cohort study aimed to analyze characteristics of PE patients admitted in Internal Medicine wards of Tuscany, Italy. RESULTS: 272 (60.1%) of 452 patients enrolled in the study were females. Females were older than males (76.6 ± 12.0 vs. 73.5 ± 13.4 years, p = 0.0005). Mean length of hospital stay was longer in females (11.3 vs. 9.5 days, p = 0053). Reduced mobility was more frequent in females (46.3% vs. 35.5%, p = 0.0322), whereas COPD and active cancer were in males (20% vs. 9.9%, p = 0.0034, and 39.4% vs. 23.8%, p = 0.0004, respectively). Incidental diagnosis of PE was performed more often in males compared to females (19.3% vs. 11.4%, p = 0.0289). No sex difference was found in diagnostic approach, despite females underwent more often to legs ultrasonography compared to males (90.7% vs. 79.4%, p = 0.0008). Both all cause and PE-related mortality were higher in males (12.2 and 8.3% vs. 7.7 and 5.1%, respectively), despite difference was not significant. Females were found to have more likely central PE and distal deep vein thrombosis compared to males (57.7% vs. 43.8%, p = 0.0039, and 22.9% vs. 13.9%, p = 0.0206, respectively). None difference was found in shock index and median simplified PESI score between females and males, whereas according to 2008 ESC prognostic model females were more likely to be categorized at high or intermediate risk than in males (81.5% vs. 71.5%, p = 0.0159). Echocardiographic right heart dysfunction was found more often in females than in males (56.5% vs. 44%, p = 0.0124). No sex difference was found neither on acute treatment nor in prescription of vitamin K antagonists at hospital discharge. Bleeding events were significantly higher in females compared to males (4.7% vs. 0.5%, p = 0.0189). CONCLUSION: Understanding the difference between females and males is of utmost importance for physicians who manage acute PE in clinical practice. Females present major pulmonary thromboembolic burden, more frequently right heart dysfunction and treatment-related bleedings but lower in-hospital mortality than males. Our study could implicate that management of acute PE should be tailored according to sex. Prospective studies are warranted to better clarify this topic.

Recurrent episodes of hemorrhagic alveolitis in relapsing catastrophic antiphospholipid syndrome: the same side of the dark moon.

Catastrophic antiphospholipid syndrome (CAPS) is a rare variant of antiphospholipid syndrome characterized by widespread thrombotic microangiopathy and multiorgan failure. Clinically, CAPS signs and symptoms can mimic vasculitis of systemic lupus erythematosus, disseminated intravascular coagulation, and thrombotic thrombocytopenic purpura. CAPS is burdened by high mortality, nearly 50% in most series. However, patients surviving the acute phase rarely suffer of CAPS relapses. Moreover, concomitant pulmonary hemorrhagic alveolitis is a very rare complication warranting an ominous prognosis. Only few reports of relapsing CAPS are described in literature, and pathogenetic mechanisms are poorly understood and the optimal treatment is yet unknown. We report a case of a young man suffering from multiple relapses of CAPS and recurrent hemorrhagic pulmonary alveolitis refractory to aggressive combination treatment.