Background Utilization of Emergency Medical Services (EMS) declined during COVID-19 pandemic, but most of the studies analyzed components of the EMS system individually. The study aimed to evaluate ...the indirect impact of COVID-19 pandemic on the utilization of all the components of the EMS system of Tuscany Region (Italy) during the first pandemic wave. Methods Administrative data from the health care system of Tuscany were used. Changes in utilization for out-of-hospital emergency calls and emergency vehicle dispatched, emergency department (ED) visits, and patients being admitted from the ED to an inpatient hospital bed (hospitalizations from ED) during the first pandemic wave were analyzed in relation with corresponding periods of the previous two years. Percentage changes and 95%CI were calculated with Poisson models. Standardized Ratios were calculated to evaluate changes in in-hospital mortality and hospitalizations requiring ICU. Results Significant declines were observed in the utilization of all the EMS considered starting from the week in which the first case of COVID-19 was diagnosed in Italy till the end of the first pandemic wave. During the epidemic peak, the maximum decreases were observed: -33% for the emergency calls, -45% for the dispatch of emergency vehicles, -71% for ED admissions. Furthermore, a decline of 37% for hospitalizations from ED was recorded. Significant decreases in ED admissions for life threatening medical conditions were observed: acute cerebrovascular disease (-36%, 95% CI: -43, -29), acute myocardial infarction (-42%, 95% CI: -52, -31) and renal failure (-42%, 95% CI: -52, -31). No significant differences were found between the observed and the expected in-hospital mortality and hospitalizations requiring ICU during the epidemic peak. Conclusion All the components of the EMS showed large declines in their utilization during COVID-19 pandemic; furthermore, major reductions were observed for admissions for time-dependent and life-threatening conditions. Efforts should be made to ensure access to safe and high-quality emergency care during pandemic.
•Impacts of COVID-19 containment measures on other respiratory infections are unknown•Region-wide population-based studies are needed to estimate this impact•The incidence of pneumonia in older ...people decreased during the COVID-19 pandemic•This decrease coincided with the adoption of COVID-19 containment measures•Health service planning during pandemics should take into account this phenomenon
To evaluate the indirect effect of COVID-19 large-scale containment measures on the incidence of community-acquired pneumonia (CAP) in older people during the first epidemic wave of COVID-19 in Tuscany, Italy.
A population-based study was carried out on data from the Tuscany healthcare system. The outcome measures were: hospitalization rate for CAP, severity of CAP hospitalizations, and outpatient consumption of antibacterials for CAP in people aged 65 and older. Outcomes were compared between corresponding periods in 2020 (week 1 to 27) and previous years.
Compared with the average of the corresponding periods in the previous 3 years, significant reductions in weekly hospitalization rates for CAP were observed from the week in which the national containment measures were imposed (week 10) until the end of the first COVID-19 wave in July (week 27). There was also a significant decrease in outpatient consumption in all antibacterial classes for CAP.
The implementation of large-scale COVID-19 containment measures likely reduced the incidence of CAP in older people during the first wave of the COVID-19 pandemic in Tuscany, Italy. Considering this indirect impact of pandemic containment measures on respiratory tract infections may improve the planning of health services during a pandemic in the future.
Highlights • Most hip fractures occur in fragile patients. • A co-managed approach reduces mortality after hip fracture surgery in the elderly. • There is no significant difference in mortality rates ...between early and late surgery. • A surgery delay could be necessary to stabilise patients with comorbidity
Abstract
Earlier in 2020, seven Italian regions, which cover 62% of the Italian population, set up the Mimico-19 network to monitor the side effects of the restrictive measures against Covid-19 on ...volumes and quality of care. To this aim, we retrospectively analysed hospital discharges data, computing twelve indicators of volume and performance in three clinical areas: cardiology, oncology, and orthopaedics. Weekly indicators for the period January–July 2020 were compared with the corresponding average for 2018–2019; comparisons were performed within 3 sub-periods: pre-lockdown, lockdown, and post-lockdown. The weekly trend of hospitalisations for ST-segment elevation myocardial infarction (STEMI) showed a 40% reduction, but the proportion of STEMI patients with a primary PTCA did not significantly change from previous years. Malignant neoplasms surgery volumes differed substantially by site, with a limited reduction for lung cancer (< 20%) and greater declines (30–40%) for breast and prostate cancers. The percentage of timely surgery for femoral neck in the elderly remained constantly higher than the previous 2 years whereas hip and knee replacements fell dramatically. Hospitalisations have generally decreased, but the capacity of a timely and effective response in time-dependent pathways of care was not jeopardized throughout the period. General trends did not show important differences across regions, regardless of the different burden of Covid-19. Preventive and primary care services should adopt a pro-active approach, moving towards the identification of at-risk conditions that were neglected during the pandemic and timely addressing patients to the secondary care system.
Cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) in the advanced stages have similar symptom burdens and survival rates. Despite these similarities, the majority ...of the attention directed to improving the quality of end-of-life (EOL) care has focused on cancer.
To assess the extent to which the quality of EOL care received by cancer, CHF, and COPD patients in the last month of life is diagnosis-sensitive.
This is a retrospective observational study based on administrative data. The study population includes all Tuscany region residents aged 18 years or older who died with a clinical history of cancer, CHF, or COPD. Decedents were categorized into two mutually exclusive diagnosis categories: cancer (CA) and cardiopulmonary failure (CPF). Several EOL care quality outcome measures were adopted. Multivariable generalized linear model for each outcome were performed.
The sample included 30,217 decedents. CPF patients were about 1.5 times more likely than cancer patients to die in an acute care hospital (RR 1.59, 95% C.I.: 1.54-1.63). CPF patients were more likely to be hospitalized or admitted to the emergency department (RR 1.09, 95% C.I.: 1.07-1.10; RR 1.15, 95% C.I.: 1.13-1.18, respectively) and less likely to use hospice services (RR 0.08, 95% C.I.: 0.07-0.09) than cancer patients in the last month of life. CPF patients had a four- and two-fold higher risk of intensive care unit admission or of undergoing life-sustaining treatments, respectively, than cancer patients (RR 3.71, 95% C.I.: 3.40-4.04; RR 2.43, 95% C.I.: 2.27-2.60, respectively).
The study has highlighted the presence of significant differences in the quality of EOL care received in the last month of life by COPD and CHF compared with cancer patients. Further studies are needed to better elucidate the extent and the avoidability of these diagnosis-related differences in the quality of EOL care.
To estimate the effects of cycling promotion on major non-communicable diseases (NCDs) and costs from the public healthcare payer's perspective.
Health impact assessment and economic evaluation using ...a dynamic model over a ten-year period and according to two cycling promotion scenarios.
Cycling to work or school in Florence, Italy.
All individuals aged 15 and older commuting to work or school in Florence.
The primary outcome measures were changes in NCD incidence and healthcare direct costs for the Tuscany Regional Health Service (SST) due to increased cycling. The secondary outcome was change in road traffic accidents.
Increasing cycling modal share in Florence from 7.5% to about 17% (Scenario 1) or 27% (Scenario 2) could decrease the incidence of type 2 diabetes by 1.2% or 2.5%, and the incidence of acute myocardial infarction (AMI) and stroke by 0.6% or 1.2%. Within 10 years, the number of cases that can be prevented is 280 or 549 for type 2 diabetes, 51 or 100 for AMI, and 51 or 99 for stroke in Scenario 1 or Scenario 2, respectively. Average annual discounted savings for the SST are estimated to amount to €400,804 or €771,201 in Scenario 1 or Scenario 2, respectively. In Florence, due to the high use of vulnerable motorized vehicles (such as scooters, mopeds, and motorcycles), road traffic accidents are expected to decline in both our scenarios. Sensitivity analyses showed that health benefits and savings for the SST are substantial, the most sensitive parameters being the relative risk estimates of NCDs and active commuting.
Effective policies and programs to promote a modal shift towards cycling among students and workers in Florence will contribute to reducing the NCD burden and helping long-term economic sustainability of the SST.
Carbapenemase-producing Enterobacterales (CPE), particularly those producing metallo-β-lactamases, are among the most challenging antibiotic-resistant pathogens, causing outbreaks of ...difficult-to-treat nosocomial infections worldwide. Since November 2018, an outbreak of New Delhi metallo-β-lactamases-positive CPE (NDM-CPE) has emerged in Tuscany, Italy. In this study, we aimed to investigate the NDM-CPE associated with the outbreak and characterise the responsible Klebsiella pneumoniae clone.
We used whole-genome sequencing and bioinformatic analysis to characterise NDM-CPE isolates that caused bloodstream infections in 53 patients at 11 hospitals in Tuscany and that were collected between Jan 1, 2018, and July 5, 2019 (ie, the early phase of the outbreak and preceding months). The CPE isolates characterised in this study were isolated and identified at the species level and as NDM producers by six diagnostic microbiology laboratories that serve the 11 hospitals. We used comparative genomic analysis, antimicrobial susceptibility testing, plasmid conjugal transfer assays, evaluation of virulence potential in the Galleria mellonella infection model, and serum bactericidal assays to further characterise the clone causing the outbreak.
The outbreak was sustained by an ST147 K pneumoniae producing NDM-1, which had a complex resistome that mediated resistance to most antimicrobials (except cefiderocol, the aztreonam–avibactam combination, colistin, and fosfomycin). The clone belonged to a sublineage of probably recent evolution, occurred by the sequential acquisition of an integrative and conjugative element encoding the yersiniabactin siderophore, an FIB(pQil)-type multiresistance plasmid carrying blaNDM-1, and a transferable chimeric plasmid, derived from virulence elements of hypervirulent K pneumoniae, carrying several resistance and virulence determinants. Infection of G mellonella larvae revealed a variable virulence potential. The behaviour in serum bactericidal assays was different from typical hypervirulent K pneumoniae strains, with variable grades of serum resistance apparently associated with mutations in specific chromosomal loci (csrD, pal, and ramR).
This description of a sublineage of ST147 K pneumoniae with a complex resistome and virulome that is capable of sustaining a large regional outbreak adds to existing research on the evolutionary trajectories within high-risk clones of K pneumoniae. Global surveillance programmes are warranted to track the dissemination of these lineages, and to prevent and control their spread.
Italian Ministry of Health and Department of Experimental and Clinical Medicine, University of Florence.
Background: Low coverage of influenza vaccination in nursing home (NH) staff may be attributed to factors such as vaccine confidence (VC) and vaccine literacy (VL). Our study aimed to evaluate the ...role of VL and VC in predicting the intention to get the influenza vaccine in a sample of employees of NHs in Tuscany, Italy. Methods: Data from staff members in Tuscany were collected using an online questionnaire that examined influenza vaccination history, intentions, demographic information, health status, and VL. Statistical analyses explored the relationships between VC, VL, and vaccination intentions. Results: The study included 1794 respondents, (86.3%) and assistants/aides (58.1%), with a median age of 46 years. The intention to get vaccinated was significantly higher among those with health risk conditions, and there was a positive association between VC and VL, specifically its interactive/critical component. The mediation analysis showed that VC completely mediated the relationship between VL and the intention to get vaccinated, with significant effects observed in different subgroups. Conclusions: VC is a key factor that mediates the effect of VL on vaccine intention. These results suggest that interventions aimed at improving VL alone may not be sufficient to increase vaccine uptake unless VC is also addressed.
Infections associated with orthopaedic implants represent a major health concern characterized by a remarkable incidence of morbidity and mortality. The wide variety of clinical scenarios encountered ...in the heterogeneous world of infections associated with orthopaedic implants makes the implementation of an optimal and standardized antimicrobial treatment challenging. Antibiotic bone penetration, anti-biofilm activity, long-term safety, and drug choice/dosage regimens favouring outpatient management (i.e., long-acting or oral agents) play a major role in regards to the chronic evolution of these infections. The aim of this multidisciplinary opinion article is to summarize evidence supporting the use of the different anti-staphylococcal agents in terms of microbiological and pharmacological optimization according to bone penetration, anti-biofilm activity, long-term safety, and feasibility for outpatient regimens, and to provide a useful guide for clinicians in the management of patients affected by staphylococcal infections associated with orthopaedic implants Novel long-acting lipoglycopeptides, and particularly dalbavancin, alone or in combination with rifampicin, could represent the best antibiotic choice according to real-world evidence and pharmacokinetic/pharmacodynamic properties. The implementation of a multidisciplinary taskforce and close cooperation between microbiologists and clinicians is crucial for providing the best care in this scenario.
Cardiovascular complications in patients undergoing non-cardiac surgery are associated with longer hospital stays and higher in-hospital mortality. The aim of this study was to assess the incidence ...of in-hospital myocardial infarction and/or myocardial injury in patients undergoing hip fracture surgery and their association with mortality. Moreover, we evaluated the prognostic value of troponin increase stratified on the basis of peak troponin value. The electronic records of 1970 consecutive hip fracture patients were reviewed. Patients <70 years, those with myocardial infarction <30 days, and those with sepsis or active cancer were excluded from the study. Troponin and ECG were obtained at admission and then at 12, 24, and 48 h after surgery. Echocardiography was made before and within 48 h after surgery. Myocardial injury was defined by peak troponin I levels > 99th percentile. A total of 1854 patients were included. An elevated troponin concentration was observed in 754 (40.7%) patients in the study population. Evidence of myocardial ischemia, fulfilling diagnosis of myocardial infarction, was found in 433 (57%). ECG and echo abnormalities were more frequent in patients with higher troponin values; however, mortality did not differ between patients with and without evidence of ischemia. Peak troponin was between 0.1 and 1 µg/L in 593 (30.3%). A total of 191 (10%) had peak troponin I ≥ 1 µg/L, and 98 died in hospital (5%). Mortality was significantly higher in both groups with troponin increase (HR = 1.37, 95% CI 1.1-1.7,
< 0.001 for peak troponin I between 0.1 and 1 µg/L; HR = 2.28, 95% CI 1.72-3.02,
< 0.0001 for peak troponin ≥1 µg/L) in comparison to patients without myocardial injury. Male gender, history of coronary heart disease, heart failure, and chronic kidney disease were also associated with in-hospital mortality. Myocardial injury/infarction is associated with increased mortality after hip fracture surgery. Elevated troponin values, but not ischemic changes, are related to early worse outcome.
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