Hospital-Acquired SARS-Cov-2 Infections in Patients: Inevitable Conditions or Medical Malpractice?

Medical-legal aspects in infectious diseases

This article reviews the medico-legal aspects associated with infectious diseases, highlighting their complexity and the challenges they pose. Infectious diseases cause not only an increase in morbidity and mortality in the healthcare setting but also involve complex legal issues. Healthcare-Associated Infections (HAIs) represent a growing risk with the increase in invasive procedures and can lead to patient complications and legal claims against healthcare professionals and institutions. The consequences of medical malpractice in this context are discussed, such as diagnostic delays, inappropriate use of treatments, and lack of adequate testing, which can have serious sequelae or even result in the patient's death. The review focuses on highlighting the importance of prevention, considering that healthcare-associated infections can be difficult to avoid, posing complex legal challenges. It concludes that managing infectious diseases and their legal consequences requires careful consideration of clinical practice guidelines, prevention and control strategies, and effective communication with patients. An integrated and evidence-based approach is advocated to address these challenges, emphasizing continuous education, the use of advanced diagnostic technologies, and interdisciplinary collaboration.

Emergency Department closed reduction of dislocated THR: the REDDTHR Prospective Multi-centre Study

INTRODUCTION

Dislocation is a potentially devastating complication severely affecting outcomes post total hip arthroplasty (THR). We aimed to assess the efficacy and safety of closed reduction of a dislocated THR within the Emergency Department (ED).

METHODS

A prospective multi-centre study was conducted over a 1-year period from November 2020 to December 2021 within 10 hospitals based in the East of England. Collected data included patient demographics, agent used for sedation, hospital length of stay, implant type and discharge destination. Patients were analysed according to whether successful reduction was performed in the ED or not. The primary outcome was length of stay, with secondary outcomes including discharge destination and pain post-procedure.

RESULTS

We studied 99 patients with an average age of 77.02 years, with 39 (39%) patients being male. 11 patients had revision hip replacements and 88 patients had primary THRs. 57 (57.6%) underwent closed reduction in the Emergency department, of which 44 (77.2%) were successful. Successful closed reduction was significantly associated with lower patient age (p = 0.02), lower American society of Anesthesiologists (ASA) score (p < 0.01) and use of propofol (p < 0.01). Patients who underwent successful ED closed reduction had a lower hospital stay than those that did not (1 vs. 3 days, p < 0.01), however there was no significant difference in discharge destination.

CONCLUSIONS

When adopted, success following closed reduction is increased in younger patients with less comorbidities following use of propofol sedation. Following sedation, patients have a significantly shorter hospital stay. Increasing uptake of closed reduction of THR dislocation within the ED in suitable patients with evidence-based best practice protocols will maximise patient outcomes whilst allowing efficient resource utilisation.

Infection control practices in public sector hospitals of Punjab: a critical analysis

INTRODUCTION

Infection prevention and control (IPC) is imperative towards patient safety and health. The Infection Prevention and Control Assessment Framework (IPCAF) developed by WHO provides a baseline assessment at the acute healthcare facility level. This study aimed to assess the existing IPC level of selected public sector hospital facilities in Punjab to explore their strengths and deficits.

METHODS

Between October and April 2023, 11 public sector hospitals (including tertiary, secondary and primary level care) were selected. Data were collected using the IPCAF assessment tool comprising eight sections, which were then categorised into four distinct IPC levels- inadequate, basic, intermediate and advanced. Key performance metrics were summarised within and between hospitals.

RESULTS

The overall median IPCAF score for the public sector hospitals was 532.5 (IQR: 292.5-690) out of 800. Four hospitals each scored 'advanced' as well as 'basic' IPC level and three hospitals fell into 'intermediate level'. Most hospitals had IPC guidelines as well as IPC programme, environments, materials and equipments. Although 90% of secondary care hospitals had IPC education and training, only 2 out of 5 (40%) tertiary care and 2 out of 3 (67%) primary care hospitals have IPC or additional experts for training. Only 1 out of 5 tertiary care hospitals (20%) were recorded in an agreed ratio of healthcare workers to patients while 2 out of 5 (40%) of these hospitals lack staffing need assessment.

CONCLUSION

Overall the sampled public sector (tertiary, secondary and primary) hospitals demonstrated satisfactory IPC level. Challenging areas are the healthcare-associated infection surveillance, monitoring/audit and staffing, bed occupancy overall in all the three categories of hospitals. Periodic training and assessment can facilitate improvement in public sector systems.

Thymol, a Monoterpenoid within Polymeric Iodophor Formulations and Their Antimicrobial Activities

Antimicrobial resistance (AMR) poses an emanating threat to humanity's future. The effectiveness of commonly used antibiotics against microbial infections is declining at an alarming rate. As a result, morbidity and mortality rates are soaring, particularly among immunocompromised populations. Exploring alternative solutions, such as medicinal plants and iodine, shows promise in combating resistant pathogens. Such antimicrobials could effectively inhibit microbial proliferation through synergistic combinations. In our study, we prepared a formulation consisting of Aloe barbadensis Miller (AV), Thymol, iodine (I2), and polyvinylpyrrolidone (PVP). Various analytical methods including SEM/EDS, UV-vis, Raman, FTIR, and XRD were carried out to verify the purity, composition, and morphology of AV-PVP-Thymol-I2. We evaluated the inhibitory effects of this formulation against 10 selected reference strains using impregnated sterile discs, surgical sutures, gauze bandages, surgical face masks, and KN95 masks. The antimicrobial properties of AV-PVP-Thymol-I2 were assessed through disc diffusion methods against 10 reference strains in comparison with two common antibiotics. The 25-month-old formulation exhibited slightly lower inhibitory zones, indicating changes in the sustained-iodine-release reservoir. Our findings confirm AV-PVP-Thymol-I2 as a potent antifungal and antibacterial agent against the reference strains, demonstrating particularly strong inhibitory action on surgical sutures, cotton bandages, and face masks. These results enable the potential use of the formulation AV-PVP-Thymol-I2 as a promising antimicrobial agent against wound infections and as a spray-on contact-killing agent.

Forensic Pathology and Legal Issues in COVID-19: Case Report and Literature Review

Autopsy investigations of deaths following nosocomial coronavirus disease 2019 (COVID-19) infection have enormous medical and social significance, as autopsies are essential for the correct statistical recording of COVID-19 deaths, presenting new lessons, which is important to policymakers and in the improvement of public health in general.  Our study is based on the presentation of a case of a road traffic accident involving an elderly 73-year-old female with a complication of nosocomial COVID-19 infection and death leading to forensic pathological investigation. This involved autopsy, histopathological examinations, and other tests, and highlighting the importance of medicolegal matters, including the legal and ethical practicalities encountered in healthcare. This article highlights the fact that patients who have sustained various traumatic injuries accompanied by nosocomial COVID-19 infection have higher risks of morbidity and mortality. The significance of the role of a Forensic Pathologist in dealing with the analysis of injuries and the performance of autopsies to determine the cause, mechanism, and manner of death. In addition, the important lesson of testing patients for COVID-19 more regularly during a long hospital admission period, to offer early treatment and isolation, including avoiding the further spread of the COVID-19 infection variants to patients and healthcare professionals, thereby minimising and preventing hospital-acquired infection and death is stressed.

Comparing COVID-19 severity in patients hospitalized for community-associated Delta, BA.1 and BA.4/5 variant infection

Background

Despite decreasing COVID-19 disease severity during the Omicron waves, a proportion of patients still require hospitalization and intensive care.

Objective

To compare demographic characteristics, comorbidities, vaccination status, and previous infections in patients hospitalized for community-associated COVID-19 (CAC) in predominantly Delta, Omicron BA.1 and BA.4/5 SARS-CoV-2 waves.

Methods

Data were extracted from three national databases-the National COVID-19 Database, National Vaccination Registry and National Registry of Hospitalizations.

Results

Among the hospitalized CAC patients analyzed in this study, 5,512 were infected with Delta, 1,120 with Omicron BA.1, and 1,143 with the Omicron BA.4/5 variant. The age and sex structure changed from Delta to BA.4/5, with the proportion of women (9.5% increase), children and adolescents (10.4% increase), and octa- and nonagenarians increasing significantly (24.5% increase). Significantly more patients had comorbidities (measured by the Charlson Comorbidity Index), 30.3% in Delta and 43% in BA.4/5 period. The need for non-invasive ventilatory support (NiVS), ICU admission, mechanical ventilation (MV), and in-hospital mortality (IHM) decreased from Delta to Omicron BA.4/5 period for 12.6, 13.5, 11.5, and 6.3%, respectively. Multivariate analysis revealed significantly lower odds for ICU admission (OR 0.68, CI 0.54-0.84, p < 0.001) and IHM (OR 0.74, CI 0.58-0.93, p = 0.011) during the Delta period in patients who had been fully vaccinated or boosted with a COVID-19 vaccine within the previous 6 months. In the BA.1 variant period, patients who had less than 6 months elapsed between the last vaccine dose and SARS-CoV-2 positivity had lower odds for MV (OR 0.38, CI 0.18-0.72, p = 0.005) and IHM (OR 0.56, CI 0.37- 0.83, p = 0.005), but not for NIVS or ICU admission.

Conclusion

The likelihood of developing severe CAC in hospitalized patients was higher in those with the Delta and Omicron BA.1 variant compared to BA.4/5.

In Support of Universal Admission Testing for SARS-CoV-2 During Significant Community Transmission

Many hospitals have stopped or are considering stopping universal admission testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We discuss reasons why admission testing should still be part of a layered system to prevent hospital-acquired SARS-CoV-2 infections during times of significant community transmission. These include the morbidity of SARS-CoV-2 in vulnerable patients, the predominant contribution of presymptomatic and asymptomatic people to transmission, the high rate of transmission between patients in shared rooms, and data suggesting surveillance testing is associated with fewer nosocomial infections. Preferences of diverse patient populations, particularly the hardest-hit communities, should be surveyed and used to inform prevention measures. Hospitals' ethical responsibility to protect patients from serious infections should predominate over concerns about costs, labor, and inconvenience. We call for more rigorous data on the incidence and morbidity of nosocomial SARS-CoV-2 infections and more research to help determine when to start, stop, and restart universal admission testing and other prevention measures.

Green Synthesized Polymeric Iodophors with Thyme as Antimicrobial Agents

Antimicrobial resistance (AMR) is a growing concern for the future of mankind. Common antibiotics fail in the treatment of microbial infections at an alarming rate. Morbidity and mortality rates increase, especially among immune-compromised populations. Medicinal plants and their essential oils, as well as iodine could be potential solutions against resistant pathogens. These natural antimicrobials abate microbial proliferation, especially in synergistic combinations. We performed a simple, one-pot synthesis to prepare our formulation with polyvinylpyrrolidone (PVP)-complexed iodine (I2), Thymus Vulgaris L. (Thyme), and Aloe Barbadensis Miller (AV). SEM/EDS, UV-vis, Raman, FTIR, and XRD analyses verified the purity, composition, and morphology of AV-PVP-Thyme-I2. We investigated the inhibitory action of the bio-formulation AV-PVP-Thyme-I2 against 10 selected reference pathogens on impregnated sterile discs, surgical sutures, cotton gauze bandages, surgical face masks, and KN95 masks. The antimicrobial properties of AV-PVP-Thyme-I2 were studied by disc diffusion methods and compared with those of the antibiotics gentamycin and nystatin. The results confirm AV-PVP-Thyme-I2 as a strong antifungal and antibacterial agent against the majority of the tested microorganisms with excellent results on cotton bandages and face masks. After storing AV-PVP-Thyme-I2 for 18 months, the inhibitory action was augmented compared to the fresh formulation. Consequently, we suggest AV-PVP-Thyme-I2 as an antimicrobial agent against wound infections and a spray-on contact killing agent.

Effect of Hospital-associated SARS-CoV-2 Infections in Cardiac Surgery: A Multicenter Study

BACKGROUND

The effect of hospital-associated SARS-CoV-2 infections in cardiac surgery patients remains poorly investigated, and current data are limited to small case series with conflicting results.

METHODS

A multicenter European collaboration was organized to analyze the outcomes of patients who tested positive with hospital-associated SARS-CoV-2 infection after cardiac surgery. The study investigators hypothesized that early infection could be associated with worse postoperative outcomes; hence 2 groups were considered: (1) an early hospital-associated SARS-CoV-2 infection group comprising patients who had a positive molecular test result ≤7 days after surgery, with or without symptoms; and (2) a late hospital-associated SARS-CoV-2 infection group comprising patients whose test positivity occurred >7 days after surgery, with or without symptoms. The primary outcome was 30-day mortality. Secondary outcomes included all-cause mortality or morbidity at early follow-up and SARS-CoV-2-related hospital readmission.

RESULTS

A total of 87 patients were included in the study. Of those, 30 were in the early group and 57 in the late group. Overall, 30-day mortality was 8%, and in-hospital mortality was 11.5%. The reintubation rate was 11.4%. Early infection was significantly associated with higher mortality (adjusted OR, 26.6; 95% CI, 2, 352.6; P < .01) when compared with the late group. At 6-month follow-up, survival probability was also significantly higher in the late infection group: 91% (95% CI, 83%, 98%) vs 75% (95% CI, 61%, 93%) in the early infection group (P = .036). Two patients experienced COVID-19-related rehospitalization.

CONCLUSIONS

In this multicenter analysis, hospital-associated SARS-CoV-2 infection resulted in higher than expected postoperative mortality after cardiac surgery, especially in the early infection group.

Green synthesis of silver nanoparticles from Cassia Auriculata: Targeting antibacterial, antioxidant activity, and evaluation of their possible effects on saltwater microcrustacean, Artemia Nauplii (non-target organism)

Due to their huge surface area to volume ratio, metallic nanoparticles are becoming increasingly important in numerous spheres of life. Here, initially, we aimed to evaluate the potential use of Cassia auriculata (CA) extract to synthesize silver nanoparticles (AgNPs). Then, we evaluated its antimicrobial potential and antioxidant capacity, as well as performed in silico analysis, and investigated the possible non-toxic effect of AgNPs on Artemia nauplii. Fourier transform infrared (FTIR) spectroscopy, scanning and transmission electron microscopy (SEM/TEM), energy dispersive spectroscopy (EDX), X-ray diffraction (XRD), and dynamic light scattering (DLS) studies were used to characterize the biosynthesized AgNPs. Our data indicate that Bacillus cereus, Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus bacteria were susceptible to the biosynthesized AgNPs, whose effect was concentration-response. With a ZOI of 10 mm, the AgNPs were most efficient against gram-positive B. cereus bacteria at the highest concentration (75 μg/mL). The biosynthesized AgNPs (at 25 to 125 μg/mL) showed good antioxidant activity in the DPPH (2,2-diphenyl-1-picryl-hydrazyl-hydrate) and FRAP (ferric reducing antioxidant power) assays. Oleanolic acid from CA exhibited strong binding affinity and high binding energy to E. coli and B. cereus (-9.66 and - 9.74 kcal/mol) on in silico research. According to the comparative non-toxicity analysis, AgNPs, AgNO₃, and CA bark extract had the least toxic effects on A. nauplii, with respective mortality rates of 28.14, 32.26, and 38.42 %, respectively. In conclusion, the current work showed that AgNPs produced from CA bark could be a promising material for diverse applications.

Management of the Medico-Legal Dispute of Healthcare-Related SARS-CoV-2 Infections: Evaluation Criteria and Case Study in a Large University Hospital in Northwest Italy from 2020 to 2021

Healthcare-related SARS-CoV-2 infection is an issue of particular concern during the pandemic. It has important repercussions on the National Health System, which represents a source of medical-legal health disputes. In the healthcare context, there are reports of negative screening at hospital admission (via nasopharyngeal swabs) and subsequent diagnosis of SARS-CoV-2 infection during hospitalization. Such cases cannot be considered a priori of healthcare-related infections but require extensive in-depth evaluation. In this study, we propose an empirical classification to frame cases of SARS-CoV-2 infection diagnosed in the hospital (first negative admission swab, with subsequent positive test during hospitalization). The classification is based on five categories: nosocomial, probably nosocomial, indeterminate, probably community, and community cases. We analyzed patients who died after testing positive for SARS-CoV-2 during hospitalization (with initial negative screening) in the largest hospital in Northwest Italy from February 2020 to 31 December 2021. A total of 383 cases were tracked and are listed as follows: 41 cases (11%) were classified as nosocomial (i.e., 3.2% of COVID-19 deaths). In contrast, 71 cases (19%) were classified as probably nosocomial, 69 (18%) were indeterminate (i.e., the clinical, radiological, and laboratory characteristics did not provide information on the genesis of the infection), 166 (43%) were classified as probably community cases, and 36 (9%) were defined as community cases. Deceased patients with nosocomial SARS-CoV-2 infection constituted the following: 3.23% (41/1266) with respect to the total number of COVID-19 deaths, 1.1% (41/3789) with respect to those who entered the hospital with a negative swab and 0.82% (41/4672) with respect to the total of deaths from any cause of death. In this paper we discuss the topic and issues of nosocomial COVID-19 in hospitalized patients and address the medicolegal implications.

Status of infection prevention and control capacity in Korean hospitals: implications for disaster response and pandemic preparedness

OBJECTIVES

This study aims to explore the association of hospital infection prevention and control (IPC) structure (i.e. a dedicated IPC team and/or IPC committee) and IPC capacity in Korean hospitals, as well as its implications in the response and preparedness to COVID-19.

STUDY DESIGN

This was a cross-sectional study using data collected through a nationwide survey.

METHODS

Participating hospitals completed an online questionnaire. Participation was voluntary. The survey questionnaire was developed by the government in consultation with IPC experts. The questionnaire was distributed to 2108 hospitals, including both acute and long-term care hospitals. The independent variables were the presence of an IPC team and/or IPC committee. The dependent variables were IPC activities and capacity measures, which were based on the World Health Organisation (WHO) recommendations on the core components in IPC.

RESULTS

A total of 1442 hospitals completed the survey. Hospitals with IPC structures conducted significantly more IPC activities in all outcome measures compared with hospitals without IPC structures, with the exceptions of monitoring hand hygiene and screening for infectious diseases that showed non-significant differences. Hospitals with IPC structures showed a significant difference in performance in IPC risk assessment, operating outbreak response teams and appraisal of hospital IPC policies compared with hospitals without IPC structures.

CONCLUSIONS

The presence of a dedicated IPC team and IPC committee was associated with increased IPC activities and IPC capacity. Hospitals with IPC teams and IPC committees showed strong implementation of planning, appraisal, resource management and outbreak response, indicating that strengthening IPC structures within hospitals is the key to more effective IPC and disaster response.

Healthcare-Associated COVID-19 across Five Pandemic Waves: Prediction Models and Genomic Analyses

Background: Healthcare-associated SARS-CoV-2 infections need to be explored further. Our study is an analysis of hospital-acquired infections (HAIs) and ambulatory healthcare workers (aHCWs) with SARS-CoV-2 across the pandemic in a Belgian university hospital. Methods: We compared HAIs with community-associated infections (CAIs) to identify the factors associated with having an HAI. We then performed a genomic cluster analysis of HAIs and aHCWs. We used this alongside the European Centre for Disease Control (ECDC) case source classifications of an HAI. Results: Between March 2020 and March 2022, 269 patients had an HAI. A lower BMI, a worse frailty index, lower C-reactive protein (CRP), and a higher thrombocyte count as well as death and length of stay were significantly associated with having an HAI. Using those variables to predict HAIs versus CAIs, we obtained a positive predictive value (PPV) of 83.6% and a negative predictive value (NPV) of 82.2%; the area under the ROC was 0.89. Genomic cluster analyses and representations on epicurves and minimal spanning trees delivered further insights into HAI dynamics across different pandemic waves. The genomic data were also compared with the clinical ECDC definitions for HAIs; we found that 90.0% of the ‘definite’, 87.8% of the ‘probable’, and 70.3% of the ‘indeterminate’ HAIs belonged to one of the twenty-two COVID-19 genomic clusters we identified. Conclusions: We propose a novel prediction model for HAIs. In addition, we show that the management of nosocomial outbreaks will benefit from genome sequencing analyses.

Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework (IPCAF)

INTRODUCTION

Infection prevention and control (IPC) in healthcare settings is imperative for the safety of patients as well as healthcare providers. To measure current IPC activities, resources, and gaps at the facility level, WHO has developed the Infection Prevention and Control Assessment Framework (IPCAF). This study aimed to assess the existing IPC level of selected tertiary care hospitals in Bangladesh during the COVID-19 pandemic using IPCAF to explore their strengths and deficits.

METHODS

Between September and December 2020, we assessed 11 tertiary-care hospitals across Bangladesh. We collected the information from IPC focal person and/or hospital administrator from each hospital using the IPCAF assessment tool.. The score was calculated based on eight core components and was used to categorize the hospitals into four distinct IPC levels- Inadequate, Basic, Intermediate, and Advanced. Key performance metrics were summarized within and between hospitals.

RESULTS

The overall median IPCAF score was 355.0 (IQR: 252.5-397.5) out of 800. The majority (73%) of hospitals scored as 'Basic' IPC level, while only 18% of hospitals were categorized as 'Intermediate'. Most hospitals had IPC guidelines as well as environments, materials and equipments. Although 64% of hospitals had IPC orientation and training program for new employees, only 30% of hospitals had regular IPC training program for the staff. None of the hospitals had an IPC surveillance system with standard surveillance case definitions to track HAIs. Around 90% of hospitals did not have an active IPC monitoring and audit system. Half of the hospitals had inadequate staffing considering the workload. Bed occupancy of one patient per bed in all units was found in 55% of hospitals. About 73% of hospitals had functional hand hygiene stations, but sufficient toilets were available in only 37% of hospitals.

CONCLUSION

The majority of sampled tertiary care hospitals demonstrate inadequate IPC level to ensure the safety of healthcare workers, patients, and visitors. Quality improvement programs and feedback mechanisms should be implemented to strengthen all IPC core components, particularly IPC surveillance, monitoring, education, and training, to improve healthcare safety and resilience.

SARS-CoV-2 indoor environment contamination with epidemiological and experimental investigations

SARS-CoV-2 has been detected both in air and on surfaces, but questions remain about the patient-specific and environmental factors affecting virus transmission. Additionally, more detailed information on viral sampling of the air is needed. This prospective cohort study (N = 56) presents results from 258 air and 252 surface samples from the surroundings of 23 hospitalized and eight home-treated COVID-19 index patients between July 2020 and March 2021 and compares the results between the measured environments and patient factors. Additionally, epidemiological and experimental investigations were performed. The proportions of qRT-PCR-positive air (10.7% hospital/17.6% homes) and surface samples (8.8%/12.9%) showed statistical similarity in hospital and homes. Significant SARS-CoV-2 air contamination was observed in a large (655.25 m³ ) mechanically ventilated (1.67 air changes per hour, 32.4-421 L/s/patient) patient hall even with only two patients present. All positive air samples were obtained in the absence of aerosol-generating procedures. In four cases, positive environmental samples were detected after the patients had developed a neutralizing IgG response. SARS-CoV-2 RNA was detected in the following particle sizes: 0.65-4.7 μm, 7.0-12.0 μm, >10 μm, and <100 μm. Appropriate infection control against airborne and surface transmission routes is needed in both environments, even after antibody production has begun.

Better cardioprotection in atrial septal defect patients treated with cardiopulmonary bypass beating heart technique without the application of aortic cross clamp

Background and objectives: Creatine phosphokinase-myocardial band fraction (CPK-MB) and cardiac troponin I (cTnI) are cardiac specific biochemical markers which are raised in myocardial ischemia. The aim of this study was to determine cardiac injury by comparing the levels of cardiac enzymes CPK-MB and cTnI in atrial septal defect (ASD) patients whose operative repair was done under cardiopulmonary bypass (CPB) using beating heart technique with and without the application of aortic cross clamp. Materials and Methods: This study was carried out in the Department of Cardiothoracic and Vascular Surgery in a Tertiary Care Hospital over a period of 2 years. A total of 60 atrial septal defect (ASD) patients were operated and repair of the defect was done under the CPB using beating heart technique. Aortic cross clamp was applied in 22 patients (Group-A) while 38 patients were operated without cross clamp (Group-B) during the procedure. Blood samples were collected 24 hours prior and 12 hours post procedure for the estimation of CPK MB and cTnI levels. Results: Mean age of the atrial septal defect patients was 23.83±10.97 years and 60% and 40% of the patients were females and children (age < 18 years) respectively. Serum CPK-MB and cTnI l levels were in the normal range in all the patients before surgery and increased significantly post procedure. Twelve hours after surgery, the mean CPK-MB and cTnI levels were significantly low in Group-B patients compared to Group-A patients (CPK-MB: 56.39±23.55 U/L vs. 34.38±15.97U/L , p= 0.0004; cTnI: 9.37±4.97 ng/ml vs. 5.92±4.17ng/ml, p = 0.009). Conclusion: Post surgery CPK-MB and cTnI levels were significantly higher in ASD patients who underwent CPB surgery with aortic cross clamp compared to those in whom aortic cross clamp was not applied. Therefore, application of aortic cross clamp during the procedure induces greater levels of ischemic injury to the heart. IMC J Med Sci. 2023; 17(1): 001. DOI: https://doi.org/10.55010/imcjms.17.001 *Correspondence: Feroze Mohammad Ganai, Department of CVTS, Superspeciality Hospital, Shireen Bagh, Srinagar, Jammu and Kashmir, India. Email address: ferose999@yahoo.com

Prediction of hospital-onset COVID-19 infections using dynamic networks of patient contact: an international retrospective cohort study

BACKGROUND

Real-time prediction is key to prevention and control of infections associated with health-care settings. Contacts enable spread of many infections, yet most risk prediction frameworks fail to account for their dynamics. We developed, tested, and internationally validated a real-time machine-learning framework, incorporating dynamic patient-contact networks to predict hospital-onset COVID-19 infections (HOCIs) at the individual level.

METHODS

We report an international retrospective cohort study of our framework, which extracted patient-contact networks from routine hospital data and combined network-derived variables with clinical and contextual information to predict individual infection risk. We trained and tested the framework on HOCIs using the data from 51 157 hospital inpatients admitted to a UK National Health Service hospital group (Imperial College Healthcare NHS Trust) between April 1, 2020, and April 1, 2021, intersecting the first two COVID-19 surges. We validated the framework using data from a Swiss hospital group (Department of Rehabilitation, Geneva University Hospitals) during a COVID-19 surge (from March 1 to May 31, 2020; 40 057 inpatients) and from the same UK group after COVID-19 surges (from April 2 to Aug 13, 2021; 43 375 inpatients). All inpatients with a bed allocation during the study periods were included in the computation of network-derived and contextual variables. In predicting patient-level HOCI risk, only inpatients spending 3 or more days in hospital during the study period were examined for HOCI acquisition risk.

FINDINGS

The framework was highly predictive across test data with all variable types (area under the curve [AUC]-receiver operating characteristic curve [ROC] 0·89 [95% CI 0·88-0·90]) and similarly predictive using only contact-network variables (0·88 [0·86-0·90]). Prediction was reduced when using only hospital contextual (AUC-ROC 0·82 [95% CI 0·80-0·84]) or patient clinical (0·64 [0·62-0·66]) variables. A model with only three variables (ie, network closeness, direct contacts with infectious patients [network derived], and hospital COVID-19 prevalence [hospital contextual]) achieved AUC-ROC 0·85 (95% CI 0·82-0·88). Incorporating contact-network variables improved performance across both validation datasets (AUC-ROC in the Geneva dataset increased from 0·84 [95% CI 0·82-0·86] to 0·88 [0·86-0·90]; AUC-ROC in the UK post-surge dataset increased from 0·49 [0·46-0·52] to 0·68 [0·64-0·70]).

INTERPRETATION

Dynamic contact networks are robust predictors of individual patient risk of HOCIs. Their integration in clinical care could enhance individualised infection prevention and early diagnosis of COVID-19 and other nosocomial infections.

FUNDING

Medical Research Foundation, WHO, Engineering and Physical Sciences Research Council, National Institute for Health Research (NIHR), Swiss National Science Foundation, and German Research Foundation.

A Topic Modeling Analysis of the Crisis Response Stage during the COVID-19 Pandemic

The core of disaster management is the ability to respond spontaneously and rapidly to unexpected situations and also to apply planned and adaptable responses that follow manuals and guidelines. This study aimed to observe the changes in information during the COVID-19 pandemic period by collecting and analyzing information announced on a hospital intranet by an infection control team. This study performed text mining of large amounts of data to investigate notices about in-hospital strategies towards COVID-19 to identify changes in the coping strategies during the pandemic. Notices announced within the infection control rooms of 12 university hospitals in South Korea from 1 January to 31 August 2020 were searched. Four representative topics were identified based on the stepwise keywords shown in the topic modeling analysis: (1) “Understanding the new infectious disease”, (2) “Preparation of a patient care and management system”, (3) “Prevention of spread and securing employee safety” and (4) “Improvement of the management system according to the revision of guidelines”. Countries where an infectious disease emerges should provide accurate information on the disease and guidelines to determine how to respond. Medical institutions must revise and complement them while considering their specific circumstances. To efficiently respond to an infectious disease crisis, governments and medical institutions must cooperate closely, and implementing a systematic response is crucial.

COVID-19 and head and neck oncology

The COVID-19 pandemic has generated a plethora of unique challenges which have forced Otolaryngologists/Head and Neck Surgeons to adapt the ways in which patients with head and neck cancer are diagnosed and managed. This article aims to describe the impact of COVID-19 on the practice of head and neck oncology, as well as provide evidence-based management recommendations for head and neck cancer during a public health emergency such as the current pandemic.

Management strategy for control and prevention of SARS-CoV-2 infection in hospital settings - a brief review

The current pandemic of COVID-19 has spread worldwide rapidly. Many countries are struggling with the third pandemic wave despite having the vaccine distribution to frontline workers and people at high risk. Several studies have suggested a high possibility of hospital-acquired COVID-19. Therefore, it is vital to have proper recommendations and guidelines to prevent COVID-19 transmission in hospitals. Eliminating hospital-acquired infection is impossible, but reducing the rate and severity is possible by following appropriate guidelines. This paper reviews the strategies and recommendations that can be helpful for a hospital authority to control and prevent SARS-CoV-2 infection among the patients and healthcare workers. IMC J Med Sci 2022; 16(2): 006. DOI: https://doi.org/10.55010/imcjms.16.016 *Correspondence: Akash Ahmed, Department of Mathematics & Natural Sciences, BRAC University, Dhaka, Bangladesh. Email: akash.ahmed@bracu.ac.bd

Developing Novel Biointerfaces: Using Chlorhexidine Surface Attachment as a Method for Creating Anti-Fungal Surfaces

There is an increasing focus in healthcare environments on combatting antimicrobial resistant infections. While bacterial infections are well reported, infections caused by fungi receive less attention, yet have a broad impact on society and can be deadly. Fungi are eukaryotes with considerable shared biology with humans, therefore limited technologies exist to combat fungal infections and hospital infrastructure is rarely designed for reducing microbial load. In this study, a novel antimicrobial surface (AMS) that is modified with the broad-spectrum biocide chlorhexidine is reported. The surfaces are shown to kill the opportunistic fungal pathogens Candida albicans and Cryptococcus neoformans very rapidly (<15 min) and are significantly more effective than current technologies available on the commercial market, such as silver and copper.

Ethicomedicolegal aspects of the COVID-19 health services in preparing regulations and intermediaries for clinical dispute resolution: a systematic review

BACKGROUND The COVID-19 pandemic has caused many medical, ethical, and medicolegal changes, including constant adjustments in service guidelines. Continuing to revise healthcare regulations and guidelines can potentially cause clinical disputes or medical negligence that require ethical and legal solutions. This study aimed to determine the ethical and medicolegal aspects of the potential factors that cause clinical disputes during the pandemic and provide anticipative solutions to national ethicomedicolegal policies. METHODS A systematic literature search in PubMed, ScienceDirect, ClinicalKey, and Google Scholar was performed using keywords “clinical dispute,” “ethics,” “medicolegal,” “ethicolegal,” and “COVID-19”. The inclusion criteria were articles that contained information on shortage, justice, ethical distribution in intensive care, the possibility of lawsuits and disputes among stakeholders during the pandemic, and stakeholders’ roles in managing the pandemic. Key evidence was analyzed and synthesized following national ethicomedicolegal policies. RESULTS We identified 19 articles from the 4 databases. Based on the literature, the main ethicomedicolegal impact of the COVID-19 pandemic appears in 3 aspects: (1) a shortage of fair and ethical intensive care services with fair and ethical distribution efforts, (2) legal protection for medical personnel from legal charges while providing health services during the pandemic, and (3) the government’s role in managing the pandemic together with the stakeholders involved. CONCLUSIONS Ethicomedicolegal clinical dispute management and its norms require an update, especially when deciding the complexity of COVID-19 service standards. Ethicomedicolegal professionals are needed as intermediaries to manage cases of clinical disputes and to implement fair malpractice criteria in Indonesia.

Pediatric Dental Emergency Visits and Treatment during Lockdown in the COVID-19 Pandemic: A Retrospective Study

The COVID-19 pandemic has affected all the professions of life, particularly the healthcare sector. In dentistry, prevention of viral spread among healthcare professionals and patients was a substantial challenge. The virus can directly or indirectly infect dentists during dental procedures. This study focuses on the purpose of pediatric patients’ emergency visits to dental clinics and the treatments practiced during the lockdown. It compares the purpose of emergency pediatric patient visits in dental clinics and their treatments before, during, and after the lockdown periods. Computerized data for two consecutive years (2019 and 2020), between 19 March and 30 April and after the lockdown period from 1 May to 12 June 2020, were collected from five random dental clinics in Israel. The emergency visits of patients under 18 years before, during, and after the lockdown was organized into demographic characteristics, the purpose of the visits, and the treatments with medication or dental procedures. Categorical variables were compared and correlated with the chi-squared test and Pearson’s test, respectively, by using SPSS version 21. During the lockdown, emergency cases got appointments for a physical checkup. Herein, we found higher cases of emergency visits of pediatric patients with pain (n = 281, 32.6%) than trauma (n = 18, 24.7%), followed by infection (n = 31, 28.4%) and treatment continuation (n = 7, 20.6%) during the lockdown period, compared to before and after the lockdown periods. The patients treated with medication and dental procedures during lockdown were significantly different (p < 0.001) than before and after the lockdown. Extraction (n = 81, 41.5%), filling (n = 84, 50.6%), fluoride (n = 13, 92.9%), and pulp treatment (n = 92, 42.6%) were substantially practiced in pediatric patients during the lockdown. Further, this study confirmed the rapid adaptation of professional dentists to deal with non-vaccinated pediatric patients and reinforced the better preparation and requirements for such challenges in the future.

Seroprevalence of SARS-CoV-2 antibodies in healthcare workers at a tertiary care hospital in Riyadh, Saudi Arabia

Background

The SARS-CoV-2 pandemic has led to a strain on medical resources. The development of countermeasures to prevent its spread is evolving. Healthcare workers (HCWs) are at high risk for contracting and transmitting the disease.

Methods

Serology testing of volunteer HCWs was performed at King Faisal Specialist Hospital and Research Center in Riyadh (the Center) in order to determine the prevalence of SARS-CoV-2 antibodies, as well as the associated risk factors, in the hope of implementing adequate prevention and control measures.

Results

1076 subjects participated in this study, of whom 24.3% were seropositive. The majority were nurses (379, 35%) or physicians (245, 22.2%). 392 (36.4%) of the 1076 subjects were caregivers for COVID-19 patients, and 463 (43.0%) reported contact with infected employees. There was a statistically significant association between taking care of COVID-19 patients and being diagnosed with COVID-19 (chi-square test, p = 0.046). There was a significant association between being in contact with infected employees and having a positive IgG result (chi-square test, p < 0.001).

Conclusions

A baseline analysis of SARS-CoV-2 seropositivity in HCWs at a large tertiary care hospital in Riyadh was performed as the first part of a prospective study of HCWs. The reported seropositivity was 24.3% - higher than that of other hospitals in Riyadh. IgG testing was very useful in the detection of previous SARS-CoV-2 infection, as it has high negative predictive value.

Nationwide surveillance system to evaluate hospital-acquired COVID-19 in Brazilian hospitals

Background

Although the risk of SARS-CoV-2 transmission within hospitals has been well recognized, there is a paucity of data on its occurrence. Our aim was to report the incidence of hospital-acquired (HA) COVID-19 at Brazilian hospitals.

Methods

We investigated the incidence of HA COVID-19 in Brazilian hospitals using data from a national surveillance system, from August 2020 through September 2021. Definitions of HA COVID-19 were: (1) symptom onset >14 days after hospital admission plus a positive SARS-CoV-2 RNA or antigen test; (2) symptom onset on days 8–14 after admission, plus a positive SARS-CoV-2 RNA or antigen test positive, plus documented high-risk exposure. We performed descriptive analyses and reported HA COVID-19 rates using pooled mean and percentile distribution.

Results

A total of 48,634 cases of HA COVID-19 were reported from 1428 hospitals. Incidence ranged from 0.16/1000 patient-days at neonatal intensive care units (ICUs) to 5.8/1000 patient-days at adult ICUs. The highest incidence of HA COVID-19 was during the months March to July 2021, similar to that which was observed for community-acquired COVID-19.

Conclusions

This report provides a national view of the burden of HA COVID-19. The highest incidence of HA COVID-19 similar that which was observed for community-acquired COVID-19. We believe that this reflects the difficulty of implementing preventive measures. Further studies evaluating risk factors for the hospital transmission of SARS-Cov-2 should clarify strategies to minimize the risk of HA COVID-19 and may be applicable to other respiratory diseases. Furthermore, the implementation of a national system to evaluate HA COVID-19 has the potential to shine a light on this problem and lead to interventions in each hospital.

The Impact of the COVID-19 Pandemic on the Practice of Forensic Medicine: An Overview

During the COVID-19 pandemic, forensic sciences, on the one hand, contributed to gaining knowledge about different aspects of the pandemic, while on the other hand, forensic professionals were called on to quickly adapt their activities to respond adequately to the changes imposed by the pandemic. This review aims to clarify the state of the art in forensic medicine at the time of COVID-19, discussing the following: the influence of external factors on forensic activities, the impact of autopsy practice on COVID-19 and vice-versa, the persistence of SARS-CoV-2 RNA in post-mortem samples, forensic personnel activities during the SARS-CoV-2 pandemic, the global vaccination program and forensic sciences, forensic undergraduate education during and after the imposed COVID-19 lockdown, and the medico-legal implications in medical malpractice claims during the COVID-19 pandemic. The COVID-19 pandemic has greatly influenced different aspects of human life, and, accordingly, the practical activities of forensic sciences that are defined as multidisciplinary, involving different expertise. Indeed, the activities are very different, including crime scene investigation (CSI), external examination, autopsy, and genetic and toxicological examinations of tissues and/or biological fluids. At the same time, forensic professionals may have direct contact with subjects in life, such as in the case of abuse victims (in some cases involving children), collecting biological samples from suspects, or visiting subjects in the case of physical examinations. In this scenario, forensic professionals are called on to implement methods to prevent the SARS-CoV-2 infection risk, wearing adequate PPE, and working in environments with a reduced risk of infection. Consequently, in the pandemic era, the costs involved for forensic sciences were substantially increased.

Unplanned intubation after total hip and total knee arthroplasty: Assessing preoperative risk factors

OBJECTIVE

The purpose of this study is to assess preoperative patient attributes as risk factors for unplanned intubation after primary total knee and total hip arthroplasty.

METHODS

This was a retrospective analysis of data collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) who experienced postoperative intubation were included in the study. A multivariate regression was used to assess preoperative characteristics as risk factors for postoperative intubation.

RESULTS

Multivariate regression determined that perioperative transfusion of packed RBC's, cardiac comorbidities, patients older than 73, dyspnea with moderate exertion, dyspnea while at rest, diabetes mellitus requiring medical therapy, pulmonary comorbidities, current dialysis usage, body mass index greater than 29.9, and current smoker within the last year were variables associated with an increased risk of unplanned intubation after THA. Additionally, multivariate regression determined that anemia, perioperative transfusion of packed RBC's, cardiac comorbidities, patients older than 73, dyspnea with moderate exertion, diabetes mellitus requiring medical therapy, pulmonary comorbidities, and current dialysis usage were associated with unplanned intubation after TKA.

CONCLUSION

This study identifies numerous risk factors for intubation after THA or TKA.

Asymptomatic RT-PCR positive COVID-19 patients in orthopaedic pre-operative evaluation during the peak of the second wave

Introduction

Asymptomatic COVID-19 patients are the most challenging and feared obstacles in resuming these surgical procedures. The purpose of this study was to evaluate the proportion of asymptomatic carriers detected by RT-PCR in pre-operative orthopaedic evaluation during the peak of the second wave.

Methods

514 asymptomtomatic COVID-19 patients, negative for TOCC (Travel, Profession, Cluster, Contact) risk factors were observed retrospectively. A nasopharyFngeal RT-PCR test was obtained 48 to 72 h before the surgery in all cases. Possible risk factors for a positive test was identified.

Results

The detected asymptomatic COVID-19 infection rate during the peak of the second wave among the pre-operative orthopaedic patients was 12.3%. Younger age, female gender, longer duration of admission to RT-PCR test interval were found to be significant (p= < 0.05) risk factors for asymptomatic RT-PCR to be positive. The hazard ratio (HR) for being asymptomatic RT-PCR positive was 4.3 (p = 0. 025), while the RT-PCR was performed at 14 days, but the HR increased to 9.2 (p = 0.049) when the test was performed after 45 days.

Conclusion

According to our findings, pre-operative testing to rule out COVID-19 should be regarded as a critical step in preventing the disease clusters in hospitals.

Clinical impact of SARS-CoV-2 infection among patients with vulvar cancer: the Gemelli Vul.Can multidisciplinary team

BACKGROUND

'Severe acute respiratory syndrome coronavirus-2' (SARS-CoV-2) infection has dramatically affected the management of patients with cancer, who are most vulnerable to the consequences of the infection. Patients with vulvar cancer are frequently elderly and affected by multiple co-morbidities, thus representing a particularly frail population.

OBJECTIVE

To assess the clinical impact of the SARS-CoV-2 infection among patients scheduled for treatment for active vulvar cancer.

METHODS

Data on patients with vulvar tumors referred to Fondazione Policlinico Universitario Agostino Gemelli IRCCS between February 2020 and July 2021 were retrospectively analyzed. Patients with a positive reverse transcription polymerase chain reaction in nasopharyngeal swab were considered as positive for SARS-Cov-2.

RESULTS

One hundred and ninety-one patients with vulvar cancer were evaluated and scheduled for treatment. The median age was 72 years (range 35-94). Seven (3.7%) patients were diagnosed with SARS-Cov-2 infection: three (42.9%) had their treatment delayed, with no apparent consequences, two (28.6%) had their treatment delayed and later abandoned because of clinical worsening due to oncologic disease progression, and two (28.6%) contracted the infection in the post-operative period and died due to respiratory complications.

CONCLUSIONS

In most cases the infection had major clinical implications, being associated with significant delays in oncologic treatments and extremely high mortality when contracted in the post-operative period.

Identification of SARS-CoV-2 RNA in healthcare heating, ventilation, and air conditioning units

Evidence continues to grow supporting the aerosol transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To assess the potential role of heating, ventilation, and air conditioning (HVAC) systems in airborne viral transmission, this study sought to determine the viral presence, if any, on air handling units in a healthcare setting where coronavirus disease 2019 (COVID-19) patients were being treated. The presence of SARS-CoV-2 RNA was detected in approximately 25% of samples taken from ten different locations in multiple air handlers. While samples were not evaluated for viral infectivity, the presence of viral RNA in air handlers raises the possibility that viral particles can enter and travel within the air handling system of a hospital, from room return air through high-efficiency MERV-15 filters and into supply air ducts. Although no known transmission events were determined to be associated with these specimens, the findings suggest the potential for HVAC systems to facilitate transfer of virions to locations remote from areas where infected persons reside. These results are important within and outside of healthcare settings and may present necessary guidance for building operators of facilities that are not equipped with high-efficiency filtration. Furthermore, the identification of SARS-CoV-2 in HVAC components indicates the potential utility as an indoor environmental surveillance location.

Identification of SARS-CoV-2 RNA in healthcare heating, ventilation, and air conditioning units

Evidence continues to grow supporting the aerosol transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To assess the potential role of heating, ventilation, and air conditioning (HVAC) systems in airborne viral transmission, this study sought to determine the viral presence, if any, on air handling units in a healthcare setting where coronavirus disease 2019 (COVID-19) patients were being treated. The presence of SARS-CoV-2 RNA was detected in approximately 25% of samples taken from ten different locations in multiple air handlers. While samples were not evaluated for viral infectivity, the presence of viral RNA in air handlers raises the possibility that viral particles can enter and travel within the air handling system of a hospital, from room return air through high-efficiency MERV-15 filters and into supply air ducts. Although no known transmission events were determined to be associated with these specimens, the findings suggest the potential for HVAC systems to facilitate transfer of virions to locations remote from areas where infected persons reside. These results are important within and outside of healthcare settings and may present necessary guidance for building operators of facilities that are not equipped with high-efficiency filtration. Furthermore, the identification of SARS-CoV-2 in HVAC components indicates the potential utility as an indoor environmental surveillance location.

A Systematic Review and Meta-Analysis of Inpatient Mortality Associated With Nosocomial and Community COVID-19 Exposes the Vulnerability of Immunosuppressed Adults

Background

Little is known about the mortality of hospital-acquired (nosocomial) COVID-19 infection globally. We investigated the risk of mortality and critical care admission in hospitalised adults with nosocomial COVID-19, relative to adults requiring hospitalisation due to community-acquired infection.

Methods

We systematically reviewed the peer-reviewed and pre-print literature from 1/1/2020 to 9/2/2021 without language restriction for studies reporting outcomes of nosocomial and community-acquired COVID-19. We performed a random effects meta-analysis (MA) to estimate the 1) relative risk of death and 2) critical care admission, stratifying studies by patient cohort characteristics and nosocomial case definition.

Results

21 studies were included in the primary MA, describing 8,251 admissions across 8 countries during the first wave, comprising 1513 probable or definite nosocomial COVID-19, and 6738 community-acquired cases. Across all studies, the risk of mortality was 1.3 times greater in patients with nosocomial infection, compared to community-acquired (95% CI: 1.005 to 1.683). Rates of critical care admission were similar between groups (Relative Risk, RR=0.74, 95% CI: 0.50 to 1.08). Immunosuppressed patients diagnosed with nosocomial COVID-19 were twice as likely to die in hospital as those admitted with community-acquired infection (RR=2.14, 95% CI: 1.76 to 2.61).

Conclusions

Adults who acquire SARS-CoV-2 whilst already hospitalised are at greater risk of mortality compared to patients admitted following community-acquired infection; this finding is largely driven by a substantially increased risk of death in individuals with malignancy or who had undergone transplantation. These findings inform public health and infection control policy and argue for individualised clinical interventions to combat the threat of nosocomial COVID-19, particularly for immunosuppressed groups.

Systematic Review Registration

PROSPERO CRD42021249023.

The Transbrachial Venous Approach for Pelvic Congestion Syndrome Embolization: An Easy Way to Outpatient Procedure

BACKGROUND

Pelvic congestion syndrome (PCS) is a frequent finding in adult women and transcatheter embolization of dilated and refluxing veins is the treatment of choice. The procedure can be performed through different venous accesses such as the transfemoral, transjugular, and the transbrachial access. The aim of this study was to demonstrate the feasibility and safety of the transbrachial approach for transcatheter embolization in this pathology in 201 women. Advantages and disadvantages of this access were discussed.

METHODS

Between January 2007 and October 2020, female patients who underwent transcatheter embolization for PCS were selected. Embolization procedural details such as venous access sites and embolized veins were collected.

RESULTS

Two hundred and one patients were selected for pelvic vein embolization due to PCS. The basilic vein was punctured in 103 patients (51.2%), the cephalic vein was chosen in 76 patients (37.8%) and deep brachial veins in 19 (9.6%). Technical success was observed in 198 (98.5%) cases. Only one major adverse effect was registered; one patient presented with hematoma of the arm that could be managed conservatively.

CONCLUSION

The transbrachial venous approach for PCS embolization is safe, effective and minimal invasive. It provides a significant patient comfort, has a low complication rate and can be performed on an outpatient basis.

Controversies and Challenges of Mass Vaccination against SARS-CoV-2 in Italy: Medico-Legal Perspectives and Considerations

The worldwide spread of SARS-CoV-2 and the pandemic has resulted in a serious global crisis in the health, social and economic spheres. After an initial period of enthusiasm related to the efficacy of vaccines, in many European countries, a growing distrust in the population has matured, due to the reporting of severe adverse effects. Throughout the world, some cases of adverse events after the administration of the vaccine have been reported. In this communication, we want to discuss all the medico-legal aspects related to the global vaccination companion in terms of medical professional responsibility, informed consent and vaccination obligation, with particular attention to the Italian situation. Health professionals are tasked with promoting confidence in vaccination for the general population. Complete and detailed information and reliance on scientific research is essential to understand the great importance of the vaccination campaign. From a criminal point of view, we must avoid blaming health professionals in the case of side effects. At the same time, we must protect the population, ensuring compliance with the indications, guidelines, and an adequate method of administration. On the other hand, from a civil law perspective, it is correct to ensure full protection of those rare cases in which the administration of the vaccine is related to adverse events. Without a broad and global vaccination campaign, it will be impossible to overcome COVID-19.

Antimicrobial Properties of Lepidium sativum L. Facilitated Silver Nanoparticles

Antibiotic resistance toward commonly used medicinal drugs is a dangerously growing threat to our existence. Plants are naturally equipped with a spectrum of biomolecules and metabolites with important biological activities. These natural compounds constitute a treasure in the fight against multidrug-resistant microorganisms. The development of plant-based antimicrobials through green synthesis may deliver alternatives to common drugs. Lepidium sativum L. (LS) is widely available throughout the world as a fast-growing herb known as garden cress. LS seed oil is interesting due to its antimicrobial, antioxidant, and anti-inflammatory activities. Nanotechnology offers a plethora of applications in the health sector. Silver nanoparticles (AgNP) are used due to their antimicrobial properties. We combined LS and AgNP to prevent microbial resistance through plant-based synergistic mechanisms within the nanomaterial. AgNP were prepared by a facile one-pot synthesis through plant-biomolecules-induced reduction of silver nitrate via a green method. The phytochemicals in the aqueous LS extract act as reducing, capping, and stabilizing agents of AgNP. The composition of the LS-AgNP biohybrids was confirmed by analytical methods. Antimicrobial testing against 10 reference strains of pathogens exhibited excellent to intermediate antimicrobial activity. The bio-nanohybrid LS-AgNP has potential uses as a broad-spectrum microbicide, disinfectant, and wound care product.

Acute leukemia and SARS-CoV-2 infection: clinical characteristics and risk factors for mortality

Patients with acute leukemia (AL) have a high mortality rate from coronavirus disease 2019 (COVID-19). However, studies including patients with AL and COVID-19 are few. Fifty-one patients with AL and COVID-19 were included in our study. The mortality rate was 17/51 (29.4%). In all cases, death was associated with COVID-19 pneumonia. The major driver of outcome was the disease status (worse outcome was observed in newly diagnosed (OR, 6.00; 95% CI, 1.133 - 15.188) and patients with bone marrow aplasia (OR 4.148 [95% CI 1.133 - 15.188])). Higher mortality rate was associated with lower platelet count, prolonged PT, higher ISTH DIC score, CRP and LDH. Moreover, careful risk-benefit assessment regarding the continuation of anticancer therapy is required in patients receiving nonintensive and supportive therapy. Considering the high frequency of intrahospital viral transmission (50.98%), isolation of AL patients in single rooms, and permanent symptom monitoring and testing should be prioritized.

Impact of COVID-19 on Outcomes for Patients With Cervical Cancer in India

PURPOSE

The COVID-19 pandemic has placed unprecedented demands on the health system. This led to delays in the initiation and completion of cancer treatment. We assessed the long-term health consequences because of the delay in diagnosis and treatment for cervical cancer due to COVID-19 in India.

METHODS

We used a Markov-model–based analysis assessing the lifetime health outcomes of the cohort of women population at risk from cervical cancer in India. The decrease in survival for those with the treatment interruption was calculated based on the number of days the treatment was extended beyond the standard duration. Furthermore, to model the impact of late diagnosis and delayed treatment initiation, the patients were assumed to have upstaged during the delay period, as per natural progression of disease.

RESULTS

We estimate 2.52% (n = 795) to 3.80% (n = 2,160) lifetime increase in the deaths caused by cervical cancer with treatment restrictions ranging from 9 weeks to 6 months, respectively, as compared to no delay. On the contrary, 88-238 deaths because of COVID-19 disease are estimated to be saved during this restriction period among the patients with cervical cancer. Overall, the excess mortality because of cervical cancer led to 18,159-53,626 life-years being lost and an increase of 16,808-50,035 disability-adjusted life-years.

CONCLUSION

Delays in diagnosis and treatment are likely to lead to more cervical cancer deaths as compared to COVID-19 mortality averted among the patients with cervical cancer. Health systems must reorganize in terms of priority setting for provision of care, starting with prioritizing the treatment of patients with early-stage cervical cancer, increasing use of teleconsultation, and strengthening the role of primary care physicians in provision of cancer care.

Facile Synthesis of Bio-Antimicrobials with "Smart" Triiodides

Multi-drug resistant pathogens are a rising danger for the future of mankind. Iodine (I₂) is a centuries-old microbicide, but leads to skin discoloration, irritation, and uncontrolled iodine release. Plants rich in phytochemicals have a long history in basic health care. Aloe Vera Barbadensis Miller (AV) and Salvia officinalis L. (Sage) are effectively utilized against different ailments. Previously, we investigated the antimicrobial activities of smart triiodides and iodinated AV hybrids. In this work, we combined iodine with Sage extracts and pure AV gel with polyvinylpyrrolidone (PVP) as an encapsulating and stabilizing agent. Fourier transform infrared spectroscopy (FT-IR), Ultraviolet-visible spectroscopy (UV-Vis), Surface-Enhanced Raman Spectroscopy (SERS), microstructural analysis by scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS), and X-Ray-Diffraction (XRD) analysis verified the composition of AV-PVP-Sage-I₂. Antimicrobial properties were investigated by disc diffusion method against 10 reference microbial strains in comparison to gentamicin and nystatin. We impregnated surgical sutures with our biohybrid and tested their inhibitory effects. AV-PVP-Sage-I₂ showed excellent to intermediate antimicrobial activity in discs and sutures. The iodine within the polymeric biomaterial AV-PVP-Sage-I₂ and the synergistic action of the two plant extracts enhanced the microbial inhibition. Our compound has potential for use as an antifungal agent, disinfectant and coating material on sutures to prevent surgical site infections.

COVID-19 Pandemic and Equal Access to Vaccines

The COVID-19 pandemic has evidenced the chronic inequality that exists between populations and communities as regards global healthcare. Vaccination, an appropriate tool for the prevention of infection, should be guaranteed by means of proportionate interventions to defeat such inequality in populations and communities affected by a higher risk of infection. Equitable criteria of justice should be identified and applied with respect to access to vaccination and to the order in which it should be administered. This article analyzes, as regards the worldwide distribution of anti-COVID-19 vaccines, the various ways the principle of equity has been construed and applied or even overlooked. The main obstacle to equal access to vaccines is vaccine nationalism. The perception of equity varies with the differing reference values adopted. Adequate response to needs appears to be the principal rule for achieving the criterion of equity in line with distributive justice. Priorities must be set equitably based on rational parameters in accordance with current needs. The entire process must be governed by transparency, from parameter identification to implementation. The issue of equal access to vaccination affects the entire world population, necessitating specific protective interventions. In light of this, the World Health Organization (WHO) has devised the COVAX plan to ensure that even the poorest nations of the world receive the vaccine; certain initiatives are also supported by the European Union (EU). This pandemic has brought to the fore the need to build a culture of equitable relationships both in each country’s own domain and with the rest of the world.

Effect of e-Health Literacy on COVID-19 Infection-Preventive Behaviors of Undergraduate Students Majoring in Healthcare

This study examined and verified the level of e-health literacy (e-HL) and infection preventive behaviors related to COVID-19 among undergraduate students majoring in healthcare. An online survey was conducted with 274 university students majoring in nursing, clinical pathology, and occupational therapy in South Korea. The e-HL consisted of functional, communicational, and critical literacy, and preventive behaviors were based on the Prevention Guideline on Droplet Infection. The mean score for e-HL was 3.62, with nursing students obtaining the highest scores. The overall e-HL score and the scores on its three sub-dimensions were related to infection-preventive behaviors. Moreover, e-HL affected infection-preventive behaviors (p < 0.001). Findings from this study highlight the necessity of education for improving the e-HL of undergraduate students majoring in healthcare to strengthen infection-preventive behaviors and protect patients from infectious diseases.

Fit Testing Retrofitted Full-Face Snorkel Masks as a Form of Novel Personal Protective Equipment During the COVID-19 Pandemic

Objective: Bottlenecks in the personal protective equipment (PPE) supply chain have contributed to shortages of PPE during the COVID-19 pandemic, resulting in fractures in the functionality of healthcare systems. This study was conducted with the aim of determining the effectiveness of retrofitted commercial snorkel masks as an alternative respirator for healthcare workers during infectious disease outbreaks.Methods: A retrospective analysis was performed, analyzing qualitative and quantitative fit test results of the retrofitted Aria Ocean Reef® full-face snorkeling mask on healthcare workers at the McGill University Health Centre between April-June 2020. Historical fit test results, using medical-grade respirators, for healthcare workers were also analyzed.Results: During the study period, 71 participants volunteered for fit testing, 60.6% of which were nurses. The overall fit test passing rate using the snorkel mask was 83.1%. Of the participants who did not previously pass fit testing with medical-grade respirators, 80% achieved a passing fit test with the snorkel respirator.Conclusions: The results suggest that this novel respirator may be an effective and feasible alternative solution to address PPE shortages, while still providing healthcare workers with ample protection. Additional robust testing will be required to ensure that respirator fit is maintained, after numerous rounds of disinfection.

COVID-19-related deaths in residential care homes for elderly: The situation in Italy

The whole population is susceptible to infection but elderly people with previous diseases are at greater risk. All these epidemiological data show that older age represents an important risk factor for infection and especially for mortality. In recent weeks an increase in mortality among the elderly has been observed in many Italian residential care homes. In these accommodations a worrying spread of COVID-19 cases has been ascertained. According to the ISS report, 7.4% of the total deaths in care homes for elderly involved patients with SARS-CoV-2 infection and 33.8% involved patients with flu-like symptoms.

Herein, we discuss the dangerous spread of COVID-19 in residential care homes for elderly. In addition, we present a case of an elderly person admitted to a residential care home, whose COVID-19 diagnosis was performed only after death.

Antimicrobial Hexaaquacopper(II) Complexes with Novel Polyiodide Chains

The non-toxic inorganic antimicrobial agents iodine (I2) and copper (Cu) are interesting alternatives for biocidal applications. Iodine is broad-spectrum antimicrobial agent but its use is overshadowed by compound instability, uncontrolled iodine release and short-term effectiveness. These disadvantages can be reduced by forming complex-stabilized, polymeric polyiodides. In a facile, in-vitro synthesis we prepared the copper-pentaiodide complex [Cu(H2O)6(12-crown-4)5]I6 · 2I2, investigated its structure and antimicrobial properties. The chemical structure of the compound has been verified. We used agar well and disc-diffusion method assays against nine microbial reference strains in comparison to common antibiotics. The stable complex revealed excellent inhibition zones against C. albicans WDCM 00054, and strong antibacterial activities against several pathogens. [Cu(H2O)6(12-crown-4)5]I6 · 2I2 is a strong antimicrobial agent with an interesting crystal structure consisting of complexes located on an inversion center and surrounded by six 12-crown-4 molecules forming a cationic substructure. The six 12-crown-4 molecules form hydrogen bonds with the central Cu(H2O)6. The anionic substructure is a halogen bonded polymer which is formed by formal I5- repetition units. The topology of this chain-type polyiodide is unique. The I5- repetition units can be understood as a triodide anion connected to two iodine molecules.