Implementation of community health care services to counter the SARS-CoV2 pandemic

BACKGROUND

The COVID-19 pandemic has ravaged many countries worldwide since December 2019. The high infection rates, and the need for health care assistance for individuals with comorbidities, strained the national health care systems around the world. Outbreak peaks increased the burden on hospitals that where perceived as high-risk places by people, who often decided to cancel or defer hospital visits. Thus, Italian Local Health Authorities had to develop new organizational models to meet the increased health care needs of the population. The aim of this study is to assess the impact of strengthened community health services on the hospital burden.

METHODS

We analysed the number of Emergency Department access at the Hospital De Lellis covered by the Local Health Authority in Rieti, from March 2020 to November 2021. We then assessed the effects of community health services: the Special District Continuing Care Units (SDCUs) and the the COVID hub, on the COVID-19-related ED access, admission and mortality rates. A Chi-squared test for trend and three multivariable logistic regression models were used to investigate the trends and the possible predictors of COVID ED access, COVID hospital admissions, and deaths.

RESULTS

Being male (OR = 1.41, CI95% 1.05-1.90; p = 0.022) and older age (OR = 1.03, CI95% 1.02-1.04; p < 0.0001) increase the likelihood of hospitalisation for Sars-CoV-2. The implementation of the nursing and medical SDCUs contributed to reducing COVID-19-related deaths (OR = 0.09, CI95% 0.03-0.29; p < 0.0001). The simultaneous implementation of the COVID hub and of the nursing SDCUs had a synergistic effect in reducing the likelihood of hospitalisation (OR = 0.24, CI95% 0.09-0.65; p = 0.005). The subsequent implementation of the medical SDCUS has further contributed to lowering the admission rates. These protective effects persisted also after potential cofounders, such as age, sex, clinical condition on admission, and the immunisation status, were adjusted.

CONCLUSIONS

These measures have helped in the management of patients in a complex context such as that of a pandemic by reducing the hospital load and playing an important role in the management of the pandemic. Further studies could assess the transferability of this model in a non-pandemic context.

Porphyromonas gingivalis and the pathogenesis of rheumatoid arthritis: analysis of various compartments including the synovial tissue

Introduction

We evaluated the presence of Porphyromonas gingivalis (Pg) DNA in the synovial tissue through synovial biopsy and in other compartments of rheumatoid arthritis (RA) patients in comparison with patients affected by other arthritides. Possible links with clinical, immunologic and genetic features were assessed.

Methods

Peripheral blood (PB), sub-gingival dental plaque, synovial fluid (SF) and synovial tissue samples were collected from 69 patients with active knee arthritis (32 with RA and 37 with other arthritides, of which 14 had undifferentiated peripheral inflammatory arthritis - UPIA). Demographic, clinical, laboratory and immunological data were recorded. The presence of Pg DNA was evaluated through PCR. The HLA-DR haplotype was assessed for 45 patients with RA and UPIA.

Results

No differences arose in the positivity for Pg DNA in the sub-gingival plaque, PB and SF samples between RA and the cohort of other arthritides. Full PB samples showed a higher positivity for Pg DNA than plasma samples (11.8% vs. 1.5%, P = 0.04). Patients with RA showed a higher positivity for Pg DNA in the synovial tissue compared to controls (33.3% vs. 5.9%, P <0.01). UPIA and RA patients carrying the HLA DRB1*04 allele showed a higher positivity for Pg DNA in the synovial tissue compared to patients negative for the allele (57.1% vs. 16.7%, P = 0.04). RA patients positive for Pg DNA in the sub-gingival plaque had a lower disease duration and a higher peripheral blood leucocyte and neutrophil count. The presence of Pg DNA did not influence disease activity, disease disability or positivity for autoantibodies.

Conclusions

The presence of Pg DNA in the synovial tissue of RA patients suggests a pathogenic role of the bacterium. The higher positivity of Pg DNA in full peripheral blood and synovial tissue samples compared to plasma and synovial fluid suggests a possible intracellular localization of Pg, in particular in patients positive for HLA-DR4.

Association between the response to B cell depletion therapy and the allele*2 of the HS1,2A enhancer in seropositive rheumatoid arthritis patients

OBJECTIVE

Several studies underline the relevance of the genetic background for the response to therapy. We evaluated the relationship between the polymorphism of the HS1,2A enhancer, located in the 3' regulatory region of the heavy immunoglobulin chain (IgH), and the response to B cell depletion therapy (BCDT) with Rituximab (RTX).

METHODS

Fifty rheumatoid arthritis (RA) patients (42 women; disease duration 13.9 ± 10.6 years) treated with RTX, not responsive to previous DMARDs and/or TNFα inhibitors therapies, and 220 healthy subjects were enrolled in the study. Patients were genotyped for HS1,2A enhancer polymorphism, as previously described. Disease activity was assessed every three months according to the European League Against Rheumatism's (EULAR) criteria.

RESULTS

All RA patients were seropositive for at least one of the tested autoantibodies: rheumatoid factor (FR IgA, FR IgM e FR IgG), anti-cyclic citrullinated peptides (anti-CCP IgA, anti-CCP IgM e anti-CCP IgG) and anti-vimentin antibodies. RA patients had an increased frequency of the allele*2 (60.0%) of the HS1,2A enhancer compared to healthy subjects (42.0%; OR(95%ICs): 2.07 (1.33-3.22)). Patients with a good EULAR response at 6 months follow-up visit had an increased frequency of genotype 2/2 (47.1%) compared to poor-responders RA patients (genotype 2/2: 18.2%, OR(95%ICs): 4.00 (1.09-14.68)). All the patients with a good EULAR response had the allele*2, thus showing a possible association with the allele in this population.

CONCLUSIONS

The presence of allele*2 seems to be related to a good response to BCDT with RTX in seropositive RA patients, thus highlighting the role of the HS1,2A enhancer in B cell maturation and class-switch recombination.

PTPN22 1858C>T polymorphism distribution in Europe and association with rheumatoid arthritis: case-control study and meta-analysis

Objective

The PTPN22 rs2476601 polymorphism is associated with rheumatoid arthritis (RA); nonetheless, the association is weaker or absent in some southern European populations. The aim of the study was to evaluate the association between the PTPN22 rs2476601 polymorphism and RA in Italian subjects and to compare our results with those of other European countries, carrying out a meta-analysis of European data.

Methods

A total of 396 RA cases and 477 controls, all of Italic ancestry, were genotyped for PTPN22 rs2476601 polymorphism. Patients were tested for autoantibodies positivity. The meta-analysis was performed on 23 selected studies.

Results

The PTPN22 T1858 allele was significantly more frequent in RA patients compared to controls (5.7% vs. 3.7%, p = 0.045). No clear relationship arose with the autoantibodies tested. The 1858T allele frequency in Italian RA patients was lower than the one described in northern European populations and similar to the frequency found in Spain, Turkey, Greece, Tunisia. A clear-cut North-South gradient arose from the analysis.

Conclusions

The PTPN22 T1858 allele is associated with RA in the Italian population. A North-South gradient of the allele frequency seems to exist in Europe, with a lower prevalence of the mutation in the Mediterranean area.