The role of skin tests with polyethylene glycol and polysorbate 80 in the vaccination campaign for COVID-19: results from an Italian multicenter survey

Summary

Background. International guidelines suggested skin tests with Polyethylene-glycol (PEG) and polysorbate 80 (PS-80), to investigate a possible hypersensitivity to these excipients either to identify subjects at risk of developing allergic reactions to Covid-19 vaccines, or in patients with suspected IgE mediated hypersensitivity reactions (HR) to the Covid-19 vaccine. The main purpose of this study was to investigate the prevalence of PEG and PS sensitization in patients with a clinical history of HR to drugs containing PEG/PS and in patients with a suspected Covid-19 vaccine immediate HR. Methods. This was a multicenter retrospective study conducted by allergists belonging to 20 Italian medical centers. Skin testing was performed in 531 patients with either a clinical history of suspected hypersensitivity reaction (HR) to drugs containing PEG and/or PS-80 (group 1:362 patient) or a suspected HR to Covid-19 vaccines (group 2: 169 patient), as suggested by the AAIITO/SIAAIC guidelines for the "management of patients at risk of allergic reactions to Covid-19 vaccines" [1]. Results. 10/362 (0.02%) had positive skin test to one or both excipients in group 1, 12/169 (7.1%) in group 2 (p less than 0.01). In group 2 HRs to Covid-19 vaccines were immediate in 10/12 of cases and anaphylaxis occurred in 4/12 of patients. Conclusions. The positivity of skin test with PEG and or PS before vaccination is extremely rare and mostly replaceable by an accurate clinical history. Sensitization to PEG and PS has to be investigated in patients with a previous immediate HR to a Covid-19 vaccine, in particular in patients with anaphylaxis.

P340 PARADOXICAL DIVERGENCE BETWEEN RATE OF SURVIVAL AND QUALITY INDICATOR OF CARE IN MYOCARDIAL INFARCTION ACCORDING TO PNE–AGENAS (ITALIAN NATIONAL HEALTHCARE OUTCOMES PROGRAM)

Background

The Italian National Healthcare Outcomes Program (PNE – AGENAS) each year provides quality performance measures for our Hospitals. Some measures refer directly to hard events such as mortality, others are focused over procedures that should be related to subsequent events, including mortality. The rate of PCI performed within 48 hours (48h–PCI) in patients with acute myocardial infarction (AMI) is currently used as a performance measures. An arbitrary standard of 35–40% of 48h–PCI for patients with AMI is considered the goal for a satisfactory practice.

Methods

We analyzed the PNE–AGENAS performance measures for the year 2020. Overall 1652 MI have been recorded in 2020 in Tuscany. We considered those Hospitals with > 100 AMI. We related the 30 day and one–year mortality with the 48h–PCI of the 20 Hospitals identified. Of these latter 13 are Hospitals with a 24h PCI service.

Results

All the hospitals hosting a catheterization laboratory largely overcame the 48h–PCI quality standard although with a wide variation among sites (70,8 – 90.4%). On the contrary all the Hospitals without a cath–lab did not even approach the standard (0–33.%). The analysis of the mortality data both at 30 day and at 1 year showed a wide variability among Hospitals without an appreciable difference. The 30–day mortality rate ranged from 2 to 15% without any relationship with the 48h–PCI. In some cases better survival rates were recorded for those Hospitals with the worse 48h–PCI.

Conclusions

Several factors makes 48h–PCI a useless and even confounding measure of performance. As a matter of fact this measure does not consider the type of MI treated (STEMI vs NSTEMI), nor the presence or not of a cath lab. Also it does not take account for the case mix of the population of AMI treated. Patients with STEMI represents about 30% of the activity of an Hospital with a 24h cath –lab. It is obviously easy for such an Hospital to satisfy the proposed standard as these patients should receive their PCI well before 24 hours. The contemporary organizations do cooperate and are organized as networks. The 48h–PCI should be only used to evaluate these networks, not the single hospitals. In conclusion our analysis by showing the divergent and paradoxical phenomena of better or similar survival in spite of longer or similar 48hPCI highlights the need to abandon this useless and even confounding measure to evaluate the Cardiology practice in the Italian Hospital.

P32 SELF–LEARN IMPLEMENTATION OF ULTRASOUND FOR THE STUDY AND ULTRASOUND–GUIDED PUNCTURE OF VASCULAR ACCESSES IN THE IMPLANTATION OF PACEMAKERS AND IMPLANTABLE DEFIBRILLATORS

Background

The vascular access represents a crucial phase in the management of complications related to the implantation of devices. After the use of the axillary vein, which allows the elimination of intrathoracic complications as well as the subclavian crush of the catheters, the ultrasound–guided approach could represent the next step for the reduction of vascular complications.

Experience

All implants performed (n = 86) by an independent operator who implemented ultrasound to minimize complications related to central access were reviewed. During the first phase, the ultrasound–guided approach involved the study of vascular accesses before the start of the implant. The assessment took place before the preparation of the sterile field, for the localization of the axillary approach and for the study of the anatomical variants. It was immediately followed by the use of skin marks. The use of markers made it possible to attempt surgical isolation of the cephalic vein as a first approach. In case of failure, or the need for multiple accesses, the transition to central access could be facilitated by the presence of skin markers. This approach have not significantly modified the probability of successful axillary vein puncture without the use of venography (75% vs 71%, p NS). In the last phase all implants were performed with ultrasound–guided puncture with sterile technique before skin incision (n = 26). The procedures involved dual chamber (61%), single chamber (19%), CRTD (11%), dual chamber ICD. Ultrasound showed all cases of hypoplastic cephalic vein (15%). In the first three months of implementation, the success rate was 71.4% with 1 self–healing case of apical pneumothorax. In the following months the success rate rapidly increased to 94.1% (p < 0.05) with no pneumo or hemothorax. The median time to effective puncture was 28 seconds (8–450sec) in the second phase. It was possible to isolate the cephalic vein in 40% of cases for two or three chamber implants.

Conclusions

The ultrasound study of the accesses performed before the incision allows to identify the anatomy and to define the course of the axillary vascular system and its relationships. When performed with a sterile approach, it allows direct ultrasound–guided puncture before the surgical incision, with a high success rate from the early stages of implementation.

The Clean Care Contest: promoting hand hygiene among healthcare and medical students

INTRODUCTION

Despite continuing efforts, compliance rates and knowledge of best practices in hand hygiene remain disappointing. Recognizing that conventional educational tools seem out of touch with young people and that the med and messages contents need refreshing, the Italian Study Group of Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health devised a novel approach to promote the creation of innovative educational tools for improving knowledge of, and compliance with, hand hygiene rules among healthcare and medical students.

METHODS

A contest in creating educational material on hand hygiene practices involved university students of nursing and medicine, and of other healthcare degrees. Students from the universities of the GISIO network were invited to create educational material (e.g., videos, posters, presentations, leaflets, and screensavers) to be presented by May 5th 2019 during the World Hand Hygiene Day / Save Lives: Clean Your Hands Global Annual Initiative of the World Health Organization). A local and a national winners were awarded.

RESULTS

Three different local and national contests were performed during 2016, 2017 and 2018. During the three-year period, more than 270 educational tools have been developed: 130 (48%) were judged useful for hand hygiene promotion campaigns. The most frequent projects participating in the contests were videos (39%), posters (29%), leaflets (14%), and others (18%) submitted by more than 1,500 students of nursing (40%), medicine (31%), dentistry (7%), and of other healthcare courses in 14 universities. Products were evaluated by a local committee and, subsequently, local winners represented their University in a national contest.

CONCLUSIONS

The contest provided a framework for the creation of innovative and potentially effective educational tools via an engaging approach that leveraged student creativity. Given the need to improve compliance rates, this study suggests that new ways can be advantageously explored to teach hand hygiene procedures and increase awareness of the importance of their consistent use among healthcare and medical students.

Silent cerebral embolisation during TAVI: evolution, predictors and neurocognitive effects

Background

Most patients undergoing transcatheter aortic valve implantation (TAVI) develop silent cerebral ischemic lesions (SCIL) detectable at magnetic resonance imaging (MRI). The natural history and clinical relevance of SCIL are not well established. We aimed to assess the characteristics, predictors, evolution, and neurocognitive effects of SCIL.

Methods

Cerebral MRI was performed within 7 days before TAVI to assess baseline status and age-related white matter changes (ARWMC) score. MRI was repeated postoperatively to assess the occurrence, location, number and dimensions of SCIL. Patients developing SCIL underwent a third MRI at 3–5 months follow-up. A neurocognitive evaluation was performed before TAVI, at discharge and at 3-month follow-up.

Results

Of the 117 patients enrolled, 96 underwent a postprocedural MRI; SCIL were observed in 76% of patients, distributed in all vascular territories, with a median number of 2 lesions, median diameter 4.5 mm, and median total volume 140 mm3. Independent predictors of SCIL occurrence were a higher baseline ARWMC score and the use of self-expanding or mechanically-expanded bioprostheses. Among 47 patients who underwent follow-up MRI, only 26.7% of postprocedural SCIL evolved into a gliotic scar. SCIL occurrence was associated with a more pronounced transient neurocognitive decline early after TAVI and with a lower recovery at follow-up.

Conclusions

SCIL occur in the vast majority of patients undergoing TAVR and are predicted by a more diffuse white matter damage at baseline and by the use of non-balloon-expandable prostheses. Although most SCIL disappear within months, their occurrence has a limited but significant impact on neurocognitive function.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): unrestricted grants from Edwards Lifesciences SA, Nyon, Switzerland, and from Medtronic Italia SpA, Milan, Italy

SARS-CoV-2: Sanitize a hospital

Issue

During the SARS-CoV-2 pandemic, several critical issues emerged. One of these was to identify which was the best terminal disinfection strategy for hospital rooms of a COVID-19. Description of the problem. Our University Hospital adopted ozone disinfection two years ago, recognized internationally as a 'safe gas' and is an excellent disinfectant for its characteristics of attacking and oxidizing each type of organic and inorganic compound and specifically also works against SARS-CoV-2.

Results

23 ozone generators were purchased, 20 ozonizers were assigned to departments with high environmental sanitation needs, 3 ozonizers supplied to the ozonator team. For the correct use of the equipment, 200 operators were trained in a certified way. The rooms are ozonated with pre-established frequency and whenever a COVID-19 patient is cared for. The ozonation team sanitizes rooms in wards that are not equipped but that may have hosted patients with carriers. Indications have been given in all the wards to create the ozonation room, that can be used as an ozone disinfection chamber, where it is possible to place garrisons and furnishings, even large-sized, that cannot be disinfected in other ways (in addition to sanitization with hypochlorite). The team also provides for the ozonation of ambulances with a predetermined periodicity or in the case of transport of patient carrying SARS-CoV-2. All activities are monitored with a special traceability card.

Lessons

Terminal disinfection of environments that have hosted patients with COVID-19. Terminal disinfection of the devices used on patients with COVID-19. Increased safety for operators carrying out environmental sanitation.

Key messages

Fight SARS-COV-2 with ozone.

Disinfecting with ozone is safety for everyone.

Reverse shoulder arthroplasty using a "L" shaped allograft for glenoid reconstruction in a patient with massive glenoid bone loss: case report

Primary reverse total shoulder arthroplasty (RSA) has demonstrated to relieve pain, restore function and active elevation in patients with Cuff Tear Arthropathy. This condition of muscular imbalance could lead, in the long-term, to morphologic changes of the glenoid's anatomy. Insufficient bone stock of glenoid is a major challenge and without reconstruction, may be inadequate to support a glenoid component. Many authors have proposed the use of a bone graft in these cases and different techniques have been described to reconstruct severe bone loss of the glenoid but no ideal approach has currently been identified. We report the use of a "L" shaped frozen allograft for glenoid reconstruction in a patient with massive, uncontained glenoid bone loss, undergoing a reverse shoulder arthroplasty in a "one step" procedure. At 1-year follow-up both x-rays and CT showed graft incorporation with no resorption of bone and the patient reported continued stability of the shoulder and a high-level of satisfaction in terms of pain and function.

New approach for evaluating the public health risk of living near a polluted river

Chemical, physical and microbial analyses were conducted in the Sarno River basin to obtain a comprehensive description of the overall quality of the water bodies. The collection period lasted 12 months, between 2005 and 2006, with high frequency of sampling and analysis. More than 6,000 analytical determinations were performed on samples collected at six sampling points along the Sarno River and two points each on tributaries Solofrana and Cavaiola. The results indicated the presence of inorganic contaminants, which, in most cases, were below the Italian State water quality thresholds. The organic contamination showed an increasing trend, with respect to previous determinations, thus demonstrating the major contribution of untreated urban wastewater to the overall pollution of the river. Moreover, this study was designed to explore the correlation between the presence of microbial indicators of fecal contamination in Sarno River and their presumable presence in the aerosol surrounding the river, thus pointing to the possible environmental hazard associated with the presence of pathogens in the air.

Surveillance of nosocomial infections: a preliminary study on yeast carriage on hands of healthcare workers

Hospital-acquired fungal infection is increasing. The aim of this preliminary study was to evaluate the frequency and distribution of yeast carriage on the hands of healthcare workers (HCW) from different departments. The study was conducted in three departments (Surgery, Intensive Care Unit, Obstetrics and Gynaecology) of a hospital in Campania, southern Italy. Over a six-month period, 50 healthcare workers were randomly tested. Imprints of palms and fingertips were taken monthly during the morning shift. The plate with yeast was counted and Candida species were identified. Risk factors for hand contamination were determined. Hand carriage of yeast and Candida species in the three departments were found in the following percentages: Surgery (50% and 49%); Intensive Care Unit (61% and 57%); Obstetrics and Gynaecology (65% and 59%). No significant difference in the frequency or distribution of yeast and Candida sp. recovered in the three departments was ascertained by comparing every two months' data, the hand carriage of yeast and Candida species found in the three departments; this varied - min to max - according to the following percentages: Surgery [(45%-54%) and (42%-58%)]; Intensive Care Unit [(53%-66%) and (56%-59%)]; Obstetrics and Gynaecology [(62%-69%) and (57%-63%)]. The only factor associated with yeast carriage on the hands of healthcare workers was the absence of gloving during healthcare procedure (p = 0.0192). We conclude that in our study yeast carriage on the HCWs' hands is common in the three departments investigated, but its causes are unclear. Careful use of gloving may reduce pathogenic yeast on hands.

Surveillance of nosocomial infections: a preliminary study on hand hygiene compliance of healthcare workers

The observance of hand hygiene compliance is important to reduce cross-infection by micro-organisms. The aim of this preliminary study was to evaluate the level of hand hygiene in healthcare workers from different departments, with particular emphasis on transient flora. The study was conducted in three departments (Surgery, Intensive Care Unit, Obstetrics and Gynecology) of a hospital in Campania, southern Italy. Over a six-month period, 50 healthcare workers were randomly tested. Imprints of palms and fingertips were taken monthly during the morning shift. The number of colonies per plate was counted and transient pathogens were identified. Risk factors for hand contamination were determined. Total flora was found in the following CFU means per palm and per five fingertips (95% CI): Obstetrics and Gynecology [palms 130 CFUs (95% CI 85-180); fingertips 125 CFUs (95% CI 92-160)]; ICU [palms 80 CFUs (95% CI 58-99); fingertips 62 CFUs (95% CI 45-82)]; Surgery [palms 75 CFUs (95% CI 41-120); fingertips 70 CFUs (95% CI 52-90)] Transient flora was found on 39% of healthcare workers' hands. The only factor associated with hand contamination by transient flora was the absence of gloving during healthcare procedure (P = 0.02).

Assignment of the TCRA/TCRD locus to sheep chromosome bands 7q1.4-->q2.2 by fluorescence in situ hybridization

Two genomic clones for the TCRA/TCRD locus have been isolated and characterized in sheep. The first clone corresponds to a new sheep Valpha element, the other to the entire Cdelta gene. Chromosomal mapping by fluorescence in situ hybridization (FISH) of Valpha and Cdelta clones localized the TCRA/TCRD locus on sheep chromosome region 7q14-->q22. This is the first physical assignment for genomic clones on sheep chromosome 7 by FISH. Moreover, the present data put the ovine 7q14-->q22 and the human 14q11.2 regions in the same syntenic group.

Tuberous sclerosis

Tuberous sclerosis (epiloia, Bourneville-Pringle syndrome) is an inherited disease with an autosomal pattern. Both sexes are affected equally with varied expression in successive generations. Two cases of this unusual disorder in siblings are reported. They illustrate heredofamilial nature, dissimilar expression, mutations, and oral manifestations.