Variation in Cause-Specific Mortality Rates in Italy during the First Wave of the COVID-19 Pandemic: A Study Based on Nationwide Data

Italy was a country severely hit by the first coronavirus disease 2019 (COVID-19) pandemic wave in early 2020. Mortality studies have focused on the overall excess mortality observed during the pandemic. This paper investigates the cause-specific mortality in Italy from March 2020 to April 2020 and the variation in mortality rates compared with those in 2015–2019 regarding sex, age, and epidemic area. Causes of death were derived from the national cause-of-death register. COVID-19 was the leading cause of death among males and the second leading cause among females. Chronic diseases, such as diabetes and hypertensive, ischemic heart, and cerebrovascular diseases, with decreasing or stable mortality rates in 2015–2019, showed a reversal in the mortality trend. Moreover, mortality due to pneumonia and influenza increased. No increase in neoplasm mortality was observed. Among external causes of death, mortality increased for accidental falls but reduced for transport accidents and suicide. Mortality from causes other than COVID-19 increased similarly in both genders and more at ages 65 years or above. Compared with other areas in Italy, the Lombardy region showed the largest excess in mortality for all leading causes. Underdiagnosis of COVID-19 at the beginning of the pandemic may, to some extent, explain the mortality increase for some causes of death, especially pneumonia and other respiratory diseases.

Missed training, collateral damage from COVID 19?

Background: during the COVID-19 pandemic a total lockdown was enforced all over Italy starting on March 9th. This resulted in the shrinking of economic activities. In addition, all formal occupational security-training courses were halted, among them the 81/08 law lectures and Basic Life Support-Defibrillation (BLS-D) laymen training courses. The aim of the study was to evaluate the impact of the pandemic on BLS-D laymen training courses in the Lombardy region. Methods: BLS-D training courses records for the Lombardy region were analysed. The analysis was conducted from 2016 to 2020 as part of the Hippo project. Results: between 2017 and 2019 BLS-D trained laymen kept increasing, moving from 53,500 trained individuals up to 74,700. In 2020 a stark reduction was observed with only 22,160 individuals trained. Formal courses were not halted completely during 2020. Still, in the months available for training, the number of individuals enrolled showed a sharp 50% reduction. Conclusions: laymen training courses for emergency management are a fundamental component of primary prevention practice. The 81/08 and 158/12 Italian laws have decreed this practice mandatory on the workplace. Following the enforcement of the lockdown and the subsequent interruption of emergency management courses, efforts will be necessary to re-establish and guarantee the high quality training of the pre-pandemic period.

Control of the COVID-19 System by Vaccination Using a New Control Engineering Technique

In this work, a novel control engineering method is proposed to achieve a control strategy by vaccination for the COVID-19 epidemic. A proper mathematical model with vaccination control is developed for the COVID-19 system based on the Susceptible-Exposed-Infectious-Recovered (SEIR) epidemiological model after conducting some analyses and assumptions that reflect the COVID-19 features. Then, the proposed control law is designed using the feedback linearization approach and the H-infinity control framework. In addition, a model reference control is incorporated to ensure that satisfactory time responses are obtained. The Black Hole Optimization (BHO) technique is used to attain the optimality of the proposed control method. Following that, the reported statistics and vaccination plan of the Lombardy region of Italy are utilized to assess the effectiveness of the proposed control law. Ultimately, the simulation results illustrate that the proposed control law can effectively control the COVID-19 system and correctly perform the vaccination plan by tackling the system’s nonlinearity and uncertainty and realizing elegant asymptotic tracking characteristics with reasonable control effort.

Respiratory rehabilitation for patients with COVID-19 infection and chronic respiratory failure: a real-life retrospective study by a Lombard network

The Lombardy region has been one of the areas most affected by the COVID-19 pandemic since the first months of 2020, providing real-life experiences in the acute phase. It is unclear how the respiratory rehabilitation network responded to this emergency. The aims of this retrospective study were: i) to analyze clinical, functional, and disability data at admission; ii) describe assessment tools and rehabilitative programs; iii) evaluate improvement after rehabilitation. The study was conducted on data collected from ten pulmonary rehabilitation centers in Lombardy, between the period of March 1st 2020 to March 1st 2021, in patients with respiratory failure recovering from COVID-19 both at admission and discharge. The study included demographics, comorbidities, nutritional status, risk of falls, disability status (Barthel index; Short Physical Performance Battery (SPPB); 6 minutes walking test (6MWT), symptoms (dyspnoea with Barthel Dyspnoea and MRC Dyspnoea Scale), length of stay, discharge destination, need for mechanical ventilation, respiratory function, assessment/outcomes indices, and prescribed rehabilitative programs. 413 patients were analyzed. Length of stay in acute and rehabilitative units was less than 30 days. Fifty % of patients used non-invasive ventilation during their stay. Functional status was mildly compromised for forced volumes and oxygenation, while severely compromised for diffusion capacity. Independency was low while physical performance status very low. At discharge, 318 (77%) patients were sent home, 83 (20.1%) were transferred to an acute unit and 12 (2.9%) passed away. Barthel Index and 6MWT were the most used, while MRC score was the least used outcome parameter. The 5 main rehabilitative activities were walking (90.8 %), transfer from bed to armchair (77.5%), limb mobilization in bed (76%), balance (71.2%), and cycle-ergometer or treadmill (43.1%). A huge difference was found in admission, discharge, and delta change among different rehabilitative centers. When available, all outcomes showed a significant improvement. With the limitation of a retrospective study with a clear amount of missing data, COVID-19 subjects admitted to rehabilitative centers presented a reduced physical performance, symptoms of dyspnoea, and severe disability. The 6MWT and Barthel index were the most used measurement.

An Improved Method for Assessing Simple Sequence Repeat (SSR) Variation in Echinochloa crus-galli (L.) P. Beauv (Barnyardgrass)

Echinochloa crus-galli (L.) P. Beauv. (barnyardgrass) is one of the most noxious weeds infesting Italian rice fields. It is characterized by high genetic intraspecific variability and has developed resistance to several classes of herbicides. The aim of our study was to assess, for the first time in Italy, the genetic diversity in E. crus-galli from differently managed rice fields in the Lombardy region (Northern Italy) using eight specific SSR markers. To this purpose, an amplification protocol was optimized, testing different DNA concentrations, PCR mixtures, and temperatures. A total of 48 alleles were identified in 144 samples. SSR fingerprint analysis using R 3.6.3 software (poppr, polysat, and StAMPP) allowed us to handle SSRs as codominant and polyploid data. The results suggested that genetic richness and diversity were high. The analysis of molecular variance (AMOVA) indicated that genetic variation exists mainly between agronomic managements (47.23%) and among populations (37.01%). Hierarchical clustering and PCoA were in concordance with the identification of four distinct genetic groups. Our results confirm that SSR markers represent a valuable and affordable tool for the assessment of E. crus-galli genetic diversity and would grant useful information to plan more targeted, effective, and sustainable control strategies against barnyardgrass. The improved methodology applied here allowed us to assess the genetic variability of an allo-hexaploid species without information loss and biased results.

Moral Distress Trajectories of Physicians 1 Year after the COVID-19 Outbreak: A Grounded Theory Study

The COVID-19 pandemic has confronted emergency and critical care physicians with unprecedented ethically challenging situations. The aim of this paper was to explore physicians’ experience of moral distress during the pandemic. A qualitative multicenter study was conducted using grounded theory. We recruited 15 emergency and critical care physicians who worked in six hospitals from the Lombardy region of Italy. Semi-structured interviews about their professional experience of moral distress were conducted from November 2020–February 2021 (1 year after the pandemic outbreak). The transcripts were qualitatively analyzed following open, axial, and selective coding. A model of moral distress was generated around the core category of Being a Good Doctor. Several Pandemic Stressors threatened the sense of Being a Good Doctor, causing moral distress. Pandemic Stressors included limited healthcare resources, intensified patient triage, changeable selection criteria, limited therapeutic/clinical knowledge, and patient isolation. Emotions of Moral Distress included powerlessness, frustration/anger, and sadness. Physicians presented different Individual Responses to cope with moral distress, such as avoidance, acquiescence, reinterpretation, and resistance. These Individual Responses generated different Moral Outcomes, such as moral residue, disengagement, or moral integrity. The Working Environment, especially the team and organizational culture, was instrumental in restoring or disrupting moral integrity. In order for physicians to manage moral distress successfully, it was important to use reinterpretation, that is, to find new ways of enacting their own values by reframing morally distressing situations, and to perceive a cooperative and supportive Working Environment.

The Project to Complete the Regional Topographic Geodatabase in Lombardy, Italy

The Regional Topographic Geodatabase (DBTR) was officially defined in 2005 as the multi-scale (1:1,000 – 1:2,000 – 1:5,000 – 1:10,000) cartographic reference for urban and regional planning in Lombardy Region. The DBTR had been previously introduced at national level to take over traditional numerical topographic maps adopted for urban planning, with the aim to provide a base map to be implemented either at regional level (Regional Geoportal) and by local administrations. The DBTR is structured by following some national guidelines that define either the content and the topological structure, that makes simple its implementation in GIS environment. The construction of the entire DBTR has historically gone through different phases, with the consistent support of the regional subsidiary policy. But when the effects of the world economic crisis in 2008 became tangible in the budget of public administrations, the growth of the project faced an important break. In 2017 the administration of Lombardy Region has promoted and financed a new project finalized to the completion of the DBTR. A temporary association of mapping companies won the tender and completed the project by summer 2020, despite of the difficulties related to the COVID-19 pandemic. A team led by Politecnico di Milano was appointed for the quality assessment. The proposed paper would like to present this project and the operational solutions applied for the production of the new subsections of the DBTR, as well as its quality assessment/validation.

Use of Antibiotic Treatment in Pregnancy and the Risk of Several Neonatal Outcomes: A Population-Based Study

Background: Limited evidence is available on the safety and efficacy of antimicrobials during pregnancy, with even less according to the trimester of their use. Objective: This study aimed to evaluate the association between exposure to antibiotics therapy (AT) during pregnancy and short-term neonatal outcomes. Methods: We considered 773,237 deliveries that occurred between 2007–2017 in the Lombardy region of Italy. We evaluated the risk of neonatal outcomes among infants that were born to mothers who underwent AT during pregnancy. The odds ratios and the hazard ratios, with the 95% confidence intervals, were estimated respectively for early (first/second trimester) and late (third trimester) exposure. The propensity score was used to account for potential confounders. We also performed subgroup analysis for the class of AT. Results: We identified 132,024 and 76,921 singletons that were exposed to AT during early and late pregnancy, respectively. Infants born to mothers with early exposure had 17, 11, and 16% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. Infants that were exposed in late pregnancy had 25, 11, and 13% increased risk of preterm birth, low birth weight, and low Apgar score, respectively. The results were consistent in the subgroup analysis. Conclusion: Our results suggested an increased risk of several neonatal outcomes in women exposed to ATs during pregnancy, albeit we were not able to assess to what extent the observed effects were due to the infection itself. To reduce the risk of neonatal outcomes, women that are prescribed AT during pregnancy should be closely monitored.

Geospatial Correlation Analysis between Air Pollution Indicators and Estimated Speed of COVID-19 Diffusion in the Lombardy Region (Italy)

Background: the Lombardy region in Italy was the first area in Europe to record an outbreak of COVID-19 and one of the most affected worldwide. As this territory is strongly polluted, it was hypothesized that pollution had a role in facilitating the diffusion of the epidemic, but results are uncertain. Aim: the paper explores the effect of air pollutants in the first spread of COVID-19 in Lombardy, with a novel geomatics approach addressing the possible confounding factors, the reliability of data, the measurement of diffusion speed, and the biasing effect of the lockdown measures. Methods and results: all municipalities were assigned to one of five possible territorial classes (TC) according to land-use and socio-economic status, and they were grouped into districts of 100,000 residents. For each district, the speed of COVID-19 diffusion was estimated from the ambulance dispatches and related to indicators of mean concentration of air pollutants over 1, 6, and 12 months, grouping districts in the same TC. Significant exponential correlations were found for ammonia (NH3) in both prevalently agricultural (R2 = 0.565) and mildly urbanized (R2 = 0.688) areas. Conclusions: this is the first study relating COVID-19 estimated speed of diffusion with indicators of exposure to NH3. As NH3 could induce oxidative stress, its role in creating a pre-existing fragility that could have facilitated SARS-CoV-2 replication and worsening of patient conditions could be speculated.

Relationship between out-of-hospital cardiac arrests and COVID-19 during the first and second pandemic wave. The importance of monitoring COVID-19 incidence

Background The relationship between COVID-19 and out-of-hospital cardiac arrests (OHCAs) has been shown during different phases of the first pandemic wave, but little is known about how to predict where cardiac arrests will increase in case of a third peak. Aim To seek for a correlation between the OHCAs and COVID-19 daily incidence both during the two pandemic waves at a provincial level. Methods We considered all the OHCAs occurred in the provinces of Pavia, Lodi, Cremona, Mantua and Varese, in Lombardy Region (Italy), from 21/02/2020 to 31/12/2020. We divided the study period into period 1, the first 157 days after the outbreak and including the first pandemic wave and period 2, the second 158 days including the second pandemic wave. We calculated the cumulative and daily incidence of OHCA and COVID-19 for the whole territory and for each province for both periods. Results A significant correlation between the daily incidence of COVID-19 and the daily incidence of OHCAs was observed both during the first and the second pandemic period in the whole territory (R = 0.4, p<0.001 for period 1 and 2) and only in those provinces with higher COVID-19 cumulative incidence (period 1: Cremona R = 0.3, p = 0.001; Lodi R = 0.4, p<0.001; Pavia R = 0.3; p = 0.01; period 2: Varese R = 0.4, p<0.001). Conclusions Our results suggest that strictly monitoring the pandemic trend may help in predict which territories will be more likely to experience an OHCAs’ increase. That may also serve as a guide to re-allocate properly health resources in case of further pandemic waves.