Social distancing measures for COVID-19 are changing winter season

Health authorities worldwide have adopted measures of social distancing and movement restrictions, in addition to other public health measures to reduce exposure and to suppress interhuman SARS-CoV- 2 transmission. In Italy, a national lockdown with school closure was introduced from March to May 2020. From November 2020, Italy has been divided into zones according to regional epidemiological data, with primary schools reopened, associated with the mandatory use of face masks and different levels of social distance measures. For children with symptoms suggestive of COVID-19, the surveillance mechanism for the control of SARS-CoV- 2 infection is based on the performance of a real-time PCR on a nasopharyngeal swab. A diagnostic test has been introduced at the tertiary-level university hospital, Institute for Maternal and Child Health, IRCCS \u201cBurlo Garofolo\u201d of Trieste, consisting of a multiple nucleic acid amplification assay for 13 common viral respiratory pathogens on nasopharyngeal swab (Respiratory Flow Chip assay (Vitro, Sevilla, Spain), including SARS-CoV- 2, influenza A and B, adenovirus, other coronaviruses, parainfluenza virus 1\u20134, enteroviruses, bocavirus, metapneumovirus, respiratory syncytial virus (RSV), rhinoviruses, Bordetella pertussis, Bordetella parapertussis and Mycoplasma pneumoniae. Before routine utilisation, international standard quality control samples for each pathogen were used for test validation, and no cross-detection was found between the different pathogens. Criteria for testing referral did not change during the study period. Weekly variability of the number of total tests performed was due to the normal variations of acute illness. During the last winter season, from September 2020 (week 39) to February 2021 (week 7), 1138 nasopharyngeal swabs were tested for patients younger than 17 years old (figure 1). No influenza A or B nor RSV was detected during this period. The most common pathogen was rhinovirus (n=505), followed by adenoviruses (n=131), other coronaviruses (n=101) and SARS-CoV- 2 (n=57). Our data show that common winter pathogens circulation changed, and influenza virus and RSV did not produce a seasonal epidemic in the 2020\u20132021 winter season. These data suggest that social distancing measures and mask wearing profoundly changed the seasonality of winter paediatric respiratory infections that are mainly spread by respiratory droplets. The reasons why rhinovirus remains the main pathogen despite social distancing and face mask use are still a matter of debate. Similar data showing a decrease of common viral respiratory infections during the winter season have recently been reported in the southern hemisphere.1\u20134 Our data refer to a single institute, covering paediatric population of the Trieste Province (about 230 000 inhabitants), limiting the generalisation of our findings. However, our results highlight the need for continuing surveillance for the delayed spread of such viruses during spring and summer

Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005\u20132015

Although there is no evidence that elevated rates of cesarean sections (CS) translate into reduced maternal/child perinatal morbidity or mortality, CS have been increasingly overused almost everywhere, both in high and low-income countries. The primary cesarean section (PC S) has become a major driver of the overall CS (OCS) rate, since it carries intrinsic risk of repeat CS (RCS) in future pregnancies. In our study we examined patterns of PCS, pl compared with planned TO LAC anned PCS (PPCS), vaginal birth after 1 previous CS (VBAC-1) and associated factors in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from its 11 maternity centres (coded from A to K) during 2005\u20132015. By fitting three multiple logistic regression models (one for each delivery mode), we calculated the adjusted rates of PCS and PPCS among women without history of CS, whilst the calculation of the VBAC rate was restricted to women with just one previous CS (VBAC-1). Results, expressed as odds ratio (OR) with 95% confidence interval (95%CI), were controlled for the effect of hospital, calendar year as well as several factors related to the clinical and obstetric conditions of the mothers and the newborn, the obstetric history and socio-demographic background. In FVG during 2005\u20132015 there were 24,467 OCS (rate of 24.2%), 19,565 PCS (19.6%), 7,736 PPCS (7.7%) and 2,303 VBAC-1 (28.4%). We found high variability of delivery mode (DM) at hospital level, especially for PCS and PPCS. Breech presentation was the strongest determinant for PCS as well as PPCS. Leaving aside placenta previa/abuptio placenta/ante-partum hemorrhage, further significant factors, more importantly associated with PCS than PPCS were non-reassuring fetal status and obstructed labour, followed by (in order of statistical significance): multiple birth; eclampsia/pre-eclampsia; maternal age 40\u201344 years; placental weight 600-99 g; oligohydramios; pre-delivery LoS 3\u20135 days; maternal age 35\u201339 years; placenta weight 1,000\u20131,500 g; birthweight < 2,000 g; maternal age 65 45 years; pre-delivery LoS 65 6 days; mother\u2019s age 30\u201334 years; low birthweight (2,000\u20132,500 g); polyhydramnions; cord prolaspe; 656 US scas performed during pregnancy and pre-term gestations (33\u201336 weeks). Significant factors for PPCS were (in order of statistical significance): breech presentation; placenta previa/abruptio placenta/ante-partum haemorrhage; multiple birth; pre-delivery LoS 65 3 days; placental weight 65 600 g; maternal age 40\u201344 years; 656 US scans performed in pregnancy; maternal age 65 45 and 35\u201339 years; oligohydramnios; eclampsia/pre-eclampsia; mother\u2019s age 30\u201334 years; birthweight <2,000 g; polyhydramnios and pre-term gestation (33\u201336 weeks). VBAC-1 were more likely with gestation 65 41 weeks, placental weight <500 g and especially labour analgesia. During 2005\u20132015 the overall rate of PCS in FVG (19.6%) was substantially lower than the corresponding figure reported in 2010 for the entire Italy (29%) and still slightly under the most recent national PCS rate for 2017 (22.2%). The VBAC-1 rate on women with history of one previous CS in FVG was 28.4% (25.3% considering VBAC on all women with at least 1 previous CS), roughly three times the Italian national rate of 9% reported for 2017. The discrepancy between the OCS rate at country level (38.1%) and FVG\u2019s (24.2%) is therefore mainly attributable to RCS. Although there was a marginal decrease of PCS and PPCS crudes rates over time in the whole region, accompained by a progressive enhancement of the crude VBAC rate, we found remarkable variability of DM across hospitals. To further contain the number of unnecessary PCS and promote VBAC where appropriate, standardized obstetric protocols should be introduced and enforced at hospital level. Decision-making on PCS should be carefully scrutinized, introducing a diagnostic second opinion for all PCS, particularly for term singleton pregancies with cephalic presentation and in case of obstructed labour as well as non-reassuring fetal status, grey areas potentially affected by subjective clinical assessment. This process of change could be facilitated with education of staff/ patients by opinion leaders and prenatal counseling for women and partners, although clinical audits, financial penalties and rewards to efficient maternity centres could also be considered

Disruption of Parasite hmgb2 Gene Attenuates Plasmodium berghei ANKA Pathogenicity

Eukaryotic high-mobility-group-box (HMGB) proteins are nuclear factors involved in chromatin remodeling and transcription regulation. When released into the extracellular milieu, HMGB1 acts as a proinflammatory cytokine that plays a central role in the pathogenesis of several immune-mediated inflammatory diseases. We found that the Plasmodium genome encodes two genuine HMGB factors, Plasmodium HMGB1 and HMGB2, that encompass, like their human counterparts, a proinflammatory domain. Given that these proteins are released from parasitized red blood cells, we then hypothesized that Plasmodium HMGB might contribute to the pathogenesis of experimental cerebral malaria (ECM), a lethal neuroinflammatory syndrome that develops in C57BL/6 (susceptible) mice infected with Plasmodium berghei ANKA and that in many aspects resembles human cerebral malaria elicited by P. falciparum infection. The pathogenesis of experimental cerebral malaria was suppressed in C57BL/6 mice infected with P. berghei ANKA lacking the hmgb2 gene (Δhmgb2 ANKA), an effect associated with a reduction of histological brain lesions and with lower expression levels of several proinflammatory genes. The incidence of ECM in pbhmgb2-deficient mice was restored by the administration of recombinant PbHMGB2. Protection from experimental cerebral malaria in Δhmgb2 ANKA-infected mice was associated with reduced sequestration in the brain of CD4(+) and CD8(+) T cells, including CD8(+) granzyme B(+) and CD8(+) IFN-γ(+) cells, and, to some extent, neutrophils. This was consistent with a reduced parasite sequestration in the brain, lungs, and spleen, though to a lesser extent than in wild-type P. berghei ANKA-infected mice. In summary, Plasmodium HMGB2 acts as an alarmin that contributes to the pathogenesis of cerebral malaria.Pitié-Salpêtrière, Institut Pasteur (Paris)

Videogame playing as distraction technique in course of venipuncture.

Background: needle-related procedures (venipuncture, intravenous cannulation) are the most common source of pain and distress for children. reducing needle related pain and anxiety could be important in order to prevent further distress, especially for children needing multiple hospital admissions. the aim of the present open randomized controlled trial was to investigate the efficacy of adding an active distraction strategy (videogame) to eMlA premedication in needle-related pain in children. Methods: one-hundred and nine children (4 -10 years of age) were prospectively recruited to enter in the study. ninety-seven were randomized in two groups: CC group (conventional care: eMlA only) as control group and Ad group (active distraction: eMlA plus videogame) as intervention group. outcome measures were: selfreported pain by mean of FPS-r scale (main study outcome), observer-reported pain by FlACC scale, number of attempts for successful procedure. Results: in both groups FPS-r median rate was 0 (interquartile range: 0-2), with significant pain (FPS-r>4) reported by 9% of subjects. FlACC median rate was 1 in both groups (interquartile range 0-3 in CC group; 0-2 in Ad group). the percentage of children with major pain (FlACC>4) was 18% in CC group and 9% in Ad group (p=0.2). the median of necessary attempts to succeed in the procedures was 1 (interquartile range 1-2) in both groups.. Conclusion: Active distraction doesn't improve eMlA analgesia for iv cannulation and venipuncture. even though, it resulted in an easily applicable strategy appreciated by children. this technique could be usefully investigated in other painful procedures

Multicenter randomized, double-blind controlled trial to evaluate the efficacy of laser therapy for the treatment of severe oral mucositis induced by chemotherapy in children: laMPO RCT

Objectives: To demonstrate the efficacy of laser photobiomodulation (PBM) compared to that of placebo on severe oral mucositis (OM) in pediatric oncology patients. The primary objective was the reduction of OM grade (World Health Organization [WHO] scale) 7 days after starting PBM. Secondary objectives were reduction of pain, analgesic consumption, and incidence of side effects. Methods: One hundred and one children with WHO grade\ua0>\ua02 chemotherapy-induced OM were enrolled in eight Italian hospitals. Patients were randomized to either PBM or sham treatment for four consecutive days (days +1 to +4). On days +4, +7, and +11, OM grade, pain (following a 0\u201310 numeric pain rating scale, NRS) and need for analgesics were evaluated by an operator blinded to treatment. Results: Fifty-one patients were allocated to the PBM group, and 50 were allocated to the sham group. In total, 93.7% of PBM patients and 72% of sham patients had OM grade\ua0<\ua03 WHO on day +7 (P\ua0=\ua00.01). A significant reduction of pain was registered on day +7 in the PBM versus sham group (NRS 1 [0\u20133] vs. 2.5 [1\u20135], P\ua0<\ua00.006). Reduced use of analgesics was reported in the PBM group, although it was not statistically significant. No significant adverse events attributable to treatment were recorded. Conclusions: PBM is a safe, feasible, and effective treatment for children affected by chemotherapy-induced OM, as it accelerates mucosal recovery and reduces pain

User fees in private non-for-profit hospitals in Uganda: a survey and intervention for equity

BACKGROUND: In developing countries, user fees may represent an important source of revenues for private-non-for-profit hospitals, but they may also affect access, use and equity. METHODS: This survey was conducted in ten hospitals of the Uganda Catholic Medical Bureau to assess differences in user fees policies and to propose changes that would better fit with the social concern explicitly pursued by the Bureau. Through a review of relevant hospital documents and reports, and through interviews with key informants, health workers and users, hospital and non-hospital cost was calculated, as well as overall expenditure and revenues. Lower fees were applied in some pilot hospitals after the survey. RESULTS: The percentage of revenues from user fees varied between 6% and 89% (average 40%). Some hospitals were more successful than others in getting external aid and government subsidies. These hospitals were applying lower fees and flat rates, and were offering free essential services to encourage access, as opposed to the fee-for-service policies implemented in less successful hospitals. The wide variation in user fees among hospitals was not justified by differences in case mix. None of the hospitals had a policy for exemption of the poor; the few users that actually got exempted were not really poor. To pay hospital and non-hospital expenses, about one third of users had to borrow money or sell goods and property. The fee system applied after the survey, based on flat and lower rates, brought about an increase in access and use of hospital services. CONCLUSION: Our results confirm that user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

SummaryBackground The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context. Methods We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI). Findings Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa. Interpretation Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden. Funding Bill & Melinda Gates Foundation