With the rapid development of technologies for type 1 diabetes, economic evaluations are integral in guiding cost-effective clinical and policy decisions. We therefore aimed to review and synthesise the current economic literature for available diabetes management technologies and outline key determinants of cost-effectiveness.A systematic search was conducted in April 2019 that focused on modelling or trial based economic evaluations. Searched databases included Medline, Medline in-process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, EconLit, Cost-effectiveness analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO from inception. We assessed quality of included studies with the Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making an ISPOR-AMCP-NPC good practice task force report. Screening of abstracts and full-texts, appraisal, and extraction were performed by two independent researches.We identified 16,772 publications, of which 35 were analysed and included 11 health technologies. Despite a lack of consensus, most studies reported that insulin pumps (56%) or interstitial glucose sensors (62%) were cost-effective, although incremental cost-effectiveness ratios ranged widely . Cost-effectiveness for combined insulin pumps and glucose sensors was less clear. Determinants of cost-effectiveness included treatment effects on glycosylated haemoglobin and hypoglycaemia, costing of technologies and complications, and measures of utility.Insulin pumps or glucose sensors appeared cost-effective, particularly in populations with higher HbA1c levels and rates of hypoglycaemia. However, cost-effectiveness for combined insulin pumps and glucose sensors was less clear.The study was registered with PROSPERO, number CRD42017077221. Millions of adults are estimated to be living with type 1 diabetes and are dependent on exogenous insulin to regulate blood glucose levels . The comIncreasingly advanced technologies have been developed over the last 40 to 50 years to improve glycaemia and prevent complications of diabetes –9. HowevGiven the rapid development of technologies, it is critical for economic evaluations of all technologies to be synthesised to guide cost-effective device selection. There have been few systematic reviews of economic evaluations to date, and these become increasingly outdated as new devices become available and healthcare funding changes. The 2015 systematic review of continuous subcutaneous insulin infusion (CSII) pumps concluded this form of insulin delivery was cost-effective compared to multiple daily injections (MDI) . AnotherTherefore, we provide a systematic review and narrative synthesis of economic outcomes for diabetes management technologies among adults with type 1 diabetes, following network geometry analogous to network meta-analyses. We aimed to summarise currently available economic evaluations for insulin delivery, glucose sensing, and decision support technologies, and identify factors conducive to cost-effectiveness in order to guide clinician and care provider decisions.We performed a systematic review and narrative synthesis. We searched Medline, Medline in-process and other non-indexed citations, EMBASE, PubMed, All Evidenced Based Medicine Reviews, EconLit, Cost-effectiveness analysis Registry, Research Papers in Economics, Web of Science, PsycInfo, CINAHL, and PROSPERO from the date of their inception to 24 April 2019, limited to the English language.>18 years of age) with type 1 diabetes. Pregnancy was an exclusion. Because HbA1c reflects the preceding weeks to months of glycaemia, expert consensus opinion deemed 6 weeks to be the minimum study duration that would reasonably allow interpretation of treatment effects for interventions. Very few economic evaluations modelled an entirely adult cohort with all input parameters also based on studies limited to adult participants. We therefore excluded studies if the modelled cohort was limited solely to paediatric participants (< 18 years of age). We considered studies that compared technologies for insulin delivery, glucose monitoring, insulin dosing advice, or multiple daily injections (MDI) and self-monitoring of blood glucose via capillary testing (SMBG). Because every individual with type 1 diabetes must have at least one method for insulin delivery and glucose monitoring, we considered 11 intervention-pairs based on the results of our searches. The electronic database searches were supplemented by manual searches of reference lists of review articles.We included full and partial economic evaluations that were based on modelling or randomised controlled trials (RCTs) of parallel and crossover study design, six or more weeks in duration, and included community dwelling adults (https://www.ncbi.nlm.nih.gov/pubmed/29530081) [The lead investigator (AP) screened titles, abstracts, and full text articles where appropriate with independent duplication for a convenience sample . Three investigators  reviewed the main reports and supplementary materials, and assessed the relevance and credibility for all eligible studies. Two investigators  extracted relevant summary estimates for economic outcomes. Any discrepancies were resolved by consensus or deferral to a senior reviewer (SZ or DL). The protocol of this analysis has been published (9530081)  and the 9530081) . The PRIhttps://www.oanda.com/currency/converter/ [The primary outcomes of interest were costs and cost-effectiveness. Clinical outcomes from our review protocol have been reported separately . We extrnverter/ ; and infnverter/ .We assessed the studies’ relevance and credibility by following the good practice task force report by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), Academy of Managed Care Pharmacy (AMCP), and the National Pharmaceutical Council (NPC) . BecauseThis study was registered with PROSPERO, number CRD42017077221.We identified 16,772 records, of which 152 potentially eligible publications were retrieved in full text  utilised Markov models, and 20 of these (71%) used the Centre for Outcomes Research and Evaluation (CORE) Diabetes Model. Five studies used ‘author developed’ Markov models, three used the Sheffield Type 1 Diabetes Policy Model (patient-level Markov model), and another two were trial based. Nine of the cost-effectiveness analyses were reported from the societal perspective, and 22 were reported from the healthcare funder’s perspective in the base case. Real option analysis with cash flow simulations took the market perspective.A number of country settings were considered, including ten economic evaluations from the United Kingdom UK, 29%), nine from Europe (26%), eight from the United States of America , four from Canada (11%), two from Australia (6%), two from Spain (6%), and one from Colombia (3%). One publication from Canada presented a cost-effectiveness evaluation and separate budget impact analysis. Technologies with economic evaluation(s) included MDI, CSII, SMBG, CGM, flash glucose monitoring (FGM), as well as integrated CSII with CGM . See Fig. 9%, nine After adjustment for inflation, patient time costs were reported as $1821 USD  829–2768) higher for CSII and CGM compared to MDI and SMBG over a 1-year period of intervention in the USA . Cost-caOf the 35 studies eligible for analysis, 26 received funding or material support from manufacturers of insulin pumps or glucose sensors. The majority of these  reported base case ICERs below willingness-to-pay thresholds, were deemed to have minimal impact on budget, or to reduce costs in cost-calculations. A component of non-commercial funding was reported for 12 of the studies from our review. Four of these reported a favourable economic evaluation for the intervention arms, of which three also received a component of commercial funding or material support from manufacturers of diabetes management technologies. All of the nine studies with base case results from the societal perspective reported advanced technology to be cost-effective although sensitivity analyses including only direct costs had minimal impact on conclusions. Overall, there were 24 (69%) studies that reported favourable economic evaluations for the intervention arms. ICERs per life year gained were infrequently reported, and results were similar to ICERs per QALY gained.Freestanding interstitial-glucose monitoring appeared to be cost-effective in eight of 13 (62%) studies prior to inflation, although ICERs ranged widely. Two of four studies reported that CGM and MDI were cost-effective when compared to SMBG and MDI. When adjusted for inflation, ICERs for CGM and MDI ranged from $37,470 AUD  per QALY gained in the Canadian setting  through When compared to CSII and SMBG, integrated systems of CSII and CGM with a suspend function for low glucose were reported as cost-effective for eight of ten (80%) relevant studies at the time of their publication. When adjusted for inflation and exchange rates, the ICERs for studies reporting that integrated systems were cost-effective ranged from $19,695 AUD  per QALY gained in Denmark for participants at risk of hypoglycaemia  through CSII and SMBG were reported as cost-effective when compared to MDI and SMBG in five of nine (56%) studies. ICERs below willingness-to-pay thresholds, when adjusted for inflation and currency, ranged from $29,860 AUD   per QALYThe comparisons of MDI and SMBG with either non-integrated or integrated CSII and CGM systems  reported that modern technologies were generally not cost-effective. Non-integrated systems were reported as not cost-effective when compared to MDI with SMBG, with an adjusted ICER of $383,717 AUD  per QALY gained in the USA . IntegraWe developed a visual network of comparisons from the literature Fig.  and founUp until 2009, all economic evaluations compared CSII to MDI and modelled an HbA1c reduction of 1.2% (13.1 mmol/mol) in favour of CSII based on the meta-analysis by Weissberg-Benchell et al. . SensitiComparisons of CGM to SMBG cited HbA1c reductions ranging from 0.23%   to 0.6% Treatment effects for a hybrid closed loop system were based on a pivotal trial and before-and-after study without comparator arms , 50. TheHypoglycaemia for integrated systems with low glucose suspend were usually modelled as no events compared to 2.2 events per 100 patient months for CSII and SMBG, based on the RCT by Ly et al. . ReductiThe only economic evaluation that considered integrated systems with CGM alarms compared to MDI with SMBG utilised their own review article (in Spanish) as the source for their clinical assumptions . AuthorsThe comparative effectiveness of various diabetes management technologies was largely based on either reduction of HbA1c values or reduced rates of hypoglycaemia. Rates of hypoglycaemia were utilised to variably estimate long-term costs incurred from lost productivity and the direct costs of ambulance and hospital admissions. However, HbA1c was the primary basis for predicting long-term complication rates and therefore contributed largely to estimates of cost. This was exemplified by sensitivity analyses, in which an increase in relative treatment effect on HbA1c from 0.6%  to 1.2% (13.1 mmol/mol) for non-integrated CSII and CGM systems reduced ICERs from $229,675 to $29,037 (2010 USD) per QALY gained . FurtherApart from the impact of clinical effectiveness on costs, international health systems valued complications differently and authors variably determined utility weights. For example, the costing of ischaemic heart disease varied from $4,486 (2003 GBP)  to $35,2This review of 35 economic evaluations comprising 11 management strategies and 14 technology comparisons found variable results. While most studies favoured the cost-effectiveness of advanced diabetes management technologies, some comparisons had few studies, and ICERs ranged widely below and above willingness-to-pay thresholds.Estimates of cost-effectiveness were sensitive to glycaemic indicators such as the treatment impact on HbA1c and rates of hypoglycaemia as well as baseline glycaemic control. Base case scenarios often modelled the effect of HbA1c reduction alone, applying the conservative assumption that hypoglycaemia rates were equivalent between groups. The majority of studies reporting that CSII or CGM technology was cost-effective modelled a treatment effect for HbA1c greater than 1.0% (10.9 mmol/mol) and 0.5% (5.5 mmol/mol), respectively. When the base-case modelled only one aspect of glycaemic control, sensitivity analyses that included both HbA1c reduction and prevention of hypoglycaemia often decreased ICERs below willingness-to-pay thresholds. Furthermore, our finding that CSII technology was cost-effective across multiple settings is in keeping with prior reviews , 40.Data sources for the glycaemic impact of technologies had significant potential to impact results of cost-effectiveness analyses. Economic evaluations of CSII technology compared to MDI modelled HbA1c reductions ranging from 0.51% (5.6 mmol/mol) to 1.2% (13.1 mmol/mol), citing meta-analyses by Pickup et al. and Weissberg-Benchell et al. respectively , 45. TheSevere hypoglycaemia also exerted a large impact on cost-effectiveness, but the chosen data sources may not have been transferrable to long-term modelling. The approaches to hypoglycaemia included the assumption of equivalent rates between management strategies or utilising meta-analysis and RCT estimates ranging from 13.1  to 84.7Apart from the clinical impact of management strategies, the costing of diabetes management technologies and the complications of diabetes varied across international settings. The generalisability and transferability of results from economic evaluations may therefore be limited primarily to the healthcare systems in which they were performed. Despite authors citing valid sources for the utility and disutility weights of diabetes and numerous complications, these values also varied across studies with no consensus in the literature. This was of particular relevance due to the crucial role of QALYs in deriving ICERs. For example, the utility for fear of hypoglycaemia was a key driver of cost-effectiveness for integrated systems with low glucose suspend in the base-case scenarios where glycaemic effects were assumed to be equivalent or only marginally different to the control arm. Similarly for flash glucose monitoring, the utility increment associated with a 25.8% reduction in non-severe hypoglycaemia was a key driver of cost-effectiveness while modelling equivalent HbA1c and severe hypoglycaemia event rates . HoweverOur study is the largest review of economic evaluations to date, with the broadest consideration of technologies in the management of type 1 diabetes. While pooling of cost-effectiveness data was not possible, we were able to summarise the existing landscape of economic evidence and outline common factors present among technologies considered cost-effective in various settings. Furthermore, we followed a systematic approach outlined in our published protocol, and reported our review in line with the PRISMA statement guidelines . LimitatMost studies in our network reported that newer diabetes management technologies were cost-effective although ICERs varied widely. Insulin pumps or glucose sensors appeared cost-effective, especially in populations with the most to gain from such interventions such as those with higher HbA1c levels and rates of hypoglycaemia. Results for combined insulin pump and glucose-sensing technology was less clear, although hybrid closed loop therapy and systems with low glucose suspend appeared cost-effective in comparison to CSII and SMBG. An important limitation is that pump therapy is not universally funded by many countries which highlights the need for economic evaluations that compare integrated systems to the more ubiquitous standard of care comprising MDI and SMBG.Notwithstanding the limitations of the evidence base, our systematic review and narrative synthesis provides the most comprehensive and contemporary evidence to guide economic comparison between diabetes management technologies. While it was not feasible to quantitatively compare data across studies, we believe that uniformity of reporting costs and utilities would greatly assist in comparing economic evaluations within healthcare systems. Furthermore, the rapid pace of technology development means that studies struggle to remain current. We therefore advocate for economic evaluations of all clinically relevant combinations of technology in different healthcare systems as well as the adoption of living systematic reviews to facilitate rapid incorporation of evidence into clinical practice guidelines. A current focus should be on economic evaluations of closed loop systems and comparison with the most ubiquitous treatment strategy which, for many countries remains multiple daily injections and capillary blood glucose testing.Additional file 1. PRISMA 2009 Checklist. Description: Completed PRISMA 2009 checklist.Additional file 2. Supplementary appendix. Description: Reference list of included records and study identifiers from the systematic review.Additional file 3. Table 1. Treatments, treatment effects, costs, and quality adjusted life years. Description: Table outlining the details of treatment comparisons, modelled treatment effects, cited costs, and reported quality adjusted life years as appropriate.Additional file 4. Table 2. Study summaries. Description: Table outlining summaries of each study in the systematic review.Additional file 5. Table 3. Assessment of study relevance and credibility. Description: Table outlining the assessment of relevance and credibility for each study in the systematic review.


The purpose of this pilot study was to investigate the feasibility of a perfusion catheter to deliver liquid paclitaxel into arterial segments. A clinically relevant rabbit ilio-femoral injury model was utilized to determine the impact of liquid paclitaxel delivered locally into the vessel wall using a perfusion catheter at 1 h to 14 days. Treatment by two clinically available forms of liquid paclitaxel, a solvent-based (sb) versus an albumin-bound (nab), along with a control , were investigated. Pharmacokinetic results demonstrated an increase in the retention of the sb-paclitaxel versus the nab-paclitaxel at 1 h; however, no other differences were observed at days one, three, and seven. Histological findings at 14 days showed significantly less neointimal area in the sb-paclitaxel treated arteries as compared with the nab-paclitaxel and the uncoated balloon-treated arteries. Additionally, percent area stenosis was significantly less in the sb-paclitaxel group. These results support the concept of local liquid delivery of paclitaxel into the arterial segments. There are more than three million people affected by peripheral artery disease (PAD) every year in the U.S. Disparate from coronary artery disease, PAD is characterized by a substantial plaque burden and often presents with long and complex lesions ,2. EndovCurrent endovascular treatments, including DES and DCBs, have limitations leading to inconsistent outcomes, patient readmission, and repeat revascularization. Stents tend to fracture due to the severe biomechanical environment of peripheral arteries ,6,7,8. PTo overcome the limitations of stents, DCBs were developed to locally deliver therapeutics to inhibit restenosis without the need of a permanent platform serving as a drug reservoir. DCBs rely on the transfer of the anti-proliferative drug, which is coated on the surface of the balloon, to the lumen of the arterial wall by simple contact of the balloon to the artery. DCBs are coated with a crystalline form of paclitaxel designed to adhere to the abluminal surface of the artery. Clinical studies have shown promising results with DCBs, but only in relatively short and simple lesions and mostly to treat disease in arteries above the knee ,12.In the periphery, paclitaxel has been the anti-proliferative drug of choice of DCBs due to its potency and binding affinity, making it an attractive drug for single use with long lasting effects ,14. PaclCurrent DCBs and DES use the dry (or powder) form of paclitaxel, which has a crystalline structure. Crystallinity of the paclitaxel drug increases its residency and local arterial pharmacokinetics and reduces solubility of the drug. This increase in residency is somewhat needed as the drug is positioned on the luminal surface and not within the medial wall. However, by placing the drug onto the luminal surface, there is a potential for the crystalline paclitaxel drug to become dislodged (mobilized), travelling to distal organs and tissue. Previously reported pre-clinical studies have demonstrated fibrinoid necrosis in downstream tissues of DCB-treated peripheral segments, along with higher paclitaxel levels in nontargeted tissue, suggesting increased emboli debris from crystalline paclitaxel ,21.In this pilot study, we investigated a new approach to deliver the therapeutic drug paclitaxel for peripheral applications. Specifically, we tested the use of a perfusion catheter to locally deliver the liquid form of paclitaxel directly into the vessel wall. Currently two available forms of liquid paclitaxel exist, a solvent-based (sb-) paclitaxel and an albumin-bound (nab-) paclitaxel, primarily used to treat cancer patients. The aim of this pilot study was to investigate the effectiveness of the solvent-based paclitaxel versus the albumin-bound paclitaxel form delivered locally by a perfusion catheter in a clinically relevant rabbit femoral-iliac injury model.n = 4) versus the nab-paclitaxel (n = 4) at 1 h ; however, no other differences were observed at days one, three, and seven. There was a significant drop in sb-paclitaxel between 1 h and one day , but none between the other treatment time points.In vivo studies were performed using a rabbit ilio-femoral injury model. The nab-paclitaxel and sb-paclitaxel were successfully delivered to the external iliac arteries using the perfusion catheter. An angiogram of the drug-filled perfusion catheter within the external iliac artery is shown in 2 vs sb-paclitaxel: 1.11 ± 0.26 mm2 vs nab-paclitaxel: 1.15 ± 0.28 mm2, p = 0.006). At 14 days, there was significantly less neointimal area in the sb-paclitaxel treated arteries as compared with nab-paclitaxel treated arteries and the balloon-injured control group . Additionally, percent area stenosis was also significantly less in the sb-paclitaxel group . Morphometric analysis demonstrated similar area measurements, including the external elastic lamina (EEL), internal elastic lamina (IEL), and lumen, for all treatment groups . Medial p = 0.02). Medial SMC loss, in the circumferential direction, showed similar results . No aneurysmal dilatation or thrombosis was observed in any treated artery.Histological analysis demonstrated no injury and no endothelial cell loss at 14 days . InflammThis study was designed to evaluate the efficacy of local liquid paclitaxel delivery to arterial segments in a clinically relevant rabbit ilio-femoral injury model. Two clinically available forms of paclitaxel, a solvent-based liquid paclitaxel and an albumin-bound liquid paclitaxel, were utilized to quantify the pharmacokinetics of paclitaxel retention within the arterial wall and histologically evaluate the treated arteries. Pharmacokinetic results indicated greater retention of the solvent-based liquid paclitaxel as compared with albumin-bound paclitaxel. Histologically, there was a significant decrease in neointimal hyperplasia and stenosis in arteries treated with the solvent-based liquid paclitaxel as compared to the albumin-bound liquid paclitaxel and the balloon-injured arteries. Additionally, drug-induced medial smooth muscle cell loss was more frequently observed in the solvent-based liquid paclitaxel treated arteries. These results indicate the effectiveness of a local liquid approach to deliver and retain liquid paclitaxel in arterial segments.In this pilot study, the use of liquid forms of paclitaxel was investigated a potential therapy to inhibit restenosis. The selected intravenous (liquid) forms of paclitaxel have been utilized to treat patients with breast, ovarian, prostate and other forms of solid tumor cancers for the past four decades. In comparing the different forms of paclitaxel, the half-life of liquid (intravenous) paclitaxel is within hours ,22, wherp = 0.17).Prior to testing, we performed bench-top studies to determine the optimal pressure range to deliver the liquid paclitaxel. The bench-top studies indicated that a pressure range of 0.1 to 0.4 atm was sufficient to drive the liquid paclitaxel sub-intimal, into the medial area . The buiAlthough all arteries were treated under similar conditions, the biological effect of paclitaxel was only observed in the sb-paclitaxel group. The difference in biological outcome, as determined by neointimal growth and vascular SMC loss, is most likely due to greater levels of paclitaxel retained in the arterial wall by the sb-paclitaxel group as compared with nab-paclitaxel. Axel et al. have previously demonstrated that paclitaxel, in a single dose-application of 20 min to 24 h, can inhibit vascular SMC growth up to 14 days.  Paclitaxp = 0.0004). The nearly 10-fold increase in paclitaxel measurement suggest the acute adhesion of the paclitaxel Cremophor EL to the extracellular matrix of the artery, consisting mostly of collagen, is greater as compared to the nanoparticle albumin carrier. A recent study demonstrated greater drug delivery of albumin-conjugated cancer drug when combined with a collagen-binding domain [Differences in the pharmacokinetic and biological outcomes of these two forms of liquid paclitaxel—solvent-based and albumin-bound forms—may be attributed to differences in solvents. Paclitaxel is extremely lipophilic and hydrophobic and therefore must be delivered in a mixture of solvents that allow it to be administered in the liquid form. The primary solvent in sb-paclitaxel is Cremophor EL (polyethoxylated castor oil), which surrounds the drug in a micelle and allows it to be transported in blood. The nab-paclitaxel does not require a solvent to solubilize the drug and is formulated with human serum albumin. Our results indicated greater acute retention of the sb-paclitaxel versus the nab-paclitaxel at 1 h -paclitaxel  and a solvent-based (sb)-paclitaxel . The nab-paclitaxel is available in a solid form designed to be reconstituted with saline to make an injectable suspension. For this pilot study, the nab-paclitaxel particles were measured by weight and reconstituted with saline to a concentration of 6 mg/mL. The reconstituted nab-paclitaxel was then combined with saline and iohexol  in a 1:2:2 ratio by volume  to achieve a final paclitaxel concentration of 1.2 mg/mL. Similarly, the sb-paclitaxel purchased in liquid form (6 mg/mL) was combined with saline and iohexol in a 1:2:2 ratio by volume to achieve a final paclitaxel concentration of 1.2 mg/mL.In our study, the perfusion catheter was used to deliver both forms of the liquid paclitaxel. The delivery of the liquid paclitaxel is accomplished by pressure differences created by an increase in treatment chamber pressure by the device, thereby driving the drug across tissue and into the medial layer. Because of this technique, it was not necessary for the therapeutic agent to be aspirated prior to removal of the device. Most importantly, this approach avoids the accumulation of drug on the luminal surface, as seen with drug coated balloons and drug eluting stents. Lastly, potential drug loss during tracking and positioning of the delivery device to the location of treatment is eliminated.This study protocol was approved by the University of South Alabama’s Institutional Animal Care and Use Committee (#568228) and conformed to the position of the American Heart Association on use of animals in research. A total of 16 rabbits (32 artery segments) were used for pharmacokinetic analysis, and a total of 6 rabbits (12 artery segments) were used for histological analysis. Two rabbits (4 artery segments) were allocated for each time point for both treatments. The experimental preparation of the animal model has been previously reported . Briefly®, 85–150 mg/kg, single injection), and the treated artery segments were removed based on landmarks identified by angiography. The time points were selected to demonstrate the acute retention of liquid paclitaxel delivery. The explanted segments were then stored at −80 °C and shipped on dry ice to the bioanalytical laboratory . As previously described, quantification of arterial paclitaxel levels was performed using a validated high-performance liquid chromatography (HPLC)-electrospray ionization- tandem mass spectrometry system (LC-MS/MS) [Following 1 h, 1 day, 3 days, and 7 days, animals were anesthetized and euthanized (intravenous FATAL-PLUSC-MS/MS) ,28,29.Following the 14-day timepoint, animals were anesthetized and euthanized, and the treated artery segments were removed based on landmarks identified by angiography. The arteries were perfused by saline and formalin-fixed under physiological pressure prior to removal. The segments were stored in 10% formalin at room temperature and then processed to paraffin blocks, sectioned, and stained with hematoxylin and eosin (H&E) or Verhoeff’s elastin stain (VEG).Histological sections were digitized, and measurements were performed using ImageJ software (NIH). Cross-sectional area measurements included the external elastic lamina (EEL), internal elastic lamina (IEL), and lumen area of each section. Using these measurements, the medial area (EEL-IEL), neointimal area (IEL-lumen), and percent area stenosis (100 × (IEL-Lumen)/(IEL)) were calculated as previously described ,31,32.Morphological analysis was performed by light microscopy using a grading criterion as previously published ,31,32. Pp < 0.05 was considered statistically significant.All values are expressed as mean ± standard deviation (SD). Quantitative data were compared with analysis of variance (ANOVA), followed by Tukey’s test for multiple comparisons, using GrapPad Prism 8 . Non-parametric data were evaluated by Wilcoxon signed-rank test. A value of Our overall results support the concept of local liquid delivery of paclitaxel into the arterial segments. In comparison of two clinically available forms of liquid paclitaxel, the solvent-based paclitaxel demonstrated greater arterial retention following treatment, accompanied with a decrease in neointimal growth. The histopathologic findings showed biological effect, as indicated by vascular smooth muscle cell loss, without evidence of thrombus, toxicity or inflammation. Together, these results indicate the effectiveness of a local liquid approach to deliver and retain liquid paclitaxel in arterial segments. Additional studies are warranted to further evaluate the safety and efficacy of the use of sb-paclitaxel in local liquid delivery devices—an approach that has the potential to impact millions of patients suffering with PAD by improving outcomes and quality of life.


A similar pattern of correlation was found for PCs. Within-district and within-PC variation are the primary source of variation for child malnutrition in India. Our results suggest the importance of considering heterogeneity within districts and PCs when planning and administering child nutrition policies.In India, districts serve as central policy unit for program development, administration and implementation. The one-size-fits-all approach based on average prevalence estimates at the district level fails to capture the substantial small area variation. In addition to district average, heterogeneity within districts should be considered in policy design. The objective of this study was to quantify the extent of small area variation in child stunting, underweight and wasting across 36 states/Union Territories (UTs), 640 districts (and 543 PCs), and villages/blocks in India. We utilized the 4th round of Indian National Family Health Survey (NFHS-4) conducted in 2015–2016. The study population included 225,002 children aged 0–59 months whose height and weight information were available. Stunting was defined as height-for-age z-score below 2 SD from the World Health Organization child growth reference standards. Similarly, underweight and wasting were each defined as weight-for-age < -2 SD and weight-for-height < -2 SD from the age- and sex-specific medians. We adopted a four-level logistic regression model to partition the total variation in stunting, underweight and wasting. We computed precision-weighted prevalence of child anthropometric failures across districts and PCs as well as within-district/PC variation using standard deviation (SD) measures. For stunting, 56.4%  of the total variation was attributed to villages/blocks, followed by 25.8%  to states/UTs, and 17.7%  to districts. For underweight and wasting, villages/blocks accounted for 38.4%  and 50% , respectively, of the total contextual variance in India. Similar findings were shown in multilevel models incorporating PC as a geographical unit instead of districts. We found high positive correlations between mean prevalence and SD for stunting (r = 0.780,  In India, districts are the sub-division of states that serve as central administrative unit. The Transformation of Aspirational Districts initiative, which identified 115 “aspirational” districts, exemplifies the significance of districts in policy administration in India. The Government of India selected these districts based on performance indicators across six developmental domains and prioritized allocation of human and financial resources to advance progress in aspirational districts3. Similarly, POSHAN Abhiyaan, India’s national nutrition flagship programme, has been rolled out in different phases based on district-level prevalence of child undernutrition5. Both of these programmes adopted district-level average for policy decision and resource allocation.Monitoring and evaluation of health status in developing countries are primarily based on prevalence estimates across macro policy units. States or provinces often serve as a principal unit of measurement, in addition to increasing efforts to use the second-level geography10. For example, a recent study on women’s Body Mass Index (BMI) across 58 low- and middle-income countries found that between-individual differences contributed to nearly 80% of the total variation in BMI6. In India, inter-village variation accounts for the largest share of poverty and child sex ratio8. These results imply that districts with above average performance might have significant underlying degree of inequality.However, increasing volume of evidence suggests that district average may mask substantial socioeconomic inequity across smaller area in India. Recent studies using multilevel modeling have consistently reported large small area variation in diverse development and health outcomes2. Previous studies that characterized geographic inequality of childhood anthropometric indicators across states and districts revealed high burden in northern and central states13. Yet, the variation within state or smaller levels of geography has not been fully explored.Despite of the underlying socioeconomic heterogeneity within districts, little is known about the intra-district (i.e. inter-village/block) variation in child malnutrition outcomes. Child malnutrition has been a central health concern in India, as it attributed to 68.2% of under-five deaths in 201714. The MPs hold governmental authority on resource allocation and policy implementation at the national and PC levels. For instance, MPs have decision-making power to mobilize the funds from Member of Parliament Local Area Development (MPLAD) Scheme15. While the lack of political identifiers in nationally representative surveys has hampered presenting PC-level progress in population health and development, recent studies developed methodologies to link the Census and other surveys to PCs18. These methods enabled computation of PC-level estimates for child undernutrition17, yet within-PC variation has been neither investigated nor quantified.In addition to districts, Parliamentary Constituencies (PCs) in India are a comparable geographical unit to districts that serve a political role. The Members of Parliament (MPs), elected from 543 PCs, represent in the Lok Sabha, the lower house equivalent in IndiaIn this paper, we aimed to characterize and measure the variation of child malnutrition across 36 states and Union Territories (UTs), 640 districts and 543 PCs, and small area (villages/bocks) in India. First, we performed a multilevel analysis to partition the variation in child undernutrition across these geographies. These estimates can be interpreted as the relative importance of each geographic unit in determining the variation in child undernutrition outcomes. Then, we computed village/block-specific precision-weighted estimates of child undernutrition. Using these estimates, we present not only the overall mean of children malnutrition across districts and PCs, but also the within-district and within-PC variation for the first time in terms of SD. Lastly, we presented the relationship between the mean and SD across districts and PCs to highlight the importance of considering small area inequality measures when defining highly burden areas.We obtained the data from the fourth round of National Family Health Survey (NFHS-4) of India  conducted in 2015–2016. For the first time, NFHS-4 collected and provided information for all 640 districts nested in 29 states and 7 UTs of India. The NFHS-4 contained a sample of 247,743 living children aged 0–59 months. After excluding those with missing information on child’s height and weight , 225,002 children remained in the final analytic sample.Enumeration Area with a measure of size equal to the number of households (or the population) in that area, mostly provided by the population census19.In NFHS-4, the households were selected from a two-stage cluster sampling frame. According to DHS sampling manual, a cluster was defined as a group of adjacent households which served as the primary sampling units (PSU) for the efficiency of field work. A cluster is an 19. Therefore, in NFHS-4, a cluster was a PSU or a segment of PSU. The resulting list of households served as sampling frame for selection of households in the second stage. A fixed number of 22 households were selected from each PSU based on equal probability systematic sampling.In the first stage, villages and census enumeration blocks (hereafter referred as villages/blocks) were selected as PSUs for rural and urban areas, respectively. A household listing operation was then carried out by visiting each of the selected PSUs and listing all residential households. In the PSUs with more than 300 households were divided into segments of 100–150 households20. Stunting was defined as height-for-age z-scores less than − 2 SD, underweight as weight-for-age z-scores less than − 2SD, and wasting as weight-for-height z-scores less than − 2SD. Age- and sex-specific z-scores were computed using the raw height and weight collected by skilled and trained field investigators of the NFHS-4. For children aged between 24 and 59 months, standing height was taken, whereas recumbent length was measured for children younger than 24 months. The weight was measured by skilled health investigators using digital solar-powered scales along with adjustable short measuring boards.The primary outcome variables were three anthropometric failures—stunting, underweight and wasting. We defined all three outcomes following the World Health Organization (WHO) child growth reference standards18. We adopted a four-level logistic model to partition the total variation in child undernutrition outcomes (Y) by four levels of child i (level-1), cluster j (level-2), district or PC k (level-3), and state/UT l (level-4): 2/3 or 3.2920.PC membership for each child was identified following a previously published methodologyz: .All maps were generated using ArcGIS Desktop 10.6. The shapefiles for 640 districts as per the year 2011 and 543 PCs as per the year 2014 were obtained from the Community Created Maps of India (CCMA) project  within a district or PC Fig. . Of the The within-district small area variation was measured by SD of stunting, underweight and wasting. Figure Within-PC small area variation (measured as between-village/block SD) in child stunting ranged from 1.9 to 9.8 with the median of 5.5 Fig. B. In casp < 0.001). About 41% (264 districts) of the districts were clustered in the quadrant of high mean and high SD and in the quadrant of low mean and low SD. Similarly, a high and positive correlation was observed between mean prevalence of underweight and SD across all districts  and within-district (or within-PC) variation in child stunting, underweight and wasting. This implies that districts and PCs with higher overall burden also tend to have larger small area variation. These findings could guide policy design in several aspects.We aimed to quantify and examine variation in child anthropometric failures across four important geographical levels: states/UTs, district, PCs, and villages/blocks in India. Three salient findings emerged from our analysis. First, among the multiple geographies considered, small area variation within districts (and PCs) accounted for the largest share of the total variance in child undernutrition. This finding on the substantial small area variation is consistent with findings from prior multilevel studies on the socioeconomic and health inequities across villages in IndiaFirst, this information could contribute to selecting an appropriate geographic unit to serve as a building block for effective administration, governance, monitoring, and evaluation. In a populous country like India with limited resources, widespread developmental concerns, and geographical and socio-cultural heterogeneities, identifying the most relevant geographic policy units are crucial for designing interventions. Despite such relevance, existing data, academic research, and policy discourse on development and health in India largely rely on average performances of districts. This masks the potential utility of other important policy units and the existence of substantial small area variation underlying within districts.Abhiyaan focus on average district-level prevalence and performances4. However, the results from variance partitioning suggest the need to consider small area variation when selecting policy units for action. This finding is critical to attain desired reductions in the mean prevalence and underlying inequality of child anthropometric failures. For example, Bilaspur district of Chhattisgarh have mean prevalence of child stunting of 34.05% which is below the national mean prevalence. However, within Bilaspur, substantial small area variation (SD: 7.89) was observed with the mean prevalence ranging from < 1 to 75% across villages/blocks. In this case, district average may mask the specific needs of different villages or municipal wards in Bilaspur. To identify high-burden villages/blocks within districts, health programmes should incorporate inequality metrics in performance evaluation.Second, our findings provide integral information for the current initiatives in India to reduce child undernutrition. For example, ongoing programs such as POSHAN 17. The PC-level estimates presented in this study could be further utilized to target smaller geographic areas to address pressing public health agenda.Third, we observed high intra-PC inequality in child undernutrition across villages/blocks. The estimates from our multilevel model suggest that villages/blocks accounted for a relatively higher share in the total variation of child anthropometric failures. This finding possesses direct political utility as MPs hold governmental authority in resource allocation decisions. For example, MPs also raise funds by collaborating with several NGOs and think tanks. Given such authority, a detailed understanding of the within-PC variation is essential. By providing intra-PC variation estimates, we aimed to provide a monitoring framework that can potentially improve governmental accountability in reducing the burden of child malnutrition. In this regard, a few recent studies have also emphasized the use of political units as a monitoring framework to enhance evidence-based discourse among policymakersFourth, the strong and positive correlation between mean prevalence and inter-village/block variations (SD) across districts and PCs suggest the importance of considering inequality within districts. In this study, we showed that districts and PCs with higher overall burden are also subject to higher inequality. For instance, mean prevalence of stunting in Punch district of Jammu and Kashmir is 26.69% with high values of SD (6.78%). Although current strategy in India is to identify target-areas based on district-level averages of health status, we argue that considering small area variation within districts and PCs can further enhance efficiency by reducing the risk of missing high-burden areas nested within otherwise well-performing districts (or PCs).This study has a few limitations. While we focus on villages and blocks to capture small area variation, rural villages and urban blocks are not directly comparable in terms of size and administrative role. Further, our precision-weighted estimates for mean prevalence and inter-village/block SD across districts and PCs do not adjust for demographic and socioeconomic correlates that may be driving higher burden of child undernutrition for some districts and PCs.In conclusion, our findings suggest that health and nutritional inequality exists across smaller geographic area, which calls for more precise policy attention. The results presented in this paper could be utilized to determine whether it is more appropriate to target the general population or subpopulation in specific regions in order to improve the effectiveness of ongoing initiatives related to child malnutrition in India. The analyses conducted in this paper could be applied to other developing countries that share similar task of reducing the burden of child malnutrition.Supplementary Information


Background: Self-care is an important perspective to aging and transitional states in diabetes management. Population studies have shown that lower cognitive function is associated with worse self-care abilities. Several guidelines have emphasized the importance of assessing cognitive function in older people with diabetes and tailoring treatment plan accordingly. Those guidelines do not specify which tools are the most appropriate for this population. One approach to delineate which tools should be used is to assess which tools best correlate with self-care capacity.Objective: To assess which cognitive assessment tools best correlate with self-care capacity in older people with type 2 diabetes.Methods: Cross-sectional study, conducted amongst individuals with diabetes over the age of 60. The association between self-care capacity indices and different cognitive assessment tools was examined. Principal Component self-care constructs were determined and the association between these and the different cognitive assessment tools was examined.Results: A significant association was found between the Principal Component self-care construct and the Montreal Cognitive Assessment and MindstreamsTM scores. In a stepwise regression model including only the Montreal Cognitive Assessment score, a significant association was found between this score and the Principal Component self-care construct. The same was not found in a model that included only the MindstreamsTM scores.Conclusions: The Montreal Cognitive Assessment, previously validated as a brief cognitive screening tool, may be useful as an adjunct to assess the self-care capacity of older individuals with diabetes. Future studies in the clinic are needed to evaluate if using this tool may improve treatment plans. Self-care is a cornerstone in diabetes management and may be one of the important abilities lost as an individual moves between transition states. Involving a variety of health-promoting behaviors, such as appropriate diet and physical activity, self-care management has been shown to have positive effects on glucose control and in the prevention of the long-term consequences of diabetes –3. CogniThe American Diabetes Association (ADA), as well as a number of published guidelines –12, haveSelf-care was defined by the World Health Organization (WHO) as monitoring and responding to environmental and biological conditions by making adaptive adjustments in the different aspects of diabetes treatment . VariousAt the Center for Successful Aging with Diabetes, a multi-disciplinary evaluation is conducted. This includes collection of cognitive assessment and self-care capacity indices  among people with diabetes over the age of 60. This evaluation provides us an opportunity to assess the association between self-care capacity indices and different cognitive instruments commonly used.This was a cross-sectional study conducted in individuals with diabetes over the age of 60, attending the Center for Successful Aging with Diabetes at the Sheba Medical Center . The indHebrew speaking individuals with diagnosis of type 2 diabetes over the age of 60, either self-referred or referred by treating physician because of difficulties in managing their disease, were included. Diabetes diagnosis was determined by a diabetes specialist, based on medical history and diabetes medication. Excluded were people with significant hearing, visual, motor or cognitive impairment that may had precluded neuropsychological testing and responding to self-report questionnaires. Others exclusion criteria included illiteracy, any major non-diabetes related illness expected to reduce life expectancy or a significant disability that interfere with study participation.Self-Care CapacityThe following variables were considered to be part of the self-care capacity construct:(a)Summary of Diabetes Self-Care Activities Assessment (SDSCA) (b) The score on a physical activity questionnaire (PAQ), based on the Baecke (c) Carbohydrate consumption/total caloric intake, according to a Food Frequency Questionnaire (FFQ) validated for the older population (d) Report of whether or not the individual ever experienced an episode of severe hypoglycemia, requiring external assistance for recovery, as defined by the ADA (e) Hemoglobin A1c (HbA1c). (SDSCA)  questione Baecke  questionpulation ; (d) Rep the ADA ; (e) HemCognitive FunctionMindstreamsTM (NeuroTrax)   computerThe Montreal Cognitive Assessment (MoCA) (The Digit Symbol Substitution Test (DSST) , that measures verbal production, semantic memory and language  t (MoCA) , a brieft (DSST) , a subset (DSST) , pertaint (DSST) , 24. Agelanguage . This telanguage , 27. AgeOther CovariatesGeneral, medical and diabetes related data variables were collected by a diabetes specialist, through history, physical examination, and blood work.All data was coded and unified into a common database. Continuous variables were summarized using means and standard deviations (SD)/medians and interquartile ranges, binary variables were summarized using counts and percentages. SDSCA diet and exercise domains were analyzed as continuous variables. Other SDSCA domains were dichotomized into “daily”/“less than daily” (blood-glucose testing and medication domains) or by their median (foot-care domain). To evaluate the association between each self-care capacity component and the cognitive evaluation tools, linear regressions were conducted on normally distributed self-care variables and logistic regression on other variables.To examine the configuration of self-care capacity data in a multivariable space, Principal Component Analysis (PCA) was conducted. This statistical method was used to reduce the set of inter-correlated self-care capacity variables into a few dimensions, that gather as big amount as possible of the original variables variability . Using tWe used stepwise linear regression to assess which cognitive assessment tools were significantly associated with each PC self-care construct, adjusted for age and gender. Further analysis was performed in separate regression models, including only cognitive assessment tools that were found to be significantly associated with the PC self-care construct. Statistical analysis was performed using version 3.5.0 of R statistical software .The analysis pertains to 122 consecutive participants who conducted the evaluation day at the Center for Successful Aging with Diabetes and for whom completed data was available. Participants mean age was 70.4 years (SD = 6.2), included a majority of men (64.8%), with a mean of 15.4 years (SD = 2.9) of education and a mean diabetes duration of 16.3 years (SD = 9.3). 36.4% were insulin users and their mean HbA1c was 7.6 (SD = 1.4). The mean (SD) MoCA, standardized DSST and NeuroTrax GCS scores were 24.1 (3.4), 9.6 (3.0), and 98.3 (9.0), respectively . Using tTwo sets of self-care capacity variables were used to the create the Principal Component self-care constructs (PCs), as summarized in Set 1 included all self-care capacity variables. The PCA using this set of variables revealed two PCs (PC1 & PC2) with eigenvalues >one, accounting together for 39% of the total variance. In this analysis, the first PC (PC1) was mainly composed (PCs loadings ≥ |0.5|) of HbA1c, SDSCA blood-glucose testing and the PAQ score . The secSet 2 included all self-care capacity variables that were not strongly associated with the PCs constructed using set 1 (PCs loadings < |0.6|): Carbohydrate consumption/total caloric intake, severe hypoglycemia, SDSCA blood-glucose testing, medication and foot-care. The analysis using this set of variables (set 2) constructed two PCs, explaining together 49% of the total variance. PC1 was mainly composed of SDSCA blood-glucose testing and foot-care, while PC2 was mainly composed of SDSCA medication.R2 = 0.29) of PC self-care construct 1. Among the cognitive scores included in this model, the MoCA and the NeuroTrax (GCS and domain specific) scores were significantly associated with this construct . In model 3, DSST and VF Phonetic scores were significantly associated with PC1 (set 2). In model 4, NeuroTrax GCS was the only significant score to be associated with PC2 (set 2)  .p < 0.000, R2 = 0.19). The same was not found in a model that included the NeuroTrax GCS and specific domain scores  has not been validated for the older population. Fourth, the study aimed to elucidate cognitive tools that are associated with self-care. Self-care is a construct that does not have a measurable definition, thus limiting our ability to define the relationship between it and the cognitive assessment tools. In order to overcome this, a multitude of variables that compose the self-care construct were considered and analyzed together, using the PCA method. This method may be valuable to explore the multidimensional construct of self-care capacity.Considering the projected prevalence of diabetes as the population is aging, tailoring treatment require efficient cognitive evaluation tools. The MoCA, previously validated as a brief cognitive impairment screening tool, may be useful as an adjunct to assess the self-care capacity of older individuals with diabetes. Future studies are needed to assess its use in different types of diabetes (like type 1), to understand the role of mediating factors (like cognitive reserve) and if using the MoCA in the clinic, as a screening tool, may improve tailoring of treatment plan.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Ethical Committee of the Sheba Medical Center. The patients/participants provided their written informed consent to participate in this study.NG, MA, OG-T, TY, and RN contributed to acquisition and interpretation of data. TC-Y and NM contributed to acquisition, interpretation, analysis of data, and drafting this manuscript. TC-Y also made substantial contribution to conception and design of the research described. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling Editor declared a past co-authorship with the author TC-Y.


There is recent evidence that coronavirus disease 2019 (COVID-19) infection results in a prothrombotic state that may increase the risk of venous thromboembolism. Both COVID-19 infection and pulmonary emboli can present with dyspnoea, tachypnoea, hypoxaemia and an elevated D-dimer. Identifying a pulmonary embolus in a patient with COVID-19 and differentiating it from the typical clinical and biochemical features of COVID-19 is challenging.We report four cases, and reviewed two further cases in the literature, of a pulmonary embolus in patients who presented to the emergency department with COVID-19 and no other risk factor for a pulmonary embolus.We identified a series of atypical features that should raise suspicion for a pulmonary embolus: pleuritic chest pain; haemoptysis; atrial fibrillation; tachycardia; hypotension; late onset deterioration; evidence of right heart strain; or a disproportionally elevated D-dimer in comparison to ferritin. Coronavirus disease 2019 (COVID-19) is a novel disease that usually presents with mild symptoms; however, in 14% of patients it can result in a severe disease requiring hospitalisation.A 72-year-old woman presented to the emergency department (ED) after she attended the hospital for a routine ophthalmology appointment and felt dyspnoeic. She had experienced one week of lethargy, feeling generally unwell and loss of taste, and one day of dyspnoea, palpitations, and diarrhoea. She did not complain of fevers, cough, or chest pain. She was entirely independent and had a history of hypertension, seasonal asthma, and glaucoma. On assessment she was tachypnoeic (32 breaths per minute) with increased work of breathing and had oxygen saturations of 90% on 15 litres of oxygen via a non-rebreather mask. She was in atrial fibrillation with a rapid ventricular response (125–170 beats per minute) and was hypotensive (87/62 millimetres of mercury [mmHg]).Venous and arterial blood samples were taken and sent for analysis . A chestA 62-year-old man was brought into the ED by ambulance with three days of worsening dyspnoea, reduced appetite, myalgia, intermittent diarrhoea, abdominal cramping and one episode of vomiting, but no chest pain. He had experienced a fever three weeks previously and tested positive for COVID-19 before self-isolating and completing a course of azithromycin. He was previously independent and his only medical history was hypertension and hypercholesterolaemia. On assessment in the ambulance he had oxygen saturations of 52% on room air which improved to 88% on 15 litres of oxygen via a non-rebreather mask. In the ED he was tachypnoeic (24 breaths per minute), with saturations of 97% on 15 litres of oxygen. He was tachycardic (113 breaths per minute), normotensive (100/72 mmHg), and an electrocardiogram (ECG) showed sinus tachycardia with no evidence of right heart strain.A CXR showed extensive, bilateral peripheral patchy opacification suspicious for COVID-19. A CTPA demonstrated bilateral acute pulmonary emboli with no features of right heart strain and extensive peripheral ground-glass and peri-lobular consolidation consistent with COVID-19. The patient was treated with treatment dose tinzaparin and high-flow oxygen. A nasopharyngeal aspirate confirmed COVID-19 infection RT-PCR.A 78-year-old man was brought into the ED by ambulance with four days of fever, dry cough, lethargy, myalgia, coryza, dyspnoea and one episode of haemoptysis, but no chest pain. He had a history of benign prostate hyperplasia and hypercholesterolaemia, but was otherwise active and independent. On assessment with the ambulance service he was in respiratory distress and had oxygen saturations of 60% on room air. On assessment in the ED he had oxygen saturations of 88% on 15 litres of oxygen via a non-rebreather mask and tachypnoeic (35 breaths per minute). He was normotensive (120/94 mmHg) but had cool peripheries with a peripheral capillary refill time of five seconds. An ECG showed he was in atrial fibrillation with a rapid ventricular response (140 beats per minute) with ST depression in lateral leads and no evidence of right heart strain.What do we already know about this clinical entity?Coronavirus disease 2019 (COVID-19) infection can cause significant hypoxaemia that is predominantly thought to be secondary to acute respiratory distress syndrome.What makes this presentation of disease reportable?These patients with COVID-19 infection developed pulmonary emboli; these cases highlight atypical features that should raise suspicion for a pulmonary embolus.What is the major learning point?Emergency clinicians should consider a pulmonary embolus in patients with COVID-19 who present with atypical clinical and biochemical features.How might this improve emergency medicine practice?This may reduce the rate of undiagnosed pulmonary emboli that can be treated to improve outcomes in patients with COVID-19.A CXR showed bilateral consolidation suspicious for COVID-19. A point-of-care echocardiogram showed reduced right ventricular free wall contractility. A CTPA showed multiple subsegmental pulmonary emboli throughout the right hemithorax and left lower lobe with evidence of right heart strain (right ventricle:left ventricle ratio >1:1) and extensive ground-glass changes. The patient was taken to the intensive care unit (ICU) due to progressive hypoxia where he was intubated and ventilated and treated with treatment dose tinzaparin. A nasopharyngeal aspirate confirmed COVID-19 infection RT-PCR.A 63-year-old man presented with two weeks of myalgia, fever and lethargy, and three days of haemoptysis and pleuritic chest pain. He was independent with no comorbidities. He had normal observations and a normal examination. An ECG showed new right bundle branch block. A CXR showed bilateral peripheral areas of consolidation suspicious for COVID-19. A CTPA demonstrated bilateral pulmonary emboli with complete occlusion to the left lower lobar artery, a right sided pulmonary infarct, right heart strain (right ventricle:left ventricle ratio of 1.4:1), and patchy ground-glass shadowing suggestive of COVID-19. He was treated with treatment dose tinzaparin.There has been one case report of a pulmonary embolus in a patient with COVID-19 who was identified after an echocardiogram demonstrated right heart strain .In the context of COVID-19, raising clinical suspicion for a pulmonary embolus and distinguishing it from the typical features of COVID-19 is difficult as 30% of inpatients with COVID-19 are dyspnoeic, 76% are hypoxaemic, and 29% are tachypnoeic (respiratory rate >24 breaths per minute).7All four patients we reported had significantly elevated D-dimer values; however, as both a marker of thrombosis and acute inflammation, the diagnostic value of the D-dimer is poor. Ninety percent of inpatients with COVID-19 have an elevated D-dimer, although a value of >1000 nanograms per microlitre (ng/mL)  is an independent risk factor for death.Ferritin is another acute phase protein that is elevated in patients with COVID-19, with higher levels in non-survivors than with survivors but does not appear to be elevated as a result of venous thrombosis.Concerns have been raised of using contrast in a patient population that may be at increased risk of acute kidney injury.In all cases in this series, there were no pre-existing risk factors for venous thromboembolism, although COVID-19 itself may be a risk factor. Seventy-one percent of non-survivors with COVID-19 met the criteria for disseminated intravascular coagulation which appears to be predominantly prothrombotic.15All patients were treated with treatment dose tinzaparin whilst thrombolysis was avoided due to the risk of haemorrhage. One study found that heparin prophylaxis in COVID-19 positive inpatients with a D-dimer >3000 ng/L reduced the 28-day mortality.11We reported four cases of COVID-19 patients presenting with an acute pulmonary embolus. It is important to be aware of atypical features of COVID-19 infection that may be more suggestive of a pulmonary embolus such as pleuritic chest pain, haemoptysis, atrial fibrillation, tachycardia, hypotension, late onset deterioration, evidence of right heart strain, or a disproportionally elevated D-dimer in comparison to ferritin.Further investigation is required into the role of prophylactic anticoagulation in COVID-19 patients and the pathogenesis of the hypercoagulable state including the role of antiphospholipid antibody. A regression analysis exploring predictive factors to the identification of PE will aid the pre-test probability, distinguishing those needing CTPA.


Coronavirus disease (COVID-19) is spreading worldwide. The reported possible neurological symptoms are varied and range from subtle neurologic deficits to unconsciousness. Knowledge regarding the detection, diagnosis, treatment, and follow-up of COVID-19-associated neurological damage is still limited. We report a case of serious neurological damage and mental abnormalities in a patient who was finally confirmed to have COVID-19 based on IgM and IgG antibodies in the cerebrospinal fluid (CSF).A 68-year-old man had slight flu-like symptoms and transient loss of consciousness in early February. Exaggerated unconsciousness and deteriorating mental abnormalities occurred over the next month without severe respiratory symptoms. Craniocerebral computed tomography showed normal results, but antibodies against severe acute respiratory syndrome coronavirus 2 were 100 times higher in the CSF than in the serum; tests for viral ribonucleic acid showed negative results with both a nasopharyngeal swab and CSF sample.COVID-19 pneumonia was diagnosed based on symptoms and positive results for IgM and IgG in the CSF.Antiviral, fluid, and nutritional support were administered for 30 days before admission without obvious improvement. A further 18 days of routine antiviral therapy, immunoglobulin therapy (10 g per day for 5 days), and antipsychotic drug treatment were administered.The patient's neurological and mental abnormalities were greatly ameliorated. He was discharged with mild irritability, slight shaking of the hands, and walking fatigue. These symptoms have persisted up to our last follow-up .We believe this is the first case involving neural system injury in a patient who confirmed COVID-19 based on CSF antibody test results. Negative ribonucleic acid test results, strong positivity for antibodies, and high protein levels in the CSF suggest the possibility of autoimmune encephalitis secondary to COVID-19. This case highlights additional novel symptoms of COVID-19, and these data are important for the assessment and follow-up of COVID-19 patients. Phylogenetic analysis of these coronaviruses based on full-length genome sequences shows that SARS-CoV-2 has about 45–90% similarity with SARS-CoV and 20% to 60% similarity with MERS-CoV. Researchers are racing to learn more about the epidemiology and clinical characteristics of this new viral infection. We report a case of serious neurological damage and mental abnormalities in a patient who was finally confirmed to have COVID-19 infection based on IgM and IgG antibodies in the cerebrospinal fluid (CSF), despite testing negative for viral ribonucleic acid (RNA) using both a nasopharyngeal swab and CSF sample; tests for plasma antibodies also showed negative results.The novel coronavirus disease, coronavirus disease 2019 (COVID-19), has become a pandemic and is currently spreading around the world and causing concern in the medical community.2A 68-year-old man temporarily lost consciousness on February 2, 2020 with slight cough, vomiting, fatigue, and low fever (37.5°C). There was no apparent sputum production, sore throat, chest tightness, difficulty breathing, headache, or limb convulsion. Chest computed tomography (CT) showed ground-glass shadows in both lungs. He was recommended to isolate at home due to a suspicion of “new coronavirus pneumonia.” Aggravated fatigue accompanied by headache, dizziness, nausea, and coma occurred on February 8. Emergency craniocerebral CT revealed lacunar lesions in the left basal ganglia region and chest CT showed dispersive and patchy shadows bilaterally in the lungs with partial consolidation; the lesion had enlarged. The patient was clinically diagnosed with “new coronavirus pneumonia” and was hospitalized. He awoke 48 h later with headache and vomiting after antiviral treatment and fluid and nutritional support. During this period, the patient underwent 2 viral RNA tests by pharyngeal swab, both of which were negative. On February 23, the patient once again slipped into a comatose state without any apparent cause. He woke up 4 days later unable to walk and with uroclepsia, coprolalia, and persecution delusion. He was transferred to our hospital on March 3. The patient had a history of diabetes and hypertension under good control. His wife was also diagnosed with "new coronavirus pneumonia” a few days after his diagnosis. Her symptoms were mild without loss of consciousness or mental abnormalities. There was no reported history of mental disorders in the family.His blood oxygen saturation maintained above 95% without supplemental oxygen even in his poor condition after admission. Slight neck stiffness, trembling of the hands, and grade 4 muscle strength were detected. Laboratory investigations showed normal liver function, renal function, electrolyte level, and coagulation function. Leucocyte and lymphocyte count and percentage were all within a reasonable range. SARS-CoV-2 IgM antibodies in the plasma were slightly high and IgG antibodies in the plasma were within the normal range . A repeated craniocerebral CT showed results similar to those obtained on February 8; another chest CT showed ameliorated lung opacities  may affect the central nervous system in 1 of 2 ways: 1 is by spreading from the peripheral to the central nervous system through nerve fibers, and the other is by passing through the blood-brain barrier.We believe this is the first case of central and peripheral neurological damage and mental abnormalities with confirmed COVID-19 infection by CSF antibody tests. This patient showed aggressive neurologic damage and mental abnormalities without severe respiratory symptoms. There was no obvious point in time when neurological damage began, and the neurological damage lasted for months. Craniocerebral CT images were normal, and SARS-CoV-2 antibody titers were 100 times higher in the CSF than in serum with negative RNA test results.The negative RNA tests in this case indicate a low level of virus replication, and strong positive antibodies and high protein level in the CSF are suggestive of autoimmune encephalitis or encephalopathy secondary to coronavirus infection. The neurologic symptoms of this patient were possibly induced by the immune response to infection rather than due to direct virus damage. However, more answers need to be uncovered, including(1)understanding who is susceptible to this kind of neurological damage,(2)whether psychiatric abnormalities are common in patients with COVID-19 encephalitis,(3)whether this patient's fatigue was directly caused by encephalitis or combined with an impaired peripheral nervous system,(4)whether antibody tests are an essential exam for CSF tests as well as RNA tests,(5)whether regular immunoglobulin therapy for COVID-19 could prevent and delay the development of neurologic damage in general, and(6)the possible short- and long-term harm to the nervous system by COVID-19.Further studies must be conducted to investigate the neurological damage caused by this novel coronavirus.We suggest that physicians who encounter patients from pandemic hotspots with abnormal neurologic damage and mental abnormalities protect themselves carefully, even if the RNA test for the virus shows negative results. Antibody tests for CSF as well as RNA tests are necessary for patients with neurological symptoms, and long-term follow-up is recommended for these patients. The findings of this case are important for the assessment and follow-up of COVID-19 patients.W.M. and F.Q responded for the care of the patient, W.M. W.L. and Y.G. were involved in the diagnosis, management and treatment. Y.G. and T.L. reviewed relevant papers. All authors contributed equally to writing the manuscript.


Hantaviridae, order Bunyavirales) can cause two serious syndromes in humans: hemorrhagic fever with renal syndrome (HFRS), associated with the Old World orthohantaviruses, and hantavirus cardiopulmonary syndrome (HCPS), associated with orthohantaviruses in the Americas. In Europe, four different orthohantaviruses  are associated with human disease. As disease severity and zoonotic source differ between orthohantavirus species, conclusive determination of the infecting species by either RT-PCR or comparative virus neutralization test (VNT) is of importance. Currently, the focus reduction neutralization test (FRNT) is considered the ‘Gold Standard’ for orthohantavirus VNTs, however this test is laborious and time-consuming. Consequently, more high-throughput alternatives are needed. In this study, we developed a comparative orthohantavirus microneutralization test (MNT) including all four human pathogenic orthohantavirus species circulating in Europe. The assay was validated using RT-PCR-confirmed rodent (n=17) and human sera (n=17), DOBV-suspected human sera (n=3) and cohorts of orthohantavirus-negative rodent (n=3) and human sera (n=85). 16/17 RT-PCR-confirmed rodent sera and 18/20 of the RT-PCR-confirmed and DOBV-suspected human sera were serotyped successfully, while for the remaining rodent (n=1) and human sera (n=2) no neutralizing titers could be detected. All negative control sera tested negative in the MNT. The assay was subsequently evaluated using a clinical cohort of 50 orthohantavirus patients. Orthohantavirus infection was confirmed in all 50 patients, and 47/50 (94%) sera were serotyped successfully, confirming PUUV as the major cause of orthohantavirus infections in Netherlands. Notably, two previously unrecognized SEOV cases from 2013 were diagnosed using the MNT, underlining the added value of the MNT in a diagnostic setting. In conclusion, we demonstrate the successful development and clinical implementation of a comparative European orthohantavirus MNT to determine the infecting virus species in European HFRS patients. Identification of the causative species is needed for an adequate Public Health response and can support individual patient care. For many labs, the implementation of orthohantavirus neutralization tests has not been a straightforward procedure. This issue will be addressed by the rollout of the comparative MNT to multiple European laboratories to support patient diagnostics, surveillance and Public Health responses.Orthohantaviruses (family  Hantaviridae, order Bunyavirales  carried by the bank vole (Myodes glareolus); Seoul virus (SEOV) carried by different species of rats (Rattus spp.); and Tula virus (TULV) carried by the common vole  ((A. agrarius), is generally believed to be only present in Asia, some studies suggested that it may also be present in eastern parts of Europe (Four different orthohantavirus species are associated with human disease in Europe: Dobrava/Belgrade virus (DOBV) carried by three closely related species of the genus arvalis) . Additiof Europe .Of the orthohantaviruses with confirmed presence in Europe, DOBV is associated with the most severe form of HFRS with case fatality ratio’s (CFR) up to 12%, depending on the genotype . SEOV isArvicolinae-borne orthohantaviruses, while DOBV and SEOV (together with HNTV) are part of the serogroup of Murinae-borne orthohantaviruses. Unfortunately, however, as high levels of cross-reactive antibodies are observed within but also between the different serogroups , the infecting virus species cannot be determined conclusively using routine serological assays . To date, multiple variations of orthohantavirus neutralization assays have been described , howeverGreen monkey kidney Vero-E6 cells (ATCC C1008 CRL1586) were maintained in Dulbecco’s Modified Eagle’s MEM  supplemented with 5% heat-inactivated fetal bovine serum , 100 U/ml penicillin and 100 U/ml streptomycin . Cells were cultured at 37°C under 5% CO2.via the European Virus Archive (EVAg). Stocks were created by passaging twice on Vero-E6 cells using a low multiplicities of infection (MOI 0.001-0.1), and harvesting 7–14 days post infection.DOBV strain SK/Aa , PUUV strain Sotkamo , SEOV strain 80–39 , and TULV strain Moravia (no longer available from EVAg) were all acquired 50) assay adapted for indirect detection of virus-infected cells. Briefly, tenfold viral dilutions were inoculated on Vero-E6 cells and incubated for 7  or 12 days (PUUV) at 37°C, which corresponded to peak titers during virus culture (data not shown). Subsequently, cells were fixed using 4% PFA and permeabilized using 0.02% Triton X-100 in PBS. Subsequently, cells were washed with PBS and stained using mouse anti-hanta nucleoprotein   or mouse anti-hantavirus Dobrava strain nucleoprotein  (for DOBV) as primary antibodies and goat anti-mouse-AlexaFluor488  as a secondary antibody. Positive wells were visualized using a Leica DMIL LED fluorescence microscope and scored by eye. TCID50 titers were calculated using the Spearman and Kärber algorithm  or 12 (PUUV) days at 37°C, before cells were fixed, permeabilized and stained as described above. Virus-positive cells were visualized using a Leica DMIL LED fluorescence microscope. The neutralization titer was determined by scoring the wells in which infection was inhibited ≥ 95% compared to the positive control (MNT95).The orthohantavirus neutralization test was designed as a microneutralization tests (MNT) as previously described for the Influenza A virus and the orthohantaviruses HTNV and SEOV  with an R. norvegicus sera (n=3) that previously tested negative in both RT-PCR and the orthohantavirus FRNT in Uppsala, Sweden  originated from Dutch patients and were diagnosed using the genotype-specific RT-qPCRs described by , while sMurinae-borne) orthohantaviruses. Two of three sera were known to be convalescent (both samples were taken more than one year after onset of symptoms), while for the third serum the status was unknown. None of these sera were confirmed by RT-PCR.In addition, a small serum panel from DOBV-suspected human patients (n=3) kindly provided by Sabine Lederer from Euroimmun  was tested in the orthohantavirus MNT. All samples showed the highest IgG titers against DOBV in the Euroimmun mosaic immunofluorescent assay (IFA) , with a Finally, 85 randomly selected sera collected from healthy Dutch blood donors in 2016 were included as negative controls.Sera of 50 Dutch patients clinically suspected of an orthohantavirus infection, collected in the period 2013–2017, and diagnosed with an orthohantavirus infection based on routine serology were selected for testing in the orthohantavirus MNT. Initial routine orthohantavirus diagnostics were performed using the Euroimmun mosaic IFA , in whic50), it was not possible to determine levels of neutralization of PUUV and TULV infection robustly using this approach (data not shown).The aim of this work was to set up a MNT including all human pathogenic orthohantaviruses circulating in Europe, namely DOBV, PUUV, SEOV, and TULV. Initially, we designed the European orthohantavirus MNT according to the approach of , in whic95 titer, corresponding to the highest antibody dilution that inhibited infection ≥ 95%, was determined by eye. As shown in 95 titer was preferred over an end-point neutralization titer (complete inhibition of infection), as at times small breakthrough infections could be observed that prevented the determination of an end-point neutralization titer, even though clear neutralization was observed.Consequently, the MNT was designed with a fluorescence-based read-out, in which the MNT95 titers of the rodent serum validation panel. Neutralization titers of ≥ 40 were considered positive  from multiple rodent species, previously determined to be serologically (IgG) and RT-PCR positive for either DOBV, PUUV, SEOV or TULV, was used. positive . Additiorotyping .A. agrarius), no neutralization was observed. As this serum was only weakly positive in the IFT, it is possible that the serum was taken early after infection of the respective rodent and neutralizing antibodies were not yet present at the time of sampling.Close to all rodent sera (16/17) had distinct neutralizing titers toward the infecting virus species and could be serotyped as expected Table 3.For most sera (n=11/17), some degree of cross-neutralization toward the non-infecting other orthohantaviruses was observed, which was most prominent toward the orthohantaviruses from the same serogroup (PUUV ↔ TULV and SEOV → DOBV) . Cross-nR. norvegicus sera that were found to be positive in a genus-wide orthohantavirus ELISA but were previously determined to be negative in both RT-PCR and an orthohantavirus FRNT (95 (data not shown).As a negative control, wild-caught rus FRNT , were teNext, we aimed to validate the orthohantavirus MNT using sera of RT-qPCR-confirmed human orthohantavirus cases . For this purpose, we used sera from 11 Dutch and six Slovenian patients with a RT-qPCR-confirmed orthohantavirus infection diagnosed in the period from 2011 to 2017. Of these patients, 10 were RT-qPCR positive for PUUV (9 Dutch patients and 1 Slovenian patient), two were positive for SEOV (both Dutch patients) and five were positive for DOBV . As human TULV infections are rare, no sera from RT-qPCR confirmed TULV patients were available.Neutralizing titers for the RT-qPCR-confirmed patient sera are shown in In addition to the RT-PCR-confirmed rodent and human sera, a small serum panel  from patients with a suspected DOBV infection was tested in the MNT. As expected, sera of all three patients were serotyped as DOBV infections Table 5.As the incidence of orthohantavirus infections in Netherlands is relatively low , 85 randTo evaluate the MNT in a clinical diagnostic setting, a cohort consisting of 50 Dutch patients diagnosed with an orthohantavirus infection based on routine serology was tested in the comparative MNT. All sera (100%) showed neutralizing titers against at least one of the orthohantaviruses, and could thus be confirmed as orthohantavirus infections based on Gold Standard serology Table 6.95 titers of 80 and 40, respectively) while no cross-neutralization within the serogroups was observed (both DOBV and PUUV were negative). Most likely this patient was infected with SEOV, as the patient owned SEOV-positive rats.Of the sera that could not be serotyped, two sera (15-03 and 16-12) showed a neutralizing titer for both PUUV and TULV with only a two-fold difference, and were thus considered inconclusive. A third inconclusive serum (17-09b) showed a rather atypical neutralization profile of cross-neutralization between the different serogroups  for serotyping orthohantavirus infections. This is in line with two previous studies  that shoA. agrarius serum remained negative in the MNT . For both PUUV and DOBV neutralizing antibodies could already be detected in the first few days after infection . These 95 of 640, the highest neutralizing titer measured against DOBV in this study), which might explain the low levels of cross-neutralization toward PUUV and TULV. This explanation is supported by the notion that also R. norvegicus sera with high neutralizing titers against SEOV (≥1280) showed some degree of cross-neutralization toward PUUV. Interestingly, however, cross-neutralization from the Arvicolinae-borne orthohantaviruses (PUUV and TULV) toward the Murinae-borne orthohantaviruses (DOBV and SEOV) was not observed during validation, even though some rodent and human sera had neutralizing titers of ≥5120 toward either PUUV or TULV. It was, however, observed once in the diagnostic cohort  might be difficult to serotype due to high cross-reactivity in the VNT . Here, rc cohort .The vast majority of cases (44/50) in our clinical cohort of orthohantavirus infections were identified as caused by PUUV, which confirms the assumption that PUUV is the major cause of orthohantavirus infections in Netherlands . Three hA. flavicollis) has only limited presence in Netherlands and is considered not to carry the virus. TULV, on the other hand, is circulating among the common vole populations at multiple locations in Netherlands  and Slovenian Animal Ethics Committee .TH, JR, and CR contributed to the design of the study. TH, IZ, MH, and AV performed the experiments. JR, MM, TA-Ž, AV, and MK provided critical samples for validation and assessment of the assay. TH and CR wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A significant reduction in the incidence of total MDR bacterial infections was observed during the pandemic compared to in prepandemic years (p < 0.05). We also found a significantly higher incidence of MDR bacterial infections in COVID-19 departments compared with other medical departments , with extended-spectrum β-lactamase Klebsiella pneumoniae as the pathogens presenting the highest increase. This study demonstrates that maintaining a high level of preventive measures could help tackle an important health problem such as that of the spread of MDR bacteria.Multidrug-resistant (MDR) organisms are emerging as some of the main healthcare problems worldwide. During the COVID-19 pandemic, several Infection Prevention and Control (IPC) measures have been adopted to reduce nosocomial microorganism transmission. We performed a case–control study to identify if the incidence of MDR bacterial infections while using pandemic-related preventive measures is lower than in previous years. From 2017 to 2020, we monitored hospital discharges over a four-month period (P #) (1 March to 30 June) in St. Andrea Hospital, Rome. In total, we reported 1617 discharges. Pearson’s chi-squared test was used to identify significant differences. A value of  Hospital-associated infections (HAIs) are emerging as some of the main healthcare problems worldwide. Recently, there has been increasing attention on this problem and on how to prevent it. Mostly being linked to multidrug-resistant (MDR) organisms, HAIs cause about 99,000 deaths each year in the US , with anThe continuous selective pressure dictated by the widespread and sometimes unjustified use of broad-spectrum antibiotics has led to the selection of bacteria increasingly resistant to most modern forms of antibiotics. The race to develop new classes of antibiotics is often counterbalanced by the equally rapid evolution of resistant forms of bacteria.Since there are few therapeutic options in the case of an infection by extensively resistant or panresistant bacteria, the World Health Organization (WHO) highlights how preventive measures are the most efficient strategy to face the rise of MDR organisms . It has been shown how microorganism contamination of healthcare workers’ hands contributes to the spread of HAIs in hospital settings , and errSevere acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a human coronavirus that causes COVID-19, a highly infectious respiratory disease. From Wuhan, China, where the first cases were reported, it rapidly spread to the rest of the world, causing a pandemic . To dateDuring the COVID-19 pandemic, several Infection Prevention and Control (IPC) measures have been adopted to reduce nosocomial microorganism transmission ,11.A great effort is being made by healthcare personnel to contain the in-hospital spread of the virus. For the first time, the prolonged use of intensive preventive measures, previously adopted only in high-risk units, has been rolled out continuously and on a large scale. Since prevention appears to be the best way to deal with the spread of MDR bacteria and HAIs, great effort has been made by the scientific community to understand the most effective preventive strategies. The overall objective of this study is to provide an overview of MDR bacterial infections over the past four years. Analyzing the trend of MDR infections, this study aims to better understand the impact and efficacy of preventive measurements in reducing the incidence of other HAIs. The purpose is to assess whether hygiene measures adopted during the pandemic have a protective role against the spread of MDR bacteria in hospital settings.We performed a case–control study to identify if the incidence of MDR bacterial infections while using pandemic-related preventive measures is lower than in previous years. From 2017 to 2020, we monitored hospital discharges over a 4-month period (P #) (1 March to 30 June) in St. Andrea Hospital, Rome. In total, we reported 1617 discharges.In our center, before the pandemic, only basic prevention measures to avoid the spread of microorganisms were routinely adopted. Patients infected with MDR bacteria were isolated in the cohort areas, managed with gloves and disposable gowns, and subjected to active surveillance by our hygiene and prevention department. Surgical masks were used only in high-risk units or when dealing with severe neutropenic patients. During the pandemic, several additional measures have been adopted: constant use of adequate personal protective equipment, change of gloves and gowns in-between patients, increased attention to hand hygiene, segregation of patients with fever or respiratory symptoms, visiting limitations, universal masking policies, and social distancing measures recommended by the World Health Organization (WHO) ,10,11.Clostridium difficile infection is confirmed by the presence of diarrhea plus stool tests positive for Clostridium difficile.According to the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC), MDR is defined by a resistance to at least one agent in three or more antimicrobial categories . Diagnosp ≤ 0.05 was considered statistically significant.MDR bacterial infections that arose during the hospitalization period are reported in p < 0.05).We compared the rates of total MDR infections after the introduction of preventive measures with the rate of MDRI over P # 2017, P # 2018, and P #2019. For the four most common bacteria, we individually compared the infection rate during P # 2020 with the average infection rate between P # 2017 and P # 2019. (* = We examined 1617 discharges over a four-month period (P #) (1 March to 30 June) from 2017 to 2020 . p < 0.05, CIs 95%). COVID-19 departments showed a higher MDR infection incidence than non-COVID-19 departments of the same year (29.2% vs. 19.2%) . No difference in MDRBI incidence was found between P # 2017, P # 2018, and P # 2019  and non-COVID-19 (29.2%) departments showed a lower incidence of total MDR bacterial infection compared to previous years  (P # 2019 .p < 0.05). The incidence of total infection by MDR bacteria was 45.2 cases per 100 discharges during P # 2017, 44.2 during P # 2018, 41.4 during P # 2019, 19.2 during P # 2020 in non-COVID-19 departments, and 29.3 during P # 2020 in COVID-19 departments. A significant reduction in the incidence of total MDR bacterial infections was observed during the pandemic compared to in prepandemic years , and Acinetobacter baumannii.The most common MDR pathogens isolated during the period were in order of frequency: methicillin-resistant From the analysis of the infection rates of the four most common pathogens, several points deserve to be mentioned. p < 0.01). COVID-19 departments showed a higher methicillin-resistant Staphylococcus aureus, Clostridium difficile, and Acinetobacter baumannii infection incidence than non-COVID-19 departments of the same year (not significant). COVID-19 departments showed a significantly higher Klebsiella pneumoniae infection incidence than non-COVID-19 departments of the same year (p < 0.05).During P # 2020, non-COVID-19 departments showed a lower incidence of the four most frequent MDR bacteria compared to previous years (Staphylococcus aureus showed the highest prepandemic incidence and the highest reduction in IPC measures adopted in P # 2020 (from 14 to 4.2 cases per 100 discharges). The difference was statistically significant (p < 0.05). Methicillin-resistant β-lactamase Klebsiella pneumoniae infection between P # 2017 and P # 2019 was 9.4 cases per 100 discharges. During the pandemic, a statistically significant reduction of its infection incidence in non-COVID-19 departments was observed (4.8 cases per 100 discharges) (p < 0.05), but no difference was observed in COVID-19 departments (10.6 cases per 100 discharges). The mean incidence of extended-spectrum Acinetobacter baumannii infection between P # 2017 and P # 2019 was 6.3 cases per 100 discharges. During the pandemic, the infection incidence decreased at 3 cases per 100 discharges in non-COVID-19 departments . In a similar way, during P # 2020, a significant reduction of Clostridium difficile infection incidence was observed (7.8 vs. 3 cases per 100 discharges) (p < 0.05) (The incidence of  < 0.05) .p < 0.05), with extended-spectrum β-lactamase Klebsiella pneumoniae infection showing the highest increase (4.8 vs. 10.6 cases per 100 discharges) (p < 0.05).Additional findings emerged comparing COVID-19 departments with other medical departments during the pandemic. In fact, during this period, COVID-19 patients showed a significantly higher incidence of total MDR infections compared with no-COVID-19 patients (19.2 vs. 29.3 cases per 100 discharges)  employments, and contact precautions are strongly recommended, evidence for their efficacy in HAI prevention is still weak. Despite the limited period of observation, our study demonstrates that such strategies are effective in reducing the spread of HAIs and MDR bacteria. At the beginning of the pandemic, PPE-like disposable medical coats, latex gloves, and surgical masks were employed by health care personnel as well as the disinfection of surfaces and frequent hand washing. Regarding the no-COVID-19 departments, relatives’ visits were reduced from two times to one time per day and were limited to only one family member at a time. Each visitor had to adopt universal masking policies and social distancing measures recommended by the World Health Organization (WHO) ,11. Any Staphylococcus aureus diffusion, during the COVID-19 pandemic, the incidence of this infection has shown a strong reduction. A study from Lei et al. [Unlike what was observed during the severe acute respiratory syndrome (SARS) outbreak in 2003 , when pri et al.  reportedClostridium difficile, as already reported in previous works [Clostridium difficile infection incidence during the pandemic [Regarding us works ,16, IPC pandemic . A possiClostridium difficile infections, an alteration of the intestinal microbiota in COVID-19 patients has already been proposed as a possible contributing cause of these HAIs [Another important finding of this study is that COVID-19 patients have a higher incidence of MDR bacterial infections compared to non-COVID-19 patients, despite the fact that IPC measures were even stricter in the first group. This finding could be explained by the widespread use of broad-spectrum antibiotics in COVID-19 patients, which may be responsible for an increase in the incidence and the selection of multidrug-resistant bacteria . Furtherese HAIs .This study certainly has some limitations. First of all, it was conducted in a single center; therefore, it was difficult to generalize the findings that emerged since MDRB prevalence is often specific to each hospital. Furthermore, our study does not explain which of the measures adopted during emergency played a major role in the reduction of HAIs and MDR bacterial infections. Clostridium difficile infections [Other articles have demonstrated that intensification in hand hygiene practices is not effective in preventing fections . This diAnother limitation of this study is that it does not take into account the consumption of antibiotics during the periods analyzed. It is well known that the incidence of MDR bacteria is directly proportional to the excessive and inappropriate use of antibiotics, which select resistant strains of bacteria. As previously described, one of the explanations for the higher incidence of bacteria in COVID-19 patients is that often in these departments, there is broad-spectrum antibiotic use.However, the patients compared in the non-COVID-19 wards from P # 2017 to P # 2020 were all from the medical departments of the same structure; thus, it is assumed that, on average, there has been the same use of antibiotics over the years.We can speculate that greater attention paid by health personnel along with all preventive measures in their complex has led to the reduction in MDR bacterial infections. A possible take-home message (recommending the use of IPC measures even after the pandemic) would clash with several logistical and organizational problems, requiring a radical change in the working methods of healthcare personnel.This study demonstrates that maintaining a high level of preventive measures could help tackle an important health problem such as the spread of HAIs and MDRB. The COVID-19 pandemic and its associated healthcare efforts have given us the opportunity to better understand effective measures for HAI and MDRB prevention. These findings do not reveal which of the measures adopted during the emergency played a major role in HAI reduction. We can speculate that all practices adopted in their complex led to a smaller spread of MDR organisms. Herein, we also identify the pathogen most sensitive to such measures and the most common infectious agents in COVID-19 patients.We hope this study will foster a better understanding of the risk factors related to MDR bacterial infections and promote the use of effective preventive measures even after the pandemic.