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The alarm was launched in recent days by family doctors: «Hospitals are bursting, family doctors are collapsing. Politics must be examined of conscience. One of the critical points is represented by Usca, Special Continuity Units (1200 have been established throughout Italy with the Decree “Cura Italia” of March 17). “They are the link between family doctors and hospitals – explained the general secretary of the Italian doctors union (Smi), Pina Onotri -. We know that in some regions some Units have been irregular, but we have no information. If you need an ultrasound to screen for pneumonia patients or a blood test to decide whether to prescribe heparin, all we can do is send them to the hospital. So, skip home care. That is what the Continuity Units should have done. The DL “Cura Italia” indicates the duty of the Usca “to monitor the clinical situation of those who are positive for Covid in isolation and administer therapies to the sick at home, relieving pressure on hospitals and general practitioners. ‘
Five hundred thousand in home isolation
The fact is that within a few weeks the family doctors found themselves 500 thousand Covid patients to manage (about 95% of all cases), without having the tools to do so. About the Usca 30 parliamentarians presented an urgent question to the Minister of Health Roberto Speranza. Undersecretary Sandra Zampa responded that the Ministry of Health is collecting data from the Regions. But the family doctors insist: “We are left alone on the front line, overwhelmed by an immense workload.“. In Milan, where the increase in infections is exponential, only 4 Usca are in operation. For her part, the Lombard councilor for welfare Giulio Gallera announced the creation of territorial Covid diagnosis centers, “managed by specialists from local health authorities with family doctors and pediatricians, community nurses, in collaboration with municipal administrations.” The objective is “Integrate territorial medicine services with those specialized in hospitals.Gallera has promised that the diagnostic centers will be operational throughout the region in a short time.
Vital sign tracking
“The more we manage to keep the sick at home, the less will be the overload in the emergency room and hospital facilities,” said the president of the Higher Health Council. Franco Locatelli. The challenge is to identify people with symptoms that motivate hospitalization, which represent only 5-8% of the total, confirms Emanuele Nicastri, specialist in infectious diseases at the Lazzaro Spallanzani Institute in Rome. “It’s critic close monitoring of vital signs, in particular oxygen saturation »explains Nicastri. But how are patients in home isolation treated? There are three medications that have been shown to be effective in curing Covid: the antiviral remdesivir (marketed under the name Veklury, after approval by the European Medicines Agency, but for hospital use only), the corticosteroid dexamethasone and the anticoagulant enoxaparin (low molecular weight heparin). The last two drugs are in group A, so they can be prescribed by the family doctor and taken at home. But the question is not so simple, also because there are risks in combination with other widely used drugs. The CEO of the Italian drug agency recalled this, Nicola Magrini: “Patients at home, in the initial stages of Covid, should not abuse antibiotics or combine tachipyrine and cortisone.”
Paracetamol only with fever or pain
For Emanuele Nicastri, patients in home isolation should take only paracetamol, with a temperature higher than 38 ° or pain in joints and muscles. “All the rest of the therapy in this phase does not have scientific evidence, in fact in some cases it is harmful,” says the infectious diseases specialist, who advises “not to use cortisone in the first 7 days of illness, and in particular in the absence desaturation “. because it could delay or reduce our immune response. However, some doctors propose the idea of using cortisone and heparin at home to avoid aggravating symptoms (and thus the need for hospitalization). How Spanish Salvador, Director of the Department of Cardiac Surgery at the Monza Polyclinic. “The coronavirus enters the pulmonary capillaries and reproduces itself in its inner wall called the endothelium,” the cardiac surgeon wrote in a note, “in this way it determines progressive inflammation of the lungs and thrombosis of the microcirculation. Home administration of heparin and cortisone could counteract the onset of inflammatory and thrombotic processes from the beginning ”.
If the saturation is less than 94
Call for caution Francesco Scaglione, Professor of Pharmacology at the University of Milan and clinical pharmacologist at Hospital Niguarda. “The question of therapies for home patients is under the attention of experts, also here in Lombardy. In recent months we have seen that some drugs are very useful due to the consequences caused by the virus, but even today we do not have specific therapies for Covid. But let’s take a step back. When the virus reaches the multiplication peak, it may disappear or induce a immune dysregulation, with serious consequences: cytokine inflammation, pulmonary edema, microembolism. Well, all the studies done on cortisone (dexamethasone) show that if it is given too soon, it can make the disease worse and even increase mortality in people who do not need oxygen. Here because the “main” criterion is that of saturation: a value obtainable with a simple oximeter, which we should all have at home. The alert should be activated when the saturation is less than 94. Heparin is used in the presence of pneumonia and in bedridden elderly, who are already at risk of thromboembolism.
Asymptomatic patients and with risk factors
Regarding the asymptomatic (many), Professor Scaglione has no doubts: “They should not take absolutely nothing.” The case of subjects at risk of serious complications, such as hypertensive people, who represent the majority of Covid victims: «For these patients a closer monitoring by the doctor is necessary, but the marker to observe is always the saturation. As long as it is possible to stay home, let’s do so and avoid rushing to the emergency room.. The main parameter to decide that it is time to go to the hospital is precisely a saturation below 94, which does not even rise with the administration of oxygen (which can be done at home) ”. This last point had represented a big problem between March and April, due to lack of oxygen and cylinders. Today we are not in the same situation but, in parallel with the increase in infections, there is an increase in the need for oxygen at home. “The situation is not as alarming as it was during the first wave,” he says. Antonello Mirone, president of Federfarma Servizi -, but it is advisable to move on time. There is still no widespread shortage, but there are territories of greater suffering on which we must act ».
November 8, 2020 (change November 8, 2020 | 09:54)
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