key: cord-0683737-8vwi3lpo
authors: Lugli, Gianmarco; Ottaviani, Matteo Maria; Botta, Annarita; Ascione, Guido; Bruschi, Alessandro; Cagnazzo, Federico; Zammarchi, Lorenzo; Romagnani, Paola; Portaluri, Tommaso
title: The Impact of the SARS-CoV-2 Pandemic on Healthcare Provision in Italy to non-COVID Patients: a Systematic Review
date: 2022-01-01
journal: Mediterr J Hematol Infect Dis
DOI: 10.4084/mjhid.2022.012
sha: a997e582f1c9beae2577df5133cf26767701cace
doc_id: 683737
cord_uid: 8vwi3lpo

BACKGROUND: Italy has been one of the countries most affected by the SARS-CoV-2 pandemic, and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. Therefore, we investigated the management of non-COVID-19 patients across all medical specialities in Italy. METHODS: A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from February 20 to June 25 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialities combined with our geographical focus (Italy) and COVID-19. RESULTS: Of the 4643 potentially eligible studies identified by the search, 247 were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialities have been affected by the re-organization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine. CONCLUSIONS: Our work highlights the changes in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyse future directions for the healthcare system in the case of new pandemic scenarios.

Since the first case of the novel coronavirus was reported in Wuhan, China, in December 2019, a viral infection spread at an alarming rate worldwide. On January 30, 2020, the World Health Organization (WHO) described COVID-19 as a Public Health Emergency of International Concern, and by March 11, 2020 , it was officially declared a pandemic. 1 Italy was the first European country to be affected by , with the first case being diagnosed on February 20 in a man living in the province of Lodi (NorthWest Italy). 2 The epidemic went on to affect all regions in Italy, with higher incidence rates in the north. The peak of the COVID-19 epidemic in Italy was reached in the last week of March, with over 5500 new cases per day.

Since then, there has been a gradual decline due to strict containment measures that shaped the Italian lockdown phase. However, especially during the first phase of the epidemic, the outbreak put the Italian National Health System (Servizio Sanitario Nazionale, SSN) under unprecedented pressure.

In an attempt to direct the available resources at counteracting and limiting the effects of the pandemic, deferrable and non-urgent medical activities were suspended. On the other hand, patients with lifethreatening conditions, such as myocardial infarction and stroke, or chronic conditions, such as diabetes, retained the right to their medical needs being met.

In these circumstances, several medical domains have been constrained by different resource allocations with unpredictable long-term consequences on patient health care. [3] [4] [5] Here, we present a systematic review of the literature, which illustrates the direct and indirect effects of the COVID-19 pandemic on the management of non-COVID patients across all medical specialities.

Methods. This systematic review was performed in accordance with PRISMA guidelines. 6 The search was conducted on June 25 2020, on three databases: PubMed, Embase, and Scopus, without any date restriction. All the keywords were investigated within the title and abstract in both "AND" and "OR" combinations. Our keywords included all medical specialities (and potential synonyms) combined with our geographical focus (Italy or Italian) and COVID-19. The full search strategy is reported in Supplementary Material Table 1 . Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Selection of the Studies. The literature search returned original papers published between 1979 and 2020especially for the keyword "coronavirus." Since our focus was the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the first positive case in Italy was detected on February 20, the literature search was restricted to the period from February 20 to June 25 2020. The databases were queried via an R script on their respective APIs, checked and cleaned for duplicates (via title, DOI and/or database id), and exported into Excel.

In the second stage, studies were selected based on their titles and abstracts: each study was independently evaluated by three different raters (AnB, GA, GL). When there was a lack of agreement among the screeners, ensemble majority voting was used for the final decision. The full texts of the selected papers were thus analyzed by two reviewers in terms of relevance and inclusion/exclusion criteria (MMO and GA). When these reviewers disagreed over the inclusion or exclusion of a paper, a third reviewer was responsible for the final decision (GL). In addition, the reference lists of selected papers were reviewed in order to find pertinent studies not identified during the initial search.

Inclusion and Exclusion Criteria. The simultaneous cooccurrence of the following characteristics was considered for the inclusion of articles: (i) articles focusing on the SARS-CoV-2 infection/COVID-19 disease; (ii) articles focusing on the impact on patients based in Italy or on the Italian hospital organization; (iii) articles detailing COVID-19-associated changes in the Italian hospital care for non-COVID-19 patients. All the investigated articles were published in English or Italian.

Type of Studies. Original papers, editorials, comments, research letters, case series, and studies focusing on non-COVID patients in Italy were included.

Data Extraction and Quality Assessment. Data were extracted from the papers by one of the investigators (TP) and were subsequently checked for accuracy by other reviewers (GL, AnB). Disagreements regarding data extraction among reviewers were solved by consensus. Extracted data included: type of medical specialty involved (surgical, medical, or public health), geographical location (north, south, centre or nationwide), type of patients (COVID/non-COVID), type of study (article or research letter/comment/editorial). Unfortunately, no quality assessment was possible as over 32% of entries were not articles but consisted of comments, research letters, opinions or editorialsfor which no quality guidelines are available.

Investigated Outcomes. This systematic review investigated the impact of the COVID-19 pandemic on patients' healthcare provision and hospital organization in Italy since the day the country was put in lockdown. 7 Our primary goal was to identify potential short-term and long-term effects on the health of non-COVID patients. Our secondary goals were to identify: (i) organizational and/or clinical settings and decisions that were particularly effective (or counterproductive) during the pandemic; and (ii) similarities and differences across medical specialities and regional areas.

The results are shown in Figure 1 . After searching the databases, we identified 4643 papers from three different databases. Database merges and the removal of duplicates resulted in 1262 records, of which 100 were immediately removed as they were not related to COVID-19 (articles published before the pandemic in Italy). A total of 1162 records were then screened: 166 were removed as not relevant to Italy; 534 were removed as they referred to COVID-19 patients rather than non-COVID-19 patients. A total of 247 were deemed eligible, of which 81 consisted of comments/letters/opinions/editorials.

Oncology and radiotherapy were the most represented category (47 papers) , followed by surgery (24 for general surgery, 9 for neurosurgery, 2 for cardiosurgery, 2 for vascular surgery, and 3 other types), cardiology (19) , and dermatology 14. There was one paper each for rheumatology and microbiology.

Overall, 133 papers were related to clinical disciplines, 89 to surgery, and 24 to services. In terms of geographical distribution, many papers provided general recommendations without a specific geographical identification (75) . Lombardy was the most represented region (72) , followed by Lazio (21) and Emilia Romagna (15) . In the south, Campania was the most represented region (11) , followed by Puglia (4) . Marche, Piedmont and Friuli Venezia Giulia had 7 papers each, Tuscany and Veneto 9 each. Overall, 73 were general/nationwide, 105 pertained to northern regions, 54 to central regions, and 15 to southern regions and islands. The studies included are reported in Supplementary Material Table 2 .

In general, non-COVID patients admitted to emergency departments (ED) decreased and remained well below the standard levels. [8] [9] [10] [11] The youngest age classes declined dramatically, while the oldest age classes progressively increased, remaining considerably above the standard rate of the local ED. 12 Table 1 shows the most relevant data regarding cardiovascular emergencies, including stroke. In northern Italy, the emergency gradually took over most cardiology intensive care units (ICUs). 13 As expected, the net effect of this re-organization was a significant reduction in sites and staff committed to the treatment of cardiovascular diseases. [14] [15] [16] [17] [18] Comparing out-of-hospital cardiac arrests in the same period of the previous year, Baldi et al. found that the median arrival time of the emergency medical service was three minutes longer in 2020, and the proportion of patients who received cardiopulmonary resuscitation from bystanders was 15.6% lower. Among patients in whom resuscitation was attempted by emergency medical services, the incidence of out-of-hospital death was 14.9% higher in 2020 than in 2019. 9 This finding was confirmed by additional studies highlighting an unpredictable decrease in acute coronary syndrome-related hospitalization in highvolume centres 10, 19, [20] [21] and pacemaker implantation during the weeks following the COVID-19 outbreak. [21] [22] [23] [24] [25] Of note, one study showed a 49% reduction in acute heart failure admission to the hospital. 26 The patients admitted had longer door-to-balloon and symptoms to PCI times, higher hs-cTnI levels at presentation, lower residual left ventricular function at discharge, and higher predicted late cardiovascular mortality on the GRACE score. 19 Two studies 11, 27 also reported fewer patients with minor strokes and transient ischemic attacks (TIAs), longer onset-to-door and door-to-treatment times for major strokes, and reduced transfers from spokes centres. As a result, the number of patients who underwent intravenous thrombolysis or bridging therapy (combined intravenous and thrombectomy) decreased by − 26% and −30%, respectively.

In addition, as a consequence of the reduction in the patient eligibility for bridging therapy, the number of primary thrombectomies (performed with all the necessary personal protective equipment owing to the risk of infection) 28 increased by 41%. Most of these patients had very serious strokes that would have benefited from early diagnoses. 11 The decrease in hospital admissions, confirmed by a survey across multiple countries, including Italy, 29, 30 resulted in increased door-to-needle times and missed therapeutic windows for patients suffering from severe strokes. 31 The reduction in available Intensive Care Units (ICU) beds, massively dedicated to COVID-19 patients with acute respiratory failure, and the fear of infection resulted in the shrinkage of surgical activities in all fields [32] [33] [34] [35] [36] and a reduction in urgent endoscopic procedures in COVID-free hospitals. 37 Each sub-speciality defined various non-deferrable surgical procedures that had to be guaranteed, causing a drop in consultations requested by emergency departments, as in the case of urgent urology. 38 The surgical community also faced a shortage of blood components derived from fewer donations due to lockdown and fear of infection. 39 To compensate for the initial fall (−10%) in blood donations in the first week of March, the government promoted a national media campaign on the importance and safety of blood donation as a priority to maintain basic healthcare services for non-COVID patients. 40 No blood-transmitted SARS-CoV-2 infection has been reported to date. 41 Children's emergency departments also showed a substantial decrease in visits, 42 and that might reflect the scarcity of resources or the reluctance of parents and health care workers to expose children to the risk of viral infection in a healthcare setting, in addition to lower rates of acute infections and trauma. 43 However, this phenomenon has been detrimental to the health of non-COVID child patients: 12 cases of delayed access to hospital care were reported during the week of March 23-27 across five hospitals of an Italian Children's Hospital Research Network. Half of the children were admitted to an ICU, and four died, highlighting the high risk of delaying access to hospital care. 44 As a result, life- No deterioration of glucose control was observed but an improvement (more stable rhythms of life and more regular meals time)

The hybrid closed loop (HCL) system allowed physicians to download detailed data during the teleconsulting through a web-based program.

Dermatology Chronic inflammatory skin disease (psoriasis, threatening conditions (i.e. abdominal pain, severe ketoacidosis) seemed to be more frequent, requiring, in some cases, an aggressive approach. 43 The same phenomenon affected dermatology. 45 Tartari et al. compared two different weeks, before and after the outbreak of the COVID-19 pandemic in Italy, showing a decrease in unjustified referrals (93% reduction) in dermatological emergency services. 46 Despite medical care for emergencies and urgent treatments being continuously provided throughout the pandemic, the lack of personnel, resources, and ICUs beds and the patients' fear of being infected in hospital affected patient management and substantially delayed the provision of ordinary medical activities. These initial data seem to show a decrease in emergencies and an increase in mortality.

To tackle the massive impact of the overflow of SARS-CoV-2 infected patients, hospitals in Italy had to undergo a significant re-organization. [47] [48] [49] [50] [51] [52] In order to manage conditions needing non-deferrable treatment while avoiding the risk of infection, hub-andspoke centres were created and widely used throughout the country. 48, [53] [54] [55] [56] In the hub-and-spoke model, the main campus or hub supplies the most intensive medical services, while satellite campuses or spokes offer more limited services at sites distributed across the neighbouring area. 57 Neurological surgery was particularly affected by the ICU re-organization, as it often requires a period of intensive monitoring in ICUs. 22, [58] [59] [60] All the cases of elective neurological surgery were deferred, while urgent neurosurgical pathologies (above all traumas) and nondeferrable tumour cases were transferred to hubs. 27, [29] [30] [31] [32] [33] [61] [62] [63] Some minimal activities were still performed at spoke centres, only for critical cases or when specific tools were required (i.e. gamma knife treatment of neoplastic lesions). [64] [65] [66] [67] This provided an unprecedented opportunity for transversal collaboration among different teams, representing real innovation in such a competitive setting. 56, 62 A hub-and-spoke system was also organized for vascular surgery and cardiac surgery units. All elective surgery was reduced, and urgent surgery (including aortic aneurysms, valvular diseases or severe coronary diseases) was performed only in hub centres, preferring the endovascular to the open surgical approach whenever possible. [68] [69] [70] A transcatheter approach was generally preferred, as it usually does not require an ICU bed or a ventilator. 69 The limitation of all non-urgent surgical activities also applied to general surgery [71] [72] [73] [74] [75] [76] and obstetrics. 76, 77 In highly-infected areas (such as Lombardy), hub centres were created 78 to treat only advanced symptomatic tumours, [78] [79] [80] while elective oncological surgery procedures continued to be performed in less-affected regions. 78, 81 This was an important issue for oncological patients, especially the older ones. [82] [83] [84] [85] Many possible ways of minimizing the risks were proposed: to postpone treatments or elective surgery for stable cancer in endemic areas, provide patients with greater personal protection, and offer more intensive surveillance or treatment. [86] [87] [88] For example, neoadjuvant treatments were recommended or increased to defer surgical admission for as long as possible. 78, 81, [89] [90] For other medical conditions requiring surgery under particular circumstances, such as relapse of inflammatory bowel disease, dedicated hubs were identified. [91] [92] [93] Interestingly, a tendency toward treatments to reduce hospitalization was also found in medical oncology. 94, 95 Some regions such as Tuscany created home care protocols to avoid exposure to hospital settings. 96 Oncological care delivery and cancer diagnosis [97] [98] [99] were dramatically reduced by the SARS-CoV-2 outbreak, even though suboptimal care and treatments may result in worse cancer-related outcomes. Oncologists were thus asked to preserve patients' continuum of care while adopting mitigation strategies to reduce the likelihood of infection in all cancer patients. [100] [101] [102] [103] [104] [105] [106] [107] [108] [109] Arduino et al. described a worrying delay in diagnosing oral cancer in northwest Italy during the Covid pandemic. 110 Moreover, the cessation of elective activities, screening programs, 111 and the drastic reduction in services regarding breast cancer restricted evaluations to only clinical observations of palpable lesions with the elevated risk of missing new diagnoses. 112 Although not requiring a structural reorganization, palliative care was forced to find a new balance between family member visits and patients' needs. [113] [114] [115] [116] In orthopaedics, the re-organization led to the identification of poly-specialist major trauma centres and specialistic referral centres for minor trauma or nondeferrable orthopaedic surgeries (i.e. septic arthritis or malignant tumours). [117] [118] [119] [120] [121] [122] [123] [124] There was a reduction in the number of proximal femur fractures in two centres, as well as a reduction in hip and knee arthroplasties. 125, 126 A similar re-organization was also carried out for plastic surgery: only post-traumatic, oncological and burn treatments were guaranteed. 127-129 A new approach based on enzymatic debridement was proposed for burns to reduce the need for burn surgery. 130 In urology, only urgent, non-deferrable procedures (colicky flank pain, gross hematuria and acute urinary retention) were authorized after careful multidisciplinary evaluation, which led to a drop in urological surgical activities. [131] [132] [133] [134] [135] [136] Whenever possible, alternative treatments not requiring general anaesthesia (i.e. radiotherapy for genitourinary cancers) were suggested as preferable. 131, 133, 137 Oral and maxillofacial surgery, otolaryngology, and ophthalmology also suspended all non-urgent treatments, especially considering healthcare workers' high risk of infection while manipulating the upper airways and eyes. [138] [139] [140] [141] [142] [143] [144] [145] Only the treatment of trauma, malignant neoplasms, and severe infections was guaranteed. 139, [146] [147] [148] [149] In the context of radiotherapy, all follow-up visits involved a phone call in advance in order to postpone non-urgent cases. [150] [151] [152] [153] The initial consultations of patients needing treatment for malignant tumours were conducted as normal, as were certain treatments such as bone metastases radiotherapy. 154-157 Specific approaches, such as short fractionated radiotherapy, were suggested. 158 All non-urgent and deferrable radiation treatments were delayed, while therapies for patients with better prognoses (benign and functional diseases) were postponed. 159, 160 Dermatology departments were also involved in an extensive re-organization. 161-162 Dermatological antineoplastic treatments were provided in the dermatology clinics of many centres, such as Bologna, Naples, Modena and Ancona, which also maintained urgent dermatological procedures and consultations required by other hospital wards. [163] [164] [165] [166] As awareness of the severity of the COVID-19 increased, some patients were concerned about continuing their medications; however, all centres followed specific recommendations and advised patients not to suspend these drugs without consultation. [167] [168] [169] [170] Lastly, microbiology labs underwent unprecedentedly high workloads with the increasing number of samples (swabs or serological tests) to analyze for the identification of Sar-Cov-2 infection. An extensive re-organization of the microbiology lab activities thus also occurred. In a large teaching hospital in Rome, the introduction of night shifts and the creation of a dedicated team significantly improved the number of samples processed without interfering with the daily laboratory routines. 171

Dialysis units experienced a profound change in their management with the introduction of COVID-19 isolation rooms and the identification of dedicated healthcare professionals. 172,173 Rombolà et al. proposed three actions to be taken in order to dialyze non-COVID patients safely: hygiene measures, the use of PPE to protect patients and the healthcare team, and the protection of the dialysis ward with an isolated area for testing patients suspected of infection. 174 In general, all transplant programs were profoundly affected by the pandemic. [175] [176] [177] First of all, the wall-towall screening of donors and recipients was established to identify positive patients who would not be able to donate or receive blood, in view of the high mortality rates COVID-19 in immunocompromised patients. [177] [178] [179] [180] Secondly, the widespread reduction in available ICU beds led to an estimated 15% drop in transplants compared with the last five years' average, such as liver transplantations. 177,181 transplantation was thus suggested only in true end-stage organ failure, preferring conservative treatments (maximizing pharmacological therapy) in all other patients. [181] [182] [183] [184] Management of Deferrable Conditions and Telemedicine. The management of chronic conditions also suffered. 185 Cesari et al. found that the integration of care services collapsed: admissions to post-acute/long-term care facilities were reduced, and several person-tailored interventions were suspendede.g., physical therapists for mobilization. 183 Lasevoli et al. reinforced the view that the current pandemic has had dramatic consequences for the mental health of serious psychiatric patients. 186 All this inevitably led to a drastic reduction and a substantial re-organization of the clinical activity in many specialities ( Table 1) , postponing elective treatments and switching to telemedicine (TM) for consultation or not to leave vulnerable high-need patients without proper follow-up. [187] [188] The implementation of TM occurred in different ways and to varying degrees depending on the specific centre and specialty. An online questionnaire administered to the 176 Directors of Italian Radiation Oncology Departments revealed that to guarantee the continuity of care, in 78 centres (62.4%) activated telematic consultations for RT treatments. 152 A similar survey for RT centres in the Lombardy region revealed that 84% of RT facilities cancelled out-patient follow-up visits, 68% activated telematic consultation and 30% adopted working from home solutions. 153 Another survey administered to 122 medical oncology departments homogeneously distributed on the national territory revealed that in 72% of cases, alternative ways to get in touch with patients had been used, like telephonic interviews with the interpretation of laboratory and radiologic examination reports. According to Pietrantonio et al., WhatsApp turned out to be adequate to give a rapid answer to most queries from oncologic patients. 105 Brunasso et al. started a teledermatology service in smart working using phone calls and e-mails by which they could monitor almost 94% of their patients. 189 In a Department of Urology in Northern Italy, 55% of cases were screened undergoing telephone consultation. 190 TM has been shown to have beneficial impacts on heart failure outcomes in a comparative analysis between 2020 and 2019 by Salzano et al. 191 Finally, TM positively impacted patients' life as documented by a survey in which 85% of patients were satisfied with the remote interview modality and the reduction of economic and time costs related to going to the clinic. Most of those subjects (90%) expressed their willingness to continue to be included in remote evaluation programs. 192 Almost all specialities benefited from TM during the pandemic. The results are summarized in Table 1 .

Discussion. On March 11 2020, the World Health Organisation (WHO) declared the COVID-19 pandemic. 1 However, Italy was already in lockdown, with decrees limiting mobility and strengthening the National Health System. On March 9, 2020, most outpatient services were temporarily suspended, except for a few treatments that were considered urgent and non-deferrable. 7 Clinical support for early isolation, treatment, and, where needed, intensive care of COVID-19 patients (or suspect cases) became the priority, with a massive allocation of dedicated resources.

A large increase in all-cause mortality was revealed during the epidemic, greater than the number of deaths attributed to COVID-19 cases. The possible causes of this increase include a large number of severe undiagnosed COVID-19 cases, reduced access to health services due to the disruption of normal working processes, or the fear of contamination of sick patients affected by other diseases and possibly other factors. 8 We provided a snapshot, across all medical specialities, of how the provision of treatments to non-COVID patients in Italy has been impacted by the shortage of resources imposed by the pandemic.

Measures put in place to mitigate the outbreak, such as social distancing and confinement, contributed to discouraging access to the emergency department (E.D.) all over the country and those conditions requiring urgent care. As a result, there was a significant decrease in overall E.D. admissions and a substantial reduction in all-speciality surgical consultations. [9] [10] [11] More studies are needed to confirm these data and to evaluate the impact on death rates; however, recent reports from other countries seem to confirm this trend. 193, 194 Cardiovascular emergencies paid significant tolls with a significant delay in time-sensitive emergency operations. [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] More recent evidence, consistent with our results, showed a significant decrease in the mean number of endovascular therapies per hospital performed before and after COVID-19 confinement along with a significant increase in mean stroke onset-to groin puncture time. 195 A delayed presentation of STEMI patients that may lead to worsened prognosis and unnecessary deaths has also been observed. 196 Moreover, an additional study confirmed that more in-hospital cardiovascular deaths occurred in March 2020 compared with March 2019, a finding due to late hospital presentations and consequent greater disease severity that affected eligibility and outcome of cardiovascular procedures 197 As stated before, the hospitalisation system was remodelled to allocate appropriate resources to manage patients with COVID-19; consequently, hubs were identified for specialised medical activities. Hub-andspoke centres represented an important change in care provision, especially in the most affected regions, involving almost all specialities. However, data on the efficacy of this reorganisation, measured in terms of health outcomes (such as mortality), are lacking. To date, only a few reports suggest a tendency toward a decrease in diagnosis for non-deferrable conditions despite the hub-and-spoke organisation. 98, 100, 111 Cautious and evidence-based studies are needed to properly assess the overall impact of this model on measurable outcomes. Nevertheless, the hub-and-spoke system seems to be a valid model, at least, in the management of ischemic emergencies. 198 A pandemic is a dynamic scenario, requiring reorganisation and flexibility of healthcare delivery. T.M., which consists of distributing health-related services and information via telecommunication technologies, proved a pragmatic approach to managing deferrable conditions during the COVID-19 pandemic in Italy. Moreover, TM allows for more flexibility on the side of both the clinician and the patient, as consultations can easily be rescheduled, and meetings can be held from home. 199 Notably, when looking at the world scenario, T.M. is thought to play an important role in delivering digital health to the general population. 200 Almost all specialities benefited from T.M. during the pandemic, with short-term results particularly encouraging in some cases. The pandemic has generally demonstrated that information technologies should be more promoted independently from this specific context. 153 However, a longer follow-up is needed to assess the efficacy of these measures on common health outcomes. [199] [200] [201] Avoiding face-to-face contact via T.M. has been one of the most effective measures to limit the spread of SARS-Cov-2 infection, although many issues have been raised, such as privacy management and the lack of clear guidelines.. [202] [203] [204] [205] [206] We strongly encourage overcoming these limitations to promote further the multiple opportunities of T.M. in tune with its pivotal role during the second phase of the COVID-19 pandemic in Italy. 207 T.M. has deeply influenced non-COVID patient care, enabling the remote diagnosis and monitoring of patients and allowing clinical data sharing between patients and physicians. 208, 209 One limitation of this systematic review is the heterogeneity in publication type, which prevented the execution of a meta-analysis to summarise the findings together with a quality assessment. Another important issue is the potential underreporting, although the studies covered the whole country's experiences. Finally, while also providing a snapshot of the first modification during the pandemic, this work does not include more recent Italian studies.

Our work thus suggests that a public health crisis has resulted from the pandemic, a concern raised in other countries too, such as France and Denmark; indeed, a danish study demonstrated that mortality rates for patients admitted to hospitals with non-covid-19 diseases (such as respiratory disease, cancer, pneumonia and sepsis) were higher. 210, 211 More detailed, nationwide population-based cohort studies are needed to assess whether emergency management benefited from the reorganisation adopted and evaluate hospital admissions and mortality rates for non-covid patients. Nevertheless, the system and telemedicine undoubtedly playedand continue to playa crucial role in dealing with nondeferrable and deferrable conditions, respectively. ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: the work was supported by the Center for Excellence and Transdisciplinary Studies (CEST) and C.R.T. Foundation, Turin. The funder of the study had no role in the study design, data collection, data analysis, data interpretation, or writing the report; no financial relationships with any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work. All authors had full access to all study data and had final responsibility for the decision to submit for publication. The authors are thankful to Professor Paolo Vineis for his critical assistance in writing the paper. 

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Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams: A Guidance Statement from the Society of Vascular and Interventional Neurology

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Letter: Back Pain and Accesses to Emergency Departments During

COVID-19 and stroke-A global World Stroke Organization perspective

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Emergency Endoscopy During the SARS-CoV-2 Pandemic in the North of Italy: Experience from St. Orsola University Hospital-Bologna

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Correspondence from Northern Italy about our experience with COVID

Emergency general surgery in Italy during the COVID-19 outbreak: first survey from the real life

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Covid-19 outbreak in Italy

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The impact of the SARS-CoV-2 outbreak on the safety and availability of blood transfusions in Italy

A COVID-19 outbreak's lesson: Best use of the paediatric emergency department

An Italian paediatric department at the time of Coronavirus: a resident's point of view

Delayed access or provision of care in Italy resulting from fear of COVID-19

Which are the "emergent" dermatologic practices during COVID-19 pandemic?

Changes in emergency service access after spread of COVID-19 across Italy

2019-ncov's epidemic in middle province of northern Italy: Impact, logistic & strategy in the first line hospital

Executive management summary and short report of outcome

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Reorganization of a large academic hospital to face COVID-19 outbreak: The model of Parma

Surgical Strategy During the COVID-19 Pandemic in a University Metropolitan Hospital in Milan

La pandemia COVID-19: Riorganizzazione della Cardiologia in un ospedale della Regione Lombardia

COVID-19 e coronaropatia: Uso selettivo e collaborativo delle risorse durante le crisi sanitarie

The Italian USL Toscana Centro model of a vascular hub responding to the COVID-19 emergency

Fast reshaping of intensive care unit facilities in a large metropolitan

The hub-and-spoke organization design revisited: a lifeline for rural hospitals

Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy

Neurosurgical Practice During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic: A Worldwide Survey

Neurosurgical activity during COVID-19 pandemic: an expert opinion from China

Effects of the COVID-19 Outbreak in Northern Italy: Perspectives from the Bergamo Neurosurgery Department

Letter to the editor by Dobran Mauro, Paracino Riccardo, and Iacoangeli Maurizio regarding 'Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy

The management of emergency spinal surgery during the COVID-19 pandemic in Italy

Letter : The Resiliency of the Neurosurgeon in the Midst of COVID-19 Pandemic Storm : The Italian Experience From the Frontline

Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations

Remodulation of neurosurgical activities in an Italian region (Emilia-Romagna) under COVID-19 emergency: maintaining the standard of care during the crisis

Maintaining stereotactic radiosurgical treatments during Covid-19 outbreak: the case of the Gamma Knife Unit in Brescia -Italy

Routine in an Italian High-Volume Vascular Surgery Unit during the COVID-19 Era: How the Pandemic Changed the Vascular Daily Practice

The COVID-19 outbreak and its impact on hospitals in Italy: the model of cardiac surgery

COVID-19 outbreak and Cardiac Surgery: position paper from the COVID-SICCH Task Force of the Italian Society for Cardiac Surgery

COVID-19 outbreak in Northern Italy: Viewpoint of the Milan area surgical community

Pediatric endoscopic procedures during the COVID-19 pandemic: an Italian center experience

A Snapshot of Elective Oncological Surgery in Italy During COVID-19 Emergency: Pearls, Pitfalls, and Perspectives

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown

COVID-19) outbreak: what the department of endoscopy should know

Preparing an obstetric unit in the heart of the epidemic strike of COVID-19: quick reorganization tips

Obstetric network reorganization during the COVID-19 pandemic: Suggestions from an Italian regional model

Coronavirus pandemic and colorectal surgery: practical advice based on the Italian experience

Laparoscopy at all costs? Not now during COVID-19 outbreak and not for acute care surgery and emergency colorectal surgery: A practical algorithm from a hub tertiary teaching hospital in Northern Lombardy

COVID-19: The European institute of oncology as a 'hub' centre for breast cancer surgery during the pandemic in Milan (Lombardy region, northern Italy) -A screenshot of the first month

Italian society of colorectal surgery recommendations for good clinical practice in colorectal surgery during the novel coronavirus pandemic

Coronavirus Disease 2019 Emergency and Cancer in the South of Italy: What's New for the Oncologist?

Coronavirus: Older Persons With Cancer in Italy in the COVID-19 Pandemic

Cancer care under the outbreak of COVID-19: A perspective from Italian tertiary referral center for surgical oncology

Endocrine surgery during COVID-19 pandemic: do we need an update of indications in Italy?

Cancer care during the spread of coronavirus disease 2019 (COVID-19) in Italy: Young oncologists' perspective

Metastatic melanoma treatment with checkpoint inhibitors in the COVID-19 era: experience from an Italian Skin Cancer Unit

Caring for Patients With Cancer During the COVID-19 Outbreak in Italy

Management of ovarian cancer during the COVID-19 pandemic

COVID-19 global pandemic: options for management of gynecologic cancers. The experience in surgical management of ovarian cancer in the second highest affected Italian region

Maintaining the Quality Standards of Care for Inflammatory Bowel Disease Patients During the COVID-19

Challenges in the Care of IBD Patients During the CoViD-19 Pandemic: Report From a "Red Zone" Area in Northern Italy

Impact of the COVID-19 pandemic on Gastroenterology Divisions in Italy: a national survey'. Dig liver

Metronomic oral vinorelbine and lung cancer therapy during the COVID 19 pandemic: A single-center experience

Results of Multilevel Containment Measures to Better Protect Lung Cancer Patients From COVID-19: The IEO Model

Home Care for Cancer Patients During COVID-19 Pandemic: The Double Triage Protocol

Cancer diagnostic rates during the 2020 'lockdown', due to COVID-19 pandemic, compared with the 2018-2019: an audit study from cellular pathology

CHRONIC LYMPHOCYTIC LEUKEMIA MANAGEMENT IN ITALY DURING THE COVID-19 PANDEMIC. A CAMPUS CLL REPORT

Children with cancer in the time of COVID-19: An 8-week report from the six pediatric onco-hematology centers in Lombardia

Comment on 'Reorganisation of medical oncology departments during the novel coronavirus disease-19 pandemic: A nationwide Italian survey

Fighting cancer in coronavirus disease era: organization of work in medical oncology departments in Emilia Romagna region of Italy

Italian survey on managing immune checkpoint inhibitors in oncology during COVID-19 outbreak

A Guide for Oncologic Patient Management during Covid-19 Pandemic: The Initial Experience of an Italian Oncologic Hub with Exemplificative Focus on Uro-Oncologic Patients

Cancer treatment during the coronavirus disease 2019 pandemic: Do not postpone, do it

Systemic Treatment of Patients With Gastrointestinal Cancers During the COVID-19 Outbreak: COVID-19-adapted Recommendations of the National Cancer Institute of Milan

How coronavirus disease 2019 outbreak is impacting colorectal cancer patients in Italy: A long shadow beyond infection

The Shifting Landscape of Genitourinary Oncology During the COVID-19 Pandemic and how Italian Oncologists Reacted: Results from a National Survey

Reorganisation of medical oncology departments during the novel coronavirus disease-19 pandemic: a nationwide Italian survey

COVID-19 Pandemic and the Crisis of Health Systems: The Experience of the Apulia Cancer Network and of the Comprehensive Cancer Center Istituto Tumori 'Giovanni Paolo II' of Bari

The outbreak of Novel Coronavirus disease (COVID-19) caused a worrying delay in the diagnosis of oral cancer in north-west Italy: The Turin Metropolitan Area experience

BRCA testing in a genomic diagnostics referral center during the COVID-19 pandemic

Breast Cancer Diagnosis in Coronavirus-Era: Alert From Italy

Palliative Care in the Time of COVID-19

The Role and Response of Palliative Care and Hospice Services in Epidemics and Pandemics: A Rapid Review to Inform Practice During the COVID-19 Pandemic

Response and role of palliative care during the COVID-19 pandemic: A national telephone survey of hospices in Italy

Management strategies adopted by a pediatric palliative care network in northern Italy during the COVID-19 pandemic

Changes of clinical activities in an orthopaedic institute in North Italy during the spread of COVID-19 pandemic: a seven-week observational analysis

Management of orthopaedic and traumatology patients during the Coronavirus disease (COVID-19) pandemic in northern Italy

Operational strategies of a trauma hub in early coronavirus disease 2019 pandemic

CoViD-19 and ortho and trauma surgery: The Italian experience

Trauma service reorganization in Bologna (Italy) during COVID-19 pandemic

The deep impact of novel CoVID-19 infection in an Orthopedics and Traumatology Department: the experience of the Piacenza Hospital

Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action

Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy

Teleurology in the Time of Covid-19 Pandemic: Here to Stay?

Telemedicine experience from a heart failure university tertiary referral centre

Telemedicine is a useful tool to deliver care to patients with Amyotrophic Lateral Sclerosis during COVID-19 pandemic: results from Southern Italy

Impact of COVID-19 pandemic on ST-elevation myocardial infarction in a non-COVID-19 epicenter

COVID-19: Stroke Admissions, Emergency Department Visits, and Prevention Clinic Referrals

Acute Stroke Management During the COVID-19 Pandemic: Does Confinement Impact Eligibility for Endovascular Therapy

Impact on hospital admission of STelevation myocardial infarction patients during coronavirus disease 2019 pandemic in an Italian Hospital

Increased cardiovascular death rates in a COVID-19 low prevalence area

Emergency management of the COVID-19 pandemic in a vascular surgery department of a large metropolitan hospital in Italy. Preparation, escalation, de-escalation, and normal activity

Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy

World Heart Day 2021: COVID-19, digital health, and tackling cardiovascular disease

Teleurology in the Time of Covid-19 Pandemic: Here to Stay?

Community Mental Health Care in the COVID-19 Response: An Italian Example

COVID-19 risk contagion: Organization and procedures in a South Italy geriatric oncology ward

COVID-19 disease emergency operational instructions for Mental Health Departments issued by the Italian Society of Epidemiological Psychiatry

Telemedicine During The COVID-19 in Italy: A Missed Opportunity?

A Frail Health Care System for an Old Population: Lesson form the COVID-19 Outbreak in Italy

The Italian Fight Against the COVID-19 Pandemic in the Second Phase: The Renewed Opportunity of Telemedicine

Telemedicine during Covid-19 pandemic: Advantage or critical issue?

Telemedicine and the 2019 Coronavirus (SARS-CoV-2)

What if the worst consequences of COVID-19 concerned non-COVID patients?

First wave of COVID-19 hospital admissions in Denmark: a Nationwide population-based cohort study

Italian pediatric respiratory society recommendations on pediatric pulmonary function testing during COVID-19 pandemic

Telemedicine experience from a heart failure university tertiary referral centre

Cardiac rehabilitation activities during the COVID-19 pandemic in Italy. Position Paper of the AICPR (Italian Association of Clinical Cardiology, Prevention and Rehabilitation)

Impact of COVID-19 pandemic on the daily management of biotechnological therapy in inflammatory bowel disease patients: Reorganisational response in a high-volume Italian inflammatory bowel disease centre

Gastroenterology department operational reorganisation at the time of covid-19 outbreak: An Italian and Chinese experience

COVID-19 pandemic perception in adults with celiac disease: an impulse to implement the use of telemedicine: COVID-19 and CeD. Dig liver

A negative fallout of COVID-19 lockdown in Italy: life-threatening delay in the diagnosis of celiac disease. Dig liver

Management of Patients With Crohn's Disease and Ulcerative Colitis During the Coronavirus Disease-2019 Pandemic: Results of an International Meeting

How to Guarantee the Best of Care to Patients with Cancer During the COVID-19 Epidemic: The Italian Experience

Patients With Cancer and COVID-19: A WhatsApp Messenger-Based Survey of Patients' Queries, Needs, Fears, and Actions Taken

Tor Vergata University-Hospital in the Beginning of COVID-19-Era: Experience and Recommendation for Breast Cancer Patients

Personalized Risk-Benefit Ratio Adaptation of Breast Cancer Care at the Epicenter of COVID-19

Management of breast cancer in an EUSOMA-accredited Breast Unit in Lombardy, Italy, during the COVID-19 pandemic

Reorganization Tips from a Sarcoma Unit at Time of the COVID-19 Pandemic in Italy: Early Experience from a Regional Referral Oncologic Center

Impact of COVID-19 pandemic on patients with large-vessel vasculitis in Italy: a monocentric survey

Taking care of systemic sclerosis patients during COVID-19 pandemic: rethink the clinical activity

An academic allergy unit during COVID-19 pandemic in Italy

Health-Related Quality of Life in Common Variable Immunodeficiency Italian Patients Switched to Remote Assistance During the COVID-19 Pandemic

How sexual medicine is facing the outbreak of COVID-19: experience of Italian urological community and future perspectives

How the andrological sector suffered from the dramatic Covid 19 outbreak in Italy: supportive initiatives of the Italian Association of Andrology (SIA)

COVID-19: lessons from the Italian reproductive medical experience

A picture of the covid-19 impact on IVIRMA fertility treatment clinics in Spain and Italy

COVID-19: the perspective of Italian embryologists managing the IVF laboratory in pandemic emergency

SARS-CoV-2 infection, male fertility and sperm cryopreservation: a position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) (Società Italiana di Andrologia e Medicina della Sessualità)

COVID-19 and ART: the view of the Italian Society of Fertility and Sterility and Reproductive Medicine

The Adaptation of Management of Chronic Migraine Patients With Medication Overuse to the Suspension of Treatment Protocols During the COVID-19 Pandemic: Lessons From a Tertiary Headache

Impact of COVID-19 related healthcare crisis on treatments for patients with lysosomal storage disorders, the first Italian experience

Dealing with immunemediated neuropathies during COVID-19 outbreak: practical recommendations from the task force of the Italian Society of Neurology (SIN), the Italian Society of Clinical Neurophysiology (SINC) and the Italian Peripheral Nervous System

Telemedicine is a useful tool to deliver care to patients with Amyotrophic Lateral Sclerosis during COVID-19 pandemic: results from Southern Italy

On being a neurologist in Italy at the time of the COVID-19 outbreak

Self-reported needs of patients with Parkinson's disease during COVID-19 emergency in Italy

Glycemic Control in Type 1 Diabetes Mellitus During

Quarantine and the Role of In-Home Physical Activity

Glycaemic Control Among People with Type 1 Diabetes During Lockdown for the SARS-CoV-2 Outbreak in Italy

Blood Glucose Control During Lockdown for COVID-19: CGM Metrics in Italian Adults With Type 1 Diabetes

Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy

Biologics for patients affected by hidradenitis suppurativa in the COVIDwww.mjhid.org

19 era: data from a referral center of Southern Italy

Teledermatology and chronic skin diseases: real life experience in a Southern Italian Dermatologic Centre

Mental Health in the Coronavirus Disease 2019 Emergency-The Italian Response

Mental health services in Italy during the COVID-19 outbreak. The lancet

Mental Health Services in Lombardy during COVID-19 outbreak

COVID-19 Diary From a Psychiatry Department in Italy

Psychological support and psychotherapy via digital devices in Covid-19 emergency time: Some critical issues

Psychiatry EC of the IS of. Mental health services in Italy during the Covid-19 Pandemic

How Paediatric Psycho-oncology is changing during the COVID-19 Epidemic in Italy: New approaches. Psychooncology

Lessons after the early management of the COVID-19 outbreak in a pediatric transplant and hemato-oncology center embedded within a COVID-19 dedicated hospital in Lombardia, Italy. Estote parati

Ensuring continuity of care for children with inherited metabolic diseases at the time of COVID-19 : the experience of a metabolic unit in Italy

Consensus statement of the Italian society of pediatric allergy and immunology for the pragmatic management of children and adolescents with allergic or immunological diseases during the COVID-19 pandemic

From high volume to 'zero' proctology: Italian experience in the COVID era

Being a foot and ankle surgeon in Italy in the era of COVID-19

Natura non facit saltus: a phase 2 proposal to manage brain tumors cases from the neuro-oncology section of the Italian Society of Neurosurgery (SINch®)

Expert consensus from the Italian Society for Colposcopy and Cervico-Vaginal Pathology (SICPCV) for colposcopy and outpatient surgery of the lower genital tract during the COVID-19 pandemic

Elective procedures for prostate cancer in the time of Covid-19: a multidisciplinary team experience

Teleurology in the Time of Covid-19 Pandemic: Here to Stay?

Instant paper from the field' on rehabilitation answers to the Covid-19 emergency

Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine (PRM) physicians' activities in Italy. An official document of the Italian PRM Society (SIMFER)

Instant paper from the field' on rehabilitation answers to the Covid-19 emergency

Italian Physical Therapists' Response to the Novel COVID-19 Emergency

Role of Rehabilitation Department for Adult Covid-19 Patients: the Experience of the San Raffaele Hospital of Milan

AND (coronavirus OR COVID-19) AND (telehealth) Query11: (ITALY[TIAB] OR ITALIAN[TIAB]) AND (coronavirus OR COVID-19) AND (cardiology)

Simone 94 32343497 10.1056/NEJMc2009166 Reduced Rate of Hospital Admissions for ACS during Covid-19 Outbreak in Northern Italy

Reorganisation of medical oncology departments during the novel coronavirus disease-19 pandemic: a nationwide Italian survey

Response and role of palliative care during the COVID-19 pandemic: A national telephone survey of hospices in Italy

COVID-19 outbreak and cancer radiotherapy disruption in italy: Survey endorsed by the italian association of radiotherapy and clinical oncology (AIRO)

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology Jereczek-Fossa, Barbara Alicja; Pepa, Matteo; Marvaso, Giulia

Covid-19 global pandemic: options for management of gynecologic cancers. The experience in surgical management of ovarian cancer in the second highest affected Italian region

COVID-19 Outbreak and Cancer Radiotherapy Disruption in Lombardy, Northern Italy

Glycemic control in type 1 diabetes mellitus during COVID-19 quarantine and the role of in-home physical activity

Metastatic melanoma treatment with check point inhibitors in the COVID-19 era: experience from an Italian Skin Cancer Unit

Urgent Pacemaker Implantation Rates in the Veneto Region of Italy after the COVID-19 Outbreak

Unpredictable Fall of Severe Emergent Cardiovascular Diseases Hospital Admissions During the COVID-19 Pandemic: Experience of a Single Large Center in Northern Italy

United European gastroenterology journal

Fighting cancer in coronavirus disease era: organization of work in medical oncology departments in Emilia Romagna region of Italy

Impact of the COVID-19 epidemic on census

Emergency and Cancer in the South of Italy: What's New for the Oncologist? Frontiers in medicine Ingenito

How to create a No fly zone: a Northern Italy experience

Short fractionation radiotherapy for early prostate cancer in the time of COVID-19: long-term excellent outcomes from a multicenter Italian trial suggest a larger adoption in clinical practice

La Radiologia medica

Protect Healthcare Workers and Patients from COVID-19: The Experience of Two Tertiary Ophthalmology Care Referral Centers in Italy

Routine in an Italian high-volume Vascular Surgery Unit during the COVID-19 era: how the pandemic changed the vascular daily practice. Annals of vascular surgery Mangialardi, Maria Lucia; Orrico

Impact of COVID-19 epidemic on maxillofacial surgery in Italy

Elective procedures for prostate cancer in the time of Covid-19: a multidisciplinary team experience. Prostate cancer and prostatic diseases

Effects of COVID-19 Pandemic on Otolaryngology Surgery in Italy: The Experience of Our University Hospital

Infection control measures in ophthalmology during the COVID-19 outbreak: A narrative review from an early experience in Italy

COVID-19 outbreak and Cardiac Surgery: position paper from the COVID-SICCH Task Force of the Italian Society for Cardiac Surgery

The deep impact of novel CoVID-19 infection in an Orthopedics and Traumatology Department: the experience of the Piacenza Hospital

Changes of clinical activities in an orthopaedic institute in North Italy during the spread of COVID-19 pandemic: a seven-week observational analysis

Children with cancer in the time of COVID-19: An 8-week report from the six pediatric onco-hematology centers in

Community Mental Health Care in the COVID-19 Response: An Italian Example

Emergency general surgery in Italy during the COVID-19 outbreak: first survey from the real life

Telemedicine experience from a heart failure university tertiary referral centre

Italian pediatric respiratory society recommendations on pediatric pulmonary function testing during COVID-19 pandemic. Italian journal of pediatrics

Blind toward those who fight blindness? European journal of ophthalmology Arrigo, Alessandro; Aragona, Emanuela; Parodi, Maurizio Battaglia; Loperfido, Francesco; Bandello

Radiotherapy in Southern Italy at the time of COVID-19: options for radiation oncology units

infection, male fertility and sperm cryopreservation: a position statement of the Italian Society of Andrology and Sexual Medicine (SIAMS) (Societ.. Italiana di Andrologia

Taking care of systemic sclerosis patients during COVID-19 pandemic: rethink the clinical activity

Teledermatologic monitoring for chronic cutaneous autoimmune diseases with smartworking during Covid-19 emergency in a tertiary center in Italy

The COVID-19 outbreak in dermatologic surgery: resetting clinical priorities

The impact of COVID-19 pandemic on urological emergencies: a single-center experience

A Guide for Oncologic Patient Management during Covid-19 Pandemic: The Initial Experience of an Italian Oncologic Hub with Exemplificative Focus on Uro-Oncologic Patients

A snapshot of urgent upper gastrointestinal endoscopy care during the Covid-19 outbreak in Italy

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown

Blood Glucose Control During Lockdown for COVID-19: CGM Metrics in Italian Adults With Type 1

Blood supply and transfusion support in southern Italy: findings during the first four weeks of the SARS-CoV-2 pandemic. Blood transfusion = Trasfusione del sangue Grandone

Cancer diagnostic rates during the 2020 'lockdown', due to COVID-19 pandemic, compared with the 2018-2019: an audit study from cellular pathology

Cardiac patient care during a pandemic: how to reorganise a heart failure unit at the time of COVID-19

Cardiac rehabilitation activities during the COVID-19 pandemic in Italy. Position Paper of the AICPR (Italian Association of Clinical Cardiology, Prevention and Rehabilitation)

Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace

CHRONIC LYMPHOCYTIC LEUKEMIA MANAGEMENT IN ITALY DURING THE COVID-19 PANDEMIC. A CAMPUS CLL REPORT

Consensus statement of the Italian society of pediatric allergy and immunology for the pragmatic management of children and adolescents with allergic or immunological diseases during the COVID-19 pandemic

Continuing our work: transplant surgery and surgical oncology in a tertiary referral COVID-19 center

COVID 19 infection requires strengthening of the chronic care model: the impact on liver transplant practice at a high-volume center in Italy. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society De Simone

COVID-19 and kidney transplantation: an Italian Survey and Consensus

COVID-19 pandemic perception in adults with celiac disease: an impulse to implement the use of telemedicine. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver Siniscalchi, Monica; Zingone, Fabiana; Savarino

Endocrine surgery during COVID-19 pandemic: do we need an update of indications in Italy? Endocrine Lombardi

Head & neck Alterio

Head and neck cancer surgery in COVID-19 pandemic in Northern Italy. Oral oncology Riva, Giuseppe; Pizzo, Claudia; Fassone, Elisabetta; Pecorari

How Paediatric Psycho-oncology is changing during the COVID-19 Epidemic in Italy: New approaches. Psycho-oncology Zucchetti, Giulia; Bertolotti, Marina; Fagioli

How the COVID-19 pandemic changed the Plastic Surgery activity in a regional referral center in Northern Italy

Impact of COVID-19 epidemic on coronary care unit accesses for acute coronary syndrome in Veneto region

Italian survey on managing immune checkpoint inhibitors in oncology during COVID-19 outbreak

Management of breast cancer in an EUSOMAaccredited Breast Unit in Lombardy, Italy, during the COVID-19 pandemic

Management strategies adopted by a pediatric palliative care network in northern Italy during the COVID-19 pandemic

Managing ophthalmic practices in a referral emergency COVID-19 hospital in north-east Italy

Mental health services in Italy during the Covid-19 Pandemic

Natura non facit saltus: a phase 2 proposal to manage brain tumors cases from the neuro-oncology section of the Italian Society of

Oculoplastic management of patients in the Covid-19 era: experience from an Italian tertiary referral center

Operational strategies of a trauma hub in early coronavirus disease 2019 pandemic

Pediatric endoscopic procedures during the COVID-19 pandemic: an Italian center experience. Pediatric surgery international Duci, Miriam; Antoniello, Luca Maria

Psychological support and psychotherapy via digital devices in Covid-19 emergency time: Some critical issues. The Medico-legal journal Tullio, Valeria; Perrone, Giulio; Bilotta, Clio; Lanzarone, Antonietta; Argo

Remodulation of neurosurgical activities in an Italian region (Emilia-Romagna) under COVID-19 emergency: maintaining the standard of care during the crisis

Reorganization Tips from a Sarcoma Unit at Time of the COVID-19 Pandemic in Italy: Early Experience from a Regional Referral Oncologic Center

ROLE OF REHABILITATION DEPARTMENT FOR ADULT COVID-19 PATIENTS: THE EXPERIENCE OF THE SAN RAFFAELE HOSPITAL OF MILAN. Archives of physical medicine and rehabilitation Iannaccone, Sandro; Castellazzi

Stroke care during the Covid-19 pandemic: Experience from three large European countries

Systemic Treatment of Patients With Gastrointestinal Cancers During the COVID-19 Outbreak: COVID-19-adapted Recommendations of the National Cancer Institute of Milan

Tor Vergata University-Hospital in the Beginning of COVID-19-Era: Experience and Recommendation for Breast Cancer Patients

all COVID 19-positive patients, but do not forget those negative with chronic diseases. Internal and emergency medicine Mauro

Which are the "emergent" dermatologic practices during COVID-19 pandemic?

Analysis of preventive measures and new indications in a teaching hospital in central Italy during the Covid-19 emergency

A COVID-19 outbreak's lesson: best use of the pediatric emergency department Acta paediatrica

Blood supply and transfusion support in southern Italy: Findings during the first four weeks of the SARS-CoV-2 pandemic

Covid-19 in patients on dialysis: infection prevention and control strategies Giornale italiano di nefrologia : organo ufficiale della Societa italiana di nefrologia

 10.1002/ijgo.13158 Expert consensus from the Italian Society for Colposcopy and Cervico-Vaginal Pathology (SICPCV) for colposcopy and outpatient surgery of the lower genital tract during the COVID-19 pandemic. The dramatic COVID-19 outbreak in italy is responsible of a huge drop in urological surgical activity: A multicenter observational study.