The COVID-19 pandemic is threatening health systems worldwide, requiring extraordinary efforts to contain the virus and prepare health care systems for unprecedented situations. In this context, the entire health care workforce must be properly trained to guarantee an effective response. Just-in-time training has been an efficient solution for rapidly equipping health care workers with new knowledge, skills, and attitudes during emergencies; thus, it could also be an effective training technique in the context of the response to the COVID-19 pandemic. Because of the unexpected magnitude of this health crisis, the health care workforce must be trained in 2 areas: (1) basic infection prevention and control, including public health skills that are the core of population-based health management and (2) disaster medicine principles, such as surge capacity, allocation of scarce resources, triage, and the ethical dilemmas of rationing medical care. This Perspective reports how just-in-time training concepts and methods were applied in a tertiary referral hospital in March 2020, during the COVID-19 pandemic in Northern Italy, one of the hardest hit places in the world. The COVID-19 just-in-time training was designed to provide hospital staff with the competencies they need to work proficiently and safely inside the hospital, including an understanding of the working principles and standard operating procedures in place and the correct use of personal protective equipment. Moreover, this training was intended to address the basic principles of disaster medicine applied to the COVID-19 pandemic. Such training was essential in enabling staff to rapidly attain competencies that most of them lacked because disaster medicine and global health are not included in the curricula of Italian medical and nursing schools. Although a formal evaluation was not performed, this is a useful example of how to create just-in-time training in a large hospital during a crisis of an unprecedented scale.

White matter hyperintensities (WMHs) have been associated with neurological complications including cognitive impairment. WMHs have been often described in HIV positive subjects and they have been linked to neurocognitive impairment, cerebrospinal fluid (CSF) residual viral replication and biomarkers of monocyte activation. Aim of this study was to grade WMHs in HIV-positive individuals using a simple visual scale and to explore their severity with clinical, neurocognitive and biomarker characteristics. Brain MRIs were retrospectively evaluated by two reviewers who rated WMHs following the "age-related white matter changes (ARWMC)" scale. 107 adult HIV-positive patients receiving lumbar punctures for clinical reasons were included. 70 patients (66.6%) were diagnosed with WMHs. Average WMH scores were higher in treated [7 (1-11)] vs. naïve individuals [3 (0-6)] (p = 0.008). Higher WHMs scores were observed in patients with chronic renal impairment along with chronic hepatitis (naïve) and longer HIV duration (treated participants). No consistent associations between plasma, CSF biomarkers and WMHs scores were found. 45 patients underwent full neurocognitive tests and WMHs scores were non-significantly higher in patients diagnosed with HAND [6.5 (0.5-8.3) vs. 1.5 (0-7), p = 0.165]; screening (IHDS and FAB), visuo-spatial (Corsi's) and auditory-verbal memory (disillabic words repetition) tests scored worse in patients with higher WMHs. In our population of HIV-positive patients with low CD4 nadir and partial CD4 cell recovery the burden of WMHs was associated with the duration of HIV infection and with commonly observed comorbidities (such as renal and hepatic impairment). Given the association with worse neurocognition, further studies on tailored interventions are needed.

Recent studies support the idea that residual cerebrospinal fluid HIV RNA in the setting of plasma viral suppression is associated with compartmental immune activation but the link to neuronal damage is debated. Some authors have reported an incomplete antiviral efficacy in macrophage-derived cells but targeted antiretroviral regimen switches have not been performed. Additionally, improvements in neurocognition using drugs with better central nervous system penetration or maraviroc (associated with favorable immunological properties) have been observed in pilot studies. Trials evaluating specific interventions for cardiovascular health (including brain white matter abnormalities) and neurotoxicity of antiretrovirals are warranted. Central nervous system-targeted antiretroviral strategies are needed in patients with uncontrolled cerebrospinal HIV replication, and they may be suggested in subjects with low CD4 nadir, individuals carrying drug-resistant viruses, and those with compartmental immune activation.

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