The Post-Lockdown Era: What Is Next in Italy?

1 Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia,” University of Catania, Catania, Italy, 2 Medico-Legal Unit, University Hospital “Policlinico Vittorio Emanuele,” Catania, Italy, 3 Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy, 4 Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo, Italy, 5 Department of Biology, Temple University, Philadelphia, PA, United States

and pericytes, are almost ubiquitarian, and not only present in the endothelial cells of alveolar membranes (Letko et al., 2020;Shang et al., 2020).
In addition, molecular mimicry has been proposed as a mechanism inducing autoimmune damage at the endothelial level (Cappello, 2020), but the lack of histological specimens has hindered the possibility to test this hypothesis.
Collecting cadavers' samples or biological fluids and swabs can also be useful in the control of epidemics, as shown during previous infectious disease outbreaks. It is a fact that, during the West Africa Ebola epidemic, in the Ebola Virus Disease (EVD) surveillance strategy, RNA virus was isolated in body fluids days or months after the onset of the disease from any living or deceased individual who had, or had had, clinical symptoms compatible with EVD. Thanks to this procedure, it was possible to monitor the number of infected patients in order to recognize new sources of transmission and to control the epidemic phenomenon (Kreuels et al., 2014;Kreuels et al., 2015;Petrosillo et al., 2015;Varkey et al., 2015;Castillo et al., 2016;Vetter et al., 2016). Without performing systematically autopsies on all patients who die of (or with) COVID-19 disease, we will never find the end of the skein.
In view of what has been stated, we also want to denote raise a political issue: the WHO suggested performing post-mortem examinations for those who die of/with COVID-19 following recommended safety procedures (WHO Interm Guidance, 2020). Although the first data about the autopsy findings suggested the pivotal role of autopsy in the management of unknown disease, many governments-including the Italian one-did not make sufficient efforts to permit forensic doctors and gross pathologists to finally perform autopsies on these corpses (Pomara et al., 2020;Salerno et al., 2020). In Italy, in the first phase of the outbreak, the Ministry of Health with a specific act (Circular of General Direction of Health Prevention) discouraged the use of autopsies for COVID-19 deaths (Italian Ministry of Health, 2020a): indeed, to date, only one study has been published about the Italian experience in the COVID-19 post-mortem examination. Carsana et al. described the histological examination of lung tissue samples from 38 consecutive patients who died from COVID-19 between the 29 th of February and the 24 th of March (Carsana et al., 2020). Considering that in Italy more than 30,000 people have died from or with COVID-19, it is possible to confirm that almost no autopsies have been performed. The 1 st of June the Italian Ministry of Health revised its act (Italian Ministry of Health, 2020b) by authorizing autopsies on people who died for/with COVID-19, but in our opinion-due to the current epidemic data in Italy-it was a big mistake and a missed opportunity to not have done this sooner.
We cannot, though, underestimate the importance of autopsy as a diagnostic tool to understand the underlying mechanisms behind death. In accordance with the WHO, post-mortem examination for deceased persons infected with COVID-19 should be consistent with those used for any autopsies of people who have died from an acute respiratory illness, following the recommended safety procedures.
Political and health authorities should therefore be aware that performing systematic autopsies on patients who die following COVID-19 infection can provide significant responses concerning the real mechanisms underlying virus related deaths and organ injury. Encouraging autopsy practice as an investigative tool could also help physicians to define effective treatment to reduce mortality. Another essential aspect is related to "COVID-19 survivor" management. In our opinion, a COVID-19 survivor is a person who has been infected by the virus with a hospitalization period in the intensive care unit, who is still living. When a person becomes a survivor after completing treatment, several issues should be discussed: what are the consequences of the infection? Which are the organs that have been damaged? Which are the organs involved? The management of the COVID-19 survivor is the next challenge for the scientific community. Furthermore, other severe diseases should be considered for COVID-19 survivors such as depression and anxiety in order to provide them the best possible medical care to improve their quality of life.
As the authors reported, measures are urgently needed to avoid unnecessary deaths and we suggest that autopsy is an important tool to learn from inevitable deaths. Moreover, improving our knowledge about the COVID-19 infection, may provide useful insights in order to establish, as soon as possible, the proper guidelines for the medical management of COVID-19 survivors.

AUTHOR CONTRIBUTIONS
Conceptualization: CP, GV, and FC. Writing-original draft preparation: CP, GV, and FC. Writing-review and editing: CP, GV, and FC. All authors contributed to the article and approved the submitted version.