Screening for colorectal cancer by full colonoscopy in first-degree relatives of colorectal cancer patients: a multicentric study by the Italian League for the Fight against Cancer

Background

Colorectal cancer currently presents the third-highest incidence of cancers worldwide, making secondary prevention through screening programs for colorectal cancer, usually by Fecal Occult Blood Testing, an essential preventive medicine intervention. First-degree relatives of colorectal cancer patients are a particularly at-risk group, with indications to consider direct screening by full colonoscopy. Colonoscopy is considered the gold standard for diagnosing colorectal cancer, as it has high sensitivity and specificity, and is both a diagnostic and therapeutic tool. However, it requires significant organizational and financial resources, and has a small but relatively higher risk of complications as opposed to fecal occult blood testing. The present study aimed to assess the appropriateness of a screening program without age restrictions of CRC by full colonoscopy in asymptomatic, first-degree adult relatives of patients with colorectal cancer, aiming both to actively increase screening coverage and to determine the detection rate of precancerous lesions and colorectal cancer in this population.

Study Design

Uncontrolled interventional study - colorectal cancer screening by full colonoscopy for at-risk population.

Methods

The Italian League for the Fight against Cancer started a colorectal cancer screening program by full colonoscopy for first-degree relatives of colorectal cancer patients in 1998 in the province of Latina, Lazio Region, Italy. The program was expanded to the provinces of Rieti, Lazio Region, and Sassari, Sardinia Region, in 2014 and 2016 respectively, and was concluded in 2018. Subjects were actively and voluntarily recruited by the study's working group. Subjects that had already been subjected to a full colonoscopy in the preceding 5 years were excluded from this study. Identified neoplastic lesions were treated either directly or referred to the Day Hospital setting, and histologically diagnosed following World Health Organization guidelines.

Results

In total, 2,288 subjects (age range 15-88, mean 52.3 yrs, M/F = 946/1,204) were screened by colonoscopy, of which 103 (4.5%) were incomplete and 2,173 (95.0%) complete, with data on colonoscopy performance missing for 12 participants. Out of 468 positive outcomes on colonoscopy, diagnosis for 422 (204M/173F), 19.4% of total subjects, was adenomatous polyps and 46 (20M/20F), 2.1% of total subjects, was colorectal cancer. Female sex was a protective factor against a positive test outcome, with a 35% reduction compared to male sex, with OR=0.64 95%CI (0.52-0.80). On the other hand, being over 50 years of age was found to be a risk factor, making a positive outcome more than twice as likely, with OR=2.3 95%CI (1.8-2.9). Subjects over 50 also had significantly more instances of multiple adenomas being found, however the size distribution of found adenomas was not significantly different between subjects under and over 50, despite size being a predictor of risk of neoplastic progression.

Conclusions

Given the high detection rate of precancerous lesions and colorectal cancer in the studied population, it is our opinion that guidelines should continue to recommend earlier and more frequent screening in first-degree relatives of patients with colorectal cancer, and, barring the introduction of more cost-effective and/or lower risk procedures with a similar efficacy profile, maintain the use of colonoscopy as the main screening option.

Accuracy of an Air-Puff Dynamic Tonometry Biomarker to Discriminate the Corneal Biomechanical Response in Patients With Keratoconus

PURPOSE

The aim of this study was to assess accuracy of the mean corneal stiffness ( kc , N/m) parameter to discriminate between patients with keratoconus and age-matched healthy subjects.

METHODS

Dynamic Scheimpflug imaging tonometry was performed with Corvis ST (Oculus Optikgeräte GmbH, Germany) in patients with keratoconus (n = 24; study group) and age-matched healthy subjects (n = 32; control). An image processing algorithm was developed to analyze the video sequence of the Corvis ST air-puff event and to determine the geometric and temporal parameters that correlated with the corneal tissue biomechanical properties. A modified 3-element viscoelastic model was used to derive the kc parameter, which represented the corneal tissue resistance to deformation under load. Receiver operating characteristic curves were used to assess the overall diagnostic performance for determining the area under the curve, sensitivity, and specificity of the kc in assessing the corneal tissue deformation to the Corvis ST air-puff event in keratoconus and control eyes. The Corvis Biomechanical Index ( CBI ) was analyzed for external validation.

RESULTS

The kc parameter was significantly different between keratoconus and controls ( P < 0.001), ranging from 24.9 ±3.0 to 34.2 ±3.5 N/m, respectively. It was highly correlated with CBI (r = -0.69; P < 0.001); however, the kc parameter had greater specificity (94%) than CBI (75%), whereas the 2 biomarkers had similar area under the curve (0.98 vs. 0.94) and sensitivity (96% vs. 92%) in predicting the occurrence of keratoconus.

CONCLUSIONS

The kc parameter extracted by video processing analysis of dynamic Scheimpflug tonometry data was highly accurate in discriminating patients with clinically manifest keratoconus compared with controls.

Estimated prevalence of keratoconus in the largest metropolitan area of Italy

PURPOSE

To estimate the prevalence of keratoconus in a population of subjects undergoing first eye examination in an eye clinic in Italy.

METHODS

A single-center, cross-sectional, study was conducted involving patients who underwent first eye examination at an eye clinic in Rome between September 2021 and June 2022. The prevalence of keratoconus was determined by Placido-disk corneal topography using the maximum keratometry (Kmax) value and the Cone Magnitude and Location Index (CLMI) for keratoconus screening. Subjective analysis was performed by two experienced corneal specialists, who classified the outcome into two groups: normal and keratoconus. Risk factors, including family history of keratoconus, allergy or atopy, thyroid disease, eye rubbing habit and gender were also examined.

RESULTS

A total of 512 subjects between 7 and 81 years old were evaluated. The inter-observer agreement to classify subjects in normal or keratoconus group was excellent (k = 1.0); the estimated prevalence in the specific population was 2.1%. Presence of positive family history (9% of keratoconus vs 5% normal), concomitant allergy or atopy (27% vs 9%) and eye rubbing habit (18% vs 4%) were associated with a higher risk of disease.

CONCLUSION

This study reported a high estimated prevalence of keratoconus in a metropolitan area of Italy, as found in recent studies in the Mediterranean and Middle East countries. Screening for keratoconus is highly recommendable and easily feasible with corneal topography under expert supervision and may be indicated primarily in young population to improve early detection and prompt therapeutic management for halting disease progression.

Heart failure 'the cancer of the heart': the prognostic role of the HLM score

AIMS

The multi-systemic effects of heart failure (HF) resemble the spread observed during cancer. We propose a new score, named HLM, analogous to the TNM classification used in oncology, to assess the prognosis of HF. HLM refers to H: heart damage, L: lung involvement, and M: systemic multiorgan involvement. The aim was to compare the HLM score to the conventional New York Heart Association (NYHA) classification, American College of Cardiology/American Heart Association (ACC/AHA) stages, and left ventricular ejection fraction (LVEF), to assess the most accurate prognostic tool for HF patients.

METHODS AND RESULTS

We performed a multicentre, observational, prospective study of consecutive patients admitted for HF. Heart, lung, and other organ function parameters were collected. Each patient was classified according to the HLM score, NYHA classification, ACC/AHA stages, and LVEF assessed by transthoracic echocardiography. The follow-up period was 12 months. The primary endpoint was a composite of all-cause death and rehospitalization due to HF. A total of 1720 patients who completed the 12 month follow-up period have been enrolled in the study. 520 (30.2%) patients experienced the composite endpoint of all-cause death and rehospitalization due to HF. 540 (31.4%) patients were female. The mean age of the study population was 70.5 ± 12.9. The mean LVEF at admission was 42.5 ± 13%. Regarding the population distribution across the spectrum of HLM score stages, 373 (21.7%) patients were included in the HLM-1, 507 (29.5%) in the HLM-2, 587 (34.1%) in the HLM-3, and 253 (14.7%) in the HLM-4. HLM was the most accurate score to predict the primary endpoint at 12 months. The area under the receiver operating characteristic curve (AUC) was greater for the HLM score compared with the NYHA classification, ACC/AHA stages, or LVEF, regarding the composite endpoint (HLM = 0.645; NYHA = 0.580; ACC/AHA = 0.589; LVEF = 0.572). The AUC of the HLM score was significantly better compared with the LVEF (P = 0.002), ACC/AHA (P = 0.029), and NYHA (P = 0.009) AUC.

CONCLUSIONS

The HLM score has a greater prognostic power compared with the NYHA classification, ACC/AHA stages, and LVEF assessed by transthoracic echocardiography in terms of the composite endpoint of all-cause death and rehospitalization due to HF at 12 months of follow-up.

Emotional abilities in preadolescents and adolescents with long-term cochlear implant use

OBJECTIVES

Emotional abilities (EAs) are particularly important during preadolescence/adolescence, two challenging periods characterized by significant biological, physical, and cognitive changes. The present study attempted to a holistic EA approach in preadolescents/adolescents with cochlear implants (CI) and typical hearing (TH), considering various aspects such as perception, cognitive facilitation, comprehension, and management of emotions. A secondary aim was to identify significant demographic and audiological factors of EA development.

METHODS

CI/TH groups were matched for chronological age, nonverbal IQ, gender, economic income, and maternal level of education. Each group consisted of 43 participants (age range 10-18 years). EAs were evaluated by using the multi-trait/method IE-ACCME test. Auditory-linguistic assessments included participants' lexical skills and Matrix performance as well.

RESULTS

EA performance for perception and cognitive facilitation did not show any statistically significant CI/TH group differences (p > 0.05). Significant CI/TH differences emerged for emotion comprehension and management: CI group performed significantly worse in understanding emotional blends (t = 2.56, p = 0.014) but better in personal emotion management (t = -2.01, p = 0.048). For the CI group, gender showed statistically significant effects on cognitive facilitation in sensations, with males performing better than females (U = 129, p = 0.018). TH preadolescents showed significantly lower scores in understanding emotional changes in comparison to TH adolescents (U = 125.5, p = 0.01). Emotional blends understanding showed a weak negative correlation with Matrix performance (r = - 0.38, p = 0.013) and a moderate positive correlation with lexical skills (r = 0.40, p = 0.008). Relationships management showed various significant correlations: weak negative correlations with age at CI (r = - 0.38, p = 0.011) and Matrix performance (r = - 0.36, p = 0.016) as well as weak positive correlations with nonverbal-IQ (r = 0.38, p = 0.013) and positive moderate correlations with lexical skills (r = 0.49, p < 0.001).

CONCLUSION

Cochlear implantation seems to show significant positive effects on emotional development in children, allowing them to achieve age appropriate EAs as they grow up and become preadolescents/adolescents. EA assessment in CI users may not only support monitorization of EA trajectory, but also early identification of any EA disorders, so that subjects with low EA profiles could be timely and properly intervened.

Supermicrosurgery with perforator-to-perforator anastomoses for lower limb reconstructions - A systematic review and meta-analysis

BACKGROUND

Supermicrosurgical flaps based on perforator-to-perforator microanastomoses have been described for lower limb reconstruction. This approach offers the benefit of raising short pedicles while sparing axial vessels, which effectively enables complex reconstructive techniques in comorbid patients at high risk of reconstructive failure. The aim of our study is to assess the surgical outcomes of perforator-to-perforator based flaps in comparison to conventional free flaps for reconstructions of the lower limb district, through a systematic review of literature and meta-analysis.

METHODS

A search on PubMed, Embase, Cohrane, and Web of Science was performed between March-July 2022. No restrictions were placed on study date. Only English manuscripts were assessed. Reviews, short communications, letters, correspondence were excluded after reviewing their references for potentially relevant studies. A Bayesian approach was used to conduct the meta-analysis comparing flap-related outcomes.

RESULTS

From 483 starting citations, 16 manuscripts were included for full-text analysis in the review, and three were included in the meta-analysis. Out of 1556 patients, 1047 received a perforator-to-perforator flap. Complications were reported in 119 flaps (11.4%), which included total flap failure in 71 cases (6.8%), partial flap failure in 47 cases (4.5%). Overall flap complications had a HR of 1.41 (0.94-2.11; 95% C.I.). Supermicrosurgical and conventional microsurgical reconstructions were not associated with statistically significant differences (p = .89).

CONCLUSION

Our evidence supports the safety of surgical outcomes, with acceptable flap complication rates. Nevertheless, these findings are limited by poor overall quality which must be addressed and used to encourage higher-level evidence in the field.

The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section

OBJECTIVE

To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS).

METHODS

This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups.

RESULTS

A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay.

CONCLUSIONS

Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.

Accuracy of Pancreatic Stone Protein for diagnosis of sepsis in children admitted to pediatric intensive care or high-dependency care: a pilot study

BACKGROUND

Pancreatic Stone Protein (PSP) is one of the most promising diagnostic and prognostic markers. The aim of the study was to assess the accuracy of PSP, compared to C-Reactive Protein (CRP), and Procalcitonin (PCT) for sepsis diagnosis in pediatric patients. Furthermore, we explored the correlation of PSP levels with sepsis severity and organ failure measured with PELOD-2 score.

METHODS

Forty pediatric patients were enrolled following admission to pediatric intensive care, high dependency care or pediatric ward. PSP blood levels were measured in Emergency Department (nanofluidic point-of-care immunoassay; abioSCOPE, Abionic SA, Switzerland) on day 1, 2, 3, 5 and 7 from the onset of the clinical signs and symptoms of sepsis or SIRS. Inclusion criteria were: 1) patient age (1 month to 18 years old), 2) signs and symptoms of SIRS, irrespective of association with organ dysfunction. Exclusion criteria were: 1) hemato-oncological diseases and/or immunodeficiencies, 2) pancreatic diseases.

RESULTS

Septic patients showed higher PSP levels than those with non-infectious systemic inflammation. The optimal cut-off in diagnosis of sepsis for PSP at day 1 was 167 ng/ml resulted in a sensitivity of 59% (95% IC 36%-79%) and a specificity of 83% (95% IC 58%-96%) with an AUC of 0.636 for PSP in comparison to AUC of 0.722 for PCT and 0.503 for C-RP. ROC analysis for outcome (survival versus no survival) has showed AUC 0.814 for PSP; AUC 0.814 for PCT; AUC of 0.657 for C-RP.

CONCLUSIONS

PSP could distinguish sepsis from non-infectious systemic inflammation; however, our results need to be confirmed in larger pediatric population.

Real-life comparison of mortality in patients with SARS-CoV-2 infection at risk for clinical progression treated with molnupiravir or nirmatrelvir plus ritonavir during the Omicron era in Italy: a nationwide, cohort study

Background

Comparative data on mortality in COVID-19 patients treated with molnupiravir or with nirmatrelvir plus ritonavir are inconclusive. We therefore compared all-cause mortality in community-dwelling COVID-19 patients treated with these drugs during the Omicron era.

Methods

Data collected in the nationwide, population-based, cohort of patients registered in the database of the Italian Medicines Agency (AIFA) were used. To increase completeness of the recorded deaths and date correctness, a cross-check with the National Death Registry provided by the Ministry of the Interior was performed. We included in this study all patients infected by SARS-CoV-2 treated within 5 days after the test date and symptom onset between February 8 and April 30, 2022. All-cause mortalities by day 28 were compared between the two treatment groups after balancing for baseline characteristics using weights obtained from a gradient boosting machine algorithm.

Findings

In the considered timeframe, 17,977 patients treated with molnupiravir and 11,576 patients with nirmatrelvir plus ritonavir were included in the analysis. Most patients (25,617/29,553 = 86.7%) received a full vaccine course including the booster dose. A higher crude incidence rate of all-cause mortality was found among molnupiravir users (51.83 per 100,000 person-days), compared to nirmatrelvir plus ritonavir users (22.29 per 100,000 person-days). However, molnupiravir-treated patients were older than those treated with nirmatrelvir plus ritonavir and differences between the two populations were found as far as types of co-morbidities were concerned. For this reason, we compared the weight-adjusted cumulative incidences using the Aalen estimator and found that the adjusted cumulative incidence rates were 1.23% (95% CI 1.07%-1.38%) for molnupiravir-treated and 0.78% (95% CI 0.58%-0.98%) for nirmatrelvir plus ritonavir-treated patients (adjusted log rank p = 0.0002). Moreover, the weight-adjusted mixed-effect Cox model including Italian regions and NHS centers as random effects and treatment as the only covariate confirmed a significant reduced risk of death in patients treated with nirmatrelvir plus ritonavir. Lastly, a significant reduction in the risk of death associated with nirmatrelvir plus ritonavir was confirmed in patient subgroups, such as in females, fully vaccinated patients, those treated within day 2 since symptom onset and patients without (haemato)-oncological diseases.

Interpretation

Early initiation of nirmatrelvir plus ritonavir was associated for the first time with a significantly reduced risk of all-cause mortality by day 28 compared to molnupiravir, both in the overall population and in patient subgroups, including those fully vaccinated with the booster dose.

Funding

This study did not receive funding.

External validation of the ADA score for predicting thrombosis among acutely ill hospitalized medical patients from the APEX Trial

The ADA (Age-D-dimer-Albumin) score was developed to identify hospitalized patients at an increased risk for thrombosis in the coronavirus infectious disease-19 (COVID-19) setting. The study aimed to validate the ADA score for predicting thrombosis in a non-COVID-19 medically ill population from the APEX trial. The APEX trial was a multinational, randomized trial that evaluated the efficacy and safety of betrixaban vs. enoxaparin among acutely ill hospitalized patients at risk for venous thromboembolism. The study endpoints included the composite of arterial or venous thrombosis and its components. Metrics of model calibration and discrimination were computed for assessing the performance of the ADA score as compared to the IMPROVE score, a well-validated VTE risk assessment model. Among 7,119 medical inpatients, 209 (2.9%) had a thrombosis event up to 77 days of follow-up. The ADA score demonstrated good calibration for both arterial and venous thrombosis, whereas the IMPROVE score had adequate calibration for venous thrombosis (p > 0.05 from the Hosmer-Lemeshow test). For discriminating arterial and venous thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.620 [95% CI: 0.582 to 0.657] vs. 0.590 [95% CI: 0.556 to 0.624]; ∆ c statistic = 0.030 [95% CI: -0.022 to 0.081]; p = 0.255). Similarly, for discriminating arterial thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.582 [95% CI: 0.534 to 0.629] vs. 0.609 [95% CI: 0.564 to 0.653]; ∆ c statistic = -0.027 [95% CI: -0.091 to 0.036]; p = 0.397). For discriminating venous thrombosis, the ADA score was modestly superior to the IMPROVE score (c statistic = 0.664 [95% CI: 0.607 to 0.722] vs. 0.573 [95% CI: 0.521 to 0.624]; ∆ c statistic = 0.091 [95% CI: 0.011 to 0.172]; p = 0.026). The ADA score had a higher sensitivity (0.579 [95% CI: 0.512 to 0.646]; vs. 0.440 [95% CI: 0.373 to 0.507]) but lower specificity (0.625 [95% CI: 0.614 to 0.637] vs. 0.747 [95% CI: 0.737 to 0.758]) than the IMPROVE score for predicting thrombosis. Among acutely ill hospitalized medical patients enrolled in the APEX trial, the ADA score demonstrated good calibration but suboptimal discrimination for predicting thrombosis. The findings support the use of either the ADA or IMPROVE score for thrombosis risk assessment. The applicability of the ADA score to non-COVID-19 populations warrants further research.Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT01583218.

A randomized clinical trial assessing theranostic-guided corneal cross-linking for treating keratoconus: the ARGO protocol

The Assessment of theranostic guided riboflavin/UV-A corneal cross-linking for treatment of keratoconus (ARGO; registration number NCT05457647) clinical trial tests the hypothesis that theranostic-guided riboflavin/UV-A corneal cross-linking (CXL) can provide predictable clinical efficacy for halting keratoconus progression, regardless of treatment protocol, i.e., either with or without epithelial removal. Theranostics is an emerging therapeutic paradigm of personalized and precision medicine that enables real-time monitoring of image-guided therapy. In this trial, the theranostic software module of a novel UV-A medical device will be validated in order to confirm its accuracy in estimating corneal cross-linking efficacy in real time. During CXL procedure, the theranostic UV-A medical device will provide the operator with an imaging biomarker, i.e., the theranostic score, which is calculated by non-invasive measurement of corneal riboflavin concentration and its UV-A light mediated photo-degradation. ARGO is a randomized multicenter clinical trial in patients aged between 18 and 40 years with progressive keratoconus aiming to validate the theranostic score by assessing the change of the maximum keratometry point value at 1-year postoperatively. A total of 50 participants will be stratified with allocation ratio 1:1 using a computer-generated stratification plan with blocks in two treatment protocols, such as epithelium-off or epithelium-on CXL. Following treatment, participants will be monitored for 12 months. Assessment of safety and performance of theranostic-guided corneal cross-linking treatment modality will be determined objectively by corneal tomography, corneal endothelial microscopy, visual acuity testing and slit-lamp eye examination.

The Mediating Role of Sleep Quality in the Relationship between Negative Emotional States and Health-Related Quality of Life among Italian Medical Students

Sleep problems have been shown to be related to adverse outcomes concerning physical and mental well-being. Furthermore, mental health issues and sleep problems were reported to be highly prevalent among medical students and physicians, and were found to be associated with worse academic and clinical performance in these populations. This study aims to investigate the prevalence of poor sleep to examine the associations between sleep quality and health-related quality of life (HRQoL), and to explore the possible mediating role of sleep in the relationship between psychological distress and HRQoL itself in a sample of medical and dental students attending a large Italian university. Participants (n = 407, mean age: 24.2 ± 2.4) answered an online questionnaire comprising the 21-item Depression Anxiety Stress Scale, the Pittsburgh Sleep Quality Index, and the Short Form-12 health survey. Up to 62% of the participants reported poor sleep quality. Controlling for psychological distress, sleep quality components were found to be associated with physical and mental HRQoL. Mediation analysis showed that overall sleep quality mediated all the single associations between anxiety, depression, and stress and HRQoL. These preliminary findings suggest that the quality of sleep is important for the well-being of medical students and that targeting sleep issues in this academic population may be beneficial.

306 HEART FAILURE AS THE CANCER FOR THE HEART: THE PROGNOSTIC ROLE OF THE HLM SCORE

Background

The multiorgan involvement of heart failure is similar to the spread observed in cancer. We proposed a new score, named HLM, analogous to TNM classification used in oncology. HLM refers to (i) H: heart damage, instead of “T” for tumor; (ii) L: lung involvement, instead of “N” for lymph nodes; (iii) M: systemic multiorgan involvement, instead of “M” for metastasis.

Objectives

to compare HLM score to NYHA class, ACC/AHA stages and left ventricular ejection fraction (LVEF) classification, to assess the most accurate prognostic tool for HF patients.

Methods

We performed a multicentric, observational, prospective study of consecutive patients admitted for HF, or at risk for HF. Parameters for heart, lungs and organs’ function were collected. Each patient was classified according to HLM, NYHA, ACC/AHA stages and LVEF classification. Patients were followed up for 12 months. The primary composite endpoint was all-cause death and rehospitalization due to HF.

Results

We enrolled 1720 patients who completed the 12-month follow-up. As shown by Kaplan Meier curves, HLM was the most accurate score to predict primary endpoint at 12- month. The area under the ROC curve (AUC) was greater for HLM score than NYHA, ACC/AHA stages and LVEF classification, regarding the composite endpoint (HLM=0.645; NYHA=0.580; ACC/AHA=0.589; LVEF=0.572) (Figure 1). HLM score related AUC showed statistically significant differences compared to LVEF (p=0.002), ACC/AHA (p=0.029) and NYHA (p=0.009).

Conclusions

HLM score has a greater prognostic power compared to other nosologies, in terms of the composite endpoint of all-cause death and rehospitalization due to HF, at 12-month follow-up.

Key words: heart failure; HLM score; prognosis; mortality; rehospitalization.

Figure 1.

Coeliac disease in the COVID-19 pandemic: does HLA have a protective effect?

BACKGROUND

The coronavirus disease 2019 (COVID-19), an acute respiratory disease caused by a novel coronavirus (SARS-CoV-2), is emerging as a worldwide public health emergency. Several scientific contributions reported the potential relevance of human leukocyte antigen (HLA) polymorphism and susceptibility to viruses, such as SARS-CoV. In our study, we examined a population of coeliac subjects presenting the HLA haplotype DQ2 and/or DQ8. Our aim was to evaluate whether HLA DQ2 and/or DQ8 haplotype play a role in SARS-CoV-2-infection. The aim was also to evaluate the difficulty in following the gluten-free diet due to all the adversities produced by the pandemic, such as the food supply disruption, and the difficulties in managing the clinical follow-up.

METHODS

191 consecutive coeliac patients completed a questionnaire on their current clinical status, psychological effects, and management of the gluten-free diet experienced during the COVID-19 pandemic and questions regarding possible SARS-CoV-2 infection.

RESULTS

Out of the 191 patients who participated in the study, 42 were full-blown coeliac and 149 were in remission. From the answers provided, 84.8% of patients declared that they no longer consider themselves vulnerable to COVID-19 as they suffer from coeliac disease; 94.2% of patients did not encounter any difficulties in managing the gluten-free diet or in acquiring specific foods and 64.9% of patients in our study underwent diagnostic testing for SARS-CoV-2. Out of this number, 31.5% did so due to contacts with subjects affected by COVID-19, 26.6% for work related reasons, 11.3% due to flu-like symptoms and 30.6% for other reasons. Only 5.8% of the enrolled patients received a diagnosis of COVID-19. Out of all the patients in our population who were diagnosed with COVID-19, 94.8% developed no symptoms and none of them needed hospitalization or intensive care.

CONCLUSION

The hypothesis that the HLADQ2 and/or DQ8 haplotype plays a protective role against SARS-CoV-2 infection, as against other viral infections, is intriguingly suggestive.KEY MESSAGESCOVID-19 as a public health emergency;SARS-CoV-2 and possible complications in coeliac disease;Role of HLA DQ2 and/or DQ8 in SARS-CoV-2 infection.

Coeliac disease in the COVID-19 pandemic: does HLA have a protective effect?

BACKGROUND

The coronavirus disease 2019 (COVID-19), an acute respiratory disease caused by a novel coronavirus (SARS-CoV-2), is emerging as a worldwide public health emergency. Several scientific contributions reported the potential relevance of human leukocyte antigen (HLA) polymorphism and susceptibility to viruses, such as SARS-CoV. In our study, we examined a population of coeliac subjects presenting the HLA haplotype DQ2 and/or DQ8. Our aim was to evaluate whether HLA DQ2 and/or DQ8 haplotype play a role in SARS-CoV-2-infection. The aim was also to evaluate the difficulty in following the gluten-free diet due to all the adversities produced by the pandemic, such as the food supply disruption, and the difficulties in managing the clinical follow-up.

METHODS

191 consecutive coeliac patients completed a questionnaire on their current clinical status, psychological effects, and management of the gluten-free diet experienced during the COVID-19 pandemic and questions regarding possible SARS-CoV-2 infection.

RESULTS

Out of the 191 patients who participated in the study, 42 were full-blown coeliac and 149 were in remission. From the answers provided, 84.8% of patients declared that they no longer consider themselves vulnerable to COVID-19 as they suffer from coeliac disease; 94.2% of patients did not encounter any difficulties in managing the gluten-free diet or in acquiring specific foods and 64.9% of patients in our study underwent diagnostic testing for SARS-CoV-2. Out of this number, 31.5% did so due to contacts with subjects affected by COVID-19, 26.6% for work related reasons, 11.3% due to flu-like symptoms and 30.6% for other reasons. Only 5.8% of the enrolled patients received a diagnosis of COVID-19. Out of all the patients in our population who were diagnosed with COVID-19, 94.8% developed no symptoms and none of them needed hospitalization or intensive care.

CONCLUSION

The hypothesis that the HLADQ2 and/or DQ8 haplotype plays a protective role against SARS-CoV-2 infection, as against other viral infections, is intriguingly suggestive.KEY MESSAGESCOVID-19 as a public health emergency;SARS-CoV-2 and possible complications in coeliac disease;Role of HLA DQ2 and/or DQ8 in SARS-CoV-2 infection.

A Survey on Methodological Issues of Clinical Research Studies Reviewed by Independent Ethic Committees during the COVID-19 Pandemic in Italy

The struggle for information and the hasty search for answers caused by the COVID-19 pandemic threatened the possibility of lowering study quality, as well as ethical committees' review standards during the outbreak. Our investigation aimed to assess the impact of COVID-19 on the quality of clinical research studies submitted to Italian Ethics Committees in the period between April and July 2020. All 91 Italian ethics committees were contacted via email in order to collect anonymized information on the type and quality of COVID-19-related studies submitted to each committee during the study period. The present study summarizes the characteristics of the 184 study applications collected, pointing out, especially, how the quality of the study population and statistical analysis are crucial variables in determining the study approval. Nevertheless, despite the need for high-quality and open scientific information, especially exacerbated by this particular historical period, only a minority of the ethics committees (20.9%) agreed to share their data; such scarce participation, beyond biasing the representativeness of the results obtained by the present study, more importantly, hinders the broader goal of creating trust between researchers and the general public.

Association of serum Krebs von den Lungen-6 and chest CT as potential prognostic factors in severe acute respiratory syndrome SARS-CoV-2: a preliminary experience

PURPOSE

To correlate in COVID-19 pneumonia CT-based semi-quantitative score of pulmonary involvement with high serum levels of KL-6, a biomarker of disease severity.

METHODS

Between March 28 to May 21, 2020, 196 patients with strong suspicion of SARS-CoV-2 were evaluated with RT-PCR for SARS-CoV-2, chest CT scan and blood test, including KL-6 serum protein, in our Emergency Unit. The final population included only patients who underwent blood sampling for KL-6 within 5 days from CT scan (n = 63), including n = 37 COVID-19-positive patients and n = 26 with negative RT-PCR testing for SARS-CoV-2 (control group). A semi-quantitative CT score was calculated based on the extent of lobar involvement (0:0%; 1, < 5%; 2:5-25%; 3:26-50%; 4:51-75%; 5, > 75%; range 0-5; global score 0-25).

RESULTS

CT score was significantly correlated with serum value of KL-6 (r = 27, p = 0.035). This correlation was also present in COVID-19 positive patients (r = 0.423, p = 0.009) and CT score median value was significantly higher in patients with high KL-6 value (> 400 U/mL; 12.00, IQR 5.00-18.00, p-value 0.027). In control group, no statistically significant correlation was found between CT score and KL-6 value and CT score was higher in patients with high KL-6, although this difference was not statistically significant (5.00, IQR:1.75-8.00 versus 3.50, IQR:2.00-6.50). "Crazy paving" at the right upper (n = 8; 61.5%) and middle lobe (n = 4; 30.8%) and "consolidation" at the middle lobe (n=5; 38.5%) were observed in COVID-19 group with a significant difference between patients with high KL-6 value.

CONCLUSION

CT score is highly correlated with KL-6 value in COVID-19 patients and might be beneficial to speed-up diagnostic workflow in symptomatic cases.

THE ADA (AGE-D-DIMER-ALBUMIN) SCORE TO PREDICT THROMBOSIS IN SARS-CoV-2

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2)-related pneumonia is associated with venous and arterial thrombosis . Aim of the study was to find-out a new score for predicting thrombosis in patients with SARS-CoV-2. Methods: We included a cohort of 674 patients affected by SARS-CoV-2, not requiring intensive care units, and followed-up during the hospitalization until discharge. Routinary analyses performed at in-hospital admission included also serum albumin and D-dimer while arterial and venous thromboses were the end-points of the study. Results: During the follow-up thrombotic events 110 were registered; patients with thrombotic events were older and had lower albumin and higher D-dimer, compared to thrombotic event-free ones. On multivariable logistic regression with step by stepwise procedure age, serum albumin, D-dimer, were independently associated with thrombotic events. The linear combination of age, D-dimer, albumin allowed to build-up the ADA score, whose AUC was 0.752 (95% CI, 0.708-0.795). ADA score was internally validated by bootstrap sampling procedure giving an AUC of 0.752 (95% CI: 0.708 - 0.794). Conclusions: Combination of age, D-dimer, albumin in the ADA score allows identifying SARS-CoV-2 patients at higher risk of thrombotic events.

Sleep Quality and Its Associations with Physical and Mental Health-Related Quality of Life among University Students: A Cross-Sectional Study

The association between sleep problems and quality of life has been well documented and the COVID-19 pandemic seemingly had an impact on both sleep quality and health-related quality of life (HRQoL). However, recent evidence about this relationship among university students is limited. The aims of this study are to investigate the prevalence of poor sleep quality and insomnia and to explore the associations between these outcomes, perceived stress, and HRQoL among Italian university students. An anonymous questionnaire comprising the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, the Short Form-12 health survey, and the Perceived Stress Scale was administered to a convenience sample of 1279 students (1119 females and 160 males, mean age: 23.4 ± 2.5 years) attending one of the largest Italian universities. A total of 65% of the participants showed poor sleep quality, whereas 55% reported insomnia symptoms. Students reporting poor sleep quality and insomnia obtained higher perceived stress scores and lower physical and mental HRQoL scores. Controlling for health-related variables and perceived stress, hierarchical regression analyses showed that sleep quality components added a significant contribution to the prediction of both physical (ΔR² = 0.1) and mental (ΔR² = 0.02) HRQoL. As a whole, these findings confirm the relevance of sleep for university students’ well-being and might inform the development of health promotion interventions for this population.

Osa patients vs laryngopharyngeal reflux disease: Non-invasive evaluation with NBI and pepsin detection in tears

Obstructive sleep apnea (OSA) and laryngopharyngeal reflux disease (LPR) are two common diseases that lower patients’ quality of life. OSA is defined by cyclic events of airflow obstruction that occurs during sleep, while LPR is characterized by upper airway inflammatory signs and symptoms due to the return of gastroduodenal gaseous and liquid elements. pH-metry is the gold standard in LPR diagnosis, but considering its invasiveness among other negative traits, questionnaires that catalog symptoms and signs of the disease such as reflux symptom index (RSI) and reflux finding score (RFS) are preferred. Moreover, LPR can be evaluated by testing the presence of pepsin in tears, and narrowband imaging (NBI) has been introduced for the early diagnosis of larynx oncological disease. This paper aims to test whether LPR is more frequent in OSA patients than in control ones, performing a non-invasive protocol composed of RSI and RFS test (with light vs. NBI techniques) followed by pepsin detection in tears. Sixty-eight LPR patients were enrolled in the study (45 with OSA and 23 without OSA). A strong linear relationship between apnea-hypopnea index (AHI) and oxygen desaturation index (ODI) was found, and patients who presented pepsin in tears had higher values of AHI and ODI in comparison to patients without it. Pathological RFS and NBI showed higher values of AHI and ODI in comparison to the control group. Furthermore, pathological RSI showed higher values of AHI and ODI in comparison to the control group. In conclusion, this diagnostic combined non-invasive protocol may be a good method to perform an early diagnosis of LPR.

Plasmonic Metasurfaces for Specific SERS Detection of Shiga Toxins

The interest in the development of nanoscale plasmonic technologies has dramatically increased in recent years. The photonic properties of plasmonic nanopatterns can be controlled and tuned via their size, shape, or the arrangement of their constituents. In this work, we propose a 2D hybrid metallic polymeric nanostructure based on the octupolar framework with enhanced sensing property. We analyze its plasmonic features both numerically and experimentally, demonstrating the higher values of their relevant figures of merit: we estimated a surface-enhanced Raman spectroscopy (SERS) enhancement factor of 9 × 10⁷ and a SPR bulk sensitivity of 430 nm/RIU. In addition, our nanostructure exhibits a dual resonance in the visible and near-infrared region, enabling our system toward multispectral plasmonic analysis. Finally, we illustrate our design engineering strategy as enabled by electron beam lithography by the outstanding performance of a SERS-based biosensor that targets the Shiga toxin 2a, a clinically relevant bacterial toxin. To the best of our knowledge, this is the first time that a SERS fingerprint of this toxin has been evidenced.

ECG evaluation in 11 949 Italian teenagers: results of screening in secondary school

AIM

There is lack of evidence regarding the screening role of ECG for sudden cardiac death (SCD) prevention. Our aim was to evaluate the prevalence of ECG abnormalities among teenagers according to sport participation and competitive status.

METHODS

Eleven thousand nine hundred and forty-nine Italian pupils from 179 secondary schools (13-19 years) were consecutively enrolled. ECG abnormalities were divided into minor and major. Medical history, clinical examination and sport activity information were acquired. Further evaluations were suggested in case of major ECG abnormalities. Follow-up was performed at 2 years.

RESULTS

N = 1945 (16%) pupils had ECG abnormalities. Major ECG abnormalities were detected in 13% of the cohort, minor in 34%. ECG abnormalities were more common in nonathletes compared with athletes. A diagnosis of cardiac disease was reached in 25 (1.6%) of the pupils with major ECG abnormalities.

CONCLUSION

ECG abnormalities are common among young populations and more prevalent in nonathletes. Among pupils with major ECG abnormalities 1.6% had a cardiac disease diagnosis. Our results are in line with the data supporting ECG screening in the general young population.

Well-being, Perceived Stress and Their Relations with Health-Relevant Behaviours Among Italian Medical Students: a Cross-Sectional Study at Sapienza University of Rome

Medical education is widely known to be demanding and stressful, with elevated levels of anxiety and depression among medical students. This study aims at examining well-being, perceived stress and quality of life in a sample of Italian first-year medical students in order to investigate the relations between these variables and individual characteristics and behaviours. An anonymous cross-sectional questionnaire was administered to a sample of 407 Italian first-year medical students. Psychological well-being, perceived stress and quality of life were assessed using standardised questionnaires PGWBI, PSS, SF-12. Data were analysed with multivariate statistical methods. Significant differences in PGWBI, PSS and SF-12 scores were found between males and females (with poorer scores for females), between smokers and non-smokers (with poorer scores for smokers) and between students who reported cannabis use in their lifetime and students who did not (with poorer scores for those who smoked cannabis). Logistic regression showed that gender (OR 0.38, 95% CI 0.24–0.61), reported cannabis use (OR 1.82, 95% CI 1.07–3.09) and regular physical exercise (OR 0.54, 95% CI 0.34–0.86) were significant predictors of distress. In summary, this study shows that female medical students and students who reported negative health behaviours and sporadic drug use reported lower psychological well-being and quality of life and higher stress, while positive health behaviours might prevent distress.

Evaluation of Vestibular Function in Patients Affected by Obstructive Sleep Apnea Performing Functional Head Impulse Test (fHIT)

PURPOSE

Obstructive sleep apnoea (OSA) is a common disease with significantly related complications. Since a connection between the vestibular nucleus and sleep regulator pathways has been demonstrated, vestibular evaluation in OSA patients was partially studied and none used functional head impulse test (fHIT) for this purpose. This paper aimed at evaluating the vestibular function in patients affected by OSA using fHIT, selecting patients who did not present any other related to cardiovascular, neurological, or metabolic diseases.

PATIENTS AND METHODS

Patients enrolled had a diagnosis of OSA by polysomnography type III and were cataloged according to American Association of Sleep Medicine criteria. Each patient underwent fHIT. Statistical significance was set at 0.05.

RESULTS

A total of 85 patients were enrolled in the study of which 50 had a diagnosis of OSA and were included in the case group, while 35 belonged to the control group. In 88.6% of subjects of the case group was evidenced a vestibular impairment with a substantial difference between the two study groups (p<0.05).

CONCLUSION

The results show that the incidence of vestibular lesions in patients with obstructive sleep apnoea is underestimated and that fHIT can identify these lesions early.

Pfizer-BioNTech COVID-19 Vaccine in Gynecologic Oncology Patients: A Prospective Cohort Study

Objective: To evaluate the safety and immunogenicity of the Pfizer-BioNTech COVID-19 vaccine in gynecologic oncology patients under chemotherapy. Methods: A prospective cohort study including gynecologic oncology women who were under chemotherapy or had completed it within 6 months at the time of the study. All patients received a two-dose schedule of the Pfizer-BioNTech COVID-19 vaccine. Results were compared with a control group of healthy women vaccinated in the same period. Results: Overall, 44 oncologic patients with a mean age of 61.3 ± 10.7 years were enrolled: 28 (63.6%) had ovarian cancer, 9 (20.4%) endometrial, and 7 (16%) cervical. The IgG antibody titer after 1 month from vaccination was low in 9 (20.5%) patients, moderate in 21 (47.7%), and high in 14 (31.8%). The 3-month titer was null in 2 (4.5%) patients, low in 26 (59.1%), moderate in 13 (29.5%), and high in 3 (6.8%). Patients ≥ 50 years reported lower 1-month (p = 0.018) and 3-month (p = 0.004) titers compared with <50 years. Patients with BMI < 30 kg/m² had a higher 1-month titer compared with BMI ≥ 30 kg/m² (p = 0.016). Compared with healthy women (n = 44), oncologic patients showed a lower 3-month titer (p < 0.001). None of the patients experienced serious adverse effects. Conclusions: The COVID-19 vaccine was safe and immunogenic in gynecologic oncology patients under chemotherapy. Serological monitoring and further vaccine shots should be considered to boost protection.

575 Heart failure as the cancer for the heart: the prognostic role of the new TNM-like classification

Aims

Heart failure (HF) is the pandemic of the third millennium accounting for the highest mortality rate among general population, second only to lung cancer. Beside heart, HF can affect lungs and peripheral organs, such as kidney, liver, brain, erythropoiesis, leading to multiorgan dysfunction. This is similar to spread of cancer. We proposed a new staging system of HF, named HLM, analogous to TNM classification used in oncology, which refers to heart damage (H), instead of T for tumour, lung involvement (L), instead of N for lymphnodes, and malfunction (M) of peripheral organs, instead of M for metastasis. The aim of this study was a comparison of HLM score with NYHA classes, ACC/AHA stages and HF classification by left ventricular ejection fraction (LVEF), to assess the most accurate prognosis tool for HF patients, in terms of a composite endpoint of all-cause death and hospitalization.

Methods and results

We performed a multicentre observational, prospective study of consecutive patients admitted for HF, or at risk for HF. All parameters for heart, lungs, and peripheral organ function were collected and examined. Each patient was classified according to HLM, NYHA, ACC/AHA scores and LVEF, at hospital admission and at discharge. The composite endpoint was all-cause death and rehospitalization; the secondary endpoints were all-cause death, cardiac death, and rehospitalization. Patients were followed up at 12 months. We enrolled 2152 patients. Among those, 1720 patients completed the 12-months follow-up. Comparing HLM with other nosologies, the area under the ROC curve (AUC) was greater for HLM score than NYHA, ACC/AHA and LVEF scores regarding the composite endpoint (HLM = 0.644; NYHA = 0.580; ACC/AHA = 0.572; EF = 0.572) and all-cause death (HLM = 0.713; NYHA = 0.596; ACC/AHA = 0.594; EF = 0.565). HLM score related AUC showed statistically significant differences compared to LVEF (P &lt; 0.001), ACC-AHA (P &lt; 0.001), and NYHA (P &lt; 0.001) scores’ AUC, in terms of all-cause death and the composite of all-cause death and rehospitalization, at 12 months follow-up. Moreover, the AIC and BIC values to predict the composite of all-cause death and rehospitalization, all-cause death, cardiac death and rehospitalization rate at 12 months follow-up were always lower for HLM model compared with the others.

Conclusions

According to our results, HLM score has greater prognostic power compared to other nosologies, in terms of composite outcome, rehospitalization, and all-cause death, as well as all-cause death, cardiac death, and rehospitalization, at 12 months follow-up in HF patients. HLM score overcomes the cardiocentric view of HF and it addresses the pathophysiological mechanisms underlining heart abnormalities. Such a multivariable, holistic staging system may be used in HF patients, in order to improve clinical management and to reduce healthcare costs.

How lockdown measures, during COVID-19 pandemic, matter on psoriatic patient's perception: Study on 600 patients on biologic therapy

Background

The outbreak of coronavirus disease-2019 (COVID-19) is a public health crisis of global proportion. In psoriatic patients treated with biologic agents, evidence is not yet available on susceptibility to infection with the novel SARS-CoV-2 coronavirus, and data about the perception of COVID-19 and its impact on these patients are lacking.

Aims

The aim of this observational, spontaneous study was the evaluation of the impact of anti COVID-19 measures in “fragile population” such as patients with a chronic inflammatory disease. Thus, we evaluated the impact of perceived risk on quality of life of patients with moderate to severe psoriasis, in our outpatient clinic, and how their perceptions changed before and after the adoption of Covid-19 emergency measures following the Italian Ministerial Decree in March 9, 2020.

Methods

Using a series of questions, our study surveyed adult patients with moderate to severe psoriasis receiving treatment with biologic agents (n = 591), before and after the adoption of COVID-19 emergency measures.

Results

Most patients (97%) had been sufficiently informed by healthcare staff about COVID-19 spread. A significant change was observed in social activity reduction before and after the adoption of the measures (18% vs. 90% of patients; P < 0.0001). Similarly, patients were more likely to suspend ongoing therapy after the measures were adopted than before (87% vs. 34% of patients; P < 0.0001). Following the measures, older patients were significantly more inclined to suspend therapy and reduce social activities than younger patients.

Conclusions

Government COVID-19 emergency measures further curtailed already reduced social activities in psoriatic patients, and led to a greater inclination to suspend biologic therapy, more so in older patients, despite there being no evidence to support this suspension. These vulnerable patients may need support from clinicians in order to maintain treatment adherence.

Real-world safety and efficacy of direct oral anticoagulants in atrial fibrillation: a systematic review and meta-analysis of 605 771 patients

AIMS

To analyse the safety and efficacy of direct oral anticoagulants (DOACs) in real-world studies including atrial fibrillation (AF) patients.

METHODS AND RESULTS

Systematic review and meta-analysis of observational studies including AF patients on DOACs. Primary endpoints: any, major, gastrointestinal (GI), intracranial haemorrhage (ICH), and haemorrhagic stroke (HS). Secondary endpoints: ischaemic stroke (IS), systemic embolism (SE), myocardial infarction (MI), and all-cause of death. A set of pair-wise meta-analyses using a random effect model and a random effect network meta-analysis under a Bayesian framework were performed. Prospero registration number: CRD42019137111. We included 21 studies with 605 771 AF patients. Apixaban was associated with lower major and GI bleeding compared with Rivaroxaban [hazard ratio (HR) 2.0, 95% confidence interval (CI) 1.6-2.5] and Dabigatran (HR 1.6, 95% CI 1.3-2.1). The latter drug performed better than Rivaroxaban (HR 1.2, 95% CI 1.0-1.5). Dabigatran and Apixaban had a similar association with HS, but Apixaban performed better than Rivaroxaban (HR 1.8, 95% CI 1.1-3.0). Apixaban had a similar association with Rivaroxaban and Dabigatran for ICH, the latter drug performing better than Rivaroxaban (HR 1.3, 95% CI 1.0-1.7). Rankograms showed that Apixaban was likely to be the first-choice treatment in relation to any (65%) major (100%) and GI bleeding (100%) followed by Dabigatran (46%, 100%, 99%, respectively). Dabigatran and Apixaban had similar rank as first choice for ICH (44% and 55%) and HS (52% and 48%). DOACs showed similar association with IS/SE, MI, all-cause of death.

CONCLUSIONS

Analysis of real-world studies shows significant differences for safety among DOACs.

Dietary Compliance and Quality of Life in Celiac Disease: A Long-Term Follow-Up of Primary School Screening-Detected Patients

Background: Whether the diagnostic approach for celiac disease (CD) can really affect quality of life (QoL) and dietary compliance remains controversial. Aims: This study aimed to evaluate QoL and compliance to gluten-free diet (GFD) in adolescents/young adults diagnosed with CD through a screening strategy during childhood compared to age-matched CD patients diagnosed by case-finding and to assess whether follow-up at a referral center for CD influences compliance and QoL. Materials and Methods: Thirty-seven CD patients who were diagnosed by screening programs (SC-group) and 38 age-matched CD patients diagnosed due to symptoms (CF-group) were enrolled. Patients were asked to answer a questionnaire on QoL, dietary compliance, and follow-up care for CD. Results: Twenty-nine patients of the SC-group (median age 18.0 years, interquartile range [IQR] 16.0-19.0) and 31 patients of the CF-group (median age 17.0 years, IQR 15.5-18.0) completed the questionnaire. No significant difference relating adherence to the GFD and QoL was shown between the two groups. The majority (93.5%) of CF-group regularly had annual follow-up at a referral center compared to 37.9% of the SC-group (p < 0.001). Conclusion: The diagnostic strategy does not seem to impact QoL and dietary compliance. However, implementation of follow-up might still be necessary for patients identified through screening.

New statistical RI index allow to better track the dynamics of COVID-19 outbreak in Italy

COVID-19 pandemic in Italy displayed a spatial distribution that made the tracking of its time course quite difficult. The most relevant anomaly was the marked spatial heterogeneity of COVID-19 diffusion. Lombardia region accounted for around 60% of fatal cases (while hosting 15% of Italian population). Moreover, 86% of fatalities concentrated in four Northern Italy regions. The 'explosive' outbreak of COVID-19 in Lombardia at the very beginning of pandemic fatally biased the R-like statistics routinely used to control the disease dynamics. To (at least partially) overcome this bias, we propose a new index RI = dH/dI (daily derivative ratio of H and I, given H = Healed and I = Infected), corresponding to the ratio between healed and infected patients relative daily changes. The proposed index is less flawed than R by the uncertainty related to the estimated number of infected persons and allows to follow (and possibly forecast) epidemic dynamics in a largely model-independent way. To analyze the dynamics of the epidemic, starting from the beginning of the virus spreading-when data are insufficient to make an estimate by adopting SIR model-a "sigmoidal family with delay" logistic model was introduced. That approach allowed in estimating the epidemic peak using the few data gathered even before mid-March. Based on this analysis, the peak was correctly predicted to occur by end of April. Analytical methodology of the dynamics of the epidemic we are proposing herein aims to forecast the time and intensity of the epidemic peak (forward prediction), while allowing identifying the (more likely) beginning of the epidemic (backward prediction). In addition, we established a relationship between hospitalization in intensive care units (ICU) versus deaths daily rates by avoiding the necessity to rely on precise estimates of the infected fraction of the population The joint evolution of the above parameters over time allows for a trustworthy and unbiased estimation of the dynamics of the epidemic, allowing us to clearly detect the qualitatively different character of the 'so-called' second wave with respect to the previous epidemic peak.

Direct Oral Anticoagulants in Patients With Atrial Fibrillation and Advanced Liver Disease: An Exploratory Meta-Analysis

Direct oral anticoagulants (DOACs) have had a positive impact in preventing cardioembolic stroke in patients with atrial fibrillation (AF) who were associated with lower bleeding complications; however, data on subjects with concomitant advanced liver diseases (ALDs) are poor. This meta‐analysis evaluates bleeding and thromboembolic complications in patients with coexisting AF and ALD who were treated with DOACs or vitamin K antagonists (VKAs). We performed a meta‐analysis of randomized controlled trials and observational studies identified by the PubMed and Embase databases using a combination of the following keywords: “direct oral anticoagulants,” “advanced liver disease,” “cirrhosis,” “bleeds,” “stroke.” No time restriction was applied to the research. Two physicians reviewed data on outcome measures and assessed the quality rating. The main outcome was major bleeding, and the secondary outcomes were bleedings (all, intracranial, and gastrointestinal) and ischemic strokes. A total of four studies (one prospective, three retrospective) were identified involving 3,483 subjects with AF and ALD; of these, 1,547 were on VKAs and 1,936 on DOACs. Advanced liver disease was defined as liver cirrhosis or fibrosis‐4 score >3.25. Compared to VKA use, DOAC use was associated with reduced risk for major bleedings (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.44‐0.77; P < 0.001), total bleedings (HR, 0.45; 95% CI, 0.36‐0.55; P < 0.05), intracranial hemorrhage (HR, 0.51; 95% CI, 0.32‐0.80; P < 0.004), and gastrointestinal bleedings (HR, 0.61; 95% CI, 0.42‐0.88; P < 0.008). Efficacy analysis showed no significant difference between VKA‐ and DOAC‐treated patients (HR, 0.83; 95% CI, 0.58‐1.15; P = 0.31). Conclusion: In patients with AF and ALD, the safety and efficacy profile of DOACs did not appear to differ from those with AF without ALD.

A versatile and compact surface plasmon resonance spectrometer based on single board computer

The widespread diffusion of low-cost but high-performance hardware is enhancing the realization of scientific equipment with features at the research laboratory level. In this paper, we demonstrate hardware implementation of a surface plasmon resonance compact device with high accuracy and measurement times appropriate for many applications. Image acquisition is realized by a Raspberry Pi single board computer with a camera module, and a Python code is used to process data. A flexible optical setup can work in two different configurations, namely, the inspection mode and angle resolved measurement mode. The inspection mode is used to precisely locate the light-emitting diode interrogation beam on the sample, avoiding uneven or faulty regions. The measurement mode allows us to monitor in real time the position of the minimum reflectivity with subpixel resolution. Performance tests show a resolution in the bulk refractive index of 4.9 × 10^-6 refractive index units for 10 s acquisition time.

Experimental gingivitis in patients with and without altered passive eruption

BACKGROUND

Individuals with altered passive eruption (APE) are assumed to be more susceptible to periodontal diseases. To date, this hypothesis has not been sufficiently supported by scientific evidence. The aim of this study, using an experimental gingivitis model, was to examine the development and resolution of gingival inflammation in patients with APE when compared to patients with normal gingival anatomy.

METHODS

A localized experimental gingivitis was induced in 9 patients with APE (test group) and 9 patients without APE (control group) in the maxillary right quadrant. After 21 days, patients were instructed to resume proper home oral hygiene procedures. At baseline (day 0) and at days 7, 14, 21, 28, 35, and 42, plaque index (PlI), gingival index (GI), and gingival crevicular fluid volume (GCF) were evaluated for teeth 6 (canine), 7 (lateral incisor) and 8 (central incisor) of test and control groups.

RESULTS

During the experimental gingivitis phase (days 0 to 21), the rate of change in gingival inflammation (GI) was dramatically different between the APE test group and the control group. On day 21, at the time of maximum plaque accumulation, the GI of the APE test group was a 109% greater than the GI of the test group (P ≤ 0.001) despite similar plaque levels (P = 0.436). During the resolution of inflammation phase (days 22 to 42), the APE test group continued to exhibit statistically higher GI scores than the control group (P = 0.029).

CONCLUSION

In the presence of similar amounts of plaque deposits and plaque accumulation rates, APE patients exhibited differences in the development and resolution of plaque-induced gingival inflammation when compared to controls.

Thrombolysis in elderly stroke patients in Italy (TESPI) trial and updated meta-analysis of randomized controlled trials

BACKGROUND

Since its approval, the use of alteplase had been limited to patients aged ≤80 years.

AIMS

TESPI trial had been designed to evaluate whether alteplase treatment within 3 h in patients with acute ischemic stroke aged >80 years resulted in favorable benefit/risk ratio compared with standard care. The meta-analysis of randomized controlled trials was updated to put findings in the context of all available evidence.

METHODS

TESPI was a multicenter, open-label with blinded outcome evaluation, randomized, controlled trial. Main clinical endpoints were 90-day favorable functional outcome (mRS score 0-2) and mortality and symptomatic intracerebral hemorrhage. The trial was prematurely terminated for ethical reasons after publication of IST-3 trial which provided evidence of treatment benefit in elderly.

RESULTS

Of the planned 600 patients, 191 (88 assigned to alteplase) were enrolled. Overall, 24/83 (28.9%) alteplase patients had a favorable outcome compared to 22/95 (23.2%) controls (non-significant absolute difference of 5.7% for alteplase; OR 1.35, 95% CI 0.69-2.64, P = 0.381). Rates of death were non-significantly lower in the alteplase patients (18.1% vs. 26.5%); rates of symptomatic intracerebral hemorrhage were similar between the two groups (5.9% vs. 5.1%). The updated meta-analysis showed consistent results with prior estimates and add weights.

CONCLUSIONS

The effects of alteplase observed in this interrupted trial did not reach statistical significance, probably for the small numbers, but are consistent with and add weight to the sum total of the randomized evidence demonstrating that alteplase is beneficial in patients with acute ischemic stroke aged over 80 years, particularly if given within 3 h.

A Randomized Double-Blind, Cross-Over Trial of very Low-Calorie Diet in Overweight Migraine Patients: A Possible Role for Ketones?

Here we aimed at determining the therapeutic effect of a very low-calorie diet in overweight episodic migraine patients during a weight-loss intervention in which subjects alternated randomly between a very low-calorie ketogenic diet (VLCKD) and a very low-calorie non-ketogenic diet (VLCnKD) each for one month. In a nutritional program, 35 overweight obese migraine sufferers were allocated blindly to 1-month successive VLCKD or VLCnKD in random order (VLCKD-VLCnKD or VLCnKD-VLCD). The primary outcome measure was the reduction of migraine days each month compared to a 1-month pre-diet baseline. Secondary outcome measures were 50% responder rate for migraine days, reduction of monthly migraine attacks, abortive drug intake and body mass index (BMI) change. Only data from the intention-to-treat cohort (n = 35) will be presented. Patients who dropped out (n = 6) were considered as treatment failures. Regarding the primary outcome, during the VLCKD patients experienced -3.73 (95% CI: -5.31, -2.15) migraine days respect to VLCnKD (p < 0.0001). The 50% responder rate for migraine days was 74.28% (26/35 patients) during the VLCKD period, but only 8.57% (3/35 patients) during VLCnKD. Migraine attacks decreased by -3.02 (95% CI: -4.15, -1.88) during VLCKD respect to VLCnKD (p < 0.00001). There were no differences in the change of acute anti-migraine drug consumption (p = 0.112) and BMI (p = 0.354) between the 2 diets. A VLCKD has a preventive effect in overweight episodic migraine patients that appears within 1 month, suggesting that ketogenesis may be a useful therapeutic strategy for migraines.

Alexithymia, Metacognition, and Theory of Mind in Children and Preadolescents With Migraine Without Aura (MWoA): A Case-Control Study

Background: Some studies have demonstrated the high impact of headache and migraine in several areas of children and adolescents' life. In recent years, there has been an increase in scientific interest in the relationship between migraine and emotional regulation, investigating the possible consequences of emotional dysregulation on physical and mental health. While some studies have been carried out on the relationship between alexithymia and headache or migraine (especially in adults), no data exist on relationship between Theory of Mind (TOM), metacognition, and alexithymia in children and adolescents with migraine. Methods: Children with diagnosis of migraine without aura (MWoA) (36 males and 34 females) were compared to a healthy control group (31 males and 39 females). The age range was from 8 to 13 years in both groups. All children completed the Alexithymia Questionnaire for Children (AQC) for the assessment of alexithymia levels and the Domain of Social Perception included in the NEPSY-II to evaluate levels of TOM. Metacognitive development was evaluated with Io e La Mia Mente for children aged between 8 and 10 years and with Metacognitions Questionnaire for Children (MCQ-C) for children from 11 to 13. Results: There were no differences between children with MWoA and the control group in metacognitive abilities; only in the subscale "Negative Meta Worrying" of MCQ-C girls scored higher than boys, regardless of the group they were part of. Also, in the NEPSY-II subscale there were no statistically significant differences between the two groups. Children with MWoA scored higher in the AQC subscales "Difficulty Identifying Feelings" and "Difficulty Describing Feelings" than controls. Moreover, children between 8 and 10 years statistically differed from older children in "Difficulty Identifying Feelings" and in Total Score. Conclusion: Our data suggest that children with MWoA have no metacognitive and TOM problems compared to a healthy group. The experimental group showed higher traits of alexithymia, confirming what suggested by other studies in the literature. Future research will have to focus on migraine with aura and tension-type headache to evaluate any differences with children with MWoA.

Evaluation of the efficacy of a new low-level laser therapy home protocol in the treatment of temporomandibular joint disorder-related pain: A randomized, double-blind, placebo-controlled clinical trial

Objective: This study analyzed a home, low-level laser therapy (LLLT) protocol to manage temporomandibular joint disorders (TMJDs)-related pain.Methods: Ninety TMJD patients (12M, 78F) between 18 and 73 years were randomly subdivided into three groups. Study group (SG) received 1-week home protocol LLLT by B-cure Dental Pro: 808 nm, 5 J/min, 250 mW, 15 KHz for 8', 40 J each, over pain area, twice daily. Placebo group (PG) followed the same protocol using sham devices. Drugs group (DG) received conventional drugs. Pain was evaluated by visual analog scale (VAS) before and after therapy.Results: Statistical analysis showed that treatment was effective (F(2,83) = 4.882; p = .010). Bonferroni post-hoc analysis indicated a lower pain decrease in PG. SG registered a 34-point decrease per patient, while in PG and DG, the reduction was 25.6 and 35.3, respectively.Conclusion: The study supports the efficacy of home LLLT management of TMJD related pain.

The efficacy of interprofessional simulation in improving collaborative attitude between nursing students and residents in medicine. A study protocol for a randomised controlled trial

Background: Effective collaboration among health professionals is an essential component to ensure quality of care. Many adverse events experienced by patients are attributed to misunderstanding or poor communication among members of the interprofessional team. Interprofessional simulation is a learning strategy used to improve collaboration and facilitate communication between medical and nursing students. Aim of the work: To determine the efficacy of educational program based on high-fidelity interprofessional simulation aimed at improving collaborative attitude. Method: For this purpose, a protocol for a planned single-center, non-blinded and Randomized Controlled Trial (RCT) was chosen. The present has been approved by the Ethics Committee of Area Vasta Emilia Nord (Italy) (n° 479/2018). All students attending the second and third year of nursing and all resident physicians in anesthesia, reanimation, intensive care and pain management of University of Modena and Reggio Emilia, will be recruited and randomly assigned to two groups. The Experimental Group (EG) will receive an educational intervention based on high-fidelity simulation and the Control Group (CG) will attend a traditional classroom lesson. Jefferson Scale of Attitudes toward Physician-Nurse Collaboration (JSAPNC) and Readiness for Interprofessional Learning Scale (RIPLS) will be administered before and after the educational program in both the EG and CG. Conclusion: Expected outcomes is that, at the end of the study, nursing students and resident physicians who participated in the interprofessional simulation show significantly higher levels of interprofessional collaboration compared to the CG, evaluated through the JSAPNC.

Cardiovascular features of possible autonomous cortisol secretion in patients with adrenal incidentalomas

BACKGROUND

Low-grade incomplete post-dexamethasone cortisol suppression in patients with adrenal incidentalomas - recently defined as possible autonomous cortisol secretion (pACS) - has been associated with increased cardiovascular events and mortality. However, prospective studies documenting cardiac abnormalities in these patients are lacking.

SUBJECTS AND METHODS

Between July 2016 and September 2017, 71 consecutive patients with adrenal lesions were prospectively screened for hypercortisolism by dexamethasone suppression test (NCT 02611258). Complete anthropometric, metabolic and hormonal parameters were recorded along with full cardiac ultrasound assessment and noninvasive measurement of arterial stiffness. All patients underwent chemical-shift magnetic resonance imaging to characterize the lesions. Cardiovascular outcomes were recorded in blind.

RESULTS

According to post-dexamethasone suppression cortisol values (post-DST), 34 patients had pACS and 37 non-functioning adenomas (NFA). The two groups were similar in sex, BMI, age distribution, cardiovascular risk factors and comorbidities. Left ventricular mass index (LVMI^BSA) was increased in pACS compared to NFA (P = 0.006) and mildly correlated to the post-DST cortisol level (rho = 0.347; P = 0.004). The post-DST cortisol levels explained up to 13.7% of LVMI^BSA variance (P = 0.002). Compared to NFA, patients with pACS had a higher prevalence of diastolic dysfunction (35.1% vs 82.6%; P = 0.001) and worse arterial stiffness assessed by pulse wave velocity (P = 0.033).

CONCLUSIONS

In apparently asymptomatic patients, mild autonomous cortisol secretion can sustain early cardiac and vascular remodeling, independently of other risk factors. The morphological and functional cardiovascular changes observed in pACS underline the need for further studies to correctly define the long-term management of this relatively common condition.

Chronic inflammatory demyelinating polyneuropathy: evaluation of the vestibular system with cervical and ocular vestibular evoked myogenic potentials

PURPOSE

To investigate the possibility of vestibular damage in a group of patients suffering from chronic inflammatory demyelinating polyneuropathy (CIDP) using a diagnostic protocol including the caloric test, C-VEMPs and O-VEMPs.

METHODS

Twenty patients suffering from CIDP (mean age 58.5 years, range 33-80 years; 4 women and 16 men) were investigated. To assess any eventual audio-vestibular involvement, all patients of the study underwent pure tone audiometry, Fitzgerald-Hallpike caloric vestibular test, C-VEMPs and O-VEMPs.

RESULTS

In 11 patients with CIDP values of both O-VEMPs and C-VEMPs were either absent or abnormal. An absent trace at O-VEMPs testing occurred in 36% of these pathological patients, whereas an increase of n10 latency and amplitude was present in the other 64% .

CONCLUSIONS

A specific diagnostic protocol including the caloric test, C-VEMPS, O-VEMPS, could be useful when employed for identifying vestibular damage in CIDP patients.

Comparison of efficacy of antiplatelet treatments for patients with claudication

It was the aim of the present study to investigate if antiplatelet treatment reduced cardiovascular events in patients with claudication and/ or an ankle/brachial index (ABI) ≤0.99 and to analyse if specific antiplatelet treatment had a different impact on clinical outcome. We performed a meta-analysis of 29 clinical randomized trials on antiplatelet therapy for prevention of vascular death, myocardial infarction, and stroke in 10,735 peripheral artery disease patients. The primary end-point utilizing in the meta-analysis construction was Cardiovascular Adverse Event. We found 1,900 (17.70%) patients in trials with aspirin, 5,326 (49.61%) in those with thienopyridines, 2,324 (21.65%) in those with picotamide and 1,185 (11.04 %) in those with others antiplatelet drugs. A statistically significant effect of antiplatelet treatment [odds ratio (OR) 0.839; 95% confidence interval (CI) 0.729–0.965; p=0.014] was observed. There was a statistically significant reduction of clinical outcome [OR 0.779; 95% CI 0.639–0.950; p=0.014] in the thienopyridine-treated group vs. control. Patients treated with picotamide [OR 0.785; 95% CI 0.495–1.243; p=0.302] or aspirin [OR 0.847; 95%CI 0.653–1.097; p=0.084] showed reduced cardiovascular outcomes, that, however, did not reach significance. The study confirms that anti-platelet treatment reduces vascular outcome in claudicants. Significant reduction was observed with thienopyridines while data regarding aspirin and picotamide were inconclusive.

Effect of aspirin on renal disease progression in patients with type 2 diabetes: A multicenter, double-blind, placebo-controlled, randomized trial. The renaL disEase progression by aspirin in diabetic pAtients (LEDA) trial. Rationale and study design

Type 2 diabetes mellitus (T2DM) is one of the most common causes of chronic kidney disease and kidney failure. It has been estimated that the annual decline of estimated glomerular filtration rate (eGFR) among patients with T2DM is approximately 2.0-2.5mL min^-1 y^-1. Cyclooxygenase-dependent eicosanoids, such as 11-dehydro-thromboxane (Tx)B₂, are increased in T2DM patients and are potentially involved in the regulation of renal blood flow. Animal models showed that cyclooxygenase inhibitors, such as aspirin, are associated with improvements in renal plasma flow and eGFR values.

HYPOTHESIS

The primary end point of the LEDA trial is to evaluate the 1-year decline of eGFR in T2DM patients treated or not with low-dose aspirin (100mg/d). Secondary end points will be the rapid decline in renal function, defined as a reduction of eGFR ≥5mL/min, and change of renal function class after 1-year follow-up. Furthermore, urinary excretion 11-dehydro-TxB₂ will be related to renal function modifications.

STUDY DESIGN

A phase 3 no-profit, multicenter, double-blind, randomized intervention trial of aspirin 100mg/dvs placebo (ClinicalTrials.gov Identifier: NCT02895113). All patients will be monitored at 6 and 12months after randomization to assess drug adherence and eGFR changes.

SUMMARY

The LEDA trial is the first double-blind, placebo-controlled, randomized clinical trial aimed at examining whether aspirin treatment may beneficially affect kidney function in patients with T2DM by reducing the annual eGFR decline. The trial will also examine whether the potential renoprotective effects of aspirin might be partly due to its inhibition of TxB₂ production.

Delayed Effect of Active Pressure Treatment on Endolymphatic Hydrops

Objective: To identify eventual correlations between the effect of low-pressure treatment and endolymphatic hydrops in Ménière patients. Material and Methods: The study group consisted of subjects affected by definite Ménière disease (2015) and a severe degree of disability, who received a ventilation tube with or without a low-pressure treatment before undergoing a surgical procedure (vestibular neurectomy). After the placement of the ventilation tube, the subjects were either left alone with the tube or received 1 month of self-administered low-pressure therapy with a portable device. In all subjects, an electrocochleography (ECochG) was performed and specific questionnaires - Dizziness Handicap Inventory (DHI) and Functional Scale Level (FSL) - were completed before starting either arm of treatment, at the end of treatment, and then 3 and 6 months later. Results: All selected subjects presented with an ECochG pattern that was indicative of endolymphatic hydrops before starting either treatment. At the end of pressure treatment, 80% showed symptomatic improvement while maintaining the hydropic ECochG pattern. At the 3-month control stage, the hydropic pattern resulted normalized (<0.5) in all the improved subjects. Conclusions: Although 1 month of low-pressure treatment provided a positive symptomatological outcome, normalization of the hydropic ECochG parameters occurred only at a later time. Therefore, it is possible to assume that endolymphatic hydrops could be concurrent with a non-symptomatic stage of Ménière disease, and that the anti-hydropic effect of the low-pressure treatment, if any, would present with a certain delay after its completion.

Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry

Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the "Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry" (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68 % men; 64 ± 12 years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44 %) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child-Pugh score; hepatocellular carcinoma was present in 20 %. The prevalence of ultrasound-detected portal vein thrombosis was 17 % (n = 126); it was asymptomatic in 43 % of the cases. Notably, more than half of the portal vein thrombosis patients (n = 81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p < 0.001), Child-Pugh Class B + C (p < 0.001), hepatocellular carcinoma (p = 0.01), previous upper gastrointestinal bleeding (p = 0.030) and older age (p = 0.012) were independently associated with portal vein thrombosis. Portal vein thrombosis is a frequent complication of cirrhosis, particularly in patients with moderate-severe liver failure. The apparent undertreatment of patients with portal vein thrombosis is a matter of concern and debate, which should be addressed by planning interventional trials especially with newer oral anticoagulants. Clinicaltrials.gov identifier NCT01470547.