Implementing the Verbal and Electronic Handover in General and Psychiatric Nursing Using the Introduction, Situation, Background, Assessment, and Recommendation Framework: A Systematic Review

Background

Patient handover (handoff in America) is the transfer of information and accountability among nurses assigned to patient care. Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is currently the most popular framework for framing handovers. However, research shows that incomplete handovers and information transfers among healthcare providers and nurses exist and are responsible for adverse patient events.

Materials and Methods

The current systematic review aims to view contemporary literature on handover, especially but not exclusively in psychiatric settings, and to extract current conditions from Electronic Patient Records (EPRs) using the ISBAR framework. A total of fifty-five scientific papers were selected to support the scoping review. Eligibility criteria included structured research to analyze outcomes, completed by reviewing policy papers and professional organization guidelines on I/SBAR handovers.

Results

Our systematic review shows that the application of ISBAR increases interprofessional communication skills and confidence and the quality of the transfer of clinical information about patients, resulting in increased patient safety and quality of care.

Conclusions

Implementing the knowledge and application of structured patient handover will respond to current recommendations for service improvement and quality of care. Furthermore, nurses who use ISBAR also reported its benefits as they feel they can deliver what is required for patient care information in a structured, fast, and efficient way. A further increase in the efficacy of handovers is reported by using EPR.

Huntington's disease prevalence in Asia: a systematic review and meta-analysis

INTRODUCTION

The epidemiological studies on Huntington's disease (HD) in the Asian population suggest that prevalence rates are significantly lower than in the Western population. We conducted a systematic review of epidemiological studies of HD in Asia to compare the level of impact of the disease on the Asian population.

METHODS

Original articles and reviews about HD prevalence in the Asian population were found through databases such as Embase, Medline, and PsychInfo. Relevant articles were analysed by scrutinising of references, including specific key words. A meta-analysis was performed on prevalence rates to find the degree of similarities with I2. Point Prevalence was measured as the number of people affected by HD in a 100,000 population and expressed as Point Prevalence (PP)= Number of people affected/100,000 with 95% Confidence Intervals (CI95).

RESULTS

Results from the random-effect meta-analysis show the highest point prevalence of HD in the Middle East with PP=4.0 (CI95=2.90-5.30). The lowest point prevalence was found in the Chinese population with PP=0.25 (CI95=0.16-0.36). Europe remains at a high prevalence compared to Asian countries with PP=1.00 (CI95=0.82-1.19). The overall prevalence in Asia is PP=0.70 (CI95=0.44-1.0).

CONCLUSION

Our study reveals that HD disease affects the population of Asia to a lesser extent than in Europe. The plausible explanation for differences in prevalence is that in some countries, the affected individuals will not self-refer to HD screening for fear of social stigma, negative influence in marriage, and lack of genetic and neurological testing. Another explanation is that studies that used genetic testing exclusively were able to identify the CAG repeats, subgroups of CAG repeat A1 & A2, and haplogroup C, which has less predisposition to high HD prevalence in Asians compared to the Caucasian population.

Biopsychosocial theories of borderline personality disorder: a meta-synthesis and psychopathological network model from a systematic review

BACKGROUND

Borderline personality disorder (BPD) is a complex mental health condition with an altered image of self, impulsive acts, suicidal ideation, and self-harm requiring intensive care in outpatient and inpatient settings. The biopsychosocial (BPS) model adopted in the current study extracted the outcomes of a research about the diagnosis, causes and treatment of BPD. A network model helped link these results in a unitary model with applications in clinical practice for assessment and intervention.

METHODS

We conducted a literature review of current studies on the BPS causes of BPD and merged them through meta-synthesis. The results were then elaborated with a psychopathological network analysis for linking the extracted factors with higher degree of centrality in the network and merged in a final comprehensive model.

RESULTS

The theoretical modelisation suggests that BPS causes merged with the diathesis-stress model persistently activate the cortico-limbic system and prefrontal cortex, induce neuroinflammation, and stimulate suicidal and parasuicidal ideation and behaviours modulated by psychological and pharmacological treatment.

CONCLUSIONS

Using a network model in psychopathology allowed the merging of data about BPD into a unitary and dynamic pattern which can be helpful to direct assessments and interventions in clinical practice.

Factitious disorder comorbid with borderline personality disorder and dysthymia: from medically unexplained physical symptoms to functional neurological disorder

INTRODUCTION

In this study, we introduce the concept of comorbidity between factitious disorder (FD), borderline personality disorder (BPD), dysthymia (DY), medically unexplained physical symptoms (MUPS) and functional neurological disorder (FND) characterising patients who may tend to exaggerate physical or psychiatric symptoms of presentation to a general or psychiatric hospital with a constellation of signs that do not receive confirmation from further clinical and instrumental assessments. The similarities between these syndromes and the constant presence of borderline personality in the psychopathology make it the possible link between all these syndromes.

MATERIALS AND METHODS

The authors captured the typical appearance and characterisation of FD-BPD-DY-MUPS-FND (Com-1) syndrome in adult and non-forensic acute psychiatric hospitals in the United Kingdom (UK) and adjacent liaison psychiatric teams through case vignettes. Each case vignette merged similar clinical cases and was cross-analysed using information from various mental health and medical professionals and bridging primary and secondary carers' records.

RESULTS

The findings suggest striking similarities between the syndromes making borderline personality the bridge pathology for FD, MUPS and FND. The complexity of the diagnosis of these cases is discussed in the study, together with prototypical presentations.

CONCLUSIONS

Improving the management of these often-occurring diseases requires multidisciplinary coordination across psychiatry, general care, neurology and surgery departments.

Comorbidity Between Factitious and Borderline Personality Disorder: A Narrative Analysis

BACKGROUND

Factitious disorder (FD) illnesses have increased recently, primarily due to comorbidity with borderline personality disorder (BPD). Psychiatrists, hospital doctors, and general practitioners are interested in and concerned about patients with comorbid FD-BPD.

SUBJECTS AND METHODS

We used a qualitative analysis of prototypical narratives collected as vignettes by merging individual contributions, case histories, naturalistic observations, and data from mental health practitioners into specific descriptions. Our study used a phenomenological and narrative method to illustrate the contents and behaviours in FD-BPD comorbidity.

RESULTS

Fourteen case vignettes were created from our case studies. These categories included knowledge of symptoms and medical terms, dramatisation, symptoms ambiguity, unexplainable deterioration of symptoms, symptom inventiveness, craving for painkillers, conflicts with health carers, hospital migration, piling of medication and search for invasive diagnostic procedures.

CONCLUSIONS

The combined use of narrative analysis and naturalistic observation has helped identify a unique comorbid condition of FD-BPD, which is not yet clearly described in its behavioural components by the international literature. The current study presents novel findings into a condition becoming progressively popular in psychiatric and medical settings.

The Prevalence of Huntington Disease in Asia Highlights Needs in Clinical, Genetic and Instrumental Diagnosis: A Systematic Review and Meta-Analysis

The epidemiological analyses on Huntington's Disease (HD) indicate that prevalence rates in the Asian population are significantly lower than in the Western population. The research aims to explore the prevalence of HD in Asian countries. Point Prevalence (PP) is equivalent to the number of people affected by HD per 100,000 inhabitants. A meta-analysis was completed on prevalence rates to extract the global PP and the degree of heterogeneity of I² to confirm or discard similarities of PP of HD in Asian countries. Nine major studies were identified. A random-effect meta-analysis showed PP prevalence in Asia of 0.52 (CI95%=0.36-0.75). There is also a significant difference between PP of Asia vs Europe (p<0.001), confirming a lower prevalence of HD in Asian countries except for Pakistan, Punjab, and Gujarat, which have the higher prevalence in Asia. Our study reveals that Huntington's Disease affects Asia's population with variable figures globally to a lesser extent than Europe, although some Middle East countries present the highest global prevalence. The possible reasons are explored. The following are take-home messages derived from the current study. HD in Asia shows a point prevalence lower than European Countries, probably due to differences in clinical, instrumental and diagnostic procedures. Stigma linked to HD and its impact on family and society can reduce people's mindfulness to undergo targeted assessment. Further research is required to estimate the true prevalence of HD worldwide and promote better diagnostic screening using genetic testing. The true prevalence of HD is probably underestimated, and there is the need to provide education in the general population about this condition and testing.

P11.43.B The impact of neutrophils-to-lymphocytes ratio on survival in patients affected by brain metastases and treated with Gamma Knife Radiosurgery

Background

The Neutrophil-to-Lymphocyte ratio (NLR) is a biomarker for host systemic inflammation. Elevated NLR may result from neutrophilia, lymphopenia or both and is associated with poor prognosis and treatment responses in various malignant tumors, such as breast, gastric, colorectal and lung cancer. It was found that in patients treated with GK-SRS for brain metastases (BM) from non-small cell lung cancer (NSCLC), median survival was significantly longer in patients with NLR &lt; 5 at the time of radiosurgery and after treatment (within 1 month from SRS). High percentage of neutrophils, low percentage of lymphocytes and elevated platelet-to-lymphocyte ratio were predictive of poor OS in patients with brain metastases. Further evidences are needed to support and better define these findings.

Material and Methods

We retrospectively examined 111 consecutive patients with BMs from NSCLC (95 patients) and melanoma (16 patients) treated with GK-SRS. A total of 695 lesions were treated (median lesion number per patient 6; range 1-18), the median volume was 0.108 cc (range 0.004-33.44 cc).

NLR was calculated using N/L, where N and L, respectively, refer to peripheral blood neutrophils (N) and lymphocyte (L) counts at the timepoint nearest to the SRS treatment. Kaplan-Meier analysis described the survival time according to NLR. Univariable and multivariable Cox regression analyses were used to confirm the impact of NLR on overall survival.

Results

Median (IQR) age at diagnosis of brain metastases was 64 yrs (55-70), median (IQR) NLR was 6.7 (1.3-32), and median (IQR) overall survival was 13.5 months (1-42). At univariable Cox-regression analyses, lower NLR was associated with improved overall survival (HR: 1.05; p=0.004). Total number of lymphocytes, neutrophils and monocytes were not associated with improved overall survival (all p&gt;0.1). At multivariable Cox regression analyses, after adjusting for patient age, sex and the use of DEX therapy, NLR represented an independent predictor of overall survival (HR: 1.06; p=0.003).

Conclusion

NLR represents an independent prognostic factor in patients affected by BMs from NSCLC and melanoma. Inflammation and immunity may play a critical role in these patients. Further analysis examining more specific neutrophils or lymphocytes subsets may increase our understanding of cancer etiology and progression.

Should mindfulness-based cognitive therapy be used for psychosis? A systematic review of the literature and meta-analysis

BACKGROUND

In England, psychosis incidence is 31.7×100,000 persons per year. Mindfulness-based interventions for psychosis (MBIp) might reduce its symptoms; however, the research outcomes on its effect size (ES) vary considerably. This project aims to ascertain the existing evidence.

METHODS

Eight publications from a pool of over 260 studies were extracted and analysed at meta-analysis for ES as satisfying the inclusion criteria.

RESULTS

MBIp has a moderate ES (r=0.34; p<.001) on psychosis with a 95% confidence interval (CI) of 0.26-0.42 (small to high).

DISCUSSION

MBIp improves psychosis symptoms. However, the studies analysed show heterogeneity in ES. Hence only conditional recommendations can be made for MBIp.

COVID-19, loneliness, social isolation and risk of dementia in older people: a systematic review and meta-analysis of the relevant literature

OBJECTIVES

During the COVID-19 lockdown, social isolation and feelings of loneliness (SIFL) in the older population have increased, and they can be a risk of dementia, especially in vulnerable older people. The current research is a systematic review meta-analysis of the studies that approach the risk of dementia in older people with SIFL.

METHODS

The ten studies selected for meta-analysis utilised an opportunistic sample of older people in the community from age 50 to above with no dementia and enrolment. The populations consisted of cohorts of an average of 8,239 people, followed for a mean period of 6.41 years. Random effect meta-analysis summarised the Cox Proportional Hazard Ratios and Relative Risks of the individual studies.

RESULTS

Results of the meta-analysis show that in older people, the risk of developing dementia because of the impact of prolonged loneliness and social isolation is about 49 to 60% [HR/HR = 1.49; CI₉₅=1.37-1.61] higher than in those who are not lonely and socially isolated.

CONCLUSION

The biopsychosocial model of dementia supports the need for more integrated social programs and reduced risks for the older persons who, during the COVID-19 lockdown, have suffered from deprivation of support from primary carers and restricted social interactions.KeypointsDuring the COVID-19 lockdown, social isolation and feelings of loneliness in the general population have increased.Older persons are more vulnerable to social isolation and feelings of loneliness (SIFL).SIFL in older people has been associated with an increased risk of dementia.The current study's findings suggest the need to improve healthcare policies to reduce the impact of SIFL in older persons during the COVID-19 pandemic.

The assessment of interprofessional practice in mental health nursing with ethnographic observation and social network analysis: a confirmatory and bibliometric network study using VOSviewer

INTRODUCTION

Despite numerous techniques for assessing mental health nursing abilities and accomplishments, most practice in psychiatric wards is based on observable clinical behaviours and actions. VOSviewer can perform bibliographic network analysis (BNA), extracting all central topics that identify core behavioural skills in mental health nursing and essential elements in interprofessional practice (IPP).

AIM

The current study captures the critical concepts in mental health nursing assessment by performing a BNA of essential topics on ethnography, social network analysis, and interprofessional care.

METHODS

A qualitative BNA with a VOSviewer extracted relevant topics from a total of 542 articles obtained from Microsoft API. A subsequent confirmatory quantitative analysis with NVIVO weighed the percentages of the relevant issues and words extracted by the VOSviewer. Boolean keywords searched were 'ethnography,' 'social network analysis,' 'interprofessional', 'psychiatry' and 'hospital'.

RESULTS

Major themes identified in ethnography, IPP, and social network analysis for nursing assessment were those of 'communication' (11.63%), 'whole' (9.29%), 'knowledge' (7.66%), 'person' (7.52%), 'activity' (6.31%) and 'collaboration' (6.10%).

DISCUSSION

The current study has proven the value of BNA in extracting relevant topics in target literature. VOSviewer captured salient issues in mental health nursing assessment, including ethnographic observations, social network analysis, and IPP. The results confirmed the value of focusing on collaborative care, reciprocity, knowledge management, and information sharing in assessing mental health nursing performances.

Pregabalin abuse and dependence during insomnia and protocol for short-term withdrawal management with diazepam: examples from case reports

Introduction:

Pregabalin (PGN) is an anxiolytic, analgesic, antiepileptic, and hypnotic medication. There are concerns about its abuse in the community for managing chronic insomnia and other risks when assumed in overdose or combination with other abuse substances. PGN is classified as a controlled medication. While its discontinuation is accompanied by rebound insomnia and other neurological symptoms, cross-tapering PGN with short-term diazepam (DZ) during inpatient admissions has shown promising results in dealing with PGN withdrawal symptoms accompanied by rebound insomnia.

Material and Methods:

We report three cases that began abusing their prescribed PGN. During hospital admission, our teams used a protocol for cross-tapering PGN with DZ to reduce withdrawal symptoms. Other sedative medications are suspended while alcohol is not allowed if patients are on leave from the hospital. Standardized scales for assessment were clinical global impression scale-severity (CGI-S), generalized anxiety disorder scale (GAD-7), and insomnia severity index (ISI).

Results:

The cross-tapering PGN with DZ showed similar clinical outcomes with reduced withdrawal symptoms and rebound insomnia during two weeks of cross-tapering. Eventually, DZ, too, is stopped in the hospital to avoid another dependence syndrome.

Conclusion:

As emerging in the current study, PGN has strong addictive effects in people who have insomnia and is mostly abused for its hypnotic or sleep-inducing properties when other medications have failed. As applied in the current study, DZ can manage PGN withdrawal symptoms with rebound insomnia while cross-tapering. DZ is then discontinued.

Social Network Analysis of Alzheimer's Teams: A Clinical Review and Applications in Psychiatry to Explore Interprofessional Care

INTRODUCTION

Understanding the social networks of professionals in psychiatric hospitals and communities working with persons with Alzheimer's (PWA) disease helps tackle the flow of knowledge in patient care and the centrality of team members in providing information and advice to colleagues.

OBJECTIVES

To use Social Network Analysis (SNA) to confirm or reject the hypothesis that psychiatric professionals have equal status in sharing information and advice on the care of PWA and have reciprocal ties in a social network.

METHODS

The sample consisting of 50 psychiatric professionals working in geriatric psychiatry in the UK completed an anonymous online survey asking them to select the professional categories of the colleagues in the interprofessional team who are most frequently approached when providing or receiving advice about patient care and gathering patient information. SNA is both a descriptive qualitative analysis and a quantitative method that investigates the degree of the prestige of professionals in their working network and the reciprocity of their ties with other team members.

FINDINGS

The social network graphs and numerical outcomes showed that interprofessional teams in geriatric psychiatry have health carers who play central roles in providing the whole team with the knowledge necessary for patient care; these are primarily senior professionals in nursing and medical roles. However, the study reported that only 13% of professionals had reciprocal ties within teams.

CONCLUSION

The current research findings show that the impact of psychiatric health carers in interprofessional teams caring for PWA is not evenly distributed. Those with apparently higher seniority and experience are more frequently consulted; however, other more peripheral figures can be equally valuable in integrated care.

Psychiatric training during covid-19 pandemic benefits from integrated practice in interprofessional teams and ecological momentary e-assessment

OBJECTIVES

During the current covid-19 pandemic, healthcare students had to stop their face-to-face attendance at medical colleges and universities. This condition has resulted in a change in how learning and assessment of psychiatric and interprofessional practice occur. The pandemic has also increased clinical mentors' need to follow their mentees' educational progress via virtual technology, including smartphone-based educational apps. The aim of the study is to propose a model in psychiatric and medical interprofessional practice e-assessment.

METHODS

In this study, 228 undergraduate healthcare students underwent a training period in interprofessional practice across specialties being assessed by Ecological Momentary e-Assessment (EMeA), and consisting of ongoing or before/after Interprofessional Education (IPE) learning evaluations with the assistance of an IPE-app linked to online surveys. The Goodness of Fit Test Chi-square and t-test statistics analyzed the data.

RESULTS

Surveys during, at entry and exit points in IPE captured increased percentages of learners, specifically, reporting high patient satisfaction with interprofessional teams (c2=22.54; p<.01), learners experiencing very good quality of care when delivered by interprofessional teams (c2=30.02; p<.01) assessed by distance technology, and learners selecting less frequently peers from the same clinical background when support was needed in patient care (c2=19.84; p<.01).

CONCLUSIONS

Contextual assessment (in the real-time and real-world scenario) of IPE learning moments via EMeA shows its value and applicability during the current covid-19 pandemic when the assessment of learning cannot occur face-to-face between learners and teachers. All healthcare students, including those on psychiatric rotations, could log in their progress, self-reflective assessments, and responses to coordinated care in interprofessional teams, without needing direct contact with their clinical tutors, and while treating patients with mental and physical illnesses, also including covid-19 positive patients.

POS1341 TOCILIZUMAB FOR THE TREATMENT OF IMMUNE-RELATED ADVERSE EVENTS TO IMMUNE CHECKPOINT INHIBITORS: A CASE SERIES

Background:

Immune checkpoint inhibitors (ICI) are pharmacological agents effectively used in the treatment of several malignant tumors. The hyperactivation of the immune system induced by ICI may trigger an inflammatory involvement of healthy tissues, a phenomenon referred to as immune-related adverse event (irAE). No clinical trials are available to guide the management of irAEs. Observational data suggest tocilizumab might be effective in severe cases of irAEs, but data are scant. The possibility of continuing ICI treatment despite the development of irAE and the subsequent initiation of tocilizumab has never been evaluated.

Objectives:

To evaluate the efficacy and safety of tocilizumab, as monotherapy or alongside the continuation of ICI treatment, in the management of irAEs.

Methods:

We retrospectively identified patients who developed irAEs and were referred to our specialized Clinic between May 2018 and December 2020. Among these patients, we identified those who had been treated with tocilizumab and collected information about their oncologic history and outcome, ICI therapy and irAEs.

Results:

Thirty-nine patients were referred to our outpatient Clinic following the development of irAEs. Five of them were treated with tocilizumab. Disease and demographic features are reported in Table 1. At irAEs onset all patients were treated with glucocorticoids. A steroid-sparing agent was started to permit an adequate prednisone tapering without the irAE relapsing. Before tocilizumab start, two patients were treated with methotrexate monotherapy, one with anakinra monotherapy, and one with methotrexate and anakinra combination therapy. A significant therapeutic effect was confirmed in all patients and no significant adverse reactions were reported. ICI therapy was permanently discontinued in two patients. In the other three cases, cancer immunotherapy was safely continued alongside tocilizumab without further irAEs occurring. Only one patient experienced tumor progression two years after ICI suspension and subsequently died despite the improvement of his myocardial inflammatory involvement.

Conclusion:

In our cohort, tocilizumab proved to be an effective and safe therapy for the management of irAEs.

Our case series also supports the possibility of maintaining ICI while introducing tocilizumab for irAE treatment. This combined approach might represent a suitable therapeutic option to guarantee a significant anti-inflammatory activity without losing the oncologic response.

References:

[1]Kostine M et al, Ann Rheum Dis, 2021;80:36-48.

Table 1.

Clinical characteristics of patients who developed irAEs secondary to ICI therapy and who received tocilizumab.

Patient 1Patient 2Patient 3Patient 4Patient 5Age at irAE onset (years)6952725775SexMaleMaleMaleFemaleFemaleNeoplastic histologyNSCLCNSCLCNSCLCNSCLCPleural mesotheliomaICI treatmentNivolumabNivolumabPembrolizumabPembrolizumabPembrolizumabirAEMyocarditisArthritisCutaneous vasculitisArthritisArthritisLarge vessel vasculitis ICI discontinuation due to irAEYesNoNoNoYes PDN initial dose (mg daily)5037.5252537.5 DMARD therapy *T16: ANKT20: TCZT26: TCZ + MMFT5: MTXT6: MTX + ANKT11: MTX + TCZT3: MTXT11: MTX + TCZT4: MTXT6: MTX + TCZT3: TCZ irAE outcomeImprovementLow disease activityLow disease activityRemissionRemissionFollow-up length (months)Since oncologic diagnosisSince TCZ start50104725572255268Oncological outcomeProgressive disease and deathComplete responseStable diseaseStable diseaseComplete response

* Treatment chronology is referred to as a T followed by the number of months since irAE onset.

ANK, anakinra; ICI, immune checkpoint inhibitor; irAE, immune-related adverse events; DMARD, disease modifying anti-rheumatic drug; MTX, methotrexate; NSCLC, non-small cell lung cancer; PDN, prednisone; TCZ, tocilizumab.

Disclosure of Interests:

Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Nicola Farina: None declared, Alessandro Tomelleri: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, MSD, Pfizer, Giulio Cavalli Speakers bureau: SOBI, Chiara Lazzari: None declared, Roberto Ferrara: None declared, Marina Garassino: None declared, Vanesa Gregorc: None declared, Lorenzo Dagna Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, SOBI, Celgene Janssen, MSD, MP

Case reports of first psychiatric presentations during CoViD-19 pandemic

CoViD-19 pandemic has created a global concern in the whole population. The psychiatric and social impact of the viral infection is recorded differently by the community. However, more vulnerable individuals with negative psychiatric history are presenting to mental health hospitals for admission, assessment and treatment due to abnormal reactions to CoViD-19 pandemic. The current study reports six clinical cases of first psychiatric presentation that were characterised by sudden onset of symptoms, manic and psychotic symptoms, adverse response to stress, psychomotor agitation and behaviours out of character. The presentation was short-lived and responded to typical antipsychotics and antidepressants. The posed diagnoses were acute and transient psychotic disorder and acute stress reaction.

Psychiatry in Time of COVID-19 Pandemic

COVID-19 or Coronavirus pandemic has generated a very serious and grave global concern regarding the health of every person in the whole world. Besides, due to the rapid diffusion of the viral infection, there are already alarms on how to deal with the psychiatric aspects of COVID-19 pandemic in persons with an established diagnosis of psychiatric disorders, staff, and those in self-isolation. What is the influence of COVID-19 on mental health? The current study will review the psychiatric implications of COVID-19 pandemic on the general population, the bearing of social isolation, the prevention behaviours, and clinical cases of people who required psychiatric admission to hospital due to the emotional impact of COVID-19 social circumstances.

FRI0478 SEROLOGICAL AUTOIMMUNITY IN PATIENTS WITH RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS: CORRELATION WITH SEVERITY AND TREATMENT

Background:

Immune checkpoint inhibitors (ICIs) can induce a variety of rheumatic immune-related adverse events (Rh-irAEs). Few data are available on which features can predict the occurrence of long-lasting and severe Rh-irAE

Objectives:

To describe the serological features associated with long-lasting and severe Rh-irAE.

Methods:

ICI-treated patients were identified. Patients’ demographics, histotype of cancer, ICI, time interval from ICI start to Rh-irAE onset, characteristics of Rh-irAEs were recorded. Patients were tested for autoimmunity panel (a-IP): RF, ACPA, ANA, anti-SSA, anti-SSB, anti-Sm, anti-RNP, anti-Jo1, ANCA, ASMA, AMA, anti-dsDNA, anti-tireoglobulin, anti-tireoperoxidas, IgM and IgG anti-cardiolipin and anti-β2 glicoprotein I, crioglobulins. All patients were treated with steroids (CS). In case of flare of the Rh-irAE, csDMARDs or bDMARDs were started. Associations between a-IP status and need for DMARD start was evaluated. Non parametric tests were used.

Results:

22 Rh-irAE were included (see Table 1). Median age at Rh-irAE onset was 70 (50 – 84) years. 2 patients (9%) had a personal history of psoriasis. Median time from ICI start to Rh-irAE onset was 5 (1 – 26) months. 11 patients (50%) developed 1 Rh-irAE, 10 (45.4%) 2 and 1 (4.5%) 3. The most frequent were arthritis (A, 14, 63.6%), cutaneous vasculitis (CV, 5, 22.7%), PMR-like (4, 18.2%), polymyositis (PM, 4, 18.2%), myocarditis (Myo, 3, 13.6%) and dermatomyositis (DM, 2, 9.1%). Median initial prednisone dose was 25 (10 – 75) mg daily. In 14 patients (63.6%) a csDMARD was started upon steroids tapering. 9 patients (41%) were treated with methotrexate (MTX, 4, 18.2%) with hydroxychloroquine (HCQ, 2, 9.1%) with mycophenolate (MMF, 2, 9.1%) with colchicine (colch). 6 patients were treated with bDMARDs. 3 patients (50%) were treated with anakinra (ANK), 2 (33.3%) with IVIG and 3 (50%) with tocilizumab (TCZ). 13 patients (59.1%) were a-IP+. A significantly higher percentage of a-IP+ patients received DMARDs (11, 84.6%) compared to a-IP- patients (2, 22.2%,p = 0.0007). A significantly higher percentage of a-IP+ patients were treated with bDMARDs (5, 38.5%) compared to a-IP- patients (0, 0%, p = 0.05). We analysed whether in csDMARD-treated patients the need for bDMARDs was higher in a-IP+ but we found no statistical significance (45.4% vs 0%, p = 0.487).

Table 1.

Characteristics and treatment of Rh-irAEs patients.

Age, SexCancerICIOnset (monts)Rhem-irAETreatmentResponseICI stopAutoAb169, MLung, adenoNivo3MyoCS, MMF, ANK, TCZLDAY, DpANCA270, MBladderAtezo1A,CS, MTXRemY, TNeg379, MLung SCCPembro1ACSRemNoRo52452, MLung, LCCNivo6A, CVCS, MTX, ANK, TCZLDANoANA 1:160 s582, MLung, LCCPembro3PMRCSRemNoNeg656, MMelanomaPembro26PMR, PMCS, MTXDeathY, DANA 1:160 s, pANCA772, MLung, adenoPembro5A, CVCS, MTX, TCZHDA (TCZ)Y, TANA 1:160 s874, MLung, adenoPembro1PMRCS, MTXLDANoANA 1:160 s975, MLung, adenoPembro1PM, MyoCSRemY, DNeg1075, MLung, adenoNivo9ACSRemNoNeg1168, FLung, adenoAtezo18ACS, MTXLDAY, TNeg1235, MMelanomaNivo2ACS, MTXLDANoANA 1:640 s1379, MLung, SCCNivo15A, PMRCS, MTX, ANKDeath (NR)Y, DRo521477, MLung, adenoPembro8DMCS, HCQ, IVIGLDAY, DANA 1:320 PCNA1567, MLung, adenoNivo13ACS, MTXLDANoASMA1674, MLung, SCCAtezo1A, CVCS, HCQ, ColchLDAY, DNeg1770, MLung, adenoNivo5A, CVCSRemY, DNeg1870, MLung, adenoPembro15ACSLDANoASMA1969, MLung, adenoNivo5DMCS, HCQ, MMF, IVIG, TacroMDAY, TANA 1:!60 s2084, MH&N, SCCNivo3PhCSRemY, DNeg2167, MLung, adenoDurva5A, PM, MyoCSLDAY, DANA 1:160 h2250, FLung, LCCNivo1A, CVCS, HCQRemY, DNeg

Conclusion:

The presence of serological autoimmunity might be helpful in detecting patients with Rh-irAEs refractory to steroid therapy.

Disclosure of Interests:

Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Alessandro Tomelleri: None declared, Roberto Ferrara: None declared, Chiara Lazzari: None declared, Giacomo De Luca Speakers bureau: SOBI, Novartis, Celgene, Pfizer, MSD, Diego Signorelli: None declared, Alessandra Bulotta: None declared, Vanesa Gregorc: None declared, Marina Garassino: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI

Length of Admission Into Psychiatric Hospitals According to Diagnoses

Introduction

In recent years, psychiatry in the United Kingdom has faced an important challenge due to the shortage of beds for patients with increased lengths of stay. Available resources have been saturated due to the reduced capability of psychiatric hospitals to provide spaces for patients needing access to psychiatric care.

Objectives

This research provides a figure of length of stay linked to psychiatric pathology at discharge.

Aim

To establish the length of admission of psychiatric patients.

Methods

The sample comprised 137 discharges from a general adult psychiatric ward distributed over the first 8 months of 2016. Results were analyzed by descriptive statistics and meta-analysis.

Results

Overall, longer periods of admission were recorded for psychoses and shorter periods for adjustment disorders. Psychoses had a median length of admission of 28 days (range = 3–374); borderline personality disorders, 10 days (range = 1–249); mood disorders, 14 days (range = 2–74); drug addictions, 6 days (range = 1–222); and adjustment disorders, 5 days (range = 1–55). Meta-analysis (Fig. 1) provided a confidence interval estimate for the whole model of 24.314 days (95% CI = 13.00–35.621) with P < .001. Meta-analysis results also provided t2 = 101.061, Cochrane's Q (df = 4) = 14.327, I2 = 72.081, with P = .006.

Conclusions

Psychoses are conditions that require longer admissions, whereas adjustment disorders are more transient pathologies. Borderline personality disorder is somewhat of a hybrid condition. Overall, patients remain in hospital for about a month (24 days).

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychiatric Risk Assessment Scale (PRAS)

Introduction

The aim of psychiatry is the prediction of risks.

Objectives

Creation of the Psychiatric Risk Assessment Scale (PRAS) (Table 1).

Aims

To assess psychiatric inpatients for risk to self and others.

Methods

The PRAS comprises 20 risk items that rate five probabilities of occurrence: 0% (nil), 25% (low), 50% (moderate), 75% (high) and 100% (severe). Cut-off score indicates “moderate” risk = 50. The mathematical formulas for the risks are as follows:

– severity of risk (SR) = average for the whole table multiplied by %;

– number of significant risk events (NSRE) = count of risks scored from 50% to 100% divided by 20 (items);

– probability of occurrence of risks (POR = NSRE%);

– range probability of death (RPD) = range score of (overdose + suicide + reckless activities)%.

Two raters assessed independently n = 8 patients. Kappa inter-rater statistic was used by dichotomous results (above-below cut-off score).

Results

Inter-rater Kappa = 0.60 indicates a moderate inter-rater agreement. In the sample, only 2 patients scored above the cut-off score of 50, indicating a level of moderate-to-severe risk. For the other patients, the average SR = 36%, indicating low-to-moderate risk.

Conclusions

PRAS is constantly used to assess the likelihood that the care provided to patients admitted to hospital is sufficient or whether major remedial action is required.

Table 1

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Ecological Momentary Assessments and Interventions in Alzheimer's Caregiving

BACKGROUND

Caregivers of persons with Alzheimer's Disease (AD) often experience feelings of lack of support and information from specialists when operating in real scenarios, inclusive of old-age psychiatric wards, care homes, community, and patient's home.

OBJECTIVE

AD caregivers can provide narrative about what issues need to be addressed in Ecological Momentary Assessment (EMA) to capture real-time and real-scenario needs in AD caregiving, and Ecological Momentary Interventions (EMI) as online e-learning to assist in areas of concerns.

METHOD

Twelve focus group discussions took place with AD caregivers for a total of 62 people interviewed. Once major themes in surveys and learning were identified by using discourse analysis, AD caregivers expressed the likelihood that these themes (where 0 meant "nil" and 1 meant "completely") would address their focal needs in caregiving and topics in learning. Z scores for proportions and Cohen's d effect size were calculated for each item reporting the averaged scores.

RESULTS

AD caregivers indicated that the major areas of concern that could benefit from an EMA/EMI online platform were: support (d=3.08), collaboration (d=1.85), medication review (d=1.21), dealing with grief and mourning, and time (d=0.97). Moreover, they identified personal resources available to provide help to colleagues: support (d=1.34), information (d=0.97), collaboration (d=2.06), hospital admission (d=3.08), and hospital discharge (d=5.50).

CONCLUSION

Focus groups and narratives can be the initial stage in creating a dedicated AD app supporting EMA/EMI in AD care.

Social Network Analysis of Dementia Wards in Psychiatric Hospitals to Explore the Advancement of Personhood in Patients with Alzheimer's Disease

Background:

Little is known on investigating how healthcare teams in dementia wards act for promoting personhood in persons with Alzheimer’s disease (PWA).

Objective:

The current research aimed to identify the social networks of dementia health carers promoting the personhood of PWA in acute or long-term dementia wards in public and private psychiatric hospitals.

Methods:

We used a mixed-method research approach. Ethnographic observations and two-mode Social Network Analysis (SNA) captured the role and social networks of healthcare professionals promoting PWA personhood, using SocNetv version 2.4. The social network graphs illustrated how professionals participated in PWA care by computing the degree of centrality (%DC) for each professional; higher values indicated more statistical significance of a professional role compared to others in the provision of personhood care. The categories of personhood were biological, individual, and sociologic. Nurses, doctors, ward managers, hospital managers, clinical psychologists, occupational therapists, care coordinators, physiotherapists, healthcare assistants, and family members were observed if they were promoting PWA personhood.

Results:

The highest %DC in SNA in biological personhood was held by the ward nurses (36%), followed by the ward doctors (20%) and ward managers (20%). All professional roles were involved in 16% of cases in the promotion of individual personhood, while the hospital managers had the highest %DC (33%) followed by the ward managers and nurses (27%) in the sociologic personhood.

Conclusion:

All professional roles were deemed to promote PWA personhood in dementia wards, although some limitation exists according to the context of the assessment.

Probability analysis of compassion: Enhancing compassionate care in psychiatry through mirror neurons

Introduction

The probability that psychiatric care becomes compassionate is higher when individual subjects, groups or organizations utilize mirror neurons to attune with the emotional world of their clients.

Objectives

To create an algorithm for compassionate care in mental health by attunement of mirror neurons.

Aims

To predict the probability of the occurrence of sympathetic care in mental health.

Methods

Naturalistic observation of health care organizations identified the major nodes-agents of the organizational-neural network leading to a compassionate care (events A): individual, group, organization and society. Negative influences on compassionate care are (events B) subjective and collective acts.

Results

The probability that compassionate care occurs as a result of a single mediator's action was only 0.167 (16%). The probability that compassion results from training mirror neurons were as follows:.Multiple event probability formula:

– probability of event A that occurs P(A) = 0.667 (66%) [positive subject + group + organization + society)];

– probability of event B that occurs P(B) = 0.333 [negative individual and group];

– probability that both the events occur P(A∩B) = P(A) × P(B) = 0.222 [inhibitory influence];

– probability that either of event occurs P(A∪B) = P(A) + P(B) − P(A∩B) = 0.778.

Conclusions

The probability of organizational compassion (PA) is high when all the agents interact. As compassion is reinforced by mirror neurons, a reduction in the number of people involved in compassionate care also means the final outcome is less likely to appear.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Ecological momentary assessment and physiological self-evaluation improve mindfulness of stress-related events during interprofessional training. Meta-analysis of a pilot study

Introduction

Self-reflective learning improves interprofessional education (IPE).

Objectives

Promoting ecological momentary assessment (EMA) of IPE via an online app. This shall allow contextual recording of students’ heart rate during and after pivotal moments of their training, thus improving mindfulness of stressful events (MSE).

Aims

To make health care students mindful of the effect of their anxiety about learning, patient safety and performance.

Methods

Thirty-two undergraduate students contextually recorded their heart rate with a pulse-oximeter before and after each learning moment: discussion of a clinical case during ward rounds (ClinDis), attending patients as an interprofessional team (BedPat) and self-reflective practice at the end of each day of training (SelfRef). Results were recorded on a dedicated app linked to an online survey. Meta-analysis with Tau squared (t2), Cochrane's Q and I2 provided the results.

Results

Meta-analysis (Fig. 1) of IPE events was significant at P = 0.003, with t2 = 16.515, Q (5d.f.) = 17.913, and I2 = 72.088%. The bedside care had the higher statistically significant heterogeneity in the before-after event with t2 = 53.275, P = 0.001, Q (5d.f.) = 10.803 and I2 = 90.74% due to an increase in heart rate after patient care (BedPatAft).

Conclusions

EMA reinforces self-reflection in IPE by making students mindful of the impact of educational emotions on team performance and patients’ quality of care.

Fig. 1

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Probability of Relapse Scale (PRORES) for psychiatric inpatients

Introduction

The prediction of relapse in presentation is central to psychiatric prognosis.

Objectives

The Probability of Relapse Scale (PRORES) (Table 1) is used by the authors to predict the likelihood of relapse by psychiatric inpatients.

Aims

To tailor better care plans by knowing the likelihood of relapse and readmission to hospital.

Methods

Eighteen inpatients were diagnosed with the ICD-10 codes. Results were reported on a 5-point probability scale from 0 (less severe) to 10 (most severe). The 5 items are: degree of severity of illness, degree of patient's insight, frequency of readmission into hospital, probability of discontinuation of therapy and probability of relapse in the 4–6 weeks after discharge.

Results

With the cut-off score at 25 (score 5 × 5 items), indicating a moderate level of relapse, we ascertained that 100% of patients with a personality disorder (usually borderline) and substance misuse relapse are readmitted shortly after discharge, compared with 85.71% of those with psychoses and 66% of those with mood disorders.

Conclusions

The PRORES can help support those patients who are at elevated risks of relapsing due to any of the major causes: discontinuation of treatment, chronicity and poor insight into their own condition (Table 1).

Table 1

Disclosure of interest

The authors have not supplied their declaration of competing interest.

How Satisfied are Patients with Interprofessional Teams? Meta-analysis of a Pilot Study

Introduction

A doctor–patient encounter is a dyadic interaction between two people, one needing help and the other providing it. However, the encounter between an interprofessional team and a patient is changing this picture.

Objectives

To measure how patient satisfaction changes when patients are treated by an interprofessional team.

Aims

Ecological momentary assessment (EMA) directly evaluates patient satisfaction when patients interact with interprofessional teams. This research is a before-and-after study of undergraduate health care students undergoing interprofessional education. Answers to questions on a 5-point Likert scale (from “Totally satisfied” to “Totally unsatisfied”) were uploaded online on a survey platform linked to a dedicated app.

Methods

Twenty-nine undergraduate students before, and eight after, interprofessional training reported their evaluation of patient satisfaction with interprofessional teams. Meta-analysis used Tau2, Cochrane's Q and I2.

Results

Meta-analysis showed a homogeneity in the answers before and after IPE training (P = 0.4) and variability of only I2 = 39%, with t2 = .006, and Q (4 df) = 4.0. To a certain degree, the study showed a drop before and after in students who report their patients being “moderately satisfied” (from 20.7% to 0%), with C.I. 95% = 4.702 (0.238–92.713) (Fig. 1).

Conclusions

This study requires further inquiry on why a moderate level of patient satisfaction declines when patients are treated by an interprofessional team.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Can Patients Differentiate When They Receive Integrated Care by Interprofessional Teams? Meta-analysis of a Pilot Study

Introduction

A patient's quality of care and satisfaction depends greatly on the perception of being treated and attended to by an integrated team of professionals.

Objectives

To make students mindful of a patient's perception of being treated by a blended interprofessional team when undergraduate students in training perform as a team in the patient's care.

Aims

To assess if patients under the care of interprofessional teams perceive, they are being treated by an integrated team.

Methods

Twenty-three undergraduate students undergoing a seven-day period of interprofessional training interviewed their common patients after each day of practice. Responses were given on a “yes-no-do not know” scale to the following question: “a team of students from different professions has just treated and cared for you. Do you think they have acted like a well-coordinated team?” Results were obtained by meta-analysis.

Results

In 60.9% of cases (Tau2 = 0.042; Q (2df) = 12.663; Het. P-value = 0.002; I2 = 84.206%) (Fig. 1), patients perceived they were treated by a well-coordinated interprofessional team; however, this perception was not affected by the days of training by the same IPE team.

Conclusions

Results suggest that other interpersonal factors might be involved in team-to-patient interactions that are barely affected by interprofessional training.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Fig. 1

What is the Prevailing Diagnosis on Admission Into Adult Psychiatric Wards? A Meta-analysis of Trends in the United Kingdom

Introduction

There seems to be an upsurge in psychiatric admissions related to female patients with borderline personality disorder. Does this reflect the actual trend?

Objectives

Study of the typology of admission into acute psychiatric wards for an adult population.

Aims

To understand the trend of actual psychopathology in the general population admitted into psychiatric wards.

Methods

A total population of 197 psychiatric admissions was diagnosed in the period March 2015–March 2016 in a general psychiatric ward in the United Kingdom. The four major diagnostic categories were: personality disorder (mostly inclusive of borderline p.d.) (n = 77), paranoid schizophrenia (n = 24), schizoaffective (n = 11) and other (n = 82). Meta-analysis of the population analyzed the results. Gender was divided into 82 male and 125 female admissions, with 181 informal admissions, 68 under Sections of the Mental Health Act, and 5 under recall from Community Treatment Order.

Results

Meta-analysis (Fig. 1) of the whole study showed a statistically significant heterogeneity in results with Tau squared t2 = 0.031, Cochrane's Q (df = 3) = 141.90, P < .001, and I2 = 97.87, a prevalence of borderline personality disorder over other diagnoses; a prevalence of female over male admissions, (t2 = .02, Q (df = 1) = 18.67, P < .001, I2 = 94.64), and a prevalence of patients admitted informally (t2 = 0.131, Q (df = 2) = 586.366, P < .001, I2 = 99.65).

Conclusions

The prevailing population of acute psychiatric wards for the general adult population is females who are admitted informally with diagnosis of borderline personality disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychopathology of the General Population Referred by Primary Care Physicians for Urgent Assessment in Psychiatric Hospitals

Objective: The aim of this study was to evaluate the type, severity and progression of psychiatric pathologies in a sample of 372 outpatients (age range 18-65 years) referred by their primary general practitioners (GPs) to an Urgent Referral Team (URT) based in a psychiatric hospital in Aberdeen, Scotland. This team offers immediate appointments (1- to 7-day delays) for rapid assessments and early interventions to the outpatients referred by their primary family doctors. Method: One-sample t-test and z statistic were used for data analysis. From the total population, a convenience sample of 40 people was selected and assessed to evaluate whether follow-up appointments after the first visit could reduce the severity of suicidal ideation, depression and anxiety in the outpatients seen by the URT. A two-sample t-test and a Wilcoxon signed-rank test were used to assess the variations in the scores during the follow-up visits. Results: We found a statistically significant prevalence of depressive disorders, comorbid with anxiety at first presentation in people who were females, white, never married, living with a partner, not studying and not in paid employment. The common presentation of borderline personality disorder and dysthymia in this population underscores its vulnerability to major socioeconomic challenges. Conclusion: The data confirmed the impact that primary care cooperation with psychiatric hospitals can have on the psychiatric system, and as a reflection, on the population's mental health and well-being. In fact, active cooperation and early diagnosis and intervention will help detect cases at risk in the general population and reduce admissions into hospitals.

[Implementing clinical pathways: some practical notes]

The traditional biomedical paradigm is no longer a guarantee of quality for health care, facing increasingly difficult challenges caused by chronic diseases and increasingly fragmented resources that current healthcare systems are dealing with. Health care organizations, considered to be the most complex enterprises of the modern era, must be able to focus on the flow of patients, integrating primary and secondary care through tools such as the Integrated Care Pathways (ICP). This brief discussion attempts to define the ICP its purposes, the elements that characterize it, its limitations and the mechanisms to push for a successful implementation. In order to highlight the elements and basic steps for the creation of an ICP, the authors have compared five different clinical pathways, whose implementation they have contributed to. The comparison was made using two grids: the first showing the essential elements for the definition of lCP and the second one with features that can facilitate their effectiveness. The conclusions of the work show what, pursuing the construction of a pathway, we must never forget: to analyze the gap between the clinical-care activities performed and the theoretical framework provided by the evidence; to see the barriers to change that may impede the implementation; to involve all actors in the system, with particular attention to patients and their associations, and finally to provide a plan for information and education, addressed to health professionals and patients as well.

HIPK2 phosphorylates ΔNp63α and promotes its degradation in response to DNA damage

Homeodomain-interacting protein kinase 2 (HIPK2) is an emerging player in cell response to genotoxic agents that senses damage intensity and contributes to the cell's choice between cell cycle arrest and apoptosis. Phosphorylation of p53 at S46, an apoptosis-specific p53 posttranslational modification, is the most characterized HIPK2 function in response to lethal doses of ultraviolet (UV), ionizing radiation or different anticancer drugs, such as cisplatin, roscovitine and doxorubicin (DOX). Indeed, like p53, HIPK2 has been shown to contribute to the effectiveness of these treatments. Interestingly, p53-independent mechanisms of HIPK2-induced apoptosis were described for UV and tumor growth factor-β treatments; however, it is unknown whether these mechanisms are relevant for the responses to anticancer drugs. Because of the importance of the so-called 'p53-independent apoptosis and drug response' in human cancer chemotherapy, we asked whether p53-independent factor(s) might be involved in HIPK2-mediated chemosensitivity. Here, we show that HIPK2 depletion by RNA interference induces resistance to different anticancer drugs even in p53-null cells, suggesting the involvement of HIPK2 targets other than p53 in response to chemotherapy. In particular, we found that HIPK2 phosphorylates and promotes proteasomal degradation of ΔNp63α, a prosurvival ΔN isoform of the p53 family member, p63. Indeed, effective cell response to different genotoxic agents was shown to require phosphorylation-induced proteasomal degradation of ΔNp63α. In DOX-treated cells, we show that HIPK2 depletion interferes with ΔNp63α degradation, and expression of a HIPK2-resistant ΔNp63α-Δ390 mutant induces chemoresistance. We identify T397 as the ΔNp63α residue phosphorylated by HIPK2, and show that the non-phosphorylatable ΔNp63α-T397A mutant is not degraded in the face of either HIPK2 overexpression or DOX treatment. These results indicate ΔNp63α as a novel target of HIPK2 in response to genotoxic drugs.

[An organizational model for safety management in health services]

The authors are reporting a practical experience about safety management of health workers through the adoption of a management model inspired to the indications of International Standard for Quality Management. In the discussion they describe the integration path between the Prevention and protection Service and the Quality Office of the University Hospital of Bologna in order to promote the accomplishment of a progressive spirit of collaboration through the implementation of a shared and common management system which helped in the adoption of appropriate Improvement solutions in order to protect the safety of the health workers.

HIPK2 is involved in cell proliferation and its suppression promotes growth arrest independently of DNA damage

INTRODUCTION/OBJECTIVES

The serine/threonine kinase homeodomain-interacting protein kinase 2 (HIPK2) is a co-regulator of an increasing number of transcription factors and cofactors involved in DNA damage response and development. We and others have cloned HIPK2 as an interactor of the p53 oncosuppressor, and have studied the role of this interaction in cell response to stress. Nevertheless, our original cloning of HIPK2 as a p53-binding protein, was aimed at discovering partners of p53 involved in cell differentiation and development, still controversial p53 functions. To this aim, we used p53 as bait in yeast two-hybrid screening of a cDNA library from mouse embryo (day 11 postcoitus) when p53 is highly expressed.

METHODS AND RESULTS

In this study, we directly explored whether HIPK2 and p53 cooperate in cell differentiation. By measuring HIPK2 expression and activity in skeletal muscle and haemopoietic differentiation, we observed inverse behaviour of HIPK2 and p53--excluding cooperation activity of these two factors in this event. However, by HIPK2 depletion experiments, we showed that drastic HIPK2 suppression promotes cell-cycle arrest by induction of the cyclin-dependent kinase inhibitor p21(Waf-1/Cip-1). HIPK2 activity is independent of DNA damage and takes place in cell-cycle-arresting conditions, such as terminal differentiation, growth factor deprivation, and G(0) resting.

CONCLUSIONS

HIPK2 was found to be involved in cell-cycle regulation dependent on p21(Waf-1/Cip-1) and independent of DNA damage.

[Prospective observational study of pneumonia in an Italian hospital]

A prospective observational study was conducted during a two-year period to evaluate the prevalence of hospitalized pneumonia in six hospital units of the Bologna S.Orsola-Malpighi hospital (Italy). The selected units were: general surgery, general medicine, internal medicine, geriatrics, respiratory physiopathology and pneumology, with a total of 205 beds and around 4,800 admissions per year. Data were collected from the clinical cards and cases of pneumonia were distinguished by origin (community-acquired or hospital-acquired according to CDC definition), individual and clinical characteristics, and aetiology. The study involved 486 cases of pneumonia: 75 hospital-acquired and 411 community-acquired (84.6%). Patients affected by hospital-acquired pneumonia were older (average age 77 years) compared to community-acquired cases (74 years) and show a more homogeneous gender distribution (males: 48.0% vs 59.4%). Hospital stays (42 vs 21 days) and mortality rates (24.0% vs 11.7%) were significantly higher in hospital-acquired pneumonia. The incidence rate of nosocomial pneumonia was 7.4 per 1000 hospitalized patients and increased to 17-23 per 1000 in the pneumology and respiratory physiopathology units. Only 16.9% of cases had an aetiological diagnosis (14.1% community-acquired; 31.8% hospital-acquired); the most common isolates were S. aureus and P. aeruginosa. The hospital-acquired cases were caused by Gram-negative bacilli more often than the community-acquired cases, and infections were more frequently polymicrobial (37.5% vs 3.4%). In order to reduce morbidity and mortality due to pneumonia it is important to implement prevention measures in the community (i.e. specific vaccination campaigns), improve clinical protocols for aetiological diagnosis in hospitalised patients and increase epidemiological surveillance of hospital-acquired infections.