Climate change and health: time for action!

Issue

For several weeks, prophylactic messages against the extension of Covid-19 have saturated the public space. To protect populations, efficient measures have been rapidly put to limit the movement of people and manufactured goods. These policies have reduced global greenhouse gas emissions as well as air pollution, especially in China.

Problem

If climate change were an epidemic, we would probably have already restored it. But it results directly from the thermo-industrial activities linked to the consumption society. For Friel (Lancet, 2020), the dramatic consequences of this disturbances have to be considered as an essential health issue. She advocates for 'climate change and health alliances'.

Results

Within such alliances, health professionals have the responsibility (1) to describe the morbidity inherent in our thermo-industrial societies (2) to alert populations, and (3) to work with allies to tackle climate change and protect human populations, starting with the most vulnerable. This type of alliance is underway in the battle against air pollution, as it has been for years for fighting smoking. Alliances are intended to extend to all population health issues, with a complete decompartmentalization of minds and practices at large scale.

Lessons

Health professionals have to be mindful not to cause any harm while practicing. The health system alone produces up to 8% of global greenhouse gas in developed countries (Pichler, 2019; HCWH, 2019). There is room for action. Since 2009, the British health care system (NHS) has adopted an efficient decarbonation policy, reducing global emission from 8 to 4%, but this outstanding initiative remains an exception worldwide.

Key messages

A review of public health strategies is necessary to meet the energy, environmental and health issues, both in terms of health risks due to climate change and of decarbonation of care activities.

Health professionals have the responsibility to alert populations and to work with allies to tackle climate change and protect human populations.

Discontinuously supervised aerobic training vs. physical activity promotion in the self-management of type 2 diabetes in older Italian patients: design and methods of the 'TRIPL-A' randomized controlled trial

Background

Physical activity (PA) has health benefits for people with type 2 diabetes (T2D). Indeed, regular PA is considered an important part of any T2D management plan, yet most patients adopt a sedentary lifestyle.

Exercise referral schemes (ERS) have the potential to effectively promote physical activity among T2D patients, and their effectiveness may be enhanced when they are supported by computer-based technologies.

The ‘TRIPL-A’ study (i.e., a TRIal to promote PhysicaL Activity among patients in the young-old age affected by T2D) aims to assess if realizing an innovative ERS, based on a strong partnership among general practitioners, specialist physicians, exercise specialists, and patients, and supported by a web-based application (WBA), can effectively lead sedentary older T2D patients to adopt an active lifestyle.

Methods

A randomized controlled design will be used, and an ERS, supported by a WBA, will be implemented. 300 physically inactive T2D patients (aged 65–74 years) will be assigned to either an intervention or control arm. Control arm patients will only receive behavioral counseling on physical activity and diet, while intervention arm patients will also undergo an 18-month (3 day/week), discontinuously supervised aerobic exercise training program. The trial will be divided into six three-month periods: during first, third and fifth period, an exercise specialist will supervise the training sessions and, using the WBA, prescribe exercise progression and monitor exercise adherence. Patients will exercise on their own in the other periods.

Patients’ sedentary behaviors (primary outcome), PA level, fitness status, metabolic profile, psychological well-being, quality of life, and use of health care services (secondary outcomes) will be assessed at baseline and at 6, 12, and 18 months from baseline.

Repeated measure ANCOVAs will be used to compare the intervention and control arm with respect to each study outcome measure.

Discussion

Primary and secondary outcome results will allow us to evaluate the effectiveness of an ERS, specifically designed for the management of T2D clinical conditions and supported by a WBA, in promoting PA within Italian primary care settings.

Trial registration

This trial is retrospectively registered under the Australian New Zealand Clinical Trials Registry (reference number: ACTRN12618001164280; registered 13 July 2018).

Impact of primary cancer features on behaviour of colorectal liver metastases and survival after hepatectomy

Background

Markers of tumour biology may be valuable prognostic indicators after hepatic resection of colorectal cancer liver metastases (CRLMs). Identification of the aggressiveness of these metastases might inform the appropriateness of hepatic surgery.

Methods

Patients undergoing liver resection for CRLMs between January 2001 and July 2013 in four tertiary hospitals were reviewed. A mathematical model to estimate CRLM doubling times was constructed for patients with metachronous metastases. Tumour doubling time was investigated in relation to the features of colorectal cancer, including KRAS status. The hazard rate for recurrence and death following hepatectomy was explored through the Kernel‐smoothed estimator.

Results

Of 1063 patients undergoing liver resection for CRLMs, 361 with metachronous metastases undergoing single‐stage hepatectomy were analysed. The mean doubling time in patients not receiving chemotherapy between surgery for colorectal cancer and CRLM was 71·4 days. Tumour doubling time was shorter in patients with more advanced primary tumour stages, with mutant KRAS and in those who did not receive chemotherapy. For fast‐growing CRLMs (doubling time less than 48 days), the risk of recurrence was highest within the first postoperative year, and was about 7 per cent per month.

Conclusion

Primary features of colorectal cancer were linked to aggressiveness of CRLMs as measured by doubling time.

Abstract P4-13-03: Variations in breast reconstruction rate in France according to patient and site characteristics: A nationwide retrospective study of nearly 20,000 patients

Background: Breast reconstruction (BR) for women who undergo mastectomy for cancer offers psychological benefits and improves quality of life. However its use remains limited, especially for women over 65 years, with a large degree of international variation. The aim of this study was to find out factors influencing the surgical decision of BR in France where cancer related healthcare costs are fully reimbursed.

Methods: We used the French medico-administrative database to identify all primary mastectomies for breast carcinoma in 2012 and studied the rate of immediate (IR) or delayed breast reconstruction (DR) up to December 2015.

Variations of BR rates were evaluated according to

- patient age, social deprivation index,

- profile of the hospital where the mastectomy was performed: type of hospital (cancer center, CC; university hospitals, UH; private, PrivH; or public, PubH), and hospital activity (surgical acts for breast cancer in 2012);

- disparities across administrative regions in terms of number of CC or UH, number of plastic surgeons, gynecologist-obstetrician surgeons and general surgeons in the region.

A hierarchical three-level logistic regression was used with SAS GLIMMIX to model the probability of BR taking into account clustering of observations (patients in hospitals, hospitals in regions). Splines were used to explore the functional form of the relationship between continuous variables and BR rate. Akaike information criterion was used for model selection.

Results: Among the 19,466 women who had a mastectomy in 2012, 5,328 (27.4%) subsequently had a BR: IR for 13.7% and DR for 13.7%. The BR rate significantly varied with age (p<0.0001), resulting in a much smaller BR rate in patients older than 65 compared to younger (7.5% vs 42.1%, p<0.0001). In case of BR, IR was more frequent than DR in older patients (66% of BR), whereas both were equally balanced before 65. BR rates decreased with increasing social deprivation index (from 32.7% to 21.5%, from the first to the fourth quartile of the distribution). BR rates significantly varied according to hospital type (35.0% in CC, 29.8% in UH, 25.9% in PrivH and 18.6% in PubH). BR rates were significantly lower in small activity hospital (varying from 13.4% in hospital with <=50 annual breast surgery to 35.1% in hospitals with >500), especially in older patients (varying from 3.1% to 10.3%). We also observed important heterogeneity of BR rates across administrative regions, but these variations were not explained by the number of CC or UH, the number of plastic surgeons, the number of gynecologist-obstetrician surgeons or the number of general surgeons in the region. In multivariate analysis, BR rate was significantly associated with age (p<0.0001), social deprivation index (p<0.0001), type of hospital (p=0.002) and hospital activity (p<0.0001), with persistent heterogeneity across administrative regions.

Conclusions: We identified substantial variations in BR rates across the French hospitals. Controlling for possible confounders, older patients have less breast reconstruction. This apparent heterogeneity can be part of women choice, however it suggests unequal access to high quality procedures for older women with breast cancer.

Citation Format: Regis C, Le J, Le Teuff G, Cucchi M, Boulanger L, Hannebicque K, Giard S, Chauvet M-P, Quemenr J, Ledeley M-C. Variations in breast reconstruction rate in France according to patient and site characteristics: A nationwide retrospective study of nearly 20,000 patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-03.

Average treatment effect of hepatic resection versus locoregional therapies for hepatocellular carcinoma

Background

When comparing the efficacy of surgical and non-surgical therapies for hepatocellular carcinoma (HCC), a major limitation is the causal inference problem. This concerns the impossibility of seeing both outcomes of two different treatments for the same individual at the same time because one is inevitably missing. This aspect can be addressed methodologically by estimating the so-called average treatment effect (ATE).

Methods

To estimate the ATE of hepatic resection over locoregional therapies for HCC, data from patients treated in two tertiary care settings between August 2000 and December 2014 were used to obtain counterfactual outcomes using an inverse probability weight survival adjustment.

Results

A total of 1585 patients were enrolled: 815 underwent hepatic resection, 337 radiofrequency ablation (RFA) and 433 transarterial chemoembolization (TACE). The option of operating on all patients who had tumour ablation returned an ATE of +9·8 months for resection (effect size 0·111; adjusted P = 0·064). The option of operating on all patients who had TACE returned an ATE of +27·9 months (effect size 0·383; adjusted P < 0·001). The ATE of surgery was negligible in patients undergoing ablation for very early HCCs (effect size 0·027; adjusted P = 0·627), independently of albumin–bilirubin (ALBI) grade; or in patients with ALBI liver function grade 2 (effect size 0·083; adjusted P = 0·213), independently of tumour stage. In all other instances, the ATE of surgery was notably greater. Operating on patients who had TACE with multinodular HCC beyond the Milan criteria resulted in a mild ATE (effect size 0·140; adjusted P = 0·037).

Conclusion

ATE estimation suggests that hepatic resection is a better treatment option than ablation and TACE in patients with HCC.

Induction therapy with alemtuzumab (campath) in combined liver-kidney transplantation: University of Bologna experience

BACKGROUND

Combined liver-kidney transplantation (LKT) is considered to be a safe procedure, but the appropriate immunosuppressive regimen is unclear.

PATIENTS AND METHODS

Between January 1997 and October 2011, 55 patients were listed for LKT: 45 (82%) were effectively transplanted, 5 (9.2%) died whereon here the waiting list, 3 (5.5%) temporarily out of waiting list, 1 (1.8%) was on waiting list and 1 (1.8%) refused LKT. Five LKTs treated with cyclosporine (CyA) were excluded from the analysis. Mean recipient age was 50.32 ± 10.32 years (14-65), MELD score at time of LKT was 19.22 ± 4.69 (8-29), mean waiting list time was 8.14 ± 9.50 months (0.1-35.76), and follow-up, 4.09 ± 3.02 years (0.01-10.41). Main indications for LKT were policystic disease (n = 15; 37%), hepatitis virus C (HCV)-related cirrhosis (n = 9; 22%) metabolic disease (n = 5; 13%), hepatitis virus B (HBV) cirrhosis (n = 4; 10%), alcoholic cirrhosis (n = 4; 10%), and cholestatic disease (n = 3; 8%). Immunosuppressive regimen was based on tacrolimus and steroids in 40 cases with induction therapy with alemtuzumab (Campath; 0.3 mg/kg) in 13 of 40 instances cases administered on day 0 and day 7.

RESULTS

Postoperative mortality was 2.5%. Acute cellular rejection episodes were biopsy-proven in 2 (5%) cases, post-LKT infections developed in 17 cases (42.5%), and de novo cancer developed in 3 (7.5%) cases. Similar 5-year overall survivals were obtained irrespective of the LKT indication: 100% in cholestatic and alcoholic cirrhosis patients, 86% in policystic disease, 75% in metabolic disease and HBV patients, and 66% in HCV cirrhosis. Overall survivals for the alemtuzumab vs without-induction therapy groups at 1, 3, and 5-years were 100%, 85.7%, and 85.7% vs 76%, 76%, and 70%, respectively (P = .04).

CONCLUSION

An immunosuppressive regimen based on tacrolimus and steroids with induction therapy with alemtuzumab was safe, with excellent long-term results for combined LKT.

The Italian Register of Biological Prostheses

BACKGROUND

A wide variety of meshes are available for surgical treatment of abdominal wall defects. These meshes are constructed with different materials with different biological properties.

METHODS

A prospective database was instituted (January 2009-December 2010) to register biological prostheses (BPs) implanted in Italy.

RESULTS

A total of 193 cases were registered. The mean age of the patients was 53.1 years (SD ±7.4). The ratio of males to females was 1.3 to 1. The mean body mass index was 28.2 (SD ±4.1). The breakdown of American Society of Anesthesiologists (ASA) scores was as follows: ASA I, 35.7%; ASA II, 27.5%; ASA III, 31.6%, and ASA IV, 5.2%. For ventral-incisional hernias, the mean duration of surgery was 101.1 min (SD ±25.3), while for inguinal-femoral hernias it was 49.2 min (SD ±19.1). The rate of urgent procedures was 36.7%. The surgical field was clean in 57.4% of cases, clean-contaminated in 21.3%, contaminated in 12.3% and dirty in 9%. Techniques used for inguinal-femoral hernias were as follows: Lichtenstein in 66.7%, plug and mesh in 3.8%, transabdominal-preperitoneal in 25.7% and intraperitoneal onlay mesh in 3.8%. The following prostheses were used: swine intestinal submucosa in 54.9%, porcine dermal collagen in 39.9% and bovine pericardium in 5.2%. In 45.1% of cases the prostheses were cross-linked. Techniques used for ventral-incisional hernias were as follows: onlay in 3.6%, inlay in 5.5%, sublay in 62.7% and underlay via laparoscopy in 28.2%. The mean overlap was 4.1 cm (SD ±1.2). No intestinal anastomosis was necessary in 65.3% of cases; however, small/large bowel resection and anastomoses were necessary in 22.3 and 12.4% of cases, respectively. Intraoperative blood transfusion was necessary in 10.4% of procedures. The skin was completely closed in 84% of procedures. At the 1-month follow-up, there were no complications in 54.4% of cases. Among the cases with complications, 10 patients (5.8%) experienced recurrence, and the postoperative readmission rate was 12.9%. The average visual analog scale (VAS) score for pain was 2.9 (SD ±1.2) at rest. At the 1-year follow-up, there were no complications in 96.4% of cases. Two patients experienced recurrence, and the postoperative readmission rate was 3.6%. The average VAS score for pain was 1.8 (SD ±0.8) at rest.

CONCLUSIONS

This register shows that BPs are highly versatile and can be used in either open or laparoscopic surgery in all kinds of patients and in contaminated surgical fields. However, due to the very good outcomes of synthetic meshes and the high costs of BPs, the latter should only be used in selected cases.

The p53 codon 72 (Arg72Pro) polymorphism is associated with the degree of insulin resistance in type 2 diabetic subjects: a cross-sectional study

Tumor suppressor protein p53 has been demonstrated to regulate genes involved in energy generating metabolic pathways and apoptosis. To date, a new field of research is the involvement of TP53 codon 72 (Arg72Pro) polymorphism in the diabetic disease. The aim of this study was to evaluate whether the genotype and the related genetic models of Arg72Pro polymorphism of TP53 (rs1042522) are associated with insulin resistance and its metabolic parameters in diabetic and non-diabetic subjects. We examined 335 type 2 diabetic patients (65.5 ± 8.4 years) and 367 non-diabetic subjects (60.5 ± 11.7 years). The results were validated in a validation sample consisting of 199 type 2 diabetic (66.2 ± 8.5 years) and 224 non-diabetic subjects (61.2 ± 12.7 years). In the study sample, the analysis of covariance, adjusted for the effects of age, gender and BMI, showed a significant genotype-diabetes effect on insulin resistance evaluated by HOMA-IR (p = 0.038). This result was mediated by variations in fasting plasma insulin (p = 0.027), as no TP53 genotype-diabetes effects were detected for fasting plasma glucose. In particular, in the diabetic subjects, Pro/Pro genotype was associated with lower values of HOMA-IR with respect to Arg/Arg (p = 0.013) and Arg/Pro (p = 0.006) carriers. No difference in HOMA-IR between diabetic and non-diabetic Pro/Pro carriers was found. Significant recessive model-diabetes interaction effects on fasting insulin and HOMA-IR adjusted for age, sex and BMI were found (p = 0.007 and p = 0.029, respectively). Linear regression analyses, based on the assumption of an additive genetic model adjusted for age, sex and BMI, highlight p53 gene-diabetes interaction effects on fasting insulin (β = -1.27; p = 0.001) and HOMA-IR (β = -0.22; p = 0.006). The results of statistical analyses on fasting insulin and HOMA-IR were all confirmed in the validation sample. Furthermore, the logistic regression models confirmed that the effect of HOMA-IR levels on diabetes was moderated by Pro/Pro genotype in both study and validation samples (OR = 0.29, p = 0.034, 95 % CI = 0.09-0.91, OR = 0.37, p = 0.035, 95 % CI = 0.15-0.93, respectively). Our findings suggest that p53 codon 72 (Arg72Pro) polymorphism influences insulin resistance in type 2 diabetic patients independently of body mass.

Comparison of the Treatment with Paroxetine and Reboxetine in Panic Disorder: A Randomized, Single-Blind Study

INTRODUCTION

Serotonergic agents have greater effectiveness than noradrenergic ones in the treatment of Panic Disorder (PD). However preliminary studies suggested that reboxetine might be effective in the treatment of PD. We compared the effectiveness and tolerability of reboxetine and paroxetine in the treatment of PD.

METHODS

Sixty-eight patients with PD were assigned to treatment groups in a single-blind, randomized design. Each patient was assessed at day 0 and 90 by the Panic Associated Symptoms Scale (PASS), the Sheehan Disability Scale (SDS) and the Fear Questionnaire (FQ). Side effects were also recorded.

RESULTS

Reduction of PASS scores was significantly greater in the paroxetine group than in the reboxetine one. Vice versa we did not find any significant differences for other outcome measures. Sexual dysfunction and weight gain were significantly less frequent in the reboxetine group.

CONCLUSIONS

The results showed a greater effect of paroxetine on panic attacks than reboxetine, while no differences for anticipatory anxiety and avoidance were found, suggesting a different role of noradrenaline and serotonin in the treatment of PD.

Combined modality treatment with a weekly brief chemotherapy (ACOP-B) followed by locoregional radiotherapy in localized-stage intermediate- to high-grade non-Hodgkin's lymphoma

BACKGROUND

A cooperative study was undertaken to evaluate the efficacy and toxicity of a very brief course of chemotherapy followed by locoregional radiotherapy in patients with localized-stage intermediate- to high-grade non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHOD

From January 1988 to November 1994, 84 patients with localized stages IA and IIA intermediate- to high-grade NHL underwent a combined modality treatment. All patients underwent a six-week chemotherapy regimen, ACOP-B (doxorubicin 50 mg/sqm and cyclophosphamide 350 mg/sqm on weeks 1, 3, 5; vincristine 1.4 mg/sqm and bleomycin 10 mg/sqm on weeks 2, 4, 6; prednisone 50 mg p.o. daily throughout the first two weeks and thereafter every other day), followed by locoregional radiotherapy (36 Gy).

RESULTS

The median age was 58 years, with 35% older than 65 years; 52 patients had stage I and 32 stage II; 39 patients had extranodal +/- nodal involvement, and 4 had testicular involvement. Treatment was well tolerated, with only 38% suffering from mild mucositis and no toxic deaths. Seventy-nine patients achieved CR after ACOP-B and 83 at the end of the program. With a median follow-up of four years, relapse-free survival was 79% with 15 relapses (93% disseminated). Two patients with testis lymphoma had CNS relapses. Overall survival was 90% at four years.

CONCLUSION

This combined program is effective and probably curative in localized stage intermediate- to high-grade NHL, with low toxicity, also in elderly people. Patients with NHL of the testis, as primary site, require CNS prophylaxis due to the high likelihood of CNS relapse.

[Donath-Landsteiner hemolytic anemia. Physiopathological, diagnostic and therapeutic aspects]

Donath-Landsteiner hemolytic anemia accounts for one third of all immunologic hemolytic syndromes in pediatric patients. Diagnosis is suggested by results of the direct Coombs test which is positive with anti-C3d, evidence of erythrophagocytosis on admission blood smears, and results of the Donath-Landsteiner test. Anti-P specificity should be routinely looked for. Management, required once the diagnosis is established, is symptomatic. Warmed red blood cell concentrates should be used for blood transfusions. Exposure to cold should be avoided. Use of maintenance corticosteroid therapy is no longer acceptable.

Effect of platelet-activating factor and its specific receptor antagonist on glomerular permeability to proteins in isolated perfused rat kidney

Platelet-activating factor (PAF) is a lipid mediator of inflammation believed to play a role in glomerulonephritis by favoring immune complex formation and modulating the subsequent inflammatory reaction. Some evidence indicates that PAF may also be one of the mediators of proteinuria. Previous work suggested that PAF can increase glomerular permeability to proteins, activating platelets and inflammatory cells to release cationic proteins. In the present study, we addressed the possibility that PAF might directly increase glomerular permeability to proteins independently of platelets and inflammatory cells. We used a preparation of isolated rat kidney perfused with an artificial cell-free medium. After stabilization and two 10-minute control clearance periods, kidneys perfused in a closed circuit were exposed to PAF (2 nM or 10 nM final concentration) or 2-lyso-PAF (10 nM final concentration) or vehicle for 40 minutes. Glomerular filtration rate, measured as creatinine clearance, and renal vascular resistance did not significantly change when either PAF (2 nM or 10 nM) or 2-lyso-PAF, or vehicle were added to the perfusion fluid. Unlike vehicle or 2-lyso-PAF, addition of PAF at the final concentration of 2 and 10 nM to the perfusate produced a dose-dependent progressive increase in urinary protein excretion. PAF-induced proteinuria was prevented by L-652,731, a specific PAF receptor antagonist, suggesting that PAF's effect on glomerular permeability to proteins is likely to be related to its biologic activity. Several pharmacologic manipulations addressed to the potential mediators of PAF effect on glomerular permeability to proteins would exclude that the effect of PAF on isolated perfused kidney is mediated by cyclooxygenase or lipoxygenase products, or is the result of oxygen-free radical generation. The possibility that PAF enhances glomerular permeability to proteins by changing the glomerular barrier electrostatic properties was explored using polyethylene-imine. Electron microscopy examination revealed no difference in the distribution of electron-dense deposits along the glomerular basement membrane in kidneys exposed to 10 nM PAF or vehicle.