Diagnostic accuracy and interobserver agreement of cholangioscopy for indeterminate biliary strictures: A single-center experience

BACKGROUND AND STUDY AIMS

Characterization of indeterminate biliary strictures (IDBS) still represents a major challenge. Digital single-operator cholangioscopy (DSOC) could potentially overcome limits of conventional biopsy and brush sampling. The aim of this study was to compare diagnostic accuracy of visual evaluation and DSOC-guided biopsies to conventional trans-papillary sampling techniques and to evaluate the inter-observer agreement (IOA) on visual diagnosis.

PATIENTS AND METHODS

All consecutive patients undergoing DSOC-guided biopsy after conventional sampling techniques for IDBS during a six-year period were retrospectively evaluated. Final diagnosis was based on histological evaluation of the surgical specimen if available or a clinical follow-up of at least 6 months. For IOA, 20-second DSOC clips were retrospectively reviewed by 6 experts and 6 trainees and classified according to the Monaco Classification.

RESULTS

Thirty-five patients underwent DSOC for IDBS in the study period; 14 patients (F = 9) with a median age of 64 years (range 53-76) met the study aim. After DSOC, strictures location was changed in three patients (additional yield of 21.4 %). Intraductal DSOC-guided biopsy were technically successful in all cases, with an adequacy of 92.8 %. No adverse events were recorded. Final diagnosis was benign disease in five cases and cholangiocarcinoma in the others. For IOA, 29 videos were evaluated with almost perfect agreement for final diagnosis (kappa 0.871; agreement 93.1, p <0.001), although overall accuracy of DSOC visual finding was 73.6 % and 64.4 % for experts and trainees, respectively.

CONCLUSIONS

DSOC could improve diagnostic accuracy for IDBS, since it showed high sensitivity for visual finding and high specificity for DSOC guided-biopsy. Visual diagnosis seems reliable for diagnosis using the Monaco Classification.

Emergence of Long-Range Angular Correlations in Low-Multiplicity Proton-Proton Collisions

This Letter presents the measurement of near-side associated per-trigger yields, denoted ridge yields, from the analysis of angular correlations of charged hadrons in proton-proton collisions at sqrt[s]=13  TeV. Long-range ridge yields are extracted for pairs of charged particles with a pseudorapidity difference of 1.4<|Δη|<1.8 and a transverse momentum of 1 Collapse

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First Measurement of the |t| Dependence of Incoherent J/ψ Photonuclear Production

The first measurement of the cross section for incoherent photonuclear production of J/ψ vector mesons as a function of the Mandelstam |t| variable is presented. The measurement was carried out with the ALICE detector at midrapidity, |y|<0.8, using ultraperipheral collisions of Pb nuclei at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. This rapidity interval corresponds to a Bjorken-x range (0.3-1.4)×10^{-3}. Cross sections are given in five |t| intervals in the range 0.04<|t|<1  GeV^{2} and compared to the predictions by different models. Models that ignore quantum fluctuations of the gluon density in the colliding hadron predict a |t| dependence of the cross section much steeper than in data. The inclusion of such fluctuations in the same models provides a better description of the data.

Sarco/endoplasmic reticulum calcium ATPase 3 (SERCA3) expression in gastrointestinal stromal tumours

Accurate characterisation of gastrointestinal stromal tumours (GIST) is important for prognosis and the choice of targeted therapies. Histologically the diagnosis relies on positive immunostaining of tumours for KIT (CD117) and DOG1. Here we report that GISTs also abundantly express the type 3 Sarco/Endoplasmic Reticulum Calcium ATPase (SERCA3). SERCA enzymes transport calcium ions from the cytosol into the endoplasmic reticulum and play an important role in regulating the intensity and the periodicity of calcium-induced cell activation. GISTs from various localisations, histological and molecular subtypes or risk categories were intensely immunopositive for SERCA3 with the exception of PDGFRA-mutated cases where expression was high or moderate. Strong SERCA3 expression was observed also in normal and hyperplastic interstitial cells of Cajal. Decreased SERCA3 expression in GIST was exceptionally observed in a zonal pattern, where CD117 staining was similarly decreased, reflecting clonal heterogeneity. In contrast to GIST, SERCA3 immunostaining of spindle cell tumours and other gastrointestinal tumours resembling GIST was negative or weak. In conclusion, SERCA3 immunohistochemistry may be useful for the diagnosis of GIST with high confidence, when used as a third marker in parallel with KIT and DOG1. Moreover, SERCA3 immunopositivity may be particularly helpful in cases with negative or weak KIT or DOG1 staining, a situation that may be encountered de novo, or during the spontaneous or therapy-induced clonal evolution of GIST.

ψ(2S) Suppression in Pb-Pb Collisions at the LHC

The production of the ψ(2S) charmonium state was measured with ALICE in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV, in the dimuon decay channel. A significant signal was observed for the first time at LHC energies down to zero transverse momentum, at forward rapidity (2.5 Collapse

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Metabolic tumor volume predicts outcome in patients with advanced stage follicular lymphoma from the RELEVANCE trial

BACKGROUND

We investigated the prognostic value of baseline positron emission tomography (PET) parameters for patients with treatment-naïve follicular lymphoma (FL) in the phase III RELEVANCE trial, comparing the immunomodulatory combination of lenalidomide and rituximab (R2) versus R-chemotherapy (R-chemo), with both regimens followed by R maintenance therapy.

PATIENTS AND METHODS

Baseline characteristics of the entire PET-evaluable population (n = 406/1032) were well balanced between treatment arms. The maximal standard uptake value (SUVmax) and the standardized maximal distance between tow lesions (SDmax) were extracted, the standardized distance between two lesions the furthest apart, were extracted. The total metabolic tumor volume (TMTV) was computed using the 41% SUVmax method.

RESULTS

With a median follow-up of 6.5 years, the 6-year progression-free survival (PFS) was 57.8%, the median TMTV was 284 cm3, SUVmax was 11.3 and SDmax was 0.32 m-1, with no significant difference between arms. High TMTV (>510 cm3) and FLIPI were associated with an inferior PFS (P = 0.013 and P = 0.006, respectively), whereas SUVmax and SDmax were not (P = 0.08 and P = 0.12, respectively). In multivariable analysis, follicular lymphoma international prognostic index (FLIPI) and TMTV remained significantly associated with PFS (P = 0.0119 and P = 0.0379, respectively). These two adverse factors combined stratified the overall population into three risk groups: patients with no risk factors (40%), with one factor (44%), or with both (16%), with a 6-year PFS of 67.7%, 54.5%, and 41.0%, respectively. No significant interaction between treatment arms and TMTV or FLIPI (P = 0.31 or P = 0.59, respectively) was observed. The high-risk group (high TMTV and FLIPI 3-5) had a similar PFS in both arms (P = 0.45) with a median PFS of 68.4% in the R-chemo arm versus 71.4% in the R2 arm.

CONCLUSIONS

Baseline TMTV is predictive of PFS, independently of FLIPI, in patients with advanced FL even in the context of antibody maintenance.

Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

The innovative dimension of the research training programmes under H2020-MSCA-ITN: a methodological approach to track, measure and analyse innovative aspects and provide policy-feedback conclusions

Innovative research training programmes funded by the European Union are essential for the forging of highly skilled researchers to tackle, via breakthrough ideas and solutions, the challenges of our society. Being able to track, measure and analyse innovative aspects of the Marie Sklodowska-Curie Actions, Innovative Training Networks under the Horizon2020 funding scheme enables the impact assessment of such programmes, while filtering best practices and the generated knowledge that could ultimately breed and create further innovation. In parallel, it helps the identification of areas for improvement, the understanding of new needs to be accommodated and the co-design and implementation of EU funding policy activities to further promote innovation and excellence for researchers across Europe and beyond. In this study, a novel methodological approach is proposed for tracking and analysing innovation, using a representative sample of projects. Basic innovation indicators are examined and considered from the existing literature and from the applicable Multi-Annual Framework Programme Horizon2020. Additional ones are defined, complemented by questionnaires/surveys findings, to capture innovative aspects for which the standard indicators do not apply. Data mining and data visualization tools are used for the collection and processing of data. Innovation Radar (IR) reports and HorizonResultsBooster services are also engaged for the cross-validation of the identified innovative aspects. The study provides first-level input for policy-feedback activities, by identifying scientific domains and EU countries that may potentially require more attention for innovation generation. It highlights domains that are front-runners and can be used as examples or best practices for under-represented domains in terms of innovative outputs. Collaboration with organisations, defined as medium/high innovators, can increase innovation generation and success in future projects. Best practices are collected to serve as references for designing impactful future training programmes. The excellence of the H2020-MSCA-ITN actions is confirmed via the generated innovations.

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Measurement of the Lifetime and Λ Separation Energy of _{Λ}^{3}H

The most precise measurements to date of the _{Λ}^{3}H lifetime τ and Λ separation energy B_{Λ} are obtained using the data sample of Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV collected by ALICE at the LHC. The _{Λ}^{3}H is reconstructed via its charged two-body mesonic decay channel (_{Λ}^{3}H→^{3}He+π^{-} and the charge-conjugate process). The measured values τ=[253±11(stat)±6(syst)]  ps and B_{Λ}=[102±63(stat)±67(syst)]  keV are compatible with predictions from effective field theories and confirm that the _{Λ}^{3}H structure is consistent with a weakly bound system.

Measurement of the J/ψ Polarization with Respect to the Event Plane in Pb-Pb Collisions at the LHC

We study the polarization of inclusive J/ψ produced in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC in the dimuon channel, via the measurement of the angular distribution of its decay products. We perform the study in the rapidity region 2.5 Collapse

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Self-care in children and young people with complex chronic conditions: a qualitative study using Emotional Text Mining

Objectives

To explore: (1) self-care behaviors in children and young people (range: 6 months-24 years) with complex chronic conditions, characterized by the diagnosis of a severe chronic condition, substantial family-identified needs, functional limitations associated with technology dependence, and intensive use of healthcare services; (2) the contribution to self-care of family members and other persons involved in the child's health and daily life context (e.g., health professionals and teachers), and (3) the principal factors that might have influenced the self-care process associated with developmental age.

Methods

A qualitative descriptive study was conducted in an Italian academic tertiary pediatric hospital between September 2020 and May 2021. Overall, 25 focus groups and 7 online interviews were conducted via videoconferencing. Textual data were analyzed using Emotional Text Mining to identify three levels of communication: the factors, the main themes (clusters), and the sub-themes.

Results

A total of 104 participants were enrolled, including 27 patients with complex chronic conditions (12 males, mean age = 11.1 ± 4.40), 33 parents, 6 siblings, 33 health professionals, and 5 teachers. Participants described the process of self-care through four main factors: "self-care", "external settings", "family", and "management". Five clusters (themes) were identified: (1) Self-care management (device; consulting); (2) Shift of agency (influencing factors; parents; school); (3) Self-care support (normal life and personal development; multidisciplinary support); (4) Daily self-care maintenance/monitoring; (5) Treatment adherence. Self-care management was mostly relevant for parents of children aged between 6 months and 3 years.

Conclusion

The self-care process varies according to the needs related to the specific developmental age and the evolution of the clinical condition over time. The contribution of the family, health professionals, and social networks is fundamental for adequate self-care. To help families manage the unstable condition of their children at home, it is necessary to strengthen support networks implement home care, and ensure continuity of care.

First Measurement of Antideuteron Number Fluctuations at Energies Available at the Large Hadron Collider

The first measurement of event-by-event antideuteron number fluctuations in high energy heavy-ion collisions is presented. The measurements are carried out at midrapidity (|η|<0.8) as a function of collision centrality in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV using the ALICE detector. A significant negative correlation between the produced antiprotons and antideuterons is observed in all collision centralities. The results are compared with a state-of-the-art coalescence calculation. While it describes the ratio of higher order cumulants of the antideuteron multiplicity distribution, it fails to describe quantitatively the magnitude of the correlation between antiproton and antideuteron production. On the other hand, thermal-statistical model calculations describe all the measured observables within uncertainties only for correlation volumes that are different with respect to those describing proton yields and a similar measurement of net-proton number fluctuations.

Enhanced Deuteron Coalescence Probability in Jets

The transverse-momentum (p_{T}) spectra and coalescence parameters B_{2} of (anti)deuterons are measured in p-p collisions at sqrt[s]=13  TeV for the first time in and out of jets. In this measurement, the direction of the leading particle with the highest p_{T} in the event (p_{T}^{lead}>5  GeV/c) is used as an approximation for the jet axis. The event is consequently divided into three azimuthal regions, and the jet signal is obtained as the difference between the toward region, that contains jet fragmentation products in addition to the underlying event (UE), and the transverse region, which is dominated by the UE. The coalescence parameter in the jet is found to be approximately a factor of 10 larger than that in the underlying event. This experimental observation is consistent with the coalescence picture and can be attributed to the smaller average phase-space distance between nucleons in the jet cone as compared with the underlying event. The results presented in this Letter are compared to predictions from a simple nucleon coalescence model, where the phase-space distributions of nucleons are generated using pythia8 with the Monash 2013 tuning, and to predictions from a deuteron production model based on ordinary nuclear reactions with parametrized energy-dependent cross sections tuned on data. The latter model is implemented in pythia8.3. Both models reproduce the observed large difference between in-jet and out-of-jet coalescence parameters, although the almost flat trend of the B_{2}^{Jet} is not reproduced by the models, which instead give a decreasing trend.

A Cell-Phone Medication Error eHealth App for Managing Safety in Chronically Ill Young Patients at Home: A Prospective Study

Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.

Participation of nurses and allied health professionals in research activities: a survey in an academic tertiary pediatric hospital

BACKGROUND

Involvement in research activities is complex in pediatric nursing and allied health professionals (AHPs). It is important to understand which individual factors are associated with it to inform policy makers in promoting research.

METHODS

A cross-sectional observational study was conducted to describe the level of participation in research activities over the last ten years of nurses and AHPs working in a tertiary pediatric hospital. A large sample of nurses and AHPs working in an Italian academic tertiary pediatric hospital completed an online self-report questionnaire between June and December 2018. Three multivariate logistic regression analyses were performed to predict participation in research projects, speaking at conferences, and writing scientific articles.

RESULTS

Overall, data from 921 health professionals were analyzed (response rate = 66%), of which about 21% (n = 196) reported participating in a research project, while 33% (n = 297) had attended a scientific conference as a speaker, and 11% (n = 94) had written at least one scientific paper. Having a Master or a Regional Advanced Course, working as an AHP or a ward manager, as well as regularly reading scientific journals and participation in an internal hospital research group or attendance in a specific course about research in the hospital, significantly predicted participation in research projects, speaking at conferences and writing scientific papers. It is important to foster research interest and competencies among health professionals to improve participation in research projects, speaking at conferences, and writing scientific papers.

CONCLUSIONS

Overall, we found a good level of attendance at conferences as speakers (33%), a moderate level of participation in research (21%), and low levels for writing scientific papers (11%). Our study highlighted the need to support participation in research activities among nurses and AHPs. Policymakers should identify strategies to promote research among nurses and AHPs, such as protected rewarded time for research, specific education, strengthened collaboration with academics, and financial support. Moreover, hospital managers should promote the development of research culture among health professionals, to improve their research competencies and evidence-based practice.

Analysis of microbiome in GISTs: looking for different players in tumorigenesis and novel therapeutic options

Preclinical forms of gastrointestinal stromal tumor (GIST), small asymptomatic lesions, called microGIST, are detected in approximately 30% of the general population. Gastrointestinal stromal tumor driver mutation can be already detected in microGISTs, even if they do not progress into malignant cancer; these mutations are necessary, but insufficient events to foster tumor progression. Here we profiled the tissue microbiota of 60 gastrointestinal specimens in three different patient cohorts—micro, low‐risk, and high‐risk or metastatic GIST—exploring the compositional structure, predicted function, and microbial networks, with the aim of providing a complete overview of microbial ecology in GIST and its preclinical form. Comparing microGISTs and GISTs, both weighted and unweighted UniFrac and Bray–Curtis dissimilarities showed significant community‐level separation between them and a pronounced difference in Proteobacteria, Firmicutes, and Bacteroidota was observed. Through the LEfSe tool, potential microbial biomarkers associated with a specific type of lesion were identified. In particular, GIST samples were significantly enriched in the phylum Proteobacteria compared to microGISTs. Several pathways involved in sugar metabolism were also highlighted in GISTs; this was expected as cancer usually displays high aerobic glycolysis in place of oxidative phosphorylation and rise of glucose flux to promote anabolic request. Our results highlight that specific differences do exist in the tissue microbiome community between GIST and benign lesions and that microbiome restructuration can drive the carcinogenesis process.

Exploring the Open COVID Pledge in the fight against COVID‐19: a semantic analysis of the Manifesto, the pledgors and the featured patents

Coronavirus disease‐19 (COVID‐19) has stimulated urgent innovative responses to tackle the current crisis and unveil new trajectories enabling recovery as early as possible. In the quest for solutions to the pandemic, organizations have been forced to join efforts with an unprecedented number of different stakeholders, including competitors, rising new appropriation‐related challenges. To ease these issues and facilitate collaborative efforts, some initiatives have come into being to encourage the release of Intellectual Property (IP) rights to unlock new possibilities from their use and possibly foster the collective innovation process. The Open COVID Pledge (OCP) stands out as the most visible project that has gained momentum at the international level, as it has increasingly involved well‐known top‐patenting companies, willing to publicly commit to making their IP relevant to COVID‐19 freely available. Drawing from all the available information (the World Wide Web, the participating companies' press releases and official websites, and the documents of pledged patents), we propose a research design, applying a semantic method to allow an augmented understanding of the main characteristics of this pledge. Our findings point out that the OCP has got a great media resonance on the overall web, also thanks to the commitment of large top‐patenting pledgors; results also show that while the official communications of the participant companies resemble very much the general OCP Manifesto of providing free access to their patent portfolio, the semantic analysis of the pledged patents unveils details on available technologies that mostly refer to the real‐time search and analysis of information and devices for the detection of the diffusion of the virus. Overall, this analysis contributes to providing contextual information on the available IP, towards the desired direction of putting the pledge to work and have an impact on follow‐on innovation, which represents the underlying rationale of the initiative in the fight against COVID‐19.

BRIDGE -1 TRIAL: BReak Interval Delayed surgery for Gastrointestinal Extraperitoneal rectal cancer, a multicentric phase III randomized trial

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The lengthening of the surgical interval has a positive impact on pathological complete response (pCR) rate.

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Lengthening the surgical interval from the end of preoperative chemoradiation is not detrimental to survival outcomes in locally advanced rectal cancer.

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Prospective validation of the impact of surgical interval lengthening on complete response and survival outcomes in a randomized trial.

Design

Methods

Conclusions

THUNDER 2: THeragnostic Utilities for Neoplastic DisEases of the Rectum by MRI guided radiotherapy

Background

Neoadjuvant chemoradiation therapy (nCRT) is the standard treatment modality in locally advanced rectal cancer (LARC). Since response to radiotherapy (RT) is dose dependent in rectal cancer, dose escalation may lead to higher complete response rates. The possibility to predict patients who will achieve complete response (CR) is fundamental. Recently, an early tumour regression index (ERI) was introduced to predict pathological CR (pCR) after nCRT in LARC patients.

The primary endpoints will be the increase of CR rate and the evaluation of feasibility of delta radiomics-based predictive MRI guided Radiotherapy (MRgRT) model.

Methods

Patients affected by LARC cT2-3, N0-2 or cT4 for anal sphincter involvement N0-2a, M0 without high risk features will be enrolled in the trial. Neoadjuvant CRT will be administered using MRgRT. The initial RT treatment will consist in delivering 55 Gy in 25 fractions on Gross Tumor Volume (GTV) plus the corresponding mesorectum and 45 Gy in 25 fractions on the drainage nodes. Chemotherapy with 5-fluoracil (5-FU) or oral capecitabine will be administered continuously.

A 0.35 Tesla MRI will be acquired at simulation and every day during MRgRT. At fraction 10, ERI will be calculated: if ERI will be inferior than 13.1, the patient will continue the original treatment; if ERI will be higher than 13.1 the treatment plan will be reoptimized, intensifying the dose to the residual tumor at the 11^th fraction to reach 60.1 Gy.

At the end of nCRT instrumental examinations are to be performed in order to restage patients. In case of stable disease or progression, the patient will undergo surgery. In case of major or complete clinical response, conservative approaches may be chosen. Patients will be followed up to evaluate toxicity and quality of life.

The number of cases to be enrolled will be 63: all the patients will be treated at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome.

Discussion

This clinical trial investigates the impact of RT dose escalation in poor responder LARC patients identified using ERI, with the aim of increasing the probability of CR and consequently an organ preservation benefit in this group of patients.

Trial registration

ClinicalTrials.gov Identifier: NCT04815694 (25/03/2021).

Peroral-cholangioscopy to plan surgery for protruding biliary lesions: report of four cases

Intraductal biliary lesions can involve the main hepatic confluence. Assessment of the extension of pedunculated biliary lesions during per-oral cholangioscopy (POCS) can optimize and personalize the surgical strategy. Four consecutive cases of pedunculated biliary lesions were analysed. Cholangioscopy was performed with a disposable single-operator cholangioscope. POSC was successfully performed in four patients (three female, mean age 50 years), showing involvement of the main biliary confluence in three of four pedunculated biliary lesions; direct biopsy sampling was diagnostic in two of three cases (in one patient, biopsy were not performed due to the smooth appearance of the intrabiliary lesion). No adverse events occurred after POCS. Surgery required excision of the main hepatic confluence in two of three cases (one patient was not resectable). POCS can diagnose intrabiliary extension of protruding biliary lesions, providing important information to plan the surgical intervention.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases: analysis of short- and long-term outcomes

Background

Peritoneal metastases carry the worst prognosis among all sites of colorectal cancer (CRC) metastases. In recent years, the advent of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival for selected patients with limited peritoneal involvement. We report the evolution of CRS and HIPEC for colorectal peritoneal metastases at a tertiary referral center over a 10-year period.

Methods

Patients with colorectal peritoneal metastases undergoing CRS and HIPEC were included and retrospectively analyzed at a tertiary referral center from January 2006 to December 2015. Main outcomes included evaluation of grade III/IV complications, mortality rate, overall and disease-free survival, and prognostic factors influencing survival on a Cox multivariate analysis.

Results

Sixty-seven CRSs were performed on 67 patients during this time for colorectal peritoneal metastases. The median patient age was 57 years with 55.2% being female. The median peritoneal carcinomatosis index (PCI) was 7, with complete cytoreduction achieved in 65 (97%) cases. Grade > 2 complications occurred in 6 cases (8.9%) with no mortality. The median overall survival for the entire cohort was 41 months, with a 3-year overall survival of 43%. In case of complete cytoreduction, median overall and disease-free survival were 57 months and 36 months respectively, with a 3-year disease-free survival of 62%. Complete cytoreduction and nonmucinous histology were key factors independently associated with improved overall survival.

Conclusions

CRS and HIPEC for limited peritoneal metastases from CRC are safe and effective, with acceptable morbidity. In selected patients, it offers a highly favorable long-term outcomes.

The interplay between digital transformation and governance mechanisms in supply chains: evidence from the Italian automotive industry

Purpose

This paper aims to investigate the effect of specific subsets of digital technologies and governance mechanisms (i.e. relational and contractual) on the efficiency of the automotive supply chain (SC).

Design/methodology/approach

Building on the Transaction Costs Economic (TCE) theory, and on the literatures on the governance and Digital Transformation of SCs, the research employs a multi-respondent survey on a sample of 101 Italian automotive suppliers. It analyses the interplay between investments in network and physical–digital interface technologies and buyer–supplier relationship governance models in a joint product development effort. The related effects on costs, from the automotive suppliers' perspective, are considered.

Findings

The results confirm the TCE assumptions on governance mechanisms being appropriate to enhance cost performance, but in particular show that digital technologies shape the governance of buyer–supplier relationships with different patterns. The features of synchronisation and accessibility, as ensured by network technologies, are found to strengthen the impact of contractual governance, while the adoption of physical–digital interface technologies, and their enhanced features of virtualisation and traceability, further enhance the impact of relational governance on the efficiency improvements of suppliers.

Practical implications

SC actors need to recognise the importance of long-term collaboration and superior coordination through investments in specific subsets of digital technologies, to ensure a higher product and production data codifiability, transparency and thus integration at both an intra- and an inter-firm level.

Originality/value

This study is one of the first to have considered Digital Transformation in SCs from the suppliers' perspective and its implications on the efficiency of relationship governance with buyers.

Pediatric nurses in pediatricians' offices: a survey for primary care pediatricians

BACKGROUND

The role played by nurses in caring for children in pediatricians' officies in the community is crucial to ensure integrated care. In Italy, pediatricians are responsible for the health of children aged 0-14 years living in the community. This study aimed to describe Italian primary care pediatricians' opinions about the usefulness of several nursing activities that pediatric nurses could perform in pediatricians' offices.

METHODS

An online survey with pediatricians working in primary care in Italy was conducted between April-December 2018. A 40-item questionnaire was used to assess four types of nursing activities: clinical care, healthcare education, disease prevention, and organizational activities. The answers ranged from 1 (not useful at all) to 6 (very useful). Moreover, three open-ended questions completed the questionnaire.

RESULTS

Overall, 707 pediatricians completed the online survey. Participants were mainly female (63%), with a mean age of 57.74 (SD = 6.42). The presence of a pediatric nurse within the pediatrician's office was considered very useful, especially for healthcare education (Mean 4.90; SD 1.12) and disease prevention (Mean 4.82; SD 1.11). Multivariate analysis confirmed that pediatricians 'with less working experience', 'having their office in a small town', and 'collaborating with a secretary and other workers in the office' rated the nurse's activities significantly more useful.

CONCLUSIONS

A pediatric nurse in the pediatrician's office can significantly contribute to many activities for children and their families in the community. These activities include clinical care, healthcare education, disease prevention, and the organizational processes of the office. Synergic professional activity between pediatricians and pediatric nurses could ensure higher health care standards in the primary care setting.

Using an App to monitor postoperative pain at home in pediatric patients

A prospective comparative study was conducted in 487 pediatric patients (69% male, mean age = 6.4 ± 4.0) to evaluate (a) the incidence, intensity, and characteristics of pain in pediatric patients at home during the first 24 hours and 5 days after surgery and (b) the factors associated with higher pain intensity, including the impact of an application (App) compared to the paper-and-pencil approach. Postoperative pain was assessed by patients or their parents at home using the 'Bambino Gesù' Children's Hospital (Ospedale Pediatrico Bambino Gesù, OPBG) tool for participants aged 4-17 years or the Faces, Legs, Arms, Cry, and Consolability scale for participants less than four years old. Participants were assigned to two groups: those who used the paper-and-pencil version of the pain scale and those who used the App. Overall, 209 of the 472 (44%) participants reported pain during the first 24 hours, and 92 of the 420 (22%) reported pain between one and five days after surgery. Higher pain intensity scores were associated with being in the App group, directly assessing own pain, and using the OPBG tool. The App was effective in facilitating pain assessment. Health professionals could empower pediatric patients and their parents in assessing pain at home through a dedicated App.

Laparoscopic vs Open Resection of Gastrointestinal Stromal Tumors (GISTs) from Gastric Origin: different approaches for different diseases

BACKGROUND

Although minimally invasive techniques are currently recognized as effective and validated treatment for small gastric gastrointestinal stromal tumors (GISTs), the role of laparoscopy is not yet established. The aim of this study was to evaluate the outcomes of laparoscopic treatment of gastric GISTs compared to the results obtained in a group of patients treated with conventional surgery.

METHODS

A retrospective analysis was performed, using a prospectively maintained comprehensive database of 100 patients treated for gastric GIST in the period from 2000 to 2015. Thirty-six patients were treated laparoscopically and 64 patients underwent conventional surgery. The analyzed medical data included clinical and pathological features of removed tumors, perioperative parameters as well as short and long-term results of surgical treatment.

RESULTS

Histopathological examination confirmed radical resection for all patients. No deaths were reported in the 90-day post-operative period. Patients in laparoscopic group had significantly shorter length of hospital stay (5.5 vs. 7 days, p<0.0001), fewer extended and combined surgical procedures (11.2% vs 34.4% and 2.8% vs 39%; p=0.02 and p<0.001, respectively), and a smaller tumor size compared to laparotomic group (3 vs 6 cm, p<0.0001). The median post-operative follow-up for the entire study population was 42 months. During this period, 11 patients died and 4 of them developed a tumor recurrence. None of them was in the laparoscopic group.

CONCLUSIONS

Laparoscopy in the treatment of gastric GISTs has unquestionable advantages, but its choice is strictly related to tumor features.

Radiofrequency ablation for intraductal extension of ampullary adenomatous lesions: proposal for a standardized protocol

Background and study aims  Intraductal extension of ampullary adenoma represents a challenging endoscopic issue. Intraductal radiofrequency ablation (RFA) has been recently suggested, but evidence and standardization of this technique are still lacking. This study aimed to provide a long-term evaluation of clinical efficacy and safety of intraductal RFA ablation with a standardized algorithm of treatment. Patients and methods  Data were prospectively collected from consecutive patients with intraductal extension of adenomatous ampullary lesions from January 2016 to November 2018. Endpoints of the study were clinical success evaluated on histology results at the last follow-up, technical success, and adverse events assessment. Results  Nine patients with intraductal (biliary ± pancreatic) extension of ampullary adenomas were treated with RFA during the study period. Histology on the papillectomy specimen confirmed intraductal involvement with low-grade dysplasia (LGD) in five cases (56 %), high-grade dysplasia (HGD) in three (33 %), and HGD with intramucosal adenocarcinoma in one patient (11 %). Additional argon plasma coagulation to ablate the adenoma on the duodenal mucosa was applied in five patients (56 %). Technical success was 100 %. One patient (11 %) with failed pancreatic stenting, developing acute pancreatitis after RFA, recovered with medical therapy. After a median follow-up of 21 months (IQR 20-31), six patients (67 %) achieved clinical success being free of recurrence, whereas one was diagnosed with persistence of adenocarcinoma, one with recurrent HGD, and one with recurrent LGD. Conclusions  In our experience, intraductal RFA achieved acceptable results after a 2-year follow-up. Further studies are required to confirm our results and to select those patients most likely to respond.

Eulerian-Lagrangian modeling of cough droplets irradiated by ultraviolet-C light in relation to SARS-CoV-2 transmission

It is well known that several viruses, as well as SARS-CoV-2, can be transmitted through airborne diffusion of saliva micro-droplets. For this reason, many research groups have devoted their efforts in order to gain new insight into the transport of fluids and particles originated from human respiratory tracts. This paper aims to provide a contribution to the numerical modeling of saliva droplets' diffusion produced by coughing. It is worth noting that droplets' diameters of interest in this work are such that represent typical emission during a cough. Aerosolization effects are neglected since emitted droplets' diameters are greater than 10 µm. In particular, the well-known problem around the safety distance to be held for avoiding virus transmission in the absence of external wind is further investigated. Thus, new indices capable of evaluating the contamination risk are introduced, and the possibility to inactivate virus particles by means of an external ultraviolet-C (UV-C) radiation source is studied. For this purpose, a new model which takes into account biological inactivation deriving from UV-C exposure in an Eulerian-Lagrangian framework is presented.

Survival advantage of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced gastric cancer: experience from a Western tertiary referral center

BACKGROUND

Selection criteria and prognostic factors for patients with advanced gastric cancer (AGC) undergoing cytoreductive surgery (CRS) plus hyperthermic intra-operative peritoneal chemotherapy (HIPEC) have not been well defined and the literature data are not homogeneous. The aim of this study was to compare prognostic factors influencing overall (OS) and disease-free survival (DFS) in a population of patients affected by AGC with surgery alone and surgery plus HIPEC, both with curative (PCI, Peritoneal Carcinomatosis Index >1) and prophylactic (PCI=0) intent.

METHODS

A retrospective analysis of a prospectively collected database was conducted in patients affected by AGC from January 2006 to December 2015. Uni- and multivariate analyses of prognostic factors were performed.

RESULTS

A total of 85 patients with AGC were analyzed. Five-year OS for surgery alone, CRS plus curative HIPEC, and surgery plus prophylactic HIPEC groups was 9%, 27%, and 33%, respectively. Statistical significance was reached comparing both prophylactic HIPEC vs surgery alone group (p = 0.05), curative HIPEC vs surgery alone group (p = 0.03), and curative vs prophylactic HIPEC (p = 0.04). Five-year DFS for surgery alone, CRS + curative HIPEC, and surgery + prophylactic HIPEC groups was 9%, 20%, and 30%, respectively. Statistical significance was reached comparing both prophylactic HIPEC vs surgery alone group (p < 0.0001), curative HIPEC vs surgery alone group (p = 0.008), and curative vs prophylactic HIPEC (p = 0.05).

CONCLUSIONS

Patients with AGC undergoing surgery plus HIPEC had a better OS and DFS with respect to patients treated with surgery alone.

miRNA landscape in primary tumors and matched metastases in gastrointestinal stromal tumors

Aim: Gastrointestinal stromal tumor management is extremely challenging, particularly the metastatic disease. The underlying mechanism in metastasis spread remains largely unknown. We aimed to characterize miRNAs involved in the metastatic process in gastrointestinal stromal tumor. Material & methods: Eight primary tumors and 18 synchronous metastases were analyzed through miRNA Taqman arrays or assays. Results: miRNAs profiles revealed similar expression in primary site and metastases. Pair-wise correlation coefficient between primary tumor and metastases was significant for each patient (p < 0.0001 for all profiled patients). Conclusion: Our study, the largest including primary tumors and metastases so far performed, highlighted perpetuation of miRNAs features in metastatic lesions and that the primary origin appears to be the main determinant of the metastases miRNA profile.

Electronic Assessment and Tracking of Pain at Home: A Prospective Study in Children With Hematologic or Solid Tumors

This study aimed to evaluate the intensity and characteristics of pain, which was assessed at home by children with cancer or their parents using an app for mobile devices, for a 1-month poststudy enrollment. The participants of this observational prospective study were outpatients at the hematology/oncology department of an academic hospital in Italy, aged between 0 and 21 years, and receiving hospital-at-home care. Patients or their parents were asked to assess pain levels for one month at home using the Faces, Legs, Arms, Cry, and Consolability (FLACC) scale for patients aged <4 years and the Ospedale Pediatrico Bambino Gesù (OPBG) tool for patients aged 4 to 21 years. At study conclusion, parents were asked to complete a survey about their satisfaction with the app and to rate their child's health in general, pain intensity, and frequency in the past 4 weeks. Of the 124 participants using the app, 94 (75.8%) reported pain (≥1) at least once during the 1 month. Of these, 53 (56.4%) at most reported mild pain, 33 (35.1%) moderate pain, and eight (8.5%) severe pain. The abdomen was identified as the most frequent (56.3%) pain site by patients aged 4 to 21 years. The child's maximum pain intensity during the study period was negatively correlated with the parent's report of the child's health during the past month (r = -.29, p < .01). Most of the participants were satisfied with the app and the information received about app usage. In conclusion, the app facilitated pain assessment and tracking in patients receiving hospital-at-home care.

Impact of COVID-19 pandemic on pediatric patients with epilepsy - The caregiver perspective

The recent COVID-19 pandemic has disrupted care systems around the world. We assessed how the COVID-19 pandemic affected children with epilepsy in Italy, where lockdown measures were applied from March 8 to May 4, 2020. We compiled an Italian-language online survey on changes to healthcare and views on telehealth. Invitations were sent to 6631 contacts of all patients diagnosed with epilepsy within the last 5 years at the BambinoGesù Children's Hospital in Rome. Of the 3321 responses received, 55.6% of patients were seizure-free for at least 1 year before the COVID-19-related lockdown, 74.4% used anti-seizure medications (ASMs), and 59.7% had intellectual disability. Only 10 patients (0.4%) became infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Seizure frequency remained stable for most patients during the lockdown period (increased in 13.2%; decreased in 20.3%), and seizure duration, use of rescue medications, and adherence to treatment were unchanged. Comorbidities were more affected (behavioral problems worsened in 35.8%; sleep disorder worsened in 17.0%). Visits were canceled/postponed for 41.0%, but 25.1% had remote consultation during the lockdown period (93.9% were satisfied). Most responders (67.2%) considered continued remote consultations advantageous. Our responses support that patients/caregivers are willing to embrace telemedicine for some scenarios.

A huge esophageal Schwannoma occurring in a Caucasian young male: a case report

OBJECTIVE

Gastrointestinal schwannomas are rare benign mesenchymal tumors originating from Schwann cells, the nerve sheath belonging to the Auerbach's plexus or, less frequently, to Meisser's plexus. The esophagus is the least common site accounting for less than 2% of all esophageal tumors, and the upper to mid portion is usually involved. Esophageal schwannomas affect more frequently middle-aged Asian women. The most common symptom is dysphagia. Diagnosis requires histological and immunohistochemical studies and the standard of care is surgical resection.

CASE REPORT

We present the case of a 22-year-old Caucasian male who was admitted to our hospital for progressive dysphagia and acute chest pain. An EGDS showed an elongated bulging of the lower esophagus with signs of a subcentimetric mucosal erosion. A CT-scan showed a lower esophageal ectasia and a huge postero-lateral wall mass measuring 37x28x70 mm. An endoscopic ultrasonography showed a hypoechoic heterogeneous mass with multiple anechoic areas and a fine needle biopsy was performed. Histological examination showed tissue made up of spindle cells with mild eosinophilic cytoplasm and rare nuclear atypia, which were intensively and diffusely positive for the S100 protein on immunohistochemical studies thus allowing pre-operative diagnosis of "ancient" schwannoma. after a multidisciplinary discussion, the patient underwent a surgical resection. Since the tumor had a transmural extension, a subtotal esophagectomy was performed to achieve complete resection with negative margins.

CONCLUSIONS

This is the first case of a young Caucasian male patient with an "ancient" schwannoma of the lower esophagus, a benign but locally advanced lesion treated by subtotal esophagectomy.

Pharmacogenetics in the treatment of gastrointestinal stromal tumors - an updated review

INTRODUCTION

Gastrointestinal stromal tumors (GIST) are the best example of a targeted therapy in solid tumors. The introduction of tyrosine kinase inhibitors (TKIs) deeply improved the prognosis of this tumor. However, a degree of inter-patient variability is still reported in response rates and pharmacogenetics may play an important role in the final clinical outcome.

AREAS COVERED

In this review, the authors provide an updated overview of the pharmacogenetic literature analyzing the role of polymorphisms in both GIST treatment efficacy and toxicity.

EXPERT OPINION

Besides the primary role of somatic DNA in dictating the clinical response to TKIs, several polymorphisms influencing their pharmacokinetics and pharmacodynamics have been identified as being potentially involved. In the last 10 years, many potential biomarkers have been proposed to predict clinical response and toxicity after TKI administration. However, the evidence is still too limited to promote a clinical translation. To date, the somatic mutational status represents the main player in clinical response to TKIs in GIST treatment; however, pharmacogenetics could still explain the degree of inter-patient variability observed in GIST patients. A combination of different theoretical approaches, experimental model systems, and statistical methods is clearly needed, in order to translate pharmacogenetics to clinical practice in the near future.

A detailed analysis of the recurrence timing and pattern after curative surgery in patients undergoing neoadjuvant therapy or upfront surgery for gastric cancer

BACKGROUND AND OBJECTIVES

The aim of this study was to determine whether the administration of neoadjuvant therapy (NAD) affects the incidence, timing, and pattern of recurrence in patients treated by curative gastrectomy.

METHODS

Sixty-nine patients undergoing NAD and R0 gastrectomy were compared with 198 patients undergoing upfront surgery using the propensity score matching (PSM) method. Disease-free survival (DFS), disease-specific survival (DSS), and progression-free survival (PFS) analyses were conducted with a log-rank test and Cox regression. Risk factors for recurrence were assessed by logistic regression.

RESULTS

Among 69 patients with NAD, 28 (40.6%) experienced recurrence, and signet-ring cell (SRC) carcinoma was the only factor independently associated with recurrence. In the whole sample, NAD did not influence DFS, DSS, rate of recurrence, or PFS. After PSM, the variables associated with DFS were cN1, type of gastrectomy, the presence of SRCs, and the presence of lymphovascular invasion. Variables independently associated with recurrence were cN1, type of gastrectomy, and the presence of SRCs.

CONCLUSIONS

NAD had no impact on DFS, DSS, or the pattern of recurrence in any patients with gastric cancer. To define a better treatment strategy, future studies should focus on subtypes that do not respond to the current neoadjuvant regimens.

Aesthetic appreciation of musical intervals enhances behavioural and neurophysiological indexes of attentional engagement and motor inhibition

From Kant to current perspectives in neuroaesthetics, the experience of beauty has been described as disinterested, i.e. focusing on the stimulus perceptual features while neglecting self-referred concerns. At a neurophysiological level, some indirect evidence suggests that disinterested aesthetic appreciation might be associated with attentional enhancement and inhibition of motor behaviour. To test this hypothesis, we performed three auditory-evoked potential experiments, employing consonant and dissonant two-note musical intervals. Twenty-two volunteers judged the beauty of intervals (Aesthetic Judgement task) or responded to them as fast as possible (Detection task). In a third Go-NoGo task, a different group of twenty-two participants had to refrain from responding when hearing intervals. Individual aesthetic judgements positively correlated with response times in the Detection task, with slower motor responses for more appreciated intervals. Electrophysiological indexes of attentional engagement (N1/P2) and motor inhibition (N2/P3) were enhanced for more appreciated intervals. These findings represent the first experimental evidence confirming the disinterested interest hypothesis and may have important applications in research areas studying the effects of stimulus features on learning and motor behaviour.

Beauty in mind: Aesthetic appreciation correlates with perceptual facilitation and attentional amplification

Neuroaesthetic research suggests that aesthetic appreciation results from the interaction between the object perceptual features and the perceiver's sensory processing dynamics. In the present study, we investigated the relationship between aesthetic appreciation and attentional modulation at a behavioural and psychophysiological level. In a first experiment, fifty-eight healthy participants performed a visual search task with abstract stimuli containing more or less natural spatial frequencies and subsequently were asked to give an aesthetic evaluation of the images. The results evidenced that response times were faster for more appreciated stimuli. In a second experiment, we recorded visual evoked potentials (VEPs) during exposure to the same stimuli. The results showed, only for more appreciated images, an enhancement in C1 and N1, P3 and N4 VEP components. Moreover, we found increased attention-related occipital alpha desynchronization for more appreciated images. We interpret these data as indicative of the existence of a correlation between aesthetic appreciation and perceptual processing enhancement, both at a behavioural and at a neurophysiological level.

P6556Prevention of long-lasting atrial fibrillation through device therapy in dual-chamber pacemakers: analysis on 1384 patients of the role of Reactive ATP and atrial preventive pacing

Background

Atrial fibrillation (AF) is the most prevalent heart rhythm disorder in clinical practice and it is associated with poor quality of life and increased risks of heart failure, dementia, stroke, and death. Moreover AF management is a huge cost for healthcare systems. AF is irregular, typically originates from the pulmonary veins, and as such, requires cardioversion to terminate persistent episodes. AF is not susceptible to pace-termination, however, the MINERVA trial has shown that AF may transform in slower organized rhythms such as atrial flutter or atrial tachycardia, which can often be terminated by atrial anticahycardia pacing (ATP); in particular by Reactive ATP, a specific ATP feature which can be re-armed when atrial arrhythmias get slower or more regular. The MINERVA trial showed that the combination of ATP, preventive atrial pacing algorithms and minimal ventricular pacing (MVP) was associated with lower progression to persistent and permanent AF, compared with standard DDD pacing mode and to MVP mode, in pacemaker patients with clinical history of AF.

Purpose

We aimed to confirm MINERVA trial results in real-world clinical practice and to evaluate whether AF prevention was associated with preventive atrial pacing or solely with ATP. Indeed in our project atrial preventive pacing algorithms were not enabled and the pacing mode (DDD or MVP) was chosen according to patients' AV conduction characteristics.

Methods

Consecutive dual-chamber pacemaker patients with sinus node disease and device detected AT/AF were prospectively followed by 30 Italian cardiologic centers in an observational research. Clinical and device data were collected and reviewed by expert cardiologists to assess AT/AF occurrence through in clinic visit and/or remote transmissions of device data.

Results

A total of 239 patients (73 years old, 56% male) wearing a dual-chamber pacemaker with Reactive ATP were included in the project, followed for a median observation period of 13 months and compared with 1145 patients included in the MINERVA trial followed for a median observation period of 34 months and programmed with DDD pacing mode (383 patients), MVP (389 patients) and MVP+Reactive ATP+preventive algorithms (373 patients). As shown in the following figure incidence of 7 consecutive days of AF in the patients treated by DDD/MVP+Reactive ATP in real-world clinical practice was very similar to that found in the MINERVA trial arm programmed with MVP+Reactive ATP+preventive algorithms.

Incidence of AF longer than 7 days

Conclusions

Our analysis performed in a population of sinus node disease patients with dual-chamber pacemakers confirmed MINERVA trial results in terms of prevention of long-lasting AF episodes. In particular these results confirm the benefit associated with the use of Reactive ATP, rather than preventive atrial pacing algorithms.

Stemness underpinning all steps of human colorectal cancer defines the core of effective therapeutic strategies

BACKGROUND

Despite their lethality and ensuing clinical and therapeutic relevance, circulating tumor cells (CTCs) from colorectal carcinoma (CRC) remain elusive, poorly characterized biological entities.

METHODS AND FINDINGS

We perfected a cell system of stable, primary lines from human CRC showing that they possess the full complement of ex- and in-vivo, in xenogeneic models, characteristics of CRC stem cells (CCSCs). Here we show how tumor-initiating, CCSCs cells can establish faithful orthotopic phenocopies of the original disease, which contain cells that spread into the circulatory system. While in the vascular bed, these cells retain stemness, thus qualifying as circulating CCSCs (cCCSCs). This is followed by the establishment of lesions in distant organs, which also contain resident metastatic CCSCs (mCCSCs).

INTERPRETATION

Our results support the concept that throughout all the stages of CRC, stemness is retained as a continuous property by some of their tumor cells. Importantly, we describe a useful standardized model that can enable isolation and stable perpetuation of human CRC's CCSCs, cCCSCs and mCCSCs, providing a useful platform for studies of CRC initiation and progression that is suitable for the discovery of reliable stage-specific biomarkers and the refinement of new patient-tailored therapies. FUND: This work was financially supported by grants from "Ministero della Salute Italiano"(GR-2011-02351534, RC1703IC36 and RC1803IC35) to Elena Binda and from "Associazione Italiana Cancro" (IG-14368) Angelo L. Vescovi. None of the above funders have any role in study design, data collection, data analysis, interpretation, writing the project.

The rs17084733 variant in the KIT 3' UTR disrupts a miR-221/222 binding site in gastrointestinal stromal tumour: a sponge-like mechanism conferring disease susceptibility

Several miRNAs are dysregulated in gastrointestinal stromal tumours (GIST), and miR-221/222 appear to have a prominent role in GIST biology. Therefore, we investigated the role of DNA variants located in miR-221/222 precursor sequences and their target KIT 3'UTR. Ninety-five polymorphisms were analysed in 115 GIST cases and 88 healthy controls. KIT 3'UTR rs17084733 and pri-miR-222 rs75246947 were found significantly associated with GIST susceptibility. Specifically, KIT rs17084733 A allele was more common in GIST, particularly in KIT wild-type (WT) patients (Padj = 0.017). rs17084733 variant is located within one of the three miR-221/222 binding sites in the KIT 3'UTR, resulting in a mismatch in this seed region. Conversely, KIT mRNA levels were lower in patients carrying the variant allele, except for KIT mutant GIST. Luciferase assay data in GIST cells, generated using a construct containing all the three miR-221/222 binding sites, are consistent with KIT mRNA levels in GIST patients. Reporter assay data, generated using a construct containing only the site encompassing rs17084733, confirmed that this is a functional variant disrupting the miR-221/222 binding site. In conclusion, this is the first study investigating the role of SNPs on miR-221/222 precursor sequences and their binding region on KIT 3'UTR in GIST. We identified the KIT variant rs17084733 as a possible novel genetic biomarker for risk of developing KIT-WT GIST. Moreover, our findings suggest the role of one of the three miR-221/222 binding sites on KIT 3'UTR as endogenous sponge, soaking up and subtracting miR-221/222 to the other two sites characterized by a higher affinity.

Succinate Dehydrogenase-Deficient Gastrointestinal Stromal Tumors: Small Steps Toward Personalized Medicine?

Various molecular triggers define heterogeneous subsets of gastrointestinal stromal tumors (GISTs), differing in clinical behavior and drug sensitivity. KIT/PDGFRA-wild-type GISTs, including those succinate dehydrogenase (SDH)-deficient, are overall unresponsive to the tyrosine kinase inhibitors commonly used, fostering the development of specific alternative therapeutic strategies. Epigenetic inactivation of O⁶-methylguanine-DNA methyltransferase (MGMT) through promoter methylation leads to effectiveness of alkylating agents in several human cancers. SDH-deficient GISTs typically feature widespread DNA methylation. However, the actual occurrence of MGMT methylation in these tumors, potentially predisposing them to respond to alkylating drugs, has not been investigated so far. Here we discuss the recent findings concerning the occurrence of MGMT methylation in different GIST subgroups, including SDH-deficient ones, as a premise for a possible reappraisal of alkylating agents specifically targeting these small, otherwise overall chemorefractory, GIST subgroups.

Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients

Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.