Evidence and recommendations for a value-based decision making on vaccinations

Issue/problem

Vaccinations are one of the most successful public health measures and contribute to the achievement of Sustainable Development Goals. Despite this, there are still several challenges, such as poor resources, unequal access, and vaccine hesitancy. An exploitation of the full value of vaccinations could help contrasting them.

Description of the problem

A dual approach was followed to exploit full value of vaccinations. First, the four pillars of value pinpointed by the Expert Panel on Effective Ways of Investing in Health of the European Commission, namely personal, societal, allocative, and technical value, were considered to carry out a systematic review of available papers addressing the value of vaccinations. The synthesis of data was the submitted to a panel of international experts in vaccinations who gave inputs on recommendations to drive a value-based decision-making.

Results

Overall, 54 papers published from 2010 onwards addressed at least one pillar of value with most of them (83.3%) assessing a single one. Two-thirds of papers addressed the technical pillar, namely the economic value, in most cases without catching the broad economic implications. Very few studies addressed allocative and societal value highlighting the need to generate evidence to support the application of these pillars. Furthermore, some aspects of the allocative pillar, such as equity, accessibility, and appropriate use, were not addressed so far. Recommendations on research on full value of vaccinations, decision-making process and public engagement were eventually issued.

Lessons

The project allowed to apply for the first the value-based approach to vaccinations. This led to the identification of current gaps in the assessment of full value of vaccinations and to recommendations to foster a value-based decision-making. These results have international relevance because of the growing attention to the value-based approach for sustainable health systems.

Key messages

The full value of vaccinations need to be further investigated according to the four pillars pinpointed by the Expert Panel on Effective Ways of Investing in Health. Different actions could be promoted with respect to research, decision-making process and public engagement in order to exploit the full value of vaccination and drive a value-based decision-making.

Efficacy and correlative analyses of avelumab plus axitinib versus sunitinib in sarcomatoid renal cell carcinoma: post hoc analysis of a randomized clinical trial

BACKGROUND

Among patients with advanced renal cell carcinoma (RCC), those with sarcomatoid histology (sRCC) have the poorest prognosis. This analysis assessed the efficacy of avelumab plus axitinib versus sunitinib in patients with treatment-naive advanced sRCC.

METHODS

The randomized, open-label, multicenter, phase III JAVELIN Renal 101 trial (NCT02684006) enrolled patients with treatment-naive advanced RCC. Patients were randomized 1 : 1 to receive either avelumab plus axitinib or sunitinib following standard doses and schedules. Assessments in this post hoc analysis of patients with sRCC included efficacy (including progression-free survival) and biomarker analyses.

RESULTS

A total of 108 patients had sarcomatoid histology and were included in this post hoc analysis; 47 patients in the avelumab plus axitinib arm and 61 in the sunitinib arm. Patients in the avelumab plus axitinib arm had improved progression-free survival [stratified hazard ratio, 0.57 (95% confidence interval, 0.325-1.003)] and a higher objective response rate (46.8% versus 21.3%; complete response in 4.3% versus 0%) versus those in the sunitinib arm. Correlative gene expression analyses of patients with sRCC showed enrichment of gene pathway scores for cancer-associated fibroblasts and regulatory T cells, CD274 and CD8A expression, and tumors with The Cancer Genome Atlas m3 classification.

CONCLUSIONS

In this subgroup analysis of JAVELIN Renal 101, patients with sRCC in the avelumab plus axitinib arm had improved efficacy outcomes versus those in the sunitinib arm. Correlative analyses provide insight into this subtype of RCC and suggest that avelumab plus axitinib may increase the chance of overcoming the aggressive features of sRCC.

Improvement of left ventricular systolic performance during sacubitril/valsartan in a cohort of patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan is a well-established therapeutic option for patients with heart failure with reduced ejection fraction (HFrEF). While it was clearly demonstrated to improve patients’ clinical conditions, its potential role in inducing left ventricle (LV) reverse remodeling is still under investigation. 

Purpose

to evaluate clinical and echocardiographic effect of sacubitril/valsartan on a cohort of patients with HFrEF after six months of therapy.

Methods

36 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. A standard and advanced echocardiographic evaluation was performed before starting the therapy and after six months of follow up (FU). Off-line analysis of left ventricle global longitudinal strain (GLS), longitudinal strain of the free wall of the right ventricle (RVFWSL) and left atrial strain (LAS) was conducted. Clinical and biochemical parameters were evaluated as well.

Results

At six months of FU NYHA class improved in the vast majority of patients (NYHA class III at baseline vs FU: 56% vs 5%, p 0.001). We observed a significant reduction in LV end-diastolic (99.62 ± 33.24 vs 91.54 ± 33.36, p 0.043) and end-systolic (69.99 ± 26.01 vs 58.68 ± 25.7, p 0.001) volumes and an improvement of LV ejection fraction (30.4 ± 5.02 vs 37.3 ± 6.4, p < 0.001). After six months of therapy, GLS significantly improved (-9.71 ± 2.87 vs -13.04 ± 3.14, p < 0.001). No differences in left and right atrial volumes (respectively 56.6 ± 29 vs 54 ± 30, p 0.349; 54.7 ± 23.7 vs 48.3 ± 19, p 0.157), RVFWSL (-16,5 ± 5,4 vs -16,8 ± 1,5) and LAS (14 ± 6 vs 19 ± 8, p 0.197) were found at FU. 

Conclusion

Left ventricular function evaluated with standard and advanced echocardiographic parameters improved after six months of therapy with sacubitril/valsartan in HFrEF patients. Reduction in LV volumes was found as well.

Echo Analysis Baseline Echo Analysis (n= 36) 6 Months FU Echo Analysis (n= 36) p LVEDVi, mL/m2 99, 62 ± 33,24 91,54 ± 33,36 0,043 LVESVi, mL/m2 69,99 ± 26,01 58,68 ± 25,7 0,001 LVEF, % 30,4 ± 5, 02 37,3 ± 6,4 < 0,001 E/E’ average 12,16 ± 3,74 9,71 ± 1,33 0,023 LS Endo Average ,% -9,71 ± 2,87 -13,04 ± 3,14 < 0,001 LVEF left ventricular ejection fraction, LVEDVi: left ventricular end diastolic volume indexed, LVESVi: left ventricular end systolic volume indexed; LS: longitudinal strain

The impacts of intensive mining on terrestrial and aquatic ecosystems: A case of sediment pollution and calcium decline in cool temperate Tasmania, Australia

Mining causes extensive damage to aquatic ecosystems via acidification, heavy metal pollution, sediment loading, and Ca decline. Yet little is known about the effects of mining on freshwater systems in the Southern Hemisphere. A case in point is the region of western Tasmania, Australia, an area extensively mined in the 19th century, resulting in severe environmental contamination. In order to assess the impacts of mining on aquatic ecosystems in this region, we present a multiproxy investigation of the lacustrine sediments from Owen Tarn, Tasmania. This study includes a combination of radiometric dating (¹⁴C and ²¹⁰Pb), sediment geochemistry (XRF and ICP-MS), pollen, charcoal and diatoms. Generalised additive mixed models were used to test if changes in the aquatic ecosystem can be explained by other covariates. Results from this record found four key impact phases: (1) Pre-mining, (2) Early mining, (3) Intense mining, and (4) Post-mining. Before mining, low heavy metal concentrations, slow sedimentation, low fire activity, and high biomass indicate pre-impact conditions. The aquatic environment at this time was oligotrophic and dystrophic with sufficient light availability, typical of western Tasmanian lakes during the Holocene. Prosperous mining resulted in increased burning, a decrease in landscape biomass and an increase in sedimentation resulting in decreased light availability of the aquatic environment. Extensive mining at Mount Lyell in the 1930s resulted in peak heavy metal pollutants (Pb, Cu and Co) and a further increase in inorganic inputs resulted in a disturbed low light lake environment (dominated by Hantzschia amphioxys and Pinnularia divergentissima). Following the closure of the Mount Lyell Co. in 1994 CE, Ca declined to below pre-mining levels resulting in a new diatom assemblage and deformed diatom valves. Therefore, the Owen Tarn record demonstrates severe sediment pollution and continued impacts of mining long after mining has stopped at Mt. Lyell Mining Co.

Hadron Therapy, Magnetic Nanoparticles and Hyperthermia: A Promising Combined Tool for Pancreatic Cancer Treatment

A combination of carbon ions/photons irradiation and hyperthermia as a novel therapeutic approach for the in-vitro treatment of pancreatic cancer BxPC3 cells is presented. The radiation doses used are 0–2 Gy for carbon ions and 0–7 Gy for 6 MV photons. Hyperthermia is realized via a standard heating bath, assisted by magnetic fluid hyperthermia (MFH) that utilizes magnetic nanoparticles (MNPs) exposed to an alternating magnetic field of amplitude 19.5 mTesla and frequency 109.8 kHz. Starting from 37 °C, the temperature is gradually increased and the sample is kept at 42 °C for 30 min. For MFH, MNPs with a mean diameter of 19 nm and specific absorption rate of 110 ± 30 W/g_Fe3o₄ coated with a biocompatible ligand to ensure stability in physiological media are used. Irradiation diminishes the clonogenic survival at an extent that depends on the radiation type, and its decrease is amplified both by the MNPs cellular uptake and the hyperthermia protocol. Significant increases in DNA double-strand breaks at 6 h are observed in samples exposed to MNP uptake, treated with 0.75 Gy carbon-ion irradiation and hyperthermia. The proposed experimental protocol, based on the combination of hadron irradiation and hyperthermia, represents a first step towards an innovative clinical option for pancreatic cancer.

The prognostic role of micro-RNAs in Head and Neck Cancers: an umbrella review

Head and neck cancer (HNC) represents the sixth most common cancer and the seventh cause of cancer-related deaths worldwide. Because of HNC high mortality and morbidity a support from the development of new biomarkers and personalized care for patients is needed. The role of micro-RNAs (miRs), as new epigenetic biomarkers, aimed at improving early diagnosis, predicting prognosis and establishing effective cancer therapies, has recently received considerable attention. The aim of this study was to conduct an umbrella review that synthetizes all the findings of systematic reviews already available in literature that investigate the prognostic role of miRs as potential biomarkers in the field of tertiary prevention of HNC.

We selected systematic reviews, published in English until December 2019, related to human HNC with meta-analysis of observational studies that reported quantitative prognostic measures, Hazard Ratios (HRs), of Overall Survival (OS) or Disease-Free Survival (DFS). The methodological quality of the included reviews was assessed using the Assessment of Multiple Systematic Reviews AMSTAR 2 tool.

Six systematic reviews were included in the umbrella review. The most reported miRNAs were: miR21; the Let7 family (c,d,g), miR17, 18 family, 20a, 29 family, 125b, 375. A total of 4 reviews assessed miR-21 expression in HNC patients, all showing its upregulation.

The most frequently studied miR was miR21 which was reported either in the OS and DFS statistical analyses. The OS analysis showed a significant lower prognosis when miR21 was upregulated.

It is involved in oncogenic and oncosuppressive cell signals pathways: the overexpression of miR21 was shown to be associated with cell proliferation, migration, invasion and survival. Recently the cumulative effects of sets of miRs has been increasingly studied and they might be stronger predictor of survival than single. The role of miRNAs as a prognostic biomarker specifically in HNC still need to be investigated.

Key messages

Some miRs were demonstrated to have as tumor-suppressing and oncogenic roles according to their level of regulation (up/down-regulation) in Head and Neck cancer patients. The role of miRs as prognostic biomarkers in HNC patients still need to be addressed by performing large scale to verify and enhance the power of evidence and clinical utility of these.

The long-term effects of mandatory military on health outcomes

Introduction

In the past many young men spent a period of time in military service. To enter in the military service the person should pass a health visit where the physical and mental health conditions were verified. We focus our analysis on the Italian military service that was stopped to be mandatory in 2004, to explore if health visits during the military service have effects in preventing future illnesses. To do that we compare health outcomes of the cohort of Italian people born in 1985 and in 1987, i.e. before and after the suppression of the mandatory military service, respectively.

Methods

Data on demographic characteristics of men potentially enrolling the last compulsory military visit and the one after the abrogation were obtained from the Italian National Statistics Institute. For health outcomes, we obtained for the same population the health records of hospital admissions from 2007 to 2017. A difference-in-difference analysis was performed to calculate whether the probability of being differed among the two cohorts of people.

Results

A total of 215,081 males born in 1985 and 210,616 males born in 1987 were admitted to hospital in the period 2007-2017. A decreasing trend from 2007 to 2017 in overall hospitalization rates were observed for both cohorts of 1987 (1.26 to 1.15) and 1985 (1.22 to 1.13). The regression model showed a significant lower probability for the 1985 cohort, respect to the 1987, of being admitted for an infectious or parasite disease (coefficient -0.83; 95% CI: -1.15 - -0.51) and for tumours (coefficient = -0.83, 95% CI:-1.57 - -0.09)

Conclusions

To our knowledge, this is the first study that attempted to quantify the potential preventive impact in the male population of the physical examination during the mandatory military visit. With an age difference of 2 years between the 2 cohorts, the results show a significant reduction in terms of hospital admission for certain types of health conditions

Key messages

The mandatory military service was helpful in detecting certain diseases whose diagnosis would otherwise be delayed or undetected. Physical and mental examinations for mandatory military service, could see how a potential screening programme of prevention among young men.

Updated efficacy results from the JAVELIN Renal 101 trial: first-line avelumab plus axitinib versus sunitinib in patients with advanced renal cell carcinoma

BACKGROUND

The phase 3 JAVELIN Renal 101 trial (NCT02684006) demonstrated significantly improved progression-free survival (PFS) with first-line avelumab plus axitinib versus sunitinib in advanced renal cell carcinoma (aRCC). We report updated efficacy data from the second interim analysis.

PATIENTS AND METHODS

Treatment-naive patients with aRCC were randomized (1 : 1) to receive avelumab (10 mg/kg) intravenously every 2 weeks plus axitinib (5 mg) orally twice daily or sunitinib (50 mg) orally once daily for 4 weeks (6-week cycle). The two independent primary end points were PFS and overall survival (OS) among patients with programmed death ligand 1-positive (PD-L1+) tumors. Key secondary end points were OS and PFS in the overall population.

RESULTS

Of 886 patients, 442 were randomized to the avelumab plus axitinib arm and 444 to the sunitinib arm; 270 and 290 had PD-L1+ tumors, respectively. After a minimum follow-up of 13 months (data cut-off 28 January 2019), PFS was significantly longer in the avelumab plus axitinib arm than in the sunitinib arm {PD-L1+ population: hazard ratio (HR) 0.62 [95% confidence interval (CI) 0.490-0.777]}; one-sided P < 0.0001; median 13.8 (95% CI 10.1-20.7) versus 7.0 months (95% CI 5.7-9.6); overall population: HR 0.69 (95% CI 0.574-0.825); one-sided P < 0.0001; median 13.3 (95% CI 11.1-15.3) versus 8.0 months (95% CI 6.7-9.8)]. OS data were immature [PD-L1+ population: HR 0.828 (95% CI 0.596-1.151); one-sided P = 0.1301; overall population: HR 0.796 (95% CI 0.616-1.027); one-sided P = 0.0392].

CONCLUSION

Among patients with previously untreated aRCC, treatment with avelumab plus axitinib continued to result in a statistically significant improvement in PFS versus sunitinib; OS data were still immature.

CLINICAL TRIAL NUMBER

NCT02684006.

PETER PHAN: An MRI phantom for the optimisation of radiomic studies of the female pelvis

PURPOSE

To develop a phantom for methodological radiomic investigation on Magnetic Resonance (MR) images of female patients affected by pelvic cancer.

METHODS

A pelvis-shaped container was filled with a MnCl₂ solution reproducing the relaxation times (T₁, T₂) of muscle surrounding pelvic malignancies. Inserts simulating multi-textured lesions were embedded in the phantom. The relaxation times of muscle and tumour were measured on an MR scanner on healthy volunteers and patients; T₁ and T₂ of MnCl₂ solutions were evaluated with a relaxometer to find the concentrations providing a match to in vivo relaxation times. Radiomic features were extracted from the phantom inserts and the patients' lesions. Their repeatability was assessed by multiple measurements.

RESULTS

Muscle T₁ and T₂ were 1128 (806-1378) and 51 (40-65) ms, respectively. The phantom reproduced in vivo values within 13% (T₁) and 12% (T₂). T₁ and T₂ of tumour tissue were 1637 (1396-2121) and 94 (79-101) ms, respectively. The phantom insert best mimicking the tumour agreed within 7% (T₁) and 24% (T₂) with in vivo values. Out of 1034 features, 75% (95%) had interclass correlation coefficient greater than 0.9 on T₁ (T₂)-weighted images, reducing to 33% (25%) if the phantom was repositioned. The most repeatable features on phantom showed values in agreement with the features extracted from patients' lesions.

CONCLUSIONS

We developed an MR phantom with inserts mimicking both relaxation times and texture of pelvic tumours. As exemplified with repeatability assessment, such phantom is useful to investigate features robustness and optimise the radiomic workflow on pelvic MR images.

1634 3D transoesofageal echocardiography in detection of anterior leaflet laceration during mitraclip implantation

Background

MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication.

Methods

An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated.

The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer.

Results

A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged.

Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence.

Conclusion

3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing.

Abstract 1634 Figure. Image 1

European network staff eXchange for integrAting precision health in the health Care sysTems” project

Background

Precision health aims to prevent and predict illness, maintaining health and quality of life for as long as possible, by drawing on the new technological and data science tools to translate volumes of research and clinical data into information that citizens, patients and doctors can use.

Objective

The ExACT consortium, funded by the Marie Curie Research and Innovation Staff Exchange (RISE) 2017 - Horizon 2020, is aimed at building a community of academic and non-academic institutions that generates high quality, multidisciplinary collaboration by exchanging knowledge in research and training activities on precision health.

Results

From 2019 to 2023, 74 secondments are foreseen; staff involved will be trained on precision health research topics unavailable at their home institutions. The research topics include 5 domains: Integration of Big Data and digital solutions into healthcare systems; design and promotion of innovative citizen engagement models; education of healthcare professionals and leadership; HTA in precision health; Ethical-legal, social, organisational and policy issues surrounding precision health.

Conclusions

Secondees will produce key reports, policy recommendations, scientific papers, and informative materials for citizens, fostering public-private interplay and fostering integration of precision health in the EU health systems, contributing to better health for EU citizens.

Key messages

Once the secondees are back in their home institution, they will use competences acquired during the secondment to advance the research, and transfer the knowledge to the home organization. Sharing knowledge,building synergies and expertise and encouraging best practices,among top-level institutions,will stimulate translational effort for implementing precision health in EU health system.

Paying attention to personnel in organizational changes: the impact of hospital mergers

Background

The importance of paying attention to personnel satisfaction for the well-being of an organization is clearly stated also in healthcare organization. The trend of mergers of healthcare organizations represents an evident case of organizational change that could undermine personnel satisfaction if not adequately managed. The aim of our study was to investigate the impact of hospital merger on personnel perceptions and satisfaction.

Methods

A systematic review of the literature was carried out by querying scientific databases and grey literature. A search string was built using keywords including: merger, healthcare, personnel, satisfaction and synonyms. Inclusion criteria were primary studies reporting the outcome of interest and set in hospitals that has undergone a merger. Studies characteristics such country setting, design and time frame of the study, number and role of personnel interviewed and main findings were extracted and narratively synthesized.

Results

Search resulted in 3662 studies of which 9 were finally included in the analysis. Studies were mainly represented by post-merger qualitative research (77.8%) of which 55.6% semi and 54.4% structured interviews. Sample size ranged from 14 to 3119 and was represented by unspecified employees (55.6%), nurses and hospital executives (22.2% both). Findings showed that hospital executives consider merger positively especially regarding increased negotiation skills and costs reduction. Conversely, the other personnel mainly expressed critical issues as differences in organization of hospitals merged, goals and confirmation uncertainty, communication impairment and especially no involvement in follow-up in the post-merger phase.

Conclusions

The merger process strongly impacts healthcare personnel satisfaction, depending on the role played in the organization. If an initial enthusiasm and staff engagement in pre-merger phase is seen, this is not generally followed by their proper involvement over time.

Key messages

As personnel satisfaction and perceptions are strongly related to healthcare quality, they represent a central point in the merger process of healthcare organization. More attention must be paid to follow-up staff satisfaction after the merger in a continuous staff engagement to ensure the success of merger process as well as that of all organizational changes.

Parathyroid scintigraphy in primary hyperparathyroidism: comparison between double-phase and subtraction techniques and possible affecting factors

PURPOSE

Parathyroid scintigraphy is superior to other imaging techniques in detecting hyperfunctioning parathyroid glands. It is mainly performed using double-phase or dual-tracer subtraction methods. Neither of the techniques is perfect and different protocols are being used. We aimed to evaluate the accuracy of double-phase and subtraction methods in detecting abnormal gland as well as the potential effects of coexisting thyroid disease and clinical-laboratory data.

METHODS

We considered patients with primary hyperparathyroidism who underwent parathyroid surgery, after a parathyroid scintigraphy between April 2015 and February 2017. Sixty-eight patients were included; in 45 cases (66.2%), a thyroid disease was coexistent. Diagnostic performances of the two techniques were compared. The effect of thyroid disease and clinical-pathological data on examination interpretation was considered.

RESULTS

Double-phase scintigraphy showed higher sensitivity and accuracy in detecting the exact abnormal gland compared to the digital subtraction (90% and 75% vs. 76% and 66%, respectively). For double-phase technique, sensitivity and accuracy were higher in cases with no thyroid disease when compared to those with thyroid disease (92% and 86% vs. 88% and 69%, respectively). Similarly, for digital subtraction, sensitivity and accuracy were higher in the absence of thyroid disease compared to their presence (84% and 79% vs. 70% and 58%, respectively). There was no significant variation in the performance of both techniques, considering clinical-laboratory data.

CONCLUSIONS

Double-phase scintigraphy has been more accurate than digital subtraction. The presence of thyroid disease could be a possible limit, affecting the subtraction more than the double-phase technique. Clinical data did not influence the scintigraphic outcome.

The role of the Cincinnati Prehospital Stroke Scale in the emergency department: evidence from a systematic review and meta-analysis

INTRODUCTION

Stroke is one of the leading causes of morbidity, disability, and mortality in high-income countries. Early prehospital stroke recognition plays a fundamental role, because most clinical decisions should be made within the first hours after onset of symptoms. The Cincinnati Prehospital Stroke Scale (CPSS) is a validated screening tool whose utilization is suggested during triage. The aim of this study is to review the role of the CPSS by assessing its sensitivity and specificity in prehospital and hospital settings.

METHODS

A systematic review and a meta-analysis of the literature reporting the CPSS sensitivity and specificity among patients suspected of stroke were undertaken. Electronic databases were searched up to December 2018, and the quality assessment was carried out by using the Revised Quality Assessment of Diagnostic Accuracy Studies -2  (QUADAS-2).

RESULTS

Eleven studies were included in the meta-analysis. Results showed an overall sensitivity of 82.46% (95% confidence interval [CI] 74.83-88.09%) and specificity of 56.95% (95% CI 41.78-70.92). No significant differences were found in terms of sensitivity when CPSS was performed by physicians (80.11%, 95% CI 66.14-89.25%) or non-physicians (81.11%, 95% CI 69.78-88.87%). However, administration by physicians resulted in higher specificity (73.57%, 95% CI 65.78-80.12%) when compared to administration by non-physicians (50.07%, 95% CI 31.54-68.58%). Prospective studies showed higher specificity 71.61% (95% CI 61.12-80.18%) and sensitivity 86.82% (95% CI 74.72-93.63) when compared to retrospective studies which showed specificity of 33.37% (95% CI 22.79-45.94%) and sensitivity of 78.52% (95% CI 75.08-81.60).

CONCLUSIONS

The CPSS is a standardized and easy-to-use stroke screening tool whose implementation in emergency systems protocols, along with proper and consistent coordination with local, regional, and state agencies, medical authorities and local experts are suggested.

Topsoil radiological characterisation of L-54M reactor surroundings preliminary to decommissioning operations

The radiological characterization of the topsoil of the L-54M reactor surroundings carried out in this work aims at obtaining the reference blank point for the forthcoming decommissioning operations and ascertain if unexpected radionuclide release occurred during the operational life of the plant. Standardised methods have been employed in order to collect representative samples and reliable results. Suitable sample pre-treatment procedures were applied. Gamma and beta spectrometric analyses were carried out to measure the activity concentrations of ⁶⁰Co ¹³⁷Cs, ¹⁵²Eu, ²⁴¹Am and ⁹⁰Sr. These have been considered as representative radionuclides that could have been originated from reactor operations and that could still be present at four decades post reactor shutdown.