Crowdfunding for unmet medical needs: the case of CAR-T and Gofundme

Background

Crowdfunding (CF) is the practice of financing a project by raising money from a large number of people. Many patients use online CF platforms to fund medical needs, whether unmet by their healthcare service - therefore to be sought elsewhere -, or when unable to afford them. CAR-T (Chimeric antigen receptor T-cells) is an innovative therapy approved to treat several types of lymphoma and with potential to treat many other cancers. CAR-T is available in most countries through clinical trials only and its diffusion is limited by high costs. Gofundme is a CF platform ’leader in online medical fundraising’. The objective of this study is to shed some light on the phenomenon of CF for CAR-T therapy, describing the campaigns started on Gofundme.

Methods

We extracted data from CAR-T campaigns started in Europe and publicly available on Gofundme until March 2019. Data related to each campaign has been analyzed and reported through descriptive analyses.

Results

Since 2017, 26 CAR-T treatment campaigns have been started. Due to the privacy policy of the platform, we were able to retrieve data from only 12 of them; 3 campaigns were closed, thus not disclosing enough data to be included. Nine campaigns were studied: 4 from Italy, 4 from the UK, 1 from Spain. The United States were the main destination. The median campaign goal was 180k€. The number of campaign shares on social media and the percentage of goal raised seemed to be linked.

Conclusions

CF is unquestionably a good expression of the Internet: it channels empathy towards important causes, providing tangible help. However, when applied to healthcare - especially to experimental treatments -, several questions arise. Patients affected by treatment resistant cancers may be prone trying new treatments to keep the hope alive, even when indication is missing or scientific evidence is lacking. Policymakers should monitor healthcare related CF campaigns, both for equity and safety reasons.

Key messages

Policymaker should monitor healthcare related CF campaigns, both for equity and safety reasons. Healthcare related crowdfunding campaigns could be interpreted as an indicator of unmet medical needs.

Food and lifestyle education at primary and secondary school: an Italian project on health promotion

Background

Nutrition and life styles have a crucial role as health determinants. In particular, an intervention on eating habits and physical activity/inactivity does heavily influence obesity and overweight prevention, alongside associated diseases. Preteen and teenage profile is critical for developing the state of health in adulthood, and it is heavily determined by the sociocultural family background. For this reason, school could become an important actor in health promotion, in the form of coordinated and cross-disciplinary courses about food and behaviors. The aim of the study is to verify the effect of an intervention of food education in several schools.

Methods

This cross-sectional study, originated from the “sCOOL FOOD” project of Monte dei Paschi Foundation of Siena, involves schools of southeastern Tuscany, Italy. The project currently engages various classes from primary and secondary schools in which year-round awareness campaigns are conducted. The activities consist in theory classes and workshops held by professionals or teachers of the school previously trained for the purpose. A same questionnaire was administered to families before and after each campaign, exploring eating habits, lifestyle and biometrics. The data analyzed so far date from October 2017 to May 2018. Wilcoxon signed-rank test was performed on the distributions of children BMI classes, defined according to IOTF cutoffs, obtained exclusively from participants who submitted both questionnaires.

Results

308 paired records of data were collected as mentioned above. We found that, after the campaign, children BMI classes distribution shift towards reduction was statistically significant (z=-2.053; p < 0.05).

Conclusions

Since the intervention was able to influence a childhood health determinant, it could be an opportunity to compensate those family dynamics that could lead towards health disadvantages in adulthood.

Key messages

A coordinated and cross-disciplinary food and lifestyle year-round education campaign at school can impact on health determinants of children. School can correct unfavorable eating and lifestyle behaviors determined by family habits.

Mortality trends for multiple sclerosis in Italy

Background

Multiple sclerosis (MS) is the immune-mediated inflammatory disease affecting myelinated axons of the central nervous system with enormous socio-economic impact. The aim of this study was to analyze mortality trends for MS in Italy.

Methods

The mortality data relative to period 1980-2015 were provided by Italian Institute of Statistics, data were aggregated in 5 intervals (1980-1986; 1987-1993; 1994-2000; 2001-2008; 2008-2015). The Age-Standardized mortality Rates (SR) with respective 95% confidence intervals (95%CI) were calculated (using the European standard 2013) in order to evaluate the mortality trends (in confrontation to the initial period) and Standardized Mortality Ratios (SMR), in order to confront mortality in 5 major geographic areas: North-East (NE), North-West (NW), Central Italy (CI), South Italy (SI) and Islands (I).

Results

During the study period 4959 deaths for males and 7433 for females were observed. The SRs were significantly higher for females (0.71;95%CI:0.70-0.73 vs. 0.56; 95%CI:0.54-0.57).

Significantly higher SMR were observed for both sexes in I (M:123.3 vs F:112.7), for females also in NE (106.5) and NW (115.8). Significantly lower SMR for both sexes were observed in SI (M:88.8; F:71.4) and for males in CI (90.9).

The observed SRs during the five intervals for males were: 0.65(95%CI 0.60-0.69); 0.52 (95%CI 0.49-0.56); 0.46 (95%CI 0.43-0.49); 0.53 (95%CI 0.49-0.56); 0.59 (95%CI 0.56-0.62); and for females: 0.69 (0.65-0.73); 0.69 (0.65-0.73); 0.61 (0.58-0.65); 0.68 (0.65-0.72); 0.81(0.77-0.84); respectively. An initial decrease of SRs was observed for males until 2001-2007 in confrontation to the initial period (p < 0.05). For females significant increase of SRs was observed in 2008-2015 (p < 0.05).

Conclusions

An increase of mortality for MS, observed for females, especially after 2000 may reflect the raising prevalence of MS in Italy. Important geographical differences were observed for five main areas.

Key messages

During the study period an increase of mortality for MS was observed for females. Important differences were observed between five main Italian geographic areas.

Hospital acquired infection, evaluation of point of prevalence in a 147 beds italian hospital

Background

Hospital Acquired Infections (HAI) have become a public health priority worldwide, leading to higher medical costs, prolonged hospital stays, and increased mortality. The point of prevalence analysis (PPA) of HAI and antibiotics (ATB) consumption is extremely relevant for its social and economic impact. Aim of this study is to evaluate the prevalence of HAI and to analyze ATB consumption in 147 beds hospital.

Material and Methods

This prevalence study was conduced on March 23, 2018, we analyzed the clinical documentation of 78 patients hospitalized in the Hospital of Val D’Elsa, Siena, Italy and searched for evidence of HAI and for all indication of ATB therapy in all hospital wards. HAI were defined according to guidelines of European Centers for Disease Control and Prevention (ECDC 4.2) using Stata 12.

Results

We analyzed a total of 78 patients (51,3% female), average age was 71,6 (sd ± 23,4) years, mean lenght of stay 7,2 (sd ± 7,9) days. Patients included in the study were recovered mostly in General Medicine ward (62,8%); 23% of patients underwent surgery. Fifty-one point three of patients had Peripheral Venous Catheter, 17,9% Central Venous Catheter and 47,4% Urinary Catheter. Three infections were discovered (PPA 3,8%); 2 HAIs were found in Medicine ward, the third one in the Intensive Care Unit. The chi-square test did not show statistically significant differences with the last year’s results in the same wards (p = 0.3305). Fifty-four percent of all patients received ATB, the most used class were third generation Cephalosporines (50%), followed by Carbapenems (19%) and Fluoroquinolones (7%).

Conclusions

PPA of HAI was 3,8%, comparable to last year’s (3,5%). This is a positive result when compared to regional and national point prevalence study realized by ECDC in 2012 (6,2% in Tuscany Region, 6% in Italy). Our analysis showed that ATB consumption was quite high: and it is in agreement with those provided by the Tuscany Region.

Key messages

in our hospital we report an excellent result about the pint of prevalence of hospital acquired infections 3,8%. The antibiotics consumption in our hospital is quite high, the most frequently used antibiotic class is the third generation Cephalosporines.

Could chips and nuts be vector of food-borne outbreaks during happy hour?

Background

A Greater tendency to eat meals outside the home has led to an increase in the attendance of restaurants, cafes, and fast food. That is one of the reasons why the global interest in handling food has risen over the years. The aim of this study is to understand the level of microbial contamination in the food that is served along happy hour in cafe.

Methods

This cross sectional pilot study was performed from April to May 2018 in the city of Siena, central Italy (<60000 citizens). Ten cafes were randomly selected. Samples of peanuts and potatoes were obtained in three different moments, at the beginning (T0), in the middle (T1), at the end (T2) of happy hours events. Collection of the samples was obtained using sterile kit and laboratory analysis was conducted in the University lab. The samples were located on selective medium and the growth of microbial pathogens were checked at 24 and 48 hours. The tested microorganisms were Enterococci, Staphylococci, Coliforms bacteria, Molds, and Yeasts. The statistical analyses were conducted using the Wilcoxon test using Stata 12.

Results

A significant Yeasts contamination appeared only on chips at T0, while within T0 and T1 we found a significant increase of Enterococci, Staphylococci, and Yeasts (p < 0.05) both in peanuts and chips. Comparing T1 and T2 only Yeasts showed significant growth in potatoes (p = 0.04). Between T0 and T2 we also found the growth of Coliforms bacteria in peanuts (p = 0.03).

Conclusions

We showed an increase in the microbial load associated with food handling, mostly of Enterococci. Long exposure time increased the likelihood of contamination and the possibility to exceed the dose for the occurrence of good outbreak. It is likely that offering small portions of handling food would reduce the manipulation by participants and the risk of food-borne outbreaks.

Key messages

Define the most frequent microrganisms could be associated with backed food and evaluate which one of these can exceed the dose for the occurrence of disease in long time. Reflect on the likelihood that the risk of food-borne outbreak caused by manipulation of happy hour participants, may result in an increase in hospital admissions.

Pediatric vaccination appointment scheduling: experience from an Italian clinic

Issue/problem

Since 2012 pediatric vaccination coverages in Italy have been decreasing. Negative trends have been recorded especially for hexavalent and MMR vaccines. In mid-2017 the Italian government passed an act making ten vaccines compulsory. Most recent data show the act is working, however other aspects of the process should be improved.

Description of the problem

Parents are invited to bring their children to the clinic through letters or telephone calls. Vaccination appointments are scheduled during weekdays, either in the morning, the afternoon, or both. Each session is carried out by a physician and a nurse, with a new patient scheduled every ten minutes. Appointments and vaccinations are registered on the vaccine-specific electronic health record (SISPC).

Results

In March 2019, the vaccination clinic worked 21 days for a total of 29 sessions. 823 appointments were available, 797 of them (96.8%) had a patient scheduled before the session started. 547 (68.6%) attended the vaccination appointment, 98.4% of them were vaccinated (538, 67.5% of the total patients scheduled). Among those who did not attend the scheduled appointment, only 108 (43.2%) agreed to reschedule. Eventually, only 58.3% of these patients attended the rescheduled appointment. No statistically significant differences among those who attended and those who did not attend the appointment were found among the variables retrieved from SISPC: day, time, vaccination planned (type, and if mandatory or not), sex, age.

Lessons

A third of available vaccination appointments in our clinic were lost. Despite the ease through which patients can reschedule an appointment, many choose not to and left their appointments unattended. Although missing a vaccination appointment can be appropriate - e.g. when the child is sick - and great effort should be put to achieve the goal of improving coverages, policymakers should also consider provisions to discourage such behaviors for a better use of resources.

Key messages

A third of available vaccination appointments in our clinic were lost in a month. Keeping in mind the goal of improving coverages, policymakers should aim for the best possible use of resources.

One-year activity of a “Casa de Espera” (Maternity Waiting Home) in the south of Angola

Background

Maternity Waiting Homes (MWHs) are structures usually located close to health facilities able to provide emergency obstetric care. Women can decide to be hosted in MWHs and when labour begins they move to the health facility for the delivery. Although the effectiveness of MWHs is debated, literature shows increasing findings about their importance. Aim of the study is to describe a one-year activity of a MWH located in Angola.

Methods

Since 2000, Italian Non-Governmental Organization (NGO) Doctors with Africa CUAMM supports the activities of the hospital of Chiulo in the district of Ombadja (Cunene province). Among the implemented projects, the NGO supports the local MWH (in Portuguese, “casa de espera”), providing dedicated staff and food for all the women hosted in the MWH. The MWH team routinely performs antenatal care visits and brief talks regarding maternal health. In case of pregnancy complications, the staff promptly refers women to the nearby hospital. The MHW team is also involved in routine data collection.

Results

In 2018, 703 women were admitted in the MWH. Three-hundred and forty-two (48.6%) were between 18 and 24 years of age. Four-hundred and eighty-two (68.6%) were invited to join the MWH by personnel of local health facilities, while 160 (22.8%) by family members and 61 (8.7%) by community health workers/traditional birth attendants. Age less than 18, previous abortion and/or caesarean were the most assessed factors for high risk pregnancy. In 2018, 1364 deliveries were performed in the hospital, and 593 (43.5%) concerned women hosted in the MWH.

Conclusions

To achieve the 2030 Sustainable Development Goals targets regarding maternal and neonatal mortality, the implementation of MHWs could represent an effective tool, especially in countries such as Angola where these indicators show a weak annual reduction. Regarding Chiulo’s MWH, an improvement of data collection could lead to a better comprehension of the efficacy of the facility.

Key messages

In the SDGs era, countries with a high burden of maternal and neonatal mortality should implement various and integrated approaches to achieve significant reductions of these indicators. Although the effectiveness of maternity waiting homes is still debated, increasing findings suggest that they could represent an effective tool to contain mother and child mortality.

Caesarean Delivery Rates in Birth Centres: confrontation using Robson Classification

Background

A caesarean section (CS) is a life-saving procedure, reducing perinatal mortality and morbidity, over last decades CS rates are increasing. In 2015 the Robson classification (RC) was introduced by WHO as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities and between them. The aim of this cross-sectional study was to identify the most numerous groups according to RC.

Methods

All women, who delivered by CS from January 2015 to June 2017 in two hospitals in the province of Siena (Italy): I level Birth Centre of Grosseto (GR) and II level Birth Centre of Siena (SI) were included. Age, type of hospital and group based on RC were extracted from Medical Register. The RC divides women into 10 groups based on 5 basic obstetric characteristics (parity, number of foetuses, previous CS, onset of labour, gestational age, foetus presentation). The percentages of the group’s contribution to the overall CS rate were calculated and confronted for two birth centres. All analysis was performed with Stata.

Results

A total of 2115 women was analysed, 50.5% from SI. Average age was 34.3±5.7; significantly higher for SI (34.7±5.6vs33.9±5.8). Most contributing groups were group V: multiparous, singleton, cephalic, term, with previous CS (24.2%), group II: nulliparous, singleton, cephalic, term, induced labour or CS (24%), group I: nulliparous, singleton, cephalic, term, spontaneous labour (11.45%), group VIII: multiple pregnancy (10.7%) and group X: singleton, cephalic, pre-term (10.4%).

Differences for type of birth centre were observed for groups I, II, V and VIII: I and VIII were more numerous in SI, II and V in GR (chi2; p < 0.05).

Conclusions

The most numerous groups were I, II e V, concordant with literature. Reduction of CS rates in group V could be obtained through lowering of primary CS rates and by promotion of Vaginal Birth After CS. Healthcare professionals could help to reduce labour-related anxiety and elective CS rates.

Key messages

The most contributing groups to overall caesarean section rates were groups I, II e V, as reported in literature. Reduction of CS rates could be obtained through lowering rates of primary CS, but also by promotion of Vaginal Birth After CS.

MRSA contamination in ambulances: a systematic review

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is a multidrug resistant organism (MDRO) frequently involved in skin, soft tissue and bone infections. Moreover, it is one of the most frequently isolated pathogen in bloodstream infections in European countries. Because of its capacity to survive on inanimate surfaces, this microorganism could be detected not only on hospital environment, but also in other healthcare settings such as ambulances. We performed a systematic review in order to study the level of MRSA contamination in ambulances (vehicle surfaces and medical equipment).

Methods

In March 2019 we searched studies in PubMed using the key search terms “MRSA, ambulance”. We included different designs of studies in English.

Results

The research yielded 18 publications: after title, abstract and full text’s analysis, 9 manuscripts were included in this review. Studies were conducted from 2007 to 2018 in USA, Egypt, Poland, Germany and South Korea. Overall, the number of ambulances sampled for MRSA was 511 (min. 3-max. 150), and 64 (12.5%) resulted contaminated by MRSA. Sampling points examined for each vehicle varied from 5 to 33, for a total of 5872 (min. 39-max. 2136) samplings performed. The amount of MRSA positive samplings was 145/5872 (2.5%) (min. 1-max. 43). Stretcher resulted the most frequently contaminated fomite (29 of the 145 MRSA positive samplings, 20%).

Conclusions

Despite MRSA prevalence is decreasing in Europe, recent studies showed how this MDRO could still be responsible of a remarkable burden in terms of attributable deaths and costs. Implementing effective sanitation procedures with a continuative monitoring of the processes is highly recommended in all the healthcare settings, including ambulances. Automated terminal disinfection of these vehicles, adopting technologies such as ultraviolet germicidal irradiation or hydrogen peroxide aerosol, could reduce bacterial contamination hosted on surfaces and medical equipment.

Key messages

Although the percentage of isolates of MRSA in European countries is decreasing, the burden this multidrug resistant organism in terms of mortality and costs remains remarkable. Ambulances must be considered as a potential reservoir of MRSA because of its ability to survive on inanimate surfaces, and adequate sanitation procedures should be frequently performed.

Italian adolescents and sexual health: what has changed during the last 20 years?

Background

In the majority of European countries, sex education is mandatory, but Italy is still an exception. Despite sexually transmitted diseases (STD) are believed to be less common today, long-time “forgotten” disease, as syphilis, are returning. The aims of study are i) to examine the knowledge and perceptions of adolescents regarding sex education and STD and ii) to compare our results with Italian national survey.

Methods

This descriptive cross-sectional study was conducted in 6 middle schools in Siena (Italy) during May-June 2018. Data were anonymous collected using a validate questionnaire previously adopted by the Italian National Institute of Health (NIH). The results were compared with the national survey realized in 1998 by NIH. The analysis was performed using Stata 12.

Results

From 691 questionnaires, 540 returned fulfilled (78% response rate). The majority (95%) of respondents considered sex education “important” and thought it should be guaranteed by the school; 48% described information received so far as “sufficient”, 40% as “adequate”. “School” was indicated as the principal source of information (44%), instead of “friends” which resulted in 1998. The respondents were asked to choose from the list the STDs they knew: 96% indicated “AIDS”, 62% “syphilis”, 38% “HBV” and 36% “gonorrhoea”. In comparison to 1998, knowledge of syphilis has decresed (2018:17% vs. 1998:62%) and HBV (2018:38% vs. 1998:58%). Regarding STD, the “mass media” were cited as the principal source of information (56%), followed by “school” (41%) and “General Practitioner” (20%).

Conclusions

In comparison to 1998 sex education in Italian schools improved, but the knowledge of adolescents regarding the STD worsened. This result can be attributed to the fact that the survey of 1998 was realized during the years when the AIDS awareness was higher. It is necessary to further improve the sex education in Italy in order to prevent STDs.

Key messages

The “forgotten” sexually transmitted diseases are becoming common again, the adequate sex education in schools is necessary to prevent them. In confrontation to 1998, the sex education in Italian schools improved, but the knowledge of adolescents regarding the STD worsened.

Aerobic exercise and Orexin A: role of sympathetic activity and redox system

Aerobic exercise is associated with the sympathetic activation evoking adaptive responses to sustain muscle engagement. Physical exercise can cause alterations in the cardiovascular activity and cellular stress may occur which could be marked by either heart rate (HR), or galvanic skin response (GSR). Moderate plasma levels of reactive oxygen species (ROS) are considered as health markers, absolving to important roles such as adaptive cellular responses to exercise. Orexin A, a hypothalamic peptide, causes a widespread stimulation of the sympathetic nervous system, playing a role in many physiological functions.

The Danger Signal Extracellular ATP Is Involved in the Immunomediated Damage of α-Sarcoglycan-Deficient Muscular Dystrophy

In muscular dystrophies, muscle membrane fragility results in a tissue-specific increase of danger-associated molecular pattern molecules (DAMPs) and infiltration of inflammatory cells. The DAMP extracellular ATP (eATP) released by dying myofibers steadily activates muscle and immune purinergic receptors exerting dual negative effects: a direct damage linked to altered intracellular calcium homeostasis in muscle cells and an indirect toxicity through the triggering of the immune response and inhibition of regulatory T cells. Accordingly, pharmacologic and genetic inhibition of eATP signaling improves the phenotype in models of chronic inflammatory diseases. In α-sarcoglycanopathy, eATP effects may be further amplified because α-sarcoglycan extracellular domain binds eATP and displays an ecto-ATPase activity, thus controlling eATP concentration at the cell surface and attenuating the magnitude and/or the duration of eATP-induced signals. Herein, we show that in vivo blockade of the eATP/P2X purinergic pathway by a broad-spectrum P2X receptor-antagonist delayed the progression of the dystrophic phenotype in α-sarcoglycan-null mice. eATP blockade dampened the muscular inflammatory response and enhanced the recruitment of forkhead box protein P3-positive immunosuppressive regulatory CD4⁺ T cells. The improvement of the inflammatory features was associated with increased strength, reduced necrosis, and limited expression of profibrotic factors, suggesting that pharmacologic purinergic antagonism, altering the innate and adaptive immune component in muscle infiltrates, might provide a therapeutic approach to slow disease progression in α-sarcoglycanopathy.