Volunteering in an emergency project in response to the COVID-19 pandemic crisis: the experience of Italian midwives

Objectives

During the first wave of the COVID-19 pandemic, the Region of Lombardy in Italy and its Regional Emergency Service (AREU) created a dedicated 24/7 free phone service to help the Lombard population. After an invitation from their professional order, local midwives collaborated on the AREU project as volunteers to address the needs of women from antenatal to postnatal periods. The aim of this article was to explore the experiences of midwives who volunteered in the AREU project.

Study design

A qualitative study using an interpretative phenomenology approach (IPA).

Methods

The experiences of midwives volunteering in AREU (N = 59) were explored using audio diaries. Written diaries were also offered as an alternative. Data collection took place between March and April 2020. Midwives were provided with semi-structured guidance that indicated the main areas of interest of the study. The diaries were thematically analysed following a temporal criterion; a final conceptual framework was created from emerging themes and subthemes.

Results

The following five themes were identified: (1) choosing to join the volunteer project; (2) the day-to-day difficulties; (3) strategies to cope with the unexpected; (4) professional relationships; and (5) reflecting on the personal experience.

Conclusions

This is the first study to investigate the experiences of Italian midwives who volunteered in a public health project during a pandemic/epidemic. According to participants, taking part in the volunteer activities was informed by and impacted on both their professional and personal lives. Overall, the experiences of midwives who volunteered in AREU were positive and of humanitarian value. Providing midwifery services within a multidisciplinary team for the benefit of public health represented both a challenge and personal/professional enrichment.

Treatment-emergent central sleep apnoea after surgery for obstructive sleep apnoea

Central sleep apnoea (CSA) is a lack of drive to breathe during sleep, which can occur in physiologic as well as in pathologic conditions. A particular type of CSA, defined treatment-emergent CSA (TECSA), may occur after the treatment of obstructive sleep apnoea syndrome (OSAS), either with CPAP or surgery. TECSA is transitory and seems to be related to the severity of OSAS. We describe a 51-year-old man affected by severe OSAS who developed severe, transient CSA immediately after upper airways surgery. We believe that CSA was triggered by the sudden variation in nocturnal arterial PCO₂, which decreased from 52.3 mmHg before surgery to 42.0 mmHg after surgery. It is conceivable that, due to long-lasting severe OSAS, our patient lowered his chemosensitivity to PCO₂. Consequently, the resolution of obstructive apnoeas and the restoration of normal nocturnal values of PCO₂ may have reduced the nocturnal PCO₂ to the point of being inadequate to stimulate ventilation.

Abstract P5-14-12: Long-term outcome of HER2-normal early stage breast cancer (ESBC) patients (Pts) treated with docetaxel-cyclophosphamide (TC) chemotherapy (CTx): Mature results of a single-institution experience

BACKGROUND

Anthracycline(A)-containing regimens (AReg) became an established standard (neo)adj CTx for ESBC following fairly consistent demonstration of a modest superiority over older anti-metabolite/alkylating CTx. However, substantial translational data and a recently presented pooled analysis [Blum, 2016] suggest that this superiority could be largely driven by greater benefits in specific ESBC subgroups, i.e. HER2-altered BrCa (due to co-amplification of topoisomerase 2 and HER2), and triple-negative BrCa (TNBC). A are cardiotoxic (including late onset of cardiomyopathic congestive heart failure) and potentially leukaemogenic. In late 2006, following the results of the first USONC randomized clinical trial that showed superior outcomes of the non-AReg TC (docetaxel/cyclo­phosphamide) over AC, we established a routine, uniform policy of TC for all Pts receiving (neo)adj CTx for HER2-normal ESBC. We report the mature follow up of this single-institution unselected experience.

METHODS

We performed a retrospective outcome analysis of all Pts who received at least 1 cycle of (neo)adj TC (docetaxel 75 mg/m2 + cyclophosphamide 600 mg/m2 IV every 3 weeks) at our Department for HER2-normal ESBC and with at least 5 years of follow up (FU). Pts were identified by systematic analysis of the dataset of the Oncology Pharmacy Unit. Information on tumour characteristics [e.g. axillary lymph nodes (N) metastases, hormonal receptors (HR) and HER2 status] and Pts FU were retrieved and collected into an ad hoc designed database. Pts with node-positive (N+) ESBC received TC×6 cycles, and Pts with high-risk node-negative (N−) [e.g. primary tumour (T) >2 cm, or HRneg, or T >3 cm] ESBC received TC×4 cycles. Pts received adjuvant hormone therapy and radiotherapy as per standard of care. From 2008 on, many lower risk HR+/N− Pts were not given CTx due to OncotypeDx availability.

RESULTS

Between September 2006 and December 2015, 810 female HER2-normal ESBC Pts were treated with (neo)adj TC. In the final outcome analysis we included 464 Pts treated before June 2011 thus having a minimum FU of 5 years. Pts characteristics are: median age 53 yrs (range 30-77), N− 246 (53%), N+ 218 (47%), hormone receptors positive (HR+) 391 (84%), TNBC 73 (16%). The database was locked as of June 1st 2016. Median FU from first cycle of TC is 7.5 yrs (range 5.3-10). 63 BrCa-specific relapse events (defined as time to local, regional or distant recurrence, invasive contralateral breast cancer, excluding non-breast second primaries) have been observed, accounting for an overall Relapse-Free Survival (RFS) rate of 86.4%. 42 deaths have occurred, 36 (86%) due to BrCa, accounting for an Overall Survival (OS) rate of 91%. RFS and OS rates for the different Pts subgroups are reported in Table 1

Table 1 - Outcome parameters RFS (%)OS (%)All Pts8691HR+/N-9396HR+/N+8190TN/N-9191TN/N+5858

CONCLUSIONS

These mature data with long FU suggest that the outcome for a large cohort of unselected Pts with HER2-normal HR+ ESBC (regardless of nodal status) and for TN/N− ESBrCa treated with nonAReg TC is excellent. However, N+TN ESBrCa in this setting remains a significant clinical challenge.

Citation Format: Losurdo A, Gullo G, Buckley C, Lowry C, Ballot J, Silva N, Hammond L, Crown J. Long-term outcome of HER2-normal early stage breast cancer (ESBC) patients (Pts) treated with docetaxel-cyclophosphamide (TC) chemotherapy (CTx): Mature results of a single-institution experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-14-12.

Abstract P4-04-06: Immune balance between tumor-infiltrating lymphocytes and tumor-associated macrophages impacts the outcome of triple negative breast cancer patients

Background: Stromal tumor-infiltrating lymphocytes (TILs) are emerging as a robust prognostic factor in triple negative breast cancer (TNBC). However, the prognostic value of TILs may be also influenced by the complex landscape of the tumor immune microenvironment. In this study, we aimed to assess the correlation between TILs and tumor-associated macrophages with pro-tumoral functions (M2 TAMs), and to determine the prognostic role of TAM/TIL ratio in TNBC.

Methods: Formalin-fixed, paraffin-embedded tissues were retrospectively collected from 189 patients with histologically confirmed invasive ductal TNBC. Stromal TILs were evaluated on H&E slides. The content of CD163-positive M2 TAMs in tumor stroma was assessed by immunohistochemistry. Whole tumor slides were independently assessed by two pathologists blinded for patient characteristics and outcome. CD163 staining was dichotomized into absent/moderate or dense infiltration; 50% stromal TILs was used as threshold (Salgado, 2015). Statistical analyses were performed using Spearman's correlation, Fisher's exact tests, Kaplan-Meier and Cox regression analyses.

Results: TNBC patients treated with adjuvant chemotherapy who experienced tumor recurrence showed a significant lower content of stromal TILs (p < 0.0001) and a higher infiltration of CD163-positive TAMs (p = 0.020) compared to patients without recurrence. Stromal TILs were also associated with lymph node positivity (p = 0.036). Univariate and multivariate analysis confirmed the importance of stromal TILs as a prognostic marker of recurrence-free survival (RFS), and overall survival (OS). Importantly, we found that stromal TILs inversely correlated with CD163-positive TAMs (rs = -0.539; p < 0.0001), indicating the significance of the balance between distinct immune components in the tumor microenvironment. Consistently, TNBC patients with a high TAM/TIL ratio had significantly shorter RFS (Log-rank p < 0.0001) and OS (Log-rank p < 0.0001) than patients with low TAM/TIL ratio. TAM/TIL ratio also retained its independent prognostic significance for RFS (HR = 7.02; 95%CI 2.09 - 23.59, p = 0.002) and OS (HR = 7.11; 95%CI 2.10 - 24.05, p = 0.002) in multivariate analysis.

Conclusions: Distinct immune cell subpopulation may have a specific role in modulating the immune response against breast tumor. A high content of TAMs with pro-tumoral functions may influence the recruitment of lymphocytes and suppress antitumor immunity. Indeed a high TAM/TIL ratio could help to identify a subset of TNBC patients at high risk for relapse and reduced OS. The understanding of the biological and clinical relevance of immune balance in tumor microenvironment warrants further investigations, and may be useful for the stratification of TNBC patients who may benefit from the addition of immunomodulatory therapies.

Citation Format: Bottai G, Raschioni C, Losurdo A, Di Tommaso L, Roncalli M, Santarpia L. Immune balance between tumor-infiltrating lymphocytes and tumor-associated macrophages impacts the outcome of triple negative breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-04-06.

Hyoid myotomy without suspension: a surgical approach to obstructive sleep apnoea syndrome

The aim of this study was to verify if hyoid myotomy without hyoid suspension is effective in surgical treatment of obstructive sleep apnoea syndrome (OSAS). We recruited six patients with OSAS, aged between 34 to 60 years, with retropalatal and retrolingual upper airway obstruction, non-obese (BMI < 27) and non-compliant to continuous positive airway pressure therapy. Pre-surgical clinical and instrumental evaluations included clinical examination, cephalometry, polysomnography (PSG) and sleep endoscopy. Surgical treatment included nasal surgery, uvulopalatopharyngoplasty, tonsillectomy and hyoid myotomy without hyoid suspension. Follow-up evaluations were performed with serial PSGs, performed early (one week after surgery), and at 1, 6 and 18 months after surgery. We observed that surgery was followed by immediate normalisation of breathing parameters evaluated by PSG that persisted after 18 months. Thus, hyoid myotomy without suspension combined with nasal and palatal surgery may be considered a valid treatment of non-obese OSAS patients with retrolingual and retropalatal collapse. Furthermore, we suggest that hyoid bone suspension, binding it to mandibular or to thyroid cartilage, might be unnecessary in selected cases.

Psychological functioning measures in patients with primary insomnia and sleep state misperception

OBJECTIVE

Sleep state misperception (SSM) is a term used in the International Classification of Sleep Disorders to indicate people who mistakenly perceive their sleep as wakefulness. SSM is a form of primary insomnia. The aim of this study was to record psychological functioning measures (anxiety, depression, ability to feel pleasure, obsessive-compulsive traits) in a population of patients with primary insomnia and to evaluate the relationship between these measures and the patients' perception of their sleep.

MATERIALS AND METHODS

Seventy-six consecutive patients with primary insomnia were enrolled: 34 men and 42 women, mean age 53.9 ± 13.1. Sleep study included the following: Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Berlin's Questionnaire and home-based polysomnography. Psychometric evaluation included the following: Self-Administered Anxiety Scale, Beck's Depression Inventory, Maudsley's Obsessive Compulsive Inventory, Snaith-Hamilton Pleasure Scale, Eating Attitude Test.

RESULTS

All patients with insomnia had psychometric scores higher than the general population, but very few patients, in both groups, had anxiety or depression scores consistent with severe mood or anxiety disorders. Comparisons between subjective and objective scores confirmed that most sleep parameters were underestimated. Patients with SSM had lower anxiety scores as compared to patients without SSM.

CONCLUSIONS

The study did not succeed in identifying any predictor of sleep misperception. We speculate that a group of patients, rather than being extremely worried by their insomnia, may have a sort of agnosia of their sleep.

Potential impact of the 70-gene signature in the choice of adjuvant systemic treatment for ER positive, HER2 negative tumors: a single institution experience

PURPOSE

We investigated in a single institution series of 124 women with operable breast cancer whether tumor clinicopathological features could predict the 70-gene signature (Mammaprint, MP) results, and whether MP results could help to make decisions for the use of chemotherapy (CT) in patients (pts) with ER positive breast cancer beyond recommendations of international guidelines.

RESULTS

Among the 68 ER/PgR positive, HER2 negative tumors, Ki-67 ≥ 20% was the only significant predictor of a high risk-MP among standard clinicopathological features. In candidates for endocrine therapy with undetermined benefit from CT according to international guidelines, MP results would have led to different treatment decisions in 13/46 (28%) and in 20/68 (29%) pts according to NCCN and St. Gallen recommendations, respectively.

CONCLUSIONS

Ki-67 independently predicted high risk-MP in ER/PgR positive, HER2 negative tumors. MP results would have led to discordant treatment recommendations in about 30% of cases, generally increasing indication rate for CT. The results of large randomized trials are warranted in order to understand whether we should rely on multigene assays rather than on standard clinicopathological features for treatment decisions.

Low-dose "metronomic chemotherapy" with oral cyclophosphamide and methotrexate in metastatic breast cancer: a case report of extraordinarily prolonged clinical benefit

We report the case of a 34-year-old woman affected by breast cancer that had metastasized to the bone. She had been treated with oral cyclophosphamide and methotrexate (metronomic chemotherapy) and achieved 3.5 years of clinical remission. To our knowledge, this is the first description of such a prolonged response to therapy. This case report adds weight to known data on metronomic treatment and supports further investigation of this therapy.

Palonosetron compared to ondansetron in the prevention of chemotherapy-induced nausea and vomiting: Activity, safety, and cost-effectiveness evaluation

e20573

Background: Chemotherapy(CT)-induced nausea and vomiting (CINV) are common adverse effects in cancer patients. The control of CINV is a relevant objective for the patient's quality of life and also aims to optimize cancer treatment. 5-HT3- receptor antagonists (RAs) are commonly used to prevent CINV. Palonosetron, the only second generation 5-HT3-RA, has a significantly longer half-life and a higher binding activity than the first generation of 5-HT3RAs. Methods: To evaluate the activity, safety and farmacoeconomic profile of palonosetron compared to ondansetron as antiemetic prophylaxis for highly (HEC) or moderately (MEC) emetogenic chemotherapy, 235 consecutive chemo-naïve patients (pts) were assigned (1:1) to receive palonosetron 250 mcg i.v. plus dexamethasone 8 mg i.v. 30 min before CT on day 1 (Group A) or ondansetron 8 mg i.v. plus dexamethasone 8 mg i.v. on day 1, followed by 8 mg os twice daily over 3 days (Group B). Results: The 2 treatment groups were comparable with respect to tumour type (breast 52%, lung 20%, colorectal cancer 11%, ovarian 8%, head & neck 5%, other 4%) and emetogenic potential of CT (HEC in 78 pts, AC-based chemotherapy in 123, MEC in 35). FLIE questionnaires were completed on days 2–5. Complete response (CR) rate for the acute period was 82% in pts given HEC in group A versus 63.2% in group B, 93.4 % versus 80.6% in pts given AC and 100% versus 94.4% in pts given MEC. For the delayed period: 74.4% in group A versus 63.2% in group B for pts receiving HEC, 90.2% versus 71% in pts given AC and 94% versus 88.9% in pts given MEC. FLIE analysis showed a reduced impact of CINV on daily life in group A (p<0.05). The pharmacoeconomic evaluation showed favourable cost effectiveness profiles for palonosetron, with a saving of about 50% per cycle/per patient over ondansetron. A not significant reduced incidence of headache and constipation was observed in group A. Conclusions: Palonosetron was effective in preventing CINV following HEC, AC and MEC in both acute and delayed phases, as well as being cost effective. The CR rates were maintained throughout subsequent cycles of CT, with a significant positive impact on daily functioning and quality of life.

No significant financial relationships to disclose.