Assessing satisfaction in simulation among nursing students: psychometric properties of the Satisfaction with Simulation Experience - Italian Version scale

BACKGROUND

The Satisfaction with Simulation Experience scale is a 5-point Likert scale that measures students' satisfaction in medium and high-fidelity simulation scenarios. This study aims at investigating the psychometric properties of the Satisfaction with Simulation Experience - Italian Version scale.

METHODS

A multi-centre cross-sectional study was conducted. The scale was administered to a sample of 266 undergraduate nursing students from two Italian universities after attending a medium- and high-fidelity simulation session in November 2022 and March 2023. Cronbach's alpha coefficient and item-total correlation were sorted out to assess internal consistency and reliability. The test-retest method was used as a measure of scale stability over time as well as the confirmatory factor analysis to verify construct validity.

RESULTS

The Cronbach's alpha value was 0.94 for the overall scale, indicating excellent reliability, and it was 0.84 or higher for each subscales, indicating good reliability. A large correlation coefficient of 0.60 or higher was found between each item and its subscale and between each item and the overall scale score. A medium test-retest correlation coefficient was found for most items (r > 0.30). The confirmatory factor analysis confirmed the factorial structure found in the original study.

CONCLUSIONS

Satisfaction is an important teaching and learning quality indicator along with the achievement of learning outcomes in simulation. The Satisfaction with Simulation Experience - Italian Version scale showed good reliability and validity; therefore, it could be a useful tool to assess simulation impact in Italian nursing students. The extensive utilization of the Satisfaction with Simulation Experience scale, along with its various validated versions, could facilitate assessing satisfaction in simulation across diverse contexts and enable comparisons of findings across studies in different countries.

Changing Trends in B-Cell Non-Hodgkin Lymphoma Treatment: The Role of Novel Monoclonal Antibodies in Clinical Practice

We are currently witnessing a dramatic shift in our approach to the treatment of B-cell non-Hodgkin lymphoma (B-NHL). In the evolving clinical landscape, novel treatments for this clinically heterogeneous disease span a wide range of interventions, encompassing targeted agents, cell therapy approaches, and novel monoclonal antibodies (NMABs). Among these, the latter are likely to exert the most profound impact due to their distinctive high efficacy and versatile applicability. NMABs represent a heterogeneous group of agents, including naked antibodies, immunotoxins, and T-cell-engaging molecules. In recent times, several NMABs have either gained regulatory approval or are on the verge of introduction into clinical practice, addressing multiple therapeutic indications and treatment regimens. Their anticipated impact is expected to be broad, initially in the context of relapsed/refractory (R/R) disease and subsequently extending to early treatment lines. The scope of this review is to provide a comprehensive overview of the biological characteristics, clinical properties, efficacy, and toxicity profiles of NMABs that have recently been introduced or are nearing integration into clinical practice.

Argas ticks (Ixodida: Argasidae) on migratory birds from Africa: first record of a genotype close to Argas africolumbae in Italy

In spring, migratory birds reach Europe, mainly from sub-Saharan Africa or from northern African countries. Avian species may be implicated in the spread of pathogens, either as reservoirs, hosts or carriers of infected ectoparasites. In 2021, on Ventotene Island (Latium region, Italy) within a project focused on the potential incoming pathogens via migratory birds from Africa, we found two larvae of Argas sp., on the redstart Phoenicurus phoenicurus, that shared morphological features with the African Argas (Argas) africolumbae. Comparison of the tested larval DNA sequences to the adult reference sequences showed the highest identity (> 92%) with homologous sequences of A. africolumbae collected in South Africa and in Spain. This study reports the first detection of Argas africolumbae-like specimens in Italy.

Understanding chronic pain in the ubiquitous community: the role of open data

The combined use of social media, open data, and Artificial Intelligence has the potential to support practitioners and empower patients/citizens living with persistent pain, both as local and online communities. Given the wide availability of digital technology today, both practitioners and interested individuals can be connected with virtual communities and can support each other from the comfort of their homes. Digital means may represent new avenues for exploring the complexity of the pain experience. Online interactions of patients, data on effective treatments, and data collected by wearable devices may represent an incredible source of psychological, sociological, and physiological pain-related information. Digital means might provide several solutions that enhance inclusiveness and motivate patients to share personal experiences, limiting the sense of isolation in both rural and metropolitan areas. Building on the consensus of the usefulness of social media in enhancing the understanding of persistent pain and related subjective experiences via online communities and networks, we provide relevant scenarios where the effectiveness and efficiency of healthcare delivery might be improved by the adoption of the digital technologies mentioned above and repeated subsequently. The aim of this perspective paper is to explore the potential of open data, social media, and Artificial Intelligence in improving the prevention and management of persistent pain by adopting innovative non-biomedical approaches.

The role of Bruton's kinase inhibitors (BTKi) in accelerated Chronic Lymphocytic Leukemia (a-CLL): a case of successful response to acalabrutinib

OBJECTIVES

The use of Bruton's tyrosine kinase (BTK) inhibitors has changed the clinical history of patients with chronic lymphocytic leukemia (CLL) in both naïve and relapsed/refractory settings. "Accelerated" chronic lymphocytic leukemia (a-CLL) is a relatively rare form of CLL representing less than 1 % of all CLL cases. a-CLL patients usually have a more aggressive course and a reduced overall survival was reported with conventional chemo-immunotherapy approaches.

METHODS

The role of Bruton Tyrosine Kinase-inhibitor, ibrutinib, in a-CLL is well established with encouraging preliminary results.

RESULTS

We report a case of a-CLL-treated first-line with second-generation BTKi, acalabrutinib with a prompt clinical response. As known, it is the first literature report on acalabrutinib in a-CLL highlighting the role of second-generation BTKi also in this high-risk setting.

CONCLUSIONS

Target therapies (Bruton Kinase inhibitors and Bcl2 inhibitors) have improved the therapeutic landscape of CLL. The availability of therapeutic targets requires greater diagnostic accuracy to choose the most appropriate therapy for each patient.

High Levels of Circulating Tumor Plasma Cells as a Key Hallmark of Aggressive Disease in Transplant-Eligible Patients With Newly Diagnosed Multiple Myeloma

PURPOSE

High levels of circulating tumor plasma cells (CTC-high) in patients with multiple myeloma are a marker of aggressive disease. We aimed to confirm the prognostic impact and identify a possible cutoff value of CTC-high for the prediction of progression-free survival (PFS) and overall survival (OS), in the context of concomitant risk features and minimal residual disease (MRD) achievement.

METHODS

CTC were analyzed at diagnosis with two-tube single-platform flow cytometry (sensitivity 4 × 10^-5) in patients enrolled in the multicenter randomized FORTE clinical trial (ClinicalTrials.gov identifier: NCT02203643). MRD was assessed by second-generation multiparameter flow cytometry (sensitivity 10^-5). We tested different cutoff values in series of multivariate (MV) Cox proportional hazards regression analyses on PFS outcome and selected the value that maximized the Harrell's C-statistic. We analyzed the impact of CTC on PFS and OS in a MV analysis including baseline features and MRD negativity.

RESULTS

CTC analysis was performed in 401 patients; the median follow-up was 50 months (interquartile range, 45-54 months). There was a modest correlation between the percentage of CTC and bone marrow plasma cells (r = 0.38). We identified an optimal CTC cutoff of 0.07% (approximately 5 cells/µL, C-index 0.64). In MV analysis, CTC-high versus CTC-low patients had significantly shorter PFS (hazard ratio, 2.61; 95% CI, 1.49 to 2.97, P < .001; 4-year PFS 38% v 69%) and OS (hazard ratio, 2.61; 95% CI, 1.49 to 4.56; P < .001; 4-year OS 68% v 92%). The CTC levels, but not the bone marrow plasma cell levels, affected the outcome. The only factor that reduced the negative impact of CTC-high was the achievement of MRD negativity (interaction P = .039).

CONCLUSION

In multiple myeloma, increasing levels of CTC above an optimal cutoff represent an easy-to-assess, robust, and independent high-risk factor. The achievement of MRD negativity is the most important factor that modulates their negative prognostic impact.

AB1206 JUVENILE PRIMARY FIBROMYALGIA SYNDROME. RESULTS FROM A VOSVIEWER-BASED BIBLIOMETRIC NETWORK ANALYSIS

Background

In 1985, Yunus and Masi described the juvenile primary fibromyalgia syndrome (JPFS). It is a chronic musculoskeletal pain syndrome that affects children and adolescents [2] with an estimated prevalence that varies from 1.2 to 6.2% [3]. Clinical features are widespread persistent pain, sleep disturbance, fatigue, and the presence of multiple discrete tender points on physical examination. Notably, this syndrome can impact the quality of life status and psychosocial development of children and adolescents [4]. Despite a lot of research being conducted, several aspects on etiology and pathogenesis, clinical characteristics, and evaluation, as well as therapy should be better explained.

Objectives

This bibliometric analysis is aimed at dissecting the developed research in the subject. It could provide helpful findings for predicting the direction of future studies, implementing corrective measures, and improving research networks.

Methods

The global literature on JPFS was scanned in the Web of Science (WOS) online database. The search string applied to identify the closest matching articles was “Juvenile primary Fibromyalgia Syndrome (all field)“. All data were acquired on January 30, 2022. The information for the documents that met the requirements were extracted. The source was Journal Citation Reports™ 2020 (Clarivate Analytics). The literature analysis and knowledge visualization software tool VOSviewer (version 1.6.17) was used to analyze the co-occurrence of keywords (interconnection), co-citation (bibliographic coupling), co-citation analysis for sources, and countries, and analysis of the most productive organizations and networks.

Results

A total of 66 articles on JPFS were published from 1985 to January 2022, in WOS (n=24; median 2). About article types, 38 were research articles, 16 reviews, 8 meeting abstracts, 2 letters, 1 book chapters, 1 correction, 1 proceeding papers.

The analysis of keywords provided by authors showed that of 235 keywords, 38 met the threshold (interconnection 3). The most frequent keywords were Children (n=14); Adolescent (n=13), and Functional disability (n=10) (Figure 1)

Figure 1.

Co-occurrence of keywords

For the co-citation study, we used cited sources (journals) as unit (minimum numbers of citations of a source 15). Of 563 sources, 23 met the threshold. For each source, the total strength of the co-citation links with other sources was rated. The JOURNAL OF RHEUMATOLOGY (IF 4.66; Q2) obtained 22 links and 173 citations.

Most documents came fro the US (n=40; links=5), and Israel.

The analysis of affiliations was conducted by considering the cut-off 2 as the minimum number of documents of an organization. Out of 59 organizations, 23 met the threshold. The University of Cincinnati produced a total length strength of 3675 (11 documents).

Conclusion

This bibliometric network analysis on JPFS can be helpful for planning future research. It highlights the strength of representative scietists and core research teams. Research networks should be built, and high-value investigations are warranted.

References

[1]Yunus MB, Masi AT. Juvenile primary fibromyalgia syndrome. A clinical study of thirty-three patients and matched normal controls. Arthritis Rheum. 1985;28(2):138-45

[2]Coles ML, Uziel Y. Juvenile primary fibromyalgia syndrome: A Review- Treatment and Prognosis. Pediatr Rheumatol Online J. 2021;19(1):74

[3]Durmaz Y, Alayli G, Canbaz S, Zahiroglu Y, Bilgici A, Ilhanli I, et al. Prevalence of juvenile fibromyalgia syndrome in an urban population of Turkish adolescents: impact on depressive symptoms, quality of life and school performance. Chin Med J. 2013;126(19):3705–3711

[4]Coles ML, Weissmann R, Uziel Y. Juvenile primary Fibromyalgia Syndrome: epidemiology, etiology, pathogenesis, clinical manifestations and diagnosis. Pediatr Rheumatol Online J. 2021;19(1):22

Disclosure of Interests

None declared

Neutralising antibodies to West Nile virus detected in horses in Windhoek, Namibia

West Nile virus (WNV) is a vector-borne virus maintained in nature by a bird-mosquito cycle. However, it can occasionally and accidentally infect horses and human beings, leading to sometimes severe or even fatal outcomes in these species. Therefore, the monitoring of its circulation and disease occurrence is of relevance. Unfortunately, it is underdiagnosed or not diagnosed in several African counties, including Namibia, where no data is currently available for horses. In this study, 98 horses in three different stables in the Windhoek city area were investigated. They were found to have a seroprevalence of approximately 7%. Positive reactions were seen at all three stables, suggesting a greater than expected prevalence of the virus. This is the first report of serological evidence for the presence of the virus in horses in Nambia. Even though clinical signs were not reported in any of the stables from which the sera were derived, the seroprevalence to the virus suggests that horses with high genetic and/or economic value could benefit from vaccination against WNV. Because of the zoonotic potential of the virus, these findings are also of significance to human health authorities.

AB1134 BIBLIOMETRIC NETWORK ANALYSIS ON TOCILIZUMAB TREATMENT FOR COVID-19 PATIENTS

Background

Tocilizumab is a humanized monoclonal antibody. It provokes inhibition of the proinflammatory signals by binding to IL-6 receptors [1]. Due to these properties, it is used in inflammatory arthritis conditions and in cytokine release syndromes [2]. Notably, given its ability to intercept proinflammatory cascades, tocilizumab is an important option for patients with critical forms of COVID-19 [3]. Nevertheless, several aspects about the use of tocilizumab in this clinical setting should be better explained [4].

Objectives

This bibliometric analysis is aimed at dissecting the developed research in the subject. It could provide useful findings for predicting the direction of future studies, implementing corrective measures, and enhancing research networks.

Methods

The global literature on tocilizumab treatment for COVID-19 was scanned in the Web of Science (WOS) online database. The search terms applied to identify the closest matching articles included “tocilizumab” and “COVID-19”. All data were acquired on January 29, 2022. The information for the documents that met the requirements were extracted. The source was Journal Citation Reports™ 2020 (Clarivate Analytics). The literature analysis and knowledge visualization software tool VOSviewer (version 1.6.17) was used to analyze the co-occurrence of keywords (interconnection), co-citation (bibliographic coupling), co-citation analysis for sources, and countries, and analysis of the most productive organizations and networks.

Results

A total of 1019 articles on tocilizumab treatment for COVID-19 patients were published from 2020 to January 2022, in WOS. Of those: 462 in 2020, 546 in 2021, 11 on January 29, 2022. About article types, 697 were research articles, 322 reviews.

The analysis of keywords provided by authors showed that of 50 keywords, 17 met the threshold (interconnection 2). The most frequent keywords were EFFICACY, and OFF-LABEL USE (Figure 1)

Figure 1.

Co-occurrence of keywords

For the co-citation study, we used cited sources (journals) as unit (minimum numbers of citations of a source 1, maximum 3). Of 45 sources, 27 met the threshold. For each source, the total strength of the co-citation links with other sources was rated.

The minimum number of documents per country was 2. Thus, 23 countries met the threshold. The largest number of partnerships regarded the US, and Italy.

The analysis of affiliations was conducted by considering the cut-off 1 and 5 as the minimum and maximum number of documents. Out of 151 organizations, 94 met the threshold.

Conclusion

This bibliometric network analysis on tocilizumab treatment for COVID-19 patients can be useful for planning future research. It highlights the strength of representative scholars and core research teams. Additional networks should be built, and high-value clinical studies are needed.

References

[1]Sebba A. Tocilizumab: The first interleukin-6-receptor inhibitor. Am J Health Syst Pharm 2008;65:1413–1418

[2]Tanaka T, Narazaki M, Ogata A, et al. A New Era for the Treatment of Inflammatory Autoimmune Diseases by Interleukin-6 Blockade Strategy. Semin Immunol 2014;26:88–96

[3]Maraolo AE, Crispo A, Piezzo M, et al. The Use of Tocilizumab in Patients with COVID-19: A Systematic Review, Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Studies. J Clin Med 2021;10:4935

[4]Ascierto PA, Fu B, Wei H. IL-6 modulation for COVID-19: the right patients at the right time? J Immunother Cancer 2021;9:e002285

Disclosure of Interests

None declared

Dynamics of particle network in composite battery cathodes

Improving composite battery electrodes requires a delicate control of active materials and electrode formulation. The electrochemically active particles fulfill their role as energy exchange reservoirs through interacting with the surrounding conductive network. We formulate a network evolution model to interpret the regulation and equilibration between electrochemical activity and mechanical damage of these particles. Through statistical analysis of thousands of particles using x-ray phase contrast holotomography in a LiNi_0.8Mn_0.1Co_0.1O₂-based cathode, we found that the local network heterogeneity results in asynchronous activities in the early cycles, and subsequently the particle assemblies move toward a synchronous behavior. Our study pinpoints the chemomechanical behavior of individual particles and enables better designs of the conductive network to optimize the utility of all the particles during operation.

Does open data tell us everything?

The community of the entire planet is still grappling with the management of the Sars-CoV-19 pandemic and in some countries the spread of the infection is as serious as it was in Italy in the first months of 2020. In this issue of the magazine Kalli M et al. describe the situation in Chad.[...].

Dose/schedule-adjusted Rd-R vs continuous Rd for elderly, intermediate-fit patients with newly diagnosed multiple myeloma

Lenalidomide-dexamethasone (Rd) is standard treatment for elderly patients with multiple myeloma (MM). In this randomized phase 3 study, we investigated efficacy and feasibility of dose/schedule-adjusted Rd followed by maintenance at 10 mg per day without dexamethasone (Rd-R) vs continuous Rd in elderly, intermediate-fit newly diagnosed patients with MM. Primary end point was event-free survival (EFS), defined as progression/death from any cause, lenalidomide discontinuation, or hematologic grade 4 or nonhematologic grade 3 to 4 adverse event (AE). Of 199 evaluable patients, 101 received Rd-R and 98 continuous Rd. Median follow-up was 37 months. EFS was 10.4 vs 6.9 months (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.51-0.95; P = .02); median progression-free survival, 20.2 vs 18.3 months (HR, 0.78; 95% CI, 0.55-1.10; P = .16); and 3-year overall survival, 74% vs 63% (HR, 0.62; 95% CI, 0.37-1.03; P = .06) with Rd-R vs Rd, respectively. Rate of ≥1 nonhematologic grade ≥3 AE was 33% vs 43% (P = .14) in Rd-R vs Rd groups, with neutropenia (21% vs 18%), infections (10% vs 12%), and skin disorders (7% vs 3%) the most frequent; constitutional and central nervous system AEs mainly related to dexamethasone were more frequent with Rd. Lenalidomide was discontinued for AEs in 24% vs 30% and reduced in 45% vs 62% of patients receiving Rd-R vs Rd, respectively. In intermediate-fit patients, switching to reduced-dose lenalidomide maintenance without dexamethasone after 9 Rd cycles was feasible, with similar outcomes to standard continuous Rd. This trial was registered at www.clinicaltrials.gov as #NCT02215980.

COVID-19 pandemic and eating disorders: What impact on specific and general psychopathology?

Introduction

The coronavirus disease 2019 (COVID-19) pandemic and the resulting containment measures, such as “lockdown” and “social distancing”, have had important consequences on people’s mental and physical health.

Objectives

We aimed to study the effect of social isolation and subsequent re- exposure and eventual changes in general and ED-specific psychopathology in people with Eating Disorders (EDs).

Methods

Three-hundred twelve Italian people with EDs (179 Anorexia Nervosa, 83 Bulimia Nervosa, 48 Binge Eating Disorder and 22 Other Specific Feeding Eating Disorder) were asked to fill-in an online survey to explore several dimensions such as: anxiety, depression, panic, insomnia, suicide ideation, stress, post-traumatic stress and obsessive-compulsive symptoms. Differences in ED specific and general symptoms among the 3 investigated time periods (before, during and after the end of lockdown) were assessed with a one-way ANOVA with repeated measures. Subsequently, ED diagnosis was introduced as covariate in the analysis in order to investigate the possible contribution on psychopathological changes.

Results

ED core symptoms increased during the lockdown but most of them returned to pre-COVID19 levels at re-opening. The severity of general psychopathology also increased during the lockdown and persisted high in the following phase, except for depression and suicide ideation. None of this symptoms was affected by ED diagnosis, participants’age and illness duration.

Conclusions

People with EDs showed worsening of both general and specific psychopathology; moreover, changes in general psychopathology persisted in the re-opening period suggesting a higher stress vulnerability in this kind of patients.

Disclosure

No significant relationships.

Keyword

COVID19 and Eating Disorders

Tick species from Africa by migratory birds: a 3-year study in Italy

The role of resident or migratory birds in dispersal of tick species and tick-borne pathogens is still poorly known in Italy. We report here the results of a 3-year project based on sampling ticks from migratory birds, as well as from the vegetation at three stop-over sites for migrants, namely the islands of Ventotene (Latium), Asinara (Sardinia) and Ustica (Sicily). During the spring seasons from 2017-2019, in total 2681 ticks were collected, 2344 of which were sampled from migratory birds and 337 from the vegetation. Ticks were identified by morphology or by molecular tools when necessary. In total, 16 tick species were identified among which the following were exclusively found on birds: Hyalomma rufipes (43.3%), Hy. truncatum (0.1%), Ixodes frontalis (11.8%), Ix. inopinatus (0.2%), Ix. ricinus (3%), Haemaphysalis punctata (0.08%), Hae. erinacei (0.1%), Amblyomma variegatum (0.08%) and Argas vulgaris 0.1%), whereas five species were exclusively collected from the vegetation: Rhipicephalus bursa (10.5%), Rh. turanicus (5.9%), Rh. sanguineus sensu lato (2%), Rh. pusillus (2.4%), Hae. sulcata (0.08%). Hy. marginatum (10.3%) and Ix. ventalloi (9.3%) were found both on birds and on the vegetation on the island Ustica. It is worth noting that the search for ticks on the vegetation did not detect allochthonous tick species. Although we found several interesting local species and allochthonous ticks like Hy. rufipes, Am. variegatum and Ar. vulgaris on birds, further investigations are needed to better define the possible role of migratory birds in the introduction of ticks and tick-borne diseases in Italy, above all after the evidence of imported ticks positive to Crimean Congo hemorrhagic fever (CCHF) virus in several European countries.

Production and Easy One-Step Purification of Bluetongue Recombinant VP7 from Infected Sf9 Supernatant for an Immunoenzymatic Assay (ELISA)

Bluetongue (BT) is non-contagious, vector-borne viral disease of domestic and wild ruminants, transmitted by midges (Culicoides spp.) and is caused by Bluetongue virus (BTV). BTV is the type species of the Orbivirus genus within the Reoviridae family and possesses a genome consisting of 10 double-stranded RNA segments encoding 7 structural and 4 nonstructural proteins. Viral Protein 7 (VP7) is the major sera group-specific protein and is a good antigen candidate for immunoenzymatic assays for the BT diagnosis. In our work, BTV-2 recombinant VP7 (BTV-2 recVP7), expressed in Spodoptera frugiperda (Sf9) cells using a baculovirus system, was produced and purified by affinity chromatography from the supernatant of infected cell culture. The use of the supernatant allowed us to obtain a high quantity of recombinant protein with high purity level by an easy one-step procedure, rather than the multistep purification from the pellet. RecVP7-BTV2 was detected using a MAb anti-BTV in Western blot and it was used to develop an immunoenzymatic assay.

Lenalidomide in Pretreated Patients with Diffuse Large B-Cell Lymphoma: An Italian Observational Multicenter Retrospective Study in Daily Clinical Practice

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma subtype, and approximately 50% of the patients are >60 years of age. Patients with relapsed/refractory (rr) disease have a poor prognosis with currently available treatments. Lenalidomide is available in Italy for patients with rrDLBCL based on a local disposition of the Italian Drug Agency.

SUBJECTS, MATERIALS, AND METHODS

An observational retrospective study was conducted in 24 Italian hematology centers with the aim to improve information on effectiveness and safety of lenalidomide use for rrDLBCL in real practice.

RESULTS

One hundred fifty-three patients received lenalidomide for 21/28 days with a median of four cycles. At the end of therapy, there were 36 complete responses (23.5%) and 9 partial responses with an overall response rate (ORR) of 29.4%. In the elderly (>65 years) subset, the ORR was 33.6%. With a median follow-up of 36 months, median overall survival was reached at 12 months and median disease-free survival was not reached at 62 months. At the latest available follow-up, 29 patients are still in response out of therapy. Median progression-free survivals differ significantly according to age (2.5 months vs. 9.5 in the younger vs. elderly group, respectively) and to disease status at the latest previous therapy (15 months for relapsed patients vs. 3.5 for refractory subjects). Toxicities were manageable, even if 30 of them led to an early drug discontinuation.

CONCLUSION

Lenalidomide therapy for patients with rrDLBCL is effective and tolerable even in a real-life context, especially for elderly patients.

IMPLICATIONS FOR PRACTICE

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma, and approximately 50% of the patients are >60 years of age. Patients with relapsed/refractory (rr) disease have a poor prognosis, reflected by the remarkably short life expectancy of 12 months with currently available treatments. The rrDLBCL therapeutic algorithm is not so well established because data in the everyday clinical practice are still poor. Lenalidomide for patients with rrDLBCL is effective and tolerable even in a real-life context, especially for elderly patients.

Total body irradiation dose escalation decreases risk of progression and graft rejection after hematopoietic cell transplantation for myelodysplastic syndromes or myeloproliferative neoplasms

A non-myeloablative regimen of fludarabine and 200 cGy total body irradiation combined with post-grafting immunosuppression with mycophenolate mofetil and a calcineurin inhibitor facilitates allogeneic hematopoietic cell transplantation from HLA-matched related or unrelated donors in older patients and/or those with comorbidities. However, outcomes of prior studies have been disappointing in patients with myelodysplastic syndromes or myeloproliferative neoplasms due to high incidences of progression or graft failure (together termed hematopoietic cell transplantation-failure). We hypothesized that escalating the total body irradiation dose may improve the outcomes and subsequently performed a phase II total body irradiation dose-escalation trial. Patients with median age 66 years were enrolled in two arms to receive non-myeloablative conditioning followed by hematopoietic cell transplantation with total body irradiation dose escalation for excessive hematopoietic cell transplantation-failure: Arm A: myeloproliferative neoplasm/myelodysplastic syndrome low risk (n=36); and Arm B: myelodysplastic syndrome high-risk/chronic myelomonocytic leukemia (n=41). Total body irradiation dose levels were: Level-1 (300 cGy), Level-2 (400 cGy), or Level-3 (450 cGy). Patients received intravenous fludarabine 30 mg/m² for three days. Total body irradiation was administered on day 0 followed by infusion of peripheral blood stem cells from HLA-matched related (n=30) or unrelated (n=47) donors. Post-grafting immunosuppression with mycophenolate mofetil and cyclosporine was administered. The primary end point was day 200 hematopoietic cell transplant failure, with the objective of reducing the incidence to <20%. The primary end point was reached on Arm A at dose Level-1 (300 cGy total body irradiation) with a cumulative incidence of day 200 hematopoietic cell transplant failure of 11%, and on Arm B at dose Level-3 (450 cGy) with a cumulative incidence of day 200 hematopoietic cell transplant failure of 9%. Increasing the total body irradiation dose leads to a higher success rate with non-myeloablative conditioning by reducing relapse and rejection. Further studies are necessary to decrease non-relapse mortality, especially among patients with high-risk disease. Trial registered under clinicaltrials.gov identifier: NCT00397813.

Osteonecrosis of the Jaw in Myeloma Patients Receiving Denosumab or Zoledronic Acid. A Commentary of the Pivotal Trial by Raje et al. Published on Lancet Oncology

The recent randomized trial, published by Raje et al., on Lancet Oncology is potentially practice changing. It proposes that denosumab is a valid alternative to zoledronic acid in the treatment of myeloma patients. However, several points need further data and more details, such as information on incidence, diagnosis, and follow-up of osteonecrosis of the jaw (ONJ) cases, observed among treated patients. Adopted definition to adjudicate ONJ cases, type of registration of potential ONJ cases, length of observation are possible causes of potential underestimation of ONJ incidence in their study. Future updated evaluations with longer follow-up, and including actuarial estimation, are required for final judgment on ONJ risk in myeloma patients receiving denosumab, and comparison with ONJ risk by zoledronic acid.

Rituximab plus bendamustine as front-line treatment in frail elderly (>70 years) patients with diffuse large B-cell non-Hodgkin lymphoma: a phase II multicenter study of the Fondazione Italiana Linfomi

We conducted a phase II study to assess activity and safety profile of bendamustine and rituximab in elderly patients with untreated diffuse large B-cell lymphoma (DLBCL) who were prospectively defined as frail using a simplified version of the Comprehensive Geriatric Assessment (CGA). Patients had to be over 70 years of age, with histologically confirmed DLBCL. Frail patients were those younger than 80 years with a frail profile at CGA or older than 80 years with an unfit profile. Treatment consisted of 4-6 courses of bendamustine [90 mg/m² days (d)1-2] and rituximab (375 mg/m² d1) administered every 28 days. Other main study end points were complete remission rate and the rate of extra-hematologic adverse events. Forty-nine patients were enrolled of whom 45 were confirmed eligible. Overall, 24 patients achieved a complete remission (53%; 95%CI: 38-68%) and the overall response rate was 62% (95%CI: 47-76%). The most frequent grade 3-4 adverse event was neutropenia (37.8%). Grade 3-4 extra-hematologic adverse events were observed in 7 patients (15.6%; 95%CI: 6.5-29.5%); the most frequent was grade 3 infection in 2 patients. With a median follow up of 33 months (range 1-52), the median progression-free survival was ten months (95%CI: 7-25). The study shows promising activity and manageable toxicity profile of BR combination as first-line therapy for patients with DLBCL who are prospectively defined as frail according to a simplified CGA, as adopted in this trial (clinicaltrials.gov identifier: 01990144).

Khorana score and histotype predicts incidence of early venous thromboembolism in non-Hodgkin lymphomas. A pooled-data analysis of 12 clinical trials of Fondazione Italiana Linfomi (FIL)

Current data suggests that the risk of venous thromboembolism (VTE) in patients with non-Hodgkin lymphoma (NHL) is comparable to that observed in patients with solid tumours, although more robust confirmatory analyses are required. With that in mind, we investigated the occurrence of VTE in a pooled analysis of 12 "Fondazione Italiana Linfomi" (FIL) prospective clinical studies. Specifically, we wished to assess the cumulative incidence of VTE in NHL patients, evaluate the predictive value of the Khorana Score (KS), and identify other potential risk factors for VTEs. Data for VTE occurrence were retrieved from study databases and pharmacovigilance reports. Our analysis includes 1717 patients from 12 prospective phase II and III trials, including newly diagnosed NHL. We observed 53 VTEs (any grade) in 46 patients, with 20 severe VTEs in 17 patients. The cumulative incidences for "all-grade" or grade ≥3 VTEs were 2.9 % (95 % CI: 2.1-3.8) and 1.1 % (95 % CI: 0.6-1.6), respectively. KS categories were positively associated with the risk of VTE of any grade, and with severe events (i. e. grade ≥3; Gray's test p-values = 0.048 and 0.012, respectively). Among NHL patients, those with diffuse large B-cell lymphoma (DLBCL) showed a greater risk of (any grade) VTE (HR: 3.42, 95 % CI: 1.32-8.84, p-value = 0.011). Our study indicates that 1) VTE is a relevant complication for NHL patients, 2) KS is predictive of VTE events and 3) DLBCL histotype is an independent risk factor for VTE incidence, for which preventative interventions could be considered.

Predicting the Need for Intra-operative Large Volume Blood Transfusions During Thoraco-abdominal Aortic Aneurysm Repair

OBJECTIVE

Thoraco-abdominal aortic aneurysm (TAAA) repair is a complex procedure performed in patients at high cardiovascular risk. High volume intra-operative bleeding is often recorded, and the amount of intra-operative blood product transfusion is associated with relevant morbidity and mortality. The aim of the study was to identify pre-operative predictors of intra-operative large volume blood transfusions (LVBT) to stratify patients pre-operatively.

METHODS

This was a retrospective analysis of prospectively collected data of all patients who underwent open TAAA surgery at San Raffaele Scientific Institute from January 2009 to December 2015. Intra-operative red blood cell (RBC) transfusions were administered to maintain a hematocrit of at least 30%. A LVBT was defined as a transfusion of at least four RBC units, corresponding to 1000 mL.

RESULTS

The study population included 428 patients: 260 (61%) received fewer than 4 RBC units, and 168 (39%) were transfused with at least 4 RBC units. In patients who underwent LVBT, higher mortality was observed after surgery (p=.003), longer intensive care unit admission (p=.004), and longer mechanical ventilation compared with less transfused patients (p=.0002). The patients who received fewer units were administered a higher dose of heparin during the surgical operation compared with patients of the LVBT group: 3400±1100 vs. 2900±1300 IU (international units) (p=.0004). Pre-operative chronic renal failure (OR 1.8), the pre-operative haemoglobin value (OR 0.8), and the need for urgent or emergent surgery (OR 3.15) were independent predictors of LVBT on multivariate analysis.

CONCLUSIONS

The identification of patients at risk of intra-operative LVBT during TAAA surgery is critical as these patients experience a worse outcome. Nevertheless, only few independent predictors are available for clinical practice.

Online access and motivation of tutors of health professions higher education

The case study of PUNTOZERO as an open web lab for activities, research and support to 5 Master's courses for the health professions is described. A virtual learning environment integrated in a much wider network including social networks and open resources was experimented on for five Master's Courses for the health professions at the University of Parma. A social learning approach might be applied by the engagement of motivated and skilled tutors. This is not only needed for the improvement and integration of the digital and collaborative dimension in higher education, but it aims to introduce issues and biases of emerging e-health and online networking dimensions for future healthcare professionals. Elements of e-readiness to train tutors and improve their digital skills and e-moderation approaches are evident. This emerged during an online and asynchronous interview with two tutors out of the four that were involved, by the use of a wiki where interviewer and informants could both read and add contents and comments.

Usutu virus infections in humans: a retrospective analysis in the municipality of Modena, Italy

OBJECTIVE

To monitor the spread and to evaluate the role for public health of Usutu virus (USUV) in an endemic area of Italy.

METHODS

The survey was retrospectively conducted by detecting USUV RNA and USUV antibodies in cerebrospinal fluid and serum samples collected between 2008 and 2011 from 915 patients with or without neurologic impairments in the area of the municipality of Modena, Italy. Organs of birds and pools of mosquitoes were also tested for USUV RNA. Positive samples were partially sequenced and used for phylogenetic analysis.

RESULTS

The presence of USUV RNA (1.1%; 95% confidence interval (CI) 0.6-2.0) was significantly (p <0.05) higher than that of West Nile virus (0%; 95% CI 0-0.33). USUV antibody level was 6.57% (95% CI 4.87-8.82), and it was significantly higher (p <0.05) compared to that of West Nile virus (p 2.96, 95% CI 1.89-4.62). Partial genome sequencing of USUV strains detected in humans, birds and mosquitoes revealed high nucleotide sequence identity within them and with the USUV strains isolated in Central Europe.

CONCLUSIONS

USUV infection in humans is not a sporadic event in the studied area, and USUV neuroinvasiveness has been confirmed.

A phase II study on the role of gemcitabine plus romidepsin (GEMRO regimen) in the treatment of relapsed/refractory peripheral T-cell lymphoma patients

Background

There is no consensus regarding optimal treatment for peripheral T-cell lymphomas (PTCL), especially in relapsed or refractory cases, which have very poor prognosis and a dismal outcome, with 5-year overall survival of 30 %.

Methods

A multicenter prospective phase II trial was conducted to investigate the role of the combination of gemcitabine plus romidepsin (GEMRO regimen) in relapsed/refractory PTCL, looking for a potential synergistic effect of the two drugs. GEMRO regimen contemplates an induction with romidepsin plus gemcitabine for six 28-day cycles followed by maintenance with romidepsin for patients in at least partial remission. The primary endpoint was the overall response rate (ORR); secondary endpoints were survival, duration of response, and safety of the regimen.

Results

The ORR was 30 % (6/20) with 15 % (3) complete response (CR) rate. Two-year overall survival was 50 % and progression-free survival 11.2 %. Grade ≥3 adverse events were represented by thrombocytopenia (60 %), neutropenia (50 %), and anemia (20 %). Two patients are still in CR with median response duration of 18 months. The majority of non-hematological toxicities were mild and transient. No treatment-related death occurred and no toxicity led to treatment interruption.

Conclusions

GEMRO combination regimen shows efficacy data similar to those of single-agent romidepsin with additional hematologic toxicities. Synergy observed in preclinical phase did not turn into ability to improve clinical outcomes.

Trial registration

The trial was registered under EudraCT 2012-001404-38; ClinicalTrials.gov number, NCT01822886.

PO-03 - Khorana score and histotype predict the incidence of early venous thromboembolism (VTE) in Non Hodgkin Lymphoma (NHL). A pooled data analysis of twelve clinical trials of Fondazione Italiana Linfomi (FIL)

BACKGROUND

Recent studies show that the risk of VTE in NHL pts is similar to that observed in high risk solid tumors (i.e. pancreatic, ovarian cancer). VTE in NHL occurs in most cases within three months from diagnosis and can have substantial impact on treatment delivery and outcome as well as on quality of life. However few data are available on potential predictors.

AIMS

To better clarify the epidemiology of early (within six months from treatment start) VTE in NHL we conducted a pooled data analysis of 12 clinical trials from FIL. Our analysis included basic demographic features, lymphoma-related characteristics as well the Khorana score (based on histology, BMI, platelets WBC and HB counts) which is extensively used in solid tumors to predict VTE risk.

PATIENTS AND METHODS

From Jan. 2010 to Dec. 2014, all pts with B-cell NHL enrolled in prospective clinical trials from FIL for frontline treatment were included. For 9 studies study period included the entire trial population was included. The analyses were conducted based on CRFs as well as pharmacovigilance reports. VTE definition and grading was stated according to standard criteria of toxicity (CTCAE V4.0). Cumulative incidence of VTE from the study enrollment was estimated using the method described by Gooley et al. accounting for death from any causes as a competing risk. The Fine & Gray survival model was used to identify predictors of VTE among NHL pts. Factors predicting the grade of VTE were investigated using an ordinal logistic regression model. This pooled data analysis was approved by local IRB.

RESULTS

Overall, 1,717 patients belonging to 12 studies were evaluated. Eight were phase I/II or II (25% of pts) and 4 phase III (75% of pts). M/F ratio was 1.41, Median age was 57, (IQ range (IQR) 49-66). Histologies were: DLCL-B 34%, FL 41%, MCL 18%, other 6%. Median BMI was 25 (IQR 22-28). Median Hb, WBC and platelets counts were 13g/dl) (IQR 11.5-14.2), 7.1*10^(9)/l (IQR 5.6-10.3), 224*10^(9)/l (IQR 169-298), respectively. 1189 pts were evaluable Khorana score: 58% low risk, 30% intermediate risk, 12% were high risk. Human erythropoetin support was given to 9% of patients. All pts received Rituximab. Planned therapeutic programs included ASCT in 27% of pts, conventional chemotherapy in 67% a conventional chemotherapy plus lenalidomide in 6%. Overall 59 any grade VTE episodes occurred in 51 pts (2.9%), including 21 grade III-IV VTE (18 pts). None was fatal. Median time from study enrolment to VTE was 63 days (IQR: 35-110). Considering death as a competitive event the 6 months cumulative incidence of VTE was 2,2% in low risk Khorana score, 4.5% (95%IC: 2.3-6.7) in intermediate and 6.6% (95%IC: 2.4-10.8) in high risk (p=0.012) (figure 1). Khorana score was predictive also for grade III-IV events as they were 0,7% (95% CI:0.1-1.4) in low risk and 2.0% (95% CI:0.8-3.3) in intermediate-high risk (p=0.048). The results were similar also after excluding lenalidomide containing studies. The Fine and Gray multivariate analyses, adjusted for age and stage, showed that Khorana score (intermediate risk adjHR=1.96; 95%IC: 0.84-4.56 and high risk adjHR=3.81; 95%IC: 1.51-9.58) and DLCL-B histotype (adjHR=2.58; 95% CI: 1.01-6.55) were independently associated to an increased risk of VTE. Moreover an ordinal logistical regression model indicated that the increase of one point in the Khorana score resulted in an increased risk of VTE (OR=1.85; 95% CI: 1.23-2.79).

CONCLUSIONS

Our results suggest that DLCL-B histotype and Khorana score are predictors of VTE in NHL. The latter might become a simple and effective tool to assess the risk of VTE in NHL. Prospective validation including also patients not eligible for clinical trials is needed.