Family matters inside the order Agaricales: systematic reorganization and classification of incertae sedis clitocyboid, pleurotoid and tricholomatoid taxa based on an updated 6-gene phylogeny

The phylogenetic position of several clitocyboid/pleurotoid/tricholomatoid genera previously considered incertae sedis is here resolved using an updated 6-gene dataset of Agaricales including newly sequenced lineages and more complete data from those already analyzed before. Results allowed to infer new phylogenetic relationships, and propose taxonomic novelties to accommodate them, including up to ten new families and a new suborder. Giacomia (for which a new species from China is here described) forms a monophyletic clade with Melanoleuca (Melanoleucaceae) nested inside suborder Pluteineae, together with the families Pluteaceae, Amanitaceae (including Leucocortinarius), Limnoperdaceae and Volvariellaceae. The recently described family Asproinocybaceae is shown to be a later synonym of Lyophyllaceae (which includes also Omphaliaster and Trichocybe) within suborder Tricholomatineae. The families Biannulariaceae, Callistosporiaceae, Clitocybaceae, Fayodiaceae, Macrocystidiaceae (which includes Pseudoclitopilus), Entolomataceae, Pseudoclitocybaceae (which includes Aspropaxillus), Omphalinaceae (Infundibulicybe and Omphalina) and the new families Paralepistaceae and Pseudoomphalinaceae belong also to Tricholomatineae. The delimitation of the suborder Pleurotineae (= Schizophyllineae) is discussed and revised, accepting five distinct families within it, viz. Pleurotaceae, Cyphellopsidaceae, Fistulinaceae, Resupinataceae and Schizophyllaceae. The recently proposed suborder Phyllotopsidineae (= Sarcomyxineae) is found to encompass the families Aphroditeolaceae, Pterulaceae, Phyllotopsidaceae, Radulomycetaceae, Sarcomyxaceae (which includes Tectella), and Stephanosporaceae, all of them unrelated to Pleurotaceae (suborder Pleurotineae) or Typhulaceae (suborder Typhulineae). The new family Xeromphalinaceae, encompassing the genera Xeromphalina and Heimiomyces, is proposed within Marasmiineae. The suborder Hygrophorineae is here reorganized into the families Hygrophoraceae, Cantharellulaceae, Cuphophyllaceae, Hygrocybaceae and Lichenomphaliaceae, to homogenize the taxonomic rank of the main clades inside all suborders of Agaricales. Finally, the genus Hygrophorocybe is shown to represent a distinct clade inside Cuphophyllaceae, and the new combination H. carolinensis is proposed. Taxonomic novelties: New suborder: Typhulineae Vizzini, Consiglio & P. Alvarado. New families: Aphroditeolaceae Vizzini, Consiglio & P. Alvarado, Melanoleucaceae Locq. ex Vizzini, Consiglio & P. Alvarado, Paralepistaceae Vizzini, Consiglio & P. Alvarado, Pseudoomphalinaceae Vizzini, Consiglio & P. Alvarado, Volvariellaceae Vizzini, Consiglio & P. Alvarado, Xeromphalinaceae Vizzini, Consiglio & P. Alvarado. New species: Giacomia sinensis J.Z. Xu. Stat. nov.: Cantharellulaceae (Lodge, Redhead, Norvell & Desjardin) Vizzini, Consiglio & P. Alvarado, Cuphophyllaceae (Z.M. He & Zhu L. Yang) Vizzini, Consiglio & P. Alvarado, Hygrocybaceae (Padamsee & Lodge) Vizzini, Consiglio & P. Alvarado, Lichenomphaliaceae (Lücking & Redhead) Vizzini, Consiglio & P. Alvarado. New combination: Hygrophorocybe carolinensis (H.E. Bigelow & Hesler) Vizzini, Consiglio & P. Alvarado. New synonyms: Sarcomyxineae Zhu L. Yang & G.S. Wang, Schizophyllineae Aime, Dentinger & Gaya, Asproinocybaceae T. Bau & G.F. Mou. Incertae sedis taxa placed at family level: Aphroditeola Redhead & Manfr. Binder, Giacomia Vizzini & Contu, Hygrophorocybe Vizzini & Contu, Leucocortinarius (J.E. Lange) Singer, Omphaliaster Lamoure, Pseudoclitopilus Vizzini & Contu, Resupinatus Nees ex Gray, Tectella Earle, Trichocybe Vizzini. New delimitations of taxa: Hygrophorineae Aime, Dentinger & Gaya, Phyllotopsidineae Zhu L. Yang & G.S. Wang, Pleurotineae Aime, Dentinger & Gaya, Pluteineae Aime, Dentinger & Gaya, Tricholomatineae Aime, Dentinger & Gaya. Resurrected taxa: Fayodiaceae Jülich, Resupinataceae Jülich. Citation: Vizzini A, Alvarado P, Consiglio G, Marchetti M, Xu J (2024). Family matters inside the order Agaricales: systematic reorganization and classification of incertae sedis clitocyboid, pleurotoid and tricholomatoid taxa based on an updated 6-gene phylogeny. Studies in Mycology 107: 67-148. doi: 10.3114/sim.2024.107.02.

Overview on novel strategies and current guidelines for hematopoietic stem cell mobilisation and collection

The success of the autologous stem cell transplantation is strictly related to an adequate hematopoietic stem cell mobilization and collection. The minimum threshold for a successful mobilization is currently defined as 2 × 106/kg CD34+ cells. However, the optimal stem cell mobilization strategy is still controversial. The availability of plerixafor, a selective and reversible CXCR4 inhibitor, has been associated with an higher use of chemo-free protocols by many centres. In the near future, it is conceivable that artificial intelligence may became more accurate and comprehensive, possibly guiding clinicians in choosing the optimal mobilisation treatment for the various patients undergoing hematopoietic stem cell transplantation. Machine learning-based scoring models may be the basis for the development of "intelligent" mobilisation algorithms.

Cost-Effectiveness of brexucabtagene autoleucel for relapsed/refractory mantle cell lymphoma

Brexucabtagene autoleucel is a chimeric anti CD19 antigen receptor T-cell therapy that allows durable responses in relapsed/refractory (R/R) mantle cell lymphoma (MCL). The present study compared the clinical and economic outcomes of R/R MCL patients (pre-exposed to ibrutinib and chemoimmunotherapy) treated with brexucabtagene autoleucel versus Rituximab, bendamustine, cytarabine (R-BAC) in the Italian Healthcare System. A partitioned-survival model extrapolated survival and healthcare costs of R/R MCL patients over a lifetime horizon. Discounted and quality-adjusted life expectancy (QALY) was 6.40 versus 1.20 for brexucabtagene autoleucel versus R-BAC and lifetime costs were €411,403 versus €74,415, respectively, which corresponds to a cost of €64,798 per QALY gained. The results were highly sensitive to brexucabtagene autoleucel acquisition cost and to assumptions on long-term survival, therefore the cost-effectiveness of brexucabtagene autoleucel for patients with R/R MCL requires validation with longer follow-up data and in specific risk subgroups.

Overview of the European species of the genus Clitocella (Entolomataceae, Agaricales) with notes on extralimital taxa

A revision, based on morphological and multigene analysis, of the Clitocella species currently present in Europe is provided. Portions of nrITS rDNA, nr28S rDNA (LSU), RNA polymerase II second largest subunit (RPB2), translation elongation factor 1-alpha (EF-1α), and ATPase subunit 6 (ATP6), were used to sort out the relationships of the species within the genus. Three subgenera were recognized: Clitocella subg. Clitocella encompassing C. popinalis, C. colorata, C. mundula, C. nigrescens, C. obscura and the new species C. solaris from Switzerland; the new Clitocella subg. Paraclitopilus including C. fallax and C. blancii; and the new Clitocella subg. Rhodopleurella for accommodating C. termitophila, a peculiar entity characterized by a pleurotoid habit and growing on decaying, abandoned termite nests in the Dominican Republic. Clitocella colorata originally described from China is here reported and described for the first time in Europe (Italy and Estonia). Rhodocybe cupressicola and Clitopilus ammophilus are reduced to later synonyms of Rhodopaxillus nigrescens; similarly, Clitopilus amarus is treated as a later synonym of Omphalia fallax while Rhodocybe amarella and R. ochraceopallida of Rhodopaxillus blancii. Finally, Austrian and Swedish herbarium collections identified as Rhodocybe, a doubtful taxon considered by several modern authors occasionally as either a similar but distinct species from R. popinalis or as a dwarfish, puny and odourless form of R. popinalis, have been proved to be R. tugrulii, a species recently described from Turkey and Estonia, and also later reported from Italy and USA. Citation: Vizzini A, Consiglio G, Marchetti M. 2023. Overview of the European species of the genus Clitocella (Entolomataceae, Agaricales) with notes on extralimital taxa. Persoonia 50: 123-157. https://doi.org/10.3767/persoonia.2023.50.04.

Reduction of double chin without surgery using ascorbic acid and ascorbyl-palmitate solution: a clinical study

OBJECTIVE

The purpose of the present clinical study is to assess the effectiveness of a lipolytic solution containing sodium salt of ascorbic acid at 0.24% and a surfactant agent at 0.020% ascorbyl-palmitate (SAP) for the treatment of double chin.

PATIENTS AND METHODS

A total of 10 healthy adult subjects affected by double chin (8 female and 2 male) were evaluated in the present investigation. The patients were admitted to a total of 4 sessions, with biweekly procedures, without no other active agents addiction.

RESULTS

In all the subjects a reduction of the convexity of the chin after the treatment with SAP was observed. Improvement in submental appearance was achieved in 90% (9/10) of the patients. One patient did not see any improvement in submental appearance after two section treatments and withdrew from the treatment.

CONCLUSIONS

In conclusion, in the present study, a new adipocytolytic solution consisting of sodium ascorbate mixed with ascorbyl-palmitate was used with success as a surfactant agent for the treatment of double chin.

Evaluation of the efficacy and safety of hyaluronic acid and supplemented with amino acids, and glutathione or colin, for the prevention and treatment of wrinkles on the face, neck, décolleté and hands

OBJECTIVE

Hyaluronic acid has been used for a long time as a biorevitalizer to treat skin aging both in single formulation and in association with other compounds such as amino acids or vitamins. The purpose of this study was to evaluate the efficacy and safety of class III medical devices SKIN B, SKIN R, SKIN OX, SKIN COLIN, for the treatment of wrinkles on the face, neck, décolleté and hands. These medical devices are all based on hyaluronic acid and supplemented with amino acids (SKIN B and SKIN R) and glutathione (SKIN OX) or colin (SKIN COLIN). This gives broader possibilities to the aesthetic surgeon for personalization and pharmacological diversification based on the patient's deficits to treat.

PATIENTS AND METHODS

A total of 60 subjects affected by skin damage such as rhytidids, dehydration, reduced sebum production and skin hypoxia were enrolled. The patients were treated with a session of mesotherapy every 7 days for 30 days, followed by other 2 sessions every 15 days for 30 days and the follow-up on day 90. The primary efficacy endpoint was evaluated by means of a 0-10 visual analog scale at day 60; the secondary efficacy endpoint was evaluated by means of a 0-10 visual analog scale at day 90.

RESULTS

All patients completed the 3-month follow-up. Treatment with SKIN B, SKIN OX, SKIN COLIN and SKIN R medical devices for the prevention and treatment of wrinkles on the face, neck, décolleté and hands were associated with favorable and positive results. A clear reduction of wrinkles has been clinically observed with improvement in the texture, brightness, and turgor of the skin. No adverse events were reported.

CONCLUSIONS

The medical devices SKIN B, SKIN SKIN OX, SKIN COLIN produce an aesthetic improvement in patients affected by skin defects, when administered by mesotherapy technique. This study confirms the safety and efficacy of the medical devices based on hyaluronic acid supplemented with amino acids and glutathione or colin.

Three-dimensional transvaginal ultrasound vs magnetic resonance imaging for preoperative staging of deep myometrial and cervical invasion in patients with endometrial cancer: systematic review and meta-analysis

OBJECTIVES

To evaluate and compare the diagnostic test accuracy (DTA) of three-dimensional transvaginal ultrasound (3D-TVS) and magnetic resonance imaging (MRI) for deep myometrial infiltration (DMI) and cervical invasion for preoperative staging and surgery planning in patients with endometrial cancer (EC).

METHODS

This systematic review and meta-analysis investigated the DTA of MRI and 3D-TVS for DMI and cervical invasion in patients with EC. A literature search was performed using MEDLINE, Scopus, EMBASE, ScienceDirect, The Cochrane library, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, EU Clinical Trials Register and World Health Organization International Clinical Trials Registry Platform to identify relevant studies published between January 2000 and December 2021. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool.

RESULTS

Five studies, including a total of 450 patients, were included in the systematic review. All five studies compared the DTA of 3D-TVS vs MRI for DMI, and three studies compared the DTA of 3D-TVS vs MRI for cervical invasion. Pooled sensitivity, positive likelihood ratio and negative likelihood ratio for detecting DMI using 3D-TVS were 77% (95% CI, 66-85%), 4.57 and 0.31, respectively. The respective values for detecting DMI on MRI were 80% (95% CI, 73-86%), 4.22 and 0.24. Bivariate metaregression indicated a similar DTA of 3D-TVS and MRI (P = 0.80) for the correct identification of DMI. Pooled ln diagnostic odds ratio for detecting cervical invasion was 3.11 (95% CI, 2.09-4.14) for 3D-TVS and 2.36 (95% CI, 0.90-3.83) for MRI. The risk of bias was low for most of the four domains assessed in QUADAS-2.

CONCLUSION

3D-TVS demonstrated good diagnostic accuracy in terms of sensitivity and specificity for the evaluation of DMI and cervical invasion, with results comparable with those of MRI. Thus, we confirmed the potential role of 3D-TVS in the preoperative staging and surgery planning in patients with EC. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

P314 WHEN TAKO–TSUBO TRAPS… NOT ONLY OCTOPUSES

The case we present involves a 75 years–old woman with no cardiological past medical history, who presented to our attention complaining of sudden onset thoracic pain associated with dyspnea, dry cough, nausea and an episode of vomit. She called 911 rapidly coming to our Hospital. In the Emergency room an EKG showed ST segment depression in the inferior leads and in the blood test a remarkable increase in HS–Troponin level was evident. An echocardiogram showed mid and apical left ventricle segments hypokinesia with moderately reduced Ejection Fraction (45%); notably, right ventricle was increased in dimension with moderate tricuspid regurgitation and mild pulmonary hypertension. Because of this last find, D–dimer was checked and a pulmonary angio– CT was performed which excluded active pulmonary embolism. Next day she underwent coronary angiography which showed no coronary lesion able to explain the clinical and echocardiographic presentation; left ventriculography was also performed showing an increase in end–systolic volume with hypokinesia of the anterolateral, apical and diaphragmatic walls and an Ejection Fraction (EF) of 30%. These findings allowed us to make the diagnosis of Tako–Tsubo syndrome, also known as stress–induced cardiomyopathy. Few days later, a cardiac magnetic resonance (CMR) was performed showing whole apical and antero–lateral mid ventricular hypokinesia with compensatory hyperkinesia of basal segments; T2–weighted sequences were positive at the hypokinetic segments with no specific Late Gadolinium Enhanced (LGE) images. What’s more, an atrial septal defect type “ostium secundum” was clearly evident, causing a left–to–right shunt hemodynamically significant (Qp/Qs of about 2,8) with right atrial and right ventricle dilatation. Pulmonary artery and its main branches were dilated too. After these findings, lady underwent right heart cardiac catheterization that reported a Qp/Qs of 3,24 and a shunt flow of 8,78 L/min, with a cardiac index of 2,5 L/min/m2 and normal pulmonary vascular resistance (0,7 Wood Units). Because of these measures the patient was discharged from our Cardiology Unit and referred to the Interventional Cardiology centre of our city for the percutaneous closure of the hemodynamically significant atrial septal defect.

This case is curious because it shows how things in Cardiology can be deeply and unpredictably connected.

P141 CORRELATION BETWEEN TAKO–TSUBO SYNDROME AND OCCULT CANCER

Introduction

Tako–Tsubo Syndrome (“TTS”) is a cardiomyopathy characterized by an acute reversible left ventricular dysfunction, mainly triggered by emotional or physical stress. Several variants have been reported, including reverse TTS, characterized by hypokinesia of basal segments and hyperkinesis of the apical ones. TTS has a clinical presentation similar to acute coronary syndrome but without evidence of obstructive coronary artery disease. A surprising association between TTS and cancer arose out of recent studies.

Case Presentation

74–year–old patient got to the emergency room of our hospital for the appearance, apparently in the health, in the absence of physical or emotional stress of oppressive chest pain. On the ECG, there was evidence of ST–segment elevation in inferior leads, for which urgent coronary angiography was performed. It did not show significant stenotic lesions nor evidence of elevated troponin values. The Echocardiogram showed hypokinesia of the basal segments and hyperkinesis of the mid–apical ones, with EF 40%. In the following days, the patient performed MRI–heart with detection of LGE of the intramyocardial type (non–ischemic pattern) in correspondence with the inferior wall in the medioventricular area. During hospitalization on routine chest x–ray, hypodiaphanous image was found in the left apex for which an HR CT scan of the chest was performed which a lesion in the left apical lung area with spiculated margins of a heteroplastic nature, associated with multiple bilateral lesions suggestive of secondaryism. Therefore, the patient was taken over by the Oncology service.

Conclusions

Such case confirms the association between TTS and occult cancer. In the absence of obvious physical or emotional stress that may explain the onset of TTS, it is important to research for any silent neoplastic pathology. The literature shows that the prevalence of malignant diseases is high in patients with TTS. Recent studies have pinpointed the activation of the sympathetic nervous system promotes cardiac inflammation by upregulating ICAM–1 and the expression of p53. Furthermore, inflammation can lead to the activation of p38 MAP Kinase, thus contributing to myocardial stunning. The specific role of inflammation as a cofactor of adrenaline–induced stunning deserves further investigation in the specific context of malignant tumors, which are frequently associated with an enhanced inflammatory state.

P300 ACUTE MYOCARDITIS COMPLICATED BY VENTRICULAR ARRHYTHMIAS

Background

Many kinds of arrhythmias may occur in patients with myocarditis at any stage of the disease. However, as compared to the other clinical presentations, arrhythmic myocarditis has been poorly described in literature.

Case Report

A 20–year–old girl, without CVRF or comorbidities, presented at the ED because of palpitations and epigastric pain irradiated to left arm. 12–lead ECG evinced elevated HR and aspecific repolarization abnormalities. Blood samples showed high cTn value and normal PCR value. Echocardiography showed a preserved LVEF, without abnormalities. Patient was hospitalized with a diagnosis of suspect acute myocarditis. Following hospital stay has been complicated by recurrent episodes of chest pain with concomitant increase of cTn that finally had presented a sinusoidal trend (peak 12830ng/L). At the same time, continuous ECG monitoring has been showing frequent but short term ventricular extrasystole activity, so B–blocker therapy was optimized. On ECG monitoring, appearance of short runs of asymptomatic mono– and polymorphic NSVT and after a few days appearance of polymorphic NSVT “torsade de pointes” like, symptomatic for presyncope. New changes in kinetics appear on the echocardiogram: hypokinesia of medio–apical segments of lateral, anterior wall septum. Therapy with metoprolol and lidocaine iv was started with subsequent stabilization of the rhythm. CMR presented data suggestive of myocarditis. Patient performed several BEM at different time and centers: diagnostic signs of myocarditis were not be found. Autoimmune and infectious disease screening, abdominal echography and a PET TC total body were been performed to research a potential etiology, without positive result. Patient has been discharged with wearable defibrillator and we waited for the ICD implantation in secondary prevention. Follow–up CMR showed a resolution of inflammation and no signs of fibrosis. Blood samples did not demonstrate a rise of cTn. After discharged, she has not had news onset of ventricular arrhythmias.

Conclusion

The mechanisms underlying the occurrence of ventricular arrhythmias during myocardial inflammation are less clear. Arrhythmias usually being self–limited with no recurrences that follow the acute phase. Management of acute life–threatening arrhythmias is generally supportive and there is a lack of evidence to support the use of specific antiarrhythmic agents. Wearable life vest has been presented as a possible therapeutic option.

P144 PEMBROLIZUMAB–INDUCED MYOCARDITIS

Introduction

Patients treated with Immunocheckpoint Inhibitors (ICI) can develop adverse cardiovascular events, most frequently myocarditis, but also arrhythmias, conduction abnormalities, pericarditis, Takotsubo syndrome, ACS, heart failure, cardiac arrest. Myocarditis occurs early, within the first 3–4 administrations of therapy, and is fraught with a high mortality rate.

Case Presentation

80–year–old patient with renal pelvic carcinoma who underwent nephroureterectomy and subsequent adrenalectomy. Twenty days after the first cycle of Pembrolizumab, the patient is admitted to cardiology for syncope and ECG finding of Left Posterior Fascicular Block (LPFB) and right bundle branch block (RBBB) with significant increase in troponin without any alterations in regional kinetics and normal ventricular function (EF). The patient also complains of widespread muscle pain and severe hyponatremia on blood tests. On ECG monitoring, alternation of RBBB with associated LPFB and Left Posterior Fascicular Block, left bundle branch block, first and second degree atrio–ventricular block (AV block) and on day II appearance of complete paroxysmal AV block controlled with temporary pacemaker implantation. On the 4th day, we documented changes in the segmental motion of the left ventricle (LV) and progressive gradual worsening of the EF. During the hospitalization the patient manifested episodes of general malaise with profuse sweating and marked hypotension with possible SIADH picture. In suspicion of acute myocarditis, peripheral myositis and possible Pembrolizumab SIADH, the patient was treated with high dose methylprednisolone (1000 mg / day) with little benefit. On the 6th day the patient was found in critical condition, severely suffering, hypotensive and oliguric, resigned herself.

Conclusions

Our case highlights how even a single dose of Pembrolizumab can trigger an acute inflammatory pattern affecting the myocardium with prevalent involvement of the conduction tissue even before the appearance of alterations in the kinetics and ventricular dysfunction. During ICI therapy cycles it is therefore important to monitor the ECG and troponin levels in order to be able to diagnose myocardial involvement early. In fact, although this complication is rare, it is burdened by a high mortality rate. The only treatment currently available involves the suspension of immunotherapy and the administration of high–dose methylprednisolone.

Link between gut microbiota dysbiosis and chronic kidney disease

During chronic kidney disease (CKD), typical alterations in the gut microbiota are observed. The kidney no longer plays the role of the main excretory organ as this function is performed by the intestine. In CKD patients, an alteration of intestinal permeability and a degradation of the protective mucous layer are observed. These changes in the intestinal barrier allow the passage of bacterial material from the intestine to the bloodstream through the intestinal wall. This phenomenon contributes to the induction of the chronic inflammatory state, typical of CKD. In nephropathic patients, there is an increase in circulation of p-cresyl sulfate (p-CS), indoxyl sulphate (IS), indole-3 acetic acid (IAA) and trimethylamine-N-oxide (TMAO), all gut-derived uremic toxins. The changes in gut microbiota composition are related to CKD stage and this phenomenon is exacerbated in hemodialysis (HD) adult and pediatric patients. Interestingly, it is observed a positive shift in gut microbiota composition after renal transplantation and at the same time a reduction of circulating gut-derived uremic toxins. Either gut dysbiosis or uremic toxins accumulation contribute to the CKD onset and progression.

Social inequalities and nutritional disparities: the link between obesity and COVID-19

OBJECTIVE

Cohort studies, clinical audits of patients with COVID-19 in hospital and routine primary care records provided evidence-based insights on the relationship between excess weigh, obesity and COVID-19. The purpose of this umbrella review is to highlight the relationship between nutritional quality and social inequalities related to CDNCD, obesity and SARS-CoV-2 infection.

MATERIALS AND METHODS

Only articles published from 2008 to the present were included in the search to show an updated picture of the topic. The search for published studies was conducted in February 2021 in the scientific databases PubMed (MEDLINE). The terms used for the search were "COVID-19", "Obesity", "Disparities", "Nutritional inequalities", "Chronic degenerative non-communicable diseases" and "review" OR "systematic review" OR "meta-analysis" separated by the Boolean operator AND.

RESULTS

1874 reviews were found, but only 99 met the objective. Obese or dysmetabolic patients are those who had a worse course of disease following COVID-19. This data was observed not only for Chinese and Caucasians, but also and above all among Africans, African Americans, Latinos and indigenous people. Plausible mechanisms to explain the association between obesity and COVID-19 outcomes, included the role of excess adipose tissue on respiratory function, metabolic dysfunction, the cardiovascular system, enhanced inflammatory response and impaired response to infection.

CONCLUSIONS

Today, chronic non-communicable degenerative diseases (CDNCDs) are responsible for 70% of public health expenditure, affecting 30% of the population (one or more chronic diseases). Unfortunately, given the health emergency due to SARS-CoV-2, infectious diseases are currently more at the center of attention. However, the spread of infectious communicable diseases and CDNCDs is facilitated in situations of social disparity. In fact, in the poorest countries there are the highest rates of malnutrition and there is a greater risk of contracting viral infections, as well as, paradoxically, a risk of comorbidity, due to access to cheaper food and qualitatively poor, with high caloric density.

Health Technology Assessment for COVID19: an approach for the Horizon Scanning of health innovations

Background

The COVID-19 pandemic definitely changed the approach to technologies evaluation, firstly in terms of timeliness. In order to answer to this need, a new methodology was proposed, joining the elements of horizon scanning with the Multi-Criteria Decision Analysis (MCDA). In this work we describe the results of 2 case studies of application.

Methods

By means of an assessment matrix, a multidisciplinary expert panel gave a score based on a Likert scale and related to potential value and perceived risk for each technology. Economic, clinical and ethical criteria were considered as a summary of Health Technology Assessment (HTA) main domains. The final scores were then weighted by the MCDA and a scatter plot defined 4 positioning scenarios according to the balance of values and risks resulted, each conducting to an appropriate recommendation (full HTA report or reject). A Monte Carlo simulation was also carried out for the assessment of variability of results.

Results

An individual protection device for COVID-19 and a contact tracing app were assessed. The first technology was placed in the “Danger Zone” of the graph, because of its high costs and organizational complexity. The second one was placed in the “Comfort Zone” of the graph, due to low costs and easiness of implementation and management. For this innovation a recommendation for a full HTA and a pilot testing was given. In both cases, the Monte Carlo simulation confirmed the results of previous analyses.

Conclusions

The implementation of this new tool presented for the large amount of innovations created in response to COVID-19 could be supportive for decision makers, especially in pandemic times when a rapid answer is necessary. Improvements in the subjective judgement process, by introducing an objective approach, is now ongoing as it could enhance the strength of the final decision.

Key messages

In a pandemic time as the current, HTA should be as rapid as possible without losing scientific robustness. The methodology described could be an answer in support to the decision-making process, allowing an adequate and quick priority setting.

Non–Small-Cell Lung Cancer: Real-World Cost Consequence Analysis

Background

The present work aimed at conducting a real-world data analysis on the management costs and survival analysis comparing data from non-small-cell lung cancer (NSCLC) cases diagnosed in the Veneto region before (2015) and after (2017) the implementation of a regional diagnostic and therapeutic pathway including all new diagnostic and therapeutic strategies.

Methods

This study considered 254 incidental cases of NSCLC in 2015 and 228 in 2017 within the territory of the Padua province (Italy), as recorded by the Veneto Cancer Registry. Tobit regression analysis was performed to verify if total and each item costs (2 years after NSCLC diagnosis) are associated with index year, adjusting by year of diagnosis, sex, age, and stage at diagnosis. Logistic regression models were run to study overall mortality at 2 years, adjusting by the same covariates.

Results

The 2017 cohort had a lower mortality odd (odds ratio, 0.93; P = .02) and a significant increase in the average overall costs (P = .009) than the 2015 cohort. The Tobit regression analysis by cost item showed a very significant increase in the average cost of drugs (coefficient = 5,953, P 5 .008) for the 2017 cohort, as well as a decrease in the average cost of hospice care (coefficient = -1,822.6, P = .022).

Conclusions

Our study showed a survival improvement for patients with NSCLC as well as an economic burden growth. Physicians should therefore be encouraged to follow new clinical care pathways, while the steadily rising related costs underscore the need for policymakers and health professionals to pursue the most rational utilization of public resources.

Key messages

Our work underscores the importance of real-world assessment of costs in oncology, especially in case of a disease like NSCLC, which has such a high impact on treatment costs and patient outcomes. New therapies prolong survival for patients with NSCLC but their sustainability reminds of the importance of prevention: the earlier the diagnosis, the longer the survival and the lower the costs.

A prospective evaluation of COVID-19 associated coagulopathy with acute coronary syndrome (ACS)

Background

Hospitalised COVID-19 pneumonia patients are characterised by the occurrence of a hypercoagulable state associated to a high risk of thromboembolic events. The main laboratory findings of this coagulopathy include D-dimer increase, mild thrombocytopenia, prolonged PT, and increase endothelial activation biomarkers (vWF, thrombomodulin). No data are available about coagulation profile in patients presenting with an acute coronary syndrome (ACS) combined with SARS-CoV-2 infection.

Purpose

In this prospective study, we aimed to evaluate the contribute of concomitant SARS-CoV-2 infection to the haemostatic system derangement (i.e., from endothelial cell activation to fibrinolytic phase) observed in patients presenting with ACS. Further, the role of haemostatic biomarkers (HB) for in-hospital mortality risk prediction was also explored.

Methods

Consecutive patients admitted to our hospital for ACS at peak intensity of local pandemia were enrolled into this study. At admission, all patients underwent routine blood examinations with blood count, serum biochemical tests and an extensive coagulation profiling. Data from coronary angiography and percutaneous coronary intervention (PCI), when performed, were collected. In-hospital major adverse cardio and cerebrovascular events –MACCEs- (total and cardiovascular death, stroke, systemic or pulmonary embolism, re-MI and bleedings) are reported.

Results

A total of 99 (76M/23F) consecutive patients with a median age of 66.7 (±12.1) were enrolled. According to nasal swab, 24 patients were SARS-CoV-2 positive and 75 negative. The two groups, similar in age, sex and cardiovascular risk factors, significantly differed in presenting symptoms (p<.001) and radiological signs of pneumonia (p<.0001). At admission, there were no differences in routine laboratory values between groups. Differently, analysis of the HB showed significantly higher values of D-dimer, vWF antigen, vWF activity and vWF; RiCof, t-PA and PAI-1 and lower levels of ADAMTS-13 in the positive group. Furthermore, among ACS patients, both STEMI and NSTEMI subjects, positive for SARS-CoV-2, had significantly higher plasma values of all the HB compared to the respective negative counterparts, with SARS-CoV-2 positive STEMI subjects displaying the highest values. When performed, PCI finished more frequently with a final TIMI flow <3 (p=.004) in positive patients. The in-hospital rate of MACCEs was 24% (24/99 patients) with a higher (p<.0001) prevalence in SARS-Co-V2 positive group. Cardiovascular mortality accounted for the majority of deaths (8/10; p=.019). At multivariable analysis, we identified dyspnoea at presentation, vWF antigen and leukocyte values as independent risk factors for in-hospital death.

Conclusions

In patients presenting with ACS combined with SARS-Cov-2 infection an additional HB asset derangement with stronger endothelial cell activation occurs which negatively impact the outcome, regardless of the invasive treatment.

Funding Acknowledgement

Type of funding sources: None.

P12.09 Clinical features and management of normal pressure hydrocephalus associated with non-obstructive vestibular schwannoma

BACKGROUND

Some (elderly) patients present a communicating (normal pressure) hydrocephalus (NPH) in association with or secondary to vestibular schwannoma (VS). We aim to investigate the usefulness ventriculo-peritoneal shunt (VPS) without tumor removal.

MATERIALS AND METHODS

8 patients aged from 50 to 78 years received both diagnosis of VS (mean maximum diameter 21 mm, range 13–28 mm) and NPH. None presented the classical Hakim’s triad. They presented isolated ataxia with gait impairment and loss of equilibrium. It was hard to distinguish if these symptoms were due to NPH or to VIII cranial nerve compression. They underwent TAP test, through a lumbar puncture with a very slow whithdrawal of at least 30 ml of cerebrospinal fluid (CSF).

RESULTS

None of the 8 patients presented improvement after lumbar puncture. Despite this, we decided to proceed with VPS in 4 patients because of a high risk of falls.... All these 4 patients showed clinical improvement after VPS.. The VS were treated as follows: 4 surgery, 2 radiosurgery, 2 observation.

CONCLUSIONS

Although some authors indicate VS removal as the best option to improve also NPH symptoms, some patients present high risk of falls in the presence of a small VS. These clinical features are more likely to be relayed related to NPH instead of VS.. VPS carries lower postoperative risks compared to VS removal. For this reason, VPS has to be considered, even without a positive response to a TAP test, as a good alternative to improve quality of life in patient affected by NPH associated with VS.

O-140 Uterine septum: clinical implications on fertility and obstterics outcomes. A systematic review and meta-analysis

Study question

How does the septate uterus and his metroplasty influence pregnancy rate (PR), live birth rate (LBR), spontaneous abortion rates (SA) and preterm labour rates (PL)?

Summary answer

Uterine septum is associated with a poor reproductive outcome. Metroplasty reduce the rate of SA but non-conclusive evidence can be extrapolated about PR and PL.

What is known already

Different studies evaluated the correlation between uterine septum and reproductive outcomes. On one hand, studies reported its association with poor obstetrics outcomes. On the other hand, recent studies raised doubts about the effectiveness of septum metroplasty to improve reproductive outcomes, although recent position papers continue to propose metroplasty in patients with a septate uterus and a history of infertility or miscarriages. Debate is still ongoing on reproductive outcomes of uterine septum on infertile patients and especially on patients with recurrent miscarriage, leading to an unanswered question whether or not these women should be treated.

Study design, size, duration

Systematic review and meta-analysis of published studies that evaluated the clinical impact of uterine septum and its metroplasty on reproductive and obstetrics outcomes. The meta-analysis included study with infertile patients or patients with a history of recurrent miscarriage.

Searches were conducted using the following search terms: uterine septum, septate uterus, metroplasty, pregnancy rate, live birth rate, spontaneous miscarriage, infertility, preterm delivery. Primary outcomes were PR and LBR. Secondary outcomes were SA and PL.

Participants/materials, setting, methods

The meta-analysis was written following the PRISMA guidelines. Fifty-nine full-text articles were preselected based on title and abstract. Endpoints were evaluated in three subgroups: 1) infertile/recurrent miscarriage patients with septum versus no septum 2) infertile/recurrent miscarriage patients with treated versus untreated septum 3) infertile/recurrent miscarriage patients before-after septum removal. Odds-ratios (OR) with 95% confidence intervals (CI) were calculated for outcome measures. Random-effect meta-analysis was performed and a p-value less than 0.05 was considered statistically significant.

Main results and the role of chance

Data from 37 articles were extracted. In the first subgroup (10 studies), a lower PR and LBR were associated with septate uterus vs. controls, respectively (OR 0.39, 95% CI 0.26 to 0.58; p < 0.000; low-heterogeneity and OR 0.21, 95% CI 0.12 to 0.39; p < 0.0001; small-heterogeneity) and a higher proportion of SA and PL was associated with septate uterus vs. controls, respectively (OR 4.17, 95% CI 2.83 to 6.15; p < 0.000; moderate-heterogeneity and OR 2.18, 95% CI 1.27 to 3.76; p = 0.005; low-heterogeneity). In the second subgroup (8 studies), PR and PL were not different in removed vs. unremoved septum, respectively (OR 1.10, 95% CI 0.49 to 2.49; p = 0.82; moderate heterogeneity and OR 0.44, 95% CI 0.18 to 1.08; p = 0.08;low-heterogeneity) and a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.40, 95% CI 0.17 to 0.95; p = 0.001; substantial-heterogeneity). In the third subgroup (19 studies), the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93 to 82.13; p < 0.0001; moderate-heterogeneity) and the proportion of SA and PL was lower after the removal of septum, respectively (OR 0.02, 95% CI 0.02 to 0.04; p < 0.000; moderate-heterogeneity and OR 0.05, 95% CI 0.03 to 0.08; p = <0.000; low-heterogeneity).

Limitations, reasons for caution

The present meta-analysis is limited by the observational design of included studies because, in literature, there are no prospective randomized controlled trials (RCTs). In the second and third subgroup of analysis clinical heterogeneity within and between studies represents another limitation.

Wider implications of the findings

The results of this meta-analysis confirm the detrimental effect of uterine septum on PR, LBR, SA and PL. Its treatment seems to reduce the rate of SA. Metroplasty should still be considered as good clinical practice in patients with a history of infertility and recurrent abortion.

Trial registration number

Not applicable

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.

P–519 Investigation of embryo chromosomal constitution and live birth rate after vitrified-warmed euploid single blastocyst transfer across ranges of maternal body-mass-index

Study question

Does maternal body-mass-index (BMI) associate with blastocysts’ chromosomal constitution and clinical outcomes in infertile patients undergoing preimplantation genetic testing for aneuploidies (PGT-A)?

Summary answer

A higher euploidy rate per biopsied blastocyst was reported among underweight women. Overweight women were instead subject to higher miscarriage (MR) and lower live-birth-rates (LBR).

What is known already

Different studies in the literature revealed an association between BMI and infertility, suggesting a J-shaped relationship: both underweight and overweight women can suffer from infertility issues. Even if IVF might increase the success rate in both these categories of patients, it seems insufficient per se to overcome the complex and multifactorial fertility impairment derived from unbalanced nutritional intakes. Miscarriage, in particular, is common in both underweight and overweight women. However, most of the literature is based on chromosomally-untested embryos. Study design, size, duration: Retrospective observational study. Only the first IVF cycle with ≥1 biopsied blastocyst from each woman was included. The primary outcome was the association between maternal BMI (underweight, BMI<18.5, n = 160; normal-weight, BMI=18–25, N = 1392; overweight, BMI>25, N = 259) and the mean euploidy rate per cohort of biopsied blastocysts (m-ER). The secondary outcomes were the association between maternal BMI with clinical (mainly MR and LBR), gestational and perinatal outcomes after first vitrified-warmed single euploid blastocyst transfers.

Participants/materials, setting, methods

We included 1811 women undergoing PGT-A at a private IVF center between April–2013 and March–2020. The secondary outcomes were investigated on 1125 first vitrified-warmed single euploid blastocyst transfers from all patients obtaining ≥1 transferable blastocyst. Only ICSI with ejaculated sperm and continuous culture in standard incubators were performed. Logistic regressions were conducted to identify putative confounders and adjust the results accordingly.

Main results and the role of chance

Except for a lower maternal age among underweight women (38.3±3.1 versus 38.9±3.4 yr, p < 0.01) and higher among overweight ones (39.3±3.6 yr, p = 0.04), no difference was reported with respect to normal-weight women in terms of duration of infertility, hormonal levels, main cause of infertility, sperm quality, and reproductive history. The mean number of biopsied blastocysts was ∼3 in all groups. The m-ER shows a decreasing trend as the maternal BMI increases between 17 and 22–23, to then plateau. In fact, a significant difference was reported between underweight (50.8%±36.4%) and normal-weight women (41.4%±37.5%, p < 0.01). A linear regression adjusted for maternal age confirmed this moderate association between increasing BMI and m-ER (unstandardized-coefficient-B –0.6%, 95%CI:–1.1% to –0.1%, p = 0.02).

Morphological quality and day of full-blastulation among transferred euploid blastocysts was similar in the three groups. Overweight women showed higher MR per pregnancy (N = 20/75, 26.7%, 95%CI:17.4%–38.3% versus N = 67/461, 14.5%, 95%CI:11.5%–18.2%; OR 2.0, 95%CI:1.1–3.6, p = 0.01) and lower LBR per transfer (N = 55/154, 35.7%, 95%CI:28.3%–43.8% versus N = 388/859, 45.2%, 95%CI:41.8%–48.6%; OR adjusted for euploid blastocysts’ features 0.67, 95%CI:0.46–0.96, p = 0.03). Clinical outcomes were instead similar among underweight and normal-weight women. All gestational and perinatal outcomes were comparable in the tree groups.

Limitations, reasons for caution

Our study is limited by its retrospective nature, and the fact that maternal BMI was measured only before oocyte retrieval and not before embryo transfer. Moreover, the reduced sample size did not allow for further relevant sub-analyses among solely obese women.

Wider implications of the findings: When possible nutritional/lifestyle modifications should be encouraged to adjust maternal BMI before IVF. Overweight patients should be especially informed of their higher risk for miscarriage. Yet, BMI is just a gross marker, future studies based on body fat localization and percentage (e.g. by bioelectrical impedance analyses) are desirable.

Trial registration number

None

Malar augmentation with Hyaluronic acid enriched with glycine and proline: a clinical evaluation

The aging process causes skin modification and wrinkle formation with an alteration of the face harmony and imperfections. The aim of the present investigation was to evaluate a cross-linked hyaluronic acid enriched with glycine and proline for zygomatic malar region infiltrations. A total of twenty healthy female patients were treated for zygomatic hypotonia. The level of patients and surgeon satisfaction was evaluated by global aesthetic improvement scale (GAIS) at baseline, immediately after the procedure and at 6 months from the treatment. The healing phase was uneventful, and no complications were reported in the perioperative and follow-up periods. No significant differences were reported between patients and surgeon GAIS score (p<0.05). A significant difference of GAIS score was reported immediately after the procedure and at 6 months if compared to the baseline (p<0.05). The cross-linked hyaluronic acid enriched with glycine and proline is a useful biomaterial for zygomatic- malar augmentation with no significant local complications and a high stability and satisfaction level of the procedure.

Critical illness-related corticosteroid insufficiency in dogs with systemic inflammatory response syndrome: A pilot study in 21 dogs

Critical illness-related corticosteroid insufficiency (CIRCI) refers to a lack of adequate corticosteroid activity, which occurs in up to 48% of dogs with sepsis. However, data regarding the occurrence of CIRCI in critically-ill dogs are still scarce. This study aimed to assess: (1) the relationship between CIRCI and clinicopathological inflammatory markers, hypotension and mortality; and (2) the impact of low-dose hydrocortisone treatment on survival. Twenty-one dogs diagnosed with systemic inflammatory response syndrome (SIRS) were enrolled in a prospective case-control study. All dogs were initially evaluated for adrenal function with an ACTH stimulation test and dogs with Δcortisol ≤ 3 μg/dL were diagnosed with CIRCI. Mean arterial pressure (MAP), white blood cell (WBC), band neutrophils (bNs), c-reactive protein (CRP), and 28-day mortality rate were assessed. Fourteen dogs were treated with low-dose hydrocortisone. The relationships between CIRCI and MAP, WBC, bN, CRP, basal cortisol and mortality were investigated, as was the association between mortality and hydrocortisone treatment. Ten of 21 (48%) dogs were diagnosed with CIRCI. Increased bNs were associated with the presence of CIRCI (P = 0.0075). CRP was higher in dogs with CIRCI (P = 0.02). Fourteen of 21 (66%) dogs died during the study (6/14 had CIRCI). Basal hypercortisolemia (>5 μg/dL) was associated with increased risk of mortality (P = 0.025). Based on our diagnostic criteria, CIRCI occurs frequently in dogs with SIRS and was associated with increased bNs and increased CRP. In this study, CIRCI and low-dose hydrocortisone treatment were not significantly associated with mortality, but basal hypercortisolemia was associated with increased mortality.

The role of IL-6 gene polymorphisms in the risk of lipedema

OBJECTIVE

Lipedema is a disorder of adipose tissue characterized by abnormal subcutaneous fat deposition, leading to swelling and enlargement of the lower limbs and trunk. The aim of this study was to evaluate the lipedema phenotype by investigating the role of polymorphisms related to IL-6 (rs1800795) gene in people with diagnosis of lipedema. The second aim was to identify indicators of body composition, useful for a differential analysis between subjects with lipedema and the control group.

PATIENTS AND METHODS

Two groups are involved in the study, 45 women with lipedema (LIPPY) and 50 women randomly chosen from the population as Control (CTRL). Clinical and demographical variables recorded include weight, height, body mass index (BMI) and circumference measurements. Body composition (Fat mass, FM; lean mass, LM) was assessed by Dual-energy X-ray Absorptiometry (DXA). The genetic tests for IL-6 (rs18oo795) gene were performed for both groups, using a saliva sample.

RESULTS

The study of the relationship between the IL-6 (rs1800795) gene polymorphism, the anthropometric values and the body composition indices has provided the following significant results: subjects with diagnosis of lipedema present statistically significant increased values with regard to weight, BMI, waist, abdomen and hip circumferences, arms, legs and whole FM (% and kg), gynoid FM (kg), legs LM (kg) and ASMMI. Moreover, the value of the waist hip ratio was found to be decreased.

CONCLUSIONS

For the first time, we suggested that IL-6 gene polymorphism could characterize subjects with lipedema respect to Normal Weight Obese and obese subjects. The intra-group comparisons (LIPPY carriers vs. LIPPY non-carriers and CTRL carriers vs. CTRL non-carriers) showed no statistically significant values. In contrast, the inter-group comparisons (LIPPY non-carriers vs. CTRL non-carriers and LIPPY carriers vs. CTRL carriers) resulted statistically significant. We have identified other indices, such as leg index, trunk index, abdominal index, total index, that could be promising clinical tools for diagnosis of the lipedema phenotype and for predicting the evolution of the disease.

Child brides: the age estimation problem in young girls

The aim of this work is to study a sample of girls from 15 different countries using Third Molar Maturity Index (I3M ), to assess the probability that a girl has reached the legal age of 18 years. The studied sample consisted of 3228 Orthopantomograms of healthy female subjects from 15 different countries. The cut-off value of I3M = 0.08 was tested to discriminate adults (≥18 years) and minors (<18 years). X-ray images were processed by computer-aided drafting program ImageJ. The information on sensitivity and specificity of I3M coming from the 15 countries was pooled together using a bivariate Bayesian modeling approach. Specificity of the I3M test did not change when the country was considered, and its value remains greater than 85% for each studied country. This method is useful to estimate the age of the girls involved in suspected early marriage because of the high probability of correctly identifying a minor with similar results observed among tested populations.

Estimated direct costs of non-small-cell lung cancer by stage and care phase: a whole disease model

Background

Non-small-cell lung cancer (NSCLC) is the first cause of cancer-related death among men and the second among women worldwide. It also poses an economic threat to the sustainability of healthcare services. This study estimates the direct costs of care for patients with NSCLC by stage at diagnosis and management phase of pathway recommended in local and international guidelines.

Methods

Based on the most up-to-date guidelines we developed a detailed “whole-disease” model that lists the probabilities of all potentially necessary diagnostic and therapeutic actions involved in the management of each stage of NSCLC. Then we assigned the cost sustained by the public authorities to each procedure, obtaining an estimate of the total and average per-patient costs of each stage of the disease and management phase in Veneto Region, Italy.

Results

The mean expected cost of a patient with NSCLC is 22,968 € in the first year: 20,222 € in stage I, 23,935 € in stage II, 23,027 € in stage III, 22,915 € in stage IV and 31,749 € for Pancoast's tumors. In the second year the mean per patient-costs patient ranged from 2,722 €, for a patient with stage I disease, to 13,396 € for a patient with stage IV, with an overall average cost of 8,307 €. In the early stages, the main cost was due to surgery, whereas in the more advanced stages radiotherapy, medical therapy, treatment for progressions and supportive care become variously more important.

Conclusions

Our study enabled a prediction of the direct costs and outcomes for patients diagnosed with NSCLC on a two-year timeline after the diagnosis. An estimation of the direct costs of NSCLC, and in general for cancer, appears fundamental to predict the burden of new oncological therapies and treatments on healthcare services, and, in our opinion, our model could represent a useful tool for policy-makers in the optimization of resources allocation.

Key messages

Whole disease model allows an economic evaluation of a clinical pathway. The model is able to estimate direct costs of NSCLC by disease stage and management phase within a time horizon of two years. High cost-surgery makes the early stages no less expensive than advanced stages during the first year. In the second year, an advanced stage case costs almost five times more than an early stage case.

Developing and cross-validation of new equations to estimate fat mass in Italian population

OBJECTIVE

Obesity is a global burden that involves more than 500 million people. The objective of this work is to develop and cross-validate the new sex-specific equations to estimate fat mass, based on anthropometric parameters and to compare with other equations.

PATIENTS AND METHODS

We evaluated 38762 subjects by dual-energy X-ray absorptiometry (DXA) and enrolled 1434 women and 640 men, aged between 18 and 65 years. Then, we randomized 480 men and 1080 women in developing set and 160 men and 354 women in the cross-validation set. Statistical analysis as multiple regression and Bland-Altman methods were performed.

RESULTS

Sex-specific equations were created based on developing set. Then, based on the cross-validating set, these equations were validated and were observed to agree with fat mass by DXA, better than other equations, such as BAI and RFM.

CONCLUSIONS

These new sex-specific equations represent an easy tool, since they require only two circumferences, to be used in clinical practice. In the next future, these equations could be validated and refine on specific Italian sub-populations, divided by gender and age, such as the military.

Multisession radiosurgery for intracranial meningioma treatment: study protocol of a single arm, monocenter, prospective trial

Background

Single session radiosurgery represents a widely accepted treatment for intracranial meningiomas. However, this approach could involve a high risk of treatment-related complications when applied to large volume lesions. In these cases and for those not suitable for surgical resection, radiosurgery in multisession setting could represents a viable option. The literature results are reassuring in terms of correlated adverse events as well as in terms of tumor control. However, no prospective long-term results are available. In this scenario, we design a prospective monocentric phase II study, in order to verify the safety of a multisession radiosurgery schedule delivering 25 Gy in 5 daily fractions.

Methods

Patients diagnosed with large and/or near to critical structures, intracranial meningiomas have been treated by means of multisession radiosurgery in both exclusive and postoperative settings. The primary study aim is safety that has been being prospectively scored based on international scales, including NCI Common Toxicity criteria, version 4.03, Barrow Neurological Institute pain intensity score, Barrow Neurological Institute facial numbness score and House-Brackmann Facial Nerve Grading System for qualitative analysis. Secondary aim is treatment efficacy in terms of local control that has been being assessed on volumetric analysis.

Discussion

This is the first prospective phase II trial on multisession radiosurgery for large and/or near to critical structures intracranial meningiomas. If positive results will be found, this study could represent the starting point for a phase III trial exploring the role of multisession radiosurgery in the exclusive and postoperative radiation therapy treatment of intracranial meningiomas.

Trial registration

Trial registration: clinicaltrials.gov platform (Multisession Radiosurgery in Large Meningiomas –MuRaLM- identifier NCT02974127). Registered: November 28, 2016. Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02974127?term=radiosurgery&cond=Intracranial+Meningioma&draw=2&rank=1

Stereotactic Radiotherapy for Parasagittal and Parafalcine Meningiomas: Patient Selection and Special Considerations

Treatment options for intracranial meningiomas are surgical resection alone, surgery followed by adjuvant radiation therapy (RT), or exclusive RT. Parasagittal and parafalcine meningiomas are a subgroup of meningeal disease located close to the vascular structures. Considering the frequent venous invasion, a complete resection is not possible in the majority of cases, and even if a Simpson Grade I resection can be performed, the risk of recurrence is relevant. To date, few studies are focused on parasagittal and parafalcine meningiomas. Because of their specific related issues, particular considerations on decision-making process, outcome, and toxicity follow-up are mandatory. In fact, parasagittal and parafalcine meningiomas require a clear-cut radiological assessment, as well as a tailored toxicity risk evaluation. Moreover, similarly to other meningioma sites, also for parasagittal and parafalcine ones, a standardization of local control, toxicity, and quality of life evaluation is needed in order to lead to a pooled analysis of the results. In this context, our aim was to review the literature data regarding the role of both single-session and multisession radiosurgery (RS), and stereotactic radiotherapy (SRT) for parasagittal and parafalcine meningioma management, summarizing available data on safety and efficacy. It was also discussed how RS and SRT can be performed in a setting of evolving views concerning the treatment paradigm of the parasagittal and parafalcine meningiomas.

Identification of a strategy for disinvestment in the Italian National Health Service (NHS)

Key messages

Identifying effective strategies for disinvestment of health technologies is crucial, considering continuous health innovation and improvement and development opportunities. HTA methodologies, such as reassessment, could support disinvestment processes and represent a systematic and objective approach to be implemented and used at different levels of Italian NHS.

Call for a European collaboration in the use of Real World Data in Health Technology Assessment

Issue/problem

Modern patient care requires a heavy investment in innovative health technologies while at the same time it is facing a fiscal sustainability challenge in the health care system. Evidence on effectiveness of health technologies informing Health Technology Assessments (HTA) have traditionally been based on randomized control trials (RCTs). However, RCTs are expensive and the external validity is relatively low which makes it difficult to assess effectiveness and long-term outcomes in clinical practice especially in diverse populations.

Description of the problem

Real-World Data (RWD) studies use observational data routinely collected to gather information on the delivery and outcome of care. RWD studies cost less than RCTs and are considered to have a high external validity. Results from RWD studies are therefore a good supplement to support evidence from RCT in HTA-reports. However, RWD are not still fully used in HTA. This is partially due to concerns about data quality and accessibility.

Effects/changes

In order to provide a deeper insight into how health technologies are working in real-world settings across Europe, it is time to systematically including RWD in HTA. A first step should be to call for a European collaboration to map relevant sources of RWD that can be used in HTA and define the quality and main format, in which they can be analysed and used. Common legislations and guidelines regarding which RWD should be accepted as sources of information for HTA should be elaborated.

Lessons

Through a European collaboration, the quality and accessibility of RWD should be secured in order to use evidence from RWD studies to inform HTA on effectiveness of health technologies.

Sharing hospital-based health technology assessments internationally

Issue/problem

National healthcare systems worldwide are at a critical point due to the fiscal sustainability challenges faced. At the same time, healthcare systems are under pressure to meet the global demand for adaptation of medical innovations arriving into the market persistently.

Description of the problem

Hospitals often serve as the entry point for new technologies to the healthcare system. It is therefore extremely important that Health Technology Assessments (HTA) are available in timely order to accurately inform decision-makers on both short- and long-term effects of a health technology to avoid inappropriate investments. Hospital based HTA (HB-HTA) was developed to accommodate the need for evidence-based hospital-specific information in a timely manner. A substantial increase in the use of HB-HTA has been observed in the last years. However, only few reports are being published. A database for the structured collection of HB-HTA reports could help the dissemination and collaboration between hospitals.

Effects/changes

A survey answered by an international group of experts knowledgeable in HB-HTA from eighteen different countries has showed that there is an interest to realize the collection and dissemination of HB-HTA reports on an international scale. However, confidentiality and resources for a database are barriers for the dissemination of HB-HTA reports. The challenge will therefore be to overcome these barriers and design a database containing high quality, comparable and complete HB-HTA reports with proper data security, regular maintenance and user support.

Lessons

International collaboration in HB-HTA is the key to timely inform decision-makers without compromising the quality of the data or the methodology.

Value of copeptin and the S-100b protein assay in ruling out the diagnosis of stroke-induced dizziness pattern in emergency departments

Background

Dizziness is a frequent reason for visiting emergency departments (EDs). Differentiating stroke from other causes is challenging for physicians. The role of biomarkers has been poorly assessed. We evaluated whether copeptin and S100b protein (PS100b) assessment, alone or in combination, could rule out stroke in patients visiting EDs for dizziness.

Methods

We included patients 18 years of age or older, visiting the adult ED of a French university hospital for a new episode of dizziness evolving for less than 72 h. All patients underwent standardized physical examination (HINT [Head Impulse test, Nystagmus, test of skew deviation] maneuvers), copeptin and S-100b protein (PS100) measurement and injected brain imaging. Stroke diagnosis involved diffusion-weighted magnetic resonance imaging or, if not available, neurological examination and contrast brain CT scan compatible with the diagnosis.

Results

Of the 135 patients participating in the study, 13 (10%) had stroke. The sensitivity, specificity and positive and negative predictive values of copeptin/PS100 combination were 100% (95%CI, 77–100%), 48% (40–57%), 14% (11–27%) and 100% (94–100%), respectively. Values for copeptin alone were 77% (CI95% 0.50–0.91), 50% (CI95% 0.49–0.58), 14% (CI95% 0.08–0.24), 93% (CI95% 0.87–0.98), and for PS100 alone were 54% (CI95% 0.29–0.77), 97% (CI95% 0.92–0.99), 64% (CI95% 0.35–0.84), 95% (CI95% 0.90–0.98).

Conclusions

Absence of copeptin and PS100 elevation seems to ruling out the diagnosis of stroke in patients visiting the ED for a new episode of dizziness. These results need to be confirmed in a large-scale study.

Mythicomycetaceae fam. nov. (Agaricineae, Agaricales) for accommodating the genera Mythicomyces and Stagnicola, and Simocybe parvispora reconsidered

The analysis of a combined dataset including 5.8S (ITS) rDNA, 18S rDNA, 28S rDNA, and rpb2 data from species of the Agaricineae (Agaricoid clade) supports a shared monophyletic origin of the monotypic genera Mythicomyces and Stagnicola. The new family Mythicomycetaceae, sister to Psathyrellaceae, is here proposed to name this clade, which is characterised, within the dark-spored agarics, by basidiomata with a mycenoid to phaeocollybioid habit, absence of veils, a cartilaginous-horny, often tapering stipe, which discolours dark brown towards the base, a greyish brown, pale hazel brown spore deposit, smooth or minutely punctate-verruculose spores without a germ pore, cheilocystidia always present, as metuloids (thick-walled inocybe-like elements) or as thin-walled elements, pleurocystidia, when present, as metuloids, pileipellis as a thin ixocutis without cystidioid elements, clamp-connections present everywhere, and growth on wood debris in wet habitats of boreal, subalpine to montane coniferous forests. Simocybe parvispora from Spain (two collections, including the holotype), which clusters with all the sequenced collections of Stagnicola perplexa from Canada, USA, France and Sweden, must be regarded as a later synonym of the latter.

Role of phase angle in the evaluation of effect of an immuno-enhanced formula in post-surgical cancer patients: a randomized clinical trial

OBJECTIVE

Neoplastic disease is frequently associated with poor nutritional status or severe malnutrition. Diet and nutritional intervention are becoming increasingly important for prognosis and quality of life in cancer patients. Accessible and repeatable tools for assessing nutritional status with body composition techniques seems to be fundamental. The aim of this study was to evaluate the effects of immunonutrition on body composition parameters, inflammatory response and nutritional status in patients at stage III of head and neck squamous carcinoma (HNSCC).

PATIENTS AND METHODS

In our work, 50 malnourished subjects with HNSCC staging III were recruited and treated with oral diet (OD) or enteral nutrition (EN). Patient under EN followed, for the first three days, enteral standard nutrition (ESN) and then enteral immunonutrition (EIN). Nutrition state was evaluated on days 0, 3, and 8 through body composition and biochemical analyses.

RESULTS

After 8 days, the EIN treatment showed a significant improvement in phase angle, pre-albumin, retinol binding protein and transferrin compared to the OD treatment.

CONCLUSIONS

Our results showed that immunonutrition treatment improves the nutritional status of neoplastic patients, supporting chemotherapy. The phase angle is not only a predictor of cancer survival, but has also proved to be useful in the surveillance of nutritional status improvement as well as biochemical indices.

Antifungal activity of oils macerates of North Sardinia plants against Candida species isolated from clinical patients with candidiasis

Antibiotic resistance is one of the bigger problem of public health: the rise of multi-drug resistant organisms causes a challenge in the treatment of infective diseases. Anti-Candida resistance to conventional antifungal agents has increased in the last period. Our research was intended to evaluate antimicrobial activity of oil macerate (OM) of Helichrysum microphyllum Cambess. subsp. tyrrhenicum Bacch., Brullo & Giusso and OM of Hypericum perforatum subsp. angustifolium against several clinical strains. The study included 30 patients with candidiasis who had not received any antifungal treatment before they were enrolled. A collection of 30 clinical isolates belonging to 5 different species of Candida spp. was selected for this study. The data obtained showed an interesting activity of both Oil Macerate especially against C. krusei and C. parapsilosis. On the contrary, H. microphyllum Oil Macerate has had a better activity than the H.perforatum especially in relation to C. glabrata and C. krusei.

Podocyte GSK3 is an evolutionarily conserved critical regulator of kidney function

Albuminuria affects millions of people, and is an independent risk factor for kidney failure, cardiovascular morbidity and death. The key cell that prevents albuminuria is the terminally differentiated glomerular podocyte. Here we report the evolutionary importance of the enzyme Glycogen Synthase Kinase 3 (GSK3) for maintaining podocyte function in mice and the equivalent nephrocyte cell in Drosophila. Developmental deletion of both GSK3 isoforms (α and β) in murine podocytes causes late neonatal death associated with massive albuminuria and renal failure. Similarly, silencing GSK3 in nephrocytes is developmentally lethal for this cell. Mature genetic or pharmacological podocyte/nephrocyte GSK3 inhibition is also detrimental; producing albuminuric kidney disease in mice and nephrocyte depletion in Drosophila. Mechanistically, GSK3 loss causes differentiated podocytes to re-enter the cell cycle and undergo mitotic catastrophe, modulated via the Hippo pathway but independent of Wnt-β-catenin. This work clearly identifies GSK3 as a critical regulator of podocyte and hence kidney function.