Can we predict adolescent cannabis use? A Bayesian semi-parametric approach to project future trends

Despite its decrease in many Western countries, cannabis remains the most used illicit substance among adolescents. This study aims to summarize cannabis consumption during the last two decades and project trends among 15-year-olds in the 2021-22 HBSC survey. A Bayesian semi-parametric hierarchical model was adopted to estimate the trend of cannabis consumption using data of about 287,000 adolescents from the 2001/2002 to the 2017/2018 HBSC wave and the 38 countries that met the inclusion criteria. Data show an overall decline in most countries for both boys and girls. However, in 22 countries of 38 cannabis use is expected to increase again in our projection. The discussion of these findings should take into account cultural, policy, social factors and unpredictable events such as the Covid-19 pandemic, that can significantly impact future trends leading to discrepancies between the projected and observed values. However, these discrepancies can provide insight into understanding the potential impact of preventive strategies and the underlying processes responsible for changes in cannabis use over time.

Loss of Personal Autonomy and Dignity-Related Distress in End-Of-Life Cancer Patients

The objective of this cross-sectional study is to investigate Dignity-Related Loss of Personal Autonomy (DR-LPA) intended as loss of relational independence causing dignity-related distress. Moreover, it analyzes its possible relationships with demoralization, spirituality, quality of life, hope, and coping styles in a sample composed of 207 end-of-life cancer patients. These variables have been assessed through the following rating scales: Patient Dignity Inventory - Italian version, Demoralization Scale - Italian version, Functional Assessment of Cancer Therapy Scale - General Measure, Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being, Brief Coping Orientation to Problem Experienced, and Herth Hope Index. The results have shown that most of the DR-LPA items were considered a problem by most patients. Functional, social, emotional, and spiritual wellbeing, disheartenment, age, and sex emerged as significant predictors of DR-LPA. In conclusion, this study showed that DR-LPA can be a relevant concern for patients at the end-of-life and for this reason it becomes necessary for psychosocial provides to consider it to deliver better dignity conserving care.

Disease control of acromegaly does not prevent excess mortality in the long term: results of a nationwide survey in Italy

OBJECTIVE

This study aimed to assess the long-term outcome of patients with acromegaly.

DESIGN

This is a multicenter, retrospective, observational study which extends the mean observation period of a previously reported cohort of Italian patients with acromegaly to 15 years of follow-up.

METHODS

Only patients from the centers that provided information on the life status of at least 95% of their original cohorts were included. Life status information was collected either from clinical records or from the municipal registry offices. Standardized mortality ratios (SMRs) were computed comparing data with those of the general Italian population.

RESULTS

A total of 811 patients were included. There were 153 deaths, with 90 expected and an SMR of 1.7 (95% CI 1.4-2.0, p < 0.001). Death occurred after a median of 15 (women) or 16 (men) years from the diagnosis, without gender differences. Mortality remained elevated in the patients with control of disease (SMR 1.3, 95% CI 1.1-1.6). In the multivariable analysis, only older age and high IGF1 concentrations at last available follow-up visit were predictors of mortality. The oncological causes of death outweighed the cardiovascular ones, bordering on statistical significance with respect to the general population.

CONCLUSIONS

Mortality remains significantly high in patients with acromegaly, irrespectively of disease status, as long as the follow-up is sufficiently long with a low rate of patients lost to follow-up. Therapy strategy including radiotherapy does not have an impact on mortality. Oncological causes of death currently outweigh the cardiovascular causes.

Surgical treatment of popliteomeniscal fascicles tears is associated with better patient-reported outcome measures. A systematic review and meta-analysis

PURPOSE

Popliteomeniscal fascicles (PMFs) are a component of the popliteal hiatus complex in the knee, and their injury primarily affects young athletes participating in sports activities involving twisting movements. The identification of PMFs tears presents a challenge, often accompanied by lateral pain and a locking sensation. The objective of this systematic review (SR) and meta-analysis is to enhance the suspicion and recognition of PMFs tears, aiming to facilitate the treatment of this condition, particularly in symptomatic young patients.

METHODS

A comprehensive search, focused on studies examining PMFs injuries and their treatment, was conducted in four databases, PubMed, Scopus, Embase, and Web of Science. The ROBINS-I tool was used to evaluate the risks of bias. The PRISMA flow diagram was used to conduct the research and select the included studies. A meta-analysis was conducted for the Lysholm score, the Tegner Activity Scale, and the subjective IKDC score. The present SR and meta-analysis was registered on PROSPERO.

RESULTS

Five clinical studies were included in the final analysis, comprising 96 patients. All the patients underwent a preoperative MRI assessment and a diagnostic arthroscopy to detect the PMFs tears, with a subsequent surgical procedure either open or arthroscopically performed. Surgery was associated with the resolution of symptoms. A statistically significant improvement in the Lysholm score (p: 0.0005) and the subjective IKDC score (p: 0.003) after the surgical procedure with respect to the preoperative evaluation was found.

CONCLUSION

This SR and meta-analysis showed a significant improvement in the Lysholm score and subjective IKDC score following surgery for PMFs tears. However, controversy persists regarding the optimal surgical approach, with current literature favoring arthroscopic procedures.

LEVEL OF EVIDENCE

IV.

Cytotoxic pathways activated by multifunctional thiosemicarbazones targeting sigma-2 receptors in breast and lung carcinoma cells

BACKGROUND

Multifunctional thiosemicarbazones (TSCs) able to bind sigma receptors and chelate metals are considered as a promising avenue for the treatment of pancreatic cancer due to the encouraging results obtained on in vitro and in vivo models. Here, we assessed the biochemical mechanism of these TSCs also on lung (A549) and breast (MCF7) cancer cells.

METHODS

The density of sigma-2 receptors in normal (BEAS-2B and MCF10A) and in lung and breast (A549 and MCF7) cancer cells was evaluated by flow cytometry. In these cells, cytotoxicity (MTT assay) and activation of ER- and mitochondria-dependent cell death pathways (by spectrofluorimetric assays to measure Caspases 3/7/9; qRT-PCR detection of GRP78, ATF6, IRE1, PERK; MitoSOX, DCFDA-AM and JC-1 staining), induced by the TSCs FA4, MLP44, PS3 and ACThio1, were evaluated.

RESULTS

FA4 and PS3 exerted more potent cytotoxicity than MLP44 and ACThio1 in all cancer cell lines, where the density of sigma-2 receptors was higher than in normal cells. Remarkably, FA4 promoted ER- and mitochondria-dependent cell death pathways in both cell models, whereas the other TSCs had variable, cell-dependent effects on the activation of the two proapoptotic pathways.

CONCLUSIONS

Our data suggest that FA4 is a promising compound that deserves to be further studied for lung and breast cancer treatment. However, the other multifunctional TSCs also hold promise for the development of therapies towards a personalized medicine approach. Indeed, the presence of the sigma-2 receptor-targeting moiety would lead to a more specific tumor delivery embracing the characteristics of individual tumor types.

Risk Behaviors among Migrant Adolescents in Italy

Adolescence is a critical period for engaging in health risk behaviors. Migrant adolescents may face unique challenges due to acculturation stress. This study aims to monitor substance use and problem gambling among migrant adolescents living in Italy. Data from the 2017/18 Health Behavior in School-Aged Children survey in Italy were analyzed. The 18,794 participants included 15-year-olds, categorized as native or migrants, with ethnic backgrounds from Western, Eastern European, or non-Western/non-European countries. Girls had higher smoking rates, while boys exhibited higher prevalence of alcohol-related risk behaviors, cannabis use, and gambling. Boys from Eastern European countries displayed a greater risk of drunkenness (OR: 1.58, 95% CI: 1.06-2.37), particularly in the first generation, while those from Western countries showed a higher risk of multiple substance use (OR: 1.44, 95% CI: 1.05-1.96). Girls from Eastern European and non-Western/non-European countries had a lower risk of alcohol consumption (OR: 0.50, 95% CI: 0.29-0.85; OR: 0.55, 95% CI: 0.33-0.91, respectively). Finally, boys, especially those from Eastern European and non-Western/non-European countries, had a significantly higher risk of problem gambling (OR: 1.83, 95% CI: 1.04-3.22; OR: 2.10, 95% CI: 1.29-3.42, respectively). This disparity was more pronounced in the first generation, possibly due to acculturation challenges and socio-economic factors. Risk behaviors in adolescents are influenced by complex interplays of gender, cultural factors, and migration generation. Preventive strategies should consider these factors to effectively address substance use and gambling in this heterogeneous population.

Healthcare Professional Communication on Sexual Health: A Report from the Italian Working Group on Adolescents and Young Adults with Cancer

BACKGROUND

Sexual function is an important concern for adolescent and young adult (AYA) with cancer. The aim of this study was to explore the attitude of Italian health care professionals who deal with AYA patients with cancer toward sexual health communication.

MATERIALS AND METHODS

A 11-question survey was developed by the AIOM (Associazione Italiana di Oncologia Medica) and AIEOP (Associazione Italiana Ematologia Oncologia Pediatrica) AYA workgroup and sent to AIOM and AIEOP members.

RESULTS

The sample comprised 360 respondents, 54.2% AIEOP and 45.8% AIOM members. Eighty percent were physicians, 14.5% nurses, 4.7% psychologists, and 0.8% other professionals. Medical oncologists are more used to investigate about AYA sexual health than pediatric oncologists (58.2% vs. 46.2%), even if pediatrics more frequently refer patients to specific and shared protocol (40% vs. 26.1%). Both AIOM and AIEOP participants mostly talk about sexual health only on request or occasionally (78.8% and 79%, respectively). Clinician-reported barriers to communication identified in this study are lack of preparation and embarrassment for both the categories, plus the presence/interference of parents for pediatrics and lack of time for medical oncologists. Overall, less than 5% of clinicians in our survey received specific training on potential sexual health issues in AYA patients with cancer and only 2% felt adequately prepared to speak about it.

CONCLUSION

Sexual health is a key component of comprehensive care for AYA with cancer during treatments. This study highlighted the need of Italian providers for specific training and guidelines on sex-related health issues encountered by AYA patients.

Adjuvant mitotane versus surveillance in low-grade, localised adrenocortical carcinoma (ADIUVO): an international, multicentre, open-label, randomised, phase 3 trial and observational study

BACKGROUND

Adjuvant treatment with mitotane is commonly used after resection of adrenocortical carcinoma; however, treatment remains controversial, particularly if risk of recurrence is not high. We aimed to assess the efficacy and safety of adjuvant mitotane compared with surveillance alone following complete tumour resection in patients with adrenocortical carcinoma considered to be at low to intermediate risk of recurrence.

METHODS

ADIUVO was a multicentre, open-label, parallel, randomised, phase 3 trial done in 23 centres across seven countries. Patients aged 18 years or older with adrenocortical carcinoma and low to intermediate risk of recurrence (R0, stage I-III, and Ki67 ≤10%) were randomly assigned to adjuvant oral mitotane two or three times daily (the dose was adjusted by the local investigator with the target of reaching and maintaining plasma mitotane concentrations of 14-20 mg/L) for 2 years or surveillance alone. All consecutive patients at 14 study centres fulfilling the eligibility criteria of the ADIUVO trial who refused randomisation and agreed on data collection via the European Network for the Study of Adrenal Tumors adrenocortical carcinoma registry were included prospectively in the ADIUVO Observational study. The primary endpoint was recurrence-free survival, defined as the time from randomisation to the first radiological evidence of recurrence or death from any cause (whichever occurred first), assessed in all randomly assigned patients by intention to treat. Overall survival, defined as time from the date of randomisation to the date of death from any cause, was a secondary endpoint analysed by intention to treat in all randomly assigned patients. Safety was assessed in all patients who adhered to the assigned regimen, which was defined by taking at least one tablet of mitotane in the mitotane group and no mitotane at all in the surveillance group. The ADIUVO trial is registered with ClinicalTrials.gov, NCT00777244, and is now complete.

FINDINGS

Between Oct 23, 2008, and Dec 27, 2018, 45 patients were randomly assigned to mitotane and 46 to surveillance alone. Because the study was discontinued prematurely, 5-year recurrence-free and overall survival are reported instead of recurrence-free and overall survival as defined in the protocol. 5-year recurrence-free survival was 79% (95% CI 67-94) in the mitotane group and 75% (63-90) in the surveillance group (hazard ratio 0·74 [95% CI 0·30-1·85]). Two people in the mitotane group and five people in the surveillance group died, and 5-year overall survival was not significantly different (95% [95% CI 89-100] in the mitotane group and 86% [74-100] in the surveillance group). All 42 patients who received mitotane had adverse events, and eight (19%) discontinued treatment. There were no grade 4 adverse events or treatment-related deaths.

INTERPRETATION

Adjuvant mitotane might not be indicated in patients with low-grade, localised adrenocortical carcinoma considering the relatively good prognosis of these patients, and no significant improvement in recurrence-free survival and treatment-associated toxicity in the mitotane group. However, the study was discontinued prematurely due to slow recruitment and cannot rule out an efficacy of treatment.

FUNDING

AIFA, ENSAT Cancer Health F2-2010-259735 programme, Deutsche Forschungsgemeinschaft, Cancer Research UK, and the French Ministry of Health.

New Findings on Presentation and Outcome of Patients With Adrenocortical Cancer: Results From a National Cohort Study

CONTEXT

Because of the rarity of adrenocortical cancer (ACC), only a few population-based studies are available, and they reported limited details in the characterization of patients and their treatment.

OBJECTIVE

To describe in a nationwide cohort the presentation of patients with ACC, treatment strategies, and potential prognostic factors.

METHODS

Retrospective analysis of 512 patients with ACC, diagnosed in 12 referral centers in Italy from January 1990 to June 2018.

RESULTS

ACC diagnosed as incidentalomas accounted for overall 38.1% of cases, with a frequency that increases with age and with less aggressive pathological features than symptomatic tumors. Women (60.2%) were younger than men and had smaller tumors, which more frequently secreted hormones. Surgery was mainly done with an open approach (72%), and after surgical resection, 62.7% of patients started adjuvant mitotane therapy. Recurrence after tumor resection occurred in 56.2% of patients. In patients with localized disease, cortisol secretion, ENSAT stage III, Ki67%, and Weiss score were associated with an increased risk of recurrence, whereas margin-free resection, open surgery, and adjuvant mitotane treatment were associated with reduced risk. Death occurred in 38.1% of patients and recurrence-free survival (RFS) predicted overall survival (OS). In localized disease, age, cortisol secretion, Ki67%, ENSAT stage III, and recurrence were associated with increased risk of mortality. ACCs presenting as adrenal incidentalomas showed prolonged RFS and OS.

CONCLUSION

Our study shows that ACC is a sex-related disease and demonstrates that an incidental presentation is associated with a better outcome. Given the correlation between RFS and OS, RFS may be used as a surrogate endpoint in clinical studies.

Interventions to Promote End-of-Life Conversations: A Systematic Review and Meta-Analysis

CONTEXT

Although several interventions aimed to promote end-of-life conversations are available, it is unclear whether and how these affect delivery of end-of-life conversations. Measuring the processes associated with high-quality end-of-life care may trigger improvement.

OBJECTIVES

To estimate the effect of interventions aimed to promote end-of-life conversations in clinical encounters with patients with advanced chronic or terminal illness or their family, on process indicators of end-of-life conversations.

METHODS

Systematic review with meta-analysis (PROSPERO no. CRD42021289471). Four databases (PubMed, CINAHL, PsycINFO, and Scopus) were searched up to September 30, 2021. The primary outcomes were any process indicators of end-of-life conversations. Results of pairwise meta-analyses were presented as Risk Ratio (RR) for occurrence, standardized mean difference (SMD) for quality and ratio of means (ROM) for duration. Meta-analysis was not performed when fewer than four studies were available.

RESULTS

A total of 4,663 articles were scanned. Eighteen studies were included in the systematic review and 16 entered at least one meta-analysis: documented occurrence (n = 8), patient-reported occurrence (n = 4), patient-reported-quality (n = 4), duration (n = 4). There was significant variability in settings, patients' clinical conditions, and professionals. No significant effect of interventions on documented occurrence (RR 1.54, 95% CI 0.84-2.84; I2 91%), patient-reported occurrence (RR 1.52, 95% CI 0.80-2.91; I2 95%), patient-reported quality (SMD 0.83, 95% CI -1.06 to 2.71; I2 99%), or duration (ROM 1.20, 95% CI 0.95-1.51; I2 65%) of end-of-life conversations was found. Data on frequency were conflicting. Interventions targeting multiple stakeholders promoted earlier and more comprehensive conversations.

CONCLUSION

Heterogeneity was considerable, but findings suggest no significant effect of interventions on occurrence, patient-reported quality and duration of end-of-life conversations. Nevertheless, we found indications for interventions targeting multiple stakeholders to promote earlier and more comprehensive conversations.

Fitting Early Phases of the COVID-19 Outbreak: A Comparison of the Performances of Used Models

The COVID-19 outbreak involved a spread of prediction efforts, especially in the early pandemic phase. A better understanding of the epidemiological implications of the different models seems crucial for tailoring prevention policies. This study aims to explore the concordance and discrepancies in outbreak prediction produced by models implemented and used in the first wave of the epidemic. To evaluate the performance of the model, an analysis was carried out on Italian pandemic data from February 24, 2020. The epidemic models were fitted to data collected at 20, 30, 40, 50, 60, 70, 80, 90, and 98 days (the entire time series). At each time step, we made predictions until May 31, 2020. The Mean Absolute Error (MAE) and the Mean Absolute Percentage Error (MAPE) were calculated. The GAM model is the most suitable parameterization for predicting the number of new cases; exponential or Poisson models help predict the cumulative number of cases. When the goal is to predict the epidemic peak, GAM, ARIMA, or Bayesian models are preferable. However, the prediction of the pandemic peak could be made carefully during the early stages of the epidemic because the forecast is affected by high uncertainty and may very likely produce the wrong results.

Who Stays, Who Moves on and the Host Population: A Picture of Adolescents' Perceived Well-Being and Risk Behaviours

The study aims to evaluate the health profile of first- and second-generation Romanian immigrants living in Italy compared to their adolescent peers in the country of origin (Romania) and the host population (Italian-borns). Analyses were performed on the 2013/2014 Health Behaviour in School-aged Children (HBSC) survey data. Romanian natives showed lower levels of health complaints and higher life satisfaction than Romanian migrants, who were similar to the host population, especially the second-generation ones. A comparable prevalence of being bullied was registered among Romanians, both native and immigrant, with significantly lower levels among Italian natives. Bullying others showed the second-generation migrants share a similar prevalence with the host population. The prevalence of liking school a lot was three times higher among the Romanian natives than among their peers living in Italy. Thanks to the HBSC data, this study is the first to examine the health of adolescent migrants from both the perspective of the host country and the population of origin. The results highlight the need for a more nuanced approach to studying immigrant populations, taking into account both the host country's perspective and the health patterns of the population of origin.

Impact of Hypothermic Oxygenated Machine Perfusion on Hepatocellular Carcinoma Recurrence after Liver Transplantation

BACKGROUND

Machine perfusion may be able to mitigate ischemia-reperfusion injury (IRI), which increases hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). This study aimed to investigate the impact of dual-hypothermic oxygenated machine perfusion (D-HOPE) on HCC recurrence in LT.

METHODS

A single-center retrospective study was conducted from 2016 to 2020. Pre- and postoperative data of HCC patients undergoing LT were analyzed. Recipients of a D-HOPE-treated graft were compared to those of livers preserved using static cold storage (SCS). The primary endpoint was recurrence-free survival (RFS).

RESULTS

Of 326 patients, 246 received an SCS-preserved liver and 80 received a D-HOPE-treated graft (donation after brain death (DBD), n = 66; donation after circulatory death (DCD), n = 14). Donors of D-HOPE-treated grafts were older and had higher BMI. All DCD donors were treated by normothermic regional perfusion and D-HOPE. The groups were comparable in terms of HCC features and estimated 5-year RFS according to the Metroticket 2.0 model. D-HOPE did not reduce HCC recurrence (D-HOPE 10%; SCS 8.9%; p = 0.95), which was confirmed using Bayesian model averaging and inverse probability of treatment weighting-adjusted RFS analysis. Postoperative outcomes were comparable between groups, except for lower AST and ALT peak in the D-HOPE group.

CONCLUSIONS

In this single-center study, D-HOPE did not reduce HCC recurrence but allowed utilizing livers from extended criteria donors with comparable outcomes, improving access to LT for patients suffering from HCC.

Off-label and compassionate use of targeted anticancer therapies: The experience of an Italian pediatric cancer center

INTRODUCTION

In Europe, despite recent advances in clinical development, most of the drugs currently used to treat childhood cancers are adult medicines, prescribed outside of the authorized indication. In this context, a monocentric retrospective cohort analysis was conducted, evaluating pediatric, adolescent, and young adult patients affected by onco-hematologic disease, treated with targeted therapies used off-label or as compassionate use.

METHODS

The analysis was conducted on 45 patients aged less than or equal to 30 years with cancer, having received at least one targeted therapy prescribed as off-label or compassionate use at a large Italian pediatric center between January 1, 2016 and June 30, 2021. Data collected included information on the patient and tumor, data on off-label/compassionate treatment, and data on safety and efficacy.

RESULTS

Total 25 out of 45 patients treated with off-label or compassionate targeted therapies were affected by onco-hematological diseases. Overall, 22 out of the 52 agents (42%) were prescribed in patients with relapsed neoplasm and 39% (20/52) in patients with refractory diseases. Complete response was observed in more than half (27/52) of treatments. At least one adverse reaction occurred in 76% (n = 22) of agents administered to patients with onco-hematological tumor and in 43% (n = 10) of agents prescribed to patients with solid tumor.

CONCLUSION

This work aims to provide a snapshot of off-label and compassionate use prescriptions in a large Italian pediatric cancer center. This study confirms that targeted agents for unauthorized indications are often prescribed in pediatric patients with cancer, especially after disease relapse and that these treatments are mostly tolerable and effective.

Effectiveness of Workplace Health Promotion (WHP) interventions in university employees: a scoping review

Workplace Health Promotion (WHP) interventions proved to be effective in several workplace contexts. Currently, the effectiveness of such interventions in the academic workplace is lacking, albeit evidence suggests similar patterns to those occurring in other workplace sectors. The aim of this study was to review WHP interventions in the university workplace that led to improve health- and work-related outcomes. Articles were selected using Pubmed, Web of Science, Scopus, Embase, PsycInfo, Cinhal and FSTA, using search strings focused on health- and/or work-related outcomes and involving University WHP interventions published between January 2010 and July 2021. The majority of the 12 studies selected reported positive results in their individuality, especially regarding health-related outcomes [biological such as weight loss, physical activity, mental health and lifestyle habits] and work-related outcomes concerning improvements either for the employee or for the working system. Studies on economic advantage and Return on Investment were limited and reported contrasting results. In conclusion, we have highlighted how the studies on effectiveness of WHP interventions in the university context are few and heterogeneous and need to be encouraged further research in order to build specific guidelines that are effective.

Diagnostic and Therapeutic Algorithm for Appendiceal Tumors and Pseudomyxoma Peritonei: A Consensus of the Peritoneal Malignancies Oncoteam of the Italian Society of Surgical Oncology (SICO)

Aim: Pseudomyxoma peritonei (PMP) is an uncommon pathology, and its rarity causes a lack of scientific evidence, precluding the design of a prospective trial. A diagnostic and therapeutic algorithm (DTA) is necessary in order to standardize the disease treatment while balancing optimal patient management and the correct use of resources. The Consensus of the Italian Society of Surgical Oncology (SICO) Oncoteam aims at defining a diagnostic and therapeutic pathway for PMP and appendiceal primary tumors applicable in Italian healthcare. Method: The consensus panel included 10 delegated representatives of oncological referral centers for Peritoneal Surface Malignancies (PSM) affiliated to the SICO PSM Oncoteam. A list of statements regarding the DTA of patients with PMP was prepared according to recommendations based on the review of the literature and expert opinion. Results: A consensus was obtained on 33 of the 34 statements linked to the DTA; two flowcharts regarding the management of primary appendiceal cancer and peritoneal disease were approved. Conclusion: Currently, consensus has been reached on pathological classification, preoperative evaluation, cytoreductive surgery technical detail, and systemic treatment; some controversies still exist regarding the exclusion criteria for HIPEC treatment. A shared Italian model of DTA is an essential tool to ensure the appropriateness and equity of treatment for these patients.

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis

Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.

The management of postoperative disease recurrence in patients with adrenocortical carcinoma: a retrospective study in 106 patients

OBJECTIVE

The management of adrenocortical carcinoma (ACC) recurrences remains controversial, and we present herein our experience with postoperative ACC recurrences.

DESIGN AND METHODS

Retrospective analysis in a single reference center of 106 patients with ACC recurrence.

RESULTS

The median follow-up was 45 months, the median recurrence-free survival (RFS) 12 months (IQR 6-23), and the median overall survival (OS) 45 months (IQR 29-75). ACC recurrences occurred as a unique lesion (group A) in 35.8%, multiple lesions in a single organ (group B) in 20.8%, and affecting multiple organs (group C) in 43.4% of patients. Baseline characteristics of patients stratified by the type of recurrence did not differ between them, except RFS, which was significantly longer in group A. Locoregional treatments were used in 100% of patients of group A, 68.2% in group B, and 26.1% in group C. After treatment of recurrence, 60.4% of patients became free of disease attaining a second RFS of 15 months (IQR 6-64). Margin status RX and R1, percent increase in Ki67, and recurrence in multiple organs were associated with an increased risk of mortality, while adjuvant mitotane treatment and longer time to first recurrence were associated with reduced risk. Recurrence in multiple organs and systemic treatment of recurrence had a negative impact on survival from the treatment of recurrence.

CONCLUSIONS

This study shows that patients with ACC have a better prognosis when the disease recurs as a single lesion and supports the use of locoregional treatments to treat disease recurrence.

Visuospatial Deficits Are Associated with Pisa Syndrome and not Camptocormia in Parkinson's Disease

Background

Pisa syndrome (PS) and camptocormia (CC) are postural abnormalities frequently associated with Parkinson's disease (PD). Their pathophysiology remains unclear, but the role of cognitive deficits has been postulated.

Objectives

To identify differences in the neuropsychological functioning of patients with PD with PS or CC compared with matched patients with PD without postural abnormalities.

Methods

We performed a case-control study including 57 patients with PD with PS (PS+) or CC (CC+) and 57 PD controls without postural abnormalities matched for sex, age, PD duration, phenotype, and stage. Patients were divided into four groups: PS+ (n = 32), PS+ controls (PS-, n = 32), CC+ (n = 25), and CC+ controls (CC-, n = 25). We compared PS+ versus PS- and CC+ versus CC- using a neuropsychological battery assessing memory, attention, executive functions, visuospatial abilities, and language. Subjective visual vertical (SVV) perception was assessed by the Bucket test as a sign of vestibular function; the misperception of trunk position, defined as a mismatch between the objective versus subjective evaluation of the trunk bending angle >5°, was evaluated in PS+ and CC+.

Results

PS+ showed significantly worse visuospatial performances (P = 0.025) and SVV perception (P = 0.038) than their controls, whereas CC+ did not show significant differences compared with their control group. Reduced awareness of postural abnormality was observed in >60% of patients with PS or CC.

Conclusions

Low visuospatial performances and vestibular tone imbalance are significantly associated with PS but not with CC. These findings suggest different pathophysiology for the two main postural abnormalities associated with PD and can foster adequate therapeutic and prevention strategies.

Highly cross-linked polyethylene versus conventional polyethylene in primary total knee arthroplasty: comparable clinical and radiological results at a 10-year follow-up

PURPOSE

Highly crosslinked polyethylene (HXLPE) was introduced in total knee arthroplasty (TKA) to reduce wear and consequent revisions for loosening due to conventional polyethylene (CPE) wear. This study aims to analyse whether HXLPE is as safe as CPE and could improve the TKA clinical and radiological results in a long-term follow-up.

METHODS

This retrospective study included all consecutive starting series of 223 patients with severe primary knee osteoarthritis (OA), with a minimum follow-up of 10 years treated between July 1st, 2007, and July 31st, 2010. After excluding patients who did not respect the inclusion and exclusion criteria, 128 patients were included in the analysis of this study. The patients were then divided into two groups according to the type of polyethylene (PE) implanted: CPE or HXLPE liners. All patients were evaluated for clinical and radiological parameters, causes and revision rates related to the type of PE implanted.

RESULTS

HXLPE appears to be as safe as CPE in TKA, reporting no higher revisions for osteolysis, prosthesis loosening, infection, and mechanical failure. Nevertheless, no statistically significant differences were found between the two groups in the clinical and radiological outcomes evaluated.

CONCLUSIONS

Clinical, radiological results, and revision rates are similar between HXLPE and CPE in TKA after 10 years of follow-up, although HXLPE benefits remain controversial.

LEVEL OF EVIDENCE

III.

The Impact of Health and Social Care Professionals' Education on the Quality of Serious Illness Conversations in Nursing Homes: Study Protocol of a Quality Improvement Project

Health and social care professionals (HCPs) who work in nursing homes (NHs) are increasingly required to sustain serious illness conversations about care goals and preferences. Although these conversations may also be challenging for experienced HCPs and the literature recognizes high-quality communication as key to providing patient-centered care, so far, no specific educational program has been developed for the NH setting to improve HCPs' communication skills. Our study aims to test the feasibility and potential effectiveness of an innovative, blended communication skills training program (Teach-to-Communicate) targeting the HCPs who work in NHs. This program includes classroom-based theory, experiential learning, and e-learning, and relies on interdisciplinary contexts and several didactic methods. The study consists of two phases: phase I is the development of written resources that employ focus group discussion involving field experts and external feedback from key stakeholders. Phase II consists of a multicenter, pilot, pre-post study with nested qualitative study. The Teach-to-Communicate training program is expected to enhance the quality of communication in NH and HCPs' confidence in sustaining serious illness conversations, reduce family carers' psycho-emotional burden and improve their satisfaction with the care received, and increase advance care planning documentation. Our protocol will provide insight for future researchers, healthcare providers, and policymakers and pave the way for blended educational approaches in the field of communication skills training.

Emergency Department Visits Before, After and During Integrated Home Care: A Time Series Analyses in Italy

BACKGROUND

Integrated home care (IHC) is one strategy to provide care to people with multiple chronic conditions, and it contributes to the reduction of unnecessary emergency department (ED) use, but there are conflicting results on its effectiveness. In this study, we assessed the frequency and characteristics of ED visits occurring before, during, and after IHC in a large cohort of IHC patients enrolled over 6 years.

METHODS

The analysis included 39 822 IHC patients identified in Italian administrative databases. Patients were grouped in tertiles according to IHC duration (short, intermediate, and long) and the number of ED visits during IHC was compared to that the 12 months before IHC enrolment and in the 12 months after IHC discharge across IHC duration groups.

RESULTS

We observed a reduction in ED visits during IHC. IHC was significantly associated with a reduction in ED visits in the long and short IHC duration groups. A non-significant reduction in ED visits was observed in the intermediate IHC duration group. A 90% reduction in ED visits during IHC and a 45% reduction after IHC was observed in the short IHC duration group. Corresponding reductions were 17% and 64% during and after IHC, respectively, in the long IHC duration group.

CONCLUSION

IHC was effective in reducing ED visits, but expansion of IHC to include additional necessary services could further reduce ED visits. Investment in the creation of a structured, effective network of engaged professionals (including community care services and hospitals) is crucial to achieving this.

Suicide spectrum among young people during the COVID-19 pandemic: A systematic review and meta-analysis

BACKGROUND

There are concerns that suicidal behaviors are arising among adolescents. The COVID-19 pandemic could have worsened the picture, however, studies on this topic reported contrasting results. This work aimed to summarise findings from the worldwide emerging literature on the rates of suicidality among young people during the COVID-19 pandemic.

METHODS

A systematic review and meta-analysis were performed, searching five electronic databases for studies published from January 1, 2020 until July 27, 2022. Studies reporting rates for each of the three considered outcomes (suicide, suicidal behaviors, and suicidal ideation) among young people under 19 years old during the COVID-19 pandemic were included. Random-effects meta-analyses were conducted, and the intra-study risk of bias was assessed. When pre-COVID-19 data were available, incidence rate ratio (IRR) and prevalence ratio (PR) estimates were calculated between the two periods. All the analyses were performed according to the setting explored: general population, emergency department (ED), and psychiatric services. The review protocol was registered on PROSPERO (CRD42022308014).

FINDINGS

Forty-seven observational studies were selected for more than 65 million subjects. The results of the meta-analysis showed a pooled annual incidence rate of suicides of 4.9 cases/100,000 during 2020, accounting for a non-statistically significant increase of 10% compared to 2019 (IRR 1.10, 95% CI: 0.94-1.29). The suicidal behaviors pooled prevalence during the COVID-19 pandemic was higher in the psychiatric setting (25%; 95% CI: 17-36%) than in the general population (3%; 1-13%) and ED (1%; 0-9%). The pooled rate of suicidal ideation was 17% in the general population (11-25%), 36% in psychiatric setting (20-56%) and 2% in ED (0-12%). The heterogeneity level was over 97% for both outcomes in all settings considered. The comparison between before and during COVID-19 periods highlighted a non-statistically significant upward trend in suicidal behaviors among the general population and in ED setting. The only significant increase was found for suicidal ideation in psychiatric setting among studies conducted in 2021 (PR 1.15; 95% CI: 1.04-1.27), not observed exploring 2020 alone.

INTERPRETATION

During the pandemic, suicide spectrum issues seemed to follow the known pattern described in previous studies, with higher rates of suicidal ideation than of suicidal behaviors and suicide events. Governments and other stakeholders should be mindful that youth may have unique risks at the outset of large disasters like the COVID-19 pandemic and proactive steps are necessary to address the needs of youth to mitigate those risks.

FUNDING

The present study was funded by the University of Torino (CHAL_RILO_21_01).

COVID-19 hospitalizations and patients' age at admission: The neglected importance of data variability for containment policies

Introduction

An excess in the daily fluctuation of COVID-19 in hospital admissions could cause uncertainty and delays in the implementation of care interventions. This study aims to characterize a possible source of extravariability in the number of hospitalizations for COVID-19 by considering age at admission as a potential explanatory factor. Age at hospitalization provides a clear idea of the epidemiological impact of the disease, as the elderly population is more at risk of severe COVID-19 outcomes. Administrative data for the Veneto region, Northern Italy from February 1, 2020, to November 20, 2021, were considered.

Methods

An inferential approach based on quasi-likelihood estimates through the generalized estimation equation (GEE) Poisson link function was used to quantify the overdispersion. The daily variation in the number of hospitalizations in the Veneto region that lagged at 3, 7, 10, and 15 days was associated with the number of news items retrieved from Global Database of Events, Language, and Tone (GDELT) regarding containment interventions to determine whether the magnitude of the past variation in daily hospitalizations could impact the number of preventive policies.

Results

This study demonstrated a significant increase in the pattern of hospitalizations for COVID-19 in Veneto beginning in December 2020. Age at admission affected the excess variability in the number of admissions. This effect increased as age increased. Specifically, the dispersion was significantly lower in people under 30 years of age. From an epidemiological point of view, controlling the overdispersion of hospitalizations and the variables characterizing this phenomenon is crucial. In this context, the policies should prevent the spread of the virus in particular in the elderly, as the uncontrolled diffusion in this age group would result in an extra variability in daily hospitalizations.

Discussion

This study demonstrated that the overdispersion, together with the increase in hospitalizations, results in a lagged inflation of the containment policies. However, all these interventions represent strategies designed to contain a mechanism that has already been triggered. Further efforts should be directed toward preventive policies aimed at protecting the most fragile subjects, such as the elderly. Therefore, it is essential to implement containment strategies before the occurrence of potentially out-of-control situations, resulting in congestion in hospitals and health services.

Assessment of Glucose Lowering Medications' Effectiveness for Cardiovascular Clinical Risk Management of Real-World Patients with Type 2 Diabetes: Targeted Maximum Likelihood Estimation under Model Misspecification and Missing Outcomes

The results from many cardiovascular (CV) outcome trials suggest that glucose lowering medications (GLMs) are effective for the CV clinical risk management of type 2 diabetes (T2D) patients. The aim of this study is to compare the effectiveness of two GLMs (SGLT2i and GLP-1RA) for the CV clinical risk management of T2D patients in a real-world setting, by simultaneously reducing glycated hemoglobin, body weight, and systolic blood pressure. Data from the real-world Italian multicenter retrospective study Dapagliflozin Real World evideNce in Type 2 Diabetes (DARWINT 2D) are analyzed. Different statistical approaches are compared to deal with the real-world-associated issues, which can arise from model misspecification, nonrandomized treatment assignment, and a high percentage of missingness in the outcome, and can potentially bias the marginal treatment effect (MTE) estimate and thus have an influence on the clinical risk management of patients. We compare the logistic regression (LR), propensity score (PS)-based methods, and the targeted maximum likelihood estimator (TMLE), which allows for the use of machine learning (ML) models. Furthermore, a simulation study is performed, resembling the structure of the conditional dependencies among the main variables in DARWIN-T2D. LR and PS methods do not underline any difference in the effectiveness regarding the attainment of combined CV risk factor goals between the two treatments. TMLE suggests instead that dapagliflozin is significantly more effective than GLP-1RA for the CV risk management of T2D patients. The results from the simulation study suggest that TMLE has the lowest bias and SE for the estimate of the MTE.

A Bayesian Sample Size Estimation Procedure Based on a B-Splines Semiparametric Elicitation Method

Sample size estimation is a fundamental element of a clinical trial, and a binomial experiment is the most common situation faced in clinical trial design. A Bayesian method to determine sample size is an alternative solution to a frequentist design, especially for studies conducted on small sample sizes. The Bayesian approach uses the available knowledge, which is translated into a prior distribution, instead of a point estimate, to perform the final inference. This procedure takes the uncertainty in data prediction entirely into account. When objective data, historical information, and literature data are not available, it may be indispensable to use expert opinion to derive the prior distribution by performing an elicitation process. Expert elicitation is the process of translating expert opinion into a prior probability distribution. We investigated the estimation of a binomial sample size providing a generalized version of the average length, coverage criteria, and worst outcome criterion. The original method was proposed by Joseph and is defined in a parametric framework based on a Beta-Binomial model. We propose a more flexible approach for binary data sample size estimation in this theoretical setting by considering parametric approaches (Beta priors) and semiparametric priors based on B-splines.

A topic trend analysis on COVID-19 literature

Objective

In the past 2 years, the number of scientific publications has grown exponentially. The COVID-19 outbreak hugely contributed to this dramatic increase in the volume of published research. Currently, text mining of the volume of SARS-CoV-2 and COVID-19 publications is limited to the first months of the outbreak. We aim to identify the major topics in COVID-19 literature collected from several citational sources and analyze the temporal trend from November 2019 to December 2021.

Methods

We performed an extensive literature search on SARS-Cov-2 and COVID-19 publications on PubMed, Scopus, and Web of Science (WoS) and a structural topic modelling on the retrieved abstracts. The temporal trend of the recognized topics was analyzed. Furthermore, a comparison between our corpus and the COVID-19 Open Research Dataset (CORD-19) repository was performed.

Results

We collected 269,186 publications and identified 10 topics. The most popular topic was related to the clinical pictures of the COVID-19 outbreak, which has a constant trend, and the least popular includes studies on COVID-19 literature and databases. "Telemedicine", "Vaccine development", and "Epidemiology" were popular topics in the early phase of the pandemic; increasing topics in the last period are "COVID-19 impact on mental health", "Forecasting", and "Molecular Biology". "Education" was the second most popular topic, which emerged in September 2020.

Conclusions

We identified 10 topics for classifying COVID-19 research publications and estimated a nonlinear temporal trend that gives an overview of their unfolding over time. Several citational databases must be searched to retrieve a complete set of studies despite the efforts to build repositories for COVID-19 literature. Our collected data can help build a more focused literature search between November 2019 and December 2021 when carrying out systematic and rapid reviews and our findings can give a complete picture on the topic.

Risk behaviors among migrant adolescents in Italy

Background

Over the last decade, the student population migrated to Italy has quadrupled, but studies on their potentially harmful behaviors such as substance use are still scarce. The aim of this research is to monitor risk behaviors among migrant adolescents in Italy and provide appropriate indications for the definition of targeted policies and interventions.

Methods

A representative sample of 15 year-old adolescents was drawn from the 2018 Italian Health Behavior in School-aged Children (HBSC) survey data. Smoking habits, alcohol consumption and drunkenness were investigated and differences with Italian peers were assessed.

Findings

Results were based on more than 18,500 students, of which 16% were migrants: 32.7% from Western countries (We), 32.5% from Eastern European countries (Ee), and 34.8% from non-Western/non-European countries (nW). Compared with natives, students from nW countries showed a lower risk of smoking habits (OR: 0.72, 95%CI: 0.58-0.89) and weekly alcohol consumption (OR:0.57, 95%CI:0.43-0.75), whereas drunkenness was more prevalent among Ee migrants (OR: 1.42, 95%CI: 1.10-1.83). Overall, both migrant and Italian girls showed a lower risk of unhealthy behaviors than boys.

Conclusions

Compared to the native counterparts, migrant adolescents showed differences in substance use according to their ethnic background. We observed two different immigration patterns: the Western immigrants, who came from countries with higher affluence and share similar risk behaviors with native peers, and non-Western immigrants, who came from less affluent countries and seemed to maintain the risk behaviors of their culture of origin.

Key messages

Suicidality among children and adolescents “in the COVID-19 era”: a worldwide metanalytic picture

Background

The impact of the COVID-19 pandemic on adolescent suicidality is still controversial. The present systematic review and meta analysis aim to summarise findings from emerging literature about prevalences of the main suicidal outcomes among children and adolescents under 19 years old, and to compare them with the pre-pandemic period.

Methods

Five databases (PubMed, Embase, Scopus, CINAHL and Web of Science) were systematically searched for studies published in English from January 1st, 2020 until November 3rd, 2021, reporting prevalence for suicidal ideation (SI), suicidal behaviors (SB) and suicide (S) in the general population aged <19 during the COVID-19 pandemic. Single-study prevalence data were pooled using random-effects meta-analysis. If studies reported prevalence estimates for both pre- and during-pandemic periods, prevalence ratio (PR) comparing the two periods has been computed and pooled.

Results

Sixteen observational studies were selected: 10 about SI, 9 about SB and 3 about S. During the pandemic, prevalence of SI among adolescents was 21% (95% CI 12-34%) while prevalence of SB was 3% (95% CI 1-10%). Comparing pre- and during- pandemic prevalences, a significant overall increase in SB was observed (PR 1.35; 95% CI 1.06-1.72) while the prevalence rates of SI remained substantially steady (PR 0.95; 95% CI 0.64-1.39). A narrative review on the population-based data on suicide rates suggested an escalating trend since Summer 2020, after an initial stability of the phenomenon.

Conclusions

During the COVID-19 pandemic SB showed a 35% increase and suicides rates escalated after a initial stability. School closures might be involved, representing an initial protective factor for suicidality, while after the reopenings we could have assisted to a suicide rebound, especially among the most vulnerable young people.

Key messages

• The topic of suicidality among young people is still affected by a cultural stigma that hampers the development of both academic research, early detection and preventive policies.

• The increase in suicidal behaviors among youths after the COVID-19 outbreak highlights a major public health issue that requires adequate supporting policies to control and prevent this phenomenon.

Temporal trends of suicidality among adolescents in the last decade in Piedmont, Northwestern Italy

Background

Over the last decade, trends of suicidality among adolescents remain unclear. We conducted a cross-sectional study using surveillance data collected over the past 10 years in the Piedmont region, Italy, to explore temporal trends in suicidality among hospitalized adolescents.

Methods

This was a retrospective study over an 11-year period of time. The target cohort was adolescents aged 13-19 discharged from inpatient/day-hospital care with at least one suicidality-related ICD9-CM code (i.e., suicidal ideation-SI, suicidal risk-SR and suspected suicide-SS) between 2011 and 2021 in Piedmont (Northwestern Italy). Social-economic related data is available from Census 2011. Yearly incidence rates (IR) were calculated based on the overall hospitals’ catchment population and by sex. Poisson regression model was estimated to evaluate the trend over time and the association with sex, and a potential effect of the COVID-19 pandemic. A non-linear trend was allowed by modelling natural splines.

Results

We included 490 adolescents (median age: 15 years, IQR: 13-16), 380 girls and 110 boys, with ICD9-CM codes for SI (264; 53.9%), SR (142; 29%), SS (90; 18.4%) at first discharge. Girls showed a higher risk of repeated inpatient care than boys (19.2% vs 7.3%, p < 0.01). Since 2013, yearly suicidality IRs started increasing linearly in boys (+1.7/100,000 per year, 95%CI: 0.7-2.8). Apparently, suicidality IRs increasing in girls were observed since 2011 (+5.8/100,000 per year, 95%CI 2.8-8.9) and were significantly higher than in boys (p < 0.001).

Conclusions

Suicidality among young inpatients increased in Piedmont during the last decade. Females seemed to be more affected than males. Further research is needed to better understand gender-related risk factors for suicidality.

Key messages

• There has been an increase in the number of adolescents reporting suicidal ideation in the last decade, especially in girls.

• Intervention strategies are urgently needed to reverse a potentially alarming trend in suicidality among young people.

Level of Diffusion and Training of Lung Ultrasound during the COVID-19 Pandemic - A National Online Italian Survey (ITALUS) from the Lung Ultrasound Working Group of the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI)

PURPOSE

 The goal of this survey was to describe the use and diffusion of lung ultrasound (LUS), the level of training received before and during the COVID-19 pandemic, and the clinical impact LUS has had on COVID-19 cases in intensive care units (ICU) from February 2020 to May 2020.

MATERIALS AND METHODS

 The Italian Lung Ultrasound Survey (ITALUS) was a nationwide online survey proposed to Italian anesthesiologists and intensive care physicians carried out after the first wave of the COVID-19 pandemic. It consisted of 27 questions, both quantitative and qualitative.

RESULTS

 807 responded to the survey. The median previous LUS experience was 3 years (IQR 1.0-6.0). 473 (60.9 %) reported having attended at least one training course on LUS before the COVID-19 pandemic. 519 (73.9 %) reported knowing how to use the LUS score. 404 (52 %) reported being able to use LUS without any supervision. 479 (68.2 %) said that LUS influenced their clinical decision-making, mostly with respect to patient monitoring. During the pandemic, the median of patients daily evaluated with LUS increased 3-fold (p < 0.001), daily use of general LUS increased from 10.4 % to 28.9 % (p < 0.001), and the daily use of LUS score in particular increased from 1.6 % to 9.0 % (p < 0.001).

CONCLUSION

 This survey showed that LUS was already extensively used during the first wave of the COVID-19 pandemic by anesthesiologists and intensive care physicians in Italy, and then its adoption increased further. Residency programs are already progressively implementing LUS teaching. However, 76.7 % of the sample did not undertake any LUS certification.

Rehabilitation in children and adolescents undergoing stem cell transplantation: A pilot study focused on motor performance

OBJECTIVES

The aim of this pilot trial is evaluating the preliminary effectiveness of two in-hospital interventions in the maintenance of motor performance in children/adolescents undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives investigated the interventions' feasibility, impact on fatigue and to what degree the subjects' maintained their ankle dorsiflexion range of movement (ROM), functional mobility, muscle strength and flexibility.

METHODS

This trial included 5- to 18-year-old participants, affected by oncological and non-oncological diseases during hospitalisation for autologous/allogenic HSCT. The subjects were assigned to an exercise group (EG), or a counselling group based on a cluster model based on inpatient timeframe. The EG subjects performed strengthening, stretching and aerobic exercises for 30 min/5 days a week. Both groups followed rehabilitation counselling indications (RCI), 7 days a week.

RESULTS

Forty-nine participants were enrolled (median age = 12.9 years) (EG n = 36). In both groups the participants maintained their baseline motor performance and ankle ROM, and the children/adolescents and parents reduced their levels of fatigue. However, the interventions were not effective in maintaining strength.

CONCLUSION

In maintaining the subjects' motor performance, the RCI results are significant because they pave the way for the application in clinical practice contexts where there are poor rehabilitation resources. Clinical Trials registration NCT03842735.

Regional Differences in Mortality Rates During the COVID-19 Epidemic in Italy

OBJECTIVE

The coronavirus disease 2019 (COVID-19) outbreak started in Italy on February 20, 2020, and has resulted in many deaths and intensive care unit (ICU) admissions. This study aimed to illustrate the epidemic COVID-19 growth pattern in Italy by considering the regional differences in disease diffusion during the first 3 mo of the epidemic.

METHODS

Official COVID-19 data were obtained from the Italian Civil Protection Department of the Council of Ministers Presidency. The mortality and ICU admission rates per 100,000 inhabitants were calculated at the regional level and summarized by means of a Bayesian multilevel meta-analysis. Data were retrieved until April 21, 2020.

RESULTS

The highest cumulative mortality rates per 100 000 inhabitants were observed in northern Italy, particularly in Lombardia (85.3; 95% credibility intervals [CI], 75.7-94.7). The difference in the mortality rates between northern and southern Italy increased over time, reaching a difference of 67.72 (95% CI, 66-67) cases on April 2, 2020.

CONCLUSIONS

Northern Italy showed higher and increasing mortality rates during the first 3 mo of the epidemic. The uncontrolled virus circulation preceding the infection spreading in southern Italy had a considerable impact on system burnout. This experience demonstrates that preparedness against the pandemic is of crucial importance to contain its disruptive effects.

Moral Distress and Burnout in Neonatal Intensive Care Unit Healthcare Providers: A Cross-Sectional Study in Italy

Moral distress (MD) in healthcare providers is widely recognized as a serious issue in critical care contexts. It has the potential to have negative impacts on both personal and professional wellbeing, the quality of care provided and staff turnover. The aim of this study was to investigate the relationship between MD and burnout among neonatal intensive care unit (NICU) healthcare professionals and identify the possible factors associated with its occurrence. Participants were asked to complete an online survey, which covered sociodemographic and professional information and included two self-report questionnaires (Italian Moral Distress Scale-Revised and Maslach Burnout Inventory). The sample comprised 115 healthcare providers (nurses and physiotherapists: 66.1%; physicians: 30.4%; healthcare assistants: 3.5%) working in four NICUs located within the province of Turin, Italy. The results revealed overall low levels of MD, with no significant differences between nurses/physiotherapists and physicians. Nurses/physiotherapists showed a statistically significant higher percentage of personal accomplishment burnout (32.9%) compared with physicians (8.6%; p = 0.012). MD was associated with the emotional exhaustion dimension of burnout. Spirituality and/or religiousness was shown to be a moderating variable. Further research is needed to deepen our understanding of the correlation between MD and burnout and the role of spirituality and/or religiousness as moderators.

A deep learning approach for Spatio-Temporal forecasting of new cases and new hospital admissions of COVID-19 spread in Reggio Emilia, Northern Italy

Background

Since February 2020, the COVID-19 epidemic has rapidly spread throughout Italy. Some studies showed an association of environmental factors, such as PM₁₀, PM_2.5, NO₂, temperature, relative humidity, wind speed, solar radiation and mobility with the spread of the epidemic.

In this work, we aimed to predict via Deep Learning the real-time transmission of SARS-CoV-2 in the province of Reggio Emilia, Northern Italy, in a grid with a small resolution (12 km × 12 km), including satellite information.

Methods

We focused on the Province of Reggio Emilia, which was severely hit by the first wave of the epidemic. The outcomes included new SARS-CoV-2 infections and COVID-19 hospital admissions. Pollution, meteorological and mobility data were analyzed. The spatial simulation domain included the Province of Reggio Emilia in a grid of 40 cells of (12 km)². We implemented a ConvLSTM, which is a spatio-temporal deep learning approach, to perform a 7-day moving average to forecast the 7th day after. We used as training and validation set the new daily infections and hospital admissions from August 2020 to March 2021. Finally, we assessed the models in terms of Mean Absolute Error (MAE) compared with Mean Observed Value (MOV) and Root Mean Squared Error (RMSE) on data from April to September 2021. We tested the performance of different combinations of input variables to find the best forecast model.

Findings

Daily new cases of infection, mobility and wind speed resulted in being strongly predictive of new COVID-19 hospital admissions (MAE = 2.72 in the Province of Reggio Emilia; MAE = 0.62 in Reggio Emilia city), whereas daily new cases, mobility, solar radiation and PM_2.5 turned out to be the best predictors to forecast new infections, with appropriate time lags.

Interpretation

ConvLSTM achieved good performances in forecasting new SARS-CoV-2 infections and new COVID-19 hospital admissions. The spatio-temporal representation allows borrowing strength from data neighboring to forecast at the level of the square cell (12 km)², getting accurate predictions also at the county level, which is paramount to help optimise the real-time allocation of health care resources during an epidemic emergency.

The NEVERMIND e-health system in the treatment of depressive symptoms among patients with severe somatic conditions: A multicentre, pragmatic randomised controlled trial

Background

This study assessed the effectiveness of the NEVERMIND e-health system, consisting of a smart shirt and a mobile application with lifestyle behavioural advice, mindfulness-based therapy, and cognitive behavioural therapy, in reducing depressive symptoms among patients diagnosed with severe somatic conditions. Our hypothesis was that the system would significantly decrease the level of depressive symptoms in the intervention group compared to the control group.

Methods

This pragmatic, randomised controlled trial included 425 patients diagnosed with myocardial infarction, breast cancer, prostate cancer, kidney failure, or lower limb amputation. Participants were recruited from hospitals in Turin and Pisa (Italy), and Lisbon (Portugal), and were randomly assigned to either the NEVERMIND intervention or to the control group. Clinical interviews and structured questionnaires were administered at baseline, 12 weeks, and 24 weeks. The primary outcome was depressive symptoms at 12 weeks measured by the Beck Depression Inventory II (BDI-II). Intention-to-treat analyses included 425 participants, while the per-protocol analyses included 333 participants. This trial is registered in the German Clinical Trials Register, DRKS00013391.

Findings

Patients were recruited between Dec 4, 2017, and Dec 31, 2019, with 213 assigned to the intervention and 212 to the control group. The sample had a mean age of 59·41 years (SD=10·70), with 44·24% women. Those who used the NEVERMIND system had statistically significant lower depressive symptoms at the 12-week follow-up (mean difference=-3·03, p<0·001; 95% CI -4·45 to -1·62) compared with controls, with a clinically relevant effect size (Cohen's d=0·39).

Interpretation

The results of this study show that the NEVERMIND system is superior to standard care in reducing and preventing depressive symptoms among patients with the studied somatic conditions.

Funding

The NEVERMIND project received funding from the European Union's Horizon 2020 Research and Innovation Programme under grant agreement No. 689691.

Outcome of liver transplantation with grafts from brain-dead donors treated with dual hypothermic oxygenated machine perfusion, with particular reference to elderly donors

Prompted by the utilization of extended criteria donors, dual hypothermic oxygenated machine perfusion (D-HOPE) was introduced in liver transplantation to improve preservation. When donors after neurological determination of death (DBD) are used, D-HOPE effect on graft outcomes is unclear. To assess D-HOPE value in this setting and to identify ideal scenarios for its use, data on primary adult liver transplant recipients from January 2014 to April 2021 were analyzed using inverse probability of treatment weighting, comparing outcomes of D-HOPE-treated grafts (n = 121) with those preserved by static cold storage (n = 723). End-ischemic D-HOPE was systematically applied since November 2017 based on donor and recipient characteristics and transplant logistics. D-HOPE use was associated with a significant reduction of early allograft failure (OR: 0.24; 0.83; p = .024), grade ≥3 complications (OR: 0.57; p = .046), comprehensive complication index (-7.20 points; p = .003), and improved patient and graft survival. These results were confirmed in the subset of elderly donors (>75-year-old). Although D-HOPE did not reduce the incidence of biliary complications, its use was associated with a reduced severity of ischemic cholangiopathy. In conclusion, D-HOPE improves postoperative outcomes and reduces early allograft loss in extended criteria DBD grafts.

A prognostic model integrating PET‐derived metrics and image texture analyses with clinical risk factors from GOYA

Image texture analysis (radiomics) uses radiographic images to quantify characteristics that may identify tumour heterogeneity and associated patient outcomes. Using fluoro‐deoxy‐glucose positron emission tomography/computed tomography (FDG‐PET/CT)‐derived data, including quantitative metrics, image texture analysis and other clinical risk factors, we aimed to develop a prognostic model that predicts survival in patients with previously untreated diffuse large B‐cell lymphoma (DLBCL) from GOYA (NCT01287741). Image texture features and clinical risk factors were combined into a random forest model and compared with the international prognostic index (IPI) for DLBCL based on progression‐free survival (PFS) and overall survival (OS) predictions. Baseline FDG‐PET scans were available for 1263 patients, 832 patients of these were cell‐of‐origin (COO)‐evaluable. Patients were stratified by IPI or radiomics features plus clinical risk factors into low‐, intermediate‐ and high‐risk groups. The random forest model with COO subgroups identified a clearer high‐risk population (45% 2‐year PFS [95% confidence interval (CI) 40%–52%]; 65% 2‐year OS [95% CI 59%–71%]) than the IPI (58% 2‐year PFS [95% CI 50%–67%]; 69% 2‐year OS [95% CI 62%–77%]). This study confirms that standard clinical risk factors can be combined with PET‐derived image texture features to provide an improved prognostic model predicting survival in untreated DLBCL.

Impact of the COVID-19 lockdown on psychological health and nutritional habits in Italy: results from the #PRESTOinsieme study

OBJECTIVES

The present work aims to present the results of the 'PRESTOinsieme' (which is 'we will be together soon' in English). The web-based survey (www.prestoinsieme.com) describes changes in lifestyle habits and symptoms of psychological discomfort in the Italian population during the COVID-19 lockdown.

DESIGN

Cross-sectional online survey disseminated by messaging apps (ie, WhatsApp and Telegram) and social networks (ie, Instagram, Facebook and LinkedIn).

SETTING

Italy.

PARTICIPANTS

Italian population older than 16 years of age.

EXPOSURE

COVID-19 lockdown.

MAIN OUTCOMES AND MEASURES

Survey respondents filled out a set of validated questionnaires aimed at assessing lifestyle habits and psychological health, that is, the General Health Questionnaire (GHQ-12) to screen for psychological distress, the Impact of Event Scale-Revised (IES-R) to screen for post-traumatic stress and the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Survey respondents totalled 5008. Moderate or severe psychological distress was reported in 25.5% and 22% of survey respondents, respectively. Lower age, female gender, being unemployed (OR 1.57, 95% CI 1.22 to 2.02) or being a student (OR 1.73, 95% CI 1.31 to 2.28) were predictors of more severe depressive symptoms.

CONCLUSIONS

The present study is one of the largest population-based surveys conducted in Italy during the first COVID-19 lockdown, providing valuable data about the Italian population's psychological health. Further studies should be conducted to understand whether psychological distress persists after the end of the lockdown.

Gender-specific side effects of chemotherapy in pancreatic cancer patients

Pancreatic carcinoma incidence showed a significant increase in men over the last few years and the prognosis remains poor. Patients are treated with different pharmacological plans with no evidence about gender-specific adverse effects. We aimed to investigate differences in the incidence of chemotherapy side effects in the treatment of pancreatic cancer, to provide insights toward a personalized assistance based in individual needs. The sample population is composed of 207 patients. Regression model highlighted the predictive role of female gender for alopecia, constipation, hand-foot syndrome, and epigastric pain. Also, considering single therapeutic schemes, gender differences have been reported. Moreover, evaluating the effect of age, a general reduced risk of toxicity has been reported in younger patients. To personalize chemotherapy and increase patient survival rate and life quality during the therapy, gender medicine and pharmacology studies are recommended.

Forecasting Frequent Alcohol Use among Adolescents in HBSC Countries: A Bayesian Framework for Making Predictions

(1) Aim: To summarize alcohol trends in the last 30 years (1985/6–2017/8) among 15-year-olds in Health Behaviour in School-aged Children (HBSC) countries (overall sample size: 413,399 adolescents; 51.55% girls) and to forecast the potential evolution in the upcoming 2021/22 HBSC survey. (2) Methods: Using 1986–2018 prevalence data on weekly alcohol consumption among 15-year-olds related to 40 HBSC countries/regions, a Bayesian semi-parametric hierarchical model was adopted to estimate trends making a clusterization of the countries, and to give estimates for the 2022 HBSC survey. (3) Results: An overall declining trend in alcohol consumption was observed over time in almost all the countries. However, compared to 2014, some countries showed a new increase in 2018 and 2021/22 estimates forecast a slight increase in the majority of countries, pointing out a potential bounce after a decreasing period in frequent drinking habits. (4) Conclusions: The clusterization suggested a homogenization of consumption habits among HBSC countries. The comparison between 2022 observed and expected data could be helpful to investigate the effect of risk behaviour determinants, including the pandemic impact, occurring between the last two waves of the survey.

First randomized trial on adjuvant mitotane in adrenocortical carcinoma patients: The Adjuvo study

1

Background: The ESE-ENSAT guidelines on ACC management suggest adjuvant mitotane for patients at high risk of recurrence. This indication has limited evidence base, lacking results from randomized controlled trials. No suggestion for or against adjuvant mitotane in low-risk patients was given, since studies did not stratify patients for prognosis. The randomized controlled study ADIUVO compared the efficacy of adjuvant mitotane treatment vs. observation in prolonging recurrence-free survival (RFS) in patients at low-intermediate risk of recurrence. Methods: The main inclusion criteria were: stage I-III ACC, R0 surgery, and Ki-67 ≤10%. Patients were randomly assigned 1:1 to adjuvant mitotane or observation. The primary endpoint of the study was RFS. Patients who refused randomization were eligible for the ADIUVO OBSERVATIONAL study. In this prospective, observational study, patients were managed as in ADIUVO except for randomization. A total of 91 patients were enrolled in ADIUVO, 45 in the mitotane and 46 in the observation arm. Baseline characteristics of patients were perfectly matched between the 2 arms: median age, 51 vs. 50.5 years; female, 73% vs. 67%; stage I, 20% vs. 26%; stage II, 67% vs. 63%, stage III, 13% vs. 11%; ACC secretion 44% vs. 36%; Weiss 5 vs. 5; respectively. In ADIUVO OBSERVATIONAL, 42 patients were treated with mitotane and 53 were untreated. Baseline characteristics of patients were matched between the 2 groups and with mitotane and observation groups in ADIUVO. Thus, the ADIUVO OBSERVATIONAL cohort was analyzed in parallel to deal with the lower than expected recruitment in ADIUVO. Results: In the ADIUVO study, recurrences were 8 in the MIT and 11 in the OBS arm, while deaths were 2 and 5, respectively. RFS and overall survival (OS) did not significantly differ between the 2 arms. In the OBS arm, the HR for recurrence was 1.321 (95%CI, 0.55-3.32, p = 0.54) and HR for death 2.171 (95%CI, 0.52-12.12, p = 0.29). The survival analysis in the ADIUVO OBSERVATIONAL study confirmed that of ADIUVO. Given the outcome of both studies, the NNT is 55. Conclusions: ACC patients at low-intermediate risk of recurrence after surgery are a minority; however, they show a far better prognosis than expected (5-yr RFS is 75%) and do not benefit significantly from adjuvant mitotane. The results of the ADIUVO study do not support routine use of adjuvant mitotane in this subset of patients, who may thus avoid a potentially toxic treatment. This is an important step toward personalization of ACC care. Clinical trial information: NCT00777244.

Exploring the Use and Usefulness of Educational Resources Among Nurses During the First Wave of the COVID-19 Pandemic: A Cross-Sectional Study

Nurses needed to learn rapidly how to care for patients with coronavirus disease 2019 (COVID-19). This cross-sectional study identified the educational resources RNs used to learn how to care for these patients, measured the perceived usefulness of the content of these resources, and explored the most relevant educational content sought during the first wave of the pandemic. A total of 799 RNs completed an online survey. Significant differences were found in the educational resources used between RNs who cared for patients with COVID-19 and RNs who did not, as well as for RNs who changed units following the pandemic. The educational resources most often used were also ranked as most useful. The most relevant educational content sought was related to respiratory care techniques and infection containment. These findings provide insight into the educational resources available during the first wave of the COVID-19 pandemic. They could help in developing educational programs relevant to nurses' needs during future pandemics. [J Contin Educ Nurs. 2022;53(2):63-69.].

Mental Well-Being: 2010-2018 Trends among Italian Adolescents

(1) Aims: To explore temporal trends 2010-2018 of well-being among Italian adolescents and to evaluate potential explanatory factors. (2) Methods: Italian nationality representative samples of students aged 11, 13, and 15 years were recruited in 2010, 2014, and 2018; Health Behaviour in School-aged Children (HBSC), for an overall number of 165,000 teenagers. Multivariable logistic regression models were performed to fit the trends over time of life satisfaction (LS), psychological (PSY-HC) and somatic health complaints (SOM-HC) considering the contextual factors: school work pressure, social support (family, school, peers), socioeconomic status, geographic area, and immigration background; (3) Results: From 2010 to 2018 while LS was steady, health complaints increased, mainly for PSY-HC, in all age and gender groups. Trend of PSY-HC affected mainly 15-years-olds: rates among boys varied from 29.6% to 35.9% (OR: 1.13, 95%CI: 1.02-1.25); among girls from 49.1% to 63.3% (OR: 1.56, 95%CI: 1.42-1.72). High school work pressure and poor social support play a central role in worsening well-being outcomes; (4) Conclusions: Our findings pictured a remarkable worsening trend of teenagers' well-being, especially among 15-year-old girls. Further research will be required to investigate this breaking up of the connection between psychophysical symptomatology and cognitive perception of life satisfaction.

Limited Role of Hair Cortisol and Cortisone Measurement for Detecting Cortisol Autonomy in Patients With Adrenal Incidentalomas

Several studies demonstrated the diagnostic accuracy of hair glucocorticoid measurement in patients with overt Cushing syndrome, but few data are available for patients with adrenal incidentaloma (AI) and cortisol autonomy. The aim of our study was to assess whether measurement of 5 corticosteroid hormones with the ultra-high-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method in the keratin matrix is useful to stratify patients with AI by the presence of autonomous cortisol secretion [ACS] (defined as serum cortisol after 1 mg dexamethasone suppression test (DST) > 138 nmol/l) or possible ACS [PACS] (defined as serum cortisol after 1 mg DST > 50 nmol/l but ≤138 nmol/l). We analysed data of 67 AI patients (32 with cortisol autonomy) and 81 healthy subjects. We did not find any significant statistical difference comparing hair cortisol, cortisone, and 20β-dihydrocortisol concentrations between healthy controls and AI patients, while 6β-hydroxycortisol and 11-deoxycortisol were undetectable. Moreover, no significant difference was found in hair cortisol, cortisone, and 20β-dihydrocortisol levels of AI patients with or without cortisol autonomy. Finally, we did not find any correlation in patients with AI between hormonal concentrations in the keratin matrix and serum, salivary, and urinary cortisol levels, or with body mass index. In conclusion, our findings suggest that hair glucocorticoid measurement is not suitable as a diagnostic test for cortisol autonomy (ACS and PACS).

Comparable results between crosslinked polyethylene and conventional ultra-high molecular weight polyethylene implanted in total knee arthroplasty: systematic review and meta-analysis of randomised clinical trials

PURPOSE

Total knee arthroplasty (TKA) has experienced exponential growth over the last decade, including increasingly younger patients with high functional demands. Highly crosslinked polyethylene (HXLPE) has been proven effective in reducing osteolysis and loosening revisions while improving long-term survival and performance in total hip arthroplasty; nevertheless, this superiority is not demonstrated in TKA. The aim of this systematic review and meta-analysis was to examine whether HXLPE improved overall survival and postoperative functional and radiological outcomes compared to conventional polyethylene (CPE) in TKA.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, a literature search of five databases (PubMed, Medline, Scopus, Science Direct and Embase) was made. A PICOS model was performed. The initial screening identified 2541 studies. Each eligible clinical article was analysed according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (LoE). Only randomised clinical trials (RCTs) of LoE 1 and 2 were included. The methodological quality of the articles was assessed using the Risk of Bias 2 (RoB 2) tool.

RESULTS

Six clinical studies were included in the final study. This systematic review and meta-analysis were registered on the International Prospective Register of Systematic Reviews (PROSPERO). A total of 2285 knees were included. Eight outcomes (total reoperations, reoperations for prosthesis loosening and infections, radiolucent lines, osteolysis, mechanical failure, postoperative KSS knee score and function score) were analysed. For none of them, a statistically significant difference was found about the superiority of HXLPE over CPE (p > 0.05).

CONCLUSIONS

There were no statistically significant differences between HXLPE and CPE for TKA concerning clinical, radiological, and functional outcomes; nevertheless, HXLPE did not show higher failure rates or complications and can be safely used for TKA.

LEVEL OF EVIDENCE

II.

Psychosocial factors associated with complicated grief in caregivers during COVID-19: Results from a preliminary cross-sectional study

The COVID-19 pandemic has changed how end-of-life ceremonies are performed, affecting grief processing and bereavement experiences. In this study, caregivers of patients who died with COVID-19 during the first wave of the pandemic were asked to complete an online survey designed to detect psychosocial factors associated with the presence of complicated grief (CG). The results show CG present in 48.4% of caregivers. The marital and cohabitant status during lockdown, the perceived sense of guilt and depression levels were significantly associated with the presence of CG, whereas attendance at the funeral and social support were found to be significant protective factors.

Oversampling and replacement strategies in propensity score matching: a critical review focused on small sample size in clinical settings

Background

Propensity score matching is a statistical method that is often used to make inferences on the treatment effects in observational studies. In recent years, there has been widespread use of the technique in the cardiothoracic surgery literature to evaluate to potential benefits of new surgical therapies or procedures. However, the small sample size and the strong dependence of the treatment assignment on the baseline covariates that often characterize these studies make such an evaluation challenging from a statistical point of view. In such settings, the use of propensity score matching in combination with oversampling and replacement may provide a solution to these issues by increasing the initial sample size of the study and thus improving the statistical power that is needed to detect the effect of interest. In this study, we review the use of propensity score matching in combination with oversampling and replacement in small sample size settings.

Methods

We performed a series of Monte Carlo simulations to evaluate how the sample size, the proportion of treated, and the assignment mechanism affect the performances of the proposed approaches. We assessed the performances with overall balance, relative bias, root mean squared error and nominal coverage. Moreover, we illustrate the methods using a real case study from the cardiac surgery literature.

Results

Matching without replacement produced estimates with lower bias and better nominal coverage than matching with replacement when 1:1 matching was considered. In contrast to that, matching with replacement showed better balance, relative bias, and root mean squared error than matching without replacement for increasing levels of oversampling. The best nominal coverage was obtained by using the estimator that accounts for uncertainty in the matching procedure on sets of units obtained after matching with replacement.

Conclusions

The use of replacement provides the most reliable treatment effect estimates and that no more than 1 or 2 units from the control group should be matched to each treated observation. Moreover, the variance estimator that accounts for the uncertainty in the matching procedure should be used to estimate the treatment effect.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01454-z.

Interventions to reduce arterial puncture-related pain: A systematic review and meta-analysis

BACKGROUND

Arterial puncture-related pain remains unaddressed across several clinical settings. Analgesic techniques are not routinely employed before arterial puncture despite the recommendation that local anesthesia be used, except in emergencies. A comprehensive review of interventions aimed at reducing arterial puncture-related pain and their potential effectiveness is lacking, and the benefit of some interventions is uncertain.

OBJECTIVE

To describe interventions aimed at reducing arterial puncture-related pain and provide an estimate of their effectiveness.

DESIGN

Systematic review and meta-analysis (PROSPERO no. CRD42020212299).

DATA SOURCE(S)

PubMed, CINAHL EBSCO, EMBASE, the Cochrane Database of Systematic Reviews, and Scopus were searched from their inception to 7 October 2020. No temporal or language limits were applied.

METHODS

Published, quantitative studies on interventions aimed at reducing arterial puncture-related pain among adults were included. Screening, quality appraisal, and data extraction were undertaken independently by two reviewers. Random effects meta-analyses were performed to assess the association between interventions aimed at reducing arterial puncture-related pain and patients' perceived pain using difference in means (MD) with 95% confidence intervals (CIs). A funnel plot and Egger test were used to assess publication bias.

RESULTS

The titles and abstracts of the 2446 identified articles were screened, and 43 and 31 studies were finally included in the systematic review and meta-analysis, respectively. Interventions to reduce arterial puncture-related pain included: topical anesthetics (n = 16), cryotherapy (n = 9), local anesthetic infiltration (n = 5), narrower needle gage (n = 5), ultrasound-guided procedure (n = 3), topical anesthetics combined with local anesthetic infiltration (n = 1), iontophoresis using anesthetics (n = 1), engineered blood gas syringe (n = 1), jet injector (n = 1), and local massage (n = 1). Topical anesthetics [MD -0.58, 95% CI -1.00, -0.15], cryotherapy [MD -1.13, 95% CI -1.72, -0.53], and local anesthetic infiltration [MD -1.13, 95% CI -1.72, -0.53] reduced arterial puncture-related pain. No benefit was found for narrower needle gage [MD -0.07, 95% CI -0.86, 0.71] or ultrasound-guided procedure [MD -1.74, 95% CI -3.51, 0.03]. No publication bias was detected.

CONCLUSIONS

Local anesthetic infiltration provided the greatest pain reduction and should be considered standard practice. Cryotherapy may be a safe, convenient alternative to local anesthetic infiltration. Topical anesthetics had limited benefit, and their lengthy time of onset makes them unsuitable for critical or emergency situations, though they may represent an option when comorbid conditions make cooling impossible. Caution must be used when interpreting these results, given the high risk of bias in the methods of included studies and the heterogeneity across the studies.