Who needs education on LGBTQIA+ healthcare inclusion?

The topic of education on healthcare needs and equity of care for LGBTQIA+ populations is an extremely current issue. There is a demand for education on these topics not only from medical and other health sciences students but also from established healthcare professionals. Given this widespread educational deficiency, it is natural to ask whether the teaching class is prepared to satisfy these requests or in turn needs training on these issues and above all whether it is capable of transmitting attention and sensitivity on the issues of inclusion and equality in needs of healthcare.

Modernizing Gender, Sex, and Sexual Orientation Data Through Engagement and Education

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The VES-13 and G-8 tools as predictors of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients: A single-center study

Background

Adjuvant hormone treatment of postmenopausal breast cancer is mainly based on aromatase inhibitors. Adverse events associated with such class of drugs are particularly severe in elderly patients. Therefore, we investigated the possibility of ab initio predict which elderly patients could encounter toxicity.

Methods

In light of national and international oncological guidelines recommending the use of screening tests for multidimensional geriatric assessment in elderly patients aged ≥70 years and eligible for active cancer treatment, we assessed whether the Vulnerable Elder Survey (VES)-13 and the Geriatric (G)-8 could be predictors of toxicity associated with aromatase inhibitors. Seventy-seven consecutive patients aged ≥70 diagnosed with non-metastatic hormone-responsive breast cancer and therefore eligible for adjuvant hormone therapy with aromatase inhibitors, were screened with the VES-13 and the G-8, and underwent a six-monthly clinical and instrumental follow-up in our medical oncology unit, from September 2016 to March 2019 (30 months). Said patients were identified as vulnerable (VES-13 score ≥3 or G-8 score ≤14) and fit (VES-13 score <3 or G-8 score >14). The likelihood of experiencing toxicity is greater among vulnerable patients.

Results

The correlation between the VES-13 or the G-8 tools and the presence of adverse events is equal to 85.7% (p = 0.03). The VES-13 demonstrated 76.9% sensitivity, 90.2% specificity, 80.0% positive predictive value, 88.5% negative predictive value. The G-8 demonstrated 79.2% sensitivity, 88.7% specificity, 76% positive predictive value, 90.4% negative predictive value.

Conclusion

The VES-13 and the G-8 tools could be valuable predictors of the onset of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients aged ≥70.

Anorexia nervosa and autoimmune comorbidities: A bidirectional route?

Immunological dysfunctions in eating disorders have recently gained increasing scientific attention. Furthermore, the reciprocal association between anorexia and autoimmune diseases is of particular interest and suggests a role of autoimmunity in the pathogenesis of eating disorders. Anorexia nervosa (AN) and autoimmune diseases are linked by a bidirectional relationship based on common immunopathological mechanisms. In this review, in addition to reporting the numerous cases described in which autoimmune disorders are associated with anorexia or vice versa, we summarize the many aspects of this relationship between the immune system (IS) and AN. We describe how the microbiota affects the IS, disrupts gut-brain communication, and possibly triggers eating disorders. We also describe the shared immunological pathways of autoimmune and eating disorders and in particular the occurrence of disrupted T cell tolerance and autoantibodies in AN. The described observations represent the starting point for possible, future research directions.

The true story of the "strong and gentle" Acciano's Giant

This is the story of a giant who lived in Abruzzo 200 years ago. He became a symbol for his people and a strong resilience generator. Gigantism, in the history of humanity has always attracted attention, albeit passing over the centuries from myth, from divinity to the freak phenomenon, the freak of nature that becomes a spectacle to show off. The attraction for understanding the pathophysiological mechanisms underlying gigantism developed by the end of 19th century. Increased levels of growth hormone (GH) or insulin-like growth hormone 1 (IGF1) causes overgrowth in pituitary gigantism. The imposing size of the body, in our imagination, represents strength and health, reason why in our imagination it almost becomes a divine mythical image. The story of the Acciano's Giant represents a cultural heritage that passes from one generation to the next, that contributes in giving a sense of identity and continuity. It provides a link from past to present and to the future. Encourages a sense of identity and responsibility contributing to social cohesion, helping individuals to feel members of one community. A disease, represented by the Giant, has become a symbol capable of bringing the community together and giving it the strength to react to environment, nature and history. This is a lesson that teaches us the sense of community.

The shadow zone of capillaroscopy in the classification of the Raynaud's phenomenon

Raynaud's phenomenon (RP) is a frequent clinical finding in the general population that can be observed across multiple medical specialties and nailfold videocapillaroscopy is a first line imaging tool to early differenziate primitive and secondary forms of RP. According to the criteria of LeRoy and Medsger normal nailfold capillaries characterize a primary RP. The recognition of vascular alterations at capillaroscopy is the key to a correct framing of the phenomenon. Capillaroscopy is of significant practical value as it allows a reliable predictive assessment of the developmental risk of the disorder. However, to date, the variety of nomenclature for subjects affected by RP generates uncertainty in patient management and in the possibility of comparing studies. The capillaroscopic findings have a very broad range of normality and a significant presence of non specific microvascular abnormalities are reported also in patients with primary RP. The presence of these non specific vascular changes can make it difficult to differenziate primary and secondary RP. Here we highlight some critical points in the capillaroscopic distinction of primary and secondary RP and relaunch the debate on the classification of the RP because it is likely that what we identify today as the primary RP (pRP) collects different clinical entities with different prognostic significance and different therapeutic needs.

Recognizing Microcirculatory Disorders in Musicians to Preserve a Good State of Health and the Best Artistic Performance

We read with great interest, in the December 2021 issue of the journal, three papers by Clorinda Panebianco, Ari Cantuária Vilela et al., and Tamara Borger et al. concerning musculoskeletal complaints in musicians. These authors have successfully addressed the topic of the highly prevalent complaints and disorders among musicians that impact their wellbeing and performance abilities. Unfortunately, even if musculoskeletal disorders are among the most frequent and painful, we must also remember other occupational disorders that affect musicians, often overlooked and underestimated, can have the same clinical and performance impact. Among these "forgotten" diseases, it seems important to remember the microcirculation disorders.

Cholinergic Urticaria, an Effective and Safe "Off Label" Use of Dupilumab: A Case Report with Literature Review

Cholinergic Urticaria (CholU) is a form of generalized urticaria induced by an increase in core body temperature that activates the sweat reflex. Clinically it is characterized by localized and highly itchy wheals with surrounding erythema and can occur in response to exercise, hot baths and/or emotional stress. Dupilumab is a fully human monoclonal antibody specifically designed to simultaneously inhibit the activity of interleukin-4 (IL-4) and interleukin-13 (IL-13), which play a key role in the inflammation cascade of type 2. We report the case of a 26-year-old man suffering from CholU for 3 years, unresponsive to standard treatment in which off-label therapy was undertaken with Dupilumab, 600 mg subcutaneous as a loading dose and then 300 mg every 15 days. The daily Visual Analogue Scale (VAS) score was used to assess the efficacy of the therapy. Already after the first two administrations, the patient no longer had CholU episodes and resumed regular sporting activity, with a marked improvement in the quality of life. A possible mechanism of Dupilumab in reducing the manifestations of CholU is the blocking of the IL-4 pathway and the expression of the high-affinity IgE receptor (FcεR1) on B cells, mast cells (MCs) and basophils. By decreasing the production of FcεR1, the adhesion of IgE to the surface of MCs decreases with consequent reduction of MCs activation and histamine release. Further experience and large-scale studies may be needed to establish whether Dupilumab can be a therapeutic alternative in CholU, especially in patients who do not respond to standard treatment.

Sex differences in the efficacy of omalizumab in the treatment of chronic spontaneous urticaria

Background

Omalizumab is shown to be effective in the treatment of chronic spontaneous urticaria (CSU), a disease with high personal and social impact. Sex differences in CSU are recognized with women more frequently affected. Scarce is the knowledge about response to omalizumab between sex groups. We sought to identify any differences based on the sex of patients receiving omalizumab.

Methods

We evaluated data of patients diagnosed with CSU refractory to high-dose second-generation H1 antihistamines and treated with 300 mg omalizumab every 4 weeks for 6 months and then at relapse.

Results

Discussion: All patients, regardless of sex, age, or any other factor, achieved the clinical remission of the disease after the first 3 doses with a reduction of the disease activity indices and impact on the quality of life. Recurrences predominate in men, two months after the suspension of the drug. Respect to sex and recurrence we did not find any correlation with age, body mass index, peripheral eosinophil counts, total IgE levels, D-dimer, plasma prothrombine level or C-reactive protein. We found no sex differences in tolerability and safety. CSU in girls may persist longer and have worse prognosis, but no one has so far noted sex differences in response to omalizumab.

Conclusions

Although there are no certainties on the mechanism of action of omalizumab in CSU, the noticeable difference in response between males and females lead us to suppose a role of the hormonal balance both on the pathogenesis of the CSU and on the efficacy of OmAb.

The Microbiota-Bone-Allergy Interplay

Emerging knowledge suggests an increasing importance of gut microbiota in health and disease. Allergy and bone metabolism are closely interconnected, and the possible negative effects of common therapies are not the only aspects of this relationship. The immune system is influenced by the microbiota-host interactions, and several pieces of evidence suggest the existence of an interplay between microbiota, bone metabolism, and allergies. Understanding these inter-relationships is essential for the development of new potential strategies of treatment and prevention targeting microbiota. A wide range of substances and germs, prebiotics and probiotics, are capable of influencing and modifying the microbiota. Prebiotics and probiotics have been shown in several studies to have different actions based on various factors such as sex, hormonal status, and age. In this review, we summarize the latest knowledge on the topic, and we discuss practical implications and the need for further studies.

Raynaud's phenomenon in a drummer player: Microvascular disorder and nailfold video capillaroscopic findings

Drummers are usually exposed to intensive physical stress and occupational diseases that have been only partially investigated. The majority of studies focus on musculoskeletal problems while microvascular abnormalities have been less considered. We report on a case of a 19-year-old drummer affected by Raynaud's phenomenon. The patient underwent nailfold video capillaroscopy that showed a non-specific pattern, with granular flow, dyshomogeneous capillary morphology, increased efferent/afferent loop ratio and many enlarged capillaries. The continuous exposition to vibration in drummers could determinate microvascular abnormalities with related cold induced disorders and Raynaud's phenomenon. Nailfold video capillaroscopy is a tool that allows to detect the alterations of the microcirculation and to carry out the follow-up of the patients with low cost, non-invasiveness, repeatability, high sensibility and specificity.

Capillaroscopic Evidence of Microvascular Damage in Volleyball Players

Volleyball players experience repetitive stress that involves their hands and, in particular, their fingers. Literature reports that repetitive trauma can lead to local vascular abnormalities, such as reduced capillarization and lower resting blood flow. These anomalies could be related to the presence of dysfunctional endothelium. The aim of this study is to correlate the capillaroscopic findings by nailfold video capillaroscopy (NVC) to volleyball practice in order to early detect possible anomalies and perform an adequate follow-up to avoid damages that could negatively affect sport practice and the players' health status. In this study, 38 subjects were enrolled, 19 volleyball players and 19 healthy non-players as a comparison group. In almost all the players, we found capillaroscopic alterations of the "aspecific pattern" type without substantial gender differences. We may assume that the repeated traumas involving players' fingers can negatively modify their microcirculation. Based on these observations, it could be a desirable clinical practice to screen professional volleyball players with NVC in order to implement preventive strategies aimed at protecting the health of athletes.

Henoch-Schönlein Purpura Following the First Dose of COVID-19 Viral Vector Vaccine: A Case Report

A 76 year-old female came to our observation one week after the vaccination with ChAdOx1 nCoV-19 AZD1222 for the onset of purpuric rash on her gluteal and legs regions associated with coxalgia and episodes of macrohaematuria. Henoch-Schönlein purpura (HSP) was diagnosed on the basis of the revised criteria developed by the European League Against Rheumatism, the Paediatric Rheumatology International Trials Organization, and the Paediatric Rheumatology European Society (EULAR/PRINTO/PRES). HSP is a common IgA-mediated small vessel vasculitis, typical of childhood, that affects several systems and is characterized by a tetrad of dermatological, abdominal, joint, and renal manifestations. The Etiology of HSP is not completely understood, but it was observed following upper respiratory tract infections, medications, vaccinations, and malignancies. HSP has previously been reported following immunization with various vaccines, mostly within 12 weeks post, suggesting a possible correlation. To our knowledge, this is the first report of the possible association between COVID-19 ChAdOx1 nCoV-19 AZD1222 and the onset of HSP in a previously healthy woman. No similar cases were reported amongst 23.848 participants in the ChAdOx1 nCoV-19 AZD1222 trial.

Vitamin D Deficiency, Osteoporosis and Effect on Autoimmune Diseases and Hematopoiesis: A Review

Vitamin D (VD) is essential for bone homeostasis, but it is also involved in pleiotropic effects on various organs and tissues. In adults, VD deficiency can cause or exacerbate osteoporosis and induce osteomalacia. However, every tissue and cell in the body has a VD receptor, including the brain, heart, stomach, pancreas, skin, gonads, and immune cells, and a deficiency may modify the function of these organs. Thus, the wide-ranging actions of VD help to explain why a reduction in VD amount has been correlated with numerous chronic diseases. In fact, VD deficiency increases the risk of osteoporosis and several other diseases and complications characterized by impaired bone metabolisms, such as autoimmune diseases, inflammatory bowel diseases, allergy, endocrinological diseases, hematological malignancies, and bone marrow transplantation. This review aims to investigate the link between VD deficiency, osteoporosis, and its concomitant diseases. Further epidemiological and mechanistic studies are necessary in order to ascertain the real role of hypovitaminosis in causing the reported diseases; however, adequate vitamin supplementation and restoration of metabolic normality could be useful for better management of these pathologies.

The VES-13 and G-8 tools as predictors of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients: A single-center study

Background

Adjuvant hormone treatment of postmenopausal breast cancer is mainly based on aromatase inhibitors. Adverse events associated with such class of drugs are particularly severe in elderly patients. Therefore, we investigated the possibility of ab initio predict which elderly patients could encounter toxicity.

Methods

In light of national and international oncological guidelines recommending the use of screening tests for multidimensional geriatric assessment in elderly patients aged ≥70 years and eligible for active cancer treatment, we assessed whether the Vulnerable Elder Survey (VES)-13 and the Geriatric (G)-8 could be predictors of toxicity associated with aromatase inhibitors. Seventy-seven consecutive patients aged ≥70 diagnosed with non-metastatic hormone-responsive breast cancer and therefore eligible for adjuvant hormone therapy with aromatase inhibitors, were screened with the VES-13 and the G-8, and underwent a six-monthly clinical and instrumental follow-up in our medical oncology unit, from September 2016 to March 2019 (30 months). Said patients were identified as vulnerable (VES-13 score ≥3 or G-8 score ≤14) and fit (VES-13 score <3 or G-8 score >14). The likelihood of experiencing toxicity is greater among vulnerable patients.

Results

The correlation between the VES-13 or the G-8 tools and the presence of adverse events is equal to 85.7% (p = 0.03). The VES-13 demonstrated 76.9% sensitivity, 90.2% specificity, 80.0% positive predictive value, 88.5% negative predictive value. The G-8 demonstrated 79.2% sensitivity, 88.7% specificity, 76% positive predictive value, 90.4% negative predictive value.

Conclusion

The VES-13 and the G-8 tools could be valuable predictors of the onset of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients aged ≥70.

Non-coding RNAs, osteoarthritis and the microbiome: new therapeutic targets?

we read with great interest the article by J Wei et al. "Association between gut microbiota and symptomatic hand osteoarthritis: data from the Xiangya Osteoarthritis Study" recently published in the Journal and shedding light on the association between gut microbiome and the presence of symptomatic hand osteoarthritis (OA). Their findings help understand the role of microbiome in the development of SHOA and [1] could became the target of emerging therapies [2].

Peripheral Vascular Abnormalities in Anorexia Nervosa: A Psycho-Neuro-Immune-Metabolic Connection

Immune, neuroendocrine, and autonomic nervous system dysregulation in anorexia nervosa lead to cardiovascular complications that can potentially result in increased morbidity and mortality. It is suggested that a complex non-invasive assessment of cardiovascular autonomic regulation-cardiac vagal control, sympathetic vascular activity, and cardiovascular reflex control-could represent a promising tool for early diagnosis, personalized therapy, and monitoring of therapeutic interventions in anorexia nervosa particularly at a vulnerable adolescent age. In this view, we recommend to consider in the diagnostic route, at least in the subset of patients with peripheral microvascular symptoms, a nailfold video-capillaroscopy as an easy not invasive tool for the early assessing of possible cardiovascular involvement.

Reviewing the Significance of Vitamin D Substitution in Monoclonal Gammopathies

Vitamin D is a steroid hormone that is essential for bone mineral metabolism and it has several other effects in the body, including anti-cancer actions. Vitamin D causes a reduction in cell growth by interrupting the cell cycle. Moreover, the active form of vitamin D, i.e., 1,25-dihydroxyvitamin D, exerts various effects via its interaction with the vitamin D receptor on the innate and adaptive immune system, which could be relevant in the onset of tumors. Multiple myeloma is a treatable but incurable malignancy characterized by the growth of clonal plasma cells in protective niches in the bone marrow. In patients affected by multiple myeloma, vitamin D deficiency is commonly correlated with an advanced stage of the disease, greater risk of progression, the development of pathological fractures, and a worse prognosis. Changes in the vitamin D receptor often contribute to the occurrence and progress of deficiencies, which can be overcome by supplementation with vitamin D or analogues. However, in spite of the findings available in the literature, there is no clear standard of care and clinical practice varies. Further research is needed to better understand how vitamin D influences outcomes in patients with monoclonal gammopathies.

Invasive Ductal Breast Cancer with Osteoclast-Like Giant Cells: A Case Report Based on the Gene Expression Profile for Changes in Management

We report the case of a 49-year-old woman diagnosed with a rare histotype of early breast cancer (BC), invasive ductal carcinoma with osteoclast-like giant cells (OGCs), from the perspective of gene profile analysis tests. The patient underwent a quadrantectomy of the right breast with removal of 2 cm neoplastic nodule and three ipsilateral sentinel lymph nodes. The Oncotype Dx gave a recurrence score (RS) of 23, and taking into account the patient's age, an RS of 23 corresponds to a chemotherapy benefit of 6.5%. After a multidisciplinary collegial discussion, and in consideration of the patient's age, the absence of comorbidity, the premenopausal state, the rare histotype and the Oncotype Dx report, the patient was offered adjuvant chemotherapy treatment followed by hormone therapy. This case may be an example of the utility of integrating gene expression profiling tests into clinical practice in the adjuvant treatment decision of a rare histotype BC. The Oncotype Dx test required to supplement the histological examination made us opt for the proposal of a combined treatment of adjuvant chemotherapy followed by adjuvant hormone therapy. It demonstrates the importance of considering molecular tests and, in particular, the Oncotype Dx, in estimating the risk of disease recovery at 10 years in order to identify patients who benefit from hormone therapy alone versus those who benefit from the addition of chemotherapy, all with a view toward patient-centered oncology. Here, we discuss the possible validity and limitations of the Oncotype Dx in a rare luminal A-like histotype with high infiltrate of stromal/inflammatory cells.

Gender Differences in Osteoporosis: A Single-Center Observational Study

Purpose

Osteoporosis affects more than 200 million people worldwide: its prevalence increases with age and is actually growing due to the constant population aging. Women are at greater risk than men, but in recent years it has become increasingly evident that osteoporosis represents a significantly important problem also for men. However, osteoporosis in men is still poorly studied, underdiagnosed and inadequately treated.

Materials and Methods

We conducted an observational study to identify any gender disparities in osteoporosis screening. For this purpose we observed people consecutively admitted at our Outpatient Service for the Diagnosis of Osteoporosis during the last 3 years. Patients underwent clinical and laboratory assessment and bone mineral density (BMD) measurements by dual-energy X-ray absorptiometry. Bone turnover serum markers have been evaluated and stratified according to gender.

Results

Out of 3,752 patients, 2,376 subjects who met the inclusion criteria were identified. As expected, the great majority (94.5%) of the screened subjects were women and only 5.4% were men. Women exhibited lower BMD compared to men (T-score values: −2.33±1.14 vs. −1.31±1.55; p<0.001), whereas the prevalence of fractures in osteoporotic men was significantly higher (50% vs. 31%; p<0.001). Women had lower vitamin D and higher bone remodeling markers compared to men. Secondary osteoporosis was more frequent in men (66.67%) than in women (20.83%) and the calculated risk for hip fractures was higher in osteoporotic men compared to women (11.47±10.62 vs. 6.87±7.73; p<0.001).

Conclusions

Here we highlighted that men are under-screened for osteoporosis and exhibit secondary osteoporosis more frequently than women.

Osteoporosis: Current and Emerging Therapies Targeted to Immunological Checkpoints

Osteoporosis is a skeletal pathology characterized by compromised bone strength leading to increased risk of fracture, mainly the spine and hip fractures. Osteoporosis affects more than 200 million people worldwide and because of the skeletal fractures it causes, represents a major cause of morbidity, disability and mortality in older people. Recently, the new discoveries of osteoimmunology have clarified many of the pathogenetic mechanisms of osteoporosis, helping to identify new immunological targets for its treatment opening the way for new and effective therapies with biological drugs. Currently, there are basically two monoclonal antibodies for osteoporosis therapy: denosumab and romosozumab. Here, we focus on the modern approach to the osteoporosis management and in particular, on current and developing biologic drugs targeted to new immunological checkpoints, in the landscape of osteoimmunology.