Education of clinical reasoning in patients with multimorbidity: a scoping review and perspectives for technology-enhanced learning

Multimorbidity is defined as the co-existence of two or more chronic diseases in a patient, and it is increasing in prevalence. This condition poses new problems for clinical reasoning. Few studies inquire regarding the construct of reasoning in multimorbidity and the teaching/learning methods. The objectives of this scoping review were searching for a definition of the construct of clinical reasoning in multimorbidity and the related learning methods, and special ways in which information technology can help. We searched PubMed, Scopus, ERIC and CORE databases. After an iterative process of selection and thematic analysis, we selected 30 articles, that were thematized in three classes: the multimorbid patient as a teacher (8 articles), defining a framework of competence (11 articles), representing multimorbidity and related clinical reasoning (11 articles). In this last theme were also grouped studies using technology to enhance learning. The construct of clinical reasoning in multimorbidity expands over three domains: clinical (including managing uncertainty, anticipating, and detecting evolutions and conflicting guidelines, and setting priorities); relational (concerning communicating uncertainty and developing a feasible, shared plan of care with the patient; organizational) (managing the wide system of resources needed to take care of a multimorbid patient). The preferred teaching methods are based on the encounter with real or expert patients, technology enhanced case-based learning and graphical representations of clinical cases. Perspectives of research should be addressed to permit the learner to experience a patient's life-long experience by moving forward and back over time while exploring interactions among diseases and social determinants with respect to possibly conflicting treatments. Perspectives on rich, technology-enhanced simulations should be researched

Trends in Net Survival from Vulvar Squamous Cell Carcinoma in Italy (1990–2015)

Objective: In many Western countries, survival from vulvar squamous cell carcinoma (VSCC) has been stagnating for decades or has increased insufficiently from a clinical perspective. In Italy, previous studies on cancer survival have not taken vulvar cancer into consideration or have pooled patients with vulvar and vaginal cancer. To bridge this knowledge gap, we report the trend in survival from vulvar cancer between 1990 and 2015. (2) Methods: Thirty-eight local cancer registries covering 49% of the national female population contributed the records of 6274 patients. Study endpoints included 1- and 2-year net survival (NS) calculated using the Pohar-Perme estimator and 5-year NS conditional on having survived two years (5|2-year CNS). The significance of survival trends was assessed with the Wald test on the coefficient of the period of diagnosis, entered as a continuous regressor in a Poisson regression model. (3) Results: The median patient age was stable at 76 years. One-year NS decreased from 83.9% in 1990–2001 to 81.9% in 2009–2015 and 2-year NS from 72.2% to 70.5%. Five|2-year CNS increased from 85.7% to 86.7%. These trends were not significant. In the age stratum 70–79 years, a weakly significant decrease in 2-year NS from 71.4% to 65.7% occurred. Multivariate analysis adjusting for age group at diagnosis and geographic area showed an excess risk of death at 5|2-years, of borderline significance, in 2003–2015 versus 1990–2002. (4) Conclusions: One- and 2-year NS and 5|2-year CNS showed no improvements. Current strategies for VSCC control need to be revised both in Italy and at the global level

Peer assisted learning: a meta-ethnographic synthesis of qualitative studies and recommendations for cardiovascular training, practice, and research

Introduction: Peer assisted learning (PAL) is a common method to complement more traditional teaching. Several systematic reviews and meta-analyses described the most used ways of implementation and showed that it is effective in fostering learning. A synthesis of qualitative data is missing, to highlight the perceived value by the students and to drive a successful implementation. Evidence acquisition: The search was performed in Pubmed, Scopus and ERIC databases, with a combination of the search strings. The quality of the retrieved articles was assessed through the Critical Appraisal Skills Checklist. The analysis was performed according to the meta-ethnographic method. Fifteen articles were considered for the analysis, saturation was reached after 12 articles. Evidence synthesis: Three main themes emerged from the analysis: PAL is effective when implemented in a safe environment, PAL is a driver of development of students' abilities and identity, and the "dark side" of PAL. Nine sub-themes emerged as components of the themes. The final line of argument highlighted the ambivalence of PAL, as an expression of the ambivalence of the still developing professional identity of students. Conclusions: This meta-ethnographic synthesis summarizes the elements of success and the threats of PAL, a method that is particularly suitable for the cardiovascular domain. It must be implemented according to some precautions, such as organization and protected time, tutor selection, training and support, a clear integration and endorsement in the framework of the medical curriculum

Cancer Care During COVID-19 Era: The Quality of Life of Patients With Thyroid Malignancies

Background: The Covid-19 pandemic's potential psychological impact has been widely discussed on the basis of expert opinion and previous experience with emergencies of this type. We conducted a survey of cancer patients to explore more objectively the outbreak's impact on their emotional well-being and quality of life. Methods: Between March 18 and April 4, 2020, at an endocrine cancer center in Rome, Italy, 137 patients were asked to complete an online 6-item questionnaire developed by our staff to explore the emotional effects of the Covid-19 outbreak in Italy (Covid-19 Emotional Impact Survey, C-19EIS). For validation purposes, we also asked participants to complete an online version of the validated Italian translation of the EORTC QLQ-C30 questionnaire. Responses were analyzed in relation to responders' age, sex, and clinical status (advanced/metastatic disease undergoing systemic treatment vs. stable metastatic thyroid cancer in active surveillance vs. low-risk thyroid cancers with no evidence of structural disease during standard follow-up). Results: Response rates were high (51% for the C-19EIS, 44.5% for the EORTC QLQ-C30). Overall C-19EIS scores indicated high concern over the outbreak (median 8/12). Scores were higher in women (8 [IQR 5–9] vs. 6 [IQR 5–8] in men; p = 0.048) and in patients <65 years (8 [IQR 5–9] vs. 6 [IQR 4–8] in older patients; p = 0.013). No differences emerged across clinical status groups. C-19EIS scores were inversely correlated with the EORTC QLQ-C30 Emotional function subscale (rho −0.69; p < 0.001). Conclusions: There is objective evidence that the Covid-19 outbreak is causing substantial emotional distress among cancer patients, regardless of their disease severity or current health-care needs

Stress in ballet: looking for the mind body unit for a chance to cure

Stress in ballet: looking for the mind body unit for a chance to cure OBJECTIVES The aim of this study was to analyze psychological stress, their causes and mechanisms in a population of professional dancers of a prestigious Italian company. These data may provide the basis to work out individual-centered stress prevention concepts. BACKGROUND AND AIMS Dancers usually work under major physical workload and psychological stress conditions. The aim of this study was to analyze stress risk factors, their causes and mechanisms in a population of professional dancers, and elaborate the adoption of preventive measures. MATERIALS AND METHODS The study was carried out on a sample of 38 Italian ballet dancers, from a company of a large Italian city, 26 women and 12 men aged between 18 and 56 years. We used the HSE (health and safety executive) Indicator Tool. Than we focused on the patterns of illness afflicting performing artists and explained possible management strategies. RESULTS In none of the seven organizational dimensions analyzed (demand, control, managers’ support, peer support, relationships, role and change) the required standards were achieved. In particular, the situation among female dancers is worrisome and suggests that living conditions of these patients need to be understood. CONCLUSIONS In ballet higher attention is paid to the physical resources which doesn't correspond to the psychic dimension. Hence there is requirement to develop a cultural and therapeutic approach that proposes an idea of ​​original mind-body unity like the one present in the Human Birth Theory by Massimo Fagioli

Intraoperative Neuromonitoring and Optical Magnification in the Prevention of Recurrent Laryngeal Nerve Injuries during Total Thyroidectomy

Background and Objectives: Recurrent laryngeal nerve (RLN) paralysis is a fearful complication during thyroidectomy. Intraoperative neuromonitoring (IONM) and optical magnification (OM) facilitate RLN identification and dissection. The purpose of our study was to evaluate the influence of the two techniques on the incidence of RLN paralysis and determine correlations regarding common outcomes in thyroid surgery. Materials and Methods: Two equally sized groups of 50 patients who underwent total thyroidectomies were examined. In the first group (OM), only surgical binocular loupes (2.5×–4.5×) were used during surgery, while in the second group (IONM), the intermittent NIM was applied. Results: Both the operative time and the length of hospitalization were shorter in the OM group than in the IONM group (median 80 versus 100 min and median 2 versus 4 days, respectively) (p p = 0.05). The OM group reported a four-fold higher risk of developing transient hypocalcemia than the IONM group (OR 3.78, adjusted OR 4.11, p = 0.01). Despite two cases of temporary bilateral RLN paralysis in the IONM group versus none in the OM group, no statistically significant difference was found (p > 0.05). No permanent RLN paralysis or hypoparathyroidism have been reported. Conclusions: Despite some limitations, our study is the first to compare the use of IONM with OM alone in the prevention of RLN injuries. The risk of recurrent complications remains comparable and both techniques can be considered valid instruments, especially if applied simultaneously by surgeons

The Size of a Thyroid Nodule with ACR TI-RADS Does Not Provide a Better Prediction of the Nature of the Nodule: A Single-Center Retrospective Real-Life Observational Study

We investigated if thyroid nodule size has a predictive value of malignancy on a par with composition, echogenicity, shape, margin, and echogenic foci, and what would be the consequence of observing the rule of the American College of Radiology (ACR) to perform a fine-needle aspiration biopsy (FNAB). We conducted a retrospective real-life observational study on 86 patients who underwent surgery after a standardized diagnostic protocol. We divided the TR3, TR4, and TR5 classes into sub-classes according to the size threshold indicating FNAB (a: up to the threshold for no FNAB; b: over the threshold for FNAB suggested). We computed sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for the different sub-classes and Youden’s index (Y) for the different possible cutoffs. Each sub-class showed the following PPV (0.67, 0.68, 0.70, 0.78, 0.72), NPV (0.56, 0.54, 0.51, 0.52, 0.59), and Y (0.20, 0.20, 0.22, 0.31, 0.30). In this real-life series, we did not find a significant difference in prediction of malignancy between the sub-categories according to the size threshold. All nodules have a pre-evaluation likelihood of being malignant, and the impact and utility of size thresholds may be less clear than suggested by the ACR TIRADS guidelines in patients undergoing standardized thyroid work up

Premio "miglior abstract" Congresso AIS 2019, Firenze 6-8 novembre 2019

Introduzione: Il Disturbo Depressivo Maggiore (DDM) e l’uso di antidepressivi risultano essere frequenti tra le pazienti oncologiche, in particolare in quelle affette da carcinoma mammario. Gli studi presenti in letteratura non sono concordi sulla connessione dei due eventi né tantomeno sull'aumento di prevalenza del DDM nelle pazienti con diagnosi di carcinoma mammario. È chiaro però ormai che tra variabili quali l’età della paziente, lo stile di vita, lo stadio e le caratteristiche della malattia, anche il DDM rientri tra i fattori prognostici per valutare la sopravvivenza della paziente. Non bisogna dunque sottovalutare il disturbo dell’umore al momento della diagnosi di cancro. Materiali e metodi: Il nostro campione di studio comprende 817 pazienti affette da carcinoma mammario, arruolate nel nostro Centro dal 2014 ad oggi (maggio 2019), con età media di 52 anni (30-94 anni). La diagnosi di DDM è stata effettuata attraverso il Patient Health Questionnaire-9 che ha fornito un punteggio basato sull'algoritmo del Diagnostic And Statistical Manual Of Mental Disorders per il DDM (sintomi somatici esclusi). L'onere della sintomatologia è stata valutata sommando i punteggi sui sintomi somatici della scala di valutazione di Edmonton Symptom Assessment Scale, esclusi depressione, ansia e benessere. Inoltre le pazienti hanno risposto a questionari standard che valutavano la Quality Of Life. Discussione e conclusioni: Le donne che guariscono dal cancro al seno risultano maggiormente predisposte a DDM, disturbi di ansia, del sonno e altri problemi di natura psichica. La depressione clinica non è un disturbo solo psicologico, ma una malattia che può indebolire l’organismo anche sul piano biologico. Le pazienti colpite da DDM hanno un maggiore rischio di recidive e di mortalità. Gli effetti biologici della depressione si esprimono con un indebolimento delle difese immunitarie ma anche con alterazioni di diversi sistemi di regolazione ormonale e aumento di produzione di citochine. Inoltre tale disturbo dell’umore è spesso causa di non aderenza alla terapia, negazione della patologia e disconoscimento della stessa, interferendo con l’andamento della patologia e riducendo la risposta ai trattamenti proposti dai sanitari. Ancora alcuni chemioterapici e altre sostanze utilizzati per trattamento del tumore, possono indurre depressione. Pertanto, incentivando la diagnosi precoce e il trattamento di problemi di salute mentale che si presentano già alla diagnosi, possiamo aiutare le donne ad affrontare meglio malattia e sue conseguenz

"Disturbo depressivo maggiore e carcinoma mammario: esperienza in un singolo centro"

Introduzione: Il Disturbo Depressivo Maggiore (DDM) e l’uso di antidepressivi risultano essere frequenti tra le pazienti oncologiche, in particolare in quelle affette da carcinoma mammario. Gli studi presenti in letteratura non sono concordi sulla connessione dei due eventi né tantomeno sull'aumento di prevalenza del DDM nelle pazienti con diagnosi di carcinoma mammario. È chiaro però ormai che tra variabili quali l’età della paziente, lo stile di vita, lo stadio e le caratteristiche della malattia, anche il DDM rientri tra i fattori prognostici per valutare la sopravvivenza della paziente. Non bisogna dunque sottovalutare il disturbo dell’umore al momento della diagnosi di cancro. Materiali e metodi: Il nostro campione di studio comprende 817 pazienti affette da carcinoma mammario, arruolate nel nostro Centro dal 2014 ad oggi (maggio 2019), con età media di 52 anni (30-94 anni). La diagnosi di DDM è stata effettuata attraverso il Patient Health Questionnaire-9 che ha fornito un punteggio basato sull'algoritmo del Diagnostic And Statistical Manual Of Mental Disorders per il DDM (sintomi somatici esclusi). L'onere della sintomatologia è stata valutata sommando i punteggi sui sintomi somatici della scala di valutazione di Edmonton Symptom Assessment Scale, esclusi depressione, ansia e benessere. Inoltre le pazienti hanno risposto a questionari standard che valutavano la Quality Of Life. Risultati: Delle 817 pazienti il 40% aveva DDM. Tra queste il 22% presentava depressione da moderatamente grave a grave, le quali presentavano complessivamente una scarsa qualità della vita. 22 pazienti hanno riferito che la loro QOL complessiva era scarsa e 34 pazienti hanno riferito di essere insoddisfatte della loro salute. È stata rilevata inoltre un'associazione tra DDM e punteggi QOL: le pazienti con depressione avevano punteggi più bassi in tutti i domini rispetto alle altre. Inoltre la diagnosi di DDM è risultata essere più frequente tra le pazienti con diagnosi istologica di Carcinoma Duttale Infiltrante Triple Negative, CDI HER-2 Like, stadio di malattia più avanzato, scolarità inferiore, mancanza di occupazione e stato civile celibe, divorziata, o comunque con scarso sostegno familiare. Discussione e conclusioni: Le donne che guariscono dal cancro al seno risultano maggiormente predisposte a DDM, disturbi di ansia, del sonno e altri problemi di natura psichica. La depressione clinica non è un disturbo solo psicologico, ma una malattia che può indebolire l’organismo anche sul piano biologico. Le pazienti colpite da DDM hanno un maggiore rischio di recidive e di mortalità. Gli effetti biologici della depressione si esprimono con un indebolimento delle difese immunitarie ma anche con alterazioni di diversi sistemi di regolazione ormonale e aumento di produzione di citochine. Inoltre tale disturbo dell’umore è spesso causa di non aderenza alla terapia, negazione della patologia e disconoscimento della stessa, interferendo con l’andamento della patologia e riducendo la risposta ai trattamenti proposti dai sanitari. Ancora alcuni chemioterapici e altre sostanze utilizzati per trattamento del tumore, possono indurre depressione. Pertanto, incentivando la diagnosi precoce e il trattamento di problemi di salute mentale che si presentano già alla diagnosi, possiamo aiutare le donne ad affrontare meglio malattia e sue conseguenze

Effects of Inositol Hexaphosphate and Myo-Inositol Administration in Breast Cancer Patients during Adjuvant Chemotherapy

Background: Treatment of breast cancer (BC) includes locoregional and systemic therapies depending on tumor and patient’s characteristics. Inositol hexaphosphate (IP6) is known as a strong antioxidant agent, able to improve local (i.e., breast region) side effects, functional status and quality-of-life. We investigated some potential beneficial effects, including hematological and local, of the combined therapy with oral myo-inositol administration and topical IP6 application in patients undergoing surgery for BC and eligible to adjuvant chemotherapy. Methods: We considered BC patients randomly assigned to the Inositol Group (oral myo-inositol + IP6 local application for the entire neoadjuvant treatment period) and to the Control Group (standard of care). The EORTC QLQ-BR23 and QLQ-C30 questionnaires were administered to both groups and blood parameters were assessed as per clinical routine practice at baseline (before starting adjuvant chemotherapy), T1 (after the first two doses of epirubicin-cyclophosphamide regimen), T2 (at the end of epirubicin-cyclophosphamide regimen), T3 (after the first six doses of paclitaxel regimen), and T4 (at the end of the paclitaxel treatment). Results: A total of 36 BC patients were considered, 18 in the Inositol Group and 18 in the Control Group. The Inositol Group showed a lower decrease in red blood cells, hemoglobin levels and white blood cells with respect to controls (p ≤ 0.02), as well as amelioration in scores related to breast and arm local symptoms (p ≤ 0.02), body image (p = 0.04) and quality-of-life related symptoms (p ≤ 0.04). Conclusions: In our cohort of BC patients, a combined treatment with oral myo-inositol + IP6 local application was able to improve local symptoms and quality-of-life related symptoms which represent clinically relevant aspects associated with patient’s prognosis