Ospedale Martini

Introduction. Physician-patient communication is a pivotal element in the management of chronic kidney disease (CKD), yet it is sometimes reduced to a mere transmission of information. Ineffective communication undermines therapeutic adherence, delays clinical decision-making, and negatively impacts patients' quality of life. Methods. We conducted a panoramic review of the literature, with a specific focus on nephrology context, examining how various aspects (communication barriers, patient expectations, use of multimedia tools, digital self-monitoring) affect clinical outcomes and can transform from critical issues into resources for improving the therapeutic alliance and adherence. Results. Evidence shows that: (1) physician-patient communication, expectations, and genuine understanding directly influence clinical outcomes; (2) digital tools such as educational/storytelling videos, online platforms, institutional social media channels, and dedicated apps improve health literacy and patient engagement; (3) self-monitoring and smart devices can help strengthen awareness and foster the doctor-patient relationship, even remotely; (4) therapeutic adherence can be significantly improved through empathetic and shared care relationships, including through digital media, countering misinformation and mistrust. Conclusions. Innovating communication in nephrology requires moving beyond the traditional information-delivery model, embracing narrative and digital approaches, and recognizing communication as a fully-fledged therapeutic intervention.

ObjectiveDrug‐resistant epilepsy (DRE) affects approximately one‐third of people with epilepsy (PwE) despite advancements in anti‐seizure medications and presents significant challenges in epilepsy care. This Delphi consensus study aimed to examine key aspects of DRE, including its definition, predictors, and therapeutic strategies.MethodsA steering committee consisting of clinicians and researchers with expertise in epilepsy was responsible for formulating the statements. A total of 22 statements were developed across four thematic areas. Expert opinions from 99 Italian epileptologists were collected over two structured rounds of voting.ResultsThe study highlighted a certain disagreement on the current International League Against Epilepsy definition of DRE, with experts advocating for a definition that better incorporates individual complexities. Strong agreement emerged on the importance of quality of life, psychiatric comorbidities, and multidimensional care in defining therapeutic success.SignificanceThe findings of this study underscored the need for a patient‐centered perspective of drug resistance and therapeutic success. Enhancing collaboration across specialties is critical for refining clinical practices and addressing unmet needs for PwE.Plain Language SummaryAbout one in three people with epilepsy continues to have seizures despite trying several anti‐seizure medications. This study asked Italian epilepsy experts for their opinions on how to define and manage drug‐resistant epilepsy. The experts agreed that treatment success should not be measured by seizure control alone but also by improvements in quality of life. They also recommended more personalized care that considers each patient's unique condition.

Abstract Background and Aims We evaluated the feasibility of an early triple lipid lowering therapy (LLT) with PCSK9 inhibitors in patients with acute coronary syndromes (ACS). Methods In this multicenter experience, we consecutively enrolled patients with ACS from July 2023 to July 2024. The prescribed LLT was evaluated at discharge. Triple therapy with a high–intensity statin plus ezetimibe and PCSK9i was recommended in the following cases: patients already on statin or combination statin/ezetimibe therapy with LDL–C values › 70 mg/dl; patients not on LLT at the time of admission with LDL–C values › 70 mg/dl and at least one of diabetes mellitus (DM), multivessel coronary artery disease (MV) or peripheral arterial disease (PAD); patients not on LLT at the time of admission and with LDL–C values › 140 mg/dl even in the absence of DM, MV or PAD. A six–month follow–up was planned to determine LDL–C target attainment, compliance, side effects, and cardiovascular events. Results We consecutively enrolled 217 patients discharged with high–intensity statin plus ezetimibe and in–hospital addition of PCSK9i (triple therapy). Of the 217 patients discharged in triple LLT, the median age was 61 years, 23% were female, 41% were current smokers, DM was present in 18%, and 49% had history of hypertension. The diagnosis at admission was ST–Elevation Myocardial Infarction in 53%, Non–ST–Elevation Myocardial Infarction in 32%, and unstable angina in 15% of cases; 12% of patients had history of myocardial infarction and 7% had history of peripheral artery disease (PAD); 20% were already on at least one statin therapy and the median LDL–C value at admission was 131 mg/dl. We have follow up at six months in 168 patients. In these patients the median LDL–C value was 42 mg/dl with a reduction of 68% (Figure 1). We achieved a 92% of patients at target (LDL ‹ 55 mg/dl). 7 patients ) had unplanned percutaneous coronary angioplasty, 2 patients died. Conclusions In conclusion, the use of an early and strong lipid lowering approach in very high risk patients with in–hospital or at discharge PCSK9i administration is feasible, safe and it allows for the rapid achievement of target LDL–C levels and enables over 90% of patients to reach their target without the need for short–term follow–up (4–6 weeks) to adjust lipid–lowering therapy.Figure 1

Postoperative complications (PCs) are a major cause of mortality following elective major abdominal surgery (EMAS). The increasing complexity of abdominal procedures, particularly in oncology, may significantly affect patient outcomes. However, this has also introduced a higher variability in postoperative management, and the use of tailored approaches to address critical issues such as hemodynamic stabilization, infection management, and respiratory failure. While elective admission to intensive care units (ICU) is a standard practice to manage high-risk surgical patients, ICU resource allocation is often influenced by local practices and bed availability.This document presents a framework for preoperative ICU admission planning after EMAS. It focuses on the identification of patient and surgical risk factors—using established scoring systems—and provides statements to determine ICU admission. The aim is to optimize resource allocation, reduce PCs, and prevent unplanned ICU admissions. This good clinical practice statement was developed through a multidisciplinary panel formed by selected members coming from SIAARTI (Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care), SIC (Italian Society of Surgery) and ANIARTI (National Association of Critical Area Nurses).The designed scientific board developed, through a systematic literature review and a consensus methodology, a roadmap for defining the priorities of perioperative care based on the complexity of the patient and the surgical procedure. Eventually, the panel worked out statements about six voted queries that could have supported the preoperative indication to postoperative ICU admission.Evaluation of patients’ characteristics, comorbidities, and surgical factors are all essential to plan ICU admission for immediate postoperative patient care after EMAS.The presence and severity of comorbidities, assessed through various severity scores, play a crucial role in predicting PCs and guiding ICU admission decisions. Tools such as the American Society of Anesthesiologists physical status, Charlson Comorbidity Index, and Rockwood Frailty Index, along with surgical risk scores and intraoperative events, help define the need for intensive care. Preoperative frailty assessment—achieved using the Clinical Frailty Scale—is essential to anticipate postoperative care needs. Finally, during the postoperative phase, continuous monitoring and reassessment in the post-anesthesia care unit are key to determine whether ICU admission is required. Establishing high-dependency units and tailored care pathways based on individual patient needs and available resources will enhance patient outcomes and optimize postoperative care.

Abstract Background The recently published Expert Consensus Statement on the Practical Management of Remote Device Clinic offers evidence-based recommendations for managing patients with cardiovascular implantable electronic devices (CIEDs). Purpose We examined data from a remote monitoring (RM) database to evaluate adherence to RM recommendations in current clinical practice. Methods According to RM guidelines, patients should be enrolled within 2 weeks of implantation for earlier detection of actionable events, and in any case, within 3 months, as it is associated with improved survival. Continuous connectivity should be maintained. In patients with continuous connectivity, alert-based RM may replace structured intermittent device follow-up. We analyzed data from 4427 CIED patients followed on the LATITUDE (Boston Scientific) remote network at 20 Italian centers. Patients were enrolled between 2010 and 2023, with a median RM duration of 37 months (25th-75th percentile: 21-60). Results The number of patients enrolled at the centers significantly increased during the observation period (Figure). In the overall RM population, we identified a group of patients (56%) enrolled after implantation (within 6 months) and a group of patients enrolled late during their follow-up. In the first group, RM receiver activation occurred within 2 weeks in 62% and within 3 months in 90% of patients. The second group consisted mainly of patients not yet in RM at the time of COVID-19 outbreak and included to allow RM of all patients at the centers. Overall, 96% of enrolled patients performed remote data transmissions during the observation period. As of the July 2023 data extraction, 1405 (33%) patients were not monitored, with no significant differences among CIED types (CRT-D: 37%; ICD: 32%; S-ICD: 32; Pacemaker: 30%). Most not-monitored patients (30%) had not transmitted data for over a year, likely due to patient death, CIED extraction, or other irreversible causes. For the remaining 3%, the recent loss of connection (occurring within a timeframe shorter than the scheduled transmission interval) should have prompted interventions to restore connection. Scheduled device transmissions occurred at least once every 3 months in 94% of patients. Considering individual device programming, the 2836 patients with consistent connectivity performed 25,281 scheduled transmissions in one year. Conclusions In current clinical practice, RM adoption is continually increasing, with generally observed adherence to post-implantation patient enrollment recommendations. However, a significant proportion of patients may activate RM earlier. Centers must implement solutions to ensure transmission continuity in a substantial percentage of patients. Nevertheless, the workload generated by this activity could be effectively balanced by adopting an alert-based RM strategy and reducing unnecessary scheduled transmissions.Enrolled patients trend

Introduction/BackgroundIn 2009 a regional audit on ovarian cancer treatment was run in the Cancer Care Network of Piemonte and Valle d’Aosta in Italy. High dispersion of patients in many low-volume hospitals was documented and 37.5% of patients received sub-optimal care. We present the re-audit and feedback (A&F) intervention performed in 2017–2020 and its impact on the quality of care.MethodologyEight key recommendations on the initial management of ovarian cancer were selected from international guidelines. Thirteen indicators were used to describe the level of adherence to these recommendations. A global indicator of adherence (GIA) was measured as the mean percentage of compliance across all the indicators. All incident cases of ovarian cancer in the resident population were included in the audit, between May 2017 and September 2020. Data were collected in a web-based database. Multiple feedbacks were provided during the audit. Overall survival was identified as outcome indicator.ResultsAmong 1030 women (236–23% early and 794–77% advanced stage) the pattern of care resulted sub-optimal in about 25% of patients. During the audit, overall adherence improved from 51.3% in the first study semester to 70.4% in the last one (estimated difference +17.7%; 95%CI 12.8–22.7). The largest improvement was evidenced in the diagnostic-staging phase (figure1). Overall survival at 4 years was 87.8% among early and 39.4% among advanced stages. During the follow-up (that included the COVID period), no clear trend in 2-year survival was detected, but each 10% increase in GIA was positively associated with a better 2-year overall survival (HR 0.85; 95%CI 0.80–0.91).ConclusionA&F was effective in improving the quality of care for ovarian cancer in Piemonte, even if a clear trend effect on short-term survival was not evident. This successful experience of A&F can be replicable in other settings and different cancers.DisclosuresThe authors have no disclosures to declare. Funding: This work was supported by the Italian Ministry of Health and the Regione Piemonte as part of the Easy-Net Project, grant number NET-2016–02364191. 580 Figure 1Adjusted estimated effect (OR) of the study period (180 days) on the adherence (%) to selected recommendations

Although active surveillance for patients with low-risk prostate cancer (LRPC) has been recommended for years, its adoption at the population level is often limited. To make active surveillance available for patients with LRPC using a research framework and to compare patient characteristics and clinical outcomes between those who receive active surveillance vs radical treatments at diagnosis. This population-based, prospective cohort study was designed by a large multidisciplinary group of specialists and patients' representatives. The study was conducted within all 18 urology centers and 7 radiation oncology centers in the Piemonte and Valle d'Aosta Regional Oncology Network in Northwest Italy (approximate population, 4.5 million). Participants included patients with a new diagnosis of LRPC from June 2015 to December 2021. Data were analyzed from January to May 2023. At diagnosis, all patients were informed of the available treatment options by the urologist and received an information leaflet describing the benefits and risks of active surveillance compared with active treatments, either radical prostatectomy (RP) or radiation treatment (RT). Patients choosing active surveillance were actively monitored with regular prostate-specific antigen testing, clinical examinations, and a rebiopsy at 12 months. Outcomes of interest were proportion of patients choosing active surveillance or radical treatments, overall survival, and, for patients in active surveillance, treatment-free survival. Comparisons were analyzed with multivariable logistic or Cox models, considering centers as clusters. A total of 852 male patients (median [IQR] age, 70 [64-74] years) were included, and 706 patients (82.9%) chose active surveillance, with an increasing trend over time; 109 patients (12.8%) chose RP, and 37 patients (4.3%) chose RT. Median (IQR) follow-up was 57 (41-76) months. Worse prostate cancer prognostic factors were negatively associated with choosing active surveillance (eg, stage T2a vs T1c: odds ratio [OR], 0.51; 95% CI, 0.28-0.93), while patients who were older (eg, age ≥75 vs <65 years: OR, 4.27; 95% CI, 1.98-9.22), had higher comorbidity (Charlson Comorbidity Index ≥2 vs 0: OR, 1.98; 95% CI, 1.02-3.85), underwent an independent revision of the first prostate biopsy (OR, 2.35; 95% CI, 1.26-4.38) or underwent a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11) were more likely to choose active surveillance vs active treatment. After adjustment, center at which a patient was treated continued to be an important factor in the choice of treatment (intraclass correlation coefficient, 18.6%). No differences were detected in overall survival between active treatment and active surveillance. Treatment-free survival in the active surveillance cohort was 59.0% (95% CI, 54.8%-62.9%) at 24 months, 54.5% (95% CI, 50.2%-58.6%) at 36 months, and 47.0% (95% CI, 42.2%-51.7%) at 48 months. In this population-based cohort study of patients with LRPC, a research framework at system level as well as favorable prognostic factors, a multidisciplinary approach, and an independent review of the first prostate biopsy at patient-level were positively associated with high uptake of active surveillance, a practice largely underused before this study.

Kleefstra syndrome (KS) or 9q34.3 microdeletion syndrome (OMIM #610253) is a rare genetic condition featuring intellectual disability, hypotonia, and dysmorphic facial features. Autism spectrum disorder, severe language impairment, and sleep disorders have also been described. The syndrome can be either caused by a microdeletion in 9q34.3 or by pathogenic variants in the euchromatin histone methyltransferase 1 gene (EHMT1, *607001). Although epilepsy has been reported in 20 to 30% of subjects, a detailed description of epileptic features and underlying etiology is still lacking. The purpose of this study is to investigate epilepsy features in a cohort of epileptic patients with KS. This multicenter study investigated eight patients with KS and epilepsy. Our findings were compared with literature data. We included five patients with 9q or 9q34.33 deletions, a subject with a complex translocation involving EHMT1, and two with pathogenic EHMT1 variants. All patients presented with moderate to severe developmental delay, language impairment, microcephaly, and infantile hypotonia. Although the epileptic manifestations were heterogeneous, most patients experienced focal seizures. The seizure frequency differs according to the age of epilepsy onset, with patients with early-onset epilepsy (before 36 months of age) presenting more frequent seizures. An overtime reduction in seizure frequency, as well as in antiseizure drug number, was observed in all patients. Developmental delay degree did not correlate with seizure onset and frequency or drug resistance. Epilepsy is a frequent finding in KS, but the underlying pathogenetic mechanism and specific features remain elusive.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical trial updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.We present the final analysis of the phase III noninferiority, randomized ShortHER trial comparing 9 weeks versus 1 year of adjuvant trastuzumab with chemotherapy in patients with human epidermal growth factor receptor 2-positive (HER2+) early breast cancer (BC). Women with HER2+ BC were randomly assigned to anthracycline-taxane combinations plus 1-year trastuzumab (arm A, long) or 9-week trastuzumab (arm B, short). Here, we report the second coprimary end point overall survival (OS), updated disease-free survival (DFS), and outcomes according to hormone receptor status, age, and nodal status. At a median follow-up of 9 years, 10-year DFS is 77% versus 78% in the long versus short arm, respectively. Ten-year OS is 89% versus 88% in the long versus short arm, respectively. 10-year DFS rates in the long versus short arm according to nodal status are N0 81% versus 85%; N1-3 77% versus 79%; and N4+ 63% versus 53%. Ten-year OS rates in long versus short arm according to nodal status are N0 89% versus 95%%; N1-3 92% versus 89%; and N4+ 84% versus 64%. The updated analysis of the ShortHER trial shows that 1-year trastuzumab is the standard treatment for patients with HER2+ early BC as noninferiority cannot be claimed. However, numerically, the differences for the patients at low or intermediate risk (N0/N1-3) is negligible, while patients with N4+ have a clear benefit with 1-year trastuzumab.