Exploring the Impact of a Nurse-Led Narrative Interview on Newly Diagnosed Hematologic Patients: A Holistic Qualitative Single-Case Study Protocol

Background and Aims Haematological malignancies can present with kidney manifestations of various types. At first presentation kidney biopsy can help to diagnose the malignancy, whereas during follow-up a biopsy can differentiate between malignancy-related and unrelated findings. The aim of our study was to investigate the spectrum of kidney diseases associated with haematological malignancies. Method In this single-center retrospective study we analyzed patients with native kidney biopsies and a diagnosis of a haematological malignancies over a 10-year period (2015–2024) at our University hospital. Results We identified 79 patients (male n = 41, female = 38) with 82 native kidney biopsies. The diagnosis of the haematological malignancy (other than MGUS) was known in 50% at time of biopsy, mean age of the patients was 63 years. 11 patients presented after bone marrow transplantation. Impaired kidney function (65/82 with creatinine >1.2 mg/dl) and proteinuria were the main biopsy indications. Proteinuria >3g/g were present in one third (28/82 patients). The spectrum of kidney disease included AL-amyloidosis (n = 21), cast nephropathy (n = 10), lymphoma infiltration (n = 11), glomerulonephritis (n = 8) including cryoglobulinemia (n = 5), interstitial nephritis (n = 8), thrombotic microangiopathy (n = 11) and others manifestations (including podocytopathies) (Table 1). Lymphoma infiltration occurred in different malignancy types (DLBC, B-ALL, marginal zone lymphoma, immunocytoma, CLL, CMML, multiple myeloma). In biopsies after bone marrow transplantation thrombotic microangiopathy (n = 8) and interstitial nephritis (n = 2) were the main findings. Among the 41 patients with the diagnosis of a haematological malignancy based on kidney biopsy the main findings were AL-amyloidosis (32%), cast nephropathy (20%), cryoglobulinemia (12%), lymphoma infiltration (12%) and others. Conclusion Our study confirms the broad spectrum of kidney lesions with haematological malignancies. While kidney biopsy can reveal the diagnosis of haematological malignancy in so far undiagnosed patients, it is helpful in differentiation of unrelated kidney disease versus kidney involvement in patients with known haematological disease.

Mutational Analysis of Clonal Hematopoiesis in Solid Tumor Patients Illustrates the Critical Role of Systemic Anti-Cancer Therapies in the Evolution of Somatic Leukemia Disease Alleles

This observational study evaluated SARS-CoV-2 IgG seroprevalence and related clinical, demographic, and occupational factors among workers at the largest tertiary care University-Hospital of Northwestern Italy and the University of Turin after the first pandemic wave of March–April 2020. Overall, about 10,000 individuals were tested; seropositive subjects were retested after 5 months to evaluate antibodies waning. Among 8769 hospital workers, seroprevalence was 7.6%, without significant differences related to job profile; among 1185 University workers, 3.3%. Self-reporting of COVID-19 suspected symptoms was significantly associated with positivity (Odds Ratio (OR) 2.07, 95%CI: 1.76–2.44), although 27% of seropositive subjects reported no previous symptom. At multivariable analysis, contacts at work resulted in an increased risk of 69%, or 24% for working in a COVID ward; contacts in the household evidenced the highest risk, up to more than five-fold (OR 5.31, 95%CI: 4.12–6.85). Compared to never smokers, being active smokers was inversely associated with seroprevalence (OR 0.60, 95%CI: 0.48–0.76). After 5 months, 85% of previously positive subjects still tested positive. The frequency of SARS-COV-2 infection among Health Care Workers was comparable with that observed in surveys performed in Northern Italy and Europe after the first pandemic wave. This study confirms that infection frequently occurred as asymptomatic and underlines the importance of household exposure, seroprevalence (OR 0.60, 95%CI: 0.48–0.76).

BackgroundThe management of non-fermentative gram-negative bloodstream infection (NFGN-BSI) offers numerous challenges. In this study the aim is to analyse a large cohort of patients with NFGN-BSI recruited in the northern Italy to describe epidemiology, etiological and susceptibility pattern, therapeutic management and outcome.MethodsMulticentre retrospective cohort study of patients hospitalised at three large teaching hospitals in northern Italy in a fourth year period.Results355 BSI episodes were analyzed, due to P. aeruginosa (72.7%), A. baumannii (16.6%), and Stenotrophomonas maltophilia (10.7%). Overall, 21.4% of isolates were defined as DTR, highest rate among A. baumannii (64.4%). All-cause 30-day mortality rate was 17.5%. Rates of XDR or DTR A. baumannii isolation were significantly higher in non-surviving patients. Independent risk factors for 30-day mortality were: age (HR 1.03, 95%CI 1.00–1.04, p = 0.003), septic shock (HR 2.84, 95%CI 1.67–4.82, p < 0.001) and BSI due to Acinetobacter baumannii (HR 2.23, 95%CI 1.27–3.94, p = 0.005).ConclusionThe overall prevalence of DTR was high in the NFGN BSI cohort analyzied, mainly among Acinetobacter baumannii episodes (64.4%). Acinetobacter baumannii is showed to be an independent predictor of mortality. These evidences marked the urgent need of new therapeutic options against this pathogen.Trial registration number: 79/2017/O/OssN. Approved: March14th, 2017.

ObjectivesGenomic surveillance of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) is crucial for virulence, drug-resistance monitoring, and outbreak containment.MethodsGenomic analysis on 87 KPC-Kp strains isolated from 3 Northern Italy hospitals in 2019-2021 was performed by whole genome sequencing (WGS), to characterize resistome, virulome, and mobilome, and to assess potential associations with phenotype resistance and clinical presentation. Maximum Likelihood and Minimum Spanning Trees were used to determine strain correlations and identify potential transmission clusters.ResultsOverall, 15 different STs were found; the predominant ones included ST307 (35, 40.2%), ST512/1519 (15, 17.2%), ST20 (12, 13.8%), and ST101 (7, 8.1%). 33 (37.9%) KPC-Kp strains were noticed to be in five transmission clusters (median number of isolates in each cluster: 5 [3-10]), four of them characterized by intra-hospital transmission. All 87 strains harbored Tn4401a transposon, carrying blaKPC-3 (48, 55.2%), blaKPC-2 (38, 43.7%), and in one case (1.2%) blaKPC-33, the latter gene conferred resistance to ceftazidime/avibactam (CZA). Thirty strains (34.5%) harbored porin mutations; of them, 7 (8.1%) carried multiple Tn4401a copies. These strains were characterized by significantly higher CZA minimum inhibitory concentration compared with strains with no porin mutations or single Tn4401a copy, respectively, even if they did not overcome the resistance breakpoint of 8 ug/mL. Median 2 (IQR:1-2) virulence factors per strain were detected. The lowest number was observed in ST20 compared to the other STs (p<0.001). While ST307 was associated with infection events, a trend associated with colonization events could be observed for ST20.ConclusionsIntegration of genomic, resistance score, and clinical data allowed us to define a relative diversification of KPC-Kp in Northern Italy between 2019 and 2021, characterized by few large transmission chains and rare inter-hospital transmission. Our results also provided initial evidence of correlation between KPC-Kp genomic signatures and higher MIC levels to some antimicrobial agents or colonization/infection status, once again underlining WGS's importance in bacterial surveillance.

The diagnosis and treatment of hematologic malignancies has undergone significant advancements over the past few decades, resulting in enhanced outcomes. For hematologic malignancies diagnosed during pregnancy, this poses new questions. As possibilities continue to expand and the rising global incidence results in an increasing number of diagnoses within the pregnant population, there is a pressing need to gain a deeper understanding of the potential options for pregnant women and the impact on the newborn. As knowledge of the effects of cancer treatment increases, more women are receiving adequate cancer diagnosis and treatment during pregnancy. This paper presents an expert opinion on the use of diagnostic modalities and treatment options, including chemotherapy, radiation therapy, and immunotherapy, for acute leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, myeloproliferative neoplasms, aplastic anemia, and multiple myeloma during pregnancy.

Objectives:Anesthesiologists represent an occupational group exposed to specific occupational hazards, including potential exposure to waste anesthetic gas released during medical procedures. In recent decades, halogenated anesthetic gases, such as desflurane and sevoflurane, have largely replaced nitrous oxide, due to better safety profiles and lower adverse health effects. However, possible long-term effects of low concentration exposures are unknown. A longitudinal analysis of health surveillance data was performed to test for possible changes over time in key markers of liver and kidney function. Moreover, the authors assessed the appropriateness of applying linear mixed models to occupational health data.Material and Methods:A retrospective cohort study was conducted using health surveillance data from a cohort of anesthesiologists and a cohort of unexposed physicians working at the Polyclinic Hospital San Martino of Genoa, Italy, during 2016–2022. A 2-level linear mixed model with covariance structure of first order autoregressive model (AR(1)) type at the first level and unstructured type at the second level was applied.Results:One hundred seventy subjects were included in the analysis, equally divided between exposed and unexposed. At the first and last periodic examination, liver and kidney markers were not statistically different in the 2 cohorts. The only significant change found related to estimated glomerular filtrate, which was found at the last follow-up to be greater among the exposed (M = 104.18 vs. 90.07, p = 0.007). The linear mixed model showed that anesthetic gas exposure was not associated with any of the outcomes. These results suggest the absence of increase in liver and kidney profile markers in the study population.Conclusions:Health surveillance data, aggregated and analyzed with appropriate statistical models, allow inferences to be made about potential health effects of workers due to uncontrolled exposures. To this end, the linear mixed model represents a powerful tool for longitudinal analysis of data derived from monitoring workers.

Objective: Despite the UK national guidance for Managing Emergencies in Eating Disorders (MEED) being widely used, little is known about how the guidance has been embedded into clinical practice or implemented across services. Methods: Clinicians (n = 13) working in community child and adolescent eating disorder services and medical wards were interviewed about their experience of using the MEED guidance in their clinical practice. Open-ended questions were used. Reflexive thematic analysis was used to analyse interview data. Results: Reflexive thematic analysis of responses identified three main themes. These were the following: (1) a common language, (2) looking beneath the surface, and (3) refeeding syndrome—a rare event in youth. These themes evidenced the important role of the MEED guidance in child and adolescent eating disorders and highlighted both the benefits and limitations of the current guidance. Conclusions: This study demonstrated that MEED was most helpful as a tool to clearly communicate acuity of medical risks between services, aiding multi-agency working required to manage both physical and mental health risks of young people with AN. The absence of parameter risk stratification and the lack of consistency on refeeding guidance across adolescent and adult guidance were highlighted as areas that future research should focus on.

IntroductionThere is a global interest in cancer immunotherapy. Clinical trials have found that one group, immune checkpoint inhibitors (ICIs), has demonstrated clinical benefits across various cancers. However, research focused on...

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Background and objectives: Streptococcus pneumoniae urinary antigen (u-Ag) testing has recently gained attention in the early diagnosis of severe and critical acute respiratory syndrome coronavirus-2/pneumococcal co-infection. The aim of this study is to assess the effectiveness of Streptococcus pneumoniae u-Ag testing in coronavirus disease 2019 (COVID-19) patients, in order to assess whether pneumococcal co-infection is associated with different mortality rate and hospital stay in these patients. Materials and Methods: Charts, protocols, mortality, and hospitalization data of a consecutive series of COVID-19 patients admitted to a tertiary hospital in northern Italy during COVID-19 outbreak were retrospectively reviewed. All patients underwent Streptococcus pneumoniae u-Ag testing to detect an underlying pneumococcal co-infection. Covid19+/u-Ag+ and Covid19+/u-Ag- patients were compared in terms of overall survival and length of hospital stay using chi-square test and survival analysis. Results: Out of 575 patients with documented pneumonia, 13% screened positive for the u-Ag test. All u-Ag+ patients underwent treatment with Ceftriaxone and Azithromycin or Levofloxacin. Lopinavir/Ritonavir or Darunavir/Cobicistat were added in 44 patients, and hydroxychloroquine and low-molecular-weight heparin (LMWH) in 47 and 33 patients, respectively. All u-Ag+ patients were hospitalized. Mortality was 15.4% and 25.9% in u-Ag+ and u-Ag- patients, respectively (p = 0.09). Survival analysis showed a better prognosis, albeit not significant, in u-Ag+ patients. Median hospital stay did not differ among groups (10 vs. 9 days, p = 0.71). Conclusions: The routine use of Streptococcus pneumoniae u-Ag testing helped to better target antibiotic therapy with a final trend of reduction in mortality of u-Ag+ COVID-19 patients having a concomitant pneumococcal infection. Randomized trials on larger cohorts are necessary in order to draw definitive conclusion.

Total laryngectomy followed by radiotherapy is a life-preserving treatment for patients with locally advanced laryngeal cancer. This study explored how persons who had undergone total laryngectomy perceived themselves as cancer survivors in the follow-up phase. A descriptive phenomenological approach was adopted. We employed a purposive sampling strategy to collect data through interviews at the otorhinolaryngology outpatient clinics of two research hospitals in northern Italy. The interviews were transcribed verbatim and analysed, following the seven analytical steps of Colaizzi's descriptive analysis. The final sample included 19 patients. The following main themes were identified: (i) accepting a life with the "without" to survive; (ii) feeling unpleasant emotions; (iii) getting the hang of communication again; and (iv) reclaiming one's role. Together, they highlight the lived experiences of laryngectomised patients during the follow-up phase and how they perceived themselves as cancer survivors. Laryngectomised patients are a uniquely vulnerable population. This study provides insights into how surgical procedures change and affect their lives over time to improve care models, patient education, and support systems. Survivors must be adequately prepared to transition from treatment and return to the community. This preparation should begin before treatment is started. Functional education, accurate information, and psychological support must be arranged and provided before surgery. Regarding the post-treatment phase, it is essential to support voice rehabilitation and peer support, and improve the family network, to ensure these patients' reintegration into society and social recognition.

Scaratti and colleagues present a practice-based ethnographic study focusing on lived experiences of healthcare professionals in leading roles. It draws on narrative accounts of head nurses produced and discussed during group sessions held in four hospitals in Northern Italy. Three perspectives are discussed: (1) the interpretation of one’s leading role, (2) the exercise of authority and power, and (3) the organisational authorship, defined here as a relational, embedded, and contextual activity leaving a mark on working activities and organisational roles. The chapter offers rich insights into the daily realities of head nurses’ practices, which are influenced by the inherently liminal and hybrid positions that they occupy in organisational contexts. It thereby contributes to our understanding of the intersubjective and relational aspects of leadership.

The first case of carbapenemase-producing Enterobacteriaceae in Italy was reported in 2009. We performed a study over a period of seven months in 2010 to survey the circulation of Klebsiella pneumoniae carbapenemases (KPC) ina 1,500-bed university hospital in northern Italy and report the presence and rapid increase of these multidrug-resistant bacteria. The results raise a major concern about these pathogens and demonstrate the urgent need for infection control and antibiotic stewardship programmes.

The Organisation for the Economic Cooperation and Development (OECD) has defined a biological resource centre (BRC) as a service provider and a repository of living cells, genomes, organisms and information relating to heredity and the functions of biological systems. To promote a rational use of resources and to facilitate the exchange of biological materials among different countries, the OECD has proposed to establish a global BRC network. The building of a BRC is a process similar to those applied to several other types of facilities involved in biomedical laboratory research and therapy, with a special attention to cryobiology and information technology. The latter issues represent core elements for long‐term storage at subzero temperatures of biological materials and for their management and distribution to interested users in compliance to predefined rules. The management of a BRC does not differ from the management of a biomedical institution. However, general management rules must be translated into specific modalities and tools fit for the organization of a BRC. This article describes the management of the Center of Transfusion Medicine, Cellular Therapy and Cryobiology (CTMC), which is the BRC of a large public university hospital in Northern Italy. The CTMC currently stores 92 561 biological samples (vials) collected and studied by 15 clinical and research groups within the hospital. The samples are stored and distributed according to individual contracts between the CTMC and each hospital unit using its services.