Ballet after breast cancer: Investigating the feasibility, acceptability, and participant experiences of a novel 16-week classical ballet intervention for breast cancer survivors

Aim: The 'Ballet after breast cancer' study sought to investigate the feasibility, acceptability, and participant experiences of a 16-week classical ballet intervention for breast cancer survivors, delivered face-to-face and/or online. Method(s): Breast cancer survivors attended 2 x 1-h weekly ballet classes for 16 weeks. Primary outcomes of feasibility and acceptability were assessed according to rates of enrolment and attendance, and feedback questionnaire. Secondary outcomes included quality of life (QOL), upper-body disability, shoulder range of motion (ROM), muscular strength, aerobic capacity, and physical activity levels. Participants were invited to attend study focus groups. Semi-structured discussions regarding perceived changes following ballet participation, program design and delivery, and recommendations for future implementation were subject to thematic analysis. Result(s): Thirty-one participants (77.5% of target) enrolled in the program. Classes commenced face-to-face and moved online due to COVID-19 restrictions. Twenty-nine commenced the intervention [Female, 53.3 +/- 10.8 yrs (Mean +/- SD)] attending 77.6% [67.6, 87.5] (Mean [95%CI]) of sessions. Seventeen participants (54.4 +/- 11.9yrs;54.2 +/- 43 mnths post-diagnosis [Mean +/- SD]) attended focus groups. Based on rates of enrolment and attendance, and participant feedback, the program was deemed feasible and acceptable. Significant improvements in shoulder ROM and reductions in sedentarity were achieved. Participants reported improved physical capacity and psychological, social, and cognitive wellbeing. In discussing experiences, five themes emerged: Embracing normal;Connection to others;Acceptance without judgement;Engagement;Learning and progress. The characteristics of the ballet instructor emerged as key determinants of program engagement/enjoyment. Recommendations to improve future programs included a hybrid delivery model, facilitated socialisation, and the provision of learning resources. Conclusion(s): Classical ballet delivered face-to-face and/or online is a feasible and acceptable activity after breast cancer, leading to perceived improvements in physical, psychological, social and cognitive wellbeing. The study provided preliminary evidence showing ballet can improve shoulder ROM and reduce sedentarity. Findings invite future research investigating the comparative effectiveness of ballet and honing its implementation after breast cancer.

Leo&Giulia: a cartoon series to promote health and prevention in primary school-aged children : Anna Odone

Background Coronavirus (COVID-19) pandemic control measures actively involved people who were called to adopt new and unusual lifestyles. In this context, children had to stay home from school for weeks, had to adapt to new teaching methods and give up socializing. In many countries, not much attention was paid to the educational sector, and, ultimately, to children's physical and psychological well-being. Objectives In this context, we developed an innovative health education audio-visual model to teach children about public health, empower them to adopt preventive behaviours and limit the risk of infection transmission in schools and in the community. Results We designed and produced the animated cartoon series “Leo&Giulia” to convey solid scientific content and key public health messages related to the ongoing COVID-19 pandemic to primary school-aged children. Contents and dialogues were validated by a scientific committee composed of experts in the fields of public health, paediatrics, infectious diseases, and neuroscience, as well as communication experts. The first episode of Leo&Giulia focused on COVID-19 and explained to children what SARS-CoV2 was, its transmission and why schools were closed. Endorsed by the European Commission, it was broadcasted by national public and private television channels and went viral on social media. The second episode of Leo&Giulia, funded by the Italian Ministry of Research, was launched in April 2022 and focused on vaccines and immunization explaining to children how vaccines work and why herd immunity is important for collective health. Conclusions Leo&Giulia is an innovative health education project to help children to better understand how to cope with COVID-19 as a public health challenge. More broadly, the series aims to increase youth engagement by promoting public health values and healthy behaviours. Key messages • Health promotion targeting children is important and contributes to societal health and wellbeing. • Cartoon series are an innovative digital health education tool that effectively increase youth engagement on public health values.

Assessing determinants of SARS-CoV-2 infection in a large older adult representative sample : Giansanto Mosconi

Most COVID-19-related deaths occurred in older adults, however to date, evidence on determinants of SARS-CoV-2 infection in this population is limited and mostly based on case series without a comparison group. A telephone-based cross-sectional study was conducted in November 2020 on a representative sample of 4,400 people aged ≥65 years from the Italian region of Lombardy. We determined the prevalence of participants reporting a SARS-CoV-2 infection in the period between the onset of the pandemic and the time of the interview. To investigate the determinants of the infection, we estimated odds ratios (OR) and their corresponding 95% confidence intervals (CI) thorough unconditional multiple logistic models. We further evaluated if the infection was a determinant of a worsening in mental health wellbeing. Overall, 4.9% of participants reported a history of SARS-CoV-2 infection. No significant relationship between sex and infection was observed. SARS-CoV-2 infection was less frequently reported in subjects aged ≥70 (OR = 0.55;95% 0.41-0.74) compared to 65-69 years. We didn't observe any trend after 70 years of age. Participants reporting at least one chronic condition had a lower infection rate compared to healthy subjects (OR = 0.68 95% CI: 0.49-0.93). Separated/divorced subjects more frequently reported infection than married/cohabiting ones (OR = 2.33 95% CI: 1.29-4.20). Self-reported history of SARS-CoV-2 infection resulted being a determinant of an increase in depressive symptoms (OR = 1.57;95% CI: 1.17-2.10). In this large study - among the few assessing the determinants of SARS-CoV-2 infection in a representative sample of older adults -, the prevalence of a history of infection in November 2020 approached 5%. We found that persons aged 70 and above and those with chronic conditions, thus individuals with likely less social interactions, were less frequently exposed to SARS-CoV-2 infection.

Healthcare services access during the COVID-19 pandemic among older people : Paola Bertuccio

The COVID-19 pandemic strongly impacted older people, not only in terms of clinical outcome but also in care provision. Investigating trends of changes in healthcare services access among older subjects during the pandemic, along with studying potential determinants, is of utmost interest to identify the most at-risk individuals. We used data from LOST in Lombardia, a cross-sectional study conducted on a representative sample of 4,400 older adults (aged 65 or more) in autumn 2020. Data were collected about lifestyles, mental health, and access to healthcare services before and during the pandemic. To investigate potential determinants of changes in healthcare access, we presented prevalence ratios (PRs) estimated through multivariable log-binomial regression models. Twenty-one per cent of the participants increased telephone contacts with general practitioner (GP), 9.6% specialist visits for a fee, while 22.4% decreased GP visits, 7.5% ED access, 6% hospitalisations, 12.3% outpatient visits, 9.1% diagnostic exams. The prevalence of the cancellation or delay of medical appointments by the patient's decision was 23.8%, with higher proportions among men, among individuals aged 75 or over as compared to those aged 65-74, and among individuals with a higher self-reported economic status (p-value<0.05). People with comorbidities more frequently cancelled or postponed visits, reduced ED access or hospitalisations. Moreover, individuals with worsened mental health status showed a higher prevalence to cancel or delay visits and to reduce ED access. The decrease in healthcare provision and consultations could result in mortality and morbidity excess. Our results should inform targeted intervention to bridge the gaps and overcome the health inequalities that the pandemic has deepened. Exploring the underlying reasons and determinants for healthcare avoiding or delaying among the most vulnerable groups is crucial for epidemic preparedness and planning future interventions.

Can YouTube be used as a credible source of information for COVID-19 vaccination in Italy? : Angela Ancona

Background The COVID-19 pandemic led to an ‘infodemic', as defined by the WHO, which made it difficult to be accurately informed on public health topics. For this purpose, many people use social media as a source of information, mainly YouTube. Given the great resonance of this platform, our study aims at assessing quality and reliability of its content regarding the COVID-19 vaccination. Methods During March 2022, six searches were performed on the Italian YouTube platform using the following terms: “Covid vaccination”, “Covid vaccine”, “Coronavirus vaccination”, “Coronavirus vaccine”, “Sars-Cov-2 vaccination” and “Sars-Cov-2 vaccine”. A total of 329 videos were analysed, after removing 271 duplicated videos, and classified in seven types of channel. The reliability of the content was evaluated through the HoNCode score, while quality was tested using the validated DISCERN tool. Results The most frequent category was ‘Internet Media’ (33%), while the less frequent one was ‘Educational Medical’ (7%). The content reliability (i.e. HoNCode score) resulted higher for videos produced by medical healthcare workers than non-medical ones. Concerning the quality, the DISCERN score resulted significantly higher for the Educational channels (median 46.0 for medical and 41.3 non-medical ones) as compared to Internet Media (26.5) and New Agencies (24.3). Conclusions Although YouTube has implemented a policy against misinformation related to the COVID-19 vaccination, the study highlights that there is extreme heterogeneity in reliability and quality of videos. Content produced by non-medical users, especially “Internet Media” and “News Agencies” categories should be evaluated with attention by users, as their quality is not appropriate to the importance of the topic. Key messages • Because of to the heterogeneity of its content, YouTube should be evaluated carefully when used as a source of information for Covid-19 vaccination. • Content produced by non-medical users, is generally of poor quality, not appropriate to the importance of the topic.

Evaluation of the effects of anticancer treatments in cancer patients undergoing SARS-COV2 vaccination (VAX-on study: Breast cancer subgroup analysis)

Background: Since the beginning of the covid19 pandemic, clinical and demographic data showed that cancer patients are at high risk of developing severe consequences of Sars-Cov2 disease. For this reason, vaccination is strongly recommended, especially for patients on active treatment. Nevertheless, the efficacy of the Sars-Cov2 vaccine in cancer patients is not fully investigated. Our trial aim to explore the seroconversion in a large series of vaccinated cancer patients undergoing active treatment. Here we present a subgroup analysis concerning patients affected by breast cancer. Methods: The "VAX-on" is a single-center study that enrolled 366 cancer patients who underwent oncological treatment within the last six months. The study was approved by the ethics committee and all patients had to sign specific informed consent to be enrolled. Subjects were vaccinated against Sars-Cov2 with mRNA vaccine BNT162b2 (Comirnaty)-Pfizer BioNTech. Blood samples were obtained to quantify the production of specific anti-Spike IgG antibodies at day 21 from the first dose and at 6-8 weeks after the second dose. The antibody laboratory title cut-off of 50 U.A./mL defined the seroconversion. Results are shown as Mean and Standard Deviation for Scontinuous variable, percentage (%) for categorical ones. The Mann-Whitney test or Chi-Square test were used to compare continuous or categorical groups, respectively. Results: A total of 100 patients with breast cancer were enrolled. Clinical and demographic data are summarized in Table 1. The median age was 60.5 years and the majority had an ECOG PS of 0 (75%). Almost all were women (97%), with advanced cancer in 60% of cases. In early or advanced setting 46% patients were treated with chemotherapy while 54% were on target therapy (also including monoclonal antibody and CDK4/6 inhibitors). The mean antibody title after the first dose of mRNA Comirnaty vaccine was 2185.03±9303.26 U.A./mL (M±SD), while after the second dose the mean antibody title rise to 6492.10±10425.95 (M±SD). After the first dose 61% of patients were considered as immunized, meanwhile after the second dose 86% of patients resulted immunized (defined as an antibody title >50 U.A./mL). In the 9 patients in treatment with steroids (prednisone > 10mg/die or equivalent), there was a trend to a decreased antibody development compared to patients without chronic use of steroids (p 0.06 and 0.05 after the first and second dose, respectively). Of interest, patients using G-CSF (12%) had a significant reduction in the production of Sars-Cov2 antibody after vaccination compared to patients who did not use them (p 0.02 and <0.001 after the first and second dose, respectively), with only 75% resulted positively immunized after the second dose (p=0.04). No differences were seen when comparing patients in advanced with non-advanced stage. Conclusions: Our study demonstrated 86% seroconversion in cancer patients after the second dose of mRNA vaccine regardless of disease stage or type of cancer treatment received. Further evaluations are needed to define whether the use of corticosteroids and G-CSF have an impact on seroconversion.

Antineoplastic treatment class modulates COVID-19 mRNA-BNT162b2 vaccine immunogenicity in cancer patients: a secondary analysis of the prospective Vax-On study.

BACKGROUND: Preliminary analysis from the Vax-On study did not find a correlation between cancer treatment type and antibody response to COVID-19 vaccination. We carried out a secondary subgroup analysis to verify the effects of comprehensive cancer treatment classification on vaccine immunogenicity. METHODS: The Vax-On study prospectively enrolled patients who started a two-dose messenger RNA-BNT162b2 vaccine schedule from 9 March 2021 to 12 April 2021 (timepoint-1). Those on active treatment within the previous 28 days accounted for the exposed cases. Patients who had discontinued such treatment by at least 28 days or received intravesical therapy represented the control cases. Quantification of immunoglobulin G (IgG) antibodies against the receptor binding domain of the S1 subunit of the SARS-CoV-2 spike protein was carried out before the second dose (timepoint-2) and 8 weeks thereafter (timepoint-3). Seroconversion response was defined at ≥50 arbitrary units/ml IgG titer. Classification of antineoplastic agents was based on their pharmacodynamic properties. RESULTS: Three hundred and sixty-six patients were enrolled (86 and 260 as control and exposed cases, respectively). Univariate analysis revealed a significantly lower IgG titer after both doses of vaccine in subgroups treated with tyrosine kinase inhibitors (TKIs), multiple cytotoxic agents, alkylating agents, and topoisomerase inhibitors. At timepoint-3, seroconversion response was significantly impaired in the topoisomerase inhibitors and mechanistic target of rapamycin (mTOR) inhibitors subgroups. After multivariate testing, treatment with alkylating agents and TKIs was significantly associated with a reduced change in IgG titer at timepoint-2. Treatment with mTOR inhibitors resulted in a similar interaction at each timepoint. Cyclin-dependent kinase 4/6 inhibitor treatment was independently correlated with an incremental variation in IgG titer at timepoint-3. Specific subgroups (TKIs, antimetabolites, alkylating agents, and multiple-agent chemotherapy) predicted lack of seroconversion at timepoint-2, but their effect was not retained at timepoint-3. Eastern Cooperative Oncology Group performance status 2, immunosuppressive corticosteroid dosing, and granulocyte colony-stimulating factor use were independently linked to lower IgG titer after either dose of vaccine. CONCLUSIONS: Drugs interfering with DNA synthesis, multiple-agent cytotoxic chemotherapy, TKIs, mTOR and cyclin-dependent kinase 4/6 inhibitors differentially modulate humoral response to messenger RNA-BNT162b2 vaccine.

Urban Green Spaces and Public Health Outcomes: a systematic review of literature

Background As stressed by COVID-19 pandemic, urbanicity might represent a risk factor for chronic non-communicable diseases or generally impacting on healthy lifestyle, among them physical activity. Methods In light of this, we performed a systematic review aimed to explore the association between urban greenspaces and two important health indicators for both mental and physical health. In particular, our aims were to analyze the association between publicly accessible urban greenspaces exposure, and mental health outcomes (MH) and objectively-measured physical activity (PA). The review was conducted from 2000/01/01 to 2020/09/30 searching in two electronic databases: PubMed/Medline and Excerpta Medica dataBASE (EMBASE). Only articles in English were included. Results Out of 356, a total of 34 studies were included in our review, of which 19 assessed MH outcomes, the remaining dealt with PA. Only a few included studies found a non-effect or a negative effect on MH outcomes, whereas, all the others demonstrated a positive effect of urban greenspace and both MH and PA. However, our results stressed not only the importance of green space presence, but also the importance of maintenance, renovation, closeness to residential areas, the presence of interactive activities, and perceived security aspects. Conclusions To conclude, even some methodological limitations of the included studies, results are concordant in demonstrating that urban greenspaces show potentially beneficial effects on mental health and physical activity. Our results are significant for public health experts and policymakers involved in urban planning, community health promotion, and improvement of health and social equity. Key messages Urban green spaces are important factors, impacting on both physical and mental health. Policymakers involved in urban planning should pay more attention in urban green spaces.

Hospital hand hygiene monitoring: internal audits and the role of public health residents

Background Healthcare workers (HCW) adherence to hand hygiene (HH) is the most effective infection prevention and control (IPC) measure to fight healthcare-associated infections (HAI) and is a crucial component for standard precautions, especially in a pandemic context. As suggested by the WHO and Joint Commission Network Project, evaluating adherence to HH is essential to identify deficiencies and promote improvement interventions. Methods San Raffaele Hospital in Milan, Italy, adopted internal audits to measure HCWs' adherence to HH according to WHO Guidelines. Public health (PH) residents were enrolled as auditors. They were trained with WHO technical manual for observers and handovers among residents. WHO observation form was used for collection. Process index was HH adherence, stratified by profession, unit, opportunity and indication. Results 8 PH medical residents carried out observations from January 2018 to December 2019. 434 HCWs were observed in 26 hospital units (191 nurses, 148 physicians, 83 healthcare assistants and 11 other professionals). Global adherence was 53%, calculated on 1,969 opportunities, and 2,221 indications observed, followed by 932 hands rubbing and 110 handwashing. Most observations involved nurses (adherence of 53%) and physicians (54%). Global adherence was generally higher in medicine, specialist surgery and intensive-care units while lower in general surgery and rehabilitation units. Indications with the highest adherence were “after body fluid exposure risk” (69%) and “after touching a patient” (64%). The lowest adherence (44%) was observed for “before clean/aseptic procedure” indication. The belief that gloves use may replace HH might partially explain the data. Conclusions Global HH adherence was in line with significant published data and was far better than 2016 data but slightly lower than observations in 2018 when the program started. We believe 2020 HH compliance could have changed due to HCW involvement in IPC against COVID-19. Key messages Hand hygiene (HH) audits represent a crucial tool of clinical governance and risk management: auditors’ training, monthly and annual reports, and feedbacks allowed to structure a virtuous process. If HH audits aim to improve practice we should understand when HH is most beneficial, assessing quality, improving performances through achievable targets using reproducible methods and technologies.

The efficacy of ultraviolet light-emitting technology against coronaviruses: a systematic review.

The ongoing pandemic of COVID-19 has underlined the importance of adopting effective infection prevention and control (IPC) measures in hospital and community settings. Ultraviolet (UV)-based technologies represent promising IPC tools: their effective application for sanitation has been extensively evaluated in the past but scant, heterogeneous and inconclusive evidence is available on their effect on SARS-CoV-2 transmission. With the aim of pooling the available evidence on the efficacy of UV technologies against coronaviruses, we conducted a systematic review following PRISMA guidelines, searching Medline, Embase and the Cochrane Library, and the main clinical trials' registries (WHO ICTRP, ClinicalTrials.gov, Cochrane and EU Clinical Trial Register). Quantitative data on studies' interventions were summarized in tables, pooled by different coronavirus species and strain, UV source, characteristics of UV light exposure and outcomes. Eighteen papers met our inclusion criteria, published between 1972 and 2020. Six focused on SARS-CoV-2, four on SARS-CoV-1, one on MERS-CoV, three on seasonal coronaviruses, and four on animal coronaviruses. All were experimental studies. Overall, despite wide heterogenicity within included studies, complete inactivation of coronaviruses on surfaces or aerosolized, including SARS-CoV-2, was reported to take a maximum exposure time of 15 min and to need a maximum distance from the UV emitter of up to 1 m. Advances in UV-based technologies in the field of sanitation and their proved high virucidal potential against SARS-CoV-2 support their use for IPC in hospital and community settings and their contribution towards ending the COVID-19 pandemic. National and international guidelines are to be updated and parameters and conditions of use need to be identified to ensure both efficacy and safety of UV technology application for effective infection prevention and control in both healthcare and non-healthcare settings.

Validation Checklist for Massive Vaccination Centers.

Abstract: Starting from the minimum requirements indicated by Lombardy Region, a validation checklist has been developed by experts in design, healthcare layout planning, hygiene and public health, planning and compliance, in order to provide managers of COVID-19 massive vaccination centers with a useful and easy-to-use tool to ensure quality, safety and efficiency of the different activities performed.

Application of the "immunization islands" model to improve quality, efficiency and safety of a COVID-19 mass vaccination site.

Abstract: After SARS-CoV-2 vaccines development came at an unprecedented speed, ensuring safe and efficient mass immunization, vaccine delivery be-came the major public health mandate. Although mass-vaccination sites have been identified as essential to curb COVID-19, their organization and functioning is challenging. In this paper we present the planning, implementation and evalua-tion of a massive vaccination center in Lombardy - the largest Region in Italy and the most heavily hit by the pandemic. The massive hub of Novegro (Milan), managed by the Gruppo Ospedaliero San Donato, opened in April 2021. The Novegro mass-immunization model was developed building a la-yout based on the available scientific evidence, on comparative analysis with other existing models and on the experience of COVID-19 immunization delivery of Gruppo Ospedaliero San Donato. We propose a "vaccine islands" mass-immunization model, where 4 physicians and 2 nurses operate in each island, with up to 10 islands functioning at the same time, with the capacity of providing up to 6,000 vaccinations per day. During the first week of activity a total of 37,900 doses were administered (2,700/day), most of them with Pfizer vaccine (85.8%) and first doses (70.9%). The productivity was 10.5 vaccines/hour/vaccine station. Quality, efficiency and safety were boosted by ad-hoc personnel training, quality technical infrastructure and the presence of a shock room. Constant process monitoring allowed to identify and promptly tackle process pitfalls, including vaccine refusals (0.36%, below expectations) and post-vaccinations adverse reactions (0.4%). Our innovative "vaccine islands" mass-immunization model might be scaled-up or adapted to other settings. The Authors consider that sharing best practices in immunization delivery is fundamen-tal to achieve population health during health emergencies.