Modena experience of first year of Diagnostic and Therapeutic Care pathways of utero and cervix cancer

Background: Gynecological cancers of the uterus and cervix are common malignancies in women. The correct management of these tumors involves many figures. Material and methods: Therefore, to respond to these multidisciplinary needs in June 2019 in Azienda Ospedialiero-Universitaria of Modena was born a Diagnostic and Therapeutic Care Pathways (DTCP) with gynaecologists, radiotherapists, medical oncologists, radiologists, nuclear medical doctors, pathologists, anaesthesiologists, a nurse Case Manager and a patients' association representative. A molecular biologist, endocrinologists and nutritionists have already enriched the team after the first year of activity. The group performs weekly collegial discussions of clinical cases and cohort visits, continued in the COVID era. Results: The new diagnoses in the first year of activity were 53 endometrial cancers (EC) and 24 cervical ones (CC). The median age at diagnosis was 51 years between EC patients and 70 years in CC. 87% of EC were endometrioid subtypes, while 65% CC were squamous cell ones. 70% EC patients (pts) were stage (st) I (52% IA and 48% IB), 5,5% st II, 9,4% st III and 11,3% st IV. Immunohistochemical analysis for estrogen and progesterone receptor, p53 and mismatch repair (MMR) proteins were performed on 20 EC. All tumours tested are p53 negative. We found 3 pts who had MMR deficiency, none of them diagnosed with Lynch syndrome at the subsequent genetic counselling. After surgery, 66% pts in st I underwent observation and 34% made radiotherapy (RT). Among st II pts, 1 patient performed RT, one other platinum- based chemotherapy (pCT) and the third did not perform any adjuvant treatment for ECOG. All except one st III pts (67%) underwent pCT with RT. Among st IV one received surgery, pCT and palliative RT, the others (83%) made pCT. Most CC were diagnosed in early st. 9 pts underwent upfront surgery, followed in 2 cases with RT and in 3 with RT and pCT. One patient received neoadjuvant chemo-RT. Radical RT with weekly cisplatin was performed in 9 pts, other 4 pts made RT alone due to advanced age and/or ECOG. One patient started observation for age, ECOG and absence of symptoms. Conclusions: In our experience, DTCP allows the optimization of the diagnostic and therapeutic strategy in EC and CC pts, especially in most complex cases.

First wave of COVID-19 pandemic and caesarean delivery rate in Italy

INTRODUCTION When COVID-19 first spread in Europe, it was unclear if the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be transmitted from mother to fetus. Hence, doubts arose as the best way to deliver considering that caesarean delivery (CD) indeed could prevent vertical transmission. METHODS We calculated CD rate in 5 Italian regions (Lombardy, Emilia-Romagna, Tuscany, Umbria, Sardinia) differently affected by the first wave of the pandemic. Data were retrospectively obtained from each birth center and aggregated by areas (provinces). Data related to March-April 2020, corresponding to first COVID-19 peak in Italy, were compared with the March-April 2019 as well with November-December 2019, and odds ratio (ORs) were calculated. RESULTS A total of 24 provinces were included, covering 21.8% of the Italian population. Overall CD rate did not differ in the three examined periods: neither in the comparison of March-April 2019 (reference period) versus November-December 2019 (OR: 0.98 95% CI 0.93-1.05) nor in the comparison of the reference period versus March-April 2020 (OR: 1.03;95 % CI 0.98-1.09). CD rate did not change even in areas with the highest incidence of COVID-19. Only 17 out of 3.257 CDs was due to direct COVID-19 complications (0.5%;95% CI 0.3-0.8). No pregnant women with COVID-19 proven infection died. CONCLUSIONS The first wave of COVID-19 pandemic did not significantly affect delivery mode in Italy, even in areas with the highest infection rates.

Stillbirths during SARS-CoV-2 virus pandemic: What has changed?

The coronavirus SARS-CoV-2 was identified as the causative agent for a series of atypical respiratory diseases in China in December 2019. This infection was officially declared a pandemic by the WHO on March 2020, and it has affected over 170 million people in the world. In Emilia-Romagna, there is a Surveillance System of stillbirth (SB) since 2014. It records and audits, in a multidisciplinary way, each single case reported by every birth centre of the Region. In this study, we compared SB information collected in the Surveillance System database in pandemic period (March to December 2020) with the ones in the same period, recorded in the previous 6 years. SB was defined according to WHO recommendation. The numbers of birth per years was obtained by Birth certificates (CedAP). During pandemic, there were 89 SB out of 25,225 births allowing a rate of 3.52/1000. For the same period, in the previous 6 years, SB rate ranged from 3.00 (83/27,625) in 2018 to 3.55 (91/26,493) in 2019. Overall, SB rate did not change. No cases of SB were detected in pregnant women affected by SARS-CoV-2 infection. Risk factors as maternal age, years of education, country of origin, gestational weight gain and smoking did not change, while an increased number of SB was recorded in multiparous women (OR 1.62, 95%IC 1.02-2.55) and in overweight ones (OR 1.64, 95%IC 1.03-2.62). Overall, the proportion of preterm births was not substantially different between pandemic period compared to the previous period (OR 1.34, IC95% 0.81-2.23). However, there was a significant increase of SB cases occurring at 22+0-24+6 weeks (OR 3.55, 95%IC 1.49-8.45). Moreover, we found almost double increase of small for gestational age (SGA) infants (OR 1.88, 95%IC 1.16-3.05) and SB related to multiple pregnancy (OR 2.15, 95%IC 1.01-4.56) in pandemic period. The multivariate analysis confirms a higher risk of SB in overweight mothers with SGA infants at 22+0-24+6 weeks during pandemic (respectively OR 1.65, 95%IC 1.01-2.69, OR 1.73, 95%IC 1.03-2.92, and OR 2.18, 95%IC 1.13-4.19) (Table 1). According to ReCoDe classification, there were not significant changes in the frequency of SB causes, compared to the previous period. However, there was a trend toward an increase of the placental abruption cases (17/89 vs 67/555: OR 1.72, 95%IC 0.96-3.09). The quality of pregnancy care was evaluated by using CESDI grade, where grades 2 and 3 refer to substandard care (2: different management might have made a difference to outcome;3: different management would have been reasonably expected to have made a difference to outcome). At audit, cases with grade 2 or 3 during pandemic was 6%, similar to the reference period (10%). No significantly changes occurred in the number of obstetric evaluations as well as in the number of ultrasounds exams. Globally, SARS-CoV-2 pandemic did not substantially influence SB incidence and pregnancy cares. The pandemic restrictions might have affected the access of women at risk to pregnancy services, especially in the first half of gestation, with subsequent low detection rate of SGA.

Covid-19 and blood analysis: Vaio hospital Experience

INTRODUCTION: In March 2020 OMS declared the global outbreak of SARS-CoV-2. Vaio hospital has been intended only for covid patients since 23th March until 18th may 2020. AIM OF THE STUDY: We observe the trend of leucocyte and lymphocyte counts, IL-6, PCR, PCT, LDH, D-dimer, AST and ALT at entrance in emergency room and at the end of hospitalization. MATERIALS AND METHODS: We have examined 43 covid patients, 10 women and 33 men. 25 of 43 patients has received intensive care (58%) and 7 of these 25 (28%) have died. IL-6 and PCT detections were performed by Acces2 immunoassay (Beckman Coulter), leucocyte and lymphocyte counts were performed on XM-1080 flow cytometer (Sysmex), PCR was determined with AU5800 (Beckman Coulter) immunoassay, AST, ALT and LDH with immunoenzymatic test were performed on AU5800, PT and D-dimer test on ACL TOP 550 (Werfen) with clot detection and immunoassay rispectively. For data statistical analysis we calculate mean, frequencies and t test (excel, Windows 10, Microsoft). RESULTS: The mean measure at the early stage of hospitalization were: IL-6 105.33 pg/mL, leucocyte count 6,79 ∗103/μL, lymphocyte count 0.994∗103/μL, PCR 92,73 mg/L, D-dimer 2745 μg/L, LDH 758 U/L, PCT 0,195 ng/mL, AST 58,71 U/L and ALT 61 U/L. The IL-6 alive patients mean value (112,46 pg/mL) was statistically different (t test p=0,04) from IL-6 dead patients mean value (274,33 pg/mL) and the alive patients mean age (60,6 years) wasn't statistically different (t test p=0,15) from dead patients mean age (66,9 years). At the end of hospitalization we observe an increase of lymphocyte and a decrease of PCR for alive patients and an increase of PCT only for dead patients. There is a significative difference (t test p<0,01) for the lymphocyte count between alive patients (mean values 2,11∗103/μL) and dead patients (mean values 0.57∗103/μL), and between PCR (t test p<0,01) alive patients (mean values 45 mg/L) and dead patients (mean value 243,42 mg/L) and also between PCT (t test p<0,01) alive patients (mean value 0,24 ng/mL) and dead patients (mean value 2,45 ng/mL). DISCUSSION: The increase of number of lymphocyte is a favorable prognostic indicator, as well as low values of inflammatory markers (IL-6 and PCR).