In transplant-ineligible patients with multiple myeloma (MM), disease relapse represents a critical step in the therapeutic pathway. The increasingly early use of frontline regimens containing anti-CD38 monoclonal antibodies has led to significant improvements in clinical outcomes, while simultaneously increasing the complexity of treatment selection in subsequent lines, particularly in elderly and frail patients. Current guidelines recommend the use of combination regimens based on triplets in the second-line setting, preferably incorporating mechanisms of action different from those previously employed. In this context, selinexor, an oral selective inhibitor of exportin-1 (XPO1), represents an innovative therapeutic option due to its ability to restore tumor suppressor protein activity and enhance the efficacy of other antimyeloma agents, including proteasome inhibitors. Data from the phase III BOSTON trial demonstrated that the selinexor-bortezomib-dexamethasone (SVd) combination is associated with a clinically meaningful benefit in terms of progression-free survival and overall survival in patients with relapsed MM, with a particularly relevant advantage in patients treated in the second-line setting who were not previously exposed to bortezomib. Overall, the SVd regimen may represent an effective and sustainable second-line therapeutic strategy, capable of combining antitumor activity with manageable tolerability, and addressing the clinical needs of a patient population increasingly representative of contemporary hematologic practice.
We base this commentary on a direct experience: ten months after the initiation of peer review for one of our manuscripts submitted to a first-quartile journal, the process remains ongoing. This situation prompted us to reflect more broadly on a growing systemic problem in scientific publishing: reviewer fatigue and the increasing difficulty editors face in identifying qualified, willing reviewers. While peer review remains the cornerstone of scientific quality assurance, we believe its sustainability is increasingly threatened by an inherently imbalanced system that strongly incentivizes manuscript submission while offering little formal recognition for reviewing activity. In our view, reviewer fatigue is a multifactorial phenomenon. A key driver is the unpaid nature of peer review, which is typically performed during personal time in the context of rising clinical and administrative workloads, particularly in anesthesiology. This burden is compounded by the proliferation of scientific journals and the exponential growth in manuscript submissions, a trend further accelerated by the widespread adoption of artificial intelligence tools that lower barriers to manuscript production. Increasing subspecialization further narrows the pool of eligible reviewers, concentrating the reviewing burden on a limited number of already overextended experts. We also consider insufficient editorial triage an important and often underappreciated contributor. When manuscripts with fundamental methodological or conceptual flaws are routinely sent for external review, reviewer motivation declines and editorial timelines are unnecessarily prolonged. Additional factors - including limited training in peer review, lack of feedback, and absence of academic recognition - further erode the perceived value of reviewing. We discuss several potential strategies, including formal recognition systems, targeted use of AI for preliminary manuscript screening, and stricter desk rejection policies. In conclusion, we view reviewer fatigue as a systemic threat to the integrity and efficiency of peer review that demands urgent, balanced, and concrete action by the scholarly community.
Over the past decade, the concept of skin failure has received increasing international attention, including definitions such as terminal ulcers, Skin Changes at Life's End (SCALE), and unavoidable pressure injuries. In the absence of a shared Italian translation, in this paper we adopt the term "end-of-life skin lesions" to describe end-stage skin failure, keeping the term international for consistency with the literature. The emerging paradigm recognizes the skin as an organ that, under conditions of global physiological deterioration, can undergo terminal failure, especially in the last weeks or days of life, but also in highly complex acute settings. End-of-life skin lesions are often characterized by sudden onset, rapid progression, irregular margins, purplish discoloration or early necrosis, and poor response to conventional treatments, even in the presence of appropriate preventive strategies. Distinguishing between avoidable lesions and lesions expressing non-preventable multisystem collapse is crucial both for clinical practice and for medico-legal and organizational implications, in a context where terminology and operational criteria are still heterogeneous and the absence of specific coding limits epidemiological surveillance and the quality of documentation. From a healthcare perspective, the approach must focus on comfort, proportionality, and the reduction of burden: protection of residual skin, control of pain, exudates, and odor, and critical reevaluation of invasive interventions inconsistent with care objectives. In response to these needs, the Italian Wound Care Scientific Association (AISLeC) and the Italian Palliative Care Scientific Association (SICP) have initiated a collaboration to develop Recommendations for Good Clinical-Care Practice, promoting shared terminology, integrated pathways between wound care and palliative care, and educational support for caregivers for decisions truly focused on dignity and quality of life.
Antibiotics can cause adverse drug reactions (ADRs) and hypersensitivity reactions (HSRs) through a variety of mechanisms. At our hospital, patients admitted with musculoskeletal tissue infection are followed by infectious disease consultants. The pharmacist only provides the therapy after verifying the correspondence (molecule, dosage and posology) of the motivated request (RMP) with the infectious disease consultancy. The aim was to identify adverse drug reactions, report them and providing training. Following the pharmacist's analysis of the infectious disease consultations, ADRs relating to antibiotics were identified and they were entered into the Network of Pharmacovigilance data from Italy, also managing any integrations, and subsequently collected in an Excel file. A qualitative analysis of clinical status, suspected drugs, adverse drug reactions (ADRs) description and its degree of seriousness were collected. A training course was organised "Rischio infettivo: Strumenti, best practice e approfondimenti". The most involved drugs were daptomycin and piperacillin tazobactam; the most observed adverse reactions were dermatological manifestations, eosinophilia, increased transaminases. Most of the reports were not serious. They organized 13 training courses and formats 400 health workers. Our experience confirms an under-reporting and has highlighted that the contribution to reporting by hospital doctors and nurses is closely related to the valuable work of awareness and support of hospital pharmacists. They assist clinicians in detecting phenomena that may underline the onset of adverse reactions and, consequently, carry out a reporting activity that guarantees useful information for the management of antibiotic therapy. Disseminating and discussing the results of pharmacovigilance is an aspect that motivates the healthcare professional to report. Working to increase the identification of ADRs and the consequent reporting allows us to contribute to the appropriate prescription of antibiotics, avoiding the onset of resistance and also the exposure of the individual patient to serious and disabling side effects.
Antimicrobial resistance (AMR) is a major global public health challenge, particularly in Italy, where surveillance data show high resistance rates for several pathogen-antibiotic combinations. This study aimed to evaluate trends in systemic antibiotic consumption in hospital settings within a Local Health Authority in Emilia-Romagna using PNCAR indicators. A retrospective analysis of systemic antibiotic consumption (Anatomical Therapeutic Chemical Classification System - ATC, class J01) was conducted at the Piacenza Local Health Authority between 2021 and 2024, using the WHO AWaRe classification. Data were expressed as DDD and DDD per 100 bed-days across seven hospital departments. The European Surveillance of Antimicrobial Consumption (ESAC) indicator for broad-spectrum antibiotics was calculated. An economic analysis of antibiotic expenditure per inpatient day was also performed and compared with regional and national benchmarks. The hospital antibiotic consumption (ATC J01) showed an overall decline, decreasing from 113.3 DDD/100 bed-days in 2022 to 97.5 in 2024. AWaRe analysis revealed a marked reduction in Access antibiotics and a concomitant increase in Watch agents, while Reserve use remained stable. Amoxicillin-clavulanic acid and ceftriaxone were the most frequently prescribed antibiotics. The ESAC indicator remained stable at approximately 54%. Contextualizing antibiotic consumption data within local epidemiology allows a more accurate interpretation of prescribing patterns and supports the development of tailored stewardship interventions. Integrating local monitoring with national surveillance systems could strengthen the evaluation of PNCAR targets.
Telemedicine is a key component of Digital Health (e-Health) and constitutes a key tool capable, through information and communication technologies, of broadening access to care, providing continuity of assistance, and improving the monitoring of patients with chronic diseases. This study investigated clinicians' perspectives on the use of telemedicine in ophthalmology, analyzing the results of an e-consensus conducted with the RAND/UCLA method, to evaluate the appropriateness of potential clinical practice recommendations (CPRs) for these technologies. Two rounds of questions have been administered between June and October 2024 to a panel of 28 clinicians out of 70 invited (40%) and an engineer with specific experience in telemedicine for the first round and 27 for the second plus the engineer. The outputs - albeit based on small numbers - suggest that, in Italy, telemedicine is judged most appropriate for non-strictly clinical phases (such as medical history collection, reporting, defining patient-satisfaction goals, and follow-up). By contrast, considerable uncertainty persists regarding its use for diagnostic procedures or for identifying diseases.
Scientific reflection on artificial intelligence (AI) in healthcare places strong emphasis on the need for adequate infrastructures and shared standards, but it also reminds us that technology alone is not enough. What is truly required is a mature digital culture, both organized and organizational, capable of guiding innovation while keeping it deeply human. AI can indeed become a valuable ally in restoring centrality to the care relationship, which today is often overshadowed by administrative overload and increasing organizational fragmentation. As The Lancet recently pointed out, medicine risks losing its most authentic dimension: the time devoted to listening, observing, and being present. In complex territorial settings, where geography shapes access to care, digital transition demands competent governance, clinical leadership, and investments in the digital literacy of healthcare professionals. When designed with ethics and common sense, AI can lighten the bureaucratic burden; but without a responsible vision, it risks becoming a new constraint, worsening rather than relieving burnout. The true progress of healthcare will depend on our ability to keep humanity at the heart of every innovation. The most advanced technology will never be the one that replaces humans, but the one that gives them back time, attention, and care.
DLBCL represents the prototype of aggressive lymphomas; despite therapeutic advances, a substantial proportion of patients remain refractory to first-line treatment. Anti-CD19 CAR-T therapy has revolutionized the second-line setting for patients with early relapse or refractory disease; however, real-world data in patients refractory to modern polatuzumab-containing regimens remain limited. We report the case of a 73-year-old woman with stage IVB GCB-type DLBCL, refractory to Pola-R-CHP and subsequently unresponsive to R-GEMOX. She was considered eligible for second-line axicabtagene ciloleucel. Due to rapid disease progression and worsening abdominal pain, palliative debulking radiotherapy to the abdominal mass was used as bridging therapy, achieving effective local control and clinical benefit. Following lymphodepleting conditioning, CAR-T infusion was well tolerated, with only grade 1 cytokine release syndrome and no ICANS. At 3 months post-infusion, PET imaging documented a complete metabolic response. This case supports the efficacy and feasibility of second-line CAR-T therapy even after failure of polatuzumab-based treatment and highlights radiotherapy as an effective and safe bridging strategy in patients with bulky or symptomatic disease.
Healthcare-associated infections (HAIs) represent a significant health and economic problem, with high frequency and severity. The project aims to analyse the existing organisational model in order to maximise value for both patients and healthcare providers through Lean and Value-Based Healthcare (VBHC) methodologies. From 2023 to 2024, a Lean programme, OPAT v2.0, was implemented to transfer antibiotic administration from the hospital to patients' homes, monitoring processes, costs and results using company databases and VBHC analysis. The costs of administration, antibiotic consumption and the economic impact of home care compared to hospital outpatient care were evaluated. In 2024, 268 personalised administrations were provided to home-based patients, for a total cost of € 107,011 in antibiotics. The estimated cost for home administration ranges from € 112,381.20 to € 243,064.80, while the hospital cost ranges from € 204,328.21 to € 464,442.10. The VBHC analysis showed significant economic savings in the home model compared to the hospital model, although this was limited by the availability of nursing staff and means of transport to patients' homes. The most commonly used antibiotics were ertapenem, daptomycin and ceftolozane tazobactam, the main choice being linked to the lower number of daily administrations. The OPAT v2.0 model demonstrates clinical and economic effectiveness, reducing hospital costs and improving quality of care. However, full implementation requires better territorial organisation, with home administration only for non-self-sufficient patients, while self-sufficient patients should be administered at district clinics in order to relieve congestion in hospital clinics.
Recent political positions in the United States have reignited debate over alleged links between medical interventions and autism, including advice to avoid acetaminophen in pregnancy, the promotion of folinic acid as a potential preventive or therapeutic measure, and the restriction of several pediatric vaccinations previously universally recommended. These claims have raised concern within the scientific community due to their potential to spread misinformation and weaken established preventive practices. The most robust available evidence, including large population-based cohorts, sibling-comparison studies, and recent systematic reviews and meta-analyses, does not support a causal association between prenatal acetaminophen exposure and the risk of autism spectrum disorder, attention-deficit/hyperactivity disorder, or intellectual disability. Likewise, while folates play a key role in preventing neural tube defects, current data do not support the use of folinic acid to prevent or treat autism. Limiting pediatric vaccination recommendations in the absence of new, high-quality evidence may reduce vaccine coverage and increase the circulation of preventable infectious diseases. The dissemination of non-evidence-based messages, particularly when endorsed by institutional figures, poses a tangible threat to public health and public trust.
In patients with chronic respiratory failure and a stable oxygen requirement ≤4 L/min, switching from liquid oxygen to oxygen concentrators represents a potential strategy to optimize home oxygen therapy, although structured real-world experiences remain limited. This study describes the experience of the COMBO Project implemented by the Turin City Local Health Authority, aimed at the planned implementation of a therapeutic switch from liquid oxygen to oxygen concentrators and the assessment of its organizational and management outcomes. A retrospective descriptive-comparative observational study was conducted by comparing two periods (May-December 2023 and May-December 2024). A total of 129 patients eligible for the therapeutic switch were analyzed; for patients who completed the transition, a descriptive counterfactual scenario was developed to estimate the expected economic impact. The switch was successfully completed by 104 patients (80.6%). During the observation period, a 69% increase in the use of oxygen concentrators and a 3.9% reduction in liquid oxygen consumption were observed. Comparison with the counterfactual scenario showed an expected cost reduction of 2.56%. The main critical issues related to the transition process involved clinical, logistical, and prescribing aspects among patients who did not complete the switch. The COMBO Project experience demonstrates the feasibility of a structured therapeutic switch model in territorial healthcare settings; the value of the intervention lies primarily in process organization and in the coordinating role of the Territorial Pharmaceutical Service, while the observed economic impact should be interpreted as an expected benefit. The model appears potentially replicable in similar healthcare contexts.
Artificial intelligence (AI) promises to redefine production systems, decision-making processes, and even social relationships, but it raises critical (and ethical) questions about its environmental impact. The paradox is clear: AI can be both part of the solution and part of the problem. On one hand, it enables better forecasting of extreme weather events thanks to data collected from satellites and sensors, supports "smart" electrical grids that integrate renewable sources such as solar and wind power, strengthens "precision agriculture" by optimizing irrigation and fertilization, and makes smart cities more sustainable through intelligent mobility systems and energy optimization. On the other hand, it introduces unavoidable environmental costs linked to high energy and water consumption, the limited availability of raw materials needed to build data-center components, and the challenge of disposing of them sustainably. Experts propose shifting from energy-hungry Red AI to Green AI, based on lighter, less complex models powered by renewable energy. Techniques such as federated learning and pruning, combined with the use of sustainable data centers, recyclable hardware, and distributed architectures, make it possible to drastically reduce consumption without sacrificing performance. The challenge for the future will be to govern AI with a vision that balances innovation and sustainability, environmental justice and technological progress.
This retrospective single-center study describes the use and content of Advance Care Planning (ACP) forms in a sample of 50 anonymized medical records of patients enrolled in a home-based primary palliative care program. ACP was documented in 62% of cases, with frequent reporting of hospitalization preferences (90.3%) and appointment of a healthcare proxy (90.3%), whereas treatment decisions and palliative sedation were less frequently addressed (45.2% and 16.1%, respectively). ACP discussions always involved the patient and the general practitioner (100%), with frequent participation of family members (87%) and palliative care nurses (61%), and only marginal involvement of other healthcare professionals (16%). These findings suggest that ACP is already integrated into clinical practice in this home-based primary palliative care setting; however, additional support may be needed to address more complex shared clinical decisions. Further, larger multicentric studies are needed to better understand the barriers and facilitators to ACP implementation in clinical practice.
Medicine today faces a crisis rooted in several factors: increased social complexity, evolving patient expectations, and the need to move beyond purely technical and standardized models. The article discusses the importance of restoring the human relationship between caregiver and patient, the value of the philosophy of care, and a renewed focus on each person's uniqueness. It highlights a shift toward a more systemic and integrated approach, with the "One Health" model linking human, animal, and environmental health. Healthcare training must adapt to these new challenges, promoting a personalized and multidisciplinary perspective and making humanities a core competency. Strengthening health systems requires transforming medical education, aiming for excellence in postgraduate training and ongoing professional development.
Healthcare-associated infections (HAIs) are infections that occur during hospitalization or healthcare treatment, representing a major public health threat. They have serious consequences: clinical (deterioration of conditions, increased mortality and disability), economic (costs to families and healthcare systems), and legal (professional liability). A substantial proportion of HAIs are preventable. Antimicrobial resistance further complicates management, with multidrug-resistant strains on the rise in Europe and globally. A fundamental pillar of effective programs against HAIs and antibiotic-resistant bacteria is the active and responsible involvement of all healthcare professions and disciplines, both in hospitals and communities. Implementing infection prevention and control requires a multidisciplinary approach, shared responsibilities, ongoing training, the use of tools such as bundles and audits with feedback, and, above all, a culture of safety that promotes effective adherence to prevention practices.
Relapsed or refractory B-cell acute lymphoblastic leukemia (R/R B-ALL) represents a complex clinical scenario, and the advent of immunotherapy has radically changed the therapeutic options available for these patients. The introduction of CAR-T cell therapy for patients over 25 years old offers a new treatment opportunity, with high remission rates and durable responses. A 67-year-old female patient with multiple comorbidities was diagnosed with Philadelphia-negative B-ALL and treated with induction therapy according to the GIMEMA LAL1913 protocol plus rituximab with dose reductions due to age, achieving a complete MRD-negative complete remission (CR). During the sixth month of maintenance therapy, a relapse was diagnosed. The patient was then referred for brexu-cel treatment, following bridging therapy with inotuzumab which led to the achievement of MRD-positive remission. Brexu-cel therapy was complicated by grade 1 CRS, grade 1 ICANS, and an episode of atrial fibrillation, but ultimately led to a complete MRD-negative CR. The patient remains in complete MRD-negative remission over one year after therapy, without the need for further treatment. Brexu-cel represents an effective treatment option for patients with R/R B-ALL. In patients with comorbidities and significant transplant-related risks, prolonged remissions can be maintained even without additional consolidation therapies. Optimization of bridging therapy, monitoring, and toxicity management is essential.
The retrospective observational study by Assimakis et al. on Advance Care Planning (ACP) implemented in primary (or general) home palliative care found that 62% of medical records closed due to completion of the care pathway contained a ACP in which the patient's wishes were documented in 83.9% of cases and that of the family members in 90.3%. The PCC was formulated by the General Practitioner (GP) with the patient in all cases except in cases of dementia or delirium, in which it was carried out with a family member previously appointed as a proxy by the patient. In 61% of cases, the community care nurse (district nurse) also contributed to the PCC. Advance will concerned possible hospitalization (90.3%), while indications on treatments (45.2%) and palliative sedation (16.1%) were less frequently documented. The study demonstrates that PCC can be implemented in daily care practices, even in general practice and in the community care, provided there is sufficient awareness and training on the topic. The latter are greatly facilitated by the presence of the Local Palliative Care Network.
Gastric cancer (GC) and esophagogastric junction cancer (EGJC) impose a severe global burden, with traditional treatments plagued by poor efficacy, high toxicity, and chemoresistance. Claudin 18.2 (CLDN18.2), a highly tissue-specific target, is abnormally overexpressed in GC/EGJC with limited overlap with HER2 positivity or PD-L1 CPS ≥5, making it ideal for precision therapy. Zolbetuximab, a CLDN18.2-targeted ADC, exerts anti-tumor effects via "targeted binding-endocytosis-MMAE release", reducing systemic toxicity versus traditional chemotherapy. Pivotal trials (MONO, FAST, SPOTLIGHT/GLOW, ILUSTRO) confirmed its monotherapy efficacy and superior PFS/OS when combined with chemotherapy (EOX, mFOLFOX6, CAPOX) in CLDN18.2-positive (≥70% staining), HER2-negative advanced GC/EGJC patients, with manageable safety. SPOTLIGHT/GLOW laid the foundation for its first-line approval. Post-approval, it may expand to other CLDN18.2-positive tumors and neoadjuvant/adjuvant therapy, with combination regimen optimization. However, MMAE's long-term cumulative toxicity, uncertain safety in special populations, and rare severe adverse reactions require real-world validation. This review systematically summarizes zolbetuximab's research progress, providing a reference for clinical application and future studies.
This article analyzes the role of artificial intelligence (AI) in academic writing, proposing an approach that considers chatbots as artificial collaborators rather than tools to circumvent the difficulties of scientific production. The analysis is structured around three dimensions. First, in academic writing AI can assist with routine sections of papers while maintaining human control over methodological and bibliographic aspects, which represent the core of scientific validity. Second, AI-based peer review (AIPR) could revolutionize peer review by incorporating capabilities difficult for humans to manage: scientometric analysis, recognition of argumentative biases, and verification of methodological procedures. Third, potential "cognitive laziness" is addressed through the Hegelian master-slave dialectic metaphor: every technology that incorporates human competencies replaces them, but simultaneously generates new competencies. In the hypertrophic world of contemporary textual production, chatbots can serve as guides to navigate informational complexity, albeit with the limits of artificial rationality.
Environmental diseases include a wide spectrum of pathologies whose development is influenced by physical, chemical and biological factors external to the individual. Recent WHO estimates show that 24% of global deaths are due to environmental factors as air pollution, climate change, toxic chemicals and poor hygiene. The Province of Alessandria, Piedmont, Italy, has been subjected to contamination due to industrial plants where hazardous materials have been used. To investigate the level of awareness of the population about environmental pathologies, the Research and Innovation Department of the Azienda Ospedaliero-Universitaria of Alessandria and ASL AL distributed a survey to secondary school students and citizens of Alessandria and Casale Monferrato, in two phases between 2022 and 2023. The sample comprises 230 participants equally divided by gender and with different levels of education. The survey explores knowledge of environmental causes of diseases and their impact on mortality and possible preventive measures. The majority of the sample associate environmental diseases with human pathologies (89.1%), with a higher awareness among students (91% compared to 86.6% of citizens). The main causes identified are air pollution (70.4%) and toxic substances in the air and water (64.8%). 84.8% identify cancer and 69.6% COPD as associated diseases. 56.4% estimate an impact of environmental factors between 10 and 15% on global mortality. The main preventive measures include the use of cleaner fuels (83.9%), improved hygiene measures (70%) and the promotion of sustainable mobility (70%). This survey reveals a fair degree of awareness of environmental diseases, but also an underestimation of associated mortality. Therefore, it is necessary to improve education and communication on environmental risks through targeted campaigns and educational interventions. Future studies should broaden the sample and analyze percentage differences between subgroups to optimize educational and preventive actions.