The optimal timing of hepatitis C therapy in liver transplant-eligible patients: Cost-effectiveness analysis of new opportunities.

Different strategies of DAAs treatment are currently possible both pre- and postliver transplantation (LT). Clinical and economic consequences of these strategies still need to be adequately investigated; this study aims at assessing their cost-effectiveness. A decision analytical model was created to simulate the progression of HCV-infected patients listed for decompensated cirrhosis (DCC) or for hepatocellular carcinoma (HCC). Three DAAs treatment strategies were compared: (i) a 12-week course of DAAs prior to transplantation (PRE-LT), (ii) a 4-week course of DAAs starting at the time of transplantation (PERI-LT) and (iii) a 12-week course of DAAs administered at disease recurrence (POST-LT). The population was substratified according to HCC presence and, in those without HCC, according to the MELD score at listing. Data on DAAs effectiveness were estimated using a cohort of patients still followed by 11 transplant centres of the European Liver and Intestine Transplant Association and by data available in the literature. In this study, PRE-LT treatment strategy was dominant for DCC patients with MELD<16 and cost-effective for those with MELD16-20, while POST-LT strategy emerged as cost-effective for DCC patients with MELD>20 and for those with HCC. Sensitivity analyses confirmed PRE-LT as the cost-effective strategy for patients with MELD≤20. In conclusion, PRE-LT treatment is cost-effective for patients with MELD≤20 without HCC, while treatments after LT are cost-effective in cirrhotic patients with MELD>20 and in those with HCC. It is worth reminding, though, that the final choice of a specific regimen at the patient level will have to be personalized based on clinical, social and transplant-related factors.

Coping and parental role competence of mothers of preterm infant.

AIM: The study was aimed at obtaining knowledge about mothers' experiences of preterm birth. The objective of the study is to explore coping strategies and self- perceived parental competence, in mothers of infant born moderately and severely preterm and admitted to the Neonatal Intensive Care Unit (NICU). METHODS: The study involved a group of 16 mothers of moderately preterm children (weeks' gestational age: mean=34, SD=2 and birth weight: mean=2000 g, SD=200 g) and a group of 14 mothers of severely preterm children (weeks' gestational age: mean=29, SD=2 and birth weight: mean=1700 g, SD=350 g). The following instruments were used with mothers to investigate focus areas of research: Coping Orientation to the Problems Experienced-New Italian Version (COPE-NVI), to analyse coping strategies of mothers, and a Q-sort, a self report on maternal competence. RESULTS: Data did not show statistically significant differences between the two groups of mothers, both in regard to considered coping strategies (social support, avoidance, problem focused orientation, transcendent orientation, positive aptitude), and the indicators of maternal self-perceived competence (coping, scaffolding, caregiving) (Mann-Whitney U test(n1=16 and n2=14)>0.05). CONCLUSION: This study, highlighting the lack of differences between the two groups of mothers involved, seems to point out that, beyond the levels of prematurity, the condition of preterm birth itself is precisely the main stressor factor for mothers.

Systematic review with meta-analysis: the haemodynamic effects of carvedilol compared with propranolol for portal hypertension in cirrhosis.

BACKGROUND: Propranolol is recommended for prophylaxis of variceal bleeding in cirrhosis. Carvedilol is a nonselective beta-blocker with a mild anti-alfa-1-adrenergic activity. Several studies have compared carvedilol and propranolol, yielding inconsistent results. AIM: To perform a systematic review and meta-analysis of the randomised clinical trials comparing carvedilol with propranolol for hepatic vein pressure gradient reduction. METHODS: Studies were searched on the MEDLINE, EMBASE and Cochrane library databases up to November 2013. The weighted mean difference in percent hepatic vein pressure gradient reduction and the relative risk of failure to achieve a hemodynamic response (reduction ≥20% of baseline or to ≤12 mmHg) with each drug were used as measures of treatment efficacy. RESULTS: Five studies (175 patients) were included. Indication to treatment was primary prophylaxis of variceal bleeding in 76% of patients. There were overall three acute (60-90 min after drug administration) and three long-term (after 7-90 days of therapy) comparisons. The summary mean weighted difference in % of reduction in hepatic vein pressure gradient was: acute -7.70 (CI -12.40, -3.00), long-term -6.81 (CI -11.35, -2.26), overall -7.24 (CI -10.50, -3.97), favouring carvedilol. The summary relative risk of failure to achieve a hemodynamic response with carvedilol was 0.66 (CI 0.44, 1.00). Adverse events were nonsignificantly more frequent and serious with carvedilol. However, quality of trials was mostly unsatisfactory. CONCLUSIONS: Carvedilol reduces portal hypertension significantly more than propranolol. However, available data do not allow a satisfactory comparison of adverse events. These results suggest a potential for a cautious clinical use.

[Narrative inquiries representations and self-esteem in the child affected by tumor: a pre-test pilot study]. / Schemi narrativi sul sè e autostima nel bambino con neoplasia: uno studio pilota pre-test.

AIM: The contribution reports on a pre-test pilot study, based on the single-case method (N>1 and N=1 one by one), aimed to investigate whether resilience factors regards self-narrative representation, self-esteem and their likely correlations in child suffering from tumour. METHODS: The administration of specific investigation instruments (TMA - multidimensional self-esteem test, and a narrative inquiry framed on purpose) has been planned by the survey. The participating subjects set up a group of 7 children, 10 year olds, suffering from tumour. The individuation of such subjects has been carried out in terms of some "drawing variables" such as the existence of tumour, its diagnosis (12 months before commencing the research), the continuity of medical treatment and the lack of terminal stage of disease. RESULTS: The study has highlighted the lack of a statistically remarkable impairment of self-narrative and self-esteem in children suffering from tumour belonging to the reference group. These levels of self-narrative and self-esteem are possible resilience factors in children suffering from tumour. CONCLUSION: The acquired data about specific resilience elements in child suffering from tumor directs to research with national and international sample.

Clinical course of ulcerative colitis.

AIM: To provide a review of studies on prognosis in ulcerative colitis by reviewing the relevant population-based cohort studies. On the basis of incidence and population studies, ulcerative colitis has a favourable clinical course, with good quality of life, a chronic course characterized by at least one relapse, and a surgery rate of 30% after 10 years from diagnosis. Patients affected by severe ulcerative colitis have a higher risk of colectomy, and some clinical variables may predict the disease's clinical course. Most patients respond to steroids and only a low percentage become dependent, or non-responders to steroids. Patients who have a long-lasting ulcerative colitis (>10 years) or are affected by an extensive disease have an increased risk of developing colorectal cancer, while those treated with immunosuppressants for long period of time may have an increased risk of developing lymphomas. Data on mortality in ulcerative colitis patients are not homogeneous, but if a real risk exists it is in patients with extensive or severe disease. The evidence that patients with severe ulcerative colitis are often non-smokers may explain why in one study the mortality rate was lower.

[School in hospital: an opportunity for the hospitalized child to overcome the illness risk]. / La scuola in ospedale: un'opportunità di "attraversamento" del rischio per il bambino ospedalizzato.

AIM: The paper reports research on the subject of "Overcoming the illness risk in the School in Hospital service" the aim of which was to monitor this particular service so as to assess whether or not the activities proposed are directed by the model of overcoming inherent risks as defined and reported here. Four research directions were taken to verify the hypothesis whereby the service takes on a supportive-transformative value which enables the hospitalized child to study through his/her illness and is thus able to develop by activating support, protection and diagnosis functions. METHODS: The investigation was carried out using the single case methodology which provided for continuous observation lasting for the entire hospital period in the paediatric wards of 2 hospital in Sicily. The research involved 58 children aged between 7 and 12; chronically ill or long-stay patients, and 100 mothers of hospitalized children. The research also observed the effects of the intervention activated by "School in Hospital" on the child and on his reference models. Various instruments of an observational, projective and psycho-social investigation type were utilized in relation to the 2 main subjects of the research, the development outcomes on the subjects involved and the activities proposed by the service. RESULTS: The overall results confirm the supportive-transformative value of the "School in Hospital" service. CONCLUSIONS: The data obtained suggest that the service should be promoted within hospital structures as a specific form of the caring approach.

Hepatitis C infection in an Italian population not selected for risk factors.

AIMS/BACKGROUND: This study estimated the prevalence of HCV infection and relationship with viremia in a general population. The inhabitants of Albavilla town were personally invited to participate. METHODS: Out of 3997 inhabitants falling within the age range 18-85 years, 2403 (participation rate 60.1%) were examined for transaminases, HCVAb, HCVRNA, genotype and immunoblot assay. The following information was collected: sex, age, blood transfusions, surgery, use of glass syringes, drug addiction, alcohol consumption, tattoos and body mass index. RESULTS: 115 (4.8%) were HCVAb+, the prevalence being 1.2% under 40 years. Transfusion in the past was the only risk factor for HCV infection. Among the HCVAb+ subjects, 71 (61.7%) were HCVRNA+. 40.8% of the HCVAb+/HCVRNA+ group had normal ALT, compared with 68% of those with HCVAb+/HCVRNA-. The HCV genotypes in the 71 HCVRNA+ subjects were: 2a/2c in 58 (81.7%), 40% of them with normal ALT;1b in 11 (15.5%), none with normal ALT; genotype 3 in two (2.8%). CONCLUSION: The prevalence of HCVAb in this general population was 4.8%. About 3% were HCVRNA positive and of these genotype 2a/ 2c was present in 81.6%.

Serum cholesterol and chronic hepatitis C.

Total serum cholesterol levels have been studied in 100 patients with histological diagnoses of chronic hepatitis B and 100 wit chronic Hepatitis C, all without cirrhosis, and two age- and sex-matched control groups (B and C). Mean serum cholesterol levels of the groups were compared also in relation to sex, liver function, duration of the disease, alcohol intake, mass index, liver enzymes, presence of liver steatosis and severity of the liver disease on the basis of the histological activity index. The percentages of patients with serum cholesterol level < 150 mg/dl and > 240 mg/dl were also calculated. The mean serum cholesterol level was significantly lower in hepatitis C: 176 md/dl vs 194 mg/dl of hepatitis B (p = 0.004) and 198 of control C (p = 0.000). Twenty eight hepatitis C patients had serum cholesterol < 150 mg/dl vs 10 with hepatitis B (p = 0.001). In multivariate regression analysis, only the type of virus infection was independent related to serum cholesterol level (p = 0.0063).