Causes and length of stay of readmission among individuals with traumatic spinal cord injury: a prospective observational cohort study.

BACKGROUND: Secondary conditions may reduce function and participation in individuals with chronic Spinal Cord Injury (SCI). The knowledge of reasons for readmission to the hospital may be enlightening to prevent them and remodel the health services. STUDY DESIGN: Multicenter prospective observational study of all consecutive readmissions of persons with SCI after rehabilitation completion. OBJECTIVES: To explore the characteristics of individuals with SCI readmitted to the hospital, the reasons for readmissions and the burden on hospitalization in terms of length of stay (LoS) for different conditions. SETTING: 31 Italian specialized SCI centers. METHODS: Data on people with traumatic SCI readmitted to SCI centers were recorded about: age, sex, SCI level and severity group, geographical origin, readmission causes, clinical interventions during hospitalization, LoS and discharge destination. Linear and multiple logistic regression analyses were performed considering LoS (days) as dependent variable for correlations with independent variables. All tests were two-sided. RESULTS: Among 1039 persons with traumatic SCI enrolled (mean age 46, males 85%, tetraplegia 43%), 59.09% of the readmissions were caused by urological problems, 39.74% by pressure injury and 35.41% by spasticity (68% readmitted for ≥2 causes, associated with longer LoS). The mean LoS was 48 days: pressure injury, rehabilitative needs, sexual, bowel, and pain problems were associated with longer and urological problems with shorter LoS. People from the South of the country were frequently (68%) readmitted to the northern centers. CONCLUSIONS: Urological problems, pressure injury and spasticity were the most frequent causes of re-hospitalization in individuals with traumatic SCI. The migration trend seeking SCI-specific treatments suggests geographic areas to which health care organizations need to pay more attention.

Traumatic spinal cord injury in Italy 20 years later: current epidemiological trend and early predictors of rehabilitation outcome.

STUDY DESIGN: Multicenter prospective observational study of people with acute traumatic spinal cord injury (TSCI) admitted to rehabilitation. OBJECTIVES: To update epidemiological characteristics of a TSCI Italian population and verify the impact of patient characteristics at admission on two outcomes: functional gain (SCIM III) and discharge destination. SETTING: Thirty-one SCI centers for comprehensive rehabilitation in 13 Italian regions. METHODS: All consecutive individuals admitted with acute TSCI were enrolled from October 1, 2013 to September 30, 2014; data were recorded on rehabilitation admission and discharge. Functional gain and discharge destination were identified as outcome measures and statistically analyzed with patient characteristics at admission to identify early outcome predictors. RESULTS: Five hundred and ten individuals with TSCI met inclusion criteria; falls represented the most frequent etiology (45%). On admission, AIS A-B-C tetraplegia was reported in 35% of cases; AIS A-B-C paraplegia in 40%; AIS D paraplegia/tetraplegia in 25%. The majority were discharged home (72%). The mean (SD) SCIM gain was 38 ± 26 points. A predictive model was found for discharge setting: individuals with fall-related injuries, severe SCI (AIS A-B-C tetraplegia), tracheal cannula or indwelling catheter on admission, were less likely to be discharged home (OR 95% CI 0.15 [0.06, 0.35]). A model with a lower predictive power was found for SCIM gain, with lower score expected for females, older age, higher severity of SCI, a longer onset of injury admission interval (OAI), and mechanical ventilation on admission. CONCLUSIONS: Prognostic factors in early rehabilitation are still hard to identify, making it difficult to correctly approach customized rehabilitation.

Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study.

The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome. As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included. A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14-2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44-3.15), hyperthermia (HR, 1.70; 95% CI, 1.18-2.45), pneumonia (HR, 1.76; 95% CI, 1.18-2.61), heart failure (HR, 2.87; 95% CI, 1.34-6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53-3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39-0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36-0.84) significantly increased 6-month survival. In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.

Acute Phase Predictors of 6-Month Functional Outcome in Italian Stroke Patients Eligible for In-Hospital Rehabilitation.

PURPOSE: The aim of the study was to assess early poststroke prognostic factors in patients admitted for postacute phase rehabilitation. METHODS: A 1-yr multicenter prospective project was conducted in four Italian regions on 352 patients who were hospitalized after a first stroke and were eligible for postacute rehabilitation. Clinical data were collected in the stroke or acute care units (acute phase), then in rehabilitation units (postacute phase), and, subsequently, after a 6-mo poststroke period (follow-up). Clinical outcome measures were represented using the Barthel Index and the modified Rankin Scale. Univariate and multivariate analyses were performed to identify the most important prognostic index. RESULTS: Modified Rankin Scale score, minor neurologic impairment, and early out-of-bed mobilization (within 2 days after the stroke) proved to be important factors related to a better recovery according to Barthel Index (power of prediction = 37%). Similarly, age, premorbid modified Rankin Scale score, and early out-of-bed mobilization were seen to be significant factors in achieving better overall participation and activity according to the modified Rankin Scale (power of prediction = 48%). Barthel Index at admission and certain co-morbidities were also significant prognostic factors correlated with a better outcome. CONCLUSIONS: According to the Barthel Index and modified Rankin Scale, early mobilization is an early predictor of favorable outcome. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Incorporate prognostic factors of good clinical outcomes after stroke in developing treatment plans for patients admitted to rehabilitation; (2) Identify acute phase indicators associated with favorable 6-mo outcome after stroke; and (3) Recognize the cut-off for early mobilization linked to better outcome in stroke survivors admitted to rehabilitation. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Parotid adenoid cystic carcinoma: Retrospective single institute analysis.

PURPOSE: Adenoid cystic carcinoma (ACC) is a uncommon salivary malignant tumor. Our aim was to review our experience with parotid ACC, to identify clinical-pathological parameters predictive for outcome. MATERIALS AND METHODS: We retrospectively reviewed 228 patients affected by parotid gland carcinomas surgically treated at our Institution. Forty-four ACC were included in this study. Multivariate analysis risk models were built to predict recurrence free probability (RFP), distant recurrence free probability (DRFP), overall survival (OS) and disease free survival (DFS). RESULTS: Twenty-one patients (47.7%) died from ACC and 2.3% for other causes. The 41% presented local-regional recurrence, with a regional-RFP rate of 93%, and the 34% reported distant metastases (DM). The five and ten-year OS rates were 74% and 50%, respectively. CONCLUSIONS: Recurrences were mainly influenced by the presence of perineural invasion and nerve paralysis, whilst female gender and age<50 were predictors for good prognosis.

Current trends and outcomes of breast reconstruction following nipple-sparing mastectomy: results from a national multicentric registry with 1006 cases over a 6-year period.

BACKGROUND: Reconstruction options following nipple-sparing mastectomy (NSM) are diverse and not yet investigated with level IA evidence. The analysis of surgical and oncological outcomes of NSM from the Italian National Registry shows its safety and wide acceptance both for prophylactic and therapeutic cases. A further in-depth analysis of the reconstructive approaches with their trend over time and their failures is the aim of this study. METHODS: Data extraction from the National Database was performed restricting cases to the 2009-2014 period. Different reconstruction procedures were analyzed in terms of their distribution over time and with respect to specific indications. A 1-year minimum follow-up was conducted to assess reconstructive unsuccessful events. Univariate and multivariate analyses were performed to investigate the causes of both prosthetic and autologous failures. RESULTS: 913 patients, for a total of 1006 procedures, are included in the analysis. A prosthetic only reconstruction is accomplished in 92.2 % of cases, while pure autologous tissues are employed in 4.2 % and a hybrid (prosthetic plus autologous) in 3.6 %. Direct-to-implant (DTI) reaches 48.7 % of all reconstructions in the year 2014. Prophylactic NSMs have a DTI reconstruction in 35.6 % of cases and an autologous tissue flap in 12.9 % of cases. Failures are 2.7 % overall: 0 % in pure autologous flaps and 9.1 % in hybrid cases. Significant risk factors for failures are diabetes and the previous radiation therapy on the operated breast. CONCLUSIONS: Reconstruction following NSM is mostly prosthetic in Italy, with DTI gaining large acceptance over time. Failures are low and occurring in diabetic and irradiated patients at the multivariate analysis.

Laryngeal preneoplastic lesions and cancer: challenging diagnosis. Qualitative literature review and meta-analysis.

BACKGROUND: Multi-step cancerogenesis guides laryngeal cancer onset and it includes a wide variety of pre-cancerous lesions macroscopically challenging to identify and distinguish from initial cancerous foci. OBJECT: Different modalities of diagnostic techniques of laryngeal epithelial lesions exist and they do not offer a single system to make a differential diagnosis. Hence, this meta-analysis aimed to synthesize the validity of each single diagnostic tool to improve laryngeal patient management. METHODS: A systematic review of literature was led searching for articles mentioning the following terms: larynx, laryngeal precancerous lesions, laryngeal cancer, white light (WL) endoscopy, stroboscopy, contact endoscopy (CE), autofluorescence (AF), ultrasound (US), narrow band imaging (NBI), computed axial tomography (CAT), magnetic resonance imaging (MRI), positron emission tomography (PET), CAT/PET. Then, a quantitative analysis was carried on for paper published after 2005 onward. RESULTS: The search identified 7215 publications, of which 3616 published after 2005, with a final results of a total of 214 articles stratified and included by our selection criteria. 42 out of 214 articles were selected for quantitative synthesis. 25 out of 41 studies had a good quality score, 16 were fair. CONCLUSIONS: A comprehensive overview of the most recent advances in laryngeal imaging technology combined with all of the information needed to interpret findings and manage patients with voice disorders can be found herein. Our flow-chart allows clinicians in risk-stratify patients and select proper examination modalities to provide appropriate care. Study limitations, together with possible clinical and research implications have been counted.

Preferential sampling and Bayesian geostatistics: Statistical modeling and examples.

Preferential sampling refers to any situation in which the spatial process and the sampling locations are not stochastically independent. In this paper, we present two examples of geostatistical analysis in which the usual assumption of stochastic independence between the point process and the measurement process is violated. To account for preferential sampling, we specify a flexible and general Bayesian geostatistical model that includes a shared spatial random component. We apply the proposed model to two different case studies that allow us to highlight three different modeling and inferential aspects of geostatistical modeling under preferential sampling: (1) continuous or finite spatial sampling frame; (2) underlying causal model and relevant covariates; and (3) inferential goals related to mean prediction surface or prediction uncertainty.

Preferential sampling in veterinary parasitological surveillance.

In parasitological surveillance of livestock, prevalence surveys are conducted on a sample of farms using several sampling designs. For example, opportunistic surveys or informative sampling designs are very common. Preferential sampling refers to any situation in which the spatial process and the sampling locations are not independent. Most examples of preferential sampling in the spatial statistics literature are in environmental statistics with focus on pollutant monitors, and it has been shown that, if preferential sampling is present and is not accounted for in the statistical modelling and data analysis, statistical inference can be misleading. In this paper, working in the context of veterinary parasitology, we propose and use geostatistical models to predict the continuous and spatially-varying risk of a parasite infection. Specifically, breaking with the common practice in veterinary parasitological surveillance to ignore preferential sampling even though informative or opportunistic samples are very common, we specify a two-stage hierarchical Bayesian model that adjusts for preferential sampling and we apply it to data on Fasciola hepatica infection in sheep farms in Campania region (Southern Italy) in the years 2013-2014.

Spatial analysis of incidence of cutaneous melanoma in the Friuli Venezia Giulia region in the period 1995-2005.

Incidence distribution of cutaneous melanoma depends on phenotypic characteristics of population and geographic location. In Italy, in the period 1999-2003 Friuli Venezia Giulia (FVG) region had the second highest incidence rates for males and the third for females. We analysed melanoma and lip cancer incidence data of the FVG cancer registry for the period 1995-2005. We used Bayesian hierarchical spatial models to describe the spatial pattern by gender. We decomposed the geographical distribution of the risk in two parts: a component linked to chronic exposure and a component related to intermittent exposure. In order to model the chronic component we considered the geographical distribution of incidence cases of lip cancer, for which chronic occupational solar radiation exposure is a documented risk factor. We also analysed the distribution by site and we calculated standardised rates for body surface area. This study documents a significant gradient in the incidence of cutaneous melanoma in FVG. High-standardized incidence rates are present in the area of Trieste and in the coastal area. The descriptive analysis by age group and by site, showed risks associated with intermittent exposures in both genders. For the coastal area the risk is especially high for sites traditionally linked to high cumulative exposures (face and neck), especially among men. The results suggest diagnostic preventive interventions in the populations living in the area of Trieste, given the high rates observed in the young age groups.

Geostatistical integration and uncertainty in pollutant concentration surface under preferential sampling.

In this paper the focus is on environmental statistics, with the aim of estimating the concentration surface and related uncertainty of an air pollutant. We used air quality data recorded by a network of monitoring stations within a Bayesian framework to overcome difficulties in accounting for prediction uncertainty and to integrate information provided by deterministic models based on emissions meteorology and chemico-physical characteristics of the atmosphere. Several authors have proposed such integration, but all the proposed approaches rely on representativeness and completeness of existing air pollution monitoring networks. We considered the situation in which the spatial process of interest and the sampling locations are not independent. This is known in the literature as the preferential sampling problem, which if ignored in the analysis, can bias geostatistical inferences. We developed a Bayesian geostatistical model to account for preferential sampling with the main interest in statistical integration and uncertainty. We used PM10 data arising from the air quality network of the Environmental Protection Agency of Lombardy Region (Italy) and numerical outputs from the deterministic model. We specified an inhomogeneous Poisson process for the sampling locations intensities and a shared spatial random component model for the dependence between the spatial location of monitors and the pollution surface. We found greater predicted standard deviation differences in areas not properly covered by the air quality network. In conclusion, in this context inferences on prediction uncertainty may be misleading when geostatistical modelling does not take into account preferential sampling.

Nipple sparing mastectomy: Surgical and oncological outcomes from a national multicentric registry with 913 patients (1006 cases) over a six year period.

BACKGROUND: Nipple sparing mastectomy is deemed surgically and oncologically safe based on a long lasting literature data from reviews of single institution series. This study aims at evaluating surgical and oncological outcomes of NSM on a large multi-institutional scale, by means of the Italian National registry. METHODS: In July 2011 a panel of Italian specialists agreed upon and designed a National database of NSM. Centers with at least 150 cancers per year and following the National follow-up schedule guidelines could participate inserting any NSM case performed, retrospectively and prospectively from that moment on. In March 2015 analysis of data was accomplished. Dataset for this study consists of cases performed in the period between January 1st 2009 and December 31st 2014. RESULTS: 913 Women were included in the analysis, for a total of 1006 procedures. Prophylactic mastectomies were 124 (12.3%). MRI utilization increased over time. NSM failure rate, with NAC removal for any reason was 11.5%. NAC necrosis rate was 4.8%. Larger skin-flap necrosis rate was 2.3%. Major surgical complications rate was 4.4%. Oncological outcomes were calculated among primitive EBC cases only: locoregional recurrences rate was 2.9%, NAC recurrence 0.7%. Systemic recurrence rate was 1.0%. Five deaths (0.7%) were registered. CONCLUSIONS: More than 10% of NSM procedures are prophylactic mastectomies. MRI is gaining more importance over time. Surgical and oncological results show that NSM is effective. This National multicentric analysis enables a comparison of results with no geographical differences and a "safe" state of the art of NSM in Italy.

Microinvasive breast cancer: pathological parameters, cancer subtypes distribution, and correlation with axillary lymph nodes invasion. Results of a large single-institution series.

BACKGROUND: Microinvasive breast cancer is a rare entity in which an invasive component not exceeding 1 mm is found, mostly in a ductal carcinoma in situ setting. Its diagnosis can be difficult and must rely upon immunohistochemistry markers. Many studies have analyzed pathological characteristics of this cancer to delineate its biological profile and possibly identify risk factors of axillary lymph nodes infiltration, which might be present and therefore clinically relevant. Starting from a relative large number of cases we aimed to analyze pathological data, cancer subtypes distribution, and their correlation to nodal metastasis, comparing our results to the existing recent literature. METHODS: All cases of microinvasive breast cancer were retrieved from institutional database from 1992 to 2014. Pathological parameters were analyzed for entire cohort. Moreover, cases submitted to standardized sentinel node biopsy in a restricted period, 2000-2014, were selected to correlate pathology and cancer subtype to axillary lymph nodes status. RESULTS: 174 cases (1.4 % of operated breast cancers) were evaluated in the larger period, 1992-2014. Neither specific pathological parameters were expressed nor a peculiar cancer subtype was represented. 126 cases were selected for axillary staging analysis. Eighteen cases (14.3 %) had lymph nodes metastasis, 10 ITCs (7.9 %), 3 micrometastases (2.4 %), and 5 macrometastases (4 %). An associated intraductal component of carcinoma over 20 mm in maximum dimension resulted significant at multivariate analysis, but only if including ITCs, while this risk factor was not reproduced for micro- and macrometastases only. CONCLUSIONS: Microinvasive breast cancer does not seem to have specific pathological and biological traits. An associated intraductal component of carcinoma >20 mm in size is a specific risk factor for ITCs nodal metastasis. Its clinical significance is anyway limited and therefore sentinel node biopsy should be performed case by case and not routinely.

Haemonchus contortus: spatial risk distribution for infection in sheep in Europe.

Haemonchus contortus is a species of gastrointestinal strongyles of primary concern for sheep. This highly pathogenic, blood-feeding helminth negatively influences animal health, welfare and productivity. In order to elucidate the current scenario in terms of prevalence and intensity of H. contortus infection in sheep farms across Europe, a standardized crosssectional survey was conducted in three pilot areas in Ireland, Switzerland and Italy, all part of the EU funded GLOWORM project. Two consecutive field surveys (in 2012 and 2013) were conducted in the three countries in the same period (August-October) in 259 sheep farms in total. Harmonized, diagnostic procedures (from farm to laboratory) based on pooled samples, the FLOTAC technique and coproculture were used. The georeferenced parasitological results were modelled (at the pilot area level) following a Bayesian geostatistical approach with correction for preferential sampling and accounting for climatic and environmental covariates. The observed H. contortus prevalence rates did vary between the countries showing high values in Switzerland (77%) and Italy (73%) compared to Ireland (4%). Spatial patterns of H. contortus distribution were detected in Switzerland and Italy with a north-south gradient. The latent factor analysis highlighted the importance of seasonality and annual cyclicity within country (particularly in southern Italy), while mean temperature and rainfall dominated between country variations in the prevalence of H. contortus infection.

Subcutaneous Direct-to-Implant Breast Reconstruction: Surgical, Functional, and Aesthetic Results after Long-Term Follow-Up.

UNLABELLED: Direct-to-implant breast reconstruction can be achieved more easily by means of soft-tissue replacement devices such as dermal matrices and synthetic meshes. The feasibility of a subcutaneous approach has been recently investigated by some studies with different devices functioning as implant support. Aim of this study is to analyze the long-term results, both objective and subjective, of a previous nonrandomized trial comparing prepectoral (subcutaneous) and retropectoral breast reconstructions. METHODS: Patients enrolled in a nonrandomized prospective trial, comparing the standard retropectoral reconstruction and the prepectoral subcutaneous approach, using a titanium-coated mesh in both techniques, were followed up and evaluated for long-term results. Cases were compared in terms of the causes and rate of reinterventions, of the postoperative BREAST-Q questionnaire results, and of an objective surgical evaluation. RESULTS: The subcutaneous group had a rate of implant failure and removal of 5.1% when compared with 0% in the retropectoral group. Aesthetic outcome was significantly better for the subcutaneous group both at a subjective and at an objective evaluation. Capsular contracture rate was 0% in the subcutaneous group. CONCLUSIONS: A higher rate of implant failure and removal, although not significant, always because of skin flaps and wound problems, should be taken into account for a careful patients selection. The subcutaneous breast reconstruction shows good long-term results. A coherent subjective and objective cosmetic advantage of this approach emerges. Moreover, no capsular contracture is evident, albeit in a relatively limited number of cases.