Early anakinra treatment improves cardiac outcome of multisystem inflammatory syndrome in children, regardless of disease severity.

OBJECTIVE: The main aim of this study was to define the best treatment option for multisystem inflammatory syndrome in children (MIS-C) and to analyse the role of anakinra. METHODS: This is a multicentre retrospective cohort study. Patients were treated according to the attending physician's decision. The patients were divided into four groups on the basis of the first treatment at time of admittance: (i) IVIG, (ii) IVIG and methylprednisolone (≤2 mg/kg/day), (iii) IVIG with high-dose methylprednisolone (>2 mg/kg/day) and (iv) anakinra with or without IVIG and/or methylprednisolone. Primary outcomes were defined as the presence of at least one of the following features: death, the failure of initial treatment, meaning the need for additional treatment for clinical worsening and cardiac involvement at the end of follow-up. RESULTS: Two hundred thirty-nine patients were recruited. At univariate analysis, persistent heart involvement at discharge was more frequent in those not receiving anakinra as initial treatment (3/21 vs 66/189; P = 0.047). After comparisons between the four treatment regimens, adjusting for the propensity score, we observed that early treatment with anakinra was associated with a lower probability of developing persistent heart disease at the end of follow-up (odds ratio: 0.6; 95% CI: 0.4-1.0). CONCLUSION: We report that early treatment with anakinra is safe and very effective in patients with severe MIS-C. In addition, our study suggests that early treatment with anakinra is the most favourable option for patients with a higher risk of developing a severe disease outcome.

Cause specific mortality in an Italian pool of asbestos workers cohorts.

BACKGROUND: Asbestos is a known human carcinogen and is causally associated with malignant mesothelioma, lung, larynx and ovarian cancers. METHODS: Cancer risk was studied among a pool of formerly asbestos-exposed workers in Italy. Fifty-two Italian asbestos cohorts (asbestos-cement, rolling-stock, shipbuilding, and other) were pooled and their mortality follow-up was updated to 2018. Standardized mortality ratios (SMRs) were computed for major causes of death considering duration of exposure and time since first exposure (TSFE), using reference rates by region, age and calendar period. RESULTS: The study included 63,502 subjects (57,156 men and 6346 women): 40% who were alive, 58% who died (cause known for 92%), and 2% lost to follow-up. Mortality was increased for all causes (SMR: men = 1.04, 95% confidence interval [CI] 1.03-1.05; women = 1.15, 95% CI 1.11-1.18), all malignancies (SMR: men = 1.21, 95% CI 1.18-1.23; women = 1.29, 95% CI 1.22-1.37), pleural and peritoneal malignancies (men: SMR = 10.46, 95% CI 9.86-11.09 and 4.29, 95% CI 3.66-5.00; women: SMR = 27.13, 95% CI 23.29-31.42 and 7.51, 95% CI 5.52-9.98), lung (SMR: men = 1.28, 95% CI 1.24-1.32; women = 1.26, 95% CI 1.02-1.53), and ovarian cancer (SMR = 1.42, 95% CI 1.08-1.84). Pleural cancer mortality increased during the first 40 years of TSFE (latency), reaching a plateau thereafter. CONCLUSIONS: Analyses by time-dependent variables showed that the risk for pleural neoplasms increased with latency and no longer increases at long TSFE, consistent with with asbestos clearance from the lungs. Peritoneal neoplasm risk increased over all observation time.

Nurses' compliance to standard precautions prior to and during COVID-19.

AIMS: To measure nurses' compliance with standard precautions during the COVID-19 pandemic, compare findings with previous assessments and describe the barriers affecting nurses' compliance. BACKGROUND: Healthcare providers' compliance with standard precautions is still limited worldwide. Implementation of infection control policies in hospitals is needed internationally, especially during a pandemic. Surprisingly, studies exploring nurses' compliance with standard precautions are lacking during COVID-19. METHODS: A multicenter cross-sectional study was adopted in two Italian hospitals. Nurses' compliance with standard precautions was measured through The Compliance with Standard Precautions Scale (Italian version). An open-ended question explored the barriers to nurses' compliance with standard precautions. Reporting, followed the STROBE guidelines. RESULTS: A total of 201 nurses were enrolled in 2020. Nurses' compliance with standard precautions was suboptimal. A statistically significant improvement in the compliance rate with standard precautions was observed between pre- and during COVID-19 assessments. High compliance was found in the appropriate use of surgical masks, gloves and sharps disposal. Nurses perceived personal, structural and organizational barriers to standard precautions adherence. CONCLUSION: Nurses' compliance with standard precautions was not 100%, and different factors impeded nurses to work safely. Our findings provide institutional leaders and educators with the basis for implementing policies to optimize nurse safety, well-being and patient care. IMPLICATIONS FOR NURSING AND HEALTH POLICIES: Nurses have the right to work safely, and when the shortage of personal protective equipment and nurses during an emergency threatens healthcare quality worldwide, policymakers are challenged to act by establishing an effective allocation of resources for consistent compliance with standard precautions. Moreover, nurses should actively engage in the implementation of infection control policies to improve safe behaviours among citizens and students accessing hospitals.

Rapid Immunochromatography on Fresh Intestinal Biopsy Is Highly Accurate in Detecting Intestinal Antitransglutaminase Antibodies.

INTRODUCTION: Intestinal antitransglutaminase antibodies (I-anti-TG2) are a specific marker of celiac disease (CeD). The aim of this study was to evaluate the diagnostic accuracy of a novel application of an immunochromatographic assay referred to as Rapid_AntiTG2 to detect I-anti-TG2 on intestinal biopsy lysate. METHODS: Consecutive pediatric patients referred to a single center for elective upper endoscopy were enrolled. Biopsies were taken from duodenal bulb and distal duodenum. For each sampling site, 2 biopsies were analyzed for standard histology, 1 biopsy was cultured to perform the reference standard assay for I-anti-TG2 detection (endomysium [EMA] biopsy), and 1 biopsy was mechanically lysed to perform Rapid_AntiTG2. The primary outcome was the diagnostic accuracy of Rapid_AntiTG2 on biopsy lysate compared with that of the gold standard (serology + histopathology) for CeD diagnosis. The secondary outcome was the agreement of Rapid_AntiTG2 with EMA biopsy. RESULTS: One hundred forty-eight patients were included. Of them, 79 were those with CeD (64 classical CeD, 2 seronegative CeD, and 13 potential CeD) and 69 were controls. Rapid_AntiTG2 on biopsy lysate had very high diagnostic accuracy (sensitivity 100%, specificity 97%, LR+ 34.1, LR- 0.01) in separating patients with CeD from controls. Diagnostic accuracy was unchanged in patients with potential and seronegative CeD. Rapid_AntiTG2 on biopsy lysate had almost perfect agreement with the EMA biopsy reference test (99% agreement, Cohen K 0.97). DISCUSSION: I-anti-TG2 can be detected with an immunochromatographic assay after simple mechanical lysis of fresh intestinal biopsy with very high diagnostic accuracy. The test is quick and easy to perform and can be widely available in any endoscopy unit. Its implementation would allow a better understanding of the prognostic value of I-anti-TG2 and help clinicians in cases of suspected CeD that are difficult to classify.

Monitoring gestational weight gain: setting up a regional surveillance system in Italy.

BACKGROUND: In many countries, including Italy, there are few national data on pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG), despite these being important predictors of maternal and neonatal health outcomes. This dearth of information makes it difficult to develop and monitor intervention policies to reduce the burden of disease linked to inadequate BMI status and/or GWG in pregnant women. This study describes the setting up and initial implementation of a regional surveillance system on pre-pregnancy BMI and GWG. METHODS: Between 1 January 2017 and 31 December 2018, anthropometric data were collected from all pregnant women accessing public health services in the Friuli Venezia Giulia region (Italy) for first ultrasound check (T1) and at delivery (T2). Anthropometric data collected at T1 (self-reported pre-pregnancy weight and measured weight and height) and T2 (measured weight and self-reported pre-pregnancy weight and height) were compared. RESULTS: The system was able to reach 43.8% of all the women who gave birth in the region, and provided complete data for 6400 women of the 7188 who accessed the services at T1. At the beginning of pregnancy 447 (7.0%) women were underweight, 4297 (67.1%) had normal weight, 1131 (17.7%) were overweight and 525 (8.2%) had obesity. At delivery, 2306 (36.0%) women were within the appropriate weight gain range, while for 2021 (31.6%) weight gain was insufficient and for 2073 (32.4%) excessive. Only minor differences were observed between measured and self-reported anthropometric data. CONCLUSIONS: The surveillance system offers an overview of the weight status of women during pregnancy. About 1/3 of women entered pregnancy with unsatisfactory BMI and 2/3 did not achieve the recommended weight gain. This surveillance system can be an effective tool to guide public health interventions.

A multi-method quasi-experimental study to assess compassion satisfaction/fatigue in nurses, midwives and allied health professionals receiving a narrative medicine intervention.

AIMS: To: (1) measure the impact of a narrative medicine intervention on compassion fatigue and compassion satisfaction of nurses, midwives and allied health professionals; (2) explore participants' working experiences and (3) their impressions of the intervention. DESIGN: Multi-methods, quasi-experimental before-after intervention design. METHODS: The intervention consisted of 20 narrative medicine sessions (60 h). Healthcare providers (N = 48) from a mother-and-child hospital in Italy completed the 'Professional quality of life' questionnaire before and after the intervention (January 2020-April 2021). Baseline scores served as internal controls. Open-ended questions explored participants' touching experiences at work and their evaluation of the intervention. A thematic content analysis was performed. Reporting followed the TREND and SRQR guidelines. RESULTS: The differences before-after intervention in compassion satisfaction or fatigue scores were not statistically significant. Three themes emerged from participants' touching experiences: "Witnessing death and sufferance"; "Witnessing violence" and "Organizational stressors during COVID-19". A statistically significantly higher median score for post-intervention compassion satisfaction was found among participants who reported at least one touching experience compared to those who had no touching experience. Four themes emerged from the reported strengths of the program: "Learning to exteriorize feelings"; "Team building"; "Useful to rework personal/professional journey" and "Develops professional empowerment". Two themes emerged from reported weaknesses: "Programme organization" and "Participants' difficulties in sharing experiences". CONCLUSION: A time-limited narrative medicine intervention is not sufficient to produce significant changes in satisfaction or compassion fatigue, especially if implemented during a pandemic. However, such an intervention holds promise for supporting nurses and midwives' professional empowerment and promoting continuity of compassionate care. IMPACT: For those at risk of compassion fatigue, policymakers need to invest in training in narrative medicine, which promotes team building, and employee well-being and thus favours compassionate care. Such programmes should be offered to undergraduate students to nurture compassion and attention to self. PATIENT OR PUBLIC CONTRIBUTION: Does not apply as the study only includes health care providers.

Adolescents' pain and distress during peripheral intravenous cannulation in a paediatric emergency setting.

The objective of the study is to investigate pain and distress experienced by a group of adolescents and children during peripheral intravenous cannulation in a paediatric emergency department. This cross-sectional study was performed between November 2019 and June 2020 at the paediatric emergency department of the Institute for Maternal and Child Health of Trieste, Italy. Eligible subjects were patients between 4 and 17 years old undergoing intravenous cannulation, split into three groups based on their age: adolescents (13-17 years), older children (8-12 years), and younger children (4-7 years). Procedural distress and pain scores were recorded through validated scales. Data on the use of topical anaesthesia, distraction techniques, and physical or verbal comfort during procedures were also collected. We recruited 136 patients: 63 adolescents, 48 older children, and 25 younger children. There was no statistically significant difference in the median self-reported procedural pain found in adolescents (4; IQR = 2-6) versus older and younger children (5; IQR = 2-8 and 6; IQR = 2-8, respectively). Furthermore, no significant difference was observed in the rate of distress between adolescents (79.4%), older (89.6%), and younger (92.0%) children. Adolescents received significantly fewer pain relief techniques.Conclusion: This study shows that adolescents experience similar pain and pre-procedural distress as younger children during peripheral intravenous cannulation. What is Known: • Topical and local anaesthesia, physical and verbal comfort, and distraction are useful interventions for pain and anxiety management during intravenous cannulation in paediatric settings. • No data is available on pain and distress experienced by adolescents in the specific setting of the emergency department. What is New: • Adolescents experienced high levels of pre-procedural distress in most cases and similar levels of pain and distress when compared to younger patients • The number of pain relief techniques employed during procedures was inversely proportional to patient's age, topical or local anaesthesia were rarely used.

Prevalence of children witnessed violence in a pediatric emergency department.

Witnessed violence is a form of child abuse with detrimental effects on child wellbeing and development, whose recognition relies on the assessment of their mother exposure to intimate partner violence (IPV). The aim of this study was to assess the frequency of witnessed violence in a population of children attending a pediatric emergency department (ED) in Italy, by searching for IPV in their mother, and to define the characteristics of the mother-child dyads. An observational cross-sectional study was conducted from February 2020 to January 2021. Participating mothers were provided a questionnaire, which included the Woman Abuse Screening Tool (WAST) and additional questions about their baseline data and health. Descriptive analysis was reported as frequency and percentage for the categorical variables and median and interquartile range (IQR) for quantitative variables. Mothers and children screened positive and negative for IPV and witnessed violence, respectively, were compared by the chi-square test or the exact Fisher test for categorical variables, and by the Wilcoxon-Mann-Whitney test for continuous variables. Out of 212 participating mothers, ninety-three (43.9%) displayed a positive WAST. Mothers tested positive were mainly Italian (71%, p 0.003), had a lower level of education (median age at school dropout 19, p 0.0002), and a higher frequency of unemployment (p 0.001) and poor personal health status (8.6%, p 0.001). The children of mothers tested positive showed a higher occurrence of abnormal psychological-emotional state (38.7%, p 0.002) and sleep disturbances (26.9%, p 0.04). CONCLUSION: IPV was common in a population of mothers seeking care for their children in a pediatric ED. WHAT IS KNOWN: • Witnessed violence is a form of child abuse, usually inferred by their mothers' exposure to IPV. The latter is suffered by one in three women worldwide. WHAT IS NEW: • This study shows a 43.9% prevalence of IPV among mothers attending an Italian pediatric ED. • Positive mother-child dyads displayed a higher frequency of poor mothers' health status and children's abnormal emotional state and sleep disturbances.

The first winter of social distancing improved most of the health indexes in a paediatric emergency department.

AIM: We compared visits to a tertiary level paediatric emergency department (PED) in Italy, during winter 2020-2021, when COVID-19 social distancing measures were in place, with winter 2019-2020. METHODS: This was a retrospective analysis of an electronic database. We obtained the number of visits and the ages, main complaints, triage codes, discharge diagnoses and outcomes of patients who accessed the PED from the 1 October 2020 to 28 February 2021. These were compared to the same period in 2019-2021. RESULTS: Visits fell by 52%, from 10982 in 2019-2020 to 5317 in 2020-2021 (p < 0.0001). The reductions were 52% in neonates, 58% in infants, 53% in toddlers, 61% in preschool children, 48% in school children and 46% in adolescents. Non-urgent and urgent triage codes declined. Respiratory and gastrointestinal infections fell by 72% and 71% respectively. Injuries declined by 42%, mainly among adolescents. Accidental intoxication, psychiatric symptoms and substance or alcohol abuse declined by 24%, 33% and 64%. Hospital admissions reduced by 8% and admissions to intensive care fell by 29%. CONCLUSION: During the first winter of pandemic social distancing visits to an Italian PED fell by 52%, with higher reductions in younger children and infants, and hospital admissions fell by 8%.

SBI is uncommon in the absence of paediatricians' gut feeling and abnormal respiratory pattern.

AIM: According to the Italian national statistical institute, severe bacterial infections (SBI) in Italy are responsible for 1.7% of mortality under 5 years of age and their recognition is often challenging, especially in the first stages of the disease. We tried to estimate the prevalence of SBI in our target population and to identify signs and symptoms that could guide in the initial evaluation of a child with a possible SBI. METHODS: We designed a prospective, multicentre study and enrolled patients aged 0-14 years at the first evaluation to the emergency department with an acute illness lasting a maximum of 5 days. The presence of variables suggestive of SBI was collected for every enrolled patient. One week after the enrolment, every patient was followed up by telephone. RESULTS: SBI is more likely to be detected with the 'gut feeling' in both univariate and multivariate models (univariate OR: 7.16, 95% CI: 4.08-12.56; multivariate OR: 5.34, 95% CI: 2.78-10.25), while abnormal breathing pattern resulted significative only in univariate model (OR 3.83, 95% CI: 1.98-7.40). Nevertheless, their associated sensitivity is low. CONCLUSION: SBI is uncommon in the absence of paediatricians' gut feeling and abnormal respiratory pattern.

Need for pharmacological analgesia after cast immobilisation in children with bone fractures: an observational cross-sectional study.

BACKGROUND: Bone fractures are a common reason for children and adolescents to seek evaluation in the ED. Little is known about the pain experienced after cast immobilisation and discharge from the ED and its optimal management. We aimed to investigate the administration of pharmacological analgesia in the first days after cast immobilisation and to identify possible influencing variables. METHODS: A prospective observational cross-sectional study was conducted at the ED of the children's hospital, Institute for Maternal and Child Health of Trieste, Italy, from October 2019 to June 2020. Patients aged 0-17 years with bone fractures were included. The primary outcome was the administration of analgesia during the 10 days following discharge, while secondary outcomes were the associated variables, including age, gender, fracture type and location, the mean limitation in usual activities and the frequency of re-evaluation at the ED for pain. Data were recorded through a questionnaire, completed by caregivers and collected by the researchers mainly through a telephone interview. The primary endpoint was evaluated as the ratio between the number of children who took at least one analgesic dose and the total enrolled children, while Χ2 or Fisher's exact tests were used to assess secondary outcomes. RESULTS: During the study period, 213 patients, mean age 10 years (IQR: 8-13), were enrolled. Among them, 137 (64.3%) did not take any analgesic during follow-up. Among children who were administered analgesia, 22 (28.9%) received it only on the first day, and 47 (61.8%) for less than 5 days. One hundred and sixty one patients (75.6%) did not report any limitation in usual activities because of pain. The administration of analgesia was not related to the child's age, gender or fracture site. Displaced fractures were associated with significantly more frequent analgesia being taken (OR 5.5, 95% CI 1.4 to 21.0). CONCLUSION: Although some studies recommend scheduled analgesic treatment after discharge for bone fractures, this study would suggest analgesia on demand in children with non-displaced fractures, limiting scheduled analgesia to children with displaced fractures.

Is ultrasonography mandatory in all children at their first febrile urinary tract infection?

BACKGROUND: This study investigated whether performing kidney ultrasound (KUS) only in children presenting either a pathogen other than E. coli at their first febrile urinary tract infection (fUTI) or experiencing fUTI recurrence would increase missed diagnoses of kidney anomalies. METHODS: Patients aged 2-36 months with fUTI who underwent KUS evaluation from 2 January 2013 to 31 June 2018 were enrolled. Cystourethrography was performed after pathological KUS or recurring fUTIs. Thereafter, we retrospectively assessed the detection rate of kidney anomalies through performing KUS only in patients with atypical pathogen at first fUTI or with recurring fUTIs. RESULTS: In 263 patients included, the isolated pathogen was E. coli in 223 cases (84.8%) and atypical in 40 cases (15.2%). KUS detected kidney anomalies in 14/223 (6.3%) of fUTIs caused by E. coli and in 11/40 (27.5%) of fUTIs caused by an atypical pathogen (OR 5.5, 95%CI 2.5-14.5). Cystourethrography was performed in 40 patients and vesicoureteral reflux (VUR) found in 20 cases. None of the high grade VUR diagnoses or other kidney anomalies would have been lost through a different diagnostic protocol that required the presence of an atypical pathogen at the first fUTI or a fUTI recurrence to perform the KUS. CONCLUSIONS: A diagnostic protocol that requires presence of an atypical pathogen at the first fUTI or a second episode of fUTI to perform the KUS would allow a reduction in the number of negative ultrasounds with a negligible risk of missed diagnoses of kidney anomalies.

Retrospective study 2005-2015 of all cases of fetal death occurred at ≥23 gestational weeks, in Friuli Venezia Giulia, Italy.

BACKGROUND: Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available. METHODS: Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age ≥ 23 weeks. RESULTS: The incidence of IUFD was 2.8‰ live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks. CONCLUSION: The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs.

Maternal suicide in Italy.

Suicide has been identified as one of the most common causes of death among women within 1 year after the end of pregnancy in several high-income countries. The aim of this study was to provide the first estimate of the maternal suicide ratio and a description of the characteristics of women who died by suicide during pregnancy or within 1 year after giving birth, induced abortion or miscarriage (i.e., maternal suicide) in 10 Italian regions, covering 77% of total national births. Maternal suicides were identified through the linkage between regional death registries and hospital discharge databases. Background population data was collected from the national hospital discharge, abortion and mortality databases. The previous psychiatric history of the women who died by maternal suicide was retrieved from the regionally available data sources. A total of 67 cases of maternal suicide were identified, corresponding to a maternal suicide ratio of 2.30 per 100,000 live births in 2006-2012. The suicide rate was 1.18 per 100,000 after giving birth (n = 2,876,193), 2.77 after an induced abortion (n = 650,549) and 2.90 after a miscarriage (n = 379,583). The majority of the women who died by maternal suicide (34/57) had a previous psychiatric history; 15/18 previously diagnosed mental disorders were not registered along with the index pregnancy obstetric records. Suicide is a relevant cause of maternal death in Italy. The continuity of care between primary, mental health and maternity care were found to be critical. Clinicians should be aware of the issue, as they may play an important role in preventing suicide in their patients.

Pain Intensity and Risk of Bone Fracture in Children With Minor Extremity Injuries.

OBJECTIVES: Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS: We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS: We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS: In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.

Changing Epidemiology of Liver Involvement in Children With Celiac Disease.

OBJECTIVES: Available data indicate that liver involvement is present in a significant proportion of children with celiac disease (CD) at the diagnosis (elevated transaminases 15%-57%, autoimmune liver disease 1%-2%). We sought to evaluate prevalence, clinical course, and risk factors for liver involvement in a large cohort of children with CD. METHODS: Children (age 0-18 years) diagnosed with CD from March 2010 to April 2016 were enrolled. Liver involvement was considered to be present when alanine transaminase (ALT) levels were >40 U/L (hypertransaminasemia [HTS]). Patients with HTS were re-evaluated after at least 12 months of a gluten-free diet. RESULTS: CD was diagnosed in 806 patients during the study period; of these, ALT levels were available for 700 patients (86.9%), and were elevated in 27 (3.9%, HTS group); median ALT and aspartate transaminase levels in the HTS group were 57 U/L (interquartile range 49-80 U/L) and 67 U/L (interquartile range 53-85 U/L), respectively. Younger age, malabsorption symptoms, and low hemoglobin or ferritin were significantly more common in the HTS group at univariate analysis. At multivariate analysis, only age ≤4.27 years correlated with risk of liver involvement (odds ratio 3.73; 95% confidence interval: 1.61-8.66). When retested on a gluten-free diet, all but 3 patients normalized ALT levels; of these, 1 was diagnosed with sclerosing cholangitis. CONCLUSIONS: Liver involvement in celiac children is now less frequent than previously reported, possibly due to changing CD epidemiology. Younger age is the only risk factor. Associated autoimmune liver disease is rare.

Comparison of primary breast cancer and paired metastases: biomarkers discordance influence on outcome and therapy.

AIM: Discordance between primary tumor and paired metastases biology has been widely detected in metastatic breast cancer. The aim of this study was to evaluate the prognostic impact of Ki67, estrogen receptor (ER), progesterone receptor (PR) and HER2 discordance. METHODS: We retrospectively analyzed a cohort of 544 patients affected by metastatic breast cancer. Variation in ER, PR, Ki67 and HER2 expression between primary site and recurrence was tested through the McNemar test. RESULTS: A significant variation was observed in respect to ER, PR and Ki67 status (12.65%, p = 0.0072; 49.71%, p < 0.0001; 35%, p < 0.0001, respectively). Among patients with ER or PR discordance, the driver of therapeutic decisions was the ER status. Moreover, we observed a therapy-related reduction of ER in taxanes or aromatase inhibitors-exposed patients (odds ratio: 3.59; 95% CI: 1.66-7.77; p = 0.001 and odds ratio: 2.07; 95% CI: 0.96-4.44; p = 0.06, respectively). CONCLUSION: Biopsy of metastatic lesions may influence the decision-making process translating into better outcome.

Cancer incidence in a cohort of asbestos-exposed workers undergoing health surveillance.

OBJECTIVES: To compare a local cohort of 2488 men occupationally exposed to asbestos and enrolled in a public health surveillance program with the 1995-2009 cancer incidence of the general population of Friuli Venezia Giulia (FVG) region, Northeast Italy, we conducted a historical cohort study. METHODS: Standardized incidence ratios (SIRs), with 95% confidence interval (95% CI), for specific cancer sites were estimated in the cohort and in subgroups of workers employed in shipbuilding between 1974 and 1994. For internal comparisons, we calculated incidence rate ratios (IRRs) for all cancers, lung cancer and mesothelioma, by level of exposure to asbestos and sector of employment adjusted for smoking habits and age at start of follow-up. RESULTS: Among cohort members the SIR was 8.82 (95% CI 5.95-12.61) for mesothelioma and 1.61 (95% CI 1.26-2.04) for lung cancer. In subgroup analyses, the SIR for lung cancer in subjects hired in shipbuilding between 1974 and 1984 was 2.09 (95% CI 1.32-3.13). In the overall cohort, a borderline increased incidence was also found for stomach cancer (SIR = 1.53 95% CI 0.96-2.31). Internal comparisons within the cohort show that among men with high asbestos exposure level the relative risk was almost threefold for lung cancer (IRR = 2.94 95% CI 1.01-8.57). CONCLUSIONS: This cohort experienced an excess in the incidence of both mesothelioma and lung cancer, showing increasing incidence rates at higher level of asbestos exposure. For lung cancer, the relative incidence was highest among workers hired in shipbuilding between 1974 and 1984.

Mortality in a cohort of asbestos-exposed workers undergoing health surveillance.

BACKGROUND: The coastal area of Friuli Venezia Giulia (FVG) region, north-eastern Italy, was characterized by work activities in which asbestos was used until the early 1990s, particularly in shipbuilding. A public health surveillance program (PHSP) for asbestos-exposed workers was established, although limited evidence exists about the efficacy of such programs in reducing disease occurrence and mortality. OBJECTIVES: To compare mortality in a cohort of 2,488 men occupationally exposed to asbestos, enrolled in a PHSP in FVG between the early 1990s and 2008, with that of the general population of FVG and Italy. METHODS: Standardized Mortality Ratios (SMR), with 95% Confidence Interval (95% CI), for all causes, all cancers, lung (LC) and pleural cancer (PC) were estimated in the cohort and in subgroups of workers with the first hire in shipbuilding that caused asbestos exposure (<1974, 1974-1984, 1985-1994). RESULTS: A strong excess in mortality for PC with reference to FVG (SMR=6.87, 95% CI 4.45-10.17) and Italian population (SMR=13.95, 95% CI 9.02-20.64) was observed. For LC, the FVG-based SMR was 1.49 (95% CI 1.17-1.89) and the Italy-based 1.43 (95% CI 1.12-1.81). Mortality among workers with the first hire in shipbuilding before 1974 was high for PC (FVG-based SMR=8.98, 95% CI 5.56-13.75; Italy-based SMR=18.41, 95% CI 11.40-28.17) and for LC (FVG-based SMR =1.60, 95% CI 1.18-2.11; Italy-based SMR=1.54, 95% CI 1.14-2.03). Further, for LC between 1974 and 1984, the FVG-based SMR was 2.45 (95% CI 1.06-4.82), and the Italy-based SMR was 2.33 (95% CI 1.01-4.60). CONCLUSIONS: This cohort experienced an excess mortality for pleural and lung cancer, compared with regional and national populations. For lung cancer, the excess was stronger in workers with the first hire in shipbuilding before 1985, suggesting a key role of asbestos exposure.