Epidemiology, therapy and outcome of hepatocellular carcinoma between 2010 and 2019 in Piedmont, Italy.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second leading cause of cancer deaths worldwide. It is often diagnosed at an advanced stage and therefore its prognosis remains poor with a low 5-year survival rate. HCC patients have increasingly complex and constantly changing characteristics, thus up-to-date and comprehensive data are fundamental. AIM: To analyze the epidemiology and main clinical characteristics of HCC patients in a referral center hospital in the northwest of Italy between 2010 and 2019. METHODS: In this retrospective study, we analyzed the clinical data of all consecutive patients with a new diagnosis of HCC recorded at "Santa Croce e Carle" Hospital in Cuneo (Italy) between 1 January 2010 and 31 December 2019. To highlight possible changes in HCC patterns over the 10-year period, we split the population into two 5-year groups, according to the diagnosis period (2010-2014 and 2015-2019). RESULTS: Of the 328 HCC patients who were included (M/F 255/73; mean age 68.9 ± 11.3 years), 154 in the first period, and 174 in the second. Hepatitis C virus infection was the most common HCC risk factor (41%, 135 patients). The alcoholic etiology rate was 18%, the hepatitis B virus infection etiology was 5%, and the non-viral/non-alcoholic etiology rate was 22%. The Child-Pugh score distribution of the patients was: class A 75%, class B 21% and class C 4%. The average Mayo end-stage liver disease score was 10.6 ± 3.7. A total of 55 patients (17%) were affected by portal vein thrombosis and 158 (48%) by portal hypertension. The average nodule size of the HCC was 4.6 ± 3.1 cm. A total of 204 patients (63%) had more than one nodule < 3, and 92% (305 patients) had a non-metastatic stage of the disease. The Barcelona Clinic Liver Cancer (BCLC) staging distribution of all patients was: 4% very early, 32% early, 23% intermediate, 34% advanced, and 7% terminal. Average survival rate was 1.6 ± 0.3 years. Only 20% of the patients underwent treatment. Age, presence of ascites, BCLC stage and therapy were predictors of a better prognosis (P < 0.01). A comparison of the two 5-year groups revealed a statistically significant difference only in global etiology (P < 0.05) and alpha-fetoprotein (AFP) levels (P < 0.01). CONCLUSION: In this study analyzing patients with a new diagnosis of HCC between 2010-2019, hepatitis C virus infection was the most common etiology. Most patients presented with an advanced stage disease and a poor prognosis. When comparing the two 5-year groups, we observed a statistically significant difference only in global etiology (P < 0.05) and AFP levels (P < 0.01).

Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection.

OBJECTIVES: To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population. DESIGN: Prospective observational single-center cohort study. SETTING AND PARTICIPANTS: Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered. METHODS: A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively. RESULTS: Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001). CONCLUSIONS: Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Human herpes virus 8-negative effusion-based lymphoma in a patient with persistent serous effusions.

Diffuse large B-cell lymphoma is the most common histologic diagnosis among the aggressive lymphomas, accounting for 30% of all lymphomas. Human herpes virus 8-negative effusion-based lymphoma (HHV8-negative EBL) is a rare form of lymphoma, under recognized and still not well characterized in the literature. In contrast to primary effusion lymphoma (PEL), HHV8-negative EBL is characterized by malignant effusion in essentially serous body cavity with no detectable contiguous tumor masses and is no associated with human immunodeficiency virus and HHV8 infections. The presence of comorbid medical conditions can hide this type of lymphoma and made diagnosis more challenging. Here, we describe a rare case of an 82-year-old male suffering from peritoneal and pleural effusion and Hepatitis B virus related cirrhosis diagnosed with HHV8-negative EBL.

Multidrug-Resistant Bloodstream Infections in Internal Medicine: Results from a Single-Center Study.

OBJECTIVES: Infections due to multidrug-resistant organisms (MDROs) are expanding globally and are associated with higher mortality rates and hospital-related costs. The objectives of this study were to analyze the trends of MDRO bacteremia and antimicrobial resistance rates in Internal Medicine wards of our hospital and to identify the variables associated with these infections. METHODS: During a 6-year period (July 1, 2011-June 30, 2017), patients with positive blood culture isolates hospitalized in the Internal Medicine wards in the Santa Croce and Carle Hospital in Cuneo, Italy, were assessed. We performed an analysis taking into consideration the time trends and frequencies of MDRO infections, as well as a case-control study to identify clinical-demographic variables associated with MDRO bacteremias. RESULTS: During the study period a total of 596 blood cultures were performed in 577 patients. The most frequently identified organism was Escherichia coli (33.7%), followed by Staphylococcus aureus (15.6%) and S epidermidis (7.4%). The percentage of resistance to methicillin among S aureus isolates showed a decreasing trend, whereas rates of extended-spectrum ß-lactamase-producing Enterobacteriaceae and carbapenemase-producing Klebsiella pneumoniae increased during the study period. Multivariate analysis showed that the nosocomial origin of the infection, hospitalization during the previous 3 months, residence in long-term care facilities, presence of a device, antibiotic exposure during the previous 3 months, and cerebrovascular disease were independently associated with bacteremia by resistant microorganisms. CONCLUSIONS: Our analysis reveals a concerning microbiological situation in an Internal Medicine setting, in line with other national and regional data. The risk variables for infection by MDRO identified in our study correspond to those reported in the literature, although studies focused on Internal Medicine settings appear to be limited.

RDW-based clinical score to predict long-term survival in community-acquired pneumonia: a European derivation and validation study.

An excess long-term mortality has been observed in patients who were discharged after a community-acquired pneumonia (CAP), even after adjusting for age and comorbidities. We aimed to derive and validate a clinical score to predict long-term mortality in patients with CAP discharged from a general ward. In this retrospective observational study, we derived a clinical risk score from 315 CAP patients discharged from the Internal Medicine ward of Cuneo Hospital, Italy, in 2015-2016 (derivation cohort), which was validated in a cohort of 276 patients discharged from the pneumology service of the Barakaldo Hospital, Spain, from 2015 to 2017, and from two internal medicine wards at the Turin University and Cuneo Hospital, Italy, in 2017. The main outcome was the 18-month follow-up all-cause death. Cox multivariate analysis was used to identify the predictive variables and develop the clinical risk score in the derivation cohort, which we applied in the validation cohort. In the derivation cohort (median age: 79 years, 54% males, median CURB-65 = 2), 18-month mortality was 32%, and 18% in the validation cohort (median age 76 years, 55% males, median CURB-65 = 2). Cox multivariate analysis identified the red blood cell distribution width (RDW), temperature, altered mental status, and Charlson Comorbidity Index as independent predictors. The derived score showed good discrimination (c-index 0.76, 95% CI 0.70-0.81; and 0.83, 95% CI 0.78-0.87, in the derivation and validation cohort, respectively), and calibration. We derived and validated a simple clinical score including RDW, to predict long-term mortality in patients discharged for CAP from a general ward.

Fever During Anti-integrin Therapy: New Immunodeficiency.

BACKGROUND: The causes of inflammatory bowel disease (IBD) have not yet been clearly elucidated, but it is known that genetic susceptibility, altered gut microbiota and environmental factors are all involved, and that a combination of these factors causes an inappropriate immune response, resulting in impaired intestinal barrier function. With regard to the treatment of IBD, the use of conventional immunosuppressive drugs has been complemented by more specific therapeutic agents, including biological drugs. Systemic immune suppression is a risk factor for cytomegalovirus (CMV) infection, which is associated with considerable morbidity and mortality in immunocompromised hosts. CASE REPORT: A 33-year-old male patient was admitted to our medical unit complaining of a 10-day history of fever, fatigue and headache. He had been suffering from ulcerative colitis and primary sclerosing cholangitis for five years and was currently being treated with azathioprine and vedolizumab. In the past he had already taken infliximab, adalimumab and golimumab without any clinical response. After the exclusion of systemic infectious diseases, his serology was consistent with a primary CMV infection. This was successfully treated with intravenous ganciclovir therapy. CONCLUSION: Vedolizumab is an anti-integrin biological agent approved for IBD treatment. Its gut-selective mechanism of action would appear to increase its safety profile, however data on this are still limited. Moreover, it should always be remembered that IBD patients have an increased risk of CMV infection, both primary and reactivation, because of their concurrent immunosuppression. LEARNING POINTS: It is important to consider CMV infection (primary and reactivation) in patients affected by IBD.

The prophylaxis of venous thromboembolism in medical outpatients: results of a survey among italian general practitioners.

BACKGROUND: Although the majority of venous thromboembolic events occurs in primary care, most of the studies concerning its prophylaxis investigate hospitalized patients. Therefore, in primary care, many clinical decisions have to be taken in the absence of great clinical evidence derived from studies performed directly on outpatients. The objective of our study is to evaluate the clinical approach of Italian General Practitioners to the prophylaxis of venous thromboembolism in medical outpatients. METHODS: A web-based questionnaire was emailed to 766 Italian General Practitioners. In the questionnaire there were four exemplary clinical cases concerning hypothetical patients at venous thromboembolic risk. RESULTS: Overall 232 questionnaires were returned. Approximately 40% of the participants reported to assess thrombotic and hemorrhagic risk with a risk assessment model but nevertheless only a narrow minority had recourse to a suitable and validated score for this purpose. In the chronically bedridden patient about half of the participants administered a heparin or an antiplatelet drug for long time. In acute outpatients at high venous thromboembolic risk there was a considerable underuse of heparin prophylaxis and graduated compression stockings were often considered as a first prophylactic option. Prolonged heparin prophylaxis in the post-acute setting was also the practice for half of the participants. CONCLUSIONS: Italian General Practitioners approach these "grey" areas of uncertainty in a significantly heterogeneous way and sometimes in sharp contrast to the recent evidence.  The present findings stress the need for further targeted educational programs and new high quality studies to further deep this clinical context.

Vena Cava Filters and In-Hospital Case Fatality Among Patients With Pulmonary Embolism: Results From a Large Population-Based Study.

In patients with venous thromboembolism (VTE), vena cava filters (VCFs) are currently only recommended when anticoagulant treatment is contraindicated or if VTE has recurred despite adequate anticoagulation. However, evidence on the efficacy of filter in patients with VTE is not compelling. We evaluated potential efficacy of VCF in reducing in-hospital mortality in a large population of patients presenting with a first episode of pulmonary embolism (PE). Patients were collected using regional hospital-discharge databases covering a population of more than 13 million of inhabitants in Northern Italy. For each year of observation, we calculated the proportion of cases with VCF among all PE incident cases. The temporal trend of VCF application during the study period was also derived. The effect of VCF use on in-hospital case-fatality rate was evaluated with a multivariate regression model and with the use of propensity score matching. During the study period (2002-2012), 60 813 patients were hospitalized for a first episode of acute PE. In-hospital case-fatality rate for PE was 13.3%. Vena cava filters were used in 745 (1.22%) patients. The annual use of VCF remained stable from 2002 to 2008, while it progressively decreased afterward. After adjustment for available confounders, case-fatality rate remained significantly lower in patients who received VCF compared to the one registered in patients who did not (odds ratio [OR] 0.46; 95% confidence interval [CI]: 0.34-0.62). Propensity score matching gave similar results (OR: 0.42; 95% CI: 0.30-0.61). Vena cava filters were infrequently used in patients with acute PE. Insertion of VCF appeared to sensibly reduce all-cause in-hospital mortality in this subgroup of patients.

Red cell distribution width predicts mid-term prognosis in patients hospitalized with acute heart failure: the RDW in Acute Heart Failure (RE-AHF) study.

The aim of the study was to evaluate the prognostic role of red cell distribution width (RDW) in a broad population of patients hospitalized for acute heart failure (AHF). In a retrospective cohort observational study, 451 consecutive patients discharged for AHF were categorized in patients with low RDW (≤ 14.8%) and high RDW (> 14.8%). The rates of death from all causes or of hospital readmission for worsening heart failure and death were determined after a median follow-up of 18 months. The overall population has a median age of 80 years (IQR 72-85), 235 patients (52%) were males. Patients with a higher RDW have more comorbidities and a higher Charlson Index. At follow-up, 200 patients (44%) had died and 247 (54%) had died or were readmitted for HF: in the cohort with low RDW, 70 patients (36.4%) had died, whereas in the cohort with high RDW, 165 patients (63.7%) had died: the unadjusted risk ratio of patients with high RDW was 2.03 (log-rank test: p < 0.0001). In a multivariate Cox regression model, the hazard ratio for death from any cause in the 'high RDW' cohort is 1.73 (95% confidence interval 1.2-2.48; p = 0.003); the RDW adds prognostic information beyond that provided by conventional predictors, including age; etiology of HF; anemia; hyponatremia; estimated glomerular filtration rate; NT-proBNP levels; Charlson comorbidity score, atrial fibrillation, functional status, therapy with renin-angiotensin-aldosterone system inhibitors, beta-blockers. RDW is a powerful marker of worse long-term outcomes in patients with AHF, and its prognostic value is maintained beyond that provided by other well-established risk factors or biomarkers.

Characteristics and management of pyogenic liver abscess: A European experience.

Pyogenic liver abscess (PLA) are space-occupying lesions in the liver associated with high morbidity and mortality. The aim of this study is to review an Italian hospital experience in epidemiological, clinical patterns, and management of PLA.We performed a retrospective, descriptive case series at a single center assessing demographic characteristics, presentation patterns, etiological factors, microbiological etiology, and management for patients treated for PLA between 2000 and 2016.Around 109 patients were identified. The majority of patients presented with fever (73%); right upper abdominal pain in 63.3%, vomiting and nausea in 28.4%. The most common laboratory abnormality among included items was increased C-reactive protein and fibrinogen blood levels, respectively, in 98% and 93.9% of cases. Abdominal ultrasound was the diagnostic investigation in 42.4% of cases; CT scan and MR imaging were performed in 51.1% and 3.3% of cases respectively. We observed blood or pus culture study in 99 cases of which only 53.5% came with positive microbial reports. The most common organism identified was Escherichia coli (26.5%), followed by Streptococcus spp (13.2%). Early antibiotic treatment started on all patients and 66.7% of cases required different approaches, Ultrasound or CT-guided needle aspiration of PLA was performed in 13 patients (11%) and percutaneous abscess drainage was performed on 72 patients (67%).PLA is a diagnostically challenging problem due to nonspecific presenting characteristics. The microbiological yield identified was a typical European spectrum with a preponderance of Escherichia coli infections. Once recognized, percutaneous drainage and antibiotic treatment are the mainstay of management for PLA.