Diagnostic and infection control strategies for Clostridioides difficile infections in a setting of high antimicrobial resistance prevalence.

Clostridioides difficile (CD) is a major nosocomial pathogen and the leading cause of antibiotic-associated diarrhoea. In light of the strong association between antimicrobial use and CD infections (CDI), it may be hypothesised that areas at higher prevalence of antimicrobial resistance, like the region of Campania in southern Italy, could also have a higher rate of CDI. In this multicentre, region-based, prospective study, we analysed such issues, exploiting CDI incidence data collected from local hospitals. In 2016, the Italian National Centre for Disease Control supported a project involving three Italian regions: Friuli Venezia Giulia, Lazio and Campania. In Campania, a network of 49 hospitals willing to participate in the project was created. The project consisted of two phases: a survey on practice patterns concerning CDI and an epidemiological surveillance study. We identified a stringent need to improve awareness about CDI among the regional health-care community, as a widespread lack of surveillance programmes for CDI control was observed (existing in only 40% of participating facilities). Moreover, almost half of the participating hospitals (n=16, 43%) had no standardised procedures or protocols to control and prevent CDI. In the second phase of the study, we collected data of CDI cases during a six-month surveillance programme. In all, 87 CDI cases were observed, for a total of 903,334 patient bed-days and 122,988 admissions. According to the above data, CDI incidence was 0.96 cases/10000 patient bed-days, much lower than expected based on prior studies conducted elsewhere. The results of our study suggest CDI remains a rather neglected clinical issue in Campania. Despite a high burden of antimicrobial resistance and antimicrobial use in our geographic setting, we observed a very low incidence of CDI. Such a low incidence could be explained by underdiagnosis, but could also be related to actual diet, the lower patient age or the specific genetic background. However, further studies are warranted to either confirm or rebut the above hypotheses.

Multifocal gastrointestinal stromal tumor: A case report with CT, surgical, and histopathologic correlation.

Mutifocal gatrointestinal stromal tumors (GISTs) are rare conditions that are usually associated with other syndromes or reported in pediatric cases. The sporadic form represents only 11% of GISTs. The imaging features on a contrast-enhanced computed tomography examination, surgery and histopathology of a rare case of a sporadic multifocal small bowel GISTs in an emergency setting are described. This case highlights how GISTs appearances on an imaging computed tomography may vary. Radiologists can have difficulty in defining the point of origin of large lesions. In our case, laparotomy open surgery was mandatory to figuring out the correct diagnosis.

[A critical analysis of the degree of care humanization in the Hospitals of the Provincia Romana San Giovanni di Dio Fatebenefratelli (FBF)]. / Valutazione del grado di Umanizzazione: una indagine critica condotta negli Ospedali della Provincia Romana Fatebenefratelli.

In the Hospitals of the Ordine della Provincia Romana San Giovanni di Dio Fatebenefratelli (FBF) (consisting of four hospitals located in three Italian regions) Patient Centeredness has always been considered a central point. In 2015, the Central Hospitals' Health Direction decided to use a check-list for the evaluation of the degree of Patient Centered Care Facilities, drawn up by the National Agency for Regional Health Services (Age.Na.S) during the 2010 Research Project "Experimentation and transfer of organizational empowerment models for evaluating and improving the quality of health services." The aim of the work was to measure the "Patient Centered Care degree" of the FBF structures by means of the Age.Na.S. check-list in order to identify effective and sustainable improvement measures, and to evaluate the applicability and the critical points of the questionnaire. The check-list was divided into four areas: care systems oriented at citizen's respect and centrality; physical accessibility, liveability and comfort of the places of care; access to information, simplification and transparency; care of the relationship with the patient and the citizen. The four areas were divided into 12 sub-areas, 29 criteria and 144 items with sub-items (248 questions), defined as quantitative or qualitative variables allowing for an evaluation of observed reality. Some items from different areas have been grouped into Focus and Operational Units (UU.OO./Facilities). The results of the Age.Na.S. study were used to compare the results obtained in the Roman Province FBF structures with the national ones. The Medical Directors and the responsible of FBF Quality Systems completed the cheek-list. A working group within the Central Hospitals' Health Direction analysed the data and processed the results, using the same scores provided by Age.Na.S.. The analysis of the results was divided into three levels. Focus and UU.OO./Facilities scores were calculated based on Age.Na.S. INDICATIONS: The distinction into three levels of analysis allowed for a thorough study of results, from the evaluation of the areas to the items. By comparing the results, the overall final value (range 6-6.5) and single area scores are close to the national average for beds number category in all the FBF hospitals. The most critical criteria, recurring in different levels are: 1.1.2 (Activities/projects to promote sociability and continuity with the outside world); 3.2.3 (Content and accessibility of the website); 4.1.2 (Training and support to the staff for the care of the relationship with the patient) and 4.2.3 (Training of the front-office staff), which had a < 4 score in at least three hospitals and generally achieve a value below the national average (level II and III of analysis). The analysis was extremely useful for detecting positive and negative aspects in the structures under examination. It also permitted to plan improvement measures based on set priorities and objective criteria, aimed at enforcing organizational empowerment models for improving the quality of patient-focused health services. However, during the compilation we found difficulties related to the applicability of the questionnaire. Indeed some questions, while having the same impact on the overall score, are less relevant, considering the patient centrality as main aim. It would be desirable that Age.Na.S. considers in a future survey the observations from hospitals joining previous investigations, in order to facilitate the use of the questionnaire and to improve this tool, which proved to be highly effective.

Targeting angiogenesis and tumor microenvironment in metastatic colorectal cancer: role of aflibercept.

In the last decades, we have progressively observed an improvement in therapeutic options for metastatic colorectal cancer (mCRC) treatment with a progressive prolongation of survival. mCRC prognosis still remains poor with low percentage of 5-year survival. Targeted agents have improved results obtained with standard chemotherapy. Angiogenesis plays a crucial role in colorectal cancer growth, proliferation, and metastasization and it has been investigated as a potential target for mCRC treatment. Accordingly, novel antiangiogenic targeted agents bevacizumab, regorafenib, and aflibercept have been approved for mCRC treatment as the result of several phase III randomized trials. The development of a tumor permissive microenvironment via the aberrant expression by tumor cells of paracrine factors alters the tumor-stroma interactions inducing an expansion of proangiogenic signals. Recently, the VELOUR study showed that addition of aflibercept to FOLFIRI regimen as a second-line therapy for mCRC improved significantly OS, PFS, and RR. This molecule represents a valid second-line therapeutic option and its peculiar ability to interfere with placental growth factor (PlGF)/vascular endothelial growth factor receptor 1 (VEGFR1) axis makes it effective in targeting angiogenesis, inflammatory cells and in overcoming resistances to anti-angiogenic first-line treatment. Here, we discuss about Aflibercept peculiar ability to interfere with tumor microenvironment and angiogenic pathway.