Diaphragmatic morphological post-mortem findings in critically ill COVID-19 patients: an observational study

Our study investigates the post-mortem findings of the diaphragm's muscular structural changes in mechanically ventilated COVID-19 patients. Diaphragm samples of the right side from 42 COVID-19 critically ill patients were analyzed and correlated with the type and length of mechanical ventilation (MV), ventilatory parameters, prone positioning, and use of sedative drugs. The mean number of fibers was 550±626. The cross-sectional area was 4120±3280 μm2, while the muscular fraction was 0.607±0.126. The overall population was clustered into two distinct populations (clusters 1 and 2). Cluster 1 showed a lower percentage of slow myosin fiber and higher fast fiber content than cluster 2, 68% versus 82%, p<0.00001, and 29.8% versus 18.8%, p=0.00045 respectively. The median duration of MV was 180 (41-346) hours. In cluster 1, a relationship between assisted ventilation and fast myosin fiber percentage (R2=-0.355, p=0.014) was found. In cluster 2, fast fiber content increased with increasing the length of the controlled MV (R2=0.446, p=0.006). A high grade of fibrosis was reported. Cluster 1 was characterized by fibers' atrophy and cluster 2 by hypertrophy, supposing different effects of ventilation on the diaphragm but without excluding a possible direct viral effect on diaphragmatic fibers.

Risk of developing psoriatic arthritis in psoriasis cohorts with arthralgia: exploring the subclinical psoriatic arthritis stage

OBJECTIVE

Subjects with subclinical psoriatic arthritis (PsA), defined as the presence of arthralgia in psoriasis (PsO), are at higher risk of PsA but scant real-world data exist. Our aims were to (1) estimate the probability of PsA development in subclinical PsA, (2) characterise subclinical PsA symptoms and (3) determine the clinical patterns at PsA diagnosis.

METHODS

Patients with PsO, mainly subclinical PsA, were evaluated longitudinally in two European cohorts. The key outcome was new-onset PsA. Musculoskeletal symptoms including inflammatory and non-inflammatory symptoms before PsA diagnosis were collected. Occurrence of PsA was analysed with survival analysis and cumulative incidence functions (CIFs).

RESULTS

384 patients with PsO were included with a mean follow-up of 33.0 (±20.9) months. 311 of 384 (80.9%) had subclinical PsA with a PsA incidence rate of 7.7 per 100 patient-years. Subclinical PsA displayed a higher risk of PsA development compared with PsO (HR=11.7 (95% CI 1.57 to 86.7), p=0.016). The probability of new-onset PsA estimated by the CIF was 9.4% (95% CI 4.7% to 10.6%) at month 12 and 22.7% (95% CI 17.2% to 28.6%) at month 36. 58.9% of cases reported inflammatory symptoms in the months immediately prior to PsA diagnosis but prior non-inflammatory symptoms were evident in 83.9% prior to PsA diagnosis. Peripheral joint swelling was the predominant PsA presentation pattern (82.1%).

CONCLUSIONS

The probability of PsA development among subclinical PsA was relatively high, emphasising the importance of emergent musculoskeletal symptoms when aiming for PsA prevention. Joint swelling was the dominant feature in new-onset PsA, likely reflecting clinical confidence in recognising joint swelling.

High flow nasal oxygen vs. conventional oxygen therapy over respiratory oxygenation index after esophagectomy: an observational study

Background

Postoperative pulmonary complications after esophagectomy still represent a matter of concern. High flow nasal cannula (HFNC) early after major abdominal and thoracic surgery has demonstrated some advantages over conventional oxygen therapy. Data about respiratory effect of HFNC after esophagectomy is scarce. The primary aim of this study is to investigate if the early use of HFNC after esophagectomy could enhance patients' postoperative respiratory oxygenation (ROX) index and, ultimately, reduce postoperative pneumonia.

Methods

In this single center retrospective study all patients undergoing to esophagectomy for cancer from May 2020 to November 2022 were evaluated. Historical cohort (HC) received postoperative oxygen supplementation with Venturi mask or nasal goggles, and a cohort was put under HFNC (HFNC cohort). ROX index, blood gas analysis, radiological atelectasis score (RAS), post-operative complications' data and information on hospital stay have been collected and analyzed.

Results

Seventy-one patients were included for the final statistical analysis, 31 in the HFNC and 40 in the HC cohort. Mean age was 64±10 years and body mass index (BMI) was 26 [24-29] kg/m2. ROX index was higher in the HFNC patients than in the HC, 20.8 [16.7-25.9] vs. 14.9 [10.8-18.2] (P<0.0001). In the HFNC cohort patients, pH was higher, 7.42 [7.40-7.44] vs. 7.39 [7.37-7.43] than HC, while PaCO2 was lower in HFNC cohort compared with HC, 39 [36-41] vs. 42 [39-45] mmHg, respectively (P=0.01). RAS was similar between the two cohorts of patients, 1.5±0.98 vs. 1.4±1.04 in the HFNC and the HC cohort, respectively (P=0.611). Lower acute respiratory failure (ARF) rate was recorded among HFNC than HC cohort, 0% vs. 13% respectively, P=0.06. No difference in pneumonia frequency between two cohorts was shown.

Conclusions

HFNC improved the ROX index after esophagectomy through significant respiratory rate reduction. This tool should be considered for early respiratory support after extubation in this category of patients, not only as a rescue therapy for ARF, but also to optimize early postoperative respiratory function. Whether this will improve patients' outcomes requires further large randomized controlled trials.

Assessing the impact of structured reporting on learning how to report lung cancer staging CT: A triple cohort study on inexperienced readers

PURPOSE

To assess the clinical utility of chest computed tomography (CT) reports for non-small-cell lung cancer (NSCLC) staging generated by inexperienced readers using structured reporting (SR) templates from the Royal College of Radiologists (RCR-SR) and the Italian Society of Medical and Interventional Radiology (SIRM-SR), compared to traditional non-systematic reports (NSR).

METHODS

In a cohort of 30 NSCLC patients, six third-year radiology residents reported CT examinations in two 2-month-apart separate sessions using NSR in the first and NSR, RCR-SR, or SIRM-SR in the second. Couples of expert radiologists and thoracic oncologists in consensus evaluated completeness, accuracy, and clarity. All the quality indicators were expressed on a 100-point scale. The Wilcoxon signed ranks, and Wilcoxon-Mann Whitney tests were used for statistical analyses.

RESULTS

Results showed significantly higher completeness for RCR-SR (90 %) and SIRM-SR (100 %) compared to NSR (70 %) in the second session (all p < 0.001). SIRM-SR demonstrated superior accuracy (70 % vs. 55 %, p < 0.001) over NSR, while RCR-SR and NSR accuracy did not significantly differ (60 % vs. 62.5 %, p = 0.06). In the second session, RCR-SR and SIRM-SR surpassed NSR in completeness, accuracy, and clarity (all p < 0.001, except p = 0.04 for accuracy between RCR-SR and NSR). SIRM-SR outperformed RCR-SR in completeness (100 % vs. 90 %, p < 0.001) and accuracy (70 % vs. 62.5 %, p = 0.002), with equivalent clarity (90 % for both, p = 0.27).

CONCLUSIONS

Inexperienced readers using RCR-SR and SIRM-SR demonstrated high-quality reporting, indicating their potential in radiology residency programs to enhance reporting skills for NSCLC staging and effective interaction with all the physicians involved in managing NSCLC patients.

Are adverse events related to the completeness of clinical records? Results from a retrospective records review using the Global Trigger Tool

Clinical record (CR) is a tool for recording details about the patient and the most commonly used source of information for detecting adverse events (AEs). Its completeness is an indicator of the quality of care provided and may provide clues for improving professional practice. The primary aim of this study was to estimate the prevalence of AEs. The secondary aims were to determine the completeness of CRs and to examine the relationship between the two variables. We retrospectively reviewed randomly selected CRs of patients discharged from the Academic Hospital of Udine (Italy) in the departments of general surgery, internal medicine, and obstetrics between July and September 2020. Evaluation was performed using the Global Trigger Tool and a checklist to evaluate the completeness of CRs. The relationship between the occurrence of AEs and the completeness of CRs was analyzed using nonparametric tests. A binomial logistic regression analysis was also performed. We reviewed 291 CRs and identified 368 triggers and 56 AEs. Among them, 16.2% of hospitalizations were affected by at least one AE, with a higher percentage in general surgery. The most common AEs were surgical injuries (42.6%; 24) and care related (26.8%; 15). A significant positive correlation was found between the length of hospital stay and the number of AEs. The average completeness of CRs was 72.9% and was lower in general surgery. The decrease in CR completeness correlated with the increase in the total number of AEs (R = -0.14; P = .017), although this was not confirmed by regression analysis by individual departments. Our results seem to suggest that completeness of CRs may benefit patient safety, so ongoing education and involvement of health professionals are needed to maintain professional adherence to CRs.

[How to optimize Audit&Feedback: experience from the EASY-NET programme]

This is the second of a series of papers dedicated to the EASY-NET research programme (NET-2016-02364191). The rationale, structure and methodologies are described in the previous contribution. Scientific literature demonstrated that Audit & Feedback (A&F) is an effective strategy for continuous quality improvement and its effectiveness varies considerably according to factors that are currently little known. Some recent publication pointed out, with the contribution of an international group of experts, 15 suggestions to optimize A&F and developed a tool to evaluate their application. This tool, called REFLECT-52, includes 52 items related to the 15 suggestions and organized into four categories relating to the "Nature of the desired action", to the "Nature of the data available for feedback", to the "Feedback Display" and to the "Intervention delivery". Then, the aim of this work was to evaluate the level of adherence of A&F interventions tested in EASY-NET to suggestions from the literature by using a slightly adapted version of the REFLECT-52 tool, in its original language. In EASY-NET, 14 A&F interventions with different characteristics and in different clinical and organizational contexts were tested in seven Italian regions, each of these was evaluated by the respective research groups. Overall, the level of adherence was high in three of the four categories analysed, with some difficulties reported regarding the nature of the data available for feedback. In fact, contrary to what the literature suggests, it was not possible to send repeated feedback for some interventions and, in some cases, the data available for feedback presented a delay longer than one year. In summary, this analysis has confirmed a high level of compliance of the interventions tested with the suggestions from the literature, but it has also allowed researchers to identify critical aspects that need to be addressed for the future development of these strategies.

Diarrhoea and constipation during artificial nutrition in intensive care unit: A prospective observational study

PURPOSE

To describe the occurrence of gastrointestinal (GI) complications, specifically diarrhoea and constipation, in artificially (enterally or parenterally) fed critically ill patients within their first seven-day stay in Intensive Care Unit (ICU).

METHODS

Observational prospective study conducted from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021, in an ICU of a 1000-bed third-level hospital. General characteristics, nutritional variables, and medications administered were recorded and analysed. This study was registered on ClinicalTrials.gov (Identifier: NCT05473546).

RESULTS

In total, 100 critically ill patients were included. Diarrhoea was present in 44 patients (44.0%), while constipation occurred in 22 (22.0%) patients. Patients with diarrhoea were generally those admitted for respiratory failure, whereas patients without diarrhoea were mostly affected by neurological disorders (22.7% vs 25%, respectively; p = 0.002). Likewise, patients with constipation were primarily those admitted for trauma (36.4%). Trauma patients were almost 24 times more likely to be constipated than patients with respiratory failure (OR 23.99, CI 1.38-418.0) and patients receiving diuretics were over 16 times more likely to have diarrhoea than patients not receiving diuretics (OR 16.25, IC 1.89-139.86).

CONCLUSION

GI complications of enteral nutrition represent still a very common issue in ICU. The main predictor of constipation was an admission for trauma whereas the main predictor of diarrhoea was the use of diuretics. Clinicians should consider and integrate these findings into more personalized nutritional and management protocols to avoid gastrointestinal complications.

Can a chest HRCT-based crash course on COVID-19 cases make inexperienced thoracic radiologists readily available to face the next pandemic?

OBJECTIVE

To test the inter-reader agreement in assessing lung disease extent, HRCT signs, and Radiological Society of North America (RSNA) categorization between a chest-devoted radiologist (CR) and two HRCT-naïve radiology residents (RR1 and RR2) after the latter attended a COVID-19-based chest high-resolution computed tomography (HRCT) "crash course".

METHODS

The course was built by retrospective inclusion of 150 patients who underwent HRCT for COVID-19 pneumonia between November 2020 and January 2021. During a first 10-days-long "training phase", RR1 and RR2 read a pool of 100/150 HRCTs, receiving day-by-day access to CR reports as feedback. In the subsequent 2-days-long "test phase", they were asked to report 50/150 HRCTs with no feedback. Test phase reports of RR1/RR2 were then compared with CR using unweighted or linearly-weighted Cohen's kappa (k) statistic and intraclass correlation coefficient (ICC).

RESULTS

We observed almost perfect agreement in assessing disease extent between RR1-CR (k = 0.83, p < 0.001) and RR2-CR (k = 0.88, p < 0.001). The agreement between RR1-CR and RR2-CR on consolidation, crazy paving pattern, organizing pneumonia (OP) pattern, and pulmonary artery (PA) diameter was substantial (k = 0.65 and k = 0.68), moderate (k = 0.42 and k = 0.51), slight (k = 0.10 and k = 0.20), and good-to-excellent (ICC = 0.87 and ICC = 0.91), respectively. The agreement in providing RSNA categorization was moderate for R1 versus CR (k = 0.56) and substantial for R2 versus CR (k = 0.67).

CONCLUSION

HRCT-naïve readers showed an acceptable overall agreement with CR, supporting the hypothesis that a crash course can be a tool to readily make non-subspecialty radiologists available to cooperate in reading high burden of HRCT examinations during a pandemic/epidemic.

The impact of COVID-19 on myocardial infarctions, strokes and out-of-hospital cardiopulmonary arrests: an observational retrospective study on time-sensitive disorders in the Friuli Venezia Giulia region (Italy)

The COVID-19 global pandemic has changed considerably the way time-sensitive disorders are treated. Home isolation, people's fear of contracting the virus and hospital reorganisation have led to a significant decrease in contacts between citizens and the healthcare system, with an expected decrease in calls to the Emergency Medical Services (EMS) of the Friuli-Venezia Giulia (FVG) region. However, mortality in clinical emergencies like acute ST-elevation myocardial infarction (STEMI), stroke and out-of-hospital cardiopulmonary arrest (OHCA) remained high. An observational retrospective cross-sectional study was carried out in FVG, taking into account the period between March 1, 2020, and May 31, 2020, the first wave of the COVID-19 pandemic, and comparing it with the same period in 2019. The flow of calls to the EMS was analysed and COVID-19 impact on time-sensitive disorders (STEMIs, ischemic strokes and OHCPAs) was measured in terms of hospitalisation, treatment and mortality. Despite a -8.01% decrease (p value ˂0.001) in emergency response, a 10.89% increase in calls to the EMS was observed. A lower number of advanced cardiopulmonary resuscitations (CPR) (75.8 vs 45.2%, p=0.000021 in April) and ROSC (39.1 vs 11.6%, p=0.0001 in April) was remarked, and survival rate dropped from 8.5 to 5%. There were less strokes (-27.5%, p value=0.002) despite a more severe onset of symptoms at hospitalisation with NHISS˃10 in 38.47% of cases. Acute myocardial infarctions decreased as well (-20%, p value=0.05), but statistical significances were not determined in the variables considered and in mortality. Despite a lower number of emergency responses, the number of calls to the EMS was considerably higher. The number of cardiac arrests treated with advanced CPR (ALS) was lower, but mortality was higher. The number of strokes decreased as well, but at the time of hospitalisation the clinical picture of the patient was more severe, thus affecting the outcome when the patient was discharged. Finally, STEMI patients decreased; however, no critical issues were observed in the variables taken into account, neither in terms of response times nor in terms of treatment times.

Prostate Cancer Treatment-Related Toxicity: Comparison between 3D-Conformal Radiation Therapy (3D-CRT) and Volumetric Modulated Arc Therapy (VMAT) Techniques

Objective: This paper illustrates the results of a mono-institutional registry trial, aimed to test whether gastrointestinal (GI) and genitourinary (GU) toxicity rates were lower in localized prostate cancer patients treated with image-guided volumetric modulated arc therapy (IG-VMAT) compared to those treated with IG-3D conformal radiation therapy (IG-3DCRT). Materials and Methods: Histologically proven prostate cancer patients with organ-confined disease, treated between October 2008 and September 2014 with moderately hypofractionated radiotherapy, were reviewed. Fiducial markers were placed in the prostate gland by transrectal ultrasound guide. The prescribed total dose was 70 Gy in 28 fractions. The mean and median dose volume constraints for bladder and rectum as well as total volume of treatment were analyzed as potentially prognostic factors influencing toxicity. The Kaplan−Meier method was applied to calculate survival. Results: Overall, 83 consecutive patients were included. Forty-two (50.6%) patients were treated with 3D-CRT and 41 (49.4%) with the VMAT technique. The median follow-up for toxicity was 77.26 months for the whole cohort. The VMAT allowed for a dose reduction to the rectum and bladder for the large majority of the considered parameters; nonetheless, the only parameter correlated with a clinical outcome was a rectal dose limit V66 > 8.5% for late GI toxicity G ≥ 2 (p = 0.045). Rates of G ≥ 2 toxicities were low among the whole cohort of these patients treated with IGRT. The analysis for rectum dose volume histograms (DVHs) showed that a severe (grade ≥ 2) late GI toxicity was related with the rectal dose limit V66 > 8.5% (p = 0.045). Conclusions: This study shows that moderate hypofractionation is feasible and safe in patients with intermediate and high-risk prostate cancer. Daily IGRT may decrease acute and late toxicity to organs at risk and improve clinical benefit and disease control rate, cutting down the risk of PTV geographical missing. The adoption of VMAT allows for promising results in terms of OAR sparing and a reduction in toxicity that, also given the small sample, did not reach statistical significance.

Symptoms of Anxiety and Depression within the UNiversity community: the cross-sectional UN-SAD study

The increasing complexity of academia, with its demanding working conditions and uncertain career opportunities, may affect the mental health of academics and potentially lead to mental health problems. The aim of this study is to determine the prevalence of depressive and anxiety symptoms in the academic population of the University of Udine and to compare symptoms in senior and younger academics and administrative staff.

A cross-sectional survey was conducted between June and December 2020, involving academic and administrative staff in all departments. The prevalence of depressive and anxiety symptoms was assessed using the PHQ-9 and GAD-7 tools. The relationship between mental health outcomes and job role was analyzed using nonparametric tests and ordinal logistic regression.

A total of 366 individuals participated: 109 junior academics, 146 senior and 111 administrative staff. The proportion of women was 55.7% and the mean age was 47.9 years. The prevalence of depressive and anxiety symptoms in the studied population was 25.7% (95% IC 21.5–30.4) and 22.7% (95% IC 18.7–27.2) respectively, with junior academics having the higher prevalence of both symptoms. Univariate models suggest a higher risk for anxiety symptoms OR 1.89 (1.13–3.17) for women.

The prevalence of depressive symptoms is higher in our academic community than in the general population, especially among junior academics. These findings may reflect the impact of uncertain career and challenging environment on the mental health of young academics. Universities should provide more support to young academics so that they can contribute effectively and healthily to the advancement of research.

AB1347 ASYMPTOMATIC SACROILIITIS DETECTED BY MAGNETIC RESONANCE ENTEROGRAPHY IN PATIENTS AFFECTED BY CROHN’S DISEASE: PREVALENCE AND ASSOCIATION WITH CLINICAL DATA IN A MULTICENTER STUDY OF ADULT AND PEDIATRIC POPULATION

Background

Magnetic resonance enterography (MRE) is usually performed in patients with Crohn’s disease (CD) for evaluating small bowel involvement. Inflammatory bowel disease (IBD) mainly affect the gastrointestinal tract, although patients may present extraintestinal manifestations (1). Musculoskeletal symptoms are the most frequent extraintestinal manifestation in IBD, especially in CD. Furthermore, sacroiliitis at imaging occurs in about 6-46% of CD patients and may correlate with axial spondyloarthritis (2,3).

Objectives

The primary aim of our study was to assess the prevalence of sacroiliitis in adult and pediatric patients affected by CD who performed MRE. We also evaluated the inter-rater agreement for MRE sacroiliitis and the association between sacroiliitis and patients’ clinical data.

Methods

We included consecutive patients with CD diagnosis (4), who underwent an MRE in the period between December 2012 and May 2020. We excluded patients with a known diagnosis of SpA; patients with confirmed or suspected inflammatory back pain; and patients treated at the time of MRE with systemic Disease-Modifying Antirheumatic Drugs (DMARDs), which influence both bowel and joint disease (i.e., conventional DMARDs, and biologic DMARDs).

Two radiologists assessed the prevalence of sacroiliitis at MRE. We evaluated the inter-rater agreement for sacroiliitis and assessed the correlation between sacroiliitis and demographic, clinical, and endoscopic data.

Results

We retrospectively identified 100 adult and 30 pediatric patients. The prevalence of sacroiliitis at MRE was 20% in adults and 6.7% in pediatric patients. The inter-rater agreement for sacroiliitis was substantial (k=0.62, p<0.001) in the adults, and moderate (k=0.46, p=0.011) in the pediatric cohort. Age ≥50 years and the time between CD diagnosis and MRE (≥86.5 months) were significantly associated with sacroiliitis in adult patients (p=0.049 and p=0.038, respectively).

Conclusion

Asymptomatic sacroiliitis at MRE is a frequent and reliable abnormality in adult patients with CD, associated with age of the patients ≥ 50 years and CD duration. Detecting sacroiliitis at MRE in patients affected by CD may help the appropriate and early referral to the rheumatologist.

References

[1]Vavricka SR, Schoepfer A, Scharl M, Lakatos PL, Navarini A, Rogler G. Extraintestinal Manifestations of Inflammatory Bowel Disease. Inflammatory Bowel Diseases. 2015 Aug 1;21(8):1982–92.

[2]Salvarani C, Fries W. Clinical features and epidemiology of spondyloarthritides associated with inflammatory bowel disease. World J Gastroenterol. 2009 May 28;15(20):2449–55.

[3]Fragoulis GE, Liava C, Daoussis D, Akriviadis E, Garyfallos A, Dimitroulas T. Inflammatory bowel diseases and spondyloarthropathies: From pathogenesis to treatment. World J Gastroenterol. 2019 May 14;25(18):2162–76.

[4]Maaser C, Sturm A, Vavricka SR, Kucharzik T, Fiorino G, Annese V, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. Journal of Crohn’s and Colitis. 2019 Feb 1;13(2):144–64.

Disclosure of Interests

Ivan Giovannini Speakers bureau: not relevant for this study, Lorenzo Cereser: None declared, Ilaria Tinazzi: None declared, Carmelo Cicciò: None declared, Floria Maria Murru: None declared, Matteo Bramuzzo Speakers bureau: not relevant for this study, Marco Marino Speakers bureau: not relevant for this study, Annarita Tullio: None declared, Salvatore De Vita Speakers bureau: not relevant for this study, Alen Zabotti Speakers bureau: not relevant for this study

Musculoskeletal ultrasound for treating rheumatoid arthritis to target-a systematic literature review

OBJECTIVE

We aimed to systematically review the literature to retrieve evidence on the diagnostic and prognostic value of musculoskeletal ultrasound for a treat to target (T2T) approach in RA.

METHODS

Eight research questions were developed addressing the role of ultrasound (including different ultrasound scores and elementary lesions) for diagnosis, monitoring and prognosis of RA. PubMed and EMBASE were searched (2005-2020). Articles on RA and reporting data on musculoskeletal ultrasound were included and extracted according to the underlying questions, and risk of bias assessed according to the study design.

RESULTS

Out of 4632 records, 60 articles were included. Due to clinical heterogeneity, meta-analysis was not possible. Ultrasound better predicted disease relapses with respect to clinical examination in patients in remission, while both methods performed similarly in predicting response to therapy, achievement of remission and radiographic progression. Ultrasound was superior to clinical examination in diagnosing joint involvement using another imaging modality, such as magnetic resonance imaging, as reference. Limited ultrasound scores performed like more extensive evaluations for the detection of joint inflammation and for outcome prediction. Higher ultrasound scores of synovitis were linked to poor outcomes at all disease stages, but a specific cut-off distinguishing between low- and high-risk groups did not emerge.

CONCLUSIONS

These data confirm the pivotal role of ultrasound when evaluating synovial inflammation and when identifying RA patients at higher risk of relapse. Further research is needed to better define the role of ultrasound in a T2T management strategy in moderately-to-highly active RA.

Asymptomatic sacroiliitis detected by magnetic resonance enterography in patients with Crohn's disease: prevalence, association with clinical data, and reliability among radiologists in a multicenter study of adult and pediatric population

OBJECTIVES

Patients with Crohn's disease (CD) usually undergo magnetic resonance enterography (MRE) for evaluating small bowel involvement. Musculoskeletal symptoms are the most frequent extraintestinal manifestation in inflammatory bowel diseases, especially in CD, with sacroiliitis at imaging occurring in about 6-46% of patients and possibly correlating with axial spondyloarthritis. The primary study aim was to assess the prevalence of sacroiliitis in adult and pediatric patients with CD performing an MRE. We also evaluated the inter-rater agreement for MRE sacroiliitis and the association between sacroiliitis and patients' clinical data.

METHOD

We retrospectively identified 100 adult and 30 pediatric patients diagnosed with CD who performed an MRE between December 2012 and May 2020 in three inflammatory bowel disease centers. Two radiologists assessed the prevalence of sacroiliitis at MRE. We evaluated the inter-rater agreement for sacroiliitis with Cohen's kappa and intraclass correlation coefficient statistics and assessed the correlation between sacroiliitis and demographic, clinical, and endoscopic data (Chi-square and Fisher's tests).

RESULTS

The prevalence of sacroiliitis at MRE was 20% in adults and 6.7% in pediatric patients. The inter-rater agreement for sacroiliitis was substantial (k = 0.62, p < 0.001) in the adults and moderate (k = 0.46, p = 0.011) in the pediatric cohort. Age ≥ 50 years and the time between CD diagnosis and MRE (≥ 86.5 months) were significantly associated with sacroiliitis in adult patients (p = 0.049 and p = 0.038, respectively).

CONCLUSIONS

Sacroiliitis is a frequent and reliable abnormality at MRE in adult patients with CD, associated with the age of the patients ≥ 50 years and CD duration.

Symptoms of Anxiety and Depression among Italian UNiversity academics: the 2020 UN-SAD study

Background

The potential impact of demanding working conditions and career opportunities on the mental health of academic professionals has recently arisen some concerns, possibly resulting in psychological distress. This study aims to assess the prevalence of depression and anxiety within Udine University, comparing academic and administrative staff.

Methods

A cross-sectional survey involving regular (RP) and short-term academic professionals (STP), and administrative staff (AS) was carried out between June and December 2020 throughout the administration of an online anonymous survey. Prevalence of depressive and anxiety symptoms was assessed using PHQ-9 and GAD-7 tools. Demographic information about age, gender, marital status and seniority was collected. Relationship between mental health outcomes and professional role was analysed using nonparametric tests and ordinal logistic regression.

Results

All 5 university departments participated for a total of 366 people, being 109 of them STP, 146 RP and 111 AS. 55,7% of them were female, with a mean age of 47,9 years. Compared to administrative and regular staff, short-term professionals have a higher prevalence (95%CI) of both depressive (39,4% (30,8 - 48,8) vs 14,4% (9,6 - 21,0) vs 27,0% (19,6 - 35,9); p &lt; 0,001) and anxiety symptoms (STP: 33,0% (24,9 - 42,3); RP: 15,1% (10,2 - 21,8); AS: 22,5% (15,8 - 31,1); p &lt; 0.005). Multivariate models suggest an increased risk of depression OR 1.61 (0.98-2.64) and anxiety OR 2.08 (1.27-3.41) for female.

Conclusions

The higher prevalence of depressive and anxiety symptoms among STP could represent the effect on younger academics' mental health of the career uncertainty and challenging arena. The difference between AS and STP in psychological distress could be explained by the different job security status. More support should be given by universities to young academics for their both effective and healthy contribution to the progress of research.

Key messages

The high level of external pressure, referred as “publish or perish”, can play an important role in determining academics’ mental health. Investment to provide coping tools for young academics could be strategical for researchers’ empowerment.

Relationship between clinical record completeness and occurrence of adverse events within hospitals

Introduction

Clinical record (CR) is an appropriate source for adverse events (AEs) detection and Italian law requires its compilation. Its completeness is used as an indicator of the quality of care provided and offers guidance on system changes to improve professional practice. This study aimed at assessing the completeness of CRs, describing AEs' rate and triggers, and investigating the relationship between CR completeness and the occurrence of AEs.

Methods

A retrospective review of CRs was conducted, randomly selecting patients discharged from Internal Medicine (IM), General Surgery (GS) and Obstetrics (O) between June and September 2020 at the Academic Hospital of Udine (Italy). The completeness of CRs was assessed using a 65-items checklist developed by the hospital Quality Unit. Triggers and rate of AEs were detected by using Global Trigger Tool. Relationship between AEs and completeness of CR was analyzed using nonparametric tests.

Results

Among 93 reviewed CRs, 91.4% were from the GS, 5.4% from IM and 3.2% from O. Patient mean age was 64.6±18, women were 51.6%. The average completeness of CRs was 50.4% [30.4%-83.5%]. Identified triggers and AEs were 125 and 29 respectively, with at least one AE every 23.7% admissions, 31.2 AEs per 100 admissions and 40 AEs per 1000 patient-days. The most frequent AEs were surgical damage (51.7%; 15) and hospital-acquired infection (24.1%; 7). Hospitalization length for patients with at least one AE was 12.6 days, whereas it was 6.3 days without AEs. A significant positive correlation (R = 0.36; p &lt; 0.001) was found between length of hospitalization and number of AEs. The increase in CR completeness is associated with the decrease of the total number of AEs (R=-0.18; p = 0.083).

Conclusions

These findings suggest a direct association between the number of AEs and the length of hospital stay. The correlation between CR completeness and AEs suggest that patient safety could benefit from the improvement of clinical record compilation.

Key messages

More studies are needed to understand if the occurrence of AEs to patients may cause a prolonged length of hospitalization. A better compilation of CRs should allow to reach a more effective communication between healthcare workers, creating a work environment less prone to errors and AEs.

Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up

OBJECTIVES

We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection.

METHODS

Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57 ± 12 vs 62 ± 11 years, P = 0.07), with a mean AR of 47 vs 43 mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9 ± 8 years (6 months to 40 years).

RESULTS

Actuarial survival of discharged patients at 5, 10 and 15 years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P = 0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15 years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P = 0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P = 0.026] and age (HR 0.9, P = 0.016) were independently associated with proximal reoperation.

CONCLUSIONS

AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45 mm.

A Retrospective Cohort Study of Histology-Proven Neuroendocrine Neoplasms in the Italian Area of Udine

AIMS

The aim of this study was to investigate the epidemiology of histology-proven Neuroendocrine neoplasms (NENs) in an Italian area.

BACKGROUND

NENs are a rare and poorly known disease and the global incidence and prevalence appear to be increasing over the past decades.

OBJECTIVE

The objectives of this study were to estimate the incidence and trends of NENs in a 250,000-inhabitant area in the North-East of Italy in the 1998-2018 period and to compare them with international data.

METHODS

This retrospective cohort study was based on the analysis of anonymous health administrative databases, linked with each other at individual patient level through an anonymous stochastic key. NENs were identified from the anatomical pathology database. The standardized incidence rate (2010ESP and US2000) ± 95% CI per 100,000 were calculated, both annually and globally, for the whole period. Incidence was also calculated for specific anatomical sites and by gender. Trends for the considered periods and sites were summarized through the annual percent change (APC) and average increase (cases per 100,000 per year).

RESULTS

In the 1998-2018 period, the standardized incidence rate of NENs in the area of Udine was 2.49 (APC 3.33). A total of 162 cases were observed (51.2% males). Differences in incidence and trend were observed between sexes. The obtained results were consistent with those reported in other countries, confirming a significant and steady increase in NENs incidence in the last twenty years.

CONCLUSION

This study provides new epidemiological data on NENs in Italy. The observed sex differences deserve further investigations.

Bentall procedure with the CarboSeal™ and CarboSeal Valsalva™ composite conduits: long-term outcomes

 

OBJECTIVES

Data on the long-term results with the standard CarboSeal™ mechanical conduit used for the modified Bentall procedure are lacking as well as information on performance of the Valsalva CarboSeal™ conduit.

METHODS

We have analysed 208 recipients of a standard (n = 110) or a Valsalva (n = 98) CarboSeal™ conduit. The median age was 60 years and 90% were males; 35 (17%) had type A aortic dissection and 65 (30%) a bicuspid aortic valve. Data were retrospectively analysed and results were compared between the 2 conduit models.

RESULTS

Early mortality was 1.9%; the mean follow-up was 175 ± 95 for standard and 94 ± 51 months for Valsalva conduits (P < 0.01). Actuarial survival was 86 ± 4%, 75 ± 6%, 59 ± 7% and 51 ± 9% at 5, 10, 15 and 20 years, respectively. There were 13 thromboembolic episodes with 3 deaths with an actuarial freedom of 98 ± 1%, 94 ± 2%, 90 ± 3% and 89 ± 4% at 5, 10, 15 and 20 years, respectively. Reoperation on the aortic root was performed in 9 patients for endocarditis (n = 8) and pseudoaneurysm at the right coronary button (n = 1) with an actuarial freedom of 97 ± 1%, 95 ± 2%, 92 ± 3% and 87 ± 4% at 5, 10, 15 and 20 years, respectively. There were no differences between the 2 conduit models in survival and major postoperative complications.

CONCLUSIONS

The CarboSeal™ conduit has shown gratifying overall performance up to 20 years and appears a valid option for a modified Bentall operation, when a mechanical prosthesis is indicated. Both CarboSeal™ conduit models provided not statistically different overall long-term results.

Sensitivity to change and clinical correlations of the novel DACtylitis glObal Sonographic (DACTOS) score in psoriatic arthritis

OBJECTIVE

The aim of the study is to assess the performance of the DACTOS (DACtylitis glObal Sonographic) score in a PsA dactylitis clinical setting. In particular, we evaluated the ability of DACTOS to identify the affected fingers, its sensitivity to change after treatment, the correlations between DACTOS and clinical parameters, and the capacity of the score to identify the treatment responders.

METHODS

Forty-six consecutive patients with symptomatic PsA hand dactylitis were enrolled. A total of seventy-three dactylitic digits were evaluated clinically and sonographically before and after treatment in this observational and prospective study. Clinical assessment included the Leeds Dactylitis Index-basic (LDI-b) score and visual analogue scales for pain (VAS-p) and functional impairment (VAS-FI). Sonographic lesions were investigated using high-frequency ultrasound with grey scale and power Doppler features according to the DACTOS score. Correlations between the DACTOS score and the clinical parameters were assessed at baseline, 1 month (T1) and 3 months (T3).

RESULTS

We observed significant improvements in all of the assessed clinical parameters and the DACTOS scores after dactylitis treatment. There was a statistically significant correlation between the variation of all clinical parameters (VAS-p, VAS-FI and LDI-b) and the DACTOS score at T1 and T3 evaluations. We found statistically significant differences in the DACTOS score between clinical responder and non-responder groups (P < 0.001) and between clinical remission and non-remission groups (P < 0.001).

CONCLUSION

The DACTOS score performs well in real-life clinical settings in terms of sensitivity to change and correlations with clinical features in PsA dactylitis.

Audit and Feedback in emergency: a systematic review and an Italian project to investigate and improve quality of care

The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.

Salivary Gland Ultrasonography in Sjögren's Syndrome: A European Multicenter Reliability Exercise for the HarmonicSS Project

Objectives: Salivary gland ultrasonography (SGUS) is increasingly applied for the management of primary Sjögren's syndrome (pSS). This study aims to: (i) compare the reliability between two SGUS scores; (ii) test the reliability among sonographers with different levels of experience.

Methods: In the reliability exercise, two four-grade semi-quantitative SGUS scoring systems, namely De Vita et al. and OMERACT, were tested. The sonographers involved in work-package 7 of the HarmonicSS project from nine countries in Europe were invited to participate. Different levels of sonographers were identified on the basis of their SGUS experience and of the knowledge of the tested scores. A dedicated atlas was used as support for SGUS scoring.

Results: Twenty sonographers participated in the two rounds of the reliability exercise. The intra-rater reliability for both scores was almost perfect, with a Light's kappa of 0.86 for the De Vita et al. score and 0.87 for the OMERACT score. The inter-rater reliability for the De Vita et al. and the OMERACT score was substantial with Light's Kappa of 0.75 and 0.77, respectively. Furthermore, no significant difference was noticed among sonographers with different levels of experience.

Conclusion: The two tested SGUS scores are reliable for the evaluation of major salivary glands in pSS, and even less-expert sonographers could be reliable if adequately instructed.

Ultrasound assessment of lacrimal glands: a cross-sectional study in healthy subjects and a preliminary study in primary Sjögren's syndrome patients

OBJECTIVES

This study aimed to: i) perform an ultrasonographic (US) evaluation of the lacrimal glands (LGs) in healthy subjects in order to define the sonographic elementary lesions which could be identified in the LGs and describe their frequencies in healthy subjects; ii) test the intra and inter-rater agreement between four rheumatologists; iii) preliminary assess whether the elementary lesions of the LGs let us differentiate healthy subjects from primary Sjögren's syndrome (pSS) patients.

METHODS

A consensus meeting was held to define the sonographic lesions to be evaluated. Healthy subjects and pSS patients underwent lacrimal glands ultrasound (LGUS) examinations in two Italian Rheumatology Clinics. A web-based reliability exercise was performed on healthy subjects' images by four rheumatologists. Afterward, images of pSS patients were evaluated for the presence of the sonographic lesions previously defined and compared to the US findings in healthy subjects.

RESULTS

Fifty-seven healthy subjects and 17 pSS patients were evaluated. The intra and inter-rater reliability score was good-excellent for almost all the agreed US features assessed (glandular parenchyma visibility, size, homogeneity, hypoechoic areas, hyperechoic spots, fibrous gland appearance, fatty deposition). Among the LGUS elementary lesions in pSS patients compared with healthy subjects, we detected a significantly difference in glandular inhomogeneity [13/33 (39.4%) vs. 9/63 (14.3%), p=0.01], and in fibrous gland appearance [3/33 (9.1%) vs. 0/63 (0%), p=0.04].

CONCLUSIONS

In this preliminary study, LGUS proved to have a good-excellent intra and inter-rater reliability. The glandular parenchyma inhomogeneity and the fibrous gland appearance could help differentiate pSS patients from healthy subjects.

Exercise training alone or in combination with high-protein diet in patients with late onset Pompe disease: results of a cross over study

Background

Late onset Pompe disease (LOPD) is a lysosomal neuromuscular disorder which can progressively impair the patients’ exercise tolerance, motor and respiratory functions, and quality of life. The available enzyme replacement therapy (ERT) does not completely counteract disease progression. We investigated the effect of exercise training alone, or associated with a high-protein diet, on the exercise tolerance, muscle and pulmonary functions, and quality of life of LOPD patients on long term ERT.

Methods

The patients were asked to participate to a crossover randomized study comprehending a control period (free diet, no exercise) followed by 2 intervention periods: exercise or exercise + diet, each lasting 26 weeks and separated by 13 weeks washout periods. Exercise training included moderate-intensity aerobic exercise on a cycle ergometer, stretching and balance exercises, strength training. The diet was composed by 25–30% protein, 30–35% carbohydrate and 35–40% fat. Before and after each period patients were assessed for: exercise tolerance test on a cycle-ergometer, serum muscle enzymes, pulmonary function tests and SF36 questionnaire for quality of life. Compliance was evaluated by training and dietary diaries. Patients were contacted weekly by researchers to optimize adherence to treatments.

Results

Thirteen LOPD patients, median age 49 ± 11 years, under chronic ERT (median 6.0 ± 4.0 years) were recruited. Peak aerobic power (peak pulmonary O₂ uptake) decreased after control, whereas it increased after exercise, and more markedlyafter exercise + diet. Serum levels of lactate dehydrogenase (LDH) significantly decreased after exercise + diet; both creatine kinase (CK) and LDH levels were significantly reduced after exercise + diet compared to exercise. Pulmonary function showed no changes after control and exercise, whereas a significant improvement of forced expiratory volume in 1 sec (FEV1) was observed after exercise + diet. SF36 showed a slight improvement in the “mental component” scale after exercise, and a significant improvement in “general health” and “vitality” after exercise + diet. The compliance to prescriptions was higher than 70% for both diet and exercise.

Conclusions

Exercise tolerance (as evaluated by peak aerobic power) showed a tendency to decrease in LOPD patients on long term ERT. Exercise training, particularly if combined with high-protein diet, could reverse this decrease and result in an improvement, which was accompanied by improved quality of life. The association of the two lifestyle interventions resulted also in a reduction of muscle enzyme levels and improved pulmonary function.

Management of immune-related adverse events: A single-center retrospective analysis in a real-world scenario

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Background: Immune checkpoint inhibitors (ICI), anti CTLA-4 and anti PD-1/PD-L1 agents, have demonstrated an improvement in survival outcome in several malignancies. Therapy with ICI is characterized by immune-related adverse events (irAEs) as a result of exuberant immune system activation. Despite good tolerance for ICI, the potentially severe and life-threatening irAEs underscore the importance of investigating optimal management strategies. Methods: A retrospective series of 130 consecutive patients (pts) treated with ICI from Jan 2012 to Dec 2017 was analyzed. Adverse events with a potential immunological etiology were defined as irAEs and graded according to CTCAE v.4.0. The aim of the study was to evaluate irAEs management in an academic hospital center. Results: Pts with a diagnosis of NSCLC n = 64 (49%), melanoma n = 55 (42%), kidney n = 9 (7%) and others n = 2 (2%) were investigated. Baseline ECOG PS was ≤ 1 in 96% of the pts. ICI represented first line treatment for 27% pts, second line for 57% and third or further line for the remaining 16%. 18% were treated with ipilimumab and 82% with anti PD-1/PD-L1 agents (nivolumab 60%, pembrolizumab 21%, atezolizumab 1%). Overall, 50 (38% of pts) developed an irAE.42% of irAEs were grade 1, 38% grade 2, 14% grade 3 and 6% grade 4. The most frequent irAEs were endocrinopathies in 17 pts (34%), followed by cutaneous toxicity in 9 pts (18%) and colitis and diarrhea in 7 pts (14%). A total of 373 unscheduled accesses were observed, 89 (24%) of them were due to irAEs: 78 were unplanned consultations in the oncology department and 11 in the emergency department. irAEs led to hospitalization in 14 pts for 118 days, cumulatively. Grade ≥ 2 colitis was the most frequent irAE associated with hospitalization, it occurred in 4 pts (29%). Colitis and diarrhea required the longest hospitalization (range 4-31 days). 48% (24 pts) required immunosuppressive treatment. Systemic steroids were the most common immunosuppressive agents used. Only one patient received infliximab as second line immunosuppressive treatment after steroid failure. Totally, irAEs required 67 specialist consultancies and additional diagnostic examinations. 15 pts required ICI discontinuation because of irAEs. Conclusions: In our center prevalence and severity of irAEs were similar to literature data. Considered the complexity of irAEs management, multidisciplinary approach and a trained hospital network plays a key role for a more efficient diagnostic and treatment work-up in pts who received ICI therapy and experienced irAEs.

Glycaemic control, antidiabetic medications and influenza vaccination coverage among patients with diabetes in Udine, Italy

Objective

The objectives of this study were to estimate influenza vaccination coverage among patients with diabetes mellitus in an Italian 250 000-inhabitant area in the 2017-2018 season and to assess whether glycaemic control and pharmacological treatment were associated with the likelihood of being vaccinated.

Design

In this cross-sectional study, we analysed anonymous health administrative databases, linked with each other at the individual patient level through a stochastic key: diabetes mellitus registry, vaccinations, drug prescriptions and laboratory database.

Setting

The study was conducted in the catchment area of the University Hospital of Udine ('the Udine area'), a 250 000-inhabitant area in the northeast of Italy.

Participants

The study included all subjects included in the regional registry of patients with diabetes mellitus, living in the Udine area as of 1 October 2017.

Main outcome measures

Vaccination coverage in the 2017-2018 influenza season was calculated. The association between patients' characteristics and the likelihood of being vaccinated was assessed through multivariate log binomial regression.

Result

53.0% of 15 900 patients with diabetes living in the area were vaccinated. Coverage increased with age, approaching 75% at ≥85 years. Patients lacking recent glycated haemoglobin testing were less likely to be vaccinated (43.4% vaccination coverage), as were those not treated pharmacologically (44.4% vaccination coverage). Patients treated with both insulin, metformin and other antidiabetic medications were more likely to be vaccinated than those treated with metformin alone (58.1% vaccination coverage; adjusted relative risk=1.07, 95% CI 1.01 to 1.14).

Conclusion

Influenza vaccination coverage was suboptimal in this Italian population of patients with diabetes. Strategies to improve diabetes management could in turn positively affect influenza coverage.

Peer education for medical students on health promotion and clinical risk management

CONTEXT

Health promotion (HP) and clinical risk management (CRM) topics are seldom discussed during medical school lessons. Peer-assisted learning (PAL) has long occurred informally in medical education, and interest in this method has recently grown, as it is considered a valuable technique for both tutors and tutees.

AIMS

The aim was to evaluate the impact of HP and CRM PAL intervention on medical students' (tutees) knowledge level.

SETTINGS AND DESIGN

A PAL intervention has been implemented at Udine University medical school during 2017. It was composed of lectures and practical activities conducted by ten near-peer tutors.

METHODS

The effectiveness has been evaluated by giving tutees: (1) a knowledge multiple-choice questionnaire, before and after the intervention; (2) a satisfaction questionnaire; and evaluating (3) tutees' group assignments.

STATISTICAL ANALYSIS USED

We performed descriptive analysis; then McNemar, Wilcoxon signed rank, Wilcoxon Mann-Whitney, and t-tests were applied.

RESULTS

The number of students addressed by PAL intervention was 62. Difference in total correct answers among pre- and post-intervention questionnaires showed a statistically significant improvement (P < 0.0001), both when analyzing it globally and by area (HP/CRM). Students' satisfaction for CRM was greater than for HP area (P = 0.0041).

CONCLUSIONS

This educational intervention based on PAL showed its effectiveness producing a statistically significant improvement in students' knowledge. Our findings confirm that PAL could be a feasible method for HP and CRM topics.

Data linkage analysis of giant cell arteritis in Italy: Healthcare burden and cost of illness in the Italian region of Friuli Venezia Giulia (2001-2017)

Giant cell arteritis (GCA) is the most common vasculitis in adults. However, comprehensive analyses of the healthcare burden are still scarce. The aim of the study is to report the healthcare burden and cost of illness of GCA in the Friuli Venezia Giulia (FVG) region of Italy, based on a data linkage analysis. To this end, a retrospective study was conducted through the integration of many administrative health databases of the FVG region as the source of information. Cases were identified from two verified, partially overlapping sources (the rare disease registry and medical exemption database). From 2001 to 2017, 208 patients with GCA were registered. The prevalence of GCA in the population aged ⩾ 45 years as of December 31, 2017 was 27.2/100,000 inhabitants (95% CI 23.5-31.4). The mean time of observation was 4.5 ± 3.6 years. A total of 3182 visits (338 per 100 patient-years) was recorded. The most frequent specialty visits were rheumatology (n = 610, 19.2%), followed by internal medicine (n = 564, 17.7%). A total of 287 hospitalizations (30 per 100 patient-years) were reported. A total of 13,043 prescriptions (1386 per 100 patient-years) were registered. More than half of the patients were prescribed an immunosuppressive agent. The overall estimated direct healthcare cost was €2,234,070, corresponding to €2374 per patient-year. Overall, GCA is a rare disease which implies a high healthcare cost.

Customer satisfaction survey in Friuli Venezia Giulia university canteens

Background

Customer satisfaction represents an innovative approach to measure strengths and weaknesses of an organization and is useful for a customer-focused management and culture development. Our survey’s aim was to investigate perceived quality and needs of customers in the university canteen sector.

Methods

Between April and June 2018, an anonymous online questionnaire was distributed by “agenzia regionale per il diritto agli studi superiori” (ARDISS) among university students in Friuli Venezia Giulia, Italy. The questions covered 3 thematic areas: attendance of the service, quality of services and opinions on new initiatives. Furthermore, there was an open question to collect students’ suggestions or proposals to improve the service. Satisfaction about the service was evaluated through five topics: environments, hygiene, staff, meals, global satisfaction. Collected data were analyzed with descriptive, univariate and multivariate analyses. Statistical analyses were performed using 9.4 SAS software.

Results

Response rate was 20.5% (1933/9404). Multiple logistic regression analyses showed a difference in meal choice (entire vs reduced) between institutional canteen and partner cafeterias users (p &lt; 0.0001) and that male (p &lt; 0.0001) and foreign students (p 0.0003) prefer entire meal instead of reduced. Percentage of students who prefer entire meal is reduced (p &lt; 0.0001) if price range increases. Univariate and multivariate analyses showed that high quality perception is associated with lower price range and no suggestions about food and environments (p &lt; 0.0001); multivariate analyses also showed an association between high quality perception and high canteen attendance (p &lt; 0.05).

Conclusions

The survey showed an association between meal choice and students’ profile and between perceived quality and customer’s features. These data and further analyses may help to select areas where an intervention could improve service quality and, therefore, customer satisfaction.

Key messages

Customer satisfaction is an important tool to measure and improve university canteen service quality. These results helped us to identify services’ strengths and weaknesses according to students’ opinions; this could be useful to select improvement areas.

Education and training in adult metabolic medicine: Results of an international survey

Adult metabolic medicine (AMM) is an expanding medical subspecialty, due to the increasing number of adult patients with inherited metabolic diseases (IMD). However, a formal training and postgraduate education in this field is not available in the majority of countries. Existing adult metabolic specialists (AMS) come from many different backgrounds. The aim of this survey was to assess the state of play as regards education and training in AMM worldwide. Members of the Society for the Study of Inborn Error of Metabolism adult metabolic group (n = 89) were asked to take part in this survey. Forty-two AMS (47.2%) from 18 different countries completed the questionnaire. The most common specialties were internal medicine (38.1%), endocrinology (26.2%), genetics (21.4%), and neurology (21.4%). Ninety-five percent of respondents considered that practical clinical experience had contributed importantly for their professional development, while only 27% felt the same for formal academic education. The current state of available education and training was judged as generally poor or fair (73% of the respondents). The most suggested ways of improving education and training in AMM were: to facilitate international internships; to implement courses on adult-IMD; and to create a formal academic education. The skills considered most important for AMS were: recognition of signs and symptoms of diseases, knowledge of the available treatments, and ability to perform a correct follow up. In conclusion, worldwide, current available education and training in AMM is considered inadequate. This survey emphasizes the need for development of new, formal training opportunities to improve knowledge, and competence in this rapidly expanding field.

Why we should take care of the competing risk bias in survival analysis: A phase II trial on the toxicity profile of radiotherapy for prostate cancer

Aim

The aim of the present study is to evaluate and quantify the bias of competing risks in an Italian oncologic cohort comparing results from different statistical analysis methods.

Background

Competing risks are very common in randomized clinical trials and observational studies, in particular oncology and radiotherapy ones, and their inappropriate management causes results distortions widely present in clinical scientific articles.

Materials and methods

This is a single-institution phase II trial including 41 patients affected by prostate cancer and undergoing radiotherapy (IMRT-SIB) at the University Hospital of Udine.Different outcomes were considered: late toxicities, relapse, death.Death in the absence of relapse or late toxicity was considered as a competing event.

Results

The Kaplan Meier method, compared to cumulative incidence function method, overestimated the probability of the event of interest (toxicity and biochemical relapse) and of the competing event (death without toxicity/relapse) by 9.36%. The log-rank test, compared to Gray's test, overestimated the probability of the event of interest by 5.26%.The Hazard Ratio's and cause specific hazard's Cox regression are not directly comparable to subdistribution hazard's Fine and Gray's modified Cox regression; nonetheless, the FG model, the best choice for prognostic studies with competing risks, found significant associations not emerging with Cox regression.

Conclusions

This study confirms that using inappropriate statistical methods produces a 10% overestimation in results, as described in the literature, and highlights the importance of taking into account the competing risks bias.

Implant of ATOMS® system for the treatment of postoperative male stress urinary incontinence: results of a single centre

Purpose:

The aim of our study is to evaluate the efficacy and safety of ATOMS^® system for the treatment of postoperative male stress urinary incontinence (SUI).

Materials and methods:

We retrospectively evaluated all patients treated at our institution for postoperative male SUI with ATOMS^® implant. We excluded patients with low bladder compliance (< 20 mL / cmH₂O), uncontrolled detrusor overactivity, detrusor underactivity (BCI < 100), urethral or bladder neck stricture and low cystometric capacity (< 200 mL).

Results:

From October 2014 to July 2017 we treated 52 patients, mean age 73.6 years. Most of them (92.3%) had undergone radical prostatectomy, 3.85% simple open prostatectomy, 3.85% TURP; 28.8% of patients had undergone urethral surgery, 11.5% adjuvant radiotherapy; 57.7% had already undergone surgical treatment for urinary incontinence. The average24 hours pad test was 411.6 g (180 – 1100). The mean follow-up was 20.1 months (8.1 – 41.5) 30.8% of patients were dry, 59.6% improved ≥ 50%, 7.7% improved < 50% and 1.9% unchanged. In total 73.1% reached social continence. There was a significant reduction of the 24 hours pad test and ICIQ - UI SF scores (p < 0.01).

In the postoperative follow-up we detected complications in 8 patients (19%): 5 cases of displacement of the scrotal port, in 2 cases catheterization difficulties, one case of epididimitis and concomitant superficial wound infection; no prosthesis infection, nor explants.

Radiotherapy, previous urethral surgery,previous incontinence surgery were not statistically related to social continence rates (p 0.65;p 0.11;p 0.11).

Conclusions:

The ATOMS^® system is an effective and safe surgical treatment of mild and moderate male postoperative SUI with durable results in the short term.

The epidemiology of psoriasis in an Italian area: population-based analysis of administrative data

BACKGROUND

Data on the epidemiology of psoriasis are limited. The objective of this study was to estimate the prevalence and the incidence rate of psoriasis in a reproducible and efficient population-based assessment in a Northeastern Italian area around the city of Udine.

METHODS

A retrospective population-based analysis was conducted linking at the individual patient level, through a unique encrypted identifier, four electronic administrative health databases, with full coverage of the residing population: the hospital discharge database, the ambulatory care database, the pharmaceutical prescriptions database, and the database of exemptions from medical charges. Incident and prevalent cases of psoriasis were identified through predefined algorithms.

RESULTS

The estimated prevalence of psoriasis in the study area was 1.84%, while incidence rate was 0.96/1000 person-years; 13.6% of prevalent cases had arthritis. Prevalence turned out to increase with age and was higher in males. Arthritis was more common among females. Biological medications were prescribed to 2% of patients in 2015.

CONCLUSIONS

Our estimates of incidence and prevalence of psoriasis and description of patients characteristics in the North-East of Italy add knowledge to the existing body of scientific data on the epidemiology of this disease at the international level and provide useful information for health planners at the local level.

Functional Decline in Residents Living in Nursing Homes: A Systematic Review of the Literature

OBJECTIVES

To describe the functional dependence progression over time in older people living in nursing homes (NHs).

DESIGN

A systematic review of the literature was performed. Studies involving individuals 65 years and older living in NHs, describing their functional decline, improvement or stability in activities of daily living (ADLs), were eligible. The search strategy was applied in MedLine, Cochrane, CINAHL, and SCOPUS databases; aimed at identifying an unbiased and complete list of studies, searching by hand was also performed. The methodological quality of the 27 studies included was assessed.

RESULTS

Functional trajectories were documented mainly through multicenter study design including sample size ranging from 2 to 9336 NHs, from 1983 to 2011 throughout a single or multiple follow-ups (>20). The average rate of decline was expressed in different metrics and periods of time: from 3 months with a decline of -0.13 points of 28, to 6 months (-1.78 points of 2829) to 1.85 years (-0.5 points of 6). Eating and toileting were the most documented ADLs and the decline is approximately 0.4 points and 0.2 to 0.4 points of 5 a year, respectively. Among the covariates, individual factors, such as cognitive status, were mainly considered, whereas only 13 studies considered facility-level factors.

CONCLUSIONS

Findings report the slow functional decline mainly in women living in US NHs, in years when residents were admitted with a low or medium degree of functional dependence. Considering that in recent years residents have been admitted to NHs with higher-level functional dependence, studies measuring each single ADL, using standardized instruments capable of capturing the signs of decline, stability, or improvement are strongly recommended. Among the covariates, evaluation of both individual and facility-level factors, which may affect functional decline, is also suggested.