Effectiveness of Vitamin D Supplementation on Disease Course in Inflammatory Bowel Disease Patients: Systematic Review With Meta-Analysis

BACKGROUND

The vitamin D role in bone metabolism is well known; however, recent evidence suggests the impact of vitamin D in immune modulation and its implications in immune-mediated diseases, including inflammatory bowel disease (IBD).

METHOD

We performed a systematic review with meta-analysis by a specific protocol (PROSPERO: CRD42022311184; March 2022, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=311184). Randomized clinical trials involving IBD patients treated with vitamin D supplementation, compared with placebo, that evaluated the risk of clinical relapse and disease activity were included. Literature search was performed using Medline, Scopus, and Cochrane CENTRAL through January 2022.

RESULTS

Out of 1448 articles, 12 (11 full-texts and 1 abstract) were included. Seven randomized clinical trials reported data on the clinical relapse as dichotomous outcome, while 7 studies reported data on disease activity expressed as continuous variables. The pooled risk ratio of clinical relapse was 0.64 (95% confidence interval, 0.46-0.89; I2 = 25%) among 458 IBD patients. However, this seems to be solid only in Crohn's disease (CD) patients. In fact, only 2 studies, involving 67 patients with ulcerative colitis, were included in the analysis. CD patients in clinical remission had a strong significant risk reduction in clinical relapse (risk ratio, 0.47; 95% confidence interval, 0.27-0.82; I2 = 0%), suggesting that it could be a specific subgroup with maximum clinical benefit of vitamin D supplementation.

CONCLUSIONS

This meta-analysis shows that vitamin D supplementation can reduce the risk of clinical relapse in IBD patients, especially in CD patients in clinical remission. In a subgroup analysis, it was not significant (due to small number of studies and low number of patients), and well-powered studies are needed, in particular for ulcerative colitis patients.

Burden of delayed discharge on acute hospital medical wards: A retrospective ecological study in Rome, Italy

INTRODUCTION

Delayed discharge represents the difficulty in proceeding with discharge of patients who do not have any further benefit from prolonged stay. A quota of this problem is related to organizational issues. In the Lazio region in Italy, a macro service re-organization in on the way, with a network of hospital and territorial centers engaged in structuring in- and out- of hospital patient pathways, with a special focus on intermediate care structures. Purpose of this study is to quantify the burden of delayed discharge on a single hospital structure, in order to estimate costs and occurrence of potential resource misplacement.

MATERIAL AND METHODS

Observational Retrospective study conducted at the Santo Spirito Hospital in Rome, Italy. Observation period ranged from 1/09/2022, when the local database was instituted, to 1/03/2023 (6 months). Data from admissions records was anonymously collected. Data linkage with administrative local hospital database was performed in order to identify the date a discharge request was fired for each admission. Surgical discharges and Intensive Care Unit (ICU) discharges were excluded from this study. A Poisson hierarchical regression model was employed to investigate for the role of ward, Severity of Disease (SoD) and Risk of Mortality (RoM) on elongation of discharge time.

RESULTS

1222 medical ward admissions were recorded in the timeframe. 16% of them were considered as subject to potentially elongated stay, and a mean Delay in discharge of 6.3 days (SD 7.9) was observed.

DISCUSSION AND CONCLUSIONS

Delayed discharge may cause a "bottleneck" in admissions and result in overcrowded Emergency Department, overall poor performance, and increase in overall costs. A consisted proportion of available beds can get inappropriately occupied, and this inflates both direct and indirect costs. Clinical conditions on admission are not a good predictor of delay in discharge, and the root causes of this phenomenon likely lie in organizational issues (on structure\system level) and social issues (on patient's level).

The long-term effect on surgery-free survival of biological compared to conventional therapy in Crohn's disease in real world-data: a retrospective study

BACKGROUND

The introduction of biological drugs has led to great expectations and growing optimism in the possibility that this new therapeutic strategy could favourably change the natural history of Inflammatory Bowel Disease (IBD) and, in particular, that it could lead to a significant reduction in surgery in the short and long term. This study aims to assess the impact of biological versus conventional therapy on surgery-free survival time (from the diagnosis to the first bowel resection) and on the overall risk of surgery in patients with Crohn's disease (CD) who were never with the surgical option.

METHODS

This is a retrospective, double-arm study including CD patients treated with either biological or conventional therapy (mesalamine, immunomodulators, antibiotics, or steroids). All CD patients admitted at the GI Unit of the S. Salvatore Hospital (L'Aquila. Italy) and treated with biological therapy since 1998 were included in the biological arm. Data concerning the CD patients receiving a conventional therapy were retrospectively collected from our database. These patients were divided into a pre-1998 and post-1998 group. Our primary outcome was the evaluation of the surgery-free survival since CD diagnosis to the first bowel resection. Surgery-free time and event incidence rates were calculated and compared among all groups, both in the original population and in the propensity-matched population.

RESULTS

Two hundred three CD patients (49 biological, 93 conventional post-1998, 61 conventional pre-1998) were included in the study. Kaplan-Meier survivorship estimate shows that patients in the biological arm had a longer surgery-free survival compared to those in the conventional arm (p = 0.03). However, after propensity matching analysis, conducted on 143 patients, no significant difference was found in surgery-free survival (p = 0.3). A sub-group analysis showed shorter surgery-free survival in patients on conventional therapy in the pre-biologic era only (p = 0.02; Hazard Ratio 2.9; CI 1.01-8.54) while no significant difference was found between the biologic and conventional post-biologic groups (p = 0.15; Hazard Ratio 2.1; CI 0.69-6.44).

CONCLUSION

This study shows that the introduction of biological therapy has only a slight impact on the eventual occurrence of surgery in CD patients over a long observation period. Nevertheless, biological therapy appears to delay the first intestinal resection.

Predicting Factors of Plasma HIV RNA Undetectability after Switching to Co-Formulated Bictegravir, Emtricitabine, and Tenofovir Alafenamide in Experienced HIV-1 Patients: A Multicenter Study

Switching to bictegravir, emtricitabine, and tenofovir alafenamide (BIC/FTC/TAF) from other antiretroviral regimens is safe and effective for virologically suppressed people living with HIV (PLWH). The term virological suppression includes both low but detectable HIV viremia and undetectable HIV viremia, and the latter is possibly associated with a lower immune activation state. Herein, we describe a 24-month follow-up of experienced PLWH with plasma HIV RNA undetectable or detectable < 50 copies/ml switching to BIC/FTC/TAF. A previous 12-month monitoring was available, and the factors correlated with treatment efficacy. This retrospective multicenter study included PLWH who switched to BIC/FTC/TAF in the period of 2019-2022, and who were HBsAg and HCV RNA negative. The follow-up study times were 6 (T6), 12 (T12), 18 (T18), and 24 (T24) months after the switch (T0). Survival analysis with multiple-failure-per-subject design, Kaplan-Meier survival estimates, multivariate analysis of variance, multilevel linear regression, and a hierarchical ordered logistic model were applied. A total of 329 PLWH had plasma HIV RNA which was either undetectable or detectable at <50 copies/mL at T0, and 197 responded to all inclusion criteria: M/F 140/57; the median CD4+ cell count was 677 cells/mm3; and HIV RNA at T0 was undetectable in 108 patients. Most of the 197 patients (122, 61.9%) were on a previous INSTI-based regimen. HIV RNA undetectability was more frequent at each follow-up point in patients with HIV RNA that was undetectable at T0, and it showed a higher frequency throughout the follow-up period in patients with always-undetectable HIV RNA in the 12 months before the switch. A higher nadir CD4 cell count had a predictive role, and HBcAb positivity had no influence. In conclusion, the switch could be programmed and possibly delayed on a case-by-case basis in order to achieve persistent plasma HIV RNA undetectability. Undiagnosed loss of HBcAb has no detrimental consequences on the response to BIC/FTC/TAF.

Improving clinical diagnostic accuracy and management of False penile fractures characterizing typical clinical presentation: a systematic review and meta-analysis

PURPOSE

False penile fractures (FPF) represent a rare sexual emergency characterized by blunt trauma of penis in the absence of albuginea's injury, with or without lesion of dorsal penile vein. Their presentation is often indistinguishable from true penile fractures (TPF). This overlapping of clinical presentation, and lack of knowledge about FPF, can lead surgeons often to proceed directly to surgical exploration without further examinations. The aim of this study was to define a typical presentation of false penile fractures (FPF) emergency, identifying in absence of "snap" sound, slow detumescence, penile shaft ecchymosis, and penile deviation main clinical signs.

METHODS

We performed a systematic review and meta-analysis based on Medline, Scopus and Cochrane following a protocol designed a priori, to define sensitivity of "snap" sound absence, slow detumescence and penile deviation.

RESULTS

Based on the literature search of 93 articles, 15 were included (73 patients). All patients referred pain, most of them during coitus (n = 57; 78%). Detumescence occurred in 37/73 (51%), and all patients described detumescence occurrence as "slow". The results show that single anamnestic item have a high-moderate sensibility in the diagnosis of FPF, and the highest sensitive item was penile deviation (sensibility = 0.86). However, when more than one item is present, overall sensitivity increases greatly, closing to 100% (95% Confidence Interval 92-100).

CONCLUSION

Surgeons can consciously decide between additional exams, a conservative approach, and rapid intervention using these indicators to detect FPF. Our findings identified symptoms with excellent specificity for FPF diagnosis, giving clinicians more useful tools for making decisions.

Intra- and Extra-Hospitalization Monitoring of Vital Signs-Two Sides of the Same Coin: Perspectives from LIMS and Greenline-HT Study Operators

BACKGROUND

In recent years, due to the epidemiological transition, the burden of very complex patients in hospital wards has increased. Telemedicine usage appears to be a potential high-impact factor in helping with patient management, allowing hospital personnel to assess conditions in out-of-hospital scenarios.

METHODS

To investigate the management of chronic patients during both hospitalization for disease and discharge, randomized studies (LIMS and Greenline-HT) are ongoing in the Internal Medicine Unit at ASL Roma 6 Castelli Hospital. The study endpoints are clinical outcomes (from a patient's perspective). In this perspective paper, the main findings of these studies, from the operators' point of view, are reported. Operator opinions were collected from structured and unstructured surveys conducted among the staff involved, and their main themes are reported in a narrative manner.

RESULTS

Telemonitoring appears to be linked to a reduction in side-events and side-effects, which represent some of most commons risk factors for re-hospitalization and for delayed discharge during hospitalization. The main perceived advantages are increased patient safety and the quick response in case of emergency. The main disadvantages are believed to be related to low patient compliance and an infrastructural lack of optimization.

CONCLUSIONS

The evidence of wireless monitoring studies, combined with the analysis of activity data, suggests the need for a model of patient management that envisages an increase in the territory of structures capable of offering patients subacute care (the possibility of antibiotic treatments, blood transfusions, infusion support, and pain therapy) for the timely management of chronic patients in the terminal phase, for which treatment in acute wards must be guaranteed only for a limited time for the management of the acute phase of their diseases.

Polypharmacy Management in a Gender Perspective: At the Heart of the Problem: Analysis of Major Cardiac Diseases, SARS-CoV-2 Affection and Gender Distribution in a Cohort of Patients in Internal Medicine Ward

BACKGROUND

COVID-19 patients with any pre-existing major cardio-vascular disease (CVD) are at the highest risk of viral infection and of developing severe disease. The pathophysiological mechanism is characterized by the viral link to angiotensin-converting enzyme 2 (ACE2) and the involvement of the endothelial system with the release of cytokines and the inflicting of direct damage to the myocardium, the induction of microthrombosis, and the initiation of alterations in oxygen diffusion. The aim of the study is to analyze the clinical course and outcomes in patients (gender-stratified) with pre-existing major CVD.

METHODS

Out of the 1833 (973 M/860 F) patients admitted to the Internal Medicine COVID-19 Unit of "Castelli Hospital", Lazio, Italy, from 1 January 2021 to 31 December 2021, 600 patients (320 M/280 F) with a mean age of 77 (78.6 M/75.1 F) previously had CVD. Demographic characteristics, length of the stay (LOS) and oxygen therapy were evaluated.

RESULTS

All of the CVD COVID-19 patients underwent non-invasive ventilation (NIV). CVD was linked with increased LOS (21 days F/22 M) compared to no CVD (19 days). In total, 32.7% of total patients had major CVD.

CONCLUSIONS

Timely identification and evaluation of patients with pre-existing major CVD are fundamental for adequate treatment based on gender, severity, state of illness and for risk reduction.

SARS-CoV-2 Neutralizing Antibodies to B.1 and to BA.5 Variant after Booster Dose of BNT162b2 Vaccine in HIV Patients COVID-Naïve and on Successful Antiretroviral Therapy

Live virus neutralization is the gold standard to investigate immunity. This prospective observational study aimed to determine the magnitude of response against the original B.1 lineage and against the BA.5 lineage six months after the third BNT162b2 mRNA vaccine dose in patients with HIV infection on successful antiretroviral treatment and no previous SARS-CoV-2 infection. A total of 100 subjects (M/F 83/17, median age 54 years) were included in the analysis: 95 had plasma HIV RNA <40 copies/mL, the median CD4+ T cell count at the administration of the third dose was 580 cells/mm³, and the median nadir CD4+ T cell count was 258 cells/mm³. Neutralizing antibodies (NtAb) against B.1 were detectable in all the subjects, but those to BA.5 were only detected in 88 (p < 0.001). The median NtAb titer to B.1 was significantly higher than that to BA.5 (393 vs. 60, p < 0.0001), and there was a strong positive correlation between the paired measurements (p < 0.0001). Linear regression on a subset of 87 patients excluding outlier NtAb titers showed that 48% of the changes in NtAb titers to BA.5 are related to the changes in value titers to B.1. SARS-CoV-2 variants evolve rapidly, challenging the efficacy of vaccines, and data on comparative NtAb responses may help in tailoring intervals between vaccine doses and in predicting vaccine efficacy.

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy

Background

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs.

Methods

The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors.

Results

A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p &lt; 0.001).

Conclusion

The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

Cannabinoid Therapeutic Effects in Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

(1) Introduction: Inflammatory Bowel Disease (IBD) patients may benefit from cannabinoid administration supplementary therapy; currently no consensus on its effect has been reached. (2) Methods: a systematic review of RCTs on cannabinoid supplementation therapy in IBD has been conducted; data sources were MEDLINE, Scopus, ClinicalTrials. (3) Results: out of 974 papers found with electronic search, six studies have been included into the systematic review, and five of them, for a grand total of 208 patients, were included into the meta-analysis. (4) Conclusions: cannabinoid supplementation as adjuvant therapy may increase the chances of success for standard therapy of Crohn’s Disease during the induction period; no statement on its potential usage during maintenance period can be derived from retrieved evidence. Its usage in Ulcerative Colitis is not to be recommended. If ever, low-dose treatment may be more effective than higher dosage. Mean CDAI reduction was found stronger in patients treated with cannabinoids (mean CDAI reduction = 36.63, CI 95% 12.27–61.19) than placebo. In future studies, it is advisable to include disease activity levels, as well as patient-level information such as genetic and behavioral patterns.

Is COVID 19 introducing a new model of internal medicine ward?

Background

Covid 19 has recently been defined as a syndemia, because it combines the epidemic emergency of Sars Cov 2 with that of non-communicable diseases. This aspect is particularly known in internal medicine wards (IM), which have had to split up to support these new criticalities.

Methods

Delphi method has been used to make the Ishikawa's diagram to analyze the reasons of the death in COVID ward. Each item was attributed a score according to a pros/cons and opportunities/threats system, derived from evidence in the literature. Scores were presented in a Cartesian graph showing the positioning according to the potential value and the perceived risk associated with the items. In the end, the performances of MC (Covid ward, split in I wave, II wave and overall) and MCF (internal medicine Covid-free ward) have been compared through the Barber's nomogram.

Results

MCF hospitalized 790 patients (-23,90% compared to 2019), Overall-MC patients: 50% of the 2019 MCF. Main cause of mortality-risk: patients originating from local facilities (+7%) and comorbidities (58% Chronic renal failure, 41% cancer, 90% age, 70% COVID 19 WHO stage 3. >3 comorbidities: 100%, ≥5: 24,7%). Length of stay: 8-60 days (mean value, MV: 17) for MC, 2-12 (MV 8) for MCF. Turnover Index: 10 day for MC II, 8 MC I, 1 for MCF. 25% of patients in MC have been treated with Non Invasive Ventilation (NIV), with high cost hospitalization-related.

Conclusions

Internal-Medicine ward model is a ward strictly tied to the community both before and after hospitalization. COVID 19 proposes a new model of IM, nearly subintensive ward, with NIV and continuous monitoring of vital signs, long length of stay and low turnover index. Is this the internal medicine ward for the future?

Key messages

COVID 19 proposes a new model of Internal Medicine ward, nearly subintensive ward, with Non Invasive Ventilation and continuous monitoring of vital signs, long length of stay and low turnover index.

Covid 19 mortality is strictly connected with the origin from territorial health-assisted residences.

Effectiveness and safety of DOACs for the prevention of recurrent VTE: a prospective cohort study

Background

In the direct oral anticoagulants (DOACs) era, extended anticoagulation after 6–12 months of treatment is an attractive strategy in patients with venous thromboembolism (VTE). Real-life data on the clinical benefit of DOAC over time is lacking.

Purpose

The aim of this study is to assess the effectiveness and safety of DOACs in patients with acute VTE treated for variable periods.

Methods

Data on patients with an objective diagnosis of acute VTE treated with DOACs were included in prospective cohort study. Study outcomes were recurrent VTE and major bleeding (ISTH definition).

Results

Overall, 934 patients were included (mean age 67.0±16.0, male gender 51.4%). Three-hundred and forty-six patients had a deep vein thrombosis (37.0%), 98 (10.5%) had isolated pulmonary embolism and 490 (52.5%) had both. One-hundred and sixty-nine patients (18.1%) had an active cancer, 59 (6.3%) a history of cancer and 365 patients (39.1%) an unprovoked VTE. During DOAC treatment (mean 21.6 months), 7 recurrent VTEs and 25 major bleedings occurred. In 546 and in 98 patients, DOAC was continued with full and reduced doses, respectively. In 290 patients (43.8% unprovoked, 13.8% active cancer, 42.4% associated with non-cancer risk factor), anticoagulants were withdrawn (average treatment duration 8.8 months) and 22 recurrent VTEs occurred over a follow-up off-treatment period of 31.9 months. In these patients, 2 episodes of major bleeding were observed. Overall, 201 patients died; fatal PE occurred in 4 and fatal bleeding in 1 patient. Time course for recurrent VTE according to 2019 ESC risk for recurrence is reported in the Figure.

Conclusions

In this cohort study, DOACs showed a good risk to benefit profile in the extended phase after an acute VTE event.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Cumulative incidence of recurrent VTE

From the bench to practice - Field integration of community-based services for older citizens with different levels of functional limitation across European Regions

The meeting of the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) action group A3 together with members of the Reference site collaborative network (RSCN) in December 2019 in Rome focused on integration of evidence-based approaches on health and care delivery for older citizens at different levels of needs with expertise coming from stakeholder across Europe. It was the final aim of the group to co-create culturally sensitive pathways and facilitate co-ownership for further implementation of the pathways in different care systems across Europe.

The study design is a mixed method approach. Based on data analysis from a cohort of community-dwelling over-65 citizens in the framework of a longitudinal observational study in Rome, which included health, social and functional capacity data, three personas profiles were developed: the pre-frail, the frail and the very frail personas. Based on these data, experts were asked to co-create care pathways due to evidence and eminence during a workshop and included into a final report.

All working groups agreed on a common understanding that integration of care means person-centered integration of health and social care, longitudinally provided across primary and secondary health care including citizens’ individual social, economic and human resources.

Elements for consideration during care for pre-frail people are loneliness and social isolation, which, lead to limitation of physical autonomy in the light of reduced access to social support. Frail people need adaption of environmental structures and, again, social resource allocation to maintain at home. Very frail are generally vulnerable patients with complex needs. Most of them remain at home because of a strong individual social support and integrated health care delivery.

The approach described in this publication may represent a first approach to scaling-up care delivery in a person-centered approach.

Burden of COVID-19 on Italian Internal Medicine Wards: Delphi, SWOT, and Performance Analysis after Two Pandemic Waves in the Local Health Authority "Roma 6" Hospital Structures

Background: COVID-19 causes major changes in day-to-day hospital activity due to its epidemiological characteristics and the clinical challenges it poses, especially in internal medicine wards. Therefore, it is necessary to understand and manage all of the implicated factors in order to maintain a high standard of care, even in sub-par circumstances. Methods: This was a three-phase, mixed-design study. Initially, the Delphi method allowed us to analyze the causes of poor outcomes in a cohort of an aggregate of Italian COVID-19 wards via an Ishikawa diagram. Then, for each retrieved item, a score was assigned according to a pros/cons, opportunities/threats system. Scores were also assigned according to potential value/perceived risk. Finally, the performances of MCs (Medicine-COVID-19 wards) and MCFs (Medicine-COVID-19-free: Internal Medicine wards) units were represented via a Barber's nomogram. Results: MCFs hospitalized 790 patients (-23.90% compared to 2019 Internal Medicine admissions). The main risk factors for mortality were patients admitted from local facilities (+7%) and the presence of comorbidities (>3: 100%, ≥5: 24.7%). A total of 197 (25%) patients were treated with non-invasive ventilation (NIV). The most deaths (57.14%) occurred in patients admitted from local facilities. Conclusions: Medicine-COVID-19 wards show higher complexity and demand compared to non-COVID-19 ones and they are comparable to sub-intensive therapy wards. It is necessary to promote the use of NIV in such settings.

Adequacy of hospitals in Rome to an unconventional event (CBRNe): TTX simulation and HTA

Background

Rome hosts thousands of sensible targets. Healthcare reaction has been guaranteed by 6 advanced Emergency Departments (EDs) and 7 basic ones. Everyday Rome hosts 6 millions of people/die, ± 2 million in particular occasions. About National Stockpile Antidotes (SNA), Rome hosts 3 warehouses. In case of events, stockpiles are activated with a long-time call; then stockpiles are charged in delivering trucks.

Methods

Study analyzes PEIMAF (State of emergency plans for massive influx of injures) of advanced EDs in Rome and their adequacy in a possible CBRNe attack. Hypothesis of C/N attack on Saint Peter's Square during Angelus on Wednesday (at 12.00 AM) or E attack in Trastevere on Saturday (at 9.00 PM). Analysis of activation of SNA and travel times between SNA warehouse and EDs. Comparison with French EDs during Paris attacks.

Results

EDs are chronically undermanned in ordinary conditions already, and would have issues in hosting a very large number of critical patients all at once. Some hospitals do not inform their workers about PEIMAF or they do not consider CBRNe emergencies in their PEIMAF, and even if it has been considered, hardly any simulation/exercitation is ever performed. Moreover, news of the CBRNe attack may not reach immediately the healthcare personal already at work in EDs; this is extremely problematic since they could be at major risk of contamination in case of CBRNe attacks. Furthermore, without a standardize protocol active in the whole city, no cross-hospital organization can be performed.

Conclusions

All data point towards the weakness and fragmentation of actual organizative system. Time of activation and charging are crucials for first aid efficacy and efficiency; a smart call system can reduce the activation time of SNA. A better organization of SNA in major Rome hospitals can reduce delivering time and help save more lives.

Key messages

Basing on our experience, we can say that all the resilience health strategies, especially when connected to terrorist/CBRNe events, should be managed by the National Government. the capability to face up these kind of events should be up to time-dependent networks, especially considering those hospitals with medium-high intensity healthcare.

Occupational exposure for asbestos-related disease groups: geomapping of the last 5 years in Italy

Background

Asbestos-related diseases are a public health challenge in Italy: the country has been a major producer and user of asbestos since World War II until complete ban in 1992. Several contaminated sites and structures across the country have never been decontaminated: incidence peak of asbestos-related diseases is expected somewhen between 2015 and 2020. Study objective is to investigate incidence of asbestos-related diseases in Italy in the last 5 years, from both a chronological and geographical perspective.

Methods

Ascertained diagnoses of asbestos-related diseases among workers were collected from the INAIL public registry from 2014 to 2018. Yearly incidence rate was estimated per province (incident cases per million workers) and mapped by year. Global incidence quota by working sector and sub-sector was also calculated.

Results

8.620 cases have been reported. Incidence rate rapidly increased from 2014, peaking at 7,2 new cases per 100.000 workers in 2015. Afterwards, the number of ascertained cases decreased. There is a clear gradient distribution between northern and southern Italian provinces, with the highest rates in Northern Italy (especially in year 2014) and declining over time. Mesothelioma (all variants) was the most common disease, (2.995 cases, 35% of total), followed by pleural plaques (2.955 cases, 34%), pneumoconiosis (1.327 cases, 15%) and cancer of lungs/respiratory tract (1.298 cases, 14%). Most affected category was that of metal workers, but construction, transportation and electricity workers were also affected.

Conclusions

Detailed surveillance with mapping support is an effective tool for public health servants to locally manage prevention programs targeted on occupational risk. This is especially true for areas with active industries in the most affected sectors.

Key messages

Asbestos does not mean mesothelioma, but also other diseases that impact on workforce health status. Pneumoconiosis and other oral and respiratory cancers are also associated with asbestos exposure. Risk management should be tailored for a wider array of worker types than usually considered, since such exposure happens in sectors that are not traditionally related to asbestos exposure.

PARE0015 UNDERSTANDING THE NEEDS OF PATIENTS WITH OSTEOARTHRITIS TO INFLUENCE THE DEVELOPMENT OF RELEVANT PATIENT-CENTERED PRODUCTS & TREATMENTS

Background:

Osteoarthritis (OA) is the most common form of arthritis and affects over 30 million adults in the United States of America.1There is no cure for osteoarthritis, and unlike other forms of arthritis where great treatment advances have been made in recent years, progress has been much slower in osteoarthritis.2However, there is increasing interest in removing barriers to treatment development, and the U.S. Food & Drug Administration has adopted and implemented new patient-focused drug development meetings to ensure the patient voice is informing new treatments.3

Objectives:

To gain a robust understanding of the barriers, needs and hopes of patients with OA to influence the development of relevant patient-centered products and treatments.

Methods:

A 34-question web-based survey was distributed between November 1 - 10, 2019. Survey invitations were sent via e-newsletters and e-mails to patients engaged with the Arthritis Foundation. The first survey question screened out patients who had not been diagnosed with OA.

Results:

2,437 patients diagnosed with OA completed the survey. There are 5 key findings:

1.Patients would like pain (90%) addressed more than any other symptom. Other symptoms such as fatigue (50%), sleep (39%), ability to walk (35%), stiffness (32%), ability to stand (16%), and ability to go up & down the stairs (14%) were ranked significantly below pain.

2.Patients use a variety of techniques to manage their OA and related symptoms. Physical activity (62%) and heat & cold interventions (62%) are the most prevalent. Approximately half of the patients use topical cream (53%), supplements & vitamins (51%), NSAIDS (50%), and/or acetaminophen (48%). Approximately one-third of patients utilize diet/nutrition (39%), assistive devices (38%), cortisone injections (36%), and/or physical therapy (34%). Other methods, including surgery (26%), were utilized less frequently.

3.41% of respondents reported they were “very interested” in participating in OA clinical trials; 40% reported “somewhat interested.” Only 19% reported they were “not interested.” The top 2 reasons patients were not interested included fear of possible risks/unknow effects (48%) and potential impact on other health problems (44%).

4.Primary care physicians are diagnosing (44%) and treating (48%) OA patients more than any other health care provider.

5.Many daily living tasks are difficult, and patients are interested in in tools/equipment to help. Yard work (66%), opening jars (64%), and cleaning the house (63%) are the most difficult. Over half of patients reported that physical activity (57%) and getting up and down from a chair (54%) are difficult. Patients would like tools/equipment to help them clean the house (54%) and help with physical activity (50%).

Conclusion:

OA patients use a variety of management techniques yet are still in pain and have difficulty doing everyday tasks. These findings, along with other patient data, will be used to influence product developers to create easier to use products, to inspire researchers to focus on addressing patients’ most pressing needs, and to encourage government agencies to remove barriers and facilitate new patient-centered treatments.

References:

[1]Centers for Disease Control and Prevention. Osteoarthritis (OA). Last reviewed January 10, 2019. Retrieved fromhttps://www.cdc.gov/arthritis/basics/osteoarthritis.htm

[2]Cleveland Clinic. Osteoarthritis: Management and Treatment. Last reviewed November 26, 2019. Retrieved fromhttps://my.clevelandclinic.org/health/diseases/5599-osteoarthritis-what-you-need-to-know/management-and-treatment

[3]U.S. Food and Drug Administration. Externally led Patient-Focused Drug Development Meetings. Last reviewed August 28, 2019. Retrieved fromhttps://www.fda.gov/industry/prescription-drug-user-fee-amendments/externally-led-patient-focused-drug-development-meetings

Disclosure of Interests:

None declared

Can risk be predicted? An umbrella systematic review of current risk prediction models for cardiovascular diseases, diabetes and hypertension

OBJECTIVE

To provide an overview of the currently available risk prediction models (RPMs) for cardiovascular diseases (CVDs), diabetes and hypertension, and to compare their effectiveness in proper recognition of patients at risk of developing these diseases.

DESIGN

Umbrella systematic review.

DATA SOURCES

PubMed, Scopus, Cochrane Library.

ELIGIBILITY CRITERIA

Systematic reviews or meta-analysis examining and comparing performances of RPMs for CVDs, hypertension or diabetes in healthy adult (18-65 years old) population, published in English language.

DATA EXTRACTION AND SYNTHESIS

Data were extracted according to the following parameters: number of studies included, intervention (RPMs applied/assessed), comparison, performance, validation and outcomes. A narrative synthesis was performed. Data were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

STUDY SELECTION

3612 studies were identified. After title/abstract screening and removal of duplicate articles, 37 studies met the eligibility criteria. After reading the full text, 13 were deemed relevant for inclusion. Three further papers from the reference lists of these articles were then added.

STUDY APPRAISAL

The methodological quality of the included studies was assessed using the AMSTAR tool.

RISK OF BIAS IN INDIVIDUAL STUDIES

Risk of Bias evaluation was carried out using the ROBIS tool.

RESULTS

Sixteen studies met the inclusion criteria: six focused on diabetes, two on hypertension and eight on CVDs. Globally, prediction models for diabetes and hypertension showed no significant difference in effectiveness. Conversely, some promising differences among prediction tools were highlighted for CVDs. The Ankle-Brachial Index, in association with the Framingham tool, and QRISK scores provided some evidence of a certain superiority compared with Framingham alone.

LIMITATIONS

Due to the significant heterogeneity of the studies, it was not possible to perform a meta-analysis. The electronic search was limited to studies in English and to three major international databases (MEDLINE/PubMed, Scopus and Cochrane Library), with additional works derived from the reference list of other studies; grey literature with unpublished documents was not included in the search. Furthermore, no assessment of potential adverse effects of RPMs was carried out.

CONCLUSIONS

Consistent evidence is available only for CVD prediction: the Framingham score, alone or in combination with the Ankle-Brachial Index, and the QRISK score can be confirmed as the gold standard. Further efforts should not be concentrated on creating new scores, but rather on performing external validation of the existing ones, in particular on high-risk groups. Benefits could be further improved by supplementing existing models with information on lifestyle, personal habits, family and employment history, social network relationships, income and education.

PROSPERO REGISTRATION NUMBER

CRD42018088012.

P5588Early versus delayed oral anticoagulation in patients with acute pulmonary embolism: determinants and outcome

Background

Whether early oral anticoagulant treatment is appropriate for patients with acute pulmonary embolism (PE) regardless of PE severity is undefined. The aim of this study in patients with acute PE at intermediate risk of death were: I) to assess the determinants for the use of early vs delayed vs no oral anticoagulants in patients with acute PE and II) to assess the association between timing of oral anticoagulation and in-hospital mortality.

Methods

Prospective cohorts of patients with acute PE at intermediate risk of death according to the European Society of Cardiology Guidelines 2014 were merged in a collaborative database. The initiation of oral anticoagulation was classified as early (≤3 days) or delayed (between day 3 and 10 from diagnosis). Patients treated with parenteral anticoagulants for longer than 10 days were also included. In-hospital death was the primary study outcome.

Results

Overall, 557 patients were included in the study, 23 received thrombolytic treatment during the hospital stay. The mean duration of parenteral anticoagulation was 7±8 days (5 median), 348 patients were initiated on a direct oral anticoagulant and 79 on a vitamin K antagonist during the hospital stay. Initiation of oral anticoagulants occurred early or delayed in 209 (37%) and 218 (39%) patients, respectively and never occurred during the first 30 days in 130 (23%).

Intermediate-low risk patients more commonly received early and intermediate high delayed oral anticoagulation. Simplified PESI score of zero (OR 1.9, 95% CI 1.3–2.7) was independently associated with early oral anticoagulation; among sPESI components absence of cancer (OR 5.9, 95% CI 3.3–10) and heart rate <110 (OR 1.8, 95% CI 1.01–3.16) were independent predictors of early initiation of oral anticoagulants. The presence of both right ventricle dysfunction and injury was associated with delayed initiation of oral anticoagulants.

The incidence of death was 5.5%. Death occurred in 32 patients and was not related to the duration of parenteral anticoagulation (OR 1.01 per day, 95% CI 0.98–1.06) nor to right ventricle dysfunction but to sPESI 1 (OR 3.32, 95% CI 1.14–9.66). These results were partially confirmed in the 435 intermediate risk patients without cancer (OR 1.03, 95% CI 0.99–1.08 for days of parenteral treatment; OR 4.17, 95% CI 0.95–18 for sPESI 1).

Conclusion

The clinical severity of PE and not the timing of initiation of oral anticoagulants are associated with in-hospital death in patients with intermediate risk PE. Randomized studies are needed to definitively assess the role of heparin lead-in in patients with PE at intermediate risk for death.

Autotransfusion Program: Integrated Use of Different Techniques

A successful autologous program should enroll all appropriate patients, conserve homologous blood and minimise the exposure to the risks of donor blood.

A program of autotransfusion and proper use of blood has been implemented since 1980 with the objectives to include all eligible patients and to transfuse autologous blood only. The following strategies were adopted: critical review of transfusion indications; control of overtransfusion; avoidance of waste; systematic and integrated use of all autotransfusion techniques currently available.

Results in 1992 in elective surgery: 98% enrolment, 75% blood conservation. Exposure to homologous blood was completely avoided in 53% of the cases.

Minimally invasive right colectomy: challenges and clinical practice

AIM

Since the introduction of laparoscopic and robotic technology in surgical practice, there have been multiple reports and a few clinical trials on their use in colorectal surgery. Although the application of laparoscopy to right colectomy has been increasingly adopted in many institutions around the world, there are still several open issues regarding the effective role of robotics and single incision surgery. This is a review of the relevant surgical literature evaluating the risks, benefits, and costs of minimally invasive approaches to right colectomy (RC) surgery.

METHODS

Retrospective and prospective articles spanning the past 20 years were reviewed to identify the current application of minimally invasive surgery in RC. A review of the most relevant papers comparing open vs. laparoscopic vs. robotic approaches will illustrate the role of minimally invasive surgery in current clinical practice in terms of surgical outcomes, technical advantages and oncological outcomes. We then pooled the evidence for and against the application of laparoscopy and robotics in intracorporeal vs. extracorporeal anastomosis creation, single incision and natural orifice surgery.

RESULTS

Evidence shows that compared to open surgery, laparoscopic RC provides lower postoperative morbidity, faster return to normal bowel function and a shorter length of hospital stay, with a similar oncological outcome. The application of robotics to RC procedure has proven to be safe and feasible, however the intraoperative and postoperative outcomes are similar with the laparoscopic technique and no clear advantages have been demonstrated. When adopted in a single incision technique and natural orifice surgery, robotics can help to overcome the limitations of laparoscopy, enabling the surgeon to perform scar-less surgery.

CONCLUSION

Laparoscopy surgery, whenever performed by adequately trained surgeons, can be safely applied to right colectomy and should be considered as the gold standard procedure. In terms of robotic surgery, to date, this technology needs more evidence from multicenter randomized clinical trials. New tools and instruments are needed to expand the field of single incision and natural orifice surgery, and make it available in current clinical practice.

Progesterone receptor expression and proliferative activity in uterine tumours of pet rabbits

Endometrial adenocarcinoma is the most common uterine tumour of domestic rabbits. The present immunohistochemical study examined the expression of cytokeratin 19 (CK19), the progesterone receptor (PR), the proliferation-associated antigen Ki-67 and telomerase in normal rabbit uterine tissue and examples of endometrial hyperplasia, adenoma and adenocarcinoma. Tubulopapillary adenomas and adenocarcinomas were the most common histological subtypes in this series. Cytoplasmic expression of CK19 was recorded in two of three samples of normal endometrium and in one of three samples of endometrial hyperplasia, in all adenomas and five of six adenocarcinomas. PR was expressed within the nucleus of normal endometrial cells and in one of three samples of endometrial hyperplasia, each of four adenomas and in four of six adenocarcinomas. This finding suggests that PR expression is not directly involved in neoplastic transformation of the endometrium and that such expression is not a prognostic indicator. Nuclear labelling of telomerase activity was found in one of three normal uteri, all samples of endometrial hyperplasia, two of four adenomas, but none of the adenocarcinomas. The proliferation index as determined by Ki-67 expression was 9.7+/-2.75% (mean+/- standard-deviation (SD)) for normal endometrium, 11.29+/-2.5% for hyperplastic endometrium, 19.40+/-3.01% for benign tumours and 19.41+/-7.9% for malignant tumours. These findings may be interpreted to suggest that hormonal and anti-proliferative treatment may be more appropriate for the management of uterine carcinomas in rabbits than anti-telomerase treatment.

Hyperhomocysteinemia is associated with cognitive impairment in multiple sclerosis

Hyperhomocysteinemia (HHcy) has been associated with cognitive impairment in various neurological diseases. Cognitive impairment occurs early in multiple sclerosis (MS). Conflicting data have been reported regarding plasma total homocysteine (tHcy) levels in MS patients, and the impact of HHcy on cognitive impairment in MS is not known. This study investigated whether plasma total homocysteine levels are increased in MS and if HHcy is associated with cognitive impairment in MS. We compared tHcy levels in 94 patients with MS and 53 healthy age-matched controls. We used a neuropsychological test battery that included the Raven's Coloured Progressive Matrices, the Visual Search Test, the Trail Making Test A and B, the Immediate and Delayed Recall of a Short Story, the 30 Paired Word Associates, the Rey-Osterrieth Complex Figure Test, and the Semantic and Verbal Fluency Tests. Clinical (sex, age, type of MS, relapse, disease duration, coexisting disease, smoking habit, and physical disability) and laboratory variables (HHcy, low serum levels of folate and vit.B12, MTHFR genotype) were evaluated for their ability to predict cognitive impairment. The mean tHcy was higher in patients (13.19 micromol/L, SD5.58) than in controls (9.81 micromol/L, SD2.53; p < 0.001). Univariate analysis determined the following factors to be associated with cognitive impairment: higher age at observation, chronic progressive course of disease, longer disease duration,moderate or severe physical disability, and frequency of HHcy. With multivariate regression analysis, there remained a significant association only between frequency of HHcy and cognitive impairment (beta 0.262, p = 0.01). We conclude that tHcy levels are increased in MS and that HHcy is associated with cognitive impairment in this disease.

FMECA methodology applied to two pathways in an orthopaedic hospital in Milan

INTRODUCTION

Adverse events pose a challenge to medical management: they can produce mild or transient disabilities or lead to permanent disabilities or even death; preventable adverse events result from error or equipment failure.

METHODS

IRCCS Istituto Ortopedico Galeazzi implemented a clinical risk management program in order to study the epidemiology of adverse events and to improve new pathways for preventing clinical errors: a risk management FMECA-FMEA pro-active analysis was applied either to an existing clinical support pathway or to a new process before its implementation.

RESULTS

The application of FMEA-FMECA allowed the clinical risk unit of our hospital to undertake corrective actions in order to reduce the adverse events and errors on high-risk procedure used inside the hospitals.

Autoimmune myocarditis and dilated cardiomyopathy: focus on cardiac autoantibodies

Criteria of organ-specific autoimmunity are fulfilled in a subset of patients with myocarditis/dilated cardiomyopathy (DCM). In particular, circulating heart-reactive autoantibodies are found in patients and symptom-free relatives. These autoantibodies are directed against multiple antigens, some of which are expressed in the heart (organ-specific), others in heart and some skeletal muscle fibres (partially-heart specific) or in heart and skeletal muscle (muscle-specific). Distinct autoantibodies have different frequency in disease and normal controls. Different techniques detect one or more antibodies, thus they cannot be used interchangeably for screening. It is unknown whether the same patients produce more antibodies or different patient groups develop autoimmunity to distinct antigens. IgG antibodies, shown to be cardiac and disease-specific for myocarditis/DCM, can be used as autoimmune markers for identifying patients in whom immunosuppression may be beneficial and relatives at risk. Some autoantibodies may also have a functional role, but further work is needed.

Epoetin alfa in low hematocrit patients to facilitate autologous blood donation in total hip replacement: a randomized, double-blind, placebo-controlled, dose-ranging study

We investigated the safety and efficacy of preoperative epoetin alfa used in conjunction with preoperative autologous blood donation (PAD) in 40 anemic orthopedic surgical patients undergoing hip replacement surgery [hematocrit (Hct) </=39%]. Patients were randomized 25-35 days before surgery to twice weekly intravenous (i. v.) epoetin alfa (300, 150, or 75 IU/kg) or placebo treatments supplemented with 200 mg i.v. iron. Epoetin alfa facilitated dose-dependent increases in PAD (4.3 units, 300 IU/kg; 3.4 units, 150 IU/kg; 3.0 units, 75 IU/kg; 2.1 units, placebo), and minimized reductions in Hct associated with repeated phlebotomy. All epoetin alfa doses were well tolerated and safe. Our results indicate that preoperative epoetin alfa dose-dependently stimulates erythropoiesis and facilitates PAD in anemic orthopedic patients, which may benefit patients by reducing their exposure to the risks of allogeneic transfusion, hastening recovery and discharge from hospital.

[Atherosclerosis in childhood: the role of obesity]

A variety of studies indicates that the process of atherosclerosis begins in childhood and progresses during adulthood. Chronic obesity, inadequate caloric intake, and hypertension and smoke, are associated with an increased cardiovascular disease. The aim of this study is to investigate if the presence of some risk factors during adolescence may involve in accelerated atherosclerosis disease. 50 subjects, median age 11 +/- 0.6 SD (27 females, and 23 males) are admitted to the study. After overnight fasting we have investigated: lipoproteina A (nephelometric test), glycemia and insulin baseline and after load 120', tryglycerides, cholesterolo, apolipoproteina A, B, plasma concentrations. In addition to general medical evaluation, anthropometric measurements of weight, height, blood pressure, BMI, overnight ratio were calculated according to Tanner's charts. The means anthropometric and metabolic values in different groups were compared. One group affected with abdominal obesity state (waist-hips ratio > 0.9), the second with mid obesity condition (waist-hip ratio < 0.9). Tryglycerides, cholesterolo, insulin plasma concentrations in both groups were considered similar. However in the first group higher levels of apolipoproteina A (means 102 + 10.2 SD) and lipoproteina A were demonstrated (P = 0.03 in males, P = 0.01 Statview for Mann Whitney test). Childhood is an important period for the development of the atherosclerosis such as the presence of obesity during this time has a very high likelihood of persisting into adulthood. The severity of obesity in adults is greater in those who were obese as adolescents. In accord with other authors we have not observed abnormal tryglicerides and cholesterolo plasma concentrations, which probably are found in adulthood obesity. We believe indeed the risk factors are different in obesity of childhood, atherosclerosis may be induced by high endogenous insulin secretion and abnormal uptake of lipoprotein. However the potential consequence of excessive insulin secretion could be due in part to insulin effects on recruitment of histiocytosis cells during the development of atheroma and through the modulation of hepatic production and peripheral uptake of lipoproteins.

Comparison between intravenous and subcutaneous recombinant human erythropoietin (Epoetin alfa) administration in presurgical autologous blood donation in anemic rheumatoid arthritis patients undergoing major orthopedic surgery

BACKGROUND AND OBJECTIVES

Intravenous (i.v.) Recombinant erythropoietin (Epoetin alfa) is effective in allowing autologous blood donation in patients unable to donate because of anemia. We undertook this open pilot study in order to asses whether a low subcutaneous (s.c.) dose of Epoetin alfa would prove as effective and well tolerated as the higher i.v. dose. Such a move would also decrease costs.

MATERIALS AND METHODS

A total Epoetin alfa s.c. dose of 800 IU/kg was compared with a total i.v. dose of 1,800 IU/kg. Twenty-two rheumatoid arthritis patients, unable to donate because of hemoglobin (Hb) < 11 g/dl, received 300 IU/kg of IV Epoetin alfa twice weekly for 3 weeks (11 patients), or 100 IU/kg of s.c. Epoetin alfa twice weekly for 3 weeks plus an i.v. bolus of 200 IU/kg of Epoetin alfa at the first visit (11 patients). At each visit, all patients received 100 mg of i.v. iron saccharate and when the hematocrit (hct) > or = 34%, 350 ml of autologous blood (AB) were collected.

RESULTS

No significant differences were observed between the 2 groups of treated patients in terms of units of AB collected (2.6 +/- 0.6 vs. 2.5 +/- 0.5 units for i.v. and s.c. groups, respectively), ml of RBC produced during the study period (291 +/- 99 vs. 337 +/- 65 ml for the i.v. and s.c. groups, respectively), or in the degree of reduced exposure to allogeneic blood in comparison with the control group.

CONCLUSIONS

Lower dose of Epoetin alfa (reduced by 56%), supplemented by i.v. iron, is as effective and well tolerated as higher doses administered i.v., supplemented by i.v. iron.

A case-control study of Salmonella gastrointestinal infection in Italian children

A case-control study of 85 cases with non-typhoid Salmonella gastroenteritis, 85 outpatient controls and 79 inpatient controls was conducted among children in Monfalcone, north-east Italy, between June 1989 and June 1994. Logistic regression was used to evaluate the effect of demographic and socio-economic characteristics, duration of breastfeeding, history of intestinal illnesses and household diarrhoea, and the recent use of antimicrobials. Breastfeeding was the single most important factor associated with a 5-fold decreased risk of Salmonella infection. In addition, children who were treated with antimicrobials before onset of gastroenteritis had a 3-fold increased risk. Low social class and history of other chronic non-infectious intestinal diseases were also directly associated with illness.

Bedside transfusion errors: analysis of 2 years' use of a system to monitor and prevent transfusion errors

Clerical errors occurring during specimen collection, issue and transfusion of blood are the most common cause of AB0 incompatible transfusions. 40-50% of the transfusion fatalities result from errors in properly identifying the patient or the blood components. The frequency and type of errors observed, despite the implementation of measures to prevent them, suggests that errors are inevitable unless major changes in procedures are adopted. A fail-safe system, which physically prevents the possibility of error, was adopted in January 1993 and concurrently a quality improvement program was implemented to monitor any transfusion errors. Up to December 1994, 10,995 blood units (5,057 autologous and 5,938 allogeneic) were transfused to 3,231 patients. Seventy-one methodological errors(1/155 units) were observed, half of which were concentrated during the first 4 months of introducing the system. However the system detected and avoided four potentially fatal errors (1/2,748 units). Two cases involved the interchanging of recipient sample tubes, 1 case was due to patient misidentification and the other involved misidentification of blood units. In conclusion the system is effective in detecting otherwise undiscovered errors in transfusion practice and can prevent potential transfusion-associated fatalities caused by misidentification of blood units or recipients.

Autologous blood pre-deposit and cell salvage in orthopedic surgery

A successful autologous blood program should enrol all appropriate patients, conserve homologous blood and minimize the exposure to the risks of donor blood. A program of autotransfusion and proper use of blood has been implemented since 1980 with the objectives of including all eligible patients and to transfuse autologous blood only. The following strategies were adopted: critical review of transfusion indications; control of over-transfusion; avoidance of waste; systematic and integrated use of all autotransfusion techniques currently available. Results in 1992 in elective surgery: 98% enrolment, 75% blood conservation. Exposure to homologous blood was completely avoided in 53% of the cases.

Use of recombinant human erythropoietin to assist autologous blood donation by anemic rheumatoid arthritis patients undergoing major orthopedic surgery

BACKGROUND

In rheumatoid arthritis (RA) patients undergoing orthopedic surgery, anemia is the major factor in the use of allogeneic blood.

STUDY DESIGN AND METHODS

To determine whether recombinant human erythropoietin (rHuEPO) could allow preoperative autologous blood procurement and reduce allogeneic blood exposure, 11 RA patients who were unable preoperatively to deposit blood for autologous use because of their anemia (baseline hematocrit < 34% [0.34]) and who were scheduled for primary total hip replacement or total knee replacement were treated intravenously with 300 U per kg of rHuEPO in combination with intravenous iron saccharate (100 mg), given twice weekly for 3 weeks. The transfusion treatment was compared with that in 12 control patients with comparable baseline hematologic values who underwent the same operation.

RESULTS

Control patients could not preoperatively deposit any blood for autologous use, while all but one of the rHuEPO-treated patients deposited 2 or more units (mean, 2.6 +/- 0.6; range, 2-4) (p < 0.001). The control group received more allogeneic units (2.6 +/- 1.6 vs. 0.8 +/- 0.8) (p = 0.009). Moreover, 50 percent of the rHuEPO-treated patients, as compared with 8 percent of controls, completely avoided allogeneic transfusion.

CONCLUSION

Recombinant human erythropoietin is safe and effective in stimulating erythropoiesis, allowing preoperative donation of blood for autologous use, and reducing exposure to allogeneic blood for RA patients who are unable preoperatively to deposit blood because of anemia.

One-year use of the Bloodloc system in an orthopedic institute

Human error in patient or specimen identification due to fatigue, stress and lack of attention by technologists, nurses, interns, and physicians, can cause routinely safety procedures to be circumvented. Clerical errors may occur during the specimen collection, the issue of blood unit and the transfusion of blood. The introduction in an increasing number of hospital of preoperative autologous blood donation programs further increases the chance of error, because a single patient can predeposit multiple units of blood. In this cases there is a greater commitment not only to transfuse any blood unit that is ABO compatible but to transfuse the specific units the patient previously donated for his own use. Human error has been recognized as a significant cause of transfusion-associated fatalities. The persistence of the frequency and type of errors observed in spite of extensive efforts to eradicate them, suggests that errors are inevitable as long as large number of repetitive procedures are performed unless major system changes are adopted. A system (Bloodloc System) that physically prevents the possibility of error was adopted since January 1993 and cuncurrently a quality improvement program (QI) was implemented specifically designed to monitor: 1. the absence of the code on the blood samples, 2. the blood bank error in setting the Bloodloc, 3. the misidentification of blood samples, 4. any attempt to transfuse the wrong blood unit, 5. any attempt to transfuse, the wrong patients.

RESULTS

4895 blood units (2469 autologous and 2426 allogeneic units) were transfused to 1478 patients (849 predeposited an average of 3.3 +/- 2.0 units). The methodological errors (absence of three-letter code on the patient's specimen tube, wrong transcription of the code on the blood sample, wrong setting of the Bloodloc in the blood bank)--41 cases--were limited at the first four months of implementation of the system. In the same period however have been reported 3 potentially fatal errors which have been avoided by the Bloodloc. Two cases of misidentification of blood samples at the moment of the specimen collection, and one attempt to transfuse the wrong units to the wrong patients.

CONCLUSIONS

The Bloodloc system is effective in preventing potential transfusion-associated fatalities caused by units or recipients misidentification.

The potential role of oxygen-carrying products in autologous blood transfusion protocols

For surgical patients transfusion of autologous blood (AB) is the most useful of measures to reduce patient's exposure to homologous blood (HB). In our Institute an autotransfusion program was started in 1982 utilizing all the autotransfusion techniques currently available. The integrated use of the techniques offered to the majority of the patients the possibility of receiving AB (98% of the elective surgery patients) and a consistent conservation of HB has been achieved (60-70%). However 42% are still exposed to some HB. Critical parameters that render the patients unable to fulfill the anticipated transfusion needs with the current AB transfusion techniques are: the patient's ability to predonate sufficient AB prior to surgery and the amount of blood transfused intraoperatively that in turn depends on different "transfusion trigger". In our Institute over 50% of all the blood units are transfused the day of operation (60% being AB, 40% HB) and 50% postoperatively (only 33% being AB). For this reason, a clinical application for the oxygen-carrying products can be the replacement of the blood lost during, or immediately after the operation permitting the surgeon to operate safely at a lower Hct levels, thereby delaying the transfusion of blood and saving the AB obtained.

Autotransfusion program: integrated use of different techniques

A successful autologous program should enroll all appropriate patients, conserve homologous blood and minimise the exposure to the risks of donor blood. A program of autotransfusion and proper use of blood has been implemented since 1980 with the objectives to include all eligible patients and to transfuse autologous blood only. The following strategies were adopted: critical review of transfusion indications; control of overtransfusion; avoidance of waste; systematic and integrated use of all autotransfusion techniques currently available. Results in 1992 in elective surgery: 98% enrollment, 75% blood conservation. Exposure to homologous blood was completely avoided in 53% of the cases.

Use of erythropoietin to increase the volume of autologous blood donated by orthopedic patients

For patients who donate blood for autologous use and undergo major orthopedic surgery, low basal hematocrit (Hct) is the major cause of allogeneic blood exposure. To determine whether recombinant human erythropoietin (rHuEPO) could increase autologous blood procurement and reduce allogeneic blood exposure, a prospective randomized study was conducted in 50 women undergoing total hip replacement who had basal Hct < 40 percent (0.40). Patients were randomly placed in three groups: those receiving placebo, those receiving 300 U of rHuEPO per kg, and those receiving 600 U of rHuEPO per kg every 3 to 4 days for 21 days. Oral iron (125-270 mg/day) was given; in the last 24 patients, 100 mg of iron saccharate was administered intravenously at each donation. At each visit, 350 mL of blood was collected if Hct was > or = 34 percent (0.34). Patients receiving rHuEPO donated a greater amount of blood for autologous use than did patients in the placebo group (4.5 +/- 1.1 vs. 2.8 +/- 0.6 units; p < 0.05) and received a significantly lower amount of allogeneic blood (1.2 +/- 1.4 vs. 0.4 +/- 0.8 units; p < 0.05). No difference between the effects of the two doses of rHuEPO was observed. Iron support was a critical factor in the efficacy of treatment. No untoward effects were observed. The rHuEPO emerged as a safe and effective treatment, with adequate iron support, by which to increase preoperative deposit of autologous blood and to reduce exposure to allogeneic blood for patients with low basal Hct.

[Complications of gastroduodenal peptic ulcers]

The paper reports that the introduction of H2-antagonist histamine drugs has led to the present drastic contraction of surgical therapy and complications related to gastroduodenal peptic ulcers. Following a brief discussion of the diagnostics of the various complications of the disease, the surgical urgency is then underlined and case studies are presented (A. Vinci). Thirty-seven hemorrhagic ulcers are reported, 32 of which were completely treated with somatostatin and blood transfusions and 5 were operated for gastrosection during hemorrhage; 70 acute gastroduodenal perforations and 8 blocked pyloroduodenal stenoses are also reported. The surgical approach used for each type of complication is discussed, underlining the end-result to be attained in relation to the patient's future. It is stressed, however, that the surgeon's main goal must be to save the patient's life using the simplest and most efficacious method available.