A Model Predicting the 6-Month Disability of Patients With Traumatic Brain Injury to Assess the Quality of Care in Intensive Care Units: Results from the CREACTIVE Study

Assessing quality of care is essential for improving the management of patients experiencing traumatic brain injury (TBI). This study aimed at devising a rigorous framework to evaluate the quality of TBI care provided by intensive care units (ICUs) and applying it to the Collaborative Research on Acute Traumatic Brain Injury in Intensive Care Medicine in Europe (CREACTIVE) consortium, which involved 83 ICUs from seven countries. The performance of the centers was assessed in terms of patients' outcomes, as measured by the 6-month Glasgow Outcome Scale-Extended (GOS-E). To account for the between-center differences in the characteristics of the admitted patients, we developed a multinomial logistic regression model estimating the probability of a four-level categorization of the GOS-E: good recovery (GR), moderate disability (MD), severe disability (SD), and death or vegetative state (D/VS). A total of 5928 patients admitted to the participating ICUs between March 2014 and March 2019 were analyzed. The model included 11 predictors and demonstrated good discrimination (area under the receiver operating characteristic [ROC] curve in the validation set for GR: 0.836, MD: 0.802, SD: 0.706, D/VS: 0.890) and calibration, both overall (Hosmer-Lemeshow test p value: 0.87) and in several subgroups, defined by prognostically relevant variables. The model was used as a benchmark for assessing quality of care by comparing the observed number of patients experiencing GR, MD, SD, and D/VS to the corresponding numbers expected in each category by the model, computing observed/expected (O/E) ratios. The four center-specific ratios were assembled with polar representations and used to provide a multidimensional assessment of the ICUs, overcoming the loss of information consequent to the traditional dichotomizations of the outcome in TBI research. The proposed framework can help in identifying strengths and weaknesses of current TBI care, triggering the changes that are necessary to improve patient outcomes.

Diagnosis of sepsis in the emergency department: a real-world analysis from Lombardy, Italy

Early identification of sepsis is particularly important in the emergency department (ED). However, data on the diagnosis of sepsis in the ED are scanty, especially within the Italian context. To quantify sepsis incidence and recognition in the ED from Lombardy, Italy, we used EUOL data from the Regional Emergency Agency for the years 2017-2022. Sepsis was identified based on the ED discharge diagnosis; recognized sepsis cases were those assigned to a high-priority code at triage, while unrecognized ones were those assigned to a low priority code. Odds ratios (ORs) for sepsis recognition according to various patient characteristics were estimated using multivariable mixed-effects logistic regression models. The rate of sepsis diagnosis in ED was 1.9 per 1000 (6626 patients) in 2017 and increased to 3.4 per 1000 in 2022 (11,508 patients). In 2022, 67% of sepsis cases were correctly identified. Death in the ED was more frequent in patients with recognized sepsis (10.4%) than in those with unrecognized sepsis (2.3%). The probability of sepsis being recognized at ED admission was higher in men (multivariable OR: 1.06), in individuals with advanced age (OR: 1.71 for age ≥ 90 years vs < 60), and in those with access to the second (OR: 1.48) and third ED level (OR: 1.87). Conversely, it was lower in patients arriving at the ED through autonomous transportation (OR: 0.36). This large real-world analysis indicates an increase in sepsis cases referred to the ED in recent years. About one-third of sepsis cases are not correctly identified at triage, although more severe cases appear to be promptly recognized.

Assessing the heterogeneity of the impact of COVID-19 incidence on all-cause excess mortality among healthcare districts in Lombardy, Italy, to evaluate the local response to the pandemic: an ecological study

OBJECTIVES

The fragmentation of the response to the COVID-19 pandemic at national, regional and local levels is a possible source of variability in the impact of the pandemic on society. This study aims to assess how much of this variability affected the burden of COVID-19, measured in terms of all-cause 2020 excess mortality.

DESIGN

Ecological retrospective study.

SETTING

Lombardy region of Italy, 2015-2020.

OUTCOME MEASURES

We evaluated the relationship between the intensity of the epidemics and excess mortality, assessing the heterogeneity of this relationship across the 91 districts after adjusting for relevant confounders.

RESULTS

The epidemic intensity was quantified as the COVID-19 hospitalisations per 1000 inhabitants. Five confounders were identified through a directed acyclic graph: age distribution, population density, pro-capita gross domestic product, restriction policy and population mobility.Analyses were based on a negative binomial regression model with district-specific random effects. We found a strong, positive association between COVID-19 hospitalisations and 2020 excess mortality (p<0.001), estimating that an increase of one hospitalised COVID-19 patient per 1000 inhabitants resulted in a 15.5% increase in excess mortality. After adjusting for confounders, no district differed in terms of COVID-19-unrelated excess mortality from the average district. Minimal heterogeneity emerged in the district-specific relationships between COVID-19 hospitalisations and excess mortality (6 confidence intervals out of 91 did not cover the null value).

CONCLUSIONS

The homogeneous effect of the COVID-19 spread on the excess mortality in the Lombardy districts suggests that, despite the unprecedented conditions, the pandemic reactions did not result in health disparities in the region.

Strategies to convert hospital beds for COVID-19 patients to minimize emergency department overcrowding

Background: The shortage of hospital beds for COVID-19 patients has been one critical cause of Emergency Department (ED) overcrowding. Purpose: We aimed at elaborating a strategy of conversion of hospital beds, from non-COVID-19 to COVID-19 care, minimizing both ED overcrowding and the number of beds eventually converted. Research Design: Observational retrospective study. Study Sample: We considered the centralized database of all ED admissions in the Lombardy region of Italy during the second "COVID-19 wave" (October to December 2020). Data collection and Analysis: We analyzed all admissions to 82 EDs. We devised a family of Monte Carlo simulations to evaluate the performance of hospital beds' conversion strategies triggered by ED crowding of COVID-19 patients, determining a critical number of beds to be converted when passing an ED-specific crowding threshold. Results: Our results suggest that the maximum number of patients waiting for hospitalization could have been decreased by 70% with the proposed strategy. Such a reduction would have been achieved by converting 30% more hospital beds than the total number converted in the region. Conclusions: The disproportion between reduction in ED crowding and additionally converted beds suggests that a wide margin to improve the efficiency of the conversions exists. The proposed simulation apparatus can be easily generalized to study management policies synchronizing ED output and in-hospital bed availability.

Hb Santa Juana (β 108(G10) Asn > Ser): a low oxygen affinity hemoglobin variant in a family of Bosnian background

We present a family that carries the β-hemoglobin variant Hb Santa Juana (HBB:c.326A>G, β 108(G10) Asn>Ser), also known as Hb Serres, in three generations. All affected family members had an anomal hemoglobin fraction as detected by HPLC but normal blood count without evidence of anemia or hemolysis. Oxygen affinity (p₅₀ (O₂) = 31.9-40.4 mmHg) was decreased in all probands, compared to 24.9-28.1 mmHg in unaffected individuals. Clinical symptoms likely related to the hemoglobin variant were cyanosis during anaesthesia, while other complaints such as shortness of breath or dizziness were less clearly linked with the hemoglobin variant.

Prognostic value of respiratory parameters for COVID-19 patients in the emergency department: results from the EC-COVID study

While several studies have evaluated the prognostic weight of respiratory parameters in patients with COVID-19, few have focused on patients' clinical conditions at the first emergency department (ED) assessment. We analyzed a large cohort of ED patients recruited within the EC-COVID study over the year 2020, and assessed the association between key bedside respiratory parameters measured in room air (pO2, pCO2, pH, and respiratory rate [RR]) and hospital mortality, after adjusting for key confounding factors. Analyses were based on a multivariable logistic Generalized Additive Model (GAM). After excluding patients who did not perform a blood gas analysis (BGA) test in room air or with incomplete BGA results, a total of 2458 patients were considered in the analyses. Most patients were hospitalized on ED discharge (72.0%); hospital mortality was 14.3%. Strong, negative associations with hospital mortality emerged for pO2, pCO2 and pH (p-values: < 0.001, < 0.001 and 0.014), while a significant, positive association was observed for RR (p-value < 0.001). Associations were quantified with nonlinear functions, learned from the data. No cross-parameter interaction was significant (all p-values were larger than 0.10), suggesting a progressive, independent effect on the outcome as the value of each parameter departed from normality. Our results collide with the hypothesized existence of patterns of breathing parameters with specific prognostic weight in the early stages of the disease.

Comparative Effectiveness of Intracranial Pressure Monitoring on 6-Month Outcomes of Critically Ill Patients With Traumatic Brain Injury

Importance

While the relationship between persistent elevations in intracranial pressure (ICP) and poorer outcomes is well established for patients with traumatic brain injury (TBI), there is no consensus on how ICP measurements should drive treatment choices, and the effectiveness of ICP monitoring remains unknown.

Objective

To evaluate the effectiveness of ICP monitoring on short- and mid-term outcomes of patients with TBI.

Design, Setting, and Participants

CREACTIVE was a prospective cohort study that started in March 2014 and lasted 5 years. More than 8000 patients with TBI were enrolled at 83 intensive care units (ICUs) from 7 countries who joined the CREACTIVE Consortium. Patients with TBI who met the Brain Trauma Foundation guidelines for ICP monitoring were selected for the current analyses, which were performed from January to November 2022.

Exposure

Patients who underwent ICP monitoring within 2 days of injury (exposure group) were propensity score-matched to patients who were not monitored or who underwent monitoring 2 days after the injury (control group).

Main Outcome and Measure

Functional disability at 6 months as indicated by Glasgow Outcome Scale-Extended (GOS-E) score.

Results

A total of 1448 patients from 43 ICUs in Italy and Hungary were eligible for analysis. Of the patients satisfying the ICP-monitoring guidelines, 503 (34.7%) underwent ICP monitoring (median [IQR] age: 45 years [29-61 years]; 392 males [77.9%], 111 females [22.1%]) and 945 were not monitored (median [IQR] age: 66 years [48-78 years]; 656 males [69.4%], 289 females [30.6%]). After matching to balance the variables, worse 6-month recovery was observed for monitored patients compared with nonmonitored patients (death/vegetative state: 39.2% vs 40.6%; severe disability: 33.2% vs 25.4%; moderate disability: 15.7% vs 14.9%; good recovery: 11.9% vs 19.1%, respectively; P = .005). Monitored patients received medical therapies significantly more frequently.

Conclusions and Relevance

In this cohort study, ICP monitoring was associated with poorer recovery and more frequent medical interventions with their relevant adverse effects. Optimizing the value of ICP monitoring for TBI requires further investigation on monitoring indications, clinical interventions, and management protocols.

Tandem haematopoietic stem cell transplantation versus single cell transplant and BV maintenance in relapsed/refractory Hodgkin lymphoma: A matched cohort analysis from the LYSA

Autologous hematopoietic stem cell transplant (ASCT) is the standard curative treatment for patients with high-risk relapsed/refractory Hodgkin lymphoma (R/R HL). The AETHERA study showed survival gain with Brentuximab Vedotin (BV) maintenance after ASCT in BV-naive patients, which was recently confirmed in the retrospective AMAHRELIS cohort, including a majority of BV-exposed patients. However, this approach has not been compared to intensive tandem auto/auto or auto/allo transplant strategies, which were used before BV approval. Here, we matched BV maintenance (AMAHRELIS) and tandem SCT (HR2009) cohorts, and observed that BV maintenance was associated with better survival outcome in patients with HR R/R HL.

Parameters influencing renal response to SGLT2 inhibitors and GLP1 receptor agonists in type 2 diabetes patients with preserved renal function: a comparative, prospective study

PURPOSE

SGLT2 inhibitors (SGLT2i) and GLP1 receptor agonists (GLP1-RA) protect the kidney in type 2 diabetes (T2DM) subjects. The role of patient's phenotype years before starting the treatment in determining the kidney response to these drugs has never been evaluated.

SUBJECTS AND METHODS

Clinical and biochemical parameters were collected in 92 T2DM patients with preserved kidney function from year -4 (T-4) to year +3 (T+3) from the introduction of semaglutide or empagliflozin (T0). Glomerular filtration rate (eGFR) slopes were evaluated to identify eGFR changes (ΔGFR) and predictors of treatment response. Urinary markers of kidney impairment were measured at T0, including KIM-1, TNFR1 and L-FABP.

RESULTS

Characteristics of patients on semaglutide (n = 46) or empagliflozin (n = 37) were similar at T-4 and T0. ΔGFR from T0 to T+3 was -5.5 [-10.0; -0.7] vs -2.6 [-102.4] ml/min/1.73 m² for GLP1-RA and SGLT2i, respectively (p = ns). Compared with patients with a slower eGFR decline, those with ΔGFR > 5 ml/min/1.73 m² from T0 to T+3 (49%) or ΔGFR > 10 ml/min/1.73 m² from T-4 to T+3 (25%) had similar characteristics and urinary markers at T-4 and T0. The latter group showed greater eGFR decline from T-3 to T0, which tended to be delayed more by SGLT2i than GLP1-RA (p = 0.09).

CONCLUSION

In our cohort, subjects with T2DM and preserved renal function show similar eGFR response to treatment with GLP1-RA or SGLT2i. Baseline urinary biomarkers or prior phenotyping do not predict treatment response. An early eGFR decline identifies patients prone to lose more eGFR over time, who may benefit more from SGLT2i treatment.

Hospital-care utilization and medical cost patterns among patients with insulin-dependent diabetes

OBJECTIVE

Using claims data from an integrated payer-provider, we compared the costs incurred by insulin-dependent diabetes mellitus (IDDM) patients who received Hospital Inpatient/Observation/Emergency Department care (HIghER care) for diabetes-related events with those who did not receive such care to identify a target population for interventions in future studies.

METHODS

A retrospective study pooled real-world claims data for IDDM with type 1 or type 2 DM between July 1, 2018 and June 30, 2019. Medical claims were used to calculate the total and diabetes-related allowed medical costs to the Enterprise and per-member per month (pmpm) costs.

RESULTS

A total of 19,378 members' medical and prescription drug coverage were analyzed. Only 8.4% of the IDDM population received HIghER care but incurred 20% of medical expenses, and nearly 40% of diabetes-related medical costs. For HIghER care patients, medical spending was higher in every inpatient and outpatient category (Wilcoxon two sample tests, all p < 0.0001). Non-diabetes related prescription drug costs were greater in this group (Wilcoxon, Z = 2.2879, p = 0.0221), but diabetes-related prescription drug costs were higher for non-HIghER care (Wilcoxon, Z = -9.5918, p < 0.0001). In a longitudinal study of 29,602 patients over 24 months, prior-year receipt of HIghER care was a significant predictor of HIghER care the subsequent year (odds ratio 3.28) CONCLUSIONS: Medical spending for HIghER care patients was disproportionately high and greater in every inpatient and outpatient category. Receipt of HIghER care in the previous year was highly predictive of HIghER care episodes the following year.

Comparison of leg dynamic models for quadrupedal robots with compliant backbone

Many quadrupeds are capable of power efficient gaits, especially trot and gallop, thanks to their flexible trunk. The oscillations of the system that includes the backbone, the tendons and musculature, store and release elastic energy, helping a smooth deceleration and a fast acceleration of the hindquarters and forequarters, which improves the dynamics of running and its energy efficiency. Forelegs and hindlegs play a key role in generating the bending moment in the trunk. In this paper we present our studies aimed at modeling and reproducing such phenomena for efficient quadrupedal robot locomotion. We propose a model, called mass-mass-spring model, that overcomes the limitation of existing models, and demonstrate that it allows studying how the masses of the legs generate a flexing force that helps the natural bending of the trunk during gallop. We apply our model to six animals, that adopt two different galloping patterns (called transverse and rotatory), and compare their energy efficiency.

Benchmark of Intraoperative Activity in Cardiac Surgery: A Comparison between Pre- and Post-Operative Prognostic Models

Objectives: Despite its large diffusion and improvements in safety, the risks of complications after cardiac surgery remain high. Published predictive perioperative scores (EUROSCORE, STS, ACEF) assess risk on preoperative data only, not accounting for the intraopertive period. We propose a double-fold model, including data collected before surgery and data collected at the end of surgery, to evaluate patient risk evolution over time and assess the direct contribution of surgery. Methods: A total of 15,882 cardiac surgery patients from a Margherita-Prosafe cohort study were included in the analysis. Probability of death was estimated using two logistic regression models (preoperative data only vs. post-operative data, also including information at discharge from the operatory theatre), testing calibration and discrimination of each model. Results: Pre-operative and post-operative models were built and demonstrate good discrimination and calibration with AUC = 0.81 and 0.87, respectively. Relative difference in pre- and post-operative mortality in separate centers ranged from −0.36 (95% CI: −0.44–−0.28) to 0.58 (95% CI: 0.46–0.71). The usefulness of this two-fold preoperative model to benchmark medical care in single hospital is exemplified in four cases. Conclusions: Predicted post-operative mortality differs from predicted pre-operative mortality, and the distance between the two models represent the impact of surgery on patient outcomes. A double-fold model can assess the impact of the intra-operative team and the evolution of patient risk over time, and benchmark different hospitals on patients subgroups to promote an improvement in medical care in each center.

Acute pulmonary edema in a dog with severe pulmonary valve stenosis: A rare complication after balloon valvuloplasty

Pulmonic stenosis is a frequent congenital heart disease in dogs, and the treatment of choice is balloon valvuloplasty which is usually safe and successful. The authors describe for the first time a severe complication after balloon valvuloplasty in a five-month-old dog. After effective treatment, with a considerable drop in right ventricular pressures, the dog developed hypoxemia and dyspnea due to pulmonary edema. The dog underwent intensive care and symptoms improved after a few hours of oxygen therapy, continuous positive airway pressure, and furosemide. Although this event is rare, it could have a large impact on patient survival and should be considered in the treatment of severe pulmonary valve stenosis in the future.

High dose coupled plasma filtration and adsorption in septic shock patients. Results of the COMPACT-2: a multicentre, adaptive, randomised clinical trial

PURPOSE

This study aimed at evaluating the efficacy and safety of high-dose (> 0.2 L/kg of treated plasma per day) coupled plasma filtration-adsorption (CPFA) in treating patients with septic shock.

METHODS

Multicentre, randomised, adaptive trial, performed in 12 Italian intensive care units (ICUs). Patients aged 14 or more, admitted to the ICU with septic shock, or had developed it during the stay were eligible. The final outcome was mortality at discharge from the last hospital at which the patient received care.

RESULTS

Between May 2015, and October 2017, 115 patients were randomised. The first interim analysis revealed a number of early deaths, prompting an unplanned analysis. Last hospital mortality was non-significantly higher in the CPFA (55.6%) than in the control group (46.2%, p = 0.35). The 90-day survival curves diverged in favour of the controls early after randomisation and remained separated afterwards (p = 0.100). An unplanned analysis showed higher mortality in CPFA compared to controls among patients without severe renal failure (p = 0.025); a dose-response relationship was observed between treated plasma volume and mortality (p = 0.010).

CONCLUSION

The COMPACT-2 trial was stopped due to the possible harmful effect of CPFA in patients with septic shock. The harmful effect, if present, was particularly marked in the early phase of septic shock. Patients not requiring renal replacement therapy seemed most exposed to the possible harm, with evidence of a dose-response effect. Until the mechanisms behind these results are fully understood, the use of CPFA for the treatment of patients with septic shock is not recommended.

[Role of radiotherapy in haematology]

The management of myeloid and lymphoid disease is essentially based on chemotherapy and targeted therapies. Since radiotherapy could be responsible for severe late toxicities, essentially due to conventional bidimensional irradiation techniques, many trials have attempted to omit radiotherapy or to scale down the dose in their therapeutic strategy. Nevertheless, radiotherapy still plays a role for curative or symptomatic purposes.

PROSAFE: a European endeavor to improve quality of critical care medicine in seven countries

BACKGROUND

Long-lasting shared research databases are an important source of epidemiological information and can promote comparison between different healthcare services. Here we present PROSAFE, an advanced international research network in intensive care medicine, with the focus on assessing and improving the quality of care. The project involved 343 ICUs in seven countries. All patients admitted to the ICU were eligible for data collection.

METHODS

The PROSAFE network collected data using the same electronic case report form translated into the corresponding languages. A complex, multidimensional validation system was implemented to ensure maximum data quality. Individual and aggregate reports by country, region, and ICU type were prepared annually. A web-based data-sharing system allowed participants to autonomously perform different analyses on both own data and the entire database.

RESULTS

The final analysis was restricted to 262 general ICUs and 432,223 adult patients, mostly admitted to Italian units, where a research network had been active since 1991. Organization of critical care medicine in the seven countries was relatively similar, in terms of staffing, case mix and procedures, suggesting a common understanding of the role of critical care medicine. Conversely, ICU equipment differed, and patient outcomes showed wide variations among countries.

CONCLUSIONS

PROSAFE is a permanent, stable, open access, multilingual database for clinical benchmarking, ICU self-evaluation and research within and across countries, which offers a unique opportunity to improve the quality of critical care. Its entry into routine clinical practice on a voluntary basis is testimony to the success and viability of the endeavor.

Outcome of a modified sympathicotomy for cardiac neuromodulation of untreatable ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

OBJECTIVES This study aimed to describe the results of a modified sympathicotomy (uniportal VATs with stellate ganglion sparing) for cardiac sympathetic denervation (CSD) in the setting of untreatable ventricular tachycardia.

BACKGROUND. CSD, in patients with refractory ventricular tachycardia (VT), is comprehensively recognized as an important treatment option for patients with structural heart disease as well as congenital inherited arrhythmia syndrome. A recent case series demostrated  the feasibility of the modified technique.

METHODS We consecutively enrolled 8 patients with refractory VT. Baseline demographic, medical, and surgical data as well as arrhythmia outcomes and procedural complications were evaluated.

RESULTS A total of 8 patients ( 7 pts NIDCM, 1 pt IDCM with mean age:68+-8 years) were enrolled for the treatment of refractory VT with a modified CSD technique. Mean sympathicotomy length were 7.3 (SD 3) min per side. 3/8 patients underwent monolateral (LCSD) sympathicotomy due to strong adesion in the right pleural cavity. Mean follow up was 13 months (SD 6). No complication occurred during the sympathicotomy. An overall reduction in VT burden and VT number was observed after the CSD despite an in-hospital early recurrence in 3 patients.

CONCLUSIONS A modified CSD (sympathicotomy T2–T5) with stellate ganglion sparing and the use of unipolar radiofrequency is feasible, effective, and safe in the setting of untreatable VT. Abstract Figure. VT trend

Erythrocyte viscoelastic recovery after liver transplantation in a cirrhotic patient affected by spur cell anaemia

In physiological conditions, red blood cells (RBCs) are capable of dramatic deformations when passing through the microvasculature. This extreme deformability is closely related to the RBC biconcave shape, to the fluidic nature of the haemoglobin and the cell membrane structure, primarily consisting of a phospholipid bilayer with an underlying two-dimensional spectrin network. In many pathological and inflammatory conditions, the shape and the extreme deformability of erythrocytes appear to be significantly altered. These findings have stimulated intense research towards the search and validation of novel erythrocyte-based mechanical biomarkers, useful for disease diagnosis and therapy monitoring. In this study, we investigated with Atomic Force Microscopy (AFM) the mechanical properties of erythrocytes obtained from a 68 years old cirrhotic man diagnosed with spur cell anaemia and cold agglutinated disease, before and after liver transplantation. Mechanical changes are compared with ultrastructural alterations as studied by scanning electron microscopy and discussed according to confocal fluorescence microscopy results, showing possible alterations induced by the cirrhotic environment at the level of the RBCs cytoskeletal organisation and lipidic composition. Taken together, the results here presented show that liver transplantation not only contributes to restoring the proper RBC morphology, but it also induces recovery of the physiological viscous behaviour of cells, further stressing the relevance of viscous and dissipative forces in determining the RBC biomechanical response.

Branch pulmonary artery stent placement in a dog with heart base neoplasia

A 7-year-old French bulldog was presented for evaluation of cardiac neoplasia. Two-dimensional transthoracic echocardiography revealed a mass on the base of the heart, compressing the right pulmonary artery. Computed tomography exam confirmed that a surgical approach to remove the mass would not be viable. Stent placement in the right pulmonary artery was performed to relieve external compression caused by the neoplasia. When surgery is not feasible, pulmonary artery stenting could be one aspect of a multidisciplinary approach to palliative management of heart base neoplasia.

P0828CKD STAGE DISTRIBUTION IN AN ITALIAN PROVINCE; SEVEN YEARS OF FOLLOW UP

Background and Aims

Chronic kidney disease (CKD) is a chronic illness with important implications for the health of the population and for the commitment of resources by public health services. CKD staging makes it possible to assess the severity of the disease and its distribution in the population. The distribution of the stages of CKD diagnosed through hospitalization were analyzed using administrative database of the Local Health Authority of a province with a population of about 1 million inhabitants in northern Italy.

Method

Patients with hospital discharge with a diagnosis of CKD (ICD9CM 5851, 5852, 5853, 5854) in 2011- 2012 years, without dialysis treatment, neither transplantation procedure nor acute renal failure were selected. Demographic characteristics, comorbidities, dialysis treatment, drugs prescription and nephrological follow-up were investigated. This cohort of patients was examined over a 7-year period (2011-2017). Stage five was not considered to avoid possible misunderstanding with five D stage.

Results

1808 patients diagnosed with CKD were extracted from the 2011-2017 administrative database; of these, 1267 had a diagnosis with the CKD stage specification. The distribution of 1267 patients in the CKD stages at the first hospital discharge was as follows: 7.4% stage 1, 30.9% stage 2, 42.3% stage 3, 19.3% stage 4. The 832 patients described in the study were still alive as of Jan. 1, 2013 while 435 (34.3%) died by Dec. 31, 2012. Until Dec. 31, 2017, 503 of the 832 patients died representing the 52.8% of stage 1 patients, 62% of stage 2 patients, 58.2% of stage 3 patients, 66.4% of stage 4 patients. Males were the most prevalent gender (58.5%), without any significant difference into CKD stages. Our patients have a fairly high age as can be seen from the table 1. The presence of co-morbidities was assessed either directly for the main risk factors or by the modified Charlson index (MCI) for CKD patients. The average value of the MCI is 3.8 ± 3.1 for all patients and 3.4 ±3.0 for stage 1, 4.1 ± 3.3 for stage 2, 3.7 ± 3.1 for stage 3, 3.7 ± 2.9 for stage 4, with maximum values of 12.0, 17.0, 16.0 and 14.0 respectively. About 40% of patients had diabetes mellitus, with the highest prevalence in stage 4 (49.3%) and the lowest in stage 1 (25%). Cardiovascular disease was distributed almost equally among all patients with a value between 82% in stage 1 and 86.3% in stage 4. Cancer were present in 26.3% of patients with similar values in all stages. Just about 9% of patients underwent dialysis treatment for achieving ESRD, with a percentage of 5.6% among patients in stage 1 and 17.1% among those in stage 4. Hemodialysis represented first choice treatment (86%) compared with peritoneal one (14%). Time from the diagnosis of CKD to the first dialysis was variable with an average of 3.4 ±1.7 years; the longest interval for patients in stage 1 (5.1±1.8) and the shortest (3.0 ±1.6) for patients in stage 4. The number of nephrological visits at renal units was analyzed for an assessment of the extent of follow-up and prevention upon reaching the ESRD (table2). More than 90% of patients had prescribed drugs antagonists of the renin angiotensin system, in all stages of CKD; other antihypertensive drugs (Ca channel blockers and peripheral vasodilators) had a similar prescription level. Anemia control drugs (ESA and iron) had an incremental prescription with stages of the disease from 51.4% in stage 1 to 74% in stage 4, similarly to Ca-P metabolism control drugs ranging from 44.4% in stage 1 to 67.8% in stage 4.

Conclusion

Correct staging of CKD is very important to assess the prognosis of patients, but the major determinants of outcome are comorbidities and age of the patients. The cohort examined has a high mortality rate, far higher than reported in the literature for CKD. It should be noted that the sample was identified by hospitalization for cardiovascular diseases more than 50% complicated by diabetes and hypertension, so death represents the main outcome and not ESRD.

Cinacalcet adherence in dialysis patients with secondary hyperparathyroidism in Lombardy Region: clinical implications and costs

Background

Patients on dialysis often have secondary hyperparathyroidism (SHPT), a disorder associated with renal osteodystrophy, progressive vascular calcification, cardiovascular disease, and death. The objective of this retrospective observational study was to evaluate, in dialysis patients with SHPT, the impact of different levels of adherence to cinacalcet therapy on hospitalisations and direct healthcare costs charged to the Lombardy Regional Health Service (Italy).

Methods

Data recorded in the administrative databases on all citizens undergoing dialysis between 1 January 2011 and 31 December 2011 were selected. For the aim of this study, patients with SHPT already on dialysis in the first 6 months of 2009 who had been treated with cinacalcet for at least 365 days were selected and retrospectively analysed through to end of 2012. Healthcare resource utilisation, cinacalcet adherence, and costs for medication, hospitalisations, and diagnostic/therapeutic procedures were estimated.

Results

A total of 994 patients were identified (mean age 63.0 years, females 43.5%). The first patient tertile had an adherence to cinacalcet of <64.1%, whereas the third had an adherence of over 91.5%. Patients in the third adherence tertile experienced fewer all-causes hospitalisations than those in the first tertile (-19.2%; p=0.01423), fractures (-37.1%; p=0.59422), cardiovascular disease (-23.8%; p=0.04025), and sepsis (-32.3%; p=0.01386). The increase in costs for cinacalcet-adherent patients is almost completely offset by the reduction in costs for hospitalisations.

Conclusions

The results of the analysis suggest that there may be some correlation between a high level of cinacalcet adherence and a decrease in hospitalisations.

Real-time three-dimensional echocardiographic study of a cardiac hemangiosarcoma in a dog

A 7-year-old Golden Retriever was presented for a second opinion regarding a cardiac mass. Two-dimensional transthoracic echocardiography demonstrated presence of a mass in the area of the right atrium. The mass appeared adherent and possibly infiltrative to the external wall of the right atrium. Three-dimensional transthoracic echocardiography allowed better visualization of the neoplasia, suggesting that it was not infiltrative and contributed significantly to the decision to carry out the surgical resection of the cardiac tumor. This case report demonstrates the use of three-dimensional transthoracic echocardiography in the diagnostic evaluation of cardiac masses in dogs without the need for general anesthesia.

Case-mix affects calibration of cardiosurgical severity scores

BACKGROUND

Prognostic models are often used to assess the quality of healthcare. Several scores were developed to predict mortality after cardiac surgery, but none has reached optimal performance in subsequent validations. We validate the most used scores (EUROSCORE I and II, STS, and ACEF) on a cohort of cardiac-surgery patients, assessing their robustness against case-mix changes.

METHODS

The scores were validated on 14,559 patients admitted to 16 Italian cardiosurgical ICUs participating to Margherita-Prosafe project in 2014 and 2015. Calibration was assessed through Hosmer-Lemeshow Test, standardized mortality ratio, and GiViTI calibration test and belt. Discrimination was measured by the area under the ROC curve.

RESULTS

The study included 10,317 patients who were eligible to the calculation of the STS Score (4156 isolated valve, 4681 isolated CABG and 1480 single valve and CABG) which calibrated well in these subgroups. The ACEF Score and EUROSCORE I and II were available for 14,139, and 14,071 patients, respectively. EUROSCORE I significantly overestimated mortality; EUROSCORE II calibrated well overall, but underestimated mortality of patients undergoing complex surgery and non-elective ones. The ACEF Score calibrated poorly in elective and non-elective patients. Discrimination was acceptable for all models (AUC>0.70), but not for the ACEF Score.

CONCLUSIONS

Cardiac surgery scores calibrate poorly when the case-mix of validation and development samples differs. To grant reliability for benchmarking, they should be validated in the clinical settings on which they are applied and updated periodically. Advanced statistical tools are essential for the correct interpretation and application of severity scores.

Real-world data on healthcare resource consumption and costs before and after kidney transplantation

End-stage renal disease (ESRD) is increasing worldwide as a consequence of population aging and increasing chronic illness. Treatment consists mostly of dialysis and kidney transplantation (KTx), and KTx offers advantages for life expectancy and long-term cost reductions compared with dialysis. This study uses the administrative database of the Lombardy Region to analyze the costs of a cohort of patients with ESRD receiving KTx, covering a time period of 24 months before transplant to 12 months after. During 2011, 276 patients underwent kidney transplantation (8.7% preemptive and 91.3% non-preemptive). In the period before transplantation, the main cost driver was dialysis (66.6% for the period from -24 to -12 months and 73.8% for the period from -12 to 0 months), while in the 12 months after KTx, the most relevant cost was surgery. The total cost -24 to -12 months pre-KTx was 35 049.2€; the cost -12 to 0 months was 36 745.9€; and the cost 12 months after KTx was 43 805.8€. Non-preemptive patients showed much higher costs both pre- and post-KTx than preemptive patients. This study highlights how KTx modifies the resource consumption and costs composition of patients with ESRD vs those undergoing dialysis treatment and how KTx may be economically beneficial, especially preemptive intervention.

A49 Emerging rodent-borne viral pathogens in Italy: Overview of seroprevalence and genomic investigations

Rodents play a key role as reservoirs of many zoonotic pathogens which represent an emerging public health threat worldwide. Among these, Dobrava-Belgrade virus (DOBV) is the most pathogenic hantavirus in Europe with a case-fatality rate of up to 12 per cent, while Lymphocytic choriomeningitis virus (LCMV) has a mortality rate below 1 per cent. Both viruses are predominantly transmitted to humans through the inhalation of infected particles in aerosolized urine, feces, or saliva that are shed in the environment by chronically infected hosts, such as the yellow-necked mouse Apodemus flavicollis. Although no human cases of DOBV or LCMV have been reported in the Province of Trento (northeastern Italy) thus far, in order to evaluate the human hazard for these viruses, the prevalence of antibodies to DOBV and LCMV has been monitored using a specific immunofluorescence assay test in a wild population of A. flavicollis since 2000. These investigations have shown that the two RNA viruses circulate silently in this species in the study area. In particular, a sudden increase (up to 12.5%) in DOBV seroprevalence was observed in this rodent species between 2010 and 2012. Several efforts have been undertaken to isolate these viruses and characterize their genomes, but it has not yet been possible to detect viral RNA from seropositive mice using traditional methods such as RT-PCR. Since RNA viruses are very diverse and often difficult to isolate, innovative molecular methods based on viral targeted enrichment and high-throughput sequencing have been applied. We intend to report on this long-term seroprevalence study and provide an overview of the molecular approaches adopted in the attempt to confirm the presence of these viruses, and identify which variants are circulating in the region, as well as their pathogenicity.

Redo ileal pouch-anal anastomosis: outcomes from a case-controlled study

AIM

To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA.

METHOD

This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index.

RESULTS

Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51  (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function.

CONCLUSION

The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.

DNA methylation of genes regulating appetite and prediction of weight loss after bariatric surgery in obese individuals

PURPOSE

Epigenetic traits are influenced by clinical variables; interaction between DNA methylation (DNAmeth) and bariatric surgery-induced weight loss has been scarcely explored. We investigated whether DNAmeth of genes encoding for molecules/hormones regulating appetite, food intake or obesity could predict successful weight outcome following Roux-en-Y gastric bypass (RYGB).

METHODS

Forty-five obese individuals with no known comorbidities were stratified accordingly to weight decrease one-year after RYGB (excess weight loss, EWL ≥ 50%: good responders, GR; EWL < 50%: worse responders, WR). DNAmeth of leptin (LEP), ghrelin (GHRL), ghrelin receptor (GHSR) and insulin-growth factor-2 (IGF2) was assessed before intervention. Single nucleotide polymorphisms of genes affecting DNAmeth, DNMT3A and DNMT3B, were also determined.

RESULTS

At baseline, type 2 diabetes was diagnosed by OGTT in 13 patients. Post-operatively, GR (n = 23) and WR (n = 22) achieved an EWL of 67.7 ± 9.6 vs 38.2 ± 9.0%, respectively. Baseline DNAmeth did not differ between GR and WR for any tested genes, even when the analysis was restricted to subjects with no diabetes. A relationship between GHRL and LEP methylation profiles emerged (r = 0.47, p = 0.001). Searching for correlation between DNAmeth of the studied genes with demographic characteristics and baseline biochemical parameters of the studied population, we observed a correlation between IGF2 methylation and folate (r = 0.44, p = 0.003). Rs11683424 for DNMT3A and rs2424913 for DNMT3B did not correlate with DNAmeth of the studied genes.

CONCLUSIONS

In severely obese subjects, the degree of DNAmeth of some genes affecting obesity and related conditions does not work as predictor of successful response to RYGB.

Pseudoangiomatous stromal hyperplasia (PASH) presenting as axillary lump: case report and review of the literature

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign mesenchymal breast lesion. There are extremely rare reports of PASH arising in accessory breast tissue. To date, in literature, fewer than 10 cases of PASH occurring in axillary region have been described. We report a case presenting as axillary lump in a young woman. A 20-year-old female presented to our surgical unit for a progressively growing and painful palpable mass of the right axilla for about a year. Before surgery an ultrasound was performed. The patient underwent local excision of the lesion under local anaesthesia. Through histological and immunohistochemical examination a pseudoangiomatous stromal hyperplasia (PASH) was diagnosed. At 6 months of followup the patient is free of disease. It is important to include PASH also in the differential diagnosis of axillary lumps. Histological examination of the surgical specimen and surgery represent, respectively, the mainstay for diagnosis and therapy.

Gastric Cancer with Bone Marrow Invasion at Presentation: Case-Report and Review of the Literature

A case of extensive bone marrow infiltration due to gastric cancer is reported. A 65-year old man with an acute episode of anemia (Hb 4.1 mg/dl) and dyspnea was admitted to the Medical Department of a general hospital. Bone marrow biopsy showed extensive paratrabecular infiltration of a poorly differentiated adenocarcinoma of gastric origin. The primary tumor in the stomach was confirmed, and the patient was referred to our Institute and treated with combination chemotherapy (FAMTX) for 6 cycles. Due to the disappearance of bone marrow infiltration, the patient was considered for curative resection of the primary gastric cancer. After 27 months the patient is alive and in clinical complete remission.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

First Results from CUORE: A Search for Lepton Number Violation via 0νββ Decay of ^{130}Te

The CUORE experiment, a ton-scale cryogenic bolometer array, recently began operation at the Laboratori Nazionali del Gran Sasso in Italy. The array represents a significant advancement in this technology, and in this work we apply it for the first time to a high-sensitivity search for a lepton-number-violating process: ^{130}Te neutrinoless double-beta decay. Examining a total TeO_{2} exposure of 86.3 kg yr, characterized by an effective energy resolution of (7.7±0.5)  keV FWHM and a background in the region of interest of (0.014±0.002)  counts/(keV kg yr), we find no evidence for neutrinoless double-beta decay. Including systematic uncertainties, we place a lower limit on the decay half-life of T_{1/2}^{0ν}(^{130}Te)>1.3×10^{25}  yr (90% C.L.); the median statistical sensitivity of this search is 7.0×10^{24}  yr. Combining this result with those of two earlier experiments, Cuoricino and CUORE-0, we find T_{1/2}^{0ν}(^{130}Te)>1.5×10^{25}  yr (90% C.L.), which is the most stringent limit to date on this decay. Interpreting this result as a limit on the effective Majorana neutrino mass, we find m_{ββ}<(110-520)  meV, where the range reflects the nuclear matrix element estimates employed.

Cirrhotic patients admitted to the ICU for medical reasons: Analysis of 5506 patients admitted to 286 ICUs in 8years

PURPOSE

To describe characteristics and prognostic factors of cirrhotic patients admitted to a representative sample of Italian intensive care units (ICUs).

MATERIALS AND METHODS

All patients admitted to 286 ICUs for medical reasons between 2002 and 2010 (excluding 2007) were considered. A logistic regression model was developed on cirrhotics to predict hospital mortality. The prediction was applied to different subgroups defined by both the level of unit expertise with cirrhotics and the overall unit performance, and compared to the actual mortality.

RESULTS

5506 cirrhotic patients (32.1% admitted to the ICU for non-cirrhotic-related reasons) were compared to 130,477 controls. Hospital mortality was higher in cirrhotics (57.2% vs. 35.0%, p<0.001). ICU volume of cirrhotic patients did not influence mortality, while the overall performance of the unit did. The standardized mortality ratio for overall lower-performing units was 1.09 (95%CI: 1.05-1.14), for the average-performing units it was 1.01 (95%CI: 0.98-1.04), for the higher-performing units it was 0.92 (95%CI: 0.89-0.96).

CONCLUSIONS

The outcome of critically ill cirrhotic patients is quite poor, but not to limit their admission to the ICU. When cirrhosis accompanies other acute conditions, the general level of intensive care medicine is more important than the specific liver-oriented expertise in treating these patients.

Jugular Vein-Mammary Artery Fistula after Catheterism for Hemodialysis: Case Report

The demographic characteristics of hemodialysis (HD) patients increase the need for the tunneled cuffed permanent catheter (TCC) as a definitive vascular access (VA) for HD. The internal jugular vein is increasingly being used as a route for TCC or temporary catheter placement and can be associated with serious complications. Among them other authors have described arteriovenous fistula (AVF) creation between the common carotid artery and the right jugular vein. We describe a case of an AVF between the right internal jugular vein and the right internal mammary artery. The fistula was detected during the TCC placement in a patient who underwent several jugular and subclavian catheterisms for HD in her clinical history.

Fluidodynamic Evaluation of Arteriovenous Fistulae for Hemodialysis

Arteriovenous fistulae (AVF) are commonly used in dialysis treatment of uremic patients. However, many AVF create problems and have to be re-examined. Problems arise in the cannulation site and must be treated with antibiotics, and stenosis, both in the arterial and in the venous side of the AVF. In the worst case, the AVF must be replaced for treatment to continue. However, this can only be repeated once before the AVF site is no longer viable. This increases the discomfort, the morbidity and the mortality of the dialysis patient. Several kinds of AVF were studied to determine whether flow disturbances give rise to these complications. Many studies have already demonstrated the importance of hemodynamic factors in vascular disease pathogenesis. These factors include: the pulsatility of flow, the elasticity of the vessel, the non-Newtonian blood, flow behavior and, very importantly for AVF, the vessel geometry. In model studies, intimal changes have been observed in bends and bifurcations, regions of vessel construction and vessel stenosis. In these regions, blood flow changes abruptly and this contributes to arterial disease. We prepared several one-to-one, true-to-scale elastic silicon rubber models of different AVF. The AVF models were based on angiographic studies of chronic dialysis patients and on AVF from the arms of cadavers. The models had a similar compliance to that of the human blood vessel. Flow was visualized using photoelasticity apparatus and a birefringent blood-like fluid. This method is suitable to analyze the spatial configuration of flow profiles, to differentiate laminar flow from disturbed flow, and to visualize flow separation, vortex formation and secondary flow. It was found that AVF create disturbances that are not found under normal physiological flow conditions. The X-formed AVF was very unsatisfactory, creating significant flow disturbances. The AVF had high velocity fluctuations. These could lead, for example, to aneurysm formation. A better configuration would be an end-to-end AVF. However, this formation creates other complications. For example, there is not enough blood to the hand and parts of the hand lose feeling. The recommended AVF would be an end-to-side anastomosis. In this case, attention is needed for placement geometry, to minimize additional flow disturbances. Several models as well as patient angiographic studies are discussed.

[HPV vaccination in boys and men : update and recommendations]

High-risk oncogenic HPVs (HR-HPV) are associated in men with pre-cancerous anal dysplasia, oropharyngeal, anal and penile cancer. Anogenital warts are induced by low-risk HPVs. These manifestations are increasing among men, and especially in some high-risk groups as men who have sex with men (MSM). This review targets HPV-associated disease epidemiology as well as safety, immunogenicity, and efficacy level of HPV vaccine in men. Obstacle and cost-effectiveness analysis of HPV vaccination are discussed. Three HPV vaccines are currently available in Belgium with the 9-valent (" 9HPV " - 6/11/16/18/31/33/45/52/58) offering protection against most of HPVassociated diseases. The safe 9-valent vaccine is efficient to prevent genital warts, anal dysplasia and it decreases the recurrence of genital warts and high grade anal neoplasia in MSM with or without HIV infection. In Europe, the 9-valent vaccine could prevent in men more than 350,000 genital warts, 5,485 oropharyngeal cancers, 2,303 anal cancers et 852 grade 2/3 intraepithelial neoplasia as well as 1,113 penile cancers per year. In the Federation Wallonie-Bruxelles, the vaccine coverage reaches currently 30 % in girls and is very low in boys and men.The Superior Health Council of Belgium (CSS) recommends since 2017 the gender-neutral HPV vaccination for people up to 26 years old and to immunocompromised patients. The implementation of the CSS HPV vaccine program and its acceptability among boys and men are discussed on the basis of the most recent epidemiologic data and available costeffectiveness analysis. Ways to overcome barriers to gender-neutral HPV vaccination are suggested.

[Meningococcal B (4CMenB) vaccine : uptodate and recommendations]

Neisseria meningitidis is the cause of relatively rare invasive infections, but with very important morbi-mortality. Vaccines are already available for serogroups A, C, W, Y. A new vaccine against meningococcus B is on the Belgian market since March 2017. Serogroup B is the most prevalent in Western countries. The target populations are children and teenager, since it is at this age that peaks in the incidence of meningococcal disease are observed. The development of this vaccine has been made possible by a new process named " reverse vaccinology ", which uses the complete genome sequencing of the bacterium. Current studies focus on the immunogenicity of the vaccine, which is good for both children and teenager. However, there are still many unknowns with this vaccine such as the duration of protection and its impact on the pharyngeal carriage. Another difficulty lies in the extrapolation of the immunogenicity data among a population because this vaccine consists of protein antigens and we know that the expression and prevalence of these antigens may vary between different strains of meningococci. In England, where the vaccine has been included in the vaccination calendar, beneficial effects are demonstrated on the incidence of invasive meningococcal infections. The toxicity profile is also reassuring, only classic side effects have been observed, such as fever and local reactions. In 2017, the High Health Council issued a favorable opinion for individual protection, without recommending at this stage a collective vaccination in Belgium. After a review of the most recent data on this new vaccine, we will try to draw conclusions.