Dysmetabolism, Diabetes and Clinical Outcomes in Patients Cured of Chronic Hepatitis C: A Real-Life Cohort Study

The aim of this study was to examine the impact of features of dysmetabolism on liver disease severity, evolution, and clinical outcomes in a real‐life cohort of patients treated with direct acting antivirals for chronic hepatitis C virus (HCV) infection. To this end, we considered 7,007 patients treated between 2014 and 2018, 65.3% with advanced fibrosis, of whom 97.7% achieved viral eradication (NAVIGATORE‐Lombardia registry). In a subset (n = 748), liver stiffness measurement (LSM) was available at baseline and follow‐up. Higher body mass index (BMI; odds ratio [OR] 1.06 per kg/m², 1.03‐1.09) and diabetes (OR 2.01 [1.65‐2.46]) were independently associated with advanced fibrosis at baseline, whereas statin use was protective (OR 0.46 [0.35‐0.60]; P < 0.0001 for all). The impact of BMI was greater in those without diabetes (P = 0.003). Diabetes was independently associated with less pronounced LSM improvement after viral eradication (P = 0.001) and in patients with advanced fibrosis was an independent predictor of the most frequent clinical events, namely de novo hepatocellular carcinoma (HCC; hazard ratio [HR] 2.09 [1.20‐3.63]; P = 0.009) and cardiovascular events (HR 2.73 [1.16‐6.43]; P = 0.021). Metformin showed a protective association against HCC (HR 0.32 [0.11‐0.96]; P = 0.043), which was confirmed after adjustment for propensity score (P = 0.038). Diabetes diagnosis further refined HCC prediction in patients with compensated advanced chronic liver disease at high baseline risk (P = 0.024). Conclusion: Metabolic comorbidities were associated with advanced liver fibrosis at baseline, whereas statins were protective. In patients with advanced fibrosis, diabetes increased the risk of de novo HCC and of cardiovascular events. Optimization of metabolic comorbidities treatment by a multi‐disciplinary management approach may improve cardiovascular and possibly liver‐related outcomes.

Peptide receptor radionuclide therapy in gastroenteropancreatic NEN G3: a multicenter cohort study

Peptide receptor radionuclide therapy (PRRT) is an established treatment of metastatic neuroendocrine tumors grade 1-2 (G1-G2). However, its possible benefit in high-grade gastroenteropancreatic (GEP) neuroendocrine neoplasms (NEN G3) is largely unknown. We therefore aimed to assess the benefits and side effects of PRRT in patients with GEP NEN G3. We performed a retrospective cohort study at 12 centers to assess the efficacy and toxicity of PRRT in patients with GEP NEN G3. Outcomes were response rate, disease control rate, progression-free survival (PFS), overall survival (OS) and toxicity. We included 149 patients (primary tumor: pancreatic n = 89, gastrointestinal n = 34, unknown n = 26). PRRT was first-line (n = 30), second-line (n = 62) or later-line treatment (n = 57). Of 114 patients evaluated, 1% had complete response, 41% partial response, 38% stable disease and 20% progressive disease. Of 104 patients with documented progressive disease before PRRT, disease control rate was 69%. The total cohort had median PFS of 14 months and OS of 29 months. Ki-67 21-54% (n = 125) vs Ki-67 ≥55% (n = 23): PFS 16 vs 6 months (P < 0.001) and OS 31 vs 9 months (P < 0.001). Well (n = 60) vs poorly differentiated NEN (n = 62): PFS 19 vs 8 months (P < 0.001) and OS 44 vs 19 months (P < 0.001). Grade 3-4 hematological or renal toxicity occurred in 17% of patients. This large multicenter cohort of patients with GEP NEN G3 treated with PRRT demonstrates promising response rates, disease control rates, PFS and OS as well as toxicity in patients with mainly progressive disease. Based on these results, PRRT may be considered for patients with GEP NEN G3.

Sunitinib in patients with pre-treated pancreatic neuroendocrine tumors: A real-world study

INTRODUCTION

Besides data reported in a Phase-III trial, data on sunitinib in pancreatic Neuroendocrine Tumors (panNETs) are scanty.

AIM

To evaluate sunitinib efficacy and tolerability in panNETs patients treated in a real-world setting.

PATIENTS AND METHODS

Retrospective analysis of progressive panNETs treated with sunitinib. Efficacy was assessed by evaluating progression-free survival, overall survival, and disease control (DC) rate (stable disease (SD) + partial response + complete response). Data are reported as median (25th-75th IQR).

RESULTS

Eighty patients were included. Overall, 71.1% had NET G2, 26.3% had NET G1, and 2.6% had NET G3 neoplasms. A total of 53 patients (66.3%) had received three or more therapeutic regimens before sunitinib, with 24 patients (30%) having been treated with four previous treatments. Median PFS was 10 months. Similar risk of progression was observed between NET G1 and NET G2 tumors (median PFS 11 months and 8 months, respectively), and between patients who had received ≥ 3 vs ≤ 2 therapeutic approaches before sunitinib (median PFS 9 months and 10 months, respectively). DC rate was 71.3% and SD was the most frequent observed response, occurring in 43 pts (53.8%). Overall, 59 pts (73.8%) experienced AEs, which were grade 1-2 in 43 of them (72.9%), grade 3 in 15 pts (25.4%), and grade 4 in one patient (1.7%). Six pts (7.5%) stopped treatment due to toxicity.

CONCLUSIONS

The present real-world experience shows that sunitinib is a safe and effective treatment for panNETs, even in the clinical setting of heavily pre-treated, progressive diseases.

Continuing Medical Education in six European countries: a comparative analysis

OBJECTIVE

We examined Continuing Medical Education (CME) systems in a sample of six EU countries: Austria, Belgium, France, Italy, Norway, and the UK. The aim of this comparative study was to assess the main country-specific institutional settings applied by governments.

METHODS

A common scheme of analysis was applied to investigate the following variables: (i) CME institutional framework; (ii) benefits and/or penalties to participants; (iii) types of CME activities and system of credits; (iv) accreditation of CME providers and events; (v) CME funding and sponsorship. The analysis involved reviewing the literature on CME policy and interviewing a selected panel of local experts in each country (at least one public manager, one representative of medical associations and one pharmaceutical manager).

RESULTS

CME is formally compulsory in Austria, France, Italy and the UK, although no sanctions are enforced against non-compliant physicians in practice. The only two countries that offer financial incentives to enhance CME participation are Belgium and Norway, although limited to specific categories of physicians. Formal accreditation of CME providers is required in Austria, France and Italy, while in the other three countries accreditation is focused on activities. Private sponsorship is allowed in all countries but Norway, although within certain limits.

CONCLUSIONS

This comparative exercise provides an overview of the CME policies adopted by six EU countries to regulate both demand and supply. The substantial variability in the organization and accreditation of schemes indicates that much could be done to improve effectiveness. Although further analysis is needed to assess the results of these policies in practice, lessons drawn from this study may help clarify the weaknesses and strengths of single domestic policies in the perspective of pan-European CME harmonization.

[Blood pressure variability]

This review deals with a number of issues related to blood pressure variability. These include: historical aspects, with reference to the first pioneering observations; methodological aspects, focusing on the different methods for quantifying blood pressure variability; description of the characteristics of blood pressure variability over the 24 hours; mechanisms involved in determining the different magnitude of this phenomenon in different subjects, such as behavioral factors, central and reflex neural influences, humoral and mechanical factors; blood pressure variability as a probe to assess spontaneous baroreflex sensitivity; effects of aging and hypertension on blood pressure variability, with a discussion of the clinical relevance of this phenomenon in the prognostic evaluation of patients; effects of drugs on blood pressure variability. Finally methodological aspects related to the use of noninvasive ambulatory blood pressure monitoring in the assessment of blood pressure variability are discussed.

Different baseline sympathovagal balance and cardiac autonomic responsiveness in ischemic and non-ischemic congestive heart failure

BACKGROUND

A profound autonomic unbalance is present in heart failure: its correlation with the etiology of the disease has never been investigated.

AIMS

We characterized the sympatho-vagal balance and autonomic responsiveness of 42 patients (21 with ischemic heart failure, 21 with idiopathic dilated cardiomyopathy). Patients had comparable NYHA class, ejection fraction, exercise pVO(2), exercise ventilatory response, incidence of beta-blocking treatment. None showed periodic breathing or nocturnal arterial desaturation.

METHODS

Heart rate variability was assessed in the time and frequency domain during: (1) 10 min of quiet supine resting and free breathing; (2) 10 min of regular breathing at a frequency of 20 acts/min (=parasympathetic stimulus); and (3) 10 min of active standing (=sympathetic stimulus). The ratio of the low- to high-frequency components of each autospectrum obtained in the frequency domain (LF/HF) was used as an index of sympathovagal balance.

RESULTS

Patients with ischemic heart failure had a greater baseline sympathetic activation (higher LF/HF) than those with idiopathic dilated cardiomyopathy, maintaining some parasympathetic responsiveness as well (reduced LF/HF with regular breathing).

CONCLUSIONS

There is a distinct autonomic control according to the etiology of heart failure, a finding that may help understanding its pathophysiology, and could be useful in the clinical management of patients.