An economic evaluation of Clostridium difficile infection management in an Italian hospital environment

BACKGROUND AND OBJECTIVES

Clostridium difficile infection (CDI) accounts for the majority of nosocomial cases of diarrhea, and with recent upsurge of multidrug-resistant strains, morbidity and mortality have increased. Data on clinical impact of CDI come mostly from Anglo-Saxon countries, while in Italy only two studies address the issue and no economic data exist on costs of CDI in the in hospital setting. A retrospective cross-sectional study with pharmacoeconomic analysis was performed on the CDI series of the Policlinico Gemelli of Rome, a major 1400 bed Hospital.

PATIENTS AND METHODS

The clinical charts of 133 patients in a 26 month period were reviewed. All costs of the involved resources were calculated and statistical analysis was carried out with means and standard deviations, and categorical variables as number and percentages.

RESULTS

The results show the significant sanitary costs of CDI in an Italian hospital setting. The cost analysis of the various elements (exams, imaging studies, therapies, etc.) shows that none independently influences the high cost burden of CDI, but that it is the simple length of hospital stay that represents the most important factor.

CONCLUSIONS

Prevention of CDI is the most cost-effective approach. The major break-through in cost reduction of CDI would be a therapeutical intervention or procedure that shortens hospital length of stay.

Plasma concentrations but not serum concentrations of brain-derived neurotrophic factor are related to pro-inflammatory cytokines in patients undergoing major abdominal surgery

OBJECTIVES

To investigate peripheral brain-derived neurotrophic factor (BDNF) concentrations in the perioperative period, their relationship with transforming growth factor-β1 (TGF-β1 tumour necrosis factor-α (TNF-α), interleukin-6 (IL-6) and IL-6 genetics.

DESIGN AND METHODS

Prospective, observational study. BDNF, TGF-β1, IL-6 and TNF-α were analysed at baseline (T0), 5 h (T1), 24 h (T2) and 5 days (T3) after surgery, in 21 patients. The IL-6 -174 G/C polymorphism was genotyped.

RESULTS

Serum BDNF concentrations decreased (P=0.048), correlated with TGF-β1 (r=0.610 at T1, r=0.493 at T2, r=0.554 at T3). Plasma BDNF concentrations raised (P=0.049), correlated with IL-6 and TNF-α at T1 (r=0.495 and r=0.441, respectively). BDNF response was predictable from TNF-α and IL-6 concentrations and the IL-6 -174 G/C genotype.

CONCLUSION

Serum and plasma BDNF concentrations could relate to platelet activation and inflammatory response, respectively. IL-6 genetics played a role in the BDNF acute response.

Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach

BACKGROUND

Recently, some prognostic models for acute pulmonary embolism (PE) have been proposed. We investigated whether the Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) prognostic approaches result in different prognoses.

METHODS

Consecutive adult patients with acute PE were included. According to the ESC guidelines, high-risk patients were identified by the presence of shock/hypotension, intermediate-risk patients by elevated troponin I or right ventricular dysfunction as assessed by echocardiography, and low-risk patients by the absence of any of the above. In the PESI model, 11 clinical variables, easily accessible at the bedside, were used to generate three risk classes. The main outcomes were all-cause and PE-related in-hospital mortality.

RESULTS

Forty-one patients (8%, 95% confidence interval [CI] 5.8-10.8) of 510 died. According to the ESC model, 40% were at low risk of short-term mortality, 54% at intermediate risk, and 6% at high risk. The distribution according to the PESI model was 31% (P < 0.05 vs. ESC), 49% and 20% (P < 0.05 vs. ESC), respectively. Mortality increased through the risk classes (P < 0.01), without significant differences between the models. The ESC model identified with higher accuracy than the PESI model both high-risk and low-risk patients (P < 0.05 for both). When patients with shock/hypotension were excluded, the PESI model stratified patients into classes with increasing PE-related mortality (0.7%, 4.3%, and 11.6%, P < 0.05). Troponin I and right ventricular dysfunction added incremental prognostic value to the PESI model, particularly in normotensive patients at intermediate risk.

CONCLUSIONS

The ESC model showed higher accuracy than the PESI model in identifying high-risk and low-risk patients. In normotensive patients, the PESI model could guide clinical management as well as troponin I and echocardiography testing.

A single heterozygous nucleotide substitution displays two different altered mechanisms in the FBN1 gene of five Italian Marfan patients

The Fibrillin-1 gene (FBN1; chromosome 15q21.1) encodes a major glycoprotein component of the extracellular matrix. Mutations in FBN1, TGFBR1, TGFBR2 are known to cause Marfan syndrome (MIM 154700), a pleiotropic disorder. In the present study, we describe five novel missense FBN1 mutations in five Marfan patients that have the peculiarity to activate two contemporary mutational mechanisms: a missense mutation and exon skipping.

Peptide receptor radionuclide therapy (PRRT) of neuroendocrine tumors with somatostatin analogues

BACKGROUND

Clinical experience with the radiolabeled somatostatin analogues 90Y-DOTATOC and, more recently, 177Lu-DOTATATE, is ongoing since more than a decade in few centers. Dosimetric studies demonstrated that 90Y-DOTATOC and 177Lu-DOTATATE are able to deliver high doses to somatostatin receptor sst2-expressing tumors and low doses to normal organs.

RESULTS AND CONCLUSIONS

Clinical studies demonstrated that partial and complete objective responses in up to 30% of patients can be obtained, with a great survival benefit in treated patients. Side effects may involve the kidney and the bone marrow and are usually mild. Renal protection is used to minimize the risk of a late decrease of renal function.

COL1A2 (type I collagen) polymorphisms in the Colorado Indians of Ecuador

BACKGROUND

EcoRI, MspI and RsaI restriction fragment length polymorphisms (RFLPs) of the COL1A2 (type I collagen) gene are proving to be extremely informative markers for describing human populations; therefore they hold considerable potential for anthropogenetic research.

AIM

The objective of this study was to characterize at the DNA level the Colorado Indians from Ecuador, for whom only blood group frequency information is available, and to investigate their relationships with the Cayapa-another Ecuadoran Native American group belonging to the same linguistic affiliation-and other world populations.

SUBJECTS AND METHODS

Colorado Indians (n = 80) were analysed for the three anthropologically informative RFLPs of the COL1A2 gene. To better define the genetic relationship between this group and other populations, principal component analysis (PCA) was performed and genetic distances were estimated. Population genetic structure was tested through analysis of molecular variance (AMOVA) by comparing haplotype frequencies.

RESULTS

COL1A2 allele and haplotype frequencies showed a certain degree of heterogeneity between the two Chibchan populations of Ecuador. The AMOVA test detected a significant level of differentiation (Fst = 0.034, p = 0.0049) between Colorado and Cayapa Indians. PC and genetic distance analyses showed a clear-cut separation between African and non-African populations; within the latter, the two Native American groups were differentiated from each other.

CONCLUSIONS

The present findings suggest the presence of a low level of genetic relatedness between the Colorado and the Cayapa, despite their supposed common ethnogenesis. This confirms what has been inferred from other genetic data about the high degree of heterogeneity among Native Americans, even within the same linguistic branch, thus supporting the existence of genetic sub-structure within the central and southern American populations.

[Vitamin D deficiency and osteoporosis in a rural population of Cordoba province, Argentina]

INTRODUCTION

Vitamin D deficiency is defined when blood levels of 25-hydroxyvitamin D (25 (OH) D) is less than ng / mmol/L. The status of Vitamin D level is associated with clinical, pathological and physiological changes as increased of parathyroid hormone, bone remodeling, osteoporosis and increased risk of fractures. Moreover,vitamin D and its metabolites are known to be associated with multiple chronic diseases as diabetes mellitus, autoimmune, cardiovascular and neoplasia diseases.

OBJECTIVE

To assess the vitamin D status in a rural population of Córdoba Province in Argentina and its relation with bone mineral density.

MATERIAL AND METHODS

We prospectively studied 31 patients over 50 years old who live in a rural population of Pampa de Achala in Córdoba Province, Argentina. This city is located in Córdoba High mountains. Blood vitamin D levels were tested in 24 patients and Bone mineral density in 31 patients. Vitamin D level was determined by HPLC. The vitamin D level were considered normal between 20-50 ng/ml in the winter season and 20-80 ng/ml in the summer season. Bone mineral density of lumbar spine and femoral neck was measured by DXA GE LUNAR DPX-L, according to World Health organization classification (37). The data were analyzed by Spearman coefficient and Chi cuadrado.

RESULTS

The vitamin D levels samples were available in 24 patients. Mean blood Vitamin D level was 24.54 ng /ml. 8 of them (33%) had vitamin D level less than 20ng/ ml. 83% (20) of the analysed patients had vitamin D level less than 30 ng/ml and only 4 patients has vitamin D level more than 30 ng/ml. Low bone mineral density of lumbar spine and femoral neck was found in 66 % of the patients. 19 % of the patients were diagnosed of lumbar spine and femoral neck osteoporosis and 29 % of them had lumbar spine meanwhile 25 % had femoral neck. There was not statistically significant association between vitamin D level and bone mineral density analysed by Chi Cuadrado (p<0.07). A significant association was found between blood vitamin D level and low bone mineral density of femoral neck (Spearman 0.51) CONCLUSIONS: Vitamin D insufficiency is high in the rural adult population of Pampa de Achala in Córdoba and it could be a major health problem in this population.

FBN1 mutation screening of patients with Marfan syndrome and related disorders: detection of 46 novel FBN1 mutations

Fibrillin-1 gene (FBN1) mutations cause Marfan syndrome (MFS), an inherited connective tissue disorder with autosomal dominant transmission. Major clinical manifestations affect cardiovascular and skeletal apparatuses and ocular and central nervous systems. We analyzed FBN1 gene in 99 patients referred to our Center for Marfan Syndrome and Related Disorders (University of Florence, Florence, Italy): 85 were affected by MFS and 14 by other fibrillinopathies type I. We identified mutations in 80 patients. Among the 77 different mutational events, 46 had not been previously reported. They are represented by 49 missense (61%), 1 silent (1%), 13 nonsense (16%), 6 donor splice site mutations (8%), 8 small deletions (10%), and 3 small duplications (4%). The majority of missense mutations were within the calcium-binding epidermal growth factor-like domains. We found preferential associations between The Cys-missense mutations and ectopia lentis and premature termination codon mutations and skeletal manifestations. In contrast to what reported in literature, the cardiovascular system is severely affected also in patients carrying mutations in exons 1-10 and 59-65. In conclusion, we were able to detect FBN1 mutations in 88% of patients with MFS and in 36% of patients with other fibrillinopathies type I, confirming that FBN1 mutations are good predictors of classic MFS.

Reflux oesophagitis in children; the role of endoscopy. A multicentric Italian survey

BACKGROUND

The decision whether to perform endoscopy in children with suspected reflux oesophagitis is not a straightforward one. Few symptoms are specific for oesophagitis and the diagnosis is not always correlated even to visual findings on endoscopy.

AIM

The aim of this study was to define the role of endoscopy and especially of histology in the diagnosis of reflux oesophagitis and to examine the correlations between symptoms, endoscopic findings and histology in children with suspected gastroesophageal reflux disease.

PATIENTS AND METHODS

One hundred and thirty-six patients with a clinical diagnosis of reflux oesophagitis, aged 1-18 years (mean 8.43; standard deviation +/-4.4), were enrolled from 12 Italian Paediatrics Gastroenterology Centres; symptom score, endoscopic and histologic oesophagitis scores were observed before and after therapy with proton pump inhibitors.

RESULTS

Before therapy, a high correlation between the prevailing symptom score and endoscopic score was demonstrated, but not with histologic score: there was a significant tendency for histologic grade to exceed visual findings. After therapy, endoscopic score and histologic score were significantly improved.

CONCLUSIONS

Oesophageal biopsies increase the diagnostic accuracy of upper endoscopy. Histologic grading is often much more important than the endoscopic appearance, so that endoscopic oesophageal biopsies are very important aids in the diagnosis of oesophagitis. Appropriate clinical evaluation of symptoms must occur before endoscopic examination.

Cost-effectiveness analysis in the clinical management of patients with known or suspected lung cancer: [18F]fluorodeoxyglucose PET and CT comparison

AIM

The aim of this study was to evaluate the economic impact of the introduction of positron emission tomography (PET) in the clinical management of patients with known or suspected lung cancer through a cost-effectiveness analysis of different diagnostic strategies.

METHODS

In Italy, 75 patients with known or suspected lung cancer were included in the study. Three different diagnostic strategies were compared: 1) baseline or traditional strategy, i.e. computed tomography (CT) alone; 2) strategy A, i.e. PET for indefinite CT; 3) strategy B, i.e. PET for all. For each strategy expected costs and life expectancy, as measured by life year saved (LYS), were evaluated. Incremental cost-effectiveness ratio (ICER) was calculated to identify the most effective strategy.

RESULTS

Compared to the baseline strategy, the introduction of PET changed the clinical management in 40% of cases in strategy A and in 51% of cases in strategy B, with an optimization of the clinical management. Costs of strategy A (2735.42 Euro) and strategy B (2984.52 Euro) were, respectively, 8% and 18% higher than the baseline strategy (2534.81 Euro). LYS was 2.04 and 2.64 for strategy A and B, which were, respectively, 4% and 35% higher than the baseline strategy (1.96 LYS). The ICERs were 2507.63 Euro/LYS and 415.17 Euro/LYS for strategy A and B, respectively. Strategy A is dominated by strategy B, which is more expensive, but also more effective.

CONCLUSION

In Italy, the introduction of PET in the clinical management of all patients with known or suspected lung cancer previously evaluated with CT is cost-effective and allows to gain 2.64 life years at an annual cost of about 415 Euro.

Metabolic syndrome and pulse pressure

AIM

Pulse pressure (PP) has been reported to be increased in patients with abdominal adiposity and insulin resistance. Aim of the present study is to verify the association of high PP with metabolic syndrome (MS) and with its individual components.

METHODS

The relationship between PP and MS was studied in a sample of 1724 subjects aged (mean +/- s.d.) 52.8 +/- 1.3 years, enrolled in a screening programme for diabetes FIrenze-Bango A Ripoli (FIBAR) study, and in a consecutive series of 1775 patients with type 2 diabetes aged 64.3 +/- 9.1 years; only subjects not treated with antihypertensive medication were included in the analysis.

RESULTS

In the FIBAR sample, PP was significantly higher in subjects with MS. A significant correlation of PP was found in women with waist circumference, fasting glucose and triglyceride (r = 0.14, 0.15, and 0.09 respectively), and in men with fasting glucose only (r = 0.09); the correlation was no longer significant after adjustment for age and mean blood pressure. Similar results were obtained in the series of patients with type 2 diabetes.

DISCUSSION

High PP is associated with MS and its components, but this association seems to disappear after adjustment for age and mean blood pressure. On the basis of the present data, high PP cannot be considered as one of the alterations associated with MS.

Comparative evaluation of two perfusion solutions for liver preservation and transplantation

The University of Wisconsin solution (UW) and the Bretschneider solution (HTK) were used in 39 adult cadaveric donors: 22 perfused with UW (group 1) and 17 with HTK (group II). Donors were flushed through the aorta (UW, 5 to 6 L; HTK, 8 to 10 L) and through the portal vein (UW or HTK, 1 L). Grafts perfused with HTK showed lower levels of SGOT at postoperative day 7 than those transplanted with UW (38 +/- 19 vs 58 +/- 31, P < .05). No difference was observed in other functional and outcome parameters. No cases of primary dysfunction were observed. Six-month graft survival was 85.7% in HTK group and 80.9% in UW group (P = NS). Six unrelated deaths were observed. Five biliary complications were observed in five patients: three in the UW group and two in the HTK group. In conclusion, data fail to show major differences between the two solutions used.