HLM, a TNM-like classification for heart failure, compared with other nosologies at 12 months follow-up

Background

Heart failure (HF) is the pandemic of the third millennium with the highest mortality among general population, while lung cancer is the second most common cause of death. As cancer, HF can affect close organs, as lungs, or can reach peripheral organs (kidney, liver, brain), leading to multi-organ dysfunction, like cancer metastasis.

Purpose

We proposed a new staging system named HLM, analogous to TNM classification used in oncology, which refers to heart damage (H), lung involvement (L), and malfunction (M) of peripheral organs. The aim of this study is a comparison between HLM and NYHA, ACC/AHA and MAGGIC scores to assess the most accurate prognosis of HF patients in terms of rehospitalization for acute HF (AHF) or major adverse cardiac and cerebrovascular events (MACCE), and cardiac death.

Methods

We performed a single-center observational study of HF patients. All parameters for heart, lungs and peripheral organs function were examined. Each patient was classified according to HLM, NYHA, ACC/AHA and MAGGIC score at the entrance and at the discharge. Rehospitalization for MACCE or AHF and cardiac death were checked at 12 months follow up.

Results

We enrolled 2054 patients: 68.5% males, 31.3% females, mean age 70.18±7.48 years. Among them, overall survival curves regarding rehospitalization for MACCE, AHF and cardiac death at 12 months, show that HLM classification is as valid as the others (p<0.001). In particular, the area under the ROC curve (AUC) is greater for HLM than NYHA, ACC/AHA and MAGGIC score in terms rehospitalisation for MACCE (HLM=0.687; NYHA=0.642; ACC/AHA=0.604; MAGGIC=0.657) or AHF (HLM=0.662; NYHA=0.652; ACC/AHA=0.604; MAGGIC=0.662) and cardiac death (HLM=0.783; NYHA=0.712; ACC/AHA=0.623; MAGGIC=0.737).

Conclusion(s)

According to our results, HLM classification has greater prognostic power compared to other nosologies in terms of rehospitalization for MACCE, AHF and cardiac death for HF patients, thanks to a more accurate evaluation of the systemic impact of heart failure. Such a multivariable, holistic approach should be used in HF patients, rather than a “cardiocentric” approach, in order to address the pathophysiological mechanisms underlining heart abnormalities, improving clinical management and costs.

Funding Acknowledgement

Type of funding source: None

Can Peripherally Inserted Central Catheters Be Safely Placed in Patients with Cancer Receiving Chemotherapy? A Retrospective Study of Almost 400,000 Catheter-Days

BACKGROUND

Peripherally inserted central catheters (PICCs) are central venous catheters (CVCs) that are commonly used in onco-hematologic settings for chemotherapy administration. As there is insufficient evidence to recommend a specific CVC for chemotherapy administration, we aimed to ascertain PICC-related adverse events (AEs) and identify independent predictors of PICC removal in patients with cancer receiving chemotherapy.

MATERIALS AND METHODS

Information on adult patients with cancer with a PICC inserted for chemotherapy administration between September 2007 and December 2014 was extracted from six hospital databases. The primary outcome was PICC removal due to PICC-related AEs (occlusion, infection, or symptomatic thrombosis). Independent predictors of PICC removal were identified using a multivariate Cox regression model.

RESULTS

Among the 2,477 included patients, 419 PICC-related AEs (16.9%; 1.09 AEs per 1,000 PICC-days) were reported. AEs increased when PICC was inserted at the brachial site (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.02-1.84) and with open systems (HR, 1.89; 95% CI, 1.24-2.88) and decreased in older men (HR, 0.63; 95% CI, 0.49-0.81).

CONCLUSION

Use of PICC for chemotherapy administration was associated with a low all-AEs rate. The basilic vein was the safer site, and valved systems had fewer AEs than open systems. More research is needed to explore the interaction between AEs, sex, and age.

IMPLICATIONS FOR PRACTICE

These findings provide clinicians with evidence that peripherally inserted central catheters (PICCs) are safe for chemotherapy administration. They also suggest that clinicians should limit the use of open systems when long chemotherapy regimens are scheduled. Moreover, alternatives to PICCs should be considered when administering chemotherapy to young men.

A retrospective study of the safety of over 100,000 peripherally-inserted central catheters days for parenteral supportive treatments

The type of central vascular access device providers chosen for providing parenteral supportive treatments has evolved over the past years, going from routinely used centrally inserted catheters to a more recent trend of peripherally-inserted central catheters (PICCs) when expected treatment duration is less than 6 months. This multicenter retrospective study aimed to provide a comprehensive assessment of the safety of PICCs in administering parenteral supportive treatments. All adult inpatients and outpatients who had a PICC inserted for the administration of parenteral supportive treatments (i.e., parenteral nutrition, intravenous fluids, blood products, or antibiotics) between September 2007 and December 2014 in four public Italian hospitals were included. The primary outcome was PICC removal because of an adverse event (AE, defined as occlusion, exit-site infection, or symptomatic thrombosis). Among the 1,250 included patients, 178 PICC-related removals because of AEs (14.2%; 1.62 AEs per 1,000 PICC days) were reported. Rates of PICC removal because of occlusion, exit-site infection, and symptomatic thrombosis were 1.08, 0.32, and 0.23 per 1,000 PICC days, respectively. The median dwell-time between PICC insertion and its removal because of an AE was 67 days (interquartile range 28-180 days). Risk of PICC removal due to AE was higher with open-system PICCs [hazard ratio = 2.75, 95% confidence interval 1.52-4.96]. In this study, we found preliminary evidence that PICCs can be safely used to administer parenteral supportive treatments lasting up to 6 months. PICCs may be a relevant alternative to centrally inserted catheters for medium-term parenteral supportive treatments.

Predictors of human papilloma virus (HPV) infection in Italian women

HPV infection is a "necessary cause" of cervical cancer and it is sexually transmitted. Due to upcoming mass vaccination investigation on risk factors for infection is the basis to implement prophylactic strategy even in older women. The aim of the study was to evaluate predictors of high-risk (HR) HPV infection in adult women. Between 2006 and 2008, 100 women aged >18 years, with no previous treatment for cervical lesions, were screened for HR HPV infection in Rome, Italy. Risk factors for HPV infection were investigated through a questionnaire including: ethnicity, religion, education, marital status, sexual behavior, gynecological and obstetrical history, smoking and alcohol intake. Multivariate analysis identified the "never married-separated/divorced" status (OR: 3.38; 95% CI: 1.14-10.12) as predictor of HPV infection, while having a higher age at the first sexual intercourse (FSI) shows a protective effect (OR: 0.84; 95% CI: 0.71-1.00). A trend for the association between the infection and having more than three lifetime partners was also observed (OR: 2.57; 95% CI: 0.86-7.71). No significant association was found for other demographic characteristics investigated. These findings provide a contribution in the knowledge of an adult population defining a "high-risk" sexual behavioral profile and could be helpful to target prophylactic strategies in older woman.

Reproducibility of serial peri-ictal single-photon emission tomography difference images in epilepsy patients undergoing surgical resection

Peri-ictal single-photon emission tomography (SPET) difference images co-registered to magnetic resonance imaging (MRI) visualize regional cerebral blood flow (rCBF) changes and help localize the epileptogenic area in medically refractory epilepsy. Few reports have examined the reproducibility of SPET difference image results. Epilepsy patients having two peri-ictal and at least one interictal SPET scan who later underwent surgical resection were studied. Localization accuracy of peri-ictal SPET difference images results, interictal electroencephalography (EEG), and ictal EEG from the first (seizure 1) and second (seizure 2) seizure, as well as MRI and positron emission tomography (PET) findings, were compared using surgical resection site as the standard. Thirteen patients underwent surgical resection (11 temporal lobe and 2 extratemporal). SPET results from seizure 1 were localized to the surgical site in 12/13 (92%) patients, while SPET results from seizure 2 were localized in 13/13 (100%) patients. All other modalities were less accurate than the SPET results interictal EEG--seizure 1 6/13 (46%); ictal EEG--seizure 1 5/13 (38%); interictal intracranial EEG--seizure 2 4/9 (44%); ictal intracranial EEG--seizure 2 results 8/9 (89%); MRI 6/13 (46%); PET 9/13 (69%)[. SPET results were reproducible in 12/13 (92%) patients. SPET difference images calculated from two independent peri-ictal scans appear to be reproducible and accurately localize the epileptogenic area. While SPET difference images visualize many areas of rCBF change, the quantification of these results along with consideration of injection time improves the diagnostic interpretation of the results.