Outlier admissions of medical patients: Prognostic implications of outlying patients. The experience of the Hospital of Mestre

ABSTRACT The admission of a patient in wards other than the appropriate ones, known as the patient outlying phenomenon, involves both Medicine and Geriatric Units of many Hospitals. The aims were to learn more about the prognosis of the outlying patients, we investigated 3828 consecutive patients hospitalized in Medicine and Geriatrics of our hub Hospital during the year 2012. We compared patients\u2019 mean hospital length of stay, survival, and early readmission according to their outlying status. The mean hospital length of stay did not significantly differ between the two groups, either for Medicine (9.8 days for outliers and 10.0 for in-ward) or Geriatrics (13.0 days for both). However, after adjustment for age and sex, the risk of death was about twice as high for outlier patients admitted into surgical compared to medical areas (hazard ratio 1.8, 1.2-2.5 95% confidence interval). Readmission within 90 days from the first discharge was more frequent for patients admitted as outliers (26.1% vs 14.2%, P<0.0001). We highlight some critical aspects of an overcrowded hospital, as the shortage of beds in Medicine and Geriatrics and the potential increased clinical risk denoted by deaths or early readmission for medical outlier patients when assigned to inappropriate wards. There is the need to reorganize beds allocation involving community services, improve in-hospital bed management, an extent diagnostic procedures for outlier patients admitted in nonmedical wards

Adjuvant therapy with imatinib mesilate in a patient with intermediate risk GIST

The presented case regards a 63-year-old male patient who underwent radical surgery for an intermediate risk gastrointestinal stromal tumor (GIST) and thereafter was treated with imatinib mesilate at a daily dose of 400 mg for one year. Adjuvant therapy for primary GIST has proven benefit in extending relapse free survival in randomised controlled phase III trials; the advantage in overall survival, however, is yet to be proved. Defined risk factors for recurrence are based on GIST size, location, and mitotic rate provide useful guidelines for selecting patients for adjuvant therapy considerations. Nevertheless, it is currently unclear how to select those patients who would benefit the most, which is the optimal dose and treatment duration, and, importantly, if the use of adjuvant imatinib could enhance the chance of cure. The case report will be used as a paradigmatic springboard for further discussion

Biliary Adenofibroma of the Liver: Report of a Case and Review of the Literature

We herein report the clinicopathologic features of a rare case of biliary adenofibroma (BAF) of the liver in a 79-year-old man. Grossly, tumour presented as a well-circumscribed, 5.5-cm mass with a solid and microcystic appearance. Histological examination was typical of biliary adenofibroma, showing a proliferation of variable-sized tubulocystic structures embedded in a moderately cellular fibrous stroma. Immunohistochemistry, revealing immunoreactivity of the epithelial component to cytokeratins 7 and 19, was consistent with a bile duct origin. Notably, the stromal cells had a myofibroblastic profile, showing a diffuse and strong expression of vimentin and α-smooth muscle actin. Differential diagnosis with Von Meyenburg complex, biliary adenoma, biliary cistadenoma, congenital biliary cystsy, and hepatic benign cystic mesothelioma is provided. The occasionally reported expression of p53 in biliary adenofibroma has suggested that this tumour could represent a premalignant lesion. The absence of both cytological atypia and p53 immunoreactivity in our case confirms that BAF is a benign tumour with an indolent clinical behaviour. However, a careful histological examination of BAF is mandatory because malignant transformation of the epithelial component has been documented in two cases

Growth and development of succulent mixtures for extensive green roofs in a Mediterranean climate

Green roof systems, aimed at reducing anthropic impact on the environment, are considered environmental mitigation technologies and adopted by many countries across the world to strengthen urban ecosystem services. This study evaluates two mixtures of succulent: one of Crassulaceae and the other of Aizoaceae, used in the creation of a continuous and homogenous plant groundcover in Mediterranean environments. To assess the species mixtures, the parameters plant height, growth index, cover percentage and flowering were observed. Hydrological observations were also carried out to evaluate the rainfall retained by the test system in any given month. All data were subjected to analysis of variance. Growth indicators in the study showed trends characteristic of xeric plants, which tend to slow down in dry, summer climate conditions to the point of halting plant vertical growth and ground cover development completely. The Aizocaeae mix, during the initial stage, showed prevalent horizontal growth, confirmed by greater a greater growth index (13,21) and cover percentage (45%) compared to Sedum (Growth index: 3,61; Cover: 36%). In contrast, the Sedum mix recorded greater vertical growth at the beginning (Sedum mixture: 7.53 cm; Aizoaceae mixture: 6,11 cm). During the final stages of observations, however, greater vertical growth in the Aizoaceae (7,88 cm) became apparent together with a recovery in horizontal growth in the Sedum (79%), albeit not sufficient to outperform the Aizoaceae mixture (87%). Flowering in the two mixtures occurred between late spring and late summer. The Sedum mixture guaranteed a longer flowering period (130 days) compared to the Aizoaceae (93 days), with a gradual start followed by steady flower emission. Regarding rainfall water retention, a comparison of the mixtures in late winter/early spring revealed that the Sedum performed best (44.9 L m2 vs 37.4 L m2), whilst the Aizoaceae outperformed the Sedum in Autumn (63 L m2 vs 55 L m2), in conjunction with favorable growth rates in both species mixtures. Both mixtures demonstrated satisfying results and are considered suited to a Mediterranean environment. Furthermore, based on the different growth rates of the species in the two test mixtures, this study suggests that new combinations of Sedum and Aizoaceae together might prove more resilient in Mediterranean environments

Evidence-based appraisal of the upfront treatment for unresectable metastatic colorectal cancer patients

Colorectal cancer (CRC) is a significant health problem, with around 1 million new cases and 500000 deaths every year worldwide. Over the last two decades, the use of novel therapies and more complex treatment strategies have contributed to progressively increase the median survival of patients with unresectable advanced CRC up to approximately 30 mo. The availability of additional therapeutic options, however, has created new challenges and generated more complicated treatment algorithms. Moreover, several clinically important points are still in debate in first-line, such as the optimal treatment intensity, the most appropriate maintenance strategy, the preferred biologic to be used upfront in patients with KRAS wild-type CRC, and the need for more detailed information on tumor biology. In this moving landscape, this review analyses why the firstline treatment decision is crucial and how the choice may impact on further treatment lines. In addition, it focuses on results of major phase III randomized trial

Microchimerism in multiple sclerosis: The association between sex of offspring and MRI features in women with multiple sclerosis

Aims: During pregnancy, fetal cells can migrate to the mother via blood circulation. A percentage of these cells survive in maternal tissues for decades generating a population of fetal microchimeric cells (fMCs), whose biological role is unclear. The aim of this study was to investigate the association between the sex of offspring, an indirect marker of fMCs, and magnetic resonance imaging (MRI) features in women with multiple sclerosis (MS). Methods: We recruited 26 nulliparous MS patients (NPp), 20 patients with at least one male son (XYp), and 8 patients with only daughters (XXp). Each patient underwent brain MR scan to acquire 3D-T2w FLAIR FatSat and 3D-T1w FSPGR/TFE. Lesion Segmentation Tool (LST) and FreeSurfer were used to obtain quantitative data from MRI. Additional data were collected using medical records. Multiple regression models were applied to evaluate the association between sex of offspring and MS data. Results: Comparing NPp and XXp, we found that NPp had larger 4th ventricle volume (2.02 ± 0.59 vs. 1.70 ± 0.41; p = 0.022), smaller left entorhinal volume (0.55 ± 0.17 vs. 0.68 ± 0.25; p = 0.028), and lower thickness in the following cortical areas: left paracentral (2.34 ± 0.16 vs. 2.39 ± 0.17; p = 0.043), left precuneus (2.27 ± 0.11 vs. 2.34 ± 0.16; p = 0.046), right lateral occipital (2.14 ± 0.11 vs. 2.25 ± 0.08; p = 0.006). NPp also had lower thickness in left paracentral cortex (2.34 ± 0.16 vs. 2.46 ± 0.17; p = 0.004), left precalcarine cortex (1.64 ± 0.14 vs. 1.72 ± 0.12; p = 0.041), and right paracentral cortex (2.34 ± 0.17 vs. 2.42 ± 0.14; p = 0.015) when compared to XYp. Comparing XYp and XXp, we found that XYp had higher thickness in left cuneus (1.80 ± 0.14 vs. 1.93 ± 0.10; p = 0.042) and left pericalcarine areas (1.59 ± 0.19 vs. 1.72 ± 0.12; p = 0.032) and lower thickness in right lateral occipital cortex (2.25 ± 0.08 vs. 2.18 ± 0.13; p = 0.027). Discussion: Our findings suggested an association between the sex of offspring and brain atrophy. Considering the sex of offspring as an indirect marker of fMCs, we speculated that fMCs could accumulate in different brain areas modulating MS neuropathological processes

Tracking the 2015 Gastrointestinal Cancers Symposium: bridging cancer biology to clinical gastrointestinal oncology

The 2015 Gastrointestinal Cancers Symposium (San Francisco, CA, USA; January 15–17) is the world-class conference co-sponsored by the American Society of Clinical Oncology, the American Society for Radiation Oncology, the American Gastroenterological Association Institute, and the Society of Surgical Oncology, in which the most innovative research results in digestive tract oncology are presented and discussed. In its twelfth edition, the meeting has provided new insights focusing on the underpinning biology and clinical management of gastrointestinal malignancies. More than 3,400 health care professionals gathered from all over the world to share their experiences on how to bridge the recent novelties in cancer biology with everyday medical practice. In this article, the authors report on the most significant advances, didactically moving on three different anatomic tracks: gastroesophageal malignancies, pancreatic and biliary cancers, and colorectal adenocarcinomas

Capecitabine-induced cardiotoxicity: More evidence or clinical approaches to protect the patients' heart?

Fluoropyrimidines, such as capecitabine and 5-fluorouracil, may cause cardiac toxicity. In recent years, the incidence of this side effect has increased and it is expected to further rise due to the population aging and the disproportionate incidence of breast and gastrointestinal cancers in older individuals. The spectrum of cardiac manifestations includes different signs and symptoms and the diagnosis may be difficult. Here, we report the case of a 43-year-old woman with advanced breast cancer who was rechallenged with a capecitabine-based regimen after experiencing a cardiac adverse event during the first fluoropyrimidine exposure. This real-practice case serves as a springboard for discussion about the current evidence on differential diagnosis of capecitabine-related cardiac toxicity, its risk factors, and the underpinning mechanisms of early onset. Moreover, we discussed whether a rechallenge with fluoropyrimidines could be safe in patients who had experienced a previous cardiac adverse even

High-dose clopidogrel, prasugrel or ticagrelor: trying to unravel a skein into a ball

Antiplatelet therapy is a mainstay in the management of coronary artery disease. Indeed, optimal and rapid inhibition of platelet function is a key therapeutic goal in patients with acute coronary syndromes and those undergoing percutaneous coronary intervention. Currently, dual antiplatelet treatment with aspirin and clopidogrel is the gold standard care in patients with acute coronary syndromes or receiving coronary stents without prohibitive bleeding risk. However, recent data show that the efficacy of clopidogrel is hampered by its slow and variable platelet inhibition, with ensuing increased risk of ischemic events, including death, myocardial infarction and stent thrombosis. Novel agents such as prasugrel and ticagrelor have been developed to clopidogrel limits and thus improve cardiovascular outcomes. This article presents a comprehensive overview of the benefits and limitations of current and shortly available antiplatelet agents, providing detailed arguments in favor and against prasugrel and ticagrelor