The recurrence pattern following delayed breast reconstruction after mastectomy for breast cancer suggests a systemic effect of surgery on occult dormant micrometastases

The purpose of this study was to characterize the recurrence dynamics in breast cancer patients after delayed reconstruction. We hypothesized that surgical reconstruction might stimulate dormant micrometastases and reduce time to recurrence. All mastectomy breast cancer patients with delayed surgical reconstruction at Haukeland University Hospital, between 1977 and 2007, n\ua0=\ua0312, were studied. Our control group consisted of 1341 breast cancer patients without reconstruction. For each case, all patients in the control group with identical T and N stages and age\ua0\ub12\ua0years were considered. A paired control was randomly selected from this group. 10\ua0years after primary surgery, 39 of the cases had relapsed, compared to 52 of the matched controls. The reconstructed group was analyzed for relapse dynamics after mastectomy; the first peak in relapses was similarly timed, but smaller than for the controls, while the second peak was similar in time and size. Second, the relapse pattern was analyzed with reconstruction as the starting point. A peak in recurrences was found after 18\ua0months, and a lower peak at the 5th\u20136th year. The height of the peak correlated with the extent of surgery and initial T and N stages. Timing of the peak was not affected, neither was the cumulative effect. The relapse pattern, when time origin is placed both at mastectomy and at reconstruction, is bimodal with a peak position at the same time points, at 2\ua0years and at 5\u20136\ua0years. The timing of the transition from dormant micrometastases into clinically detectable macrometastases might be explained by an enhancing effect of surgery

Drug survival and reasons for discontinuation of the first course of biological therapy in 301 juvenile idiopathic arthritis patients

The objective of this study was to determine long-term effectiveness and safety of 1st biological treatment (BT) in a cohort of 301 juvenile idiopathic arthritis (JIA) patients (pts), non-responders to disease-modifying antirheumatic drugs (DMARDs), in terms of drug survival (continuation rate on therapy) and to identify the baseline predictors of treatment discontinuation. Each JIA pt enrolled in BT is prospectively assessed at the start of treatment and then every 2 months for the evaluation of safety and efficacy according to ACR-Pedi30 criteria. All clinical charts of pts who started a BT between November 1999 and July 2010 have been reviewed. Survival analysis methods suitable for competing risks were used to study time to drug discontinuation due to disease control (defined according to Wallace criteria) or failure [adverse event (AE), lack of efficacy (LaE) or loss of efficacy (LoE) according ACR-Pedi30]. A number of 301 JIA pts, non-responders or intolerant to DMARDs and treated with one or more cycles of BT, were identified. Median disease duration, from onset to the beginning of 1st BT, was 7.8 years (interquartil range 2.21-15.1). In total, there were 294 1st corses with anti-TNF agents, 5 with abatacept and 2 with anakinra. A number of 298 pts were included in the analysis for drug discontinuation (3 pts with no follow-up data after their first dose of BT were excluded). The median follow-up on treatment, before discontinuation due to every cause, was 53.7 months (range 0.45-124.45). One hundred and sixty-five pts discontinued BT: 27 due to disease control, 135 because of failure (78 AEs, 12 LaE and 45 LoE), 3 pts temporarily stopped for pregnancy. Among 135 pts who discontinued for failure, 117 switched to a 2nd BT. Among 27 pts who discontinued due to remission, 13 pts restarted on BT for relapse of disease activity (10 pts restarted with the same BT, 3 switched to a different one). Predictors of discontinuation due to AE were female gender (P=0.01) and longer disease duration (P=0.02). Predictors of discontinuation due to LaE or LoE were systemic onset and polyarthritis FR positive (vs other JIA subtypes) (P<0.05) and use of mAb-anti-TNF (vs sTNFR) (P=0.02). Predictors of discontinuation due to inactive disease were male gender and shorter disease duration (P<0.05). Although only few pts discontinued BT due to a complete and persistent disease control, the majority of them remained on BT for a long time, suggesting that in our cohort of JIA pts, affected by a severe long lasting refractory disease, BT was globally well tolerate and efficacious in controlling the disease

Retroperitoneal liposarcomas: The experience of a tertiary Asian center

10.1186/1477-7819-9-12World Journal of Surgical Oncology9

Pain and Frailty in Hospitalized Older Adults

Introduction: Pain and frailty are prevalent conditions in the older population. Many chronic diseases are likely involved in their origin, and both have a negative impact on quality of life. However, few studies have analysed their association. Methods: In light of this knowledge gap, 3577 acutely hospitalized patients 65&nbsp;years or older enrolled in the REPOSI register, an Italian network of internal medicine and geriatric hospital wards, were assessed to calculate the frailty index (FI). The impact of pain and some of its characteristics on the degree of frailty was evaluated using an ordinal logistic regression model after adjusting for age and gender. Results: The prevalence of pain was 24.7%, and among patients with pain, 42.9% was regarded as chronic pain. Chronic pain was associated with severe frailty (OR = 1.69, 95% CI 1.38–2.07). Somatic pain (OR = 1.59, 95% CI 1.23–2.07) and widespread pain (OR = 1.60, 95% CI 0.93–2.78) were associated with frailty. Osteoarthritis was the most common cause of chronic pain, diagnosed in 157 patients (33.5%). Polymyalgia, rheumatoid arthritis and other musculoskeletal diseases causing chronic pain were associated with a lower degree of frailty than osteoarthritis (OR = 0.49, 95%CI 0.28–0.85). Conclusions: Chronic and somatic pain negatively affect the degree of frailty. The duration and type of pain, as well as the underlying diseases associated with chronic pain, should be evaluated to improve the hospital management of frail older people

The multifaceted spectrum of liver cirrhosis in older hospitalised patients: Analysis of the REPOSI registry

Background: Knowledge on the main clinical and prognostic characteristics of older multimorbid subjects with liver cirrhosis (LC) admitted to acute medical wards is scarce. Objectives: To estimate the prevalence of LC among older patients admitted to acute medical wards and to assess the main clinical characteristics of LC along with its association with major clinical outcomes and to explore the possibility that well-distinguished phenotypic profiles of LC have classificatory and prognostic properties. Methods: A cohort of 6,193 older subjects hospitalised between 2010 and 2018 and included in the REPOSI registry was analysed. Results: LC was diagnosed in 315 patients (5%). LC was associated with rehospitalisation (age-sex adjusted hazard ratio, [aHR] 1.44; 95% CI, 1.10-1.88) and with mortality after discharge, independently of all confounders (multiple aHR, 2.1; 95% CI, 1.37-3.22), but not with in-hospital mortality and incident disability. Three main clinical phenotypes of LC patients were recognised: relatively fit subjects (FIT, N = 150), subjects characterised by poor social support (PSS, N = 89) and, finally, subjects with disability and multimorbidity (D&amp;M, N = 76). PSS subjects had an increased incident disability (35% vs 13%, P &lt; 0.05) compared to FIT. D&amp;M patients had a higher mortality (in-hospital: 12% vs 3%/1%, P &lt; 0.01; post-discharge: 41% vs 12%/15%, P &lt; 0.01) and less rehospitalisation (10% vs 32%/34%, P &lt; 0.01) compared to PSS and FIT. Conclusions: LC has a relatively low prevalence in older hospitalised subjects but, when present, accounts for worse post-discharge outcomes. Phenotypic analysis unravelled the heterogeneity of LC older population and the association of selected phenotypes with different clinical and prognostic features

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia

Report relativo a dati statistico-epidemiologici ed economici su diagnosi e trattamento del carcinoma polmonare

rapporto finale per ricerca finanziata dalla ditta ABBO

Nailfold capillaroscopy in systemic sclerosis: data from the eular scleroderma trials and research (EUSTAR) registry

Background: Microvascular findings in Systemic Sclerosis (SSc) document a significant loss of the peripheral vascular network, with loss of capillaries, deficient vascular repair and the absence of new vessel growth, and subsequent tissue ischemia and fibrosis. The sequence of these alterations in the microcirculation can be observed using a reliable, rapid, non-invasive examination such as nailfold capillaroscopy, which can be regarded as the most valuable technique for assisting the early diagnosis of SSc and monitoring the evolution of microangiopathy in overt SSc. Objectives: To obtain cross-sectional data on theuse of capillaroscopy in an international multi-centre cohort of SSc patients and to investigate the frequency of the capillaroscopic patterns and their disease-phenotype associations. Methods: This study examined data collected betweenJune 2004 and October 2011in the EULAR Scleroderma Trials And Research (EUSTAR) registry. SSc adult patients who had at least one capillaroscopy were analyzed. Patients' profiles based on clinical and laboratory data were obtained by cluster analysis and the association between profiles and capillaroscopy was investigated by multinomial logistic regression. Results: 67.6% of EUSTAR centers that responded to the survey perform capillaroscopy regularly using mainly the videocapillaroscope (70.3%), otherwise microscope (24.3%) and dermatoscope (5.4%) were used. 62 of 110 (56.4%) EUSTAR centers entered data on capillaroscopy in the EUSTAR database. 376 of 2754 patients (13.65%) were classified as scleroderma pattern absent, but non-specific capillary abnormalities were noted in 55.48% of cases. Four major patients' profiles were identified. They are characterised by a progressive severity for skin involvement, as well as an increased number of systemic manifestations. The \u201cearly\u201d and \u201cactive\u201d scleroderma patterns were generally observed in patients with mild/moderate skin involvement and a low number of disease manifestations, while the \u201clate\u201d scleroderma pattern was found more frequently in the more severe forms of the disease. Conclusions: This is the largest multicenter international study on SSc and capillaroscopy. These data indicate that capillaroscopic patterns are directly related to the extent of organ involvement and to disease progression. Widespread use of capillaroscopy may be of a great value in monitoring the disease course

Estimate cause specific survival in soft tissue retroperitoneal sarcomas in the presence of competing risks : relative and net survival

Soft Tissue Sarcomas (STSs) are a rare and heterogeneous group of malignancies that originate from mesenchymal cells almost everywhere in the body. To evaluate therapy-related benefit, disease specific survival is surely of interest, being related to the mortality associated with the specific cancer diagnosis and disease evolution. Such a probability measure refers to the hypothetical situation of cause removal, i.e. only the cause of interest is acting. The na\uefve classical approach to estimate net/cause specific survival is based only on the events attributable to the disease, while times to other death causes are censored. This is appropriate only under independence among causes of death. However, from the statistical viewpoint, cause specific survival refers to the context of \u2018competing risks\u2019 and its estimation to a non identifiable problem, due to the interrelation among different causes of death. In population based cancer survival studies, relative survival methods were proposed for estimating the excess mortality with respect to that would be expected for the population to which patients belong, matched for sex, age, and year of birth. The observed excess mortality is assumed to be cancer related, capturing both directly and indirectly related death events. Although this approach does not provide a direct estimation of net survival, under specific assumptions can be interpreted as a net survival. However, this is not always holding and, in the presence of a reliable classification of the causes of death relative survival should be compared with a direst estimate of net survival. Several non parametric estimator based on copula functions have been proposed, but they are rarely used in clinical application, mainly because of the lack of dedicated software. The copula allow to specify the bivariate distribution among causes of death, leaving unspecified the marginal ones and several copula structures have been proposed so far. An advantage of these approaches is to provide an estimate of association among times to different causes of death, which could be itself of clinical interest. The choice of the appropriate copula structure is mainly based on clinical considerations since, in the presence of competing risks, it is not possible to assesse the goodness of fit. Nevertheless published simulation studies showed the robustness of Archimedean copulas. The aim of the present work is to compare relative and net sarcoma survival estimates in a clinical-epidemiology observational cohort setting in which the classification of causes of death is reliable, to have insights on other studies on the same pathology where the causes of death is not available. 192 adult patients with retroperitoneal STS admitted at the National Cancer Institute in Milan from January 1985 to September 2007 who underwent surgery on primary localized disease were included in the present analysis. The results highlighted that patients who underwent a diagnosis of retroperitoneal sarcoma had an excess mortality. The relative survival Poisson regression model showed that age, surgical margins, grading and tumour size are prognostic factors. These results were compared to the net survival curve estimated by Copula graphic estimator with pertinent confidence intervals