MULTIDISCIPLINARY MANAGEMENT OF METASTATIC NEUROENDOCRINE TUMOURS

A 65-year-old man presented to his GP with right upper quadrant abdominal pain and weight loss. Abdominal ultrasound showed multiple gallstones and some ill-defined liver lesions. Computer tomography scan diagnosed a terminal ileal lesion causing cicatrisation of the terminal small bowel but does liver abnormality. The patient was worked up with serum gut hormone profile and magnetic resonance imaging of the liver which demonstrated multiple liver lesions and biochemical suspicion of neuroendocrine tumour (NET). The patient underwent a right hemicolectomy and excision/ ablation of 44 liver metastases. He made a good post-operative recovery and remains disease free after 18 months. We also present a brief literature review regarding advances in the management of metastatic NET.Key words: Neuroendocrine tumours, Hepatic metastases, Radiofrequency ablation, Computer tomography, Magneticresonance imagin

PROGNOSTIC POWER OF INFLAMMATORY RESPONSE SCORING SYSTEMS IN PERIAMPULLARY PANCREATIC CANCER: A SYSTEMATIC REVIEW

Introduction: Assessment of systemic inflammatory response forms the basis of several scoring systems that attempt to prognosticate patients with periampullary pancreatic carcinoma (PPC). We assessed the validity of three of these scoring systems for patients’ prognosis following intervention for PPC: Glasgow prognostic score (GPS) and its modified version (mGPS), platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR).Methods: EMBASE and MEDLINE databases were searched for all published studies until September 2018 using comprehensive text word and MeSH terms. Meta-analysis of observational studies in epidemiology guidelines was followed. All identified studies were analysed and relevant studies were included in the review.Results: Three studies which assessed the role of GPS, four studies that evaluated the use of NLR and three that assessed the role of PLR in patients with PPC were identified. None of these studies demonstrated any value in the pre-operative assessment of patients with PPC. The limited number of studies available precluded further statistical analysis.Conclusions: Based on available evidence, GPS, NLR and PLR do not appear to be useful scoring systems to predict prognosis of patients with PPC. Larger studies are warranted before the application of inflammatory scoring systems could be recommended in patients with PPC.Key words: Periampullary cancer, Glasgow prognostic score, modified Glasgow prognostic score, platelet-lymphocyte ratio, neutrophil-lymphocyte rati

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers’ knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used

LDL-cholesterol control in the primary prevention of cardiovascular diseases. An expert opinion for clinicians and health professionals

Aims: Although adequate clinical management of patients with hypercholesterolemia without a history of known cardiovascular disease is essential for prevention, these subjects are often disregarded. Furthermore, the scientific literature on primary cardiovascular prevention is not as rich as that on secondary prevention; finally, physicians often lack adequate tools for the effective management of subjects in primary prevention and have to face some unsolved relevant issues. This document aims to discuss and review the evidence available on this topic and provide practical guidance. Data synthesis: Available algorithms and risk charts represent the main tool for the assessment of cardiovascular risk in patients in primary prevention. The accuracy of such an estimate can be substantially improved considering the potential contribution of some additional risk factors (C-reactive protein, lipoprotein(a), family history of cardiovascular disease) and conditions (environmental pollution, sleep quality, socioeconomic status, educational level) whose impact on the cardiovascular risk has been better understood in recent years. The availability of non-invasive procedures to evaluate subclinical atherosclerosis may help to identify subjects needing an earlier intervention. Unveiling the presence of these conditions will improve cardiovascular risk estimation, granting a more appropriate intervention. Conclusions: The accurate assessment of cardiovascular risk in subjects in primary prevention with the use of algorithms and risk charts together with the evaluation of additional factors will allow physicians to approach each patient with personalized strategies, which should translate into an increased adherence to therapy and, as a consequence, a reduced cardiovascular risk

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

Abstract: Background: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort

COVID-19 Severity in Multiple Sclerosis: Putting Data Into Context

Background and objectives: It is unclear how multiple sclerosis (MS) affects the severity of COVID-19. The aim of this study is to compare COVID-19-related outcomes collected in an Italian cohort of patients with MS with the outcomes expected in the age- and sex-matched Italian population. Methods: Hospitalization, intensive care unit (ICU) admission, and death after COVID-19 diagnosis of 1,362 patients with MS were compared with the age- and sex-matched Italian population in a retrospective observational case-cohort study with population-based control. The observed vs the expected events were compared in the whole MS cohort and in different subgroups (higher risk: Expanded Disability Status Scale [EDSS] score > 3 or at least 1 comorbidity, lower risk: EDSS score ≤ 3 and no comorbidities) by the χ2 test, and the risk excess was quantified by risk ratios (RRs). Results: The risk of severe events was about twice the risk in the age- and sex-matched Italian population: RR = 2.12 for hospitalization (p < 0.001), RR = 2.19 for ICU admission (p < 0.001), and RR = 2.43 for death (p < 0.001). The excess of risk was confined to the higher-risk group (n = 553). In lower-risk patients (n = 809), the rate of events was close to that of the Italian age- and sex-matched population (RR = 1.12 for hospitalization, RR = 1.52 for ICU admission, and RR = 1.19 for death). In the lower-risk group, an increased hospitalization risk was detected in patients on anti-CD20 (RR = 3.03, p = 0.005), whereas a decrease was detected in patients on interferon (0 observed vs 4 expected events, p = 0.04). Discussion: Overall, the MS cohort had a risk of severe events that is twice the risk than the age- and sex-matched Italian population. This excess of risk is mainly explained by the EDSS score and comorbidities, whereas a residual increase of hospitalization risk was observed in patients on anti-CD20 therapies and a decrease in people on interferon