Tracciabilità in anatomia patologica – raccomandazioni e buone pratiche.

INTRODUCTION Traceability in pathological anatomy is increasingly a requirement related to the clinical risk that derives from its lack. The SIAPEC guideline of May 2015 suggests its application in Pathological Anatomies but does not codify the requirements for which software companies develop and issue traceability forms in the absence of mandatory requirements. METHODS By applying the “Lean Six-Sigma” methodology we have redesigned the pathological anatomy process, correctly identifying where traceability can be the added value for both the patient and the operators. OBJECTIVES The aim of the study is to analyze the flows of pathological anatomy processes to be traced using the Lean methodology and develop a best practice to guide their application. RESULTS The “Value Stream Map” and the analysis of the data collected made it possible to correctly identify the traceability points (track) to be implemented throughout the sample process in the laboratory to guarantee the safety of the process with the identification of upstream feedback (phase pre-preanalytical) and downstream (phase post-post analytical) of two moments of interface with the external user to guarantee the effectiveness of the process. DISCUSSION The inclusion of a traceability system within the pathological anatomy processes is, especially in centers with a high density of activity, a mandatory requirement. Correctly identifying the essential points to be traced, through the application of the “value stream map”, avoids the redundancy of surveys by operators which are often the primary cause of refusal to insert a tracking system. CONCLUSIONS The Lean methodology, with the "value stream map" tool, allows operators to be able to correctly map the health processes. Following a correct evaluation of the process, it is possible to identify areas for improvement and redesign a new process with more added value.INTRODUZIONE La tracciabilità in anatomia patologica è sempre più un’esigenza correlata al rischio clinico che dalla sua mancanza deriva. La linea guida della SIAPEC di maggio 2015 ne suggerisce l’applicazione nelle Anatomie Patologiche ma non ne codifica le caratteristiche per cui le aziende produttrici di software elaborano e rilasciano moduli di tracciabilità in assenza di requisiti cogenti. METODI Applicando la metodologia “Lean Six-Sigma” abbiamo ridisegnato il processo di anatomia patologica, individuando correttamente dove la tracciabilità possa essere il valore aggiunto sia per il paziente che per gli operatori. OBIETTIVI L’obiettivo dello studio è quello di analizzare con la metodologia lean i flussi dei processi di anatomia patologica da sottoporre a tracciabilità ed elaborare una best practice che ne guidi l’applicazione. RISULTATI La “Value Stream Map” e l’analisi dei dati raccolti hanno consentito di individuare correttamente i punti di tracciabilità (track) da implementare durante tutto il processo del campione in laboratorio a garanzia della sicurezza del processo con l’individuazione di feedback a monte (fase pre-preanalitica) ed a valle (fase post-postanalitica) di due momenti di interfaccia con l’utente esterno a garanzia dell’efficacia del processo. DISCUSSIONE L’inserimento di un sistema di tracciabilità all’interno dei processi di Anatomia Patologica è, soprattutto nei centri ad alta densità di attività, un’esigenza inderogabile. Individuare correttamente i punti essenziali da tracciare, attraverso l’applicazione della “value stream map”, evita la ridondanza di rilevazioni da parte degli operatori che sono spesso causa primaria di rifiuto all’inserimento di un sistema di tracking. CONCLUSIONI La metodologia Lean, con lo strumento della “value stream map” consente agli operatori di poter correttamente mappare i processi. A seguito di una corretta valutazione del processo è possibile individuare gli spazi di miglioramento e ridisegnare un nuovo processo con più valore aggiunto

Toll-like receptor-4 is involved in hepatic fibrogenesis in the course of non-alcoholic fatty liver disease

Toll-like receptor-4 (TLR4) is actively involved in liver in the response to injury from a variety of etiologies. Recently TLR4 expression by hepatic progenitor cells (HPC) and biliary epithelial cells has been associated to the progression of liver damage in chronic HCV-related hepatitis (1). HPC compartment activation in ductular reaction (DR) is a feature of progressive disease also in non-alcoholic fatty liver disease (NAFLD) (2). We aimed to investigate the association among TLR4 expression, HPC compartment activation and histopathologic features of fibrotic disease progression in NAFLD. Seventy-four patients who had undergone liver biopsy were included and immunohistochemistry for TLR4 was performed on hepatic tissue samples. CK-7 was used to evaluate HPC, bile ducts (BD)/ductules of DR and intermediate hepatocytes; α-smooth muscle actin was used to quantify the activation of hepatic stellate cells (HSC) and of portal/septal myofibroblasts (MF). HPC in BD/DR were responsible for the highest TLR4 intensity of staining. TLR4-positive HPC and BD/ DR correlated with fibrosis (p<0.01 and p<0.05), activity of MF (p<0.001 and p<0.05) and HSC (p<0.001 and p<0.001), portal and interface chronic inflammation (p<0.01 and p=0.01). The present study indicates the activation of the TLR4 expressing HPC compartment as important determinant of the progressive liver damage in NAFLD. TLR4 stimulation could represent one of the mechanisms directly linking the activation of HPC to inflammation and fibrosis in NAFLD

Portal and interface chronic inflammation are associated with the progenitor cell compartment activation during NAFLD

Background and aim: During nonalcoholic fatty liver disease (NAFLD), portal and interface chronic inflammation (PCI and ICI) are strongly associated with fibrosis by activation of hepatic stellate cell (HSC)s (Brunt et al., 2009; Vespasiani-Gentilucci et al., 2014). However, the determinants of PCI and ICI observed in NAFLD remain to be elucidated. Since portal and periportal ductular reaction is related to disease progression, we aimed to investigate if PCI and ICI are associated with hepatic progenitor cell (HPC) compartment activation. Methods: Fifty-two NAFLD patients were studied. NAFLD activity score, fibrosis, PCI and ICI were histologically evaluated. HPCs, intermediate hepatobiliary cells and bile ductules/interlobular bile ducts were evaluated by immunohistochemistry for CK-7, CK-19 and EpCAM. HSC and myofibroblast (MF) activity were determined by immunohistochemistry for α-SMA. Results: PCI and ICI strongly correlated with HPC compartment activation and with the activity of MFs (p≤0.001). Lobular inflammation, ballooning and HPC compartment activation were all associated with both PCI (p<0.01) and ICI (p<0.05) by univariate analysis. In the multivariate models, HPC compartment activation was independently associated with PCI and ICI (OR 4.4, 1.7-11.5; OR 3.4, 1.5-7.9, respectively). Conclusions: During NAFLD, PCI and ICI are strongly associated with HPC compartment activation and this association is likely one determinant subtending the strong association between PCI/ICI and fibrosis

The hepatic expression of GH/IGF1 axis components is impaired with fibrosis progression in patients with HCV-related chronic hepatitis

Background and aim: Resistance to the action of growth hormone (GH), characterized by low serum levels of insulin-like growth factor-1 (IGF1) in the face of high concentrations of GH, frequently complicates cirrhosis (Assy et al., 2008). Physiologically, the activation of GH receptor (GHR) determines phosphorylation of signal transducer and activator of transcription (STAT)-5 and the consequent induction of IGF-1 expression. The suppressor of cytokine signalling (SOCS)-3 negatively regulates this intracellular cascade. Since, to date, the hepatic expression of the GH/IGF1 axis components has been studied mainly in animal models (Blaas L et al., 2010), we aimed to evaluate their expression in the liver of patients with HCV-related chronic hepatitis. Methods: Fifty HCV patients were studied and liver samples were histologically re-evaluated for grading and staging. The expression of GH/IGF1 axis components was assessed by immunohistochemistry. Results: At the hepatocyte level, IGF-1 and phospho-STAT5 showed a negative correlation with fibrosis stage, while SOCS3 a positive one (p<0,05 for all). Furthermore, the hepatocyte expression of IGF1 was negatively correlated with its expression by hepatic stellate cells (p<0,05). Conclusions: IGF1 expression by hepatocytes was reduced with fibrosis progression, probably due to the impairment of GHR intracellular cascade. The inverse correlation between IGF1 expressed by hepatocytes and hepatic stellate cells suggests specific roles for IGF-I produced by different hepatic cells

Liver vitamin D receptor, CYP2R1 and CYP27A1 expression related to progression of metabolic and viral chronic liver damage

Background and aim: Low serum 25(OH)vitamin D3 levels were associated with the presence and prognosis of liver diseases [1]. The biological effects of 1,25(OH)2 vitamin D3 are mediated by the vitamin D receptor (VDR) and VDR has been widely detected in liver, but its expression in the course of liver disease has never been investigated [2]. We aimed to evaluate the hepatic expression of VDR and vitamin D 25-hydroxylases in patients with chronic hepatitis C (CHC) or non-alcoholic steatohepatitis (NASH) and its relationship with liver histology and serum 25(OH) vitamin D3 levels. Methods: Patients affected by CHC or NASH who had undergone liver biopsy and subjects without liver disease were included. Expression of VDR, CYP2R1 and CYP27A1 was evaluated by immunohistochemistry. Results: In CHC subjects, fibrosis stage was associated with low hepatic CYP27A1 expression, whereas in patients with VDR-negative inflammatory cells and low VDR expression on hepatocytes, the portal inflammation was significantly higher (p<0.009 and p<0.03). In NASH patients, VDR expression on cholangiocytes was inversely correlated with steatosis severity (p<0.02), lobular inflammation (p<0.01) and NAS score (p<0.03). Conclusions: The liver of patients with viral and metabolic chronic liver disease expresses VDR in a manner inversely proportional to the severity of histological lesions and a role of the vitamin D/VDR system in the progression of chronic liver damage is suggested

Globalization effects on the reports of non-endemic parasitosis in Italy

Protozoa and helminths are responsible for several intestinal parasite infections (IPIs). Generally, helminth infections are very unsafe but scarcely reported in high-income countries, while protozoa and helminth co-infections are usually reported in children living in inadequate hygienic-sanitary conditions and in rural areas. However, the impact of growing globalization, intense travelling, international adoptions and high levels of immigrants and refugees has significantly incremented the incidence of orofecal parasitosis in non-endemic areas. Although most IPs clear without treatment when population, even children, emigrate from endemic to different geographical areas, some IPIs such as strongyloidiasis may persist for decades as subclinical infections or as low-grade disease with nonspecific clinical manifestations, unless to reappear under impairment conditions. Herein we report an unusual case of Giardia lamblia and Trichuris spp. chronic asymptomatic co-infection in a healthy adopted Romanian child, living in a Central Italy rural area, and a hidden case of Strongyloides stercoralis in an adopted Burundian child, resident in South Italy, long misdiagnosed as a recurrent undefined dermatitis. Our report suggests the need to review primary care practitioner guidelines and children’s hospital procedures for appropriate IPIs screening and follow-up, hence providing new screening and prevention strategies, in agreement with international guidelines

Reelin expression by hepatic stellate cells and ductular reaction in HCV related liver fibrosis

Reelin is a secreted extracellular glycoprotein that is thought to guide migrat- ing neurons during brain development and maturation cooperating with Disabled-1 (Dab1), an adaptor protein obligate effector of reelin signalling pathway (1). Reelin is also expressed in human liver by hepatic stellate cell(HSC)s that following liver injury become activated, migrating and fibrogenic cells (2). The cross-talk between HSCs and other cells such as those of ductular reaction (DR) is believed to rule liver fibrogenesis leading to cirrhosis (3). In order to better understand the role of ree- lin in human liver tissue with ongoing fibrosis, we aim to analyse the hepatic reelin expression and its relationship with the main histological determinants of the dis- ease activity and severity. Eighty-one liver biopsies of patients with chronic hepatitis C were studied. The expression of Reelin, Dab1, and HSC markers was investigated by immunohistochemistry and immunofluorescence. The Knodell histology activity index and DR score were evaluated. Activated HSC were frequently reelin positive and a statistical correlation was found between the number of reelin positive HSCs and Knodell’s stage (r= 0,3; p<0,05). Dab1 was expressed by cells of DR and the number of reelin positive HSCs correlated with DR score in mild/moderate fibrosis (r=0,4; p<0,05). Since reelin expression by HSCs correlates with increasing fibrosis and DR, whose cells in turn express Dab1, it might act as mediator in DR activation by HSCs. Further studies are needed to test reelin as useful biomarker for liver fibrosis assess- ment

Contribution of vitamin D3 and thiols status to the outcome of COVID-19 disease in Italian pediatric and adult patients

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), was declared a global pandemic by the World Health Organization (WHO) on March 2020, causing unprecedented disease with million deaths across the globe, mostly adults. Indeed, children accounted for only a few percent of cases. Italy was the first Western country struck by the COVID-19 epidemic. Increasing age, which is one of the principal risk factors for COVID-19 mortality, is associated with declined glutathione (GSH) levels. Over the last decade, several studies demonstrated that both vitamin D (VD) and GSH have immunomodulatory properties. To verify the association between VD, GSH and the outcome of COVID-19 disease, we conducted a multicenter retrospective study in 35 children and 128 adult patients with COVID-19. Our study demonstrated a hypovitaminosis D in COVID-19 patients, suggesting a possible role of low VD status in increasing the risk of COVID-19 infection and subsequent hospitalization. In addition, we find a thiol disturbance with a GSH depletion associated to the disease severity. In children, who fortunately survived, both VD and GSH levels at admission were higher than in adults, suggesting that lower VD and thiols levels upon admission may be a modifiable risk factor for adverse outcomes and mortality in hospitalized patients with COVID-19

Sars-Cov2 Not Detected in a Pediatric Population With Acute Respiratory Infection in Primary Care in Central and Southern Italy From November 2019 to Early March 2020

Background: In December 2019, a novel coronavirus named SARS-CoV-2 started circulating in China and this led to a major epidemic in Northern Italy between February and May 2020. Young children (aged <5 years) seem to be less affected by this coronavirus disease (COVID-19) compared to adults, although there is very little information on the circulation of this new virus among children in Italy. We retrospectively tested nasopharyngeal swabs for SARS-CoV-2 in samples collected in young children between November, 2019 and March, 2020 in the context of the RSV ComNet study. Methods: Two networks of primary care pediatricians in Lazio (Central Italy) and Puglia (Southern Italy) collected nasopharyngeal swabs from children, aged <5 years, presenting with symptoms for an acute respiratory infection (ARI). The RSV ComNet study is a multicenter study implemented to estimate the burden of RSV in young children (aged <5 years) in the community. Swabs were sent to a central reference laboratory and tested for 14 respiratory viruses through RT-PCR. All collected samples were retrospectively tested for SARS-CoV-2 using RT-PCR (Istituto Superiore di Sanità protocol). Results: A total of 293 children with ARI were identified in the two participating networks. The highest number of cases were recruited in weeks 51/2019 and 3/2020. The majority of patients (57%) came from the Lazio region. All of the 293 samples tested negative for SARS-Cov2. Rhinovirus was the most frequently detected virus (44%), followed by RSV (41%) and influenza viruses (14%). Conclusions: Our study shows that in Lazio (a region of intermediate SARS-COV-2 incidence) and Puglia (a region of low incidence), the SARS-Cov2 virus did not circulate in a sample of ARI pediatric cases consulting primary care pediatricians between November 2019 and March 2020