Elastografia epatica: metodiche a confronto

Background: The cirrhotic process of liver injury is the end-stage of hepatic fibrosis, which results from progressive accumulation of extracellular matrix during the wound-healing response of the liver to repeated injury. Mortality and morbidity rates increase exponentially once cirrhosis develops. Therefore, a prompt assessment of the degree of severity of fibrosis, an accurate and timely diagnosis of liver cirrhosis and management of complications are important in guiding therapy management in chronic liver disease. Liver biopsy is often required, but it is an invasive procedure, with a risk of severe complications (1/4000–10,000). In addition, its accuracy is prone to sampling error (6) and inter-and/or intra-observer diagnostic discrepancies occur in up to 10–20% of liver biopsies. For this reason, there is increasing interest in non-invasive methods for detecting liver fibrosis. Ultrasound-based transient elastography (TE) is one of the first non-invasive imaging methods to be used in common practice. The technique is based on low-frequency vibrations: shear waves produced by the ultrasound machine propagate through the tissue and produce an elastic deformation, with the premise that liver stiffness (LS) measurements reflect the degree of hepatic fibrosis. Displacement is reflected in the variation of the acquired echo signals. The Siemens-based ARFI system and Philips Elast PQTM use conventional US to generate a shear wave directly within the liver tissues. This allows the sonographer to obtain both conventional US images and also specify a region of interest (ROI) for estimation of liver stiffness. The propagation velocity of the shear wave is reported in metres per second, and correlates with liver stiffness. The direct generation of shear wave within the liver tissue holds advantages over TE since it is not subject to chest/abdominal wall distortion of the waves. Results: 110 consecutive patients with liver disease underwent a liver biopsy and liver stiffness assessment by Philips EPIQ 7TM ultrasound system, Siemens Acuson (ARFI) ultrasound system, 2 and Echosens FibroscanTM (currently the best-validated technique). The results of these three imaging techniques were compared with histological results. A direct, strong correlation was observed between LS values assessed by TE elastography by Elast PQ and Virtual Touch (p < 0.0001) and Metavir score

Usefulness of ultrasound in the diagnosis of peritoneal tuberculosis

The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. We report a case of peritoneal tuberculosis (TB) in a 25-year-old man. In this case, ultrasound of the abdomen played an important role in the diagnostic process. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation, and the limitations of available diagnostic tests. A high index of suspicion should be considered, particularly in high-risk patients with unexplained ascites. In our case ultrasound guided the diagnosis by rapidly identifying abnormal signs, which in high-prevalence settings are extremely suggestive of peritoneal tuberculosis

A prospective evaluation of liver and spleen shearwave elastography measurements in patients with chronic liver disease

Background: Prompt assessment of the degree of severity of fibrosis is important in guiding management of therapy in chronic liver disease. In the last years ultrasound based non invasive tests for liver fibrosis have completely changed clinical practice in hepatology. There are several available equipment in the market using the shear wave elastography (SWE) technology. Despite the great interest on SWE, knowledge of the different techniques is still incomplete. Portal hypertension is a major complication of cirrhosis that is associated with significant morbidity and mortality. Aim of this study is to assess the diagnostic accuracy of spleen stiffness, area and diameter in predicting the presence of portal hypertension. Methods: 160 patients underwent same-day liver biopsy, and measurement of liver fibrosis on the right and left lobe of the liver, with the 3 shear wave elastography methods Philips Affiniti 70TM ultrasound system, Siemens Acuson (ARFI) ultrasound system, and Echosens FibroscanTM. Results: Spearman correlation between TE, ElastPQ, and VTQ results with histological fibrosis stage demonstrated a good correlation with r2 = 0.569, 0.556 and 0.448 respectively (p = 0.0001). ElastPQ L (r2= 0.411, p = 0.001), VTQ L (r2= 0.336, p = 0.001). Areas under the Curve (AUC) were: TE 0.810; ElastPQ 0.828; VTQ 0.741 for fibrosis F 0/1; TE 0.970; ElastPQ 0.832; VTQ 0.782 for fibrosis F 3/4 and TE 0.939; ElastPQ 0.856; VTQ 0.826 for cirrhosis F4. Diagnostically, there was a better accuracy of measurements of the right lobe (ElastPQ R and VTQ R) compared to measurements in the left lobe (ElastPQ L and VTQ L). Compared with 10 measurements, a minimum of six SWV measurements was required. The overall area under the curve for diagnosing mild and severe fibrosis or cirrhosis did not differ according to number of measurements (six vs 10). Significant fibrosis B, 0.567; standard error, 0.331; hazard ratio, 2.10; p= 0.010 was an independentpredictor for lower reliability. On univariate and individual performance, platelet count [area under the receiver operating characteristic (AUROC) 0.846, p value < 0.001], spleen area (AUROC 0.828, p value = 0.002) and APRI score (AUROC 0.827, p value < 0.001) were the most accurate variables in identifying the presence of portal hypertension. Conclusions: TE and ElastPQ achieved good diagnostic performance, whereas VTQ showed a lower diagnostic accuracy with AUROC ranging from 0.733 to 0.818. The data would support the best practice guidance on the utility of LSM values in aiding the clinical management of patients. Ordinal logistic regression corrected for age to assess if steatosis, ballooning, portal inflammation and lobular inflammation have an influence on the relation between SWE measurements and histology findings, showed that there is a significant interaction between steatosis (p = 0.008) and lobular inflammation and VTQ (p = 0.04) and between lobular inflammation and TE (p = 0.006). Cut off value for fibrosis F0/1 were significantly lower in the sub-group of patients with viral aetiologies compared to cut off value for fibrosis F0/1 in other aetiologies. The number of measurements required for a reliable study using the latest SWE technologies can be reduced to 6 for ElastPQ and to 7 for VTQ from the standard recommendation of 10. Spleen area, spleen stiffness and platelet count may be useful markers to assess the presence of portal hypertension in patients of various etiologies.Open Acces

Appropriateness of antiplatelet therapy for primary and secondary cardio- and cerebrovascular prevention in acutely hospitalized older people

Aims: Antiplatelet therapy is recommended for the secondary prevention of cardio- and cerebrovascular disease, but for primary prevention it is advised only in patients at very high risk. With this background, this study aims to assess the appropriateness of antiplatelet therapy in acutely hospitalized older people according to their risk profile. Methods: Data were obtained from the REPOSI register held in Italian and Spanish internal medicine and geriatric wards in 2012 and 2014. Hospitalized patients aged ≥65 assessable at discharge were selected. Appropriateness of the antiplatelet therapy was evaluated according to their primary or secondary cardiovascular prevention profiles. Results: Of 2535 enrolled patients, 2199 were assessable at discharge. Overall 959 (43.6%, 95% CI 41.5–45.7) were prescribed an antiplatelet drug, aspirin being the most frequently chosen. Among patients prescribed for primary prevention, just over half were inappropriately prescribed (52.1%), being mainly overprescribed (155/209 patients, 74.2%). On the other hand, there was also a high rate of inappropriate underprescription in the context of secondary prevention (222/726 patients, 30.6%, 95% CI 27.3–34.0%). Conclusions: This study carried out in acutely hospitalized older people shows a high degree of inappropriate prescription among patients prescribed with antiplatelets for primary prevention, mainly due to overprescription. Further, a large proportion of patients who had had overt cardio- or cerebrovascular disease were underprescribed, in spite of the established benefits of antiplatelet drugs in the context of secondary prevention

Relationship between low Ankle-Brachial Index and rapid renal function decline in patients with atrial fibrillation: a prospective multicentre cohort study

OBJECTIVE: To investigate the relationship between Ankle-Brachial Index (ABI) and renal function progression in patients with atrial fibrillation (AF). DESIGN: Observational prospective multicentre cohort study. SETTING: Atherothrombosis Center of I Clinica Medica of 'Sapienza' University of Rome; Department of Medical and Surgical Sciences of University Magna Græcia of Catanzaro; Atrial Fibrillation Registry for Ankle-Brachial Index Prevalence Assessment-Collaborative Italian Study. PARTICIPANTS: 897 AF patients on treatment with vitamin K antagonists. MAIN OUTCOME MEASURES: The relationship between basal ABI and renal function progression, assessed by the estimated Glomerular Filtration Rate (eGFR) calculated with the CKD-EPI formula at baseline and after 2 years of follow-up. The rapid decline in eGFR, defined as a decline in eGFR &gt;5 mL/min/1.73 m(2)/year, and incident eGFR&lt;60 mL/min/1.73 m(2) were primary and secondary end points, respectively. RESULTS: Mean age was 71.8±9.0 years and 41.8% were women. Low ABI (ie, ≤0.90) was present in 194 (21.6%) patients. Baseline median eGFR was 72.7 mL/min/1.73 m(2), and 28.7% patients had an eGFR&lt;60 mL/min/1.73 m(2). Annual decline of eGFR was -2.0 (IQR -7.4/-0.4) mL/min/1.73 m(2)/year, and 32.4% patients had a rapid decline in eGFR. Multivariable logistic regression analysis showed that ABI ≤0.90 (OR 1.516 (95% CI 1.075 to 2.139), p=0.018) and arterial hypertension (OR 1.830 95% CI 1.113 to 3.009, p=0.017) predicted a rapid eGFR decline, with an inverse association for angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (OR 0.662 95% CI 0.464 to 0.944, p=0.023). Among the 639 patients with AF with eGFR &gt;60 mL/min/1.73 m(2), 153 (23.9%) had a reduction of the eGFR &lt;60 mL/min/1.73 m(2). ABI ≤0.90 was also an independent predictor for incident eGFR&lt;60 mL/min/1.73 m(2) (HR 1.851, 95% CI 1.205 to 2.845, p=0.005). CONCLUSIONS: In patients with AF, an ABI ≤0.90 is independently associated with a rapid decline in renal function and incident eGFR&lt;60 mL/min/1.73 m(2). ABI measurement may help identify patients with AF at risk of renal function deterioration

Multimorbidity and polypharmacy in the elderly: Lessons from REPOSI

The dramatic demographic changes that are occurring in the third millennium are modifying the mission of generalist professionals such as primary care physicians and internists. Multiple chronic diseases and the related prescription of multiple medications are becoming typical problems and present many challenges. Unfortunately, the available evidence regarding the efficacy of medications has been generated by clinical trials involving patients completely different from those currently admitted to internal medicine: much younger, affected by a single disease and managed in a highly controlled research environment. Because only registries can provide information on drug effectiveness in real-life conditions, REPOSI started in 2008 with the goal of acquiring data on elderly people acutely admitted to medical or geriatric hospital wards in Italy. The main goals of the registry were to evaluate drug prescription appropriateness, the relationship between multimorbidity/polypharmacy and such cogent outcomes as hospital mortality and re-hospitalization, and the identification of disease clusters that most often concomitantly occur in the elderly. The findings of 3-yearly REPOSI runs (2008, 2010, 2012) suggest the following pertinent tasks for the internist in order to optimally handle their elderly patients: the management of multiple medications, the need to become acquainted with geriatric multidimensional tools, the promotion and implementation of a multidisciplinary team approach to patient health and care and the corresponding involvement of patients and their relatives and caregivers. There is also a need for more research, tailored to the peculiar features of the multimorbid elderly patient

Therapeutic Duplicates in a Cohort of Hospitalized Elderly Patients: Results from the REPOSI Study.

BACKGROUND: Explicit criteria for potentially inappropriate prescriptions in the elderly are recommended to avoid prescriptions of duplicate drug classes and to optimize monotherapy within a single drug class before a new agent is considered. Duplicate drug class prescription (or therapeutic duplicates) puts the patient at increased risk of adverse drug reactions with no additional therapeutic benefits. To our knowledge, the prevalence of elderly inpatients receiving therapeutic duplicates has never been studied. OBJECTIVES: Our objective was to assess the prevalence of therapeutic duplicates at admission, discharge, and 3-month follow-up of hospitalized elderly patients. METHODS: This cross-sectional prospective study was conducted in 97 Italian internal medicine and geriatric wards. Therapeutic duplicates were defined as at least two drugs of the same therapeutic class prescribed simultaneously to a patient. A patient's drug therapy at admission relates to prescriptions from general practitioners, whereas prescriptions at discharge are those from hospital internists or geriatricians. RESULTS: The study sample comprised 5821 admitted and 4983 discharged patients. In all, 143 therapeutic duplicates were found at admission and 170 at discharge. The prevalence of patients exposed to at least one therapeutic duplicate rose significantly from hospital admission (2.5 %) to discharge (3.4 %; p = 0.0032). Psychotropic drugs and drugs for peptic ulcer or gastroesophageal reflux disease were the most frequently involved. A total of 86.8 % of patients discharged with at least one therapeutic duplicate were still receiving them at 3-month follow-up. CONCLUSIONS: Hospitalization and drugs prescribed by internists and geriatricians are both factors associated with a small but definite increase in overall therapeutic duplicates in elderly patients admitted to internal medicine and geriatric wards. More attention should be paid to the indications for each drug prescribed, because therapeutic duplicates are not supported by evidence and increase both the risk of adverse drug reactions and costs. Identification of unnecessary therapeutic duplicates is essential for the optimization of polypharmacy

Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study.

Background: It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF. Methods: We retrospectively analyzed the data collected on elderly patients in 66 Italian hospitals, in the frame of the REPOSI project. We analyzed the clinical characteristics of patients with AF and different degrees of CI. Multivariate logistic analysis was used to explore the relationship between variables and mortality. Results: Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy. Conclusions: Elderly hospitalized patients with AF are more likely affected by CI and CKD, two conditions that expose them to a higher mortality risk. Oral anticoagulant therapy, still underused and not optimally enforced, may afford protection from thromboembolic episodes that probably concur to the high mortality