The diagnosis and treatment of sepsis have always been a challenge for the physician, especially in critical care setting such as emergency department (ED), and currently sepsis remains one of the ...major causes of mortality. Although the traditional definition of sepsis based on systemic inflammatory response syndrome (SIRS) criteria changed in 2016, replaced by the new criteria of SEPSIS-3 based on organ failure evaluation, early identification and consequent early appropriated therapy remain the primary goal of sepsis treatment. Unfortunately, currently there is a lack of a foolproof system for making early sepsis diagnosis because conventional diagnostic tools like cultures take a long time and are often burdened with false negatives, while molecular techniques require specific equipment and have high costs. In this context, biomarkers, such as C-Reactive Protein (CRP) and Procalcitonin (PCT), are very useful tools to distinguish between normal and pathological conditions, graduate the disease severity, guide treatment, monitor therapeutic responses and predict prognosis. Among the new emerging biomarkers of sepsis, Presepsin (P-SEP) appears to be the most promising. Several studies have shown that P-SEP plasma levels increase during bacterial sepsis and decline in response to appropriate therapy, with sensitivity and specificity values comparable to those of PCT. In neonatal sepsis, P-SEP compared to PCT has been shown to be more effective in diagnosing and guiding therapy. Since in sepsis the P-SEP plasma levels increase before those of PCT and since the current methods available allow measurement of P-SEP plasma levels within 17 min, P-SEP appears a sepsis biomarker particularly suited to the emergency department and critical care.
The term “failure to rescue” (FTR) has been recently introduced in the field of hepato-biliary surgery to label cases in which major postoperative complications lead to postoperative fatality. ...Perihilar cholangiocarcinoma (PHC) surgery has consistently high postoperative morbidity and mortality rates in which factors associated with FTR are yet to be discovered. The primary endpoint of this study is to compare the Rescue with the FTR cohort referencing patients’ characteristics and management protocols applied. A cohort of 224 consecutive patients undergoing surgery for PHC, between 2010 and 2021, was enrolled. Perioperative variables were analyzed according to the severity of major postoperative complications (Clavien ≥ 3a). Kaplan–Meier survival analyses were performed to determine complications’ impact on survival. Major complications were reported in 86 cases (38%). Among the major complications’ cohort, 72 cases (84%) were graded Clavien 3a–4 (Rescue group), while 14 (16%) cases were graded Clavien 5 (FTR group). Number of lymph-node metastases (OR = 1.33 (1.08–1.63)
p
= 0.006), poorly differentiated (G3) adenocarcinoma (OR = 7.55 (1.24–45.8)
p
= 0.028, reintervention (OR = 16.47 (2.76–98.08)
p
= 0.002), and prognostic nutritional index < 40 (OR = 3.01 (2.265–3.654)
p
< 0.001) rates were independent predictors of FTR. Right resection side (OR 2.4 (1.33–4.34)
p
= 0.004) increased the odds of major complications but not of FTR. No difference in overall survival was identified. A distinction of perioperative factors associated with postoperative complications’ severity is crucial. Patients developing severe outcomes seem to have different biological and nutritional profiles, showing that efficient preoperative protocols are strategic to identify and avert the risk of FTR.
In Italy, since August 2014, liver transplant (LT) candidates with model for end-stage liver disease (MELD) scores ≥30 receive national allocation priority. This multicenter cohort study aims to ...evaluate time on the waiting list, dropout rate, and graft survival before and after introducing the macro-area sharing policy.
A total of 4,238 patients registered from 2010 to 2018 were enrolled and categorized into an ERA-1 Group (n = 2,013; before August 2014) and an ERA-2 Group (n = 2,225; during and after August 2014). A Cox proportional hazards model was used to estimate the hazard ratio (HR) of receiving a LT or death between the two eras. The Fine-Gray model was used to estimate the HR for dropout from the waiting list and graft loss, considering death as a competing risk event. A Fine-Gray model was also used to estimate risk factors of graft loss.
Patients with MELD ≥30 had a lower median time on the waiting list (4 vs.12 days, p <0.001) and a higher probability of being transplanted (HR 2.27; 95% CI 1.78–2.90; p = 0.001) in ERA-2 compared to ERA-1. The subgroup analysis on 3,515 LTs confirmed ERA-2 (odds ratio 0.56; 95% CI 0.46–0.68; p = 0.001) as a protective factor for better graft survival rate. The protective variables for lower dropouts on the waiting list were: ERA-2, high-volume centers, no competition centers, male recipients, and hepatocellular carcinoma. The protective variables for graft loss were high-volume center and ERA-2, while MELD ≥30 remained related to a higher risk of graft loss.
The national MELD ≥30 priority allocation was associated with improved patient outcomes, although MELD ≥30 was associated with a higher risk of graft loss. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes.
NCT04530240
Italy introduced a new policy in 2014 to give national allocation priority to patients with a model for end-stage liver disease (MELD) score ≥30 (i.e. very sick patients). This policy has led to more liver transplants, fewer dropouts, and shorter waiting times for patients with MELD ≥30. However, a higher risk of graft loss still burdens these cases. Transplant center volumes and competition among centers may have a role in recipient prioritization and outcomes.
Display omitted
•Priority allocation for liver transplantation has been given to MELD ≥30 candidates in Italy since 2014 (ERA-2).•Donor age, MELD ≥30 and ERA-1 were independent predictors of worse graft survival.•MELD ≥30 patients had a lower median time on the waiting list in ERA-2.•Low-volume and multiple regional transplant centres were independent predictors of higher dropout rate.
Background & Aims
Sarcopenia in liver transplantation (LT) cirrhotic candidates has been connected with higher dropouts and graft losses after transplant. The study aims to create an ‘urgency’ model ...combining sarcopenia and Model for End‐stage Liver Disease Sodium (MELDNa) to predict the risk of dropout and identify an appropriate threshold of post‐LT futility.
Methods
A total of 1087 adult cirrhotic patients were listed for a first LT during January 2012 to December 2018. The study population was split into a training (n = 855) and a validation set (n = 232).
Results
Using a competing‐risk analysis of cause‐specific hazards, we created the Sarco‐Model2. According to the model, one extra point of MELDNa was added for each 0.5 cm2/m2 reduction of total psoas area (TPA) < 6.0 cm2/m2. At external validation, the Sarco‐Model2 showed the best diagnostic ability for predicting the risk of 3‐month dropout in patients with MELDNa < 20 (area under the curve AUC = 0.93; P = .003). Using the net reclassification improvement, 14.3% of dropped‐out patients were correctly reclassified using the Sarco‐Model2. As for the futility threshold, transplanted patients with TPA < 6.0 cm2/m2 and MELDNa 35‐40 (n = 16/833, 1.9%) had the worse results (6‐month graft loss = 25.5%).
Conclusions
In sarcopenic patients with MELDNa < 20, the ‘urgency’ Sarco‐Model2 should be used to prioritize the list, while MELDNa value should be preferred in patients with MELDNa ≥ 20. The Sarco‐Model2 played a role in more than 30% of the cases in the investigated allocation scenario. In sarcopenic patients with a MELDNa value of 35‐40, ‘futile’ transplantation should be considered.
Background
Patients hospitalized with COVID-19 experienced an increased risk of venous thromboembolism.
Aims
To evaluate the effect of chronic oral anticoagulation (OAC) therapy, both with vitamin K ...antagonists (VKAs) or direct oral anticoagulants (DOACs), on prognosis of COVID-19 older patients.
Methods
Single-center prospective study conducted in the Emergency Department (ED) of a teaching hospital, referral center for COVID-19 in central Italy. We evaluated all the patients ≥ 65 years, consecutively admitted to our ED for confirmed COVID-19. We compared the clinical outcome of those who were on chronic OAC at ED admission with those who did not, using a propensity score matched paired cohort of controls. The primary study endpoint was all-cause in-hospital death. Patients were matched for age, sex, clinical comorbidities, and clinical severity at presentation (based on NEWS ≥ 6). Study parameters were assessed for association to all-cause in-hospital death by a multivariate Cox regression analysis to identify independent risk factor for survival.
Results
Although overall mortality was slightly higher for anticoagulated patients compared to controls (63.3% vs 43.5%,
p
= 0.012), the multivariate adjusted hazard ratio (HR) for death was not significant (HR = 1.56 0.78–3.12;
p
= 0.208). Both DOACs (HR 1.46 0.73–2.92;
p
= 0.283) and VKAs (HR 1.14 0.48–2.73;
p
= 0.761) alone did not affect overall survival in our cohort.
Conclusions
Among older patients hospitalized for COVID-19, chronic OAC therapy was not associated with a reduced risk of in-hospital death. Moreover, our data suggest similar outcome both for patients on VKAs or in patients on DOACs.
Women who have undergone liver transplantation (LT) enjoy better health, and possibility of childbearing. However, maternal and graft risks, optimal immunosuppression, and fetal outcome is still to ...clarify.
Aim of the study was to assess outcomes of pregnancy after LT at national level.
In 2019, under the auspices of the Permanent Transplant Committee of the Italian Association for the Study of the Liver, a multicenter survey including 14 Italian LT-centers was conducted aiming at evaluating the outcomes of recipients and newborns, and graft injury/function parameters during pregnancy in LT-recipients.
Sixty-two pregnancies occurred in 60 LT-recipients between 1990 and 2018. Median age at the time of pregnancy was 31-years and median time from transplantation to conception was 8-years. During pregnancy, 4 recipients experienced maternal complications with hospital admission. Live-birth-rate was 100%. Prematurity occurred in 25/62 newborns, and 8/62 newborns had low-birth-weight. Cyclosporine was used in 16 and Tacrolimus in 37 pregnancies, with no different maternal or newborn outcomes. Low-birth-weight was correlated to high values of AST, ALT and GGT.
Pregnancy after LT has good outcome; however, maternal complications and prematurity may occur. Compliance with the immunosuppression is fundamental to ensure the stability of graft function and prevent graft-deterioration.
PDF
