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AimsTo assess survival predictivity of baseline blood cell differential count (BCDC) discretization methods in acutely ill adults visiting the emergency room over one-year.MethodsRetrospective cohort study on one-year survival of adults reporting to the emergency room of the A. Manzoni Hospital (Italy) during 2020. Automated BCDC analysis performed at baseline, assessed hemoglobin, red cell mean volume and distribution width (RDW), platelet distribution width (PDW), platelet-hematocrit, absolute red blood cells, white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils, and platelets. Discretization cutoffs were defined by: Benchmark laboratory reference values and Tailored (maximally selected rank statistics for linear and sigmoid-shaped distributed variables; optimal-equal hazard ratio (HR) method for U-shaped distributed variables. Explanatory variables (age, gender, inward admission) were analyzed using Cox multivariable regression. Receiver operating characteristic curves used the sum of Cox-significant variables in each method.ResultsOf 11052 patients (median age 67 years, interquartile range (IQR) 51–81, 48% female), 59% (n=6489) were discharged and 41% (n=4563) were admitted. After a 306-day median follow up (IQR 208–417 days), 9455 (86%) patients were alive and 1597 (14%) deceased. Increased HRs were associated with age > 73 years (HR=4.29 CI 3.78–4.87), and hospital admission (HR=2.05, CI 1.83–2.29). Age, sex, hemoglobin, mean corpuscular volume, RDW, PDW, neutrophils, lymphocytes and eosinophils were significant in overall. Benchmark included basophils and platelet count (area under the ROC curve (AUROC) 0.78). Tailored included monocyte counts and PCT (AUROC of 0.82).ConclusionsTailored discretization of BCDC provided meaningful insight regarding acute patient survival.Key messagesWhat is already known on this topicInformation on survival predictivity of BCDC is scarce, particularly in acutely ill patients considering that reference values are based on the general population.What this study addsLaboratory reference interval values predicting survival were hemoglobin, RDW, MCV, neutrophil, lymphocyte, eosinophil, and basophils counts, PLT, and PDW, independently of sex, age, and acute inward admission. Survival predictivity was improved by discretization of hemoglobin, RDW, MCV, neutrophil, lymphocyte, eosinophil, and monocyte counts, and PDW, according to the maximally selected rank statistics and optimal-equal HR method.How this study might affect research, practice, or policyBaseline BCDC discretized by tailored methods may be a useful biomarker for hazard warning in acute illness.

Background and Aim Viral pneumonia is the most relevant clinical presentation of COVID‐19 which may lead to severe acute respiratory syndrome and even death. Eosinopenia was often noticed in patients with COVID‐19 pneumonia, but its role is poorly investigated. The aim of the present study was to investigate the characteristics and clinical outcomes of patients with COVID‐19 pneumonia and eosinopenia. Methods We revised the records of consecutive patients with COVID‐19 pneumonia admitted to our ER‐COVID‐19 area in order to compare clinical characteristics and outcomes of patients with and without eosinopenia. We considered the following clinical outcomes: 4‐weeks survival; need for intensive respiratory support; and hospital discharge. Results Out of first 107 consecutive patients with pneumonia and a positive COVID‐19 nasopharyngeal swab, 75 patients showed undetectable eosinophil count (absolute eosinopenia). At 4 weeks, 38 patients (38.4%) had required intensive respiratory treatment, 25 (23.4%) deceased and 42 (39.2%) were discharged. Compared with patients without absolute eosinopenia, patients with absolute eosinopenia showed higher need of intensive respiratory treatment (49.3% vs 13.3%, P

Exacerbations of chronic obstructive pulmonary disease (COPDE) frequently require hospitalizations, may necessitate of invasive mechanical ventilation (IMV), and are associated with a remarkable in-hospital mortality. The BAP-65 score is a risk assessment model (RAM) based on simple variables, that has been proposed for the prediction of these adverse outcomes in patients with COPDE. If showed to be accurate, the BAP-65 RAM might be used to guide the patients management, in terms of destination and treatment. We conducted a retrospective, multicentre, chart-review study, on patients attending the ED for a COPDE during 2014. The aim of the study was the validation of the BAP-65 RAM for the prediction of in-hospital death or use of IMV (composite primary outcome). We assessed the discrimination and the prognostic performance of the BAP-65 RAM. We enrolled 2908 patients from 20 centres across Italy. The mean (standard deviation) age was 76 (11) years, and 38% of patients were female. The composite outcome occurred in 5.3% of patients. The AUROC of BAP-65 for the composite outcome was 0.64 (95%CI 0.59–0.68). The sensitivity of BAP-65 score ≥ 4 to predict in-hospital mortality was 44% (95% CI 34%–55%), the specificity was 84% (95% CI 82%–85%), the positive predictive value was 9% (95% CI 6%–12%), and the negative predictive value was 98% (95% CI 97%–98%). Conclusions: In patients attending Italian EDs with a COPDE, we found that the BAP-65 score did not have sufficient accuracy to stratify patients upon their risk of severe in-hospital outcomes. © 2018 European Federation of Internal Medicine

Acute exacerbations of chronic obstructive pulmonary disease (AECOPDs) frequently cause patients with COPD to access the emergency department and have a negative impact on the course of the disease. The objectives of our study were: 1) describing the socio-demographic and clinical characteristics, and the clinical management, of patients with AECOPD, when they present to the emergency department; and 2) estimating the costs related to the management of these patients. We conducted a retrospective cohort study in Italy, collecting data on 4396 patients, from 34 centres. Patients had a mean (SD) age of 76,6 (10.6) years, and 61.2% of them where males. >70% of the patients had a moderate to very high comorbidity burden, and heart failure was present in 26.4% of the cohort. The 64.6% of patients were admitted to hospital wards, with a mean (SD) length of stay of 10.8 (9.8) days. The estimated cost per patient was 2617 €. Conclusions: Patients attending the ED for an AECOPD are old and present important comorbidities. The rate of admission is high, and costs are remarkable. © 2018 European Federation of Internal Medicine

Elderly patients with chronic hepatitis C have a reduced responsiveness to antiviral therapy with Peg-interferon and ribavirin. The dose reduction or the discontinuation of ribavirin due to the occurrence of anaemia is one of the most important causes for the low sustained viral response observed in older patients. We aimed to evaluate the relationship between baseline renal function and the early onset of ribavirin-associated anaemia in older (≥60 years) patients. Using data from 348 patients with chronic hepatitis C consecutively treated with peg-interferon plus ribavirin, we investigated which factors were associated with the occurrence of anaemia in elderly patients (≥60 years). Ribavirin-induced anaemia occurred in 40.5% of patients. Older patients showed a rate of anaemia significantly higher than younger patients (51.5% vs 36.3%; P = 0.009). Consequently, the rate of ribavirin dose reduction or discontinuation due to anaemia was 35.1% in older patients and 23.5% in younger patients (P = 0.029). A significantly higher proportion of older patients had a low baseline glomerular filtration rate (GFR) compared with younger patients (56.7% vs 27.1%; P0.001). At the multivariate regression analysis, low baseline GFR (70 mL/min) was associated with an increased risk of ribavirin-associated anaemia only in the older patients (OR: 3.526; 95% CI: 1.385-8.979; P = 0.008). In this subset, baseline GFR was significantly correlated with both absolute (r = -0.320; P0.001) and relative (r = -0.324; P0.001) haemoglobin decrease within the first 8 weeks of treatment. In patients aged60 years, a low pre-treatment GFR was strongly associated with the risk to develop ribavirin-related anaemia with consequent reduction in ribavirin doses.

Background/Aims The MELD defines a score used to prioritize patients awaiting liver transplantation and includes results for bilirubin, creatinine and PT expressed as INR. It is assumed that the MELD for individual patients is the same regardless of the laboratory method used for testing, thus ensuring parity of organ allocation. Previous studies showed that the INR calibrated for patients on vitamin K antagonists (INR vka ) does not normalize results across thromboplastins, whereas an alternative calibration called INR liver does. However, implementation of INR liver calibration for thromboplastins is difficult in practice. This study aimed to assess whether easy-to-run whole-blood coagulation monitors (widely used for patients on VKA) can be calibrated to measure efficiently the INR liver and minimize the interlaboratory variability. Methods PT values for 61 cirrhotic patients were measured on native-blood with 2 monitors calibrated in terms of INR vka . PTs for these subjects were also measured with a WHO-standard for thromboplastin. Paired-PTs with the monitors and the standard were subsequently used to calibrate the monitors in terms of INR liver . INR vka and INR liver were then compared to assess for statistical significance. Results The mean INR vka obtained with the monitors and the standard were significantly different ( p liver were not. Conclusions The INR liver calibration as previously described for thromboplastins works also for the easy-to-run whole-blood coagulation monitors. Once the monitors are calibrated by the manufacturer in terms of INR liver they could be used as near-patient-testing devices directly by the personnel of liver units making the determination of the INR for patients awaiting liver transplantation much easier and standardized.

The clinical significance of diastolic dysfunction in cirrhosis, a feature of cirrhotic cardiomyopathy, is unclear. The aim of this study was to assess the utility of E/A ratio, an indicator of diastolic dysfunction, to predict ascites clearance and mortality after transjugular intrahepatic portosystemic stent shunt (TIPS) insertion.A total of 101 cirrhotic patients who received TIPS had pre-TIPS assessments of demographics, severity of liver dysfunction (Child-Pugh and Model for End-Stage Liver Disease (MELD) scores), renal function, hemodynamics, and cardiac function (two-dimensional echocardiography). An E/A ratio ofor =1 was used to indicate diastolic dysfunction. Patients were followed-up for a mean period of 24.6+/-2.4 months post TIPS.A total of 41 patients with an E/A ratio ofor =1 (group A), and 60 patients with an E/A ratio of1 (group B) were studied. Group A had significantly higher MELD scores (14.0+/-1.0 vs. 11.4+/-0.8; P=0.03), because of higher serum creatinine levels (107+/-5 vs. 86+/-6 micromol/l; P0.01). There was no difference in pre-TIPS systemic hemodynamics, systolic function, or portal pressure between the two groups. After TIPS, more patients in group B had ascites clearance (log rank, P=0.038), and the same patients had a higher probability of survival (log rank, P=0.046). There were three post-TIPS cardiac deaths in group A only. A multivariate analysis showed that an E/A of ratioor =1 was predictive of slow ascites clearance (hazard ratio=7.3, 95% confidence interval=1.3-40.7, P=0.021) and death after TIPS (hazard ratio=4.7, 95% confidence interval=1.1-20.2, P=0.035).Diastolic dysfunction, indicated by reduced E/A ratio, is prevalent in advanced cirrhosis and is associated with reduced ascites clearance and increased mortality post TIPS, possibly related to worsening of hemodynamic dysfunction in the post-TIPS period.

Models based on logistic regression analysis are proposed as noninvasive tools to predict cirrhosis in chronic hepatitis C (CHC) patients. However, none showed to be sufficiently accurate to replace liver biopsy. Artificial neural networks (ANNs), providing a prediction based on nonlinear algorithms, can improve the diagnosis of cirrhosis, a syndrome characterized by complex, nonlinear biological alterations. We compared ANNs with two logistic regression analysis-based models in predicting CHC histologically proven cirrhosis.Liver biopsy was obtained in CHC patients of two different cohorts (an internal cohort including 244 patients and an external cohort including 220 patients). One hundred and forty-four patients from the internal cohort served as a training set to construct ANNs and a logistic regression model (LOGIT). These two models and the aspartate aminotransferase-to-platelet ratio index (APRI) were tested in the remaining 100 patients (internal validation set) and in the external cohort (external validation set). Diagnostic performances were evaluated by standard indices of accuracy.In the internal validation set, ANNs, LOGIT, and APRI showed similar discrimination powers (0.88, 0.87, and 0.87 respectively). However, ANNs showed the best positive predictive value (0.86 vs. 0.67 and 0.56) and positive likelihood ratio (40.2 vs. 13.4 and 8.4). In the external validation set, the discrimination power of ANNs (0.76) was significantly higher than those of LOGIT (0.67) and APRI (0.67).Compared to conventional models, ANNs performance in predicting CHC cirrhosis is slightly better and more reproducible.

The Objective of this prospective observational study was to evaluate the applicability of the simplified acute physiology score (SAPS II) in patients admitted to an Emergency Medicine Ward in the Emergency Medicine Ward of a tertiary university hospital. We studied consecutive patients admitted to an Emergency Medicine Ward from the emergency department. The SAPS II was assessed in predicting overall in-hospital mortality in terms of sensitivity, specificity and receiver operating characteristic (ROC) curve. A total of 211 consecutive patients were admitted over a period of 2 months. Median SAPS II score was 28 (range 6-93), with a mean risk of in-hospital mortality of 0.17 (range 0.01-0.97) for the whole population, and an observed mortality of 15%. The area under the receiver operator curve (ROC) was 0.84 (0.77-0.91). Considering a cut-off value of SAPS II of 49, the sensitivity was 0.50 (95% CI 0.42-0.56), the specificity was 0.95 (0.92-0.98), the positive predictive value (PPV) was 0.64 (0.58-0.71), and the negative predictive value (NPV) was 0.91 (0.87-0.95), the positive likelihood ratio (pLH) was 9.9, and the negative likelihood ratio (nLH) was 0.5. If contrarily a cut-off value of SAPS II of 22 were used, the sensitivity would be 1.0, the specificity would be 0.21 (0.16-0.26), the PPV would be 0.18 (0.13-0.23), the NPV would be 1.0, the pLH would be 1.3, and the nLH would be 0.0. In this preliminary study, SAPS II predicted in-hospital mortality in patients admitted to an Emergency Ward.

Background: Peripheral vasodilation is the key factor in the development of hyperdynamic circulation, sodium retention and functional renal failure in patients with cirrhosis. Brachial artery flow-mediated dilation (FMD) after transient vascular occlusion is a non-invasive method to assess the shear stress-induced arterial vasodilation. Aims: To evaluate FMD in cirrhotic patients with and without ascites and to assess the relationship between FMD and intrarenal resistances. Methods: Flow-mediated dilation was determined in 32 cirrhotic patients (22 with ascites) and 12 healthy controls and correlated with the intrarenal resistive index (RI) assessed by Doppler exploration. Results: Basal diameter of the brachial artery was similar in healthy controls and in cirrhotic patients, whereas FMD was significantly higher in patients with cirrhosis and ascites [29.5% (range 10.3–50%)] than in pre-ascitic patients [17.3% (range 2.4–48.5%)] and healthy control subjects [11.6% (range 5.1–17.8%)] (P

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a treatment for portal hypertension-related complications. Accurate prediction of the outcome of patients treated with TIPS is important, because some patients have very short survival. Diastolic dysfunction is frequently observed in patients with cirrhosis. Aim: To investigate whether or not diastolic dysfunction can predict the outcome after TIPS. Methods: Echocardiography with Doppler exploration was performed before and 28 days after TIPS insertion in 32 patients with cirrhosis. Several echocardiographic measures, including the early maximal ventricular filling velocity/late filling velocity (E/A) ratio as indicative of diastolic function, as well as laboratory, clinical and demographic variables were evaluated as predictors of survival. Results: Univariate analysis revealed that the presence of diastolic dysfunction observed 28 days after TIPS (E/A ratio ⩽1) and baseline model of end-stage liver disease score were related to survival. Multivariate analysis identified diastolic dysfunction as an independent predictor of death (RR 8.9, 95% CI 1.9 to 41.5, p = 0.005). During the first year of follow–up, six out of 10 patients with an E/A ratio ⩽1 died, whereas all 22 patients with E/A ratio >1 survived. Conclusions: Diastolic dysfunction estimated using E/A ratio is a promising predictor of death in patients with cirrhosis who are treated with TIPS.

Summary Background Biopsy is the gold standard for assessing cirrhosis in patients with chronic hepatitis C virus infection, but it is expensive and at risk of complications. Alternative non-invasive methods have been developed but their usefulness remains uncertain. Aim To compare the accuracy of five non-invasive scores in detecting cirrhosis. Methods We reviewed the charts and liver biopsies of 228 consecutive, treatment-naive, hepatitis C virus-positive patients, 13.2% of whom with histological diagnosis of cirrhosis. The five alternative scores were age-platelet index, cirrhosis discriminant score, aspartate transaminases to platelet ratio index, Pohl's index, and aspartate transaminases/alanine transaminases ratio. Results The specificities of the scores were good (87–100%), but not so their sensitivities (17–67%). Accordingly positive likelihood ratios were generally good but negative likelihood ratios were suboptimal. Combinations of the scores independently related to cirrhosis only slightly change this diagnostic accuracy. Using double cut-offs to exclude/diagnoses cirrhosis, cirrhosis discriminant score classified 21% of patients without misdiagnoses and aspartate transaminases to platelet ratio index classified 85% of case with 9% of misdiagnoses. Conclusions The five scores showed variable sensitivities and specificities in detecting liver cirrhosis, both individually and in combination. The use of double cut-off points may make the cirrhosis discriminant score and aspartate transaminases to platelet ratio index useful to reduce the number of patients submitted to liver biopsy.

The transjugular intrahepatic portosystemic shunt (TIPS) has been shown to be effective in the control of refractory or recidivant ascites. However, the effect of TIPS on survival as compared with that of large-volume paracentesis plus albumin is uncertain. A multicenter, prospective, clinical trial was performed in 66 patients with cirrhosis and refractory or recidivant ascites (16 Child-Turcotte-Pugh class B and 50 Child-Turcotte-Pugh class C) randomly assigned to treatment with TIPS (n = 33) or with large-volume paracentesis plus human albumin (n = 33). The primary endpoint was survival without liver transplantation. Secondary endpoints were treatment failure, rehospitalization, and occurrence of complications. Thirteen patients treated with TIPS and 20 patients treated with paracentesis died during the study period, 4 patients in each group underwent liver transplantation. The probability of survival without transplantation was 77% at 1 year and 59% at 2 years in the TIPS group as compared with 52% and 29% in the paracentesis group (P = .021). In a multivariate analysis, treatment with paracentesis and higher MELD score showed to independently predict death. Treatment failure was more frequent in patients assigned to paracentesis, whereas severe episodes of hepatic encephalopathy occurred more frequently in patients assigned to TIPS. The number and duration of rehospitalizations were similar in the two groups. In conclusion, compared to large-volume paracentesis plus albumin, TIPS improves survival without liver transplantation in patients with refractory or recidivant ascites.

Aims. To evaluate the prevalence, incidence and clinical relevance of bacterial infection in predominantly non-alcoholic cirrhotic patients hospitalised for decompensation. Patients/Methods. A total of 405 consecutive admissions in 361 patients (249 males and 112 females; 66 Child-Pugh class B and 295 class C) were analysed. Blood, urine, ascitic and pleural fluid cultures were performed within the first 24 hours, during hospitalisation whenever infection was suspected, and again before discharge. Results. Over a one year period, 150 (34%) bacterial infections (89 community- and 61 hospital-acquired) involving urinary tract (41 %), ascites (23%), blood (21 %) and respiratory tract (17%) were diagnosed. The prevalence of bacterial peritonitis was 12%. Infections were asymptomatic in 69 cases (46%) and 130 (87%) involved a single site. Enteric flora accounted for 62% of infections, Escherichia Coli being the most frequent pathogen (25%). Community-acquired infections were associated with more advanced liver disease (Child-Pugh mean score 10.2±2. 1 versus 9.5±1.9, p

The usefulness in cirrhotic patients of hemodynamic measurements by Doppler ultrasonography (US) is still not defined. We investigated the relationships between Doppler measurements and the severity of ascites. Portal blood flow velocity and volume, and hepatic and renal arterial resistance indexes (RI) were measured in 57 cirrhotic patients (19 without ascites, 28 with responsive ascites, and 10 with refractory ascites) and 15 healthy controls. The renal arterial RI were obtained for the main renal artery, interlobar vessels, and cortical vessels. Cirrhotic patients had decreased portal blood flow and an increased congestion index (CI). Only the CI was correlated to the severity of ascites, showing that it is also a reliable measure of the severity of portal hypertension in patients with ascites. The hepatic and renal artery RI were increased in cirrhotic patients, and the two values were correlated (r = .68; P = .00001). The RI of renal interlobar and cortical vessels were higher in patients with refractory ascites than in patients without ascites (P < .02 and P < .009), and correlated with sodium excretion rate (r = −.45; P < .003), the renin-aldosterone system, and creatinine clearance (r = −.62; P < .0002). The RI decreased from the hilum of the kidney to the outer parenchyma in healthy subjects and patients with responsive ascites, but this difference disappeared in patients with refractory ascites. This indicates that the degree of renal vasoconstriction varies in different areas according to the severity of the ascites. Cortical vessels are involved mainly in patients with refractory ascites, suggesting that the intrarenal blood flow distribution in cirrhosis tends to preserve the cortical area and that severe cortical ischemia is a feature of refractory ascites.

Aim: Adherence to and the applicability of practice guidelines for the management of hepatocellular carcinoma (HCC) in field practice have not been fully addressed. We designed a multicenter field practice prospective study to evaluate the adherence to the 2005 American Association for the Study of Liver Diseases guidelines in Italy. Materials & methods: The study began in September 2008 and consecutively enrolled cirrhotic patients with newly diagnosed HCC from 30 local, nonreference centers in Italy. Patients were stratified according to Child–Pugh, the model for end-stage liver disease, tumor-node metastasis, performance status and the Barcelona Clinic Liver Cancer (BCLC) classifications. The diagnostic and therapeutic strategies adopted in each individual patient were recorded. Statistical analysis was carried out on 536 patients using all of the valuable data. Results: A total of 286 (54.5%) patients were ≥70 years old. Comorbidities, recorded in 397 (74%) patients, were classified as moderate to severe in 170 patients (43%). Overall, 174 (59%) patients with early-stage BCLC were ≥70 years; 104 (35%) of these had moderate-to-severe comorbidities and 54% were under a regular US surveillance program. Diagnosis was performed by computed tomography in 93% of patients, contrast-enhanced ultrasound in 62% and MRI in 17%. In patients with nodules of ≤2 cm, adherence to noninvasive diagnostic criteria was 56%. Adherence to the BCLC classification was shown to be suboptimal overall, particularly regarding allocation to surgical procedures, and a total of 119 patients (40%) with BCLC stage A did not receive curative therapies. Conclusions: This multicenter survey showed that, in the ‘real world’, adherence to the both the diagnostic and therapeutic American Association for the Study of Liver Diseases 2005 algorithms was low, particularly in patients with early-stage HCC. Difficulties in applying the algorithms in routine clinical practice and the high prevalence of older patients with relevant comorbidities may account for our findings. Strategies to help improve adherence to international guidelines for HCC in field practice are required.

Transjugular intrahepatic portosystemic shunt (TIPS) is a radiological interventional procedure useful in portal hypertension-related complications. It is able to resolve variceal bleeding and refract

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications occurring in cirrhotic patients with ascites. Therefore, an effective therapy is always required starting immediately after diagnosis. There are three aims of therapy: (1) to eradicate the bacterial strain responsible of the infection; (2) to prevent renal failure; and (3) to prevent SBP recurrence. The first end point is achievable by means of a large-spectrum antibiotic therapy. Empirical antibiotic therapy can be started with a third-generation cephalosporin, amoxicillin–clavulanate or a quinolone. The effectiveness of antibiotics should be verified by determining the percent reduction of polymorphonuclear cells count in the ascitic fluid. If bacteria result to be resistant to the empirical therapy, a further antibiotic must be given according to the in vitro bacterial susceptibility. In most cases, a 5-day antibiotic therapy is enough to eradicate the bacterial strain. Severe renal failure occurs in about 30% of patients with SBP, independently of the response to antibiotics, and it is associated with elevated mortality. The early administration of large amount of human albumin showed to be able to reduce the episodes of renal failure and to improve survival. After the resolution of an episode of SBP, the recurrence is frequent. Therefore, an intestinal decontamination with oral norfloxacin has been shown to significantly reduce this risk and is widely practised. However, such a long-term prophylaxis, as well as the current increased use of invasive procedures, favours the increase of bacterial infections, including SBP, contracted during the hospitalization (nosocomial infections) and sustained by multi-resistant bacteria. This involves the necessity to use a different strategy of antibiotic prophylaxis as well as a more strict surveillance of patients at risk.

This article summarizes our experience in endovascular repair of abdominal aortic aneurysm in octogenarian patients.From January 2000 to December 2005 30 patients (mean age 84 years) underwent endovascular repair of abdominal aortic aneurysm; in 28 cases a loco-regional anaesthesia has been performed. Twenty-eight bifurcated graft, one straight graft and one aorto-iliac graft have been used.No operative mortality or early endoleak have been observed; during the follow-up period (20 months) 7 endo-leaks (3 cases type I; 4 cases type II) have been reported; all patients with type I EL underwent endovascular repair; in two patients with type II EL we observed spontaneous regression; the other cases are still monitored in absence of sac enlargement. Four graft occlusions have been observed; one early thrombosis has been treated with surgical thrombectomy, two of the three late occlusions required other procedures. Five patients died during the follow-up period, three of them during the first year. No death has been aneurysm related.In accord with other recent studies, our analysis confirms the positive impact on intra-operative and early post-procedural mortality of the endovascular therapy for abdominal aortic aneurysm in octogenarian patients; no evidence of significative benefit on late survival has been observed.In conclusion we consider endovascular option as the best approach in octogenarian patients even if a longer follow-up is mandatory.

Some evidence suggests that the systemic inflammatory response syndrome (SIRS) contributes to the poor outcome of cirrhotic patients. We studied 141 cirrhotic patients consecutively admitted to a tertiary referral centre assessing prevalence of SIRS and its relationship with in-hospital outcome.Presence of SIRS was assessed on admission and during hospital stay. Main clinical outcomes were death and development of portal hypertension-related complications.Thirty-nine patients met SIRS criteria. SIRS was present on admission in 20 of 141 patients (14.1%), whereas it occurred during hospital stay in 19 of 121 (15.7%). SIRS was correlated with bacterial infection at admission (p=0.02), jaundice (p=0.011), high serum creatinine levels (p=0.04), high serum bilirubin levels (p=0.002), high international normalized ratio (p=0.046), high model of end-stage liver disease (MELD) score (p=0.001), and high SOFA score (p=0.003). During a follow-up of 14+/-8 days, 16 patients died (11%), 7 developed portal hypertension-related bleeding (5%), 16 hepatic encephalopathy (11%), and 5 hepatorenal syndrome type-1 (3.5%). SIRS was correlated both to death (p0.001) and to portal hypertension-related complications (p0.001). On multivariate analysis, SIRS and MELD were independently associated with death.SIRS frequently occurs in patients with advanced cirrhosis and is associated with a poor outcome.

Peripheral vasodilation is the key factor in the development of hyperdynamic circulation, sodium retention and functional renal failure in patients with cirrhosis. Brachial artery flow-mediated dilation (FMD) after transient vascular occlusion is a non-invasive method to assess the shear stress-induced arterial vasodilation.To evaluate FMD in cirrhotic patients with and without ascites and to assess the relationship between FMD and intrarenal resistances.Flow-mediated dilation was determined in 32 cirrhotic patients (22 with ascites) and 12 healthy controls and correlated with the intrarenal resistive index (RI) assessed by Doppler exploration.Basal diameter of the brachial artery was similar in healthy controls and in cirrhotic patients, whereas FMD was significantly higher in patients with cirrhosis and ascites [29.5% (range 10.3-50%)] than in pre-ascitic patients [17.3% (range 2.4-48.5%)] and healthy control subjects [11.6% (range 5.1-17.8%)] (P0.001). Intrarenal RI was significantly higher in patients with cirrhosis than in healthy subjects, and a direct relationship existed between FMD and intrarenal RI (r=0.66; P0.00001).These findings in vivo demonstrate that cirrhotic patients with ascites have an enhanced shear stress-induced peripheral vasodilation, which is closely related to intrarenal vasoconstriction.

The role played by coagulation defects in the occurrence of bleeding in cirrhosis is still unclear. This is partly due to the lack of tests that truly reflect the balance of procoagulant and anticoagulant factors in vivo. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time are inadequate to explore the physiological mechanism regulating thrombin, because they do not allow full activation of the main anticoagulant factor, protein C, whose levels are considerably reduced in cirrhosis. We used a thrombin generation test to investigate the coagulation function in patients with cirrhosis. Thrombin generation measured without thrombomodulin was impaired, which is consistent with the reduced levels of procoagulant factors typically found in cirrhosis. However, when the test was modified by adding thrombomodulin (i.e., the protein C activator operating in vivo), patients generated as much thrombin as controls. Hence, the reduction of procoagulant factors in patients with cirrhosis is compensated by the reduction of anticoagulant factors, thus leaving the coagulation balance unaltered. These findings help clarify the pathophysiology of hemostasis in cirrhosis, suggesting that bleeding is mainly due to the presence of hemodynamic alterations and that conventional coagulation tests are unlikely to reflect the coagulation status of these patients. In conclusion, generation of thrombin is normal in cirrhosis. For a clinical validation of these findings, a prospective clinical trial is warranted where the results of thrombin generation in the presence of thrombomodulin are related to the occurrence of bleeding.

Background/Aims : Patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) are at risk of early death due to end-stage liver failure. The aim of this study was to compare model of end-stage liver disease (MELD) and Child–Pugh scores as predictors of survival after TIPS. Methods : We studied 140 cirrhotic patients treated with elective TIPS. Concordance (c)-statistic was used to assess the ability of MELD or Child–Pugh scores to predict 3-month survival. The prediction of overall survivals was estimated by comparing actuarial curves of subgroups of patients stratified according to either Child–Pugh scores or MELD risk scores. Results : During a median follow-up of 23.7 months, 55 patients died, 14 underwent liver transplantation and seven were lost to follow-up. For 3-month survival, the discrimination power of MELD score was superior to Child–Pugh score (0.84 vs. 0.70, z =2.07; P =0.038). Unlike Pugh score, MELD score identified two subgroups of Child C patients with different overall survivals ( P =0.027). The comparison between observed and predicted survivals showed that MELD score overrates death risk. Conclusions : MELD score is superior to Child–Pugh score as predictor of short-term outcome after TIPS. Its accuracy, however, decreases for long-term predictions.

Bleeding from rupture of oesophageal varices is one of the most dreadful complications occurring in patients with cirrhosis.1 Therefore, many efforts have been made in pursuing new therapeutic strategies able to arrest variceal bleeding and prevent rebleeding. Over the last 20 years, these efforts allowed the reduction of the bleeding-related mortality of patients with cirrhosis from 40–50% to 15–20%.2 3 The result is good but still needs to be improved. Mortality in patients with cirrhosis who bleed is closely related to failure either to control bleeding within the first 48 h or to prevent early rebleeding, which occurs within the first 5 days after the index bleeding episode has ceased.1 4 Most frequent causes of death are shock, terminal liver failure, renal failure, sepsis and multiorgan failure. In patients in whom the acute bleeding is arrested, the risk of developing one of these events is markedly increased by early rebleeding. For this reason, treatments which effectively prevent early rebleeding could also reduce in-hospital mortality. The standard management of patients with cirrhosis with variceal haemorrhage includes adequate resuscitation, early administration of antibiotics to prevent bacterial infections, infusion of …

Transjugular intrahepatic portosystemic shunt or paracentesis for refractory ascites—which is best?

were treated with RFA (n=69), and the others underwent HR (n=63). The two groups were similar for liver disease status. The outcome was considered in terms of overall survival (OS) and disease-free survival (DFS) calculated by the Kaplan-Meier method. Differences among groups were validated by log-rank test. Results: The 1-, 3and 5-year OS rates for the RFA group and the HR group were 91%, 75%, 52%, and 97%, 92%, 74%, respectively. The corresponding DFS rates for the 2 groups were 64%, 28%, 5%, and 85%, 63%, 40%, respectively. OS and DFS were significantly lower in the RFA group than in the HR group (p=0.0210 and p=0.00001). The 5-year HCC recurrence rate was higher in the RFA group than in the HR group (87% vs. 60%; p = 0.0010). Conclusions: HR may provide better survival and lower recurrence rates than RFA for patients with VE HCC. HR should still be employed for those patients with a single small tumor and well-preserved liver function, as suggested by BCLC staging system. RFA should be chosen for patients with an unresectable single tumor for HCC position and grade of liver damage.

REDUCED RENAL FUNCTION IS ASSOCIATEDWITH ANEMIA DURING TREATMENT WITH PEGINTERFERON/RIBAVIRIN IN ELDERLY CHRONIC HEPATITIS C PATIENTS R. Ceriani∗ ,1, M. Andreoletti 2 , G. Borroni 3, A. Bortoli 4 , M. Casiraghi 5, M. Cazzaniga6 , P. Guerzoni7 , G. Mandelli 8 , B. Omazzi 4, M.G. Pich1, A. Prada4, N. Terreni 8, G. Spinzi 8 1Irccs Istituto Clinico Humanitas, Rozzano (MI), Italy; 2Ospedale A Manzoni, Lecco, Italy; 3Asl Milano 1, Milano, Italy; 4Ospedale G Salvini, Rho (MI), Italy; 5Ospedale Civile, Legnano, Italy; 6Irccs Policlinico S. Donato, S Donato Milanese (MI), Italy; 7Ospedale Varese, Varese, Italy; 8Ospedale Valduce, Como, Italy

One hundred ten cases of primitive hepatic hilum neoplasms (Klatskin tumor) observed from January 1970 to June 1992 are reviewed and the variations occurring in the diagnostic back-up and treatment policy are considered. The importance of careful preoperative staging is stressed. Preoperative tests should be limited to investigations supplying most informations about endo- and esobiliary diffusion of the tumoral mass (ultrasound, direct cholangiography, portography). This paper demonstrates that a surgical approach with both palliative or resective aims is suitable for all patients with no local or general contraindications. Other cases are treated with percutaneous or endoscopic biliary stenting. The authors conclude by pointing out that tumoral resection with biliodigestive anastomosis is in any case the treatment of choice in these patients as it gives a better quality of life (improved "comfort index").