Factors predicting mortality after tips for refractory ascites: a single center experience

Introduction: Transjugular intrahepatic porto-systemic shunt (TIPS) is an accepted indication for treating refractory ascites. Different models have been proposed for the prediction of survival after TIPS; aim of present study was to evaluate the factors associated with mortality after TIPS for refractory ascites. Methods: Seventy-three consecutive patients undergoing a TIPS for refractory ascites in our centre between 2003 and 2008, were prospectively recorded in a database ad were the subject of the study. Mean follow-up was 17±2 months. Forty patients were awaiting liver transplantation (LT) and 12 (16.4%) underwent LT during follow-up. Results: Mean MELD at the moment of TIPS was 15.7±5.3. Overall mortality was 23.3% (n=17) with a mean survival after TIPS of 17±14 months. MELD score (B=0.161, p=0.042), AST (B= 0.020, p=0.090) and pre-TIPS HVPG (B=0.016, p=0.093) were independent predictors of overall mortality. On multivariate analysis MELD (B=0.419, p=0.018) and pre-TIPS HVPG (B=0.223, p=0.060) independently predicted 1 year survival. Patients were stratified into categories of death risk, using ROC curves for the variables MELD and HVPG. Patients with MELD<10 had a low probability of death after TIPS (n=6, 16% mortality); patients with HVPG <16 mmHg (n=6) had no mortality. Maximum risk of death was found in patients with MELD score 19 (n=16, 31% mortality) and in those with HVPG 25 mmHg (n=27, 26% mortality). Conclusions: TIPS increases overall survival in patients with refractory ascites. Liver function (assessed by MELD), necroinflammation (AST) and portal hypertension (HVPG) are independent predictors of survival; patients with MELD>19 and HVPG>25 mmHg are at highest risk of death after TIPS

Evidence-based polytherapies and long-term mortality after acute myocardial infarction in very old subjects compared with elderly and adults: a nested case-control study

Background: Clinical trials have demonstrated that selected secondary prevention medications for patients after acute myocardial infarction (AMI) reduce mortality. Yet, these medications are generally underprescribed in daily practice, and older people are often absent from drug trials. Objectives: To examine the relationship between adherence to evidence-based (EB) drugs and post-AMI mortality, focusing on the effects of single therapy and polytherapy in very old patients (≥80 years) compared with elderly and adults (<80 years). Methods: Patients hospitalised for AMI between 01/01/2008 and 30/06/2011 and resident in the Local Health Authority of Bologna were followed up until 31/12/2011. Medication adherence was calculated as the proportion of days covered for filled prescriptions of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), β-blockers, antiplatelet drugs, and statins. We adopted a risk set sampling method, and the adjusted relationship between medication adherence (PDC≥75%) and mortality was investigated using conditional multiple logistic regression. Results: The study population comprised 4861 patients. During a median follow-up of 2.8 years, 1116 deaths (23.0%) were observed. Adherence to the 4 EB drugs was 7.1%, while nonadherence to any of the drugs was 19.7%. For both patients aged ≥80 years and those aged <80 years, rate ratios of death linearly decreased as the number of EB drugs taken increased. There was a significant inverse relationship between adherence to each of 4 medications and mortality, although its magnitude was higher for ACEIs/ARBs (adj. rate ratio=0.60, 95%CI=0.52–0.69) and statins (0.60, 0.50–0.72), and lower for β-blockers (0.75, 0.61–0.92) and antiplatelet drugs (0.73, 0.63–0.84). Conclusions: The beneficial effect of EB polytherapy on long-term mortality following AMI is evident also in nontrial older populations. Given that adherence to combination therapies is largely suboptimal, the implementation of strategies and initiatives to increase the use of post-AMI secondary preventive medications in old patients is crucial.

Resezioni epatiche eco-guidate radicali ma conservative simultanee alle resezioni colo-rettali. Un approccio sicuro al cancro colorettale avanzato

Il cancro colorettale (CRC) rimane la prima causa di morte nei paesi occidentali.Dal 15% al 25% dei pazienti affetti da CRC presenta metastasi epatiche sincrone (CRLM) al momento della diagnosi.La resezione epatica radicale rimane l’unica terapia potenzialmente curativa in presenza di CRLM con una sopravvivenza a 5 anni compresa tra il 17% ed il 35% ed a 10 anni tra il 16% e il 23% rispettivamente. La tempistica ottimale per la resezione chirurgica in caso di presentazione sincrona di CRC è controversa.Questo studio intende dimostrare che le resezioni epatiche ecoguidate radicali ma conservative simultanee ad una resezione colorettale rappresentano una tecnica sicura ed efficace nei pazienti con CRC avanzato. 48 pazienti sono stati sottoposti ad una resezione simultanea colorettale ed epatica. L’età media +SD (range) era di 64,2+9,7 (38-84).Un solo paziente è deceduto entro 30 giorni. La mortalità post operatoria è stata complessivamente del 2,1%. Nove pazienti (18,8%) hanno sviluppato una o più complicanza ,4 (8,3%) di grado III-IV sec. Clavien-Dindo e 5 (10,4%) di grado I-II. La durata complessiva dell’intervento chirurgico simultaneo è stata di 486,6+144,0 (153-804) minuti.Questo studio conferma che le resezioni colorettali ed epatiche simultanee possono essere eseguite senza un significativo aumento della morbilità e mortalità perioperatorie, anche in pazienti sottoposti ad una resezione anteriore ultrabassa ed in quelli in cui sia indicato il clampaggio intermittente dell’ilo epatico. L’IOUS è efficace nel ridurre l’estensione della resezione epatica in pazienti sia con CRLM anche multiple e bilobari .Poichè le complicanze maggiori sono frequenti dopo resezioni epatiche maggiori simultanee, riducendo l’estensione della resezione del parenchima epatico si può avere un impatto favorevole sul decorso post operatorio.Le resezioni epatiche ecoguidate radicali ma conservative simultanee ad una resezione colorettale sono una tecnica sicura ed efficace in pazienti con carcinoma colorettale avanzato e andrebbero considerate l’opzione primaria in casi selezionati