Andrea Affronti

The health of irregular and illegal immigrants: analysis of day-hospital admissions in a department of migration medicine

It is difficult to trace full details of the path which irregular or illegal immigrants follow when seeking assistance in the network of the various hospital departments and health structures. The aim of this work was to analyze the health needs of immigrant people by reviewing the types of treatment given to them in the day-hospital of our Department of Migration Medicine. Our study analyzed day-hospital admissions between 2003 and 2009. The patient charts used for managing day-hospital activity were adopted in 2002 in conformity with the “OSI project”. From these it is possible to draw up a scale picture of the distribution of each pathology in the immigrant population. The sample population consisted of 1,758 subjects, representing 7.4% of potential users. More than half came from Africa, followed by Asia, and then Europe. Gastroenterological diseases ranked first, with dyspeptic syndromes most frequently diagnosed. Infections and parasitic diseases ranked second, and the most frequent diagnoses were sexually transmitted diseases. Third were diseases of the genitourinary system. Metabolic disorders ranked fourth, among them, more than half of the cases were of diabetes mellitus, in patients from south-east Asia. Diseases of the circulatory system were sixth, with hypertension the most frequent pathology. Our data confirm a marked persistence of the phenomenon known as the “healthy immigrant effect” in these types of patients, as well as the prominent role played by “social determinants” in conditioning the health of immigrants, particularly in the case of some infectious diseases.

Hepatocellular carcinoma: Comparison of two different periods at the same center

AIMS To analyze the main etiological factors and some clinical characteristics of patients with HCC at diagnosis and to compare them with those we described ten years ago. METHODS 179 patients were included in Group 1, while 132 patients were included in Group 2. For all patients age, sex, serum markers of hepatitis B and C viruses, alcohol consumption, serum alpha feto-protein (AFP) levels and the main liver function parameters at HCC diagnosis were recorded. RESULTS Mean age was 66.0 years for Group 1 and 69.0 for Group 2 (P=0.005). HCV was responsible for 80.3% of HCC cases in Group 2 versus 72% in Group 1 (P=0.005). HBV alone and co-infection of HCV+HBV decreased, but not significantly. In Group 1 only four patients had an underlying normal liver, while in Group 2 no patients showed an underlying normal liver (P=ns). HCC was more frequently associated with Child class A in Group 2 (P=0.0001), whereas in Group 1 it was more frequently associated with class C (P=0.0001). Staging of HCC correlated inversely when patients of Groups 1 and 2 were compared (P<0.03). AFP serum levels were above normal in 72% of cases in Group 1 and in 41.5% in Group 2 (P=0.0001). CONCLUSION This study shows that over the last decade a number of characteristics of patients with HCC in our region have changed, particularly age at onset of HCC, staging of underlying liver disease and staging of HCC.

Low-grade fever: how to distinguish organic from non-organic forms

Background and aim:  Low‐grade fever (LGF) is defined as a body temperature between 37.5 and 38.3 °C, which is below the classical value reported for fever of unknown origin (FUO). We attempted to characterise its epidemiology, aetiology and clinical aspects to improve the methodological approach to diagnosis.

An update on medical management on Crohn's disease.

Introduction: The management of Crohn’s disease (CD) is continuously evolving. New issues emerging from more recent studies could influence the decision-making process in clinical practice. Areas covered: The aim of this review article is to highlight critical issues on the management of CD, new evidence from clinical trials, long-term prospective studies and real life experience, beyond the current guidelines. Expert opinion: The role of mucosal healing in clinical practice is uncertain, clinical remission remains the primary end point. The timing for the definition of steroid-resistant CD should be considered between 2 and 4 weeks. Early treatment strategy with immunomodulators is effective for inducing remission but no controlled data are available regarding long-term outcome. Combination therapy (anti-TNFs agents and immunosuppressors) is more effective than single therapy but there is a lack of long-term data and an increased risk of malignancy. The effect of mesalazine, metronidazole and azathioprine in reducing postoperative recurrence is not clinically relevant; biologics are effective, but the duration of treatment is unknown. New drugs are under investigation in order to find exit strategy for patients who no longer respond to biologics. Combination therapy set on anti-TNF-α is until now the best option both to achieve fistula healing and avoid recurrence

Hemophagocytic syndrome in a patient with disseminated tuberculosis: a case report

Hemophagocytic syndrome (HS) is a rare disorder of the immune system. It is characterized by fever, lymphadenopathy, hepatosplenomegaly, cytopenia and hyperferritinemia. The cause differs in each country suggesting a specific genetic background and epidemiology of infections, and it can be associated with malignant diseases. A rare cause of HS is tuberculosis (TB), we describe a case of HS associated with disseminated Mycobacterium tuberculosis (MT) infection in a patient from Sudan. He presented diarrhea, fever, pancytopenia, thickened and dilated bowel loops and lymph nodes enlargement at ultrasound and computed tomography scan. A bone marrow biopsy performed to rule out a lymphoma revealed a HS. The bronchoalveolar lavage (BAL) culture was then positive for MT and subsequently, radiologic aspects of lung and spleen TB involvement appeared. A disseminated tuberculosis was diagnosed. Despite antituberculous therapy, the patient died as in approximately 50% of the HS associated with TB.

Course of Crohn’s Disease

Crohn’s disease (CD) is an inflammatory bowel disease with a chronic course and it is characterized by different events within time, which are in relation to the heterogeneity of the disease. The main events during the course of disease are activity, remission, relapse, obstruction, fistulizing, surgical resection, cancer and death. Unselected inception cohort studies are the best ones on which rely in order to avoid the selection bias from referral centers. Data produced using inception-cohort have shown a more benign course of CD than expected, an increased risk of surgery over time, with a trend which has been being reduced in the last decades, together with an increased use of biologics and immunosuppressants. The clinical features of CD change over time with a decreasing frequency of inflammatory disease behavior and an increasing frequency of stricturing and /or penetrating disease behavior, it is possible to identify the main predictors of a disabling course. An increased risk of colorectal cancer and small bowel cancer, lymphoproliferative disorders, non-melanoma skin cancer, have been described in CD. However the risk of dying in CD patient when compared with general population is higher, even if in inception-cohort studies the increased risk is not always detectable.