LAUSR

Dear Editor, Since its opening in the 1980s, II Clinica Pediatrica at Ospedale Microcitemico BA.Cao^ in Cagliari, Italy has been the reference for all types of medical conditions occurring in thalassemia major (TM) patients of all ages from South Sardinia. Between 2000 and 2015, 276 subjects out of 642 (43%) transfused at the same hospital were admitted once or more to II Clinica Pediatrica for a total of 690 admissions. The mean age at first hospital admission was 24.3 ± 10.9 years (range 0.2–51 years). At the start of the observation period, all patients followed up at the abovementioned center were on desferrioxamine, with the exception of 21 who were on deferiprone. In December 2015, 15.2% were on desferrioxamine, 25.2% were on deferiprone, 45.4% were on deferasirox, 13.3% were on desferrioxamine plus deferiprone, and 0.8% were on desferrioxamine plus deferasirox. Over the entire period, the top five most prevalent causes of hospital admission were heart failure and/or arrhythmias, infections, mesenteric lymphadenitis in patients treated with subcutaneuous desferrioxamine, digestive tract diseases, and liver diseases. The causes of hospitalization varied according to patient age. Most children admitted between 0 and 10 years of age had a diagnosis of infection. After 30 years of age, infections were the second most common reason for hospital admission, surpassed by heart failure and arrhythmia. The age group characterized by the lowest number of hospital admissions was 10–20 years. Most patients in this group were admitted for mesenteric lymphadenitis. Finally, the analysis of hospital admissions overtime highlighted a progressive decrease in the total days of hospital admission in patients with TM (3514 days between 2000 and 2003, 857 days between 2004 and 2007, 518 days between 2008 and 2011, and 466 days between 2012 and 2015), despite the increasing number of patients transfused at the abovementioned center during the four periods (556, 566, 574 and 594, respectively). Specifically, the rate of patients diagnosed with mesenteric lymphadenitis progressively declined (p < 0.0001 between the years 2000–2003 and the two more recent four-year periods). The admissions for other infectious diseases significantly decreased after 2003 (p < 0.0001). In addition, the rate of patients admitted for heart disease showed a sharp decrease from the 2000–2003 period to the 2004–2007 period (p = 0.0009) and substantial stability afterward (Table 1) [1]. In conclusion, this report shows that the increasing use of oral chelators has deeply influenced the causes of hospital admission in TM in high-income countries. On one hand, the downsized adoption of desferrioxamine has involved a clear decrease in the number of hospital admissions for mesenteric lymphadenitis due to Yersinia enterocolitica which can use ferrioxamine for growth [2, 3]. On the other hand, the advent of chelation regimes that are more cardioprotective than the monotherapy with desferrioxamine supports the reduction of admissions for heart disease in parallel to the previously described decrease in mortality [4–6]. However, the absence of a further decline in the rate of patients admitted to the hospital with heart failure in the last four-year period calls for reflection on the always topical issue of therapeutical * Raffaella Origa [email protected]; [email protected]