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Background: In recent years, there has been a growing interest in developing methods based on health administrative databases to estimate prevalence of chronic diseases, hoping that this would lead to more precise and reliable estimates. The capture-recapture method can be used to improve the prevalence of a disease reducing the bias of case underestimation. Objective: To assess the prevalence of multiple sclerosis (MS) in the Liguria region in Italy using routinely collected healthcare data. Methods: Data from three sources collected in Liguria Health Authority (A.Li.Sa.) databases - hospital discharge records, drug-dispensing records, disease-specific payment exemptions from copayment to health care - and a capture-recapture method with log-linear models were used to estimate the prevalence of MS. The accuracy of the case-finding algorithm was tested using a sample of people residents in Liguria Region with a definite diagnosis of MS extracted from clinical records of Liguria AISM Rehabilitation Service as reference standard. Results: The case-finding algorithm to capture people with MS from routinely collected healthcare data used in our study found an observed crude prevalence of MS in Liguria region on 31 December 2017, of 202.4 cases per 100,000 inhabitants (95% CI: 195.3-209.5). After linkage to clinical data, the algorithm showed a sensitivity of 82.7%, with 22.1% of MS cases undetected on capture-recapture models. Consequently, the capture-recapture method prevalence estimate of 259.7 per 100,000 inhabitants (95% CI: 251.7-267.8) suggest that this region constitutes a high-risk area for MS. Conclusions: Our initial study of crude MS prevalence showed an overall regional prevalence of MS of 202.4 cases per 100,000, capture-recapture analysis would add another 20%, to those figures. This method could be considered a good alternative to the population-based study design for estimating the prevalence of MS. Key messages: Studies based on routinely collected healthcare data could help estimate the prevalence of chronic disease. To reduce the bias of case underestimation, the capture– recapture method can be useful. [ABSTRACT FROM AUTHOR]

Objectives: Most strategies for delirium prevention in older hospitalized patients are common good clinical geriatric care. We investigated whether acute geriatric ward (AGW) hospitalization, compared with acute general medical ward (AGMW) hospitalization,is associated with reduced incident delirium in older medical inpatients.Design: prospective observational study.Setting: a tertiary care, university hospital in Torino.Participants: consecutive medical patients 70 years or older admitted from the emergency department to an AGW and to an AGMW were included.Measurements: Baseline measures included demography, functional and psychocognitive status, comorbidity, physiological and clinical severity of acute illness. Incident delirium was evaluated by qualified psychiatrists according to the Confusion Assessment Method and the Delirium Rating Scale.Results: Delirium occurred in 8 of 121 patients admitted to AGW (6.6%) and in 20 of 131 patients admitted to AGMW (15.2%). After adjustment for significant differences in baseline covariates between groups, AGW hospitalization remained independently associated with less incident delirium (relative risk 0.90, 95% confidence interval: 0.024-0.331, p <0.001). In a multivariable logistic model with delirium incidence as independent variable, AGW hospitalization was independently associated with lower delirium incidence (relative risk 0.039, 95% confidence interval: 0.007-0.214, p <0.001), whereas greater cognitive impairment (p <0.001), higher Acute Physiology and Chronic Health Evaluation II score (p 0.001) and recent stressful events (p <0.001) were associated with increased delirium incidence.Conclusion: AGW hospitalization is associated with less incident delirium among older medical inpatients. Despite inherent limitations of observational studies, these hypothesis-generating findings add to previous evidence of potential benefit in delirium prevention from geriatric consultation in several hospital settings. [ABSTRACT FROM AUTHOR]

Aims: Risk stratification of patients with new-onset acute heart failure (AHF) is important but remains challenging. In the present study, we evaluated the prognostic value of a new multiparameter right ventricular dysfunction (RVD) score., Methods and Results: Patients (n = 210) hospitalized due to new-onset AHF between 2015 and 2018 were retrospectively included. Mean age was 56 ± 10 years, 24% were female and median left ventricular ejection fraction was 28% (interquartile range 20; 34%). The RVD score, tricuspid annular plane systolic excursion (TAPSE), and fractional area change (FAC) were determined at index hospitalization and after therapy titration. The 4-point RVD score included reduced TAPSE, right ventricular enlargement, moderate or severe tricuspid regurgitation and increased central venous pressure. The study endpoint was a composite of all-cause mortality, left ventricular assist device implantation, and heart transplantation. After 60 months median follow-up time, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameter between patients with and without the endpoint. After therapy titration, there were differences in TAPSE (16 vs. 19 mm, P = 0.001), FAC (33 vs. 40%, P < 0.001) and the proportion of patients with RVD score ≥2 (36 vs. 4%, P < 0.001). The presence of RVD despite therapy titration had different impact on survival depending on the parameter considered: the proportion of patients free from events after 1 year was 87% in patients with TAPSE <17 mm, 89% in patients with FAC <35% and 65% in patients with RVD score ≥2. In a multivariable analysis, RVD score ≥2 after therapy titration, but not TAPSE <17 mm or FAC < 35%, remained associated with a higher risk of the composite endpoint (hazard ratio 3.11, 95% confidence interval 1.44-6.74)., Conclusions: A novel multiparametric RVD score might improve prognostic stratification in patients with new-onset AHF. RVD after therapy titration, but not at index hospitalization is associated with a higher risk of the composite endpoint., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

After years of cost-containment policies, the Italian National Health Service (NHS) has now the chance to change and improve, especially thanks to the National Recovery and Resilience Plan (NRRP). The plan serves as a catalyst for reform, allocating substantial funds to reinforce proximity networks, facilities, and telemedicine for territorial healthcare. Mission 6, specifically dedicated to health, focuses on integrating primary healthcare, hospital, and specialty care networks, underscoring the importance of a robust primary healthcare system. In alignment with NRRP objectives, the Ligurian model introduces innovative structures, such as Community Houses (CdCs), Community Hospitals (OdCs), and Territorial Operation Centres (COTs). These interconnected components form a dynamic network designed to enhance healthcare accessibility, prevent inappropriate hospital admissions, and facilitate efficient patient transitions. The model prioritizes multidisciplinary collaboration, community engagement, and the integration of socio-healthcare services. Despite substantial NRRP funding for infrastructure, challenges related to staffing and human resources persist. The social and epidemiological context highlights concern about the economic feasibility of the reform, potential workforce shortages, and the imperative for updated regulatory frameworks. The strategic reallocation of personnel from acute hospitals to new facilities is crucial, requiring meticulous workforce planning, role definitions, and trainingIn conclusion, the Ligurian model emerges as a proactive response to the structural vulnerabilities exposed by the pandemic, aligning with international trends in emphasizing primary care, prevention, and community-based services., Competing Interests: The authors declare that they have no commercial or financial relationships that could be construed as a potential conflict of interest., (©2024 Pacini Editore SRL, Pisa, Italy.)

As known, influenza presents a multifaceted challenge to public health, causing disease that ranges from mild cases to severe pandemics with significant morbidity and mortality. Effective pandemic preparedness demands a comprehensive strategy that integrates research, surveillance, response coordination and community engagement, to mitigate the impact of future health emergencies. The pandemic preparedness cycle involves dynamic, cyclical phases of preparation and response aimed at enhancing response capacity. Italy's 2021-2023 National Strategic-Operational Plan for Pandemic Influenza (PanFlu) incorporates lessons learned from past pandemics and serves as a framework for regional plans, such as Liguria's. The Ligurian plan delineates governance structures, surveillance strategies, healthcare services and communication measures necessary for effective pandemic management. It emphasizes the need to strengthen links between emergency structures, to avoid duplication and to adopt flexible approaches to scale actions appropriately and highlights the need for risk/benefit analysis to support evidence-based decision-making as well as clear guidance on data collection and communication activities. By integrating these elements, the region's overall readiness and resilience against influenza pandemics are expected to be reinforced., Competing Interests: The authors declare that they have no commercial or financial relationships that could be construed as a potential conflict of interest., (©2024 Pacini Editore SRL, Pisa, Italy.)

Lung cancer is the leading cause of cancer-related deaths in Europe, with low survival rates primarily due to late-stage diagnosis. Early detection can significantly improve survival rates, but lung cancer screening is not currently implemented in Italy. Many countries have implemented lung cancer screening programs for high-risk populations, with studies showing a reduction in mortality. This review aimed to identify key areas for establishing a lung cancer screening program in Italy. A literature search was conducted in October 2022, using the PubMed and Scopus databases. Items of interest included updated evidence, approaches used in other countries, enrollment and eligibility criteria, models, cost-effectiveness studies, and smoking cessation programs. A literature search yielded 61 scientific papers, highlighting the effectiveness of low-dose computed tomography (LDCT) screening in reducing mortality among high-risk populations. The National Lung Screening Trial (NLST) in the United States demonstrated a 20% reduction in lung cancer mortality with LDCT, and other trials confirmed its potential to reduce mortality by up to 39% and detect early-stage cancers. However, false-positive results and associated harm were concerns. Economic evaluations generally supported the cost-effectiveness of LDCT screening, especially when combined with smoking cessation interventions for individuals aged 55 to 75 with a significant smoking history. Implementing a screening program in Italy requires the careful consideration of optimal strategies, population selection, result management, and the integration of smoking cessation. Resource limitations and tailored interventions for subpopulations with low-risk perception and non-adherence rates should be addressed with multidisciplinary expertise.

Background: Pulmonary hypertension (PH) is frequent in patients with heart failure and reduced ejection fraction (HFrEF) with 2 different phenotypes: isolated postcapillary PH (IpcPH) and, with the worst prognosis, combined pre- and postcapillary PH (CpcPH). The aims of the present echocardiography study were to investigate (1) the ability to identify PH phenotype in patients with HFrEF using the newly adopted definition of PH (mean pulmonary artery pressure >20 mm Hg) and (2) the relationship between PH phenotype and right ventricular (RV) function., Methods: One hundred twenty-four patients with HFrEF consecutively referred for heart transplant or heart failure workup were included with echocardiography and right heart catheterization within 48 hours. We estimated systolic pulmonary artery pressure (sPAP Doppler ) and used a method to detect increased pulmonary vascular resistance (>3 Wood units) based on predefined thresholds of 3 pressure reflection (PRefl) variables (the acceleration time in the RV outflow tract [RVOT], the interval between peak RVOT and peak tricuspid regurgitant velocity, and the RV pressure augmentation following peak RVOT velocity)., Results: Using receiver operator characteristic analysis in a derivation group (n = 62), we identified sPAP Doppler ≥35 mm Hg as a cutoff that in a test group (n = 62) increased the likelihood of PH 6.6-fold. The presence of sPAP Doppler >40 mm Hg and 2 or 3 positive PRefl variables increased the probability of CpcPH 6- to 8-fold. A 2-step approach with primarily assessment of sPAP Doppler and the supportive use of PRefl variables in patients with mild/moderate PH (sPAP Doppler 41-59 mm Hg) showed 76% observer agreement and a weighted kappa of 0.63. The steady-state (pulmonary vascular resistance) and pulsatile (compliance, elastance) vascular loading are increased in both IpcPH and CpcPH with a comparable degree of RV dysfunction., Conclusions: The PH phenotype can be identified in HFrEF using standard echocardiographic assessment of pulmonary artery pressure with supportive use of PRefl variables in patients with mild to moderate PH., (Copyright © 2023 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: Giant cell myocarditis (GCM) and cardiac sarcoidosis (CS) are, in contrast to acute non-fulminant myocarditis (ANFM), rare inflammatory diseases of the myocardium with poor prognosis. Although echocardiography is the first-line diagnostic tool in these patients, their echocardiographic appearance has so far not been systematically studied., Methods: We assessed a total of 71 patients with endomyocardial biopsy-proven GCM (n = 21), and CS (n = 25), as well as magnetic resonance-verified ANFM (n = 25). All echocardiographic examinations, performed upon clinical presentation, were reanalysed according to current guidelines including a detailed assessment of right ventricular (RV) dysfunction., Results: In comparison with ANFM, patients with either GCM or CS were older (mean age (±SD) 55 ± 12 or 53 ± 8 vs 25 ± 8 years), more often of female gender (52% or 24% vs 8%), had more severe clinical symptoms and higher natriuretic peptide levels. For both GCM and CS, echocardiography revealed more frequently signs of left ventricular (LV) dysfunction in form of a reduced ejection fraction (p < 0.001), decreased cardiac index (p < 0.001) and lower global longitudinal strain (p < 0.001) in contrast to ANFM. The most prominent increase in LV end-diastolic volume index was observed in CS. In addition, RV dysfunction was more frequently found in both GCM and CS than in ANFM (p = 0.042)., Conclusions: Both GCM and CS have an echocardiographic and clinical appearance that is distinct from ANFM. However, the method cannot further differentiate between the two rare entities. Consequently, echocardiography can strengthen the initial clinical suspicion of a more severe form of myocarditis, thus warranting a more rigorous clinical work-up., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Vaccinations against Streptococcus pneumoniae are included in infant immunization programs globally. However, a substantial burden due to pneumococcal disease (PD) remains. This study aimed to estimate the cost of emergency department (ED) visits and hospitalizations associated with invasive pneumococcal disease, all-cause pneumonia, and acute otitis media in children <15 years of age in the Liguria region of Italy between 2012 and 2018. The retrospective cohort study used data from the Liguria Region Administrative Health Databases and the Ligurian Chronic Condition Data Warehouse, which contain information on hospital stays, outpatient visits, laboratory/imaging techniques, surgical procedures, and pharmaceutical prescriptions. Patients with one or more ED or inpatient claim for PD (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes) were included. Cost of ED visits and hospitalizations were estimated from the diagnosis-related group system and procedures performed in the ED. In Ligurian children <15 years of age during 2012-2018, the median annual number of hospitalizations plus ED visits due to PD was 4,009, and the median estimated annual cost was €3.6 million. All-cause pneumonia accounted for the majority of hospitalization costs during the study period. Number and costs of ED visits and hospitalizations increased from 2012 to 2018. Despite widespread infant immunization in Liguria, economic costs due to PD-associated ED visits and hospitalizations remained high in children 0-14 years of age.

The SARS-CoV-2 pandemic continues to spread worldwide, generating a high impact on healthcare systems. The aim of the study was to examine the epidemiological burden of SARS-CoV-2 reinfections and to identify potential related risk factors. A retrospective observational study was conducted in Liguria Region, combining data from National Vaccines Registry and Regional Chronic Condition Data Warehouse. In the study period (September 2021 to May 2022), 335,117 cases of SARS-CoV-2 infection were recorded in Liguria, of which 15,715 were reinfected once. During the Omicron phase (which predominated from 3 January 2022), the risk of reinfection was 4.89 times higher (p < 0.001) than during the Delta phase. Unvaccinated and vaccinated individuals with at least one dose for more than 120 days were at increased risk of reinfection compared with vaccinated individuals with at least one dose for ≤120 days, respectively (odds ratio (OR) of 1.26, p < 0.001; OR of 1.18, p < 0.001). Healthcare workers were more than twice as likely to be reinfected than non-healthcare workers (OR of 2.38, p < 0.001). Lower ORs were seen among people aged 60 to 79 years. Two doses or more of vaccination were found to be protective against the risk of reinfection rather than a single dose (mRNA vaccines: OR of 0.06, p < 0.0001, and OR of 0.1, p < 0.0001; vector vaccines: OR of 0.05, p < 0.0001). Patients with chronic renal failure, cardiovascular disease, bronchopneumopathy, neuropathy and autoimmune diseases were at increased risk of reinfection (OR of 1.38, p = 0.0003; OR of 1.09, p < 0.0296; OR of 1.14, p = 0.0056; OR of 1.78, p < 0.0001; OR of 1.18, p = 0.0205). Estimating the epidemiological burden of SARS-CoV-2 reinfections and the role played by risk factors in reinfections is relevant for identifying risk-based preventive strategies in a pandemic context characterized by a high circulation of the virus and a high rate of pathogen mutations.

Streptococcus pneumoniae infection is responsible for significant morbidity and mortality, particularly in young children and older adults. The aim of this study was to investigate the incidence of hospitalisation and emergency department (ED) visits in relation to episodes of pneumococcal disease (PD) following the introduction of pneumococcal conjugate vaccines (PCVs) into the Liguria region of Italy. Between 2012 and 2018, episodes of all-cause pneumonia (80,152), pneumococcal-specific pneumonia (1254), unspecified pneumonia (66,293), acute otitis media (AOM; 17,040), and invasive PD (IPD; 1788) were identified from in-patient claims, ED and hospital discharge records, and the Liguria Chronic Condition Data Warehouse. In children < 15 years of age, pneumococcal pneumonia-related hospitalisations decreased from 35 to 13 per 100,000 person-years during the study period (p < 0.001); this decrease is potentially related to PCV use in children. All-cause pneumonia hospitalisations remained stable, whereas IPD hospitalisations increased and AOM hospitalisations decreased. In adults, hospitalisations for all-cause pneumonia increased from 5.00 to 7.50 per 1000 person-years (+50%; p < 0.001). Pneumococcal and unspecified pneumonia hospital admissions increased significantly during the study period, considerably affecting those ≥ 65 years of age. IPD hospitalisations varied across all age groups, but a significant change was not observed. Despite pneumococcal vaccination, substantial burden remains for PD in children and adults in Liguria, Italy.

Breast cancer is the most common tumor in middle-aged and older women. In 2003, the European Parliament recommended to Member States that all women with breast cancer should be treated by a multidisciplinary team and that a network of certified breast centers be organized (the centers have been called Breast Units (BUs)). With the present study, we aim to explore the impact of the introduction of the BU organizational model in the Liguria region, Italy, through different outcome indicators. An explorative retrospective analysis was conducted through the period from 2013 to 2019 to assess the impact of the introduction of the BU model in our region. We identified two periods: before (2014-2015) and after (2017-2018) the introduction of this organizational model to assess its value impact through the definition of six measurable outcome indicators. Length of hospitalization, repeated specialist outpatient diagnostic procedures and the rate of subjects who started radiotherapy treatment within 60 days improved after the introduction of BUs. The passive health migration rate only improved significantly for one local health unit (LHU), while reintervention and diagnosis-surgery time did not show any enhancement after the introduction of the BU model. The BU model seems to provide an increase in several aspects of the healthcare offered to breast cancer patients in Liguria, specifically in those areas where a shared guideline could assist healthcare workers. Future research, such as pilot studies, are needed to assess the impact of the introduction of the BU model in our reality.

Purpose: Recognition of congestion and hypoperfusion in patients with chronic left ventricular dysfunction (LVD) has therapeutic and prognostic implications. In the present study we hypothesized that a multiparameter echocardiographic grading of right ventricular dysfunction (RVD) can facilitate the characterization of hemodynamic profiles., Methods: Consecutive patients (n = 105, age 53 ± 14 years, males 77%, LV ejection fraction 28 ± 11%) referred for heart transplant or heart failure work-up, with catheterization and echocardiography within 48 h, were reviewed retrospectively. Three hemodynamic profiles were defined: compensated LVD (cLVD, normal pulmonary capillary wedge pressure (PCWP < 15 mmHg) and normal mixed venous saturation (SvO 2  ≥ 60%)); decompensated LVD (dLVD, with increased PCWP) and LV failure (LVF, increased PCWP and reduced SvO 2 ). We established a 5-point RVD score including pulmonary hypertension, reduced tricuspid annular plane systolic excursion, RV dilatation, ≥ moderate tricuspid regurgitation and increased right atrial pressure., Results: The RVD score [median (IQR 25%;75%)] showed significant in-between the three groups differences with 1 (0;1), 1 (0.5;2) and 3.0 (2;3.5) in patients with cLVD, dLVD and LVF, respectively. The finding of RVD score ≥ 2 or ≥ 4 increased the likelihood of decompensation or LVF 5.2-fold and 6.7-fold, respectively. On the contrary, RVD score < 1 and < 2 reduced the likelihood 11.1-fold and 25-fold, respectively. The RVD score was more helpful than standard echocardiography regarding identification of hemodynamic profiles., Conclusions: In this proof of concept study an echocardiographic RVD score identified different hemodynamic severity profiles in patients with chronic LVD and reduced ejection fraction. Further studies are needed to validate its general applicability., (© 2022. The Author(s).)

Background: We conducted a population-based cohort study to estimate mortality before, during and after the COVID-19 peak and to compare mortality in 2020 with rates reported in previous years, with a view to helping decision makers to apply containment measures for high-risk groups., Methods: All deaths were collected between 2015 and 2020 from municipal registry database. In 2020, weeks 1-26 were stratified in three periods: before, during and after the COVID mortality peak. The Poisson Generalized Linear regression Model showed the "harvesting effect". Three logistic regressions for 8 dependent variables (age and comorbidities) and a t-test of differences described all-cause mortality risk factors in 2019 and 2020 and differences between COVID and non-COVID patients., Results: A total of 47,876 deaths were collected. All-cause deaths increased by 38.5% during the COVID peak and decreased by 18% during the post-peak period in comparison with the average registered during the control period (2015-19), with significant mortality displacement in 2020. Except for chronic renal injuries in subjects aged 45-64 years, diabetes and chronic cardiovascular diseases in those aged 65-84 years, and neuropathies in those aged > 84 years, the weight of comorbidities in deaths was similar or lower in COVID subjects than in non-COVID subjects., Discussions: Surprisingly, the weight of comorbidities in death, compared to weight in non-COVID subjects allows you to highlight some surprising results such as COPD, IBD and Cancer. The excess mortality that we observed in the entire period were modest in comparison with initial estimates during the peak, owing to the mild influenza season and the harvesting effect starting from the second half of May., Competing Interests: Conflict of interest statement The authors declare no conflict of interest., (©2021 Pacini Editore SRL, Pisa, Italy.)

According to WHO estimates, varicella disease is responsible of a worldwide significant burden in terms of hospitalizations, complications, and deaths, with more than 90% of cases under 12 years old. This study aims at evaluating the clinical, epidemiological, and economic burden of varicella in Ligurian children, about comorbidities, organizational variables, and vaccination coverages from 2010 to 2017, in terms of Emergency Department accesses and hospitalizations. The overall hospitalization rate was 179.76 (per 100,000 inhab.), with a gradual but significant decline since 2015, when universal varicella vaccination was introduced in Liguria ( p < 0.0001). The risk of being hospitalized for complicated varicella in subjects with at least one comorbidity was significantly higher than in subjects without comorbidities ( p = 0.0016). The economic analysis showed higher costs in subjects with complicated varicella who were 0-3 years old. This age group showed higher costs also considering extra-hospital costs for both outpatient procedures and pharmaceutical costs ( p < 0.0001). The results confirm the relevant burden of varicella, especially in the 0-3 age group and in children with comorbidities. Thus, vaccination with the achievement of adequate vaccination coverages is confirmed to be a necessary control strategy to reduce hospitalizations and associated complications with important economic benefits.

Despite the availability of vaccines against Streptococcus pneumoniae , the global incidence and economic cost of pneumococcal disease (PD) among adults is still high. This retrospective cohort analysis estimated the cost of emergency department (ED) visits/hospitalizations associated with non-invasive pneumonia and invasive pneumococcal disease among individuals ≥15 years of age in the Liguria region of Italy during 2012-2018. Data from the Liguria Region Administrative Health Databases and the Ligurian Chronic Condition Data Warehouse were used, including hospital admission date, length of stay, discharge date, outpatient visits, and laboratory/imaging procedures. A ≥30-day gap between two events defined a new episode, and patients with ≥1 ED or inpatient claim for PD were identified. The total mean annual number of hospitalizations for PD was 13,450, costing ~€49 million per year. Pneumonia accounted for the majority of hospitalization costs. The median annual cost of hospitalization for all-cause pneumonia was €38,416,440 (per-capita cost: €26.78) and was €30,353,928 (per-capita cost: €20.88) for pneumococcal and unspecified pneumonia. The total number and associated costs of ED visits/hospitalizations generally increased over the study period. PD still incurs high economic costs in adults in the Liguria region of Italy.

Aims: Grading right ventricular dysfunction (RVD) in patients with left ventricular (LV) disease has earned little attention. In the present study, we established an echocardiographic RVD score and investigated how increments of the score correspond to RVD at right heart catheterization., Methods and Results: We included 95 patients with LV disease consecutively referred for heart transplant or heart failure work-up with catheterization and echocardiography within 48 h. The RVD score (5 points) included well-known characteristics of the development from compensated to decompensated right ventricular (RV) function: pulmonary hypertension, reduced RV strain, RV area dilatation, moderate/severe tricuspid regurgitation, and increased right atrial pressure (RAP) by echocardiography. Comparing three groups with increments of RVD score [1 (mild), 2-3 (moderate), and 4-5 (severe)] showed more advanced RVD with increasing RV end-diastolic pressure (P < 0.001) and signs of uncoupling to load (reduced ratio between RV and pulmonary artery elastance, P < 0.001) and more spherical RV shape (RV area/length, P < 0.001). Receiver operating characteristic curve analysis for detection of severe RV (RAP ≥ 10 mmHg) showed for the RVD score an area under the curve of 0.88 compared with 0.69, 0.68, and 0.64 for RV strain, tricuspid annular plane systolic excursion, and fractional area change, respectively. A patient with RVD score ≥ 4 had a 6.7-fold increase in likelihood of severe RVD, and no patient with RVD score ≤ 1 had severe RVD., Conclusions: In this proof of concept study, a novel RVD score outperformed the widely used longitudinal parameters regarding grading of RVD severity, with a potential role for refined diagnosis, follow-up, and prognosis assessment in heart failure patients., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

The effect of severe Herpes Zoster (HZ) on chronic diseases is a component of the real burden of this vaccine-preventable disease that is not commonly considered. A retrospective cohort study was conducted to assess the health burden of severe HZ in adults ≥50 years residing in Liguria Region from 2015 to 2017. Subjects hospitalized with and without HZ were matched (1:6 ratio). 437 subjects in the HZ cohort and 2622 subjects in the non-HZ cohort were enrolled. Previous immunodeficiency, autoimmune, and rare diseases are identified as main chronic conditions related to HZ hospitalization. Higher incidences of autoimmune (1.4% vs. 0.22%, p = 0.002) and gastrointestinal (7.04% vs. 3.62%, p = 0.015) diseases after hospitalization were observed in the HZ cohort compared to the non-HZ cohort. Significantly higher incidences were found after hospitalization versus the previous period for cardiovascular diseases (11.17% vs. 2.09%, p < 0.001), cerebral vasculopathy (6.13% vs. 0.60%, p < 0.001), non-arrhythmic myocardiopathy (4.31% vs. 0.59%, p = 0.002), and neuropathy (2.62% vs. 0.56%, p = 0.033). The HZ cohort showed a relative risk 10-fold higher for cerebral vasculopathy, 5-fold higher for cardiovascular diseases, and 7-fold higher for non-arrhythmic myocardiopathy. HZ causes a substantial impact on the chronic conditions. These data could suggest an implementation of HZ vaccination programs in the elderly and in high-risk groups.

Introduction : The aim of this study was to investigate knowledge and practices about influenza among patients on dialysis services of Italian hospitals at risk of severe influenza infection and vaccine and to identify predictive factors to vaccination adherence. Methods : A cross-sectional observational study was carried out from January 2017 to July 2017 after the 2016/2017 influenza vaccination campaign. The questionnaire was administered to all patients treated in seven large Italian dialysis services. It consisted of influenza vaccination coverage, knowledge about influenza and its vaccination, perceived risk of influenza complications, recommendations on influenza uptake received by general practitioner (GP) and nephrologist. Results : Response rate was 90% (703/781). Patients' knowledge about influenza infection and vaccine were detected by nine closed questions: 35.6% of responders answered correctly to ≥ 6 sentences, 47.5% of them reported that "influenza vaccine can cause influenza" and 45.7% believed that "antibiotics are a correct strategy to treat influenza". Levels of perceived risks of hospitalisation and death were low in 39.3% and 16.5% of patients respectively. The adherence to the last seasonal influenza vaccination was 57.5%. The multivariate predictors of influenza vaccination uptake resulted: age ≥65, male, consulting TV/radio, asking information to GP and/or nephrologist. Conclusions : The study reveals the low adherence to influenza vaccination and the subotpimal level of knowledge in dialysis patients. Different strategies, including a greater alliance among nephrologists and GPs to prevent influenza should be encouraged to improve the adherence to influenza vaccination in this at risk group.

Background: This systematic review and meta-analysis aimed at summarizing available data on the impact of PCV10 and PCV13 in reducing the incidence of CAP hospitalizations in children aged <5years., Methods: A systematic search of the literature was conducted. We included time-series analyses and before-after studies, reporting the incidence of hospitalization for pneumonia in the periods before and after the introduction of PCV10 or PCV13 into the immunization program. Pooled estimates of Incidence Rate Ratio (IRR) were calculated by using a random-effects meta-analytic model. Results were stratified according to age-groups (<24months and 24-59months) and case definitions of pneumonia (clinically and radiologically confirmed pneumonia)., Results: A total of 1533 potentially relevant articles were identified. Of these, 12 articles were included in the analysis. In children aged <24months, the meta-analysis showed a reduction of 17% (95%CI: 11-22%, p-value<0.001) an of 31% (95%CI: 26-35%, p-value<0.001) in the hospitalization rates respectively for clinically and radiologically confirmed pneumonia, respectively, after the introduction of the novel PCVs. In children aged 24-59months, the meta-analysis showed a reduction of 9% (95%CI: 5-14%, p-value<0.001) and of 24% (95%CI: 12-33%, p-value<0.001) in the hospitalization rates for clinically and radiologically confirmed pneumonia, respectively, after the introduction of the novel PCVs. High heterogeneity was detected among studies evaluating the hospitalization rate for clinically and radiologically confirmed pneumonia., Conclusions: The results of this study revealed a significant impact of PCV10 and PCV13 in reducing the hospitalizations for pneumonia, particularly in children aged <24months and for radiologically confirmed disease. Further appropriately designed studies, comparing the impact of PCV10 and PCV13, are needed in order to obtain solid data on which to establish future immunization strategies., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Coarctation of the aorta (CoA) is a common condition. Adult patients with newly diagnosed CoA and patients with recurring or residual CoA require evaluation of the severity of aortic obstruction. Cardiac catheterization is considered the gold standard for the evaluation of hemodynamically significant CoA. The European Society of Cardiology (ESC) Guidelines for the management of grown-up congenital heart disease (GUCH) include noninvasive criteria for identifying significant CoA. Our aim was to investigate the ability of the Class I and Class IIa ESC recommendations to identify significant CoA at cardiac catheterization., Design: Sixty-six adult patients with native or recurrent CoA underwent diagnostic cardiac catheterization at the GUCH unit at the Sahlgrenska University Hospital in Gothenburg from October 1998 to November 2013. Clinical and imaging data, as well as data about cardiac catheterization were retrospectively collected from patient records., Results: The Class I ESC recommendations predicted significant CoA with a sensitivity of 0.57, a specificity of 0.63, a positive predictive value of 0.67, and a negative predictive value of 0.53. The combination of Class I and Class IIa recommendations predicted significant CoA with a sensitivity of 0.75, a specificity of 0.42, a positive predictive value of 0.66 and a negative predictive value of 0.52., Conclusions: the noninvasive criteria proposed by the ESC guidelines to identify subjects with significant CoA performed poorly in our dataset. Further research is needed to develop more accurate, noninvasive criteria to evaluate CoA severity and thereby reduce the number of unnecessary cardiac catheterizations., (© 2016 Wiley Periodicals, Inc.)

Background: While the association between anxiety and postpartum depression is well known, few studies have investigated the relationship between these two states and parenting stress. Furthermore, a number of studies have found that postpartum depression affects mother-infant emotion regulation, but there has been only one study on anxiety and emotion regulation and no studies at all on parenting stress and emotion regulation. Therefore, the primary aim of our study is to identify, in a community sample of 71 mothers, the relationship between maternal depression, anxiety, and parenting stress. The second aim is to examine the relationship between anxiety, postpartum depression, and parenting stress and mother-infant emotion regulation assessed at 3 months., Methods: Mother-infant interaction was coded with a modified version of the Infant Caregiver and Engagement Phases (ICEP) using a microanalytic approach. The Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), and Parenting Stress Index-Short Form (PSI-SF) were administered to the mothers to assess depression, anxiety, and parenting stress, respectively., Results: Analysis revealed correlations between anxiety and depression, showing that parenting stress is associated with both states. In a laboratory observation, depression was correlated with both negative maternal states and negative dyadic matches as well as infant positive/mother negative mismatches; anxiety was correlated with both negative maternal states and infant negative states as well as mismatches involving one of the partners having a negative state. Multiple regression analysis showed that anxiety is a greater predictor than depression of less adequate styles of mother-infant emotion regulation. Parenting stress was not shown to predict such regulation., (© 2016 S. Karger AG, Basel.)

Background: Blood pressure (BP) variations occurring after hospital discharge in a population of older hypertensives have not been previously investigated., Design: elderly (≥65 years) hypertensives admitted to the geriatric acute ward of a university-teaching hospital were enrolled in this prospective observational study., Methods: Exclusion criteria were terminal illness, discharge to institution, and changes in antihypertensive regimen. BP was recorded in the emergency room, at ward admission, daily during hospital stay, and at discharge. Home self blood pressure measurement was performed after discharge., Results: The study population included 106 patients. There was a significant decrease in systolic BP (SBP) and diastolic BP (DBP) throughout the study time points. SBP and DBP decreased after discharge (from 135.1 ± 15.0 to 131.5 ± 16.1 mmHg and from 77.2 ± 8.4 to 71.6 ± 8.7 mmHg, respectively), the difference being significant only for DBP (p = 0.000). We further observed higher prevalence of critically low BP values (SBP <120 mmHg and DBP <70 mmHg) at home (23.6% and 48.1%, respectively) compared to discharge (8.5% and 9.4%, p = 0.006 and p = 0.000, respectively)., Conclusions: We observed a decrease in BP values, and particularly DBP values, after hospital discharge, in a sample of older hypertensives. Critically low BP values were observed at home in a high proportion of subjects, suggesting wise use of antihypertensive therapy at discharge and early monitoring of BP values at home.

Background: All over Europe, an increased use of public health services has been noticed, particularly referring to access and hospitalization among elderly in the emergency department (ED)., Methods: Prospective study at a university teaching hospital in Turin, northern Italy, recruiting subjects aged >65 years consecutively attending the medical ED during 1 month. Demography, functional and cognitive status, comorbidity, severity of acute critical illness, previous ED accesses and hospitalization, diagnosis and other relevant data for ED admission and hospitalization were considered., Results: Data were collected for 1632 patients (average age 77.6 years), 89% of the 1834 older subjects who attended the ED during the study period (29.3% of the patients attending the ED). Six hundred and fifty older subjects were admitted to the hospital (62.2% of the hospital admissions). Severity of acute critical illness, presence of chronic obstructive pulmonary disease and heart failure, a high number of drugs being taken, functional dependence and advanced age were independently associated with hospital admission. One-third of the patients appeared to be frequent users of health services with more than two visits/admissions. Higher comorbidity, partial or complete functional dependence, chronic diseases (arrhythmia, pulmonary neoplasm, diseases of the large intestine) and politherapy were associated either with frequent use of the ED and multiple admissions., Conclusions: Elderly account for a high proportion of hospitalizations, mainly determined by critical health conditions, advanced age and functional dependence. Poor health conditions (high comorbidity and presence of chronic multi-organ diseases), functional dependence but not critical social factors were the main determinants of multiple hospital admissions.

Background and Aims: Caregiving can be extremely stressful, especially when patients' ability to communicate is impaired. While the stress undergone by relatives assisting their loved ones has been widely investigated, fewer data can be found about the stress in healthcare professionals. The aim of this study is to evaluate whether a specific training course could be related to a reduction in the levels of stress of professional care-givers working with patients suffering from dementia., Methods: Work-related levels of stress of study participants were evaluated with the Staff Stress Measure Dementia Care Scale, at baseline and four months after completion of an eight-month training course., Results: We found no significant correlation between care-givers' age, gender, marital status, years of employment or perceived economic status, and their stress levels at baseline. Patients' characteristics were not related with care-givers' stress at baseline. The mean level of stress was significantly reduced (34.64±4.15 vs 26.64±3.82, p<0.001) between baseline and the study endpoint., Conclusions: Increased knowledge of management of patients affected by dementia could help professional care-givers to reduce their work-related stress. Our results add to the evidence of the benefit of personnel support in reducing levels of stress at work.

The hospital-at-home service (HHS) could be considered as an alternative to the traditional ward for elderly patients. We aimed at evaluating the home management of elderly people requiring transfusions. The ever-increasing demand on acute hospital services requires alternative methods of delivering all aspects of health care. HHS demonstrated to be as efficacious as a traditional ward for elderly and functionally compromised patients. The method was a retrospective descriptive study enrolling patients needing an hospital admission from 1st January 2007 to 31st December 2007 and reporting an hematological discharge's diagnosis as primary or secondary diagnosis. A total of 54 patients were evaluated in this study. Of them, 34 (62.9%) needed a hemocomponent transfusion for a total volume of 112 blood units and 49 platelet pools. Patients requiring at least one blood or platelet transfusion were more functionally compromised and presented a higher level of acute physiology and chronic health evaluation, compared to the non-transfused ones. The conclusion was that hematological subjects mainly the frail ones and functionally highly compromised with acute illnesses could be treated at home as an alternative of the traditional medical ward. This could be the starting point for future studies that will be able to increase the power of hospital-at-home service for this type of patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: Physical activity is effective in primary and secondary prevention of cardiovascular disease. In this study, we tested the hypothesis that exercise training improves glucose and lipid metabolism, the inflammatory/anti-inflammatory balance, and the outcome of elective percutaneous coronary intervention (PCI) in patients with stable coronary disease., Methods: Sixty-two patients scheduled to undergo PCI for stable angina were randomized to intensive physical activity (n=33) consisting of home-based exercise on a bicycle ergometer or maintain their usual sedentary life (n=29). The training program started 2 months before PCI and terminated 6 months afterwards. Clinical examination, blood sampling (fasting glucose, glycated hemoglobin, lipid profile, apolipoprotein B, apolipoprotein A1, C-reactive protein, serum amyloid A, interleukin-6, interleukin-8, and interleukin-10), and maximal exercise tests were performed at inclusion, 1 week before PCI, and 3 and 6 months afterwards., Results: Fifty-six patients [28 per group, 45 men, mean age 63 (SD 7.8) years] completed the follow-up. According to self-reports, patients in the training group exercised more often and longer [4.9 (SD 1.1) vs. 0.6 (SD 1.3) days/week, 36 (SD 12) vs. 15 (SD 31) min/session, P<0.0001]. Improvement in maximal exercise capacity was significantly better in the training group [27 (SD 27) vs. 9 (SD 27) W, P=0.02]. Exercise had no significant effects on glucose and lipid metabolism, plasma cytokines, or acute-phase reactants., Conclusion: A home-based training program significantly improved maximal exercise capacity but did not affect glucose or lipid metabolism or markers of inflammation.

We aimed to evaluate the efficacy and safety of oxycodone/acetaminophen (O/A) and codeine/acetaminophen (C/A) vs. conventional therapy (CT) without opioids in older women suffering from osteoarthritis (OA)-related pain, sub-optimally responsive to prior conventional treatments. We performed a 6 week, randomized, single blind, controlled study in three nursing homes. We enrolled 154 women with painful OA. They were assigned to treatment with O/A (n=52) and C/A (n=52) vs. CT (n=50). We evaluated at baseline and at week 6: average pain in the last week (mean pain, MeP), pain at rest (RP), pain in movement (MP) (numeric rating scale, NRS); depressive symptoms (Beck Depression Inventory-II, BDI-II); functional status (activities of daily living, ADL) and cognitive status (mini mental state evaluation, MMSE). We considered the adverse events (AEs) in the study period. At week 6, MeP, RP and MP were significantly reduced in all three groups (p<0.001); compared to CT, O/A and C/A were associated with greater reductions in MeP (p<0.001 and p=0.004, respectively), in RP (p=0.028 and p=0.032, respectively) in MP (p<0.001 and p=0.002, respectively) and with significant improvement in BDI-II score (p=0.05 and p=0.04, respectively) and ADL value (p=0.04 and p=0.05, respectively). AE rates did not differ between groups.

The prevalence of the metabolic syndrome (MS) increases with advancing age. However, aging per se is associated with increased prevalence of most of the abnormalities contributing to the MS. Whether MS in older people consistently identifies a true pathophysiological entity or a casual aggregation of aging-associated metabolic abnormalities, remains to be fully elucidated. In the present study, we aimed to evaluate whether in older subjects the aggregation of metabolic components of the MS, as defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), is consistent with a single latent variable. Age, waist circumference, systolic and diastolic blood pressure, metabolic variables were determined in 152 older (>70 years), non-diabetic, healthy men. Cronbach alpha was used to assess the internal consistency of the components contributing to the MS. Structural equation modeling, using the Normed Fit Index (NFI), the Root Mean Square Error of Approximation (RMSEA), the Comparative Fit Index (CFI), and the Tucker-Lewis Index (TLI) was used to assess the fit to a model with a single latent variable. The Cronbach alpha test showed low internal consistency among the metabolic variables (alpha=0.31). The calculated chi(2) values were 28.31 and 32.52 for model entering hypertension as dichotomous variable and for model entering blood pressure values, respectively, both expressing low fit to a model with a single latent variable. In both models, CFI (0.41 and 0.55), NFI (0.59 and 0.55), RMSEA (0.25 and 0.22) and TLI (-0.31 and -0.12) scores showed a low fit of the metabolic alterations to a single latent variable. These findings suggest caution in making diagnosis of MS at older ages, since metabolic and cardiovascular abnormalities being per se extremely common in elderly people, do not appear to cluster together under a single common factor.

Objective: This study investigated whether high-sensitivity C-reactive protein (hs-CRP) levels are independently associated with subclinical peripheral atherosclerosis., Methods: Clinical variables, cardiovascular (CV) risk factors, 10-year CV risk, the ankle-brachial Index (ABI), and the carotid intima-media thickness (cIMT) were determined in a sample of consecutive subjects free from previous CV disease, admitted for a first visit at a lipid clinic., Results: In the overall sample (320 subjects, mean age 63 years, 35.8% men), hs-CRP levels were associated with major CV risk factors, 10-year CV risk, lower ABI, and higher cIMT values. In a logistic model, after adjustment for significant covariates, the associations of hs-CRP levels with ABI and cIMT were no longer statistically significant., Conclusions: Among asymptomatic, moderate- to-high CV risk subjects, hs-CRP levels were associated with severity of peripheral atherosclerosis, but these associations were not independent of traditional CV risk factors, suggesting a limited predictive role of hs-CRP for subclinical atherosclerosis.

S9 fraction pools of liver biopsy samples, collected from 129 patients in two consecutive studies, were comparatively assayed for their ability to activate aflatoxin B1 (AFB1) and a tryptophan pyrolysate product (Trp-P-2) in a miniaturized Salmonella mutagenicity test system. Metabolic activation was not affected to a significant extent by most of the monitored variability factors, such as sex, alcohol, cigarette smoking and liver histology (minimal changes, chronic persistent (CPH) or active (CAH) hepatitis, CAH steatosis, or cirrhosis). Conversely, a significant enhancement of activation was observed for AFB1 in cases of mild CAH and especially for Trp-P-2 in hepatitis B virus carriers, irrespective of their histologic diagnosis.

Thirty-six wild-caught woodchucks (Marmota monax) were characterized according to sex, weight, trapping locality, liver pathology, and serum or hepatic markers of woodchuck hepatitis virus. Liver subcellular fractions were assayed for microsomal cytochromes P-450, aryl hydrocarbon hydroxylase, glutathione, cytosolic enzymes involved in its metabolism (glutathione S-transferase, glutathione peroxidase, and glutathione reductase), in the hexose monophosphate shunt (glucose 6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase), NADH- and NADPH-dependent diaphorases, and DT diaphorase. Moreover, liver postmitochondrial fractions were assayed for their ability to activate procarcinogens [i.e., a tryptophan pyrolysate product, aflatoxin B1, 2-aminofluorene, and trans-7,8-dihydrobenzo(a)pyrene] to mutagenic metabolites in the Ames reversion test and to decrease the activity of direct-acting mutagens [i.e., 4-nitroquinoline N-oxide, 2-methoxy-6-chloro-9-[3-(2-chloroethyl)aminopropylamino]acridine X 2HCl, and sodium dichromate]. A considerable interindividual variability in metabolism was observed among the examined woodchucks. Some of the investigated parameters were more elevated in virus carriers, especially in those suffering from chronic active hepatitis, but only a few of the recorded differences (i.e., oxidized glutathione reductase and NADPH-dependent diaphorase) were statistically significant. The comparison of the monitored activities in woodchucks and in other rodent species (rat and mouse) led to the conclusion that the liver metabolism of mutagens and carcinogens in woodchucks is more oriented in the sense of activation, while detoxification mechanisms are more efficient in rats and mice.

The thiol N-acetylcysteine (NAC), a precursor of intracellular glutathione (GSH), efficiently prevented the induction of lung tumors in Swiss albino mice, when supplemented to the diet (0.2%) both before and after an i.p. injection of the carcinogen urethan (ethyl carbamate). Irrespective of urethan administration, NAC also significantly enhanced GSH S-transferase activity in liver preparations of the same animals. These data show that, under certain conditions, it is possible to prevent chemically induced cancer by increasing the levels of physiological trapping agents.

The mutagenicity of sodium dichromate in the Ames test was decreased as a consequence of chromium(VI) reduction by tissue postmitochondrial (S-9 or S-12) fractions from untreated rats with the following rank of efficiency: liver; kidney; and lung. The effects of lung preparations were significantly enhanced following the intratracheal administration of high doses (0.25 mg/kg) of dichromate itself, 5 times per week for 4 weeks (i.e., 20 fractionated instillations). No changes were conversely detected following single weekly doses of 1.25 mg/kg for the same period (i.e., four cumulative instillations). The local stimulation of chromium(VI) metabolism was also confirmed by testing the mutagenicity of calcium chromate and chromium trioxide, whereas the metabolism of a number of other activatable or deactivatable mutagens was not significantly affected by intratracheal treatment with chromium(VI). Of three enzyme inducers injected i.p. which modified the spectral properties and/or concentration of cytochromes P-450 in liver and lung microsomes, only Aroclor 1254 proved to stimulate chromium(VI) metabolism in lung cells. In liver cells, Aroclor 1254 and to a lower extent phenobarbital induced chromium(VI) reduction, while 3-methylcholanthrene was ineffective. Pretreatment of rats with these three compounds resulted in a selective induction of the metabolic activation of promutagens [benzo(a)pyrene and its trans-7,8-diol, 2-aminofluorene, aflatoxin B1] and of the metabolic deactivation of direct-acting mutagens [2-methoxy-6-chloro-9-[3-(2-chloroethyl)-aminopropylamino] acridine X 2HCl, epichlorohydrin, 4-nitroquinolino-N-oxide] by S-12 and microsomal fractions. These findings indicate that, in addition to already recognized detoxification mechanisms operating outside target cells (26), specific and inducible chromium-reducing pathways, mediating threshold phenomena in chromium carcinogenesis, do also occur in the intracellular environment.