Antonella Sferrazza

Antiplatelet/Anticoagulant Agents and Chronic Subdural Hematoma in the Elderly

Background and Purpose In the last decade there has been an increasing use of antiplatelet/anticoagulant agents in the elderly. The aim of the study was to evaluate the association between exposure to anticoagulant/antiplatelet therapy and chronic subdural haematoma-CSDH. Methods Single institution case-control study involving 138786 patients older than 60 years who visited our academic tertiary care Emergency Department from January 1st 2001 to December 31st 2010. 345 patients with CSDH (cases) were identified by review of ICD-9 codes 432.1 and 852.2x. Case and controls were matched with a 1∶3 ratio for gender, age (±5 years), year of admission and recent trauma. A conditional logistic model was built. A stratified analysis was performed with respect to the presence (842 patients) or absence (536 patients) of recent trauma. Results There were 345 cases and 1035 controls. Both anticoagulant and antiplatelet agents were associated with an increased risk of CSDH with an OR of 2.46 (CI 95% 1.66–3.64) and 1.42 (CI 95% 1.07–1.89), respectively. OR was 2.70 (CI 95% 1.75–4.15), 1.90 (CI 95% 1.13–3.20), and 1.37(CI 95% 0.99–1.90) for patients receiving oral anticoagulants, ADP-antagonists, or Cox-inhibitors, respectively. History of recent trauma was an effect modifier of the association between anticoagulants and CSDH, with an OR 1.71 (CI 95% 0.99–2.96) for patients with history of trauma and 4.30 (CI 95% 2.23–8.32) for patients without history of trauma. Conclusions Anticoagulant and antiplatelet therapy have a significant association with an increased risk of CSDH. This association, for patients under anticoagulant therapy, appears even stronger in those patients who develop a CSDH in the absence of a recent trauma.

Prevalence of influenza vaccination among nurses and ancillary workers in Italy: Systematic review and meta analysis

Introduction: Italian Ministry of Health, recommends vaccination for seasonal influenza to all healthcare workers (HCW), particularly to nurses who have an important interaction with patients. The aim of this study is to conduct a systematic review in order to estimate the pooled prevalence of influenza vaccinations among nurses and ancillary workers in Italy and analyse the enhancing and hindering factors. Results: The review was performed using 15 articles, six containing the prevalence of vaccination for nurses and ancillary workers, while the others qualitative analysis. In all the selected articles the score calculation has been carried out by using a protocol for observational studies. The nurses and ancillary workers pooled proportion of influenza vaccination was respectively 13,47% (95%CI 9,58-17,90%) and 12,52% (95%CI 9,97-15,31%). Discussion: The Italian mean of influenza vaccination prevalence appear low if compared to other European countries, ranging from 15% to 29% in Countries such as UK, Germany, France. This situation of weakness should be seen as an opportunity to improve the vaccination rate for seasonal influenza significantly This should be done by intervening on the category which affirms caring less. In fact, this category has a priority to receive vaccination, due to their numbers and closer contact to patients. Methods: Research was conducted using medical database Scopus, PubMed, the search engine Google Scholar and ISI web of knowledge, and was concluded February 1st 2011.

Intrafamilial transmission of hepatitis C virus in Italy: a systematic review

Background Hepatitis C virus (HCV) transmission is mainly due to parenteral exposure; however, in absence of such risk factor, there are reports of intrafamilial spread of HCV and observational studies suggest an increased risk for households of infected subjects. The aim of our study was to systematically review and meta-analyse studies about HCV prevalence among households of HCV patients in Italy. Methods PubMed and Embase were searched to identify Italian studies about HCV intrafamilial transmission. Keywords used were: ‘HCV’, ‘Hepatitis C’, ‘intrafamilial’, ‘family’ and ‘Italy’. Selected studies were reviewed to assess the quality and meta-analysed using StatsDirect software. Results 25 studies were selected. The pooled overall prevalence was 9% (95% CI 7.1% to 11.1%). The highest pooled prevalence was found among sexual partners of index cases: 14.7% (95% CI 10.7% to 19.2%) globally and 9.9% (95% CI 3.6% to 18.8%) and 17.6% (95% CI 12.1% to 24%) in northern and central-southern regions, respectively. The meta-analysis of high-quality studies yielded the lowest HCV prevalence. Conclusion To be a HCV patient household is a risk factor for HCV and counselling for these households should be provided.

Health Technology Assessment of Belimumab: A New Monoclonal Antibody for the Treatment of Systemic Lupus Erythematosus

Objective. Systemic lupus erythematosus (SLE) is treated with anti-inflammatory and immunosuppressive drugs and off-label biologics. Belimumab is the first biologic approved after 50 years as an add-on therapy for active disease. This paper summarizes a health technology assessment performed in Italy. Methods. SLE epidemiology and burden were assessed using the best published international and national evidences and efficacy and safety of belimumab were synthesized using clinical data. A cost-effectiveness analysis was performed by a lifetime microsimulation model comparing belimumab to standard of care (SoC). Organizational and ethical implications were discussed. Results. Literature review showed that SLE affects 47 per 100,000 people for a total of 28,500 patients in Italy, 50% of whom are affected by active form of the disease despite SoC. These patients, if autoantibodies and anti-dsDNA positive with low complement, are eligible for belimumab. SLE determines work disability and a 2–5-fold increase in mortality. Belimumab with SoC may prevent 4,742 flares in three years being cost-effective with an incremental cost-effectiveness ratio of €32,859 per quality adjusted life year gained. From the organizational perspective, the development of clear and comprehensive clinical pathways is crucial. Conclusions. The assessment supports the use of belimumab into the SLE treatment paradigm in Italy.

Investigating the Synergistic Interaction of Diabetes, Tobacco Smoking, Alcohol Consumption, and Hypercholesterolemia on the Risk of Pancreatic Cancer: A Case-Control Study in Italy

The aims of the present research are to investigate the possible predictors of pancreatic cancer, in particular smoking status, alcohol consumption, hypercholesterolemia, and diabetes mellitus, in patients with histologically confirmed pancreatic carcinoma and to examine the synergism between risk factors. A case-control study (80 patients and 392 controls) was conducted at the Teaching Hospital “Agostino Gemelli” in Rome. A conditional logistic regression was used for the statistical analysis and results were presented as odds ratio (OR) and 95% confidence intervals (95% CI). We also investigated the possible interactions between risk factors and calculated the synergism index (SI). The multivariate analysis revealed that hypercholesterolemia and alcohol consumption resulted in important risk factors for pancreatic cancer even after the adjustment for all variables (OR: 5.05, 95% CI: 2.94–8.66; OR: 2.25, 95% CI: 1.30–3.89, resp.). Interestingly, important synergistic interactions between risk factors were found, especially between ever smoking status and alcohol consumptions (SI = 17.61) as well as alcohol consumption and diabetes (SI = 17.77). In conclusion, the study confirms that hypercholesterolemia and alcohol consumption represent significant and independent risk factors for pancreatic cancer. Moreover, there is evidence of synergistic interaction between diabetes and lifestyle factors (drinking alcohol and eating fatty foods).

The Prevention of Postmenopausal Osteoporotic Fractures: Results of the Health Technology Assessment of a New Antiosteoporotic Drug

Objective. The Health Technology Assessment (HTA) approach was applied to denosumab in the prevention of osteoporotic fractures in postmenopausal women. Method. Epidemiological, clinical, technical, economic, organizational, and ethical aspects were considered. Medical electronic databases were accessed to evaluate osteoporosis epidemiology and therapeutical approaches. A budget impact and a cost-effectiveness analyses were performed to assess economic implications. Clinical benefits and patient needs were considered with respect to organizational and ethical evaluation. Results. In Italy around four millions women are affected by osteoporosis and have a higher risk for fractures with 70,000 women being hospitalized every year. Bisphosphonates and strontium ranelate are recommended as first line treatment for the prevention of osteoporotic fractures. Denosumab is effective in reducing vertebral, nonvertebral, and hip/femoral fractures with an advantage of being administered subcutaneously every six months. The budget impact analysis estimated a reduction in costs for the National Health Service with the introduction of denosumab. Furthermore, the economic analysis demonstrated that denosumab is cost-effective in comparison to oral bisphosphonates and strontium ranelate. Denosumab can be administered in outpatients by involving General Practitioners in the management. Ethical evaluation is positive because of its efficacy and compliance. Conclusion. Denosumab could add value in the prevention of osteoporotic fractures.

Trends in avoidable hospitalization rates in Italy, 2001-2008

Background: hospitalization for Ambulatory Care Sensitive Conditions (AC SC), also known as avoidable hospitalization (AH) has been proposed as effect measure of the accessibility and effectiveness of primary care. In the last years in developed countries, including Italy, hospitalization rates have decreased as well as the rates of AH. The decline of AH-rates could be just an effect of the general trend of hospitalization. The objective of our study was to examine the adjusted trend of AH rates and to test possible associations with measures of primary care (re)organization. Methods: hospital discharges from 2001 to 2008 were analyzed. Main outcome measures were hospitalization rates, both as inpatient and day hospital. ACSCs were grouped in acute conditions, preventable through early diagnoses and treatment and chronic conditions, preventable through good ongoing control and management. Expected time-series rates of AH, estimated on the hypothesis of same time trends of Total Hospitalization (TH), were compared with observed ones using a Chi Square test. Adjusted hospitalization rates were analyzed in conjunction with indicators of primary care. Results: in the studied period, in Italy, the TH rates declined with an average decrease of 19.6%, while the decrease for AH was 16.4%. The rates of AH adjusted for the trend of TH significantly decreased only for chronic conditions. Decreasing trend of AH was correlated with the impact of reorganization of primary care in associative forms. Conclusions: the presented methodology can be used to evaluate the real effectiveness of policies aimed at reducing hospitalization for ACSCs.

A pilot survey on the quality of life in respiratory rehabilitation carried out in COPD patients with severe respiratory failure: preliminary data of a novel Inpatient Respiratory Rehabilitation Questionnaire (IRRQ)

BackgroundMeasuring the state of health is a method for quantifying the impact of an illness on the day-to-day life, health and wellbeing of a patient, providing a quantitative measure of an individual’s quality of life (QoL). QoL expresses patient point of view by a subjective dimension and can express the results of medical intervention. Pulmonary rehabilitation is an essential component in the management of COPD patients, and measuring QoL has become a central focus in the study of this disease.Although nowadays several questionnaires for measuring the QoL in COPD patients are available, there are no questionnaires specifically developed for evaluating QoL in COPD patients undergoing respiratory rehabilitation.The aim of this study was to develop a novel questionnaire for the QoL quantification in COPD patients undergoing in-patient pulmonary rehabilitation program.MethodsThe questionnaire, administered to COPD patients undergoing long-term oxygen therapy into a respiratory rehabilitation ward, was developed by a simple and graphic layout to be administered to elderly patients. It included one form for admission and another for discharge. It included only tips related to the subjective components of QoL that would be relevant for patient, although likely not strictly related to the respiratory function.A descriptive analysis was performed for the socio-demographic characteristics and both the non-parametric Wilcoxon T-test and the Cronbach’s alpha index were calculated for evaluating the sensitivity of the questionnaire to the effects of respiratory rehabilitation and for identifying its consistency.ResultsThe physical and psychological condition of the 34 COPD patients improved after the rehabilitative treatment and this finding was detected by the questionnaire (overall improvement: 14.2±2.5%), as confirmed by the non-parametric Wilcoxon test (p<0.01). The consistency detected by the Cronbach’s alpha was good for both the questionnaire at admission and at discharge (0.789±0.084 and 0.784±0.145, respectively), although some items did not adequately measure the intended outcome.ConclusionsThis proposed questionnaire represents a substantial innovation compared to previous methods for evaluating the QoL, since it has been specifically designed for hospitalized COPD patients undergoing respiratory rehabilitation with serious respiratory deficiency, allowing to effectively determining the QoL in these patients.

Prevenire le malattie croniche: sfida del futuro

Prevention of Cronic Diseases: The Challenge of the Future - This article analyzes the trend of mortality and morbidity from chronic disease in the world and in Italy. We used WHO data and Istat (National Institute of statistics) data and survey. The high incidence and prevalence of all chronic diseases, risk factors and long term care were shown through some recent prevision. In last years, these diseases are spread even in the poor countries. The WHO will expect a very high number of deaths by chronic disease: 35 million in 2005. 18 million of death for cardiovascular disease, 8 million for tumour, 4 million for respiratory disease and 1,1 million for diabetes: the majority of deaths will be in low and middle income county. It is very important to invest in prevention of chronic disease: a long term investment and a higher consideration on prevention and chronic care services are the imperatives for the future.