Rossella Miglio

Heterogeneity and symptom structure of schizophrenia

Previous studies failed to identify a consistent factor structure of the BPRS-24 in schizophrenia. Our aims were to examine the fit of all previously published factor models and then to explore unobserved population heterogeneity and identify salient latent classes. Two hundred thirty-nine patients with ICD-10 schizophrenia admitted to a random sample of all Italian public and private acute inpatient units during an index period were administered the BPRS-24. Confirmatory factor analysis (CFA) was used to test all factor models derived in previous studies. Then, factor mixture analysis (FMA) with heteroscedastic components was carried out to explore unobserved population heterogeneity. No previously reported factor solution showed adequate fit in CFA. FMA indicated the presence of three heterogeneous groups and yielded a 5-factor solution (Depression, Positive Symptoms, Disorganization, Negative Symptoms, Activation). Group 1 was characterized by higher Disorganization, lower Activation, lower psychosocial functioning, greater lifetime number of admissions, more frequent history of compulsory admission. Group 2 displayed lower Disorganization. Group 3 showed higher Activation and more frequent history of recent self-harming behavior. Our finding that a reliable factor structure for the BPRS-24 could be obtained only after assuming population heterogeneity suggests that the difficulty in identifying a consistent factor structure may be ascribed to the clinical heterogeneity of schizophrenia. As compared with clinical subtypes, the psychopathological dimensions displayed much greater discriminatory power between groups identified by FMA. Though preliminary, our findings corroborate that a dimensional approach to psychopathology can facilitate the assessment of the clinical heterogeneity of schizophrenia.

Emergency ambulance dispatches and apparent temperature: A time series analysis in Emilia-Romagna, Italy

INTRODUCTIONnIncreases in mortality associated with oppressive weather have been widely investigated in several epidemiological studies. However, to properly understand the full public health significance of heat-related health effects, as well as to develop an effective surveillance system, it is also important to investigate the impact of stressful meteorological conditions on non-fatal events. The objective of our study was to evaluate the exposure-response relationship of ambulance dispatch data in association with biometeorological conditions using time series techniques similar to those used in previous studies on mortality.nnnMETHODSnDaily data of emergency ambulance dispatches for people aged 35 or older in the summer periods from 2002 to 2006 were collected for the major towns in the Emilia-Romagna region. In the first stage of the analysis, the city-specific relationship between daily ambulance dispatches and increasing apparent temperature was explored using Generalized Additive Models while controlling for air pollution, seasonality, long-term trend, holidays and weekends. The relationship between ambulance dispatches and apparent temperature was approximated by linear splines. The effects of high temperatures on health were evaluated for respiratory and cardiovascular diseases as well as for all non-traumatic conditions. In the second stage of the analysis, city-specific effects were combined in fixed or random effect meta-analyses.nnnRESULTSnThe percent change in the ambulance dispatches associated with every 1 °C increase in the mean apparent temperature between 25 and 30 °C was 1.45% (95% confidence interval: 0.95, 1.95) for non-traumatic diseases and 2.74% (95% CI: 1.34, 4.14) for respiratory diseases. The percent increase in risk was greater on days in which the mean apparent temperature exceeded 30 °C (8.85%, 95% CI: 7.12, 10.58 for non-traumatic diseases). In this interval of biometeorological conditions, cardiovascular diseases became positively associated with the apparent temperature. The risks increased with age. The increase in risk for the non-traumatic diseases reached 13.34% for people aged 75 or older compared to 4.75% for those aged 35-64.nnnCONCLUSIONnTime series analysis techniques were adopted for the first time to investigate emergency ambulance dispatches to evaluate the risks associated with biometeorological discomfort. Our findings show a strong relationship between biometeorological conditions and ambulance dispatches.

Clinical outcomes following stent placement in refractory benign esophageal stricture: a systematic review and meta-analysis

BACKGROUND AND AIMSnThe management of refractory benign esophageal strictures (RBESs) is challenging. Stent placement has been proposed as a possible rescue strategy. We performed a systematic review and meta-analysis to examine the efficacy of this strategy in the long-term resolution of dysphagia.nnnMETHODSnPubMed, SCOPUS, and Google Scholar were searched (up to January 2015). Studies recruiting adults with RBES treated with stent placement were eligible. The success, adverse event, and migration rates were pooled by means of a random-effect model to obtain odds with a 95u200a% confidence interval (CI).nnnRESULTSnEighteen studies (444 patients) were eligible for inclusion. The pooled clinical success rate was 40.5u200a% (95u200a%CI 31.5u200a%u200a-u200a49.5u200a%), yielding odds of 0.68 (95u200a%CI 0.46u200a-u200a0.98) with high heterogeneity (I(2)u200a=u200a65.0u200a%). The meta-regression analysis showed stricture etiology as the only influencing factor. Treatment with self-expanding plastic (SEPSs) and metal stents (SEMSs) did not result in significantly higher success rates than treatment with biodegradable stents (BDSs) (46.2u200a% vs. 40.1u200a% vs. 32.9u200a%, respectively). The migration rate was 28.6u200a% (95u200a%CI 21.9u200a%u200a-u200a37.1u200a%), yielding odds of 0.40 (95u200a%CI 0.28u200a-u200a0.59), with migration rates for SEPSs and SEMSs reported as being not significantly higher than BDSs (33.3u200a% vs. 31.5u200a% vs. 15.3u200a%, respectively). The adverse event rate was 20.6u200a% (95u200a%CI 15.3u200a%u200a-u200a28.1u200a%), yielding odds of 0.26 (95u200a%CI 0.18u200a-u200a0.39) with no significant difference between stent types (19.4u200a% vs. 21.9u200a% vs. 21.9u200a%, respectively).nnnCONCLUSIONSnStent placement in patients with RBES is effective in about 40u200a% of cases. Further studies should investigate whether the clinical success rate varies according to the stricture etiology.(PROSPERO registration number: CRD42015019017.).

Does the longevity of one or both parents influence the health status of their offspring

According to the findings of some recent studies, the centenarians offspring appear to represent a promising model for research on longevity and healthy aging. This study compares the health status and the functional status of three groups of subjects: 1. individuals with two long-lived parents (one of whom centenarian), 2. individuals with only one long-lived (centenarian) parent, and 3. individuals with no long-lived parents. The goal is to verify whether the centenarians offspring display any advantage over the offspring of both non-long-lived parents and to evaluate whether the longevity of the non-centenarian parent provides a further advantage. A total of 374 subjects (mean age approximately 70 years) was examined. A threshold for longevity was established for non-centenarian parents through demographic data available for Italy (males surviving to at least 81 years of age and females to 87 years). The participants were assessed for their health and functional status by means of a standardized questionnaire and tests of physical performance. Data were analyzed using multivariate regression models adjusted for socio-demographic characteristics and risk factors for age-related pathologies. The results of the study show that centenarians offspring have a better functional status, a reduced risk for several age-related pathologies and reduced drug consumption than the offspring of non-long-lived parents. In addition, the health status of centenarians offspring does not appear to be influenced by the longevity of the second parent. It therefore seems possible to conclude that at ages around 70 years the genetic contribution to health status deriving from having one centenarian parent is not substantially improved if the other parent is also long-lived.

Attachment style and immunity: A 1-year longitudinal study

Previous cross-sectional studies suggested an association between attachment-related avoidance and altered immune function. We aimed at testing this hypothesis with longitudinal data. A random sample of 65 female nurses provided a blood sample and completed measures of perceived stress, social support, alexithymia, and attachment style. Immune assays included lymphocyte proliferative response (LPR) to Phytohemagglutinin and NK cell cytotoxicity (NKCC). State measures (perceived stress and support) and immune measures were collected again after 4, 8, and 12 months. Linear mixed effects models were used to examine the relationship between attachment and immunity. While low to moderate levels of attachment-related avoidance were not associated with NKCC, there was a significant negative association (beta -.35; p=.005) between high levels of avoidance and NKCC. No association was observed between NKCC and attachment-related anxiety, and between LPR and both attachment dimensions. While our findings should be interpreted with caution due to study limitations such as the relatively small sample size and the inclusion of only female participants, they corroborate the notion that attachment is linked to physiology and health.

Coronary revascularisation in stable patients after an acute coronary syndrome: a propensity analysis of early invasive versus conservative management in a register-based cohort study

Objectives To compare the effectiveness of in-hospital medical therapy versus coronary revascularisation added to medical therapy in patients who stabilised after an acute coronary syndrome (ACS). Design Propensity score-matched cohort study from the database of the Tampere ACS registry. Setting A single academic hospital in Finland. Participants 1149 patients with a recent ACS, but no serious coexisting conditions: recurrent ischaemic episodes despite adequate medical therapy, haemodynamic instability, overt congestive heart failure and serious ventricular arrhythmias. Primary and secondary outcome measures The composite endpoint of major acute cardiovascular events (MACEs): unstable angina requiring rehospitalisation, stroke, myocardial infarction and all-cause mortality, at 6-month follow-up. Results Compared with standard medical treatment, revascularisation was associated with a lower rate of MACEs at 6u2005months in patients of the first quintile (HR 0.81; 95% CI 0.66 to 0.99), but a higher rate of MACEs in the fifth quintile (HR 4.74, CI 1.36 to 16.49; p=0.014). There were no significant differences in the rates of MACEs in the remaining three quintiles. Patients of the first quintile were the oldest (79.7±8.3u2005years) and had a more significant (p<0.001) history of prior myocardial infarction (37%) and poor renal function (creatine, µmol/l: 114.9±70.7). They also showed the highest C reactive protein (7.3±9.5u2005mg/l) levels. Conclusions Our findings suggest that in-hospital coronary revascularisation did not lead to any advantage with signal of possible harm in the great majority of patients who stabilised after an ACS. An early invasive management strategy may be best reserved for elderly patients having high-risk clinical features and biochemical evidence of a strong inflammatory activity.

Unbiased pro-thrombotic features at diagnosis in 977 thrombocythemic patients with Philadelphia-negative chronic myeloproliferative neoplasms

In patients with Philadelphia-negative chronic myeloproliferative neoplasms (MPNs), the anti-thrombotic and/or cytoreductive treatment in the follow-up may affect the evaluation of the pro-thrombotic weight of the clinical and biological characteristics at diagnosis. In order to avoid this potential confounding effect, we investigated the relationship between prior thrombosis (PrTh: thrombosis occurred before diagnosis and before treatment) and the characteristics at diagnosis in 977 thrombocythemic patients with MPN, reclassified according to the WHO 2008 criteria. PrTh occurred in 194 (19.9%) patients, with similar rates in the different MPNs. In multivariate analysis, PrTh rate was significantly related to minor thrombocytosis (platelets ≤700×10(9)/L), leukocytosis (leukocytesu2009>10×10(9)/L), higher hematocrit (HCTu2009>45%), JAK2 V617F mutation, older age, and cardiovascular risk factors (CVRFs). The highest PrTh rate (33.9%) was associated with the coexistence of minor thrombocytosis and leukocytosis. Of note, the inverse relationship between PrTh rate and platelet count is consistent with the hemostatic paradox of thrombocytosis. In conclusion, this analysis in MPN patients disclosed the unbiased characteristics at diagnosis with a pro-thrombotic effect. Moreover, it suggests that the optimal control of blood cells counts, and CVRFs might be of utmost importance in the prevention of thrombosis during the follow-up.

Arm measurements as determinants of further survival in centenarians

Being indicators of nutritional and functional status, anthropometric characters may have great prognostic significance for survival at extremely advanced ages. For ethical and practical reasons however it is advisable to use characters such as arm measurements easily measurable even in bedridden subjects. This study compares the influence of some upper arm measurements and of Body Mass Index (BMI) on survival of the 77 subjects aged 98 years and over (98+) recruited within the MALVA project, one of the first Italian population-based studies on extremely old people. Adopting methods for multiple imputation of missing values, Gompertz regression models adjusted for gender and age were estimated for each anthropometric character or combination of characters, i.e. BMI; mid-upper arm circumference (MUAC)+elbow breadth (EB)+triceps skinfold thickness (TSF); corrected arm muscle area (CAMA). Being underweight and having a low CAMA and a low MUAC/high EB were positively associated with an increased risk of death, while no significant association was found with the condition of being overweight/obese and the triceps skinfold thickness. When anthropometric variables were included in regression models along with covariates relating to nutritional and functional status, BMI and MUAC, but not CAMA, emerged as protective factors. It is suggested that MUAC can be recommended in evaluating the health status of extremely old people and that measuring EB may help to estimate the non-boney component of the arm.

A randomised controlled trial of the effectiveness of a program for early detection and treatment of depression in primary care

OBJECTIVEnThere is considerable uncertainty about whether depression screening programs in primary care may improve outcomes and what specific features of such programs may contribute to success. We tested the effectiveness of a program involving substantial commitment from local mental health services.nnnMETHODSnProspective, randomised, patient- and evaluator-masked, parallel-group, controlled study. Participants were recruited in several urban primary care practices where they completed the PC-SAD screener and WHOQOL-Bref. Those who screened positive and did not report suicidal ideation (N=115) were randomised to an intervention group (communication of the result and offer of psychiatric evaluation and treatment free of charge; N=56) or a control group (no feedback on test result for 3 months; N=59). After 3 months, 100 patients agreed to a follow-up telephone interview including the administration of the PC-SAD5 and WHOQOL-Bref.nnnRESULTSnDepression severity and quality of life improved significantly in both groups. Intent-to-treat analysis showed no effect of the intervention. As only 37% of patients randomised to the intervention group actually contacted the study outpatient clinic, we performed a per-protocol analysis to determine whether the intervention, if delivered as planned, had been effective. This analysis revealed a significant positive effect of the intervention on severity of depressive symptoms, and on response and remission rate. Complier average causal effect analysis yielded similar results.nnnCONCLUSIONnDue to the relatively small sample size, our findings should be regarded as preliminary and have limited generalizability. They suggest that there are considerable barriers on the part of many patients to the implementation of depression screening programs in primary care. While such programs can be effective, they should be designed based on the understanding of patients perspectives.

Prognostic impact of macrometastasis linear size in sentinel node biopsy for breast carcinoma

AIMnThe aim of the present study was to evaluate the risk of axillary non-sentinel lymph-node metastases (ALN) in breast cancer patients presenting macrometastasis (Mac-m) in the sentinel lymph node (SN).nnnMATERIALS AND METHODSnA retrospective series of 1464 breast cancers from patients who underwent ALN dissection following the diagnosis of Mac-m in the sentinel node (SN) was studied. In all the cases the MAC-m linear size was evaluated and correlated with presence or absence of non-SN ALN metastases.nnnRESULTSnNon-SN metastases were detected in 644∖1464 cases (43.98%). The risk of further axillary metastases ranged from 20.2% (37/183) in cases with Mac-m between 2 and 2.9xa0mm, to 65.3% (262/401) in cases with Mac-m measuringxa0>xa010xa0mm. The risk of non-SN ALN metastases showed a 3% increase, parallel to each mm increment in SN metastasis size. The data evaluated with the receiver operating characteristic (ROC) curve showed that the Mac-m could be subdivided according to a new cut-off of 7xa0mm. pT1 tumours, with Mac-m < 7xa0mm had a risk of non-SN ALN metastases of <30%. Furthermore 109/127 of these (85.8%) had 3 or less non-SN ALN -metastases.nnnCONCLUSIONSnThe present data give a detailed description on the risk of non-SN ALN involvement, that may be useful in the evaluation of breast cancer patients. It is suggested that a Mac-m size of <7xa0mm is related to a low residual axillary disease burden in breast cancer patients with small (pT1) tumours.