Assessing Value for Money in PFI Projects: A Comparative Study of Practices in the UK and Italy

The Value for Money assessment is a critical process in procuring a Private Finance Initiative and it requires accurate ex-ante performance measurement methodologies. The British Government has set new requirements for evaluating VFM through a new assessment model composed of three main stages, namely: programme level assessment, project level assessment, and procurement level assessment. The objective of the new model for VFM assessment is to change the costly, inflexible and opaque side of PFIs in order to deliver cost-effective and improve the quality of public service provision. A theoretical analysis of the implementation of PFI shows the UK as the leading user of this procurement in Europe and Italy is the second. However, there is a disparity in the manner PFI is actually implemented in these two countries and especially how VFM is assessed. Aiming at underlying the best practices of this evaluation process for the most achievable VFM, this paper presents the new VFM assessment model of the UK and a suggestion for its potential application to the Italian PFI procurement process to improve outcomes therei

Assessing Value for Money in PFI Projects: A Comparative Study of Practices in the UK and Italy

The Value for Money assessment is a critical process in procuring a Private Finance Initiative and it requires accurate ex-ante performance measurement methodologies. The British Government has set new requirements for evaluating VFM through a new assessment model composed of three main stages, namely: programme level assessment, project level assessment, and procurement level assessment. The objective of the new model for VFM assessment is to change the costly, inflexible and opaque side of PFIs in order to deliver cost-effective and improve the quality of public service provision. A theoretical analysis of the implementation of PFI shows the UK as the leading user of this procurement in Europe and Italy is the second. However, there is a disparity in the manner PFI is actually implemented in these two countries and especially how VFM is assessed. Aiming at underlying the best practices of this evaluation process for the most achievable VFM, this paper presents the new VFM assessment model of the UK and a suggestion for its potential application to the Italian PFI procurement process to improve outcomes therein

Consensus paper on the use of BIVA (Bioeletrical Impendance Vector Analysis) in medicine for the management of body hydration

Department of Emergency Medicine, Sapienza University, Post Graduate School in Emergency-Urgency Medicine, Sant'Andrea Hospital, Rome, Italy University of North Dakota School of Medicine and Biomedical Sciences Grand Forks, ND, USA Department of Medicine, University of Padova, Italy Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH, USA Department of Nephrology, Dialysis and Dietology, SM della Misericordia Hospital, Rovigo, Italy Cardiovascular Department, San Filippo Neri Hospital, Rome, Italy Department of Nephrology Dialysis and Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy GREAT: Global Research in Acute Conditions Team Networ

Chronic Systemic Inflammatory Syndrome in patients with AECOPD presenting to Emergency Department

Background: Chronic obstructive pulmonary disease (COPD) is the fourth cause of dead in the world. Because of high incidence of comorbidities in COPD patients, it has been proposed a new hypothesis that inscribe this disease in a complex contest named Chronic Systemic Inflammatory Syndrome (CSIS). Either COPD and the most common comorbidities responsible for its clinical and natural history, like hypertension, diabetes, coronary artery disease, heart failure, recognize a pro-inflammatory state, marked, for example, by elevated C reactive protein (CRP). Methods: 113 consecutive patients presenting to Emergency Department (ED) with acute exacerbated COPD were enrolled. They underwent to full medical history and physical examination. CRP was measured at ED arrival, discharge and at 1-6-12 month follow up. CSIS was diagnosed according to specified criteria. Results: CSIS was diagnosed in 84% patients. CRP was maximally increased at admission during the exacerbation, but didn't correlate with the severity of it. At discharge, CRP values were lowest; during follow up, CRP demonstrated a chaotic behavior growing up till 6 month without any correlation with new exacerbation events. At 1 year it decreased, never reaching normal values in the majority of our patients thus confirming the presence of a persistent inflammation in COPD. Conclusions: CSIS was diagnosed in 84% of our population demonstrating that COPD patients need to be approached in a multidisciplinary way

Chronic inflammatory demyelinating polyneuropathy as a possible novel component of autoimmune poly-endocrine-candidiasis-ectodermal dystrophy.

8We describe two unrelated boys with autoimmune poly-endocrine-candidiasis-ectodermal dystrophy syndrome (APECED) who, in addition to manifesting the most common symptoms (chronic mucocutaneous candidiasis, hypoparathyroidism and Addison's disease), developed progressive muscular weakness in both the proximal and distal limbs, sensory loss and absent tendon reflexes. Electrophysiological studies disclosed a reduction of nerve conduction velocity in both patients that was consistent with the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP).This diagnosis was supported by histological demyelination in nerve biopsy specimens with patchy CD4, CD8 and CD68-positive cell infiltration in the first patient and increased protein content in the cerebrospinal fluid in the second patient. Our cases represent the first report of an association between APECED and CIDP, in which peripheral nerve demyelination may represent a novel disease component in APECED. Our findings highlight the need to explore apparently rare manifestations in patients with APECED.nonenoneValenzise M; Meloni A; Betterle C; Giometto B; Autunno M; Mazzeo A; Cao A; De Luca FValenzise, M; Meloni, A; Betterle, C; Giometto, B; Autunno, M; Mazzeo, A; Cao, A; De Luca,

Chronic migraine in the first COVID-19 lockdown. the impact of sleep, remote working, and other life/psychological changes

Aims: The objective of this study was to evaluate the impact of the first Italian COVID-19 lockdown on patients with chronic migraine (CM). Material and methods: The study was based on an e-mail survey addressed to CM patients of our headache center. The survey evaluated demographic, life style, sleep, psychological, and migraine features during the COVID-19 lockdown period and the month before. The outcomes were migraine impact on daily life and variation in attack frequency, attack duration, migraine pain intensity, migraine symptomatic drugs use per week, and efficacy. Results: Ninety-two patients completed the survey. During the lockdown period, attack frequency was stable in 40,2%, increased in 33,7%, and reduced in 26,1% of patients; attack duration was stable in 55,4%, increased in 23,9%, and reduced in 20,7%. Migraine pain was stable or reduced in 65,2% and increased in 34,8%; number of symptomatic drugs per week was stable in 50%, reduced in 29,3%, and increased in 20,7%; migraine drug efficacy was stable in 73,9%, reduced in 17,4%, and increased in 8,7%. Patients had a HIT-6 score of 64,63 ± 8,81. Significant associations were found with remote working, smoke, education, discontinuation of the therapy performed within headache center, migraine familiarity, sleep, anxiety, perceived stress, concern about future, and COVID-19. Conclusion: During the lockdown, approximately half of the patients had a clinical stability, a quarter an improvement, and another quarter a worsening. We identified different migraine-influencing elements; in particular, the remote working could represent an easy way to ameliorate migraineurs’ life

Identification of the infant-type R631C mutation in patients with the benign muscular form of CPT2 deficiency.

Carnitine palmitoyltransferase 2 (CPT2) deficiency is the most common defect of mitochondrial fatty acid oxidation; three different clinical phenotypes have been described but the adult form, involving exclusively the skeletal muscle, is the most frequent. We describe herein 3 families where 4 individuals manifested with the adult form of CPT2 deficiency. CPT2 gene molecular analysis identified the homozygous R631C mutation, so far only reported in severe infantile cases. Our data evidenced that R631C mutation is not exclusively detected in the infantile form but it may be present in a wider spectrum of CPT2 phenotypes. These findings indirectly suggest that other modulators may influence clinical severity of CPT2 deficiency

ConsensusPaper on the use of BIVA (BioelectricalImpedanceVector Analysis) in medicine for the managment of bodyhydratation.

Hydration status assessment remains a challenge overall in sub- clinical hyper/dehydration status. Biompedance Vector Analysis (BIVA) is a non invasive technique to estimate body mass and water composition by bioelectrical impedance measurements, resistance and reactance. The BIVA method is a unique non invasive technique that allows the combined evaluation of hydration and mass of soft tissues in any clinical condition without knowledge of body weight. This tool can aid physicians to make a fast and correct assessment in facilitating the management of hydration status in critical ill patients in different medicine settings (Cardiology, Nephrology,Gastroenterology, Internal Medicine, Geriatrics and Emergency Medicine). In Nephrology BIVA contribute to the appropriate diuretic prescriptions in chronic kidney diseases and to the identification of the adequate volume of fluid removed during hemodialysis (reducing hypotension and cramp episode, preventing nocturnal pulmonary edema, ameliorating blood pressure control and maintaining an effective diuresis for long time). In heart failure patients the combined use of BIVA, biomarkers and bedside ultrasonography allows to: a faster and more accurate diagnosis, distinguish cardiogenic and non cardiogenic dyspnea, support decisions about diuretic therapy, an accurate risk stratification of patients. Ultrafiltration is increasingly recognized as a crucial area of patients with advanced heart failure and fluid overload. The key management goal is careful monitoring of fluid status with early treatment and application of a systematic approach to managing patient during UF The role of combined technology in assessing. Hydration has to be defined, but BIVA seems to be of potential value for detecting adequately changes in hydration. In critical patients arriving at ED, earlier treatment is associated with decreased mortality .BIVA represents a new technology with the potential to objectively define congestive status in ED patients with AHF Further, it may have utility in identifying patients who require volume overload reduction therapy, as well as serving as an aid to ED disposition. Future studies aimed to better elucidate the role of BIVA in the management of dehydrated patients should be performed to standardize the use of this technique in these critical patients

Noninvasive hemodynamic monitoring in emergency patients with suspected heart failure, sepsis and stroke: the premium registry.

INTRODUCTION: Noninvasive hemodynamic (HD) assessments in the emergency department (ED) might assist in the diagnosis, therapeutic plan development and risk stratification of acutely ill patients. This multinational observational study was designed to initiate noninvasive HD measurements prior to any ED patient therapeutic interventions and broadly evaluate them for potential diagnostic, therapeutic and predictive value. METHODS: We enrolled patients with suspected acute heart failure (AHF), sepsis or stroke. Continuous noninvasive HD monitoring was begun using the Nexfin finger cuff device (Edwards LifeSciences, BMEYE, Amsterdam, Netherlands). Beat-to-beat HD measurements were averaged for the initial 15 minutes, prior to therapeutic intervention. We performed suspected disease group comparisons and evaluated HD predictors of 30-day mortality. RESULTS: Of 510 patients enrolled: 185 (36%) AHF, 194 (38%) sepsis and 131 (26%) stroke. HD variables were significantly different (p<0.05) amongst the groups. Cardiac output and index and stroke volume index (SVI) were highest in sepsis (6.5, 3.5, 36), followed by stroke (5.5, 2.7, 35.8), and lowest in AHF (5.4, 2.7, 33.6). The in-group HD standard deviations and ranges measurements were large, indicating heterogeneous underlying HD profiles. Presenting SVI predicted 30-day mortality for all groups. CONCLUSION: Presenting ED noninvasive HD data has not been previously reported in any large patient population. Our data suggest a potential role for early noninvasive HD assessments aiding in diagnosing of patients, individualizing therapy based on each person's unique HD values and predicting 30-day mortality. Further studies and analyses are needed to determine how HD assessments should be best used in the ED