Effectiveness of different local actions to control vitamin D prescription in Italy

Introduction. In the last decade, the significant expenditure and consumption increase of vitamin D in Italy led some regions to adopt strategies to improve prescribing appropriateness and contain expenditure. Materials and methods. Using the statistical analysis method of interrupted time series for consumption and expenditure of cholecalciferol, different types of interventions adopted in four Italian regions and their efficacy were evaluated. Results. Molise achieved the best results by adopting a health professionals’ education program in addition to a prescriber-sanction system. Emilia-Romagna also opted for a medical education strategy, but the results were less relevant due to the lack of penalties. Lazio obtained a slowdown in consumption growth by targeting on the utilization of lower-cost per defined daily dose (DDD) packs and adopting a therapeutic plan. Sardinia showed a decrease in expenditure by adopting a target threshold of lower-cost  formulation. Conclusion. The reimbursement of the lowest-cost packs within the National Health Service (NHS) undoubtedly influences spending trend, but it does not solve prescriptive  inappropriateness

Palliative care implementation in long-term care facilities : European Association for Palliative Care white paper

Objectives: The number of older people dying in long-term care facilities (LTCFs) is increasing globally, but care quality may be variable. A framework was developed drawing on empirical research findings from the Palliative Care for Older People (PACE) study and a scoping review of literature on the implementation of palliative care interventions in LTCFs. The PACE study mapped palliative care in LTCFs in Europe, evaluated quality of end-of-life care and quality of dying in a cross-sectional study of deceased residents of LTCFs in 6 countries, and undertook a cluster-randomized control trial that evaluated the impact of the PACE Steps to Success intervention in 7 countries. Working with the European Association for Palliative Care, a white paper was written that outlined recommendations for the implementation of interventions to improve palliative and end-of-life care for all older adults with serious illness, regardless of diagnosis, living in LTCFs. The goal of the article is to present these key domains and recommendations. Design: Transparent expert consultation. Setting: International experts in LTCFs. Participants: Eighteen (of 20 invited) international experts from 15 countries participated in a 1-day face-to-face Transparent Expert Consultation (TEC) workshop in Bern, Switzerland, and 21 (of 28 invited) completed a follow-up online survey. Methods: The TEC study used (1) a face-to-face workshop to discuss a scoping review and initial recommendations and (2) an online survey. Results: Thirty recommendations about implementing palliative care for older people in LTCFs were refined during the TEC workshop and, of these, 20 were selected following the survey. These 20 recommendations cover domains at micro (within organizations), meso (across organizations), and macro (at national or regional) levels addressed in 3 phases: establishing conditions for action, embedding in everyday practice, and sustaining ongoing change. Conclusions and implications: We developed a framework of 20 recommendations to guide implementation of improvements in palliative care in LTCFs. (C) 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine

Insight in cognitive impairment assessed with the Cognitive Assessment Interview in a large sample of patients with schizophrenia

The Cognitive Assessment Interview (CAI) is an interview-based scale measuring cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). The present study aimed at assessing, in a large sample of SCZ (n = 601), the agreement between patients and their informants on CAI ratings, to explore patients' insight in their cognitive deficits and its relationships with clinical and functional indices. Agreement between patient- and informant-based ratings was assessed by the Gwet's agreement coefficient. Predictors of insight in cognitive deficits were explored by stepwise multiple regression analyses. Patients reported lower severity of cognitive impairment vs. informants. A substantial to almost perfect agreement was observed between patients' and informants' ratings. Lower insight in cognitive deficits was associated to greater severity of neurocognitive impairment and positive symptoms, lower severity of depressive symptoms, and older age. Worse real-life functioning was associated to lower insight in cognitive deficit, worse neurocognitive performance, and worse functional capacity. Our findings indicate that the CAI is a valid co-primary measure with the interview to patients providing a reliable assessment of their cognitive deficits. In the absence of informants with good knowledge of the subject, the interview to the patient may represent a valid alternative

Does social cognition change? Evidence after 4 years from the Italian Network for Research on Psychoses

Background Deficits in social cognition (SC) are significantly related to community functioning in schizophrenia (SZ). Few studies investigated longitudinal changes in SC and its impact on recovery. In the present study, we aimed: (a) to estimate the magnitude and clinical significance of SC change in outpatients with stable SZ who were assessed at baseline and after 4 years, (b) to identify predictors of reliable and clinically significant change (RCSC), and (c) to determine whether changes in SC over 4 years predicted patient recovery at follow-up. Methods The reliable change index was used to estimate the proportion of true change in SC, not attributable to measurement error. Stepwise multiple logistic regression models were used to identify the predictors of RCSC in a SC domain (The Awareness of Social Inference Test [TASIT]) and the effect of change in TASIT on recovery at follow-up. Results In 548 participants, statistically significant improvements were found for the simple and paradoxical sarcasm of TASIT scale, and for the total score of section 2. The reliable change index was 9.8. A cut-off of 45 identified patients showing clinically significant change. Reliable change was achieved by 12.6% and RCSC by 8% of participants. Lower baseline TASIT sect. 2 score predicted reliable improvement on TASIT sect. 2. Improvement in TASIT sect. 2 scores predicted functional recovery, with a 10-point change predicting 40% increase in the probability of recovery. Conclusions The RCSC index provides a conservative way to assess the improvement in the ability to grasp sarcasm in SZ, and is associated with recovery

Inappropriate prescription of low molecular weight heparins for thromboprophylaxis among older hospitalized patients

Aim: To investigate the prevalence and clinical correlates of overprescribing and underprescribing of low molecular weight heparins (LMWHs) for thromboprophylaxis among older medical inpatients. Methods: Eight hundred seventy six patients (mean age 81.5 ± 7.6 years, female gender 57.2 %) enrolled in a multicenter observational study of seven acute care wards of geriatric medicine in Italy. The risk of venous thromboembolism was ascertained by calculating the Padua score for each patient. Patients receiving appropriate prescription of LMHW during stay were compared to those receiving LMHW with a Padua score <4 (overprescribing group). Similarly, patients with a high thromboembolic risk (Padua score ≥4) but not receiving LMHW (underprescribing group) were compared to patients appropriately not receiving LMHW during stay. Independent correlates of overprescribing and underprescribing were investigated by logistic regression analysis. Results: Overall, 42.8 % of patients had a Padua score ≥4. LMWHs were overprescribed in 7.3 % and underprescribed in 25.2 % of patients. The number of lost basic activities of daily living (BADL) (OR = 0.25; 95 % CI 0.15–0.41) and the number of diagnoses (OR = 0.76; 95 % CI 0.61–0.95) were inversely associated with LMWH overprescription. Conversely, older age (75–84 years: OR = 2.39; 95 % CI 1.10–5.19—85 years or more: OR = 3.25, 95 % CI 1.40–7.61), anemia (OR = 1.80, 95 % CI 1.05–3.16), pressure sores (OR = 4.15, 95 % CI 1.20–14.3), number of lost BADL at the admission (OR = 3.92, 95 % CI 2.86–5.37) and number of diagnoses (OR = 1.29, 95 % CI 1.15–1.44) qualified as significant correlates of LMWH underprescription. Discussion: Underprescription and, to a lesser extent, overprescription still represent an issue among older medical inpatients. Conclusion: Implementing risk-stratifying scores into clinical practice may improve appropriateness of LMWHs prescribing during hospitalization

Impulsive thrust collision avoidance for long-term space encounters

International audienceThis paper investigates how chance-constrained optimization techniques can be applied to the problem of collision avoidance between an active satellite and a passive space debris. The goal is to minimize the fuel consumption needed to perform evasive maneuvers reducing the collision probability below a given threshold. Specifically, we focus on the long-term collision avoidance problem and we propose two different methods, i.e., a scenario approach and a novel direct convex relaxation approach, to optimize the avoidance maneuvers while enforcing constraints on the cumulative probability of collision. The performances of these approaches are compared with a risk-selection method, and the results highlight that the direct approach is competitive with the existing methods for long-term encounters while the scenario-based method is promising for future applications in the field of spacecraft collision avoidance

Time to face the challenge of multimorbidity. A European perspective from the joint action on chronic diseases and promoting healthy ageing across the life cycle (JA-CHRODIS)

Research on multimorbidity has rapidly increased in the last decade, but evidence on the effectiveness of interventions to improve outcomes in patients with multimorbidity is limited. The European Commission is co-funding a large collaborative project named Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) in the context of the 2nd EU Health Programme 2008-2013. The present manuscript summarizes first results of the JA-CHRODIS, focuses on the identification of a population with multimorbidity who has a high or very high care demand. Identification of characteristics of multimorbid patients associated with a high rate of resource consumption and negative health outcomes is necessary to define a target population who can benefit from interventions. Indeed, multimorbidity alone cannot explain the complexity of care needs and further, stratification of the general population based on care needs is necessary for allocating resources and developing personalized, cost-efficient, and patient-centered care plans. Based on analyses of large databases from European countries a profile of the most care-demanding patients with multimorbidity is defined. Several factors associated with adverse health outcomes and resource consumption among patients with multimorbidity were identified in these analyses, including disease patterns, physical function, mental health, and socioeconomic status. These results underline that a global assessment is needed to identify patients with multimorbidity who are at risk of negative health outcomes and that a comprehensive approach, targeting not only diseases, but also social, cognitive, and functional problems should be adopted for these patients

Characterizing cognitive inhibitory deficits in mild cognitive impairment

Individuals with mild cognitive impairment -MCI- show relative weaknesses in executive functioning (EF), as well as poor memory, but the inhibition-related mechanisms behind EF impairment in MCI have not been examined systematically. The aim of the present study was to systematically investigate inhibitory function in individuals with MCI to ascertain whether pathological aging is characterized by deficits in inhibitory processes and whether such impairment is confined to specific inhibition-related mechanisms. Tasks assessing inhibition-related functions – i.e. prepotent response inhibition (measured with the Color Stroop test), response to distracters (assessed using a text with distracters task), and resistance to proactive interference (assessed with a proactive interference task) – were administered to individuals with MCI and to healthy older controls. Individuals with MCI made more intrusion errors in the proactive interference task than controls, while the two groups’ performance was comparable in prepotent response inhibition and response to distracters. This pattern of findings suggests that MCI is associated with specific inhibition problems

Characterizing cognitive inhibitory deficits in mild cognitive impairment

Individuals with mild cognitive impairment -MCI- show relative weaknesses in executive functioning (EF), as well as poor memory, but the inhibition-related mechanisms behind EF impairment in MCI have not been examined systematically. The aim of the present study was to systematically investigate inhibitory function in individuals with MCI to ascertain whether pathological aging is characterized by deficits in inhibitory processes and whether such impairment is confined to specific inhibition-related mechanisms. Tasks assessing inhibition-related functions - i.e. prepotent response inhibition (measured with the Color Stroop test), response to distracters (assessed using a text with distracters task), and resistance to proactive interference (assessed with a proactive interference task) - were administered to individuals with MCI and to healthy older controls. Individuals with MCI made more intrusion errors in the proactive interference task than controls, while the two groups' performance was comparable in prepotent response inhibition and response to distracters. This pattern of findings suggests that MCI is associated with specific inhibition problem

Insulin-like growth factor-1 and anemia in older subjects: The inchianti study

Recent studies indicate a role for the age-related decline of anabolic hormones, especially testosterone, in the onset of "anemia of aging." Some of testosterone's erythropoietic activities are mediated by insulin-like growth factor (IGF)-1, which also seems to have independent erythropoietic effects. However, the associations among IGF-1, anemia, and hemoglobin (Hb) have not been adequately investigated in older populations. METHODS:We used data from a representative sample of 953 subjects ≥65 years who participated in the InCHIANTI (Invecchiare in Chianti) Study and were not on growth hormone (GH) or erythropoietin therapy and were not diagnosed with hematologic malignancies or other cancers. Anemia was defined according to the World Health Organization (WHO) criteria by Hb level ≤13 g/dL in males and ≤12 g/dL in females. Backward multiple regression analyses including age, IGF binding protein (IGFBP)-3, testosterone, comorbidities, inflammatory markers, and anemia-related measures were used to address the relationship between IGF-1 and Hb and between IGF-1 and anemia in both sexes. RESULTS:We found that 46/410 (11.2%) males and 71/543 (13.0%) females were defined as anemic. After adjustment for age, anemic males (100 ± 54 vs. 130 ± 56, P<.001) and females (89.1 ± 48 vs. 110 ± 52, P = .001) exhibited lower IGF-1 levels than their nonanemic counterparts. IGF-1 levels were independently and negatively associated with anemia in males (β ± SE = -0.0005 ± 0.0002, P = .04) but not in females (β ± SE = -0.0002 ± 0.0002, P = .40). In both males (β ± SE = 0.002 ± 0.001, P = .03) and females (β ± SE = 0.002 ± 0.0009, P = .03), IGF-1 levels were independently and positively associated with Hb levels. CONCLUSION:In older males but not in females, IGF-1 levels are negatively associated with anemia. IGF-1 levels are independent and positive determinants of Hb concentration in both sexes