Integration between Primary Care and Mental Health Services in Italy: Determinants of Referral and Stepped Care

This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007–December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care

Probing the influence of citrate-capped gold nanoparticles on an amyloidogenic protein

Nanoparticles (NPs) are known to exhibit distinct physical and chemical properties compared with the same materials in bulk form. NPs have been repeatedly reported to interact with proteins, and this interaction can be exploited to affect processes undergone by proteins, such as fibrillogenesis. Fibrillation is common to many proteins, and in living organisms, it causes tissue-specific or systemic amyloid diseases. The nature of NPs and their surface chemistry is crucial in assessing their affinity for proteins and their effects on them. Here we present the first detailed structural characterization and molecular mechanics model of the interaction between a fibrillogenic protein, \u3b22-microglobulin, and a NP, 5 nm hydrophilic citrate-capped gold nanoparticles. NMR measurements and simulations at multiple levels (enhanced sampling molecular dynamics, Brownian dynamics, and Poisson-Boltzmann electrostatics) explain the origin of the observed protein perturbations mostly localized at the amino-terminal region. Experiments show that the protein-NP interaction is weak in the physiological-like, conditions and do not induce protein fibrillation. Simulations reproduce these findings and reveal instead the role of the citrate in destabilizing the lower pH protonated form of \u3b22-microglobulin. The results offer possible strategies for controlling the desired effect of NPs on the conformational changes of the proteins, which have significant roles in the fibrillation process

Platelet Function Testing in Patients with Acute Ischemic Stroke: An Observational Study

Background: The measurement of platelet reactivity in patients with stroke undergoing antiplatelet therapies is not commonly performed in clinical practice. We assessed the prevalence of therapy responsiveness in patients with stroke and further investigated differences between patients on prevention therapy at stroke onset and patients naive to antiplatelet medications. We also sought differences in responsiveness between etiological subtypes and correlations between Clopidogrel responsiveness and genetic polymorphisms. Methods: A total of 624 stroke patients on antiplatelet therapy were included. Two different groups were identified: "non-naive patients", and "naive patients". Platelet function was measured with multiple electrode aggregometry, and genotyping assays were used to determine CYP2C19 polymorphisms. Results: Aspirin (ASA) responsiveness was significantly more frequent in naive patients compared with non-naive patients (94.9% versus 82.6%, P < .0010). A better responsiveness to ASA compared with Clopidogrel or combination therapy was found in the entire population (P < .0010), in non-naive patients (P < .0253), and in naive patients (P < .0010). Multivariate analysis revealed a strong effect of Clopidogrel as a possible "risk factor" for unresponsiveness (odds ratio 3.652, P < .0001). No difference between etiological subgroups and no correlations between responsiveness and CYP2C19 polymorphisms were found. Conclusion: In our opinion, platelet function testing could be potentially useful in monitoring the biological effect of antiplatelet agents. A substantial proportion of patients with stroke on ASA were "resistant", and the treatment with Clopidogrel was accompanied by even higher rates of unresponsiveness. Longitudinal studies are needed to assess whether aggregometry might supply individualized prognostic information and whether it can be considered a valid tool for future prevention strategies

Survival Risk Scores for Real-Life Relapsed/Refractory Multiple Myeloma Patients Receiving Elotuzumab or Carfilzomib In Combination With Lenalidomide and Dexamethasone as Salvage Therapy: Analysis of 919 Cases Outside Clinical Trials

The present study aimed to develop two survival risk scores (RS) for overall survival (OS, SRSKRd/EloRd) and progression-free survival (PFS, PRSKRd/EloRd) in 919 relapsed/refractory multiple myeloma (RRMM) patients who received carfilzomib, lenalidomide, and dexamethasone (KRd)/elotuzumab, lenalidomide, and dexamethasone (EloRd). The median OS was 35.4 months, with no significant difference between the KRd arm versus the EloRd arm. In the multivariate analysis, advanced ISS (HR = 1.31; P = 0.025), interval diagnosis–therapy (HR = 1.46; P = 0.001), number of previous lines of therapies (HR = 1.96; P &lt; 0.0001), older age (HR = 1.72; P &lt; 0.0001), and prior lenalidomide exposure (HR = 1.30; P = 0.026) remained independently associated with death. The median PFS was 20.3 months, with no difference between the two strategies. The multivariate model identified a significant progression/death risk increase for ISS III (HR = 1.37; P = 0.002), &gt;3 previous lines of therapies (HR = 1.67; P &lt; 0.0001), older age (HR = 1.64; P &lt; 0.0001), and prior lenalidomide exposure (HR = 1.35; P = 0.003). Three risk SRSKRd/EloRd categories were generated: low-risk (134 cases, 16.5%), intermediate-risk (467 cases, 57.3%), and high-risk categories (213 cases, 26.2%). The 1- and 2-year OS probability rates were 92.3% and 83.8% for the low-risk (HR = 1, reference category), 81.1% and 60.6% (HR = 2.73; P &lt; 0.0001) for the intermediate-risk, and 65.5% and 42.5% (HR = 4.91; P &lt; 0.0001) for the high-risk groups, respectively. Notably, unlike the low-risk group, which did not cross the median timeline, the OS median values were 36.6 and 18.6 months for the intermediate- and high-risk cases, respectively. Similarly, three PRSKRd/EloRd risk categories were engendered. Based on such grouping, 338 (41.5%) cases were allocated in the low-, 248 (30.5%) in the intermediate-, and 228 (28.0%) in the high-risk groups. The 1- and 2-year PFS probability rates were 71.4% and 54.5% for the low-risk (HR = 1, reference category), 68.9% and 43.7% (HR = 1.95; P &lt; 0.0001) for the intermediate-risk, and 48.0% and 27.1% (HR = 3.73; P &lt; 0.0001) for the high-risk groups, respectively. The PFS median values were 29.0, 21.0, and 11.7 months for the low-, intermediate-, and high-risk cases. This analysis showed 2.7- and 4.9-fold increased risk of death for the intermediate- and high-risk cases treated with KRd/EloRd as salvage therapy. The combined progression/death risks of the two categories were increased 1.3- and 2.2-fold compared to the low-risk group. In conclusion, SRSKRd/EloRd and PRSKRd/EloRd may represent accessible and globally applicable models in daily clinical practice and ultimately represent a prognostic tool for RRMM patients who received KRd or EloRd

Process and outcome indicators for mental health services in Emilia Romagna Region

In Italia, il processo di de-istituzionalizzazione e di implementazione di modelli di assistenza per la salute mentale sono caratterizzati da carenza di valutazione. In particolare, non sono state intraprese iniziative per monitorare le attività relative all’assistenza dei pazienti con disturbi psichiatrici. Pertanto, l’obiettivo della tesi è effettuare una valutazione comparativa dei percorsi di cura nell’ambito della salute mentale nei Dipartimenti di Salute Mentale e Dipendenze Patologiche della regione Emilia-Romagna utilizzando indicatori ottenuti dai flussi amministrativi correnti.. I dati necessari alla costruzione degli indicatori sono stati ottenuti attraverso un data linkage dei flussi amministrativi correnti regionali delle schede di dimissione ospedaliera, delle attività territoriali dei Centri di Salute Mentale e delle prescrizioni farmaceutiche, con riferimento all’anno 2010. Gli indicatori sono stati predisposti per tutti i pazienti con diagnosi principale psichiatrica e poi suddivisi per categoria diagnostica in base al ICD9-CM. . Il set di indicatori esaminato comprende i tassi di prevalenza trattata e di incidenza dei disturbi mentali, i tassi di ospedalizzazione, la ri-ospedalizzazione a 7 e 30 giorni dalla dimissione dai reparti psichiatrici, la continuità assistenziale ospedale-territorio, l’adesione ai trattamenti ed il consumo e appropriatezza prescrittiva di farmaci. Sono state rilevate alcune problematiche nella ricostruzione della continuità assistenziale ospedale-territorio ed alcuni limiti degli indicatori relativi alle prescrizioni dei farmaci. Il calcolo degli indicatori basato sui flussi amministrativi correnti si presenta fattibile, pur con i limiti legati alla qualità, completezza ed accuratezza dei dati presenti. L’implementazione di questi indicatori su larga scala (regionale e nazionale) e su base regolare può essere una opportunità per impostare un sistema di sorveglianza, monitoraggio e valutazione dell’assistenza psichiatrica nei DSM.In Italy, the process of de-institutionalisation and implementation of a community-based model in mental health care has been characterized by a lack of evaluation. In particular, no activity is or has been in place to develop or maintain standards of quality of care. Aim of this dissertation is to compare the care pathways in mental health services in Emilia Romagna Region using process and outcome indicator obtained from administrative databases. Process and outcome indicators of mental health care for Local Health Authorities of Emilia-Romagna Region (3,724,388 adult inhabitants in 2010) were obtained through linkage of hospital discharge records, community mental health service database and drug prescription database. The study cohorts include patients with a primary ICD-9-CM diagnosis code 290.xx-319 hospitalized or treated in community mental health services in 2010. The set of indicators explores treated prevalence and incidence rates by disorders and settings, continuity between hospital and community care, retention in treatment, re-hospitalizations, antidepressant drug and mood stabilizer prescriptions. Hospitalization rates varied from 159,0 to 290,3 per 100.000 inhabitants. Treated prevalence in the study area was 15‰ and incidence was 6‰. Of the patients treated by community mental health services, about 37% had a severe mental illness. The proportion of patients re-hospitalized within 30 days from discharge was 12%. Less than 6% of patients with severe mental illness discontinued treatment with community mental health services. Calculation of the selected indicators proved to be feasible, conditional on quality checks for completeness and accuracy of the primary diagnosis. Implementation of these indicators on a larger scale and on a regular basis may provide a unique opportunity to set up a mental health surveillance system and monitor treated prevalence and incidence of mental disorders as well as continuity of care and treatment outcomes at the patient level

Crisi economica e salute mentale: analisi multi-livello nella provincia di Modena

La grande recessione ha causato costi tangibili in termini di tagli nell\u2019occupazione e nella riduzione del reddito nei Paesi Europei. L\u2019incertezza derivante dalla perdita del lavoro e l\u2019espandersi di condizioni lavorative precarie sono state gi\ue0 da tempo individuate come determinanti di una precaria salute mentale. Questo studio utilizza dati sanitari per evidenziare come con la crisi economica si sia osservato un peggioramento significativo del benessere psicologico e un aumento del ricorso agli antidepressivi nella Provincia di Modena, con effetti pi\uf9 accentuati nelle zone interessate dal terremoto. La ricerca effettuata conferma un effetto negativo sulla salute mentale: le difficolt\ue0 finanziarie, la disoccupazione e l\u2019indebitamento sono associate ad ansia e depressione e, pi\uf9 specificatamente, a \u201cdepressione motivata\u201d. Nella Provincia di Modena, caratterizzata generalmente da elevati standard sociali ed economici, la prolungata crisi economica ha avuto un impatto maggiore, ampliato ulteriormente nelle zone che hanno anche dovuto affrontare l\u2019evento traumatico del terremoto del 2012. Dalla ricerca per\uf2 non emergono solo dati negativi. Lo studio evidenzia infatti in modo altrettanto chiaro l\u2019efficacia (valutata in termini di riduzione del numero e della durata dei ricoveri) dei programmi di inclusione e coinvolgimento in politiche attive del lavoro anche in chi soffre di disturbi psichiatrici gravi

Variables related to the bed-blocker phenomenon in an acute psychiatric ward

Background The term “bed-blockers” was created in the 70s to indicate those patients who, after completing diagnostic tests and therapeutic treatment, continued to occupy hospital beds unnecessarily . Due to economic reasons, this phenomenon has been increasingly investigated, but few studies evaluated it in psychiatric wards. Aims To assess the frequency of psychiatric long-term hospitalizations and related variables. Methods From database of an acute psychiatric ward (SPDC-Modena), all hospitalizations from 1-1-2005 to 31-12-2010, with duration the 90th percentile (28 days) were selected. Frequency, psychiatric diagnosis and comorbidities of this sample (n=345) were compared with those of all other admissions in the same period (chi square test). The sample was divided into two subgroups, according to the median duration of hospitalization: A (245 hospitalizations up to 46 days) and B (100 hospitalizations exceeding 46 days). Demographic data (age, gender, nationality), clinical variables (psychiatric and organic diagnosis, according to ICD-9-CM, VGF and CGI-I scores at the discharge, pharmacotherapy), inpatient care problems (extra-psychiatric clinical activities, aggressiveness with and without restraint, activation of residential care services) and discharge needs (protected structure, nursing home, new hospitalization, home care, economic support, etc.) of A group were compared to B group ones (univariate and multivariate logistic regression). Results The 345 hospitalizations represented 8% of all psychiatric hospitalizations and differed from others due to higher frequency, statistically significant, of both “schizophrenia and other psychotic disorders” and associated organic comorbidities. The variables statistically significantly related to the length of hospitalization were: “inpatient and outpatient care network” as protective factor, “aggressiveness with restraint” and “non psychiatric clinical activities” as risk factors. Conclusions The risk of psychiatric long-stay appeared related to the same clinical factors which can induce institutional dependence. Integrated collaboration between hospital and outpatient services could significantly counteract this clinical and social issue

Hospitalization Rates and Post-Operative Mortality for Abdominal Aortic Aneurysm in Italy over the Period 2000\u20132011

BACKGROUND: Recent studies have reported declines in incidence, prevalence and mortality for abdominal aortic aneurysms (AAAs) in various countries, but evidence from Mediterranean countries is lacking. The aim of this study is to examine the trend of hospitalization and post-operative mortality rates for AAAs in Italy during the period 2000-2011, taking into account the introduction of endovascular aneurysm repair (EVAR) in 1990s. METHODS: This retrospective cohort study was carried out in Emilia-Romagna, an Italian region with 4.5 million inhabitants. A total of 19,673 patients hospitalized for AAAs between 2000 and 2011, were identified from the hospital discharge records (HDR) database. Hospitalization rates, percentage of OSR and EVAR and 30-day mortality rates were calculated for unruptured (uAAAs) and ruptured AAAs (rAAAs). RESULTS: Adjusted hospitalization rates decreased on average by 2.9% per year for uAAAs and 3.2% for rAAAs (p<0.001). The temporal trend of 30-day mortality rates remained stable for both groups. The percentage of EVAR for uAAAs increased significantly from 2006 to 2011 (42.7 versus 60.9% respectively, mean change of 3.9% per year, p<0.001). No significant difference in mortality was found between OSR and EVAR for uAAAs and rAAAs. CONCLUSIONS: The incidence and trend of hospitalization rates for rAAAs and uAAAs decreased significantly in the last decade, while 30-day mortality rates in operated patients remained stable. OSR continued to be the most common surgery in rAAAs, although the gap between OSR and EVAR recently declined. The EVAR technique became the preferred surgery for uAAAs since 2008

Clinical Validation of the INTERGROWTH-21st Standards of Fetal Abdominal Circumference for the Prediction of Small-for-Gestational-Age Neonates in Italy

Objectives: To compare the accuracy of the INTERGROWTH-21st (IG-21) with the Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG) abdominal circumference (AC) standards in the detection of small-for-gestational-age (SGA) fetuses in a high-risk population. Material and Methods: Our study included all pregnant patients with an increased risk of placental insufficiency that were seen in two Italian university hospitals between 2014 and 2015. The accuracy of IG-21 and SIEOG AC standards in the detection of SGA neonates was analyzed by means of the area under the receiver operating characteristic curve (ROC-AUC) at 4 gestational age intervals (24-27, 28-31, 32-35, >35 weeks). Results: We enrolled 428 patients (278 Italians). There was no significant difference between the ROC-AUC of AC according to IG-21 and SIEOG standards for all birthweight thresholds and gestational intervals that were considered. The diagnostic performance was similar in Italian and non-Italian patients. The accuracy was, however, limited, with values of ROC-AUC ranging between 0.80 and 0.89. Conclusions: The IG-21 and SIEOG AC standards are interchangeable for the diagnosis of SGA fetuses. The diagnostic accuracy is, however, limited. We provide figures that can be used to stratify the probability that an infant will be SGA in an obstetric population at increased risk of growth restriction