Allergic Sensitization in Rhinitis and Asthma

Allergic rhinitis (AR) is usually defined as an inflammatory disease of the nasal mucosa induced by an interaction of environmental allergens and IgE in sensitized patients. Its symptoms are sneezing, nasal itching, rhinorrhoea and nasal obstruction. Allergic rhinitis affects approximately 20- 30% of the population worldwide and its prevalence is increasing. Isolated AR is rare and it actually has to be considered as a systemic allergic disease, associated to comorbidities, such as conjunctivitis, chronic middle ear effusions, irregular sleep, sinusitis, lymphoid hypertrophy with obstructive sleep apnoea. The most relevant comorbidity is asthma, a heterogeneous disease, usually characterized by chronic airway inflammation in which many cells and cellular elements play an important role. Bronchial asthma is characterized by bronchial hyper-reactivity and symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress. A state of "minimal persistent inflammation" is permanently maintained in the lower respiratory tract of asthmatic individuals. The diagnosis of asthma is based on evidence of variable airflow limitation tested with spirometry and a positive bronchodilation reversibility test. Skin prick tests (SPTs) are widely used to demonstrate an immediate IgE-mediated allergic reaction. They represent a major diagnostic tool in the field of allergy. Skin prick tests have a high specificity and sensitivity for the diagnosis of inhalant allergens. Immunotherapy (AIT) for allergic diseases has entered in a new age characterized by the development of a few innovative therapeutic classes of standardized allergen formulations registered. Clinical randomized trials have demonstrated the efficacy of AIT in allergic rhinitis in children and in adults, expressed in terms of reduction of symptom score and use of rescue medication. The efficacy is confirmed both for subcutaneous (SCIT) and sublingual (SLIT) immunotherapy in adults and in pediatric patients. The long lasting effect of AIT after its discontinuation is an important added value of this therapy. Controlled studies are available, where the carry-over effect of AIT is demonstrated for two years after discontinuance. The capacity to prevent new sensitizations, and to modify the evolution of the disease from the rhinitis to asthma are two important features of AIT. Allergen immunotherapy showed preventive capacity and also a carryover effect once treatment is discontinued

Integrated Care for Heart Failure in Primary Care

Chronic heart failure (CHF or simply HF) is a complex clinical syndrome that involves more than 2% of the general population and over 10% of the older people. For people with reduced ventricular function (the classical HFrEF phenotype), the guideline-directed medical therapy (GDMT) (e.g., Ace-inhibitors, beta-blockers, diuretics, rehabilitation or implantable ventricular devices) demonstrated to be efficacious in reducing hospitalisations and prolonging survival. Vice-versa, the HF with preserved ejection fraction (diastolic HF or HFpEF phenotype) is a much more complex syndrome, in which co-morbidities (such as COPD, depression, anemia, and diabetes, CAD) play a significant role in the decompensation episodes

Randomised controlled trials for evaluating the prescribing impact of information meetings led by pharmacists and of new information formats, in General Practice in Italy

<p>Abstract</p> <p>Background</p> <p>Suboptimal translation of valid and relevant information in clinical practice is a problem for all health systems. Lack of information independent from commercial influences, limited efforts to actively implement evidence-based information and its limited comprehensibility are important determinants of this gap and may influence an excessive variability in physicians' prescriptions. This is quite noticeable in Italy, where the philosophy and methods of Evidence-Based Medicine still enjoy limited diffusion among practitioners. Academic detailing and pharmacist outreach visits are interventions of proven efficacy to make independent and evidence-based information available to physicians; this approach and its feasibility have not yet been tested on a large scale and, moreover, they have never been formally tested in Italy.</p> <p>Methods/Design</p> <p>Two RCTs are planned:</p> <p>1) a two-arm cluster RCT, carried out in Emilia-Romagna and Friuli Venezia Giulia, will evaluate the effectiveness of small group meetings, randomising about 150 Primary Care Groups (corresponding to about 2000 GPs) to pharmacist outreach visits on two different topics. Physicians' prescriptions (expressed as DDD per 1000 inhabitants/day), knowledge and attitudes (evaluated through the answers to a specific questionnaire) will be compared for target drugs in the two groups (receiving/not receiving each topic).</p> <p>2) A three-arm RCT, carried out in Sardinia, will evaluate both the effectiveness of one-to-one meetings (one pharmacist visiting one physician per time) and of a 'new' information format (compared to information already available) on changing physicians' prescription of specific drugs. About 900 single GPs will be randomised into three groups: physicians receiving a visit supported by "traditional" information material, those receiving a visit with "new" information material on the same topic and those not receiving any visit/material.</p> <p>Discussion</p> <p>The two proposed RCTs aim to evaluate the organisational feasibility and barriers to the implementation of independent information programs led by NHS pharmacists. The objective to assess a 10 or 15% decreases in the prescription of the targeted drugs is quite ambitious in such 'natural' settings, which will be minimally altered by the interventions themselves; this in spite of the quite large sample sizes used comparing to other studies of these kind. Complex interventions like these are not easy to evaluate, given the many different variables into play. Anyway, the pragmatic nature of the two RCTs appears to be also one of their major strengths, helping to provide a deeper insight on what is possible to achieve – in terms of independent information – in a National Health System, with special reference to Italy.</p> <p>Trial registration</p> <p>ISRCTN05866587 (cluster RCT) and ISRCTN28525676 (single GPs RCT)</p

L\u2019audit clinico nell\u2019implementazione di raccomandazioni sull\u2019assistenza dei pazienti con pregresso infarto acuto del miocardio nel Dipartimento di cure primarie dell\u2019Ausl di Bologna: un caso studio

Introduzione. I processi di audit si sono rivelati utili nell\u2019apportare dei miglioramenti nella pratica clinica sulla base delle linee guida. Lo scopo di questo studio \ue8 valutare l\u2019impatto di un processo di audit sull\u2019attitudine dei Medici di medicina generale (Mmg) alla registrazione in cartella di condizioni cliniche e trattamenti raccomandati nei pazienti con pregresso infarto acuto del miocardio (Ima) o sindrome coronarica acuta (Sca). Materiali e metodi. La popolazione studiata comprende i Mmg dell\u2019Azienda sanitaria locale di Bologna, che assistono pazienti dimessi da qualsiasi ospedale italiano tra il 2004 e il 2008, con diagnosi di Ima o Sca. I dati clinici dei pazienti eleggibili sono stati estratti dalle cartelle cliniche dei Mmg prima e dopo l\u2019intervento di audit, costituendo due database linkabili attraverso il codice identificativo del Mmg. Sono stati analizzati i dati registrati dai medici che risultano presenti nei database sia pre-audit che post-audit. Risultati. Sono risultati eleggibili 348 Mmg. La media compilativa dei valori pressori e delle informazioni sull\u2019abitudine tabagica e indice di massa corporea aumenta nella fase post-audit in modo statisticamente significativo; altre informazioni sugli stili di vita (consumo di alcol e attivit\ue0 fisica) vengono registrate solo nella fase post intervento. Anche la registrazione in cartella dei farmaci previsti in prevenzione secondaria migliora nella fase post-audit, in particolare per gli antiaggreganti (da 70,3% a 77,2%; p = 0,038) e le statine (da 71,4% a 74,8%; p = 0,022). Inoltre, dopo l\u2019intervento, l\u201987,6% dei medici registra in cartella almeno 3 dei 4 farmaci raccomandati al 60% o pi\uf9 dei propri pazienti post Ima o Sca, raggiungendo il target sottoposto a incentivo economico. Discussione. I risultati mostrano che un intervento di audit aumenta la consapevolezza dei medici dell\u2019importanza di monitorare stili di vita e altre condizioni cliniche attraverso una pi\uf9 completa registrazione delle informazioni in cartella clinica, richiamando l\u2019attenzione sulle scelte clinico-assistenziali