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

The effects of primary care monitoring strategies on COVID-19 related hospitalisation and mortality: a retrospective electronic medical records review in a northern Italian province, the MAGMA study

Background: Most symptomatic SARS-CoV-2 infections produce mild to moderate symptoms. Although most patients are managed in the outpatient setting, little is known about the effect of general practitioners' (GP) management strategies on the outcomes of COVID-19 outpatients in Italy. Objectives: Describe the management of Italian GPs of SARS-CoV-2 infected adult patients and explore whether GP active care and monitoring are associated with reducing hospitalisation and death. Methods: Retrospective observational study of SARS-CoV-2 infected adult outpatients managed by GPs in Modena (Italy) from March 2020 to April 2021. Information on management and monitoring strategies, patients' socio-demographic characteristics, comorbidities, and outcomes (hospitalisation and death due to COVID-19) were retrieved through an electronic medical record review and analysed descriptively and through multiple logistic regression. Results: Out of the 5340 patients from 46 GPs included in the study, 3014 (56%) received remote monitoring, and 840 (16%) had at least one home visit. More than 85% of severe or critical patients were actively monitored (73% daily) and 52% were visited at home. Changes over time in patients' therapeutic management were observed in concordance with the guidelines' release. Active daily remote monitoring and home visits were strongly associated with reduced hospitalisation rate (OR 0.52, 95% CI 0.33-0.80 and OR 0.50, 95% CI 0.33-0.78 respectively). Conclusion: GPs effectively managed an increasing number of outpatients during the first waves of the pandemic. Active monitoring and home visits were associated with reduced hospitalisation in COVID-19 outpatients

Cholera Toxin Impairs the Differentiation of Monocytes into Dendritic Cells, Inducing Professional Antigen-Presenting Myeloid Cells ▿

Cholera toxin (CT) is a potent adjuvant for mucosal vaccination; however, its mechanism of action has not been clarified completely. It is well established that peripheral monocytes differentiate into dendritic cells (DCs) both in vitro and in vivo and that monocytes are the in vivo precursors of mucosal CD103− proinflammatory DCs. In this study, we asked whether CT had any effects on the differentiation of monocytes into DCs. We found that CT-treated monocytes, in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin 4 (IL-4), failed to differentiate into classical DCs (CD14low CD1ahigh) and acquired a macrophage-like phenotype (CD14high CD1alow). Cells differentiated in the presence of CT expressed high levels of major histocompatibility complex class I (MHC-I) and MHC-II and CD80 and CD86 costimulatory molecules and produced larger amounts of IL-1β, IL-6, and IL-10 but smaller amounts of tumor necrosis factor alpha (TNF-α) and IL-12 than did monocytes differentiated into DCs in the absence of CT. The enzymatic activity of CT was found to be important for the skewing of monocytes toward a macrophage-like phenotype (Ma-DCs) with enhanced antigen-presenting functions. Indeed, treatment of monocytes with scalar doses of forskolin (FSK), an activator of adenylate cyclase, induced them to differentiate in a dose-dependent manner into a population with phenotype and functions similar to those found after CT treatment. Monocytes differentiated in the presence of CT induced the differentiation of naïve T lymphocytes toward a Th2 phenotype. Interestingly, we found that CT interferes with the differentiation of monocytes into DCs in vivo and promotes the induction of activated antigen-presenting cells (APCs) following systemic immunization

Home management of Covid-19 pneumonia in the early phases of the pandemic: analysis of real-life data of General Practitioners in the Province of Modena from the MAGMA study.

Primary care management of Covid-19 pneumonia in the Province of Modena in the early phases of the pandemic: data integration from MAGMA study. Retrospective study on patients affected of Covid-19 and followed by General Practitioner from March 2020 to April 2021. 5340 patients were studied, 27% of them developed pneumoniae. Among these, most of them were managed entirely at home with an elevated intensity of care. Daily remote monitoring and home visits, together with a personalized pharmacological treatment, especially for the most severe forms, appeared to be the most effective interventions in reducing hospitalizations

COVID-19’s lessons learned from Primary Care and General Practice: enduring rafts against Pandemic Waves

Background: The Pandemic heavily hit northern Italy. Since most infections have mild to moderate symptoms thus Primary Care(PC) had to quickly adapt and reorganize to contribute to reducing hospital overload end ensure continuity of care. Italian literature on COVID-19 outpatient management is scarce, and little is known about overall management strategies. The study aims to describe the overall reorganization in pharmacological and monitoring strategies adopted by Italian general practitioners(GPs) to care for SARS-CoV-2 infected outpatients during the pandemic’s first waves and to evaluate their effectiveness in COVID-19 hospitalisation. Methods: This is a retrospective cohort study of SARS-CoV-2 infected adult outpatients managed by their GPs from March 2020 to April 2021 in the province of Modena(Italy). Using electronic medical records, we extracted data on pharmacological and management strategies (home visits and remote monitoring), patient characteristics, and hospitalizations. We stratified data for disease severity and multiple logistic regression analysis was performed to assess the probability of hospitalization. Results: Of 5340 patients, 56%(83% with pneumonia) were actively monitored by 46 GPs and specifically created continuity-of-care-units. A significant reduction in paracetamol, antibiotics and hydroxychloroquine prescriptions was observed over time in concordance with newly released guidelines. FANS for moderate patients(OR=0.50 95%CI:0.25-0.99), and steroids(OR=0.52 95%CI:0.32-0.84), antibiotics(OR=0.42 95%CI:0.25-0.70) and heparin(OR=0.63 95%CI:0.38-1.04) for severe-critical patients were effective in reducing the probability of hospitalisation, yet none as much as GPs’ active monitoring(OR up to 0.32 95%CI:0.14-0.70) or home visits(OR up to 0.42 95%CI:0.20-0.88). Conclusion: Italian Primary Care showed to be resilient and prone to adapt management and pharmacological strategies effective in reducing hospitalization overload. Considering a new potential pandemic and given that the ending of the current one is still proceeding at a slow pace, strengthening and investing in territorial health systems is a key strategy for controlling hospital overload and its consequences on patients health