Switching among equivalents in chronic cardiovascular therapies : 'real world' data from Italy

Since August 2012, Italian general practitioners are required to prescribe the generic name of medicines, except for refill of chronic therapy. We evaluated the extent of switching among equivalents in chronic cardiovascular therapies, the influence of the 2012 regulatory intervention and of patient-related or drug-related factors. Prescription of off-patent antiarrhythmics, oral antidiabetics, and ACE-inhibitors dispensed from August 2011 to August 2013 within the Bologna Local Health Authority (870,000 inhabitants) were collected. The rate of actual switching among equivalents was evaluated monthly. The effect of the regulatory intervention was estimated by interrupted time series analysis. Adjusted odds ratios (aORs) of switching were calculated for: age, gender, number of different equivalents available for each drug, change in dispensing pharmacy between subsequent refills. The average monthly rates of switches were 9.6%, 16.3%, and 16.3% for antiarrhythmics, antidiabetics, and ACE-inhibitors, respectively. Values significantly increased soon after the regulatory intervention for ACE-inhibitors (+1.81%, p=0.00), antiarrhythmics (+1.46%, p=0.01) and antidiabetics (+1.09%, p=0.01), and no significant decreasing trends were observed in the following 12 months. For all drug classes, odd of switching was higher in case of change in dispensing pharmacy (up to aOR=4.31, 95CI=4.26-4.35 for ACE-inhibitors) and availability of ≥5 different equivalents (up to aOR=7.82, 95CI=7.39-8.28 for antidiabetics). Switching was lower for age ≥65 for antidiabetics and ACE-inhibitors (aOR=0.92, 95CI=0.90-0.93; 0.87, 0.86-0.88, respectively). The Italian regulatory intervention generated an immediate increase, not sustained in time, in switching among equivalents of cardiovascular therapies. Young age, high number of available equivalents and changes in dispensing pharmacy between subsequent refills were associated with switching

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

The field of inflammatory disease of the heart or "cardio-immunology " is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.Peer reviewe

Response to letter to the editor: Gallo F et al., “The economic burden of severe hypoglycemia: Two sides of the same coin” Nutr Metab Cardiovasc Dis. 2016;26:850–851

Este trabajo realiza una aproximación analítica sobre los sentidos desplegados acerca del encierro que experimentan jóvenes alojados en un Centro Cerrado de la provincia de Buenos Aires donde cumplen medidas judiciales de privación de la libertad en el marco de un proceso penal. Bajo los supuestos de la teoría de los discursos propuesta por Verón articulada con una lectura oblicua de Deleuze, se pregunta sobre las condiciones de posibilidad de una aproximación semejante a partir del análisis del encierro como motivo (Segre, 1985) en pósteres generados como obsequio para el día de la madre, planteados en base a la realización de un “autorretrato” con un mensaje dirigido a sus progenitoras o a la madre de sus hijos. A su vez se aventura a ubicar ciertas derivas conceptuales que puedan aportar al análisis de la gestualidad desde la idea de “técnicas corporales” del Mauss recuperado por Le Breton (2008).Facultad de Periodismo y Comunicación Socia

Current application of high flow oxygen nasal cannula in acute hypoxemic respiratory failure in the emergency department

High flow oxygen with nasal cannula (HFONC) is a relatively new mode of oxygen delivery. Advantages of HFONC versus conventional oxygen therapy (COT) encompass carbon dioxide washout, generation of a slight positive end-expiratory pressure and maintenance of humidified gas flow through airways. These features are mostly shared with non-invasive mechanical ventilation (NIMV), although with lack of a clearly comparable efficacy. In the last few years, HFONC has gained interest as a third alternative to COT and NIMV in the management of acute hypoxemic respiratory failure in the critically ill patient, both in intensive care units and emergency departments. The aim of this article is to review indications, effects and existing evidence on HFONC, COT and NIMV in the setting of acute hypoxemic respiratory failure

Estimation of prenatal aorta intima-media thickness from ultrasound examination

Prenatal events such as intrauterine growth restriction and increased cardiovascular risk in later life have been shown to be associated with an increased intima-media thickness (aIMT) of the abdominal aorta in the fetus. In order to assess and manage atherosclerosis and cardiovascular disease risk in adults and children, in recent years the measurement of abdominal and carotid artery thickness has gained a growing appeal. Nevertheless, no computer aided method has been proposed for the analysis of prenatal vessels from ultrasound data, yet. To date, these measurements are being performed manually on ultrasound fetal images by skilled practitioners. The aim of the presented study is to introduce an automatic algorithm that identifies abdominal aorta and estimates its diameter and aIMT from routine third trimester ultrasonographic fetal data.The algorithm locates the aorta, then segments it and, by modeling the arterial wall longitudinal sections by means of a gaussian mixture, derives a set of measures of the aorta diameter (aDiam) and of the intima-media thickness (aIMT). After estimating the cardiac cycle, the mean diameter and the aIMT at the end-diastole phase are computed.Considering the aIMT value for each subject, the correlation between automatic and manual end-diastolic aIMT measurements is 0.91 in a range of values 0.44-1.10 mm, corresponding to both normal and pathological conditions. The automatic system yields a mean relative error of 19%, that is similar to the intra-observer variability (14%) and much lower that the inter-observer variability (42%).The correlation between manual and automatic measurements and the small error confirm the ability of the proposed system to reliably estimate aIMT values in prenatal ultrasound sequences, reducing measurement variability and suggesting that it can be used for an automatic assessment of aIMT

Costs associated with emergency care and hospitalization for severe hypoglycemia

Background and aims: We aimed to determine the direct economic cost of the management of severe hypoglycemia among people with diabetes in Italy. Methods and results: Data of cases with an acceptance diagnosis of hypoglycemia between January 2011 and June 2012 were collected in 46 Emergency Departments (EDs). Emergency care costs were computed by estimating the average cost per ambulance service, ED visit and short-term (<24 h) observation period. Hospitalization expenditure was estimated using the average cost reimbursed by the Italian healthcare system for hospital admission per patient with diabetes in a specific hospital ward. We retrieved 3516 hypoglycemic episodes occurring in subjects with diabetes. Half the cases (51.8%) required referral to EDs by means of the emergency ambulance services. A total of 1751 cases (49.8%) received an ED visit followed by discharge; 604 cases (17.2%) received a short-term observation period; 1161 (33.1%) were hospitalized. Unit costs for emergency care management were estimated at \u20ac205 for an ambulance call, \u20ac23 for an ED visit, and \u20ac220 for a short-term observation. The mean hospitalization cost was estimated at \u20ac5317; the average cost per each severe hypoglycemic event totaled \u20ac1911. From a base case assumption, the total direct cost of severe hypoglycemia in patients with diabetes in Italy was estimated to be approximately \u20ac23 million per year. Conclusion: Severe hypoglycemia in patients with diabetes constitutes a remarkable economic burden for national healthcare systems. Measures for preventing hypoglycemia are mandatory in diabetes management programs considering the impact on patients and on health spending

Il Riparo Tagliente in Valpantena. Recenti scoperte relative agli ultimi cacciatori-raccoglitori paleolitici.

Il sito di Riparo Tagliente (Stallavena di Grezzana, Verona) è ubicato alla base del Monte Tregnago, sotto un riparo roccioso formato da calcari ooliti- ci, sul versante sinistro della Valpantena. Localizzato ad un altitudine di circa 226 m sul livello del mare, il riparo occupa una posizione strategica, al centro di un’area caratterizzata da un ricco mosaico di am- bienti, ognuno con differenti risorse animali e vege- tali: la pianura, il fondovalle, le scarpate rocciose e le cime del massiccio. La natura calcarea di quest’ulti- mo garantisce, inoltre, la presenza di numerose ca- vità carsiche ed una grande ricchezza in termini di risorse litiche e minerali, tra cui i ricchi affioramenti di selce e depositi d’ocra intensamente sfruttati du- rante il Paleolitico