Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study

ObjectiveSepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a “simplified 1-h bundle” (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU).MethodsEmergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort).Measurements and main resultsThe effect of QIP on bundle compliance and hospital mortality was evaluated in a before–after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the “simplified rapid (1 h) intervention bundle” (the Sepsis 6 bundle – S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients’ cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality.ConclusionA multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality

Algorithm for Individual Prediction of COVID-19–Related Hospitalization Based on Symptoms: Development and Implementation Study

BackgroundThe COVID-19 pandemic has placed a huge strain on the health care system globally. The metropolitan area of Milan, Italy, was one of the regions most impacted by the COVID-19 pandemic worldwide. Risk prediction models developed by combining administrative databases and basic clinical data are needed to stratify individual patient risk for public health purposes. ObjectiveThis study aims to develop a stratification tool aimed at improving COVID-19 patient management and health care organization. MethodsA predictive algorithm was developed and applied to 36,834 patients with COVID-19 in Italy between March 8 and the October 9, 2020, in order to foresee their risk of hospitalization. Exposures considered were age, sex, comorbidities, and symptoms associated with COVID-19 (eg, vomiting, cough, fever, diarrhea, myalgia, asthenia, headache, anosmia, ageusia, and dyspnea). The outcome was hospitalizations and emergency department admissions for COVID-19. Discrimination and calibration of the model were also assessed. ResultsThe predictive model showed a good fit for predicting COVID-19 hospitalization (C-index 0.79) and a good overall prediction accuracy (Brier score 0.14). The model was well calibrated (intercept –0.0028, slope 0.9970). Based on these results, 118,804 patients diagnosed with COVID-19 from October 25 to December 11, 2020, were stratified into low, medium, and high risk for COVID-19 severity. Among the overall study population, 67,030 (56.42%) were classified as low-risk patients; 43,886 (36.94%), as medium-risk patients; and 7888 (6.64%), as high-risk patients. In all, 89.37% (106,179/118,804) of the overall study population was being assisted at home, 9% (10,695/118,804) was hospitalized, and 1.62% (1930/118,804) died. Among those assisted at home, most people (63,983/106,179, 60.26%) were classified as low risk, whereas only 3.63% (3858/106,179) were classified at high risk. According to ordinal logistic regression, the odds ratio (OR) of being hospitalized or dead was 5.0 (95% CI 4.6-5.4) among high-risk patients and 2.7 (95% CI 2.6-2.9) among medium-risk patients, as compared to low-risk patients. ConclusionsA simple monitoring system, based on primary care data sets linked to COVID-19 testing results, hospital admissions data, and death records may assist in the proper planning and allocation of patients and resources during the ongoing COVID-19 pandemic

Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial

Aims To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban. Methods and results We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for >= 3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of alpha = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%). Conclusion Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia

Antipsychotic prescription and mortality in hospitalized older persons

Background: Recent scientific reports have shown that older persons treated with antipsychotics for dementia-related behavioural symptoms have increased mortality. However, the impact of these drugs prescribed during hospitalization has rarely been assessed. We aimed to investigate whether antipsychotics are associated with an increased risk of mortality during hospitalization and at 3-month follow-up in elderly inpatients. Methods: We analyzed data gathered during two waves (2010 and 2012) by the REPOSI (Registro Politerapie Società Italiana Medicina Interna). All new prescriptions of antipsychotic drugs during hospitalization, whether maintained or discontinued at discharge, were collected, and logistic regression models were used to analyze their association with in-hospital and 3-month mortality. Covariates were age, sex, the Short Blessed Test (SBT) score, and the Cumulative Illness Rating Scale. Results: Among 2703 patients included in the study, 135 (5%) received new prescriptions for antipsychotic drugs. The most frequently prescribed antipsychotic during hospitalization and eventually maintained at discharge was haloperidol (38% and 36% of cases, respectively). Patients newly prescribed with antipsychotics were older and had a higher Cumulative Illness Rating Scale comorbidity index both at admission and at discharge compared to those who did not receive a prescription. Of those prescribed antipsychotics, 71% had an SBT score ≥10 (indicative of dementia), 12% had an SBT score of 5–9 (indicative of questionable dementia); and 17% had an SBT score <5 (indicative of normal cognition). In-hospital mortality was slightly higher in patients prescribed antipsychotic drugs (14.3% vs 9.4%; P = 0.109), but in multivariate analysis only male sex, older age, and higher SBT scores were significantly related to mortality during hospitalization. At 3-month follow-up, only male sex, older age, and higher SBT scores were associated with mortality. Conclusion: We found that the prescription of antipsychotic drugs during hospitalization was not associated with in-hospital or follow-up mortality. Short-term antipsychotic prescriptions (for acutely ill patients) may have a different effect than long-term, repeated prescriptions

Heart failure and chronic kidney disease in a registry of internal medicine wards

Background: The aim of the present study was to evaluate the association between heart failure (HF) and chronic kidney disease (CKD) in tertiary care centers using the clinical records of patients enrolled in internal medicine departments.Patients and methods: We used the clinical records of 1380 elderly patients to identify patients with a history of HF and CKD using admission ICD codes and glomerular filtration rate (GFR) formulas. Magnitude and strength of such associations were investigated by univariable and multivariable analysis.Results: Of the 1380 patients enrolled, 27.9% had HF (age 80 \ub1 7, BMI 27 \ub1 6 kg/m2) and 17.4% CKD (age 81 \ub1 7, BMI 26.8 \ub1 6 kg/m2). Both groups were significantly older (P <' 0.0001) with BMI higher than the patients without those diagnosis (P < 0.02). Patients with a history of CKD showed higher non-fasting glycaemia (140 \ub1 86 vs. 125 \ub1 63 mg/dL, P < 0.001). CKD was significantly associated with HF (P < 0.0001). Patients with HF had an estimated GFR lower than patients without HF (P < 0.0001). Comorbidity and severity indices were significantly higher in subjects with HF (P < 0.0001) and CKD (P < 0.0001) than in those without. Multivariable analysis showed a significant association between HF and age (for five years increase OR 1.13, P < 0.009), BMI (for each 3 kg/m2 increase OR 1.15, P < 0.001), GFR (for each decrease of 10 mL/min increase OR 0.92, P < 0.002) and severity index (IS) (for each 0.25 units increase OR 1.43, P < 0.001).Conclusion: HF on admission is strongly associated with CKD, older age, BMI, and SI. These data focus the value of epidemiological studies such REPOSI in identifying and monitoring multimorbidity in elderly

Gout, allopurinol intake and clinical outcomes in the hospitalized multimorbid elderly

310nononeBackground: Increased serum uric acid has been considered a cardiovascular risk factor but no study has assessed its relation with hospital mortality or length of stay. On the basis of data obtained from a prospective registry, the prevalence of gout/hyperuricemia and its association with these and other clinical parameters was evaluated in an Italian cohort of elderly patients acutely admitted to internal medicine or geriatric wards. Methods: While the prevalence of gout was calculated by counting patients with this diagnosis hyperuricemia was inferred in patients taking allopurinol at hospital admission or discharge, on the assumption that this drug was only prescribed owing to the finding of high serum levels of uric acid. A series of clinical and demographic variables were evaluated for their association with gout/hyperuricemia. Results: Of 1380 patients, 139 (10%) had a diagnosis of gout or were prescribed allopurinol. They had more co-morbidities (7.0 vs 5.6; P < 0.0001) and consumed more drugs (6.8 vs 5.0; < b 0.0001). The CIRS (co-morbidity index) was worse in these patients (OR 1.28 95% CI 1.15-1.41). Multivariable regression analysis showed that only renal and heart failures were independently associated with gout/allopurinol intake. Moreover, this combined event was associated with an increased risk of adverse events during hospitalization (OR 1.66, 95% CI 1.16-2.36), but not with the risk of re-hospitalization, length of hospital stay or death. Conclusions: Gout/allopurinol intake has a high prevalence in elderly patients acutely admitted to hospital and are associated with renal and cardiovascular diseases, an increased rate of adverse events and a high degree of drug consumption. In contrast, this finding did not affect the length of hospitalization nor hospital mortality.noneFranchi, Carlotta; Salerno, Francesco; Conca, Alessio; Djade, Codjo D.; Tettamanti, Mauro; Pasina, Luca; Corrao, Salvatore; Marengoni, Alessandra; Marcucci, Maura; Mannucci, Pier Mannuccio; Nobili, Alessandro; Sparacio, Eleonora; Alborghetti, Stefania; Di Costanzo, Rosa; Prisco, Domenico; Silvestri, Elena; Cenci, Caterina; Barnini, Tommaso; Delitala, Giuseppe; Carta, Stefano; Atzori, Sebastiana; Guarnieri, Gianfranco; Zanetti, Michela; Spalluti, Annalisa; Serra, Maria Grazia; Bleve, Maria Antonietta; Vanoli, Massimo; Grignani, Giulia; Casella, Gianluca; Gasbarrone, Laura; Maniscalco, Giorgio; Gunelli, Massimo; Tirotta, Daniela; Brucato, Antonio; Ghidoni, Silvia; Di Corato, Paola; Bernardi, Mauro; Li Bassi, Silvia; Santi, Luca; Agnelli, Giancarlo; Iorio, Alfonso; Marchesini, Emanuela; Mannarino, Elmo; Lupattelli, Graziana; Rondelli, Pamela; Paciullo, Francesco; Fabris, Fabrizio; Carlon, Michela; Turatto, Francesca; Baroni, Maria Cristina; Zardo, Marianna; Manfredini, Roberto; Molino, Christian; Pala, Marco; Fabbian, Fabio; Nuti, Ranuccio; Valenti, Roberto; Ruvio, Martina; Cappelli, Silvia; Paolisso, Giuseppe; Rizzo, Maria Rosaria; Laieta, Maria Teresa; Salvatore, Teresa; Sasso, Ferdinando Carlo; Utili, Riccardo; Mangoni, Emanuele Durante; Pinto, Daniela; Olivieri, Oliviero; Stanzial, Anna Maria; Fellin, Renato; Volpato, Stefano; Fotini, Sioulis; Barbagallo, Mario; Dominguez, Ligia; Plances, Lidia; D'Angelo, Daniela; Rini, Giovanbattista; Mansueto, Pasquale; Pepe, Ilenia; Licata, Giuseppe; Calvo, Luigi; Valenti, Maria; Borghi, Claudio; Strocchi, Enrico; Rinaldi, Elisa Rebecca; Zoli, Marco; Fabbri, Elisa; Magalotti, Donatella; Auteri, Alberto; Pasqui, Anna Laura; Puccetti, Luca; Pasini, Franco Laghi; Capecchi, Pier Leopoldo; Bicchi, Maurizio; Sabbà, Carlo; Vella, Francesco Saverio; Marseglia, Alessandro; Luglio, Chiara Valentina; Palasciano, Giuseppe; Modeo, Maria Ester; Aquilino, Annamaria; Raffaele, Pallante; Pugliese, Stefania; Capobianco, Caterina; Postiglione, Alfredo; Barbella, Maria Rosaria; De Stefano, Francesco; Fenoglio, Luigi; Brignone, Chiara; Bracco, Christian; Giraudo, Alessia; Musca, Giuseppe; Cuccurullo, Olga; Cricco, Luigi; Fiorentini, Alessandra; Cappellini, Maria Domenica; Fabio, Giovanna; Seghezzi, Sonia; De Amicis, Margherita Migone; Fargion, Silvia; Bonara, Paola; Bulgheroni, Mara; Lombardi, Rosa; Magrini, Fabio; Massari, Ferdinando; Tonella, Tatiana; Peyvandi, Flora; Tedeschi, Alberto; Rossio, Raffaella; Moreo, Guido; Ferrari, Barbara; Roncari, Luisa; Monzani, Valter; Savojardo, Valeria; Folli, Christian; Magnini, Maria; Mari, Daniela; Rossi, Paolo Dionigi; Damanti, Sarah; Prolo, Silvia; Lilleri, Maria Sole; Micale, Giuliana; Podda, Mauro; Selmi, Carlo; Meda, Francesca; Accordino, Silvia; Monti, Valentina; Corazza, Gino Roberto; Miceli, Emanuela; Lenti, Marco Vincenzo; Padula, Donatella; Balduini, Carlo L.; Bertolino, Giampiera; Provini, Stella; Quaglia, Federica; Murialdo, Giovanni; Bovio, Marta; Dallegri, Franco; Ottonello, Luciano; Quercioli, Alessandra; Barreca, Alessandra; Secchi, Maria Beatrice; Ghelfi, Davide; Chin, Wu Sheng; Carassale, Laura; Caporotundo, Silvia; Anastasio, Luigi; Sofia, Lucia; Carbone, Maria; Traisci, Giancarlo; De Feudis, Lucrezia; Di Carlo, Silvia; Davì, Giovanni; Guagnano, Maria Teresa; Sestili, Simona; Bergami, Elisabetta; Rizzioli, Emanuela; Cagnoni, Carlo; Bertone, Luca; Manucra, Antonio; Buratti, Alberto; Tognin, Tiziana; Liberato, Nicola Lucio; Bernasconi, Giordano; Nardo, Barbara; Bianchi, Giovanni Battista; Benetti, Giampiero; Quagliolo, Michela; Centenaro, Giuseppe Riccardo; Purrello, Francesco; Di Pino, Antonino; Piro, Salvatore; Mancuso, Gerardo; Calipari, Daniela; Bartone, Mosè; Gullo, Francesco; Cortellaro, Michele; Magenta, Marina; Perego, Francesca; Meroni, Maria Rachele; Cicardi, Marco; Magenta, Antonio Gidaro Marina; Sacco, Andrea; Bonelli, Antonio; Dentamaro, Gaetano; Rozzini, Renzo; Falanga, Lina; Giordano, Alessandro; Perin, Paolo Cavallo; Lorenzati, Bartolomeo; Gruden, Gabriella; Bruno, Graziella; Montrucchio, Giuseppe; Greco, Elisabetta; Tizzani, Pietro; Fera, Giacomo; Di Luca, Maria Loreta; Renna, Donatella; Perciccante, Antonio; Coralli, Alessia; Tassara, Rodolfo; Melis, Deborah; Rebella, Lara; Menardo, Giorgio; Bottone, Stefania; Sferrazzo, Elsa; Ferri, Claudio; Striuli, Rinaldo; Scipioni, Rosa; Salmi, Raffaella; Gaudenzi, Piergiorgio; Gamberini, Susanna; Ricci, Franco; Morabito, Cosimo; Fava, Roberto; Semplicini, Andrea; Gottardo, Lucia; Vendemiale, Gianluigi; Serviddio, Gaetano; Forlano, Roberta; Bolondi, Luigi; Rasciti, Leonardo; Serio, Ilaria; Masala, Cesare; Mammarella, Antonio; Raparelli, Valeria; Fanelli, Filippo Rossi; Delfino, Massimo; Amoroso, Antonio; Violi, Francesco; Basili, Stefania; Perri, Ludovica; Serra, Pietro; Fontana, Vincenzo; Falcone, Marco; Landolfi, Raffaele; Grieco, Antonio; Gallo, Antonella; Zuccalà, Giuseppe; Franceschi, Francesco; De Marco, Guido; Chiara, Cordischi; Marta, Sabbatini; Bellusci, Martino; Setti, Donatella; Pedrazzoli, Filippo; Romanelli, Giuseppe; Pirali, Caterina; Amolini, Claudia; Rosei, Enrico Agabiti; Rizzoni, Damiano; Castoldi, Luana; Picardi, Antonio; Gentilucci, Umberto Vespasiani; Mazzarelli, Chiara; Gallo, Paolo; Guasti, Luigina; Castiglioni, Luana; Maresca, Andrea; Squizzato, Alessandro; Contini, Sara; Molaro, Marta; Annoni, Giorgio; Corsi, Maurizio; Zazzetta, Sara; Bertolotti, Marco; Mussi, Chiara; Scotto, Roberto; Ferri, Maria Alice; Veltri, Francesca; Arturi, Franco; Succurro, Elena; Sesti, Giorgio; Gualtieri, Umberto; Perticone, Francesco; Sciacqua, Angela; Quero, Michele; Bagnato, Chiara; Loria, Paola; Becchi, Maria Angela; Martucci, Gianfranco; Fantuzzi, Alessandra; Maurantonio, Mauro; Corinaldesi, Roberto; De Giorgio, Roberto; Serra, Mauro; Grasso, Valentina; Ruggeri, Eugenio; Carozza, Lorenzo Mauro; Pignatti, FabioFranchi, Carlotta; Salerno, Francesco; Conca, Alessio; Djade, Codjo D.; Tettamanti, Mauro; Pasina, Luca; Corrao, Salvatore; Marengoni, Alessandra; Marcucci, Maura; Mannucci, Pier Mannuccio; Nobili, Alessandro; Sparacio, Eleonora; Alborghetti, Stefania; Di Costanzo, Rosa; Prisco, Domenico; Silvestri, Elena; Cenci, Caterina; Barnini, Tommaso; Delitala, Giuseppe; Carta, Stefano; Atzori, Sebastiana; Guarnieri, Gianfranco; Zanetti, Michela; Spalluti, Annalisa; Serra, Maria Grazia; Bleve, Maria Antonietta; Vanoli, Massimo; Grignani, Giulia; Casella, Gianluca; Gasbarrone, Laura; Maniscalco, Giorgio; Gunelli, Massimo; Tirotta, Daniela; Brucato, Antonio; Ghidoni, Silvia; Di Corato, Paola; Bernardi, Mauro; Li Bassi, Silvia; Santi, Luca; Agnelli, Giancarlo; Iorio, Alfonso; Marchesini, Emanuela; Mannarino, Elmo; Lupattelli, Graziana; Rondelli, Pamela; Paciullo, Francesco; Fabris, Fabrizio; Carlon, Michela; Turatto, Francesca; Baroni, Maria Cristina; Zardo, Marianna; Manfredini, Roberto; Molino, Christian; Pala, Marco; Fabbian, Fabio; Nuti, Ranuccio; Valenti, Roberto; Ruvio, Martina; Cappelli, Silvia; Paolisso, Giuseppe; Rizzo, Maria Rosaria; Laieta, Maria Teresa; Salvatore, Teresa; Sasso, Ferdinando Carlo; Utili, Riccardo; Mangoni, Emanuele Durante; Pinto, Daniela; Olivieri, Oliviero; Stanzial, Anna Maria; Fellin, Renato; Volpato, Stefano; Fotini, Sioulis; Barbagallo, Mario; Dominguez, Ligia; Plances, Lidia; D'Angelo, Daniela; Rini, Giovanbattista; Mansueto, Pasquale; Pepe, Ilenia; Licata, Giuseppe; Calvo, Luigi; Valenti, Maria; Borghi, Claudio; Strocchi, Enrico; Rinaldi, Elisa Rebecca; Zoli, Marco; Fabbri, Elisa; Magalotti, Donatella; Auteri, Alberto; Pasqui, Anna Laura; Puccetti, Luca; Pasini, Franco Laghi; Capecchi, PIER LEOPOLDO; Bicchi, Maurizio; Sabbà, Carlo; Vella, Francesco Saverio; Marseglia, Alessandro; Luglio, Chiara Valentina; Palasciano, Giuseppe; Modeo, Maria Ester; Aquilino, Annamaria; Raffaele, Pallante; Pugliese, Stefania; Capobianco, Caterina; Postiglione, Alfredo; Barbella, Maria Rosaria; De Stefano, Francesco; Fenoglio, Luigi; Brignone, Chiara; Bracco, Christian; Giraudo, Alessia; Musca, Giuseppe; Cuccurullo, Olga; Cricco, Luigi; Fiorentini, Alessandra; Cappellini, Maria Domenica; Fabio, Giovanna; Seghezzi, Sonia; De Amicis, Margherita Migone; Fargion, Silvia; Bonara, Paola; Bulgheroni, Mara; Lombardi, Rosa; Magrini, Fabio; Massari, Ferdinando; Tonella, Tatiana; Peyvandi, Flora; Tedeschi, Alberto; Rossio, Raffaella; Moreo, Guido; Ferrari, Barbara; Roncari, Luisa; Monzani, Valter; Savojardo, Valeria; Folli, Christian; Magnini, Maria; Mari, Daniela; Rossi, Paolo Dionigi; Damanti, Sarah; Prolo, Silvia; Lilleri, Maria Sole; Micale, Giuliana; Podda, Mauro; Selmi, Carlo; Meda, Francesca; Accordino, Silvia; Monti, Valentina; Corazza, Gino Roberto; Miceli, Emanuela; Lenti, Marco Vincenzo; Padula, Donatella; Balduini, Carlo L.; Bertolino, Giampiera; Provini, Stella; Quaglia, Federica; Murialdo, Giovanni; Bovio, Marta; Dallegri, Franco; Ottonello, Luciano; Quercioli, Alessandra; Barreca, Alessandra; Secchi, Maria Beatrice; Ghelfi, Davide; Chin, Wu Sheng; Carassale, Laura; Caporotundo, Silvia; Anastasio, Luigi; Sofia, Lucia; Carbone, Maria; Traisci, Giancarlo; De Feudis, Lucrezia; Di Carlo, Silvia; Davì, Giovanni; Guagnano, Maria Teresa; Sestili, Simona; Bergami, Elisabetta; Rizzioli, Emanuela; Cagnoni, Carlo; Bertone, Luca; Manucra, Antonio; Buratti, Alberto; Tognin, Tiziana; Liberato, Nicola Lucio; Bernasconi, Giordano; Nardo, Barbara; Bianchi, Giovanni Battista; Benetti, Giampiero; Quagliolo, Michela; Centenaro, Giuseppe Riccardo; Purrello, Francesco; Di Pino, Antonino; Piro, Salvatore; Mancuso, Gerardo; Calipari, Daniela; Bartone, Mosè; Gullo, Francesco; Cortellaro, Michele; Magenta, Marina; Perego, Francesca; Meroni, Maria Rachele; Cicardi, Marco; Magenta, Antonio Gidaro Marina; Sacco, Andrea; Bonelli, Antonio; Dentamaro, Gaetano; Rozzini, Renzo; Falanga, Lina; Giordano, Alessandro; Perin, Paolo Cavallo; Lorenzati, Bartolomeo; Gruden, Gabriella; Bruno, Graziella; Montrucchio, Giuseppe; Greco, Elisabetta; Tizzani, Pietro; Fera, Giacomo; Di Luca, Maria Loreta; Renna, Donatella; Perciccante, Antonio; Coralli, Alessia; Tassara, Rodolfo; Melis, Deborah; Rebella, Lara; Menardo, Giorgio; Bottone, Stefania; Sferrazzo, Elsa; Ferri, Claudio; Striuli, Rinaldo; Scipioni, Rosa; Salmi, Raffaella; Gaudenzi, Piergiorgio; Gamberini, Susanna; Ricci, Franco; Morabito, Cosimo; Fava, Roberto; Semplicini, Andrea; Gottardo, Lucia; Vendemiale, Gianluigi; Serviddio, Gaetano; Forlano, Roberta; Bolondi, Luigi; Rasciti, Leonardo; Serio, Ilaria; Masala, Cesare; Mammarella, Antonio; Raparelli, Valeria; Fanelli, Filippo Rossi; Delfino, Massimo; Amoroso, Antonio; Violi, Francesco; Basili, Stefania; Perri, Ludovica; Serra, Pietro; Fontana, Vincenzo; Falcone, Marco; Landolfi, Raffaele; Grieco, Antonio; Gallo, Antonella; Zuccalà, Giuseppe; Franceschi, Francesco; De Marco, Guido; Chiara, Cordischi; Marta, Sabbatini; Bellusci, Martino; Setti, Donatella; Pedrazzoli, Filippo; Romanelli, Giuseppe; Pirali, Caterina; Amolini, Claudia; Rosei, Enrico Agabiti; Rizzoni, Damiano; Castoldi, Luana; Picardi, Antonio; Gentilucci, Umberto Vespasiani; Mazzarelli, Chiara; Gallo, Paolo; Guasti, Luigina; Castiglioni, Luana; Maresca, Andrea; Squizzato, Alessandro; Contini, Sara; Molaro, Marta; Annoni, Giorgio; Corsi, Maurizio; Zazzetta, Sara; Bertolotti, Marco; Mussi, Chiara; Scotto, Roberto; Ferri, Maria Alice; Veltri, Francesca; Arturi, Franco; Succurro, Elena; Sesti, Giorgio; Gualtieri, Umberto; Perticone, Francesco; Sciacqua, Angela; Quero, Michele; Bagnato, Chiara; Loria, Paola; Becchi, Maria Angela; Martucci, Gianfranco; Fantuzzi, Alessandra; Maurantonio, Mauro; Corinaldesi, Roberto; De Giorgio, Roberto; Serra, Mauro; Grasso, Valentina; Ruggeri, Eugenio; Carozza, Lorenzo Mauro; Pignatti, Fabi