Monitoring the appropriate prescription of low molecular weight heparins and Fondaparinux through administrative data. A retrospective observational study in the Tuscany region.

INTRODUCTION: Low Molecular Weight Heparins (LMWHs) and Fondaparinux have been widely used as anticoagulants. Mass prescription may lead to prescriptive inappropriateness, which causes Heparin-induced thrombocytopenia and other side effects. OBJECTIVES: The study investigates the appropriate prescription of LMWHs and Fondaparinux in Tuscany. We aim to validate the crude measure of prescription appropriateness of the Key Performance Indicator (KPI) "Patients treated with LMWHs and Fondaparinux every hundred residents in Tuscany" as a proxy for monitoring prescription appropriateness. METHODS: To compare a crude KPI based only on drug consumption with a refined KPI based on exclusions listed in the clinical guidelines, a retrospective observational cohort study was carried out, using the RECORD guidelines for the year 2019. The refined indicator is computed via record linkage of different datasets regarding (a) pharmaceutical services; (b) hospital discharge records; (c) outpatient services; and (d) birth certificates. We apply exclusion criteria to identify the cohort of patients. Values of the KPI are compared, by ranking, with those obtained from its refined version. A Spearman test was performed to validate the use of the crude KPI as a proxy. RESULTS: 208,717 LMWH and Fondaparinux users are identified, of which 103,299 fall within the study's inclusion criteria. 16,817 (16%) of LMWHs and Fondaparinux users are classified as high consumption. The refined version of the KPI produces the same ranking results in terms of local health districts (rho = 0.98 p<0.01). CONCLUSIONS: Although the crude KPI is less refined and detailed than the adjusted indicator computed by our study, it has proven capable to provide an accurate snapshot of the use of these drugs across the region. This analysis is useful to enable regional and local managers to run rapid and simple indicators to monitor the appropriateness of LMWHs and Fondaparinux. This analysis should be reviewed periodically to confirm its accuracy.

Monitoring Appropriate Monoclonal Antibodies Prescribing via Administrative Data: An Application to Psoriasis.

The Italian Medicines Agency (AIFA) and the Italian Regional Health Systems have implemented measures together with data collection and analysis to improve medicines' appropriate prescription. Administrative databases represent rich Real-World Evidence (RWE) sources that may be leveraged for research purposes. Thus, such heritage may allow for appropriate prescription studies to be carried out on complex pharmaceutical molecules, as the appropriateness of prescriptions is essential both for patients' treatment and to ensure healthcare systems' sustainability. This study analyzed the appropriate monoclonal antibodies (mAbs) prescribed in psoriasis treatment across Tuscany, Italy. Data were extracted from several large administrative databases collected by the Tuscan Regional Healthcare System through record linkages. The analysis showed that over 30% of the 2020 cohort of psoriatic patients could be regarded as potentially inappropriate treated, signaling that mAbs are often prescribed as first-line treatment contrary to guidelines. Variation was observed in the appropriate prescription of mAbs, across different types of mAbs and areas. The study revealed potential inappropriate prescription, and its geographic variation should raise awareness among managers about the appropriate use of resources. Despite limitations, this could represent a pilot for future studies to evaluate the appropriate prescription of mAbs in other clinic conditions and across time.

Harnessing pharmaceutical innovation for anti-cancer drugs: Some findings from the Italian regions.

BACKGROUND: Governing the provision of innovative drugs is unanimously recognized as a key factor in steering the future of health care systems, by jointly affecting health outcomes and financial sustainability. AIM OF THE STUDY: This paper describes the recent reforms in Italy governing the provision of innovative oncological drugs, with a focus on the different strategies implemented by the regions. It provides some preliminary findings about economic performance potentially associated with different governance models. METHODS: We conducted a qualitative study based on 26 face-to-face semi-structured interviews with the Regional Directors of the pharmaceutical sector of the 13 regions involved in the study. The interviews were analysed to detect the various tools regions have adopted to manage prescriptions of innovative oncological drugs and different regional models were mapped. Additionally, we collected relevant information on the regional economic outcomes from national open data sources. RESULTS: The 13 Italian regions strongly differ in how they apply national instruments and in how they devise regional governance tools. Analysis of the main economic indicators highlights that there is no direct relationship between strategies applied and performance achieved, although some preliminary results suggest a potential association between certain clinical governance models and different appropriateness performances.

Performance of care for end-of-life cancer patients in Tuscany: The interplay between place of care, aggressive treatments, opioids, and place of death. A retrospective cohort study.

Supportive and palliative care at the end of life (EOL) is a core component of health systems. Providing care at the EOL may require the interaction of several care providers working in different settings including nursing homes, home care, hospices, and hospitals. This work aims to (a) provide evidence on the performance of EOL care for cancer patients across healthcare organizations, with a focus on the place of care, aggressive treatments, opioids, and the place of death and (b) analyze factors associated with dying in hospital. A population-based retrospective study was performed using administrative data from Tuscany region (Italy). Thirteen thousand sixty-six cancer patients who died in 2016 were considered. There is a marked variability in EOL care within regional areas, with the multilevel logistic regression highlighting a greater likelihood of dying in hospital for patients who were admitted to intensive care units or previously hospitalized. There is a lower probability of dying in acute care setting for patients assisted in hospices and in both hospital and hospices/home care and for patients treated with opioids. This intraregional variation highlights the need to improve EOL planning and rethink the delivery of supportive/palliative care. Further investigations on the preferences of patients may lead to more understanding.

The true cost of cardiovascular imaging: focusing on downstream, indirect, and environmental costs.

To develop a more realistic assessment of costs, herein named "true" costs, the extra-cancer from medical radiation, environmental damage from imaging paraphernalia and radioactive wastes must be included as long-term costs from imaging examinations. It is urgent to define the "true" costs across imaging modalities as it interferes on physicians' decision to request an exam and on research projects such as cost-effectiveness analysis. Cardiology is the specialty that most will benefit from the outcome as cardiovascular exams represent almost 30% of the total exams acquired annually worldwide.

Glucose and fatty acid metabolism in a 3 tissue in-vitro model challenged with normo- and hyperglycaemia.

Nutrient balance in the human body is maintained through systemic signaling between different cells and tissues. Breaking down this circuitry to its most basic elements and reconstructing the metabolic network in-vitro provides a systematic method to gain a better understanding of how cross-talk between the organs contributes to the whole body metabolic profile and of the specific role of each different cell type. To this end, a 3-way connected culture of hepatocytes, adipose tissue and endothelial cells representing a simplified model of energetic substrate metabolism in the visceral region was developed. The 3-way culture was shown to maintain glucose and fatty acid homeostasis in-vitro. Subsequently it was challenged with insulin and high glucose concentrations to simulate hyperglycaemia. The aim was to study the capacity of the 3-way culture to maintain or restore normal circulating glucose concentrations in response to insulin and to investigate the effects these conditions on other metabolites involved in glucose and lipid metabolism. The results show that the system's metabolic profile changes dramatically in the presence of high concentrations of glucose, and that these changes are modulated by the presence of insulin. Furthermore, we observed an increase in E-selectin levels in hyperglycaemic conditions and increased IL-6 concentrations in insulin-free-hyperglycaemic conditions, indicating, respectively, endothelial injury and proinflammatory stress in the challenged 3-way system.

Realization of a poro-elastic ultrasound replica of pulmonary tissue.

In this work we describe the fabrication of a biocompatible hydrophilic scaffold composed of cross-linked gelatin that mimics the porous three-dimensional structure of pulmonary tissue as well as its water content and mechanical properties. The lung replica also reproduces the characteristic sonographic signs of pulmonary interstitial syndrome, the B-lines or ultrasound lung comets.

An in vitro model of glucose and lipid metabolism in a multicompartmental bioreactor.

The energy balance in vivo is maintained through inter-organ cross-talk involving several different tissues. As a first step towards recapitulating the metabolic circuitry, hepatocytes, endothelial cells and adipose tissue were connected in a multicompartmental modular bioreactor to reproduce salient aspects of glucose and lipid metabolism in vitro. We first examined how the two-way cellular interplay between adipose tissue and endothelial cells affects glucose and lipid metabolism. The hepatocyte cell line HepG2 was then added to the system, creating a three-way connected culture, to determine whether circulating metabolite concentrations were normalized, or whether metabolic shifts, which may arise when endothelial cells and adipose tissue are placed in connection, were corrected. The addition of hepatocytes to the system prevented the drop in the concentrations of glucose, L-alanine and lactate, and the rise in that of free fatty acids. There was no significant change in glycerol levels in either of the connected cultures. The results show that connected cultures recapitulate complex physiological systemic processes, such as glucose and lipid metabolism, and that the HepG2 hepatocytes normalize circulating metabolites in this in vitro environment in the presence of other cell types.

A flexible bioreactor system for constructing in vitro tissue and organ models.

To develop in vitro models of cells, tissues and organs we have designed and realized a series of cell culture chambers. Each chamber is purpose designed to simulate a particular feature of the in vivo environment. The bioreactor system is user friendly, and the chambers are easy to produce, sterilize and assemble. In addition they can be connected together to simulate inter-organ or tissue cross-talk. Here we discuss the design philosophy of the bioreactor system and then describe its construction. Preliminary results of validation tests obtained with hepatocytes and endothelial cells are also reported. The results show that endothelial cells are extremely sensitive to small levels of shear stress and that the presence of heterotypic signals from endothelial cells enhances the endogenous metabolic function of hepatocytes.

Modular bioreactor for primary human hepatocyte culture: medium flow stimulates expression and activity of detoxification genes.

Down-regulation of detoxification genes, notably cytochrome P450 (CYPs), in primary hepatocyte cultures is a long-standing and major concern. We evaluated the influence of medium flow in this model. Hepatocytes isolated from 12 different liver donors were cultured either in a multichamber modular bioreactor (MCmB, flow rate 250-500 µL/min) or under standard/static conditions, and the expression of 32 genes, enzyme activities and biological parameters were measured 7-21 days later. mRNA expression of genes involved in xenobiotic/drug metabolism and transport, including CYP1A1, 1A2, 2B6, 2C9, 3A4 (and activities for some of them), UDP-glucuronosyltransferase (UGT) 1A1, UGT2B4, UGT2B7, glutathione S-transferase (GSTα), and multidrug resistance protein 1 (MDR1) and MRP2, were specifically up-regulated by medium flow as compared with static controls in all cultures tested. In 2-week-old cultures, expression of detoxification genes reached levels close to or higher than those measured in freshly isolated hepatocytes. In contrast, CYP2D6 and most of other tested genes were not affected by medium flow. We conclude that medium flow specifically interferes with, and up-regulates, the activity of xenosensors and/or the expression of detoxification genes in primary human hepatocytes. Down-regulation of detoxification genes in conventional (static) cultures is therefore partly a consequence of the absence of medium circulation.

Flow-regulated glucose and lipid metabolism in adipose tissue, endothelial cell and hepatocyte cultures in a modular bioreactor.

Static cell culture has serious limitations in its ability to represent cellular behaviour within a live organism. In vivo, cells are constantly exposed to the flow of bodily fluids and contact with other cell types. Bioreactors provide the opportunity to study cells in an environment that more closely resembles the in vivo setting because cell cultures can be exposed to dynamic flow in contact with or in proximity to other cell types. In this study we compared the metabolic profile of a dynamic cell culture system to that of a static cell culture in three different cellular phenotypes: adipocytes, endothelial cells and hepatocytes. Albumin, glucose, free fatty acids, glycerol, and lactate were measured over 48 h. We show that all three cell types have increased glucose uptake in the presence of flow; lactate release was also significantly affected. We provide robust evidence that the presence of flow significantly modifies cellular metabolism. While flow provides a more uniform nutrient distribution and increases metabolite turnover, our results indicate that different cell types have specific metabolic responses to flow, suggesting cell-specific flow-regulated activation of metabolite signalling pathways.

In vitro liver model using microfabricated scaffolds in a modular bioreactor.

Hepatocyte function on 3-D microfabricated polymer scaffolds realised with the pressure-activated microsyringe was tested under static and dynamic conditions. The dynamic cell culture was obtained using the multicompartment modular bioreactor system. Hepatocyte cell density, glucose consumption, and albumin secretion rate were measured daily over a week. Cells seeded on scaffolds showed an increase in cell density compared with monolayer controls. Moreover, in dynamic culture, cell metabolic function increased three times in comparison with static monolayer cultures. These results suggest that cell density and cell-cell interactions are mediated by the architecture of the substrate, while the endogenous biochemical functions are regulated by a sustainable supply of nutrients and interstitial-like flow. Thus, a combination of 3-D scaffolds and dynamic flow conditions are both important for the development of a hepatic tissue model for applications in drug testing and regenerative medicine.

Criticality of the biological and physical stimuli array inducing resident cardiac stem cell determination.

The replacement of injured cardiac contractile cells with stem cell-derived functionally efficient cardiomyocytes has been envisaged as the resolutive treatment for degenerative heart diseases. Nevertheless, many technical issues concerning the optimal procedures to differentiate and engraft stem cells remain to be answered before heart cell therapy could be routinely used in clinical practice. So far, most studies have been focused on evaluating the differentiative potential of different growth factors without considering that only the synergistic cooperation of biochemical, topographic, chemical, and physical factors could induce stem cells to adopt the desired phenotype. The present study demonstrates that the differentiation of cardiac progenitor cells to cardiomyocytes does not occur when cells are challenged with soluble growth factors alone, but requires strictly controlled procedures for the isolation of a progenitor cell population and the artifactual recreation of a microenvironment critically featured by a fine-tuned combination of specific biological and physical factors. Indeed, the scaffold geometry and stiffness are crucial in enhancing growth factor differentiative effects on progenitor cells. The exploitation of this concept could be essential in setting up suitable procedures to fabricate functionally efficient engineered tissues. Disclosure of potential conflicts of interest is found at the end of this article.

Poly(3-hydroxybutyrate-co-3-hydroxyvalerate)/poly(epsilon-caprolactone) blends for tissue engineering applications in the form of hollow fibers.

In this work, hollow fibers to be used as guides for tissue engineering applications were produced by dry-jet-wet spinning of poly(3-hydroxybutyrate-co-3-hydroxyvalerate)/poly(epsilon-caprolactone) (PHBHV/PCL) solutions in chloroform with various weight ratios between the components (PHBHV/PCL 100/0; 80/20; 60/40; 50/50; 40/60; 20/80; 0/100 w/w). Fibers obtained from PHBHV/PCL blends had a low degree of surface and bulk porosity, depending on composition. Physicochemical characterization involving scanning electron microscopy and differential scanning calorimetry (DSC) showed that PHBHV/PCL blends are compatible. Interactions between blend components were studied by Fourier transform infrared total reflectance spectroscopy, DSC analysis, and polarized optical microscopy analysis. Homogeneity of blend composition was assessed by IR-chemical imaging analysis. PHBHV/PCL samples were found to be weakly hydrophilic and their biocompatibility was proved by in vitro tests using mouse fibroblasts. Mechanical properties of PHBHV/PCL blends were investigated by stress-strain tests, showing an increasing ductility of blend samples with increasing PCL amount. Hollow fibers supported fibroblasts attachment and proliferation depending on composition and porosity degree.