Rifaximin in diverticulosis and diverticular disease: a national survey among Italian gastroenterologists and general practitioners.

The management of patients with diverticular disease remains challenging. The aim of this national survey was to assess how gastroenterologists and general practitioners use rifaximin to manage diverticulosis and diverticular disease. Members of the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Federation of General Practitioners (FIMMG) were invited to complete a 39-item online survey concerning the use of rifaximin in five clinical settings: (1) diverticulosis; (2) reducing symptoms in symptomatic uncomplicated diverticular disease; (3) reducing the occurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (primary prevention); (4) reducing the recurrence of diverticulitis in patients with previous attacks of diverticulitis (secondary prevention); (5) treatment of uncomplicated acute diverticulitis. A total of 1094 physicians completed the survey. Overall, 25.1%, 83.5%, 68%, 74.2%, and 63% of physicians prescribed rifaximin for the clinical settings 1, 2, 3, 4, and 5, respectively. In each clinical setting, the dosage of rifaximin most frequently used was 800 mg/day, the most common duration of therapy was 7 days, and the cyclic administration of treatment (expressed in months) most frequently used was > 24 months. These results highlight that a reappraisal of the use of rifaximin in patients with diverticulosis and diverticular disease is required to reduce the gap between the evidence available and the daily clinical practice, optimizing also the use of healthcare resources.

A Multicomponent Primary-Care Intervention for Preventing Falls in Older Adults Living in the Community: The PREMIO Study.

BACKGROUND: Falls are a common cause of morbidity and functional impairment in the elderly and represent a significant health problem. General practitioners (GPs) are the first point of contact for health issues and may provide preventive services. The randomized clinical trial PREMIO was conducted by GPs to evaluate the effects of a multicomponent intervention for the prevention of falls in older adults aged ≥ 65 years at high risk of falling. METHODS: 117 GPs enrolled 1757 patients (1116 F, 641 M) and randomized them into 2 groups (intervention and control). The intervention group received medical and behavioral counseling, home risk-factor assessment, a physical-activity program and nutritional counseling. The control group received only the nutritional counseling. Both groups were followed for one year. The primary outcome was the rate of falls at home over 12 months. RESULTS: 1225 patients completed the study. Subjects receiving the intervention had, on average, fewer falls at home (percentage change -31.2%, p < 0.02) and fewer total falls (-26.0%, p < 0.02), although the reduction in the number of fallers was small (-3.9%, p = 0.05). Among the secondary endpoints, rates of general hospital or emergency-department admission and GP visits showed slight improvements (not statistically significant), while the risk of fractures was unexpectedly increased in the intervention group compared to the controls (odds ratio 2.39, p = 0.023). CONCLUSIONS: Future studies and public-health interventions to prevent domestic falls among community-dwelling older people at high risk of falling could benefit from a multicomponent approach including medication review, physical exercise and home risk assessment and should include assessment of risk factors for fractures.

A Dermatological Questionnaire for General Practitioners with a Focus on Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a skin chronic inflammatory disease typically located in several areas such as perianal, inguinal and axillary regions. In 40% to 70% of cases, general practitioners (GPs) are the first health care professionals consulted by patients suffering from HS. The role of GPs in HS management could be more substantial than it has been in the past. AIM: We developed a questionnaire to assess the knowledge of HS by GPs and to evaluate if in their perception the dermatologist is the reference medical doctor for pathology above. METHODS: The data were processed by a univariate descriptive statistical analysis. RESULTS: Our study showed GPs could recognise patients affected by HS. They have proven to know the main features of HS. Nevertheless, the second part of the questionnaire has highlighted the considerable confusion of GPs about who the reference figure is. CONCLUSION: The data registered regarding therapy and follow up too, only show a mild preponderance of dermatologist compared to other professional figures, such as a surgeon, GPs and plastic surgeon.

The 2016 Lifetime Immunization Schedule, approved by the Italian scientific societies: A new paradigm to promote vaccination at all ages.

Medical scientific societies have the core mission of producing, pooling and disseminating solid and updated scientific information. We report the successful experience of the partnership of four national Medical Scientific Societies active in Italy in producing scientific advice on vaccines and vaccination. In particular, i) the Italian Society of Hygiene, Preventive Medicine and Public Health; SitI, ii) the Italian Society of Paediatrics; SIP, iii) the "Italian Federation of General Practitioners"; FIMP, and iv) the Italian Federation of General Medicine FIMMG) have worked together since 2012 to produce shared evidence-based recommendations on vaccination schedules, namely the "Lifetime Immunization Schedule" which introduced for the first time in Italy a life-course approach to vaccination. The 2014 edition of the "Lifetime Immunization Schedule" was used as a basis to develop the 2017-2019 Italian National Prevention Plan, approved by The Italian Ministry of Health in February 2017. In this report, we present the structure, content and supporting evidence of the new 2016 "Lifetime Immunization Schedule" and we expand on the influential role of medical scientific societies in researching and advocating for effective and safe vaccination programmes' implementation at the national level.

Prevention of Herpes Zoster and its complications: From clinical evidence to real life experience.

Herpes zoster (HZ) is an acute viral illness characterized by a vesicular rash with unilateral distribution, which can also result in severe complications such as post-herpetic neuralgia (PHN), ophthalmic zoster, stroke or other neurological complications. The estimate incidence in Europe ranges between 2.0 and 4.6 cases per 1,000 person-years, with a sharp increase in >50 year-old subjects. Currently, treatment options for HZ are only partially effective in limiting the acute phase, while the management of complications is complex and often unsatisfactory. The total burden of the disease and the high costs related to its diagnostic and therapeutic management led researchers to develop a new preventive approach through a live attenuated virus vaccine. The currently available vaccine, with a high antigen content, is safe, well tolerated and reduces the incidence of HZ, PHN and the burden of illness. Several countries have introduced this vaccination, albeit with different recommendations and methods of financing. Taking into account the barriers to this immunization registered in some areas (difficulty of vaccine distribution, lack of physician recommendations, the cost of vaccine for patients, etc.), this group of Italian experts advocate that a common strategy able to guarantee a good compliance with this vaccination should be implemented. The same group addresses some practical questions concerning the use of zoster vaccine.

Preventing and managing herpes zoster: key actions to foster healthy aging.

Population aging is the demographic phenomenon characterizing all countries in the world, and it is challenging the national infrastructures, in particular health systems. However, aging itself is not associated with increased medical spending, but disability and comorbidity that affect older individuals are the actual drivers for health expenditures. Therefore, if people age in better health, medical spending may be significantly reduced. Preventative interventions proved to be effective in reducing/preventing disease and disability and often found to be cost effective, include diet and exercise interventions, medications, routine disease screenings, and immunizations. Vaccination can protect older citizens against life-threatening diseases, such as influenza, pneumococcal infections, tetanus, and against diseases which adversely impact their quality of life, such as herpes zoster (HZ). Including HZ vaccination in its citizens' lifetime immunization calendar can reinforce Europe's commitment toward active, healthy aging. This paper outlines the consensus statement of a group of Italian experts on HZ.

[Prevention of HPV cancer related through HPV-9: state of the art, potential benefits and open issues]. / HPV-9 e prevenzione dei tumori HPV correlati: stato dell'arte, potenziali benefici e problemi aperti.

HPV vaccines currently marketed in Italy (bivalent and quadrivalent against HPV 16-18 and HPV and 6,11,16,18 respectively) are an extraordinary tool for the primary prevention of HPV related diseases, particularly of the cervical cancer. Although the implementation of the organized vaccination programs has already translated (for some endpoint) in confirmation of clinical efficacy, remains excluded a significant proportion of the diseases linked to non-vaccine HPV types. The new nonavalent vaccine (HPV9), of impending commercialization, represents an evolution of the quadrivalent, the composition of which are added five high-risk HPV types (HPV 31,33,45,52,58). The high clinical-immunological efficacy in experimental trials against the new genotypes (> 96% for CIN2 +), and the equivalence immunogenic to the four already present in the previous vaccine, will render the use of HPV9 a tool able to control in an even more effective HPV disease. The potential of the new vaccine is linked to the reduction of the HPV cancer burden by 2-20% according to anatomical site, with major benefits for cervical cancer, vulvo-vaginal, penile and more limited benefits for anal tumours. Moreover, the potential benefits could be also linked to the reduction of incidence of pre-neoplastic lesions arising in the lower-genital tract, especially in the cervix (CIN2-3), so often cause lengthy and expensive diagnostic and therapeutic procedures. In the face of this broad provision of benefit from HPV9 vaccine, we have also to consider all the variables related to its introduction in the vaccination calendars: the market price, the schedule of administration (currently in three doses) and data regarding the cost-effectiveness. The authors recognize the new vaccine (currently registered only in the US) a lot of potential in the prevention of HPV-related diseases.

Reducing the burden of Herpes Zoster in Italy.

Herpes Zoster (HZ) is a viral disease with painful neuro-dermatologic manifestations. Incidence increases with age. In Italy, the estimated incidence is 6.3 cases/1000 person/year; hospital admissions are less than 2%, 69% in patients aged over 65 years. The most frequent complication of HZ is Post-Herpetic Neuralgia (PHN) characterized by metameric pain, allodynia, and hyperalgesia. In Italy 20.6% and 9.2% of HZ patients experience PHN after 3 and 6 months, respectively. Available antiviral and analgesic treatments are relatively unsatisfactory in reducing pain and length of the disease. Prevention has recently become possible with the live attenuated vaccine Oka/Merck. Clinical studies show a reduction of 51% in the incidence of the disease, 61% of its burden and 67% of PHN in vaccinees. Protection seems to be long lasting and vaccine safety matches registration requirements. Available evidence suggests that the costs for QALY (less than € 20 000) and avoided cases is favorable. Due to the heavy burden of disease, it is time to offer this vaccination to elderly population.

[Herpes Zoster and its prevention in Italy. Scientific consensus statement]. / L'Herpes Zoster e la prevenzione vaccinale in Italia. Documento scientifico di consenso.

In this paper, an Italian group of experts presents a revision of the available data about epidemiology and prevention of Herpes Zoster (HZ). HZ is an acute viral diseases caused by the reactivation of Varicella Zoster Virus (VZV). HZ is characterized by neurological and dermatological symptoms with a dermatomeric localization. The reactivation of the virus from the latent status in the sensitive ganglia increases with age and failing cell mediated immunity. In Europe, more than 95% of adults presents antibodies against VZV. Incidence of HZ is similar all over the world, related to the age of the population: from 2-3/1000 persons/year in the age group 20 to 50 years to 5/1000 in the 60 years old, 6-7/1000 between 70 and 80 up to >1/100 in older than 80. In Italy, about 157,000 new cases of HZ are estimated every year with an incidence of 6.3/1000 persons/year mostly in older adults. Among the hospitalized cases, 60% are over 65 years of age. The more frequent and severe complication of HZ is post herpetic neuralgia (PHN), characterized by severe localized pain lasting at least 3 month after the beginning of the acute phase. The pain is responsible for a sharp decrease in the quality of life. In Europe, PHN is described in 2.6-27% of HZ cases. In Italy, data obtained by a network of General Practitioner show PHN in 20.6% of HZ patients, while 9.2% of the patients still presents PHN at 6 months. The more frequent localization is thoracic; when the virus reactivate at the level of the ophthalmic division of the trigeminal nerve most patients develop ocular complications. The clinical and therapeutical managements of HZ patients is difficult and the results are often poor. Prevention of HZ e PHN in the population over 50 years is possible using a live attenuated vaccine containing VZV (Oka/Merck strain, not less than 19.400 plaque forming units), available since 2006. Efficacy of anti-HZ vaccine was demonstrated in two large clinical trials that showed a 51% reduction in the incidence of HZ and a 61% decrease of the burden of illness. Incidence of PHN showed a reduction of 67% in immunized subjects. Long-term follow-up showed a persistence of the protection even if a decrease was noted in older subjects and with time. Effectiveness studies confirm the data of clinical trials and numerous pharmaco-economical evaluation show a favorable profile of HZ vaccine. The vaccine is recommended in USA, Canada and some European countries for people over 60. The expert group concluded that HZ and PHN represent an important clinical and Public Health problem in Italy and that the possibility to prevent them should be carefully evaluated.

[Human Papillomavirus infection and vaccination: knowledge and attitudes of Italian general practitioners]. / Infezione da Papillomavirus umano e vaccinazione: conoscenze e ruolo dei medici di medicina generale.

OBJECTIVE: To assess General Pratictioner's (GPs) knowledge and attitudes about HPV infection and prevention. DESIGN AND PARTICIPANTS: A semi-structured survey was conducted from November to December 2013 among Italian GPs. Descriptive and univariate analyses were carried out. MAIN OUTCOME MEASURES AND RESULTS: 938 GPs were included in the study. 15% participated in continuing medical education courses focusing on HPV. GPs identified as HPV transmission routes: sexual (100%), cutaneous (15%), transplacental (13%), haematic (9%) and by air (2%); they considered HPV-related diseases: cervical (98%), vulvar and vaginal (42%), anal (39%), penile (38%) and oral (38%) cancer, genital warts (79%) and respiratory papillomatosis (12%). They knew HPV vaccination is to prevent HPV-associated cancer (60%), in particular cervical cancer (35%), genital warts (3%) and sexually transmitted diseases (2%). A total of 73% were aware of the existence of both available vaccines, 69% believed that immunization target population should be females before initiation of sexual activity, 87% knew the age of vaccine administration. No significant difference in knowledge was retrieved by age, gender, level of education or region of origin. CONCLUSION: We report a lack of knowledge on HPV infection and vaccination in GPs. GPs have a key role in the Italian health system. Although 12-year old patients are a small percentage of their patients, it is of fundamental importance to promote medical education and training among GPs in order to meet HPV coverage targets and control HPV-associated diseases.