Hydrochlorothiazide and Prevention of Kidney-Stone Recurrence.

BACKGROUND: Nephrolithiasis is one of the most common conditions affecting the kidney and is characterized by a high risk of recurrence. Thiazide diuretic agents are widely used for prevention of the recurrence of kidney stones, but data regarding the efficacy of such agents as compared with placebo are limited. Furthermore, dose-response data are also limited. METHODS: In this double-blind trial, we randomly assigned patients with recurrent calcium-containing kidney stones to receive hydrochlorothiazide at a dose of 12.5 mg, 25 mg, or 50 mg once daily or placebo once daily. The main objective was to investigate the dose-response effect for the primary end point, a composite of symptomatic or radiologic recurrence of kidney stones. Radiologic recurrence was defined as the appearance of new stones on imaging or the enlargement of preexisting stones that had been observed on the baseline image. Safety was also assessed. RESULTS: In all, 416 patients underwent randomization and were followed for a median of 2.9 years. A primary end-point event occurred in 60 of 102 patients (59%) in the placebo group, in 62 of 105 patients (59%) in the 12.5-mg hydrochlorothiazide group (rate ratio vs. placebo, 1.33; 95% confidence interval [CI], 0.92 to 1.93), in 61 of 108 patients (56%) in the 25-mg group (rate ratio, 1.24; 95% CI, 0.86 to 1.79), and in 49 of 101 patients (49%) in the 50-mg group (rate ratio, 0.92; 95% CI, 0.63 to 1.36). There was no relation between the hydrochlorothiazide dose and the occurrence of a primary end-point event (P = 0.66). Hypokalemia, gout, new-onset diabetes mellitus, skin allergy, and a plasma creatinine level exceeding 150% of the baseline level were more common among patients who received hydrochlorothiazide than among those who received placebo. CONCLUSIONS: Among patients with recurrent kidney stones, the incidence of recurrence did not appear to differ substantially among patients receiving hydrochlorothiazide once daily at a dose of 12.5 mg, 25 mg, or 50 mg or placebo once daily. (Funded by the Swiss National Science Foundation and Inselspital; NOSTONE ClinicalTrials.gov number, NCT03057431.).

Habitual coffee and caffeinated beverages consumption is inversely associated with arterial stiffness and central and peripheral blood pressure.

The effects of chronic coffee consumption on the cardiovascular system are still under debate. Aortic stiffness, wave reflections, and central and peripheral blood pressure (BP) are milestone indicators of cardiovascular-risk. We sought to investigate the association between coffee and caffeine consumption, arterial stiffness, and central/peripheral BP. Aortic stiffness was evaluated via pulse wave velocity (PWV); wave reflections with the augmentation index (AIx);peripheral systolic BP (SBP), diastolic BP (DBP), and central BP (cSBP/cDBP) were non-invasively assessed. Coffee and caffeine consumption was ascertained using a questionnaire. A linear inverse relationship between coffee and caffeine consumption and arterial stiffness and central and peripheral BP was found.Light coffee and caffeine consumers showed ß-coefficients for PWV-0.15, SBP-3.61, DBP-2.48, cSBP-3.21, and cDBP-2.18 (all p values < 0.05).Present findings suggest that coffee and caffeine consumption is inversely associated with arterial stiffness and central and peripheral BP in a large population sample. Interventional prospective studies are needed to demonstrate the causal association.

Insomnia disorder: clinical and research challenges for the 21st century.

BACKGROUND AND PURPOSE: Insomnia is a common and debilitating disorder that is frequently associated with important consequences for physical health and well-being. METHODS: An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years, discussed the current challenges in the field of insomnia and identified future priorities. RESULTS: The association of trajectories of insomnia with subsequent quality of life, health and mortality should be investigated in large populations. Prospective health economics studies by separating the costs driven specifically by insomnia and costs attributable to its long-term effects are needed. Ignoring the heterogeneity of insomnia patients leads to inadequate diagnosis and inefficient treatment. Individualized interventions should be promoted. More data are needed on both the impact of sleep on overnight effects, such as emotion regulation, and the potential compensatory effort to counteract diurnal impairments. Another gap is the definition of neurocognitive deficits in insomnia patients compared to normal subjects after chronic sleep loss. There are also a number of key gaps related to insomnia treatment. Expert guidelines indicate cognitive-behavioural therapy for insomnia as first-line treatment. They neglect, however, the reality of major healthcare providers. The role of combined therapy, cognitive-behavioural therapy for insomnia plus pharmacological treatment, should be evaluated more extensively. CONCLUSION: Whilst insomnia disorder might affect large proportions of the population, there are a number of significant gaps in the epidemiological/clinical/research studies carried out to date. In particular, the identification of different insomnia phenotypes could allow more cost-effective and efficient therapies.

Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals.

BACKGROUND: The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation. METHODS: Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed. RESULTS: A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction. CONCLUSIONS: Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.

Ionized and total serum magnesium in hemodialysis: predictors and variability. A longitudinal cross-sectional study.

BACKGROUND: Ionized Magnesium (ion-Mg) represents the active biological fraction of the serum magnesium content. The assessment of total serum Mg (tot-Mg) might not accurately identify patients with hypo-or hyper-magnesaemie. In hemodialysis, serum tot-Mg levels in the upper part of the distribution, have been associated with reduced mortality and fewer vascular calcifications; thus, resulting in the tendency to increase the Mg concentration in the dialysate, traditionally set at 0.5 mmol/L. METHODS: Single-center study in chronic hemodialysis patients, designed in two phases, cross-sectional and longitudinal, aimed to investigate: (1) the sensitivity for pathological values of ion-Mg compared to tot-Mg (2) the predictors of ion-Mg developing ad hoc equations; (3) the inter- and intra-individual variabilities of ion-Mg; and (4) the risk factors for hypermagnesemia. Tot-Mg, ion-Mg, and covariates of 42 hemodialysis sessions, in 42 patients during the cross-sectional phase and of 270 sessions in 27 patients in the longitudinal one were analysed. RESULTS: Ion-Mg significantly correlates with tot-Mg: ß = 0.52; r = 0.88, p < 0.001. Multiple linear regressions in normo- and hypo-albuminemic patients gave the following results: ion-Mg = tot-Mg/2-K+/50 + Ca2+/5-HCO3-/100 and ion-Mg = tot-Mg/2 + albumin/100. Ion-Mg showed a high temporal variability in the longitudinal phase (between months p < 0.001; winter vs. summer, p < 0.027). A high intra-individual variability was also found: coefficient of variation 0.116. Comparing patients with high and low intra-individual variability, we found: age 67 vs. 77 years; p < 0.001; urea 26.3 ± 0.5 vs. 21.2 ± 0.4 mmol/L, p < 0.001; nPCR 0.92 ± 0.1 vs. 0.77 ± 0.1 g/kg day, p < 0.001; PTH 46.3 ± 4 vs. 28.5 ± 3 pmol/L, p < 0.001. CONCLUSIONS: Ion-Mg can be useful in unmasking unrecognized hyper- and hypo-magnesemic and false hyper-magnesemic patients. Ion-Mg is characterized by high intra- and inter-individual variabilities particularly in younger women and those with better nutrition. Patients with greater variability could potentially be at risk if exposed to higher concentrations of magnesium in the dialysate. An interventional study, with controlled increase of magnesium concentrations in the dialysate has been planned.

Efficacy of standard and low dose hydrochlorothiazide in the recurrence prevention of calcium nephrolithiasis (NOSTONE trial): protocol for a randomized double-blind placebo-controlled trial.

BACKGROUND: Nephrolithiasis is a global healthcare problem with a current lifetime risk of 18.8% in men and 9.4% in women. Given the high cost of medical treatments and surgical interventions as well as the morbidity related to symptomatic stone disease, medical prophylaxis for stone recurrence is an attractive approach. Thiazide diuretics have been the cornerstone of pharmacologic metaphylaxis for more than 40 years. However, evidence for benefits and harms of thiazides in the prevention of calcium containing kidney stones in general remains unclear. In addition, the efficacy of the currently employed low dose thiazide regimens to prevent stone recurrence is not known. METHODS: The NOSTONE trial is an investigator-initiated 3-year prospective, multicenter, double-blind, placebo-controlled trial to assess the efficacy of standard and low dose hydrochlorothiazide treatment in the recurrence prevention of calcium containing kidney stones. We plan to include 416 adult (≥ 18 years) patients with recurrent (≥ 2 stone episodes in the last 10 years) calcium containing kidney stones (containing ≥50% of calcium oxalate, calcium phosphate or a mixture of both). Patients will be randomly allocated to 50 mg or 25 mg or 12.5 mg hydrochlorothiazide or placebo. The primary outcome will be incidence of stone recurrence (a composite of symptomatic or radiologic recurrence). Secondary outcomes will be individual components of the composite primary outcome, safety and tolerability of hydrochlorothiazide treatment, changes in urinary biochemistry elicited by hydrochlorothiazide treatment and impact of baseline disease severity, biochemical abnormalities and stone composition on treatment response. DISCUSSION: The NOSTONE study will provide long-sought information on the efficacy of hydrochlorothiazide in the recurrence prevention of calcium containing kidney stones. Strengths of the study include the randomized, double-blind and placebo-controlled design, the large amount of patients studied, the employment of high sensitivity and high specificity imaging and the exclusive public funding support. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03057431 . Registered on February 20 2017.

A multi-level strategy for a long lasting reduction in unnecessary laboratory testing: A multicenter before and after study in a teaching hospital network.

BACKGROUND: Reducing unnecessary laboratory blood testing in the hospital setting represents a challenge to improve the adequacy of healthcare and a tricky task for teaching hospitals. Our hospital network actively participates in the Choosing Wisely Campaign and is engaged in avoiding unnecessary low value interventions and investigations. We aimed to study whether a multi-level approach combining educational and web-system based interventions, could be effective in reducing laboratory testing and related costs. METHODS: Multicenter, proof of concept, prospective, observational, before and after study, in a network of public hospitals in Switzerland. All patients admitted between 1 January 2015 and 31 December 2017 were analyzed. A multi-level strategy based on online continuous monitor benchmarking and educational support was applied in the internal medicine services. The primary outcome was a significant reduction in the number of laboratory tests per patient and per day during the hospital stay. Secondary outcomes were reduction in the blood sample volume taken per patient and per day in laboratory costs. RESULTS: Over the 36 months of the study, 33 309 admissions were analyzed. A significant reduction of laboratory tests per patient and per day of hospitalisation was found:-11%, P-value<0.001; -6%, P-value <0.001. The mean monthly blood volume, per patient and per day of hospital stay and laboratory costs per patient was also significantly reduced: -7%, P-value<0.05; -3%, P-value<0.01, and -17%, P-value<0.01, respectively. CONCLUSIONS: The obtained reduction in the number of laboratory tests, blood volume withdrawn and related costs, support the idea that an open web-based system, involving all health care providers, coupled with educational interventions, can be helpful in generating awareness of prescriber habits and to catalyze changes in their behaviour. The peer pressure related to the unmasked benchmarking process did probably play a determinant role.

[Benzodiazepines in elderly patients : the dark side of a magic pill]. / Benzodiazépines chez les patients âgés : le côté sombre d'une pilule magique.

Clinical studies show that prescription of benzodiazepines increases with age, and well outside of recognized indications. It often is inappropriate and abusive. Its consequences can be very serious and considerably increase patients' morbidity and mortality. Strategies exist to stop these medications through a multidisciplinary approach. Widespread campaigns are necessary to correct what has become a significant public health problem.

Les études cliniques montrent que la prescription de benzodiazépines augmente avec l'âge et se fait en dehors des indications reconnues. Elle est souvent inappropriée et abusive. Ses conséquences peuvent être très sérieuses et augmentent considérablement la morbidité et la mortalité des patients. Des stratégies de prise en charge multidisciplinaire existent qui permettent d'interrompre ces traitements. D'importantes campagnes de sensibilisation sont nécessaires pour corriger ce qui est devenu un réel problème de santé publique.

New anthropometry-based age- and sex-specific reference values for urinary 24-hour creatinine excretion based on the adult Swiss population.

BACKGROUND: Urinary creatinine excretion is used as a marker of completeness of timed urine collections, which are a keystone of several metabolic evaluations in clinical investigations and epidemiological surveys. METHODS: We used data from two independent Swiss cross-sectional population-based studies with standardised 24-hour urinary collection and measured anthropometric variables. Only data from adults of European descent, with estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2 and reported completeness of the urinary collection were retained. A linear regression model was developed to predict centiles of the 24-hour urinary creatinine excretion in 1,137 participants from the Swiss Survey on Salt and validated in 994 participants from the Swiss Kidney Project on Genes in Hypertension. RESULTS: The mean urinary creatinine excretion was 193 ± 41 µmol/kg/24 hours in men and 151 ± 38 µmol/kg/24 hours in women in the Swiss Survey on Salt. The values were inversely correlated with age and body mass index (BMI). CONCLUSIONS: We propose a validated prediction equation for 24-hour urinary creatinine excretion in the general European population, based on readily available variables such as age, sex and BMI, and a few derived normograms to ease its clinical application. This should help healthcare providers to interpret the completeness of a 24-hour urine collection in daily clinical practice and in epidemiological population studies.

A prospective observational study comparing a non-operator dependent automatic PWV analyser to pulse pressure, in assessing arterial stiffness in hemodialysis.

BACKGROUND: Chronic kidney disease (CKD) accelerates vascular stiffening related to age. Arterial stiffness may be evaluated measuring the carotid-femoral pulse wave velocity (PWV) or more simply, as recommended by KDOQI, monitoring pulse pressure (PP). Both correlate to survival and incidence of cardiovascular disease. PWV can also be estimated on the brachial artery using a Mobil-O-Graph; a non-operator dependent automatic device. The aim was to analyse whether, in a dialysis population, PWV obtained by Mobil-O-Graph (MogPWV) is more sensitive for vascular aging than PP. METHODS: A cohort of 143 patients from 4 dialysis units has been followed measuring MogPWV and PP every 3 to 6 months and compared to a control group with the same risk factors but an eGFR > 30 ml/min. RESULTS: MogPWV contrarily to PP did discriminate the dialysis population from the control group. The mean difference translated in age between the two populations was 8.4 years. The increase in MogPWV, as a function of age, was more rapid in the dialysis group. 13.3% of the dialysis patients but only 3.0% of the control group were outliers for MogPWV. The mortality rate (16 out of 143) was similar in outliers and inliers (7.4 and 8.0%/year). Stratifying patients according to MogPWV, a significant difference in survival was seen. A high parathormone (PTH) and to be dialysed for a hypertensive nephropathy were associated to a higher baseline MogPWV. CONCLUSIONS: Assessing PWV on the brachial artery using a Mobil-O-Graph is a valid and simple alternative, which, in the dialysis population, is more sensitive for vascular aging than PP. As demonstrated in previous studies PWV correlates to mortality. Among specific CKD risk factors only PTH is associated with a higher baseline PWV. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02327962.

[Choosing Wisely: from theory to practice]. / "Choosing Wisely": von der Theorie zur Praxis.

"Choosing Wisely" is an innovative approach that the Network of Southern Switzerland Public Hospitals has decided to promote. Five standard diagnostic or therapeutic procedures have been chosen to explore the potential benefit of the "Choosing Wisely" initiative: the prescription of benzodiazepines, proton pump inhibitors or antibiotics on discharge from hospital, exposure to ionising radiation in radiological imaging and the number of blood samples taken during hospitalisation. As a first step we compared these variables in the medical and surgical departments of the four major public hospitals in Ticino. We observed significant and unexpected practical differences between specialties and between the different institutions. These results were presented to all concerned healthcare stakeholders. The next steps are to develop continuous monitoring of these indicators and specific recommendations by involving patients in the consciousness-raising process.

Prevalence of obesity and overweight and associated nutritional factors in a population-based Swiss sample: an opportunity to analyze the impact of three different European cultural roots.

PURPOSE: Obesity represents a growing public health concern worldwide. The latest data in Switzerland rely on self-reported body mass index (BMI), leading to underestimation of prevalence. We reassessed the prevalence of obesity and overweight in a sample of the Swiss population using measured BMI and waist circumference (WC) and explored the association with nutritional factors and living in different linguistic-cultural regions. METHODS: Data of 1,505 participants of a cross-sectional population-based survey in the three linguistic regions of Switzerland were analyzed. BMI and WC were measured, and a 24-h urine collection was performed to evaluate dietary sodium, potassium and protein intake. RESULTS: The prevalence of overweight, obesity and abdominal obesity was 32.2, 14.2 and 33.6%, respectively. Significant differences were observed in the regional distribution, with a lower prevalence in the Italian-speaking population. Low educational level, current smoking, scarce physical activity and being migrant were associated with an higher prevalence of obesity. Sodium, potassium and protein intake increased significantly across BMI categories. CONCLUSIONS: Obesity and overweight affect almost half of the Swiss adolescents and adults, and the prevalence appears to increase. Using BMI and WC to define obesity led to different prevalences. Differences were furthermore observed across Swiss linguistic-cultural regions, despite a common socio-economic and governmental framework. We found a positive association between obesity and salt intake, with a potential deleterious synergistic effect on cardiovascular risk.

Integrating Pharmacomechanical Treatments for Pulmonary Embolism Management within a Hub-and-Spoke System in the Swiss Ticino Region.

The Swiss Ticino regional pulmonary embolism response team (PERT) features direct access to various pharmacomechanical PE management options within a hub/spoke system, by integrating evidence, guidelines' recommendations and personal experiences. This system involves a collaborative management of patients among the hospitals distributed throughout the region, which refer selected intermediate-high or high PE patients to a second-level hub center, located in Lugano at Cardiocentro Ticino, belonging to the Ente Ospedaliero Cantonale (EOC). The hub provides 24/7 catheterization laboratory activation for catheter-based intervention (CBI), surgical embolectomy and/or a mechanical support system such as extracorporeal membrane oxygenation (ECMO). The hub hosts PE patients after percutaneous or surgical intervention in two intensive care units, one specialized in cardiovascular anesthesiology, to be preferred for patients without relevant comorbidities or with hemodynamic instability and one specialized in post-surgical care, to be preferred for PE patients after trauma or surgery or with relevant comorbidities, such as cancer. From April 2022 to December 2023, a total of 65 patients were referred to the hub for CBI, including ultrasound-assisted catheter-directed thrombolysis (USAT) or large-bore aspiration intervention. No patient received ECMO or underwent surgical embolectomy.

Reticulocyte dynamic and hemoglobin variability in hemodialysis patients treated with Darbepoetin alfa and C.E.R.A.: a randomized controlled trial.

BACKGROUND: In a simulation based on a pharmacokinetic model we demonstrated that increasing the erythropoiesis stimulating agents (ESAs) half-life or shortening their administration interval decreases hemoglobin variability. The benefit of reducing the administration interval was however lessened by the variability induced by more frequent dosage adjustments. The purpose of this study was to analyze the reticulocyte and hemoglobin kinetics and variability under different ESAs and administration intervals in a collective of chronic hemodialysis patients. METHODS: The study was designed as an open-label, randomized, four-period cross-over investigation, including 30 patients under chronic hemodialysis at the regional hospital of Locarno (Switzerland) in February 2010 and lasting 2 years. Four subcutaneous treatment strategies (C.E.R.A. every 4 weeks Q4W and every 2 weeks Q2W, Darbepoetin alfa Q4W and Q2W) were compared with each other. The mean square successive difference of hemoglobin, reticulocyte count and ESAs dose was used to quantify variability. We distinguished a short- and a long-term variability based respectively on the weekly and monthly successive difference. RESULTS: No difference was found in the mean values of biological parameters (hemoglobin, reticulocytes, and ferritin) between the 4 strategies. ESAs type did not affect hemoglobin and reticulocyte variability, but C.E.R.A induced a more sustained reticulocytes response over time and increased the risk of hemoglobin overshooting (OR 2.7, p = 0.01). Shortening the administration interval lessened the amplitude of reticulocyte count fluctuations but resulted in more frequent ESAs dose adjustments and in amplified reticulocyte and hemoglobin variability. Q2W administration interval was however more favorable in terms of ESAs dose, allowing a 38% C.E.R.A. dose reduction, and no increase of Darbepoetin alfa. CONCLUSIONS: The reticulocyte dynamic was a more sensitive marker of time instability of the hemoglobin response under ESAs therapy. The ESAs administration interval had a greater impact on hemoglobin variability than the ESAs type. The more protracted reticulocyte response induced by C.E.R.A. could explain both, the observed higher risk of overshoot and the significant increase in efficacy when shortening its administration interval. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01666301.

Circadian Urinary Excretion of Water, and Not Salt, Is Affected by the White Coat Effect.

Hypertension is an important morbidity factor. The prognostic consequences of the white-coat effect have been studied extensively. The repercussion on the circadian rhythm of urinary water and salt excretion in the same subgroup remain, conversely, among the open topics. Postulating an impaired diurnal sodium and volume excretion we decided to investigate both, in subjects with or without a white-coat effect, in the general population. A sample of 1023 subjects, has been considered. We collected 24-h urine samples, divided in day and night, and we measured the blood pressure with an Ambulatory Blood Pressure Monitoring (ABPM). ABPM values were then compared with physician collected in-office values to assign subjects to the group with or without the white-coat effect. Concerning the circadian pattern of urinary sodium excretion, we found no significant differences between the groups. There was instead in the white-coat effect group a higher night/day ratio of urinary water excretion. The white-coat effect, has been considered a potential hypertension precursor, and its consequent handling could be prospectively relevant in hypertension prevention. The absence of repercussions on the urinary circadian sodium excretion pattern and on the potentially related risk factors in subjects with a white coat effect is reassuring. The clinical significance of the impact on the night/day ratio of water excretion needs to be further investigated.

A Population-Based Scoring System to Assess the Impact of Individual Risk Factors on Vascular Health.

Arterial stiffness is an indicator of vascular health, influenced by both pathological conditions and physiological determinants, noticeably age. Augmentation index (AI) and pulse wave velocity (PWV) are used among others to assess arterial stiffness. Several risk factors may contribute to pathologically increase arterial stiffness and produce early vascular aging. Our study aims to assess the impact of individual risk factors on vascular health, evaluating the distribution of PWV and AI values in a cohort of adult people without modifiable cardiovascular risk factors while analyzing their role in accelerating vascular ageing. We performed a secondary analysis of a Swiss population-based research project, which took place in 2017 and 2018. Of the 1202 participants originally enrolled, 1097 were included in the final sample. The population was divided into without (n=388) and with risk factors (n=709), based on the presence of the following: smoking, diabetes, previous cardiovascular disease (CVD), chronic kidney disease stage 3 or more, LDL cholesterol ≥ 4.11 or treatment with hypolipidemic drugs, hypertension or treatment with antihypertensive drugs, and metabolic syndrome. Tonometric and oscillometric devices were employed to assess PWV, and the 75th percentiles of PWV and AI in the population without risk factors were calculated to identify cut-offs for the logistic regression analysis. We developed nomograms by assigning a numerical score to each independent prognostic factor; the total score estimating the probability of PWVs and AIs being over the defined cut-offs. Patients with hypertension, diabetes, and obesity showed higher PWV values (p < 0.001). In the univariate logistic regression, factors predictive for higher PWV values were diabetes, CVDs, hypercholesterolemia, and hypertension, while CVDs, antihyperlipidemic treatment, hypertension, and increased BMI were predictive in the multivariate logistic regression. Smoking did not significantly influence arterial stiffness parameters. The present study provides reference values for PWV and AI in subjects without modifiable cardiovascular risk factors and, through nomograms, a risk score stratification to assess the impact of individual risk factors on vascular health.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. METHODS: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. RESULTS: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random "first come-first serve" basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). CONCLUSION: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

The interplay between previous infection and mental health condition on antibody response to COVID-19 mRNA vaccination.

Increasing evidence has been pointing towards the existence of a bi-directional interplay between mental health condition and immunity. Data collected during the COVID-19 outbreak suggest that depressive symptoms may impact the production of antibodies against SARS-CoV-2, while a previous infection could affect the immune response and cause neuropsychological disturbances. A prospective observational study was designed to investigate the association between mental health conditions and immune response over time. We analyzed the mental health at baseline and the antibodies before and after immunization with the COVID-19 mRNA vaccine in a cohort of healthcare professionals in southern Switzerland. One-hundred and six subjects were enrolled. Anxiety, distress and depression correlated to each other. There were no correlations between the mentioned variables and the vaccine induced IgG antibodies against the receptor binding domain (RBD) of the spike protein. For those who had a previous COVID-19 infection, the antibodies increased according to the grade of depression. For those who did not, the anti-RBD IgG levels remained similar when comparing presence or absence of depression symptoms. Our results show that previous SARS-CoV-2 natural infection in subjects with mental health conditions enhances the immune response to COVID-19 mRNA vaccination. The correlation between immune response to COVID-19 vaccination, a previous exposure to the virus, and symptoms of mood disorders, makes it necessary to explore the direction of the causality between immune response and depressive symptoms.