Posterior component separation with TAR: lessons learned from our first consecutive 52 cases.

Patients with complex incisional hernia (IH) is a growing and challenging category that surgeons are facing in daily practice and represent indeed a technical challenge for most of them. The posterior component separation with TAR (PCS-TAR) has become the procedure of choice to repair most complex abdominal wall defects, including those with loss of domain, subxiphoid, subcostal, parastomal or after trauma and sepsis treated initially with "open abdomen" and in those scenarios in which the fascia closure was not performed to avoid an abdominal compartment syndrome. Most recent studies showed that the PCS-TAR represents a valid procedure in recurrent IH. The purpose of our study is to evaluate the reproducibility of the PCS-TAR, describing our experience, our surgical technique and the rate of postoperative complications and recurrences in a cohort of consecutive patients. 52 consecutive patients with complex IH, who underwent PCS-TAR at "Betania Hospital and Ospedale del Mare Hospital" in Naples between May 2014 and November 2019 were identified from a prospectively maintained database and reviewed retrospectively. There were 36 males (69%) and 16 females (31%) with a mean age of 57.88 (range 39-76) and Body mass index (BMI kg/m2) of 31.2 (24-45). More than half of patients (58%) were active smokers. Mean defect width was 13.6 cm (range 6-30) and mean defect area was about 267.9 cm2. Mean operative time was 228 min. Posterior fascial closure was reached in all cases, while anterior fascial closure only in 29 cases (56%). Mean hospital stay was 5.7 days. 27% of patients developed minor complications (Clavien-Dindo grade I-II) and one case (1.9%) major complication (Clavien-Dindo III). Seroma was registered in 23% of cases. SSI was reported to be 3.8% with no deep wound infection. Recurrence rate was 1.9% in a mean follow-up of 28 months. In Univariate analysis Bio-A surface > 600 cm2 and drain removal at discharge were significantly associated with major complications, while in a multivariate analysis only Bio-A surface > 600 cm2 was related. Considering univariate analysis for recurrences, number of drains, SSO, Clavien-Dindo score > 2 and defect area were significantly associated with recurrence, while in a multivariate analysis no variables were related. PCS-TAR is an indispensable tool in managing complex ventral hernias associated with a low rate of SSO and recurrence. Tobacco use, obesity and comorbidities cannot be considered absolute contraindications to PCS-TAR. Peri and postoperative management of complications and drainages have an impact on short term outcomes. Based on these outcomes, posterior component separation with transversus abdominis release has become our method of choice for the management of patients with complex ventral hernia requiring open hernia repair in selected patients.

Phylogenetic analysis in the clinical risk management of an outbreak of hepatitis C virus infection among transfused thalassaemia patients in Italy.

BACKGROUND: Occurrence of hepatitis C virus (HCV) infection is reduced by effective risk management procedures, but patient-to-patient transmission continues to be reported in healthcare settings. AIM: To report the use of phylogenetic analysis in the clinical risk management of an HCV outbreak among 128 thalassaemia outpatients followed at a thalassaemia centre of an Italian hospital. METHODS: Epidemiological investigation and root-cause analysis were performed. All patients with acute hepatitis and known chronic infection were tested for HCV RNA, HCV genotyping, and NS3, NS5A, and NS5B HCV genomic region sequencing. To identify transmission clusters, phylogenetic trees were built for each gene employing Bayesian methods. FINDINGS: All patients with acute hepatitis were infected with HCV genotype 1b. Root-cause analysis, including a lookback procedure, excluded blood donors as the source of HCV transmission. The phylogenetic analysis, conducted on seven patients with acute infection and eight patients with chronic infection, highlighted four transmission clusters including at least one patient with chronic and one patient with acute HCV infection. All patients in the same cluster received a blood transfusion during the same day. Two patients with acute hepatitis spontaneously cleared HCV within four weeks and nine patients received ledipasvir plus sofosbuvir for six weeks, all achieving a sustained virological response. CONCLUSION: Combined use of root-cause analysis and molecular epidemiology was effective in ascertaining the origin of the HCV outbreak. Antiviral therapy avoided the chronic progression of the infection and further spread in care units and in the family environment.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study.

BACKGROUND: A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use. METHODS: This population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005-2008, intervention: 2009-2010, post-intervention: 2011-2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates. RESULTS: The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2-150.3), 146.8 (95% CI: 143.6-150.0), and 140.8 (95% CI: 136.9-144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991-0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979-0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997-1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations. CONCLUSION: In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

How confident are physicians in deprescribing for the elderly and what barriers prevent deprescribing?

WHAT IS KNOWN AND OBJECTIVE: Deprescribing is the process of discontinuing or reducing the dosage of medications that are no longer appropriate or aligned with goals of care, which is paramount in elderly patients with multiple comorbidities and polypharmacy. The objective of this study was to assess the perceptions of primary care physicians on deprescribing for elderly patients and potential barriers to deprescribing that physicians experience in the Local Health Authority (LHA) of Parma, Emilia-Romagna, Italy. METHODS: One hundred and sixty physicians (57% of the total number of primary care physicians in Parma) attended an educational session related to deprescribing and were asked to anonymously complete a paper survey. Participants were asked to assess their level of agreement on nine questions about their perception of deprescribing and potential factors affecting the deprescribing process using a seven-point Likert-type scale. A correlation coefficient was calculated to assess the association between physicians' confidence in deprescribing and attitudes or barriers associated with deprescribing. RESULTS AND DISCUSSION: Many physicians (72%) reported general confidence in their ability to deprescribe. Most respondents (78%) reported they were comfortable deprescribing preventive medications, yet only half (53%) were comfortable deprescribing guideline-recommended therapies. Lack of evidence on discontinuing preventive medicines and concern about withdrawal side effects were reported to impede deprescribing by more than one-third of physicians. When medications were initially prescribed by another physician, 40% of physicians reported hesitance in deprescribing them. About half of physicians (45%) did not feel comfortable deprescribing when patients/caregivers believed that continuation of the medication was needed. Lack of time and difficulty engaging patients/caregivers in the deprescribing process were cited as barriers by about one in four physicians. There was no strong correlation between physicians' confidence and attitudes or barriers associated with deprescribing. WHAT IS NEW AND CONCLUSION: The study results show that physicians believe they are generally comfortable with deprescribing, although there are still several factors that hamper their ability to engage in the process. An improved understanding of physicians' views on deprescribing may help guide further research, and policies to help patients remain healthy while streamlining their medication regimen.

HCV NS3 sequencing as a reliable and clinically useful tool for the assessment of genotype and resistance mutations for clinical samples with different HCV-RNA levels.

OBJECTIVES: This study aims to evaluate the reliability and clinical utility of NS3 sequencing in hepatitis C virus (HCV) 1-infected patients who were candidates to start a PI-containing regimen. METHODS: NS3 protease sequencing was performed by in-house-developed HCV-1 subtype-specific protocols. Phylogenetic analysis was used to test sequencing reliability and concordance with previous genotype/subtype assignment by commercial genotyping assays. RESULTS: Five hundred and sixty-seven HCV plasma samples with quantifiable HCV-RNA from 326 HCV-infected patients were collected between 2011 and 2014. Overall, the success rate of NS3 sequencing was 88.9%. The success rate between the two subtype protocols (HCV-1a/HCV-1b) was similarly high for samples with HCV-RNA >3 log IU/mL (>92% success rate), while it was slightly lower for HCV-1a samples with HCV-RNA ≤3 log IU/mL compared with HCV-1b samples. Phylogenetic analysis confirmed the genotype/subtype given by commercial genotyping assays in 92.9% (303/326) of cases analysed. In the remaining 23 cases (7.1%), 1 was HCV-1g (previously defined as subtype 1a), 1 was HCV-4d (previously defined as genotype 1b) and 1 was HCV-1b (previously defined as genotype 2a/2c). In the other cases, NS3 sequencing precisely resolved the either previous undetermined/discordant subtype 1 or double genotype/subtype assignment by commercial genotyping assays. Resistance-associated variants (RAVs) to PI were detected in 31.0% of samples. This prevalence changed according to PI experience (17.1% in PI-naive patients versus 79.2% in boceprevir/telaprevir/simeprevir-failing patients). Among 96 patients with available virological outcome following boceprevir/telaprevir treatment, a trend of association between baseline NS3 RAVs and virological failure was observed (particularly for HCV-1a-infected patients: 3/21 failing patients versus 0/22 achieving sustained virological response; P = 0.11). CONCLUSIONS: HCV-NS3 sequencing provides reliable results and at the same time gives two clinically relevant pieces of information: a correct subtype/genotype assignment and the detection of variants that may interfere with the efficacy of PI.

Inappropriate prescribing in a large community-dwelling older population: a focus on prevalence and how it relates to patient and physician characteristics.

WHAT IS KNOWN AND OBJECTIVE: The prescription of potentially inappropriate medications (PIMs) for older adults is a well-known population health concern. Updated country-specific estimates of inappropriate prescribing in older adults using germane explicit criteria are needed to facilitate physician-tailored quality improvement strategies. Therefore, we sought to determine the prevalence of PIMs for older adults in Emilia-Romagna, Italy, using the updated Maio criteria. We also evaluated patient and general practitioner (GP) characteristics related to inappropriate prescribing. METHODS: Older adults (≥ 65) in 2012 were evaluated in a one-year retrospective study using administrative health care data. The 2011 Maio criteria includes 25 medications reimbursed by the Italian National Formulary, in the following categories in terms of severity: 16 medications that 'should always be avoided,' 3 that are 'rarely appropriate,' and 6 that have 'some indications although they are often misused.' To evaluate the extent of associations between patient and GP related characteristics, we used generalized estimating equations with an exchangeable covariance design to fit robust logistic regression models. RESULTS AND DISCUSSION: A total of 865,354 older adults were in the cohort and 28% had at least one PIM. Of the entire cohort, 8%, 10%, and 14% of individuals were prescribed at least one medication that 'should always be avoided,' is 'rarely appropriate,' and has 'some indications but are often misused,' respectively. Older patients (≥ 75) and females were more likely to be exposed to PIMs. 2,923 GPs were identified in the region, each having prescribed at least one PIM, of which older GPs (≥ 56), male GPs, and solo practice GPs were more likely to prescribe PIMs to their older patients. WHAT IS NEW AND CONCLUSION: The high prevalence of PIM exposure among older adults is a substantial issue in the region. Knowing how patient and GP characteristics relate to PIMs exposure may improve the design and targeting of initiatives for improving prescribing safety in this population.

Evaluating sustained quality improvements: long-term effectiveness of a physician-focused intervention to reduce potentially inappropriate medication prescribing in an older population.

WHAT IS KNOWN AND OBJECTIVES: Although quality improvement initiatives targeting physician practice patterns have been effective, evidence is lacking on their long-term sustainability. We previously demonstrated the success of a population-wide, physician-focused quality improvement intervention targeting potentially inappropriate prescribing (PIP) in an aged population of the Local Health Authority (LHA) of Parma, Italy. We sought to assess whether the decrease in PIP incidence rates achieved during the intervention was sustained after discontinuation of the intervention, and which factors modified the effectiveness of the intervention. METHODS: Using a regional administrative claims database, we assessed changes in quarterly PIP exposure incidence rates for each phase [pre-intervention (2005 Q1-2007 Q3), intervention (2007 Q4-2009 Q4) and post-intervention (2010 Q1-Q4)] of the study for both all and newly PIP-exposed patients. Piecewise-linear longitudinal logistic regression was used to model the odds of PIP exposure. RESULTS: 299 GPs (98·7%) serving 111,282 older patients were included. PIP incidence rates declined from 7·1% (pre-intervention) to 4·9% (intervention), and to 4·3% (post-intervention). There was no significant change in odds of PIP exposure following the intervention period (P = 0·52), and the rates of change in PIP exposure odds during pre-intervention and post-intervention periods were not significantly different (P = 0·39). The intervention was attributed to an 18% long-term reduction in the odds of PIP exposure. No assessed patient or GP characteristics modified this effect. Results among patients newly exposed to PIP were similar to results among all patients exposed to PIP. WHAT IS NEW AND CONCLUSION: The significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation. Because the intervention showed success across the spectrum of patients and providers, it shows promise for generalizability to other healthcare settings.

Hepatitis C virus genetic variability and the presence of NS5B resistance-associated mutations as natural polymorphisms in selected genotypes could affect the response to NS5B inhibitors.

Because of the extreme genetic variability of hepatitis C virus (HCV), we analyzed the NS5B polymerase genetic variability in circulating HCV genotypes/subtypes and its impact on the genetic barrier for the development of resistance to clinically relevant nucleoside inhibitors (NIs)/nonnucleoside inhibitors (NNIs). The study included 1,145 NS5B polymerase sequences retrieved from the Los Alamos HCV database and GenBank. The genetic barrier was calculated for drug resistance emergence. Prevalence and genetic barrier were calculated for 1 major NI and 32 NNI resistance variants (13 major and 19 minor) at 21 total NS5B positions. Docking calculations were used to analyze sofosbuvir affinity toward the diverse HCV genotypes. Overall, NS5B polymerase was moderately conserved among all HCV genotypes, with 313/591 amino acid residues (53.0%) showing ≤1% variability and 83/591 residues (14.0%) showing high variability (≥25.1%). Nine NNI resistance variants (2 major variants, 414L and 423I; 7 minor variants, 316N, 421V, 445F, 482L, 494A, 499A, and 556G) were found as natural polymorphisms in selected genotypes. In particular, 414L and 423I were found in HCV genotype 4 (HCV-4) (n = 14/38, 36.8%) and in all HCV-5 sequences (n = 17, 100%), respectively. Regardless of HCV genotype, the 282T major NI resistance variant and 10 major NNI resistance variants (316Y, 414L, 423I/T/V, 448H, 486V, 495L, 554D, and 559G) always required a single nucleotide substitution to be generated. Conversely, the other 3 major NNI resistance variants (414T, 419S, and 422K) were associated with a different genetic barrier score development among the six HCV genotypes. Sofosbuvir docking analysis highlighted a better ligand affinity toward HCV-2 than toward HCV-3, in agreement with the experimental observations. The genetic variability among HCV genotypes, particularly with the presence of polymorphisms at NNI resistance positions, could affect their responsiveness to NS5B inhibitors. A pretherapy HCV NS5B sequencing could help to provide patients with the full efficacy of NNI-containing regimens.

Risk of death associated with the use of conventional vs. atypical antipsychotic medications: evaluating the use of the Emilia-Romagna Region database for pharmacoepidemiological studies.

WHAT IS KNOWN AND OBJECTIVE: Since 2005, a mounting base of evidence has identified that conventional antipsychotic medications are associated with an increased risk of mortality among elderly patients when compared to atypical antipsychotics. This study sought to explore the feasibility of using the Emilia-Romagna Region (RER) database for comparative safety analyses by replicating and refining risk estimates of this well-known drug safety example through meta-analysis. METHODS: We identified a cohort of 23 681 Italian RER patients (aged ≥65) who initiated treatment with a conventional or atypical antipsychotic between 1 July 2009 and 30 June 2011. We compared 180-day mortality using Cox proportional hazards models adjusted for risk factors for death, use of other medications and measures of health services utilization intensity, all measured before antipsychotic initiation. We conducted a meta-analysis of studies with similar methods against which to compare our results. RESULTS: Among 14 462 and 9219 patients prescribed conventional and atypical antipsychotics, respectively, we observed 2402 (16·6%) and 821 (8·9%) deaths during follow-up. Conventional antipsychotic initiators were older and generally had higher prevalence of outcome risk factors and higher baseline health service use intensity. The crude hazard ratio (HR) was 1·95 [95% confidence interval (CI), 1·80-2·11], which decreased to 1·47 (95% CI, 1·35-1·60) after full adjustment. We identified seven published studies that examined this association using similar methods. The pooled HR from these studies was 1·34 (95% CI, 1·28-1·39). Including our study, the meta-analysis yielded a summary estimate of 1·35 (95% CI, 1·31-1·40) and did not introduce any heterogeneity (I(2)  = 0%; P = 0·455). WHAT IS NEW AND CONCLUSIONS: Our results support the use of the RER database for pharmacoepidemiological studies and provide an up-to-date and pooled estimate of the magnitude of the association between mortality and conventional vs. atypical antipsychotics.

Prognostic role of internal jugular vein preservation in neck dissection for head and neck cancer.

BACKGROUND AND OBJECTIVES: Sparing internal jugular vein (IJV) in neck dissection for head and neck cancer is controversial. We aimed at evaluating the prognostic impact of IJV preservation. METHODS: We examined 206 files of head and neck cancer patients who underwent radical or modified radical neck dissection at the Otolaryngology University of Florence. The site of primary tumor was larynx and hypopharynx in 44.66%, oropharynx in 25.24%, oral cavity in 23.3%, unknown in 4.85%, salivary glands and rhinopharynx in 0.97%. In 60.19% the IJV was resected, in 39.81% preserved. Prognostic impact of IJV preservation was assessed by Kaplan-Meier and multivariate analysis. RESULTS: Neck recurrence occurred in 25.2%: the IJV was resected in 42.31%, in 57.69% preserved (P = 0.02). At multivariate analysis, neck recurrence resulted significantly associated to extracapsular spread (ECS) (P = 0.009), IJV preservation (P = 0.01), positive margins (P = 0.02). In ECS positive patients, a higher risk of neck recurrence was documented for IJV preservation (P = 0.012). A worse prognosis was observed for patients with IJV spared (P = 0.06). CONCLUSIONS: IJV preservation is associated with an increased risk of neck failure and a worse outcome, mainly in patients with ECS of nodes.

Oestrogen receptor beta and melanoma: a comparative study.

BACKGROUND: Oncological research has focused on evaluating oestrogen receptors (ERs) in oestrogen-related tumours, and understanding the potential role of ERs in the pathophysiology of cancer. OBJECTIVES: To investigate the significance of oestrogen receptor beta (ERß) in melanoma. METHODS: We prospectively evaluated ERß expression in malignant melanoma (MM) tissue and adjacent healthy skin by quantitative immunohistochemistry at the Department of Dermatology of the University of Florence, from 1998 to 2010. RESULTS: ERß was detected with varying staining intensity in the 66 malignant melanocytic lesions. After adjusting for age and sex, we found that ERß expression was significantly lower in melanoma tissue compared with adjacent healthy skin (P < 0·0001). We also found significantly lower ERß levels in thick melanoma tissue compared with thin melanoma tissue. In addition, there was a positive association between Breslow thickness and the difference of ERß expression between healthy tissue and melanoma tissue (P = 0·0004). Consistent with sex differences in melanoma survival, men showed significantly lower levels of ERß than women in both melanoma (P = 0·05) and healthy tissues (P = 0·02). CONCLUSIONS: ERß expression is inversely associated with Breslow thickness and is significantly influenced by sex in MM.

Indolent cutaneous B-cell lymphoma: diagnosis and treatment 2012.

Among primary cutaneous B-cell lymphomas (CBCL), two main clinico-pathologic entities are recognized, i.e. marginal zone lymphoma (MZL), otherwise defined as extranodal MZL, MALT (Mucosa-Associated Lymphoid Tissue) type, and follicle center lymphoma (FCL). They are mostly characterized by indolent course (very limited risk of extracutaneous spread), very good response to non-aggressive treatment (radiotherapy is the gold standard), and excellent prognosis (>90% 5-year survival overall). The clinical presentation of MZL and FCL slightly differ concerning site predilection (trunk and upper limbs in the former, head&neck and trunk in the latter) and frequency of cases with multiple, non-contiguous lesions (higher in MZL). Histologically, MZL and FCL share the multiphasic evolution of lesions, while some distinctive features are clues to diagnosis and differential diagnosis: CD5-/CD10-/bcl2+ phenotype of neoplastic cells, "colonization" of reactive lymphoid follicles by neoplastic cells, lymphoplasmacytoid and plasma cells at the periphery of nodular infiltrates in MZL; CD5-, CD10 +/-, bcl6+, MUM-1 neg, FOX-P1 neg, IRF4 neg, IgM neg phenotype of neoplastic cells (centrocytes), and neoplastic follicles (in early lesions) in FCL.

Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy.

WHAT IS KNOWN AND OBJECTIVE: Increasing attention is being paid to inappropriate medication prescribing for the elderly. A growing body of studies have detected a prevalence of inappropriate prescribing ranging from 12% to 40% worldwide, including Regione Emilia-Romagna, Italy. To improve quality of prescribing, a multi-phase pilot project in the Local Health Unit (LHU) of Parma, Regione Emilia-Romagna, was established. This phase aimed to assess primary care physicians' knowledge of appropriate prescribing in elderly patients. METHODS: In total, 155 primary care physicians (51% of the total), convened by the LHU of Parma for an educational session, were asked to complete anonymously a 19-item paper survey. Knowledge of inappropriate medication use in the elderly was assessed using seven clinical vignettes based on the 2002 Beers Criteria. Topics tested included hypertension, osteoarthritis, arrhythmias, insomnia and depression. Data regarding physician's perceived barriers to appropriate prescribing for elderly patients were also collected. To evaluate the relationship between physician knowledge scores and physician characteristics, physicians were classified as having a 'low score' (three or below) or a 'high score' (six or more) with respect to their knowledge of prescribing for the elderly. RESULTS AND DISCUSSION: All physicians completed the survey. Most physicians (88%) felt confident in their ability to prescribe appropriate medications for the elderly. Thirty-nine physicians (25%) received a 'high score' compared to 26 (17%) who received a 'low score'. 'Lower score' respondents had been in practice for a longer time (P < 0·05) than 'higher score' respondents. Perceived barriers to appropriate prescribing included potential drug interactions (79% of respondents) and the large number of medications a patient is already taking (75%). WHAT IS NEW AND CONCLUSION: The study results show an unsatisfactory knowledge of appropriate prescribing among primary care physicians in the LHU of Parma, especially among older physicians. Educational strategies tailored to primary care physicians should be establish to enhance knowledge in this area and improve quality of prescribing.

Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study.

BACKGROUND AND OBJECTIVE: Inappropriate prescribing in the elderly population is a well-recognized problem in public health. The Beers criteria have been widely used to evaluate the quality of prescribing for the elderly. However, because the Beers criteria were developed in the United States, they are not fully applicable in Italy. The purpose of this study was to establish explicit criteria for potentially inappropriate medication prescribing (PIP) for the elderly and assess the prevalence of and factors associated with PIP among elderly residents in the Local Health Unit of Parma, Italy according to the developed criteria. METHODS: A nine-member expert panel was convened to identify a list of inappropriate medications reflecting the Italian prescribing habits. The panel decided to refine and update the 2002 Beers criteria. Consensus through a Nominal Group Technique was reached to classify the identified 23 inappropriate medications into three categories: 17 medications to be always avoided, three medications rarely appropriate, and three medications with some indications but often misused. A retrospective cohort study using the 2006 Parma Local Health Unit automated outpatient prescriptions database was conducted. The cohort comprised 91 741 elderly individuals >or=65 years with at least one prescription medication. PIP was defined as having a prescription claim for at least one inappropriate medication. RESULTS AND DISCUSSION: A total of 23 662 elderly in the cohort (25.8%) had at least one PIP. Of these, 14.1% received prescriptions for two medications of concern, and 2.0% for three or more. Using the expert panel's categories, 59.2% of the elderly receiving PIP had prescriptions for drugs that should always be avoided, 33.9% for rarely appropriate drugs, and 19.1% for drugs that have some indications but are often misused. Non-steroidal anti-inflammatory drugs (35.7% of subjects) were the most frequently occurring PIP, followed by ticlopidine (17.6%), doxazosin (15.5%), and amiodarone (13.6%). Female, older age, overall number of drugs prescribed, greater number of chronic conditions were factors associated with greater odds of receiving PIP. CONCLUSION: Via the developed criteria, the study corroborates that PIP among elderly outpatients is a substantial issue in Parma Local Health Unit, Italy. Knowledge of the prevalence of PIP and associated factors should gear efforts to develop strategies to reduce PIP in outpatient settings in Italy.