Total parenteral nutrition is associated with worse hospital outcomes among elderly diabetic patients: a propensity score matched analysis on discharge records.

Background: Recent trials and reviews have raised question about the safety of total parenteral nutrition (TPN), due to the increased rate of TPN related complications. Diabetic patients are vulnerable to hyperglycaemia, and poor studies have investigated hospital out-comes of diabetic patients requiring TPN. The aim of this study was to evaluate the association of in-hospital mortality, prolonged length of stay and transfer to long-term care facilities among diabetic patients with TPN. Methods: The study considered all hospital admissions of diabetic patients over 65 years of age performed between 2006 and 2015 in Abruzzo Region, Italy. To compare the outcomes of TPN and non-TPN patients, a propensity score matching procedure was performed. Results: A total of 140,556 admissions were analyzed. After matching, 1947 patients were included into the analyses: 649 patients with TPN and 1298 controls. TPN was significantly associated to in-hospital mortality (OR=7.15; 95%CI 5.54-9.22), prolonged LOS (OR=2.78; 95%CI 2.28-3.38) and transfer to LTCF (OR=2.16; 95%CI 1.64-2.85). Discussion: TPN is associated with poor outcomes among elderly diabetic patients in the Italian setting. Being aware of the risk factors among diabetic patients with TPN can be used to anticipate the patients' needs during the admission and the immediate post-discharge period.

Predictors of Prolonged Hospitalization and In-Hospital Mortality After Hip Fracture: A Retrospective Study on Discharge Registry.

Background: Hip fracture injury is one of the principal health problems affecting the elderly. Patients reporting hip fractures often show relevant comorbidities leading to prolonged hospital stay, significant complications and higher mortality rates. This study aims to assess the risk factors associated with prolonged hospitalization after hip fracture, in-hospital mortality and transfers to other facilities. Study design: Retrospective cross-sectional study. Methods: The study considered all admissions performed between 2006 and 2015 in Abruzzo region, Italy. Logistic regression analyses were performed to evaluate odds ratios for each risk factor as predictor of in-hospital mortality, length of stay, and transfer to other facilities. Results: Age over 85 (OR=5.38) and cancer (OR=3.62) were identified as the strongest risk predictors for in hospital mortality; diabetes (OR=2.24) and heart failure (OR=1.57) were identified as predictors of prolonged length of stay and age over 85 (OR=1.38) and atrial fibrillation (OR=1.69) were identified as predictors of transfer to other facilities. Conclusions: With the rising incidence of hip fractures, identification of modifiable factors may help to reduce morbidity and mortality.

The Revolving Door Phenomenon: Psychiatric Hospitalization and Risk of Readmission Among Drug-Addicted Patients.

BACKGROUND: Substance use may influence the onset and course of psychiatric diseases. The "Revolving door" (RD) phenomenon, which indicates repeated hospitalizations of the same patients, has become a public health. OBJECTIVES: The aim of this study was detecting the risk factors associated to hospital readmission to psychiatric wards of drug-addicted patients. METHODS: The study considered all the admissions performed between 2006 and 2015 in Abruzzo, Italy. Only the hospital discharge registry having code 304 (drug dependence) as diagnosis was taken into account. In addition, only the patients with a psychiatric DRG were included. RESULT: 325 patients performed 558 psychiatric admissions during the study period (1089 person-years). The analyses of the discharge registry showed "Psychoses" as the main DRG (73.2%). An amount of 119 patients experienced a second psychiatric admission. Psychiatric readmissions were independently predicted by Schizofrenia (HR=2.061) and Anxiety disorders (HR=0.326). CONCLUSION: Psychiatric hospitalization and readmission are frequent among drug-addicted patients. The subsequent RD phenomenon has become a public health issue, both for health and economic sides.

Trend in Hospital Admissions of Drug Addicts and Associated Factors from 2006 to 2015: an Observational Study on the Hospitals' Discharge Registries from a Region of Central Italy.

BACKGROUND: Several social, economic and political factors have contributed to the global spread of alcohol and other drugs. Drug addiction represents a huge expense for the society in terms of direct and indirect health and social consequences, as it is associated with numerous medical issues such as HIV, other infections and psychiatric disturbances. OBJECTIVES: The aim of this study was the assessment of the hospital admissions among drug addicted patients in Abruzzo Region, central Italy, from 2006 to 2015, in order to clarify the specific causes of hospitalization. METHODS: Data were collected from all hospital discharge records, taking into account only the hospital discharge registrations coded 304 (drug dependence). Multivariate logistic regression was performed to evaluate factors associated with main causes of the admission. RESULTS: Between 2006 and 2015, an amount of 2,159 drug-addicted subjects, aged 38.0±9.7 years, were admitted to hospital. Most of the admissions occurred in public hospitals (2,039, 94.4%), through the emergency room access (1,503, 69.6%) From an amount of 2,159 hospitalizations, 1,178 (54.6%) were first and 981 (45.4%) were subsequent admissions. The most frequent cause of hospitalization was "Psychosis" (419, 19.4%). The trend by range of age showed a progressive reduction in hospital admissions for patients aged < 45 y. Further, an increase in the hospitalization rate was estimated over recent years among drug addict subjects aged 25-45 years. Cannabis consumption was associated with mental disorder admissions (OR: 3.16, p<0.001), opioid consumption was associated with hepatic disorder admission (OR:2.16, p<0.001) and cardiovascular admissions (OR: 1,78, p<0.001), and cocaine was associated with cardiovascular admissions (OR:1,55, p:<0.001). CONCLUSIONS: Mental disorders result to be the leading cause of hospitalization among drug-addicts, principally associated with cannabis abuse. Opioid and cocaine abuse was associated with hepatic and cardiovascular disorders.

Predictors and Trend of Ketoacidosis Hospitalization Rate in Type 2 Diabetes Mellitus Patients from 2006 to 2015 in Abruzzo Region, Italy.

AIMS: This study aimed to assess the trend of hospitalizations for DKA in adult patients with type 2 diabetes mellitus and its associated factors. DESIGN: A retrospective cross-sectional study was performed. Data were collected from hospital discharge records (HDRs) of patients (age ≥18) with either primary or secondary discharge diagnosis for DKA and type 2 diabetes from 2006 to 2015 in Abruzzo region. Age-adjusted hospitalization rates were computed by gender and standardized on the regional population in 2006. A logistic regression model was implemented using presence of DKA as dependent variable. RESULTS: We identified 160,366 HDRs with type 2 diabetes. Out of them, 1611 (1.00%) were due to DKA. The hospitalization rates for DKA increased both for male +115.9 and female +142.8%, from 2006 to 2015. The most significant predictors of DKA were age 18-44 (aOR=4.17), uncontrolled diabetes (aOR=1.79), trauma (aOR=1.38), any infection (aOR=1.68), liver disease (aOR=1.29), fluid and electrolyte disorders (aOR=2.09), psychosis (aOR=1.69). CONCLUSIONS: Trends of DKA in adult patients with type 2 diabetes has been increasing in both male and female. Multimorbidity is an open challenge for public health, therefore better coordination is needed among different specialist consultants to reduce the occurrence of this preventable complication.

Attitudes towards compulsory vaccination in Italy: Results from the NAVIDAD multicentre study.

BACKGROUND: Vaccine hesitancy is a considerable issue in European countries and leads to low coverage rates. After a long debate, Italy has made vaccination mandatory for admission to its schools. METHODS: In the NAVIDAD study (a cross-sectional multicentre study), a 63-item questionnaire was administered to 1820 pregnant women from 15 Italian cities. The questionnaire assessed the interviewee's opinion on mandatory vaccines, as well as their socioeconomic status, sources of information about vaccines, confidence in the Italian National Healthcare Service (NHS), and intention to vaccinate their newborn. RESULTS: Information sources play a key role in determining the opinion on restoration of mandatory vaccines; in particular, women who obtained information from anti-vaccination movements are less likely to accept the vaccines (OR: 0.35, 95% CI: 0.21-0.58, p < 0.001). Women who had confidence in healthcare professional information agreed more on mandatory vaccination than did the other women (OR: 2.66, 95% CI: 1.62-4.36, p < 0.001); those who perceived that healthcare professionals have economic interest in child immunization and who declared that healthcare providers inform only on vaccinations benefits not on risks were less likely to agree on compulsory vaccination (OR: 0.66, CI 95%: 0.46-0.96, p = 0.03; OR: 0.66, CI 95%: 0.46-0.95, p = 0.03, respectively). CONCLUSION: Information sources and confidence towards health professionals are the main determinants of acceptance of mandatory vaccine restoration. To increase the acceptability of the restoration and reduce vaccine hesitancy, these aspects need to be strengthened.

Bat-man disease transmission: zoonotic pathogens from wildlife reservoirs to human populations.

Bats are natural reservoir hosts and sources of infection of several microorganisms, many of which cause severe human diseases. Because of contact between bats and other animals, including humans, the possibility exists for additional interspecies transmissions and resulting disease outbreaks. The purpose of this article is to supply an overview on the main pathogens isolated from bats that have the potential to cause disease in humans.

The biological correlates of macroscopic breast tumour structure measured using fractal analysis in patients undergoing neoadjuvant chemotherapy.

Breast cancers are evolving, multi-scale systems that are characterized by varied complex spatial structures. In this study, we measured the structural characteristics of 33 breast tumours in patients who were to receive neoadjuvant chemotherapy using dynamic contrast enhanced MRI and fractal geometry. The results showed a significant association between fractal measurements and tumour characteristics. The fractal dimension was associated with receptor status (ER and PR) and the fractal fit was associated with response to chemotherapy, measured using a validated pathological response scale, tumour grade and size. This study describes structure measures that may be a consequence of known prognostic factors during the initial and/or maturation phase of tumour growth. These results suggest that measuring tumour structure in this way can predict an individual's response to neoadjuvant therapy and may identify those who will benefit least from neoadjuvant chemotherapy, allowing alternative treatment options to be selected in those patients.

Use of a capillary input function with cardiac output for the estimation of lesion pharmacokinetic parameters: preliminary results on a breast cancer patient.

The objective of this work was to propose and demonstrate a novel technique for the assessment of tumour pharmacokinetic parameters together with a regionally estimated vascular input function. A breast cancer patient T2*-weighted dynamic contrast enhanced MRI (DCE-MRI) dataset acquired at high temporal resolution during the first-pass bolus perfusion was used for testing the technique. Extraction of the lesion volume transfer constant K(trans) together with the intravascular plasma volume fraction v(p) was achieved by optimizing a capillary input function with a measure of cardiac output using the principle of intravascular indicator dilution theory. For a region of interest drawn within the breast lesion a v(p) of 0.16 and a K(trans) of 0.70 min(-1) were estimated. Despite the value of v(p) being higher than expected, estimated K(trans) was in accordance with the literature values. In conclusion, the technique proposed here, has the main advantage of allowing the estimation of breast tumour pharmacokinetic parameters from first-pass perfusion T2*-weighted DCE-MRI data without the need of measuring an arterial input function. The technique may also have applicability to T1-weighted DCE-MRI data.

[Evaluation of the appropriateness of public hospital use using AEP, Disease Staging, and other DRG-based criteria (essential levels of care--Italian LEA): results and degree of agreement among the different methodologies]. / Valutazione dell'appropriatezza organizzativa degli ospe- dali pubblici abruzzesi tramite PRUO, Disease Staging, e mediante il calcolo dei DRG ad alto rischio di inappropria- tezza secondo i "nuovi" e "vecchi" LEA: risultati e grado di concordanza tra le diverse metodiche.

Currently, more than one instrument has been found to be reliable and valid for the assessment of hospital admission appropriateness. However; data on the level of agreement among these methodologies are extremely scarce. The study was aimed at evaluating whether the percentages of organizational (in)appropriateness resulting from some of the most diffused instruments (Italian Appropriateness Evaluation Protocol--AEP/PRUO; Disease Staging; Essential Levels of Care--LEA, version 2001 and 2008) are substantially concordant, or they largely depend upon the methodology. For each public hospital of Abruzzo, Italy, the amount of inappropriateness has been computed using six indicators: inappropriate days of care (PRUO1); totally inappropriate admissions (PRU02); early admissions DRGs according to the first Law on Italian LEA (LEA01); admissions assigned to one of the 108 potentially inappropriate DRGs according to the second Law on Italian LEA, currently inactive (LEA08). The sample was composed by all ordinary admissions made in 2006 in the Region, with the exception of PRUO indicators, which were based upon the manual revision of 2% of all admissions that could be assessed using PRUO methodology. We found a good correlation among most indicators based upon administrative discharge data (DS1, DS2 and LEA01), whereas the results obtained using PRUO and new LEA (LEA08) were discordant, and marked differences were observed also between the two PRUO indicators. Although the limitations of the study permit only preliminary conclusions, in future appropriateness evaluations it may be reasonable to use more than one indicator--allowing the creation of combined scores--and rank hospitals in large categories--avoiding excessively precise scores--as such rankings might relevantly differ depending upon the used instrument.

The accuracy of pharmacokinetic parameter measurement in DCE-MRI of the breast at 3 T.

The purpose of this work is to quantify the accuracy of pharmacokinetic parameter measurement in DCE-MRI of breast cancer at 3 T in relation to three sources of error. Individually, T1 measurement error, temporal resolution and transmitted RF field inhomogeneity are considered. Dynamic contrast enhancement curves were simulated using standard acquisition parameters of a DCE-MRI protocol. Errors on pre-contrast T1 due to incorrect RF spoiling were considered. Flip angle errors were measured and introduced into the fitting routine, and temporal resolution was also varied. The error in fitted pharmacokinetic parameters, K(trans) and v(e), was calculated. Flip angles were found to be reduced by up to 55% of the expected value. The resultant errors in our range of K(trans) and v(e) were found to be up to 66% and 74%, respectively. Incorrect T1 estimation results in K(trans) and v(e) errors up to 531% and 233%, respectively. When the temporal resolution is reduced from 10 to 70 s K(trans) drops by up to 48%, while v(e) shows negligible variation. In combination, uncertainties in tissue T1 map and applied flip angle were shown to contribute to errors of up to 88% in K(trans) and 73% in v(e). These results demonstrate the importance of high temporal resolution, accurate T1 measurement and good B1 homogeneity.

Management of tinnitus: oral treatment with melatonin and sulodexide.

The main problem arising from tinnitus is the disturbance it causes in day-to-day life and disturbance in sleep leading to fatigue and general discomfort. We attempted to study the effect of melatonin in conjunction with Sulodexide as a treatment method for tinnitus and evaluate its effectiveness. We studied 102 patients suffering from tinnitus with a Prospective Randomised Controlled Study conducted in a tertiary care ENT department. After randomisation, 34 patients were treated with melatonin and Sulodexide, another 34 were treated with melatonin alone, and the remaining 34 (control group) were managed without therapy in order to evaluate spontaneous variations in quality of tinnitus. Patients were assessed prospectively with Tinnitus Handicap Inventory and Acufenometry both pre-treatment and post-treatment. Among the patients we studied, we found better results with both Tinnitus Handicap Inventory and Acufenometry in the group who received melatonin and Sulodexide as against melatonin alone. Any improvement was noted in the control group. In conclusion, our opinion is that melatonin in combination with Sulodexide is a viable treatment option for patients suffering from central or sensorineural tinnitus.

Efficacy of a soft hand brace and a wrist splint for carpal tunnel syndrome: a randomized controlled study.

OBJECTIVE: To examine, in a randomized, controlled, single blinded trial, the efficacy of a soft hand brace and a wrist splint for carpal tunnel syndrome (CTS). METHODS: We randomized 120 patients with CTS into a group wearing the soft hand brace MANU and into another group wearing the wrist splint CAMP TIELLE at night for 3 months. We re-evaluated the patients after 3 (T1) and 9 months (T2). The primary efficacy measures were changes in scores of Boston Carpal Tunnel Questionnaire (BCTQ) and in Visual Analogical Scale (VAS) for pain and paresthesias. RESULTS: At T1, both groups showed a significant reduction in symptomatic and functional BCTQ (T0-T1 differences: MANU BCTQ sympt: 0.88 (0.68-1.08), funct: 0.45 (0.19-0.72); TIELLE BCTQ sympt: 0.78 (0.55-1.01), funct: 0.41 (0.22-0.59). At T2, a less evident benefit on symptoms persisted in both groups, except for pain VAS score that was significantly reduced only in the CAMP TIELLE group. No significant functional benefits persisted in either group. There were no differences in BCTQ and VAS scores between the two groups at T1 and T2 compared with that at baseline. CONCLUSIONS: A 3-month treatment with either the hand brace or the wrist splint induces a symptomatic and functional benefit in patients with CTS.

Treatment of central and sensorineural tinnitus with orally administered Melatonin and Sulodexide: personal experience from a randomized controlled study.

Since very little is understood about the exact aetiology of tinnitus, this has made treatment of the condition difficult. Even though approximately 10-15% of the general population suffer from tinnitus, only 2% consider it serious enough to warrant any treatment. The main problem arising from tinnitus is the disturbance it causes not only in day to day life but also in sleep, leading to fatigue and general discomfort. The present study focused on the effect of Melatonin in conjunction with Sulodexide as a treatment method for tinnitus. Overall, 102 patients suffering from tinnitus were evaluated in a prospective randomised controlled study conducted in a tertiary care ENT department. After randomisation, 34 patients were treated with Melatonin and Sulodexide, another 34 were treated with Melatonin alone, while the remaining 34 (control group) were managed without treatment in order to evaluate spontaneous variations in the quality of tinnitus. Patients were assessed prospectively with the Tinnitus Handicap Inventory and Acufenometry, both pre- and post-treatment. Among the patients studied, better results with both Tinnitus Handicap Inventory and Acufenometry were found in the group who received Melatonin and Sulodexide compared to those receiving Melatonin alone. No improvement was observed in the control group. In conclusion, Melatonin in combination with Sulodexide is, in our opinion, a viable treatment option for patients suffering from central or sensorineural tinnitus.

[Epidemiology of hospital loads in patients with multiple hospitalizations due to diabetes]. / Epidemiologia dei carichi assistenziali ospedalieri in pazienti con ricoveri ripetuti per diabete.

This study describes the results of a retrospective study carried out to evaluate the hospitalizations of patients with type 2 diabetes admitted from January to June 2001 in the teaching hospital "SS. Annunziata" of Chieti. This research evaluates the generic appropriateness using the PRUO manual and the specific appropriateness using the guidelines approved by Italian Diabetes Association, Italian Diabetes Society and Italian College of General Practitioners. A sample of 196 medical charts was examined. The percentage of inappropriate admission was 21.9%. The "critical" clinical conditions of patients were responsible for only 23.7% of inappropriate admissions. The first reason of the inappropriateness of the admission was the execution of diagnostic examinations (60.5%), followed by the execution of medical therapy (23.2%) and waiting for surgical intervention (16.3%). 46.5% of inappropriate hospitalization was prescribed by specialists. Concerning specific appropriateness, 42.3% of hospitalization was inappropriate. These findings suggest that a system for the assessment of disease management of diabetes should be started up in the Abruzzo region. Moreover, guidelines utilization should be implemented in order to get a more correct utilization of acute hospital by specialists and GPs.

Smoking behaviour, cessation attempts and the influence of parental smoking in older adult women: a cross-sectional analysis from Italy.

OBJECTIVES: To investigate the association between parental smoking during infancy/adolescence and smoking prevalence in older adult women, and to provide a description of smoking and smoking cessation patterns in this subset of the population. STUDY DESIGN: Cross-sectional survey. METHODS: Between 1999 and 2001, trained physicians in 11 health agencies throughout the Abruzzo Region, Italy, conducted semi-structured interviews on 9708 women aged 50-70 years attending mammographic screening (overall response rate 89%). Information was collected on sociodemographic characteristics, smoking habits, parental smoking during their infancy and/or adolescence, and exposure to environmental tobacco smoke (ETS) inside or outside the family. RESULTS AND CONCLUSIONS: The overall prevalence of current smoking was 15.6% (n=1516), and that of former smoking was 13.2%. Women whose parent(s) smoked were more likely to be current smokers, especially if only the mother smoked (adjusted odds ratio 4.27; 95% confidence interval 2.24-8.12). Other factors significantly associated with current smoking in the multivariate analysis were younger age, lower body mass index, higher level of education, unmarried status, and exposure to ETS either inside or outside the family environment. Eighteen percent of all current smokers were non-inhalers, and more than 60% of ex-smokers quit smoking on their first attempt. Our findings expand the existing evidence suggesting that a strong effect of parental conduct on a daughter's smoking behaviour may persist throughout life. Although more research is needed, especially to clarify the role of genetic and environmental factors in determining the mother-child smoking association, our results suggest that intensifying smoking prevention efforts directed at women with children might considerably reduce the risk of ever smoking in future female generations.

Addition of teicoplanin or vancomycin for the treatment of documented bacteremia due to gram-positive cocci in neutropenic patients with hematological malignancies: microbiological, clinical and economic evaluation.

A prospective, randomized, double-blind trial was conducted on 124 febrile patients with hematological malignancies to compare teicoplanin with vancomycin as an addition to the initial empiric amikacin-ceftazidime regimen after documented bacteremia due to gram-positive cocci. At enrollment, patients in both groups were comparable with respect to age, sex, underlying hematologic disorders and duration of neutropenia. Rates of therapeutic success were 55/63 (87.3%) in the teicoplanin group and 56/61 (91.8%) in the vancomycin group (p = 0.560). The mean duration of treatment was similar, being 12.2 and 11.4 days, respectively (p = 0.216). Patients treated with teicoplanin remained febrile for slightly longer than those treated with vancomycin (4.9 vs. 4.0 days) (p = 0.013). Thirteen patients experienced an adverse drug reaction, but without any significant difference in the two arms. Isolated staphylococci showed a progressive and significant decrease in susceptibility to both glycopeptides during the 8 study years. The economic analysis performed showed that the addition of vancomycin is cost-saving.

[Appropriateness of hospitalization in the teaching hospital of Chieti using the P.R.U.O. approach]. / Valutazione dell'appropriatezza dei ricoveri con la metodica P.R.U.O. nell'ospedale clinicizzato di Chieti.

This study describes the results of a research carried out to evaluate inappropriate admissions and totally inappropriate hospitalizations (RTI) in the teaching hospital "SS. Annunziata" of Chieti using the 1999 version of the PRUO manual. A random sample of 1218 medical charts, drawn from all the medical charts of patients admitted from June to December 2000 in the units of Medicine, Surgery and Orthopaedics, was selected. The percentage of inappropriate admissions was 38.2%, while totally inappropriate hospitalizations were 18.1%. The highest percentage of inappropriate admissions was in the class of age 55-64 years. Moreover, inappropriate admissions were more frequent in the morning hours (7:00-12:59) and, within the week, on Monday. The first reason of inappropriateness of the admission, was the execution of diagnostic examinations (62.2%), followed by the execution of medical therapy (19.3%) and waiting of surgical intervention (13.4%). Short hospitalizations (2-3 days) are more frequently totally inappropriate as compared to longer hospitalizations. These findings suggest that a system for the assessment of appropriateness of hospitalizations should be established in the Abruzzo region including all accredited public and private hospitals.

[Factors related to the uptake of breast cancer screening (mammography and breast ultrasound): a retrospective survey on a sample of resident women, 50-70 years aged, from Abruzzo region]. / Fattori predittivi dell'utilizzo di metodiche preventive per il tumore del seno (mammografia ed ecografia mammaria): indagine retrospettiva su un campione di donne abruzzesi, di età compresa tra 50 e 70 anni.

Within the context of a large breast cancer screening program we conducted a retrospective survey to identify the personal, socioeconomic and behavioural characteristics associated with previous use of mammograms (Ma) and breast ultrasound examination (US). Contact was made with a sample of more than 10,000 resident women who were asked to complete three questionnaires. Achieving an answer rate of 86%, we collected data from 9,087 women, 50-70 years aged, coming from Abruzzo, a central Italian region. 61% of the participants performed Ma, while US was performed by 34%, and 67% of women attended at least one of those examinations. Multiple logistic regression results indicated that older age, low level of education, not performing diets and breast self examination were significant predictors of a lower use of both examinations. Women that were married, mothers, on menopause, with a family history of cancer, uterine fibroma, past users of oral contraceptives were more likely to having performed Ma, but not US. Age at menarche, BMI and smoking were found not to be significant in predicting attendance for both screening examinations, with the exception of ex-smokers for US. Our findings represent an important contribution to the development of the needed tailored interventions to increase breast screening participation.