[Framework for evaluating the performance of local healthcare: international experiences and prospects for Italy.] / Framework per la valutazione della performance dell'assistenza sanitaria territoriale: esperienze internazionali e prospettive per l'Italia.

The Italian National healthcare service currently lacks a synthetic framework for measuring the primary care legislative reform established by the National recovery and resilience plan and the legislative reform, Decree number 77/2022. This paper explores the existing international and national literature on primary care' monitoring and evaluation systems with the purpose of drawing guidelines to build up a global and systematic framework. The 2022 World health organization framework is the most advanced reference point as a result of more than twenty years of theoretical and field research. Indeed, it can be regarded as the basic model to be adapted to the specificities of the current Italian legislation and organization.

Differences in the clinical characteristics of COVID-19 patients who died in hospital during different phases of the pandemic: national data from Italy.

BACKGROUND: Epidemiological data obtained during the initial wave of the COVID-19 epidemic showed that persons dying with COVID-19 were typically older men with multiple chronic conditions. No studies have assessed if the characteristics of patients dying with COVID-19 have changed in the second phase of the epidemic, when the initial wave subsided. The aim of the present study was to compare characteristics of patients dying with COVID-19 in Italy in the first 'peak' phase of the epidemic and in its second phase. METHODS: Medical charts of patients with COVID-19 who died while in hospital in Italy were reviewed to extract information on pre-existing comorbidities, in-hospital complications, and disease trajectories. The course of the epidemic was classified in two 3-month periods: March-May 2020 and June-August 2020. FINDINGS: Overall, in the Italian population, 34,191 COVID-19 deaths occurred in March-May 2020 and 1,404 in June-August 2020. Patients dying in March-May were significantly younger (80.1 ± 10.6 vs. 82.8 ± 11.1 years, p < 0.001) and less frequently female (41.9% vs. 61.8%, p < 0.001) than those dying in June-August. The medical charts of 3533 patients who died with PCR-confirmed SARS-CoV-2 infection in March-May 2020 (10.3% of all deaths occurring in this period) and 203 patients who died in June-August 2020 (14.5% of all deaths occurring in this period) were analysed. Patients who died in March-May 2020, compared to those who died in June-August 2020, had significantly lower rates of multiple comorbidities (3 or more comorbidities: 61.8% vs 74.5%, p = 0.001) and superinfections (15.2% vs. 52.5%, p < 0.001). Treatment patterns also substantially differed in the two study periods, with patients dying in March-May 2020 being less likely to be treated with steroids (41.7% vs. 69.3%, p < 0.001) and more likely to receive antivirals (59.3% vs. 41.4%, p < 0.001). Survival time also largely differed, with patients dying in March-May 2020 showing a shorter time from symptoms onset to death (mean interval: 15.0 vs. 46.6 days, p < 0.001). The differences observed between the two periods remained significant in a multivariate analysis. INTERPRETATION: The clinical characteristics of patients dying with COVID-19 in Italy, their treatment and symptom-to-death survival time have significantly changed overtime. This is probably due to an improved organization and delivery of care and to a better knowledge of disease treatment.

Clinical characteristics of individuals with Down syndrome deceased with CoVID-19 in Italy-A case series.

BACKGROUND: Persons with Down syndrome (DS) are presumed to be at high risk of severe CoVID-19, due to immune dysregulation and often compromised cardiopulmonary function. Aim of the present study is to assess epidemiological and clinical characteristics of individuals with DS deceased in Italian hospitals with CoVID-19. METHODS: We used a nationwide database of 3,438 patients deceased with RT-PCR-confirmed SARS-CoV-2 infection in Italy (10.4% of all deaths with CoVID-19 in the country at the time of analysis). Data on demographics, pre-existing comorbidities and in-hospital complications leading to death were extracted from medical charts obtained from hospitals. Data on individuals with DS deceased with CoVID-19 were obtained from this sample. RESULTS: Sixteen cases of death in individuals with DS (0.5% of all charts analyzed) were identified. Acute respiratory distress syndrome occurred in all 16 cases. Compared with individuals without DS, those with DS deceased with CoVID-19 were younger (52.3 ± 7.3 vs. 78.1 ± 10.6 years, p < .001) and presented a higher incidence of superinfections (31.2 vs. 13.0%, p = .029). Autoimmune diseases (43.8 vs. 4%, p < .001), obesity (37.5 vs. 11%, p = .009), and dementia (37.5 vs. 16.3%, p = .012) were more prevalent in individuals with DS. ICU admissions was similar in both groups (25 vs. 18.8%, p = .129). CONCLUSIONS: Individuals with DS deceased with CoVID-19 are younger than individuals without DS. Comorbidity burden and increased risk of complications (i.e., bacterial superinfections) can influence CoVID-19 prognosis in individuals with DS. Specific strategies to prevent and mitigate the effects of CoVID-19 in the population with DS are needed.

A novel HSV-1 virus, JS1/34.5-/47-, purges contaminating breast cancer cells from bone marrow.

PURPOSE: Oncolytic herpes simplex virus type 1 (HSV-1) vectors show considerable promise as agents for cancer therapy. We have developed a novel recombinant HSV-1 virus (JS1/34.5-/47-) for purging of occult breast cancer cells from bone marrow of patients. Here, we evaluate the therapeutic efficacy of this oncolytic virus. EXPERIMENTAL DESIGN: Electron microscopy was used to determine whether human breast cancer and bone marrow cells are permissive for JS1/34.5-/47- infection. Subsequently, the biological effects of JS1/34.5-/47- infection on human breast cancer cells and bone marrow were established using cell proliferation and colony formation assays, and the efficiency of cell kill was evaluated. Finally, the efficiency of JS1/34.5-/47- purging of breast cancer cells was examined in cocultures of breast cancer cells with bone marrow as well as bone marrow samples from high-risk breast cancer patients. RESULTS: We show effective killing of human breast cancer cell lines with the JS1/34.5-/47- virus. Furthermore, we show that treatment with JS1/34.5-/47- can significantly inhibit the growth of breast cancer cell lines without affecting cocultured mononuclear hematopoietic cells. Finally, we have found that the virus is effective in destroying disseminated tumors cells in bone marrow taken from breast cancer patients, without affecting the hematopoietic contents in these samples. CONCLUSION: Collectively, our data show that the JS1/34.5-/47- virus can selectively target breast cancer cells while sparing hematopoietic cells, suggesting that JS1/34.5-/47- can be used to purge contaminating breast cancer cells from human bone marrow in the setting of autologous hematopoietic cell transplantation.

Activation of the MDR1 upstream promoter in breast carcinoma as a surrogate for metastatic invasion.

PURPOSE: Activation of the MDR1 upstream promoter (USP) has been described previously in four lymphoblastic leukemia patients, where it is the major MDR1 promoter associated with P-glycoprotein overexpression. We asked whether MDR1 USP-derived transcripts were also present in breast carcinoma and assessed their potential as a biomarker. EXPERIMENTAL DESIGN: We developed a sensitive method for detecting transcripts derived from the MDR1 USP and used it to identify MDR1 USP-derived transcripts in cell model systems, in 61 breast carcinoma biopsies of the primary tumor, and in isolated malignant epithelial cells both from the primary tumor and from the associated invaded lymph nodes. RESULTS: The MDR1 USP was not active in several independent leukemic and breast cancer cell lines or nucleated peripheral blood cells (n = 9). However, transcripts derived from the MDR1 USP were detected in some drug-resistant cell lines and a high proportion of primary breast tumors (71.6%; n = 61), whereas they were present at low frequency in normal breast tissue (10%; n = 10). Activation of MDR1 USP was not due to chromosomal amplifications or rearrangements at the MDR1 locus. Transcription from the MDR1 USP correlated with metastatic node invasion [N = 0-3 versus N > 3 (N = number of lymph nodes invaded); Fisher's exact test, P = 0.011] and was detected in malignant epithelial cells from the primary tumor and those that metastasized to the lymph nodes. CONCLUSIONS: MDR1 USP activation is a surrogate marker for breast carcinoma progression and can be used as a marker to study breast cancer susceptibility.