Limitations and consequences of public health models centred on hospitals and lacking connections with territorial and home-based social and health services.

BACKGROUND: Delayed discharge from hospital to home or other care institutions is a significant problem and has been investigated in the international scientific literature for many years. Behind this condition is a health care system based on a hospital-centered concept characterized by a lack of territorial health and social welfare services. This phenomenon causes two different problems: an excessive length of hospital stay, resulting in slow turnover of bed utilization; and overcrowding in emergency rooms (ERs). The phenomenon of frequent users assumes particular importance in this context. These patients repeatedly visit the emergency department (ED) in the same year because care needs are not met by primary care services. The authors in this study tried to describe the Frequent users (FUs) population and the variables associated with this condition. MATERIALS AND METHODS: A retrospective "single-arm" descriptive study was conducted by analysing all accesses made to the ED of Policlinico Tor Vergata (PTV) from January 1, 2022, to December 31, 2022. FUs were defined as patients who had 4 or more accesses to PTV ER during the year. RESULTS: A total of 37,800 accesses occurred during the study period. A total of 31,691 users accessed the PS, with a mean age of 55.8 ± 22.2 years. There were 359 FU patients (approximately 1%) who had a total of 1984 accesses, corresponding to 5.2% of the total accesses. The triage codes for the FU patients were red, 2%; orange, 21%; blue, 45%; green, 26%; white, 5%; and not performed, 1%. Considering the 1984 FU accesses, the most frequently attributed "main problems" in the ED were "other symptoms or disorders" (54%), "psychomotor agitation" (12%), "trauma or burn" (8%), "abdominal pain" (6%), "chest pain" (4%), "dyspnea" (4%) and "urological symptoms or disorders" (4%). Multivariate analysis revealed that the main determinants of FUs were psychomotor agitation (HR = 7,23; CL95%:6,194-8,443), urological disorders (HR = 2,16; CL95%:1,68-2,76) and poor socioeconomic status (HR = 2,40; CL95%:2,213-2,663). CONCLUSIONS: The FUs phenomenon expresses an area of health and social distress where poverty and lack of territorial services oblige people to refer to the ED. Primary care interventions integrated with social support are crucial for managing access to the ED.

Multidimensional Results and Reflections on CAR-T: The Italian Evidence.

The present study aims at defining the economic and organizational impacts of the introduction of chimeric antigen receptor T-cell therapy (CAR-T) in Italy, for the management of diffuse large B-cell lymphoma (DLBCL) patients in third-line therapy, defining the overall level of sustainability for both hospitals and the National Healthcare System (NHS). The analysis focused on CAR-T and Best Salvage Care (in the following BSC), assuming the Italian hospital and NHS perspectives, over a 36-month time horizon. Process mapping and activity-based costing methodologies were applied to collect the hospital costs related to the BSC and CAR-T pathways, including adverse event management. Anonymous administrative data on services provided (diagnostic and laboratory examinations, hospitalizations, outpatient procedures, and therapies) to 47 third-line patients with lymphoma, as well as any organizational investments required, were collected, in two different Italian Hospitals. The economic results showed that the BSC clinical pathway required less resources in comparison with CAR-T (excluding the cost related to the therapy) (BSC: 29,558.41 vs. CAR-T: EUR 71,220.84, -58.5%). The budget impact analysis depicts that the introduction of CAR-T would generate an increase in costs ranging from 15% to 23%, without considering treatment costs. The assessment of the organizational impact reveals that the introduction of CAR-T therapy would require additional investments equal to a minimum of EUR 15,500 to a maximum of EUR 100,897.49, from the hospital perspective. Results show new economic evidence for healthcare decision makers, to optimize the appropriateness of resource allocation. The present analysis suggests the need to introduce a specific reimbursement tariff, both at the hospital and at NHS levels, since no consensus exists, at least in the Italian setting, concerning the proper remuneration for the hospitals who guarantee this innovative pathway, assuming high risks related to timely management of adverse events.

[Population segmentation as a tool for planning community healthcare networks: the key role of social and health information systems.] / La stratificazione della popolazione come strumento per rimodulare la rete assistenziale sul territorio: il ruolo determinante dei sistemi informativi socio-sanitari.

INTRODUCTION: Due to the ongoing demographic and epidemiological changes, today stakeholders need to have available information, based on population stratification, in order to plan the most suitable organizational model to meet the population health needs. METHODS: The legally adult population assisted and resident in Lazio Region on 31/12/2019 was equally and casually divided in two samples: the training sample (to define the model) and the validation sample (to measure model performances). On the base of the more complex model of Lazio Region, three population strata were defined: multi-chronic population, multi-chronic population with a high clinical complexity, multi-chronic population with socioeconomic vulnerability. Hospital discharge records were identified in the previous five years prior to 31/12/2019. Through appropriate classification models, it was evaluated the level with which the simplified system "from SDO" is able to approximate the more complex algorithm developed by the Lazio Region. RESULTS: Model performances, which has examined only information "from SDO", results inadequate. In fact, the Positive Predictive Value (PVV) results equal to 46.3%, 16.3% and 30.3%, respectively for the three analyzed strata. DISCUSSION: This study demonstrated that using the hospital system as the only Health Information System reduces the possibility to stratify and predict population health needs. For this reason, the improvement of the completeness and of the quality of data from different social and health information systems and their interconnection, represent the essential starting point. In addition, updating record track is needed to simplify the workload of compilers and improve data availability. These actions must also be accompanied by supportive interventions by central bodies for the regions that show the greatest weaknesses, as well as training actions that improve the level of knowledge of compilers.

Metformin associated lactic acidosis: a case series of 28 patients treated with sustained low-efficiency dialysis (SLED) and long-term follow-up.

BACKGROUND: Metformin associated lactic acidosis (MALA) is a well-known serious side effect of biguanides. However, the best treatment strategy remains a matter of debate. In the last 14 years, we observed a significant increase in hospitalizations for MALA to our Center. We report the outcomes of our clinical and therapeutic approach. METHODS: This is a single-center case series. Twenty-eight patients affected with MALA and acute kidney failure admitted between January 2000 and September 2014 were included. We analyzed comorbidities, laboratory tests and clinical parameters at admission, at 36 h and at discharge. All patients were treated with sustained low-efficiency dialysis (SLED) until normalization of serum lactate (≤ 3 mmol/L), bicarbonate (between 20 and 25 mmol/L) and potassium (between 4.0 and 5.1 mmol/L). RESULTS: The mortality rate was 21.4%, with all of the events occurring within 24 h from admission, and before or during the first hemodialysis treatment. Precipitating causes included; acute dehydration (86.4%), systemic inflammatory response syndrome (SIRS) (57.1%), sepsis (10.7%), nephrolithiasis (14.6%) and exposure to iodinated contrast (7.1%). No further episodes of lactic acidosis were described after discontinuing the drug over a mean follow-up of 27.2 months. Furthermore, while in 2010, we had a peak incidence of MALA of 76.8 cases per 100,000 patients on metformin, this rate fell after an education campaign conducted by specialists on the proper usage of metformin in patients at risk of MALA. Although the fall in incidence after the educational program was not necessarily causal, in 2014 the incidence was 32.9/100,000. CONCLUSIONS: We report an improved mortality rate in patients affected with MALA and acute kidney injury treated with SLED compared with other series published in literature. Rapid introduction of effective hemodialysis is critical in improving outcomes.

Age- and Gender-Related Differences in LDL-Cholesterol Management in Outpatients with Type 2 Diabetes Mellitus.

Background. Dyslipidemia contribute to the excess of coronary heart disease (CHD) risk observed in women with type 2 diabetes (T2DM). Low density lipoprotein-cholesterol (LDL-C) is the major target for CHD prevention, and T2DM women seem to reach LDL-C targets less frequently than men. Aim. To explore age- and gender-related differences in LDL-C management in a large sample of outpatients with T2DM. Results. Overall, 415.294 patients (45.3% women) from 236 diabetes centers in Italy were included. Women were older and more obese, with longer diabetes duration, higher total-cholesterol, LDL-C, and HDL-C serum levels compared to men (P < 0.0001). Lipid profile was monitored in ~75% of subjects, women being monitored less frequently than men, irrespective of age. More women did not reach the LDL-C target as compared to men, particularly in the subgroup treated with lipid-lowering medications. The between-genders gap in reaching LDL-C targets increased with age and diabetes duration, favouring men in all groups. Conclusions. LDL-C management is worst in women with T2DM, who are monitored and reach targets less frequently than T2DM men. Similarly to men, they do not receive medications despite high LDL-C. These gender discrepancies increase with age and diabetes duration, exposing older women to higher CHD risk.

Cholesterol esterification as a mediator of proliferation of vascular smooth muscle cells and peripheral blood mononuclear cells during atherogenesis.

BACKGROUND/AIMS: We determined growth rates, cholesterol esterification and mRNA levels for caveolin-1 (Cav-1), neutral cholesterol esters hydrolase (n-CEH) and ATP-binding cassette transporter (ABCA-1), in quiescent and growth-stimulated peripheral blood mononuclear cells (PBMCs) and intimal vascular smooth muscle cells (VSMCs) from blood and primary atherosclerotic plaques, respectively. These cells were cultured in the presence or absence of the mTOR inhibitor 40-O-(2-hydroxyethyl) rapamycin (RAD). METHODS: The rate of cell proliferation was determined by 3H-thymidine incorporation into DNA and that of lipid metabolism by utilizing 14C-acetate and 14C-oleate as precursors. Lipid deposit in the vascular cells was evaluated by Oil Red O staining and lipid mass by thin layer chromatography-linked enzymatic assay. RESULTS: Growth stimulation of PBMCs and VSMCs caused a rapid increase in intracellular cholesterol esterification and an accumulation of cholesterol esters (CEs) accompanied by a reduction of free cholesterol (FC) and Cav-1, ABCA-1 and n-CEH mRNAs. RAD reduced intracellular lipid accumulation in growth-stimulated cells and also increased expression of Cav-1, n-CEH and ABCA-1 genes. CONCLUSION: Collectively, these data provide evidence that the determination of CEs in PBMCs may be an easy prescreening test to identify subjects at risk for vascular proliferative disease and that FC, CE, Cav-1, n-CEH and ABCA-1 may be suitable targets for antiproliferative therapies.

Sex disparities in the quality of diabetes care: biological and cultural factors may play a different role for different outcomes: a cross-sectional observational study from the AMD Annals initiative.

OBJECTIVE: To investigate the quality of type 2 diabetes care according to sex. RESEARCH DESIGN AND METHODS: Clinical data collected during the year 2009 were extracted from electronic medical records; quality-of-care indicators were evaluated. Multilevel logistic regression analysis was applied to estimate the likelihood of women versus men to be monitored for selected parameters, to reach clinical outcomes, and to be treated with specific classes of drugs. The intercenter variability in the proportion of men and women achieving the targets was also investigated. RESULTS: Overall, 415,294 patients from 236 diabetes outpatient centers were evaluated, of whom 188,125 (45.3%) were women and 227,169 (54.7%) were men. Women were 14% more likely than men to have HbA1c>9.0% in spite of insulin treatment (odds ratio 1.14 [95% CI 1.10-1.17]), 42% more likely to have LDL cholesterol (LDL-C)≥130 mg/dL (1.42 [1.38-1.46]) in spite of lipid-lowering treatment, and 50% more likely to have BMI≥30 kg/m2 (1.50 [1.50-1.54]). Women were less likely to be monitored for foot and eye complications. In 99% of centers, the percentage of men reaching the LDL-C target was higher than in women, the proportion of patients reaching the HbA1c target was in favor of men in 80% of the centers, and no differences emerged for blood pressure. CONCLUSIONS: Women show a poorer quality of diabetes care than men. The attainment of the LDL-C target seems to be mainly related to pathophysiological factors, whereas patient and physician attitudes can play an important role in other process measures and outcomes.

Cholesterol esterification during differentiation of mouse erythroleukemia (Friend) cells.

Cholesterol is an essential constituent of all mammalian cell membranes and its availability is therefore a prerequisite for cellular growth and other functions. Several lines of evidence are now indicating an association between alterations of cholesterol homeostasis and cell cycle progression. However, the role of cholesterol in cell differentiation is still largely unknown. To begin to address this issue, in this study we examined changes in cholesterol metabolism and in the mRNA levels of proteins involved in cholesterol import and esterification (multi-drug resistance, MDR-3) and acylCoA: cholesterol acyltransferase (ACAT) and cholesterol export (caveolin-1) in Friend virus-induced erythroleukemia cells (MELC), in the absence or in the presence of the chemical inducer of differentiation, hexamethylene bisacetamide (HMBA). FBS-stimulated growth of MELC was accompanied by an immediate elevation of cholesterol synthesis and cholesterol esterification, and by an increase in the levels of MDR-3 and ACAT mRNAs. A decrease in caveolin-1 expression was also observed. However, when MELC were treated with HMBA, the inhibition of DNA synthesis caused by HMBA treatment, was associated with a decrease in cholesterol esterification and in ACAT and MDR-3 mRNA levels and an increase in caveolin-1 mRNA. Detection of cytoplasmic neutral lipids by staining MELC with oil red O, a dye able to evidence CE but not FC, revealed that HMBA-treatment also reduced growth-stimulated accumulation of cholesterol ester to approximately the same extent as the ACAT inhibitor, SaH. Overall, these results indicate for the first time a role of cholesterol esterification and of some related genes in differentiation of erythroid cells.