Medication use in Italian nursing homes: preliminary results from the national monitoring system.

Background: The aging population has increased concerns about the affordability, quality, and nature of long-term care for older people, emphasizing the role of nursing homes. Unlike acute hospital and primary care, there is a lack of drug consumption data in long-term care to understand regional or national healthcare policies. Objectives: This study aimed to describe medication consumption by older adults and expenditure in Italian nursing homes (NHs). Methods: Data on drug consumption and costs from the administrative medicine informational flows that detect medicines packages supplied to patients in health facilities and NHs were used. Data on the characteristics of the healthcare residence were from the Italian Health Ministry. Records for the year 2019, selecting the nursing homes exclusively providing elderly or mixed (elderly and disabled) were used. Results: In 2019, the total expenditure on medicines in NHs amounted to 25.38 million euros, the average cost to 1.30 and the expenditure per bed to 436.18 euros. Cardiovascular drugs were the highest-consuming therapeutic class (177.0 defined daily doses-DDDs/100 days of NH stay; 22.2% of total) followed by drugs acting on the alimentary tract and metabolism (167.6% and 21.0%) and blood drugs (160.4% and 20.1%). The treatment of hypertension and heart failure was widely the most frequently used, with the consumption being driven mainly by furosemide and ramipril. Antiulcer drugs were used on average in more than half of the days of NH stay (58.5 DDDs/100 days of NH stay), representing a therapeutic category for which deprescribing initiatives are recommended. On average, almost all patients received a dose of benzodiazepines, antipsychotics and antidepressants (37.6, 35.9, and 17.7 DDDs/100 days of NH stay, respectively), confirming the high prevalence of use for these medicines. Antibiotics reached 6.8 DDDs/100 days of NH stay. Conclusion: The availability of data in this specific setting allows the identification of the main interventions toward improving appropriateness and represents a challenge for drug utilization research. Data from this study suggest that proton pump inhibitors (PPIs), benzodiazepines and antibacterials can be areas of improving prescribing appropriateness.

An overview of osteopathy graduates' perceived preparedness at transition from educational environment to clinic environment one year after graduation: a cross sectional study.

BACKGROUND: This study investigated perceived preparedness to practice, one year after graduation across osteopathic education institutions (OEIs) and explored possible differences between countries where osteopathy is regulated (Reg) and countries where it is not (Unreg). METHODS: Two hundred forty-five graduates from 7 OEIs in 4 European countries, already assessed in a previous study, were contacted one year after their graduation to complete the survey. Survey tools included a questionnaire to assess perceived preparedness to practice: Association of American Medical Colleges (AAMC) questionnaire, and a questionnaire to collect socio-demographic information and practice characteristics. RESULTS: One hundred sixty-eight graduates (68.6%) completed the survey. The AAMC mean score one year after the graduation (23.19; confidence interval 22.81-23.58) was significantly higher than in the previous study (17.58; 16.90-18.26) (p < 0.001). A difference was also found between Reg (23.49; 23.03-23.95) and Unreg (22.34; 21.74-22.94) (p = 0.004). Osteopaths with a previous healthcare degree scored significantly higher on AAMC score (25.53; 24.88-26.19) than osteopaths without a previous healthcare degree (22.33; 21.97-22.69) (p < 0.001). Regulation and a previous degree were the only significant independent variables in the most predictive multivariate linear model. The model had an r2 = 0.33. CONCLUSIONS: Graduates from OEIs where osteopathy is regulated felt significantly better prepared to practice than Unreg. Systematic information searches about graduates' perception of preparedness to practice, may enable OEIs to strengthen their existing curricula to ensure their graduates are effectively prepared to practice.

The impact of incident depression on medication adherence in patients with type 2 diabetes.

BACKGROUND: Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes. METHODS: We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence. RESULTS: Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37). CONCLUSIONS: The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

The Complex Interplay Between Multisensory Integration and Perceptual Awareness.

The integration of information has been considered a hallmark of human consciousness, as it requires information being globally available via widespread neural interactions. Yet the complex interdependencies between multisensory integration and perceptual awareness, or consciousness, remain to be defined. While perceptual awareness has traditionally been studied in a single sense, in recent years we have witnessed a surge of interest in the role of multisensory integration in perceptual awareness. Based on a recent IMRF symposium on multisensory awareness, this review discusses three key questions from conceptual, methodological and experimental perspectives: (1) What do we study when we study multisensory awareness? (2) What is the relationship between multisensory integration and perceptual awareness? (3) Which experimental approaches are most promising to characterize multisensory awareness? We hope that this review paper will provoke lively discussions, novel experiments, and conceptual considerations to advance our understanding of the multifaceted interplay between multisensory integration and consciousness.

[Gallbladder calculi: what therapy of choice?]. / Calcolosi della colecisti: quale terapia in elezione?

The Authors have analyzed all different methods for the treatment of gallbladder stones which are performed today: the non invasive treatment of the gallstones (oral dissolution therapy and the extracorporeal shockwave lithotripsy), the minimally invasive procedures (contact dissolution therapy and the cholecystolithotomy) and at the end the new surgical techniques (the "minicholecystectomy" and the laparoscopic cholecystectomy). From this study and their experience, based upon 1346 standard cholecystectomy, the Authors have reached the following conclusions: 1) the cholecystectomy remains the only definitive therapy for the gallbladder stones and it is the gold standard to which must be compared the other alternative therapies; 2) the laparoscopic cholecystectomy, even though introduced recently, would become the only method used for cholecystectomy.

[Morphological findings and functional considerations on the structural adaptation of colonic grafts on the rat stomach]. / Rilievi morfologici e considerazioni funzionali sull'adattamento strutturale di innesti colici in ambiente gastrico di ratti.

Structural changes of colonic patches implanted in rat stomachs for periods of 2 to 12 months were evaluated by standard light and scanning electron microscopy. Colonic patches were sutured on the posterior wall of 116 white rats stomach body according to the following models: 1) mucosal surface to gastric lumen (60 rats); one third of the animals were given chronic doses of histamine subcutaneously; 2) peritoneal surface to gastric lumen (28 rats); 3) leiomuscular layers to gastric lumen by removing of the colonic mucosa (20 rats). Eight rats were used as controls. The colonic mucosa was shown to be highly resistant to acid secretions; only minimal surface erosions were found in animals with gastric hypersecretion following histamine stimulation. In contrast both the peritoneal surface and the colonic leiomuscular components were completely destroyed by contact with the acid juice. Both these structures were subsequently and completely colonised by the gastric mucosa.

The behaviour of infected human umbilical vein arterial grafts.

Two patients who received Human Umbilical Vein (H.U.V.) femoropopliteal by-passes to revascularize ischemic limbs, and later underwent emergency operations for acute graft thrombosis, developed H.U.V. graft sepsis. The patients presented with haemorrhage, fever, pain and a growing mass at the site of the previous emergency procedure, one and five months later. An attempt at limited H.U.V. segment substitution (case 1) failed. We then performed successful complete graft excisions combined with extra-anatomical H.U.V. revascularization. At present both patients are asymptomatic with well-functioning H.U.V. grafts, 7 and 13 months later. In both cases Light and Scanning Electron Microscopic studies were performed. Findings of these studies have been analyzed.

[Total parenteral nutrition in a general surgery department. Our initial experience]. / La nutrizione parenterale totale in un reparto di chirurgia generale. Nostra prima esperienza.

The Authors refer on their first experiences on the use of TPN with brief considerations on the results. A few precautions for the avoidance of the most common complications are reviewed.

[Artificial blood. Experimental studies on fluorocarbons as chemical blood substitutes]. / I1 sangue artificiale. Ricerche sperimentali sull'uso dei fluorocarbonati come succedanei chimici del sangue.

Fluorocarbonates are organic compounds capable of carrying oxygen and surrendering it to tissues by means of biological sound modalities. Experimentation of an emulsion consisting of perfluorotripropylamine and perfluorodecaline (Fluosol DA 20%) as a blood substitute is reported. Acute (Ht less than 1%) and chronic morphological (Ht = 15%) studies were performed on rats, and a semi-acute biochemical and morphological protocol (Ht = 21%) was experimented in pigs. The first signs of altered cerebral electrical activity occurred at Ht = 2% in the acute experiments, and death due to respiratory arrest took pace at Ht = 0.5%. In the semiacute and chronic experiments, widespread infiltration of fluorocarbonic micelles was noted on histological and electron microscope lung and liver preparations.

Vascular surgery in Behçet's syndrome: a case report.

A case of Behçet's syndrome with right femoral artery thrombosis surgically treated by femoro-popliteal TEA and lumbar sympathectomy is described. The validity of TEA even in this rare vascular disease is evidenced. After having examined the reasons leading to this surgical procedure, and good results in long-term follow-up are underlined.

Morphological evaluation of the human umbilical vein graft. An experimental study.

23 human umbilical vein segments (5 mm X 4-5 cm) were implanted into the carotid and iliac arteries of 15 dogs, removed at intervals ranging from 10 to 360 days after surgery and analyzed by light and scanning electron microscopy. 10 days after implantation, a thin layer of fibrin covered the central areas of the grafts, while thick platelet aggregates were found near the anastomoses. After 30 days, the progressive connective tissue ingrowth led to the organization of a thin fibrous inner layer on which endothelial-like cells grew, spreading from both anastomoses. The endothelialization process appeared to be almost complete at 120 days after implantation, while at 360 days the flow surface was totally lined.

Scanning electron microscopy evaluation of porous and nonporous arterial substitutes.

The fate of two different kinds of new small arterial substitutes, porous and nonporous, has been compared, particularly with regard to the structure of the luminal surface. Twenty-eight weavenit Dacron pyrolytic carbon coated grafts and 28 glutaraldehyde-tanned human umbilical vein segments were implanted into the carotid arteries of dogs. Grafts were removed at intervals, from ten to 120 days after implantation, and examined by scanning electron microscopy. The cumulative patency rate was 96.4 per cent for Dacron and 85.7 per cent for umbilical vein grafts. Ten days after implantation, the Dacron grafts were uniformly covered by a thin thrombus layer, while the umbilical vein grafts showed a thin network of fibrin on the central portion of the luminal surface of the graft and thrombotic deposits at the anastomoses. Thirty days after implantation, both types of prostheses showed the development of a thin fibrous tissue layer on the inner surface. Finally, at 120 days, an endothelial lining was observed.

[Laparosplenectomy in Hodgkin's disease]. / La laparosplenectomia nel morbo di Hodgkin.

Assessment of a series of 102 cases of laparotomy with splenectomy in the diagnosis of Hodgkin's disease is undertaken in an explantation of the indications for its employment in relation to the progress of the disease and its histological type. An account is also offered of the salient features of each surgical stage, and the findings made during surgery by comparison with those obtained in other ways, i.e. preoperative appraisal based mainly on lymphography, hepatosplenic scintiscans, and functional exploration of the liver. Analysis of the results in the light of the histological data and their clinical and pathological relations enables four conclusions to be drawn: 1) isotopic investigations and functional tests carried out prior to surgery are insufficient, or at any rate poorly reliable; 2) absence of gross criteria for the sufficiently precise determination of splenic Hodgkin sites intraoperatively; 3) discrepancy between the lymph node histology and the lymphographic picture; 4) high incidence of primary subdiaphragmatic splenic involvement. The opinion is expressed that laparosplenectomy is a sound procedure for establishing the actual extent of Hodgkin's disease, and hence permitting more logical and more accurate further management. Emphasis is also laid on the fact that removal of the spleen may protect the liver from the possible spread of the disease via the porta, and make irradiation of the left hypochondriac region with its attendant dangers unnecessary.

[Platelet function in the dog]. / Studio della funzionalità plastrinica nel cane.

Platelet aggregation with Born test was performed in 9 normal dogs. ADP, Epinephrine and Collagen were employed to stimulate platelets. With ADP, canine platelet aggregation was lower than human platelet aggregation, while, with Epinephrine and Collagen, aggregation was similar to that obtained with human platelets. Therefore the dog might be a model to study pharmacological interactions on platelet function.

[Free perforation by primary and localized hodgkin's disease of the small bowel (author's transl)]. / Perforazione ileale da morbo di Hodgkin primitivo e localizzato dell'intestino tenue.

The observation of a case of Hodgkin's disease primarily localized in the small bowel and with clinical picture of free perforation prompts the AA. to report the unusual enteric symptoms of this disease and to examine its pathologic and clinical features. Although Hodgkin's disease of the small intestine as a cause of perforation is extremely rare, the AA. describe the prominent frequency of abnormal serum proteins and of long lasting diarrhea with syndrome of florid malabsorption as primary manifestations of ileum involvement. Moreover the AA. indicate that while diagnosis of this peculiar location is rarely made clinically, it requests laparotomy and its confirmed by histologic specimen. The AA. suggests radical surgery and extensive radiotherapy in the treatment of primary Hodgkin's disease of the small bowel.

[Volvulus of the sigmoid. Case report]. / Il volvolo del sigma. Contributo casistico.

Reference is made to a series of 7 cases of volvulus of the sigmoid colon in a brief account of the aetiopathogenic factors and anatomopathological aspects most commonly assigned to this form. Its typical clinical picture and radiological diagnosis are described and the controversial matter of the best method of treatment is discussed. Comparison of the literature results suggest that elective resection is to be preferred, or non-invasive decompression followed by devolvulation and simple colopexy of the wall.

[Clinical considerations on primary malignant lymphomas of the stomach]. / Considerazioni cliniche sui linfomi maligni primitivi dello stomaco.

Starting from a critical revision of eight cases of primitive malignant gastric lymphoma that they had observed during the last four years in Surgical Clinic of University of Pavia, the AA. refer the notions in regard to this neoplastic form. After having discussed the problems of etiopathogenesis of lymphoma and the most characteristic clinical forms, the AA. describe the modern views of diagnosis and the therapy on the base of literature and their personal casistry. Outlined the necessity of a precocious diagnosis and the possibilities that gastroscopy with looked at biopsy affers, the AA., also on the base of their experience, show like selective therapy of primitive malignant gastric lymphoma, the surgical treatment with complememtary cyclic polichemioterapy.

[Subcutaneous lateral internal sphincterotomy in treatment of anal fissures (author's transl)]. / La sfinterotomia interna laterale sottocutanea nel trattamento delle ragadi anali.

The AA. describe a method of subcutaneous lateral internal sphincterotomy for anal fissure in outpatients, employing it in 87 patients; results seem very satisfactory and similar to those obtained with lateral internal sphincterotomy under direct vision.

[Internal biliary drainage in benign diseases of the extrahepatic bile ducts]. / Considerazioni sul drenaggio biliare interno nelle affezioni benigne delle vie biliari extraepatiche.

Through analysis of a fairly large series of cases treated by internal biliary drainage for non-neoplastic disorders of the terminal choledochus and papilla (72 cases of choledochal anastomosis, mostly to the duodenum; 238 cases of surgery of the Oddi sphincter), the authors present a remarkable accurate picture of the indications for this kind of surgery and of the immediate and long-term results obtained with it. Their collected observations also provide an opportunity for comparison with published reports from other quarters; in particular, the authors offer a detailed discussion of the relative advantages and limitations of the two main procedures in this category, namely papillosphincterotomy and choledocoduodenal derivation. From their own experience and in good agreement with current dominant opinion, they conclude by recommending the last-named procedure as the most rewarding, provided that the indications be correct and the operation be done with the necessary technical accuracy.