Post-stroke rehabilitation in Italy: inconsistencies across regional strategies

BACKGROUND

Remarkable differences among European countries have been found in stroke rehabilitation models, owing to the fact that stroke rehabilitation services are embedded in health care systems. Comprehensive data on service utilization by stroke survivors in Italy are lacking, but would be instrumental in improving efficiency and effectiveness of post-acute stroke care, and consequently, in containing costs and improving outcomes.

AIM

The purpose of the present study was to survey the Italian regional legislations in order to examine the provision of rehabilitation services for stroke survivors in Italy.

DESIGN

This is a cross-sectional, observational study.

SETTING

Post-stroke intra- and extra-hospital rehabilitation.

POPULATION

All decrees and resolutions as to post-acute stroke rehabilitation were collected from each Italian region.

METHOD

All decrees and resolutions were examined by the means of a check list including quantitative and qualitative characteristics, selected in accordance with national official recommendations. Each completed check list was then sent to each regional reference person, who filled in the section on the implementation of the indications and compliance.

RESULTS

The study was carried out from November 2009 to September 2010. The documents were collected from 19 out of the 20 Italian regions. The results of the study indicate that there are many, remarkable regional variations in health policies concerning post-stroke care. Instruments for evaluation and criteria for allocating stroke patients to proper rehabilitation setting vary across regions, but data on the potential impact of these variations on clinical outcomes are still lacking.

CONCLUSION

The study highlights the issue that, in Italy, delivery of post-stroke rehabilitation services is not uniform nation-wide and varies substantially across regions. The lack of a comprehensive post-acute stroke strategy is a major obstacle to service availability.

CLINICAL REHABILITATION IMPACT

The study results advocate the need for a consistent and comprehensive strategic planning of post-stroke rehabilitation in Italy.

The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients

BACKGROUND

The lack of knowledge about epidemiological and clinical data of patients with Acquired Brain Injury (ABI) admitted to Rehabilitation facilities in Italy led to the creation, in June 2008, of a data collection on-line registry.

AIM

To collect epidemiological and clinical data and to evaluate functional outcome of patients with severe traumatic and non-traumatic ABI admitted to Rehabilitation facilities in Italy between June 2008 and December 2011 and to compare data of patients with ABI of different aetiologies.

DESIGN

Observational retrospective study.

SETTING

The study involved 29 Italian Rehabilitation facilities.

POPULATION

The study enrolled 1469 patients with severe traumatic (TBI) and non-traumatic ABI (NTBI).

METHODS

Data collected included demographic (number of patients with TBI and NTBI, gender, age) and clinical characteristics (provenience, number of days elapsed between onset and rehabilitation admission, rehabilitation length of stay, discharge destination, death and vegetative state diagnosis, presence of percutaneous endoscopic gastrostomy, tracheostomy, pressure sores and paraosteoarthropathies). Functional outcome was evaluated using the Disability Rating Scale.

RESULTS

Of the whole population studied, 44.31% and 55.69% patients had suffered a TBI and a NTBI, respectively. In the NTBI group 40.09% had a cerebrovascular injury, 12.04% an anoxic brain damage, 3.6% had a brain injury of other causes. The mean age was 43.67 and 56.68 for subjects with TBI and NTBI, respectively. Patients with TBI showed a lower onset-admission interval (OAI), compared with NTBI group; no difference in rehabilitation length of stay (LOS) was recorded between groups. Patients with TBI presented a lower DRS score at admission and discharge and returned home more frequently than NTBI group.

CONCLUSIONS

The creation of a National registry allows the collection of data about patients with ABI in order to study the clinical course, the functional outcome and to establish a basis for comparison with other data sources. Clinical Rehabilitation Impact. Data collection could be useful in the evaluation and planning of rehabilitation pathways, and to assess the allocation of healthcare and rehabilitative resources.

Leishmania Amastigotes in Neoplastic Cells of 3 Nonhistiocytic Canine Tumors

Concurrent leishmaniasis and neoplasia has been reported in dogs. This study describes the presence of the protozoa within the cytoplasm of neoplastic cells in 3 different types of tumors. Leishmania amastigotes were detected by light and transmission electron microscopy and immunohistochemistry in a fibrosarcoma, a T-cell lymphoma, and an adrenocortical adenoma.

Updating on Italian stroke units: the "CCM study"

The stroke units (SUs) have been demonstrated to be efficient and cost effective for acute stroke care. Nevertheless, the level of stroke unit implementation in Italy does not correspond to expectations yet. This study is a survey, which aims at assessing the current status of in-hospital stroke care in the Italian regions and at updating SUs. The survey was conducted by means of a semi-structured questionnaire, based on 18 stroke care "quality indicators", submitted to all the Italian centres that had taken part in the SITS-MOST study, and to other centres advised by the coordinator of SITS studies and by regional opinion leaders of stroke. SUs were defined as acute wards, with stroke-dedicated beds and dedicated teams that had been formally authorised to administer rt-PA. A statistical analysis was performed by a descriptive statistics and logistic regression model. The study was carried out from November 2009 to September 2010. A total of 168 forms were sent out and 153 replies received. Seven centres, which had not performed any thrombolytic treatment, and 16 which did not fulfil the criteria for the definition of SU were excluded from the study. Most of the centres reported more than 100 stroke patient admissions per year, i.e., 122 (84%) from 100 to 500, 18 (12%) more than 500. The 19% of the centres admitted more than 30% of patients within 3 h from the symptom onset and only 30% admitted more than 30% of patients within 4.5 h. The mean number of thrombolyses performed in the last 6 months was 10 for centres with a doctor on duty 24 h a day, 6 for those that have a doctor on duty from 8 a.m. to 8 p.m. and a doctor on call for night, and 5 for centres with a doctor on call 24 h a day. The territorial distribution of the SUs is remarkably heterogeneous: 87 SUs (67%) are located in the North of Italy, 28 (22%) in the central part of Italy and only 15 (11%) in the South. The last few years have witnessed a rise in both the diffusion of SUs and access to thrombolytic therapy in Italy. Despite this, there are a few large areas, mostly in the south, where the requirements of healthcare legislation are not met, and access to a dedicated SU and thrombolytic treatment is still limited and poor.

Light and Electron Microscopic Analysis of Consecutive Renal Biopsy Specimens From Leishmania-Seropositive Dogs

Canine visceral leishmaniasis frequently causes renal damage that leads to chronic kidney disease. Fifteen dogs seropositive for Leishmania were selected and biopsied before (T0) and 60 days later after (T1) treatment with a specific anti- Leishmania pharmacological agent. Various parameters were selected for evaluating the glomerular and tubulointerstitial damage. At T0, mesangioproliferative and membranoproliferative glomerulonephritis were observed in 6 dogs, chronic glomerulosclerosis in 5, and end-stage kidney in 3; renal tissue from 1 dog was within normal histologic limits. The most frequently observed ultrastructural changes were foot-process effacement, thickening of the basement membranes, and immune deposits. One dog had mesangial immune deposits at T1 that had not been present at T0, so the diagnosis was changed to mesangioproliferative glomerulonephritis. In dogs with end-stage kidney, the number of obsolescent glomeruli and cystic atrophied glomeruli was increased at T1. However, progression of the glomerular lesions was minimal in most dogs. Worsening of tubulointerstitial scores was evident in the dogs with the most severe lesions at the first biopsy. Progression of the tubulointerstitial damage was minimal in the mildly affected dogs, and the interstitial inflammation was abated. In conclusion, renal lesions can progress over a 60-day period in canine leishmaniasis. A longer period between the renal biopsies would be necessary to demonstrate more severe changes. In addition a specific anti- Leishmania treatment could have a significant effect in the early stages of the disease.

Inhibition of the interaction between HIV-1 integrase and its cofactor LEDGF/p75: a promising approach in anti-retroviral therapy

Although 25 compounds are currently licensed as anti-HIV drugs, the development of multidrug-resistant viruses, as well as their severe side effects, compromise their efficacy and limit treatment options. The search for new targets in order to cure AIDS has revealed that the inhibition of some protein-protein interactions in the HIV life cycle may provide an important new approach to fight this disease. The interaction between HIV-1 integrase (IN) and Lens Epithelium-Derived Growth Factor (LEDGF/p75) has increasingly gained attention as a valuable target for a novel anti-retroviral strategy. This article reviews the discovery and development of molecules capable of interrupting the LEDGF/p75-IN interaction reported to date.

Report of a consultation on the optimization of clinical challenge trials for evaluation of candidate blood stage malaria vaccines, 18-19 March 2009, Bethesda, MD, USA

Development and optimization of first generation malaria vaccine candidates has been facilitated by the existence of a well-established Plasmodium falciparum clinical challenge model in which infectious sporozoites are administered to human subjects via mosquito bite. While ideal for testing pre-erythrocytic stage vaccines, some researchers believe that the sporozoite challenge model is less appropriate for testing blood stage vaccines. Here we report a consultation, co-sponsored by PATH MVI, USAID, EMVI and WHO, where scientists from all institutions globally that have conducted such clinical challenges in recent years and representatives from regulatory agencies and funding agencies met to discuss clinical malaria challenge models. Participants discussed strengthening and harmonizing the sporozoite challenge model and considered the pros and cons of further developing a blood stage challenge possibly better suited for evaluating the efficacy of blood stage vaccines. This report summarizes major findings and recommendations, including an update on the Plasmodium vivax clinical challenge model, the prospects for performing experimental challenge trials in malaria endemic countries and an update on clinical safety data. While the focus of the meeting was on the optimization of clinical challenge models for evaluation of blood stage candidate malaria vaccines, many of the considerations are relevant for the application of challenge trials to other purposes.

Electrokinetic stabilization as a reclamation tool for waste materials polluted by both salts and heavy metals

A method for detoxifying industrial wastes is presented, aiming at a safer management and reuse. Focusing, in particular, on bottom ashes from a municipal solid waste incinerator, the proposed "ElectroKinetic Stabilization" (EKS) technique requires a relatively short treatment time and improves the remediation of ashes by combining a fast extraction of chlorides by electromigration, together with a stabilization of metals through their reaction with phosphate anions, which migrate through the ash under the influence of the electric field. Heavy metals react with the phosphate anions, leading to the precipitation of metal hydroxy-apatite or chloro-apatite (for Pb and Ba), or to their trapping in a calcium-apatite mineral, that formed during the process. Along with precipitation, metal immobilization is allowed by the decrease of ash pH to 9-11 by means of H(+) produced at the anode from the electrolysis of water. The migration of salts through the wet ashes is very fast and the treatment time could be decreased to 24h. After EKS, Ba, Pb and F(-) leaching was reduced by 97%, 92% and 92%, respectively, below the allowed limits. In contrast, the final leaching of Cu and chlorides was reduced by 90% and 80%, respectively, still above the allowed limits.

Equivalence of a single saline nebulised dose of formoterol powder vs three doses of nebulised Albuterol every twenty minutes in acute asthma in children: a suitable cost effective approach for developing nations

BACKGROUND

An increase in asthma prevalence is reported from developed as well as developing nations, with rising costs from acute asthma and great expenditures to health care systems. Venezuela's Ministry of Health ambulatory facilities care for 80 % or more of a mostly urban and impoverished population of 26 million inhabitants, registering close to a million acute asthma visits per year; a nebulised fixed fenoterol-ipratropium bromide combination (Bero-dual, Boehringer-Ingelheim) in repeated dosing is the standard treatment.

OBJECTIVES

to simplify acute asthma care and management in a cost effective manner employing Formoterol Fumarate powder, a long acting beta agonist with immediate bronchodilator effects.

METHODOLOGY

Fifty acute asthmatic children (5-12 years old) were randomly assigned (25 patients in each group) to receive either a nebulised single dose (US $1.35) of two 12 microg Formoterol Fumarate capsules (Foradil 12 microg/cap, Novartis Pharma AG, Basel, Switzerland) diluted in 2.5 ml of sterile saline solution; or 3 doses of Albuterol (US $ 6.73) every twenty minutes for one hour (Glaxo Smith Kline Albuterol ampoules, 2.5 mg/2.5 ml, at a dose of 0.15 mg/kg/dose, maximum dose 2.5 mg). Symptoms score, oxygen saturation and lung function testing were recorded before and one hour after commencing treatments.

RESULTS

Both groups improved significantly on all parameters, except for FEV(1) in the Albuterol group.

CONCLUSIONS

Single dose nebulised Formoterol Fumarate (dry powder) in sterile saline solution, as depicted in this trial, is equivalent to three doses of Albuterol every twenty minutes for one hour in acute asthma in children, simplifying acute care management and at one fifth of medication costs. A pursuit of simpler and more cost effective approaches is found wanting in developing nations with depressed economies and unique cultural and socio-medical contexts; also, in countries where pharmaco-economics orients quality of health policies, novel approaches like this are worth exploring.

Photosensitized inactivation of Acanthamoeba palestinensis in the cystic stage

AIMS

To develop alternative approaches for medical and environmental control of pathogenic Acanthamoeba spp. by means of photodynamic treatment with a tetracationic Zn(II)-phthalocyanine (RLP068).

METHODS AND RESULTS

Incubation of cyst cultures with RLP068 for 1 h caused an accumulation of readily detectable concentrations of the phthalocyanine, even at doses as low as 0.5 micromol l(-1). RLP068 exhibited no dark toxicity towards cysts up to 5 micromol l(-1) concentration. A decrease of c. 50% in cyst survival in comparison with controls was measured upon incubation of the cysts with 0.5 micromol l(-1) RLP068, followed by exposure to light (600-700 nm) for 20 min at a fluence rate of 50 mW cm(-2) (60 J cm(-2)). After incubation with 3 and 5 micromol l(-1) RLP068 and irradiation, the cysts lost their excystment ability as early as day 5 and up to day 10, and were clearly damaged when observed under an interference contrast microscope.

CONCLUSIONS

These data indicate the promising use of RLP068 in phototreatment of diseases caused by pathogenic amoebae and in initial disinfection of wastewaters.

SIGNIFICANCE AND IMPACT OF THE STUDY

Rapid and extensive photodamage may be induced in the highly resistant cystic stages by means of 600- to 700-nm light sources.

Estimating incidence of bacterial meningitis with capture-recapture method, Lazio Region, Italy

To estimate the incidence of bacterial meningitis in the Lazio Region, including the city of Rome, and to assess the quality of the surveillance systems, we adopted a multiple-capture model by merging cases from three sources available in 1995-1996: the Notifiable Disease Surveillance (NDS) system, the Special Hospital Surveillance (SHS) system and the Hospital Discharge (HD) registry. A medical record revision was carried out to confirm the cases of bacterial meningitis. A total of 199 individuals was classified as probable or confirmed cases of bacterial meningitis in 1995-1996. In this period, the incidence of reported meningitis was 3.8/100,000 (population = 5,209,633). The log-linear model yielded a total estimated number of 236 cases (95% confidence interval (CI): 206-306), the estimate of incidence reaching the value of 4.5/100,000. Hospital Discharge registry showed the highest sensitivity (77%), the SHS system the highest positive predictive value (83%). In 1997-1998, the meningitis surveillance was integrated with an additional laboratory-based source and yielded 326 cases, with an incidence of reported cases of 6.3/100,000. Laboratory surveillance, involving 115 (92%) public hospitals and 84 (57%) private clinics, contributed 35 (27%) cases in addition to those notified to NDS (n = 130). Multiple-capture models, in our experience could estimate the bacterial meningitis incidence with a very good approximation. In order to improve both sensitivity and positive predictive value of surveillance, hospital and public health sources should be integrated with laboratory-based system.

Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy

OBJECTIVES

To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery.

DESIGN

Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97.

SETTING

Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city.

PARTICIPANTS

All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more.

MAIN OUTCOME MEASURES

Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed.

RESULTS

People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8. 1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80).

CONCLUSIONS

The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.