[The protocol of the Easy-Net prospective project to improve the appropriateness of caesarean section in Calabria Region.]

Italy is one of the European Countries with the highest caesarean section (CS) rate and large regional and local variability. In 2021, Calabria Region ranked as the third Italian region for the highest CS rate (38.5%). Calabria Region has joined the "Easy-Net" network program of Ministry of Health (NET-2016-02364191) on the evaluation of audit & feedback (A&F) interventions (Easy-Net https://easy-net.info/). The Easy-Net project is coordinated by The Department of Epidemiology of the Lazio Regional Health Service, and led for the Calabria Region by the Pugliese-Ciaccio Hospital of Catanzaro, with the Italian Ministry of Health and the Italian National Institute of Health. This project aims to reduce CS rate in Calabria Region, through A&F strategy interventions to improve perinatal care quality and maternal and neonatal outcomes. The adopted multi-strategic approach involves the use of Robson's classification to improve the appropriateness of the CS indications, and the A&F activities to identify health professionals' training needs and offer training update. This article describes the protocol of the Easy-Net WP6 study, "Prospective audit and feedback approach: efficacy in improving healthcare practice and reducing the caesarean section rate" (NET-2016-02364191-6). The project is organized in five phases which envisage the pre-intervention data collection relating to indicators of interest and staff attitudes on CS indication and A&F strategy. The 12 months of A&F interventions will be followed by the post-intervention data collection and the evaluation of appropriateness indicators and determinants. A study aimed at women is also planned to detect opinions regarding the use of CS. The study protocol was approved by the Ethics Committee of the Pugliese Ciaccio Hospital.

[How to optimize Audit&Feedback: experience from the EASY-NET programme]

This is the second of a series of papers dedicated to the EASY-NET research programme (NET-2016-02364191). The rationale, structure and methodologies are described in the previous contribution. Scientific literature demonstrated that Audit & Feedback (A&F) is an effective strategy for continuous quality improvement and its effectiveness varies considerably according to factors that are currently little known. Some recent publication pointed out, with the contribution of an international group of experts, 15 suggestions to optimize A&F and developed a tool to evaluate their application. This tool, called REFLECT-52, includes 52 items related to the 15 suggestions and organized into four categories relating to the "Nature of the desired action", to the "Nature of the data available for feedback", to the "Feedback Display" and to the "Intervention delivery". Then, the aim of this work was to evaluate the level of adherence of A&F interventions tested in EASY-NET to suggestions from the literature by using a slightly adapted version of the REFLECT-52 tool, in its original language. In EASY-NET, 14 A&F interventions with different characteristics and in different clinical and organizational contexts were tested in seven Italian regions, each of these was evaluated by the respective research groups. Overall, the level of adherence was high in three of the four categories analysed, with some difficulties reported regarding the nature of the data available for feedback. In fact, contrary to what the literature suggests, it was not possible to send repeated feedback for some interventions and, in some cases, the data available for feedback presented a delay longer than one year. In summary, this analysis has confirmed a high level of compliance of the interventions tested with the suggestions from the literature, but it has also allowed researchers to identify critical aspects that need to be addressed for the future development of these strategies.

Breastfeeding and presence of the companion of woman's choice during COVID-19 pandemic in Italy: regional population-based routine data and best practices at birth

OBJECTIVES

to describe the monthly trend of breastfeeding during hospitalization and the presence of companion of woman's choice during labour and birth, and the key regional responders' perspective of homogeneity/heterogeneity of the presence of the support person, before, during (February-May 2020), and after the first COVID-19 pandemic wave in a few Italian Regions.

DESIGN

two-phase study.

SETTING AND PARTICIPANTS

data from the italian birth certificate of six Italian Regions between 01.01.2019 and 31.03.2021 were analysed. Semi-structured interviews were conducted with the key regional respondents.

MAIN OUTCOME MEASURES

the frequency distributions of breastfeeding and the presence of companion of woman's choice were calculated as a whole and for each Region.

RESULTS

the infant feeding practices experienced smaller changes during COVID-19 pandemic than the presence of the companion of woman's choice during labour and birth, from January 2019 to March 2021. The highest value of exclusive breastfeeding was recorded in September 2020 (72.1%; 95%CI 71.3-72.8) in all Regions, while the lowest was recorded in March 2021 (62.5%; 95%CI 61.5-63.4). The presence of companion of woman's choice during labour and birth decreased during the pandemic and did not return to pre-pandemic levels. The highest value of presence of father during birth was recorded in March 2019 (59.0%; 95%CI 58.2-59.8), while the lowest in April 2020 (50.0%; 95%CI 49.1-50.8). The main emerging themes were: the existence of national, regional and local indications; the facilitators (e.g., Baby-Friendly Hospital Initiative implementation, strong motivation of the staff) and the critical points (e.g., inadequate analysis of the clinical-epidemiological context, inhomogeneous indications) of management of the support person presence.

CONCLUSIONS

the emergency has changed the provision of health services that not always guaranteed the application of best practices. It would be desirable to work for assessing the appropriateness of the birth certificate data to collect more accurate information and to provide clinical recommendations.

Health needs and perception of health care quality among Asylum Seekers and Refugees in an Italian local health authority: A qualitative study

Background

Migrants, Asylum Seekers and Refugees (ASRs) represent a vulnerable diversified population with increased risks of developing health problems, and in the hosting countries several barriers often hamper their access to the health services. Gathering information about ASRs' experiences and perceptions of host country health care systems may contribute to improve the quality of health care provided. The aim of this study was to explore the health needs in their bio-psycho-social meaning, and the quality of health care as perceived from the ASRs' perspective.

Methods

The qualitative descriptive study was conducted as part of the Project "G-START - testing a governance model of receiving and taking care of the Asylum Seekers and Refugees." Through purposeful and snowball sampling, four Focus Groups conducted in English, Italian and French were carried out between July and August 2019, involving 50 ASRs hosted by four reception centers located on the territory pertaining to an Italian Local Health Authority covering a general population of 500.000 people. The analysis of data was categorical, and was performed using N-Vivo software.

Results

The macro-categories emerged were the ASRs' bio-psycho-social health needs, including mental health, sexual and reproductive health, food and nutrition, knowledge of the health care system, need for inclusion; healthcare services access, including barriers before and after the access and the ability of the local health system to respond to existing and evolving demands; strengths of the healthcare and reception systems, and suggestions for improving them in the future.

Discussion and conclusions

ASRs present vulnerabilities and specific health needs, and the health care system is not always able to guarantee access or to respond to these needs. Several obstacles have been highlighted, such as linguistic barriers and lack of cultural mediation, bureaucratic and administrative barriers, lack of knowledge of the Italian health care system. An effective reorganization of services driven by a more detailed output analysis of the target population needs, together with the use of cultural mediation, peer to peer education and support, and the training of health professionals are recommended to ensure a more accessible, equitable and effective health care system at local level.

[A&F: integrating research into practice and practice into research.]

This article proposes a focus on Audit & Feedback (A&F)'s sustainability. If on one side, it is essential to ask how to bring A&F interventions out of research programs into clinical practices and contexts of care. On the other, it is fundamental to ensure that the experiences gained within care contexts can inform research, helping to define the research objectives and questions whose development can support paths of change. The reflection starts from two research programs on A&F carried out in the United Kingdom, respectively, at the regional level (Aspire) in the field of primary care and at the national level (Affinitie and Enact) in the field of the transfusion system. Aspire raised awareness of the importance of establishing a primary care implementation laboratory, which randomizes practices to different types of feedback to evaluate the effectiveness, also to improve patient care. The national Affinitie and Enact programs served to 'inform' recommendations to improve the conditions for sustainable collaboration between A&F researchers and audit programs. They represent an example to understand how to incorporate research results within a national clinical audit program. Finally, starting from the complex experience of the Easy-Net research program, the reflection moves on to how it was possible to make A&F interventions sustainable in Italy beyond research projects, in clinical-care contexts in which the resources provisions make continuous and structured interventions difficult and impractical. The Easy-Net program envisages different clinical care settings, study designs, interventions, and recipients, which require different actions to adapt research results to the specific realities to which A&F's interventions are addressed.

Development of a Defined Approach for Eye hazard identification of chemicals having surfactant properties according to the three UN GHS categories

The purpose of this study was to develop a defined approach (DA) for eye hazard identification according to the three UN GHS categories for surfactants (DASF). The DASF is based on a combination of Reconstructed human Cornea-like Epithelium test methods (OECD TG 492; EpiOcular™ EIT and SkinEthic™ HCE EIT) and the modified Short Time Exposure (STE) test method (0.5% concentration of the test substance after a 5-min exposure). DASF performance was assessed by comparing the prediction results with the historical in vivo data classification and against the criteria established by the OECD expert group on eye/skin. The DASF yielded a balanced accuracy of 80.5% and 90.9% of Cat. 1 (N = 22), 75.0% of Cat. 2 (N = 8), and 75.5% of No Cat. (N = 17) surfactants were correctly predicted. The percentage of mispredictions was below the established maximum values except for in vivo No Cat. surfactants that were over-predicted as Cat. 1 (5.6%, N = 17), with a maximum value set at 5%. The percentage of correct predictions did meet the minimum performance values of 75% Cat. 1, 50% Cat. 2, and 70% No Cat. established by the OECD experts. The DASF has shown to be successful for eye hazard identification of surfactants.

Health Belief Model efficacy in explaining and predicting intention or uptake influenza vaccination during pregnancy

INTRODUCTION

The influenza vaccination is a priority during pregnancy due to infection-related-outcomes. The study aim is to assess the acceptance by women of influenza vaccination during pregnancy based on Health Belief Model (HBM).

METHODS

A multicentre observational study was carried out with a convenience sample of 300 respondents.

RESULTS

Most women (53.7%) declared that they worried to contract influenza during pregnancy and 80.7% of them agreed that there is a risk of contracting influenza during the first months of life. Vaccine benefits (adjOR 4.3 CI 95% 1.7-10.9 p <0.01), information on vaccination (adjOR 2.6 CI 95% 1.2-5.5 p <0.01) and trust in guidelines (adjOR 3.5 CI 95% 1.6-7.3 p <0.01) are some factors associated with intent/vaccination during pregnancy.

CONCLUSIONS

HBM confirms its effectiveness in explaining/predicting health behaviours. It is necessary to create trust in the vaccinations through an integrated work of health professionals to set up training programs and to provide effective health communication.

Breastfeeding and humanitarian emergencies: the experiences of pregnant and lactating women during the earthquake in Abruzzo, Italy

Background

Emergencies have a great impact on infant and young child feeding. Despite the evidence, the recommended feeding practices are often not implemented in the emergency response, undermining infant and maternal health. The aim of this study was to explore the experiences of pregnant and lactating women during the earthquake emergency that occurred in L’Aquila on 6 April 2009.

Methods

The study design was qualitative descriptive. Data were collected by individual semi-structured interviews, investigating the mother’s experiences of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. Data analysis was categorical and was performed by using N-Vivo software.

Results

Six women who were pregnant at the time of the earthquake were interviewed in January 2010. In addition to the essential needs of pregnant and lactating women, such as those related to the emergency shelters conditions, the main findings emerged from this study were: the reconfiguration of relationships and the central role of partners and family support; the need of spaces for sharing experiences and practices with other mothers; the lack of breastfeeding support after the hospital discharge; the inappropriate donations and distribution of Breast Milk Substitutes.

Conclusions

During and after L’Aquila earthquake, several aspects of infant and young child feeding did not comply with standard practices and recommendations. The response system appeared not always able to address the specific needs of pregnant and lactating women. It is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training on infant and young child feeding at all levels and sectors of the emergency response.

AB1211 DOES BODY MASS INDEX AND METABOLIC SYNDROME IMPACT ON FIBROMYALGIA?

Background

Fibromyalgia (FBM), obesity and the metabolic syndrome (MTB) are common conditions with significant impact on health and quality of life, producing relevant economic burden for healthcare systems. Although obesity represents a negative prognostic factor for FBM, the relation between body mass index (BMI) or MTB and FBM severity is still unclear.

Objectives

The aim of our ongoing study was to evaluate the relationship between BMI or prevalent MTB and FBM severity, estimated with 3 different severity scores.

Methods

We included the first 100 women presenting with FBM, defined according to the ACR2016 diagnostic criteria, consecutively evaluated during the period of 1 year in 2 Clinic in Italy. On enrolment were assessed/recorded demographic, clinical and pharmacological characteristics, weight, height, physical activity, tenderness, pain and symptoms. The following scores were calculated: tender points count (TP), Widespread Pain Index (WPI), Polysymptomatic Distress Scale (PDS), Fibromyalgia Impact Questionnaire (FIQ) and modified Fibromyalgia Assessment Status (mFAS). BMI was calculated, and the presence of MTB was evaluated according to current definition. Patients were categorized as presenting with severe disease or moderate/mild disease according to recent definition validated in an Italian population. The prevalence of MTB and the mean ± standard deviation (SD) BMI in subgroups defined according to severity were estimated.

Results

Mean age ±SD was 57.5±12.7 years, mean BMI ±SD was 25.3±5.1, and 9.5% presented with MTB. FBM severity (mean±SD) calculated by PDS, FIQ and mFAS was respectively 25.3±9.3, 63.2±23.1, and 30.1±7.7. Patients with the highest FBM severity according to PDS (>25) were less likely to present with MTB (2.4%) compared to those with a PDS of 0-25 (20.0%, P=.026), with an adjusted (age and BMI) OR (95%CI) for presenting with MTB in patients with less severe FBM of 8.2 (0.962-69.925, P=.054). Similar results were found when the specific conditions characterizing the MTB were considered separately, except for excessive body fat around the waist (not related to severity). The BMI ±SD was comparable between patients with severe disease (25.8±5.8) according to PDS and those with less severe FBM (24.8±4.4, P=.388), with no correlation between BMI and PDS (Rho: 0.083, P=.454). Considering all other characteristics of the two groups defined according to PDS categories (PDS >25 versus PDS 0-25) a significant difference was found in mean age ±SD, greater in patients with less severe FBM (60.2±13.2) compared to those with highest FBM severity (54.8±11.6, P=.046). Similar but less significant findings were found also with FIQ and mFAS. The prevalence of MTB according to the FIQ was 7.3% for highest severity versus 14.3% for less severe FBM (P=.200), with a comparable BMI ±SD between the two groups (respectively 26.2±6.1 versus 24.4±3.7, P=.125). Corresponding figures for MTB or BMI and FBM severity according to the mFAS were respectively: prevalence of MTB in highest severity 3.0% versus 16.3% in the less severe FBM (P=.078); mean ±SD BMI in highest severity 26.4±6.2 versus 24.6±4.2 in less severe patients (P=.121).

Conclusion

The preliminary results of our ongoing analysis demonstrated a slightly inverse relationship between FBM severity and the prevalence of MTB, trending to significance, while no relationship was found between severity and BMI.

References

[1]Salaffi F. Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. Rheumatology. Volume 60, Issue 2, February 2021, Pages 728–736,

[2]Migliorini F. BMI but not age and sex negatively impact on the outcome of pharmacotherapy in fibromyalgia: a systematic review. Expert Rev Clin Pharmacol. 2021 Aug;14:1029-1038.

[3]D’Onghia M. Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis. Semin Arthritis Rheum. 2021 Apr;51:409-424.

[4]Aparicio VA. Fibromyalgia’s key symptoms in normal-weight, overweight, and obese female patients. Pain Manag Nurs. 2013 Dec;14:268-276.

Disclosure of Interests

None declared

Prevalence of breastfeeding and birth practices during the first wave of the COVID-19 pandemic within the Italian Baby-Friendly Hospital network. What have we learned?

BACKGROUND

At the beginning of the COVID-19 pandemic, healthcare workers were faced with difficult decisions about maternity care practices. The evidence-based practices recommended by the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) were confirmed by Italian national guidance.

AIM

To describe, in a number of facilities that are part of a national Baby-Friendly network, the adherence to some steps of BFHI standards during the COVID-19 emergency.

METHODS

We conducted a cross-sectional online survey, inviting all hospitals interested in the Initiative, to fill out a semi-structured questionnaire.

RESULTS

Out of the 68 participating hospitals, 30.9% were hubs and 69.1% spokes. During May 2020, 61.8% of hospitals had COVID-19 and non-COVID-19 clinical pathways, while 38.8% were only non-COVID-19. None was dedicated exclusively to COVID-19 pathways. The BFHI was effective in guaranteeing ≥80% exclusive breastfeeding, the presence of companion of mother's choice, skin-to-skin and rooming-in. The type of accreditation was associated with the presence of a companion of the mother's choice during labour (p=0.022) and with skin-to-skin (p<0.001). According to the narratives, increased interpersonal distance made interactions with mothers difficult and the absence of a birth companion was reported as a major issue.

DISCUSSION AND CONCLUSIONS

The BFHI is a highly-structured, evidence-based care model. Investing in strong collaborative care approaches contributes to hospitals' preparedness.

Quality of care at childbirth: findings of IMAgiNE EURO in Italy during the first year of the COVID‐19 pandemic

Objective

Investigate the quality of maternal and newborn care (QMNC) during childbirth in the first year of COVID‐19 pandemic in Italy, from the mothers' perspective, as key service users.

Methods

Women who gave birth in an Italian facility from March 1, 2020 to February 29, 2021 answered an online questionnaire including 40 WHO Standard‐based Quality Measures. Descriptive and multivariate quantile regression analyses were performed.

Results

In total, 4824 women were included, reporting heterogeneity of practices across regions: among 3981 women who underwent labour 78.4% (63.0%–92.0%) were not allowed a companion of choice, 44.6% (28.9%–53.3%) had difficulties in attending routine antenatal visits, 36.3% (24.9%–61.1%) reported inadequate breastfeeding support, 39.2% (23.3%–62.2%) felt not involved in medical choices, 33.0% (23.9%–49.3%) experienced unclear communication from staff, 24.8% (15.9%–39.4%) were not always treated with dignity and 12.7% (10.1%–29.3%) reported abuses. Findings in the group of women who did not experience labour were substantially similar. Multivariate analyses confirmed a significant lower QMNC index for regions in southern Italy compared to North and Central regions.

Conclusion

Mothers reported substantial inequities in the QMNC across Italian regions. Future studies should monitor QMNC over time. Meanwhile, actions to ensure high QMNC for all mothers and newborns across Italy are urgently required.

Mothers giving birth in the first year of the COVID‐19 pandemic reported substantial inequities across Italian regions in the QMNC around the time of childbirth.

Improving the quality of care for people with chronic diseases: translating recommendations to practice

INTRODUCTION

Aim of this paper is to present a guide for translating to practice an evidence-based set of Quality Criteria and Recommendations (QCR) to promote the implementation of policies and practices in the field of health promotion, disease prevention and care for people with chronic diseases.

METHODS

The guide is based on real-world experiences of eight European pilot actions using QCR as a framework for practice design, development, implementation, monitoring and evaluation. All partners implemented their respective practices by following the same agreed process.

RESULTS

The implementation method was summarized in seven steps where each of one outline a particular phase of the process. The guide provides a step-by-step tutorial for the implementation of QCR.

CONCLUSIONS

Practical experiences from the pilot actions show the potential value of using the QCR in designing and implementing practices to improve the quality of care for people with chronic diseases.

[Pre and post natal care and new organizational models during COVID-19 pandemic: the experience of the Autonomous Province of Trento]

The COVID-19 pandemic had a great impact on pre and post-natal care, and, more generally, on the female population. Health services have been characterized by significant changes that have involved a review and reorganization of care pathways and clinical practices. The midwife continued to play a key role for the health of women and children, for the continuity of care and for a health-oriented approach throughout their life. The experience of the Pre and Post Natal Care of the Autonomous Province of Trento ensured the continuity of care during the pandemic thanks to the activation of a well-established Hospital-Territory network. The dedicated Case Manager Midwife allowed continuity and appropriateness of care during all phases of the birth pathway. The possibility of having the first interview electronically led to a continuous annual increase in the first interviews. In addition, for all women in the third trimester of pregnancy, the antenatal classes are organized remotely, using simple IT supports, in videoconferencing mode, maintaining homogeneous contents and objectives throughout the territory. The involvement of fathers from the early stages of pregnancy has shown the value of co-parenting even during the pandemic. This organizational model rooted in the territory and in the network of connection between the Territory and the Hospital proved to be a resource to withstand the impact of the emergency and guaranteed appropriate and timely assistance to women, fathers and the family.

AB0379 BARICITINIB IN POLYMYALGIA RHEUMATICA AND GIANT CELL ARTERITIS: REPORT OF SIX CASES

Background:

Glucocorticoids (GC) are the cornerstone of the treatment of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), but they are associated with several adverse events (AEs). Moreover, a considerable proportion of patients relapse during GC tapering.

Objectives:

To describe the efficacy and safety of the JAK-inhibitor baricitinib (BARI) in a group of patients with PMR and/or GCA.

Methods:

Case series of patients with PMR and/or GCA with a refractory disease course, despite several lines of therapy, including methotrexate (MTX) and tocilizumab (TCZ), started treatment with BARI. All patients underwent periodic, standardised clinical and laboratory examinations, and also FDG-PET/CT. PMR-activity score (AS) was calculated at each visit except in patients with isolated large vessel vasculitis (LVV) or GCA.

Results:

A total of six patients (five females and one male, median age 64 years, range 50-83) were treated with BARI. Two of them had isolated PMR (patients #1 and #6), two had PMR with associated LVV (patients #2 and #5), and one (patient #3) had cranial-GCA. Demographic and clinical characteristics are provided in Table 1. At the time of starting BARI, patients were taking a median prednisone dose of 8.75 mg/day (range 0-25), and the 4 patients with PMR±LVV had a median PMR-activity score (PMR-AS) of 23.3 (indicating high disease activity), which decreased to 1.58 after 6 months of treatment with BARI. Two of them could stop GC and continued BARI monotherapy (in one case, BARI was tapered down to 2 mg/day after 12 months).

After starting BARI, patient #3 (GCA) could gradually taper prednisone from 25 mg/day to 10 mg/day in six months, without reporting fever or headache. After one year of treatment, she feels well while taking prednisone 7.5 mg/day.

Patient #4 (LVV) remained clinically stable during the treatment with BARI, but a follow-up FDG-PET/CT showed LVV, and we decided to stop BARI and restart TCZ. After 4 months of treatment with BARI, patient #5 suffered from pneumonia, while she was also taking prednisone 15 mg/day. BARI was therefore stopped. No other AEs attributable to BARI were detected.

Conclusion:

BARI appears as an appealing option for treating patients with PMR and/or GCA. Although these preliminary results should be confirmed by a RCT, BARI lowered rapidly disease activity and exerted a significant steroid-sparing effect, allowing GC withdrawal in 2 out of 6 patients.

Table 1.

Demographic and clinical characteristics of patients.

Patient #SexAgeDiagnosisPrevious treatmentDisease duration (months)PMR-AS1F66PMRMTX, HCQ, SSZ25.540.52F78PMR+LVVTCZ, MTX41.828.83F61GCACYC, MMF, TCZ119.8N/A4F60LVVTCZ16.4N/A5F83PMR+LVVMTX, TCZ24.415.26M50PMRMTX24.617.8

CYC: cyclophosphamide, GCA: giant cell arteritis, HCQ: hydroxychloroquine, LVV: large vessel vasculitis, MMF: mycophenolate mofetil, MTX: methotrexate, N/A: not applicable, PMR: polymyalgia rheumatica, PMR-AS: PMR-activity score, SSZ: sulfasalazine, TCZ: tocilizumab.

Disclosure of Interests:

Dario Camellino Speakers bureau: Medac, Eli Lilly, Paid instructor for: Mylan, Consultant of: Accord, Celgene, Novartis, Sanofi, Christian Dejaco Speakers bureau: Eli Lilly (<10.000€), Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, Consultant of: EffRx, Abiogen Pharma, FRANCO MARTINI: None declared, Renzo Cosso: None declared, Giuseppe Girasole: None declared, Gerolamo Bianchi Speakers bureau: Amgen, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme, and Servier, Consultant of: Abbvie, Abiogen Pharma, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac

POS1105 EFFECTS OF CHOLECALCIFEROL AND CALCIFEDIOL IN OSTEOPOROTIC WOMEN WITH SECONDARY HYPERPARATHYROIDISM DUE TO SEVERE VITAMIN D DEFICIENCY UNDERGOING ZOLEDRONIC ACID TREATMENT: A RANDOMIZED-CONTROLLED TRIAL

Background:

Secondary hyperparathyroidism (sHPTH) due to vitamin D deficiency impairs the bone mineral density (BMD) response to alendronate,1-2 but the optimal strategy for its correction in postmenopausal osteoporotic women (PMO) about to start zoledronic acid (ZOL) therapy is still unknown.

Objectives:

To evaluate the effects of cholecalciferol (D3) and calcifediol (25OHD) on serum 25-OH-vitamin D (s25OHD), parathyroid hormone (PTH) and BMD in PMO presenting with sHPTH due to vitamin D deficiency.

Methods:

PMO with s25OHD <20 ng/ml, sHPTH (PTH >65 pg/ml) and BMD T-score at the lumbar spine (LS), femoral neck (FN) or total hip (TH) < -2.5, or between -1 and -2.5 plus one vertebral/femoral fracture, were randomly assigned to receive a therapeutic dose of D3 (300.000 IU bolus) followed by 175 mcg/weekly of D3, or 175 mcg/weekly of 25OHD alone, 2 months before receiving a single intravenous infusion of ZOL (5 mg). BMD at the LS, FN and TH was assessed at baseline and after one year from ZOL. Serum calcium, PTH and s25OHD were measured at baseline, and 6- and 12-month after ZOL. Adverse and clinical events were ascertained by 3-and 9-month telephone interviews, and by 6- and 12-month clinical evaluation.

Results:

45 PMO (25OHD N=23, D3 N=22) were enrolled over one year and 32 subjects (mean age ±SD 75±10 years, range 51-91) completed the 1-year of treatment/follow-up (25OHD N=17, D3 N=15). Most PMO discontinued for protocol violation, while three deceased before study ending (25OHD N=1, D3 N=2) for reasons not related to the agents investigated. The baseline characteristics were comparable in both groups. At baseline mean s25OHD (±SE) was 8±1 ng/ml in the 25OHD group and 8±1 ng/ml in the D3 group. The corresponding figures for PTH were 111±6 pg/ml (25OHD) and 117±5 pg/ml (D3). Mean s25OHD (±SE) increased in both groups at 6- and 12-month, being significantly greater in the 25OHD group (12-month, 56±2 ng/ml) compared to the D3 group (12-month, 34±2 ng/ml, P<.001) at both time points (Figure 1). PTH (mean ±SE) decreased in both groups, being significantly lower in the 25OHD group at 12-month (25OHD 46±6 pg/ml versus D3 70±6 pg/ml, P=.007), as shown in Figure 1. BMD at the LS, FN and TH increased in both groups (with significant increases versus baseline only at the FN) without significant differences between s25OHD and D3. In PMO receiving D3 serum calcium remained stable over time, while those receiving s25OHD demonstrated a significant increase of serum calcium, with 2 PMO presenting a value close to the upper limit of the reference range at 12-month. No patient reported incident fractures or adverse events.

Conclusion:

Calcifediol 175 mcg weekly appears more potent in improving s25OHD and decreasing PTH concentrations compared to cholecalciferol therapeutic dose (300’000 IU) plus 175 mcg weekly in PMO presenting with sHPTH due to severe vitamin D deficiency about to start ZOL therapy. Further studies are warranted to clarify implications on BMD improvements on the long-term of similar 25OHD and D3 regimens.

References:

[1]Barone A et al., J Am Geriatr Soc 2007.

[2]Kincse G et al., BMC Musculoskelet Disord 2012.

Disclosure of Interests:

Giulia Botticella: None declared, Monica Pizzonia: None declared, Barbara Cossu: None declared, Roberta Bruno: None declared, Dario Camellino Speakers bureau: AbbVie, Celgene, Janssen-Cilag, Eli Lilly, Medac, Mylan, Novartis, and Sanofi, outside the submitted work, Giuseppe Girasole Speakers bureau: Abiogen Pharma and Novartis, outside the submitted work, Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, outside the submitted work, Consultant of: EffRx and Abiogen Pharma, outside the submitted work, Mario Pedrazzoni: None declared, Simona Alexovits: None declared, Franco Pleitavino: None declared, Federico Santolini: None declared, Alessio Nencioni: None declared, Gerolamo Bianchi Speakers bureau: Abbvie, Abiogen Pharma, Amgen, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme, and Servier, outside the submitted work.

POS1447 LOW-INTENSITY PULSED ELECTROMAGNETIC FIELDS IMPROVE PHYSICAL PERFORMANCE IN A DOSE-DEPENDENT MANNER: AN OBSERVATIONAL STUDY IN OLDER ADULTS WITH RHEUMATIC DISEASES

Background:

Low-intensity pulsed electromagnetic fields (PEMF) have been shown to improve gait parameters in frail older adults.1 Furthermore, the continuous exposure to PEMF (up to 1 year) have been demonstrated to produce progressive improvements in self-selected gait speed in older adults at risk of falling.2

Objectives:

To investigate the effects of two different treatment regimens of PEMF on physical performances in older adults presenting with rheumatoid arthritis (RA), osteoarthritis (OA) or severe osteoporosis (OP).

Methods:

Older adults presenting with RA, OA or OP, at increased risk of falls, evaluated in our Falls Prevention Clinic, were considered for a prospective observational study investigating the effects of PEMF on physical performances. PEMF were supplied by the THS 280 E device (THS-Therapeutic Solutions Srl, Milan, Italy). It provides a new therapeutic approach, named TEPS (Triple Energy Postural Stabilization), that represents an evolution of physical therapy.1,2 On the basis of the physician judgment, PEMF were administered following an intensive protocol, every 45 days (PEMF-45), or a standard validated protocol1,2, every 60 days (PEMF-60). All subjects were assessed at baseline and every 3 months with the following tests: 4 meters gait speed test [4MGS, seconds (sec)], timed up and go test (TUG, sec), chair stand test (CST, sec), short physical performance battery (SPPB, score), and hand grip strength (HGS) by hand dynamometer (Kg). Demographic, anthropometric and clinical characteristics, including pharmacological treatments and functional status were evaluated at baseline. Clinical and adverse events were assessed every 45 or 60 days after PEMF administration.

Results:

Overall, 94 patients were enrolled between January and December 2020. Of these, 43 subjects (N=33 PEMF-45, N=11 PEMF-60) with a valid 6-month follow-up assessment were considered for the current analysis. The two groups were comparable regarding the main baseline characteristics, and similar % of patients presented with RA, OA or OP. Mean age (±SE) was 78±7 in PEMF-45 and 77±7 in PEMF-60. As expected, all physical performance tests improved significantly from baseline to 6 months in both groups. Mean (±SE) 4MGS increased significantly more in PEMF-45 (from 3.24±0.12 sec to 2.83±0.18 sec) compared to PEMF-60 (from 3.22±0.21 sec to 3.02±0.30 sec, p=.018). Likewise, mean (±SE) CST improved more in PEMF-45 (from 12.4±0.9 sec to 8.7±0.4 sec) compared to PEMF-60 (from 11.1±1.5 sec to 9.8±0.7 sec, p=.002). No significant difference between groups was found for the other tests, although a trend toward better results in PEMF-45 was manifest: SPPB improved by 6.4% in PEMF-45 and by 3.0% in PEMF-60, and TUG decreased by 7.8% in PEMF-45 and by 6.1% in PEMF-60. During the 6 months observation period no adverse event was observed.

Conclusion:

Preliminary results of our ongoing prospective observational study suggest that a more frequent administration of PEMF produces greater improvements in some but not all physical performance parameters compared to a standard validated regimen1,2.

References:

[1]Giusti A et al., Geriatr Gerontol Int 2013. 2Giusti A et al., J Am Geriatr Soc 2014.

Disclosure of Interests:

Massimo Giovale: None declared, Giuseppina Tramontano: None declared, Rossana Galli: None declared, Simone Rando: None declared, Andrea Giusti Speakers bureau: UCB, Amgen, Kyowa Kirin, Abiogen Pharma, and Eli Lilly, outside the submitted work, Consultant of: EffRx and Abiogen Pharma, outside the submitted work, Lorenzo Bandi: None declared, Francesca Russo: None declared, Stefano Rampoldi Employee of: THS Therapeutic Solutions SRL, Luigi Carlo Bottaro: None declared, Gerolamo Bianchi Speakers bureau: Abbvie, Abiogen Pharma, Amgen, BMS, Celgene, Eli Lilly, GSK, Janssen-Cilag, Medac, MSD, Novartis, Pfizer, Roche, Sanofi, Genzyme and Servier, outside the submitted work

Verba volant, scripta manent: breastfeeding information and health messages provided to parents in the neonatal discharge summary in the Lazio Region, Italy

OBJECTIVE

We aimed to evaluate the contents of the neonatal discharge summary (NDS), an important communication tool that should contain evidence-based information.

METHODS

A quali-quantitative study of NDSs delivered from 29 hospitals of Lazio (Italy) in 2014 and 2017 was conducted. We used content analysis to assess the written information and logistic regression to estimate the association between outcomes (compliance with the International Code, health messages, and information on neonatal screenings) and some hospital's characteristics.

RESULTS

NDSs conforming to International Code were associated with low rate of C-section (p < 0.05). Hospitals belonging to Local Health Authorities (p < 0.05) and with a lower prevalence of C-section (p < 0.05) had a greater attitude to promote infant health. The year of collection was associated with information on neonatal screenings (p < 0.05).

CONCLUSIONS

An effort is required by hospitals to reduce their level of medicalization, in clinical practice and prescriptive attitudes, which affects the NDSs delivered to parents.

'A sleeping volcano that could erupt sooner or later'. Lived experiences of women with multiple sclerosis during childbearing age and motherhood: A phenomenological qualitative study

INTRODUCTION

Multiple Sclerosis (MS) mainly involves women, impacting many aspects related to childbearing age and maternity. Women with MS can have healthy pregnancies and infants. Needs, challenges and concerns of women with MS should be considered in order to improve care pathway, ensuring a patient-centred approach. Therefore, the aim of this study was to explore personal experiences, expectations, fears in women with MS.

METHODS

A descriptive phenomenological study, including women with MS during childbearing age, pregnancy and motherhood, carried out from January to April 2019. Women, enrolled in a MS centre with snowball sampling through healthcare network, were invited for a face-to-face or phone interview, digitally audio-recorded and fully transcribed. Two different sets of semi-structured interviews were developed (woman seeking pregnancy / pregnant woman and mother), together with an anonymous form, to collect some main sociodemographic data. Categorical data analysis, inductively and deductively, was processed by 3 different researchers, using Creswell extension to reduce subjective influences. QDA Miner qualitative text analysis software was used.

RESULTS

The following 6 deductive themes emerged: 1) experience with diagnosis of MS; 2) relationship with the partner, children, and family; 3) pregnancy; 4) delivery; 5) puerperium; 6) care pathway. Experiences with diagnosis can be very different between women. Communication of MS diagnosis appears as an opportunity to strengthen emotional ties, despite sorrow and concerns. Reasons for quarrels and disagreements, both in couple and parents, were due to an overly protective and supportive attitude. Some participants reported difficulty of conceiving. Pregnancy is described as a state of wellbeing, not devoid by fears and worries. Women experienced fatigue and exhaustion especially during the second stage of labour, but spontaneous delivery is described as an empowering experience. Findings about breastfeeding confirm that healthcare professionals have a crucial role regarding initiation, duration and type of breastfeeding and often scarce education and training on the topic, together with lack of reliable scientific sources, lead to a conservative approach. Healthcare providers communication and consulting emerge as indispensable skills.

CONCLUSION

The study provides a better understanding of how MS impacts women' life during childbearing age, pregnancy and motherhood. Findings support the importance of provide quality and tailored care for women with MS, according to an empathetic and patient-centred approach. Further research should be more comprehensive explorations of mothers' experiences in different cultural contexts, but also partners and offspring of women with MS.

Breastfeeding promotion and support: a quality improvement study

BACKGROUND

Breastfeeding success is determined by early skin to skin contact, early initiation of breastfeeding, rooming-in, baby-led breastfeeding, creation of a favorable environment, specific training of health professionals, and continuity of care.

OBJECTIVE

To investigate the women's satisfaction regarding the care and support received in the first days after childbirth.

MATERIAL AND METHODS

A questionnaire of 24 items was administered to mothers before discharge, from May to September 2019 at the University Hospital of Modena.

RESULTS

The predictive variables of exclusive breastfeeding were the delivery mode, age at birth and parity. The multivariate analysis showed that a high satisfaction score was associated with vaginal birth (OR=2.63, p=0.005), rooming-in during the hospitalization (OR=8.64, p<0.001), the skin to skin contact (OR=6.61, p=0.001) and the first latch-on within 1 hour after birth (OR=3.00, p=0.02).

CONCLUSIONS

Mothers' satisfaction is one of the important factors of positive experience during hospital stay and of better health outcomes.

Maternal and Infant Outcomes Associated with Maternity Practices Related to COVID-19: The COVID Mothers Study

Background: Maternity care practices such as skin-to-skin care, rooming-in, and direct breastfeeding are recommended, but it is unclear if these practices increase the risk of clinically significant COVID-19 in newborns, and if disruption of these practices adversely affects breastfeeding. Methods: We performed a retrospective cohort study of 357 mothers and their infants <12 months who had confirmed or suspected COVID-19. Subjects came from an anonymous worldwide online survey between May 4 and September 30, 2020, who were recruited through social media, support groups, and health care providers. Using multivariable logistic regression, Fisher's exact test, and summary statistics, we assessed the association of skin-to-skin care, feeding, and rooming-in with SARS-CoV-2 outcomes, breastfeeding outcomes, and maternal distress. Results: Responses came from 31 countries. Among SARS-CoV-2+ mothers whose infection was ≤3 days of birth, 7.4% of their infants tested positive. We found a nonsignificant decrease in risk of hospitalization among neonates who roomed-in, directly breastfed, or experienced uninterrupted skin-to-skin care (p > 0.2 for each). Infants who did not directly breastfeed, experience skin-to-skin care, or who did not room-in within arms' reach, were significantly less likely to be exclusively breastfed in the first 3 months, adjusting for maternal symptoms (p ≤ 0.02 for each). Nearly 60% of mothers who experienced separation reported feeling "very distressed," and 29% who tried to breastfeed were unable. Presence of maternal symptoms predicted infant transmission or symptoms (adjusted odds ratio = 4.50, 95% confidence interval = 1.52-13.26, p = 0.006). Conclusion: Disruption of evidence-based quality standards of maternity care is associated with harm and may be unnecessary.

[Interrupting the chains of transmission of COVID-19 in Italy: survey among the Prevention Departments]

BACKGROUND

the ability to implement effective preventive and control measures is rooted in public health surveillance to promptly identify and isolate contagious patients.

OBJECTIVES

to describe some organizational aspects and resources involved in the control of COVID-19 pandemic.

DESIGN

observational cross sectional study.

SETTING AND PARTICIPANTS

a survey of methods and tools adopted by the competent service (Prevention department) in the Local public health units (LHU) of the regional Health services has been performed in May 2020. The survey collected data related to activities carried out during the month of April 2020 on the surveillance system for collection of suspected cases, their virological ascertainment, the isolation procedures and contact-tracing activities by means of an online questionnaire filled in by the public health structure of the regional health system. A convenience sample of Prevention departments was recruited.

RESULTS

in 44 Prevention departments of 14 Regions/Autonomous Provinces (caring for 40% of the population residing in Italy), different services were swiftly engaged in pandemic response. Reports of suspected cases were about 3 times the number of confirmed cases in the same month. Local reporting form was used in 46% of the LHUs while a regional form was available in 42% of the Departments (in 9/14 Regions). In one fourth the forms were not always used and 2% had no forms for the reporting of suspected cases. Data were recorded in 52% of LHUs on local databases, while in 20% a regional database (in 7 Regions) had been created. A proportion of 11% did not record the data for further elaboration. The virological assessment with nasopharyngeal swabs out of the hospital setting was carried out on the average in 7 points in each LHU (median 5) and the average daily capacity was 350 (71 per 100,000) swabs. The rate of subjects newly tested during the month of April was of 893 per 100,000 new people. Data collected at the swabbing were recorded on a regional platform in 17 LHUs (39%) of 8 Regions. In 7% LHUs only positive specimens were recorded electronically. Local files were used in 27% LHUs. The interview with confirmed cases was carried out with a local questionnaire in 52% LHUs, while 14% stated that a standardized form was not used. The data collected about cases were recorded on a regional IT platform in 30% Departments (in 8 Regions) and in 41% data were registered only locally. For each confirmed case in April, a median of 4 contacts were identified. Only 13 (30%) Departments in 9 Regions have registered contact data on a regional database. Ten Departments (23%) have only hard copies, while 56% recorded data on local databases. About 5 health professionals for 100,000 resident population were involved in each LHU in each of the following activities as receiving reports of suspected cases, swabs collection, interviews of cases and contact identifications.

CONCLUSIONS

the pandemic required rapidly a great organizational effort and great flexibility to increase response capacity, which now must be strengthened and maintained. Several different tools (forms and electronic files) have been developed in each LHU and used for the same surveillance operational processes with a loss in local efficiency. The inhomogeneous data collection and recording is an obstacle for further analyses and risk identifications and is a missed opportunity for the advancement of our knowledge on pandemic epidemiology analysis. In Italy, updating the pandemic response plans is the priority, at national, regional and local level, and the occasion to fill the gaps and to improve surveillance systems to the interruption of COVID-19 transmission.

Evolution of spray and aerosol from respiratory releases: theoretical estimates for insight on viral transmission

By modelling the evaporation and settling of droplets emitted during respiratory releases and using previous measurements of droplet size distributions and SARS-CoV-2 viral load, estimates of the evolution of the liquid mass and the number of viral copies suspended were performed as a function of time from the release. The settling times of a droplet cloud and its suspended viral dose are significantly affected by the droplet composition. The aerosol (defined as droplets smaller than 5 μm) resulting from 30 s of continued speech has O(1 h) settling time and a viable viral dose an order-of-magnitude higher than in a short cough. The time-of-flight to reach 2 m is only a few seconds resulting in a viral dose above the minimum required for infection, implying that physical distancing in the absence of ventilation is not sufficient to provide safety for long exposure times. The suspended aerosol emitted by continuous speaking for 1 h in a poorly ventilated room gives 0.1-11% infection risk for initial viral loads of 10 8 - 10 10   copies ml l - l , respectively, decreasing to 0.03-3% for 10 air changes per hour by ventilation. The present results provide quantitative estimates useful for the development of physical distancing and ventilation controls.

Taking care of minor migrants' health: the professionals' perception and training needs

INTRODUCTION

In Italy, minor migrants represent 21.8% of the non-EU citizens. The care of minor migrants might be challenging as this population is characterized by higher vulnerability and special needs. The study aim was to describe the perceptions on the provision of care, the bio-psycho-social needs of migrant children and the professional training needs.

METHODS

The study is qualitative descriptive. In May 2019 three focus group, involving health and social professionals, cultural mediators and NGOs operators, were organized.

RESULTS

The study explored different areas of the provision of care to minor migrants including bio-psycho-social needs, care provision, barriers to care and professionals' training needs.

DISCUSSION AND CONCLUSIONS

The provision of care should consider the specific migration journey and narrative. In some cases healthcare is fragmented, generating obstacles to access especially in minors with lower levels of health literacy. Training plays a key role in the development of cultural competence.

Breastfeeding Protection, Promotion, and Support in Humanitarian Emergencies: A Systematic Review of Literature

BACKGROUND

Infants, young children, and their mothers are vulnerable in humanitarian emergencies. The health benefits of optimal breastfeeding practices in emergency settings have been demonstrated by many researchers. Infant and Young Children Feeding in Emergency guidelines illustrate a series of interventions to protect, promote, and support breastfeeding, but unfortunately, these recommendations are still scarcely applied.

RESEARCH AIMS

(1) To review the literature describing the effectiveness of breastfeeding protection, promotion, and support interventions in humanitarian emergency contexts; (2) to describe the influence of interventions on breastfeeding initiation, exclusivity, and duration; and (3) to evaluate relevant mother and infant/child outcomes available in the literature.

METHODS

PubMed, CINAHL, Cochrane Library, Psychology Database, JSTOR, Web of Science, EMBASE, and Ovid were searched for articles that examined breastfeeding protection, promotion, or support interventions and the resulting outcomes without any time limits (N = 10). Articles that did not include the interventions and related outcomes were excluded (n = 1,391).

RESULTS

Improved breastfeeding outcomes were reported in four (40%) papers, and three (30%) highlighted a behavioral change in infant and young child feeding practices following the implementation of the interventions. Increased knowledge about appropriate infant and young child feeding practices among mothers and humanitarian/health staff was reported in eight (80%) papers. However, outcomes were sometimes only generically reported, and some of the included papers had a low strength of evidence.

CONCLUSION

In the literature, there is a great dearth of studies evaluating the influence of interventions aimed at improving breastfeeding in emergency settings. More evidence is urgently needed to encourage and implement optimal breastfeeding practices.

The emerging issue of cognitive disorders and dementia among migrants

Background

Due to population aging, people with a migration background are (and will be) increasingly exposed to the burden of chronic, age-related diseases. Specifically, the occurrence of dementia and cognitive disorders in this population of individuals can assume special clinical and public health relevance. The ImmiDem project (GR-2016-02364975) is aimed at characterizing the emerging phenomenon of cognitive disorders in migrants in Italy.

Methods

The number of dementia and mild cognitive impairment (MCI) cases among migrants living in the extended European Union was calculated by applying the age- and gender-specific prevalence rates of these conditions to the population data of international migrants provided by Eurostat. A pilot survey was addressed to a representative sample of Italian centers for cognitive disorders and dementia (CCDDs) with the aim of collecting information on the number of migrants attending these services, the adopted diagnostic, and the possible barriers and resources in the provision of care.

Results

Nearly 700,000 cases of dementia and 680,000 cases of MCI can be estimated in the migrant population living in Europe in 2018. Nevertheless, the number of migrants referred to the surveyed CCDDs was very low and was considered as stable over the last 5 years. Most of CCDDs reported the possibility of contacting cultural mediators and/or interpreters, while only a few reported the availability and regular use of translated and/or cross-cultural cognitive assessment tools.

Conclusions

The data produced by the ImmiDem project allow a preliminary characterization of the emerging phenomenon of cognitive disturbances in the migrant population. The survey will be extended to all Italian dementia services (CDCD, day centers, residential structures). Activities aimed at identifying and promoting dedicated care pathways or good practices will also be conducted.

Key messages

The clinical and epidemiological characterization of cognitive disorders occurring in migrants represent an emerging public health matter for Western countries. The onset of dementia in migrants can result in important clinical-diagnostic and healthcare complexities.

Larval ascaridoid nematodes in horned and musky octopus (Eledone cirrhosa and E. moschata) and longfin inshore squid (Doryteuthis pealeii): Safety and quality implications for cephalopod products sold as fresh on the Italian market

The aim of this study was to evaluate the occurrence, infection level and distribution of ascaridoid larvae in cephalopod products sold in Italy. Data on the species most commonly commercialized as whole and fresh on the Italian market were collected. After comparing commercial and literature data, Eledone spp., comprising E. cirrhosa and E. moschata (horned octopus and musky octopus, respectively) and Doryteuthis pealeii (longfin inshore squid) were selected, as they had been rarely investigated. Overall, 75 Eledone spp. caught in the Mediterranean Sea (FAO area 37) and 70 D. pealeii from the Northwest Atlantic Ocean (FAO area 21) were examined by visual inspection and artificial digestion (viscera and mantle separately). Parasites were submitted to morphological and molecular analysis. Prevalence (P), mean intensity (MI) and mean abundance (MA) were calculated. In D. pealeii, 2 nematode larvae molecularly identified as Anisakis simplex s.s. were found in the viscera and in the mantle of two specimens (P: 2.9% 95% CI: 0-6.8%; MI: 1; MA: 0.028). In Eledone spp. 9 nematode larvae molecularly attributed to Hysterothylacium spp. were found in the mantle of 5 specimens (P: 6.7% 95% CI: 1-12.3%; MI: 1.8; MA: 0.12). This is the first report of A. simplex s.s. in D. pealeii. Considering the zoonotic and allergenic potential of these larvae and their localization also in the edible part (mantle), a potential public health issue exists.

AB0283 REDUCED HOSPITAL ADMISSION IN RA PATIENTS TAPERING BIOLOGIC DMARDS: PRELIMINARY ANALYSIS OF A RETROSPECTIVE STUDY

Background:

bDMARDs are among the most effective therapies in the management of inflammatory arthritides, but they are associated with potentially severe adverse events (AEs), particularly infection. Tapering strategies of bDMARDs for patients in remission/low disease activity (R/LDA) have demonstrated comparable efficacy to standard-dose treatments, but their safety profile has not been studied yet.

Objectives:

To compare the number and the causes of hospital admissions in RA patients in R/LDA continuing or tapering bDMARDs.

Methods:

Consecutive patients with rheumatoid arthritis (RA) evaluated between 2011 and 2017, were assigned, based on treating physician’s discretion, to continue the standard dose (STD) of bDMARDs or to undergo a predetermined tapering strategy (TAP), after being in R/LDA for two consecutive visits at least 3 months apart. Down-titration of bDMARDs was obtained by a stepwise increase of the dosing interval to achieve a reduction of about 30% (e.g. administration of etanercept every 10 days instead of weekly). Demographic, clinical data and concomitant treatments were retrospectively retrieved from the electronic charts of the outpatient clinics. Information about hospital admissions, including main diagnosis, period and duration of hospitalization, and death were retrieved from the Regional Healthcare System Database.

For the STD group, the observation period started with the occurrence of remission and finished with one of these events: loss of remission, switch to another bDMARD, withdrawal of the bDMARD, severe AE, death, end of the study period in (December 2017). For the TAP group, the observation period started with tapering onset and finished with one of these events: reduction of the dosing interval due to either a relapse (according to a DAS28 increase) or to a subjective, symptomatic relapse (according to the patient’s definition), switch to another bDMARD, withdrawal of the bDMARD, severe AE, death, end of the study period in (December 2017).

Results:

81 patients were included, of whom 40 underwent TAP. Demographic, clinical and treatment data are shown in table 1. Baseline characteristics were comparable between the two groups, except for the number of previous bDMARDs before observational period entry that was slightly higher in the STD group (STD 1.0±0.9 versus TAP 0.5±0.8, P=0.11).

Table 1.

Baseline demographic and clinical characteristics of the patients in remission or low disease activity.

NO TAPERING(n=41)TAPERING(n=40)p valueMean age (yrs)57±1158±130.563Mean disease duration (yrs)12±912±70.897Starting bDMARD to tapering/monitoring (months)52±4567±410.128Mean monitoring period (months)22±2419±230.632Taking sDMARD at any time ((n (%))40 (98%)37 (92%)0.359Taking glucocorticoids29 (71%)28 (70%)0.999Mean prednisone dose (mg/day)2.5±2.92.1±2.70.527DAS28 at the time of tapering or first LDA/REM2.3±0.82.3±0.90.863Previous bDMARDs >1 (n (%))10 (24.4%)4 (10%)0.140

In the STD group, 14 hospital admissions occurred, while in the TAP group there were 7 admissions (p=0.128). The corresponding figures for hospital admission due to infectious diseases were 6 in the STD group and 0 in the TAP group (p=0.026).

Conclusion:

Tapering bDMARDs in RA patients in R/LDA is associated with fewer hospital admissions, with a possible protective effect especially toward infections.

Acknowledgments:

The authors are indebted with Mrs Rosella Gramuglia and Mrs Cristina Olivieri for the management and analysis of the data on the flow of the drugs, and with Mrs Anna Consigliere, Mrs Anna Cosso, Mrs Romina Petralito and Mrs Laura Ravaschio for helping in retrieving clinical data.

Disclosure of Interests:

Dario Camellino Consultant of: I have received consultancy fees from Celgene, Sanofi, Novartis, Janssen-Cilag, Accord, Paid instructor for: I have served as a paid instructor for Mylan, Andrea Giusti Consultant of: UCB, Amgen, Janssen, Eli Lilly, Abiogen, EffRx, Speakers bureau: UCB, Amgen, Janssen, Eli Lilly, Abiogen, EffRx, Alfa-Sigma, Chiesi, Giuseppe Girasole: None declared, Chiara Craviotto: None declared, Paola Diana: None declared, Antonia Locaputo: None declared, Tiziana Caviglia: None declared, Lacramioara Luca: None declared, Gerolamo Bianchi Consultant of: Amgen, Janssen, Merck Sharp & Dohme, Novartis, UCB, Speakers bureau: Abbvie, Abiogen, Alfa-Sigma, Amgen, BMS, Celgene, Chiesi, Eli Lilly, GSK, Janssen, Medac, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Sanofi Genzyme, Servier, UCB

Long-Term Effectiveness of an E-Learning Program in Improving Health Care Professionals' Attitudes and Practices on Breastfeeding: A 1-Year Follow-Up Study

Introduction: In-service continuing education offers a unique opportunity to improve knowledge, skills, attitudes, and practices regarding breastfeeding. It has been shown that an online approach to in-service education is effective at improving practices and attitudes toward breastfeeding among health care professionals (HCPs) in the short term. Aim: To evaluate the long-term effectiveness of an online national program on infant nutrition for HCPs. Materials and Methods: We carried out a follow-up study using data from three time points: T0 (pretraining), T1 (immediately post-training), and T2 (1 year after training). The differences between T0, T1, and T2 were tested using repeated-measures ANOVA. Statistical analysis was performed using SPSS version 22.0. Results: The final sample was comprised of 4,582 participants, mainly women (87.4%). At T2, we observed a worsening of attitudes and practices (APs) as compared with T1, though those APs almost never reached the low levels observed at T0. The greatest changes over time concerned the use of drugs during breastfeeding (T0: 3.00 ± 1.33 versus T1: 1.74 ± 1.03 versus T2: 2.64 ± 1.35) and dietary restriction (T0: 2.77 ± 1.35 versus T1: 1.76 ± 1.12 versus T2: 2.57 ± 1.35). The differences between the means of APs at T0, T1, and T2 were significant (p < 0.01). Conclusion: This e-learning program was effective in improving APs regarding the protection, promotion, and support of breastfeeding. The improvement, higher immediately after training, decreased over time. E-learning project managers should propose strategies to facilitate the retention of knowledge related to the main training objectives.

The burden of chronic diseases across Europe: what policies and programs to address diabetes? A SWOT analysis

BACKGROUND

Promoting the well-being at all ages and reducing premature mortality from non-communicable diseases (NCDs) is a major target of the Sustainable Development Goals. In the frame of the JA-CHRODIS, a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis was conducted to provide different countries' insights on what makes a policy/programme addressing NCDs applicable, sustainable and effective, with a focus on diabetes.

METHODS

A qualitative study has been performed using a SWOT analysis on policies/programmes at the national/federal or subnational level.

RESULTS

By March 2016, 14 SWOTs were conducted involving 11 European countries and 57 stakeholders and Ministries of Health, reporting and analysing a total of 44 policies. The main strengths, weaknesses, opportunities and threats have been outlined as well as and the main areas for governance improvement. A binding trans-sectoral approach is necessary to tackle the underlying risk factors of inequalities. The culture of disease prevention and health promotion is still low while the biomedical paradigm prevails. A systematic gender perspective is still missing. Sharing and exchange of best practices, as sponsored by the European Commission, is acting as a motivator.

CONCLUSION

The SWOT analyses draw an overall picture of the complexity of designing and implementing good policies and programmes that are tailored to local needs. These results may apply to any context and can be used by decision-makers, managers, professionals and other stakeholders to focus on key issues, recognising areas for attention.

Dementia among migrants and ethnic minorities in Italy: rationale and study protocol of the ImmiDem project

INTRODUCTION

Due to the ongoing demographic and epidemiological transitions, estimating the phenomenon of dementia in migrants and minority groups, exploring its characteristics and challenges and implementing dedicated healthcare policies, constitute emerging and urgent matters for Western countries. In the present paper we describe the rationale and design of the 'Dementia in immigrants and ethnic minorities living in Italy: clinical-epidemiological aspects and public health perspectives" (ImmiDem) project.

METHODS AND ANALYSIS

Three main aims will be pursued by the ImmiDem project. First, a survey of all Italian dementia services will be conducted with dedicated questionnaires in order to estimate and describe the proportion and characteristics of migrants seeking help for cognitive disturbances. The different clinical approaches for diagnosing dementia and the challenges encountered in the assessment of cognitive functioning and in the provision of care in these groups of individuals will also be investigated. Second, record linkage procedures of data routinely collected in regional Health Information Systems will be conducted in order to identify and monitor migrant individuals with dementia living in the Lazio region. Third, tailored national and local care-coordination pathways and/or good practices dedicated to migrants affected by dementia and cognitive disorders will be identified and promoted.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Italian National Institute of Health (protocol 10749; 5 April 2018). The project was launched in November 2018 and will end in November 2021. The findings of the project will be disseminated through scientific peer-reviewed journals as well as to the public via the Dementia Observatory website (https://demenze.iss.it).

Methodological issues in a cross-sectional survey on cervical cancer screening using telephone interviews in Sicily (Italy): a SWOT analysis

Objective

A cross-sectional study on knowledge, perceptions, and adherence to cervical cancer screening was conducted using telephone interviews of Sicilian women that were performed in 2016. This study aimed to identify areas that need to be addressed to improve the validity of data collection and to minimize possible biases.

Methods

We performed a qualitative study through SWOT analysis, which is a multidimensional method based on evaluation of Strengths (S), Weaknesses (W), Opportunities (O), and Threats (T) of the research project. The contents of the SWOT forms underwent categorical, inductive, and deductive data analysis using the long table analysis method.

Results

The full availability of an updated address and phone number list was the main organizational aspect to be addressed. Socio-cultural context played a major role for understanding the questions and for acceptability of the topics. In some cases, a family member was a facilitating element, while in others, the family member hindered the interviews. Active involvement of general practitioners was considered essential for success of the interviews.

Conclusions

When performing a cross-sectional survey, organizational aspects and active involvement of general practitioners are crucial in the enrolment phase, regardless of the socio-cultural context.

Effortless creation of safe robots from modules through self-programming and self-verification

Industrial robots cannot be reconfigured to optimally fulfill a given task and often have to be caged to guarantee human safety. Consequently, production processes are meticulously planned so that they last for long periods to make automation affordable. However, the ongoing trend toward mass customization and small-scale manufacturing requires purchasing new robots on a regular basis to cope with frequently changing production. Modular robots are a natural answer: Robots composed of standardized modules can be easily reassembled for new tasks, can be quickly repaired by exchanging broken modules, and are cost-effective by mass-producing standard modules usable for a large variety of robot types. Despite these advantages, modular robots have not yet left research laboratories because an expert must reprogram each new robot after assembly, rendering reassembly impractical. This work presents our set of interconnectable modules (IMPROV), which programs and verifies the safety of assembled robots themselves. Experiments show that IMPROV robots retained the same control performance as nonmodular robots, despite their reconfigurability. With respect to human-robot coexistence, our user study shows a reduction of robot idle time by 36% without compromising on safety using our self-verification concept compared with current safety standards. We believe that by using self-programming and self-verification, modular robots can transform current automation practices.

Radiofrequency echographic multispectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis on lumbar spine and femoral neck

An innovative, non-ionizing technique to diagnose osteoporosis on lumbar spine and femoral neck was evaluated through a multicenter study involving 1914 women. The proposed method showed significant agreement with reference gold standard method and, therefore, a potential for early osteoporosis diagnoses and possibly improved patient management.

INTRODUCTION

To assess precision (i.e., short term intra-operator precision) and diagnostic accuracy of an innovative non-ionizing technique, REMS (Radiofrequency Echographic Multi Spectrometry), in comparison with the clinical gold standard reference DXA (dual X-ray absorptiometry), through an observational multicenter clinical study.

METHODS

In a multicenter cross-sectional observational study, a total of 1914 postmenopausal women (51-70 years) underwent spinal (n = 1553) and/or femoral (n = 1637) DXA, according to their medical prescription, and echographic scan of the same anatomical sites performed with the REMS approach. All the medical reports (DXA and REMS) were carefully checked to identify possible errors that could have caused inaccurate measurements: erroneous REMS reports were excluded, whereas erroneous DXA reports were re-analyzed where possible and otherwise excluded before assessing REMS accuracy. REMS precision was independently assessed.

RESULTS

In the spinal group, quality assessment on medical reports produced the exclusion of 280 patients because of REMS errors and 78 patients because of DXA errors, whereas 296 DXA reports were re-analyzed and corrected. Analogously, in the femoral group there were 205 exclusions for REMS errors, 59 exclusions for DXA errors, and 217 re-analyzed DXA reports. In the resulting dataset (n = 1195 for spine, n = 1373 for femur) REMS outcome showed a good agreement with DXA: the average difference in bone mineral density (BMD, bias ± 2SD) was -0.004 ± 0.088 g/cm² for spine and - 0.006 ± 0.076 g/cm² for femur. Linear regression showed also that the two methods were well correlated: standard error of the estimate (SEE) was 5.3% for spine and 5.8% for femur. REMS precision, expressed as RMS-CV, was 0.38% for spine and 0.32% for femur.

CONCLUSIONS

The REMS approach can be used for non-ionizing osteoporosis diagnosis directly on lumbar spine and femoral neck with a good level of accuracy and precision. However, a more rigorous operator training is needed to limit the erroneous acquisitions and to ensure the full clinical practicability.

E-learning to Improve Healthcare Professionals' Attitudes and Practices on Breastfeeding

INTRODUCTION

Breastfeeding training has a crucial role in increasing healthcare professionals' attitudes and in improving professional support for breastfeeding. The collaboration between the Italian National Institute of Health, UNICEF, and the Local Health Authority of Milan has led to the development of an online course on lactation and infant feeding practices.

AIM

To assess if the course was effective in improving healthcare professionals' attitudes and practices (APs).

METHODS

We conducted a prestudy-poststudy, comparing users' APs before (T0) and after (T1) the course through a 20-item questionnaire. Changes in APs were analyzed using paired t-test. Lower mean differences indicated more positive attitudes and more frequent professional practices favoring breastfeeding. Statistical analysis was carried out using SPSS version 15.0.

RESULTS

The course had 26,009 registrants and was successfully completed by 91.3% of users. The dropout rate was 8.7%. The final cohort was composed of 15,004 participants. The course improved attitudes, while minor changes were observed on practices (p < 0.05). Mean total attitude scores were 2.4 at T0 and 1.9 at T1, while mean total practice scores were 2.2 and 2.1, respectively. The main effects regarded the use of medications during breastfeeding (3.02 ± 1.29 at T0 and 1.88 ± 1.08 at T1) and the self-reported compliance with the International Code of Marketing of Breast Milk Substitutes (2.29 ± 1.24 at T0, 2.03 ± 1.21 at T1).

CONCLUSION

The noninteractive, high-coverage e-learning approach seems to be a useful tool for improving awareness and positive attitudes toward breastfeeding among healthcare professionals.

The experience of a nationwide Community of Practice to set up Regional Prevention Plans in Italy

Background

In 2010, the Italian Ministry of Health decided to start the planning process to elaborate the National Plan of Prevention 2010–2012 jointly with the 21 Regions. The National Institute of Health was responsible for supporting regional planners (RPs) by an original participatory approach of a web-based Community of Practice (CoP) to set up their own Regional Plans of Prevention. In this paper, we summarise the theoretical framework adopted, the main phases characterising the lifecycle of the nationwide CoP, the evaluation approach adopted and its findings.

Methods

Following the CoP theoretical framework from Wenger, an initial group of RPs were trained on Project Cycle Management as a planning method and thereafter they started interacting on a web-based Moodle platform for 8 months. The CoP evaluation mainly took into account aspects of ‘immediate value’, such as members interactions within the website, and several quantitative and qualitative tools were used to monitor changes over time. Data were retrieved from Moodle statistics or directly from the RPs by the means of a Knowledge, Attitude and Practice survey, a reaction survey, SWOT analysis and focus groups.

Results

The level of individual RPs knowledge increased after the initial course from 55.7% to 75%, attitudes and competence perception about the planning process method also showed an overall favourable change. During the CoP life span, the number of members increased from the original 98 RPs to include up to 600 new members on the basis of spontaneous demand. From April 2010 to January 2011, the ‘vital signs’ of the CoP were monitored, including RP logins (13,450 total logins and 3744 unique logins), views (27,522) and posts (1606) distributed in 326 forum discussion threads. Data and information retrieved from quantitative and qualitative evaluation approaches proved to be useful for the management and follow-up of the CoP.

Conclusions

The CoP experience was successful as 19 out of 20 Regions submitted their Regional Preventive Plan to their Ministry of Health within the due deadline. The CoP has proved to be an approach able to optimise resources and expertise, capitalising and generating new knowledge. However, more efforts should be deployed to define innovative ways to evaluate its values, tangible and intangible, as well as the return of investment.

A collaborative intervention to improve surgical antibiotic prophylaxis in children: results from a prospective multicenter study

PURPOSE

The use of surgical antibiotic prophylaxis (SAP) in children is poorly characterized. Our aim was to evaluate the effectiveness of a quality improvement (QI) intervention targeting SAP in children, by means of a multicenter prospective intervention study, with a before and after design.

METHODS

We prospectively investigated elective surgical procedures performed in children <18 years, prior to the QI intervention, after the intervention and at 9-month follow-up. The primary outcomes were adherence to SAP indications and SAP appropriateness, defined considering antibiotic choice, timing of first dose and duration of administration. We compared SAP adherence and appropriateness prior the QI intervention, to the post-intervention and the follow-up. We considered patient and procedure characteristics as covariates in two logistic regression models to assess the effect of the QI intervention on SAP adherence and appropriateness.

RESULTS

We collected information on 2383 procedures (pre-intervention: 784; post-intervention: 790; follow-up: 809). The QI intervention had a significant impact on the adherence to SAP indications (86.6% in the post-intervention, compared to 82.0% prior to the intervention; p < 0.05), and on its appropriateness (35.7% compared to 19.9%; p < 0.01). The impact of the intervention on SAP appropriateness was maintained at follow-up (38.3%; p < 0.01 compared to pre-intervention). All components of SAP appropriateness significantly improved after the intervention and at follow-up. The logistic regression analyses confirmed the effect of intervention in improving adherence to SAP indications and appropriateness.

CONCLUSIONS

Following the QI intervention, there was a significant improvement in quality of SAP in pediatric surgery, though more efforts are needed to increase SAP appropriateness.

Nurses' reporting of suspect adverse drug reactions: a mixed-methods study

OBJECTIVE

To assess nurses' knowledge, attitudes and practices (KAP) towards spontaneous adverse drug reactions (ADRs) reporting.

METHODS

The mixed-method study was conducted following a quanti-qualitative sequential approach: a survey (using a KAP questionnaire) followed by a focus group was performed.

RESULTS

In the quantitative findings, responders (570 hospital nurses) declared that they were unaware of the pharmacovigilance system (58.1%, n = 331); where to find the reporting form (63.5%, n = 362); how fill it in (71.6%, n = 408); to whom and how to send it (65.8%, n = 375). Only 11.1% (n = 63) reported ADRs. The qualitative phase supported the quantitative findings and provided new information about other factors that condition ADR reporting: misinterpretation of the meaning of "reporting", unawareness of nurses' autonomy in ADR reporting and fear of consequences after ADR reporting.

CONCLUSION

Nurses are not fully aware of their role in ADR reporting. We recommend educational interventions and management changes.

Testing an explanatory model of nurses' intention to report adverse drug reactions in hospital settings

AIM

To test an explanatory model of nurses' intention to report adverse drug reactions in hospital settings, based on the theory of planned behaviour.

BACKGROUND

Under-reporting of adverse drug reactions is an important problem among nurses.

METHODS

A cross-sectional design was used. Data were collected with the adverse drug reporting nurses' questionnaire. Confirmatory factor analysis was performed to test the factor validity of the adverse drug reporting nurses' questionnaire, and structural equation modelling was used to test the explanatory model.

RESULTS

The convenience sample comprised 500 Italian hospital nurses (mean age = 43.52). Confirmatory factor analysis supported the factor validity of the adverse drug reporting nurses' questionnaire. The structural equation modelling showed a good fit with the data. Nurses' intention to report adverse drug reactions was significantly predicted by attitudes, subjective norms and perceived behavioural control (R² = 0.16).

CONCLUSIONS

The theory of planned behaviour effectively explained the mechanisms behind nurses' intention to report adverse drug reactions, showing how several factors come into play.

IMPLICATIONS FOR NURSING MANAGEMENT

In a scenario of organisational empowerment towards adverse drug reaction reporting, the major predictors of the intention to report are support for the decision to report adverse drug reactions from other health care practitioners, perceptions about the value of adverse drug reaction reporting and nurses' favourable self-assessment of their adverse drug reaction reporting skills.

Are Dietary Supplements and Nutraceuticals Effective for Musculoskeletal Health and Cognitive Function? A Scoping Review

OBJECTIVE

The aim of our scoping review was to summarize the state of the art regarding micronutrients in order to identify which of them might effectively improve health status in the areas typically impaired in older people: bone, skeletal muscle, and cognitive function.

DESIGN

Scoping review.

METHODS

The Italian Study Group on Healthy Aging by Nutraceuticals and Dietary Supplements (HANDS) performed this scoping review, based on the following steps: doing a list of micronutrients related with musculoskeletal or cognitive functions, included in dietary supplements and nutraceuticals commercialized in Italy; planning a research on PubMed, according to an evidence-based approach, in order to the most relevant positive study for each micronutrient into each of the three areas involved (bone, skeletal muscle and cognitive function); identifying the micronutrients effective in maintaining or achieving an adequate health status in older people, specifying the effective and safe daily doses, according to the selected studies.

RESULTS

In literature we found 12 relevant positive studies (1 international society guidelines/recommendations, 1 systematic review, 7 randomized controlled trials, and 3 prospective cohort studies). We showed that only 16 micronutrients resulted to have appropriate scientific evidences in terms of improving musculoskeletal health and/or cognitive function in older people: beta-alanine, calcium, creatine, fluorides, leucine, magnesium, omega-3 fatty acids, potassium, vitamin B6, vitamin B9, vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K2, and zinc.

CONCLUSION

This scoping review showed that selected micronutrients in adequate doses might have an ancillary role in musculoskeletal health and cognitive functions in older people.