Italian Guidelines for the Management of Non-Functioning Benign and Locally Symptomatic Thyroid Nodules

AIM

This guideline (GL) is aimed at providing a reference for the management of non-functioning, benign thyroid nodules causing local symptoms in adults outside of pregnancy.

METHODS

This GL has been developed following the methods described in the Manual of the National Guideline System. For each question, the panel appointed by Associazione Medici Endocrinology (AME) identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence and only those classified as "critical" were considered in the formulation of recommendations.

RESULTS

The present GL contains recommendations about the respective roles of surgery and minimally invasive treatments for the management of benign symptomatic thyroid nodules. We suggest hemithyroidectomy plus isthmectomy as the first-choice surgical treatment, provided that clinically significant disease is not present in the contralateral thyroid lobe. Total thyroidectomy should be considered for patients with clinically significant disease in the contralateral thyroid lobe. We suggest considering thermo-ablation as an alternative option to surgery for patients with a symptomatic, solid, benign, single, or dominant thyroid nodule. These recommendations apply to outpatients, either in primary care or when referred to specialists.

CONCLUSION

The present GL is directed to endocrinologists, surgeons, and interventional radiologists working in hospitals, in territorial services, or private practice, general practitioners, and patients. The available data suggest that the implementation of this GL recommendations will result in the progressive reduction of surgical procedures for benign thyroid nodular disease, with a decreased number of admissions to surgical departments for non-malignant conditions and more rapid access to patients with thyroid cancer. Importantly, a reduction of indirect costs due to long-term replacement therapy and the management of surgical complications may also be speculated.

The prevalence of celiac disease and the appropriateness of the diagnosis in family medicine setting could be lower than expected

OBJECTIVE

To assess the prevalence of celiac disease (CD) and the appropriateness of this diagnosis in the family medicine setting in Italy.

PATIENTS AND METHODS

The electronic databases of 16 general practitioners working in Rome (Italy) were analyzed. The prevalence of CD according to the Italian pathology identification code issued by the Italian National Health System was assessed. In addition, patients registered as having celiac disease without being assigned a pathology identification code were interviewed.

RESULTS

Overall, a population of 22,064 patients was analyzed. 91 patients had a diagnosis of CD (0.41%), 60 of whom had a pathology identification code (0.27%), and 31 did not (0.14%). 29 of these patients were interviewed, 16 (17.58% of the CD recorded patients) of whom reported being on a gluten-free or gluten restricted diet, with reported improvement in their clinical symptoms. Half of them further stated that they would not agree to resume a restriction free diet in order to make a definitive CD diagnosis, due to the risk of symptom recurrence.

CONCLUSIONS

In a family medicine setting, the prevalence of CD seems to be lower than expected, and one third of patients diagnosed with CD do not fulfill all diagnostic criteria. Any effort to improve the diagnostic work-up for CD should also be made in this setting.

Recommendations for Cardiovascular Prevention During the Sars-Cov-2 Pandemic: An Executive Document by the Board of the Italian Society of Cardiovascular Prevention

In 2020, the Sars-Cov-2 pandemic is causing a huge and dramatic impact on healthcare systems worldwide. During this emergency, fragile patients suffering from other comorbidities, especially patients susceptible to or affected by cardiovascular disease, are the ones most exposed to the poorer outcomes. Therefore, it is still mandatory to continue to strictly adhere to the rules of cardiovascular prevention. This document aims to provide all doctors with simple and clear recommendations in order to spread useful messages to the widest number of subjects in order to continue the battle against cardiovascular diseases even in times of pandemic.

Evaluation of cardiovascular risk profile: a comparative analysis between CUORE algorithm and the Framingham risk scores

OBJECTIVE

Coronary heart diseases (CHD) are the leading cause of premature death and loss of disability adjusted life years in Europe. In order to implement appropriate health interventions as preventive tools, it is necessary to understand the epidemiological stratification of cardiovascular risk and the specific situation of each individual reality. This study investigates the reliability of two algorithms used to assess cardiovascular risk: the Framingham algorithm and the CUORE algorithm.

PATIENTS AND METHODS

Data specific on patients of General Practitioners working in the Province of Rome were considered, and a total of 996 subjects of both genders were evaluated. The goodness of fit of the regression model was evaluated using the R2 value.

RESULTS

The inferential analysis showed that the R2 value of the simple linear regression between CHD risk calculated according to the CUORE method (dependent variable) and CHD risk calculated according the Framingham method (independent variable), was initially equal to 0.350, and rose to 0.732 when the independent variables "Gender" and "Age" were added, thereby creating a multivariate regression. The R2 of the multivariate regression was 0.478 when using CHD Framingham as the dependent variable and CHD CUORE as the independent variable.

CONCLUSIONS

It emerged that the CUORE score was less reliable than the Framingham risk score; in fact, in the multiple linear regression model, the coefficient of determination was greater when the independent variable was the Framingham scale for CHD risk.

Incidence of herpes zoster and postherpetic neuralgia in Italian adults aged ≥50 years: A prospective study

Herpes zoster (HZ) mainly affects older adults and immunocompromised individuals and is usually characterized by a unilateral painful skin rash. Its most common complication, postherpetic neuralgia (PHN), may cause chronic debilitating pain lasting for months or years. This study (ClinicalTrials.gov Identifier: NCT01772160) aimed to estimate the HZ incidence and the proportion of HZ patients with PHN in the Italian population aged 50 years or older.

From 2013 to 2016, HZ-patients were recruited when presenting with acute HZ at 75 reporting general practitioners in Italy, covering 43,875 persons aged ≥50 years. PHN was defined as ‘worst pain’ rated ≥ 3 on the Zoster Brief Pain Inventory persisting or appearing over 90 days after rash onset.

The overall HZ incidence rate per 1000 person-years (PY) was estimated as 6.46 (95% confidence interval [CI]: 5.99–6.95), increasing with age to 9.12/1000 PY (95% CI: 7.50–10.99) in 75–79 year-olds. Among 391 HZ-patients who completed the study, the overall proportion with PHN was 10.23% (95% CI: 7.41–13.67) and the highest proportion was 15.56% (95% CI: 6.49–29.46) for the 75–79 year-olds. Among the 128 patients (32.7%) who reported at least one pre-existing medical condition, 35.9% reported diabetes mellitus and 32.0% reported emotional problems, stress or depression.

The study confirms previous findings that HZ and PHN cause an important clinical burden in older Italian adults. It also confirmed the age-related increasing risk of HZ and PHN.

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HZ has a strong incidence in the Italian population, the 2nd oldest worldwide.

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The estimated overall HZ incidence rate was 6.46 per 1000 person-years.

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The most common complication, PHN, was encountered by 10.23% of HZ patients.

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Strengths of the study are its prospective design and its large sample.

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Limitation: incidence may be underestimated due to cases missed in primary care.

Modifications in drug adherence after switch to fixed-dose combination of perindopril/amlodipine in clinical practice. Results of a large-scale Italian experience. The amlodipine-perindopril in real settings (AMPERES) study

OBJECTIVE

The purpose of this study was to assess the changes in adherence to treatment, in patients who switched from perindopril and/or amlodipine as a monotherapy (single-pill therapy, SPT) or two-pill combinations to fixed-dose combination (FDC) therapy.

METHODS

A large retrospective cohort study, in three Italian Local Health Units, was performed. All adult subjects who received at least one prescription of anti-hypertensive drugs between January 1, 2010 and December 31, 2014 were selected. The date of the first anti-hypertensive prescription was defined as the index-date (ID). For each patient, we evaluated the anti-hypertensive therapy and the adherence to treatment during the two 12-month periods preceding and following the ID. Changes in the level of adherence have been compared in patients who switched to the FDC of perindopril/amlodipine after the ID, as well as in patients who did not.

RESULTS

A total of 24,020 subjects were initially included in the study. Subjects treated with the free dose combination switched more frequently to FDC of perindopril/amlodipine than subjects treated with SPT (p < .001). Adherence to treatment was found to be higher in the 3,597 subjects who switched to the perindopril/amlodipine FDC therapy, than in the 20,423 subjects who did not. A significant decrease in the number of concomitant anti-hypertensive drugs has been observed in patients treated with the same FDC.

CONCLUSIONS

The results show that perindopril/amlodipine FDC increases the rate of stay-on-therapy and reduces the number of concomitant anti-hypertensive drugs in subjects previously treated with the same drugs as a two-pill combination or as SPT.

H2020 and Beyond: Skip Discrepancy between Theory and Practice of Personalized Medicine. A Position Paper by the Italian Society of Personalized Medicine

Many unsolved practical issues, from technical and scientific to ethical, legal and economic topics, are slowing down the translation of Personalized Medicine principles into medical practice. The Italian Society of Personalized Medicine exposes here its point of view, based on the real-world practice of precision medicine carried-out in Italian healthcare structures.

Prevalence and Control of Hypertension in Different Macro-Areas in Italy: Analysis of a Large Database by the General Practice

INTRODUCTION

Limited data are available on the impact of hypertension in the different regions or urban areas in Italy.

AIM

To evaluate hypertension prevalence and control among adult outpatients followed by general practitioners (GPs) in different regions and macro-areas in our Country.

METHODS

We retrospectively analysed data extracted in 2013 from the national GP Health Search-CSD database and stratified into three groups, depending on their own regions (North, Center and South). Hypertension prevalence was estimated within the overall population sample of adult individuals, whereas control was assessed in hypertensive outpatients. Hypertension diagnosis was defined according to International Classification of Diseases 9. Clinic blood pressure (BP) levels were measured according to European guidelines. BP control was defined as BP <140/90 mmHg.

RESULTS

Data from 940,806 individuals (52.0 % female) were scrutinized, among whom 363,324 (38.6 %) subjects were residents in the North, 276,643 (29.4 %) in the Center and 300,839 (32.0 %) in the South. Overall hypertension prevalence was higher in North (36.8 %) compared to South (33.8 %) and Center (29.3 %). Controlled BP levels were more frequently registered in the South (66.3 %) compared to Center (60.7 %) and North (55.6 %). In all these areas, prevalence and control of hypertension were higher in female than in male individuals.

CONCLUSIONS

The present analysis demonstrates relevant differences in hypertension prevalence and control among different macro-areas and regions in Italy. Such analysis may be useful for promoting strategies aimed at ameliorating hypertension control at local levels.

Prevalence of metabolic syndrome in the clinical practice of general medicine in Italy

BACKGROUND

Prevalence of metabolic syndrome (MS) in the clinical practice is still debated, due to different diagnostic criteria, target populations and clinical settings. Thus, the main purposes of the study were: (I) to evaluate prevalence of MS; (II) to estimate prevalence of additional cardiovascular (CV) risk factors and concomitant conditions in patients with MS followed by general practitioners (GPs) in Italy.

METHODS

GPs from three different macro-areas were asked to evaluate the first and the last three outpatients, consecutively seen during 20 consecutive weeks in 2007, whatever the reason for clinical consultation. MS was defined according to Adult Treatment Panel (ATP) III definition. Clinical data were collected locally and centrally analysed.

RESULTS

The overall population sample included 4,513 outpatients, among which 1,574 (34.9%) from Regione Lazio, 1,498 (33.2%) from Regione Piemonte, and 1,441 (31.9%) from Regione Umbria. The population analysis included 4,418 (97.9%) adult outpatients [52.1% females, (mean age, 58.0±11.8 years); mean body mass index (BMI), 26.7±4.7 kg/m(2)]. MS was diagnosed in 1,456 (33.0%) outpatients. High-normal blood pressure (BP) was the most common risk factor for MS (n=1,382; 94.9%), followed by abdominal obesity (n=1,229; 84.4%), hypertriglyceridemia (n=1,032; 70.9%), abnormal fasting glucose (n=819; 56.3%) and low high-density lipoprotein (HDL) cholesterol levels (n=730; 50.1%).

CONCLUSIONS

Using this sample of outpatients followed by GPs in Italy, our study reports a relatively high prevalence of MS and a high prevalence of associated CV and metabolic risk factors in patients with than in those without MS.

How many hypertensive patients can be controlled in "real life": an improvement strategy in primary care

Background

It is well known that hypertension control is non-satisfactory, but it is not clear how many hypertensive patients can be controlled in real life. We addressed this question implementing a simple, multifaceted improvement strategy in family practice.

Methods

Eighteen General Practitioner (GPs) agreed upon a simple improvement strategy including: 1) the use of occasional direct/indirect contacts (prescription refilling) to decrease missing blood pressure (BP) recording, and to increase therapeutic adherence, 2) the use of home BP measurements in non-controlled patients, 3) the addition of a new drug in non-controlled, but adequately adherent patients. Results were assessed after one year by automatic data extraction from the clinical records of all hypertensive subjects.

Results

The patients with a diagnosis of hypertension increased from 6.309 (age 58.5 +/- 12.4; M 45.5%) to 6.717 (age 58.6 +/- 12.9; M 45.7%): prevalence 25.3% to 27.0%. The BP recording increased: 4,305 patients (68.2%) vs 4,948 patients (78.4%) (+ 10.2%, ci 9.4%-10.9%; p < 0.001), as well as the BP control: 3,203 (50.8% of all the diagnosed hypertensive patients and 74.4% of the subjects with recorded BP value) vs 4,043 (64.1% of all the diagnosed hypertensive patients and 81.7% of the subjects with recorded BP value) (+ 13.3%, ci 12.5%-14.2%; p < 0.001 and + 7.3%, ci 6.7%-8.0%; p < 0.001).

Conclusions

Almost 82% of hypertensive subjects who contact their doctors can be easily controlled. Most non-controlled patients simply don’t see their GPs; in almost all the remaining non-controlled patients GPs fail to increase drug therapy. A further improvement is therefore possible.

Adherence to anti-osteoporotic therapies: role and determinants of "spot therapy"

A successful therapy needs high level of adherence consisting in right drug intake in terms of persistence and compliance. Our study suggests adherence is higher if spot (less than 30 days) therapies are excluded; the analysis of spot therapy causes underlines the importance of the interpersonal aspects of medical practice.

INTRODUCTION

A successful therapy needs a high level of adherence consisting in right drug intake in terms of persistence and compliance. The aim of this study was to evaluate anti-osteoporotic therapies recorded in general practitioner databases in the area of Rome, which used the same computerized medical record management. The study focused on evaluating therapy adherence, any adherence changes excluding spot therapies (less than 30 days), and any cause of early therapy discontinuation in a subgroup of patients randomly selected.

METHODS

Thirty-one databases were evaluated, including a total of 6,390 anti-osteoporotic therapies: 5,853 were prescribed to women and 537 to men. The prescribed drugs were: vitamin D (13 %), calcium (8.7 %), vitamin D + calcium (40.1 %), raloxifene (3.3 %), alendronate (16.4 %), risedronate (7.7 %), clodronate (10.4 %), or other drugs (0.4 %). Spot therapies represented 53.7 % of the total prescriptions. The difference between adherence in the total group (24.64 %) and the group excluding spot therapies (43.38 %) is significant. The main factors influencing low adherence were side effects (27 %), misinformation given by the physician (17 %), insufficient motivation (9 %), difficult intake (9 %), and no perceived benefits (9 %).

RESULTS

Our study suggests adherence is high and similar to other chronic diseases if spot therapies are excluded. The analysis of spot therapy causes suggests that an important role is played by the physician and the interpersonal aspects of medical practice, especially at the first prescriptions.

CONCLUSIONS

The physician should collaborate with patients in choosing a personalized medical treatment. Reducing spot therapy could be the real goal in order to improve anti-osteoporotic therapy adherence.

Prevalence of 'borderline' values of cardiovascular risk factors in the clinical practice of general medicine in Italy: results of the BORDERLINE study

INTRODUCTION

The prevalence of patients with 'borderline' levels of cardiovascular risk factors has been rarely investigated, being often reported in studies evaluating abnormal values of these parameters. The BORDERLINE study represents a pilot experience to primarily identify the prevalence of 'high-normal' conditions, such as pre-hypertension, lipid and glucose levels in the upper range of normality in the setting of general practice in Italy.

AIM

The aim of this study was to evaluate the prevalence of patients with 'borderline' values of cardiovascular risk factors in Italy.

METHODS

Involved physicians were asked to evaluate the first 20 outpatients, consecutively seen in June 2009. Data were collected in a study-designed case-report form, in which physicians identified thresholds rather than reported absolute values of several clinical parameters. High-normal values were defined as follows: blood pressure (BP) 130-140/85-90 mmHg; total cholesterol 180-200 mg/dL; low-density lipoprotein cholesterol (LDL-C) 130-150 mg/dL; high-density lipoprotein cholesterol (HDL-C) 30-40 mg/dL in males and 40-50 mg/dL in females; triglycerides 130-150 mg/dL and fasting glucose 100-110 mg/dL.

RESULTS

Fifty-three Italian physicians provided valuable clinical data on 826 individual outpatients, among which 692 (83.7%, 377 women, mean age 60.9 ± 13.2 years, body mass index 26.6 ± 5.0 kg/m2) were included in the present analysis. Prevalence of borderline values of systolic BP and total cholesterol levels were at least comparable with those in the normal limits of the corresponding parameters, whereas prevalence of borderline diastolic BP, LDL-C, HDL-C, triglycerides and fasting glucose levels was significantly lower than that of normal values, but higher than that of abnormal values of the corresponding parameters.

CONCLUSIONS

Using this sample of healthy subjects in the setting of general practice in Italy, our results demonstrated a relatively high prevalence of borderline values of cardiovascular risk factors, which was at least comparable with that of normal, but significantly higher than that of abnormal thresholds. These preliminary findings may prompt more extensive investigations in the area of 'borderline' cardiovascular risk. This information may, in fact, potentially enable the design of more effective prevention strategies in the future to limit the burden of cardiovascular disease in the general population in Italy. Received for publication 4 March 2011; accepted for publication 20 April 2011.

Venlafaxine-induced urinary incontinence resolved after switching to sertraline

The authors report a case of urinary incontinence (UI) that occurred in a woman after administration of venlafaxine. UI resolved after discontinuation of the drug and did not reappear after switching to sertraline therapy. A 56-year-old white woman with a diagnosis of reactive depression developed severe UI after a 30 days' treatment with venlafaxine 75 mg/day. Symptoms resolved without consequence 48 hours after discontinuation of venlafaxine. The patient was then treated with sertraline without experiencing any incontinence episodes. Urinary incontinence is an important medical condition with clinical and social implications. Further studies need to be carried out to clarify the pharmacologic differences between dual and selective 5-HT and norepinephrine reuptake inhibitors on lower urinary tract function.