Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

Introduction

Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies.

Methods

We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank.

Results

The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck.

Discussion

Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies.

Plain language summary

We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed.

Electronic supplementary material

The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.

Individual Antidepressants and the Risk of Fractures in Older Adults: A New User Active Comparator Study

Objective

To determine the risk of hip–pelvis and other non-vertebral fractures in older adults using antidepressants (ADs).

Methods

We conducted a case–control study nested in a cohort of new users of ADs aged ≥65 years without prior hip–pelvis or other non-vertebral fractures, identified in the German Pharmacoepidemiological Research Database (GePaRD) during 2005–2014. Cases were patients first hospitalized for hip–pelvis or other non-vertebral fractures. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at index date (ID) based on the supply of last dispensing. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using conditional logistic regression with current users of mirtazapine as reference (active comparator).

Results

A total of 39,853 cases of hip–pelvis fracture (80% women, median age 81 years) and 31,577 cases of other fractures (84% women, median age 79 years) were matched to >3 million controls. For hip–pelvis fracture, aORs in current users were about 1.3 with little variation between individual ADs, ranging from 1.33 for citalopram (95% CI 1.27–1.39) to 1.28 for amitriptyline (1.21–1.35). For other fractures, the aORs were highest in current users of citalopram (1.50; 1.42–1.58) and duloxetine (1.54; 1.39–1.71) and lowest for amitriptyline (1.18; 1.11–1.26) and trimipramine (1.16; 1.03–1.29). For all examined ADs, the aORs were higher for other fractures than for hip–pelvis fracture.

Conclusion

The risk of fractures varies between ADs, but for most agents is higher than the risk for mirtazapine. When treating older adults with ADs, prescribers should carefully consider the risk profile of individual ADs regarding fractures, which are a major health problem in this population.

Validation of discharge diagnosis coding for amyotrophic lateral sclerosis in an Italian regional healthcare database

Objectives: (a) to estimate the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for amyotrophic lateral sclerosis (ALS) in the Hospital Discharge Database (HDD) of the Italian region Friuli-Venezia Giulia; (b) to identify the predictors of a true positive ALS code; (c) to compare incident and prevalent cases obtained from HDD with those identified in a retrospective population-based study. Methods: Records of all patients discharged 2010-2014 with an ICD-9-CM code for ALS and other motor neuron diseases were extracted from the HDD. For each record, all the available clinical documentation was evaluated to confirm or reject the diagnosis of ALS. ALS incident and prevalent cases were identified. Validity measures were calculated both overall and stratified by patient and hospitalization characteristics. Adjusted odds ratio (aOR), with 95% confidence interval (95%CI), of a true positive code was estimated using unconditional logistic regression. Results: ALS code had sensitivity 92.9%, specificity 75.3%, positive predictive value (PPV) 92.3%, and negative predictive value (NPV) 76.8%. A true positive ALS code was predicted by concurrent codes for respiratory interventions (aOR: 3.82; 95%CI: 2.09-6.99), primary position code (2.78; 1.68-4.62), non-programed hospitalization (2.06; 1.18-3.61), male patient (1.56; 1.06-2.29), and hospitalization length <14 days (1.42; 1.07-2.84). Two hundred and thirty-six prevalent and 187 incident cases were identified, 84% of those detected in the population-based study. Conclusion: ALS code shows very good accuracy and identifies a high percentage of true positive, incident and prevalent cases, but additional sources and an algorithm based on selected variables may further improve case identification.

Anticholinergic burden and fractures: a protocol for a methodological systematic review and meta-analysis

INTRODUCTION

Medications with anticholinergic activity are used in the treatment of many diseases common in old age, including depression, psychosis, Parkinson's disease, allergies, pain and urinary incontinence. A high anticholinergic burden (ACB) is considered a major risk factor for fractures in older adults but recent studies reported inconsistent results. These inconsistencies may partly be due to differences in methodological aspects. However, no systematic review so far has addressed this association and considered study methods. Thus, we aim to conduct a systematic review and meta-analysis of observational studies addressing the association of ACB with fractures and to provide a methodological appraisal of the included studies.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE, the Science Citation Index, CENTRAL and grey literature using a strategy that combines the terms anticholinergic and fractures. We will hand search reference lists of articles. Two reviewers will independently screen all identified abstracts for eligibility and evaluate the risk of bias of the included studies using the Newcastle-Ottawa Quality Assessment Scale and RTI item bank. Discrepancies will be resolved by consensus or consultation with a third researcher. We will conduct a meta-analysis, either for the overall population or for specific and more homogeneous subgroups, if the number of studies retrieved and their heterogeneity allows it.

ETHICS AND DISSEMINATION

No ethics approval will be sought, as no original data will be collected for this review. Findings will be disseminated through peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018116737.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

Antidepressants and the risk of traumatic brain injury in the elderly: differences between individual agents

Objective

To determine the association of individual antidepressants (ADs) with the risk of traumatic brain injury (TBI) in the elderly.

Patients and methods

We conducted a case-control study nested in a cohort of new users of ADs aged ≥65 years, identified in the German Pharmacoepidemiological Research Database during 2005-2014. Cases were patients first hospitalized for TBI. Up to 100 controls per case were selected using incidence density sampling. AD use was ascertained at the index date based on the supply of last dispensing (adding 150% of the defined daily doses [DDDs]; in sensitivity analysis, no additional DDDs were considered). We estimated adjusted ORs (aORs) and 95% CIs using conditional logistic regression.

Results

Among 701,309 cohort members, 16,750 cases were identified and matched to 1,673,320 controls (in both groups: 70.4% women; median age 80 years). Compared with remote users of the same AD, current users had an aOR (95% CI) of 1.87 (1.56-2.24) for duloxetine, 1.74 (1.41-2.15) for escitalopram, 1.70 (1.58-1.83) for citalopram, 1.66 (1.40-1.97) for sertraline, 1.64 (1.24-2.15) for fluoxetine and 1.57 (1.20-2.06) for paroxetine. The aOR was lower for amitriptyline (1.45; 1.32-1.58), trimipramine (1.17; 0.99-1.38) and opipramol (1.11; 0.99-1.25). Mirtazapine had an aOR of 1.03 (0.94-1.12). Sensitivity analysis confirmed the findings.

Conclusion

The large variability between individual ADs shows the importance of considering the safety of individual agents rather than focusing on class alone.

Predictors of diagnostic delay in amyotrophic lateral sclerosis: a cohort study based on administrative and electronic medical records data

Objectives: To characterize the timing and pathway of amyotrophic lateral sclerosis (ALS) diagnosis and to identify predictors of delayed diagnosis in a retrospective cohort. Methods: The cohort included all patients with incident ALS between 2010 and 2014 in Friuli-Venezia Giulia (FVG) region, Italy, admitted to two University Hospitals. Information on demographics, clinical presentation, and healthcare use was obtained from health databases and electronic medical records (EMRs). Total diagnostic time (TDT), the interval between ALS symptoms onset and diagnosis, was compared between patient groups through Wilcoxon-Mann-Whitney test. The adjusted odds ratio (aOR), with 95% confidence interval (95% CI), of having a TDT ≥12 months was estimated using unconditional logistic regression. Results: Among 134 patients, median TDT (interquartile range [IQR]) was 11.5 months (7.1-18.3), shorter in those aged <60 years vs. ≥60 years (8.1; 5.1-11.1 vs. 12.4; 7.4-21.5; p = 0.0064), first referred to a neurologist vs. other specialist (10.2; 6.1-16.3 vs. 13.2; 8.1-24.5; p = 0.0386) and without neurologic comorbidities (11.1; 7.1-16.5 vs. 19.7; 8.8-33.7; p = 0.0243). TDT was ≥12 months in 64 (48.5%) patients and was predicted by male sex (aOR: 2.47; 95% CI: 1.06-5.75), age at onset ≥60 years (11.46; 3.13-41.9), spinal onset (2.04; 1.00-5.93), and prior therapies or first referral to a non-neurologist (3.15; 1.36-7.29). Conclusions: In this cohort, delayed diagnosis was common, particularly in older patients and in those with neurological comorbidities. Timely referral to a neurologist may improve diagnostic timing.

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

Epidemiology of amyotrophic lateral sclerosis in Friuli-Venezia Giulia, North-Eastern Italy, 2002-2014: a retrospective population-based study

OBJECTIVES

To describe the epidemiology of Amyotrophic Lateral Sclerosis (ALS) in Friuli-Venezia Giulia (FVG) region, Italy, over a 13-year period (2002-2014), estimating ALS (a) incidence, prevalence, and clinical features; (b) mortality, also comparing Udine municipality to the rest of FVG.

METHODS

We conducted a retrospective population-based study. ALS incident cases were ascertained using multiple sources and validated through expert review. We calculated crude and standardized incidence rate (IR), point prevalence and mortality rate (MR), each with 95% confidence interval. Standardized incidence (SIR) and mortality (SMR) ratio were calculated to compare Udine to FVG.

RESULTS

Among 444 incident cases (50.0% men, median age 68.5 years), onset was bulbar in 30.2%, spinal in 59.9%, mixed in 9.9%; 3.6% had familial ALS. Crude and 2000 European population standardized IR was respectively 2.81 (2.56-3.09) and 2.09 (1.89-2.29) per 100,000 person-years. Standardized male-to-female incidence ratio was 1.05. IR peaked at age 65-74 years (men: 9.93, 8.04-12.32; women: 7.74, 6.18-9.67) and decreased thereafter. Prevalence was 8.36 (6.74-9.97) cases per 100,000 inhabitants on 30 June 2009 and 7.98 (6.40-9.56) on 30 June 2014. SIR was 1.20 and SMR 1.11.

CONCLUSIONS

When assessed over a long period, incidence of ALS was in the range of Italian and European population-based registries and showed a consistent pattern by age and sex. IR and MR were only slightly higher in Udine vs. FVG.

MGMT pyrosequencing-based cut-off methylation level and clinical outcome in patients with glioblastoma multiforme

AIM

MGMT promoter methylation has been associated with improved survival in glioblastoma multiforme treated with temozolomide. However, there is no consensus on specific cut-off levels of methylation. The aims of the study were to explore the prognostic impact of MGMT methylation status and to analyze the role of specific cut-off values.

MATERIALS & METHODS

We analyzed 108 glioblastoma multiforme patients treated between 2008 and 2013 stratified according to three pyrosequencing-based quantitative methylation in: unmethylated (methylation <9%), intermediate (9-29%) and highly methylated (>29%).

RESULTS

The three-class stratification has a prognostic impact (median progression-free survival: 7.97, 11.6 and 15 months respectively; p = 0.004; median OS: 13.2, 15.8 and 19.5 months, respectively; p = 0.0002), especially in patients exposed to temozolomide.

CONCLUSION

Our study confirmed that the independent prognostic role of MGMT methylation status. An average level of methylation between all investigated CpGs of 9% may help discriminating between methylated and unmethylated tumors.

Mortality in a cohort of asbestos-exposed workers undergoing health surveillance

Background:

The coastal area of Friuli Venezia Giulia (FVG) region, north-eastern Italy, was characterized by work activities in which asbestos was used until the early 1990s, particularly in shipbuilding. A public health surveillance program (PHSP) for asbestos-exposed workers was established, although limited evidence exists about the efficacy of such programs in reducing disease occurrence and mortality.

Objectives:

To compare mortality in a cohort of 2,488 men occupationally exposed to asbestos, enrolled in a PHSP in FVG between the early 1990s and 2008, with that of the general population of FVG and Italy.

Methods:

Standardized Mortality Ratios (SMR), with 95% Confidence Interval (95% CI), for all causes, all cancers, lung (LC) and pleural cancer (PC) were estimated in the cohort and in subgroups of workers with the first hire in shipbuilding that caused asbestos exposure (<1974, 1974-1984, 1985-1994).

Results:

A strong excess in mortality for PC with reference to FVG (SMR=6.87, 95% CI 4.45-10.17) and Italian population (SMR=13.95, 95% CI 9.02-20.64) was observed. For LC, the FVG-based SMR was 1.49 (95% CI 1.17-1.89) and the Italy-based 1.43 (95% CI 1.12-1.81). Mortality among workers with the first hire in shipbuilding before 1974 was high for PC (FVG-based SMR=8.98, 95% CI 5.56-13.75; Italy-based SMR=18.41, 95% CI 11.40-28.17) and for LC (FVG-based SMR =1.60, 95% CI 1.18-2.11; Italy-based SMR=1.54, 95% CI 1.14-2.03). Further, for LC between 1974 and 1984, the FVG-based SMR was 2.45 (95% CI 1.06-4.82), and the Italy-based SMR was 2.33 (95% CI 1.01-4.60).

Conclusions:

This cohort experienced an excess mortality for pleural and lung cancer, compared with regional and national populations. For lung cancer, the excess was stronger in workers with the first hire in shipbuilding before 1985, suggesting a key role of asbestos exposure.

Hospitalizations due to respiratory failure in patients with Amyotrophic Lateral Sclerosis and their impact on survival: a population-based cohort study

Background

Respiratory failure, infections and aspiration pneumonia, are the main causes of morbidity and mortality in Amyotrophic Lateral Sclerosis (ALS). In a population-based cohort, we assessed (a) hospital utilization and (b) impact of hospitalization for respiratory failure on survival.

Methods

All patients with incident ALS in Friuli Venezia Giulia region, Italy, from 2002 to 2009, were identified through multiple sources. Diagnosis was validated through clinical documentation review. For each patient, we extracted the records of all hospitalizations after ALS diagnosis from the regional hospitalization database. Cox proportional hazards model survival Hazard Ratio (HR), with 95 % Confidence Interval (95 % CI), was calculated.

Results

Out of 262 patients, 98.1 % had at least 1 and 58.0 % ≥3 hospitalizations. Emergency admissions occurred in 77.5 % of patients and a diagnosis of respiratory failure in 55.0 %. Patients underwent a total of 885 hospitalizations. The leading diagnosis was respiratory failure (31.6 % of hospitalizations). This diagnosis occurred most frequently in emergency (45.6 %) than in elective admissions (26.4 %). The second leading diagnosis was pneumonia (14.2 %), 24.9 and 6.3 % respectively. The leading procedure was mechanical ventilation (18.4 %), performed in 29.9 % of emergency and in 12.4 % of elective admissions. After adjustment for site of onset, age and diagnostic delay, a first hospitalization for respiratory failure had a strong adverse effect on survival (HR 4.00; 95 % CI 3.00; 5.34).

Conclusions

Respiratory failure, pneumonia and aspiration pneumonia were major determinants of hospitalizations and emergency admissions and often dealt with in emergency admissions. A first hospitalization for respiratory failure had a strong adverse effect on survival. Strategies to improve home management of respiratory conditions in patients with ALS and to optimize hospital care utilization are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-016-0297-y) contains supplementary material, which is available to authorized users.

[Not Available]

INTRODUCTION

The incidence of mesothelioma in Italy shows wide geographical variation, with the highest incidence rates in Genoa and Friuli Venezia Giulia (FVG). For mesothelioma, national standard incidence rates are not available prior to the calendar year 2006.

OBJECTIVES

To estimate the Standardized Incidence rate Ratio (SIR) of mesothelioma in a cohort of former workers undergoing health surveillance because of previous asbestos exposure, when sex-, age-, and calendar year-specific rates of the national standard are not available and the number of expected cases calculated from the regional rates is biased by the size of the study cohort.

METHODS

We conducted a sensitivity analysis in a cohort of 2,488 men. We considered every Italian cancer registry available with complete data in the period 1995-2007 (N=14). We calculated, for each year and age group, the corresponding weighted mean rate of 10 registries of North-Italy (Mean W10), the weighted mean rate of all 14 registries available (Mean W14) and considered FVG standard rate.

RESULTS

During the period 1995-2007, we observed 25 incident cases of mesothelioma with expected cases that varied between 2.00 (Mean W14) and 2.56 (FVG standard rate), with a SIR of 12.49 (CI95% 8.08-18.48) and 9.76 (CI95% 6.32-14.45) respectively.

CONCLUSIONS

Our results show that the use of FVG rates as standard does not lead to significant distortions in the calculation of the expected cases. However, distortion is remarkable in the SIRs estimation. Using a weighted mean standard incidence rate may be a valid alternative for SIR estimate when national standard rates are not available.

MGMT promoter methylation status in brain metastases from colorectal cancer and corresponding primary tumors

BACKGROUND

Brain metastases (BM) from colorectal cancer are usually associated with poor prognosis. The aim of this retrospective study is to evaluate MGMT promoter methylation in BM and their corresponding primary colorectal cancer tumors.

MATERIALS & METHODS

MGMT promoter methylation status was assessed by pyrosequencing in 53 consecutive patients resected for BM. A concordance analysis between BM and matched primary tumor was performed in 39 cases.

RESULTS

MGMT methylation was found in 34 (64.2%) BM and in 25 corresponding primary tumors (64.1%). Median survival after neurosurgery was independent from MGMT promoter methylation (163 days for those with methylated MGMT versus 193 days for the unmethylated).

CONCLUSION

Epigenetic MGMT promoter methylation was common and the concordance between primary and secondary lesions was high.

Medication use during pregnancy, gestational age and date of delivery: agreement between maternal self-reports and health database information in a cohort

Background

Health databases are a promising resource for epidemiological studies on medications safety during pregnancy. The reliability of information on medications exposure and pregnancy timing is a key methodological issue. This study (a) compared maternal self-reports and database information on medication use, gestational age, date of delivery; (b) quantified the degree of agreement between sources; (c) assessed predictors of agreement.

Methods

Pregnant women recruited in a prenatal clinic in Friuli Venezia Giulia (FVG) region, Italy, from 2007 to 2009, completed a questionnaire inquiring on medication use during pregnancy, gestational age and date of delivery. Redeemed prescriptions and birth certificate records were extracted from regional databases through record linkage. Percent agreement, Kappa coefficient, prevalence and bias-adjusted Kappa (PABAK) were calculated. Odds Ratio (OR), with 95 % confidence interval (95 % CI), of ≥1 agreement was calculated through unconditional logistic regression.

Results

The cohort included 767 women, 39.8 % reported medication use, and 70.5 % were dispensed at least one medication. Kappa and PABAK indicated almost perfect to substantial agreement for antihypertensive medications (Kappa 0.86, PABAK 0.99), thyroid hormones (0.88, 0.98), antiepileptic medications (1.00, 1.00), antithrombotic agents (0.70, 0.96). PABAK value was greater than Kappa for medications such as insulin (Kappa 0.50, PABAK 0.99), antihistamines for systemic use (0.50, 0.99), progestogens (0.28, 0.79), and antibiotics (0.12, 0.63). Adjusted OR was 0.48 (95 % CI 0.26; 0.90) in ex- vs. never smokers, 0.64 (0.38; 1.08) in < high school vs. university, 1.55 (1.01; 2.37) in women with comorbidities, 2.25 (1.19; 4.26) in those aged 40+ vs. 30–34 years.

Gestational age matched exactly in 85.2 % and date of delivery in 99.5 %.

Conclusions

For selected medications used for chronic conditions, the agreement between self-reports and dispensing data was high. For medications with low to very low prevalence of use, PABAK provides a more reliable measure of agreement. Maternal reports and dispensing data are complementary to each other to increase the reliability of information on the use of medications during pregnancy. Birth certificates provide reliable data on the timing of pregnancy. FVG health databases are a valuable source of data for pregnancy research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0745-3) contains supplementary material, which is available to authorized users.

Prognostic role of KRAS, NRAS, BRAF and PIK3CA mutations in advanced colorectal cancer

AIM

To explore the prognostic value of extended mutational profiling for metastatic colorectal cancer (mCRC).

MATERIALS & METHODS

We retrospectively reviewed survival results of 194 mCRC patients that were assigned to four molecular subgroups: BRAF mutated; KRAS mutated codons 12-13 only; any of KRAS codons 61-146, PIK3CA or NRAS mutations and all wild-type. Point mutations were investigated by pyrosequencing.

RESULTS

BRAF (5.2%) and KRAS 12-13 (31.9%) mutations were associated with poorer survival (HR 2.8 and 1.76, respectively). Presenting with right-sided colon cancer, not resected primary tumor, WBC >10 × 10(9)/l, receiving less chemotherapy or no bevacizumab were all associated with inferior outcome. The all-wild-type subgroup (39.2%) reported the longest survival.

CONCLUSION

Extended mutational profile combined with clinical factors may impact on survival in mCRC.

Impact of potential inappropriate NSAIDs use in chronic pain

Pain remains one of the main reasons for medical consultation worldwide: moderate- to severe-intensity pain occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use and a careful surveillance to monitor for toxicity and efficacy is critical. This study aims to assess: 1) the pattern of use of NSAIDs and opioids in a population covered by a cloud-based pharmacovigilance surveillance system; and 2) potential inappropriate use. A retrospective 18-months systematic analysis on patients’ pain treatment was performed. The primary endpoint was evaluating the prevalence of NSAIDs and opioids use and the duration of therapy regimen. The secondary endpoint was to investigate the prevalence of NSAIDs taken for >21 consecutive days concomitant with drugs for peptic ulcer and gastroesophageal reflux disease (GORD) or antiplatelet drugs. The yearly cost for individual users of concomitant NSAIDs for more than 21 consecutive days and of GORD medications has been estimated. A total of 3,050 subjects with chronic pain were enrolled; 97% of them took NSAIDs for >21 consecutive days; about one-fourth of these users also received drugs for peptic ulcer and GORD (Anatomical Therapeutic Chemical code A02B). The yearly cost foran individual who uses NSAIDs for >21 consecutive days as well as concomitant GORD medications is 61.23 euros. In total, 238 subjects (8%) using NSAIDs for >21 days also received one antiplatelet agent. About 11% of subjects received opioids at least once and only 2% of them carried on the therapy for more than 90 consecutive days. In evaluating the escalation in dosage as a proxy of dependence risk, this study shows no dosage escalation in our cohort of chronic pain population - that is to say we show no risk of dependence.

Bevacizumab and first-line chemotherapy for older patients with advanced colorectal cancer: final results of a Community-based Observational Italian Study

BACKGROUND

Although the efficacy and safety of combining first-line chemotherapy with bevacizumab in elderly patients with colorectal cancer (CRC) is supported by the results of a phase III trial, real-practice data are limited.

PATIENTS AND METHODS

Our multi-center, community-based observational study included 233 elderly patients with CRC (median age=73 years, range=70-84 years). Baseline comorbidities and geriatric evaluation were also analyzed. Pre-specified end-points of the study were safety, tolerability and outcome results.

RESULTS

The incidence of both chemotherapy-induced and specific bevacizumab-related toxicities was low, and not influenced by baseline concurrent morbidities. Median progression free survival (PFS) and median overall survival (OS) were 9.9 months and 23.6 months, respectively. Fifty-six percent of patients received second-line chemotherapy.

CONCLUSION

The upfront treatment of older patients with CRC with chemotherapy and bevacizumab is safe and efficacious in a real-world setting. No un expected toxicities were reported. Multi-dimensional geriatric evaluation is under-used in clinical practice.

The Use of Antidepressant Medication before and after the Diagnosis of Amyotrophic Lateral Sclerosis: A Population-Based Cohort Study

Background: The prevalent use of antidepressants (ATDs) in patients with Amyotrophic Lateral Sclerosis (ALS) varies across cross-sectional and clinic-based published studies. This population-based cohort study assesses the real-world prevalence of the use of ATDs, its trajectory and the association of incident use with clinical characteristics. Methods: All patients with incident ALS in the Friuli Venezia Giulia region, Italy, from 2002 to 2009, were identified through multiple sources including health databases. Diagnosis was validated through clinical documentation review. ATDs prescriptions from 2000 to 2011 were obtained from regional database. The trajectory was estimated through generalized estimating equations for repeated measures logistic regression and the Hazard ratio (HR) of initiating ATDs through multivariate proportional hazard Cox regression. Results: In this cohort of 261 ALS cases, age-, sex-adjusted prevalence of the use of ATDs was 37.3%, higher than in general population. The trajectory increased by 16% in 1-year period across diagnosis. Age ≤67 years at diagnosis (HR 1.28, 95% CI 0.84-1.95) and bulbar onset (1.43, 95% CI 0.90-2.26) were positively associated with initiating ATDs after diagnosis. Conclusions: More than one-third of patients used ATDs. Depression may occur more frequently than previously reported. Depression may precede motor alterations and be related to both ALS diagnosis and progression.

Risk of unplanned visits for colorectal cancer outpatients receiving chemotherapy: a case-crossover study

AIM

This study was conducted to evaluate the impact of chemotherapy on the risk of unplanned visit in a cohort of colorectal cancer outpatients. Chief complaints for unplanned visits and risk factors for hospital admission were also analyzed.

PATIENTS AND METHODS

Clinical data of 229 consecutive colorectal cancer patients who were unexpectedly presented to our acute oncology clinic between 2006 and 2009 were reviewed. A case-crossover statistical analysis was applied to study the association between exposure to chemotherapy (trigger event) and the occurrence of unplanned visit (acute outcome) in three time windows (7, 15, and 21 days from the closest previous chemotherapy treatment). Cox model was used to assess the risk factors for hospitalization.

RESULTS

There were 469 unplanned visits registered. Most of the patients had Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 (80 %) and advanced cancer stage (78 %). The majority of unplanned visits (72 %) occurred within 30 days since last chemotherapy. The most frequent presenting complaints were pain, fatigue, and anorexia. The two time windows associated with higher risk of visit were 15 and 21 days from last treatment, both for early (odds ratio [OR] 3.8, CI 1.4-10.2 and OR 3.8, CI 1.4-10.2) and advanced disease stage (OR 1.71, CI 1-2.9 and OR 3, CI 1.5-5.9). Of the unplanned visits, 10 % resulted in hospital admission. Presenting with multiple symptoms and with deteriorated PS were both predictors for hospitalization.

CONCLUSION

Chemotherapy exposition triggers the need for unplanned visits over the second and third week after treatment. The prompt and effective management of unexpected events may be cost- and time-saving and reduce pressure on oncology services.

Does multiple mutational analysis of the EGFR pathway have a prognostic role in advanced colorectal cancer (CRC)?

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Background: BRAF mutation is widely recognised as a strong negative prognostic factor in advanced CRC, while the prognostic value of KRAS mutations in codons 12-13 remains controversial. Exploring mutations in other downstream components of the EGFR pathway may have an impact on survival. Methods: A consecutive cohort of 201 metastatic CRC patients treated with systemic chemotherapy were analysed for KRAS (12-13-61-146), BRAF, PIK3CA and NRAS genotypes by pyrosequencing on PyroMarkTMQ96 ID instrument (Qiagen, Germany) with commercially available kits Anti-EGFR MoAb response (Diatech Pharmacogenetics, Italy). Accurate microdissection guaranteed more than 70% of cancer cells for each sample. For the purpose of the survival analysis 4 categories were created: (1) KRAS mutated (codons 12-13 only); (2) BRAF mutated; (3) any of KRAS codons 61-146, PIK3CA or NRAS mutations; (4) all-wild type. Log-rank and Cox proportional tests were applied for statistical analysis. Results: KRAS mutations were present in 96 (47.8%) patients: 86 (42.8%) were in codons 12-13. BRAF mutations were found in 11 (5.5%) samples while PIK3CA and NRAS in 33 (16.4%) and 7 (3.5%), respectively. All mutations were mutually exclusive except for 24 (11.9%) patients with concomitant KRAS/PIK3CA mutations. Median survivals for different categories are shown. Patients harbouring BRAF mutation had the worst outcome (p=0.0006). Mutations of any codon of KRAS (12-13-61-146) also negatively impacted on survival (p=0.026), while the all wild-type (KRAS/BRAF/PIK3CA/NRAS) patients had the longest survival (p=0.002). Conclusions: This study suggests the usefulness for early molecular profiling for advanced CRC patients. Mutational analysis of all EGFR pathway components may identify different prognostic subgroups. This information may drive treatment selection in clinical practice and stratification in clinical trials. [Table: see text]

Long-term observational, non-randomized study of enzyme replacement therapy in late-onset glycogenosis type II

OBJECTIVES

Type II glycogenosis (GSDII) is a lysosomal storage disorder due to acid alpha-glucosidase (GAA) deficiency. Enzyme replacement therapy (ERT) with human recombinant alpha-glucosidase (rhGAA) has been demonstrated to be effective in the treatment of infantile forms of GSDII, but little information is available concerning late-onset phenotypes. Long-term follow-up studies are not available at present. The aim of this study was to evaluate the ERT long-term effects in late-onset GSDII.

METHODS

Twenty-four patients, including 7 juveniles and 17 adults, received bi-weekly infusion of rhGAA (20 mg/kg) for at least 36 months. Clinical conditions, muscular function (6-min walking test, 6MWT; Walton scale, WS), respiratory function (vital capacity, VC; forced expiratory volume, FEV1; arterial pCO(2)), and muscle enzymes were assessed every 6 months.

RESULTS

The 6MWT improved in both juvenile and adult patients (p = 0.01, p = 0.0002, respectively), as well as in patients with moderate to severe muscle function impairment (WS >3.5; p = 0.002). An overall improvement in WS was also observed (p = 0.0003). VC and FEV1 remained unchanged, while pCO(2) decreased (p = 0.017). Muscle enzymes decreased significantly (p < 0.0001). Two patients (8%) showed transient secondary events during ERT.

CONCLUSIONS

Long-term ERT with rhGAA was shown to be safe, well tolerated, and effective in improving motor function and in stabilizing respiratory function in late-onset GSDII. The response pattern showed a progressive clinical improvement during the follow-up period in juvenile patients, while in adults it reached and maintained a plateau after the first year of treatment.

[Scleroderma and occupational risk factors: a case-control study]

In a hospital-based case-referent study of systemic sclerosis (SSc) and occupational risk factors (55 cases and 171 referents), an excess risk for SSc was observed in men with previous occupational exposure to solvents and certain chemicals (vinyl chloride, formaldehyde). SSc was associated, even though not significantly, with occupational exposure to solvents and silica among women. The possible role of occupational exposures in the etiology of SSc, as well as the methodological limitations of the present study, are discussed.

Reproductive factors and the risk of scleroderma: an Italian case-control study

OBJECTIVE

To investigate the association between scleroderma (systemic sclerosis; SSc) and reproductive factors in a hospital-based case-control study conducted at the University Hospital of Verona in Northeastern Italy.

METHODS

Forty-six confirmed cases of SSc in women (42 with diffuse SSc and 4 with limited SSc) and 153 female control subjects with orthopedic disorders were recruited at the University Hospital. For each subject, information on age at first pregnancy, number of children and abortions, and use of oral contraceptives was obtained by means of a structured questionnaire, and information on the subject's occupational history and lifestyle factors was also sought.

RESULTS

Parous women had a reduced risk of SSc (age-adjusted odds ratio [OR] 0.3, 95% confidence interval [95% CI] 0.1-0.8) compared with nulliparous women. The risk decreased with an increasing number of children: the age-adjusted OR was 0.6 (95% CI 0.2-1.7) for those women who had had 1 child, 0.3 (95% CI 0.1-0.7) for those having had 2 children, and 0.3 (95% CI 0.1-0.8) for those having had 3 or more children. Abortive pregnancies were inversely related to SSc risk: for women who had an abortion, the OR was 0.5 (95% CI 0.2-1.5) compared with women with no history of abortion. The overall history of any pregnancy (abortive or age-adjusted complete) was associated with a reduced risk of SSc (age-adjusted OR 0.3, 95% CI 0.1-0.7).

CONCLUSION

Since the incidence of SSc is higher in women and has its peak after childbearing age, it has been hypothesized that immunobiologic modifications during pregnancy may be associated with SSc development. Our findings showing a reduced risk of SSc among parous women seem to exclude the possibility of pregnancy itself as a risk factor for SSc. The role of HLA compatibility between the mother and the fetus, however, should be evaluated in further research.

Scleroderma and occupational exposure to hand-transmitted vibration

OBJECTIVES

To determine whether occupational exposure to hand-transmitted vibration is a risk factor for scleroderma (systemic sclerosis, SSc), two case-control studies were conducted in the provinces of Trento and Verona, northeastern Italy.

METHODS

In the Trento study, 21 patients with a diagnosis of either systemic or localised scleroderma were recruited from those admitted to all hospitals of the province from 1 January 1976 to 31 December 1991. For each case, two age- and gender-matched controls were selected. In the Verona study, cases included 55 patients diagnosed with SSc and clinically followed at the rheumatology clinic of the local university hospital between 1 January 1997 and 30 June 1999. The controls included 171 subjects frequency-matched by gender and age group. In both studies, all subjects were interviewed by structured questionnaire containing items on personal characteristics, smoking and drinking habits, use of medicines, occupational history and complete medical history. Women were also investigated about silicone implants and cosmetic surgery. Jobs and job tasks involving the use of vibratory tools, with or without concomitant exposure to silica dust in mining and non-mining occupations, were carefully investigated. A minimum criterion of 6 months was required for exposure duration.

RESULTS

In the Trento study, men with scleroderma were more likely than controls to have had exposure to hand-transmitted vibration (odds ratio (OR) 1.5, 95% confidence interval (95% CI) 0.1-74.1) or silica dust (OR 5.2, 95% Cl 0.5-74.1), but the association was not significant. The scleroderma patients were miners or stone workers who had operated jackhammers and rock drills. In the Verona study, a greater, although not statistically significant, odds of SSc was observed in men exposed to hand-transmitted vibration (OR 2.4, 95% CI 0.4-14.0) and in women exposed to silica (OR 2.4, 95% Cl 0.4-15.5). The SSc patients with vibration exposure were machinery operators or metal workers who had used grinders and impact wrenches.

CONCLUSIONS

Our case-control studies did not show a significant association between scleroderma and hand-transmitted vibration, with or without concomitant exposure to silica dust. Owing to the rarity of the disease and the small number of cases in the present studies, a genetic susceptibility to connective tissue disorders in SSc patients with occupational exposure to hand-transmitted vibration and/or silica cannot be ruled out.

Residential radon and risk of lung cancer in an Italian alpine area

To evaluate whether residential radon exposure explains the excess mortality for lung cancer in an Italian alpine valley with high natural radioactivity, the authors conducted a population-based case-control study on 138 deceased cases and 291 sex- and year-of-birth-matched controls. Year-long alpha-track measurements of radon were performed in the most recent residence, and information about occupational history and lifetime smoking habits was obtained. The authors adjusted for smoking, and radon was associated with lung cancer risk among men: compared with a radon level of < 40 becquerels (Bq) per cubic meter (m3), the odds ratios for 40-76 Bq/m3, 77-139 Bq/m3, 140-199 Bq/m3, and 200+ Bq/m3 were 2.1, 2.0, 2.7, and 1.4, respectively. The association between radon and lung cancer, as determined with a multiplicative model, was found only among male smokers.

Migration, socio-economic status and the risk of colorectal cancer in Italy

To assess how the risk of cancer of the colon and rectum relates to place of birth and socio-economic status, we analysed data from an Italian case-control study. Data included 1225 cases with a recent diagnosis of cancer of the colon (ages 19-74 years), 728 cases of cancer of the rectum (ages 23-74 years) and 4154 controls (ages 19-74 years), frequency-matched with cases by age and catchment area and admitted to hospitals for a wide spectrum of acute non-neoplastic conditions. Compared with residents born in the north of Italy, migrants from the centre and south had an odds ratio (OR) of 0.7 (95% CI 0.5-0.9) for colon cancer and OR of 0.9 (95% CI 0.7-1.2) for cancer of the rectum. The inverse association of migration with colon cancer was stronger among women (OR 0.5, 95% CI 0.4-0.8) than among men (OR 0.8, 95% CI 0.6-1.1), and was independent of education and occupation. Among migrants, the direct association between education and colon cancer risk was less clear than among non-migrants. In conclusion, place of origin played an independent role in colon cancer aetiology. Results on rectal cancer were less clear, although in the same direction. Among migrants, those less susceptible to behavioural changes (e.g. women) retained most of the benefit associated with their place of origin.