Site-directed mutagenesis identifies active-site residues of the light chain of botulinum neurotoxin type A

Botulinum neurotoxins (BoNTs) are metalloproteases which block neuroexocytosis via specific cleavage and inactivation of SNARE proteins. Such proteolysis accounts for the extreme toxicity of these neurotoxins and of their prolonged effect. The recently determined structures of BoNT/A and/B allows one to design active-site mutants to probe the role of specific residues in the proteolysis of SNARE proteins. Here we present the results of mutations of the second glutamyl residue involved in zinc coordination and of a tyrosine and a phenylalanine residues that occupy critical positions within the active site of BoNT/A. The spectroscopic properties of the purified mutants are closely similar to those of the wild-type molecule indicating the acquisition of a correct tertiary structure. Mutation of the Glu-262* nearly abolishes SNAP-25 hydrolysis as expected for a residue involved in zinc coordination. The Phe-266 and Tyr-366 mutants have reduced proteolytic activity indicating a direct participation in the proteolytic reaction, and their possible role in catalysis is discussed.

Active-site mutagenesis of tetanus neurotoxin implicates TYR-375 and GLU-271 in metalloproteolytic activity

Tetanus neurotoxin (TeNT) blocks neurotransmitter release by cleaving VAMP/synaptobrevin, a membrane associated protein involved in synaptic vesicle fusion. Such activity is exerted by the N-terminal 50kDa domain of TeNT which is a zinc-dependent endopeptidase (TeNT-L-chain). Based on the three-dimensional structure of botulinum neurotoxin serotype A (BoNT/A) and serotype B (BoNT/B), two proteins closely related to TeNT, and on X-ray scattering studies of TeNT, we have designed mutations at two active site residues to probe their involvement in activity. The active site of metalloproteases is composed of a primary sphere of residues co-ordinating the zinc atom, and a secondary sphere of residues that determines proteolytic specificity and activity. Glu-261 and Glu-267 directly co-ordinates the zinc atom in BoNT/A and BoNT/B respectively and the corresponding residue of TeNT was replaced by Asp or by the non conservative residue Ala. Tyr-365 is 4.3A away from zinc in BoNT/A, and the corresponding residue of TeNT was replaced by Phe or by Ala. The purified mutants had CD, fluorescence and UV spectra closely similar to those of the wild-type molecule. The proteolytic activity of TeNT-Asp-271 (E271D) is similar to that of the native molecule, whereas that of TeNT-Phe-375 (Y375F) is lower than the control. Interestingly, the two Ala mutants are completely devoid of enzymatic activity. These results demonstrate that both Glu-271 and Tyr-375 are essential for the proteolytic activity of TeNT.

Heart Rate Turbulence Is a Powerful Predictor of Cardiac Death and Ventricular Arrhythmias in Postmyocardial Infarction and Heart Failure Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Heart rate turbulence (HRT) has been proposed as a candidate marker of altered autonomic tone, and some studies showed its prognostic value for both cardiac death (CD) and sudden death. Nevertheless, HRT is not currently used in the clinical practice.

METHODS AND RESULTS

We performed a systematic review and meta-analysis of the predictive value of HRT for the end points of total mortality, CD, and fatal and nonfatal ventricular arrhythmias in postacute myocardial infarction and heart failure patients. MEDLINE and The Cochrane Library databases were systematically searched to identify studies, which analyzed the predictive value of abnormal HRT for the defined end points. Twenty studies (25 cohorts: 12 832 patients) were identified by the systematic review, and 15 studies (20 cohorts: 11 499 patients) were included in the meta-analyses. Abnormal HRT was a predictive marker for all the end points in heart failure patients and more markedly in postacute myocardial infarction patients, where 9 out of the 10 cohorts had an ejection fraction >30%. In postacute myocardial infarction patients, HRT had pooled risk ratios of 3.53 (95% confidence interval [CI], 2.54-4.90), 4.82 (95% CI, 3.12-7.45), and 4.48 (95% CI, 3.04-6.60), and positive likelihood ratios of 3.5 (95% CI, 2.6-4.8), 4.1 (95% CI, 3.0-5.7), and 2.7 (95% CI, 2.2-3.3) for total mortality, CD, and arrhythmic events, respectively. The combination of abnormal HRT and T-wave alternans (5 cohorts: 1516 patients) increased the predictive power for CD and arrhythmic events.

CONCLUSIONS

HRT is a powerful predictor of both CD and arrhythmic events, particularly in postacute myocardial infarction patients with ejection fraction >30%. HRT power increases in combination with T-wave alternans analysis.

TMPRSS2, a SARS-CoV-2 internalization protease is downregulated in head and neck cancer patients

Background

SARS-coronavirus-2 enters host cells through binding of the Spike protein to ACE2 receptor and subsequent S priming by the TMPRSS2 protease. We aim to assess differences in both ACE2 and TMPRSS2 expression in normal tissues from oral cavity, pharynx, larynx and lung tissues as well as neoplastic tissues from the same areas.

Methods

The study has been conducted using the TCGA and the Regina Elena Institute databases and validated by experimental model in HNSCC cells. We also included data from one COVID19 patient who went under surgery for HNSCC.

Results

TMPRSS2 expression in HNSCC was significantly reduced compared to the normal tissues. It was more evident in women than in men, in TP53 mutated versus wild TP53 tumors, in HPV negative patients compared to HPV positive counterparts. Functionally, we modeled the multivariate effect of TP53, HPV, and other inherent variables on TMPRSS2. All variables had a statistically significant independent effect on TMPRSS2. In particular, in tumor tissues, HPV negative, TP53 mutated status and elevated TP53-dependent Myc-target genes were associated with low TMPRSS2 expression. The further analysis of both TCGA and our institutional HNSCC datasets identified a signature anti-correlated to TMPRSS2. As proof-of-principle we also validated the anti-correlation between microRNAs and TMPRSS2 expression in a SARS-CoV-2 positive HNSCC patient tissues Finally, we did not find TMPRSS2 promoter methylation.

Conclusions

Collectively, these findings suggest that tumoral tissues, herein exemplified by HNSCC and lung cancers might be more resistant to SARS-CoV-2 infection due to reduced expression of TMPRSS2. These observations may help to better assess the frailty of SARS-CoV-2 positive cancer patients.

The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access

Background

The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March–May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March–May 2020, group 2).

Methods

A comparison (groups 1 versus 2) and subgroup analysis were performed between patients’ demographic, medical history, surgical, clinical and management characteristics.

Results

Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08–4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33–5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89–11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05–25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01–63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11).

Conclusions

This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a “filter effect” induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

Different mechanism of blockade of neuroexocytosis by presynaptic neurotoxins

Nerve terminals are specific sites of action of a very large number of toxins produced by many different organisms. The presynaptic neurotoxins which interfere directly with the process of neurotransmitter release can be grouped in three large families: (1) the clostridial neurotoxins which act inside nerves and block neurotransmitter release via their metalloproteolytic activity directed specifically on SNARE proteins; (2) the snake presynaptic neurotoxins with phospholipase A2 activity whose site of action is still undefined and which induce the release of acetylcholine followed by impairment of synaptic functions; (3) the excitatory latrotoxin-like neurotoxins which induce a massive release of neurotransmitter at peripheral and central synapses. In this paper, the first two families are considered in terms of their modes of action and in relation to their potential use in cell biology and neuroscience as well as the therapeutic utilisation of the botulinum neurotoxins in human diseases characterised by hyperfunction of cholinergic terminals.

Application of the National Early Warning Score (NEWS) as a stratification tool on admission in an Italian acute medical ward: A perspective study

AIM

We aimed to assess the performance of the National Early Warning Score (NEWS) as tool for patient risk stratification at admission in an acute Internal Medicine ward and to ensure patient placement in ward areas with the required and most appropriate intensity of care. As secondary objective, we considered NEWS performance in two subgroups of patients: sudden cardiac events (acute coronary syndromes and arrhythmic events), and chronic respiratory insufficiency.

METHODS

We conducted a perspective cohort single centre study on 2,677 unselected patients consecutively admitted from July 2013 to March 2015 in the Internal Medicine ward of the hospital of Trento, Italy. The NEWS was mandatory collected on ward admission. We defined three risk categories for clinical deterioration: low score (NEWS 0-4), medium score (NEWS 5-6), and high score (NEWS≥7). Following adverse outcomes were considered: total and early (<72 hours) in-hospital mortality, urgent transfers to a higher intensity of care. A logistic regression model quantified the association between outcomes and NEWS.

RESULTS

For patients with NEWS >4 vs patients with NEWS <4, the risk of early death increased from 12 to 36 times, total mortality from 3.5 to 9, and urgent transfers from 3.5 to 7. In patients with sudden cardiac events, lower scores were significantly associated with higher risk of transfer to a higher intensity of care. In patients affected by chronic hypoxaemia, adverse outcomes occurred less in medium and high score categories of NEWS.

CONCLUSIONS

National Early Warning Score assessed on ward admission may enable risk stratification of clinical deterioration and can be a good predictor of in-hospital serious adverse outcomes, although sudden cardiac events and chronic hypoxaemia could constitute some limits.

Exploratory study of how Cognitive Multisensory Rehabilitation restores parietal operculum connectivity and improves upper limb movements in chronic stroke

Cognitive Multisensory Rehabilitation (CMR) is a promising therapy for upper limb recovery in stroke, but the brain mechanisms are unknown. We previously demonstrated that the parietal operculum (parts OP1/OP4) is activated with CMR exercises. In this exploratory study, we assessed the baseline difference between OP1/OP4 functional connectivity (FC) at rest in stroke versus healthy adults to then explore whether CMR affects OP1/OP4 connectivity and sensorimotor recovery after stroke. We recruited 8 adults with chronic stroke and left hemiplegia/paresis and 22 healthy adults. Resting-state FC with the OP1/OP4 region-of-interest in the affected hemisphere was analysed before and after 6 weeks of CMR. We evaluated sensorimotor function and activities of daily life pre- and post-CMR, and at 1-year post-CMR. At baseline, we found decreased FC between the right OP1/OP4 and 34 areas distributed across all lobes in stroke versus healthy adults. After CMR, only four areas had decreased FC compared to healthy adults. Compared to baseline (pre-CMR), participants improved on motor function (MESUPES arm p = 0.02; MESUPES hand p = 0.03; MESUPES total score p = 0.006); on stereognosis (p = 0.03); and on the Frenchay Activities Index (p = 0.03) at post-CMR and at 1-year follow-up. These results suggest enhanced sensorimotor recovery post-stroke after CMR. Our results justify larger-scale studies.

Morphological MRI of knee cartilage: repeatability and reproducibility of damage evaluation and correlation with gross pathology examination

OBJECTIVE

To assess the performance of a morphological evaluation, based on a clinically relevant magnetic resonance imaging (MRI) protocol, in scoring the severity of knee cartilage damage. Specifically, to evaluate the reproducibility, repeatability, and agreement of MRI evaluation with the gross pathology examination (GPE) of the tissue.

METHODS

MRI of the knee was performed the day before surgery in 23 patients undergoing total knee arthroplasty. Osteochondral tissue resections were collected and chondral defects were scored by GPE according to a semi-quantitative scale. MR images were independently scored by four radiologists, who assessed the severity of chondral damage according to equivalent criteria. Inter- and intra-rater agreements of MRI evaluations were assessed. Correlation, precision, and accuracy metrics between MRI and GPE scores were calculated.

RESULTS

Moderate to substantial inter-rater agreement in scoring cartilage damage by MRI was found among radiologists. Intra-rater agreement was higher than 96%. A significant positive monotonic correlation between GPE and MRI scores was observed for all radiologists, although higher correlation values were obtained by radiologists with expertise in musculoskeletal radiology and/or longer experience. The accuracy of MRI scores displayed a spatial pattern, characterized by lesion overestimation in the lateral condyle and underestimation in the medial condyle with respect to GPE.

CONCLUSIONS

Evaluation of knee cartilage morphology by MRI is a reproducible and repeatable technique, which positively correlates with GPE. Clinical expertise in musculoskeletal radiology positively impacts the evaluation reliability. These findings may help to address limitations in MRI evaluation of knee chondral lesions, thus improving MRI assessment of knee cartilage.

KEY POINTS

• MRI evaluation of knee cartilage shows moderate to strong correlation with gross pathology examination. • MRI evaluation overestimates cartilage damage in the lateral condyle and underestimates it in the medial condyle. • Education and experience of the radiologist play a role in MRI evaluation of knee chondral lesions.

Testing Surgical Face Masks in an Emergency Context: The Experience of Italian Laboratories during the COVID-19 Pandemic Crisis

The first wave of the COVID-19 pandemic brought about a broader use of masks by both professionals and the general population. This resulted in a severe worldwide shortage of devices and the need to increase import and activate production of safe and effective surgical masks at the national level. In order to support the demand for testing surgical masks in the Italian context, Universities provided their contribution by setting up laboratories for testing mask performance before releasing products into the national market. This paper reports the effort of seven Italian university laboratories who set up facilities for testing face masks during the emergency period of the COVID-19 pandemic. Measurement set-ups were built, adapting the methods specified in the EN 14683:2019+AC. Data on differential pressure (DP) and bacterial filtration efficiency (BFE) of 120 masks, including different materials and designs, were collected over three months. More than 60% of the masks satisfied requirements for DP and BFE set by the standard. Masks made of nonwoven polypropylene with at least three layers (spunbonded-meltblown-spunbonded) showed the best results, ensuring both good breathability and high filtration efficiency. The majority of the masks created with alternative materials and designs did not comply with both standard requirements, resulting in suitability only as community masks. The effective partnering between universities and industries to meet a public need in an emergency context represented a fruitful example of the so-called university "third-mission".

Surgical treatment of talar osteo-chondral lesions with micro-fractures, mesenchymal cells grafting on membrane, or allograft: Mid-term clinical and magnetic resonance assessment

Talar dome osteo-chondral lesions (OCL) are defects of the cartilaginous surface and subchondral bone often associated with sport practice. This retrospective observational work has the purpose of assessing: a) The clinical outcomes in the patients study group and in the three sub-groups; b) medium-term morphological and qualitative outcomes of the newly formed tissue by magnetic resonance imaging; c) if there is the correlation between new formed tissue clinical, morphological RM evaluation and qualitative clinical outcomes.

Ventricular tachycardia-inducibility predicts arrhythmic events in post-myocardial infarction patients with low ejection fraction. A systematic review and meta-analysis

Background

Inducibility of ventricular arrhythmias at electrophysiological study (EPS) has long been suggested as predictive for subsequent arrhythmic events. Nevertheless, the usefulness of EPS in the clinical practice is still unclear. We performed a systematic review and meta-analysis to assess the predictive power of EPS in primary prevention of ventricular arrhythmias in post-myocardial infarction (MI) patients with left ventricular dysfunction.

Methods

MEDLINE and the Cochrane Library databases were systematically searched to identify studies, which analyzed EPS predictive value in post-MI patients with mean EF < 40% for the composite arrhythmic endpoint defined by: sudden cardiac death (SCD), aborted SCD, ventricular tachycardia (VT), ventricular fibrillation (VF), appropriate implantable cardioverter-defibrillator (ICD) interventions.

Results

Nine studies, evaluating 3959 patients with 647 arrhythmic events, were included in the meta-analyses. EPS showed a strong predictive power for the arrhythmic endpoint with a pooled odds ratio (OR) of 4.00 (95% confidence interval [CI]: 2.30–6.96) in the whole set of studies, albeit a high level of heterogeneity among studies. EPS predictive power was higher in studies where VT-inducibility was tested (OR 6.52; 95% CI: 2.30–18.44; sensitivity 0.65, specificity 0.78, and negative predictive value 0.94), versus those assessing VT/VF-inducibility (OR 2.09; 95% CI: 1.34–3.26). VT-inducibility was predictive even when assessed within one month after MI (OR 7.85; 95% CI: 3.67–16.80).

Conclusions

Inducibility of ventricular arrhythmias at EPS is a strong predictor of the arrhythmic endpoint in post-MI patients with impaired EF, particularly when VT-inducibility is tested. EPS could help selecting the patients who can mostly benefit from ICD therapy.

Micropollutants and organic carbon concentrations in surface and deep sediments in the Tunisian coast near the city of Sousse

A radioactive tracer was used to map the plume of the effluent of a municipal water treatment plant located on the Tunisian coast, close to the city of Sousse. A sampling campaign was programmed on the basis of the radioactivity distribution. The extent of sediment contamination was investigated to determine the impact of the plant effluent. Organic carbon and organic micropollutants (PCBs and chlorinated pesticides) were analysed on resuspendable particulate matter, on grab and core sediments. The area distributions of different compounds analysed were studied and relationships were investigated between radioactivity and organic carbon and micropollutant data. The study shows that sludge particles are deposited and accumulate in the zone south of the effluent outlet, contaminating sediments. Good correlations were found which demonstrate the efficiency of the technique used to plan the sampling and the link between organic carbon and organic micropollutants.

Why do we not reverse the path? Stress can cause depression, reduction of brain-derived neurotrophic factor and increased inflammation

The aim of this paper is to describe the direction of the link between stress, depression, increased inflammation and brain-derived neurotrophic factor (BDNF) reduction. We hypothesize that severe stress or prolonged stress can be the driving factor that promote the onset of depression. Both stress and depression, if not resolved over time, activate the production of transcription factors that will switch on pro-inflammatory genes and translate them into cytokines. This cascade fosters systemic chronic inflammation and reduced plasma BDNF levels. Since people with depression have a 60% increased risk of developing type 2 diabetes (T2D) and show high levels of inflammation and low levels of BDNF, we hypothesize possible reasons that might explain why T2D, depression and dementia are often associated in the same patient.

Altered Extracellular Vesicle miRNA Profile in Prodromal Alzheimer's Disease

Extracellular vesicles (EVs) are nanosized vesicles released by almost all body tissues, representing important mediators of cellular communication, and are thus promising candidate biomarkers for neurodegenerative diseases like Alzheimer's disease (AD). The aim of the present study was to isolate total EVs from plasma and characterize their microRNA (miRNA) contents in AD patients. We isolated total EVs from the plasma of all recruited subjects using ExoQuickULTRA exosome precipitation solution (SBI). Subsequently, circulating total EVs were characterized using Nanosight nanoparticle tracking analysis (NTA), transmission electron microscopy (TEM), and Western blotting. A panel of 754 miRNAs was determined with RT-qPCR using TaqMan OpenArray technology in a QuantStudio 12K System (Thermo Fisher Scientific). The results demonstrated that plasma EVs showed widespread deregulation of specific miRNAs (miR-106a-5p, miR-16-5p, miR-17-5p, miR-195-5p, miR-19b-3p, miR-20a-5p, miR-223-3p, miR-25-3p, miR-296-5p, miR-30b-5p, miR-532-3p, miR-92a-3p, and miR-451a), some of which were already known to be associated with neurological pathologies. A further validation analysis also confirmed a significant upregulation of miR-16-5p, miR-25-3p, miR-92a-3p, and miR-451a in prodromal AD patients, suggesting these dysregulated miRNAs are involved in the early progression of AD.

Quantitative MRI T2 Mapping Is Able to Assess Tissue Quality After Reparative and Regenerative Treatments of Osteochondral Lesions of the Talus

BACKGROUND

Quantitative MRI has potential for tissue characterization after reparative and regenerative surgical treatment of osteochondral lesions of the talus (OCLTs). However available data is inconclusive and quantitative sequences can be difficult to implement in real-time clinical application.

PURPOSE

To assess the potential of T2 mapping in discriminating articular tissue characteristics after reparative and regenerative surgery of OCLTs in real-world clinical settings.

STUDY TYPE

Observational and prospective cohort study.

POPULATION

15 OCLT patients who had received either reparative treatment with arthroscopic microfracture surgery (MFS) for a grade I lesion or regenerative treatment with bone marrow derived cell transplantation (BMDCT) for a grade II lesion.

FIELD STRENGTH/SEQUENCE

1.5 T, proton density weighted TSE, T2-weighted true fast imaging with steady-state-free precession and multi-echo T2 mapping sequences.

ASSESSMENT

Patients were evaluated at a minimum postoperative follow-up of 24 months. T2 maps of the ankle were generated and the distribution of T2 values was analyzed in manually identified volumes of interest (VOIs) for both treated lesions (TX) and healthy cartilage (CTRL). The amount of fibrocartilage, hyaline-like and remodeling tissue in TX VOIs was obtained, based on T2 thresholds from CTRL VOIs.

STATISTICAL TESTS

Fisher's exact test for categorical data, nonparametric Mann-Whitney U test for continuous data. The statistical significance level was P < 0.05.

RESULTS

From CTRL VOI analysis, T2 < 25 msec, 25 msec ≤ T2 ≤ 45 msec, and T2 > 45 msec were considered as representative for fibrocartilage, hyaline-like and remodeling tissue, respectively. Tissue composition of the two treatment groups was different, with significantly more fibrocartilage (+28%) and less hyaline-like tissue (-15%) in MFS than in BMDCT treated lesions. No difference in healthy tissue composition was found between the two groups (P = 0.75).

DATA CONCLUSIONS

T2 mapping of surgically treated OCLTs can provide quantitative information about the type and amount of newly formed tissue at the lesion site, thereby facilitating surgical follow-up in a real-word clinical setting.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 3.

Proper Selection Does Make the Difference: A Propensity-Matched Analysis of Percutaneous and Surgical Cut-Down Transfemoral TAVR

Background. Transcatheter aortic valve replacement (TAVR) is an established technique to treat severe symptomatic aortic stenosis patients with a wide range of surgical risk. Currently, the common femoral artery is the first choice as the main access route for the procedure. The objective of this observational study is to report our experience on percutaneous and surgical cut-down transfemoral TAVRs comparing the two approaches. Methods. From January 2014 to January 2019, five hundred eleven consecutive patients underwent TAVR for severe symptomatic aortic stenosis. We analyzed only elective transfemoral procedures. After propensity score-matching based on age, sex, EuroSCORE II, mean aortic gradient, and left ventricular ejection fraction, we obtained two homogeneous populations: surgical cut-down (n = 119) and percutaneous (n = 225), which were labeled Group 1 and Group 2, respectively. Results. The main findings were that there were no significant procedural outcome differences between the two groups, but Group 2 patients had a shorter length of hospital stay and were more frequently discharged home. At follow-up, Group 1 patients had lower survival rates. Conclusions. An accurate preoperative assessment of the femoral access is mandatory to achieve satisfactory outcomes with transfemoral TAVRs. Nevertheless, the percutaneous approach allows shorter in-hospital stay and the need for rehabilitation, thus potentially decreasing the costs of the procedure.

Evaluation of the prevalence of the most common psychiatric disorders in patients with type 2 diabetes mellitus using the patient health questionnaire: results of the cross-sectional "DIA2PSI" study

AIMS

Common Psychiatric Disorders (CPDs) are associated with the development of overweight and obesity, the strongest risk factors for the onset and maintenance of Type 2 Diabetes mellitus (T2D). To the best of our knowledge, this is the first study to assess the prevalence of CPDs in patients with T2D in Italy.

METHODS

This is a monocentric cross-sectional study; n = 184 T2D patients were screened for CPDs using the Patient Health Questionnaire (PHQ). Primary outcome was to evaluate the prevalence of CPDs. To assess association between CPDs and risk factors, we have utilized univariable logistic regression models.

RESULTS

64.1% were men, median age was 67 (59-64) and median BMI 27 (25-30) kg/m². The 42.9% tested positive for one or more mental disorders, 25.6% for depression. Patients with higher BMI (p = 0.04) had an increased likelihood of testing positive to the PHQ. Patients who had implemented lifestyle changes (p < 0.01) and were aware that mental health is linked to body health (p = 0.07) had a reduction in the likelihood of testing positive.

CONCLUSIONS

Prevalence of CPDs in T2D patients is higher than in the general population. Since CPDs favor the onset and subsistence of T2D, integrated diabetic-psychiatric therapy is required for improvement or remission of T2D in patients with comorbid CPDs.

A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy

BACKGROUND

In medical wards, to guarantee safe, sustainable and effective treatments to heterogeneous and complex patients, care should be graduated into different levels of clinical intensity based on a standardised assessment of acute-illness severity. To support this assumption, we conducted a prospective observational study on all unselected admissions of 3,381 patients to a medium size internal Italian Medicine Unit by comparing Standard Medical Care model (SMC) to a new paradigm of patient admission based on Intensity of Medical Care (IMC).

METHODS

The SMC operated during 2013, while an IMC organizational model started in 2014. In SMC, patient's admission was performed according to bed availability only. In IMC, after the stratification of clinical instability performed using the National Early Warning Score (NEWS) and clinical judgment, patients were allocated to three different ward areas (high, middle, and post-acute medical care). We compared clinical and organizational outcomes of IMC patients (2015) to SMC patients (2013), performing adjusted logistic regression model.

RESULTS

We managed 1,609 and 1,772 patients using SMC and IMC, respectively. The IMC seemed to be associated to a lower risk of clinical worsening for patients. Comparing IMC to SMC, the odds ratio (aOR) for urgent transfers to intensive care units was 0.69 (p = 0.03), and for combination of urgent transfers and early deaths was 0.68 (p<0.01).

CONCLUSIONS

Redesigning the configuration of internal medicine ward to support urgency and competency of the clinical response by applying IMC paradigm based on the NEWS, improved outcomes in patients with acute illness and enhanced ward performances.

Intensity of medical care in internal medicine: impact on outcomes from a trend analysis over six years

In large acute medical wards treating heterogenous and complex patients, intensity of patient care should be graduated according to clinical severity. We conducted a retrospective observational study on all unselected admissions (8838) to the internal medicine ward of the Santa Chiara Hospital of Trento from 2012 to 2017. During 2012 and 2013, a standard organizational model (SMC) was in place, while an organizational model for intensity of medical care (IMC) was introduced in 2014. In SMC, patient admission was performed according to bed availability only. In IMC, patients were allocated to three different ward settings (high, medium and post-acute care) based on the stratification of clinical instability. The National Early Warning Score (NEWS) was used for the stratification, together with the clinical judgment. The implementation of the IMC model led to a decrease of mortality and urgent transfers for clinical deterioration to Intensive Care Unit and to an increase of admissions from Intensive Care Unit and from regional spoke hospitals. Redesigning delivery processes based on IMC can play a pivotal role in improving patient outcomes and bed management.

Pneumococcal and influenza vaccination coverage of heart failure patients: still a long way to go

 

In patients with heart failure (HF), respiratory infections are responsible for acute exacerbation and increased hospitalization. Vaccination may reduce the incidence and/or severity of respiratory infections, and thereby, reduce the risk of HF exacerbation. Despite current recommendation, vaccination coverage (VC) for patients with HF remains far too limited.

To study the VC of HF patients followed in our hospital and to precise the strategies desired by the patients in order to carry out the vaccination.

This was a prospective monocentric descriptive study conducted between December 2019 and January 2021. Patients with HF history hospitalized in cardiology unit (CU) and patients in a HF telemonitoring program (TP) were included. An interview was conducted by a pharmacist to find out the patient's vaccination status regarding influenza and pneumococcus, together with socio-demographic clinical data. During the interview for non-vaccinated patients, opinion and willingness to be vaccinated were obtained.

Data from 335 patients were collected (185 in CU, 150 in TP). The mean age was 69.3 years, and sex ratio was 2.6. About 65% were vaccinated against influenza in the last year (60% in CU, 72% in TP, p=0.022) and 22% had pneumococcal vaccination in the last 5 years (11% in CU, 35% in TP, p&lt;0.001). Respectively 64% of patients with HF with reduced ejection fraction (HFrEF) and 67% of patients with HF with preserved ejection fraction (HFpEF) were vaccinated against influenza (p=0,63) against 25% of patients with HFrEF and 19% with HFpEF for pneumococcus (p=0,27). 68% of the patients were in favour of the vaccination, 23% had a mixed opinion and 9% were against it. Among patients not vaccinated against influenza or pneumococcus, 17% refused to be vaccinated. Among unvaccinated patients who consider vaccination, 69% wanted to be vaccinated by their general practitioner (GP) and 7% wanted to be vaccinated by their cardiologist. Almost 1/3 of unvaccinated patients who were included in CU wanted a vaccine prescription at discharge. Among the vaccinated patients, information on the need to be vaccinated had been provided to them mostly by health insurance (73%) and their GP (19%) for the influenza vaccine and by their cardiologist (55%) and GP (32%) for the pneumococcal vaccination.

The VC of HF patients remains insufficient, particularly against pneumococcus, as described by Kopp and al. Patients in TP are more vaccinated than patients in CU, which could involve better management. Moreover, the low rate of vaccinated patients is mainly explained by a lack of awareness, as most of the unvaccinated would like to be vaccinated. About 2/3 of patients wanted to be vaccinated by their GP, and thus play a major role in their global care. The higher vaccination rate for influenza, which unlike pneumococcus benefits from a national vaccination campaign, demonstrates that improvements are needed in the institutional promotion of vaccination for HF patients.

Funding Acknowledgement

Type of funding sources: None.