The role of laboratory medicine in a value-based healthcare system: the example of heart failure patient management in the Italian context

OBJECTIVE

As of today, healthcare systems worldwide face severe challenges that undermine their sustainability. The value-based healthcare (VBHC) approach has been proposed as a strategic and methodological framework to ensure the delivery of the best patient outcomes with economic efficiency. Through the illustrative example of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for heart failure (HF) patient management in the context of the Italian National Healthcare system, this article explores the role that in vitro diagnostics (IVDs) can play in enabling value-based care models.

SUBJECTS AND METHODS

14 healthcare professionals representing the relevant professional figures involved in HF patient management met to revise the current HF patient journey and design a new care pathway that, leveraging on BNP/NT-proBNP, reflects the VBHC principles.

RESULTS

The literature recognizes the dosage of BNP/NT-proBNP as the gold stan-dard for diagnosing HF. However, as of today, these IVDs are not employed at their full potential regarding HF patient management. A new patient journey is proposed so that patients are diagnosed early and properly monitored in the aftermath of hospitalization, improving outcomes at contained costs.

CONCLUSIONS

As testified by the example of HF patient management in Italy, laboratory medicine can represent a lever for adopting value-based care models. Still, large-scale adoption of VBHC will call for structural reforms that revise how healthcare delivery is organized, measured, and reimbursed.

Evidence of D-shaped wounds in the intrasomatic bullet path: two case reports

The final appearance of gunshot wounds is influenced by both the projectile's behavior from the muzzle to the terminal target and by the intrinsic characteristics of the anatomical compartments where the lesion(s) occur. The D-shaped morphology is an uncommon yet well-known finding in the forensic literature and has been described when the surface of impact with the skin is represented by the bullet's lateral projection. Two cases where D-shaped gunshot wounds were observed are hereby presented: in both cases, interaction with multiple intermediate targets (case 1) and a human intermediate target (case 2) had been documented and confirmed by the forensic examination. Despite the different dynamics of production, this peculiar morphology was described throughout most of the intrasomatic bullet path in both the victims. The discovery of D-shaped gunshot wounds can guide the forensic pathologist in the ballistic reconstruction of the event by supporting the hypothesis of an interaction with an intermediate target that has led to deviation from the initial trajectory and destabilization of the bullet associated with loss of kinetic energy.

The Role of Sexual Prejudice and Aetiology Beliefs in the Italians' Attitudes Toward Adoption by Same-Sex Couples

Research found that those who believe sexual orientation is inborn have generally positive attitudes toward gay men and lesbian women. However, other studies have also found that these beliefs could include negative eugenic ideas. This study aims to investigate the role of people's beliefs about the aetiology of sexual orientation in attitudes toward adoption for both gay and lesbian couples in Italy. We hypothesized that this relationship would be mediated by sexual prejudice. To test the predictions, 256 Italian heterosexual participants were asked to answer questions on a scale about their beliefs regarding the aetiology of sexual orientation, sexual prejudice, and attitudes toward adoption by same-sex couples. Results confirmed that the relationship between aetiology beliefs and support for adoption by gay and lesbian couples was fully mediated by sexual prejudice. These results suggest that the belief that sexual orientation is controllable may serve to justify one's prejudice and, in turn, result in a lower support for same-sex couples' adoption.

Information technology systems to support antimicrobial stewardship programs

Problem

Inappropriate antibiotic use contributes to the emergence and spread of multidrug-resistant organisms that are responsible for life-threatening infections. Furthermore, overprescription of antibiotics is associated with an increased risk of adverse effects and higher costs.

Description of the problem

Careggi is a tertiary care teaching hospital in Italy, with nearly 1,200-bed units, involved since 2015 in antimicrobial stewardship (AMS) programs. Despite implementation programs, carbapenems (CAR) consumption rates remained higher than the national average; for this reason, the AMS hospital team started a project aimed at improving the appropriateness of this type of drug.

Results

The project started in October 2021 and involved 10 hospital Units selected as the major prescribers of CAR. The strategies were planned by a multi-professional and multi-disciplinary team of experts in AMS and were set in place by a multimodal approach focused on information technology (IT) functions implemented in the electronic medical record such as:

• time-out alerts at 72 hours inviting physicians to evaluate if the prescribed antimicrobial is still warranted or effective against the identified organism(s);

• interactive and customizable prescribing algorithms to support physicians in empirical and targeted therapies;

• electronic dashboards viewable by physicians and the AMS team to daily monitor and review CAR prescriptions.

These functions were complemented by a series of training sessions for prescribing physicians aimed to promote a more rational and appropriate antimicrobials use. Six months after the project began, an overall reduction in the prescription of CAR was observed: from 6.2 DDD/100 patient-days to 4.9 DDD/100 patient-days.

Lessons

AMS programs use different interventions to influence the behavior of prescribers toward more appropriate use of antimicrobials. IT functions represent complementary and useful tools to promote antimicrobial stewardship programs.

Key messages

• Antimicrobial stewardship programs aim at optimizing antibiotic use and reducing inappropriate antibiotic prescriptions.

• Information technology systems represent useful tools within AMS programs.

Rust stains' response to environmental stresses: An experimental study on porcine skin

Rust stains are rare marks typically caused by prolonged contact between skin and the iron components of the firearm. This study was aimed at showing how cutaneous iron deposits respond to physical and chemical changes that usually affect the integrity of biological tissues. Four samples of porcine skin were placed in contact with an iron plate. They were exposed to different stress conditions: carbonization, water immersion, sunlight exposure and burial. All the skin sections were stained with Hematoxylin and Eosin (H&E) and Perls Prussian Blue (PPB). The response to the different treatments was consistent among the skin sections, as none of the rust stains were significantly altered by the applied stresses. All the samples showed focal iron deposition in the examined sections, which appeared as blue-colored spots in a rose-to-red background. Rust mark formation is an "all or nothing" phenomenon leading to the appearance of a sign that is relatively fixed and cannot be easily modified by the most common environmental conditions. This feature suggests the permanence of rust stains both from a macroscopic and a microscopic point of view, using Perls Prussian Blue staining after the exposure of the skin samples to various environmental stresses within precise time intervals.

Families in quarantine for COVID-19 in Italy. Resilience as a buffer of parental distress and problematic children's emotions and behaviors

The pandemic of Covid-19 has had a high impact on people's lives and especially on families. In Italy, in 2020, the several forced closures led families to live indoors to manage anxiety and distress. It was considered appropriate to investigate which protective factors, like parental resilience, can mitigate the negative impact of pandemic-related distress on family life. We have conducted two online surveys during different national lockdowns for Covid-19. The first survey was conducted immediately after the disruption of the virus and the second one after nine months. We measured parental resilience and distress, anxiety, problematic behaviors, and somatization of their children (as assessed by the parents). The aim was to investigate the protective role of parental resilience in mitigating parental distress and in turn problematic emotional states and behavior of their children. Mediation analyses confirmed the hypothesis that parental resilience lowers parental distress and consequently the anxiety and behavioral disorders of their children in both acute distress (first study) and chronic distress (second study) situations. Such results suggest that the improvement of parents' resilience can buffer the negative impact of pandemic-related parental distress and children's behavioral problems on both occasions. The need for focused interventions and treatments aimed to reinforce parental resilience is discussed. Targeted prevention and support strategies are needed now, and early in case of future health crises.

What about cerebral venous sinus thrombosis? A series of three autopsy cases

Cerebral venous sinus thrombosis (CVST) is an uncommon cerebrovascular disorder that gained massive media attention in 2021, when an association between COVID-19 and its vaccines was found in several reported cases, raising the suspicion of a causative relation that is still debated.

Three cases of CVST unrelated to COVID-19 are reported in this article to highlight the difficulty in the early recognition and management of this condition, as it occurs in a variety of diseases with different clinical and pathological manifestations.

When the diagnosis cannot be achieved in the clinical setting, the role of the pathologist becomes essential in the determination of the cause of death and in the identification of the etiology of CVST.

During the autopsy, coordination between the physician and the forensic pathologist is crucial to correlate the clinical presentation with the pathological picture.

Intimate Partner Violence and Same-Sex Couples: Examining the Antecedents of the Helping Intentions of Bystanders

Researchers interested in intimate partner violence (IPV) have focused primarily on male-against-female cases. We conducted two experimental investigations to examine the influence of moral evaluation, attribution of responsibility, and right-wing authoritarianism (RWA) on the willingness of bystanders to provide help to the victim in an IPV case involving a same-sex couple. Study 1 (N = 195) surveyed a heterosexual participant sample, and Study 2 (N = 120) surveyed a sample of gay and lesbian participants. In both studies, participants read a fictitious article describing an alleged IPV episode that occurred either in a male-male or a female-female couple. Each participant read an article describing one of two versions of a case of IPV: In one account, the victim admitted to infidelity and in the other, the victim did not confess to infidelity. The participants subsequently evaluated the victim and expressed their willingness (or lack thereof) to support and provide help to the injured party. In both studies, participants in the condition that included the admission of infidelity assessed the victim to be less moral and more responsible for the violent episode. Consequently, participants of both studies expressed lesser willingness to provide help to the victim. Moreover, in Study 1, the relationship between the admission of infidelity and the respondents' willingness to support the victim was moderated by RWA. Particularly, the admission of infidelity by the victim reduced the respondents' willingness to extend support only when they reported a medium to a high level of RWA ideology. By focusing specifically on same-sex IPV cases, this study contributes to a more comprehensive understanding of the reactions of witnesses with regard to IPV. Furthermore, it provides evidence about the underlying mechanisms mitigating the intervention of bystanders in such cases and identifies boundary conditions that exacerbate their (un)willingness to intervene.

The Mediating Role of Place Attachment Dimensions in the Relationship Between Local Social Identity and Well-Being

Well-functioning communities provide a range of material and psychological resources that enhance well-being. The degree to which individuals see themselves as part of the local social group, or local social identity, i.e., the social identification with the community of the place where people are living, may play an important role in enhancing happiness and well-being, as well as relationships of people with their own living environment, i.e., place attachment. We hypothesized that local social identity influences well-being via specific components of place attachment to the residential city/town, i.e., place identity, social relations, and lack of resources (which is the opposite of place dependence). We measured local social identity, individual well-being, interdependent happiness, and place attachment in a sample of N = 375 participants. We tested our hypotheses by conducting a series of mediation analyses with local social identity as an independent variable, individual well-being and interdependent happiness as dependent variables, and place attachment subfactors, i.e., place identity, social relations, and lack of resources, as mediators. Results showed that the relation between local social identity and both individual well-being and interdependent happiness was positively mediated by place identity and social relations, while the lack of resources emerged as a negative mediator only in the relation between local social identity and individual well-being (not for interdependent happiness). Practical implications and future developments are discussed.

Adding Insult to Injury: The Effects of Intimate Partner Violence Spillover on the Victim's Reputation

This article examined indirect consequences for the victims of intimate partner violence (IPV) in terms of ostracism and reputational threats. Through an experimental vignette survey, we compared bystanders' reactions to either an intimate partner violence episode or a generic violence episode. A victim of IPV (vs. generic violence) received a more negative moral evaluation and was considered as more responsible for the violence perpetrated on her. This made participants not only anticipate a less positive reputation attributed to the victim but also report less willingness to approach and defend the victim and include her in relevant ingroups 1 year after the episode.

The Italian Version of SCORE-15: Validation and Potential Use

SCORE-15 (Systemic Clinical Outcome and Routine Evaluation) is a 15-item questionnaire for completion by family members aged 12 years and older to assess outcomes in systemic therapy. This study aimed to investigate (a) the psychometric properties and the internal consistency reliability of the Italian version of SCORE-15, (b) clinical responsiveness, and (c) normative (Italian) criteria. Furthermore, (d) the study sought to evaluate the participants' representation of both their family and their problems, analyzing open-ended questions included in the SCORE-15. Data were collected from two clinical centers for 208 families (n = 507). Results confirmed the three-factor structure (i.e., strengths, difficulties, and communication), a good internal consistency reliability, and indicated a cutoff threshold for the Italian version. Furthermore, results showed that SCORE-15 is a good instrument for clinical responsiveness and that it can be used to explore the way in which family members describe their families and problems. Overall, SCORE-15 is a brief, psychometrically robust family assessment instrument that may be used for both researchers and practitioners in several domains of clinical and social psychology.

COVID-19 lockdown in Italy: the role of social identification and social and political trust on well-being and distress

The COVID-19 pandemic has rapidly become a global health crisis, leading people to change their interpersonal behaviours to contain the spread of the virus. Italy has rapidly become the country hit second hardest in the world by the COVID-19 pandemic and the first one in Western countries. To reduce the spread of the COVID-19, people are required to change their interpersonal behaviours, reducing their social interactions in close contacts. The lockdown impact on the economy as well as on social and psychological processes is relevant, we conducted an exploratory study to examine which social factors are associated with the psychological reactions of Italians during the COVID-19 lockdown. Participants (n = 690) self-reported their social identification on three levels (i.e., Italians, Europeans and humankind), their trust toward social and political actors, and their level of welbeing, interdependent-happiness, and distress. Results showed that the relation between trust and the level of wellbeing and distress was mediated by identification with Italians and humankind, only the identification with humankind mediated the relationship between trust and the level of interdependent-happiness. The identification with Europeans did not emerge as a mediator in such relationships. The implications for dealing with COVID-19 lockdown in Italy are discussed.

The management of NDM-β-lactamase-producing carbapenem-resistant Enterobacterales in Tuscany

Issue

An important outbreak of New Delhi metallo-β-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacterales (CRE) has been reported from north-western of Tuscany since November 2018. NDM is a metallo-β-lactamase able to hydrolyze most β-lactames (including carbapenems) with limited treatment options.

Description of the Problem

From November 2018 to May 2019, 7 Tuscan hospitals notified a total of 350 infected or colonized cases. This outbreak was described in a risk assessment edited by the European Centre for Disease Prevention and Control (ECDC) in June 2019. The Ministry of Health and the Tuscany Region promptly adopted infection prevention control measures.

Results

Since July 2019, a regional task force, composed by experts in infectivology, microbiology and public health, coordinated the following actions: Publication of Regional Resolutions which have established practical guidelines for the outbreak management. These measures included:(I) the introduction of screening test for CRE by rectal swab for hospitalized patients; (II) the implementation of microbiological rapid molecular tests and genotyping of rectal swab; (III) the enhancement of standard and transmission-based precautions; (iv) the strengthening of handover between hospital setting and primary healthcare; (v) the implementation of a regional data-base for outbreak surveillance.Monthly regional meetings with the infection control teams of each hospital.Site visits (n. 44) performed by a group of experts in all healthcare facilities.

After the implementation of these measures, a trend for decrease in positive blood cultures of NDM was registered.

Lessons

The spread of NDM in Tuscany has been the opportunity to standardize and improve the approach to Multidrug-Resistant Organisms (MDROs) prevention and control.

Key messages

The spread of NDM in Tuscany has been the opportunity to standardize and improve the approach to Multidrug-Resistant Organisms (MDROs) prevention and control. The cooperation among stakeholders and the standardization of precaution measures and healthcare workers’ behavior allows to effectively face the MDROs diffusion.

The gambling disorder: family styles and cognitive dimensions

OBJECTIVE

In this study we present data from a research carried out on a population of people with gambling disorder (GD).

SUBJECTS AND METHODS

This research investigated the representation of family styles for subjects with gambling disorder, using the Family Adaptability and Cohesion Evaluation Scale (FACES-IV), their cognitive distortions through Gambling Related Cognitions Scale (GRCS-I), and the relation between these two dimensions.

RESULTS

People with GD represent families with emotional detachment, while in the area of management of relational rules and roles, they reveal a perception of disorganization. Concerning their cognitive bias, GD people show the illusion of being able to control and predict the winnings and the perception of being unable to quit playing.

CONCLUSIONS

Overall, these data provide specific directions for both the prevention and the therapeutic treatment of GD, highlighting the importance of a family therapeutic approach for the prevention of cognitive distortions.

"The face of ostracism": The impact of the social categorization on the thermal facial responses of the target and the observer

Ostracism has been shown to elicit pain in both the target and the observers. Two experiments investigated the autonomic thermal signature associated with an ostracism experience and assessed whether and how social categorization impacts the autonomic arousal of both the target and the observer. Autonomic response was assessed using thermal infrared imaging, recording facial temperature variation during an online game of ball toss (i.e., Cyberball). Social categorization was manipulated using a minimal group paradigm. The results show a more intense autonomic response during ostracism (vs. inclusion), marked by an increase in facial temperature in the nose and the perioral area. This autonomic response is stronger when individuals are ostracized by ingroup (vs. outgroup) members. Similar pattern of temperature variations emerge when individuals observe an ostracism episode involving ingroup members. Our findings advance the understanding of psycho-physiological mechanisms underlying the ostracism experience and emphasize the impact of social categorization in such mechanisms.

Group membership and social status modulate joint actions

The ability to form shared task representations is considered a keystone of social cognition. It remains, however, contentious if, and to what extent, social categorization impacts on shared representations. In the present study, we address the possibility of the modulation of action co-representation by social categorization, such as group membership and social status, as indexed by the social Simon effect. Italian participants were requested to perform a social Simon task, along with either an Italian (high-status in-group) or an Albanian (low-status out-group) participant. Results show that Italian participants co-represented the action of their partner when paired with a high-status in-group participant. Conversely, this effect was absent when they performed the task with a low-status out-group participant. Furthermore, the Albanian participants co-represented the action of their partner when paired with an Italian participant. These results suggest that group membership modulates action co-representation through the varying of the groups' relative status. The impact of this issue is boundless given the increasing multicultural nature of our society. Indeed, if multiculturalism fails, modern society does likewise.

Treatment of Acute Iliofemoral Deep Venous Thrombosis: A Strategy of Thrombus Removal

Patients with acute iliofemoral deep vein thrombosis (DVT) suffer the most severe postthrombotic sequelae. The majority of physicians treat all patients with acute DVT with anticoagulation alone, despite evidence that postthrombotic chronic venous insufficiency, leg ulceration, and venous claudication are common in patients treated only with anticoagulation. The body of evidence to date in patients with iliofemoral DVT suggests that a strategy of thrombus removal offers these patients the best long-term outcome. Unfortunately, currently published guidelines use outdated experiences to recommend against the use of techniques designed to remove thrombus, ignoring recent clinical studies showing significant benefit in patients who have thrombus eliminated. Contemporary venous thrombectomy, intrathrombus catheter-directed thrombolysis, and pharmacomechanical thrombolysis are all options that can be offered to successfully remove venous thrombus with increasing safety. The authors review evidence supporting the rationale for thrombus removal and discuss the most effective approaches for treating patients with acute iliofemoral DVT.

Analysis of acetate counter ion and inorganic impurities in pharmaceutical drug substances by capillary ion electrophoresis with conductivity detection

Capillary electrophoresis with conductivity detection is a versatile new method for the analysis of counter ions in pharmaceutical drug substances. It is a sensitive and linear technique for determining inorganic ions and short chain carboxylic acids such as acetate. Both acetate counter ion and inorganic impurities can be separated and determined in the same assay.

Effects of reperfusion after acute coronary occlusion on the beating, working heart compared to the arrested heart treated locally and globally with cardioplegia

To determine whether acutely ischemic myocardium could be more effectively salvaged by reperfusion on cardiopulmonary bypass (CPB) in the cardioplegia-treated heart than with reperfusion in the beating, working heart, 52 greyhound dogs underwent 3 hours of left anterior descending (LAD) occlusion and were randomly assigned to one of four groups. In Group I (19 dogs) the LAD occlusion was released at 3 hours and reperfusion continued in the beating, working heart for an additional 3 hours. Group II (six dogs), Group III (14 dogs), and Group IV (13 dogs) were placed on CPB and underwent 45 minutes of hypothermic ischemic arrest protected by aortic root potassium cardioplegia. In Group II, only aortic root potassium cardioplegia was given; in Group III, the ischemic area was perfused with potassium cardioplegic solution via a graft from the internal mammary artery (IMA) to the LAD. In Group IV, blood cardioplegic solution via the IMA-LAD graft was used. After the cross-clamp and local occlusion were removed, CPB was discontinued after an additional 45 minutes and reperfusion was continued off CPB for an additional 1 1/2 hours (total 6 hours). The ischemic area at risk was determined by injecting monastryl blue dye via the left atrium while the LAD was briefly reoccluded. After the animal had been sacrificed and the left ventricle had been sectioned, the area of myocardial necrosis was determined by nonstaining with triphenyltetrazolium chloride (TTC). For each group, the ratios of area of necrosis/area at risk (AN/AR) were calculated and postreperfusion arrhythmias were documented. Postreperfusion arrhythmias were noted in 11 of 12 animals in the beating, working heart group and only two of 24 in the combined CPB groups. The mean AN/AR was 66% +/- 2% in the beating, working heart (Group I), 59% +/- 6% after infusion of potassium cardioplegic solution into the aortic root (Group II), 57% +/- 6% with blood cardioplegia (Group IV), and 38% +/- 6.5% after global and local application of the potassium cardioplegic solution into the ischemic area (Group III). This study suggests that the reperfused ischemic myocardium will sustain less necrosis and less postreperfusion arrhythmias when the heart is protected by global and local cold potassium cardioplegia on CPB.

Stimulation by insulin of RNA synthesis in chick fibroblasts

After the addition of insulin to monolayers of chick fibroblasts previously incubated in serum-free medium, the rates of protein and RNA synthesis increase continuously during the first 8-10 h. Little stimulation of DNA synthesis or mitosis results with the addition of insulin alone in contrast to the addition of fresh serum which stimulates both markedly. The stimulation in RNA synthesis does not result from expansion of the nucleotide pool but is correlated with increases in RNA polymerase activity. All major classes of RNA are stimulated; processing of preribosomal RNA to 28S and 18S and the association of this mature RNA with ribosomes appear to occur normally. The kinetics of stimulation of 5S RNA differ from those of the synthesis of 4S and of ribosomal RNA. Insulin and serum appear to affect the synthesis or stability of certain transcripts differentially.