A Vulnerability Index to Assess the Risk of SARS-CoV-2-Related Hospitalization/Death: Urgent Need for an Update after Diffusion of Anti-COVID Vaccines

Background: There are algorithms to predict the risk of SARS-CoV-2-related complications. Given the spread of anti-COVID vaccination, which sensibly modified the burden of risk of the infection, these tools need to be re-calibrated. Therefore, we updated our vulnerability index, namely, the Health Search (HS)-CoVulnerabiltyIndex (VI)d (HS-CoVId), to predict the risk of SARS-CoV-2-related hospitalization/death in the primary care setting. Methods: We formed a cohort of individuals aged ≥15 years and diagnosed with COVID-19 between 1 January and 31 December 2021 in the HSD. The date of COVID-19 diagnosis was the study index date. These patients were eligible if they had received an anti-COVID vaccine at least 15 days before the index date. Patients were followed up from the index date until one of the following events, whichever came first: COVID-19-related hospitalization/death (event date), end of registration with their GPs, and end of the study period (31 December 2022). To calculate the incidence rate of COVID-19-related hospitalization/death, a patient-specific score was derived through linear combination of the coefficients stemming from a multivariate Cox regression model. Its prediction performance was evaluated by obtaining explained variation, discrimination, and calibration measures. Results: We identified 2192 patients who had received an anti-COVID vaccine from 1 January to 31 December 2021. With this cohort, we re-calibrated the HS-CoVId by calculating optimism-corrected pseudo-R2, AUC, and calibration slope. The final model reported a good predictive performance by explaining 58% (95% CI: 48-71%) of variation in the occurrence of hospitalizations/deaths, the AUC was 83 (95% CI: 77-93%), and the calibration slope did not reject the equivalence hypothesis (p-value = 0.904). Conclusions: Two versions of HS-CoVId need to be differentially adopted to assess the risk of COVID-19-related complications among vaccinated and unvaccinated subjects. Therefore, this functionality should be operationalized in related patient- and population-based informatic tools intended for general practitioners.

Dissimulation in forensic psychiatric evaluations, a case-control study of the Millon Clinical Multiaxial Inventory-III

The possible tendency of subjects to decrease, hide, or omit symptomatic aspects of their mental functioning is one of the main problems in forensic psychological and psychiatric evaluations. We aimed at verifying the possible existence of significant differences in the Millon Clinical Multiaxial Inventory-III (MCMI-III) scales scores between a sample of dissimulators (n = 40) and their non-dissimulator counterpart matched by age, sex, and diagnosis. Cases and comparisons were retrieved from the archive of a single university forensic psychiatric centre between 2013 and 2022. Results showed statistically significant higher scores in the sample of dissimulators in the Desirability, Histrionic, Narcissistic, and Compulsive MCMI-III scales than in the comparison sample. Point biserial correlation test disclosed a strong positive correlation between the Desirability, Histrionic, Narcissistic, and Compulsive scales of the MCMI-III and being in the dissimulator group of subjects while a negative correlation emerged for all the other scales except drug dependence.

Key points

The forensic setting can affect a subject's behaviour.Dissimulation is a mechanism of minimization or concealment of a psycho-pathological condition.The MCMI-III can be a useful tool for a forensic psychiatrist or forensic psychologist in assessing dissimulation.

[On the relationship between incestuousness and destructivity: some reflection from an expert case.]

INTRODUCTION

Incestuous behaviors are often placed in family constellations that are highly dysfunctional from the perspective of communication between members and also with regard to the roles and expectations held in the family. The expert case being presented reflects these characteristics.

METHODS

Beginning with an expert case of particular interest with respect to incestuousness and destructibility, the authors report considerations from a clinical criminological and forensic psychological-psychiatric point of view on the link between the two item.

CONCLUSIONS

A careful historical, anthropological, documentary reconstruction, the examination of the relational set-up of the various subjects involved, and not only the clinical and psychodiagnostic aspects, are the indispensable premises, in order to make overall sense of crimes in families of particular complexity, difficult to decipher, such as those exposed in the present scientific work.

Examining the effectiveness and duration of adjuvanted vs. non-adjuvanted influenza vaccines in protecting older adults against symptomatic SARS-CoV-2 infection

Annual influenza vaccination is one of the main public health measures able to drastically reduce the burden of this infectious disease. Some evidence suggests 'trained immunity' triggered by influenza vaccine might reduce the risk of SARS-CoV-2 infection. Adjuvanted influenza vaccines are known to induce a broader cross-reactive immunity. No studies investigated the effect of adjuvanted vs. non-adjuvanted influenza vaccines on the risk of symptomatic SARS-CoV-2 infection. A case-control analysis nested in a cohort of subjects aged ≥65 years and immunized with adjuvanted or non-adjuvanted influenza vaccines was conducted. Although no statistically significant (OR = 0.87; P = .082) difference between the two vaccine types was observed for the 9-month follow-up period, a 17% (OR = 0.83; P = .042) reduction in the odds of COVID-19 was observed for adjuvanted vaccines with a 6-month follow-up. Further evidence is needed, but these results might have implications given the complexity of the upcoming winter seasons, in which the co-occurrence of influenza, SARS-CoV-2 and other respiratory infections (e.g., syncytial virus) might be unpredictable.

Assessment of small intestinal bacterial overgrowth and methane production in patients on chronic proton-pump inhibitor treatment: prevalence and role of rifaximin in its management in primary care

BACKGROUND

Although proton pump inhibitor (PPI) drugs have considered able to induce small intestinal bacterial overgrowth (SIBO), no data are so far available from primary care (PC). We assessed the prevalence of SIBO and methane (CH4) production consequent to chronic PPI therapy using Lactulose Breath Test (LBT). Secondary aim was to explore the possible role of rifaximin in treating PPI-induced SIBO patients.

METHODS

One hundred twenty-five gastroesophageal reflux disease patients, constantly treated with PPI for at least 6 months and undergoing to LBT, were retrospectively assessed. An age-matched control population (control) of 100 patients, which had not used PPI in the last 6 months, was also enrolled. In the PPI group, SIBO positive patients and CH4 producers were treated with rifaximin 1200 mg/daily for 14 days and re-checked with LBT one month after the end of treatment. The area under the curve (AUC) before and after treatment was also calculated for both SIBO positive patients and CH4 producers.

RESULTS

In the PPI group, SIBO prevalence was significantly higher vs. controls (38/125 [30.4%] vs. 27/100 [27%], P<0.05). 77/125 (61.6%) PPI patients were found to be CH4 producers vs. 21/100 (21%) controls (P<0.05). Among SIBO patients in the PPI group, 34 (89.4%) were also CH4 producers vs. 17/27 (63%) controls (P<0.05). After treatment, LBT resulted negative in 15/22 SIBO patients (68.1%) (P<0.05) and in 18/34 CH4 producers (52.9%) (P<0.05). At the AUC analysis, an overall reduction of 54.2% for H2 in SIBO patients and of 47.7% for CH4 was assessed after rifaximin treatment (P<0.05).

CONCLUSIONS

Our data showed that chronic use of PPI could be able to increase the prevalence of SIBO and to shift the intestinal microbial composition towards a CH4-producing flora. rifaximin could represent a useful therapeutical option for PPI-induced SIBO and for modulating CH4-producing flora.

Crimes without a body: reflections on a case series of online crimes

There is a large volume of online crimes. The aim of this work is to reflect on virtual crimes that are apparently different but actually have commonalities. In these cases, the corporeal sphere that mediates interpersonal relationships is absent, and perceptions of the real world and emotional regulation may be altered, which poses the risk of destructive behaviours. From this standpoint, self/hetero-directed aggression is the result of a certain type of transition from the real to the virtual world, where the body either is not involved at all or is experienced in an aberrant manner. In this study, we present three cases that clearly illustrate this concept.

How Much Is an Abortion Worth? Was a Human "Not Formed"? An Italian Proposal

INTRODUCTION

"Human capital" is defined as an integration of innate skills and knowledge acquired by investing in the formation of an individual; it is a real "capital" that pays off in the long term. In the Italian legal system, a human being is recognised as a "person" from the moment of birth. This determines the acquisition of the personal rights of an individual. Necessarily, therefore, by law, a fetus does not own such rights; nevertheless, it has an innate "potential" to acquire such rights after birth.

OBJECTIVE

In Italian jurisprudence, in general, the damage from a loss of a parental relationship is justified by the condition of existential emptiness caused in the family by the loss of a child. Compensation for this damage in the event of abortion due to third-party responsibility presents a non-uniform recognition in the judgements of the Italian courts, but in any case, it is almost always recognised with limitations since the emotional relationship with the lost individual is defined only in terms of "potential". Consequently, in this matter, at least two questions can be raised: (i) Is the economic estimate of abortion based on objective and standardised criteria, or is it heavily influenced by subjective evaluation? (ii) Is it possible to find standard criteria that may act as guidelines to quantify the loss of that human capital "in progress"?

METHODOLOGY

The authors try to answer these questions by analysing the different approaches to this issue adopted at an international level.

CONCLUSIONS

In conclusion, the authors propose homogeneous criteria to quantify the damage caused by abortion.

Work-related stress amongst legal medical doctors: the need for systematic psychological support. An Italian perspective

Legal medical doctors (LMDs) expertise encompasses a wide range of responsibilities. Work-related stress amongst LMDs is an extremely relevant factor, which affects the quality of LMDs life and work. Whilst it is a better-known problem abroad, this issue is poorly debated in Italy, as demonstrated by this literature analysis. The aim of this paper is to better understand the main sources of stress in the practice of legal medicine in Italy, highlighting the need for systematic psychological support. The risks of work-related stress for the social and health professions are well known in literature. In Italy, however, due to a series of complex circumstances and cultural and research delays, forensic practitioners often seem to be excluded from these kinds of complex issues. The authors, after a series of considerations drawn from a review of the literature and from experience in the forensic and medical field, point out how work in this area entails risks for workers, on par with all others belonging to the helping and social-health professions. They conclude their contribution with a series of proposals for appropriate protocols to cope with such problems for workers in the forensic and medical field.

Key points

Work-related risks for the social and health professionals are widely recognized in the literature.Although legal medical doctors are often thought to be safe from these types of issues, significant risks exist for this category as well.It is important to create appropriate protocols to address outcomes for legal medical doctors.

The Doppelgänger phenomenon and death: a peculiar case of homicide by a subject with first-episode psychosis

The Doppelgänger phenomenon refers to the experience of a direct encounter with one's self, characteriswed by: (i) the perception of a figure with one's own identical physical features; or (ii) the apprehension that the perceived figure shares the same personality and identity. The Doppelgänger does not only look like the same person, it is his/her double. The perceptual element is usually a hallucination, although occasionally a false perception of an actual figure may be involved. This phenomenon has been described in individuals suffering from overwhelming fear, severe anxiety or intoxication, epilepsy, as well as in the sleep-wakefulness transition. It has also been reported in major psychoses. The fear of imminent death often precedes the Doppelgänger experience. This report presents the case of a 30-year-old man, Mr. Y, who was stabbed to death by Mr. X, his "double". The aggressor and his victim, although not related, were truly doubles; remarkably, they shared the same name and surname, age, professional activity and place of work. Moreover, they attended the same sports center but barely knew each other. The forensic psychiatric evaluations in Mr. X, subsequent to the crime committed, were suggestive of a psychotic condition. This case is unique in the scientific literature. In the most serious psychotic forms, the issue of the "double" calls into question not only the dissociative processes involved in the etiopathogenesis of the disorder, but also bio-psycho-social elements, as well as personal data in this case, which made the victim and the aggressor "identical". In the context of psychopathological functioning, the delusional mood (Wahnstimmung) that precedes the development of delirium is a sort of gateway to an impending psychotic illness, involving delusional awareness or mood (atmosphere). In psychosis, splitting is the main issue and this influence is seen as an evil, foreign, apocalyptic and unknown side no longer recognised as belonging to the self even in a physical sense. In such a situation, it is felt that the only way to survive is by suppressing one's double as a defense against disorganisation of the self.

Italian good practice recommendations on management of persons with Long-COVID

A significant number of people, following acute SARS-CoV-2 infection, report persistent symptoms or new symptoms that are sustained over time, often affecting different body systems. This condition, commonly referred to as Long-COVID, requires a complex clinical management. In Italy new health facilities specifically dedicated to the diagnosis and care of Long-COVID were implemented. However, the activity of these clinical centers is highly heterogeneous, with wide variation in the type of services provided, specialistic expertise and, ultimately, in the clinical care provided. Recommendations for a uniform management of Long-COVID were therefore needed. Professionals from different disciplines (including general practitioners, specialists in respiratory diseases, infectious diseases, internal medicine, geriatrics, cardiology, neurology, pediatrics, and odontostomatology) were invited to participate, together with a patient representative, in a multidisciplinary Panel appointed to draft Good Practices on clinical management of Long-COVID. The Panel, after extensive literature review, issued recommendations on 3 thematic areas: access to Long-COVID services, clinical evaluation, and organization of the services. The Panel highlighted the importance of providing integrated multidisciplinary care in the management of patients after SARS-CoV-2 infection, and agreed that a multidisciplinary service, one-stop clinic approach could avoid multiple referrals and reduce the number of appointments. In areas where multidisciplinary services are not available, services may be provided through integrated and coordinated primary, community, rehabilitation and mental health services. Management should be adapted according to the patient's needs and should promptly address possible life-threatening complications. The present recommendations could provide guidance and support in standardizing the care provided to Long-COVID patients.

Non-alcoholic fatty liver disease and the risk of fibrosis in Italian primary care services: GPS-NAFLD Study: GPS-NAFLD Study

BACKGROUND AND AIMS

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing globally. This study aimed to determine the prevalence of NAFLD and the probability of liver fibrosis in Italian primary care services.

METHODS

We carried out a population-based and nested case-control study including all individuals aged 18 years and above registered at Italian primary care services. Data were collected from the general practitioners' network from 2010 to 2017. NAFLD cases were identified via the ICD-9-CM and Hepatic Steatosis Index score > 36 and were matched each up to 10 controls. Other causes of liver diseases were excluded. The risk of fibrosis was assessed using the FIB-4 and NAFLD fibrosis scores (NFS).

RESULTS

NAFLD was present in 9% of the primary care population with high regional variability. Among NAFLD subjects: 25% had diabetes, 10% had chronic kidney disease, 11% had cardiovascular disease and 28% were obese. Furthermore, 30% had at least two comorbidities and 13% had cirrhosis. Once cirrhosis was excluded, the risk of any degree of fibrosis was 13.8% with NFS and 20.5% with FIB-4 in subjects <65 years.

CONCLUSIONS

Even if there is an identification gap in primary care, recorded cases with NAFLD have a high frequency of associated comorbidities. Despite regional variability, a close relation between cirrhosis and NAFLD exists (OR: 3.48, 95% CI: 3.23-3.76). Therefore, the use of non-invasive tests should be promoted in primary care as a useful tool for the early identification of fibrosis risk, independently of evidence of steatosis.

International Delphi-based consensus on the appropriate use and effect of Benzydamine hydrochloride in the treatment of sore throat

BACKGROUND

Benzydamine hydrochloride is a locally-acting Non-Steroidal Anti-Inflammatory Drug (NSAID) with combined local anesthetic and analgesic properties, indicated for the symptomatic relief of pain in acute sore throat. The aim of this study was to obtain an European Consensus among pharmacists, general practitioners and pediatricians on the appropriate use of benzydamine hydrochloride in the treatment of sore throat.

METHODS

The authors developed a Delphi questionnaire organized into 15 statements focused on 4 topics: the mechanism of action of benzydamine, the benzydamine treatment in an adult patient and in a pediatric patient, and the advantages of benzydamine over other topical treatments. The survey was administered to a panel of to 320 participants including general practitioners, pediatricians, and pharmacists from 6 European countries (Italy, Germany, Portugal, Romania, Russia, and Spain), who rated their level of agreement or disagreement with each statement on a 6-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with each statement.

RESULTS

Panelists' agreement on statements was very high. Consensus was reached for all 15 statements in the Delphi survey, with more than 98% positive agreement on topic 4, suggesting a shared view among European healthcare professionals (HCPs) about the advantages of benzydamine over other topical treatments. A strong consensus (> 99%) was reached for all the statements of topic 1 regarding the mechanism of action of benzydamine, except for its anesthetic properties (79%). Strong agreement was reached for all statements in topics 2 and 3 regarding the treatment of acute sore throat symptoms in the adult and pediatric patient, except for one on the efficacy of benzydamine in preventing post-operative sore throat, for which it was 67%.

CONCLUSION

Because all relevant publications on benzydamine are dated and there are no recommendations on its use for the symptomatic treatment of sore throat in European guidelines, this Delphi-based international consensus may be important in reinforcing the appropriate use and effect of benzydamine in the treatment of sore throat among health care professionals.

The role of personality assessment in forensic driving license renewal procedures. A study supported by the MMPI-2 test

The main function of the medical-psychological assessment to evaluate fitness to drive (FTD) is to safeguard the community against risks posed by drivers who, owing to psycho-physical disease, personality disturbances, abuse of psychotropic substances or drugs, can be a hazard to safety on the roads. In the context of psychodiagnostic investigations, the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) test is the gold standard tool supporting clinical assessments conducted to evaluate a subject's capacity to predict her/his own actions, attitudes, risk propensity, level of conformity to social norms. Other important features of the tool include the specific scales aimed at individuating behaviors adopted with the intent to elude or hide existing personality problems. These behaviors are very frequent in the field of medicolegal, psychological and psychiatric assessments, including FTD evaluations. In this study, the MMPI 2 test was administered to 154 subjects for whom Driving Licence (DL) Medical Commissions based in the south of Italy had required specific personality assessments, compared to a control group of 186 subjects with no clinical or psychodiagnostic problems. The question posed in our study was to understand whether the test was able to detect differences between the personalities of the subjects belonging to the two groups. The results obtained demonstrated significant differences between the experimental group and the controls, shown by the MMPI-2 variables, in particular the clinical Hs scale,the supplementary scales: GF, Re, AAS, APS and the content scales DEP and TRT, as well as the PSY-5 Disc and Nege scales.

To clarify the safety profile of paracetamol for home-care patients with COVID-19: a real-world cohort study, with nested case-control analysis, in primary care

BACKGROUND AND OBJECTIVE

This study aimed to compare the prescribing patterns of paracetamol in COVID-19 with those for similar respiratory conditions and investigated the association between paracetamol use and COVID-19-related hospitalization/death.

METHODS

Using a primary care data source, we conducted a cohort study to calculate the incidence rate of paracetamol use in COVID-19 and for similar respiratory conditions in 2020 and 2019 (i.e. pre-pandemic phase), respectively. In the study cohort, we nested a case-control analyses to investigate the association between paracetamol use and COVID-19-related hospitalizations/deaths.

RESULTS

Overall, 1554 (33.4 per 1000) and 2566 patients (78.3 per 1000) were newly prescribed with paracetamol to treat COVID-19 or other respiratory conditions, respectively. Those aged 35-44 showed the highest prevalence rate (44.7 or 99.0 per 1000), while the oldest category reported the lowest value (17.8 or 39.8 per 1000). There was no association for early (OR = 1.15; 95% CI: 0.92-1.43) or mid-term (OR = 1.29; 95% CI: 0.61-2.73) users of paracetamol vs. non-users. Instead, the late users of paracetamol showed a statistically significant increased risk of hospitalization/death (OR = 1.75; 95% CI: 1.4-2.2).

CONCLUSIONS

Our findings provide reassuring evidence on the use and safety profile of paracetamol to treat early symptoms of COVID-19 as in other respiratory infections.

Informed consent and biological agents in rheumatology and internal medicine

BACKGROUND

The need for highly effective therapies in rheumatologic diseases has led to the widespread and growing use of a heterogeneous class of molecules called biological agents. The increasing experience with biological agents has raised concerns about safety and efficacy issues that need to be discussed in the informed consent acquisition process.

METHODS

The authors performed a review of the literature on biological agents focusing on their most important characteristics concerning the informed consent procedures.

RESULTS

No studies specifically addressed the issue of informed consent in patients receiving biological agents. Several studies reported data about off-label use of biological agents usually with no obvious attention to informed consent shortcomings.

CONCLUSION

The reported association between biological agents and serious infections or malignancies, including reactivation of latent tuberculosis, needs specific disclosure in informed consent acquisition, together with information about the possible efficacy in clinical contexts often characterized by resistance to previous treatments. Ethical and clinical issues bound to the need for experimenting with new agents with potentially serious adverse effects deserve specific attention. Studies aimed at evaluating mental capacity to consent in subjects receiving biological agents are required.

A Cohort Study on Influenza Vaccine and All-Cause Mortality in Older Adults: Methodological Concerns and Public Health Implications

Introduction

In 2020, the restrictions adopted to control the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic led to an unprecedented reduction in influenza-related burden. As such, the reduced chance to characterize the circulating virus strains might have increased the risk of vaccine mismatch for the forthcoming winter seasons. The role of an effective influenza vaccination campaign might therefore assume even more value, especially for frail and multimorbid older individuals. Methodological concerns on confounding by indication are always debated in vaccine effectiveness studies and it might be instrumental to give a pragmatic message on an individual’s responsibility to receive the influenza vaccine. We therefore investigated the role of specific confounders to explain the association between influenza vaccine and mortality among older adults.

Methods

Using a primary care database, we formed a cohort of patients aged 65 years or older who were actively registered with their general practitioner (GP) at the beginning of each of nine influenza seasons through to the 2018/2019 season. The study index date was the related seasons’ starting date. Exposure to the influenza vaccine was operationally defined in the 2 months preceding the index date up to 2 weeks before the exit date. Cox regression models were estimated to calculate hazard ratios (HRs) and their 95% confidence intervals (CI) of death between vaccinated and unvaccinated patients in a time-dependent fashion. The potential confounders sequentially entered the model based on their increasing effect size observed in univariate analyses.

Results

Over the 10 years under study, the influenza vaccine showed a significant protective effect in terms of mortality, reaching 13% reduction (HR 0.87, 95% CI 0.80–0.95) in the 2018/2019 influenza season. When we estimated the multivariate model by sequentially adding the potential confounders, there was an inversion of HR (below the unit) that was significantly explained by the covariates coding for a prior history of lower respiratory tract infections and the presence of the pneumococcal vaccine.

Conclusion

In the current pandemic scenario, we cannot divert attention to proper use of face masks, social distancing, and hand hygiene, which are important measures to prevent influenza and other respiratory viral infections. Nonetheless, their effectiveness might be negligible without acceptable coverage for influenza vaccine, especially in older patients with a history of lower respiratory tract infections, which appears to be the main source of confounding by indication.

A firearm double homicide committed by a paranoid neigh- bor: a psychopathological study

Serious mental illness is associated with a higher risk of violent interpersonal behavior. Characteristic traits denoting a psychopatho-logical picture such as schizophrenia, depression, a borderline, or narcissistic, antisocial, or paranoid personality disorder, are frequently observed in the personality of those who have committed one or more murders. For example, mass murderers are affected by a delusional syndrome with a persecution fixation, that develops in a subject with a paranoid, anacastic personality disorder. An abnormal mental frame-work develops as a consequence of continual experiences interpreted as traumatic. We present a complex case regarding a double murder whose vic-tims were shot by a 50-year-old neighbor, who underwent a psychiatric evaluation for the assessment of criminal responsibility. In the light of the historical reconstruction of his relation sensitive delusional mindset that triggered the final reaction, his life history, the "key event" and the "triggering environment" (constant conflictual and dysfunctional rela-tions with others) led to the violence. The correct understanding of the reported case demands investigation not only of the clinical, diagnostic and psychodiagnostic aspects, but also of the perpetrator-victim/s, their relational context and the situation where the crime evolves, in order to be able to reconstruct the event in a meaningful manner.

Non-invasive neuromodulation can reduce aggressive behaviors in humans: A critical perspective

Containing aggressive behavior is an ongoing challenge in modern society. Aggressiveness is a multi-level construct that can be driven by emotions (reactive aggression) or can be "cold-blooded" and goal-directed (proactive). Aggressive behavior could arise because of a misjudgment of others' intentions or can follow frontal brain lesions leading to a reduction of impulse control and emotion regulation. In the last few years, interventional and basic research studies adopting Non-Invasive Brain Stimulation (NIBS) have significantly risen. Those techniques have been used both in healthy people, to better understand the role of certain brain regions in psychological processes, and in aggressive subjects to improve their symptoms. From an overview of the literature, focusing on the paper that uses transcranial direct current stimulation (tDCS) to reduce aggressiveness, it emerges that tDCS can (i) enhance facial emotion expression recognition, (ii) improve impulses control, and (iii) affect approach/withdrawal motivation. The current work shows the strengths and weaknesses of tDCS intervention on aggressive individuals, suggesting that this instrument could be adopted on violent people, and paves the way for intervention in some applied settings such as prison.

Aspirin Colorectal Cancer Prevention in Lynch Syndrome: Recommendations in the Era of Precision Medicine

Cancer prevention in the era of precision medicine has to consider integrated therapeutic approaches. Therapeutic cancer prevention should be offered to selected cohorts with increased cancer risk. Undoubtedly, carriers of hereditary cancer syndromes have a well-defined high cancer risk. Lynch Syndrome is one of the most frequent hereditary syndromes; it is mainly associated with colorectal cancer (CRC). Nonsteroidal anti-inflammatory drugs and, in particular, aspirin use, has been associated with reduced CRC risk in several studies, initially with contradictory results; however, longer follow-up confirmed a reduced CRC incidence and mortality. The CAPP2 study recruited 861 Lynch syndrome participants randomly assigned to 600 mg of aspirin versus placebo. Like sporadic CRCs, a significant CRC risk reduction was seen after an extended follow-up, with a median treatment time that was relatively short (2 years). The ongoing CAPP3 will address whether lower doses are equally effective. Based on pharmacology and clinical data on sporadic CRCs, the preventive effect should also be obtained with low-dose aspirin. The leading international guidelines suggest discussing with Lynch syndrome carriers the possibility of using low-dose aspirin for CRC prevention. We aim systematically promote this intervention with all Lynch syndrome carriers.

From doctor to incendiary nun: the importance of analysing the pathways of trauma

Childhood traumatic experiences have often been associated with the development of severe psychiatric disorders or, at least, with serious impairment in the victims' developing personality. Emotional abuse and neglect can cause gradual damage to Self-image and to models of self-in-relation to Others. We report a case of a woman who underwent psychiatric evaluations for marriage annulment. The issues were the as-sessment of the outcomes of early psychic trauma and the examination of the remaining individual capacities from a judicial standpoint. The examiners found that the memories of the woman's history of childhood abuse had become integrated into her personality organization. The spheres most strongly influenced were those of psycho-sexual/affective maturation and a dysfunctional bond with religion. Psychodiagnostic evaluation diagnosed a Borderline Personality Disorder. The complexity of the case suggests the need of a multi-dimen-sional analysis by an interdisciplinary team including experts in legal medicine, forensic psychiatry and psychology as well as clinical crimi-nology.

Predicting the risk of severe COVID-19 outcomes in primary care: development and validation of a vulnerability index for equitable allocation of effective vaccines

BACKGROUND

General practitioners (GPs) need a valid, user-friendly tool to identify patients most vulnerable to COVID-19, especially in the hypothesis of a booster vaccine dose. The aim of this study was to develop and validate a GP-friendly prognostic index able to forecast severe COVID-19 outcomes in primary care. Indeed, no such prognostic score is as yet available in Italy.

RESEARCH DESIGN AND METHODS

In this retrospective cohort study, a representative sample of 47,868 Italian adults were followed up for 129,000 person-months. The study outcome was COVID-19-related hospitalization and/or death. Candidate predictors were chosen on the basis of systematic evidence and current recommendations. The model was calibrated by using Cox regression. Both internal and external validations were performed.

RESULTS

Age, sex and several clinical characteristics were significantly associated with severe outcomes. The final multivariable model explained 60% (95%CI 58-63%) of variance for COVID-19-related hospitalizations and/or deaths. The area under the receiver-operator curve (AUC) was 84% (95% CI: 83-85%). On applying the index to an external cohort, the AUC was 94% (95% CI: 93-95%).

CONCLUSIONS

This index is a reliable prognostic tool that can help GPs to prioritize their patients for preventive and therapeutic interventions.

Determinants of HCV-related complications in Italian primary care patients

BACKGROUND AND AIMS

This study aimed to assess the demographic and clinical determinants of liver complications in Hepatitis C virus (HCV)-positive patients in primary care setting.

METHODS

Using the Health Search database, we selected a cohort of patients aged ≥14 diagnosed with HCV between 2002 and 2017. Patients were followed up until the occurrence of cirrhosis and other disease progressions such as oesophageal varices, hepatocellular carcinoma and/or liver transplantation. The candidate determinants for the risk of HCV-related complications included sex, age, smoking status, liver fibrosis (measured by fibrosis 4 index [FIB-4]), infections by the human immunodeficiency virus (HIV), hepatitis B virus (HBV), other forms of hepatitis, abuse of alcohol or illicit substances or drugs, obesity, metabolic syndrome, diabetes mellitus and renal disease. Cox regression was used to test the association between candidate determinants and the outcome.

RESULTS

The cohort included 8299 HCV-positive patients (50.93% men) with an overall prevalence rate equal to 0.61%. At least one HCV-related complication was found in 12.2% of patients, with a mean time-to-event equal to 8.1 year. Along with male sex and advanced age, a FIB-4 greater than 3.25 and the presence of diabetes were associated with a greater risk of HCV-related complications.

CONCLUSION

Our study shows that patients with certain demographics and clinical characteristics are more prone to incur in HCV-related complications. The knowledge and early identification of these determinants by GPs may result in reducing disease progression and related healthcare costs through a closer monitoring.

A para-religious setting for financial exploitation of the mentally incapacitated: when the habit doesn't make a monk

Exploitation and circumvention of the mentally incapacitated is a criminal offence listed in the Italian penal code (Penal Code Art. 643). It involves the exploitation and circumvention of people who are fragile and vulnerable owing to their health conditions and/or mental status, and fits into the grey area between such subjects' freedom to make decisions about their physical conditions and economic assets, and the abuse of their trust perpetrated by third parties for personal gain. The authors describe a case of financial exploitation and circumven-tion of a married couple that is remarkable in view of both the huge sums extorted from the victims and the duration of the peculiar illicit activities (that lasted more than 10 years). These were perpetrated by a charismatic figure leading a "para-religious" group. He claimed to be a prophet, but his private life was highly questionable. The method of ascertainment used to verify the victims' mentally incapacitated state is described, analyzed and commented; the diagnosis could not be deferred in view of the characteristics of the prolonged penal offences committed.

Vulnerability and ethical issues faced by general practitioners during the COVID-19 pandemic in Italy: some reflections and lessons learned

Vulnerability during the coronavirus disease 2019 (COVID-19) pandemic is an emotional state that affects all of us globally. The Italian experience shows that our general practitioners (GPs) seem to have a higher rate of death due to COVID-19 infection than other physicians.

Cognitive Efficiency and Fitness-to-Drive along the Lifespan: The Mediation Effect of Visuospatial Transformations

The way people represent and transform visuospatial information affects everyday activities including driving behavior. Mental rotation and perspective taking have recently been found to predict cognitive prerequisites for fitness-to-drive (FtD). We argue that the relationship between general cognitive status and FtD is mediated by spatial transformation skills. Here, we investigated the performance in the Mental Rotation Test (MRT) and the Perspective-Taking Test (PT) of 175 male active drivers (aged from 18 to 91 years), by administering the Montreal Cognitive Assessment (MoCA) to measure their global cognitive functioning. All participants were submitted to a computerized driving assessment measuring resilience of attention (DT), reaction speed (RS), motor speed (MS), and perceptual speed (ATAVT). Significant results were found for the effect of global cognitive functioning on perceptual speed through the full mediation of both mental rotation and perspective-taking skills. The indirect effect of global cognitive functioning through mental rotation was only found to significantly predict resilience of attention whereas the indirect effect mediated by perspective taking only was found to significantly predict perceptual speed. Finally, the negative effect of age was found on each driving measure. Results presented here, which are limited to male drivers, suggest that general cognitive efficiency is linked to spatial mental transformation skills and, in turn, to driving-related cognitive tasks, contributing to fitness-to-drive in the lifespan.

Narrative Analysis of the Impact of COVID-19 on Patients with Chronic Obstructive Pulmonary Disease, Their Caregivers, and Healthcare Professionals in Italy

Purpose

The COVID-19 pandemic has disrupted many lives, including those of people suffering from chronic obstructive pulmonary disease (COPD) and their caregivers. The main aim of this study was to use narrative medicine, a validated approach promoting quality of care to explore how the COVID-19 pandemic impacted the quality of care, quality of life, psychological factors and social factors of people affected by COPD and their caregivers and healthcare professionals (HCPs). A secondary aim was to explore the role of telemedicine in combating isolation and providing access to care.

Methods

A cross-sectional observational narrative medicine study was conducted between July and November 2020 across Italy. An online semi-structured questionnaire with a narrative plot was completed by 146 participants (79 COPD patients, 24 caregivers, and 43 HCPs). Narrations were analyzed with descriptive statistics and evaluated using NVivo 11 software to break down the text and identify recurring themes and major semantic clusters.

Results

During the first lockdown, 58.22% of responses from COPD patients indicated terror, fear and/or apprehension; at reopening, this figure was 35.44%. Among caregivers, these figures were 100% at first lockdown and 45.83% at reopening. The metaphors most commonly used by patients to describe COPD and COVID-19 were monster and murderer, respectively. Patients described their homes more often as clean and lonely than as offering no shelter. The narratives of 42 COPD patients (45.2%) described coping. Only 12.6% of COPD patients reported regular access to medical visits during lockdown, while 59.1% of general practitioners and pulmonologists reported using telemedicine, which was perceived as satisfactory by both patients and caregivers.

Conclusion

It is relevant to aim for a multidisciplinary and multilevel system of care that empowers telemedicine and integrates specific psychological support programs for COPD patients and their caregivers.

(13C)-Methacetin breath test provides evidence of subclinical liver dysfunction linked to fat storage but not lifestyle

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is characterised by the presence of hepatic steatosis in the absence of other causes of secondary hepatic fat accumulation, and is usually associated with visceral, metabolically active obesity. However, the subclinical effects of body and liver fat accumulation on liver function are still unclear.

METHODS

We used orally administered (¹³C)-methacetin and breath test to quantify the efficiency of hepatic extraction from portal blood flow and liver microsomal function in 81 participants, in relation to presence/absence of ultrasonographic NAFLD, extent of body fat accumulation, insulin resistance, dietary models, and lifestyle.

RESULTS

NAFLD was present in 23% of participants with normal weight, and prevalence increased with body fat and insulin resistance. Fat accumulation, NAFLD, and insulin resistance were associated with decreased hepatic extraction efficiency, and liver microsomal function was impaired in moderate-to-severe NAFLD. Caloric intake, dietary models, and lifestyles had a minor role in promoting functional changes.

CONCLUSIONS

The interplay between body fat accumulation, insulin resistance, and NAFLD is linked with altered hepatic extraction efficiency from blood flow and deranged microsomal function. Non-invasive diagnosis of subclinical alterations of liver function is relevant for primary and secondary prevention measures. Furthermore, the occurrence of NAFLD in lean individuals and the evidence that caloric intake, dietary models, and lifestyle played a minor role require further studies exploring the role of environmental factors in the natural history of these diseases.

LAY SUMMARY

Obesity is progressively increasing worldwide and is paralleled by fat accumulation in the liver (non-alcoholic fatty liver disease [NAFLD]), the most common chronic liver disease worldwide. NAFLD can alter liver structure and function, with a variety of consequences ranging from asymptomatic and subclinical alterations to cirrhosis and cancer. (¹³C)-Methacetin breath test, a non-invasive diagnostic tool, can reveal early subclinical alterations of liver dynamic function in individuals with obesity and in patients with NAFLD.

Protocols for Mitochondria as the Target of Pharmacological Therapy in the Context of Nonalcoholic Fatty Liver Disease (NAFLD)

Nonalcoholic fatty liver disease (NAFLD) is one of the most frequent metabolic chronic liver diseases in developed countries and puts the populations at risk of progression to liver necro-inflammation, fibrosis, cirrhosis, and hepatocellular carcinoma. Mitochondrial dysfunction is involved in the onset of NAFLD and contributes to the progression from NAFLD to nonalcoholic steatohepatitis (NASH). Thus, liver mitochondria could become the target for treatments for improving liver function in NAFLD patients. This chapter describes the most important steps used for potential therapeutic interventions in NAFLD patients, discusses current options gathered from both experimental and clinical evidence, and presents some novel options for potentially improving mitochondrial function in NAFLD.

Spatial Mental Transformation Skills Discriminate Fitness to Drive in Young and Old Adults

Literature on driving research suggests a relationship between cognition and driving performance in older and younger drivers. There is little research on adults and driving, despite them being the largest age cohort behind the wheel. Among the cognitive domains, visuospatial abilities are expected to be highly predictive of driving skills and driving fitness. The relationship between specific spatial mental transformation skills (i.e., object and self-based ones) and driving performance has not yet been examined. The present study aimed to investigate the relationship between overall cognitive functioning, self and object-based spatial mental transformation skills, and driving performance in a sample of younger and older adult drivers. Participants were comprised of one hundred younger and 83 older adult Italian drivers. Participants completed a computerized driving test assessing traffic stress resilience, visual and motor reaction time, and the ability to obtain an overview of the traffic scenario (DT, vRT, mRT, and ATAV respectively in the Shufried®-Vienna Test System-DRIVESC). The Mental Rotation Test (MRT) and the Object Perspective Taking Test (OPT) were administered in order to assess object-based and self-based spatial mental transformation skills. The Montreal Cognitive Assessment Test (MoCA) was administered control for global cognitive functioning. The effects of education and gender were also controlled in the analysis. The results of the present study suggested that: (1) The effect of age, favoring younger participants, was found in DT, vRT, mRT, and ATAVT tests. (2) The effect of global cognitive functioning was found in DT and ATAV tests. (3) The effect of the spatial mental transformation tests was found in DT, vRT (MRT only), and ATAVT (OPT only) tests. Taken together, these results suggest the specific contribution of spatial mental transformation skills in the execution of complex behaviors connected to the fitness to drive. Prospectively, the results of the present study relating spatial mental transformation skills and driving processes may be a valuable source of knowledge for researchers dealing with the relationship between cognitive resources and navigation aids.

Women and men, authors and victims of workplace bullying in Italy: a literature review

INTRODUCTION

It is known in literature that women are frequently victims of murder, sexual assault and stalking. It is interesting to investigate the gender characterization when workplace bullying occurs.

OBJECTIVES

To investigate the phenomenon of workplace bullying and to understand if there are any relevant data about the gender aspects of workplace bullying by reviewing the literature in Italy.

METHODS

Review of articles on a sample of Italian workers. The research question followed the P.E.C.O. model and the article selection is based on PRISMA statement. Fourteen research strings were applied on: Pubmed, Microsoft Academic e Science Direct. A total of 32 articles were selected.

RESULTS

There are few studies in which gender differences on workplace bullying and crimes related are analysed, in some cases it is considered in the research but not in the results section (n=6 articles). In the studies selected women are predominantly victims (n=10 articles), the aggressors instead are usually men (n=2 articles). The attacks suffered by women are frequently discriminations due to family management, children and gender related issues (n=6 articles). Men have the major consequences on mental health if compared to women (n=7 articles).

CONCLUSIONS

Gender is relevant in the characterization of workplace bullying. There is a need for further investigation focusing on gender differences between perpetrators and victims of workplace bullying offences. A unique evaluation protocol is necessary for evaluating workplace bullying, the crimes linked to it and gender differences, to obtain a more accurate comparability of data.

[Perceptions and representations of workplace bullying: a comparative analysis between Italy and France]

The aim of this research is to analyse the phenomenon of workplace bullying in two countries: Italy and France and trying to understand the differences among them. The words used to refer to it are respectively "mobbing" in Italy and "harcèlement moral" in France. The research analyse the phenomenon's characteristics through the opinion of an expert sample, belonging to different areas linked to their cultural background. They were selected by the researchers for their expertise and experience on this topic. The tool used was a semi-structured interview conducted in vivo by the researcher. The data resulting were processed as follow: a qualitative analysis was conducted through the production of short synthesis for each interview; a quantitative analysis was conducted through the attempt to standardize the qualitative answers in percentage data. The results shows the existence of different phenomenon's characteristics in the two countries.

Some reflections on the issue of homicide-suicide prompted by a case series of forensic psychology assessments

From the criminologic standpoint, as a crime committed against a psychological background of depression, homicide-suicide is a "dual death" whose significance transcends the specificity of the two events taken singly. Although diametrically opposite phenomena, in fact they share the same pulsions, to be found in aggressiveness, or the desire to eliminate the tensions underlying it. From this perspective, various attempts have been made to classify the homicide-suicide phenomenon, which have indicated that those who, through homicide, deprive themselves of their primary source of gratification may then decide to commit suicide as a result of this unbearable loss. Therefore, suicide post-homicide is a marker of the importance of the bond between the murderer and the victim. Indeed, some Authors have confirmed that the strong attachment between the two increases the likelihood of suicide of the former after the death of the latter; that the crime develops in a relational context featuring abuse and maltreatments; that it also stems from the fear of betrayal and the loss of an object that escapes all attempts to possess it, and that in many cases the destruction of the object through the crime is followed by the self-destruction of the criminal.

The aging process in prison: pathologies and health conditions in old inmates. An epidemiological research in Italy

BACKGROUND AND AIMS

Elderly may suffer from different pathologies during their detention in jail because of their age. Conditions in jails were tough and adapting to that life could be problematic for the elder population. This article aimed to analyse the pathologies and health conditions in a sample of elder inmates from Italy.

METHODS

The sample was composed by 94 elderly inmates. The research is multicentric. We selected jails from the cities of Bari, Taranto, Foggia, Lecce, Brescia, Bergamo, Cremona and Mantua. The study was conducted by interviewing the prisoners over 60 years of age, in the period between September and December 2017.

RESULTS

64% of the sample was in a "Not Optimal" health status. Most of pathologies were Cardiac pathologies (23.4%), Diabetes (12.8 %) and Surgery (9.6%). Statistically significant differences were found for heart disease (p=0.02) and Neoplasia (p=0.025) in the prison of Bari compared to all the other prisons. Statistically significant differences were found for Hypertension in Foggia and Taranto prisons compared to all the other (p=0.023). Furthermore, 18.1% of inmates ended up having an addiction.

CONCLUSIONS

Our analysis showed that in our sample physical problems were more frequent than psychological one. In fact, in spite of in the literature there was a high prevalence of mental health problems among elderly inmates, we did not find this result. However, stress conditions may increase the risk of pathologies: for example, being in jail and adapt to new hard environment may increase the risk of getting sick. Heart disease pathologies and diabetes were very common in our sample as confirmed by the literature.

The changing face of family medicine in the COVID and post-COVID era

This article describes the prospective changes and the fundamental values of the relationships between family doctors, patients and community according to an ethical-social concept of medicine. New aspects of the organization of the activity and of the roles of family doctors are reported in order to build hypotheses pointing to a modern and efficient management of patients in the coming the post-COVID era.

Usefulness of Pep-Test for Laryngo-Pharyngeal Reflux: A Pilot Study in Primary Care

Background

Gastroesophageal reflux disease is a digestive disorder characterized by nausea, regurgitation, and heartburn. Gastroesophageal reflux is the primary cause of laryngeal symptoms, especially chronic posterior laryngitis. The best diagnostic test for this disease is esophageal impedance-pH monitoring; however, it is poorly employed owing to its high cost and invasiveness. Salivary pepsin measured using a lateral flow device (Pep-test) has been suggested as an indirect marker of laryngopharyngeal reflux (LPR). The present study tested the reliability of Pep-test in diagnosing LPR in uninvestigated primary care attenders presenting with chronic laryngeal symptoms, and evaluated the raw pepsin concentration in patients with LPR.

Methods

A multicenter, non-interventional pilot study was conducted on 86 suspected patients with LPR and 59 asymptomatic subjects as controls in three Italian primary care settings. A reflux symptom index questionnaire was used to differentiate patients with LPR (score >13) from controls (score <5). Two saliva samples were collected, and comparisons between the groups were performed using two-sided statistical tests, according to variable distributions.

Results

There was no statistical difference in the salivary pepsin positivity between LPR patients and controls, whereas the pepsin intensity value was higher in controls than in LPR patients.

Conclusion

A high prevalence of pepsin positivity was observed in asymptomatic controls. Pepsin measurement should not be considered as a diagnostic test for LPR in primary care patients.

The Drives for Driving Simulation: A Scientometric Analysis and a Selective Review of Reviews on Simulated Driving Research

Driving behaviors and fitness to drive have been assessed over time using different tools: standardized neuropsychological, on-road and driving simulation testing. Nowadays, the great variability of topics related to driving simulation has elicited a high number of reviews. The present work aims to perform a scientometric analysis on driving simulation reviews and to propose a selective review of reviews focusing on relevant aspects related to validity and fidelity. A scientometric analysis of driving simulation reviews published from 1988 to 2019 was conducted. Bibliographic data from 298 reviews were extracted from Scopus and WoS. Performance analysis was conducted to investigate most prolific Countries, Journals, Institutes and Authors. A cluster analysis on authors' keywords was performed to identify relevant associations between different research topics. Based on the reviews extracted from cluster analysis, a selective review of reviews was conducted to answer questions regarding validity, fidelity and critical issues. United States and Germany are the first two Countries for number of driving simulation reviews. United States is the leading Country with 5 Institutes in the top-ten. Top Authors wrote from 3 to 7 reviews each and belong to Institutes located in North America and Europe. Cluster analysis identified three clusters and eight keywords. The selective review of reviews showed a substantial agreement for supporting validity of driving simulation with respect to neuropsychological and on-road testing, while for fidelity with respect to real-world driving experience a blurred representation emerged. The most relevant critical issues were the a) lack of a common set of standards, b) phenomenon of simulation sickness, c) need for psychometric properties, lack of studies investigating d) predictive validity with respect to collision rates and e) ecological validity. Driving simulation represents a cross-cutting topic in scientific literature on driving, and there are several evidences for considering it as a valid alternative to neuropsychological and on-road testing. Further research efforts could be aimed at establishing a consensus statement for protocols assessing fitness to drive, in order to (a) use standardized systems, (b) compare systematically driving simulators with regard to their validity and fidelity, and (c) employ shared criteria for conducting studies in a given sub-topic.

The Kanun as a self-governance code in Italian-Albanian criminal contexts: A research conducted in the Republic of Albania

The Kanun is an important manifestation of Albanian consuetudinary law in force at a given historical moment. It is characterized by the absence of institutions or bodies set up to design and impose rules, norms or precepts that could maintain order and ensure that within the community, the associates can live and carry out their activities in observance of and compliance with the rules and precepts imposed by the State authorities. Active operation according to the Kanun rules is not only common among the populations settled in the mountains of Albania but also, and above all, in the context of Albanian criminality which, as is well known, has also spread to Italy, creating partnerships and cross-contaminations with Italian crime. The research was carried out mainly in Albania at the bodies and institutions responsible for dealing with and controlling crime in the nation, but also focuses on the issue of connections with, and influences on, Italian crime.

The contribution of the TIPE (Test di Induzione PsicoErotica: PsychoErotic Induction Test) to the assessment of erotic fantasies in subjects affected by gender dysphoria: a case series

Research into sexual aspects poses a fascinating challenge that is highly cogent to clinical profiling disciplines, but also constitutes a more 'narrative and culturally oriented' approach to medicine and psychology. Assessments of subjects affected by gender dysphoria and their internal, relational and sexual world is a still more complex task, since these are very distressing and tormented issues for the subjects under study. Psychodiagnostics can be an important element in the various investigative, evaluative and therapeutic pathways. The authors have focused attention on the TIPE (Test di Induzione PsicoErotica: PsychoErotic Induction Test), an Italian projective psychodiagnostic tool that is used to explore the psychoerotic fantasies of subjects affected by gender dysphoria. The TIPE tests protocols of two samples of subjects have been examined. They projected particularly rich narrative aspects of the subjects' psychoerotic imaginary world. The first sample, a clinical series, consisted of a total of eleven subjects, nine men and two women, mean age 43 years, who were undergoing assessment, firstly psychotherapeutic and then medicolegal, for sex rectification purposes; the second sample, the controls, consisted of fourteen subjects, nine men and five women, mean age 28 years, all heterosexual and with a problem-free history of sexual identity.

Hyponatremia associated with long-term medication use in the elderly: an analysis in general practice

INTRODUCTION The aim of this study is to determine the prevalence of hyponatremia, its association with long-term medication use and underlying chronic conditions, the rate of hospitalisation and death within 3 months from its discovery and its management in community-dwelling older people. METHODS One year of data for ~5635 patients aged >65 years was extracted from the databases of 19 general practitioners (GPs); 2569 (45.6%) were checked for hyponatremia. RESULTS Hyponatremia occurred in 205 (8.0%) of 2569 checked individuals: 78.5% (161/205) had hypertension, 31.2% (64/205) diabetes, 23.9% (49/205) chronic renal failure; 38.0% (78/205) received diuretics, 36.6% (75/205) renin-angiotensin system antagonists (ACE-I/ARB) and 9.8% (20/205) serotonin reuptake inhibitors. Drug consumption was higher in hyponatremic patients, although only diuretics, ACE-I/ARB, anti-arrhythmics and opioids were significantly associated with hyponatremia. The likelihood of hyponatremia trebled when four drugs were taken, and it was seven-fold higher with the use of six drugs. Hyponatremia was associated with a higher prevalence of chronic illnesses and higher rate of hospitalisation (13.7% vs 7.7%, P = 0.005) and death (3.9% vs 1.8%, P < 0.035). The use of at least one long-term medication was associated with hospitalisation or death in hyponatremic patients (10% vs 6.3%, P = 0.010). Less than 20% of hyponatremic patients had their sodium level checked again after 1 month. DISCUSSION Hyponatremia is not uncommon among community-living older patients, especially in patients taking medications potentially causing hyponatremia. Hyponatremic patients are likely to encounter more serious events, including hospitalisation and death. Targeted training of GPs is desirable to improve their practice.

Nutrition as a Health Determinant in Elderly Patients

BACKGROUND

An adequate caloric intake is a major determinant for the health status especially when degenerative conditions become a predominant risk for difficult-to-treat diseases as in aging.

METHODS

A structured search of literature on the major databases was performed using terms as nutrition, elderly and malnutrition.

RESULTS

According to most referenced articles, it appears to be unquestionable that both organic and social risk factors [economic hardship, loneliness, institutionalization] are important as determining causes of protein-caloric malnutrition. Some anthropometric, clinical and laboratory parameters can help to make diagnosis and quantify malnutrition. However, most of them are not cheap or are not simple to perform especially in the setting of General Practice. The application of a simple questionnaire [Mini Nutritional Assessment, MNA] allows to obtain in a fast, easy and non-invasive way a valid assessment of the nutritional status in geriatric patients. The maintenance of the nutritional status is the best measure to counteract the risk of proteincaloric malnutrition and its complications which often sneakily affects elderly population and in particular frail patients.

CONCLUSION

This review, based on updated concepts, examines all the above mentioned points together with some aspects associated with malnutrition as an indicator of disease severity and health costs in the elderly population. Finally, the impact of nutritional intervention and nutrients supplementation on general indices of malnutrition are discussed as a promising strategy.

Elder abuse: perception and knowledge of the phenomenon by healthcare workers from two Italian hospitals

With ageing population the number of elderly vulnerable to abuse is expected to grow. Hospital personnel play a crucial role in identifying mistreatment. The aim of this study was to establish the level of awareness and perception of elder abuse by healthcare workers, and to understand if they are able to recognize and properly report elder abuse, as well as to identify the physical signs of abuse and neglect. A 41-question survey was administered to healthcare professionals, working in the Internal Medicine and Geriatric Wards of two different University Hospitals of Southern Italy, representative of the Italian health public system. The data collection resulted in 98 questionnaires. For the majority, neglect represents a type of abuse, whereas 40% of physicians and 37% of nurses considered this concept false. All the professionals recognized the elder abuse as a violation of the human rights, but 46.94% were not sure about the existence of standard procedures for abuse reporting/treatment. The most of the nurses and the care assistants declared they never had suspected or witnessed abuse, while few physicians stated to have suspected/witnessed abuse 1-3 times in their career. In both the suspected and witnessed cases, the healthcare personnel did not made any action, neither reported them to public authorities nor adult protective service agencies. The level of awareness and perception of elder abuse by healthcare professionals are still poor especially regarding the reporting procedures. There is still strong need for education and specific training programs on elder abuse.

The risk of assault against mental health professionals: a fatal case report and literature review

Assaults by patients against healthcare providers are an increasing phenomenon worldwide. Mental health professionals in acute facilities and rehabilitation wards have the highest risk of being attacked at work. Verbal abuse or intimidating behaviors represent the most common types of violence. Fatal assault by psychiatric patients has been rarely reported in the literature. We present a case of a female psychiatrist who was fatally stabbed in her office in a Mental Health Center. At autopsy seventy stab wounds were found: four wounds of the neck, fifty penetrating wounds of the thorax, three wounds of the abdomen, six wounds of the lumbar region, and seven wounds of the upper arms including defense injuries. The cause of death was massive blood loss due to multiple stab wounds. The perpetrator was a 44-year-old male patient who had been referred to the victim after a previous admission to hospital following experiences of suicidal ideation and confusion. The extreme and unmotivated violence in a non-acute setting were notable. A borderline-antisocial personality disorder was later diagnosed by forensic experts. This case emphasizes the significant occupational risk for mental healthcare staff to sustain life threatening injuries or death, with implications for training of clinicians, and strategies for preventing aggressive behaviors.

The wish 'not to be'. Survey of suicide cases arriving at the Prosecutor's Office of the Court in Bari in the years 2014-2016

The issue of suicide has always been a very sensitive and important problem, that raises many questions in the society where it occurs, that is not always able to oppose an adequate response. Every scientist in the field agrees that this is an act provoked by multifaceted reasons, which include cultural, social and biographical motives. Therefore, this topic also poses ethical and civil problems, as well as epistemologic and research methodology issues, because of its complexity as a subject of study. The authors propose a case-by-case contribution, evaluating the judicial acts on 73 suicides made available by the Bari Public Prosecutor's Office for the years 2014-2016. The authors believe collected and systematized data, and the ensuing considerations, can offer a contribution to the debate in the field of legal and socio-healthcare actors, who are often the first to deal with and confront this complex and tragic phenomenon.

Lying in the medicolegal field: Malingering and psychodiagnostic assessment

The simulation of mental illness, so-called "Malingering", is a very difficult phenomenon for professionals to identify when making an assessment, especially in the medicolegal and forensic psychology and psychiatry fields. When malingering, the subject implements strategies that mimic the symptoms related to a possible psychiatric disease, with the aim of misleading the operator. It is necessary, therefore, to elicit a complete medical history and make a close clinical examination and, especially, to be able to rely on appropriate diagnostic tools. Another important aspect, in the legal medicine, and forensic psychology and psychiatry fields, is the opposite strategy, namely that of dissimulating, or masking, a disease. Several diagnostic tools that the professional clinician can employ to identify dissembling strategies are considered in this article, namely the MMPI- 2, PAI, M- Fast, the SIRS and, finally, the SIMS.

Overview on the management of diverticular disease by Italian General Practitioners

BACKGROUND

Although very common in Western countries, poor epidemiological data on diverticular disease (DD) is available from the family practice.

AIMS

To evaluate the behavior of Italian General Practitioners (GPs) on approaching DD.

METHODS

Health Search Database was analyzed retrospectively.

RESULTS

On a population of 975,523 individuals, 33,597 patients had a registered diagnosis of DD ("lifetime" prevalence = 3.4%, M = 3.2%, F = 3.7%; higher values are found in females over-65 years old; low rates of complications: diverticulitis = 0.3%, bleeding = 0.002%). As risk factors, NSAIDs and ASA were taken by 14.8% and 26.5% respectively, opioids by 7.5%, corticosteroids by 5.2%; as protective factors, 30.4% were under statins and 17.7% under calcium-antagonists. Approximately 13% of patients were referred to specialists. Colonoscopy and abdominal CT were prescribed to 48.5% and to 13% of already diagnosed patients. Among DD sufferers, 27% experienced hospitalization, but only 3.4% of cases were for a DD-linked problem. Treatment included rifaximin (61%), mesalazine (14.7%), probiotics (12.4%), ciprofloxacin (7.6%).

CONCLUSION

DD has a large impact in general practice with a higher prevalence in the elderly. GPs are required to pay particular attention to risk factors both for disease development and for its complications in order to reduce the costs deriving from diagnostic procedures, referral and hospitalization.