Future changes in society and climate may strongly shape wild large-herbivore faunas across Europe

Restoring wild communities of large herbivores is critical for the conservation of biodiverse ecosystems, but environmental changes in the twenty-first century could drastically affect the availability of habitats. We projected future habitat dynamics for 18 wild large herbivores in Europe and the relative future potential patterns of species richness and assemblage mean body weight considering four alternative scenarios of socioeconomic development in human society and greenhouse gas emissions (SSP1-RCP2.6, SSP2-RCP4.5, SSP3-RCP7.0, SSP5-RCP8.5). Under SSP1-RCP2.6, corresponding to a transition towards sustainable development, we found stable habitat suitability for most species and overall stable assemblage mean body weight compared to the present, with an average increase in species richness (in 2100: 3.03 ± 1.55 compared to today's 2.25 ± 1.31 species/area). The other scenarios are generally unfavourable for the conservation of wild large herbivores, although under the SSP5-RCP8.5 scenario there would be increase in species richness and assemblage mean body weight in some southern regions (e.g. + 62.86 kg mean body weight in Balkans/Greece). Our results suggest that a shift towards a sustainable socioeconomic development would overall provide the best prospect of our maintaining or even increasing the diversity of wild herbivore assemblages in Europe, thereby promoting trophic complexity and the potential to restore functioning and self-regulating ecosystems. This article is part of the theme issue 'Ecological novelty and planetary stewardship: biodiversity dynamics in a transforming biosphere'.

COVID-19 restrictions and NUTS-3 deprivation: multilevel approach in Italy during the second wave

Background

To face the second COVID-19 wave, Italy implemented a tiered restriction system with different risk levels (yellow=low; orange=medium, red=high). It is unknown whether the effect of the tiers was equal among provinces with varying levels of socioeconomic deprivation (SED). At each restriction level, we analyzed the impact of the province's SED on the SARS-CoV-2 daily reproduction number (Rt).

Methods

We considered the Rt (Nov 2020-May 2021) as the dependent variable and the SED as the independent variable. The Rt was estimated using daily incidence data from the Civil Protection Department as the instantaneous Rt. The province SED was measured using the percentage of individuals whose yearly income was less than 10,000€ (2019 data from the Ministry of Economy and Finance). We used multilevel linear regression models with random intercepts stratified by restriction level to estimate the effect of the SED on Rt (β) and its Standard Error (SE). Our analyses adjusted the estimates for the number of days into the tier first and then for other covariates.

Results

We found different levels and trends of Rt by SED in every restriction. Days-adjusted models found a containing effect for the red and the orange tier, while the Rt had an increasing trend in yellow. Higher SED was associated with higher Rt: β was positive and significant in red (β = 0.004 SE = 0.001) and orange (β = 0.002 SE = 0.001) but not in the lowest tier (β = 0.001 SE = 0.001). We found a significant interaction between the number of days into the restriction and the SED in the complete models. Compared to less deprived, more deprived provinces had slower Rt reduction in the highest tier. However, they had steeper Rt reductions in orange and slower increasing trends in yellow.

Conclusions

The highest restriction had milder effects in more deprived provinces, while lower tiers were more effective. These results underline the importance of accounting for SED when implementing public health measures.

Key messages

• Area-level deprivation can modify the effects of public health measures.

• Socioeconomic characteristics of the areas should be considered when implementing policies aimed to prevent the spread of epidemics.

POS1251 INCIDENCE AND OUTCOMES OF SARS-CoV-2 INFECTION IN PATIENTS WITH SYSTEMIC AUTOIMMUNE RHEUMATIC DISEASES: A POPULATION-BASED STUDY OF MORE THAN FOUR MILLION INHABITANTS IN THE LAZIO ITALIAN REGION

Background

The impact of the severe acute respiratory syndrome Coronavirus 2 disease (COVID-19) pandemic on people with systemic autoimmune rheumatic diseases (SARDs) remains to be fully established. It is unclear whether SARDs are an independent risk factor for COVID-19 infection and poor outcome.

Objectives

The aim of our study is to assess the incidence and prognosis of test-proven SARS-CoV-2 infection during the first COVID-19 wave in a large population of SARD patients of the Lazio Italian region.

Methods

We retrospectively evaluated in a cohort of 4.716.119 subjects aged over 18 years and affiliated to the health system of the Lazio Italian Region, the incidence and 30-day outcomes of COVID-19 infection in 40.490 SARD pts and compared to the affiliated population as incidence rate ratio adjusted for demographics and comorbidities (adjIRR). SARD diagnosis and comorbidities were derived from medical administrative records using the Chronic Related Group classification system. Data on COVID-19 infection were derived from a dedicated regional digital network.

Results

The risk of COVID-19 infection was increased in patients with Psoriatic Arthritis (adjIRR=1.21, 95% CI 1.10-1.33) and Undifferentiated Connective Tissue Disease (adjIRR=1.26, 95% CI 1.03-1.54). The risk of hospitalisation was higher in patients with Axial Spondylarthritis (adjIRR=2.16, 95% CI 1.45-3.22), and Systemic Vasculitis (adjIRR=1.81, 95% CI 1.07-3.06) while the risk of Intensive care unit admission was higher in Systemic Erythematous Lupus (adjIRR=3.67, 95% CI 1.52-8.83) and primary Sjögren Syndrome (adjIRR=4.13, 95% CI 1.71-9.96) patients. An increased COVID-19 mortality was reported in patients with Rheumatoid Arthritis (adjIRR=1.50, 95% CI 1.04-2.17), Systemic Erythematous Lupus (adjIRR=2.67, 95% CI 1.10-6.44), primary Sjögren Syndrome (adjIRR=2.51, 95% CI 1.12-5.62), and Scleroderma (adjIRR=4.60, 95% CI 2.06-10.29).

Conclusion

The incidence of severe COVID-19 is not increased in the same percentage in SARDs. Each SARD presents a peculiar pattern in terms of increased risk of COVID-19 incidence, hospitalisation, intensive care unit admission and death, that is not linked to the immunosuppressive behaviour of the disease.

Disclosure of Interests

None declared

Prevalence of schizophrenia spectrum disorders among adults in the Lazio region, Italy: use of an algorithm based on health information systems

Introduction

Mental healthcare provision is undergoing substantial reconfiguration in many regions of the world. Such changes require a broad evidence-based approach incorporating epidemiological data and information of local needs.

Objectives

To estimate the prevalence of schizophrenia spectrum disorders (SSDs) in the Lazio region and its geographical distribution using the regional health information systems (HIS).

Methods

Cases of SSDs (15-64-year-old) were identified using an algorithm based on data from the hospital discharge registry [ICD IX CM: 295, 297, 298 (excl. 298.0)] and the ticket exemption database [code 044], between 2006 and 2019. Crude, and age- and gender-specific prevalence estimates on December 31, 2019, were calculated. To compare prevalence between different areas within the region, we calculated age- and gender-adjusted prevalence rates

Results

A total of 18,371 cases were identified. Crude prevalence rate was 4.29/1,000 (95% CI 4.29-4.30) and 5.93/1,000 (95% CI 5.92-5.949 for women and men, respectively. An increase in the prevalence rate by age was observed in both genders. The age- and gender-adjusted prevalence rate was 5.03/1,000 (95 % CI 4.96-5.10), with significant differences within the region, ranging from 4.25/1,000 in the province of Viterbo to 5.42/1,000 in the city of Rome and 6.02/1000 in the province of Frosinone.

Conclusions

Our results showed that the overall prevalence of SSDs among adults in the Lazio region is similar to estimates published in prior reviews, but an uneven regional geographical distribution was observed. While possible underestimation must be considered, HIS represents a valuable source of information useful for epidemiological surveillance and healthcare planning.

Disclosure

No significant relationships.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Audit and feedback strategies: study protocol and preliminary results from the EASY-NET project

Background

In Italy there is evidence of a large variability in health care services and health outcomes. This multi-regional project is funded on Ministry of Health and Health Regional Authorities (code NET-2016-02364191). The aims are: 1) To test the effectiveness of Audit and Feedback (A&F) interventions in improving health professional practices and patients' outcomes in different settings using both a quantitative and a qualitative approach. 2) To examine factors that may explain variations in the effectiveness of A&F. 3) To evaluate the impact of A&F in reducing avoidable differences in access to effective health care interventions in socioeconomically disadvantaged populations.

Methods

In the 7 participating Regions (about 33 million inhabitants) experimental study designs have been implemented in different clinical areas (e.g. before-after controlled study, cluster randomized trial): in Lazio emergency care and chronic diseases care, in Friuli Venezia Giulia emergency care, in Piemonte oncology care, in Emilia Romagna chronic disease care, in Lombardia cardiovascular care, in Calabria deliveries and maternal health, in Sicilia emergency care. The effectiveness of different types of A&F are compared in term of outcomes using health information system databases.

Results

Preliminary results show large heterogeneity in developing and conducting A&F, in term of team project composition, type of intervention, clinicians' behavior to be changed, outcomes indicators, professionals involved, structure and timing of data reporting, actions to be implemented after the intervention. Limited awareness and interest of clinicians in A&F interventions was found.

Conclusions

The project represents a unique opportunity to explore how A&F interventions could be better designed. Different A&F strategies will be compared in term of clinical outcomes. The identification of barriers/facilitating factors will supply knowledge on mechanisms and tools to enhance A&F effectiveness.

Key messages

The project supports providers in reducing gap between knowledge and practice. The project promotes culture of interprofessional collaboration as a key point for high quality care.

Risk of SARS-CoV-2 infection in people living with Multiple Sclerosis in the Lazio region, Italy

Background

Multiple Sclerosis (MS) patients might represent a vulnerable population to SARS-CoV-2 infection due to several factors, including the immunosuppressive or immunomodulating disease-modifying therapies (DMT) they use and the young age that expose them to a high number of contacts. This study aimed to estimate incidence of SARS-Cov-2 infection in a cohort of MS patients living in the Lazio region and to identify the risk factors for the infection.

Methods

A retrospective cohort study was performed based on regional health administrative databases linked to the new integrated surveillance system of SARS-CoV-2 infection. MS patients residing in Lazio region and aged ≥18 years on 31 December 2019 were enrolled and followed-up to 31 March 2021. Age- and gender-standardised incidence ratios (SIR) was calculated to compare the infection rate of MS cases with that of the regional general population. A large number of socio-demographic and clinical variables were explored as potential risk factors using a multivariable logistic regression model.

Results

In the Lazio region lived 10,248 individuals affected by MS (mean age 49.2±12.9; 32.2% males; 67.8% females). During the follow-up period the overall incidence of SARS-CoV-2 infection was 5.0% (n = 510), 5.2% and 4.8% among males and females, respectively. An overall SIR of 0.92 (95%CI 0.84-1.00) was estimated, and 0.97 (95%CI 0.83-1.12) and 0.89 (95%CI 0.80-0.99) for males and females, respectively. The multivariable logistic regression model identified the use of antidiabetic drugs as unique predictor of SARS-CoV-2 infection (OR = 1.69; 95%CI 1.19-2.40). No association with any DMT was observed.

Conclusions

No difference was observed in the incidence of SARS CoV-2 infection in MS patients compared with the general population. DMT does not seem to affect the risk of infection, while the higher incidence in individuals using antidiabetics could reflect the higher prevalence of diabetic population in infected people.

Key messages

This study supports previous research suggesting that the incidence of SARS-CoV-2 infection in MS population does not seem to be higher than that in the general population.

Disease Modifying Therapy at the moment of infection does not appear to affect the risk of became infected from SARS-CoV-2.

P14.56 Pattern of care of Brain Tumor patients in the last months of life: analysis of a cohort of 3045 patients in the Lazio region in the last 10 years

BACKGROUND

The final days of life of Brain Tumor patients (BT) present special challenges and often palliative care approach is underutilyzed. Several studies reported that BT patients in the last months of life receive frequent hospital readmissions and ER accesses as result of bad quality of End of Life care. Early integration of pallative care has been demonstrated to improve quality of care in advanced stage of disease and quality of death in cancer patients. With the aim to evaluate pattern of treatment and the rate of hospital readmission in the last months of life, we retrospectively analyzed a consecutive serie of BT patients discharged after a diagnosis of BT.

MATERIAL AND METHODS

Data regarding hospital readmission and treatment received in the last two months of life were collected from the Lazio Region Healthcare database. Adult patients discharged with diagnosis ICD-9 191.* between 1/1/2010 until 31/12/2019, were included in this study.

RESULTS

6672 patients were identified and 3045 who have died before 31/12/2019 were included (median age 67 y;M1700). In the last two month of life 42.6% received hospital reamission (4.6% intensive care unit) and 37.9% had ER accesses. 24.5% received chemotherapy and 12.1% radiotherapy. In the last 30 days 33% were readmitted in hospital and 24.2% were admitted in ER. 11.7% were treated with chemotherapy and 6% with radiotherapy.

CONCLUSION

Strategies to improve quality of care at the end of life and to decrease re-hospitalization and futile treatments are becoming increasingly important to improve quality of death and to reduce costs of Healthcare System.

Reliability of Data Collected by Volunteers: A Nine-Year Citizen Science Study in the Red Sea

The quality of data collected by non-professional volunteers in citizen science programs is crucial to render them valid for implementing environmental resources management and protection plans. This study assessed the reliability of data collected by non-professional volunteers during the citizen science project Scuba Tourism for the Environment (STE), carried out in mass tourism facilities of the Red Sea between 2007 and 2015. STE involved 16,164 volunteer recreational divers in data collection on marine biodiversity using a recreational citizen science approach. Through a specifically designed questionnaire, volunteers indicated which of the seventy-two marine taxa surveyed were observed during their recreational dive, giving an estimate of their abundance. To evaluate the validity of the collected data, a reference researcher randomly dived with the volunteers and filled in the project questionnaire separately. Correlation analyses between the records collected by the reference researcher and those collected by volunteers were performed based on 513 validation trials, testing 3,138 volunteers. Data reliability was analyzed through 7 parameters. Consistency showed the lowest mean score (51.6%, 95% Confidence Interval CI 44.1–59.2%), indicating that volunteers could direct their attention to different taxa depending on personal interests; Percent Identified showed the highest mean score (66.7%, 95% CI 55.5–78.0), indicating that volunteers can correctly identify most surveyed taxa. Overall, results confirmed that the recreational citizen science approach can effectively support reliable data for biodiversity monitoring, when carefully tailored for the volunteer skills required by the specific project. The use of a recreational approach enhances massive volunteer participation in citizen science projects, thus increasing the amount of sufficiently reliable data collected in a reduced time.

Mortality inequalities in Rome: the role of individual education and real estate market

Background

Several indicators at individual and area level have been used to stratify the population. The aim of this work was to investigate the association between real estate prices, education and health status in Rome.

Methods

We used the administrative cohort of residents in Rome at the 2011 census. We followed subjects aged 18+ from 2011 to 2016 using anonymous record linkage procedures with administrative databases. The census includes several individual information, comprising sex, age, education, and residential urbanistic zone. From mortality register we collected date and cause of death. Real estate prices (€/m2) were available for each urbanistic zone. We classified the population in five categories according to the quintile of the distribution (1=highest prices, 5=lowest prices). We used adjusted Cox regression models to estimate the hazard ratios (HRs) and 95%CIs.

Results

We selected 2,053,668 subjects, not living in institutions at the time of the census survey. Women were 54% of the population; the mean age was 52 years (sd 18), 22.5% had a high education (university degree) and 37% a low education (≤ junior high school). During the follow-up, 126,548 subjects died. As expected educational level was strongly associated with all-cause mortality (39% higher risk of low vs. high educated). The mortality risk increased with decreasing real estate prices, taking account of age and sex. Compared to subjects living in highest prices areas, those living in level 2 areas had a HR = 1.08 (95%CI: 1.06-1.10), those in level 3 had a HR = 1.14 (95%CI: 1.12-1.16), those in level 4 a HR = 1.16 (95%CI 1.14-1.18), and finally those living in the cheapest areas a HR = 1.22 (95%CI: 1.20-1.25). When we considered both education and real estate prizes, the HRs marginally decreased.

Conclusions

There is an independent association of both individual education and socioeconomic characteristics of the area of residence and all-cause mortality.

Key messages

There are strong socioeconomic inequalities in Rome. A simple indicator such as real estate prices can be used to tackle inequalities.

Biosimilar formulations of gonadotropins in a central Italian region: use patterns and time trends

Background

Gonadotropins (Gonas) are hormones that play a central role in the follicular growth of women but also useful in male infertility. Gonas used for infertility treatment in women are available as urinary extracts or recombinants. In 2015, the first biosimilar of follitropin alfa was authorised.

Objectives

We aimed to evaluate use patterns, temporal and spatial variations of Gonas biosimilar formulations in an central Italian region.

Methods

From administrative healthcare databases of Lazio region, we extracted prescriptions that have occurred over the years 2015-2019. Gona's use was grouped as treatment with urinary (u) and recombinant (r). Special focus was made on biosimilar r-Gona. Use patterns were investigated with respect to characteristics of the patients treated, time trends, differences among local health units and type of prescribing physician.

Results

For the study period, we retrieved 136,333 Gona dispensations for 22,325 patients. The 10,927 r-Gona biosimilar dispensations (8.01% of all claims, of which 99.43% Bemfola®, and 0.57% Ovaleap®), were mostly referred to women, aged 18-45 years, (87.11% of all patients). Median age was 37 years for women, 38 for men. Since its authorisation, biosimilar r-Gona steadily gained market from 2015 (0,4% of claims) to 2017 (22,7%) followed by a decrease in 2019 (4,3%). Biosimilars claims are more frequent in treating men (10,8%) than women (6,1%). Most biosimilar prescriptions were issued by general practitioners (86.4%), followed by specialists (10.2%) and others. Biosimilar use patterns varied between different local health units (IQR 3.2%-8,5%).

Conclusions

In clinical pratice, r-Gona biosimilar dispensation, 8,8% of Gonas. are mostly prescribed from general practitioners and are proportionately more targeted at men than women. Further investigation is needed.

Key messages

More and more men and women are using artificial insemination techniques; it is important to monitor fertility drug use patterns. In times of savings for the economic system,the use of the biosimilar drugs is of increasing interest.

Determinants of use of gonadotropin formulations to treat female infertility in an Italian region

Background

Gonadotropins (Gona) are commonly used for infertility treatment in women. They are available as urinary purified extracts (u-Gona) and recombinants (r-Gona). Objectives:We investigated if socio-demographic characteristics of treated women, year of dispensation and type of prescriber may play a role in the choice of a treatment with respect to the other.

Methods

From administrative healthcare databases, we collected claims of Gona for women, aged 18-45, enrolled in the health care system in the year preceding the first prescription (years 2009-2018). Treatment cycles were defined as a 21-day mobile time window. We identified three groups: u-Gona, r-Gona and treatment with both formulations (m-Gona). To identify determinants, we linked women with the socio-economic position (SEP), a composite deprivation index, based on the 2011 Italian Census data,categorized in 4 levels (high, medium-high, medium-low, low). We associated prescriptions with the type of prescriber, distinguishing between specialists and general practitioners.

Results

We retrieved 38,598 Gona treatment cycles prescribed to 23,412 women and distributed between formulations as follows: r-Gona 47.4%, u-Gona 26.3% and m-Gona 26.3%. The median age was 38 years for r-Gona and u-Gona, 39 for m-Gona. Comparing the type of prescriber, specialists were more likely to prescribe u-Gona instead of r-Gona (OR: 2.14; 95%CI: 2.02-2.27) than general practitioners. No relation was found between SEP and Gona formulations, except for patients with the highest level who were more likely to be prescribed with r-Gona instead of u-Gona (OR: 1.12; 95%CI: 1.03-1.21). Time trends showed that treatment choices changed over time.

Conclusions

In the Lazio region, the choice of gonadotropin formulations varied over time and was found to be related to the prescriber and partly to socio-economic position. An analysis of outcomes related to different treatments is under way.

Key messages

More and more women are using artificial insemination techniques; it is important to monitor fertility drug use patterns and determinants of the choice of a treatment. The use of fertility drugs is a multifactorial phenomenon and a matter of public health interest.

Antipsychotics and mortality among elderly with dementia: a population based study in the Lazio region

Background

Most dementia patients experience one or more behavioral and psychological symptoms (BPSD) at some time during their illness, in particular in the middle and later stages. Antipsychotic drugs (AP) are often prescribed off-label for treating BPSD, despite concerns about safety and limited efficacy. The impact of AP on short- and long-term mortality has not been fully assessed.

Objective

To assess the association between the use of APs and short- and long-term mortality in a cohort of dementia patients aged ≥ 65 years residing in the Lazio region.

Methods

We use data from regional health information systems to conduct a retrospective age, gender and comorbidity matched cohort study with a 1:3 matching ratio to pair dementia patients new AP users with non-users. For the exposed participants, the index date was defined as the date of the first drug prescription; the same date was used for non-users matched subjects. Patients were enrolled on 31/12/2016 and followed-up from the index date through 2018. Four cohorts were enrolled to analyze mortality at 30, 60, 180 and 65 days from the index date. Adjusted estimates were obtained with propensity score matching using the Greedy Nearest Neighbor Matching algorithm.

Results

We enrolled 34,625 individuals (67% females, mean age 82 years) distributed as follows: 30 days cohort, 4321 users vs 12,960 non-users; 60 days cohort, 4202 users vs 12,606 non-users; 180 days cohort, 3641 users vs 19,923 non-users; 365 days cohort, 2618 users vs 7854 non-users. Multivariate analyses showed a statistically significant excess mortality at 60, 180, and 365 days since the first prescription (HR: 1.83, HR: 1.63, and HR: 1.62, respectively).

Conclusions

This study showed that antipsychotics increase short- and long-term mortality risk in older adults with dementia. The prescription of AP should be carefully evaluated and, if it is the best option for patient and caregiver, stringently monitored.

Key messages

Antipsychotic medication use is associated with an increased all-cause mortality in elderly with dementia. The mortality risk increases in 60 days after starting their use and remains elevated at 1 year.

A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in six European countries

AIMS

Percutaneous coronary intervention reduces mortality in acute coronary syndrome patients but the cost-utility of increasing its use in elderly acute coronary syndrome patients is unknown.

METHODS

We assessed the efficiency of increased percutaneous coronary intervention use compared to current practice in patients aged ≥75 years admitted for acute coronary syndrome in France, Germany, Greece, Italy, Portugal and Spain with a semi-Markov state transition model. In-hospital mortality reduction estimates by percutaneous coronary intervention use and costs were derived from the EUROpean Treatment & Reduction of Acute Coronary Syndromes cost analysis EU project (n = 28,600). Risk of recurrence and out-of-hospital all-cause mortality were obtained from the Information System for the Development of Research in Primary Care (SIDIAP) database from North-Eastern Spain (n = 55,564). In-hospital mortality was modelled using stratified propensity score analysis. The 8-year acute coronary syndrome recurrence risk and out-of-hospital mortality were estimated with a multistate survival model. The scenarios analysed were to increase percutaneous coronary intervention use among patients with the highest, moderate and lowest probability of receiving percutaneous coronary intervention based on the propensity score analysis.

RESULTS

France, Greece and Portugal showed similar total costs/1000 individuals (7.29-11.05 m €); while in Germany, Italy and Spain, costs were higher (13.53-22.57 m €). Incremental cost-utility ratios of providing percutaneous coronary intervention to all patients ranged from 2262.8 €/quality adjusted life year gained for German males to 6324.3 €/quality adjusted life year gained for Italian females. Increasing percutaneous coronary intervention use was cost-effective at a willingness-to-pay threshold of 10,000 €/quality adjusted life year gained for all scenarios in the six countries, in males and females.

CONCLUSION

Compared to current clinical practice, broadening percutaneous coronary intervention use in elderly acute coronary syndrome patients would be cost-effective across different healthcare systems in Europe, regardless of the selected strategy.

The combined effect of surgeon and hospital volume on health outcomes: a systematic review

OBJECTIVES

To explore the interaction between surgeon volumes (SVs) and hospital volumes (HVs) on health outcomes.

MATERIALS AND METHODS

We searched MEDLINE, Embase, CINAHL, Web of Science as of May 2017. We included studies investigating the interaction between high or low SVs operating in high or low HVs. Review process follows the PRISMA guidelines. We assessed the methodological quality of the included studies using validated critical appraisal checklists.

RESULTS

Sixteen studies were included. Due to the heterogeneity of studies, it was not possible to perform a quantitative analysis. Heath outcome are worse when high SV operating in low HV vs high HV, for the majority of the conditions (colorectal cancer, cystectomy, liver resection, mitral valve surgery, pancreatico-duodenectomy). Results for low SV are better when operating in high HV vs low HV for patients undergoing pancreatic-duodenectomy for mortality, 30 days complications and length of stay. Results for low SV are worse vs high SV when operating in high HV for most considered conditions. Results were in favour of higher SV vs low SV when operating in low HV for digital replantation success after injuries, 30 days mortality and complications after pancreatic-duodenectomy.

CONCLUSIONS

The available evidence is limited. It is necessary to increase the monitoring of the association between surgeons volumes and hospitals volumes in which they operate, to ensure fairness and accuracy of care for better health outcomes.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

A novel missense mutation in the FGB gene (p.Gly302Arg) leading to afibrinogenemia. Predicted structure and function consequences

Afibrinogenemia represents the rarest form of fibrinogen deficiency. Causative missense mutations occur rarely and may improve the understanding of fibrinogen structure and function.

PATIENTS AND METHODS

The propositus was a 26-year-old Argentinian with afibrinogenemia. FGA, FGB and FGG exons and flanking regions were screened by sequencing and the mutant protein was analyzed in silico.

RESULTS

A novel missense mutation in the FGB gene (Bbeta Gly272Arg, p.Gly302Arg) was identified. In silico analysis revealed its location in a highly conserved region, which preserves the core fold of the C-terminal beta-chain and is important for proper secretion. A substitution by a positively charged large Arg residue in this area would most likely disturb the core fold by additional interactions with adjacent residues (p.Asp291, p.Asp297, p.Asp311), or by forming of non-native interactions with other proteins, thereby hindering the action of molecular chaperones. Both alternatives would disturb the regular secretion of the beta-chain.

CONCLUSIONS

The novel missense mutation in the FGB gene causes afibrinogenemia most probably by affecting the secretion of the fibrinogen beta-chain.

A novel missense mutation in the FGB gene (p.Gly302Arg) leading to afibrinogenemia

Afibrinogenemia represents the rarest form of fibrinogen deficiency. Causative missense mutations occur rarely and may improve the understanding of fibrinogen structure and function. Patients and methods: The propositus was a 26-year-old Argentinian with afibrinogenemia. FGA, FGB and FGG exons and flanking regions were screened by sequencing and the mutant protein was analyzed in silico. Results: A novel missense mutation in the FGB gene (Bbeta Gly272Arg, p.Gly302Arg) was identified. In silico analysis revealed its location in a highly conserved region, which preserves the core fold of the C-terminal beta-chain and is important for proper secretion. A substitution by a positively charged large Arg residue in this area would most likely disturb the core fold by additional interactions with adjacent residues (p.Asp291, p.Asp297, p.Asp311), or by forming of non-native interactions with other proteins, thereby hindering the action of molecular chaperones. Both alternatives would disturb the regular secretion of the beta-chain. Conclusions: The novel mis-sense mutation in the FGB gene causes afibrinogenemia most probably by affecting the secretion of the fibrinogen beta-chain.

The fibroblast growth factor-23 and Vitamin D emerge as nontraditional risk factors and may affect cardiovascular risk

OBJECTIVES

Fibroblast growth factor-23 (FGF-23) and vitamin D are hormones involved in phosphate homoeostasis. They also directly influence cardiomyocyte hypertrophy. We examined whether the relationships between levels of vitamin D or FGF-23, cardiac phenotype and outcome were independent of established cardiac biomarkers in a large cohort of community-dwelling elderly subjects.

DESIGN AND SETTING

Plasma levels of FGF-23 and vitamin D were measured in 1851 men and women (65-84 years) resident in the Lazio region of Italy. Participants were referred to eight cardiology centres for clinical examination, electrocardiography, comprehensive Doppler echocardiography and blood sampling. All-cause mortality or hospitalizations were available after a median follow-up of 47 months with record linkage of administrative data.

RESULTS

Vitamin D deficiency (<20 ng mL(-1) ) was found in 72.3% of subjects, but FGF-23 levels were normal [74 (58-97) RU per mL]. After adjustment for cardiovascular risk factors and morbidities, low concentrations of vitamin D and high levels of FGF-23 were associated with a higher left ventricular (LV) mass index. Levels of FGF-23 [hazard ratio (HR) (95% confidence interval (CI)) 1.71 (1.28-2.28), P < 0.0001] but not vitamin D [0.76 (0.57-1.01), P = 0.08] were independently associated with mortality after adjustment for clinical risk factors and two cardiac markers together (N-terminal pro-brain natriuretic peptide and high-sensitivity cardiac troponin T), but did not predict hospital admission. People with above median values of FGF-23 and below median values of vitamin D had greater LV hypertrophy and higher mortality.

CONCLUSIONS

In community-dwelling elderly individuals with highly prevalent vitamin D deficiency, FGF-23 levels were associated with LV hypertrophy and predicted mortality independently of two robust cardiac biomarkers. A causal relationship was not demonstrated, but the hormones involved in mineral metabolism emerged as nontraditional risk factors and may affect cardiovascular risk.

Inequality in 30-day mortality and the wait for surgery after hip fracture: the impact of the regional health care evaluation program in Lazio (Italy)

OBJECTIVE

INTERVENTIONS

that address inequalities in health care are a priority for public health research. We evaluated the impact of the Regional Health Care Evaluation Program in the Lazio region, which systematically calculates and publicly releases hospital performance data, on socioeconomic differences in the quality of healthcare for hip fracture.

DESIGN

Retrospective cohort study.

SETTING

and participants We identified, in the hospital information system, elderly patients hospitalized for hip fracture between 01 January 2006 and 31 December 2007 (period 1) and between 01 January 2009 and 30 November 2010 (period 2).

MAIN OUTCOME MEASURES

We used multivariate regression models to test the association between socioeconomic position index (SEP, level I well-off to level III disadvantaged) and outcomes: mortality within 30 days of hospital arrival, median waiting time for surgery and proportion of interventions within 48 h.

RESULTS

We studied 11 581 admissions. Lower SEP was associated with a higher risk of 30-day mortality in period 1 (relative risk (RR) = 1.42, P = 0.027), but not in period 2. Disadvantaged people were less likely to undergo intervention within 48 h than well-off persons in period 1 (level II: RR = 0.72, P < 0.001; level III: RR = 0.46, P < 0.001) and period 2 (level II: RR = 0.88, P = 0.037; level III: RR = 0.63, P < 0.001). We observed a higher probability of undergoing intervention within 48 h in period 2 compared with the period 1 for each socioeconomic level.

CONCLUSION

This study suggests that a systematic evaluation of health outcome approach, including public disclosure of results, could reduce socioeconomic differences in healthcare through a general improvement in the quality of care.

Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy

WHAT IS KNOWN AND OBJECTIVE

Adherence to evidence-based drug therapy after acute myocardial infarction has increased over the last decades, but is still unsatisfactory. Our objectives are to set out to analyse patterns of evidence-based drug therapy after acute myocardial infarction (AMI), and evaluating socio-demographic differences.

METHODS

A cohort of 3920 AMI patients discharged from hospital in Rome (2006-2007) was selected. Drugs claimed during the 12 months after discharge were retrieved. Drug utilization was defined as density of use (boxes claimed/individual follow-up; chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through Defined Daily Doses (chronic use: ≥80% of individual follow-up). Patterns of use of single drugs and their combination were described. The association between poly-therapy and gender, age and socio-economic position (small-area composite index based on census data) was analysed through logistic regression, accounting for potential confounders.

RESULTS AND DISCUSSION

Most patients used single drugs: 90·5% platelet aggregation inhibitors (antiplatelets), 60·0%β-blockers, 78·1% agents acting on the renin-angiotensin system (ACEIs/ARBs), 77·8% HMG CoA reductase inhibitors (statins). Percentages of patients with ≥80% of therapeutic coverage were 81·9% for antiplatelets, 17·8% for β-blockers, 64·4% for ACEIs/ARBs and 76·1% for statins. The multivariate analysis showed gender and age differences in adherence to poly-therapy (females: OR = 0·84; 95% CI 0·72-0·99; 71-80 years age-group: OR = 0·82; 95% CI 0·68-0·99). No differences were observed with respect to socio-economic position.

WHAT IS NEW AND CONCLUSION

The availability of information systems offers the opportunity to monitor the quality of care and identify weaknesses in public health-care systems. Our results identify specific factors contributing to non-adherence and hence define areas for more targeted health-care interventions. Our results suggest that efforts to improve adherence should focus on women and older patients.

Profiling hospital performance to monitor the quality of care: the case of COPD

Comparative outcomes data are widely used to monitor quality of care in the cardiovascular area; little is available in the respiratory field. We applied validated methods to compare hospital outcomes for chronic obstructive pulmonary disease (COPD) exacerbation. From the hospital information system, we selected all hospital admissions for COPD exacerbation in Rome (for 2001-2005). Vital status within 30 days was obtained from the municipality mortality register. Each hospital was compared to a pool of hospitals with the lowest adjusted mortality rate (the benchmark). Age, sex and several potential clinical predictors were covariates in logistic regression analysis. 12,756 exacerbated COPD patients were analysed (mean age 74 yrs, 71% males). Diabetes, hypertension, ischaemic heart disease, heart failure and arrhythmia were the most common coexisting conditions. The average crude mortality in the benchmark group was 3.8%; in the remaining population it was 7.5% (range 5.2-17.2%). In comparison with the benchmark, the relative risk of 30-day mortality varied widely across the hospitals (range 1.5-5.9%). A large variability in 30-day mortality after COPD exacerbation exists even considering patients' characteristics. Although these results do not detect mechanisms related to worse outcomes, they may be useful to stimulate providers to revision and improvement of COPD care management.

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

BACKGROUND

Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review.

OBJECTIVES

To evaluate the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use.

SEARCH STRATEGY

We searched the following databases up to October 2006: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK , Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress databases, reference lists of identified studies and reviews, authors were asked about any other published or unpublished relevant RCT.

SELECTION CRITERIA

Randomised clinical trials of buprenorphine maintenance versus placebo or methadone maintenance.

DATA COLLECTION AND ANALYSIS

Authors separately and independently evaluated the papers and extracted data for meta-analysis.

MAIN RESULTS

Twenty four studies met the inclusion criteria (4497 participants), all were randomised clinical trials, all but six were double-blind. The method of allocation concealment was not clearly described in the majority (20) of the studies, but where it was reported the methodological quality was good. Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.50; 95% CI: 1.19 - 1.88), medium (RR=1.74; 95% CI: 1.06 - 2.87), and high doses (RR=1.74; 95% CI: 1.02 - 2.96). The high statistical heterogeneity prevented the calculation of a cumulative estimate. However, only medium and high dose buprenorphine suppressed heroin use significantly above placebo. Buprenorphine given in flexible doses was statistically significantly less effective than methadone in retaining patients in treatment (RR= 0.80; 95% CI: 0.68 - 0.95), but no different in suppression of opioid use for those who remained in treatment. Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use.

AUTHORS' CONCLUSIONS

Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivered at adequate dosages.

Maintenance agonist treatments for opiate dependent pregnant women

BACKGROUND

The prevalence of opiate use among pregnant women ranges from 1% to 2% to as much as 21%. Heroin crosses the placenta and pregnant opiate dependent women experience a six fold increase in maternal obstetric complications such as low birth weight, toxaemia, 3rd trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neurobehavioral problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome.

OBJECTIVES

To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions on child health status, neonatal mortality, retaining pregnant women in treatment, and reducing use of substances

SEARCH STRATEGY

We searched Cochrane Drugs and Alcohol Group' Register of Trials (June 2007), PubMed (1966 - June 2007), CINAHL (1982- June 2007), reference lists of relevant papers, sources of ongoing trials, conference proceedings, National focal points for drug research. Authors of included studies and experts in the field were contacted.

SELECTION CRITERIA

Randomised controlled trials enrolling opiate dependent pregnant women

DATA COLLECTION AND ANALYSIS

The authors assessed independently the studies for inclusion and methodological quality. Doubts were solved by discussion.

MAIN RESULTS

We found three trials with 96 pregnant women. Two compared methadone with buprenorphine and one methadone with oral slow morphine. For the women there was no difference in drop out rate RR 1.00 (95% CI 0.41 to 2.44) and use of primary substance RR 2.50 (95% CI 0.11 to 54.87) between methadone and buprenorphine, whereas oral slow morphine seemed superior to methadone in abstaining women from the use of heroin RR 2.40 (95% CI 1.00 to 5.77)For the newborns in one trial buprenorphine performed better than methadone for birth weight WMD -530 gr (95% CI -662 to -397), this result is not confirmed in the other trial. For the APGAR score both studies didn't find significant difference . No differences for NAS measures used. Comparing methadone with oral slow morphine no differences for birth weight and mean duration of NAS. The APGAR score wasn't considered.

AUTHORS' CONCLUSIONS

We didn't find any significant difference between the drugs compared both for mother and for child outcomes; the trials retrieved were too few and the sample size too small to make firm conclusion about the superiority of one treatment over another. There is an urgent need of big randomized controlled trials.

Anticonvulsants for cocaine dependence

BACKGROUND

Cocaine dependence is a major public health problem that is characterized by recidivism and a host of medical and psychosocial complications. Although effective pharmacotherapy is available for alcohol and heroin dependence none exists currently for cocaine dependence despite two decades of clinical trials primarily involving antidepressant, anti convulsivant and dopaminergic medications. There has been extensive consideration of optimal pharmacological approaches to the treatment of cocaine dependence with consideration of both dopamine antagonists and agonists. Anticonvulsants have been candidates for the treatment of addiction based on the hypothesis that seizure kindling-like mechanisms contribute to addiction.

OBJECTIVES

To evaluate the efficacy and the acceptability of anticonvulsants for cocaine dependence

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Groups specialised register (issue 4, 2007), MEDLINE (1966 - march 2007), EMBASE (1988 - march 2007), CINAHL (1982- to march 2007)

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials which focus on the use of anticonvulsants medication for cocaine dependence

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the papers, extracted data, rated methodological quality

MAIN RESULTS

Fifteen studies (1066 participants) met the inclusion criteria for this review: the anticonvulsants drugs studied were carbamazepine, gabapentin, lamotrigine, phenytoin, tiagabine, topiramate, valproate. No significant differences were found for any of the efficacy measures comparing any anticonvulsants with placebo. Placebo was found to be superior to gabapentin in diminishing the number of dropouts, two studies, 81 participants, Relative Risk (RR) 3.56 (95% CI 1.07 to 11.82) and superior to phenythoin for side effects, two studies, 56 participants RR 2.12 (95% CI 1.08 to 4.17). All the other single comparisons are not statistically significant.

AUTHORS' CONCLUSIONS

Although caution is needed when assessing results from a limited number of small clinical trials at present there is no current evidence supporting the clinical use of anticonvulsants medications in the treatment of cocaine dependence. Aiming to answer the urgent demand of clinicians, patients, families, and the community as a whole for an adequate treatment for cocaine dependence, we need to improve the primary research in the field of addictions in order to make the best possible use out of a single study and to investigate the efficacy of other pharmacological agent.

Antipsychotic medications for cocaine dependence

BACKGROUND

Cocaine dependence is a public health problem characterized by recidivism and a host of medical and psychosocial complications. Cocaine dependence remains a disorder for which no pharmacological treatment of proven efficacy exists, although considerable advances in the neurobiology of this addiction could guide future medication development

OBJECTIVES

To evaluate the efficacy and the acceptability of antipsychotic medications for cocaine dependence

SEARCH STRATEGY

We searched the following sources: MEDLINE (1966 to October 2006), EMBASE (1980 to October 2006), CINAHL (1982 to October 2006), Cochrane Drug and Alcohol Group Specialised Register (October 2006). We also searched the reference lists of trials, the main electronic sources of ongoing trials (National Research Register, meta-Register of Controlled Trials; Clinical Trials.gov) and conference proceedings likely to contain trials relevant to the review. All searches included also non-English language literature.

SELECTION CRITERIA

All randomised controlled trials and controlled clinical trials with focus on the use of any antipsychotic medication for cocaine dependence

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the papers, extracted data, rated methodological quality

MAIN RESULTS

Seven small studies were included (293 participants): the antipsychotic drugs studied were risperidone, olanzapine and haloperidol. No significant differences were found for any of the efficacy measures comparing any antipsychotic with placebo. Risperidone was found to be superior to placebo in diminishing the number of dropouts, four studies, 178 participants, Relative Risk (RR) 0.77 (95% CI 0.77 to 0.98). Most of the included studies did not report useful results on important outcomes such as side effects, use of cocaine during treatment and craving. The results on olanzapine and haloperidol come from studies too small to give conclusive results.

AUTHORS' CONCLUSIONS

Although caution is needed when assessing results from a limited number of small clinical trials there is no current evidence, at the present , supporting the clinical use of antipsychotic medications in the treatment of cocaine dependence. Furthermore, most of the included studies did not report useful results on important outcomes such as side effects, use of cocaine during the treatment and craving. Aiming to answer the urgent demand of clinicians, patients, families, and the community as a whole for an adequate treatment for cocaine dependence, larger randomised investigations should be designed investigating relevant outcomes and reporting data to allow comparison of results between studies. Moreover some efforts should be done also to investigate the efficacy of other type medications, like anticonvulsant, currently used in clinical practice.

Alcoholics Anonymous and other 12-step programmes for alcohol dependence

BACKGROUND

Alcoholics Anonymous (AA) is an international organization of recovering alcoholics that offers emotional support through self-help groups and a model of abstinence for people recovering from alcohol dependence, using a 12-step approach. Although it is the most common, AA is not the only 12-step intervention available there are other 12-step approaches (labelled Twelve Step Facilitation (TSF)).

OBJECTIVES

To assess the effectiveness of AA or TSF programmes compared to other psychosocial interventions in reducing alcohol intake, achieving abstinence, maintaining abstinence, improving the quality of life of affected people and their families, and reducing alcohol associated accidents and health problems.

SEARCH STRATEGY

We searched the Specialized Register of Trials of the Cochrane Group on Drugs and Alcohol, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsychINFO from 1967. Searches were updated in February 2005. We also inspected lists of references for relevant studies.

SELECTION CRITERIA

Studies involving adults (<18) of both genders with alcohol dependence attending on a voluntary or coerced basis AA or TSF programmes comparing no treatment, other psychological interventions, 12-step variants.

DATA COLLECTION AND ANALYSIS

One reviewer (MF) assessed studies for inclusion and extracted data using a pre-defined data extraction form. Studies were evaluated for methodological quality and discussed by all reviewers.

MAIN RESULTS

Eight trials involving 3417 people were included. AA may help patients to accept treatment and keep patients in treatment more than alternative treatments, though the evidence for this is from one small study that combined AA with other interventions and should not be regarded as conclusive. Other studies reported similar retention rates regardless of treatment group. Three studies compared AA combined with other interventions against other treatments and found few differences in the amount of drinks and percentage of drinking days. Severity of addiction and drinking consequence did not seem to be differentially influenced by TSF versus comparison treatment interventions, and no conclusive differences in treatment drop out rates were reported. Included studies did not allow a conclusive assessment of the effect of TSF in promoting complete abstinence.

AUTHORS' CONCLUSIONS

No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, this medication is not used since the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group Register of Trials (January 2005), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 1, 2005), MEDLINE (1973-first year of naltrexone use in humans- January 2005), EMBASE (1974- January 2005), PsycINFO (OVID-January 1985 to January 2004). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Ten studies, 696 participants, met the criteria for inclusion in this review. Only two studies described an adequate allocation concealment. The results show that naltrexone maintenance therapy alone or associated with psychosocial therapy is more efficacious that placebo alone or associated with psychosocial therapy in limiting the use of heroin during the treatment (RR 0,72 95% confidence interval 0.58 to 0.90). If we consider only the studies comparing naltrexone with placebo, the difference do not reach the statistical significancy, RR 0.79 (95%CI 0.59 to 1.06). With respect to the number of participants re incarcerated during the study period, the naltrexone associated with psychosocial therapy is more effective than the psychosocial treatment alone; RR 0.50 (95%CI 0.27 to 0.91). No statistically significant benefit was shown in terms of retention in treatment, side effects or relapse results at follow-up for any of the considered comparisons.

AUTHORS' CONCLUSIONS

Unfortunately the studies did not provide an objective evaluation of naltrexone treatment in the field of opioid dependence. The conclusions are also limited due to the heterogeneity of the trials both in the interventions and in the assessment of outcomes.

Oral naltrexone maintenance treatment for opioid dependence

BACKGROUND

Research on the clinical application of oral naltrexone agrees on several things. From a pharmacological perspective, naltrexone works. From an applied perspective, however, this medication is not used since the medication compliance and the retention rates are very poor.

OBJECTIVES

To evaluate the effects of naltrexone maintenance treatment versus placebo or other treatments in preventing relapse in opioid addicts after detoxification.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group Register of Trials (January 2005), Cochrane Central Register of Controlled Trials (CENTRAL - The Cochrane Library Issue 1, 2005), MEDLINE (1973-first year of naltrexone use in humans- January 2005), EMBASE (1974- January 2005), PsycINFO (OVID-January 1985 to January 2004). We inspected reference lists of relevant articles and we contacted pharmaceutical producers of naltrexone, authors and other Cochrane review groups.

SELECTION CRITERIA

All randomised and controlled clinical trials which focus on the use of naltrexone maintenance treatment versus placebo, or other treatments to reach sustained abstinence from opiate drugs

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed studies for inclusion and extracted data. One reviewer carried out the qualitative assessments of the methodology of eligible studies using validated checklists.

MAIN RESULTS

Ten studies, 696 participants, met the criteria for inclusion in this review. Only two studies described an adequate allocation concealment. The results show that naltrexone maintenance therapy alone or associated with psychosocial therapy is more efficacious that placebo alone or associated with psychosocial therapy in limiting the use of heroin during the treatment (RR 0,72 95% confidence interval 0.58 to 0.90). If we consider only the studies comparing naltrexone with placebo, the difference do not reach the statistical significancy, RR 0.79 (95%CI 0.59 to 1.06). With respect to the number of participants re incarcerated during the study period, the naltrexone associated with psychosocial therapy is more effective than the psychosocial treatment alone; RR 0.50 (95%CI 0.27 to 0.91). No statistically significant benefit was shown in terms of retention in treatment, side effects or relapse results at follow-up for any of the considered comparisons.

AUTHORS' CONCLUSIONS

Unfortunately the studies did not provide an objective evaluation of naltrexone treatment in the field of opioid dependence. The conclusions are also limited due to the heterogeneity of the trials both in the interventions and in the assessment of outcomes.

Methadone at tapered doses for the management of opioid withdrawal

BACKGROUND

Despite widespread use in many countries the evidence of tapered methadone's efficacy in managing opioid withdrawal has not been systematically evaluated.

OBJECTIVES

To evaluate the effectiveness of tapered methadone compared with other detoxification treatments and placebo in managing opioid withdrawal on completion of detoxification and relapse rate.

SEARCH STRATEGY

We searched: Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005), MEDLINE (January 1966 to December 2004), EMBASE (January 1988 to December 2004), PsycINFO (January 1985 to December 2004), and reference lists of articles. We also contacted manufacturers and researchers in the field.

SELECTION CRITERIA

All randomised controlled trials which focus on the use of tapered methadone versus all other pharmacological detoxification treatments or placebo for the treatment of opiate withdrawal.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the included studies. Any doubt about how to rate the studies were resolved by discussion with a third reviewer. Study quality was assessed according to the criteria indicated in Cochrane Reviews Handbook 4.2. (Alderson 2004)

MAIN RESULTS

Sixteen trials involving 1187 people were included. Comparing methadone versus any other pharmacological treatment we observed no clinical difference between the two treatments in terms of completion of treatment, relative risk (RR) 1.12; 95% CI 0.94 to 1.34 and results at follow-up RR 1.17; 95% CI 0.72 to 1.92. It was impossible to pool data for the other outcomes but the results of the studies did not show significant differences between the considered treatments. These results were confirmed also when we considered the single comparisons: methadone with: adrenergic agonists (11 studies), other opioid agonists (four studies), chlordiazepoxide (study). Comparing methadone with placebo (one study) more severe withdrawal and more drop outs were found in the placebo group. The results indicate that the medications used in the included studies are similar in terms of overall effectiveness, although symptoms experienced by participants differed according to the medication used and the program adopted.

AUTHORS' CONCLUSIONS

Data from literature are hardly comparable; programs vary widely with regard to duration, design and treatment objectives, impairing the application of meta-analysis. The studies included in this review confirm that slow tapering with temporary substitution of long acting opioids, accompanied by medical supervision and ancillary medications can reduce withdrawal severity. Nevertheless the majority of patients relapsed to heroin use.

Effects of organic solvents on ultrafiltration polyamide membranes for the preparation of oil-in-water emulsions

Hydrophilic ultrafiltration membranes made of polyamide with molecular weight cutoff 10 and 50 kDa have been studied for the preparation of oil-in-water emulsions by a cross-flow membrane emulsification technique. Isooctane and phosphate buffer were used as disperse and continuous phase, respectively. The permeation of apolar isooctane through the polar hydrophilic membrane was achieved by pretreatment of membranes with a gradient of miscible solvents of decreasing polarity to remove water from the pores and replace it with isooctane. Four different procedures were investigated, based on the solvent mixture percentage and contact time with membranes. After pretreatment, the performance of the membranes in terms of pure isooctane permeate flux and emulsion preparation was evaluated. The influence of organic solvents on polyamide (PA) membranes has been studied by SEM analysis, which showed a clear change in the structure and morphology of the thin selective layers. The effects proved stronger for PA 10 kDa than for 50 kDa. In fact, similar pretreatment procedures caused larger pore size and pore size distribution for PA 10 kDa than for 50 kDa. The properties of emulsions in terms of droplet size distribution reflected the membrane pore sizes obtained after pretreatment. The correlation between pore size and droplet size, for the physicochemical and fluid dynamic conditions used, has been evaluated.

Heroin maintenance for chronic heroin dependents

BACKGROUND

Many medications have been used for stabilizing heroin users: Methadone, Buprenorphine and LAAM. The present review focus on the prescription of heroin to heroin dependents.

OBJECTIVES

To assess the efficacy and acceptability of heroin maintenance versus methadone or other substitution treatments for opioid dependence, in retaining patients in treatment; reducing the use of illicit substances and improving health and social functioning.

SEARCH STRATEGY

The Cochrane Central Register of Trials (CENTRAL) issue 1, 2005; MEDLINE 1966-2005, EMBASE 1980-2005 and CINAHL till 2005 (on OVID) were searched. There was no language or publication year restrictions. Many researchers were contacted for information.

SELECTION CRITERIA

Randomised controlled trials of heroin (alone or combined with methadone) maintenance treatment compared with any other pharmacological treatments for heroin dependents.

DATA COLLECTION AND ANALYSIS

The trials were independently assessed for inclusion and methodological quality by the reviewers. Data were extracted independently and double checked. Studies were not pooled together because of heterogeneity.

MAIN RESULTS

2400 references were obtained and 20 studies were eligible, 4 met the inclusion criteria for a total of 577 patients. The studies could not be analysed cumulatively because of heterogeneity of interventions and outcomes. Retention in treatment: no groups difference was found in two studies; one study (N=96) found RR=2.82 (95% CI 1.70-4.68) favouring heroin; one study (N=235) found RR 0.79 (95%CI 0.68-0.90) favouring methadone. Relapse to illegal heroin use (self- reported): in one study people using heroin in treatment was 64% (heroin group)and 59% (methadone group); in the other study the RR of heroin use was 0.33 (95%CI 0.15-0.72) favouring heroin. Criminal offence: one study showed the potential of heroin prescription in reducing the risk of being charged RR 0.32 (95% CI 0.14-0.78). Social functioning: two studies did not show statistical difference between intervention groups, and two studies considered criminal offence and social functioning as part of a multidomain outcome measure showing improvements among those treated with heroin plus methadone over those on methadone only.

AUTHORS' CONCLUSIONS

No definitive conclusions about the overall effectiveness of heroin prescription is possible. Results favouring heroin treatment come from studies conducted in countries where easily accessible Methadone Maintenance Treatment at effective dosages is available. In those studies heroin prescription was addressed to patients who had failed previous methadone treatments. The present review contains information about ongoing trials which results will be integrated as soon as available.