Use of antidepressants during COVID19 outbreak: a real-world drug-utilization study

Background

Lockdown measures implementation (LMI) to prevent COVID19 disease diffusion was associated to increased depression and anxiety cases. The main aim was to evaluate whether LMI affected prevalence and incidence of antidepressants (ADs) use, and ADs treatment interruption (TI) in the general population.

Methods

Adults (≥18 years) with at least 1 dispensing of ADs between 01/01/2019-26/09/2020 were selected from a regional Italian healthcare administrative database. Patients presenting an AD dispensing in the year preceding the first observation were considered as prevalent otherwise as incident users. We divided the studied period into 3 parts: pre-lockdown (01/01/2019-08/03/2020), lockdown (09/03/2020-14/06/2020) and post-lockdown (15/06/2020-27/09/2020). The weekly prevalence (WP) and incidence (WI) per 10,000 inhabitants were compared among periods. Incidence of TI (no dispensing refill within 30 days of the end of its validity) was computed among prevalent AD users.

Results

The WP (mean of 552.3 per 10,000 pre-lockdown vs 505.5 lockdown phase; relative change: -9%) and WI (5.2 vs 3.7; -29%) of ADs use decreased after LMI. During the post-lockdown phase WP (505.5 vs 495.9; -2%) decreased whereas the WI (3.7 vs 4.3; 16%) slightly increased in relation to the lockdown period, although differences were not statistically significant. Conversely, the incidence of TI increased during lockdown (344.7 vs 384.3; 12%) and post-lockdown (384.3 vs 394.2; 3%) periods, even not always statistically significant.

Conclusions

Our analysis showed a reduction of ADs use during the early phase of lockdown. Several factors might have impacted on the observed phenomenon (i.e, patient reluctance to start new AD treatment). Considering the mutation of the virus and the potential waves that might occur in the next months, a continuous monitoring of the impact of COVID19 on mental diseases onset and treatment adherence are suggested.

Key messages

In Italy, the implementation of lockdown measures was followed by a reduction in antidepressants use, even though evidences are that diagnoses of psychiatric disorders increased.

Future studies should monitor if these phenomena led to an increase in adverse events potentially correlated with inappropriate treatment of depression.

Patterns and trends of idarucizumab use in an Italian region: a probabilistic record-linkage approach in a real-life setting

Background

Idarucizumab is a specific reversal agent for dabigatran, a direct oral anticoagulant. In 2015, idarucizumab was approved in Europe to quickly restore coagulation and it is currently subject to additional safety monitoring. The drug is administered only during inpatient or emergency care: in such settings, its use is poorly captured by most real-world databases.

Purpose

To retrieve individual level information on idarucizumab use from an Italian record-linkage claims database in order to describe main characteristics of users.

Methods

Italy has a regional-based, universal coverage healthcare system. Healthcare delivered to each inhabitant of Tuscany, an Italian region, is registered in a record-linkage claims database (RLCD). This information can be traced at individual level using an encrypted identification code, except in the case of medicines administered in Inpatients or Emergency Care (IEC), where only date and ward of administration are recorded. All person-years (PYs) exposed to dabigatran from January 2015 to December 2018 were calculated from RLCD, using defined daily doses (DDDs) to estimate duration of each recorded dispensation. Idarucizumab use during the study period was identified from IEC, and incidence rate was calculated over PYs of dabigatran use. To identify subjects treated with idarucizumab, emergency admissions and hospital discharge records were probabilistically linked to dabigatran users, matching date and ward of admission as retrieved from RLCD. A further selection was made by a manual check of the diagnoses compatible with the indications of use of idarucizumab. Linked users were described in terms of indication and followed-up for 30 days to assess mortality.

Results

During the study period, 26,821 PYs of dabigatran use were observed, and 112 administrations of idarucizumab were recorded, corresponding to 4.2 (95% CI: 3,4–5,0) per 1,000 PYs. Overall, 103 idarucizumab administrations (92.0%) were linked to at least one patient, while 50 (44.6%) were uniquely linked to 47 patients. Most of them were men (55.3%), aged ≥80 years (68.1%). Indications were emergency surgical procedures and life-threatening bleeding in 17 (36.1%) and in 30 subjects (63.9%), respectively. Overall, 30-days mortality was 17.0% (N=8).

Conclusions

This analysis demonstrates the potential of the Tuscany database in retrieving patient-level information on idarucizumab use and sets the stage for post-marketing surveillance on its safety profile in a real-life setting.

Funding Acknowledgement

Type of funding source: None

Cardiovascular diseases burden in Italy, 1990–2017: the Global Burden of Disease Study

Background

Cardiovascular diseases (CVDs) are still the leading cause of mortality, morbidity and disability in Europe. Consequently, an exhaustive estimation of CVDs burden and cardiovascular risk factors impact is crucial for healthcare planning and resource allocation. In Italy, data on CVDs burden are sparse. This study aims to assess the global Italian CVDs burden and to analyze time changes from 1990 to 2017 within the country and in comparison to other European states.

Methods

We used data from the 2017 Global Burden of Diseases (GBD) study to estimate CVDs prevalence, mortality and disability-adjusted life-years (DALYs) in Italy from 1990 to 2017. We also analyzed burden attributable to CVDs-related risk factors. Finally, Italian estimations were compared to those of the other 28 European Union countries.

Results

CVDs were still the first cause of death (34.8% of total mortality) in Italy in 2017. A significant decrease in CVDs burden was observed since 1990: age-standardized prevalence (-12.7%), mortality rate (-53.75%), and DALYs rate (-55.54%) all decreased. Similar patterns were observed also in the majority of European countries. Despite these trends, all-ages CVDs prevalent cases increased from 5.75 million to 7.49 million. More than 80% of CVDs burden could be attributed to known modifiable risk factors such as high systolic blood pressure, dietary risks, high LDL cholesterol, and impaired kidney function.

Conclusions

Data showed a decline in cardiovascular mortality and DALYs, which reflects the success in terms of reducing disability, premature death and early incidence of CVDs. However, the burden of CVDs is still high, as population aging and the increased prevalent cases require more access to care and generate more years lived with disability, which in turn leads to higher costs for the National Health Service and society. More efficient prevention strategies at community and individual level are needed.

Key messages

Despite decreasing trends in CVDs mortality and DALYs, the burden of CVDs is still high in Italy. A joined approach of the National Health System stakeholders is needed to keep reducing the CVDs burden.

Post-stroke epilepsy and mortality: an observational study on healthcare administrative database

Background

Post-stroke epilepsy (PSE) has been associated with hospitalization and increased mortality risk. So far, evidence on PSE and mortality risk is lacking. Therefore, this study aimed to evaluate the association between PSE and mortality in different type of stroke.

Methods

A retrospective observational study was conducted using healthcare administrative databases of Lombardy, a northern Italian region (16.4% of the Italian population). Patients aged 40 years or older admitted to the hospital between 1/1/2004 and 31/12/2008 with diagnosis of hemorrhagic (HS)- or ischemic (IS)- stroke were included. Diagnosis of seizure/epilepsy was identified by using discharge ICD9-CM codes, exemption code or use of antiepileptic drugs. This date was considered the index date. For each stroke cohort case of PSE was matched with 2 non post-stroke epileptic (PNS) individuals. Demographic and clinical characteristics were compared between PSE and PSN among the stroke cohorts. Cox proportional regression model was used to estimate the hazard ratio (HRs) and 95% confidence intervals (95%CI) of mortality.

Results

In the observed period, 13,749 of patients (4,583 PSE Vs 9,166 PSN) had IS and 4,875 (1,625 PSE Vs 3,250 PNS) had HS. Individuals were ≥75-year-old with no difference among cohorts (p value >0.9). Similarly, no differences were observed for gender (p = 1.00) and Charlson'comorbidity index (p = 1.00). Early seizure occurred in 15% of ischemic cohort and 20% of hemorrhagic one. Differences in antithrombotic drug use were observed among PSE and PSN in IS (p = 0.009) and HS cohort (p = 0.03). In ischemic cohort PSE was positively associated with increased mortality risk (HRadj: 1.67; 95%CI: 1.57-1.79), whereas no significant result was observed in hemorrhagic cohort (1.06; 0.94-1.20).

Conclusions

This study demonstrated a twofold increased risk of mortality in IS cohort. Further studies need to deeply characterize possible association between PSE and mortality in HS individuals.

Key messages

Occurrence of seizure/epilepsy in ischemic post-stroke patients represents a risk factor for morality. New studies need to clarify the contrasting result observed for hemorrhagic PSE patients.

Risk of atrial fibrillation among bisphosphonate users: a multicenter, population-based, Italian study

Bisphosphonate treatment is used to prevent bone fractures. A controversial association of bisphosphonate use and risk of atrial fibrillation has been reported. In our study, current alendronate users were associated with a higher risk of atrial fibrillation as compared with those who had stopped bisphosphonate (BP) therapy for more than 1 year.

INTRODUCTION

Bisphosphonates are widely used to prevent bone fractures. Controversial findings regarding the association between bisphosphonate use and the risk of atrial fibrillation (AF) have been reported. The aim of this study was to evaluate the risk of AF in association with BP exposure.

METHODS

We performed a nested case-control study using the databases of drug-dispensing and hospital discharge diagnoses from five Italian regions. The data cover a period ranging from July 1, 2003 to December 31, 2006. The study population comprised new users of bisphosphonates aged 55 years and older. Patients were followed from the first BP prescription until an occurrence of an AF diagnosis (index date, i.e., ID), cancer, death, or the end of the study period, whichever came first. For the risk estimation, any AF case was matched by age and sex to up to 10 controls from the same source population. A conditional logistic regression was performed to obtain the odds ratio with 95% confidence intervals (CI). The BP exposure was classified into current (<90 days prior to ID), recent (91-180), past (181-364), and distant past (≥365) use, with the latter category being used as a reference point. A subgroup analysis by individual BP was then carried out.

RESULTS

In comparison with distant past users of BP, current users of BP showed an almost twofold increased risk of AF: odds ratio (OR) = 1.78 and 95% CI = 1.46-2.16. Specifically, alendronate users were mostly associated with AF as compared with distant past use of BP (OR, 1.97; 95% CI, 1.59-2.43).

CONCLUSION

In our nested case-control study, current users of BP are associated with a higher risk of atrial fibrillation as compared with those who had stopped BP treatment for more than 1 year.

Assessing the risk of osteonecrosis of the jaw due to bisphosphonate therapy in the secondary prevention of osteoporotic fractures

SUMMARY

There is evidence that the use oral bisphosphonates can lead to osteronecrosis of the jaws (ONJ). Although the occurrence of ONJ appears rare among oral bisphosphonates (BPs) users, it is important to know that it exists and can be opportunely minimized.

INTRODUCTION

The purpose of this study is to evaluate the association between BPs prescribed for the secondary prevention of osteoporotic fractures and the occurrence of ONJ.

METHODS

An Italian record linkage claims database with a target population of around 18 million individuals (6 million over 55 years of age) constituted the data source. We conducted a nested case-control study within a cohort of individuals aged 55+ years old, who were discharged from hospitals with a primary diagnosis of incident osteoporotic fracture. The date related to the discharge diagnosis of ONJ was the index date. Conditional logistic regression for matched data was fitted to estimate the odds ratio (OR) along with 95 % confidence intervals (95 % CI) for the likely association between use of BPs and the risk of ONJ.

RESULTS

Any one of the 61 ascertained cases of ONJ (incidence rate, 36.6 per 100,000 person-years) was matched to 20 controls for a total of 1120 controls. When the exposure to BPs was modeled according to recency (i.e., exposure time window prior to the index date) of use, the adjusted OR (95 % CI) for current users was 2.8 (1.3-5.9) against never users. The cumulative use of BPs has shown to increase the incidence of ONJ among patients with primary osteoporotic fractures, although not statistically significant risk has been observed.

CONCLUSIONS

Although the risk of BP-related ONJ appears low in non-oncological indications, it is important to be aware that it exists and to know how it may be predicted and possibly minimized.

Prescription of nonselective NSAIDs, coxibs and gastroprotective agents in the era of rofecoxib withdrawal - a 617,400-patient study

BACKGROUND

Gastroprotective strategies are recommended for nonsteroidal anti-inflammatory drug (NSAID) users at risk of upper gastrointestinal (UGI) complications.

AIM

To compare the use of gastroprotective strategies in NSAID users in three countries, and the subsequent impact of rofecoxib withdrawal.

METHODS

We conducted a population-based cohort study in three general practice (GP) databases: (i) United Kingdom's (UK) GP Research Database (1998-2008); (ii) Italy's (IT) Health Search/CSD Longitudinal Patient Database (2000-2007); and (iii) the Dutch (NL) Integrated Primary Care Information database (1996-2006). Study cohorts comprised incident NSAID users ≥50 years. Preventive strategies included: (i) co-prescription of gastroprotective agents; or (ii) cyclooxygenase-2-selective inhibitor use. Under-use was defined as no gastroprotection in patients with ≥1 UGI risk factor (history of UGI event, age ≥65 years, concomitant use of anticoagulants, antiplatelets or glucocorticoids). Interrupted time-series analysis was performed to assess the impact of rofecoxib withdrawal on preventive strategies.

RESULTS

The study populations consisted of 384 649 UK, 177 747 IT and 55 004 NL NSAID users. In UK, under-use of preventive strategies fell from 91% to 71% [linear trend (lt) P = 0.001], in NL from 92% to 58% (lt P < 0.001) and in IT from 90% to 76% (lt P = 0.38) in high-risk NSAID users. In 2000 and 2006, under-use was significantly lower in NL compared with UK and IT (P < 0.001) in high-risk users. After rofecoxib's withdrawal, under-use increased significantly in UK and NL.

CONCLUSIONS

The prescription of gastropreventive strategies followed a similar pattern across countries. Despite a temporary negative effect of rofecoxib withdrawal on under-use, improvement of gastroprotection with nonsteroidal anti-inflammatory drugs was observed.

Assessing 5-year incidence rates and determinants of osteoporotic fractures in primary care

PURPOSE

To assess the gender and age-related 5-year incidence rates of osteoporotic fractures, and their related predictors, in a primary care setting.

METHODS

We obtained information from the Health Search-CSD Longitudinal Patients Database (HSD). This is an Italian General Practice data repository which comprises information given by computer-based patient records of a selected group of over 900 Primary Care Physicians (PCPs). We selected all patients aged 50 to 85 years, who were actively included into the PCP's list at the beginning of the enrolment period (1st January 2002-31st December 2003). We excluded individuals who were registered in the PCPs' list for less than 1 year before the entry date (Index date) into the cohort, as well as those who were diagnosed with Paget disease or malignant neoplasm. Participants were followed up until the occurrence of osteoporotic fracture, one of the exclusion criteria, or the end of the study period.

RESULTS

The 5-year rates (per 1000 person-years) of any osteoporotic fracture were 11.56 (95% C.I. 11.33 to 11.77) among females, and 4.91 (95% C.I. 4.75 to 5.07) among males. For hip fractures, the overall incidence rates were 3.23 (95% C.I. 3.11 to 3.34) among females and 1.21 (95% C.I. 1.12 to 1.28) among males, respectively. Advanced age, history of fracture, use of corticosteroids, rheumatoid arthritis, BMI<=20, presence of osteoporosis, gastrointestinal and chronic hepatic disease, depression, chronic obstructive pulmonary disease, use of anticonvulsants and a higher number of co-medications, increased the risk of any osteoporotic fractures.

CONCLUSIONS

The use of primary care data confirms a higher incidence of osteoporotic fractures among females vs. males as well as in older individuals. Predictors of osteoporotic fractures were consistent with FRAX® algorithm. Given the clinical utility of a simple score for the assessment of absolute fracture risk among osteoporotic patients, its assessment and validation in the Italian HSD could potentially provide an applicable prediction tool.

Is suboptimal prescribing a risk factor for poor health outcomes in community-dwelling elders? The ICARe Dicomano study

PURPOSE

Mostly because of comorbidity and drugs consumption, older persons are often exposed to an increased risk of sub-optimal prescribing (SP). At present, few studies investigated the association between SP and long-term health outcomes. We examined the relation between SP and the risk of mortality and hospitalization in Italian older community-dwellers.

METHODS

Older (65+ years) community-dwelling residents of a small town in Tuscany were enrolled in a longitudinal study. SP was defined as polypharmacy (use of 5+ drugs), prescription of inappropriate drugs (ID) according to Beers' criteria, and of potentially interacting drugs (PID), evaluated in 1995 and 1999. These three forms of SP were entered as time-dependent exposures into multivariable Cox regression analysis models, whose outcomes were mortality and hospitalizations through 2003.

RESULTS

Of 1022 participants (mean age 73.0 +/- 6.8, 57% women), 220 were evaluated in 1995, 234 in 1999 and 568 in both waves. In univariate analysis, mortality was two-fold higher in participants with polypharmacy (73.4/1000 person/years, 95% CI 58.2-92.4 vs. 34.1, 95% CI 29.7-39.2; p < 0.001) or PID (72.7/1000 person/years, 95% CI 46.3-113.9 vs. 38.0, 95% CI 33.5-43.1; p < 0.001), whereas it was unrelated to the presence of ID. Hospitalization rates were independent of any form of SP. In multivariable models, polypharmacy, ID, and PID were no longer associated with an increased risk of death, and ID predicted a slightly increased risk of hospitalizations (HR 1.03, 95% CI 1.0-1.06, p = 0.048).

CONCLUSIONS

In this cohort, SP was not associated with an excess risk of poor health outcomes.

Prescribing patterns of antiepileptic drugs in Italy: a nationwide population-based study in the years 2000-2005

To evaluate prevalence of use and prescribing patterns of antiepileptic drugs (AEDs) in Italian general practice. Primary care data were obtained from the Health Search Database, a longitudinal observational database implemented by the Italian College of General Practitioners (GPs). We selected 465 061 subjects registered by the end of 2005 in the lists of 320 GPs, homogeneously distributed throughout Italy. Prevalence of AED use was assessed in the entire sample and by drug type, age group, year and main geographic area (north, centre and south/islands). Overall, 24 383 subjects (5.2%) received at least one AED prescription in the study period. Prevalence of AED use (with 95% confidence interval) increased progressively from 7.1 (6.9-7.3) in 2000 to 11.8 (11.5-12.1) in 2005 for old AEDs and from 1.1 (1.0-1.2) to 12.2 (11.9-12.5) for new AEDs. Carbamazepine, phenobarbital and valproic acid were the most common AEDs until 2003, when gabapentin became first. There were no differences in prescribing patterns in the three main geographic areas. Newer AEDs were mostly used in patients aged 65 years and older. The more widespread use of newer AEDs was for mood disorders or pain. Older AED currently remain first line drugs for epileptic disorders. An increasing use of AEDs has been recently observed over a 6-year period in Italian general practice, mostly explained by newer compounds used for conditions other than epilepsy.

Health-related quality of life in older people using benzodiazepines: a cross-sectional study

Aim of this study is to investigate the QoL older people making regular use of BDZ. All subjects aged 65-84 years attending their General Practitioners were invited to fill in a questionnaire about their consumption of BDZ and all the subjects consuming BDZ to fill in the Medical Outcome Measures Short Form-36 (MOS SF-36) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaires. A total of 2,246 subjects used BDZ and 1,109 (49.4%) of them filled in the MOS SF-36 questionnaire. 1,005 of these participants also completed the PRIME-MD questionnaire (90.6%). The presence of sleep disorders and the characteristics of the BDZ used were not associated with any score in the MOS SF-36 questionnaire, whereas the Prime diagnosis was the most important predictor, since subjects with depression and/or anxiety had a lower mean score on each scale than subjects without disorders. Among a sample of Italian seniors taking BDZ, QoL was associated with the presence of anxiety and/or depression. Age, gender, education and the presence of cardiovascular diseases or stroke were associated with specific aspects of QoL, when anxiety and depression were controlled for.

Antibiotic prescribing for dental conditions: a community-based study in southern Italy

The aim of this study was to investigate for which conditions antibiotics are being used in community dental practice, and which clinical features represent the most common reason for an antibacterial approach to the treatment of dental conditions. The study was carried out from November 1998 to June 1999. Dentists were selected according to the different areas of southern Italy, from a list provided by the Italian Society of Dentists. Out of 87 selected dentists, 33 agreed to participate and filled in 1615 questionnaires for each therapeutic intervention ending with antibiotic treatment. Analysis of data indicated that alveolar-gingival abscesses were the most commonly treated infection, accounting for 23.6% of total treatments, followed by acute periodontitis (20.6%) and disodontiasis of the 3rd molar (18.5%). Parenteral antibiotics were chosen in 7.8% of cases. Penicillins were the most commonly used group, 40.1% of total treatments, followed by macrolides (30.2%) and cephalosporins (13.4%). Moreover, penicillins were widely used for post-surgery therapy (52.1%) and disodontiasis of the 3rd molar (50.8%), while macrolides were the most commonly used group for gingivitis (44.1%) and parodontal diseases (55.0%). The choice of parenteral antibiotics was related to severe general symptoms (odds ratios [OR], 4.4; 95% CI: 2.2-9.0), pain (OR, 2.7; 95% CI: 1.2-6.1) and lymphonodal involvement (OR, 6.4; 95% CI: 2.7-15.1). In conclusion, our study demonstrates that antibiotic treatment is often based on the eradication of as many microorganisms as possible, and on the clinical assessment of the patients, rather than on any knowledge of the pathogens involved.

Exploring the relationship between alcohol consumption and non-fatal or fatal stroke: a systematic review

OBJECTIVE

Alcohol consumption has been reported to have both beneficial and harmful effects on stroke occurrence. Several studies have demonstrated a significant association with heavy drinking, but the evidence linking light-to-moderate alcohol consumption still remains unclear. This study, using a systematic review of the published literature, aimed to explore the dose-response relationship between alcohol and stroke, the effect of irregular drinking and the effect of beverage types on the risk of stroke.

METHODS

A structured search for English-language published literature since 1966 was made using several electronic databases. This was supplemented using a hand search of references in review articles and additional searches on key authors. From the 153 eligible articles, 41 studies were selected according to study design, categorization of the exposure and outcome measures.

FINDINGS

An association between recent alcohol use and stroke was consistently reported. There was also some evidence for a linear positive association for haemorrhagic stroke and alcohol consumption. Inconsistent results emerged on the J-shaped relationship between alcohol and ischaemic stroke, and the association between alcohol and non-fatal or fatal stroke combined. The importance of the pattern of drinking was also demonstrated, indicating a higher risk for irregular drinkers.

CONCLUSIONS

There is insufficient evidence to conclude that light-to-moderate alcohol drinking and wine intake have beneficial effects on stroke occurrence. On the contrary, findings from this review suggest the opportunity for a primary prevention regarding heavy drinking and binge drinking. More information regarding the risk of stroke associated with irregular alcohol drinking, and the joint effects of alcohol with other risk factors, would clarify the complex interaction between alcohol and stroke.

How do mothers signal shared feeling-states to their infants? An investigation of affect attunement and imitation during the first year of life

The present study examined how mothers signal shared feeling-states to their infants. Affect attunement and imitation were investigated cross-culturally in 39 mother-infant dyads from Sweden (N = 22) and the former Yugoslavia (N = 17) during the first year of life. Video-recordings of playful interaction between mothers and their infants were analysed using the Affect Attunement Protocol. A significant negative association between imitation and age was found, while there was a significant positive association between affect attunement and age. Single occurrences of affect attunement appeared already at two or three months of age, and by 6 months of age episodes of affect attunement were more common than imitation. Frequencies of imitation and affect attunement were similar cross-culturally and in terms of gender, although there was a significant interaction between age and gender. The results suggest that the signalling of shared feeling-states is not a static process. Mothers do not signal shared feeling-states in the same manner at different ages. Imitation is the most important process during the earliest months, but is superseded by affect attunement earlier than previously thought. The functional implications of this developmental variation are discussed.

Prescribing habits of general practitioners in choosing an empirical antibiotic regimen for lower respiratory tract infections in adults in Sicily

The survey was carried out, between September 1995 and May 1996, in order to describe the prescriptive behaviour among Sicilian general practitioners (GPs) in choosing an empirical antibiotic regimen for LRTIs in adult patients and begin an educational process which involves the same GPs in decisions regarding their prescriptions and in performing local guidelines. Each practitioner filled out a questionnaire for each therapeutic intervention which ended with an antibiotic prescription. The questionnaire also enquired into the patient's characteristics, diseases to be treated and drug prescription. Doctors were asked to give an opinion about the severity assessment of the infectious disease before choosing the antibiotic treatment, in order to evaluate the prescriptive behaviour of physicians related to the patient's symptoms. Of all Sicilian GPs approached, 76 physicians from 25 Sicilian towns, with a patient population of 96,630, agreed to participate. The GPs used 49 different molecules and six different associations of two antibiotics. The most frequently used antibacterial agents were cephalosporins (55.0%). Penicillins (11.7%), fluoroquinolones (11. 4%), macrolides (10.1%) and combinations of penicillins with beta-lactamase inhibitors (7.9%), together, represented 41.1% of the remaining antibiotic prescriptions. The choice of the route of administration was significantly influenced by age of the patients, by symptoms and signs of the disease and by the presence of concurrent diseases rather than by bacteria suspected of causing the disease. The rather marked variation in antibiotic prescribing pattern for LRTIs among Sicilian GPs reflects lack of availability or knowledge of any local or national guidelines about the management of these diseases.

Hypertension in dialysis patients

Hypertension is a major risk for cardiovascular complications in dialysis patients. The pathogenesis of hypertension is multifactorial and is not completely understood. Hypervolemia has always been considered a major pathogenetic factor. In addition, a disturbed hormone profile with an activated renin angiotensin system, increased catecholamine, vasopressin and endothelin, and perhaps decreased nitrous oxide activity seem to play a role in the high incidence of hypertension in dialysis patients. The influence of autonomic dysfunction on blood pressure control in hemodialysis patients is not clear. The frequent use of erythropoietin during the last decade may have contributed to the increased incidence of hypertension in the dialysis population. Data from the First Report on Dialysis and Transplant in Sicily showed that hypertension is the cause of end-stage renal disease in 8% of dialysis patients and that the incidence of hypertension, as a cause of end-stage renal disease, increased with age.

[Infectious diseases in general practice and antibiotic prescription. Observational study in Sicily]

Drug utilisation studies have shown wide differences, among different countries, in the prescribing behaviour in general practice. In Italy, for instance, the choice of antibiotic prescription seems to show a wider use of parental antibiotic. Aim of this study was to describe antibiotic prescribing pattern and therapeutic doses used by Sicilian general practitioners (GPs) and evaluate their prescribing attitudes regarding the use of parental ones. Each practitioner had to fill a questionnaire for each therapeutic intervention ended with an antibiotic prescription during a period of 6 months. Diagnosis and drugs were classified according to the International Classification of Diseases (ICD-10) and to Anatomical Therapeutic Chemical Classification (ATC), respectively. On 9395 prescriptions performed by 76 doctors of 25 Sicilian towns, the analysis indicated that acute respiratory symptoms represent the commonest indication (31.7%) for a medical consultation, and that Macrolides [such as azithromycin (8.8%) and clarithromycin (8.3%)], Penicillin [such as amoxycillin (7.1%%) and co-amoxiclav (8.4%)], III generation of Cephalosporins [such as cefixime (5.5%) and ceftriaxone (5.1%)] represent the most common used therapeutic groups. The choice of the route of administration was influenced by age of the patients and, more significantly, by symptoms and signs of the disease, rather than by bacteria suspected to cause the disease. In conclusion, our data clearly indicate lack of knowledge of antibacterial therapy guidelines among GPs in Sicily, as well as the need of an independent educational training in order to improve knowledge of antibiotics and to decrease the cost of the health care.

[Adverse drug reactions in childhood. A drug surveillance study in Sicily]

The aim of the present study was to investigate the spontaneous reports of suspected adverse drug reactions, observed in paediatric patients in Sicily during the period between the 1st January 1995 and the 31st August 1997. The ADRs were classified according to the "WHO Programme for International Monitoring of Adverse Reactions to Drugs". On 1020 reports, the paediatric suspected ADRs were 130 (12.7%); 23% of these was serious, and 29.2% involved children aged 3 years or less. The antimicrobial and the musculoskeletal drugs were responsible of 74.6% of the whole suspected paediatric ADRs. Cutaneous and gastrointestinal apparatus were involved in 70% of reports and were the most frequently targets of ADRs. On 57 different molecules ceftriaxone and co-amoxiclav were the most common drugs causing ADRs with a percentage of 13%. In 45.4% of ADRs the suspension of the treatment occurred, in 34.6% therapy was needed besides the suspension of the drug, whilst in 11.5% patients needed an hospital visit. In 59.2% spontaneous reports were sent by hospitals, in 32.3% by primary health care and the remaining percentage by other sources. Our investigation should stimulate physicians to better evaluate the potential side effects of drugs and the cost/effectiveness profile of paediatric therapies.

Pattern of antimicrobial drug prescribing and prescriptive behaviour for acute otitis media among physicians in Sicily

Acute otitis media (AOM) is one of the most common diseases of childhood, but it is less common in adults. Usually, in clinical practice therapy cannot wait until the laboratory report and the choice of an antibiotic prescription is initiated on an empirical basis. Moreover, several studies have shown great variability in antibiotic prescription for AOM. The study was carried out in order to describe the antibiotic prescribing pattern and the prescriptive behaviour among Sicilian general practitioners (GPs) in choosing an empirical antibiotic regimen for treatment of AOM. Each GP completed a questionnaire for each therapeutic intervention which ended with an antibiotic prescription. Diagnoses and drugs were classified according to the International Classification of Diseases (ICD-10) and to the Anatomical Therapeutic Chemical (ATC) classification system, respectively. Antibiotics, issued for AOM, accounted for 11.1% of total antimicrobial therapy in paediatrics and 3.4% in adults. The commonest therapeutic groups were: cephalosporins (44.1%), macrolides (26.1%), extended spectrum penicillins (16.1%), combination of penicillins and beta-lactamase inhibitors (11.4%). The route of administration appeared to be influenced by age of the patients, by a subjective clinical assessment of disease severity and by the presence of concurrent diseases. The diagnostic criteria and the marked variation in antibiotic prescribing pattern for AOM among Sicilian GPs reflects a lack of knowledge of any local or national guidelines.

Adult acute upper respiratory tract infections in Sicily: pattern of antibiotic drug prescription in primary care

We performed an observational study of the antibiotic-prescribing behaviour of Sicilian general practitioners (GPs) in managing acute upper respiratory tract infections (URTIs). Seventy-six GPs from 25 towns, representing a patient population of 96,630, participated in the study between September 1995 and May 1996. These physicians issued 2038 antibiotic treatment courses for acute upper respiratory tract infections: 792 for acute pharyngitis, 531 for acute tonsillitis, 304 for acute laryngitis and tracheitis, 268 for suppurative and non-suppurative acute otitis media, 124 for acute sinusitis and 19 for acute rhinitis. Forty-nine different antibiotics were prescribed. The most commonly used therapeutic groups were macrolides (38.6%), cephalosporins (27.1%), a combination of penicillins with beta-lactamase inhibitors (15.7%) and extended spectrum penicillins (13.5%). For each of the above diseases, except rhinitis, more than 30 different antibiotics were used. The choice of the route of administration appeared to be influenced by the age of the patients and, significantly, by a subjective clinical assessment of disease severity rather than by any consideration of epidemiological information or evidence from clinical trials. The rather marked variation in antibiotic-prescribing pattern for URTIs among Sicilian GPs reflects lack of availability or knowledge of any local or national guidelines.

Inhibition of nitric oxide formation reduces voluntary ethanol consumption in the rat

Brain nitric oxide is involved in the mechanisms that regulate ingestive behavior. To test whether this compound plays a role in alcohol preference, we studied the effects of different doses of NG-nitro-L-arginine (L-NO arg), an inhibitor of nitric oxide synthase (NOS), on voluntary consumption of ethanol and on blood alcohol levels produced by a single intraperitoneal dose of alcohol in the rat. L-NO arg produced a significant and dose-dependent reduction of ethanol intake (P < 0.001) without influencing total fluid consumption or feeding behavior. L-NO arg did not influence the kinetics of alcohol. Our data show that inhibition of nitric oxide formation accompanies reduction of ethanol intake and suggest a possible role for nitric oxide in ethanol self-administration.

Mediation by nitric oxide formation in the preoptic area of endotoxin and tumour necrosis factor-induced inhibition of water intake in the rat

1. Drinking was induced in rats by 24 h of water deprivation. Water intake (ml) was evaluated for a 1 h period. 2. NG-nitro-L-arginine methyl ester (L-NAME, 5-10 micrograms, i.c.v., 50-100 ng into the preoptic area (POA)), an inhibitor of nitric oxide (NO) synthase, and methylene blue (50-100 ng into POA), an inhibitor of guanylate cyclase activation, antagonized the inhibition of drinking induced by E. coli endotoxin (LPS, 640 micrograms kg-1, i.v.) and tumour necrosis factor (TNF alpha, 40 ng, i.c.v.) in 24 h water-deprived rats. 3. L-Arginine (25, 50 and 100 ng), the precursor amino acid of NO, but not the stereoisomer D-arginine (100 ng), inhibited drinking induced by water deprivation when injected into the POA 30 min before water presentation (74.4% of inhibition with the highest dose). A dose of 12.5 ng L-arginine into the POA did not exhibit antidipsogenic effects. 4. TNF alpha (20 and 40 ng, i.c.v.; 1.25, 2.5 and 5 ng into the POA) showed a dose-dependent and powerful inhibition of drinking behaviour in water-deprived rats (70.4% and 80.8%, i.c.v. and into POA, with the highest doses, respectively). A dose of 10 ng of TNF alpha given i.c.v. had no effect on the intake of water. 5. LPS and TNF alpha, given at doses (160 micrograms kg-1, i.v. and 10 ng, i.c.v., respectively) that did not influence drinking in water-deprived rats, exhibited a strong antidipsogenic effect in water-deprived rats treated with a dose of L-arginine (12.5 ng, into the POA) which did not modify drinking by itself. (LPS + L-arginine:53.6% of inhibition; TNFalpha + L-arginine: 52.0% of inhibition).6. These results suggest that NO into the POA: (1) acts as an inhibitory mechanism on thirst and (2)plays a role in the antidipsogenic effect of LPS and TNFalpha.

Food deprivation increases brain nitric oxide synthase and depresses brain serotonin levels in rats

We studied nitric oxide (NO) synthase activity and serotonin content in the diencephalon of 24 hr food deprived rats. NO synthase activity was significantly increased whereas serotonin levels together with those of tryptophan and 5-hydroxyindoleacetic acid (5-HIAA) were reduced in food deprived rats when compared to control rats. NG-Nitro-L-arginine (L-NO Arg), an inhibitor of NO synthase, was used as a tool to study the role of NO in food deprivation. Twenty-four hr food deprived male Sprague-Dawley rats were intraperitoneally (i.p.) administered L-NO Arg (12.5, 25 and 50 mg/kg) before food presentation. Control rats received a NaCl (0.9%) solution. Food consumption was monitored 1 and 2 hr after food presentation. L-NO Arg administration produced a dose-dependent reduction in food intake. Pretreatment with metergoline (2 mg/kg) but not with ritanserin (1 mg/kg) antagonized the anorectic effect of L-NO Arg. Moreover, in the diencephalon L-NO Arg significantly reduced NO synthase activity whereas it increased serotonin levels. Our data indicate that NO might have a physiological role in the regulation of food intake and suggest that brain NO may modulate the central serotoninergic system.

A new antioxidant drug limits brain damage induced by transient cerebral ischaemia

Restoration of blood flow after an ischaemic event generates the formation of oxygen radicals which could augment brain damage. The authors studied the effects of different doses (50, 100, 200 mg/kg/i.p.) of a new antioxidant, IRFI-016, [2(2,3-dihydro-5-acetoxy-4,6,7-trimethylbenzofuranyl) acetic acid] on brain damage in the Mongolian gerbil induced by 5 min of bilateral carotid occlusion (BCO) followed by reperfusion. Post-ischaemic brain malondialdehyde (MDA) levels and locomotor activity at different times and delayed neuronal death of hippocampal CA1 area on the fourth day after occlusion were evaluated. During reperfusion, after BCO, enhancement of brain MDA occurs (37.5%, 62.5% and 100% at 15, 30 and 60 min of reperfusion, respectively). Brain MDA postischaemic increases were reduced at 15 min of reperfusion to 15.4% and 44.4% by IRFI-016, 100 and 200 mg/kg, respectively. After 30 min of reperfusion brain MDA was reduced to 31.25% and 53.13% by IRFI-016 100 and 200 mg/kg, respectively. Hyperactivity and delayed neuronal death of CA1 were significantly reduced in postischaemic gerbils treated with the highest doses of IRFI-016. Results indicate that pretreatment with the antioxidant IRFI-016 improves in a dose-dependent manner brain damage induced by ischaemia and reperfusion in the gerbil.

Cloricromene antagonizes antidipsogenic effects induced by endotoxin, but not by TNF alpha, in the rat

Intravenous (640 micrograms/kg) or intracerebroventricular (0.5 and 1 microgram) injection of Escherichia coli endotoxin (LPS) causes inhibition of water intake induced by 24 hour period of water deprivation in the rat. Tumor necrosis factor alpha (TNF-alpha; 20 and 40 ng/rat) given into the lateral cerebral ventricle (i.c.v.) causes effects similar to those observed after LPS. Cloricromene, given either intravenously (1 and 2 mg/kg) or i.c.v. (250 and 500 ng), abolished the antidipsogenic effect induced by LPS (administered both i.v. and i.c.v.). Cloricromene (2 mg/kg, i.v. or 500 ng/rat, i.c.v.), on the contrary, did not modify the antidipsogenic effects induced by TNF-alpha. These data indicate that peripherally injected cloricromene (as well as that i.c.v. injected) antagonizes the effects of mediators of LPS on sites regulating thirst and suggest that cloricromene's action may be due to inhibition of brain TNF-alpha formation induced by LPS.