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Conventional wisdom is that chronic liver disease is an acquired bleeding disorder. However, the imbalance between procoagulant and anticoagulant activities can also lead to thrombosis. Studies are needed to assess the value of anticoagulants. Chronic liver disease, particularly in the end stage, is characterized by clinical bleeding and decreased levels of most procoagulant factors, with the notable exceptions of factor VIII and von Willebrand factor, which are elevated. 1 Decreased levels of the procoagulants are, however, accompanied by decreases in levels of such naturally occurring anticoagulants as antithrombin and protein C. 1 In physiologic conditions, the coagulation system is balanced by these two opposing drivers (Figure 1), but the mechanistic significance of the parallel decrease of both procoagulants and anticoagulants in patients with chronic liver disease escaped attention for many years. As a consequence, chronic liver . . .

Purposes We evaluated the prevalence and factors associated with polypharmacy and investigated the role of polypharmacy as a predictor of length of hospital stay and in-hospital mortality. Methods Thirty-eight internal medicine wards in Italy participated in the Re gistro Po literapie SI MI (REPOSI) study during 2008. One thousand three hundred and thirty-two in-patients aged ≥65 years were enrolled. Polypharmacy was defined as the concomitant use of five or more medications. Linear regression analyses were used to evaluate predictors of length of hospital stay and logistic regression models for predictors of in-hospital mortality. Age, sex, Charlson comorbidity index, polypharmacy, and number of in-hospital clinical adverse events (AEs) were used as possible confounders. Results The prevalence of polypharmacy was 51.9% at hospital admission and 67.0% at discharge. Age, number of drugs at admission, hypertension, ischemic heart disease, heart failure, and chronic obstructive pulmonary disease were independently associated with polypharmacy at discharge. In multivariate analysis, the occurrence of at least one AE while in hospital was the only predictor of prolonged hospitalization (each new AE prolonged hospital stay by 3.57 days, p  < 0.0001). Age [odds ratio (OR) 1.04; 95% confidence interval (CI) 1.01–1.08; p  = 0.02), comorbidities (OR 1.18; 95% CI 1.12–1.24; p  < 0.0001), and AEs (OR 6.80; 95% CI 3.58–12.9; p  < 0.0001) were significantly associated with in-hospital mortality. Conclusions Although most elderly in-patients receive polypharmacy, in this study, it was not associated with any hospital outcome. However, AEs were strongly correlated with a longer hospital stay and higher mortality risk.

The 3-year Specific Training Course in General Practice (STCGP) remains fragmented, lacking a national core curriculum and differing significantly across regions, leaving trainees uncertain and disconnected from the population’s needs.3–5 In contrast, several European countries invest in coherent GP training, promoting patient-centred care, teamwork and attention to social determinants of health.6 7 As part of the MedicInRete project, our study surveyed 301 Italian GP trainees about key competencies, training adequacy and the future of the STCGP as a possible university-based speciality. [...]as robust primary care forms the foundation of a resilient and equitable health system,8 investing in the training and recognition of future GPs is essential to meet Italy’s current and future healthcare challenges. The funder had no role in the design of the study, in the collection, analysis or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.

Von Willebrand disease, the most common inherited bleeding disorder that affects both males and females, is due to quantitative or qualitative defects of the multimeric glycoprotein von Willebrand factor, which cause mucous membrane bleeding but also soft tissue bleeding owing to the secondary deficiency of factor VIII. The aim of treatment is to correct this dual defect of hemostasis. In addition to the episodic management of bleeding episodes, therapy includes their short- or long-term prevention. Short-term prophylaxis is mainly warranted in order to provide effective hemostatic coverage to patients undergoing surgery or invasive procedures and to affected women at the time of delivery or during menstruations associated with excessive bleeding. The aim of long-term prophylaxis is to prevent bleeding in particular categories of patients at increased risk of frequent and spontaneous bleeding in the joints, nose, and gastrointestinal tract.

To analyze the relationship between atrial fibrillation (AF) and Charlson comorbidity index (CCI) in a population-based cohort study over a long-term follow-up period, in relation to oral anticoagulant (OAC) prescriptions and outcomes. We used data from the administrative health databases of Lombardy. All patients with AF and age 40 years and older and who were admitted to the hospital in 2002 were considered for analysis and followed up to 2014. AF diagnosis and CCI were established according to codes from the International Classification of Diseases, Ninth Revision. In 2002, 24,040 patients were admitted with a diagnosis of AF. CCI was higher in patients with AF than in those without AF (1.8±2.1 vs 0.2±0.9; P<.001). Over 12 years of follow-up, AF was associated with an increased risk of higher CCI (beta coefficient, 1.69; 95% CI, 1.67-1.70). In patients with AF, CCI was inversely associated with OAC prescription at baseline (P<.001) and at the end of the follow-up (P=.03). Patients with AF and a high CCI (≥4) had a higher cumulative incidence of stroke, major bleeding, and all-cause death (all P<.001), compared with those with low CCI (range, 0-3). Adjusted Cox regression analysis revealed that time-dependent continuous CCI was associated with an increased risk for stroke, major bleeding, and all-cause death (all P<.001). In hospitalized patients, AF is associated with an increase in CCI that is inversely associated with OAC prescriptions during follow-up. CCI is independently associated with an increased risk of stroke, major bleeding, and all-cause death.

The COVID-19 pandemic has put under pressure all the health national systems in Europe and telemedicine (TM) has been an almost unavoidable answer for primary care (PC) services to constrain the contagion. PC includes all the healthcare services that are the first level of contact for individuals. General practitioners (GPs) are the pivotal providers of PC throughout Europe. Although GP costs are mainly covered by public services or social insurances in Europe, they are still self-employed physicians everywhere, differently from their colleagues in hospitals who are traditionally employees. TM is a very general term open to various interpretations and definitions. TM can now be practiced by means of modern audio-visual devices and is an alternative to the traditional face-to-face consultation in general practice. Although the adoption of TM seems to be compelling in our era, its practical dissemination in PC has been quite slow so far, and many different concerns have been raised on it. On the whole, TM widespread adoption in PC seems to be more a matter of labor organization and health care funding than of technology and ethics. Larger-scale organizations comprising a wide range of health professionals have become a pressing priority for a modern PC, because working together is crucial to provide high-quality care to patients, and co-location should boost teamwork and facilitate the management of information technology. A national network of large organizations in PC could be rationally managed through local budgets and should increase efficiency by adopting tools such as TM.

Integrated care (IC) is a term now commonly adopted across the world, which implies a positive attitude towards addressing fragmentation of service provision inside health systems. While the principles of IC are simple, their implementation is more controversial. The ever growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by ageing multi-morbid patients. An exhaustive definition of IC should now enclose the coordination of health and social services useful to deliver seamless care across organizational boundaries. The current debate on IC is largely fueled by the modern mismatch between the growing burden of health needs for chronic conditions from the demand side and the design of health systems still largely centered on acute care from the supply side. The major reasons of persisting IC weakness in Western European nations stem from arguable choices of health policy taken in a quite recent past. The political creed in ‘market competition’ is likely to be the most emblematic. All initiatives encouraging healthcare providers to compete with each other are likely to discourage IC. Another historically rooted reason of IC weakness is the occupational status of European general practitioners (GPs). While single large-scale organizations have become a pressing priority for a modern primary care, most GPs are still selfemployed professionals working in their own cabinets. It is time to reconsider the anachronistic status of GPs so as to enhance IC in the future.

Background Drugs with anticholinergic effects are associated with adverse events such as delirium and falls as well as cognitive decline and loss of independence. Objective The aim of the study was to evaluate the association between anticholinergic burden and both cognitive and functional status, according to the hypothesis that the cumulative anticholinergic burden, as measured by the Anticholinergic Cognitive Burden (ACB) Scale and Anticholinergic Risk Scale (ARS), increases the risk of cognitive decline and impairs activities of daily living. Methods This cross-sectional, prospective study (3-month telephone follow-up) was conducted in 66 Italian internal medicine and geriatric wards participating in the Registry of Polytherapies SIMI (Società Italiana di Medicina Interna) (REPOSI) study during 2010. The sample included 1,380 inpatients aged 65 years or older. Cognitive status was rated with the Short Blessed Test (SBT) and physical function with the Barthel Index. Each patient’s anticholinergic burden was evaluated using the ACB and ARS scores. Results The mean SBT score for patients treated with anticholinergic drugs was higher than that for patients receiving no anticholinergic medications as also indicated by the ACB scale, even after adjustment for age, sex, education, stroke and transient ischaemic attack [9.2 (95 % CI 8.6–9.9) vs. 8.5 (95 % CI 7.8–9.2); p  = 0.05]. There was a dose–response relationship between total ACB score and cognitive impairment. Patients identified by the ARS had more severe cognitive and physical impairment than patients identified by the ACB scale, and the dose–response relationship between this score and ability to perform activities of daily living was clear. No correlation was found with length of hospital stay. Conclusions Drugs with anticholinergic properties identified by the ACB scale and ARS are associated with worse cognitive and functional performance in elderly patients. The ACB scale might permit a rapid identification of drugs potentially associated with cognitive impairment in a dose–response pattern, but the ARS is better at rating activities of daily living.

Background From 20 to 65 % of older adults receiving polypharmacy take at least one potentially inappropriate medication (PIM), leading to a high risk of adverse drug reactions. The term deprescribing was coined to describe a process of optimization of drug regimens through the withdrawal of PIMs. There is a paucity of evidence on the attitudes, beliefs and willingness of hospitalized patients towards deprescribing. Objective To measure at hospital discharge inpatients’ attitudes and beliefs towards polypharmacy and the potential withdrawal of one or more of their medications using the PATD (Patients’ Attitudes Towards Deprescribing) questionnaire and determine if they are associated with participant characteristics. Setting Geriatric and internal medicine wards in an Italian teaching hospital. Method Administration of the PATD questionnaire (developed and validated in an Australian outpatient setting, translated and adapted to the Italian setting for this study) to a consecutive sample of 100 older (aged ≥65 years) inpatients with polypharmacy who were interviewed by a nurse or pharmacist at the time of hospital discharge. Main outcome measure Older patients’ attitudes and beliefs towards reducing medications and participant characteristics. Results Eighty-nine percent of patients surveyed would like to reduce the number of daily medications. The desire for deprescribing was not associated with age, sex or number of medications or medical conditions; older patients were less aware of the reasons for taking medications. Conclusion The majority of hospitalized older adults with polypharmacy think they are taking a lot of drugs and would like to reduce this number. Older adults should not be considered a major limitation on deprescribing interventions. Future research should examine this issue with qualitative studies in order to gain a more in-depth understanding and explore how these findings can be translated into a multidisciplinary deprescribing process.

Individuals may have conflicts of interest (CoI) when they choose between the duties of their jobs and their own private interests. In medicine, CoI are potentially ubiquitous and their disclosure has now become the most frequent strategy to address them in professional lives. In the medical literature, CoI are classified into two different types—financial and non-financial. Financial CoI are easy to identify and can bias any kind of results in research; so, their disclosure is very important. The unsolvable dilemma is where to set the lowest limit for sums received from industry. Non-financial CoI are a very large category intrinsically related to the individuals concerned, ranging from family relationships to religious beliefs, and the mere disclosure of many of them can raise privacy and ethical issues. Two opposite narratives characterize the debate on financial CoI caused by pharmaceutical industry. The critical side argues that, because the primary goal of pharmaceutical industry is inevitably to promote its products, the best strategy is to stay away from financial CoI. On the other hand, the defensive side claims that financial CoI are boosted by ideology but meaningless in real practice, since any kind of interest can raise a potential conflict. A missing point in the debate on financial CoI is that health care is a classical example of ‘market failure’ in the economic theory. Since health cannot be considered a ‘consumer good’, the economic paradigm of ‘free market’ does not fit for healthcare products. To conclude, even though transparency on financial CoI cannot itself deter the risk of bias, rejecting it would be an even bigger mistake. At variance, mandatory disclosure of non-financial CoI risks to be confusing and questionable in many cases, paradoxically distracting attention from the potential bias created by financial CoI.