General Practice In Italy Research Articles

Building context-specific evidence to fight antimicrobial resistance: the role of Family Medicine research.

The health and economic burden of antimicrobial resistance (AMR) is a major global concern. One of the main causes of AMR is the overuse of antibiotics and Italy has higher rates of consumption of these drugs, as well as of AMR, if compared to many other European countries. To foster a more appropriate use of these drugs, initiatives that involve physicians and other healthcare professionals, citizens and institutions are urgently needed. This editorial will present a research project that aims to describe a multifaceted educational intervention structured in lessons, case based learning, consultation mapping and interactive virtual classes, and tailored to the learning needs of physicians, as revealed by the collection of their answers to a knowledge and attitudes questionnaire on antibiotic prescriptions and resistance. These kind of collaborative, non-profit, multi-professional and inter-institutional research projects are urgently needed in Italy, especially in the primary care sector, to produce the context-specific evidence necessary to bridge the gap, on the one hand, between experimental evidence and everyday practice of Family Physicians and, on the other hand, between past and future of General Practice in Italy.

Relationships Between Somatic Symptoms and Panic-Agoraphobic Spectrum Among Frequent Attenders of the General Practice in Italy.

Frequent attenders (FAs) of general practitioners (GPs) often complain of nonspecific physical symptoms that are difficult to define according to typical medical syndromes criteria but could be acknowledged as atypical manifestations of mental disorders. We investigated the possible correlation between somatic symptoms and panic-agoraphobic spectrum symptoms in a sample of 75 FAs of GPs in Italy, with particular attention to the impact on functional impairment. Assessments included the Patient Health Questionnaire, Panic-Agoraphobic Spectrum-Self-Report (PAS-SR) lifetime version, Global Assessment of Functioning, and Clinical Global Impression. The PAS-SR total and domains scores were significantly higher among low-functioning FAs, especially anxious somatizations, hypochondriasis, anxious expectation, and reassurance orientation domains, suggesting this undetected symptom may determine the selective attention to the physical symptoms, illness-phobic/hypochondriac elaboration, and GP frequent attendance, often aimed at searching for reassurance, leading to severe impact on overall functioning and often inefficacious treatments.

Prevalence and control of hypertension in the general practice in Italy: updated analysis of a large database.

Systematic assessment of blood pressure (BP) control rates may help to improve the clinical management of hypertension in clinical practice. This approach had limited application in Europe over the last three decades and only recently has been implemented in some countries. The present study is aimed at evaluating hypertension prevalence and control among adult outpatients followed by a large, representative sample of general practitioners (GPs) in Italy. We retrospectively analysed the data derived from the GP Health Search-CSD database in 2013. Hypertension prevalence and control were estimated within the overall population sample and in hypertensive outpatients, respectively, according to age and gender. Hypertension diagnosis was defined according to the International Classification of Diseases 9. Clinic BP levels were measured according to the European guidelines. BP control was defined as systolic/diastolic BP <140/90 mm Hg. Data from 911 753 individuals (52.2% females) were scrutinized. Hypertension was diagnosed in 236 377 (25.9%) patients, being higher in male aged <70 years than age-matched female. Hypertension control was recorded in 60.6% of hypertensive patients, being higher in female than male individuals aged <70 years. Our current analysis demonstrates that about 26% of adult outpatients followed in the GP setting had hypertension and that about 61% had controlled BP levels. Both prevalence and control of hypertension appear to be higher when compared with the data reported from the analysis of the same database in 2005, thus confirming a positive trend in BP control in the GP clinical setting in Italy.

Attitudes and preferences for the clinical management of hypertension and hypertension-related cardiac disease in general practice: results of the Italian Hypertension and Heart Survey.

The aim of this study was to evaluate attitudes and preferences for the clinical management of hypertensive patients with cardiac organ disease, including left ventricular hypertrophy (LVH) and coronary artery disease (CAD), in Italy. A predefined 15-item questionnaire was anonymously administered to a large community sample of general practitioners (GPs) and specialised physicians between November 2012 and June 2013. Estimated prevalence of hypertension-related clinical conditions was stratified into four groups (10-20%, 20-40%, 40-50%, >50%); preferences were reported as percentage among valid answers to the survey questionnaire. A total of 1319 physicians (672 males, age 55.0 ± 7.1 years, age of medical activity 27.1 ± 7.6 years), among whom 1264 GPs and 55 specialised physicians, was included. LVH was reported to be the most frequent marker of organ damage by the majority of physicians (73.5%). LV diastolic dysfunction was reported to be relatively frequent (>40%) by more than half of the specialised physicians (58.2%) and less frequent (10-20%) by GPs (49.8%); LV systolic dysfunction, atrial fibrillation and CAD were considered to be less frequent (10-20%) by the majority of physicians (61.3, 71.6 and 53.3%, respectively). Echocardiography was the preferred diagnostic tool used to estimate LVH (76.6%). Tight blood pressure control (130/80 mm Hg) was considered to be the most appropriate by the majority of physicians, both in hypertensive patients with LVH and in those with CAD. With the well-known limitations of a cross-sectional survey, this study provides information on attitudes and preferences for the clinical management of outpatients with hypertension and high CV risk profile in general practice in Italy.

Clinical features of constipation in general practice in Italy.

Definition and diagnosis of constipation remain challenging, partly due to different perceptions of the disease by doctors and patients. To evaluate prevalence and features of constipation among individuals seen in general practice, by comparing different diagnostic instruments. Standardized questionnaires and the Bristol stool form scale were distributed to all subjects attending 10 general practitioners for any reason in a 2-week period. The questionnaires investigated constipation defined according to: (1) self-perception (yes/no); (2) a visual analogue scale; (3) Rome III Criteria. The prevalence of constipation in 1306 subjects (790 female, 516 male) resulted: (1) 34% self-reported; (2) 28% by visual analogue scale; (3) 24% by Rome Criteria. Constipation was more frequent in females. A high frequency of symptoms of obstructed defecations was observed with differences among patients with self-reported constipation with or without Bristol stool type 1-2. Prevalence of constipation among individuals attending their GP ranges between 24 and 34%, according to the different definitions adopted. Symptoms of obstructed defecations are frequent. The combination of self-evaluation and the Bristol stool type scale is potentially useful to identify subgroups of patients with different clinical features in general practice.

Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial

The EUROACTION PLUS trial measured the effectiveness of a nurse-led preventive cardiology programme (EUROACTION) offering intensive smoking cessation PLUS optional varenicline for persistent high CVD risk smokers to reduce overall cardiovascular risk compared with usual care (UC) in general practice (GP). A parallel group randomized controlled trial in 20 GP in Italy, Netherlands, Spain, and UK. Six hundred and ninety-six current smokers, (137 vascular disease and 559 high total CVD risk), were randomized 350 to EUROACTION PLUS (EA+) and 346 to UC. Specially, trained nurses offered the EUROACTION preventive cardiology programme addressing smoking cessation, diet, physical activity, and risk factor management to reduce overall cardiovascular risk. The primary endpoint was 7 day point prevalence of self-reported abstinence (validated breath carbon monoxide <10 p.p.m.) at 16 weeks. Secondary outcomes included dietary habits, physical activity, weight, blood pressure (BP), lipid, and glucose management. One hundred and seventy-seven (51%) EA+ patients (91% opted to use varenicline) were abstinent vs. 63 (19%) in UC; OR 4.52 (95% CI: 3.20-6.39). The Mediterranean diet score of ≥9 in 149 (52%) EA+ patients vs. 97 (37%) in UC; OR 1.84 (95% CI: 1.31-2.59). Physical activity target achieved in 46 (16%) EA+ patients vs. 19 (7%) in UC; OR 2.48 (95% CI: 1.41-4.36). Target BP (<140/90 mm Hg) achieved in 150 (52%) EA+ patients vs. 112 (43%) in UC, OR 1.47 (95% CI: 1.05-2.06) with no difference in antihypertensive drugs. There were no differences in management of cholesterol or glucose. The EUROACTION preventive cardiology programme in high CVD risk smokers using optional varenicline substantially increased smoking abstinence over 16 weeks and also reduced overall cardiovascular risk compared with UC. REC reference: 09/H0402/85; EudraCT number: 2009-012451-18; http://www.controlled-trials.com/ISRCTN22073647, 12 February 2014, date last accessed.

Italian lessons: exploring general practice in Italy

The mere mention of Italy, for most people, conjures images of beautiful scenery, culinary delights, and magnificent architecture. Having thoroughly explored these particular avenues in the past, I was keen to delve into the Italian world of medicine to understand how my chosen profession works there. This was made possible thanks to funding obtained by the RCGP for 30 UK GP trainees to travel to Europe this year to spend 2 weeks observing a GP in their chosen country, with the main objective to broaden professional horizons and encourage interest in the healthcare systems of our European counterparts. As a current ST3 trainee, for whom QOF and NICE have always existed, without a doubt the most striking difference I noted was the relative lack of financial restrictions in Italy with regards to the prescribing and ordering of investigations. Medications are almost always prescribed by brand name, first because there is little pressure to prescribe generically, and second because patients have a longstanding …

General practice in Italy: from individual practice to multi-professional collaboration

In Public Health, the multiprofessional team is became essential to guarantee high quality levels of performances. General Practice, which is the basic element of the primary health care, has urgently to undertake a way which could lead it from voluntary associationism to obligatory aggregation and then to the construction of a motivation/convenience system which correlate individuals to the team activity.

Prevalence of ‘Borderline’ Values of Cardiovascular Risk Factors in the Clinical Practice of General Medicine in Italy

The prevalence of patients with 'borderline' levels of cardiovascular risk factors has been rarely investigated, being often reported in studies evaluating abnormal values of these parameters. The BORDERLINE study represents a pilot experience to primarily identify the prevalence of 'high-normal' conditions, such as pre-hypertension, lipid and glucose levels in the upper range of normality in the setting of general practice in Italy. The aim of this study was to evaluate the prevalence of patients with 'borderline' values of cardiovascular risk factors in Italy. Involved physicians were asked to evaluate the first 20 outpatients, consecutively seen in June 2009. Data were collected in a study-designed case-report form, in which physicians identified thresholds rather than reported absolute values of several clinical parameters. High-normal values were defined as follows: blood pressure (BP) 130-140/85-90 mmHg; total cholesterol 180-200 mg/dL; low-density lipoprotein cholesterol (LDL-C) 130-150 mg/dL; high-density lipoprotein cholesterol (HDL-C) 30-40 mg/dL in males and 40-50 mg/dL in females; triglycerides 130-150 mg/dL and fasting glucose 100-110 mg/dL. Fifty-three Italian physicians provided valuable clinical data on 826 individual outpatients, among which 692 (83.7%, 377 women, mean age 60.9 ± 13.2 years, body mass index 26.6 ± 5.0 kg/m2) were included in the present analysis. Prevalence of borderline values of systolic BP and total cholesterol levels were at least comparable with those in the normal limits of the corresponding parameters, whereas prevalence of borderline diastolic BP, LDL-C, HDL-C, triglycerides and fasting glucose levels was significantly lower than that of normal values, but higher than that of abnormal values of the corresponding parameters. Using this sample of healthy subjects in the setting of general practice in Italy, our results demonstrated a relatively high prevalence of borderline values of cardiovascular risk factors, which was at least comparable with that of normal, but significantly higher than that of abnormal thresholds. These preliminary findings may prompt more extensive investigations in the area of 'borderline' cardiovascular risk. This information may, in fact, potentially enable the design of more effective prevention strategies in the future to limit the burden of cardiovascular disease in the general population in Italy. Received for publication 4 March 2011; accepted for publication 20 April 2011.

Quality assessment of information about medications in primary care electronic patient record (EPR) systems

Many different brands of primary care electronic patient record (EPR) software are available to general practitioners (GPs). Their ability to support GPs in improving prescribing varies greatly. To assess, using a ten-item tool, the quality of drug information provided by EPR software to support the appropriateness of prescriptions and to propose a list of quality standards for this type of application. The eight EPR programmes most used in general practice in Italy were assessed by a multidisciplinary team using the ten-item tool. The tool evaluated information on single drugs and drug safety and information on prescription rules in force. Out of eight EPR programmes assessed, none scored more than 55% of the maximum possible score. Two achieved scores higher than 50%, one scored 48%, four ranged from 32% to 39% and one obtained 22%. Information on drug safety, such as the ability to detect interactions, to monitor laboratory parameters or to get updated information on drug safety was particularly limited. None of the eight EPR programmes contained drug information for patients, but two of them contained drug advertising. This project highlighted the poor quality of drug information provided by these EPR programmes. The ten-item tool seems suitable for assessing their quality. Based on this analysis, we have proposed a set of ten quality standards for prescribing software.

Hypertension Management

Elevated blood pressure is a major modifiable risk for cardiovascular disease (CVD) and the leading cause of preventable death worldwide. Current estimates indicate that ≈7.6 million premature deaths and 92 million disability-adjusted life years are attributable to suboptimal blood pressure.1 Most of the lifestyle causes of hypertension are well known, and clinical trials provide clear evidence that reducing blood pressure with antihypertensive drugs significantly decreases CVD morbidity and mortality. Despite this, the World Health Organization is predicting an epidemic of hypertension and, in clinical practice, most patients with hypertension are undiagnosed, untreated, or suboptimally treated.2 Against the backdrop of increasing CVD burden worldwide, the gap between what we know and do in hypertension prevention and management is a major cause for concern. Achieving optimum hypertension control to prevent hypertension-associated CVD has been a substantial challenge. There are multiple reasons for lack of blood pressure control, including health care system characteristics, as well as patient and physician characteristics.3 Treatment and control rates of hypertension are particularly low in most developing countries (typically <10%), and even developed countries have far from ideal levels …

Randomised controlled trials for evaluating the prescribing impact of information meetings led by pharmacists and of new information formats, in General Practice in Italy.

BackgroundSuboptimal translation of valid and relevant information in clinical practice is a problem for all health systems. Lack of information independent from commercial influences, limited efforts to actively implement evidence-based information and its limited comprehensibility are important determinants of this gap and may influence an excessive variability in physicians' prescriptions. This is quite noticeable in Italy, where the philosophy and methods of Evidence-Based Medicine still enjoy limited diffusion among practitioners. Academic detailing and pharmacist outreach visits are interventions of proven efficacy to make independent and evidence-based information available to physicians; this approach and its feasibility have not yet been tested on a large scale and, moreover, they have never been formally tested in Italy.Methods/DesignTwo RCTs are planned:1) a two-arm cluster RCT, carried out in Emilia-Romagna and Friuli Venezia Giulia, will evaluate the effectiveness of small group meetings, randomising about 150 Primary Care Groups (corresponding to about 2000 GPs) to pharmacist outreach visits on two different topics. Physicians' prescriptions (expressed as DDD per 1000 inhabitants/day), knowledge and attitudes (evaluated through the answers to a specific questionnaire) will be compared for target drugs in the two groups (receiving/not receiving each topic).2) A three-arm RCT, carried out in Sardinia, will evaluate both the effectiveness of one-to-one meetings (one pharmacist visiting one physician per time) and of a 'new' information format (compared to information already available) on changing physicians' prescription of specific drugs. About 900 single GPs will be randomised into three groups: physicians receiving a visit supported by "traditional" information material, those receiving a visit with "new" information material on the same topic and those not receiving any visit/material.DiscussionThe two proposed RCTs aim to evaluate the organisational feasibility and barriers to the implementation of independent information programs led by NHS pharmacists. The objective to assess a 10 or 15% decreases in the prescription of the targeted drugs is quite ambitious in such 'natural' settings, which will be minimally altered by the interventions themselves; this in spite of the quite large sample sizes used comparing to other studies of these kind. Complex interventions like these are not easy to evaluate, given the many different variables into play. Anyway, the pragmatic nature of the two RCTs appears to be also one of their major strengths, helping to provide a deeper insight on what is possible to achieve – in terms of independent information – in a National Health System, with special reference to Italy.Trial registrationISRCTN05866587 (cluster RCT) and ISRCTN28525676 (single GPs RCT)

Extending the Platinum-Free Interval with a Non-Platinum Therapy in Platinum-Sensitive Recurrent Ovarian Cancer

Background: It has been proposed that extending the platinum-free interval with intervening non-platinum therapy increases the efficacy of a later re-treatment with platinum in platinum-sensitive recurrent ovarian cancer. This hypothesis is based on data from small series and although it has not been validated prospectively, this strategy has entered general practice in Italy in the last years. The SOCRATES study retrospectively assessed the pattern of care of a cohort of patients with recurrent platinum-sensitive ovarian cancer observed in the years 2000–2002 in 37 Italian centres. Data were collected between April and September 2005. Methods: Patients with recurrent ovarian cancer with a platinum-free interval >6 months were eligible. 493 patient files were collected and 428 were eligible and analyzed. Results: The interval from the end of the 1st line to relapse was 6–12 months in 164 patients (39.5%) and >12 months in 251 cases (60.5%). Patients received a 2nd (100%), 3rd (80.1%), 4th (50.2%), 5th (28.3%), and 6th (11.9%) line of chemotherapy. At 2nd line 282 (65.9%) received platinum (group A), while 146 (34.1%) received non-platinum chemotherapy (group B). In the latter group, 67 patients received platinum at later progression (group B1), while 79 never received platinum (group B2). Median time to platinum re-treatment was 20 and 23.1 months in patients of groups A and B1, respectively. The response rate to the first platinum received was 74.4 and 57.4% in groups A and B1, respectively (p = 0.02). Group B2 was characterized by the worst response rate and survival. At multivariate analysis time of first platinum re-treatment (2nd line vs. later; p = 0.0132; OR = 2.34) and age (p = 0.0029; OR = 2.41) was independently associated with a higher possibility of response to platinum. Conclusions: With the limits of a retrospective study, our data question the hypothesis that extending the platinum-free interval with an intervening non-platinum therapy in patients with recurrent platinum-sensitive ovarian cancer improves the response rate of a further platinum re-treatment.

Parenteral Antibiotic Therapy in General Practice in Italy: A Direct Observational Study

The aim of this study was to determine the characteristics of parenteral antimicrobial therapy (PAT) in the general practice setting in Italy, the characteristics of patients and the presence of possible external factors (induced prescriptions). 204 General Practitioners (GPs) enrolled during a one-year period the first ten patients to whom they prescribed a PAT, collecting data about clinical characteristics, compliance, outcome and the therapy prescribed or induced. Results indicate that 1,892 patients received a PAT. The use of PAT was preferred for elderly patients. In 55.2% of cases the site of infection was in the lower respiratory tract, followed by urinary tract (14%) and upper respiratory tract (12%). In 98% of cases the route of administration was intramuscular. The first motivation for PAT was in about 50% of cases the severity of the illness, afterward the prescription induced by a specialist in 16% of cases, and in 9% of cases the failure of oral antibiotic therapy.

Initial treatment of hypertension and adherence to therapy in general practice in Italy

Antihypertensive agents are among the most used therapeutic classes. The approach to the pharmacological treatment of hypertension is guided by international recommendations and adherence to treatment is known to result in effective prevention of cardiovascular risk. The aim of this study was to evaluate the pattern of use of antihypertensive agents in general practice in terms of drug choice for the initial treatment of hypertension and adherence to treatments among newly recruited patients. We collected the data of all antihypertensive drugs prescribed by general practitioners (GPs) and reimbursed between January 1998 and December 2002 by a Local Health Authority of Emilia Romagna (Ravenna district, 350,000 inhabitants). We selected subjects aged 40 years and older, permanently living in the area during the whole period of the study, who received their first prescription of antihypertensives between January and December 1999, with no prescription of antihypertensive agents in the previous year. For each patient, we documented the starting regimen and evaluated adherence to treatment in terms of persistence during the years (patients were defined persistent if they received at least one prescription per year) and in terms of daily coverage (patients were defined covered if they received an amount of drugs consistent with a daily treatment). Finally, switches or addition of other therapeutic classes during the 3-year period were identified. A cohort of 6,043 subjects receiving their first antihypertensive treatment in 1999 was obtained. Regarding the starting regimen, monotherapies with angiotensin converting enzyme inhibitors (n = 1,597; 26%) or calcium channel blockers (n = 1126; 19%) were the most frequently prescribed. Of the patients, 21% started with a drug combination regimen. Regarding adherence to treatment, 18% of the cohort received only one prescription throughout the 3 years, 13% received more than one prescription but stopped the therapy during the first year, 69% were persistent during the second year and 60% also during the third year. Only 34% were covered during the first year and 24% also during the second year, whereas only 20% of the patients resulted covered throughout the 3 years. Among persistent patients, 41% maintained the same antihypertensive regimen throughout the 3 years, 25% added other drugs to the initial treatment and 34% switched to completely different regimens. Our findings reflect the lack of convergence among guidelines on the drug class(es) to be considered as first choice in the initial treatment of hypertension. Although an intervention in this field may have important implications in terms of cost savings, the ongoing debate does not allow us to draw definite conclusions on whether measures should be taken by the National Health Authority. However, the lack of adherence to antihypertensive treatment is undoubtedly a matter of concern for public health and should be addressed with appropriate interventions.

Aspirin therapy in type 2 diabetes in a general practice in Italy

Aspirin therapy in type 2 diabetes in a general practice in Italy

Somatic symptoms and depression in general practice in Italy

Among primary care attenders, depression is a common and debilitating disturbance. These patients imply higher medical costs compared with those without depression, even after controlling for comorbid physical illness. A study performed in 15 countries worldwide has shown that ICD-10 mental disorders were present in 24% of primary care attenders. Detection and management of depression in primary care have received increasing attention. Most individuals with depression have been shown to consult their GPs for somatic symptoms rather than psychological ones. In the study mentioned above, 69% of the depressed patients reported only somatic symptoms. Another study found that GPs were able to diagnose a mental disorder in 90% of subjects presenting psychopathological symptoms and in 50% of those with somatic symptoms. In the light of the above, the Italian College of General Practitioners (Società Italiana di Medicina Generale-SIMG) in the area of Varese (north of Italy) organised a course on depression. Then a study was carried out in our setting. The aim was to evaluate the frequency of depression in patients who seek care for somatic symptoms, where tests showed that these symptoms were without an organic cause.

Use of anti-asthmatic drugs in Italy: analysis of prescriptions in general practice in the light of guidelines for asthma treatment.

Our aim was to analyse anti-asthmatic drug utilisation in primary health care in a Northern Italian region in the light of guidelines for asthma treatment. We collected all prescriptions for anti-asthmatic agents reimbursed in 1998 in six local health authorities (overall population: 1,909,192 inhabitants) of Emilia Romagna (Northern Italy). The asthmatic cohort was defined as the population of subjects aged 20-44 years receiving at least one prescription of an anti-asthmatic agent devoid of indications for transient respiratory diseases. In order to include routine users, the asthmatic cohort was restricted to those subjects with at least one prescription in the first quarter of 1998. Anti-asthmatic agents were classified according to their therapeutic role as follows: maintenance therapy for mild-moderate asthma (Mm); maintenance therapy for severe asthma (Ms); quick relief for mild attack (Qm) and quick relief for severe attack (Qs). The asthmatic cohort included 11,518 subjects; of these, 47% received only one prescription in 1998. The most frequent regimens were Mm+Qm (25%) and Qm alone (23%). Some regimens appeared not to be in accordance with international recommendations. The main reasons were lack of drugs for quick relief (36%), use of long-term beta(2)-adrenoceptor agonists (Ms drugs) without quick-relief or anti-inflammatory agents (10% of the cohort and 56% of the recipients of Ms drugs) and presence of fixed-dose combinations (27%). In 76% of the patients treated with Mm drugs (mainly inhaled steroids), the total amount of drugs prescribed over the 1-year period covered less than 150 days. The use of anti-asthmatic drugs in general practice in Italy does not seem to comply with the international recommendations especially with regard to the use of quick-relief agents. Active interventions to implement guidelines and monitor the choice of drug regimens are warranted.

Nutrition in general practice in Italy

Since the early 1950s the health promoting qualities of the Mediterranean diet (characterized by low intakes of total and saturated fat and high intakes of fiber and complex carbohydrates) have been acknowledged. Unfortunately, this dietary pattern, effective in lowering the risk of coronary artery disease as well as oxidative stress and carcinogenesis, is widespread only in the southern part of Italy, whereas the eating style and morbidity pattern in northern Italy are similar to those in northern Europe. Moreover, trends in eating behaviors in southern Italy are at risk of impairing the comparative advantage given by the Mediterranean diet. The current eating profile in northern Italy and the trend in southern Italy are therefore a suitable field for educational interventions by general practitioners (GPs) to preserve and promote healthier dietary patterns. Nutrition training of GPs does not yet appear sufficient to enable them to tackle this need. The undergraduate curriculum used to include (and no longer does) only an optional course in basic nutrition; little more teaching is added during vocational training. In Piedmont, a north-western region around Turin, two four-hour seminars for vocational trainees deal with the topics of basic nutrition in children, adolescents, and adults; malnutrition in the elderly; and diet treatment of chronic renal failure. Continuing medical education covers the same topics and a further module deals with diet in the control of diabetes. An effort is needed in the nutritional training of Italian GPs to enable them to give to their patients more than merely commonsense advice.

Consequences of mental distress recognition in general practice in Italy: A follow-up study

Many reports have been recently published on the accuracy of mental distress detection by general practitioners. Recognition of ‘caseness’, irrespective of its accuracy, nevertheless determines the implementation of therapeutic interventions. This paper reports the results of a naturalistic study describing the consequences for the patients of being identified as ‘cases’ in the general practice (in terms of referral strategies at recruitment and outcome 3 months and 1 year later), in the context of care provision generated by the 1978 Italian psychiatric reform. Sixty-eight GPs recruited 878 ‘cases’ according to implicit criteria. Overall 20% of the patients were referred the psychiatric setting; only half of these for psychiatric care. After 3 months and 1 year from recruitment respectively 12% and 23% of the subjects were no longer ‘cases’. The factors contributing to predict the outcome at three months were age, symptom duration, comorbidity, presence of social context risk factors and prior psychiatric history (or presence of ‘major’ symptoms); after one year the predictors of caseness were caseness status at 3 months, and clinical severity, symptom duration and presence of somatization at recruitment. GPs remain the main care providers in the short- and long-term. The results of the study indicate the need for a reappraisal of the emphasis to be put on caseness recognition and on the development of standardized instruments for the identification of mental distress. Non-clinical variables concurring in the definition of caseness in general practice, and the factors influencing physicians' decision-making in the implementation of alternative intervention strategies should be further clarified by ad hoc studies.