Factors associated with first- versus second-generation long-acting antipsychotics prescribed under ordinary clinical practice in Italy
August
Factors associated with first- versus second- generation long-acting antipsychotics prescribed under ordinary clinical practice in Italy
Giovanni Ostuzzi 0 1
Maria Angela Mazzi 0 1
Samira Terlizzi 0 1
Federico Bertolini 0 1
Andrea Aguglia 1
Francesco Bartoli 1
Paola Bortolaso 1
Camilla Callegari 1
Mariarita Caroleo 1
Giuseppe Carrà 1
Mariangela Corbo 1
Armando D'Agostino 1
Chiara Gastaldon 0 1
Claudio Lucii 1
Fabio Magliocco 1
Giovanni Martinotti 1
Michela Nose 0 1
Edoardo Giuseppe Ostinelli 1
Davide Papola 0 1
Marco Piero Piccinelli 1
Alberto Piccoli 0 1
Marianna Purgato 0 1
Tommaso Tabacchi 1
Giulia Turrini 0 1
Mirella Ruggeri 0 1
Corrado Barbui 0 1
the STAR Network Investigators 1 2
0 0 Department of Mental Health, San Paolo Hospital , Milan , Italy , 11 Mental Health Department, USL Toscana sudest-Siena , Siena , Italy
1 Editor: Marianna Mazza, Universita Cattolica del Sacro Cuore Sede di Roma , ITALY
2 Membership of the STAR Network is provided in the Acknowledgments
Background
For many years, long-acting intramuscular (LAI) antipsychotics have been prescribed
predominantly to chronic and severe patients, as a last resort when other treatments failed.
Recently, a broader and earlier use of LAIs, particularly second-generation LAIs, has been
emphasized. To date, few studies attempted to frame how this change in prescribing took
place in real-world practice. Therefore, this study aimed to describe the clinical features of
patients prescribed with LAIs, and to explore possible prescribing differences between
firstand second-generations LAIs under ordinary clinical practice in Italy.
Methods
The STAR Network ªDepotº Study is an observational, longitudinal, multicenter study
involving 35 centers in Italy. In the cross-sectional phase, patients prescribed with LAIs were
consecutively recruited and assessed over a period of 12 months. Descriptive statistics and
multivariable logistic regression analyses were employed.
Results
Of the 451 recruited patients, 61% were males. The level of social and working functioning
was heterogeneous, as was the severity of disease. Seventy-two per cent of the patients had
a diagnosis of the schizophrenia spectrum. Seventy per cent were prescribed with
secondgeneration antipsychotic (SGA) LAIs (mostly paliperidone, aripiprazole and risperidone).
Compared to first-generation antipsychotic (FGA) LAIs, patients prescribed with SGA LAIs
were more often younger; employed; with a diagnosis of the schizophrenia spectrum or
bipolar disorder; with higher levels of affective symptoms; with fewer LAI prescriptions in the past.
Discussion
LAIs' prescribing practices appear to be more flexible as compared to the past, although this
change is mostly restricted to SGA LAIs.
Introduction
The problem of non-adherence to medications is a major concern in people with psychotic
disorders [
1
]. Antipsychotic discontinuation, is associated with poorer outcomes, including
recurrent relapses and hospitalizations, higher risk of suicide, and earlier social and functional
disability [2±4]. This is particularly relevant in early phases of disease, considering that
discontinuation is particularly frequent within the first years from the first episode of psychosis (with
estimated rates ranging from about 40% to 70%) [
5,6
], and most of these patients (from about
40% to 60% in most studies) are likely to relapse in the following few years [
7,8
]. Long-acting
intramuscular (LAI) antipsychotics' efficacy in preventing relapses and treatment
discontinuation is widely recognized [6,9±11]. Further, LAIs allow a complete tracking of medication
intake, promote the regular monitoring of clinical conditions, and lower the risk of
self-medication and harmful drug use. Also relevant disadvantages have been highlighted, such as pain
on the injection site, lack of flexibility in dose adjustments, and the impossibility of rapid
suspension in case of adverse events [
12,13
].
From their introduction, LAIs have been generally considered as a last-resort for chronic
patients with frequent relapses, low insight of disease, poor adherence to treatments,
aggressiveness and behavioral issues [12,14±16]. However, in the last decade, various factors
contributed to change this scenario. First, in addition to risperidone (marketed since 2001), other
second-generation antipsychotic (SGA) LAIs became available: olanzapine pamoate (since
2009), paliperidone palmitate 1-month (since 2009), aripiprazole long-acting (since 2010), and
paliperidone palmitate 3-months (since 2015) [
12,17
]. Second, in the same years, growing
evidence emerged in support of the use of antipsychotics (SGAs in particular) not only for
schizophrenia, but also for affective disorders [
18,19
]. Third, as the huge impact of non-adherence
on the course of disease became more evident, emphasis has been put on the need to address
this issue from the earliest phases of the disease [
20,21
]. Fourth, studies exploring the
subjective experience of patients suggest that the practicality of LAIs can notably ease patients' daily
routine, possibly improving attitudes toward medications [22±28]. These findings contributed
to progressively overcome the culturally rooted view of LAIs as coercive and stigmatizing
medications [
12,14,29,30
].
On these grounds, many researchers advocated for an earlier and broader use of LAIs
[20,21,31±34], and this viewpoint has been accounted by the most influential clinical
guidelines [35±38].
2 / 17
Despite the backdrop, few studies attempted to describe how this novel paradigm affected
prescribing practices. Available epidemiological data are limited to schizophrenia patients
[39±43] and highly selected populations [
40,44,45
]. In order to fill the gap in the research
literature, the cross-sectional phase of the STAR Network ªDepotº Study aimed at evaluating how
the claimed cultural change in LAIs prescription may have affected real-world practices, by (a)
describing the main socio-demographic and clinical features (including symptom profiles,
adherence and attitude towards treatments) of a large, representative, unselected population of
patients starting a LAI medication, and (b) exploring possible predictors of the class of LAI
prescribed.
Materials and methods
Study design
The STAR Network ªDepotº Study is an observational, longitudinal, multicenter study.
Patients prescribed with any LAI antipsychotic were consecutively recruited over a period of
12 months, and assessed after 6 and 12 months. The present paper is focused on baseline data
from the recruitment phase.
Participating centers are part of the STAR Network (Servizi Territoriali Associati per la
Ricerca—Community Services Associated for Research), a consortium of clinicians and
researchers working in Community Psychiatric Services across Italy. The main aim of this
group is to gather original data from real-world clinical practice and provide new pragmatic
insights for clinicians [46±48]. The STAR Network ªDepotº Study was conducted
independently from industry funding or support. The study protocol was approved by the Local Ethics
Committee of the Ethics Committee of the Azienda Ospedaliera Universitaria Integrata of
Verona (Comitato Etico per la Sperimentazione Clinica (CESC) of the Provinces of Verona and
Rovigo, protocol n. 57622 of the 09/12/2015), and was made publicly available at the Open
Science Framework (OSF) online repository (https://osf.io/wt8kx/). The present study was drawn
up following the `STrengthening the Reporting of OBservational studies in Epidemiology'
(STROBE) Statement items [
49
].
Participants
Measures
Patients were eligible for the study if they were (a) at least 18 years old; (b) willing to sign the
informed consent; and (c) beginning a LAI medication, provided that they did not receive any
other LAI in the previous three months. The simultaneous taking of other medications,
including oral antipsychotics, was not an exclusion criterion, nor was the setting of recruitment,
which might include hospital psychiatric wards, daytime community and residential facilities.
In order to collect socio-demographic and clinical data, the following measures were
administered at the baseline evaluation:
■ Recruitment form, which included socio-demographic information, clinical and
pharmacological information, and characteristics of the clinician who prescribed the LAI;
■ The clinician-rated Brief Psychiatric Rating Scale (BPRS) [
50
], validated in Italian
language [
51
], which assesses overall psychiatric symptoms. The overall level of
symptomatology should be considered mild, moderate and severe for scores ranging respectively
from 31 to 40, 41 to 52 and higher than 52 [
52
]. According to Shafer and colleagues [
53
],
3 / 17
five subscales were measured, namely affect, positive symptoms, negative symptoms,
resistance, and activation;
■ The self-administered Drug Attitude Inventory 10 items (DAI-10) [
54
], validated in
Italian language [
55
], which measures attitudes toward medications. The scores range
between -10 and 10, with higher scores indicating a better overall attitude toward
medications;
■ The clinician-rated Kemp's 7-point scale [
56
], compiled by the clinician, which assesses
overall adherence to treatments. The scores range from 1 to 7, with higher scores
indicating equally higher levels of adherence. Scores of 5 and above indicate an overall good
acceptance of medications.
Data management
All patients received detailed information on the nature of the study and the use of data on an
anonymised format, and were asked to sign an informed consent. The recruiter was required
to examine the mental capacity of the patients, by assessing his/her capacity of understand
both in a strict sense (i.e. comprehension of the language) and in a broad sense (i.e. the context,
the role of the examiner, the content of the research project, etc.), and to communicate his/her
decision, in order to determine whether he/she was capable to freely provide written consent.
Recruitment data were periodically forwarded from each recruiting center to the Verona
center, which had the role of coordination and scientific secretariat. Data were archived and
entered into a computerized database. Their correctness and consistency was ensured by the
double-entry technique and by a set of electronic and manual edit checks. Patient data were
recorded anonymously. A unique number both in the recruitment and follow-up forms and in
the database identified patients. Total confidentiality of data was guaranteed throughout the
entire course of the study, in accordance with the Declaration of Helsinki [57].
Statistical analysis
All statistical analyses were performed with STATA 13.0 [
58
]. Descriptive statistics were used
for information on main epidemiological characteristics of the recruited population.
Continuous variables were expressed as means and standard deviations, while categorical variables
were expressed as percentages. In order to describe possible associations between clinical and
socio-demographic characteristics and the class of LAI prescribed, both simple and
multivariable logistic regression analyses were performed. A bivariate analysis employing the class of
LAI as the dependent variable (0 = first-generation antipsychotic (FGA) LAIs; 1 = SGA LAIs)
was applied to a number of variables of clinical relevance. For the aims of the logistic model,
we employed the following dichotomous and categorical data: Italians versus non-Italians;
poor autonomy level (lives with relatives or in a residential house) versus good autonomy level
(lives alone or with partner and/or children); diploma/University degree versus other;
employed versus unemployed; schizophrenia spectrum versus bipolar disorder versus other
diagnosis; academic versus non-academic centers; Northern Italy versus Central and Southern
Italy. We also calculated the ratio between the prescribed daily dose (PDD) in the previous 12
months and the defined daily dose (DDD) [
59
]. All variables for which a statistically significant
association emerged in the bivariate analysis were included as independent variables in a
multivariable model. Subsequently, we produced a final multivariable model, including only the
independent variables for which a statistically significant association emerged from the
previous multivariable model. In order to evaluate the adequacy of the models some indices of
goodness of fit were performed. Specifically, the Hosmer-Lemeshow test, based on the
4 / 17
comparison between predicted and observed data by using deciles as stratification size, assesses
whether the model is well calibrated; McKelvey & Zavoina's pseudo R2, for its interpretation
(as percentage of explained variance) closed to the ªtraditionalº way [
60
]. Finally, Bayesian
Information Criterion (BIC) was used in the comparison between intermediate and final
multivariable models, to determine whether the exclusion of some explanatory variables decreased
the explanatory power of the last model. Regression analyses were based on robust estimator
of variance (cluster option of the STATA vce command) to account for the multicenter
observational design [
61
].
Results
Participating centers
Thirty-five Italian Community Psychiatric Centers took part in the study. Recruiting centers
included mostly non-academic mental health trusts (73.4%), however, the number of patients
recruited was equally distributed between academic and non-academic centers (54.5% vs.
45.4%, respectively). The majority of centers (73.4%) were located in Northern Italy, however
the number of patients recruited in these centers was only slightly higher than the number
recruited in Central and Southern Italy (59.4% vs. 40.6%, respectively).
Socio-demographic and clinical features
We recruited and included in the analysis 451 patients. All included participants provided an
informed, written consent. Sixty-one per cent of patients were males, with a mean age of 42.
Most patients lived with relatives (51%). Forty per cent had a diploma and 10% a University
degree. About 22% were employed at the time of recruitment. Other socio-demographic
details are reported in Table 1.
Fifty-six per cent suffered from schizophrenia, 16.5% from schizoaffective disorder, 18%
from bipolar disorder, 6% from personality disorders, and the remaining 3.5% from other
conditions, including obsessive-compulsive disorder, substance use disorders, mental retardation,
mental organic disorders, and dementia. We found high rates of alcohol and/or substance
abuse (27%) and of physical comorbidity (28%). According to the mean BPRS score, the level
of psychiatric symptoms was negligible for 12% of patients, mild for 19%, moderate for 26%,
and severe for 42%. Fifty-nine per cent of patients showed a positive attitude toward
medications according to the mean DAI-10 score, and 61% showed a good acceptance of medications
according to the mean Kemp's 7-point score. Ninety-two per cent of patients were taking at
least one oral psychotropic medication before introducing the LAI. The mean ratio between
the prescribed daily dose (PDD) and the defined daily dose (DDD) of all psychotropic drugs
taken in the previous year was 1.8 (sd 2), indicating that the cumulative dose of medications
was almost doubled with respect to the average maintenance dose. The majority of patients
were prescribed paliperidone palmitate (31%), aripiprazole LAI (25%), haloperidol decanoate
(20%) and risperidone LAI (10%) (Fig 1). Other clinical and pharmacological details are
reported in Table 2.
Comparison between classes of antipsychotic
All LAIs, n = 451
41.8 (13.4)
younger age (OR 0.97; 95% CI 0.95 to 0.98); being employed (OR 2.01; 95% CI 1.14 to 3.56);
having a higher score on the BPRS affective subscale (OR 1.09; 95% CI 1.04 to 1.14); and
having a lower number of LAIs prescribed in the past (OR 0.69; 95% CI 0.52 to 0.93). In addition,
having a diagnosis other than schizophrenia spectrum and bipolar disorder reduced the
probability of receiving SGA LAIs (OR 0.28; 95% CI 0.13 to 0.60).
The goodness-of-fit statistics indicated a moderate relationship between the type of LAIs
prescribed and the explanatory variables in both models: McKelvey and Zavoina Pseudo-R2
explained 18% and 16% of the variability. In calibration view, the models correctly classified
73% and 72% of the patients; the p-values associated with Hosmer±Lemeshow statistics were
low even though not significant, confirming moderate agreements between predicted
probabilities and observed data. Finally, the comparison between the BIC values showed a
substantial difference (25.84), preferring the final model.
Discussion
In general, present data confirm the expectation that a broader spectrum of individuals is
currently prescribed LAIs as compared to the past. A wide range of socio-demographic and
6 / 17
Fig 1. Frequency of LAIs prescribed. Legend: SGA = second-generation antipsychotic; FGA = first-generation antipsychotics;
LAI = long-acting injection.
clinical characteristics emerged. A relevant part of the cohort met the features typically
described in older studies (before the broad availability of most SGA LAIs), as patients were
mostly males in their middle adulthood, with low educational level, no employment, a
longstanding diagnosis of schizophrenia, and moderate-to-severe level of psychiatric symptoms
[15,62±65]. At the same time, relatively high functioning levels emerged in a surprisingly large
part of the population, considering that about 43% of patients lived alone or with the partner
and/or children, more than one out of five patients were employed, and half of the patients
had a diploma or a University degree. Similar considerations apply to clinical features,
considering that, beside a large number of patients with chronic conditions and severe
symptomatology, also patients with mild-to-moderate levels of symptomatology were well represented.
Further, data showed a relatively short course of disease (lower than 5 years) in about 36% of
patients, and an overall good attitude towards medications as perceived by both patients and
clinicians. Interestingly, a variety of diagnoses emerged. High rates of bipolar disorder were
expected, considering the recently broadened use of antipsychotics for affective disorders
[
18,19
]. In about 6% of patients, the LAI was probably prescribed to manage severe behavioral
symptoms arising from personality disorders or underlying somatic conditions (such as
mental retardation or dementia), although the use of antipsychotics in these cases is at least
controversial [
66,67
].
Highly selected populations from previous studies can be barely compared with the present
study, which employed a pragmatic, naturalistic approach, aimed at minimizing patients'
selection and reflect real-world practice as closely as possible.
7 / 17
All LAIs, n = 451
Schizophrenia 251 (55.9)
Schizoaffective disorder 74 (16.5)
Substance-related psychosis 2 (0.4)
Bipolar disorder 81 (18)
Obsessive-compulsive disorder 4 (0.9)
Personality disorder 27 (6)
Mental retardation 4 (0.9)
Mental organic disorder 4 (0.9)
Dementia 2 (0.4)
11.9 (10)
65 (14.4)
90 (19.9)
14 (3.1)
Cannabis 69 (76.7)
Cocaine 13 (14.4)
Other 8 (8.9)
127 (28.2)
n = number of patients; sd = standard deviation; BPRS = brief psychiatry rating scale; DAI = drug attitude inventory;
PDD = prescribed daily dose; DDD = defined daily dose
8 / 17
SGAs LAIs,
n = 316
the intermediate multivariable model includes only variables for which a statistically significant association emerged in the bivariate analysis
the final multivariable model includes only variables for which a statistically significant association emerged from the intermediate model
Bold characters indicate a p-value < 0.05.
The % reported in parenthesis refers to the ratio calculated respectively on all LAIs (first column), FGA LAIs (second column), SGA LAIs (third column)
SGA = second-generation antipsychotic; FGA = first-generation antipsychotic; n = number of patients; sd = standard deviation; OR = odds ration; CI = confidence
interval; BPRS = brief psychiatry rating scale; DAI = drug attitude inventory; PDD = prescribed daily dose; DDD = defined daily dose; H-L Chi2 = Chi-squared value of
the Hosmer-Lemeshow test; M&Z pseudo R2 = McKelvey-Zavoina pseudo R2 index; BIC = Bayesian information criterion
The use of LAIs on a broader number of clinical conditions may raise regulatory issues,
considering that licensed indications of SGA LAIs are limited only to patients with
schizophrenia in a maintenance phase with oral antipsychotics. Therefore, SGA LAIs were prescribed
off9 / 17
label to all patients without a diagnosis of schizophrenia (almost one out of five patients). On
the contrary, indications of FGA LAIs are narrower, often referring to symptom domains
rather than specific diagnosis, and may therefore be prescribed to patients with several
different diagnoses. The common off-label prescription of LAIs confirms the already well-known
trend of oral antipsychotics [
68
].
Representativeness of the cohort seems warranted also in terms of high prevalence of
comorbid physical conditions [
69,70
] (about one out of four patients had at least one
comorbidity, mostly endocrine/metabolic or cardiovascular) and of ªdual diagnosisº, considering
that one out of four used alcohol or substances [71±73].
In most cases LAIs were prescribed after severe disease relapse, considering the large
number of patients hospitalized in the previous year, the high rate of compulsory admissions, and
the long mean length of stay. This may suggest that, despite the recommendation of offering
LAIs from the early phases of disease [
37,38
], in many cases these formulations are still chosen
after failures with other treatments.
More than two out of three patients were prescribed with SGA LAIs. The most commonly
prescribed medications were paliperidone palmitate (31%), aripiprazole LAI (25%) and
haloperidol decanoate (20%). These results are in line with data from some of the previous studies
[
42,74,75
], while, in others, prescription rates appeared to be extremely heterogeneous
[
40,41,44
]. This is likely to be associated with a number of factors influencing local prescribing
patterns and with the different recruitment periods across studies (and therefore different
availability of SGA LAIs). The use of aripiprazole LAI was surprisingly high compared to other
recent studies [40±42,75]. The advantages of this medication have been repeatedly stressed: it
is relatively safe in terms of motor, metabolic and endocrine side effects (it does not usually
alter prolactin levels), and it proved to be comparable to other SGAs in terms of efficacy for
the treatment of schizophrenia [
76,77
]. Further, robust results from a recent meta-analysis
showed a better overall acceptability of aripiprazole LAI as compared to the oral counterpart,
although the interpretation of this data is still unclear [78]. On the other hand, paliperidone
substantially equals olanzapine and risperidone in terms of metabolic effects and prolactin
level increase [
76
]. Its choice over olanzapine and risperidone is likely to be related to its
enhanced practicality compared to the biweekly administration of risperidone LAI, and the
complex regulatory requirements of olanzapine pamoate. Haloperidol decanoate, besides its
possible disadvantages (e.g. motor symptoms, QTc prolongation, locally irritant preparations),
remains a widely used medication in clinical practice, possibly because of its relatively safe
metabolic profile [
76
], its low cost, and the flexibility of the LAI in terms of doses and
frequency, as compared to other LAIs (including SGAs).
The multivariable logistic model comparing FGA LAIs and SGA LAIs showed that the latter
were prescribed significantly more often to younger, employed individuals, with a diagnosis of
schizophrenia or bipolar disorder, with higher levels of affective symptoms, and without a
previous history of LAI prescription. This profile resembles closely the one pictured by those
claiming a cultural change in the clinical use of LAIs. This trend is similar to what emerged
from previous studies, although in many cases only FGA LAIs and risperidone LAI were
compared [79±81], confounders were not considered [
40,42,80
], and social and clinical variables
possibly associated with the class of LAI were not analyzed. Notably, no significant differences
emerged between patients prescribed with FGA LAIs and SGA LAIs in terms of overall
psychiatric symptoms, adherence and attitudes towards medications, both as perceived by
psychiatrists (Kemp's 7-point score) and by patients (DAI-10 score). To our knowledge, the study by
Singh and colleagues [
81
] is currently the only available one employing the DAI (in this case,
the version with 30 items), and it reached similar conclusions, although only FGA LAIs and
LAI risperidone were compared.
10 / 17
As expected according to current research [82±84], SGAs were preferred when targeting
affective symptoms. This may also reflect the common idea of FGAs as medications associated
with apathy, lack of initiative, anhedonia, indifference, blunted affect (the so-called
neuroleptic-induced deficit syndrome) [
85,86
].
This study has also limitations. First, our cross-sectional design cannot detect a causal
association between variables, and all statistical associations discussed should be regarded as
merely exploratory. Second, the use of simple rating scales (in accordance to the pragmatic
attitude of the study) might have affected the precision in measuring variables, such as
psychiatric symptoms and patients' attitudes toward medications. Third, characteristics of recruiting
centers were heterogeneous in terms of settings (e.g. community services, hospital wards,
rehabilitation facilities), and each site contributed to the recruitment to a different extent. In
addition, various local factors may have strongly influenced prescribing attitudes of each center
(e.g. local guidelines and long-standing habits, availability of medications). This, along with
our wide inclusion criteria, led to heterogeneity in the recruited population. This reflects the
complexity of real-world clinical settings, bolstering the external validity of results, but may at
the same time affect their internal validity [
87
]. To address this limitation, we employed
statistical techniques accounting for variability between centers.
Conclusions
This study showed a notable change in LAIs prescribing patterns, as compared with previous
epidemiological surveys. The advocated cultural change in the use of LAIs is currently under
way in Italian Community Psychiatric Services, as showed by more flexible and heterogeneous
prescribing patterns, addressing a wider range of clinical conditions and functioning levels.
This change appears to be mostly confined to SGA LAIs, while prescribing patterns of FGA
LAIs are practically unchanged as compared to the past, as they are mostly reserved to older
patients, with lower functioning levels, previous use of LAIs, and, commonly, behavioral issues.
Further research is needed to shed light on how LAIs can improve adherence, attitudes
toward medications, and subjective wellbeing of patients in real-world practice. This will be
the main goal of the follow-up phase of the STAR Network ªDepotº Study.
Acknowledgments
The STAR Network Investigators are: Corrado Barbui (Verona), Michela Nose (Verona),
Marianna Purgato (Verona), Giulia Turrini (Verona), Giovanni Ostuzzi (Verona), Maria Angela
Mazzi (Verona), Davide Papola (Verona), Chiara Gastaldon (Verona), Samira Terlizzi
(Verona), Federico Bertolini (Verona), Alberto Piccoli (Verona), Mirella Ruggeri (Verona),
Pasquale De Fazio (Catanzaro), Fabio Magliocco (Catanzaro), Mariarita Caroleo (Catanzaro),
Gaetano Raffaele (Catanzaro), Armando D'Agostino (Milano), Edoardo Giuseppe Ostinelli
(Milano), Margherita Chirico (Milano), Simone Cavallotti (Milano), Claudio Lucii (Siena),
Simone Bolognesi (Siena), Sara Debolini (Siena), Elisa Pierantozzi (Siena), Francesco Fargnoli
(Siena), Maria Del Zanna (Siena), Alessandra Giannini (Siena), Livia Luccarelli (Siena),
Alberto De Capua (Siena), Pasqua Maria Annese (Siena), Massimiliano Cerretini (Siena),
Fiorella Tozzi (Siena), Nadia Magnani (Grosseto), Giuseppe Cardamone (Grosseto), Francesco
Bardicchia (Grosseto), Edvige Facchi (Grosseto), Federica Soscia (Grosseto), Spyridon Zotos
(Ferrara), Bruno Biancosino (Ferrara), Filippo Zonta (Treviso), Francesco Pompei (Treviso),
Camilla Callegari (Varese), Daniele Zizolfi (Varese), Nicola Poloni (Varese), Marta Ielmini
(Varese), Ivano Caselli (Varese), Edoardo Giana (Varese), Aldo Buzzi (Varese), Marcello
Diurni (Varese), Anna Milano (Varese), Emanuele Sani (Varese), Roberta Calzolari (Varese),
Paola Bortolaso (Varese Verbano), Marco Piccinelli (Varese Verbano), Sara Cazzamalli
11 / 17
(Varese Verbano), Gabrio Alberini (Varese Verbano), Silvia Piantanida (Varese Verbano),
Chiara Costantini (Varese Verbano), Chiara Paronelli (Varese Verbano), Angela Di Caro
(Varese Verbano), Valentina Moretti (Reggio Emilia), Mauro Gozzi (Reggio Emilia), Chiara
D'Ippolito (Reggio Emilia), Silva Veronica Barbanti (Reggio Emilia), Papalini Alessandro
(Reggio Emilia), Mariangela Corbo (Chieti), Giovanni Martinotti (Chieti), Ornella Campese
(Chieti), Federica Fiori (Chieti), Marco Lorusso (Chieti), Lucia Di Capro (Chieti), Daniela
Viceconte (Chieti), Valerio Mancini (Chieti), Francesco Suraniti (Catania), Maria Salvina
Signorelli (Catania), Eugenio Rossi (Bologna), Pasqualino Lupoli (Bologna), Marco Menchetti
(Bologna), Laura Terzi (Bologna), Marianna Boso (Pavia), Paolo Risaro (Pavia), Giuseppe De
Paoli (Pavia), Cristina Catania (Pavia), Ilaria Tarricone (Bologna), Valentina Caretto
(Bologna), Viviana Storbini (Bologna), Roberta Emiliani (Bologna), Beatrice Balzarro (Bologna),
Giuseppe Carrà (Monza), Francesco Bartoli (Monza), Tommaso Tabacchi (Monza), Roberto
Nava (Monza), Adele Bono (Monza), Milena Provenzi (Monza), Giulia Brambilla (Monza),
Flora Aspesi (Monza), Trotta (Monza), Martina Tremolada (Monza), Gloria Castagna
(Monza), Mattia Bava (Monza), Enrica Verrengia (Monza), Sara Lucchi (Monza), Maria
Ginevra Oriani (Ancona), Michela Barchiesi (Ancona), Monica Pacetti (ForlÁõ), Andrea
Aguglia (Genova), Laura Rosa Magni (Brescia), Giuseppe Rossi (Brescia), Rossella Beneduce
(Brescia), Giovanni Battista Tura (Brescia), Laura Laffranchini (Brescia), Daniele Mastromo
(Milano), Farida Ferrato (Milano), Francesco Restaino (Milano), Emiliano Monzani (Milano),
Matteo Porcellana (Milano), Ivan Limosani (Milano), Lucio Ghio (Genova), Maurizio Ferro
(Genova), Vincenzo Fricchione Parise (Avellino), Giovanni Balletta (Avellino), Lelio Addeo
(Avellino), Elisa De Vivo (Avellino), Rossella Di Benedetto (Avellino), Federica Pinna
(Cagliari), Bernardo Carpiniello (Cagliari), Mariangela Spano (Treviso), Marzio Giacomin
(Treviso), Damiano Pecile (Mantova), Chiara Mattei (Fermo), Elisabetta Pascolo Fabrici
(Trieste), Sofia Panarello (Trieste), Giulia Peresson (Trieste), Claudio Vitucci (Trieste), Tommaso
Bonavigo (Trieste), Monica Pacetti (ForlÁõ), Giovanni Perini (Verona), Filippo Boschello
(Verona), Stefania Strizzolo (Vicenza), Francesco Gardellin (Vicenza), Massimo di
Giannantonio (Chieti), Daniele Moretti (Savona), Carlo Fizzotti (Savona), Edoardo Cossetta (Savona),
Luana Di Gregorio (Trento), Francesca Sozzi (Trento), Giancarlo Boncompagni (Bologna),
Daniele La Barbera (Palermo), Giuseppe Colli (Palermo), Sabrina Laurenzi (Civitanova
Marche), Carmela Calandra (Catania), Maria Luca (Catania).
Author Contributions
Conceptualization: Giovanni Ostuzzi, Maria Angela Mazzi, Giuseppe Carrà, Chiara
Gastaldon, Claudio Lucii, Giovanni Martinotti, Michela NoseÂ, Marianna Purgato, Giulia Turrini,
Corrado Barbui.
Data curation: Giovanni Ostuzzi, Maria Angela Mazzi, Samira Terlizzi, Federico Bertolini,
Davide Papola, Alberto Piccoli, Tommaso Tabacchi, Corrado Barbui.
Formal analysis: Giovanni Ostuzzi, Maria Angela Mazzi, Marianna Purgato, Corrado Barbui.
Investigation: Giovanni Ostuzzi, Samira Terlizzi, Federico Bertolini, Andrea Aguglia,
Francesco Bartoli, Paola Bortolaso, Camilla Callegari, Mariarita Caroleo, Giuseppe Carrà,
Mariangela Corbo, Armando D'Agostino, Chiara Gastaldon, Claudio Lucii, Fabio Magliocco,
Giovanni Martinotti, Michela NoseÂ, Edoardo Giuseppe Ostinelli, Davide Papola, Marco
Piero Piccinelli, Marianna Purgato, Tommaso Tabacchi, Giulia Turrini.
Methodology: Giovanni Ostuzzi, Maria Angela Mazzi, Mariangela Corbo, Claudio Lucii,
Michela NoseÂ, Marianna Purgato, Giulia Turrini, Mirella Ruggeri, Corrado Barbui.
12 / 17
Project administration: Giovanni Ostuzzi, Samira Terlizzi, Federico Bertolini, Mirella
Ruggeri, Corrado Barbui.
Resources: Giovanni Ostuzzi, Corrado Barbui.
Software: Giovanni Ostuzzi.
Mirella Ruggeri, Corrado Barbui.
Alberto Piccoli, Mirella Ruggeri, Corrado Barbui.
Carrà, Mirella Ruggeri, Corrado Barbui.
Supervision: Giovanni Ostuzzi, Giuseppe Carrà, Giovanni Martinotti, Marco Piero Piccinelli,
Validation: Giovanni Ostuzzi, Mariangela Corbo, Michela NoseÂ, Marco Piero Piccinelli,
Writing ± original draft: Giovanni Ostuzzi, Samira Terlizzi, Federico Bertolini, Giuseppe
Writing ± review & editing: Giovanni Ostuzzi, Samira Terlizzi, Federico Bertolini, Andrea
Aguglia, Francesco Bartoli, Paola Bortolaso, Camilla Callegari, Mariarita Caroleo, Giuseppe
Carrà, Mariangela Corbo, Armando D'Agostino, Chiara Gastaldon, Claudio Lucii, Fabio
Magliocco, Giovanni Martinotti, Michela NoseÂ, Edoardo Giuseppe Ostinelli, Davide
Papola, Marco Piero Piccinelli, Alberto Piccoli, Marianna Purgato, Tommaso Tabacchi,
Giulia Turrini, Mirella Ruggeri, Corrado Barbui.
13 / 17
14 / 17
15 / 17
57.
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