[Prioritizing prescriptions in a ambulatory care setting: a tool to achieve appropriateness of care in public health management]. / Il sistema di prioritarizzazione delle prescrizioni nell'ambito della specialistica ambulatoriale: uno strumento operativo nell'ottica dell'appropriatezza assistenziale.

Waiting lists are one of the main Public Health issues within developed countries. To promote appropriateness about General Practitioners' (GPs) prescriptions, during 2009 the project "Priority setting in outpatient prescriptions" in Latium Region has been approved. Regional referees, Latium Public Health Agency managers and advisors, managers and advisors of three Local Public Health Units (LPHUs) within the Latium region and some voluntarily recruited General Practitioners (each one with more than 800 patients enrolled) were included in a team work with the duty to develop the project. During two selected months of 2010, 46 GPs have forwarded overall 2.229 medical prescriptions. The six most numerous prescriptions were picked out and analyzed by the team work. 42% of these prescriptions were identified as belonging to category D of the priority level--"standard", while 42% and 41% of prescriptions bore the expressions of "control" and "diagnostic purpose" respectively. Among these ones, 75% were represented by bilateral mammography, prescribed to women aged between 50 and 69 years: but for those people bilateral mammography is already provided free of charge within the regional program of breast cancer screening, making the routine prescription by their physician a useless duplication, unacceptable in a healthcare system of good quality. Therefore at the conclusion of the project, the team work suggests proper standards be applied by healthcare professionals and GPs to achieve a significant objective: mammography appropriateness prescriptions.

[Diet guidelines for non-insulin dependent diabetes]. / Linee guida per la dieta nel diabete non insulino-dipendente.

Diet therapy is an essential instrument in the prevention and treatment of non-insulin-dependent diabetes mellitus and its complications. Nutritional advice allow to modify the mechanisms underlying deranged carbohydrate metabolism, control disease evolution and/or retard pharmacological treatment. We describe the main dietetic factors that can influence this widespread metabolic disorder.

[Nutritional evaluation and diet therapy of patients with chronic liver disease]. / Valutazione nutrizionale e trattamento dietoterapico del paziente con epatopatia cronica.

Malnutrition is prevalent in patients with advanced chronic liver disease and may be associated with a worse prognosis. Treatments often include many dietary restrictions (regarding fluids, sodium and proteins), which may further limit energy intake in addition to other factors limiting food intake (e.g. anorexia, encefalopathy). Guidelines for an optimal diet therapy in patients with different liver diseases, above all in presence of encefalopathy, are briefly reported.

Acute abdominal symptoms in malignant hypertension: clinical presentation in five cases.

Malignant hypertension causes anatomical and functional damage in several target organs, in particular brain, retina, heart and kidneys. Although vascular lesions in the gastroenteric tract are known to occur in several instances, their clinical relevance is unknown. In this study five cases of malignant hypertension, presenting with acute abdominal symptoms, are reported. A history of essential arterial hypertension was present in three patients; while one patient had a previous diagnosis of renovascular hypertension and one patient had renoparenchymal hypertension. However, in all cases the antihypertensive treatment was discontinued and inadequate before the accelerated malignant phase. The acute abdominal symptoms at presentation were due to intestinal infarction in 3 patients and acute pancreatitis in 2 patients. One patient with intestinal infarction died of postoperative cardiogenic shock. Our data are in agreement with previous reports describing the possible intra-abdominal complications of malignant hypertension. The therapeutic approach in such conditions should always consider an effective antihypertensive treatment in conjunction with surgical options.

Ambulatory blood pressure and cardiac rhythm disturbances in elderly hypertensives: relation to left ventricular mass and filling pattern.

In order to define cardiac hypertensive involvement a group of 25 consecutive elderly male hypertensive outpatients and 25 age-matched male normotensive controls underwent full non-invasive assessment of cardiac status by resting 12-lead electrocardiography, Doppler-echocardiographic examination and simultaneous ambulatory blood pressure and electrocardiographic monitorings. Elderly hypertensives showed a higher prevalence of electrocardiographic left ventricular hypertrophy, an increased echocardiographic left ventricular mass, an impaired left ventricular filling pattern and more frequent ventricular arrhythmias when compared with normotensive controls. In elderly patients, left ventricular mass was found to be correlated with 24-hour ambulatory blood pressure (r = 0.47, p < 0.01) and 24-hour ambulatory blood pressure variability (r = 0.52, p < 0.01), while ventricular arrhythmias were correlated with left ventricular mass (r = 0.52, p < 0.01), the Doppler synthetic index of diastolic function E/A ratio (r = -0.56, p < 0.01) and both 24-hour systolic (r = 0.54, p < 0.01) and diastolic (r = 0.59, p < 0.01) ambulatory blood-pressure variabilities. These data suggest that hypertension induces in elderly patients an impairment of cardiac structure and function comparable with that already shown in younger hypertensives. Therefore, the assessment of hypertensive target-organ damage currently employed in younger subjects should be also considered in elderly hypertensives, at least when no other relevant medical disease is present.

[Ischemic hepatitis: case reports and a review of the literature]. / L'epatite ischemica: contributo casistico e revisione della letteratura.

Ischemic hepatitis represents a condition in which an acute circulatory failure determines a striking elevation of both serum transaminases and total bilirubin and a prolongation of prothrombin time. Such impairment of liver function tests is due to a haemodynamic hepatocyte injury, showing focal centrilobular necrosis as the specific pathologic correlate. In this paper the authors describe four different cases of ischemic hepatitis, in which an acute derangement of liver function tests occurred as a consequence either of myocardial failure or of systemic venous congestion. Finally, the authors review all current international literature concerning the various clinical, pathologic and therapeutic features of ischemic hepatitis.

[The efficacy and tolerance of heparin-calcium at low doses in postinfarct ischemic cardiopathy]. / Efficacia e tollerabilità dell'eparina calcica a basse dosi nella cardiopatia ischemica post-infartuale.

The above study was undertaken in order to evaluate the efficacy and tolerability of low dose calcium heparin for postinfarct ischemic heart disease (CIPI). In particular, the incidence was checked of: cardiovascular death, reinfarction, angina pectoris, TIA or RIND, stroke, arterial thromboembolism, venous thromboses, heart failure, complex ventricular arrhythmias, silent myocardial ischemia. Eighty patients with CIPI were divided into two groups similar for age, sex, physical features, cardiovascular risk factors, site of infarction, length of hospitalization, complications during hospitalization, clinical and instrumental findings at discharge, concomitant pathology. Upon discharge, patients were randomized into group 1 for traditional treatment and group 2 which in addition received 12,000 U calcium heparin s.c. every 24 h. After 12 months, during which patients were submitted to periodical laboratory and instrumental (standard and dynamic ECG, echoG) evaluation, group 2 had significantly fewer cardiovascular events than group 1 both as to overall number of events and as to number of events per individual patient. Especially, silent myocardial ischemia and ventricular arrhythmias were less frequent in group 2 patients and these two events, especially if coincident, are known to have severe prognostic implications. The efficacy of low-dose calcium heparin must be attributed to the enhancement of physiological antithrombotic mechanisms with compensation of blood clotting disorders that are fairly frequent in CIPI patients. Long-term s.c. administration was well tolerated.

Prevalence of left ventricular hypertrophy and cardiac arrhythmias in borderline hypertension.

Seventy-eight men with borderline hypertension according to the World Health Organization criteria underwent echocardiographic examination, followed by simultaneous ambulatory blood pressure and electrocardiographic monitorings for 24 h. The prevalence of echocardiographic left ventricular hypertrophy was 16.6% (13/78). Borderline hypertensives with left ventricular hypertrophy had more supraventricular (P less than .001) and ventricular ectopic beats (P less than .001) than normotensive controls and borderline hypertensives without cardiac involvement. Furthermore, ventricular ectopic activity was significantly related to left ventricular mass (r = 0.58, P less than .05) in borderline hypertensives showing echocardiographic evidence of left ventricular hypertrophy. Our findings suggest that noninvasive assessment of target organ status, including echocardiography, should be employed to optimize risk stratification in borderline hypertension.

[Efficacy of the combination of nicardipine-enalapril and atenolol in severe hypertension secondary to chronic renal disease]. / Efficacité de l'association nicardipine-enalapril-aténolol dans l'hta sévère secondaire à une maladie rénale chronique.

The antihypertensive efficacy of combination therapy with N-E-A was evaluated during 6 months in 15 patients with hypertension associated with mild to moderate kidney failure. After 6 months a significant reduction of SBP and DBP (p < 0.001), with improvement of creatinine clearance and with no adverse effects on ECG, heart rate and routine laboratory tests test, was observed in 3 patients treated with N 20 mg x 2/d + E 10 mg/d + A 50 mg/d and in 8 patients treated with N 20 mg x 3 + E 10 mg x 2, + A 50 mg x 2. Four patients did not respond to this therapy.

[Effects of slow-release nicardipine on blood pressure, renal function and the renin-angiotensin-aldosterone system in patients with mild-to-moderate essential arterial hypertension]. / Effetti della nicardipina sr sulla pressione arteriosa, la funzione renale e il sistema renina-angiotensina-aldosterone in pazienti con ipertensione arteriosa essenziale lieve-moderata.

The above study was intended to assess the efficacy of nicardipine in mild to moderate essential arterial hypertension and to check whether there are medium term changes in kidney function and urinary excretion of electrolytes in the course of nicardipine treatment. Twenty patients with mild to moderate essential arterial hypertension were treated daily with 40-80 mg doses of slow-release nicardipine after a wash-out period. Systolic and diastolic blood pressure was measured with traditional sphygmomanometer on entry and after 4, 8, and 12 weeks' treatment. Also, on entry and at conclusion of the study, the following parameters were measured: plasma renin activity, creatinine clearance, 24-hour urinary excretion of Na, K, Ca, and aldosterone. Nicardipine treatment was well tolerated and no significant changes of heart rate, creatinine clearance and urinary excretion of Na, K, Ca and aldosterone were observed after 12 weeks' treatment. The efficacy of nicardipine for the management of mild to moderate hypertension was thus confirmed. The absence of a natriuretic effect after 12 weeks' treatment goes to show that any diuretic action of the drug is irrelevant to its therapeutic effect which appears to be due mainly to its vasodilatory action.

[Electrocardiographic changes in hypertensive emergencies. Their incidence and possible pathogenetic mechanisms]. / Le alterazioni elettrocardiografiche nelle emergenze ipertensive. Incidenza e possibili meccanismi patogenetici.

The aim of the study was to analyse electrocardiographic alterations in 30 patients with slight to moderate essential arterial hypertension during the course of hypertensive attacks (DAP greater than 115 mmHg). Standard hematochemical tests were performed in basal conditions, together with 24-h ECG monitoring and an echocardiogram to measure the left ventricular mass index. Echographic monitoring was carried out during hypertensive attacks and for 2 h after the return to basal pressure values. In basal conditions patients showed slight hypopotassemia (23%), left ventricular echographic involvement (57%), left ventricular hypertrophy with or without systolic strain (43%), and ventricular extrasystole (VE) classified as Lown's 1st and 2nd class (17%). During the course of hypertensive attacks, there was a significant increase in systolic strain, the appearance of anterolateral subendocardial ischemia (10%), left anterior hemiblock (3%), lateral subepicardial ischemia (3%), and a marked increase in VE (67%) which were complex in 40% of cases (Lown's classes 3, 4 and 5). A significant correlation was found between the left ventricular mass index and VE/h. The authors stress the multifactorial pathogenesis of echographic alterations and underline left ventricular involvement, acute hemodynamic strain and consequent alterations of coronary perfusion, hypopotassemia, and increased levels of circulating catecholamines.

[Evaluation of the predictive stable hypertension validity during the ergometric test in borderline hypertension]. / Valutazione della validità predittiva di ipertensione stabile del test ergometrico nell'ipertensione borderline.

Aim of this study was to assess blood pressure (BP) response to exercise in borderline hypertensive subjects and to evaluate its predictive value for subsequent established hypertension development: 74 male subjects (28 borderline subjects, 26 normotensive subjects and 20 subjects with established hypertension) underwent a maximal exercise testing in the sitting position with a bicycle ergometer at the beginning of the study and then after 1 and 2 years; besides casual BP was controlled every 3 months for 2 years. Systolic BP exceeding 220 and/or diastolic BP exceeding 105 mmHg at maximal exercise and/or diastolic BP exceeding 100 mmHg at th fifth min of recovery were considered as abnormal. On the basis of BP response to exercise we divided our study group in: normotensive subjects with a normal BP response (Group A: 88%); normotensive subjects with an abnormal BP response (Group B: 12%); borderline subjects with a normal BP response (Group C: 46%); borderline subjects with an abnormal BP response (Group D:56%). At the end of a 2-year follow-up established hypertension developed in 1 subject of Group B (33%), in 2 subjects of Group C (15%) and in 10 subjects of Group D (67%); 7 subjects of Group C returned to normotension (54%). The incidence of established hypertension is significantly higher in borderline subjects with an abnormal BP response to exercise. This finding is probably due to both functional and organic factors and stresses the predictive value of exercise testing in borderline hypertension.

[Primary gastric lymphoma]. / Il linfoma gastrico primitivo.

Primary gastric lymphoma (P.G.L.), though rare, is nevertheless the most frequent non-epithelial neoplasm of the stomach. The Authors report their experience based on 18 cases of lymphoma observed from 1975 throughout 1989. Diagnostic and therapeutic problems related to the disease are stressed, uncertain in the results the former, still discussed the latter. The crucial role of surgery, either diagnostic or therapeutic, even in advanced stages, is underlined.

A prospective study of local recurrence after resection and low stapled anastomosis in 183 patients with rectal cancer.

Local recurrence is the most serious complication of anterior resection for rectal cancer, usually occurring during the first two years after surgery. Over a five-year period, from 1981 to 1986, 183 patients underwent anterior resection for rectal carcinoma at the Surgery Ward of the University of Ferrara. Patients were followed for two years postoperatively. All operations were performed with staplers and classified according to Dukes, with 43 cases of Dukes' A; 83 cases of Dukes' B; and 57 cases of Dukes' C. In the first 24 months after surgery, the tumor recurred locally in 44 of the 183 patients (24 percent). Dukes' stage, grading distal resection margin, and histopathologic differentiation of the distal rectal ring left in the stapler after anastomosis were assessed to determine a prognostic indicator for the recurrence of the tumor. The stage:recurrence ratio was as follows: A, 1 (2 percent); B, 21 (25 percent); and C, 22 (39 percent). The grading:recurrence ratio was: G1, 13:51 (25 percent); G2, 24:110 (22 percent); and G3, 7:22 (32 percent). The ratio between distal rectal resection margin and recurrence was: 0 to 2 cm, 15:27 (56 percent); 2 to 4 cm, 16:74 (22 percent); and over 4 cm, 13:82 (15 percent). Histopathologic examination of the distal rectal ring was negative for all patients. These data confirm the direct relationship between class and local recurrence and indicate histologic grade and distal resection margin as significant prognostic parameters only when interpreted in the light of staging.

[Comparative scintigraphic functional study of 3 different reconstruction technics following total gastrectomy]. / Studio funzionale scintigrafico comparato di tre diverse tecniche di ricostruzione dopo gastrectomia totale.

Esophago-jejunal reconstruction, after total gastrectomy, is best performed by one of the following three operations: interposed jejunal loop, Roux-en-Y loop and "omega" loop with Braun anastomosis. To assess the effects of the three mentioned techniques three groups of 15 patients each were examined after total gastrectomy for I, II or III stage cancer. Four to ten months after surgery all patients underwent the following tests: a) esophago-jejunal transit with labeled solid meal; b) cholangio-scintigraphy and c) absorption test of biliary acids. A group of 10 patients, without gastrointestinal pathology, was selected for comparison. The data obtained from the comparative study, in agreement with the opinions held by many Authors and our previous research, demonstrate that the interposition of jejunal loop (Mouchet) is the reconstructive technique closest to the unoperated stomach and, for this reason, is to be preferred after total gastrectomy.

[Postoperative biliary calculosis: our experience with therapeutic strategy]. / La calcolosi biliare post-chirurgica: nostra esperienza in tema di strategia terapeutica.

The Authors report their experience in the treatment of 92 cases of post-surgical biliary tract stones: 17 early cases (18.5%) were treated by percutaneous nonsurgical extraction (10 cases) or by operative procedures (7 cases); 75 late cases (81.5%) were surgically treated. The Authors summarize the results of the treatment, discussing advantages and disadvantages of the various techniques.