L'emergenza COVID-19 nell'ottica del finanziamento del Servizio Sanitario Nazionale: analisi e proposte.

The COVID-19 pandemic crisis has strongly stressed national health systems and resulted in a global economic crisis. This paper aims to frame and evaluate the funding disbursed and the costs incurred by the National Health Service, in relation to the COVID-19 emergency. It also intends to assess current monetary policies. It aims also to suggest and provide proposals in the context of strengthening the NHS. A narrative review of the grey literature was conducted querying OpenGray, WONDER e Pro-quest's Digital Dissertations e Conference Papers Index and the major institutional websites. The ALTEMS COVID-19 Instant Reports and reports published by regional, national and European institutional bodies were used as main information sources. The discussion begins with the presentation of the economic-health and epidemiological situation, and ends with the proposal of possible initiatives aimed at economic and financial reinforcement of the NHS.

Dosimetric comparison of four high performance techniques for irradiation of breast cancer patients.

PURPOSE: The use of IMRT for the treatment of breast cancer has been growing considerably in our institution since 2009. Alternatively, helical tomotherapy (HT) using a field width of 2.5 and 5cm (HT_FW_5), volumetric-modulated arc therapy (VMAT), or proton therapy with pencil-beam scanning (PT-PBS) have also been used to reduce treatment duration or optimize organ-at-risk (OAR) sparing. The purpose of this study was to compare the 4 treatment modalities available at our site. PATIENTS AND METHODS: We studied 10 patients treated for breast cancer with lymph node involvement. The prescribed dose was 51.8Gy to the breast with a simultaneous integrated boost up to 63Gy, and 50.4Gy to lymph nodes in 28 fractions. The CTV was delineated according to ESTRO Guidelines. Dosimetric planning in routine clinical practice was performed using HT_FW_2.5. The approved clinical plan was compared to the 3 other plans. Dosimetric goals for PTV coverage were D95%≥95% and D2%≤107% of the prescribed dose. Mean and maximum doses to OAR were recorded. RESULTS: HT_FW_5 and VMAT plans ensure equivalent or even better PTV coverage compared to the initial clinically approved plan but at the cost of poorer OAR sparing. PT_PBS plans showed that an excellent PTV coverage can be maintained with significantly lower doses to OAR. CONCLUSION: HT_FW_5 and VMAT plans allow a significant reduction of treatment duration and can be a good alternative to HT_FW_2.5 for specific populations. HT_FW_2.5 could be chosen for patients at higher risk of side effects. In addition, PT_PBS should be considered in the near future as it has been shown to have a major potential benefit to lower the risk of side effects with the same level of PTV coverage.

Colour Doppler ultrasonography evaluation of vascularization in the wrist and finger joints in rheumatoid arthritis patients and healthy subjects.

OBJECTIVES: To evaluate the presence of blood flow by colour Doppler ultrasonography (CDUS) in the wrist and finger joints of rheumatoid arthritis (RA) patients and healthy subjects and to define a cut-off value of CDUS resistive index (RI). METHODS: Forty-three patients with RA and 43 healthy controls were examined by CDUS. The wrists, second and third metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were evaluated in each patient and healthy subject. Spectral Doppler analysis was performed in order to characterize the type of flow and a mean RI was measured to define a cut-off level. The area under receiver operating characteristic curve was used to evaluate the screening method's performance. RESULTS: Flow was detected in 219 of the 430 total joints (50.9%) of RA patients (111 in the wrists, 49 in the MCP and 30 in the PIP joints). Healthy subjects had a quantifiable flow in 45 of the 430 joints (10.5%) and, in particular, 39 (86.4%) in the wrist, 5 (11.14%) in the MCP and 1 (2.2%) in the PIP joints. The intra- and inter-reader agreements for the detection of Doppler signal were very good (kappa 0.82 and 0.89, respectively). Mean RI values were 0.72±0.06 in RA patients and 0.86±0.06 in healthy subjects (p<0.01). At cut-off point of RI<0.79 the sensitivity was 89.6% and the specificity was 78.8% (positive likelihood ratio 4.22). CONCLUSION: DUS is a useful tool for the detection of abnormal blood flow in inflammatory joints of RA patients.

Health technology assessment: principles, methods and current status.

PURPOSE: This paper analyses the methodological and technical aspects of health technology assessment (HTA) as a tool for evaluating health technologies and procedures, with special reference to diagnostic imaging; describes the main experiences with HTA at the international and national level; outlines the most important HTA projects in Italy, and analyses the effects of HTA on health care strategies and policies. MATERIALS AND METHODS: The work was carried out in three phases. In the first phase, the authors analysed the principles, methods and instruments of HTA; in the second, they evaluated the current status of HTA in different countries; and in the third, they defined the impact of HTA on the decision-making process in health care. RESULTS: Since the 1970s, technological innovation has been accompanied by the development of methods for the multidisciplinary assessment of the technical, scientific, economic, ethical and social aspects inherent in the use of new technologies. The method is implemented at an international level by a network of public and private bodies that carry out HTA in support of health care policies. CONCLUSIONS: Because the application of HTA is still in its early stages in Italy, it is necessary to promote its development by drawing on consolidated international experiences.

[Atrial natriuretic factor (ANF) in massive pulmonary embolism: the effects of heparin treatment]. / Il fattore natriuretico atriale (ANF) nell'embolia polmonare massiva: effetti del trattamento eparinico.

We have determined, in a group of patients suffering from massive pulmonary embolism, the ANF basic levels and the changes noticeable in anticoagulant treatment. The heparin therapy, in six patients studied, has produced a considerable clinic and functional better conditions as testified by the gradual improving from hypoxemia. The PaO2, in fact, increases from a basic value of 68.7 +/- 17.65 mmHg to 74.68 +/- 7.16 mmHg on the 7th day (p: n.s.) and to 83.66 +/- 12.46 mmHg on the 14th day (p < 0.05 on the basic value) of treatment. At the same time it has been possible to note a decreasing of plasmatic ANF mean concentrations with decrease from a basic value of 250 pg/ml to 190 pg/ml (p: n.s.) after 7 days to 185 pg/ml (p: n.s.) after 14 days of therapy. However the presents of the high values after 14 days, could be considered as evidence of a persisting change of pulmonary arterious circulation. On the basis of such notes we have tied to compare the amount of ANF, in basic conditions, with the degree of scintigraphic alterations. Of the three patients whose PRA had been previously valued (n. 4, 5, 6), n. 4 and n. 5 showed, in basic condition, a suppression of PRA and only n. 5, at the end of treatment, reached a normal range of PRA. In those three patients there hasn't been relevant changes of plasmatic aldosterone concentration during the study.

[Atrial natriuretic factor (ANF) and chronic obstructive bronchopneumonia (COBP): the effects of theophylline treatment]. / Fattore natriuretico atriale (ANF) e broncopneumopatia cronica ostruttiva (BPCO): effetti del trattamento teofillinico.

We have considered the behaviour of the atrial natriuretic factor (ANF) in eight patients suffering from chronic obstructive pulmonary disease (COPD), who have been treated with aminophylline for 24 hours. The mean of ANF concentration decreased from a basic value of 171.31 pg/ml to a value of 128.83 pg/ml (p: n.s.) after treatment. With the exception of patient n. 5 and 7, in the remaining group a significant inverse correlation between ANF and aldosterone was found in accordance with the powerful inhibitory action exerted by the ANF on the secretion of the mineralocorticoid hormone. The changes of the ANF, after a treatment with aminophylline, are characterized by considerable differences among the several patients. In all patients who had a very high basic value, we generally assist to a plasmatic concentration reduction of the hormone after methylxantine. It can be assumed that the reduction of the pulmonary arterial pressure owing to the direct vessel-dilating action of the methylxantine as well as to the effect of vein-dilating and diuretic action reduce the stimulus to the secretion of ANF.

Transvaginal sonography in the evaluation of hematometra. A report of two cases.

BACKGROUND: Transabdominal sonography is useful in the diagnosis of hematometra but may not provide information as to its cause. CASES: Two cases of postmenopausal bleeding were evaluated using both transabdominal and transvaginal sonography. Transabdominal sonography detected the presence of hematometra; transvaginal sonography detected the neoplastic lesions responsible for the hematometra. CONCLUSION: Transvaginal sonography is important in the evaluation of hematometra because it affords clear visualization of the endometrial cavity.

[Male pseudohermaphroditism due to 17-alpha-hydroxylase deficiency]. / Pseudoermafroditismo maschile da deficit di 17-alpha-idrossilasi.

A case of 17-alpha-hydroxylase deficiency in a genotypic male is described. The patient, who had grown up as a female, at the age of 18 years by chance was seen for enteritis. She presented primary amenorrhea and lack of secondary sexual characteristics combined with hypertension and mild hypokalemia due to excess of mineralcorticoids. The hormonal profile observed under basal conditions was evocative of a deficiency in 17-alpha-hydroxylase. High plasma aldosterone concentrations, in the face of suppressed PRA, were related to interference in RIA method: low plasma aldosterone values were observed when HPLC separation was applied. Eunucoid appearance and gigantism (195 cm) has rarely been observed as a fenotypic expression of this enzymatic deficit, but are justified by deficiency of both androgens and estrogens.

[Observations on a case of arterial hypertension associated with primary hyperparathyroidism and renal artery thrombosis]. / Osservazioni su un caso di ipertensione arteriosa, associata ad iperparatiroidismo primario ed a trombosi di arteria renale.

A patient with hypertension (female: aged 48 years) associated with primary hyperparathyroidism and left renal artery thrombosis is described. Taking into account that the patient was treated on the left side by lithotripsy about two years before the development of hypertension while assuming an oral dose of an estro-progestinic compound, a possible role of these two conditions is discussed in the genesis of renal artery thrombosis and development of renal hypertension.

[Primary hyperparathyroidism with prevalent neuro-muscular manifestations]. / Iperparatiroidismo primario con prevalenti manifestazioni neuro-muscolari.

A case of primary hyperparathyroidism with prevalent neuromuscular symptoms is described. Clinical, diagnostic and therapeutic implications are emphasized. Particular attention must involve a full clinical examination, electromyographic data and neuromuscular biopsy to make differentiation from primary myopathy or denervation pathology. Some similarity of electromyographic data with those observed in botulism and myastenia gravis should also be taken in mind. Hypercalcemia could play a pathological role in conditioning abnormalities of nervous impulse conduction at the level of neuromuscular junction. Another possible interference might be related to a direct effect of parathormone and hypophosphataemia on nervous impulse conduction. "Glandular hyperplasia", as observed in this case at istologic examination, rises some problems as far as the prognosis is concerned.

A new technique for reduction of prolapsed fetal membranes for emergency cervical cerclage.

A new method to replace fetal membranes that have prolapsed through an incompetent cervix, which includes overfilling of the urinary bladder, was successful in four consecutive patients who presented with this clinical entity.

[Effects of calcium antagonists on pancreatic endocrine secretion]. / Influenza dei farmaci calcio-antagonisti sulla secrezione endocrina pancreatica.

The influence of Verapamil, a calcium antagonist, on circulating levels of glucose, insulin and glucagon has been evaluated in 5 normal subjects and in 5 patients with non insulin-dependent diabetes (NIDDM). An oral glucose tolerance test was performed both in basal conditions and during intravenous infusion of the drug (5 mg/h). Administration of Verapamil didn't induce any significant change on the three parameters. The small decrease of glycemia in patients affected by NIDDM and treated with Verapamil was not related to reduction of glucagonemia.

Macrolide antibiotics and serum theophylline levels in relation to the severity of respiratory impairment: a comparison between the effects of erythromycin and josamycin.

Ten patients with exacerbated chronic asthmatic bronchitis, subdivided into two groups on the basis of respiratory failure, were treated with theophylline-ethylendiamine administered by continuous venous infusion (0.7 mg/kg/hr over a period of 132 hrs). The aim of the study was the evaluation of serum theophylline levels during administration of erythromycin or josamycin (500 mg q.i.d. orally for 48) hours). An increase of theophylline levels was registered during erythromycin treatment in the group of patients with greater impairment of the respiratory function, while in the other group no significant change was observed. During josamycin treatment serum theophylline concentrations did not show any increase in both groups and, moreover, a significant reduction (p less than 0.05) was observed in the more seriously ill patients.

Ultrasonography in preterm labor.

A prospective study was conducted with ultrasonography in a group of 48 patients who presented with significant premature uterine activity. The study attempted to characterize the ultrasonographic signs exhibited by the cervix and lower uterine segment in conjunction with preterm labor. These signs, their frequency of occurrence, and possible clinical significance are described.

[Clinical evaluation of the therapeutic effectiveness of a new drug with anti-inflammatory-balsamic action, guacetisal, in respiratory tract diseases]. / Valutazione clinica dell'efficacia terapeutica di un nuovo farmaco ad azione antiflogistico-balsamica, il guacetisal, nelle affezioni delle vie respiratorie.

In 40 patients with bronchopulmonary diseases, in prevalence of chronic type, the therapeutic value of a new antiphlogistic-balsamic compound was evaluated. The favourable results obtained, particularly as far as the rapidity of regression of signs and symptoms is concerned, showed that this drug may have a significant role in a combined scheme of treatment.

Biparietal diameter of the skull and fetal weight in the second trimester: an allometric relationship.

Ultrasonic cephalometry was performed prior to therapeutic abortion in 323 women during the second trimester of pregnancy. In 101 instances satisfactory paired measurements of intrauterine biparietal diameter and extrauterine fetal weight were obtained and these formed the basis for mathematical analysis. In midpregnancy increase in size of the fetal head and increase in body weight seem to proceed at different rates but the ratio of the rates appears to be constant--an allometric relationship of relative growth. The data were used to calculate a standard curve and a graphic method is proposed for estimating gestational age when reliable menstrual history is not available in the second trimester.