Cost-effectiveness of kidney transplantation from DCD in Italy.

INTRODUCTION: Kidney transplantation represents the best therapeutic option for patients with end-stage renal disease (ESRD), providing the best outcomes for survival, quality of life, and cost-effectiveness. To increase kidney donations, in 2007, the Italian IRCCS Policlinico San Matteo Foundation in Pavia designed and conducted Programma Alba, a protocol for organ donation after cardiac death (DCD). This study evaluated the costs and health outcomes of DCD transplantation and in all types of transplants compared with current clinical practice. PATIENTS AND METHODS: A Markov-based model was used to assess costs and health outcomes for new ESRD patients for 2008 to 2013. A health care founder perspective was used. Data sources were the Italian National Institute of Statistics and the Lombardy Registry of Dialysis and Transplantation. A microcosting analysis was performed to calculate costs related to clinical pathways for DCD. We assessed costs, survival, quality-adjusted survival, and cost-effectiveness. FINDINGS: Changing the actual practice pattern for new patients with ESRD and increasing the availability of kidneys from DCD to 10 extra transplants per year will induce an incremental cost per quality-adjusted life-year of €4255. Increases in transplantation to reach an extra 10% by transplant type would result in reduced costs and increased patient survival and quality of life compared with the current scenario. INTERPRETATION: Our data show that increasing DCD transplants would result in a cost-effective policy to expand the kidney donor pool compared with current ESRD treatment patterns. Italian policies should make an effort to increase transplant rates to optimize cost-effectiveness in ESRD service supply.

Donation after cardiac death: is a "paradigm shift" feasible in Italy?

Donation after cardiac death (DCD) is one of the growing strategies to overcome the problem of organ shortage. Cardiac death is defined as "irreversible cessation of circulatory and respiratory function"; the time interval to define irreversibility of cardiac death, the peculiarity of consent, and the framework of end-of-life decision making are the most compelling ethical issues which have been raised with DCD. National protocols that balance medical, ethical, and social issues are mandatory to guide transplant care professionals. In Italy, the 20 min cardiac arrest demonstrated by continuous electrocardiography recording is the time interval necessary for death diagnosis based on cardiopulmonary criteria. This time negatively affects donation after cardiac death because warm ischemic time (WIT) - the most important predictor of grafts' poor outcome - is prolonged. However, this time seems to be prudential to define the irreversibility of death and to respect the "dead donor rule", as established by the National Committee of Bioethics. National reference protocols regulating DCD practice are therefore a compelling issue.

Non-heart-beating organ donation in Italy.

In 2007 the non-heart-beating organ donation (NHBD) "Programma Alba" (Sunrise Programme) started in Pavia, Italy. The initial plan was to cut down waiting list for kidney transplantation, while its final aim is to shorten organ transplantation waiting lists. When compared to European countries and the USA, the Italian NHBD program has taken longer to get established. Initially Italian physicians were not entirely aware of the NHBD organ viability for transplantation, furthermore ethical issues and the need to regulate medical requirements to Italian law slowed down the NHBD program. In particular, Italian legislation provides for death ascertainment after irreversible cardiac arrest, 20-minute flat electrocardiogram. This no-touch period is longer when compared to worldwide legislation, and organ viability has been a main concern for Italian transplant doctors over the years. However, recent data let up to 40-minute warm ischemia time to preserve organ viability; this has encouraged Pavia's group to establish the NHBD "Programma Alba". It was designed according to Italian legislation from death diagnosis to graft placement, from this perspective must the significant role of the Transplant coordinator be recognized. Since 2007 seven kidneys have been gathered from seven NHBD. Of these, six NHBD kidneys have been transplanted. Currently, four patients are out of dialysis. This report is a detailed description of NHBD "Programma Alba" and its preliminary results.

[Ovarian granulosa cell tumor of juvenile type associated with pregnancy. Clinical case and review of the literature]. / Tumore ovarico a cellule della granulosa di tipo giovanile associato alla gravidanza. Caso clinico e review della letteratura.

The granulosa cell tumor is the most common sex ovary stromal tumors. Ten percent of cases present during pregnancy. Two histopathologically well defined patterns of granulosa cell tumors are known: the common adult granulosa cell tumors (AGCT) and the less frequent juvenile granulosa cell tumor (JGCT). This report describes a case of juvenile tumor of the granulosa occurring in a 22 year-old pregnant woman.

[Human error in the anesthesiological field. Up to what point is it possible to speak of prevention?]. / L'errore umano in campo anestesiologico. Fino a che punto e possibile parlare di prevenzione?

Human error (the act of judging true what is false and false what is true) has ever played and plays a significant role in the occurrence of incidents during anaesthesia. Purpose of the study. The Authors wanted to study how the different Authors analyzed the problem and to outline indications for preventive measures. Materials and methods. For this purpose we have selected papers and their references published on Journals indexed on Index. Medicus (1966-1996). The key words have been: anaesthesia or anesthesia, human error, incident and critical incident. We analyzed papers where human error in anaesthesia as a source of accidents was the main topic. The problem is analyzed starting from a classification of different errors and quantified with proper cognitive methods. Finally preventive measures are proposed. Results, Contribution of human error to the occurrence of accidents in anaesthesia ranges from 37% to 87% according to different. Authors employed techniques and sample size. Proper corrective measures on human, instrumental and environmental factors can lead to increased prevention. Conclusions. Human error exists now and will ever exist. Its gravity depends on its consequences and on preventive measures adopted.

Results of the combination of cisplatin, adriamycin and cyclophosphamide in the treatment of ovarian carcinoma.

Forty-seven women affected by Stage Ic-IV epithelial carcinoma of the ovary were treated with the combination of cisplatin, adriamycin (40-50 mg/m2 day 1), and cyclophosphamide (800 mg/m2 day 1) (CAP). Two different schedules of cisplatin were used: 20 mg/m2 day 1-->5 (CAP 5), or 80 mg/m2 on day 1 (CAP 1). In the group of patients with measurable disease the overall response rate was 52%, with a 19% complete response rate. The mean disease-free survival of patients without measurable disease was 24.0+ months. The mean survival of the whole group was 29.2+ months. The mean survival of patients with measurable disease and those without measurable disease was 21.7+ and 35.0+ months respectively. The schedule of cisplatin employed did not influence disease-free survival since the difference between the CAP 1 (21+ months) and the CAP 5 (25+ months) groups was not statistically significant. However the CAP 5 schedule seemed to be better tolerated since it of allowed the delivery be 99% of the planned dose of CDDP, while in the CAP 1 group the dose of CDDP given was only 74% of that planned.

Estradiol, progesterone, 17-hydroxyprogesterone, androstenedione and CA125 in patients with ovarian carcinoma.

Estradiol, progesterone, 17-hydroxyprogesterone, androstenedione and CA125 were assayed in 25 women (12 oophorectomized before entering the study) with ovarian carcinoma. The data from patients were ordered according to the presence or absence of the gonads. The patients with ovaries (Group A) showed significantly higher levels of estradiol (p less than 0.01), progesterone (p less than 0.01) and 17-hydroxyprogesterone (p less than 0.01) than controls. This difference was not observed between oophorectomized patients (Group B) and controls. CA125 levels were significantly higher in patients that in controls (p less than 0.001) irrespective of the ovarian status of the patients. Eleven patients were followed during chemotherapy. Significant reductions of estradiol (p less than 0.01) and CA125 (p less than 0.001) levels after three courses of chemotherapy were observed. These data confirm that women with ovarian carcinoma produce an abnormal amount of steroids. Nevertheless, a marked difference between patients with and without ovaries was observed, suggesting that reported data might be biased by the presence of gonadal tissue. Thus the clinical application of steroids as tumor markers in unselected patients is limited.

Surgical pathological staging of endometrial carcinoma and results of treatment.

114 women with endometrial carcinoma at clinical stage 1 to 3 were treated with surgery as first line of treatment. Patients were classified as being low or high risk on the basis of the surgical pathological patterns of the tumor. Disease limited to the uterine body, G1-G2 tumors and myometrial invasion of less than 1/3, identified low risk patients which received no adjuvant therapy. All the others were considered high risk and treated with radiation therapy. Patients were retrospectively restaged according to 1988 FIGO guidelines and survival was analyzed. Cox's proportional hazards method was employed to identify independent prognostic factors. Disease free survival (DFS) was 90% for stage 1, 83% for stage 2, and 43% for stage 3 patients. Lymphatic spread was associated to the poorer prognosis. Proportional hazards model showed that tumor grading, myometrial invasion and lymphatic spread were significantly related to the time of relapsing. Low risk patients showed better outcomes despite not having received adjuvant treatment, thus post-operative therapy is not indicated in this subset of patients. Radiation adjuvant therapy for high risk patients did not give satisfactory results. Failures were observed both locally and distantly calling for new adjuvant strategies. Surgical pathological staging of endometrial cancer is currently mandatory. Retroperitoneal lymph node sampling is indicated in patients with high risk pre- (advanced clinical disease, undifferentiated tumors) or intra-operative (deep myometrial invasion, enlarged pelvic nodes) prognostic factors. All prognostic indicators must be obtained from surgery and pathology in order to assess the risk of relapse.

[Hypokalemic myopathy. Our experience at an intensive care unit]. / Miopatia ipokaliemica. Nostra esperienza in un reparto di terapia intensiva.

Disturbances of potassium homeostasis are frequently iatrogenic: some drugs, especially diuretics, are sometimes taken without proper electrolyte control and replacement; this can lead to more or less severe hypokalemic states. After some physiopathologic remarks, the Authors report their experience with four patients admitted for severe hypokalemia; the clinical picture was always quite typical: severe muscle weakness (even quadriparesis), cardiac rhythm abnormalities, metabolic alkalosis. A reliable diagnostic tool is muscle biopsy that shows aspects of vacuolar myopathy.

Prediction and detection of ovulation relationship between woman's observations of cervical mucus changes, thermic and echographic parameters of ovulation.

Every woman can perceive and interpret her fertility signs such as cyclic changes of cervical mucus, sensation of wetness and lubrification of the vulva and thermal shift. 18 cycles were studied in 6 volunteers but one cycle was eliminated because ovulation did not occur. Each of the 6 women perceived the day in which cervical mucus was more abundant, clear, lubrificative and elastic and noted the "Peak" mucus day. These two data were correlated with the thermic nadir day and the day or the period of echographic ovulation showing an accurate relationship with ovulation.

Risk factors of endometrial cancer in Palermo.

A case-control study on 150 cases and 300 non-neoplastic controls admitted to the Obstetric and Gynaecologic Clinic B of the University of Palermo from 1977 to 1986 was carried out in order to assess the risk factors of corpus uteri cancer in Palermo area. Age at menarche less than 11, menopausal status, nulliparity, diabetes and obesity were found significantly associated with the risk of cancer; family history of neoplastic disease was slightly under statistical significance. It can be concluded that the same etiologic factors of endometrial cancer, as in other areas, may be operating in Palermo women.

Uterine sarcomas. A retrospective study of 17 cases.

Seventeen documented cases of uterine sarcoma were studied in an effort to establish the relationship between prognostic factors and patients' survival. The analysis of prognostic factors showed that there was a significant difference in survival between patients with stages I and II tumors and those with more advanced lesions. It has been also noted that prognosis was worse in patients with history of previous abortions and in patients who had abdominal or pelvic pain.

Ovarian function after therapy for Hodgkin's disease.

Ovarian function has been evaluated in 10 women in fertile age, free of disease, who underwent therapy for Hodgkin's disease. Women were divided into groups according to their age at the time of the diagnosis and therapy used. In the group of 6 women treated with chemotherapy alone or associated with sovradiaphragmatic roentgentherapy, 4 (66%) are regularly menstruating and 2 (33%) have become amenorrheic; while among the 4 women treated with TNI or inverted Y, 3 (75%) have become amenorrheic and 1 (25%) is regularly menstruating. 7 women were younger than 30 at the time of the diagnosis: 5 (72%) are regularly menstruating and 2 (28%) have become amenorrheic; while in the group older than 30 at the time of the diagnosis all 3 (100%) have become amenorrheic. These results show that, at present, it is not possible to predict the preservation or the renewal of the ovarian function after therapy for Hodgkin's disease; only taking in account all elements such as age, ovarian function prior to therapy and kind of treatment is it possible to propose a prognostic hypothesis.

Prognostic value of CT in head-injury coma.

The brain CT findings in 54 patients in coma 1-5 (Bozza-Marrubini scale) following craniocerebral trauma are analysed retrospectively. Attention is focused on those of the CT features that constitute indirect signs of brainstem involvement: obliteration of the suprasellar cisterns, distortion of the perimesencephalic and quadrigeminal cisterns, dilatation of the temporal horn and widening of the cerebellopontine angle cistern on the lesion side, considered anatomically and clinically responsible for coma. The patients fell into three groups: 7 with negative CT, 31 with intracranial lesions not affecting the brainstem and 16 with CT evidence of descending transtentorial herniation. The CT signs correlated significantly with coma level and survival. These CT signs can be used alongside the clinical and other instrumental data -- EEG, VEP and intracranial pressure -- as a further criterion of severity in head-injury coma.