Systematic quality control for management of ST elevation acute myocardial infarction in setting of local network.

AIM: Adherence to evidence based guidelines, assessed by measuring key indicators, allows to detect, evaluate and improve quality of care. Since 2004 in Carlo Poma Hospital, following the introduction of a network for ST-elevation myocardial infarction (STEMI) management, the authors carried out a clinical database in order to measure quality of care in STEMI patients. MATERIALS AND METHODS: A real time upgradable database was developed, to assess clinical practice in myocardial infarction management. The authors evaluated prevalence and control of risk factors, pharmacological therapies and interventional procedures, pathways and delays to care. RESULTS: From 1 February 2004 to 31 January 2008, 1,714 consecutive patients with myocardial infarction were admitted in the Intensive Care Unit (ICU). Primary percutaneous coronary intervention (PCI) was performed in 85% of STEMI patients. Door to balloon time was greater than 90 min in only 17% of patients, of whom 88% coming from emergency department and 12% transferred by 118. CONCLUSION: In the authors' experience quality indicators proved useful in the management of myocardial infarction. Implementation of 118 and improvement of pre-hospital diagnosis in setting of local network can reduce time to treatment.

[Mortality triplicates in acute myocardial infarction patients affected by chronic renal failure]. / L'insufficienza renale triplica il rischio di morte intraospedaliera nell'Infarto del Miocardio.

In order to calculate the cardiovascular risk in patients with chronic renal failure (CRF), we retrospectively analyzed 1482 acute myocardial infarctions (AMIs) treated in the ICU at C. Poma General Hospital, Mantua, Italy, from 1 December 2004 to 31 July 2007. Of these patients, 133 suffered from CRF at hospital admission (eGFR <40 mL/min/1.73 m2 body surface and/or serum creatinine >2 mg/dL). During hospitalization for AMI, the CRF-affected patients showed a 2.7 times higher relative risk of mortality than patients without CRF (Yates chi square 14.46; p = 0.0001432). The evaluated comorbidities (hypertension, type 2 diabetes, supra-aortic vascular stenosis >70%, previous PTCA, COPD, previous AMI, previous coronary artery bypass and chronic obliterative peripheral arteriopathy) increased the relative risk of death 1.2- to 3.76-fold in those affected. In accord with recent evidence in the international literature, our results point to the importance of early assessment of CRF for the prognosis of patients with AMI.

Opioids for neonates receiving mechanical ventilation.

BACKGROUND: Mechanical ventilation is a potentially painful and discomforting intervention widely used in neonatal intensive care units. Newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes. The use of drugs that reduce pain might be important in improving survival and neurodevelopmental outcomes. OBJECTIVES: To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation. SEARCH STRATEGY: Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007); MEDLINE (1966 to June 2007); EMBASE (1974 to June 2007); and CINAHL (1982 to 2007). Previous reviews and lists of relevant articles were cross-referenced. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two review authors. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, in which case a random effects model was used. MAIN RESULTS: Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects. AUTHORS' CONCLUSIONS: There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

Neonatal developmental care in infant pain management and internalizing behaviours at 18 months in prematurely born children.

BACKGROUND: Very preterm infants are exposed to adverse stressful experiences, which may result in long-term behavioural outcomes. The developmental care practices, including pain management and environmental support, can minimize the effects of stress exposure. However, developmental care quality levels may vary among Neonatal Intensive Care Units (NICUs) and little is known about how differences in developmental care quality affect long-term behavioural outcomes. The aim of this study was to examine the relation between quality levels NICUs developmental care and behaviour problems at 18 months corrected age in preterm children. METHODS: The behaviour of 134 preterm children from 22 NICUs and 123 full-term controls was examined using the questionnaire Child Behaviour Checklist 1½-5. We compared the behavioural profile of children by splitting NICUs into units with high- and low quality of developmental care according to two main care factors: (1) infant centered care (ICC) index, and (2) infant pain management (IPM) index. RESULTS: Preterm children from low-care units in IPM group reported higher scores in Internalizing Problems, compared to children from high-care units. No differences were found between preterm children from high-care in IPM and full-term children. No significant IPM effect was found for externalizing problems. No significant ICC effect emerged both for internalizing and externalizing problems. CONCLUSIONS: Findings suggest that higher quality of developmental care related to infant pain management can mitigate behavioural problems at 18 months in children born preterm, to such an extent that preterm children exhibit a behavioural profile similar to that displayed by full-term children.

Language outcomes at 36 months in prematurely born children is associated with the quality of developmental care in NICUs.

OBJECTIVE: The aim of this study was to examine the relationship between the quality levels of NICU developmental care (DC) and language skills at 36 months in very preterm (VPT) children. STUDY DESIGN: Language skills of 78 VPT children from 19 NICUs and 90 full-term controls was assessed using a standardized language test. We compared children' language task performance by splitting NICUs into units with high- and low-quality of DC according to two main factors: (1) infant centered care (ICC), and (2) infant pain management (IPM). RESULTS: VPT children from low-care units with respect to ICC obtained lower scores in sentence comprehension, compared to children from high-care units. No differences were found between preterm children from high-quality ICC NICUs and full-term children. CONCLUSIONS: Findings suggest that higher quality of DC related to infant centered care can mitigate delays in language skills at 36 months in children born VPT.

Opioids for neonates receiving mechanical ventilation.

BACKGROUND: Mechanical ventilation is a potentially painful intervention widely used in neonatal intensive care units. Since newborn babies (neonates) demonstrate increased sensitivity to pain, which may affect clinical and neurodevelopmental outcomes, the use of drugs which reduce pain might be very important. OBJECTIVES: To determine the effect of opioid analgesics (pain-killing drugs derived from opium e.g. morphine), compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation. SEARCH STRATEGY: Electronic searches included: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004); MEDLINE (1966 to June 2004); EMBASE (1974 to June 2004); and CINAHL (1982 to 2003). Previous reviews and lists of relevant articles were cross-referenced. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised controlled trials comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers independently. Categorical outcomes were analysed using relative risk and risk difference; and continuous outcomes with weighted mean difference or standardised mean difference. A fixed effect model was used for meta-analysis except where heterogeneity existed, when a random effects model was used. MAIN RESULTS: Thirteen studies on 1505 infants were included. Infants given opioids showed reduced premature infant pain profile (PIPP) scores compared to the control group (weighted mean difference -1.71; 95% confidence interval -3.18 to -0.24). Differences in execution and reporting of trials mean that this meta-analysis should be interpreted with caution. Heterogeneity was significantly high in all analyses of pain, even when lower quality studies were excluded and analysis limited to very preterm newborns. Meta-analyses of mortality, duration of mechanical ventilation, and long and short term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (weighted mean difference 2.10 days; 95% confidence interval 0.35 to 3.85). One study compared morphine with a sedative: the treatments showed similar pain scores, but morphine had fewer adverse effects. AUTHORS' CONCLUSIONS: There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam. Further research is needed.

No reflow in patients undergoing primary angioplasty for acute myocardial infarction at high risk: incidence and predictive factors.

AIM: Percutaneous coronary intervention (PCI) is a consolidated therapeutic strategy for the treatment of acute myocardial infarction (AMI), but achieving a TIMI 3 flow does not always correspond to true tissue reperfusion. The aim of the study was to evaluate the incidence and predictive factors of no reflow in patients undergoing primary angioplasty (PCI) for AMI at high risk, in the setting of a provincial cardiological emergency network. METHODS: We retrospectively analyzed the ECGs of 360 consecutive patients undergoing primary PCI, between 2001-2004, recorded before and 90 min after the procedure, and compared them with the angiographic data. RESULTS: The patients were divided into 2 groups: group A (reperfused) with a >50% reduction in ST and group B (no reflow) with a <50% reduction in ST but a TIMI 3 flow in the epicardial vessel. The 2 groups were comparable in terms of mean age, sex, diabetes and AMI site. However, there were statistically significant differences between the groups in terms of precoronary time, Killip class IV, ejection fraction, mean leukocyte count, C-reactive protein, and the periprocedural administration of abciximab. Total mortality was 6%: 14% in group B vs 3% in group A. CONCLUSIONS: Our data show that a fair percentage of patients (24%) with a TIMI 3 flow after PCI during ST-elevation MI do not show ECG signs of effective reperfusion and have a higher in-hospital mortality rate. Precoronary time and the inflammatory phlogistic substrate are important independent predictors of no reflow. Pretreatment with abciximab, particularly if it is not periprocedural, can prevent the occurrence of no reflow.

[Coronary disease: early intervention saves lives. Treatment of acute myocardial infarction in Mantova: results of thirty months of work after the implementation of a province network]. / Malattia coronarica: l'intervento precoce salva la vita. Terapia dell'infarto miocardico acuto a Mantova, risultati di trenta mesi di attivita' dopo l'attivazione di una rete provinciale.

BACKGROUND: Since June 2001, in the province of Mantova, we have undertaken a program for the management of acute myocardial infarction based on the early assessment of patient risk profiles, concerning telematic connections among care centers and on the optimization of in-hospital and out of hospital critical pathways for access to care. MATERIALS AND METHODS: Our network provides connections among the following centers: advanced life support ambulances, seven hospitals, three coronary care units, one cath lab on call 24 h a day for primary angioplasty, and one thoracic surgery division. This program, through its strong telematic platform, allows the early assessment of myocardial infarction and provides primary angioplasty to all high-risk patients, as fibrinolytic treatment is reserved only for low-risk patients admitted in peripheral hospitals. RESULTS: Two hundred and eighty patients with acute myocardial infarction were treated with angioplasty; 224 patients (80%) underwent primary angioplasty, 36 patients (13%) facilitated angioplasty and 20 patients (7%) rescue angioplasty. One hundred and thirty-two patients (47%) were first admitted to Mantova Hospital; 78 patients (28%) were referred to Mantova from peripheral hospitals and 70 patients (25%) were directly transported to the cath lab by advanced life support ambulances. Procedural success was obtained in 98% of patients, with 0.4% intraprocedural mortality. In-hospital mortality was 5.7%, while mortality in cardiogenic shock patients was 36%. The recurrence of acute myocardial infarction occurred in 1% of patients and major bleeding occurred in 2.2% of patients. One patient with cardiogenic shock died during transport. Mean door to balloon time was 67 min with a 42% reduction in the 3rd recruitment period. CONCLUSIONS: This program, developed in the setting of a provincial network for the management of acute myocardial infarction, provided primary angioplasty to all high-risk patients, with a high procedural success rate. Within a few months, time to treatment was minimized by the use of telematic facilities.

[Communication between neonatologists and obstetricians]. / La comunicazione fra neonatologi ed ostetrici.

A close communication between obstetricians and neonatologists represents a basic tool for the improvement of newborn care. We shall illustrate what obstetric/neonatological communication tools are applied in our hospital. We believe the cooperation between obstetricians and pediatricians/neonatologists is of great importance for the health of both mother and newborn, thus it should become common practice even in those hospitals where neonatological intensive therapy units do not exist.

[Leukocytoclastic vasculitis]. / Le vasculiti leucocitoclastiche.

Leukocytoclastic vasculitis is characterized by infiltration of polymorphonuclear leucocytes with leukocytoclastic (presence of nuclear pigments) and fibrinoid necrosis affecting the small vessels. Henoch-Schönlein purpura is characterized by non thrombocytopenic purpura, arthritis and arthralgia, abdominal pain and renal involvement. Hypocomplementemic urticarial vasculitis and cryoglobulinemia are exceptional in childhood.

[Echocardiographic and polycardiographic findings in multiple-transfused patients with thalassemia major]. / Indagine ecocardiografica e policardiografica in soggetti affetti da talassemia mayor politrasfusi.

Echocardiographic and policardiographic measurements were carried out in 11 thalassemic major patients between 2 and 24 years of age, kept at on average Hb level of 9,77 gr.% (+/- 1,13) and who underwent chelation therapy with Deferoxamine subcutaneous and Vit. C. The echocardiographic examination gave normal values in 7 patients. In 4 patients underwent enlargement of the left ventricle: only in the telediastolic diameter in one case, with progressive involvement of the aorta and the left atrium in another 3 cases. Such alterations, as have already been recorded by various researchers, are probably the result of a condition due to the anemia state of the younger patients, whereas in older and polytransfused patients may be attributed to iron overload. No parameters surveyed by the polycardiographic examination indicated significant alterations in cardiac efficiency, except of one patient. The importance of echocardiography should be stressed; it is a simple, non invasive way of recording early cardiac alterations in thalassemic major patients and enables long-term monitoring of cardiac function in the assessment of the effectiveness of the chelation therapy.

[Intracranial hemorrhage caused by vitamin K deficiency in early infancy. Still a problem?]. / Emorragia intracranica da deficit di vitamina K nella prima infanzia. Ancora un problema?

A case of intracranial hemorrhage in a one month old infant is reported. A review of the prodromal symptoms presented by this infant seems useful to delineate a clinical picture that should allow a timely recognition of this problem in the population at risk. Furthermore, the relative frequency of this entity, due to vitamin K deficiency, in the first months of life in exclusively breast-fed infants, confirms the advisability of vitamin K supplementation at birth.

[Monitoring of body temperature during fiber optics phototherapy]. / Monitoraggio della temperatura corporea durante l'uso della fototerapia a fibre ottiche.

Fiberoptic phototherapy is a new technique for treatment of neonatal hyperbilirubinemia; in comparison with conventional phototherapy this new technique shouldn't increase body temperature during treatment. We have recorded body temperature of 13 term newborns with hyperbilirubinemia during 18 periods of treatment and compared the records with physiologic body temperature in the same babies. No increase over normal value during treatment nor significative difference during and after treatment has been observed.

[Beta-pancreatic function in subjects with thalassemia. A 4-year follow-up]. / Funzionalità beta-pancreatica in soggetti affetti da talassemia Follow-up di quattro anni.

High Hb level transfusion scheme for treatment of thalassemia mayor has improved life prognosis but has increased also the incidence of Diabetes Mellitus. 10 patients with thalassemia major have been followed with OGTT for a period 4 years long (1979-1982). In 1979 we changed from low to high level transfusion regimen, and we began to use the pump for slow subcutaneous administration of desferrioxamine to treat iron overload. The results we obtained show a progressive increase of the average values in the insulinemic and glycemic plasma concentration from year to year. At the beginning of the follow-up period, insulinemic and glycemic values after OGTT showed a primitive pancreatic damage which evolved towards a better pancreatic function with the appearance of a peripheral insulin resistance. It is probable that both chronic hypoxia (low Hb level) and the iron overload (high Hb level) may cause, with different processes, an impairment of glucose metabolism.

[Communication in the neonatal intensive therapy unit: the opinions of parents and of medical personnel compared]. / La comunicazione in terapia intensiva neonatale: opinioni dei genitori e del personale sanitario a confronto.

Within the framework of an European international project, the issue of parents-staff communication in Neonatal Intensive Care Units was explored. 5 Italian unit participated in the project. 80 mothers and 62 fathers of singleton, not malformed, very low birthweight babies were interviewed during the fourth week of their baby's life, while the views of the health personnel (60 doctors and 106 nurses) were collected through an anonymous, self-administered questionnaire. Most of the staff feels that parents should be informed completely about their baby's conditions and prognosis, while the actual practices about transmission of information are reported differently according to professional status: more nurses than doctors feel that the information is not as complete as it should be. Uncertainty of prognosis is the most commonly quoted reason for restricting the information. Parents, on the other hand, are generally satisfied about the information received, although some of them complain about the style of communication, and especially the need to ask repeatedly in order to be informed. These results show some of the gaps existing in communication both within the staff and with parents, and suggest possible ways of improvement.

Neonatology and the caesarean section.

The origins of the use of the Caesarean section date far back in human history. Traces of this procedure can be found in Greek mythology and in the history of Ancient Rome. Many documents about the history of religion make reference to a delivery from the abdomen.

Opioids for neonates receiving mechanical ventilation: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of opioid analgesics, compared to placebo, no drug, or other non-opioid analgesics or sedatives, on pain, duration of mechanical ventilation, mortality, growth and neurodevelopmental outcomes in newborn infants on mechanical ventilation. METHODS: This was a systematic review and meta-analysis of randomised controlled trials (RCTs). Data sources used were Cochrane, MEDLINE, EMBASE and CINAHL databases, and references from review articles. RCTs or quasi-RCTs comparing opioids to a control, or to other analgesics or sedatives in newborn infants on mechanical ventilation were reviewed. RESULTS: A total of 13 studies on 1505 infants were included. Infants given opioids showed reduced Premature Infant Pain Profile (PIPP) scores compared to the control group (weighted mean difference (WMD) -1.71, 95% CI -3.18 to -0.24). Heterogeneity was significantly high in all analyses of pain. Meta-analyses of mortality, duration of mechanical ventilation and long-term and short-term neurodevelopmental outcomes showed no statistically significant differences. Very preterm infants given morphine took significantly longer to reach full enteral feeding than those in control groups (WMD 2.10 days, 95% CI 0.35 to 3.85). One study that compared morphine with midazolam showed similar pain scores, but fewer adverse effects with morphine. CONCLUSIONS: There is insufficient evidence to recommend routine use of opioids in mechanically ventilated newborns. Opioids should be used selectively, when indicated by clinical judgment and evaluation of pain indicators. If sedation is required, morphine is safer than midazolam.