Postoperative Pain Surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).

OBJECTIVE: Despite established standards, effective treatments, and evidence-based guidelines, postoperative pain control in Italy and other parts of the world remains suboptimal. Pain control has been recognized as a fundamental human right. Effective treatments exist to control postsurgical pain. Inadequate postoperative analgesia may prolong the length of hospital stays and may adversely impact outcomes. MATERIALS AND METHODS: The same multiple-choice survey administered at the SIAARTI National Congress in Perugia in 2006 (n=588) was given at the SIAARTI National Congress in Naples, Italy in 2012 (n=635). The 2012 survey was analysed and compared to the 2006 results. RESULTS: Postoperative pain control in Italy was less than optimal in 2006 and showed no substantial improvements in 2012. Geographical distinctions were evident with certain parts of Italy offering better postoperative pain control than other. Fewer than half of hospitals represented had an active Acute Pain Service (APS) and only about 10% of postsurgical patients were managed according to evidence-based guidelines. For example, elastomeric pumps for continuous IV infusion are commonly used in Italy, although patient-controlled analgesia systems are recommended in the guidelines. The biggest obstacles to optimal postoperative pain control reported by respondents could be categorized as organizational, cultural, and economic. CONCLUSIONS: There is considerable room for improvement in postoperative pain control in Italy, specifically in the areas of clinical education, evidence-based treatments, better equipment, and implementation of active APS departments in more hospitals. Two surveys taken six years apart in Italy reveal, with striking similarity, that there are many unmet needs in postoperative pain control and that Italy still falls below European standards for postoperative pain control.

Assessment of 126,913 inguinal hernia repairs in the Emilia-Romagna region of Italy: analysis of 10 years.

PURPOSE: Inguinal hernioplasty could be used as an indicator of the surgical quality offered in different health institutions and countries, thereby establishing a scientific basis from which the procedure can be critically assessed and ultimately improved. Quality assessment of hernioplasties could be conducted using two different methods: either analyzing dedicated regional/national databases (DD) or reviewing administrative databases (AD). METHODS: A retrospective study of inguinal hernioplasties was carried out in the Emilia-Romagna hospitals between 2000 and 2009. Data were obtained by analyzing Hospital Discharge records regional Databases (HDD). Descriptive and multivariate statistical analysis was performed. RESULTS: 126,913 inguinal hernioplasty procedures were performed. The annual rate was on average 34 per 10,000 inhabitants. An increase of the case mix complexity and relevant changes in procedure technique were recorded. From multivariate analysis, the following independent factors related to a hospitalization longer than 1 day emerged: procedures in urgent setting (OR 3.6, CI 3.4-3.7), Charlson's score ≥2 (OR 3.4, CI 3.1-3.7), laparoscopy (OR 2.1, CI 1.9-2.3), no mesh use (OR 2.1, CI 2-2.3), age >65 years (OR 1.9, CI 1.8-1.9), associated interventions (OR 1.9, CI 1.8-1.9), bilateral hernia (OR 1.7, CI 1.6-1.8), recurrent hernia (OR 1.2, CI 1.1-1.2) and female gender (OR 1.2, CI 1.2-1.3). Factors related to non-prosthetic hernioplasty were: bilateral hernia (OR 2.7, CI 2.5-2.9), female gender (OR 1.8, CI 1.8-2.0), emergency setting (OR 1.6, CI 1.5-1.8), recurrences (OR 1.5, CI 1.4-1.6) and associated interventions (OR 1.5, CI 1.4-1.6). CONCLUSION: Inguinal hernia should be treated as an outpatient procedure in the majority of patients. Precise guidelines are necessary. HDD demonstrated to be a good and trustworthy system to collect clinical data. When precise guidelines are lacking, legal/institutional indications play a pivotal role in shifting the hernia surgery toward a one-day surgery regimen.

Association between restless legs syndrome and hypertension: a preliminary population-based study in South Tyrol, Italy.

BACKGROUND AND PURPOSE: Restless legs syndrome (RLS) is a sleep-related movement disorder characterized by an irresistible urge to move the legs accompanied by paresthesia and/or dysesthesia that begins or worsens in the evening and night and that is partially or totally relieved by movement. Many studies have investigated the association between RLS and cardiovascular risk factors, particularly hypertension, leading to conflicting results. The aim of this study was to assess the association between RLS and hypertension considering also other cardiovascular risk factors that could act as confounders. METHODS: In all, 1709 participants of an on-going adult population-based study performed in South Tyrol, northern Italy, were enrolled. RLS was assessed through face-to-face interviews according to current International Restless Legs Syndrome Study Group diagnostic criteria. The presence of hypertension was self-reported and determined by questionnaires administered by trained study nurses. RESULTS: The association between RLS and hypertension was not significant after adjustment for age, sex, diabetes mellitus, history of myocardial infarction, raised blood lipids and body mass index (odds ratio 1.24, 95% CI 0.85-1.80, P = 0.271). CONCLUSION: Despite the small sample size of this study, RLS and hypertension were not associated in our adult population after adjustment for possible confounding factors. The presence of other cardiovascular risk factors could play a role as a confounder of this association.

Father absence and depressive symptoms in adolescence: findings from a UK cohort.

BACKGROUND: Previous studies suggest a link between parental separation or divorce and risk of depression in adolescence. There are, however, few studies that have prospectively examined the effects of timing of biological father absence on risk for depressive symptoms in adolescence while controlling for a range of confounding factors. METHOD: We examine the association between father absence occurring in early (the first 5 years) and middle childhood (5-10 years) and adolescent depressive symptoms in a sample comprising 5631 children from the UK-based Avon Longitudinal Study of Parents and Children (ALSPAC). Self-reported depressive symptoms at 14 years were assessed using the Short Mood and Feelings Questionnaire (SMFQ). Father absence was assessed from maternal questionnaires completed at regular intervals from the birth of the study child up to 10 years. RESULTS: There was evidence for an association between father absence in early childhood and increased odds of depressive symptoms at 14 years. This association was stronger in girls than in boys and remained after adjusting for a range of socio-economic, maternal and familial confounders assessed prior to the father's departure. Conversely, there was no evidence for an association between father absence in middle childhood and depressive symptoms at 14 years. CONCLUSIONS: Father absence in early childhood increases risk for adolescent depressive symptoms, particularly in girls. Future research should be aimed at identifying possible biological and psychosocial mechanisms linking father absence to depressive symptomatology to enable the development of family-based early prevention and intervention programmes targeting young children at risk.

Effectiveness and predictors of success of noninvasive ventilation during H1N1 pandemics: a multicenter study.

BACKGROUND: The use of non-invasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF) due to H1N1 virus infection is controversial. In this multicenter study we aimed to assess the efficacy of NIV in avoiding endotracheal intubation (ETI) and to identify predictors of success or failure. METHODS: In this prospective multicenter study, 98 patients with new pulmonary infiltrate(s) sustained by H1N1 virus and a PaO(2)/FiO2<300 were eligible for study; 38/98 required immediate ETI, while the others received NIV as a first line therapy; 13/60 patients failed NIV and were intubated after 5.8+5.5 hours from enrolment. The remaining 47/60 patients were successfully ventilated with NIV. RESULTS: Hospital mortality was significantly higher in those patients who failed NIV vs. those who succeeded (53.8% vs. 2.1%; OR=0.52, P<0.001). ETI was associated with higher number of infectious complications, mainly sepsis and septic shock. The OR of having one of these events in the NIV failure group vs. NIV success was 16.7, P<0.001. According to logistic regression model, a SAPS II>29 and a PaO(2)/FIO(2)≤127 at admission and PaO2/FIO(2)≤149 after 1 hr of NIV were independently associated with the need for ETI. CONCLUSION: The early application of NIV, with the aim to avoid invasive ventilation, during the H1N1 pandemics was associated with an overall success rate of 47/98 (48%). Patients presenting at admission with an high SAPS II score and a low PaO(2)/FiO(2) ratio and/or unable to promptly correct gas exchange are at high risk of intubation and mortality.

Disruption to the development of maternal responsiveness? The impact of prenatal depression on mother-infant interactions.

Both prenatal and postnatal maternal depression are independently associated with an increased risk of adverse infant development. The impact of postnatal depression on infants may be mediated through the effect of depression in reducing maternal responsiveness. However, the mechanisms underlying the effect of prenatal depression are unclear. Using longitudinal data from over 900 mother-infant pairs in a UK birth cohort (ALSPAC), we found that women with high depressive symptom scores during mid pregnancy, but NOT when their infants were 8 months, had a 30% increased risk of low maternal responsiveness when the infant was 12 months compared to women with consistently low depression. This may provide a mechanism to explain the independent association between prenatal depression and poorer infant development.

The impact of alcohol use during pregnancy on maternal responses after birth.

The aim of the study was to investigate the influence of alcohol exposure during pregnancy on a mother's responsiveness towards her infant after birth. Using longitudinal data from a subsample of 687 mother-infant dyads from a UK cohort study (Avon Longitudinal Study of Parents and Children), we investigated the influence of alcohol use during mid- and late pregnancy on observed mother-infant interactions after birth. We found that women who drank one or more glasses of alcohol a week during their mid-trimester of pregnancy were 19 % (95 % CI, 1 to 40 %; p = 0.033) more likely to show non-responsive behaviour towards their infant 12 months after birth. In contrast, we found that alcohol use during late pregnancy was not associated with later maternal responsiveness. This study adds to the growing evidence for the importance of factors during pregnancy on later maternal responsiveness. Further research is needed to replicate these findings and to examine potential mechanisms linking maternal responsiveness to alcohol use during pregnancy.

Patterns of alcohol use and multiple risk behaviour by gender during early and late adolescence: the ALSPAC cohort.

BACKGROUND: Adolescent risk behaviours such as smoking, alcohol use and antisocial behaviour are associated with increased risk of morbidity and mortality. Patterns of risk behaviour may vary between genders during adolescence. METHODS: Analysis of data from a longitudinal birth cohort to assess the prevalence and distribution of multiple risk behaviours by gender at age 15-16 years with a focus on alcohol use at age 10, 13 and 15 years. RESULTS: By age 15 years, over half of boys and girls had consumed alcohol and one-fifth had engaged in binge drinking with no clear difference by gender. At age 15-16 years, the most prevalent risk behaviours were physical inactivity (74%), antisocial and criminal behaviour (42%) and hazardous drinking (34%). Boys and girls engaged in a similar number of behaviours but antisocial and criminal behaviours, cannabis use and vehicle-related risk behaviours were more prevalent among boys, whilst tobacco smoking, self-harm and physical inactivity were more prevalent among girls. CONCLUSION: Multiple risk behaviour is prevalent in both genders during adolescence but the pattern of individual risk behaviour varies between boys and girls. Effective interventions at the individual, family, school, community or population level are needed to address gender-specific patterns of risk behaviour during adolescence.

The association between observed non-verbal maternal responses at 12 months and later infant development at 18 months and IQ at 4 years: a longitudinal study.

BACKGROUND: An infant's early environment has an important influence on their development. For example, the sensitivity and warmth of a mother's responses towards her infant is associated with the infant's later socio-emotional development. However, it is less clear whether maternal responses are associated with the infant's later cognitive development. METHOD: We used data from a large UK cohort study to investigate the association between non-verbal maternal responses and later infant development and IQ. Maternal responses were rated at 12 months during an observed mother-infant interaction. Infant development was assessed using the Griffiths scales at 18 months and IQ at 4 years was assessed using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI). Data on the infant's developmental level at 6 months (prior to the maternal response ratings) was also available. The complete case sample comprised 732 mother-infant pairs. RESULTS: There was evidence for an association between positive maternal responses and infant development at 18 months. After adjusting for infant developmental level at 6 months and other confounders, we found a difference of 0.25 standard deviations (coef 2.0, 95% CI (0.8-3.2), p=0.002) on the Griffiths scales between infant's whose mothers showed positive compared to neutral non-verbal responses at 12 months. However, an association between positive maternal responses and IQ at 4 years diminished following adjustment for maternal educational attainment. CONCLUSION: The results provide evidence that positive maternal responses are associated with improved development in infants at 18 months. However, the association between maternal response and IQ at 4 years may be explained by higher educational attainment in mothers who show positive responses. Future studies are needed to explore the influence of maternal responses on different aspects of infant development as well as the role of maternal factors such as education.

Pain management in peripheral arterial obstructive disease: oral slow-release oxycodone versus epidural l-bupivacaine.

OBJECTIVES: To compare the effectiveness of oral slow-release oxycodone (group OX, n=18) with that of epidural l-bupivacaine (group LRA, n=13) for the control of moderate/severe pain of advanced-stage peripheral arterial obstructive disease (PAOD) patients. DESIGN: Observational and retrospective analysis of advanced stage and hospitalised PAOD patients treated for pain management for at least 7 days prior to surgery or discharged from the hospital without surgery. METHODS: The outcome measures were pain intensity using the visual analogue scale under static, (VASs) and dynamic (VASd) conditions; vital signs, treatment side effects and patient satisfaction. RESULTS: In both groups, pain control was satisfactory and VAS scores median were VASs<3 and VASd<4; under dynamic conditions, pain control was better in the LRA group (p<0.01). Against few and transient side effects, most patients (n=30) found both pain treatments good or excellent. Results should be confirmed by studies with larger samples. CONCLUSIONS: In the perioperative setting, the epidural infusion of local anaesthetics, such as l-bupivacaine, is an effective technique for pain control in PAOD patients; for patients with contraindication for this technique or for non-surgical or outpatients, slow-release oxycodone is suggested as a possible alternative for the control of severe pain in these patients.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery.

BACKGROUND: : This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality. METHODS: : Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD. RESULTS: : A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021). CONCLUSION: : The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated.

[Epidemiology and epidemiologists: a survey on the presence, structure and training of epidemiologists and medical statisticians in the Veneto region]. / Epidemiologia ed epidemiologi: indagine sulla presenza, or- ganizzazione e formazione di epidemiologi e statistici medici nella Regione Veneto.

The present study aims at assessing the role of epidemiology on health decision-making processes in the public administrations of the Veneto region, north-eastern Italy. In 2003 a questionnaire was mailed to chief-executives of local public health organizations (21 Local Health Units, 2 Public Hospitals), and 18 responded. All public health organizations were practicing Epidemiology, but only 4 had dedicated services. Sixty-two people were working as epidemiologists in public health, but only half played the role for most of their Full Time Employment. Personal educational qualifications were mainly degree in Medicine (62%) and Statistical Sciences (23%). Among physicians, 78% was specialized in Hygiene and Preventive Medicine. The head office of most public health organizations (15 out of 18) appraised epidemiology as fundamental with regard to the health decision-making process, however two thirds of them reported that the epidemiological informative needs were only little or not at all satisfied. To improve the situation, most Public Health Organizations intended to perform educational activities and to use external advisors. In conclusion, Public Health Organizations of the Veneto region appreciated the importance of epidemiology in the health decision-making process. However, few resources were devoted to this field so that informative needs were only partly satisfied.

Wernicke's encephalopathy and pancreatic encephalopathy after necrotic-hemorrhagic pancreatitis. A case report.

This case report describes a case of acute necrotic-hemorrhagic pancreatitis complicated by Wernicke's encephalopathy (WE) and stresses the importance of a correct dietetic regimen. A 39-year-old Chinese male patient with negative remote pathological anamnesis was hospitalized in the Medical Department with a diagnosis of gallstones. The clinical course was complicated with the onset of acute pancreatitis. Enteral fasting was imposed with intravenous feeding without vitamin supplementation. The progressive worsening of the clinical, radiodiagnostic and laboratory profile combined with deterioration in the state of consciousness promoted, on the 36th day exploratory laparotomy revealed necrotic-hemorrhagic pancreatitis. The patient was, therefore, admitted to the Intensive Care Unit in a deep coma. The recent medical history, neurological examination, and encephalic computed tomography suggested a revealing diagnosis of WE combined with pancreatic encephalopathy.

Major abdominal surgery and postoperative pain control: are protocols enough?

Suitable postoperative pain control (POPC) requires both the application of appropriate pain therapy and the continuous supervision of its therapeutic effects. In our hospital, POPC was, until recently, limited to the first 48 postoperative hours. The purpose of this retrospective study was to assess, the evolution of POPC at the end of the first postoperative 48 hours among major abdominal surgery patients using the Acute Pain Service (APS) database. Further we sought to establish the indications to extend POPC to the entire postoperative period. Regardless of the type of protocol applied after surgery, 79.6% of cases showed pain control was still needed after the 48(th) hour. In about half of the cases, POPC was perpetuated with only the drug category or by dosage modifications, while in roughly one third of the cases we adopted both drug and administration route changes. These changes were made by the APS after a thorough evaluation of the patients' conditions and needs in terms of analgesia. Interestingly, in approximately 5% of cases the surgeon decided to interrupt pain therapy. When applying evidence-based guideline protocols, organizational issues are important as well as a better definition of the APS role in POPC, at least from the timing point of view.

Effectiveness and efficiency of intensive care medicine: variable costs in different diagnosis groups.

BACKGROUND: To establish the effectiveness of ICU treatment and the efficiency in the use of resources in patients stratified according to 10 diagnosis and two levels-of-care. To propose strategies aimed at reducing costs and improving efficiency in each patient group. METHODS: Multicentre prospective observational study. ICUs enrolled two cohorts of up to 10 consecutive patients with ICU stay >/= 48 h. Each with one of these diagnoses: trauma, brain-trauma, brain-hemorrhage, stroke, acute-on-chronic-obstructive-pulmonary disease, lung-injury/acute respiratory distress syndrome, heart failure, and scheduled/unscheduled abdominal surgery. The presence of active-life support divides high from low level-of-care treatments. Variable ICU costs were collected daily (bottom-up) for 21 days. We evaluated effectiveness (hospital survival) and efficiency (hospital-survivors variable-cost as a ratio of overall cost). RESULTS: Forty-two Italian general ICUs recruited 529 patients in 5 months. Mean ICU variable-costs significantly differed with diagnosis and level-of-care. Costs were positively affected by ICU length-of-stay, by duration of active-treatment. Outcome variably influenced costs. Medians of variable-costs per patient (1715 Euro) and patient-groups efficiencies (60.7%) identified four possible combinations between (low and high) cost and (low and high) efficiency groups. Moreover, efficiency was better than effectiveness in stroke, brain-hemorrhage and trauma, while it was worse in heart failure, acute-on-COPD or acute-lung injury. Overall ICU cost attributed only to survivors ranged from 699 (scheduled surgical) to 5906 (unscheduled surgical) Euro. Cost of non-survivors distributed to all patient was between 95 (scheduled-surgical) to 1633 (unscheduled-surgical) Euro. CONCLUSIONS: Analysis of variable patient-specific cost was used as a tool to assess intensive care performance in patient subgroups with different diagnosis and levels-of-care.

Use of sedative and analgesic drugs in the first week of ICU stay in high-level-of-care.

AIM: The aim of this study was to update the current practice of pharmacological sedation and analgesia in Italian intensive care units. DESIGN: observational, prospective, cohort study involving consecutive patients admitted during 5 months in 1999. PATIENTS were evaluated for the first 7 days of high-level-of care. SETTING: 45 adult general intensive care units. PATIENTS: 388 fulfilling enrollment criteria: admission diagnosis out of non-traumatic cerebral hemorrage, stroke, respiratory failure in chronic obstructive pulmonary disease (COPD), acute lung injury/distress syndrome (ALI/ARDS), polytrauma, head trauma, cardiac failure and major abdominal surgery; unit stay longer than 47 hours and high-level-of care treatment. RESULTS: Sedation pattern was different among diagnosis-groups. No therapy was registered in 18.8% of overall days in polytrauma vs 67.6% of cardiac patients. Opioids supply ranged from 10.1% of overall days of acute on COPD patients vs 51.4% of polytrauma patients. Propofol was the more prescribed drug, followed by opioids and benzodiazepines. Propofol was at the top in cerebrovascular disease, ALI/ARDS and COPD; opioids in abdominal surgery and trauma, benzodiazepines in cardiac failure. The average number of prescribed drugs per day was 1.5 ranging from 1.2 on COPD to 1.7 in head trauma. CONCLUSION: Diagnosis influences the pattern of sedation-analgesia during high-level-of-care period. Sedation prevalence is reasonably prescribed in trauma groups while it remains low in ALI/ARDS, post-operative, cerebrovascular, COPD and hearth failure. Particularly opioid use remains limited in post-operative patients. This surveys shows a poorly standardised sedation approach to the different phases of the therapy: induction, short and long-term sedation phase.

Use of sedative and analgesic drugs in the first week of ICU stay. A pharmaco-epidemiological perspective.

AIM: To assess the current practice of pharmacological sedation and analgesia in patients admitted in Italian intensive care units. DESIGN: observational, prospective, cohort study, involving all patients admitted during a one-month period to participating Centers in 1994. All patients were followed-up for vital status until discharge and evaluated for pharmacological sedation and analgesia for the first week of ICU stay. SETTING: 128 Italian, adult, general, intensive care units, approximately representing 1/3 of all Italian Units. PATIENTS: 2932 patients were analyzed. They generated 22612 patient-days of intensive care unit stay, 11221 of which were evaluated. RESULTS: A total of 31 different sedative drugs were used in 1751 patients. On 64% of sedated days only one drug was utilized, whereas two or more drugs were administered in the remaining days. Propofol was the most widely prescribed drug, followed by fentanyl and diazepam, while morphine accounted for 14.8% of sedated days. The analysis of the pattern of sedation over time revealed a trend to linearly reduce the use of this practice. CONCLUSIONS: Our results depict a relatively low prevalence of sedation in Italy, with the use of large number of different agents. We also observed a larger than expected use of some drugs, like propofol and fentanyl, that could be due to the unavailability of new sedative and analgesic drugs in Italy on 1994. In conclusion, Italian intensivists seem to be very conservative about the practice of pharmacological sedation in critically ill patients.

Predicting outcome in the intensive care unit using scoring systems: is new better? A comparison of SAPS and SAPS II in a cohort of 1,393 patients. GiViTi Investigators (Gruppo Italiano per la Valutazione degli interventi in Terapia Intensiva). Simplified Acute Physiology Score.

OBJECTIVES: This study sought to compare the performance of the old and new versions of the Simplified Acute Physiology Score, SAPS and SAPS II, in classifying patients according to the risk of hospital mortality. METHODS: To compare the performance of the two systems, measures of association between the scores and observed mortality were adopted, together with discrimination (area under the Receiver Operating Characteristics curve) and calibration (goodness-of-fit statistics) estimates. Subjects were 1,393 eligible patients recruited during 1 month in 1994. The outcome measure was vital status at hospital discharge. RESULTS: SAPS II was associated more strongly with hospital mortality than the earlier version. SAPS II also had better discrimination ability than SAPS (area under Receiver Operating Characteristics curve 0.80 versus 0.74) and predicted an overall number of deaths (416.5) closer to the observed figure (475) than SAPS (267.7). Conversely, neither SAPS nor SAPS II fitted our data. Both P values derived from goodness-of-fit statistics were lower than 0.05. CONCLUSIONS: SAPS II offers a real improvement compared with SAPS in its ability to explain hospital mortality, but its standard parameters do not fit our data from Italy. The role and impact of potential determinants of this lack of fit, such as random errors and confounders related to casemix and/or quality of care should be clarified before this scoring system be used outside formal research projects. Special caution is suggested when SAPS II is adopted to predict mortality to compare intensive care unit performance across different countries and systems of care.