Quality indicators in headache care: an implementation study in six Italian specialist-care centres.

BACKGROUND: Headache disorders are highly prevalent, and have a substantial and negative impact on health worldwide. They are largely treatable, but differences in structure, objectives, organization and delivery affect the quality of headache care. In order to recognize and remedy deficiencies in care, the Global Campaign against Headache, in collaboration with the European Headache Federation, recently developed a set of quality indicators for headache services. These require further assessment to demonstrate fitness for purpose. This is their first implementation to evaluate quality in headache care as a multicentre national study. METHODS: Between September and December 2016, we applied the quality indicators in six Italian specialist headache centres (Bologna, Firenze, Modena, Padova, Roma Campus Bio-Medico and Roma Sapienza). We used five previously developed assessment instruments, translated into Italian according to Lifting The Burden's translation protocol for hybrid documents. We took data from 360 consecutive patients (60 per centre) by questionnaire and from their medical records, and by different questionnaires from their health-care providers (HCPs), including physicians, nurses, psychologists and nursing assistants. RESULTS: The findings, comparable between centres, confirmed the feasibility and practicability of using the quality indicators in Italian specialist headache centres. The questionnaires were easily understood by HCPs and patients, and were not unduly time-consuming. Diagnoses were almost all (> 97%) according to ICHD criteria, and routinely (100%) reviewed during follow-up. Diagnostic diaries were regularly used by 96% of physicians. Referral pathways from primary to specialist care existed in five of the six clinics, as did urgent referral pathways. Instruments to assess disability and quality of life were not used regularly, a deficiency that needs to be addressed. CONCLUSION: This Italy-wide survey confirmed in six specialist centres that the headache service quality indicators are fit for purpose. By establishing majority practice, identifying commonalities and detecting deficits as a guide to quality improvement, the quality indicators may be used to set benchmarks for quality assessment. The next step is extend use and evaluation of the indicators into non-specialist care.

OnabotulinumtoxinA in elderly patients with chronic migraine: insights from a real-life European multicenter study.

INTRODUCTION: Although migraine prevalence decreases with aging, some older patients still suffer from chronic migraine (CM). This study aimed to investigate the outcome of OnabotulinumtoxinA (OBT-A) as preventative therapy in elderly CM patients. METHODS: This is a post hoc analysis of real-life prospectively collected data at 16 European headache centers on CM patients treated with OBT-A over the first three treatment cycles (i.e., Cy1-3). We defined: OLD patients aged ≥ 65 years and nonOLD those < 65-year-old. The primary endpoint was the changes in monthly headache days (MHDs) from baseline to Cy 1-3 in OLD compared with nonOLD participants. The secondary endpoints were the responder rate (RR) ≥ 50%, conversion to episodic migraine (EM) and the changes in days with acute medication use (DAMs). RESULTS: In a cohort of 2831 CM patients, 235 were OLD (8.3%, 73.2% females, 69.6 years SD 4.7). MHDs decreased from baseline (24.8 SD 6.2) to Cy-1 (17.5 SD 9.1, p < 0.000001), from Cy-1 to Cy-2 (14.8 SD 9.2, p < 0.0001), and from Cy-2 to Cy-3 (11.9 SD 7.9, p = 0.001). DAMs progressively reduced from baseline (19.2 SD 9.8) to Cy-1 (11.9 SD 8.8, p < 0.00001), to Cy-2 (10.9 SD 8.6, p = 0.012), to Cy-3 (9.6 SD 7.4, p = 0.049). The 50%RR increased from 30.7% (Cy-1) to 34.5% (Cy-2), to 38.7% (Cy-3). The above outcome measures did not differ in OLD compared with nonOLD patients. CONCLUSION: In a population of elderly CM patients with a long history of migraine OBT-A provided a significant benefit, over the first three treatment cycles, as good as in non-old patients.

Impact of a Multidisciplinary Team on Alcohol Recidivism and Survival After Liver Transplant for Alcoholic Disease.

BACKGROUND: Alcohol use disorders have a prevalence of 10% among the population of the United States and Europe and are one of the most frequent causes of liver cirrhosis in the Western world. Currently, alcohol-related liver cirrhosis represents one of the most frequent indications to liver transplant (LT), both as independent cause or associated with hepatitis C virus or hepatitis B virus infections. Starting from 2014, a multidisciplinary team involving surgeons, gastroenterologists, clinical toxicologists, psychiatrists, and psychologists was developed within the Modena Liver Transplant Center. METHODS: We retrospectively reviewed our prospectively maintained institutional database of liver transplants in order to identify cirrhotic patients eligible for LT with a diagnosis of alcohol use disorder. RESULTS: A total of 756 liver transplants were performed at Policlinico University Hospital, University of Modena, and Reggio Emilia, MO, Italy, between November 2000 and November 2017; 102 patients who underwent LT were considered eligible for inclusion in the study. CONCLUSIONS: The multidisciplinary approach, together with blood, urinary, and hair tests, allows identification of early recurrences and improves survival. Further studies are necessary to understand how multidisciplinary teams can change the 6-month rule in patient selection.

Lysosomal responses and metallothionein induction in the blue mussel Mytilus edulis from the south-west coast of Iceland.

It has recently been emphasized that high levels of inorganic and organic micropollutants (particularly organometals, POPs and PAHs) may be present in coastal waters at high latitudes, stressing the need to evaluate the effects of contaminants on marine organisms from sub-arctic zones. With this aim, specimens of the blue mussel Mytilus edulis were sampled in polluted and reference areas along the south-west coast of Iceland in July 2004. Samples were collected from the intertidal zone at three sites in Reykjavik harbour which are differently exposed to contaminants, and at three reference coastal sites, two located along the Reykjanes Peninsula and the third one on the northern part of Hvalfjordur fiord. Lipofuscin content, neutral lipid accumulation and lysosomal enlargement were evaluated in digestive cells from cryostat sections of the mussel hepatopancreas, and quantified by automated image analysis. Metallothionein induction was also determined in the same tissue. Results indicate that mussels from the inner part of Reykjavik harbour, which is the most sheltered and most influenced by extensive shipping traffic, were the worst affected, with the highest values in neutral lipids, lipofuscin and lysosomal swelling. At the other two harbour sites, mussels exhibited lower values, similar to those observed in organisms collected in Hvalfjordur fiord and in bay of Osar. Mussels from Kuagerdi had the lowest values.

Atmospheric bulk deposition to the Lagoon of Venice Part II. Source apportionment analysis near the industrial zone of Porto Marghera, Italy.

Multivariate statistical analyses were applied to measurements of atmospheric deposition of total particulate (TSP), inorganic elements (Al, Ca, Na, K, Mg, Si, Mn, Fe, Zn, Ni, Cr, Cu, Pb, Cd, As, Hg, V and S) and organic compounds (PAH, PCB, HCB and PCDD/F) collected in four stations, all located in the Lagoon of Venice. Aerosols at the scale of the basin (i.e., within a distance of 20 km) were mainly characterised by two end-members, one natural (composed of mineral particulate and marine spray) and one anthropogenic (with at least two different source components), affecting the sites in various ways. Variability at the two distant (>20 km) sites (Valle Dogà, Valle Figheri) was mainly due to natural components, whereas the other two stations (city of Venice, Dogaletto, approximately 5 km) were mainly impacted by industrial (and urban) sources. Total annual inputs were compared with the limits recently set by law (maximum allowed discharge=MAD). In the year of study, MAD values were exceeded for total As, Cd, Hg, Pb, dissolved Zn, PAH and PCDD/F. These results indicate that industrial sources gave rise to a quasi-permanent compositional (background) effect near the industrial area. The risk associated with atmospheric deposition should be quantified within the DSPIR framework to avoid future negative consequences in populations living in the vicinity of Porto Marghera.

Atmospheric bulk deposition to the lagoon of Venice Part I. Fluxes of metals, nutrients and organic contaminants.

First available data on atmospheric fall-out were provided by sampling monthly bulk depositions in four sites inside the Lagoon of Venice (550 km2). Sampling was carried out monthly during the period July 1998-July 1999, in one site near an industrial area (Porto Marghera; site D), another site in the city of Venice (site A), and the remaining two in the southern- and northernmost ends of the Lagoon (Valle Figheri, site C; Valle Dogà site B). The following determinations were carried out for each samples: pH, conductivity, grain-size, particulate load, and dissolved nutrients (N, P). Samples were then subdivided into soluble and insoluble fractions, and Al, Ca, Na, K, Mg, Si, Mn, Fe, Zn, Ni, Cr, Cu, Pb, Cd, As, Hg, Ti, V, S, P, Se and Sb were analysed on both fractions. Total organic micropollutants (PAH, PCB, HCB, DDT, PCDD/F) were measured. As regards particle size distribution, there was great variability among sampling sites. The percentage of the < or =2 microm grain-size fraction was higher in the southern and northern ends of the Lagoon. Small differences were found among sites for major elements, whereas higher variability was observed for inorganic and organic micropollutants, with standard deviations between 20% and 60% of the fluxes measured. Major differences in annual fluxes between the most polluted sites (mostly D and A) and background (site B) were seen for Cd (0.26 vs. 0.06 mg m(-2) year(-1)), Hg (41 vs. 15 microg m(-2) year(-1)), PCB ( approximately 2500 vs. approximately 500 ng m(-2) year(-1)) and HCB ( approximately 8000 vs. approximately 1000 ng m(-2) year(-1)). Comparisons with previous data, collected in the periods 1993-1994 and 1995-1997, were only available for a few trace metals. A definite decline in the annual Pb flux in the city of Venice was detected, from 18 to 13 mg m(-2) in 1996/1997 and 1995/1996 respectively, to approximately 5 mg m(-2) in the present study. Total annual deposition was calculated by means of two different methods, which gave very similar results: (i) the mean value of deposition in the four sites was multiplied by lagoon area (550 km2); (ii) the monthly rain isopleths were combined to normalize deposition values. The figures are: 15-34 kg of Hg and Sb, approximately 200 kg of As, approximately 100 kg of Cd and PAH, 0.7-1.3 tons of Cr, Ni and V, more than 2 tons of Cu and Pb, 17 of Zn, 55 of total P, approximately 200 of Al, and 3900 of DIN. Total fluxes of organics inside the lagoon were: PAH approximately 100 kg; HCB approximately 1 kg; DDT approximately 0.4 kg. PCB and PCDD/F fluxes were approximately 500 g and approximately 10 g, corresponding respectively to 0.1 and 0.4 g I-TE. The correlations between fluxes of inorganic micropollutants and grain-size were significant. Multivariate statistical analysis was applied to investigate more accurately relationships between the insoluble and dissolved fractions of inorganic micropollutants and grain-size fractions. In particular, significant correlations were highlighted between the dissolved fraction of As and the < or =1 mum particle size fraction. Relations between levels of SigmaPCDDF, SigmaPCDD, PCB and PAH congeners and grain-size revealed significant correlation coefficients for the remote sites (B, C), and none in the urban and industrial sites (A, D). In particular, significant correlations were highlighted between SigmaPCDDF, SigmaPCDD and particle size fraction < or =2 mum, and between benzo(a)pyrene and PCB 167 and particle size fraction 4-8 mum.

Quartz balance DNA sensor.

Single-strand DNA-containing thin films were deposited onto quartz oscillators by the Langmuir-Blodgett technique towards the realization of a device capable of sensing the presence of the complementary DNA sequences which hybridize with the immobilized ones. DNA, once complexed with aliphatic amines, appears as a monolayer in a single-stranded form by X-ray small angle scattering. A quartz nanobalance is then utilized to monitor mass increment related to specific hybridization with a complementary DNA probe. The crystal quartz nanobalance, capable of high sensitivity, indeed appears capable of obtaining a prototype of a device capable of sensing the occurrence of particular genes or sequences in the sample under investigation. The validity of the nanogravimetric assay was confirmed by independent fluorescence measurements utilizing DAPI and a CCD camera.

Measurement of atmospheric deposition of polychlorinated dibenzo-p-dioxins and dibenzofurans in the Lagoon of Venice, Italy.

Data on atmospheric fall-out of polychlorinated dibenzo-p-dioxins (PCDDs) and dibenzofurans (PCDFs) were provided by collecting bulk deposition in four stations inside the Lagoon of Venice. A total of 44 monthly samples was collected during the period July 1998-July 1999 in one site near an industrial area (Porto Marghera), one site in the city of Venice, and two sites in the southern- and northernmost ends of the Lagoon. Fluxes of PCDD/Fs were between 0.1 and 470 pg m(-2) d(-1), corresponding to 0-9.2 pg of 2,3,7,8-TCDD equivalents (TEQ) m(-2) d(-1), with a gradient increasing from remote to urban/industrial stations. Thus, annual deposition of PCDD/Fs to the Lagoon (total area=550 km2), calculated with various methods, turned out to be approximately 12 g, corresponding to approximately 400 mg TEQ. Significant differences were found among the stations, with a clear fingerprinting signature (PCDF/PCDD>1) of the deposition collected near Porto Marghera, and a reversed pattern (PCDF/PCDD<1) in the rest of the Lagoon, which pattern was similar to the sediments collected in the same locations. Lastly, the amount of bulk sigmaTEQ of all stations was compared with the guide values for dioxins in depositions proposed by De Fré et al. [Organohalogen Compounds 45 (2000) 324].

Organic pollution in a Ramsar site (Piallassa Baiona, northern Adriatic Sea).

A core collected in the Piallassa Baiona lagoon, a salt-marsh area already studied for Hg contamination related to nearby industrial sites, was analysed for organic micropollutants. Surface sediments show high concentrations of total PCBs (1148 ng g-1), PCDD/Fs (64 ng g-1) and PAHs (4801 ng g-1). According to a sedimentation rate of 0.4 cm y-1, the high increases in total PAH, PCB and PCDD/F concentrations began in the 1960s and peaked in the 1970s, in parallel with the highest Hg concentrations. Instead, the recent contamination, which primarily involves PCBs and PCDD/Fs, has been observed to be unrelated to Hg concentrations. Organic micropollutant concentrations in the sample core were compared with the sediment quality criteria provided by international guidelines, and revealed high toxic potential. This heavy contamination was also confirmed by comparison with similar environments, particularly the Lagoon of Venice. Further investigations are needed to understand better the sources of the recent contamination and to explain the different transfer pathways involved during sedimentation of the "old" material, dumped 20-30 years ago.

Atmospheric input of organic pollutants to the Venice Lagoon.

The atmospheric deposition of dioxins and furans (PCDD-Fs), dioxin-like polychlorobyphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs) and hexachlorobenzene (HCB) was determined in the Lagoon of Venice. Sampling was carried out monthly, for a total of 13 months (July 1998-July 1999) using "bulk" samplers (passive collectors of wet and dry depositions) at four sites, inside the lagoon and close to its edge. Calculated PCDD-F loadings to the Lagoon turned out to be quite homogeneous, their range being approximately 10-20 ng m-2 y-1, whereas in the station located close to the industrial zone of Porto Marghera the value was approximately 50 ng m-2 y-1. PCB deposition in the industrial fallout sampling site and in the city centre of Venice was approximately 2500 ng m-2 y-1, that is, almost five times higher than the values measured at the northern and southern lagoon stations. HCB annual loading (approximately 8000 ng m-2 y-1) was almost six times higher in the industrial zone than in the other sites (approximately 1500 ng m-2 y-1). PAH loadings in the city centre of Venice and at Porto Marghera were 314 and 389 micrograms m-2 y-1, respectively. The amount of 2,3,7,8-TCDD equivalents (TEQ) of PCDD-Fs and PCBs in the Venice and Porto Marghera bulk depositions was compared with the guideline value of 15 pg m-2 d-1 for dioxins in depositions proposed by De Fré et al. (1998). Moreover, as some of the effects which drive the risk assessment of dioxin-like compounds were also observed after exposure to other molecules, the TEQs of PAHs and HCB were also calculated: nine out of 13 samples exceeded the guideline value. Lastly, an atmospheric emission source related to vinyl chloride monomer production, which may affect atmospheric deposition on the whole Lagoon, is reported in the industrial zone of Porto Marghera.

Ablation of typical atrial flutter: a prospective study of cooled-tip versus 8-mm-tip catheters.

AIM: Both ablation catheters with irrigated system and 8mm tip-catheters have shown to be more effective for typical atrial flutter radiofrequency (RF) ablation when compared to conventional 4 mm tip catheter. The purpose of this prospective study was to compare the efficiency of radiofrequency catheter ablation (RFA) of the cavotricuspid isthmus using a new type of open irrigation-tip catheter versus 8 mm tip-catheters to eliminate atrial flutter (AFL). METHODS: Sixty consecutive patients, matched for age, presence of cardiopathy, atrial dimensions and comorbidity, underwent RF ablation of cavotricuspid isthmus (CTI) for the treatment of typical atrial flutter, using an open irrigated tip catheter - Surround Flow™ - (N.=30) or an 8-mm-tip catheter (N.=30). The RF pulses were applied point-by-point for 30 seconds, with power limited at 35 w for the irrigated catheter and by temperature control (60/70 w) for the 8-mm catheter. RESULTS: The CTI block was successfully performed in 100% of cases. There was no significant difference with regard to ablation parameters, such as total time of RF ablation (608±324 vs. 556±244 s, P=0.79), number of RF applications (12±8 vs. 10±5, P=0.56), total procedure duration (86.4±23.6 vs. 78.1±22.5 min, P=0.58) and time of fluoroscopy (12±6 vs. 14±6 min, P=0.25) and periprocedural complications (1 groin hematoma in the 8 mm group). During follow-up of 11.6 months on average, one patient in the 8 mm group had recurrence of typical atrial flutter. CONCLUSION: Efficacy and safety of CTI ablation was comparable between both techniques (open irrigated catheter and 8mm tip catheter). The ablation parameters were comparable and homogeneous between the two groups.

The hypothesis of patho-physiological correlation between chronic cerebrospinal venous insufficiency and multiple sclerosis: rationale of treatment.

BACKGROUND: The possible role of the venous system in the pathogenesis of chronic neurodegenerative diseases has been hypothesized for decades. Quite recently, the description of a venous condition defined as chronic cerebrospinal venous insufficiency (CCSVI) and its strong association with multiple sclerosis (MS) has brought back the attention of the scientific community to the hypothesis of an aetiological or concomitant role of an altered venous function in the occurrence of this pathology. CCSVI is identified by sonographic criteria, thus the indication for its possible treatment is based on ultrasound findings. METHOD: We retrospectively examined 167 consecutive patients affected by clinically defined MS and CCSVI, identified by ultrasound assessment by the presence of at least two sonographic criteria. Ultrasonographic diagnosis of CCSVI was then integrated by venography and intravascular ultrasound examination (in 43 patients). Patients were all submitted to endovascular procedure (venoplasty). RESULTS: In 37% of cases there was no correspondence between the preoperative ultrasound assessment and the venographic findings. In the event of incongruity between venography and sonography, the intravascular ultrasound examination investigation, when performed, confirmed ultrasound findings in 42% of cases and venography results in 58%. At one month in 12% of cases ultrasound assessment showed the persistence of altered flux. In 67% of cases patients reported subjective amelioration, regarding non-specific symptoms. CONCLUSION: The pathophysiology of CCSVI is yet to be defined. The superior cava venous system is highly complex in terms of anatomy and possible anomalies, as well as its haemodynamic mechanisms. Further studies are required to define the parameters of diagnosis and treatment of CCSVI.

Effects of eccentric compression by a crossed-tape technique after endovenous laser ablation of the great saphenous vein: a randomized study.

OBJECTIVES: To evaluate the effect of eccentric compression applied by a new crossed-tape technique on procedure-related pain occurrence after endovenous laser ablation (ELA) of the great saphenous vein (GSV). METHODS: From April 2005 to June 2006, 200 consecutive ELA procedures were randomized to receive (group A: 100) or not (group B: 100) an eccentric compression applied in the medial aspect of the thigh. Patients were scheduled for a seven-day examination to assess the level of pain experienced. Pain intensity was measured using a visual analogue scale giving a numerical grade from 0 (no pain) to 10 (worst pain ever). RESULTS: The intensity of postoperative pain was significantly reduced (P < 0.001) in the eccentric compression group as compared with the non-compression one. CONCLUSIONS: This technique of eccentric compression greatly reduces the intensity of postoperative pain after ELA of the GSV.