Clinical aspects and diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls.

OBJECTIVE: To evaluate the diagnostic relevance of neuroautonomic evaluation in patients with unexplained falls compared to those with a syncope etiologically unexplained after initial evaluation. METHODS: It is an observational study, comparing 298 patients with unexplained fall with 989 patients with unexplained syncope. Each patient underwent supine and upright blood pressure measurement, tilt testing (TT) and carotid sinus massage (CSM). RESULTS: Patients with unexplained falls were older (75.3 ± 11.1 vs. 63.2 ± 19.2 years, p < 0.001), were more frequently hypertensive (66.1 vs. 47.2 %, p < 0.001) and more frequently prescribed antihypertensive drugs (62.4 vs. 48.7 %, p < 0.001) or benzodiazepines (15.7 vs. 10.6 %, p = 0.01), and in a greater proportion they experienced major traumatic injuries (77.5 vs. 29.6 %, p < 0.001) as a consequence of falls. The TT was less frequently positive in patients with unexplained falls (36 vs. 51.3 %, p < 0.001), whereas a Carotid Sinus Syndrome as suggested by CSM had a similar prevalence in the two groups (14.3 vs. 10.5 %, p = 0.074). Overall, either TT or CSM were positive in 61 % of patients with unexplained falls, and in 64 % of those with syncope (p = 0.346). After matching by age 298 patients with falls (75.3 ± 11.1 years) and 298 patients with unexplained syncope (75.4 ± 11.1 years), we found that the positivity prevalence of TT and CSM were similar in the two groups. CONCLUSIONS: The positivity prevalence of TT and CSM in patients with unexplained falls compared to patients with unexplained syncope is similar. Given its high diagnostic relevance, the neuroautonomic evaluation should be routinely performed in older patients with unexplained falls.

Supine hypertension: A state of the art.

Patients with cardiovascular autonomic failure (AF) may suffer from neurogenic supine hypertension (nSH), defined as systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, after 5 min of rest in the supine position, combined with neurogenic orthostatic hypotension (nOH) in approximately 50% of the cases. nSH may be the manifestation of central or peripheral autonomic lesions. Long-term risks are hypothesized with SH, including renal dysfunction, left ventricular hypertrophy, cerebrovascular disease and cognitive impairment. Yet, large longitudinal studies investigating long-term outcomes of nSH are lacking. In clinical practice, nSH should be investigated in patients with nOH. Office screening should be performed measuring supine BP immediately after lying down and 5 min later, combined with BP measurement on active or passive standing. Home BP recordings performed by patients themselves may also be useful, while 24 h-Ambulatory Blood Pressure Monitoring (ABPM) may allow for detection of nocturnal hypertension and confirm the diagnosis. Current expert recommendations suggest treatment interventions if SBP exceeds 160-180 mmHg. Non-pharmacological strategies represent the first-line treatment approach and include head-up sleeping, avoiding supine position during the daytime, and having a snack before bedtime to lower supine BP using post-prandial hypotension. Pharmacological treatments may be considered if severe nSH persists. Short-acting antihypertensive medications administered at bedtime are preferably used in order to selectively lower supine BP and reduce pressure diuresis without worsening daytime hypotension.

The management of syncope in older adults.

Syncope is a frequent symptom in older patients. The diagnostic and therapeutic management may be complex, particularly in older adults with syncope and comorbidities or cognitive impairment. Morbidity related to syncope is more common in older persons and ranges from loss of confidence, depressive illness and fear of falling, to fractures and consequent institutionalization. Moreover, advan-ced age is associated with short and long-term morbidity and mortality after syncope. A standardized approach may obtain a definite diagnosis in more than 90% of the older patients with syncope and may reduce diagnostic tools and hospitalizations. The initial evaluation, including anamnesis, medical examination, orthostatic hypotension test and electrocardiogram (ECG), may be more difficult in the elderly, specially for the limited value of medical history, particularly for the certain diagnosis of neuro-mediated syncope. For this reason neuroautonomic assessment is an essential step to confirm a suspect of neuromediated syncope. Orthostatic blood pressure measurement, head up tilt test, carotid sinus massage and insertable cardiac monitor are safe and useful investigations, particularly in older patients. The most common causes of syncope in the older adults are orthostatic hypotension, carotid sinus hypersensitivity, neuromediated syncope and cardiac arrhythmias. The diagnostic evaluation and the treatment of cardiac syncope are similar in older and young patients and for this reason will not be discussed. In older patients unexplained falls could be related to syncope, particularly in patients with retrograde amnesia. There are no consistent differences in the treatment of syncope between older and younger population, but a specific approach is necessary for orthostatic hypotension, drug therapy and pacemaker implantation.

An object oriented decision support system for the planning of health resource allocation.

The health resource allocation problem is discussed in this paper. An object-oriented system, which consists of two parts is proposed and its implemented prototype is illustrated. The first part consists of a Geographical Information System which is able to acquire and store both geographical information regarding the territory under investigation and the socio-epidemiological information and the resource distribution in that moment on the same territory. The second part refers to the strategies and the relative algorithms carried out (using a Decision Support System) to obtain the best solution (allocation of new resources optimizing the cost/benefit ratio) after that the user has fixed a goal (e.g., the decrease of the incidence of a given disease) and has defined some constraints (e.g., a fixed budget, a given set of available resources, etc.). The object-oriented database stores different scenarios, depending on the different goals and constraints defined in input. A user friendly interface was also implemented.

Hepatocellular carcinoma: the virtual hospitalization in day-hospital.

The virtual hospitalization can be considered as the telematic evolution of the Day-Hospital, implementing the integration between hospital care and home care and predefining an hospital system which "goes to the patient home". In this paper the authors describe characteristics, motivations and advantages of this proposal, as well as the interaction model. Then the medical problem is illustrated: the liver tumors, which are the more frequent malignant neoplasms, and, in particular, the hepatocellular carcinomas, which represent about the 50% of these tumors. The Organization Model, the Information System and the Modalities of Telemonitoring for Hepatocellular Carcinoma are still illustrated and a brief conclusion is given.

Telematic evolution of day-hospital in oncology.

The telematic evolution of the Day-Hospital can be considered as the virtual hospitalization, implementing the integration between hospital care and home care and predefining an hospital system which "goes to the patient home". In this paper the authors describe tools, characteristics, and advantages of this proposal, as well as the interaction model. Then the medical problem is illustrated: the first model implemented in oncology involves the liver tumors, which are the more frequent malignant neoplasms, and, in particular, the hepatocellular carcinomas (HCC),. The Organization Model, the Information System, the Tools and the Modalities of Telemonitoring for Hepatocellular Carcinoma in telematic day-hospital are still illustrated and a brief conclusion is given.

An information system on toxicological risks linked to drug manipulation.

Aim of the project is to define and to implement an information system able to help people, who produce chemotherapic antineoplastic drugs, and health care operators, who manipulate such drugs, to prevent short and long term adverse effects connected to the above mentioned activities. The system is able to give a detailed and updated information about these problems, and to give an up-to date, from a professional point of view, to the users of the system. Also an information system prototype was implemented, which consists of an object-oriented database, a decision support system, able to manage and to plan a periodic control of workers, to verify the adverse effects of the antineoplastic chemotherapic drugs, a management system for the network communications.

Poor diagnostic performance of tilt testing in hypertensive patients with unexplained syncope.

Syncope is a common condition. Tilt testing with sublingual nitroglycerin (TT-TNT) provides a test with good specificity and positivity rate in young and old patients. Its use in hypertensive patients with unexplained syncope has not been validated. The aims of this study were to evaluate the positivity rate, specificity and tolerability of TT-TNT in hypertensive patients with unexplained syncope. Five hundred and ten subjects (mean age 55 years) were enrolled, 388 patients with unexplained syncope (73 hypertensive and 315 normotensive) and 122 controls (59 hypertensive and 63 normotensive). All subjects underwent TT-TNT. The responses were classified as positive, negative or exaggerated (aspecific). In hypertensive patients, the usual hypotensive therapy was taken on the day of the test. In hypertensive controls, the positive responses were higher than in normotensives (19% vs 6%, P<0.001). The overall specificity was 81% in hypertensives and 94% in normotensives. The positivity rate was significantly lower in hypertensives (55% vs 72%, P<0.03). There was no significant difference between young patients and patients >65 years. TT was well tolerated, and no serious side effects occurred. TT potentiated with TNT has a lower positivity rate and specificity in hypertensive than in normotensive patients with syncope.

Toward an improvement of life optimizing resource use.

In this paper an object-oriented system for the storing and the managing of epidemiological data in order to decrease the incidence of a given groups of diseases by means of health care strategy application and of the relative health care resource allocation is described. The system starts from the present epidemiological situation of the territory examined and from the real distribution on this territory of human and material health care resources. The health care manager inputs the available budget, some information regarding the population living on this area, other geographical and climatic informations, the values of certain epidemiological parameters of the diseases considered--the system has stored the mathematical and departmental models of these diseases--and the system allocates (using own allocation algorithms) human and material health care resources, optimizing the cost-benefit rate.

Expert systems and the pancreatic cancer problem: decision support in the pre-operative diagnosis.

In this paper, after reviewing the main issue in artificial intelligence, decision support systems, medical decision-making, expert systems and some of their applications in medicine, we focus on the diagnostic aspect of pancreatic cancer. We briefly examine the most significant applications both from the oncological and from the diagnostic point of view. We discuss the medical problems mentioning incidence and mortality, aetiological factors and diagnosis, considering the roles of surgery and adjuvant therapies. Finally we justify the decision to develop an expert system in such a medical domain and discuss the SPES (Surgical Pancreatic Expert System) project, its parts dealing with the different medical phases of pancreatic cancer diagnosis and therapy: pre-operative, intra-operative and adjuvant therapies. In particular we discuss diagnostic aspects of pancreatic cancer disease, pointing out the aims of the project, methodologies, tools used and future developments.

Virtual hospitalization: reality or utopia?

In this paper the problem regarding the way in which the increasing capacity and facilities of the telemedicine to link points of care, supporting services and health care sectors, is described. The virtual hospitalization is discussed, as well as its insertion in a new health care system, whose services will provide everyone with effective health care in their homes or in isolated places or in their working places or in emergencies, and which will permit remote consultations between professionals in specialized centers, hospitals and other peripheral points of care.

A system to define and allocate health care resources on a territory to improve the life quality of the populations in developing countries.

In this paper the health resource allocation problem is discussed. An object-oriented system is proposed and its implemented prototype is illustrated. It consists of two parts: a Geographical Information System, which is able to acquire and store both geographical and social-epidemiological information (including the resource distribution on that territory), and a Decision Support System, able to decide, using optimization algorithms, the new resource allocation in order to obtain a quasi-optimal solution for the cost/benefit ratio minimization problem, after having fixed the goal (e.g., the decrease of the incidence of a given disease) and constraints (e.g., a fixed budget, a given set of available resources, etc.). The object-oriented database which is part of the system can simulate and store different scenarios, depending on the different goals and constraints defined in input, by means of a user friendly interface.