PM2.5 on the London Underground.

INTRODUCTION: Despite the London Underground (LU) handling on average 2.8 million passenger journeys per day, the characteristics and potential health effects of the elevated concentrations of metal-rich PM2.5 found in this subway system are not well understood. METHODS: Spatial monitoring campaigns were carried out to characterise the health-relevant chemical and physical properties of PM2.5 across the LU network, including diurnal and day-to-day variability and spatial distribution (above ground, depth below ground and subway line). Population-weighted station PM2.5 rankings were produced to understand the relative importance of concentrations at different stations and on different lines. RESULTS: The PM2.5 mass in the LU (mean 88 µg m-3, median 28 µg m-3) was greater than at ambient background locations (mean 19 µg m-3, median 14 µg m-3) and roadside environments in central London (mean 22 µg m-3, median 14 µg m-3). Concentrations varied between lines and locations, with the deepest and shallowest submerged lines being the District (median 4 µg m-3) and Victoria (median 361 µg m-3 but up to 885 µg m-3). Broadly in agreement with other subway systems around the world, sampled LU PM2.5 comprised 47% iron oxide, 7% elemental carbon, 11% organic carbon, and 14% metallic and mineral oxides. Although a relationship between line depth and air quality inside the tube trains was evident, there were clear influences relating to the distance from cleaner outside air and the exchange with cabin air when the doors open. The passenger population-weighted exposure analysis demonstrated a method to identify stations that should be prioritised for remediation to improve air quality. CONCLUSION: PM2.5 concentrations in the LU are many times higher than in other London transport Environments. Failure to include this environment in epidemiological studies of the relationship between PM2.5 and health in London is therefore likely to lead to a large exposure misclassification error. Given the significant contribution of underground PM2.5 to daily exposure, and the differences in composition compared to urban PM2.5, there is a clear need for well-designed studies to better understand the health effects of underground exposure.

How to simplify the approach to the supra-aortic trunks.

Carotid artery stenting (CAS) represents a valid alternative to carotid endarterectomy (CEA). Possible embolization during the approach and the cannulation of the supra-aortic arterial trunks remains an important obstacle to CAS. This risk is increased in elderly patients and complex anatomies. In order to achieve satisfactory technical and clinical outcomes, a thorough understanding of the patients' individual anatomy of the arch and the access vessels is essential. The cannulation of the common carotid artery represents the key maneuver for the entire CAS procedure. This review article will present the currents techniques and devices actually use in order to facilitate the approach to the supra-aortic vessels.

Advancements in the Mo.Ma system procedure during carotid artery stenting.

AIM: The aim of this paper was to reduce the incidence of clamping intolerance, asystolia, immediate mortality and neurological complications associated with carotid artery stenting (CAS) using the Mo.Ma system (Invatec, Roncadelle Brescia, Italy) embolic protection device (EPD). METHODS: CAS was perfomed using the Mo.Ma system in 312 patients between January 2002-October 2009. From October 2008 variations to the standard technique were introduced. A total of 214 patients were treated with the standard technique, and 88 with the new technique. Improvements include the engagement of the guidewire's floppy tip through the lesion whilst the cerebral blood flow is maintained, a slow release post-dilation (1 atm/2 s), a quicker manual aspiration procedure following post-dilation, a redirection of blood flow into the external carotid artery (ECA) with the post-dilation balloon inflated in the internal carotid artery (ICA), and a further manual aspiration and the subsequent release of the Mo.Ma system. RESULTS: This study reports reduced incidence of clamping intolerance (7.9% vs. 4.5%), asystolia (0 vs. 1.9%), immediate mortality (0 vs. 0.9%) and neurological complications (1.1% vs. 3.7%). The only neurological complication associated with the new technique was a transient ischemic attack (TIA). CONCLUSIONS: The new variations of the standard Mo.Ma technique seem rational in the improvement of the safety and efficacy of CAS using an EPD, in reducing the incidence of clamping intolerance and asystolia, immediate mortality and neurological complications. This series indicates a positive trend for this revised technique, but a multicentre registry is required to validate these promising results.

Potential Cost Savings from Generic Medicines - Protecting the Prescribed Minimum Benefits

"Background: South Africa has followed a pro-generic policy since the introduction of the National Drug Policy in 1996. The selection processes in the public and private sectors have; however; remained largely disconnected; and at times contradictory. Medicines provided outside of hospitals accounted for 17of medical aid spend in 2006; up 8.8from the previous year. Of particular concern to funders has been the expenditure on the 27 chronic conditions listed as Prescribed Minimum Benefits. The Medical Schemes Act (No 131 of 1998) provides for the definition of Prescribed Minimum Benefits; which stipulate a package of services or care a medical scheme must provide for in its benefit design. There is pressure to reconsider these requirements in order to increase the affordability of medical scheme coverage. This study assessed the potential savings thatwould be achievable by substituting generics for brand name (originator) medicines listed in the chronic disease algorithms set out by the Council for Medical Schemes (CMS).Methods: All medicines listed in the 25 chronic diseases algorithms made available by the CMS were identified. Brand and generic versions were identified in the Monthly Index of Medical Specialties (MIMS; May 2006). Single exit prices inclusive of value added tax were obtained from the web site of the Pharmaceutical Blue Book and the cost per defined daily dose for one month was then calculated. Cost differentials; where available; were then identified for each medicine listed in the algorithms. Cost differentials for medicines within each algorithm were presented as the median of the difference between brand and generic medicines listed for that algorithm; and also as the median of differences between generic medicines for the same condition. Results: Three of the algorithms (diabetes insipidus; haemophilia and hypothyroidism) list medicines for which no generic equivalent was available at the time of the study. The median cost differential between brand and generic equivalents for the remaining 22 chronic conditions ranged from 19.5(for type 1 diabetes mellitus) to 97(for Addison's disease). Across the entire chronic disease algorithm set; 80 medicines with generic equivalents were listed for 22 conditions. The median cost differential between brand and generic versions of these 80 medicines was 49.9(interquartile range 32.0 to 78.5). Of all generic medicines identified; 67.5were more than 40cheaper; per defined daily dose (DDD) per month; than the branded version. In 16 medicines the cost differentials between generic versions were 1or less. Some correlation between the number of generics and the size of the cost differential was apparent (correlation coefficient 0.49). There were examples of high-cost differentials in highly competitive areas of the market. Conclusions: An argument could be made for more closely aligning the process of developing the National Essential Drugs List and the development of the CMS algorithms. By being more specific about which medicines should be covered; needless expenditure on ""me-too"" agents of doubtful additional benefit could be avoided. Where clinically warranted; appropriate choices could be provided. Finality in respect of the pricing of medicines needs to be achieved. This applies not only to the dispensing fee but also to the proposed benchmarking process and the proposed differentialbetween brand and generic medicines."

The inflammatory abdominal aortic aneurysm and coronary artery disease. Case report and review.

Inflammatory abdominal aortic aneurysm (IAAA) is defined as an unusually thickened aneurysmatic wall, encircled by a wide dense perianeurysmal and/or retroperitoneal fibrosis with adjacent tissues adhesion, and is now considered as an extreme shape of the common phlogistic process involved in atherosclerotic plaque formation. Latest studies demonstrated that inflammation plays an important role in coronary disease and in other atherosclerosis manifestations. We introduce the clinical case of a patient with IAAA who developed an acute myocardial infarction 6 months after the surgical procedure on the aorta. Through a literature review about IAAA we stress the clinical usefulness of the inflammatory markers as independent predictors in management of patients with coronary disease and we present the hypothesis, related to the introduced case, of an advanced coronary disease, aggravated or clinically revealed after the cytokine storm related to important localized inflammatory engagements or great vascular surgery treatments.

Effectiveness and safety of carotid endarterectomy under remifentanil.

AIM: The aim of this study was to evaluate the effectiveness and safety of carotid endarterectomy (CEA) with conscious sedation under remifentanil (Remifentanil anesthesia - RA) vs conventional loco-regional anesthesia (Conventional-LRA) in the current practice of a vascular surgery unit. METHODS: We introduced the ''Remifentanil-RA'' in our practice according to a two-step protocol. In the first step we performed a pilot prospective study to assess the procedure's safety and reproducibility in our setting on 60 consecutive patients with symptomatic and/or high-grade (>70%) internal carotid artery stenosis and alternately assigning them either to ''Remifentanil-RA'' or ''Conventional-LRA'' CEA. In the second step we analysed our routine operative records as to effectiveness and safety on 533 patients who consecutively underwent ''Remifentanil-RA'' CEA. We compared them with 533 age- and sex-matched historical controls who underwent ''Conventional-LRA'' CEA. RESULTS: The patients' mean age was 71.2+/-6.8 vs 71.8+/-6.1 (''Remifentanil-RA'' vs ''Conventional-LRA''). About 73% of them were male and 56% had a symptomatic carotid stenosis. Neither the pilot study nor second step comparison showed differences in outcome measures. We found only higher peri-operative nausea/ vomit (3.6% vs 0.4% ''Remifentanil-RA'' vs ''Conventional-LRA'', P<0.0002) and fewer re-operations for post-operative hematomas (3% vs 5.4% respectively, P=0.048). CONCLUSIONS: We found that ''Remifentanil-RA'' CEA was safe, effective and satisfactory. Nevertheless, with the potential problems of intubation and those already found with side effects, a randomized control trial (RCT) is needed in order to prove that this method is superior to ''Conventional-LRA'' CEA.

[Correlation between clinical-instrumental pattern in venous pathology (capillaroscopic classification of the medial peri-malleolar area)]. / La correlazione clinico-strumentale nel paziente flebopatico (stadiazione capillaroscopica dell'area patologica perimalleolare mediale di Romeo).

BACKGROUND: The high incidence of chronic venous insufficiency makes it quite an ordinary topic in the outpatients departments of vascular units. Furthermore, due to the discrepancy between symptoms and Doppler c.w reports, it is necessary to face this problem with the help of very sensitive instrumental methods. Therefore, the main aim of this article is to find out which method, among those used in the outpatients department of phlebology, is sensitive enough to establish a relationship between clinical and instrumental patterns in venous diseases. METHODS: Fifty-one subjects were studied: 44 affected by venous disease and 7 healthy subjects. All patients underwent clinical examination followed by classification by Widmer criteria, Doppler c.w., infrared photoplethysmography and capillaroscopy of the medial malleolus. RESULTS AND CONCLUSIONS: Capillaroscopy demonstrated to have the highest sensitivity, allowing to find out pathological alterations in subjects complaining of symptoms and with normal Doppler c.w. findings. Furthermore, the findings of venular networks (pathological) in the malleoli of healthy subjects, made it necessary to modify the current capillaroscopic classification (based upon three types of pictures: normal, reticular and halo formations), into a new extended version based on five steps, with three types of reticular sub-classes, in which the different gauge of the venules is satisfactorily related to the symptoms referred by the patients.

Computerized approach to active and objective quality control of patient care.

The paper describes a quality control program based on the principles of clinical methodology and indicators defined by physicians and hospital administrators according to general as well as local needs. The program is supported by a knowledge-based system which can be used in two ways: with on-line helps and hints to ensure effective and efficient medical decisions on a simulated patient for training purposes; and without facilities supporting the user to be used on an on-line setting for performance evaluation. The quality control program includes the evaluation of effectiveness and efficiency of patient care with respect to the overall process, single hypotheses and individual decisions: the evaluation regards the number and reliability of activated hypotheses, costs, time spent, number and appropriateness of investigations. The overall process is recursive, in that the results of each cycle are used by physicians to define new goals and indicants for the next cycle; quality control is active because physicians under evaluation are directly involved in the definition of goals and indicants and in the evaluation of results; evaluation is objective because indicants are predefined, and evaluation criteria are transparent.