[Implementing clinical pathways: some practical notes]. / L'implementazione dei percorsi: note pratiche.

The traditional biomedical paradigm is no longer a guarantee of quality for health care, facing increasingly difficult challenges caused by chronic diseases and increasingly fragmented resources that current healthcare systems are dealing with. Health care organizations, considered to be the most complex enterprises of the modern era, must be able to focus on the flow of patients, integrating primary and secondary care through tools such as the Integrated Care Pathways (ICP). This brief discussion attempts to define the ICP its purposes, the elements that characterize it, its limitations and the mechanisms to push for a successful implementation. In order to highlight the elements and basic steps for the creation of an ICP, the authors have compared five different clinical pathways, whose implementation they have contributed to. The comparison was made using two grids: the first showing the essential elements for the definition of lCP and the second one with features that can facilitate their effectiveness. The conclusions of the work show what, pursuing the construction of a pathway, we must never forget: to analyze the gap between the clinical-care activities performed and the theoretical framework provided by the evidence; to see the barriers to change that may impede the implementation; to involve all actors in the system, with particular attention to patients and their associations, and finally to provide a plan for information and education, addressed to health professionals and patients as well.

[Celiac disease in Emilia Romagna]. / La malattia celiaca in Emilia Romagna.

The prevalence of celiac disease is still significantly under-estimated world-wide. We compared the Emilia Romagna's with international data. We studied symptomatic patients recorded in reimbursement regional health service program. In year 2008, the patients were 7811. Our investigation did not show age related prevalence, except in the age group 0 to 1 probably due to breastfeeding. The overall prevalence is 1,8 patient/1000 of Emilia Romagna citizens. The prevalence is extremely variable in the different districts from 1:384 Parma's area to 1:909 Piacenza's. Our data confirm the underestimation previously found in other countries. Diagnosis (tests and small bowel histology) are performed, but probably a multidisciplinary effort must be made to promote knowledge and to understand pathogenesis of CD.

[Organizational model of the Cancer Institute of Romagna (I.R.S.T.) and the Romagna Cancer Network]. / Modello organizzativo dell'Istituto Tumori della Romagna (I.R.S.T.) e della Rete Oncologica Romagnola.

The quality of a treatment is strictly connected to research and technological development: to carry out competitive research, investments in advanced technologies are compulsory. To invest in research and new technologies for the diagnosis and the treatment of neoplasies at first level is compulsory as well and it also represents the most effective method to save resources. The AWR (wide area Romagna) is an health care network which is now treating approx. 9,000 cancer patients a year in a regional population of 1,095,205 residents in the provinces of Forli-Cesena, Ravenna and Rimini. I.R.S.T (The Cancer Institute of Romagna) is the "nucleus" of the oncologic network: it works as a Hub for some highly specialized activities and as a Spoke for other activities on behalf of the Local Health Authorities. I.R.S.T.'s Mission is focused on Translational Research, representing a structure fully integrated within the Regional Health System. In agreement with the AVR's Local Health Authorities and on their behalf I.R.S.T. manages all oncological research and clinical trials, in addition to facilitating innovative trials, which require particular organizational structures and technologies that are not generally available in the oncologic network.

[An organizational model for safety management in health services]. / Un modello organizzativo per la gestione della sicurezza in Sanità.

The authors are reporting a practical experience about safety management of health workers through the adoption of a management model inspired to the indications of International Standard for Quality Management. In the discussion they describe the integration path between the Prevention and protection Service and the Quality Office of the University Hospital of Bologna in order to promote the accomplishment of a progressive spirit of collaboration through the implementation of a shared and common management system which helped in the adoption of appropriate Improvement solutions in order to protect the safety of the health workers.

[State of the art and scientific evidence on the role of unidirectional airflow ventilation systems in reducing surgical site infections]. / Stato dell'arte ed evidenze scientifiche sul ruolo dei sistemi di ventilazione a flusso unidirezionale nella riduzione delle infezioni del sito chirurgico.

The use of unidirectional airflow ventilation systems in operating rooms is frequently recommended for the prevention of Surgical Site Infections (SSI). However, scientific evidence is lacking to clearly support this technology which entails high investment costs and operating expenses, as compared with traditional ventilation systems. This sparse evidence is mainly related to the small number of interventions analyzed in each study and the difficulty to distinguish the effects of ventilation and other important confounding factors, such as antibiotic prophylaxis, special operating staff clothing and adoption of educational and training programs against SSI for the surgical personnel. The different behavior of the industrialized countries towards this issue, as it comes out analyzing the existing Rules and Guidelines concerning operating rooms ventilation, reflects a precautionary approach towards a technology which, until recently, has clearly demonstrated neither benefits nor limitations. In 2008, a relevant scientific study was published, reporting results from 63 departments of 55 German hospitals for a total of 99.230 surgical interventions, in which a standardized SSI surveillance was performed. Unexpectedly, the study concluded that unidirectional airflow ventilation showed no benefit and was even associated with a significantly higher risk for severe SSI, as compared with turbulent clean air. The present review collects updates from the scientific literature and national and international Rules and Guidelines concerning the use of unidirectional airflow ventilation systems in operating rooms, analyzing all aspects involved in this issue, from the debated efficacy of these systems in reducing the incidence of SSI to the "side effects" associated to their use, as the relevant costs and the reduction of the environmental comfort for the operators.

Comparison of floor sanitation methods.

Two methods for cleaning waxed polyvinylchloride and porcelain grès hospital room floors were compared in order to determine their decontamination capacity: dry wiping followed by damp washing, and damp washing followed by dry wiping. Dry wiping followed by damp washing did not produce any significant reduction in the average bacterial load. However, damp washing followed by dry wiping reduced the bacterial load for both types of flooring. The difference was statistically significant.

[Diabetes, obesity and adenocarcinoma of corpus uteri]. / Diabete, obesità ed adenocarcinoma corporis uteri

Diabetes and obesity were noted in 21.3% and 42.3% respectively of 94 patients with adenocarcinoma corporis uteri. Hypertension and ovarian or mammary neoplasia were also common. Obese and diabetic subjects proved more sensitive to treatment with high doses of medroxyprogesterone acetate. Screening for precancerous states or carcinoma of the endometrium in obese and diabetic women is suggested.

[Cost evaluation of a ventilation system for operating theatre: an ultraclean design versus a conventional one]. / Valutazione dei costi di un impianto di ventilazione per un blocco operatorio: confronto tra sistema "ultraclean" e convenzionale.

The postoperative infection has been recognized as a critical problem in healthcare, increasing patients'complications and hospitalization costs. At the moment the scientific evidence clearly linking ventilation parameters, such as air changes per hour, bacterial counts and infection, is lacking, with the exception of prosthetic joint surgery. This study aims to evaluate the building and operating costs of an ultraclean system versus a conventional one (which satisfies the minimum performance requested by rules), also considering the debating efficacy of ultraclean ventilation on prevention of postoperative infection. The results of our study show an increase of 24% in the building costs and of 34% in the annual operating costs for the ultraclean system versus the conventional one. The estimated 24% increase of the building costs for the ultraclean ventilation system represents only a 5% increase if compared to the total cost of a not equipped operating theatre. Therefore, the increase on costs linked to the use of high performance ventilation facilities seems to be so small that overcoming current rules towards ultraclean systems could be acceptable.

Considerations on isolation rooms and alternative pressure ventilation systems.

The health-care facility environment is involved in disease transmission in essentially two different situations: 1. in cases where patients are immunocompromised and require protection from infections; 2. in cases of inadvertent exposure to environmental or airborne pathogens that can aggravate patients' existent disease and cause illness among health-care personnel. Environmental infection-control strategies and engineering controls can effectively prevent transmission of these infections. In particular the ventilation system is fundamental to the control of the concentration of airborne contaminants within a hospital isolation room because it establishes and maintains appropriate pressure differentials within special care areas of the building. Thus the incidence of health-care-associated infections can be minimized by adherence to ventilation standards suggested in the guidelines for specialized care environments such as Airborne Infection Isolation rooms (AII, as in situation 2 above), and Protective Environments (PE) rooms (as in situation 1 above). This report is a comparative review of the principal guidelines and strategies existing in the international scientific literature for the prevention of environment-associated infections in healthcare facilities using pressure differentials (positive pressure for PE rooms, negative pressure for AII rooms). The purpose of the review is also to investigate the state-of-the-art use of the "alternative pressure rooms", i.e., areas furnished with a ventilation system capable of switching pressure from positive to negative according to patients' needs. The results of the present analysis indicate an unenthusiastic reaction to these "alternative pressure rooms", although there is no scientific evidence against their use.

[Experimental hormonal carcinogenesis]. / Carcinogenesi ormonale sperimentale.

Experimental carcinogenesis associated with estrogen and progesterone treatment in the induction of mammary tumours and reported in the literature is discussed. The various investigations are compared and some theories are advanced. Techniques for the induction of ovarian tumours and tests carried out with steroids as anticarcinogenic competitive substances are reviewed. Both increased (nucleotidase, aminopeptidase) and decreased (alkaline phosphatase) enzyme values were observed in the case of estrogen induced cervicovaginal neoplasia in the ovariectomised rat.

[A case of allergy due to the use of an egg yolk vehicle in artificial insemination]. / Su un caso di sindrome allergica da uso di mestruo a base di rosso d'uovo nel corso di una inseminazione artificiale.

A case of allergy resulting from the employment of citrated homogenized egg yolk in homologous insemination is reported. The allergen was identified with the presence of egg yolk in the insemination vehicle. The various primary and secondary causes of the syndrome are discussed and the medical therapy used is described. It is suggested that intradermal skin reaction test be carried out with the individual components of the vehicle before artificial insemination with egg yolk-based vehicles is performed.

[Lysosomal enzymes in the neoplastic pathology of the uterine cervix. Study of acid phosphatase in the diagnostic test of vaginal secretions in patients with pre-invasive and invasive cancer of the uterine cervix. I. Methods and preliminary experiences]. / Gli enzimi lisosomiali nella patologia neoplastica del collo dell'utero Studio della fosfatasi acida quale test diagnostico nei secreti vaginali di pazienti portatrici di ca. preinvasivi e invasivi del collo dell'utero. Nota I - Metodiche ed esperienze preliminari

Gomori's method was used in the detection of positive -- or negative -- phosphatase granulations and their intracellular locations in vaginal secretions from 10 normal women and 20 patients with cervical neoplasia in various stages. Positive-phosphatase granulations were absent in normal subjecta and those with advanced neoplasia, whereas mainly large and medium-sized paranuclear positive granulations were a prominent feature of epithelial cells from patients from state 0-ToNoMo carcinomas. Further details will be given in a second note.

[Vaginal secretion hyaluronidase activity levels in normal and in some pathological conditions. Physiological pictures in a clinical series]. / Ricerche del livello di attività della ialuronidasi nel secreto vaginale in alcune condizioni fisio-patologiche della donna. Casistica clinica fisiologica.

A viscometric method was used to determine vagina hyaluronidase activity in 82 healthy subjects. Enzyme values (in micrograms) were referred both to a volume unit and to a standard protein unit. Each subject was also examined colposcopically, cytologically, bacteriologically and cytohormonally. Three subject groups (premenopause, menopause, senile) and three subgroups relating to commonly observed cytological pictures in benign lesions of the portio uteri were chosen. The results show a fall in concentration values from the first to the third group; no meaningful differences were observed in either the individual or the overall subgroup values.

[Activity of lysosomal alpha-arylsulfatase and beta-glucuronidase enzymes in benign and malignant breast tumors]. / L'attività degli enzimi lisosomiali alpha-arilsolfatasi e beta-glucuronidasi nei tumori benigni e maligni della mammella

The total activity per microgram of protein of alpha-arylsulphatase and beta-glucuronidase lysosomial enzymes has been determined in 20 cases of benign and malignant breast tumour. The activity of lysosomial enzymes of the normal breast tissue was always much lower than in neoplastic tissues. The difference is already fairly marked in the case of benign tumours and cystic fibroadenosis, but reaches its peak in malignant tumours where activity is 4-5 times higher than normal values. In the case of total activity, the reference is to one ml of homogenate in distilled water, and in the case of specific activity to mg of protein of the homogenate, in either case the findings are highly significant. Although these researches are at a preliminary stage, they confirm the importance of lysosomial enzyme modifications in the phenomenon of neoplastic growth in the breast.