[The diagnostic admission in an internal medicine service: clinical and economic aspects]. / Il ricovero diagnostico in medicina interna: efficacia clinica, impatto economico, criticità.

Efficacy and costs of the diagnostic process have been under extensive investigation for a long time. In this study we present a detailed, retrospective analysis of the clinical and economic aspects of 347 diagnostic admissions in a teaching hospital. We have, furthermore, investigated the clinical history of a group of 50 patients, from the beginning up to one year after definitive diagnosis, through a structured questionnaire. The results shed some light onto efficacy, cost-effectiveness and cost-profit balance of diagnostic admissions. Strategies to improve efficacy and cost-effectiveness are discussed.

Conventional surgery results in patients originally referred for transcatheter aortic valve implantation.

AIMS: Transcatheter aortic valve implantation (TAVI) is increasingly considered as a viable alternative to conventional aortic valve replacement (AVR) in high-risk patients. Long-term results, however, are still scarce and medical community hesitates in enlarging indications to lower-risk patients. Moreover, available devices are expensive and a strict potential candidate selection is necessary. METHODS: From April 2008 to August 2012, a total of 212 patients, originally referred for percutaneous treatment, were thoroughly evaluated by the aortic team of our department in order to choose the optimal procedure. Of them, 55 patients (35 women; 20 men) were considered as still acceptable candidates for conventional AVR. RESULTS: Mean age was 80.7 ±â€Š4.7 years; mean additive and logistic Euroscore I were 9.7 ±â€Š1.8 and 17.8 ±â€Š9.5%, respectively. Mean Euroscore II was 7.9 ±â€Š5.5%. Mean New York Heart Association class was 2.9 ±â€Š0.5. The majority of patients (87.2%) presented a geriatric frailty score of 0-1. Four patients showed a heavily calcified ascending aorta, and five patients (9%) underwent reoperations. Hospital mortality was 10.9% (six patients). Mean follow-up was 535.9 ±â€Š407.4 days (range: 6-1365 days). Six other patients died during this period for a mean survival of 74.4 ±â€Š6.9% at 2 years. Mean New York Heart Association class at 1 year was 1.25 ±â€Š0.5 (P < 0.01 vs. preoperative value). CONCLUSION: AVR should be indicated with caution in high-risk patients originally referred for TAVI. Despite medium-term results being good, with excellent functional status, hospital mortality is not negligible.

Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: a randomized, open-blinded, prospective study.

BACKGROUND/OBJECTIVES: Sedation with propofol should be administered by personnel trained in advanced airway management. To overcome this limitation, the use of short acting benzodiazepines by cardiologists spread widely, causing concerns about the safety of this procedure in the absence of anesthesiology assistance. The aim of the study was to compare feasibility of a cardiologist-only approach with an anesthesiologist-assisted sedation protocol during elective direct-current cardioversion (DCC) of persistent atrial fibrillation (AF). METHODS: This prospective, open-blinded, randomized study included 204 patients, which were admitted for scheduled cardioversion of persistent AF, and randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the propofol group underwent DCC with anesthesiologist assistance, while patients in the midazolam group saw the cardiologist as the only responsible for both sedation and DCC. RESULTS: Twenty-three adverse events occurred: 13 in the propofol group and 10 in the midazolam group (p=NS). Most of them were related to bradyarrhythmias and respiratory depressions. There was no need of intubation or other advanced resuscitation techniques in any of these patients. No differences were found regarding procedure tolerability and safety endpoints between the two groups. DCC procedures with anesthesiology support were burdened by higher delay from scheduled time and higher costs. CONCLUSIONS: Sedation with midazolam administered by cardiologist-only appears to be as safe as sedation with propofol and anesthesiologist assistance. Adverse events were few in both groups and easily handled by the cardiologist alone. A cardiologist-only approach to sedation provides less procedural delay, thus being easier to schedule and correlated with fewer costs.

A management of blunt thoracic trauma in an emergency department observation unit: pre-post observational study.

BACKGROUND: The best management of patients with isolated blunt thoracic trauma at high risk of pulmonary complications (HRPC-BTT: ≥3 isolated rib fractures, sternal fracture, single or few pulmonary contusions or minimal pneumothorax) is still unclear. We compared efficacy and cost-effectiveness of a new clinical pathway involving an Emergency Department Observation Unit (EDOU) with routine care. DESIGN: Retrospective before-after study. SETTING: Level II Trauma Center within a Regional Teaching Hospital. PARTICIPANTS: A consecutive series of patients with HRPC-BTT. INTERVENTIONS: a new clinical pathway involving EDOU was implemented. MAIN OUTCOMES: Death rate, tube thoracostomy, and re-admission of discharged patients. Hospital admission rate, length of hospital occupancy, overall costs, and cost-effectiveness were also compared in pre- and post-EDOU period. RESULTS: Two hundred forty patients were eligible for the study: 110 patients in the pre-EDOU period and 130 in the post-EDOU period. Thirteen (12%) of the treated patients were re-admitted to the ED in the pre-EDOU period compared with only five (4%) when the EDOU was available (p = 0.03). The rate of tube thoracostomy performed in admitted patients significantly increased after EDOU implementation: 1 of 54 (1.9%) versus 4 of 32 (12.5%; p < 0.05). The rate of hospitalization decreased from 49% in the pre-EDOU period to 24% in the post-EDOU period (p < 0,005) and the length of stay in hospital in the pre-EDOU period was longer than in the EDOU period: mean 94.7 ± 79.6 versus 65.7 ± 60.6, respectively (p < 0.02). Cost analysis revealed no relevant change in cost-effectiveness per patient (median; interquartile range): €487; €103 to 1959 versus €616; €124 to 1455, respectively, in the pre- and post-EDOU period. CONCLUSIONS: In managing patients affected by HRPC-BTT, a clinical pathway involving the EDOU seems to be more effective than routine care with little impact on cost.

[Cardiomyopathy induced by frequent premature ventricular complexes originating from the right ventricular outflow tract: left ventricular systolic function recovery after transcatheter ablation]. / Cardiomiopatia indotta da extrasistolia ventricolare frequente dal tratto di efflusso del ventricolo destro: recupero della funzione sistolica dopo ablazione transcatetere.

Left ventricular dysfunction due to frequent isolated premature ventricular complexes originating from the right ventricular outflow tract (RVOT) in patients without structural heart disease and in the absence of sustained ventricular tachycardia is a rare and poorly characterized entity. Successful identification and radiofrequency catheter ablation of the focal source of ventricular ectopy is the most effective treatment for these patients, leading to a complete normalization of ventricular dimensions and contractile function. In this article, we report two cases of left ventricular dysfunction resulting from frequent isolated premature ventricular complexes originating from the RVOT. After successful ablation of the ectopic focus, improvement of functional status and left ventricular function was observed in both patients, confirming the initial diagnostic hypothesis of a cardiomyopathy induced by repetitive ventricular ectopic beats from the RVOT.