Crossmodal plasticity following short-term monocular deprivation

A brief period of monocular deprivation (MD) induces short-term plasticity of the adult visual system. Whether MD elicits neural changes beyond visual processing is yet unclear. Here, we assessed the specific impact of MD on neural correlates of multisensory processes. Neural oscillations associated with visual and audio-visual processing were measured for both the deprived and the non-deprived eye. Results revealed that MD changed neural activities associated with visual and multisensory processes in an eye-specific manner. Selectively for the deprived eye, alpha synchronization was reduced within the first 150 ms of visual processing. Conversely, gamma activity was enhanced in response to audio-visual events only for the non-deprived eye within 100-300 ms after stimulus onset. The analysis of gamma responses to unisensory auditory events revealed that MD elicited a crossmodal upweight for the non-deprived eye. Distributed source modeling suggested that the right parietal cortex played a major role in neural effects induced by MD. Finally, visual and audio-visual processing alterations emerged for the induced component of the neural oscillations, indicating a prominent role of feedback connectivity. Results reveal the causal impact of MD on both unisensory (visual and auditory) and multisensory (audio-visual) processes and, their frequency-specific profiles. These findings support a model in which MD increases excitability to visual events for the deprived eye and audio-visual and auditory input for the non-deprived eye.

Telemonitoring for Cystic fibrosis patients of Bambino Gesù Children's Hospital during COVID-19

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive genetic pathology of the Caucasian race and it affects nearly 100,000 people worldwide (many have not been diagnosed) and, in Italy, there are about 6000 patients. In the last few years, telemedicine has proved to be an effective home care tool for patients suffering from chronic pathologies. The advent of the COVID-19 pandemic has caused an increase of communications through mobile devices.

AIM

To evaluate the role of telemonitoring during the pandemic phase of Covid-19.

MATERIALS AND METHODS

34 (M 15, F 19) (M 44%, F 56%) Cystic Fi-brosis patients were evaluated; Median age ± SD 30.97±10.59 Median FEV1 2020 74.76; number of trasmission and hospital admissions.

RESULTS

It was evident that the absolute number of telemedicine visits increased from 1456 to 1605 in the pandemic year (10% more).

CONCLUSIONS

Telemedicine became an important tool for home management of patients, in particular about chronic diseases. Telemonitoring, an integral part of telemedicine, underlined its effectiveness in all health emergency phase.

Evaluation of nutritional status through bioimpedance analysis in a group of Cystic Fibrosis patients

Cystic fibrosis (CF) is the most common genetic disease in Caucasian people. Nutritional status represents an important key in the progression of the pulmonary disease in CF. People with better nutritional status, generally, maintain good levels of physical activity. Generally Bioelectrical impedance (BIA) analysis is frequently used as a method of body composition assessment, due to easy of use, safety and low cost of this procedure. The aim of this study was to investigate nutritional parameters in cystic fibrosis patient. We performed a single group cohort study. The study examined change in nutritional values in people with CF who practice sport or not, measured by bio-impedance analysis (BIA). Inclusion criteria were people with CF diagnosis confirmed. Primary outcome was evaluate body composition and the correlation with the rate of physical activity. A total of 32 patients were included in the analysis. The most important data was a correlation between Phangle and Body cellular mass index (BCMI) Pvalue<0.01, expecially in patients who had a good levels of aerobic and anaerobic session-training. Patients who did strong physical activity training had a statistically significant values of correlation with nutritional status. Further study were necessary to find association between exercise capa city and body mass index.

The Ipaac Evaluation Tool: how to select Quality Indicators for Comprehensive Cancer Care Networks

Background

The Comprehensive Cancer Care Networks (CCCNs) represent innovative approaches for the management of cancer patients consisting of multiple cooperating health units with specific expertise in the different steps of care. Quality Indicators (QIs) constitute valid and reliable tools that allow to measure the quality of care among similar structures belonging to different health systems. Objective of this project was to develop a standardized tool in order to define a multi-step process for the selection of QIs for the evaluation of CCCNs.

Methods

Under the coordination of the Innovative Partnership for Action Against Cancer (IPAAC) joint action, our research team performed a systematic review of the scientific literature to identify the reported methodology for the selection of QIs applicable for the CCCNs' setting. An additional search of national and international Quality Assurance organizations was performed to detect any missing information.

Results

The IET (Ipaac Evaluation Tool) for QIs was developed: a methodological tool describing an 8-step process that leads to the selection of QIs feasible for the CCCN setting. The tool was implemented accordingly with the reporting standards for guideline-based performance measures of the Guideline International Network (GIN). A pilot testing of the tool was performed in order to identify its strengths and weaknesses.

Conclusions

The IET for QIs represents an innovative methodological instrument to select valid and reliable indicators for the assessment of the quality of care within the CCCN settings.

Key messages

The Quality Indicators represent valid and reliable tools to measure and compare the quality of care delivered to cancer patients in Comprehensive Cancer Care Networks. The development of the Ipaac Evaluation Tool leads to a standardized assessment of the quality of care provided for cancer patients within the CCCN setting.

Systematic review on citizens’ literacy in omic sciences and web search of initiatives to improve it

Introduction

We are assisting to a progressive change in the classical approach to patient care toward so-called personalized medicine, mainly driven by the development of omic sciences. To implement omic sciences into practice it is important to address healthcare professionals', policy makers', leaders', and citizens' literacy

Methods

As part of a project funded by the Italian Centre for Disease Prevention and Control (CCM), we carried out a systematic review (SR) on citizens' attitude, knowledge, and educational needs in omic sciences. The search was carried out on Pubmed, Web of Science, and Embase. We also conducted a separate web search on Google, Yahoo, and Bing on initiatives published in Italian and English aimed at improving citizens' literacy in the same field. Websites of retrieved initiatives were examined to identify additional resources

Results

Forty-nine studies were included in the SR. Most studies (n = 26, 66.7%) reported low levels of knowledge in omic sciences among citizens, and conflicting attitudes related to potential risks and benefits of omic sciences. Eleven studies (22%) evaluated citizens' educational needs, and most (n = 9, 82%) reported a clear knowledge gap. As for the web search, 13 initiatives were identified in Italy, 4 in Europe, and 22 in non-European Countries. Overall, 33% of them required in-person attendance, while 67% were web-based resources. The former included exhibitions, seminars, courses, symposia, information stands in public places, guided visits at research laboratories, and interactive laboratories; the latter included web-pages for reading, online lessons and courses, web portals for information, videos and short movies, animations, apps for mobile devices

Conclusions

Results show a clear need to improve citizens' literacy. To achieve this goal, the implementation of effective strategies and initiatives is crucial, hence this effort to summarize the existing ones will be essential for future plan developments.

Key messages

The current challenge is to identify effective methods of improving citizens' literacy and implementing them. Only through citizens’ empowerment the implementation of omic sciences in the Health System will be possible, since citizens are increasingly active in the health context.

Distance learning training in genetics and genomics practices for Italian healthcare professionals

Background

Genomics and related fields are becoming increasingly relevant in healthcare practice. Italy is the first European country with a structured policy of Public Health Genomics and dedicated guidelines that focus on three pillars: Health Technology Assessment of omic applications, promotion of citizens' literacy, and promotion of extensive training for all healthcare stakeholders. In January 2019 we initiated a project funded by the Italian Ministry of Health and entitled 'Capacity building and Citizens-Omics'.

Objectives

The project is coordinated by the National Institute of Health and is aimed at implementing the “Italian National Plan for innovation of the healthcare system based on omics sciences” published in 2017.

Results

The project had set-up two distance-learning courses on genetic/genomics: an advanced course for physicians and biologists, and a basic one for the remaining healthcare professionals. The courses focused on genetic/genomic testing in clinical practice, pharmacogenomics and oncogenomic and they were developed according to the main models of andragogical training (Problem-based Learning and Case-based Learning). The courses include audio-video lectures and interactive clinical cases and they will be accessible free of charge for a year (from February 17th 2020). In three weeks, we had 2129 participants (1101 physicians, 1028 biologists) for the advanced course and 10.000 for the basic one.

Conclusions

Genomic literacy among healthcare professionals is essential to ensure optimal translation to healthcare delivery of research. The distance-learning training in genetic/genomic practices represents an effective method to improve healthcare professionals' knowledge in the immediate and mid-term time scale. Our courses represent the third Italian experience in distance training in omic field. The educational effects related with online courses could potentially be relevant internationally and across a wider range of potential audiences.

Key messages

In view of the ongoing rapid developments in genetics research it is important that omic literacy among healthcare providers be enhanced to ensure translation to healthcare delivery of research. E-learning training appears to offer a cost-effective and time-efficient method of improving omic knowledge and it could be relevant across a wider range of potential audiences.

The PRECEDE-PROCEED model as a tool in Public Health screening: a systematic review

OBJETCTIVE

The aim of this systematic review was to summarize the scientific literature concerning the use of the Precede-Proceed model (PPM) applied to educational programs and health screenings contextsV.

STUDY DESIGN

Systematic review.

METHODS

The search process was based on a selection of publications listed in Medline and Scopus. The keywords used were "Precede-Proceed" AND ("screening" OR "educational programs"). Studies included in the systematic review were subdivided into those applying the model in a screening context, and those applying it within educational programs.

RESULTS

Twenty-seven studies were retrieved, mostly performed in the USA and, generally, the promoting center was the University. In the context of cancer screening, the PPM model was most of all applied to Mammography Screening (5 of 13 studies in cancer screening), and Cervical Cancer Screening (5 of 13). Another three studies within the cancer field investigated Menopause-Inducing Cancer Treatments, Oral cancer prevention, and cancer screening in general. In the remaining studies, the model was applied in various screening areas, particularly chronic and degenerative diseases. There were many different study designs, most of which cross-sectional (8), though several RTCs (8) and focus groups (5) were also found. For the cross-sectional studies the methodological quality varied between 3/10 and 9/10, whilst for the RCTs it ranged from 2/5 to 3/5.

CONCLUSIONS

The PPM provides an excellent framework for health intervention programs especially in screening contexts, and could improve the understanding of the relationship between variables such as knowledge and screening. Given the complexity of a behavioral change process, certain important predisposing factors could be measured in future studies, and during health intervention planning.

The use of quality indicators (QIs) to evaluate the oncologic care in CCCN: a systematic review

Key messages

The CCCN has been recognized as an ideal model for structuring the process of care that guarantees a complete and integrated approach for the management of oncological patients. Quality Indicators represent valid and reliable tools that should be used to perform a standardized comparison among different healthcare systems and to guarantee a homogeneous quality of care.

Current state of genomic policies in healthcare among EU member states: results of a survey of chief medical officers

Background

A need for a governance of genomics in healthcare among European Union (EU) countries arose during an international meeting of experts on public health genomics (PHG). We have conducted a survey on existing national genomic policies in healthcare among Chief Medical Officers (CMOs) of the 28 EU member states, plus Norway.

Methods

A questionnaire was sent to CMOs after a meeting on the policy implications of PHG held during the Italian presidency of the Council of EU in 2014. The survey was closed in November 2015.

Results

CMOs response rate was 65.5% (19/29). Twelve (63.2%) reported that their countries had a policy for genomics in healthcare in place, and 15 (78.9%) reported that public funding existed. Public research facilities for the development of such policies were documented in 13 (68.4%) countries, and 15 (83.3%) had working groups devoted to policy development. National agencies carrying out Health Technology Assessment of genomic-based technologies were present in nine countries (50%). Sixteen (88.9%) countries reported having agencies dealing with ethical issues related to genomic technologies. About 55% of countries disclosed the lack of information campaigns aimed at citizens, and 44.4% reported they had a legal framework for direct-to-consumer genetic tests.

Conclusion

Belgium, France, Italy, Spain and UK documented the presence of a policy on genomics in healthcare. While many caveats are necessary because of the methodology, results suggest a need for a co-ordinated effort to foster development and harmonization of dedicated policies across EU to responsibly integrate genomics policies into existing health systems.

Disinvestment in healthcare: an overview of HTA agencies and organizations activities at European level

Background

In an era of a growing economic pressure for all health systems, the interest for “disinvestment” in healthcare increased. In this context, evidence based approaches such as Health Technology Assessment (HTA) are needed both to invest and to disinvest in health technologies. In order to investigate the extent of application of HTA in this field, methodological projects/frameworks, case studies, dissemination initiatives on disinvestment released by HTA agencies and organizations located in Europe were searched.

Methods

In July 2015, the websites of HTA agencies and organizations belonging to the European network for HTA (EUnetHTA) and the International Network of Agencies for HTA (INAHTA) were accessed and searched through the use of the term “disinvestment”. Retrieved deliverables were considered eligible if they reported methodological projects/frameworks, case studies and dissemination initiatives focused on disinvestment in healthcare.

Results

62 HTA agencies/organizations were accessed and eight methodological projects/frameworks, one case study and one dissemination initiative were found starting from 2007. With respect to methodological projects/frameworks, two were delivered in Austria, one in Italy, two in Spain and three in U.K. As for the case study and the dissemination initiative, both came from U.K. The majority of deliverables were aimed at making an overview of existing disinvestment approaches and at identifying challenges in their introduction.

Conclusions

Today, in a healthcare context characterized by resource scarcity and increasing service demand, “disinvestment” from low-value services and reinvestment in high-value ones is a key strategy that may be supported by HTA. The lack of evaluation of technologies in use, in particular at the end of their lifecycle, may be due to the scant availability of frameworks and guidelines for identification and assessment of obsolete technologies that was shown by our work. Although several projects were carried out in different countries, most remain constrained to the field of research. Disinvestment is a relatively new concept in HTA that could pose challenges also from a methodological point of view. To tackle these challenges, it is necessary to construct experiences at international level with the aim to develop new methodological approaches to produce and grow evidence on disinvestment policies and practices.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2941-0) contains supplementary material, which is available to authorized users.

Long term results of hepatic resection or orthotopic liver transplantation in patients with liver metastases from gastrointestinal neuroendocrine tumors

Hepatic metastases are one of the most important prognostic factors for survival among patients affected by gastrointestinal neuroendocrine tumors (NETs). The present study aims to evaluate the impact of surgery, including hepatic resection or orthotopic liver transplantation (OLT), on the outcome of patients affected by hepatic metastases from NETs, in terms of overall survival (OS). In this multicentric retrospective study, data was collected on 26 patients, who underwent surgery for hepatic metastases from NETs in two Italian University Clinics between January 1990 and December 2012; of which, 22 patients underwent hepatic resective surgery and 4 patients OLT. Hepatic metastases were synchronous in the 53.8% of cases and metachronous in the 46.2% of cases. The median number of resected hepatic metastases was 3. Surgical radicalness (R0) was reached in the 84.6% of cases. In total, 57.7% of patients had a recurrence, 66.7% of which were intra- and 33.3% extra-hepatic. The OS of patients that underwent hepatic resections and OLT was 44.9% [95% confidence interval (CI95), 26.0-77.7%] and 50% (CI95, 12.5-100.0%) at 5 years, respectively. Although the data regarding the survival of patients receiving surgery for hepatic metastases from NETs are encouraging, randomized clinical trials are necessary to more adequately evaluate the effect of surgery on survival of this group of patients.

Liver transplantation in neurological Wilson's Disease: is there indication? A case report

Wilson's disease (WD) is an autosomal recessive disorder characterized by copper overload. In this disease, inadequate hepatic excretion leads to copper accumulation in the liver, brain, kidney, and cornea. Severe neurological symptoms can develop in patients with WD, often in the absence of relevant liver damage: it is unclear whether liver transplantation (LT) could reverse neurological symptoms, and at present LT is not recommended in this setting. We report a case of regression of neurological symptoms in a patient affected by WD with prevalent neurological involvement. A 19-year-old man with disabling neuropsychiatric symptoms from WD that included frontal ataxia, akinesia, dystonia, tremors, and behavioral disorders in the presence of preserved liver function (Model for End-Stage Liver Disease score=7; Child-Turcotte-Pugh score=A5) underwent LT in November 2009. At the time of LT, encephalic magnetic resonance imaging (MRI) indicated diffuse neurodegenerative alterations involving subtentorial and supratentorial structures; bilateral Kayser-Fleischer ring was present. Four years after LT, laboratory tests show normalized copper metabolism and excellent liver function test results. Encephalic MRI shows a substantial improvement of already-known signal alterations at nuclei thalamus and putamen, mesencephalon, and pons. Kayser-Fleischer ring disappeared from the right eye, but a little remnant is still visible in the left eye. At neurological examination, all of the previous symptoms and signs are no longer present and behavioral disorders are no longer present; psychosocial functions are completely restored. The present case provides some evidence that LT may be a valid therapeutic option for WD patients with marked neurological impairment, particularly in those no longer responsive to chelation therapy.

The cancer screening monitoring system: indicators for organised programmes and possible extension to spontaneous screening

European Commission recommends the implementation of organized screening programs for cervical cancer based on active invitation of the target population and with a systematic monitoring system and quality assurance. Nevertheless, in many Member States opportunistic screening is still the only or the main way to access Pap test. In Italy, Pap test coverage in women aged 25-64 is close to 80%, about half of them are screened in organized programs and half by opportunistic screening. Organized programs are diffused in the vast majority of the country (78% in 2009) even if in some cases they are not able to actively invite all the target population every three years (actual extension 67%); furthermore, participation rate after invitation is quite low (39%). Organized screening programs showed performance indicators in line with most of the international standards: low referral rates (2.4%), low inadequate cytological results (4.7%), and high positive predictive value for high grade cervical intraepithelial neoplasia (16.2%). Opportunistic screening has no systematic monitoring system. The coexistence of the two screening models, organized programs and opportunistic, can be a source of inappropriate use of secondary prevention duplicating the tests and favoring deviations from recommended protocols. The Italian Ministry of Health recommends re-organizing cervical cancer prevention favoring organized programs or integrating spontaneous Pap testing in an organized system. To implement such integration it is necessary to have monitoring system and quality assurance for all providers and to integrate archives in order to avoid over-testing and deviation from protocols.

Resected biliary tract cancers: a novel clinical-pathological score correlates with global outcome

BACKGROUND

Biliary tract cancer presents a poor prognosis.

AIMS

The objective of this study is to find clinical-laboratory parameters like prognostic factors to select patients who can benefit from surgery and post-operative treatments.

METHODS

Between 2005 and 2010, 41 patients underwent radical surgery at our Institution. A novel score was retrospectively calculated assigning a grade to the clinical-laboratory findings at diagnosis. 0 and 1 point were respectively assigned to the normal or abnormal parameter. Two groups were identified: SCORE 0 and SCORE 1.

RESULTS

Patients with cholangiocarcinoma or Klatskin tumours or asymptomatic at diagnosis presented a significantly better overall survival (OS) than patients with different primary sites or who presented pain, jaundice or cholangitis. At univariate analysis, high levels of aspartate aminotransferase, alanine aminotransferase and CA19-9 before surgery, hyperbilirubinemia before and after surgery had a negative correlation with OS. A worse OS was observed in patients with a higher score (median OS in the "score 0" group=30.79 months vs. median OS in the "score 1"=17.98 months).

CONCLUSION

Our results suggest that pre and post-surgery clinical-laboratory parameters and the novel score, could be useful, especially for intrahepatic tumours, in predicting the outcome in patients undergoing surgery and in selecting patients to receive adjuvant therapy.

[Implementation of the stewardship model in public health: proposal of an assessment tool for the Italian national prevention plan]

The stewardship model has been adopted as a system of governance in several countries. In Italy, the Ministry of Health has proposed the use of the stewardship model for implementing the activities of the National Prevention Plan 2010-2012. The authors present the conceptual foundations and methodology used in the development of an assessment tool (audit tool) for evaluating the level of implementation of the stewardship model with regards to the activities of the national prevention plan in all Italian regions.

In vivo hyperoxic preconditioning protects against rat-heart ischemia/reperfusion injury by inhibiting mitochondrial permeability transition pore opening and cytochrome c release

In vivo hyperoxic preconditioning (PC) has been shown to protect against ischemia/reperfusion (I/R) myocardial damage. Mitochondrial permeability transition pore (MPTP) opening is an important event in cardiomyocyte cell death occurring during I/R and therefore a possible target for cardioprotection. We tested the hypothesis that in vivo hyperoxic PC, obtained by mechanical ventilation of animals, could protect heart against I/R injury by inhibiting MPTP opening and cytochrome c release from mitochondria. Mechanically ventilated rats were first exposed to a short period of hyperoxia and isolated hearts were subsequently subjected to I/R in a Langendorff apparatus. Hyperoxic PC significantly improved the functional recovery of hearts on reperfusion, reduced the infarct size, and decreased necrotic damage as shown by the reduced release of lactate dehydrogenase. Mitochondria from hyperoxic PC hearts were less sensitive than mitochondria from reperfused heart to MPTP opening. In addition, hyperoxic PC prevented mitochondrial NAD(+) depletion, an indicator of MPTP opening, and cytochrome c release as well as cardiolipin oxidation/depletion associated with I/R. Together, these results demonstrate that hyperoxic PC protects against heart I/R injury by inhibiting MPTP opening and cytochrome c release. Thus, in vivo hyperoxic PC may represent a useful strategy for the treatment of cardiac I/R injury and could have potential applications in clinical practice.

[Mass screening and early detection of cancer: organizational characteristics of preventive services in Italy]

The commitment to fight against cancer is a part of European Community health strategies and of Italian health services planning. Interesting and useful results have been achieved in Europe and in our country where most of the population can participate to screening programmes. In Italy there are two main organisational models to deliver intervention for secondary prevention: population based and individual access. Several experimental data show population-based prevention is more fair and appropriate and achieves better results in reducing incidence and mortality rates; data are summarized. Because of this differences we go trough the different characteristics of the two models to handle them better planning and managing more efficiently a sustainable secondary-prevention.

[Risk management in a regional screening program for breast cancer in the region of Lazio, Italy]

In the Lazio Region, it has been put into effect a plan of clinical Risk Management for the Breast Cancer Screening Regional Program (BCSP), involving all of the 12 Local Health Units and the Public Health Agency of Lazio (ASP). Being the BCSP a health care service, it consists of a perfect integration of health care structures, professionals and skills working for the citizens. This program originates from an unexpressed health need and leads to a evidence-based health benefit. The BCSP provides free breast screening for 700,000 women aged between 50 and 69 in the Lazio region; the Public Health Agency carries out the clinical governance of the BCSP The prevention of errors and incidents represents a fundamental basis of governance: it is a contribution to the achievement of efficacy in breast cancer screening. The BCSP deals with screening incidents from a systemic point of view and actively involves several Local Health Units staff going through each step of the whole patient's clinical path, from the identification of the target population, to the oncological treatment of positive cases. The programme is an integration of different tools: literature research, process analysis using the HFMEA methodology and reporting system. The results reached so far are the following: the regional severity rating scale, the regional Master-List of possible adverse events, occurrence and detection rating scale.

[Colorectal cancer screening: survey of endoscopy center's physicians in Lazio region]

The aim of the present work is to describe the characteristics of digestive endoscopy centers and the physicians that work there, with particular attention to their attitudes and practices in colorectal cancer screening. A questionnaire was sent to all 80 digestive endoscopy centers in the Lazio region, identified by the annual census of Italian Society of Digestive Endoscopy (Società Italiana di Endoscopia Digestiva, SIED). Seventy-one centers (89%), returned the questionnaire. Screening activity on average represents 14% of the centers' colonoscopy workload. Colonoscopy was considered to be a "very effective" screening test by 96% of physicians, the faecal occult blood test "very effective" by 20%, and flexosigmoidoscopy "very effective" by 11%. Ninety-seven percent (97%) of physicians reported recommending any test for screening: 80% colonoscopy, 61% faecal occult blood test, 14% double contrast barium enema and 11% flexosigmoidoscopy. Despite the fact that almost all physicians reported recommending screening, the centres are only marginally involved in screening practice. Endoscopy centers' physicians tend to have an aggressive strategy for colorectal cancer prevention and exclusive trust in colonoscopy; an attitude more consistent with a clinical-diagnostic approach than with real mass screening of a healthy population.

Protective effect of melatonin against mitochondrial dysfunction associated with cardiac ischemiareperfusion: role of cardiolipin

Reactive oxygen species (ROS) are considered an important factor in ischemia/reperfusion injury to cardiac myocytes. Mitochondrial respiration, mainly at the level of complex I and III, is an important source of ROS generation and hence a potential contributor of cardiac reperfusion injury. Appropriate antioxidant strategies could be particularly useful to limit this ROS generation and associated mitochondrial dysfunction. Melatonin has been shown to effectively protect against ischemic-reperfusion myocardial damage. The mechanism by which melatonin exerts this cardioprotective effect is not well established. In the present study we examined the effects of melatonin on various parameters of mitochondrial bioenergetics in a Langerdoff isolated perfused rat heart model. After isolation of mitochondria from control, ischemic-reperfused and melatonin-treated ischemic-reperfused rat heart, various bioenergetic parameters were evaluated such as rates of mitochondrial oxygen consumption, complex I and complex III activity, H2O2 production as well as the degree of lipid peroxidation, cardiolipin content, and cardiolipin oxidation. We found that reperfusion significantly altered all these mitochondrial parameters, while melatonin treatment had strong protective effect attenuating these alterations. This effect appears to be due, at least in part, to the preservation, by ROS attack, of the content and integrity of cardiolipin molecules which play a pivotal role in mitochondrial bioenergetics. Protection of mitochondrial dysfunction was associated with an improvement of post-ischemic hemodynamic function of the heart. Melatonin had also strong protective effect against oxidative alterations to complex I and III as well as to cardiolipin in isolated mitochondria.

Critical comparison of nine different self-administered questionnaires for the evaluation of disability caused by low back pain

AIM

The aim of this study was to critically compare 9 self-administered questionnaires designed to evaluate disability caused by back pain.

METHODS

The questionnaires were analyzed considering and comparing their psychometric characteristics (reliability, validity, responsiveness, minimal clinically relevant difference), together with other practical and technical aspects (number of items, number and kind of domains, scaling of items, scoring, time to complete, validated translations, etc.). Data were obtained from scientific literature.

RESULTS

Only 3 out of 9 analyzed instruments (i.e., the Oswestry Low Back Pain Disability Questionnaire, the Quebec Back Pain Disability Scale, and the Roland-Morris Low Back Pain Disability Questionnaire) appear fully validated from a psychometric standpoint.

CONCLUSIONS

On the basis of psychometric evaluations as well as feasibility considerations, the authors suggest using either the Roland-Morris or Oswestry questionnaire as the best assessment of the level of disability caused by back pain.

[Evidence-based planning: the case of mass screening for colorectal cancer in the Lazio region of Italy]

Several population-based trials have shown the efficacy of colorectal cancer mass-screening based on guaiac faecal blood testing in a generic risk population. SCCR represents a very complex and resource-demanding public health intervention and, for this reason, its planning requires actual efficacy as a main goal. Since evidence of efficacy demonstrated by population-based trials may not actually generate effectiveness, the Regional Government of Latium Region decided to implement some experimental studies before introducing a screening programme, in order to define an evidence-based organisational model of SCCR and a feasibility evaluation of the real needs for screening. The aims of the pilot studies were to define an evidence-based organisational model, to evaluate the necessary resources and the actual quality standard of clinical examination, treatment and surgery. The aim of the feasibility study is to test the organisational model for SCCR for about 300,000 citizens residing in the Latium region. The present article illustrates the scheduling path set out, which is based on the involvement of experts, GP representatives and specialists from scientific societies and it is planned by the following actions: Definition of evidence-based recommendations; identification of further investigations; realization of experimental studies; definition of an evidence-based organisational model. The main research areas have been dealt with using randomised trials, in order to evaluate the efficacy of the involvement of GPs and the kind of test for RSOF Our work has produced evidences which were sometimes in contrast with information in the literature, demonstrating that guaiac RSOF testing is less reproducible and determines lower uptake than immunochemical testing. Our work also shows that the involvement of GPs should be based on their personal skills rather than on their role. Such evidences are fundamental to the definition of the organisational model and confirm the need of basing an evidence-based planning not only on evidences found in the literature. The necessity of this approach is strengthened by the level of organisational complexity and by the amount of resources needed to put a public health intervention into practice.

Association between ACE inhibitors use and headache caused by nitrates among hypertensive patients: results from the Italian group of pharmacoepidemiology in the elderly (GIFA)

Treatment with ACE inhibitors has shown to be effective in the prophylaxis of migraine attacks. The aim of this study was to explore whether among hospitalized hypertensive patients use of ACE inhibitors may reduce the risk of headache caused by nitrates. To this end, we used the GIFA database, that includes patients admitted to academic medical centres throughout Italy. We studied 1537 patients (mean age 75 +/- 10 years) receiving treatment with nitrates during a hospital stay and diagnosed with hypertension. Headaches that had a probable or definite causal relation with nitrates use based on the Naranjo algorithm were considered for this analysis. Of the total enrolled sample, 762 patients (50%) used ACE inhibitors during hospital stay. Headache caused by nitrates was recorded in 12/762 (1.6%) ACE inhibitor users and in 24/775 (3.2%) other participants (P = 0.049). After adjusting for potential confounders, ACE inhibitors use was associated with a significantly lower risk of headache (OR 0.43; 95% Confidence Intervals: 0.20-0.90). This result was confirmed if ACE inhibitors use was compared with use of other antihypertensive agents (OR 0.44; 95% CI 0.20-0.95). In conclusion, this study suggests that among hypertensive subjects use of ACE inhibitors is associated with a reduced risk of headache caused by nitrates.

Three-dimensional cultures of normal human osteoblasts: proliferation and differentiation potential in vitro and upon ectopic implantation in nude mice

We report the establishment in vitro of three-dimensional (3D) cultures of human osteoblasts (hOB) derived from normal adults and supported uniquely by the extracellular matrix (ECM) they deposit. Osteoblasts were cultured in 3D cultures in vitro for up to 120 days. The 3D cultures, examined at 25, 31, and 48 days, expressed protein markers of osteoblastic cells, namely osteonectin, collagen type I, fibronectin, osteopontin, bone sialoprotein, biglycan, and decorin. Sequentially, alkaline phosphatase (AP) and then Ca incorporation, mineralization of matrix (monitored by histochemistry and transmission electron microscopy), and finally osteocalcin expression, were detected in the 3D cultures. Ultrastructurally, morphology progressed from early to mature osteoblast and to osteocyte-like. Cells were embedded in a matrix with organized collagen type I fibers containing, increasingly with time of culture, needle-shaped crystals, often associated with matrix vesicles, characteristic of those in bone. During the culture (up to 120 days) there was an outgrowth of proliferating osteogenic cells from the 3D structure. Subcutaneous implantation in nude mice for 20 days of osteoblasts cultured in 3D culture for different lengths of time in vitro, showed progression of mineralization from the inner region of the implant outward, with peripheral cells being embedded in nonmineralized, collagen-rich matrix. The 3D implants were invaded by vessels derived from the host.

Hypoxic reperfusion limits functional impairment following cardioplegic arrest in isolated rat heart

BACKGROUND

Reperfusion injury decreases both systolic contractility and diastolic compliance. Several studies indicate that the sustained decrease in diastolic compliance is mainly due to reactive oxygen intermediates (ROI) generation and calcium overload.

METHODS

Male Wistar isolated rat hearts were divided into 2 groups (n=10 each), perfused according to Langendorff technique and exposed to 45 min of ischemia. Hearts belonging to the first group were reperfused with Krebs-Henseleit solution at 600 mmHg pO2; a 150 mmHg pO2 perfusate was utilized in the second group during the first minute and switched to 600 mmHg pO2 thereafter. Modifications in diastolic compliance and systolic contractility were assessed by changes in left ventricular end-diastolic (LVEDP) and developed pressure (LVDP), and first derivative of the pressure curve (dP/dt).

RESULTS

Increase in LVEDP values, with respect to pre-ischemic data, were detected at 1, 5, 10, 20 min following reperfusion at 600 mmHg pO2, and were respectively: +40.17+/-18.61, +57.5+/-28.8, +59.8+/-30.5 and +63.2+/-34.1 mmHg. At 150 mmHg pO2 they were: +15.69+/-13.13, +22.4+/-14.1, +26.2+/-13.7 and +28.9+/-15.8, with a significant difference within the first 20 min (p<0.05). At high pO2 levels, LVDP decreased of 53.0+/-27.35, 60.5+/-22.6, 59.8+/-23.3 and 50.7+/-25.0 mmHg, versus 42.7+/-25.7, 38.0+/-29.5, 39.2+/-30.9 and 38.7+/-32.7 mmHg at lower pO2 (p=NS). The correspondent values of the dP/dt were 37.8+/-27.7, 30.1+/-17.2, 32.2+/-13.6 and 35.4+/-14.0% of pre-ischemic values at high pO2, versus 43.3+/-27.09, 51.9+/-25.1, 50.1+/-24.6 and 53.1+/-29.9% at lower pO2. Statistical significance was lower for LVDP and dP/dt than LVEDP.

CONCLUSIONS

Diastolic functional impairment was partially reduced within the first 20 min following low pO2 reperfusion, but without any significant improvement of contractility.

Tobacco smoking habits, attitudes and beliefs among nurse and medical students in Tuscany

In this study we evaluated the smoking habits, beliefs and attitudes of nurse and medical students at the University of Siena and Florence, Italy. Students who entered the 1st year of school in 1998 were asked to complete a self-administered anonymous questionnaire. Two hundred medical students completed the questionnaire; they had a mean age (+/-SD) of 19.8+/-1.7 years and 68% were females. A total of 205 nurse respondents answered to the questionnaire; they had a mean age of 21.8+/-4.1 years and females were 83% of the total. The overall response rate among students always remained higher than 85%. Thirty per cent of medical students were current smokers, and 5% former-smokers. A total of 43% of nurse students were current smokers and 11.5% former-smokers. Nurse students were more likely to smoke than medical students (p = 0.001). Among current smokers, the number of daily cigarettes smoked and the degree of nicotine addiction did not differ between groups. The prevalence of maternal smoking were higher among nurse students. In spite of students' beliefs the knowledge about smoking remained generic in both groups. Nurse students were less aware than medical students of their special responsibility towards people about tobacco smoking. Such a difference remained significant also after adjustment for smoking status (p < 0.01). Students overestimated the prevalence of current smokers among health caregivers of the local hospitals, and Italian people and adolescents. Targeted and continuous training about smoking prevention should be mandatory in Italian medical and nurse schools.

Evaluation of haemostatic and fibrinolytic markers in patients with Cushing's syndrome and in patients with adrenal incidentaloma

It is known that either chronic glucocorticoid administration or endogenous hypercortisolism frequently induce an hypercoagulable condition. Since little is known about the evaluation of markers of haemostatic and fibrinolytic systems in other adrenal disorders, we studied plasminogen activator inhibitor (PAI-1), tissue-plasminogen activator (t-PA), fibrinogen and von Willebrand factor antigen (vWF-Ag) levels in 11 patients with Cushing's syndrome and in 12 patients with adrenal incidentaloma. In patients with Cushing's syndrome mean PAI-1, t-PA and vWF-Ag levels did not significantly differ from those found in 50 age- and sex-matched controls, while mean fibrinogen levels were significantly higher in patients (337.0+/-39.1 mg/dl) than in normal subjects (278.9+/-8.4 mg/dl). Patients with adrenal incidentaloma showed PAI-1, t-PA and vWF-Ag mean levels superimposable to those in controls, while fibrinogen (319.7+/-27.9 mg/dl) was slightly, although not significantly, higher than in normals. Considering the limits of normal values (as mean+/-2 SD) obtained in the control group, high PAI-1 levels were found in 2 patients with Cushing's syndrome and in 3 patients with incidentaloma. An elevation of fibrinogen levels was found in 3 patients with Cushing's syndrome and in 3 with incidentaloma. Increased vWF-Ag levels were found only in 1 patient with Cushing's syndrome. An increased t-PA level was occasionally observed only in the patient with adrenal carcinoma. On the whole, an alteration of at least one of haemostatic and fibrinolytic parameters was detected in 55% of the patients with Cushing's syndrome and in 42% of those with adrenal incidentaloma. In conclusion, early alterations of coagulation and fibrinolytic systems may be found in some patients with adrenal disorders, thus suggesting the opportunity of an accurate follow-up in order to identify possible risk factors for cardiovascular disease and thromboembolism.

Effects of estrogen therapy on arterial resistance and pulsatility in postmenopausal women

The hypothesis of this study was that changes in arterial determinants of afterload due to static muscular contraction can be modified, in postmenopausal women, by estrogen replacement therapy. Two groups of 14 postmenopausal and 15 premenopausal women were enrolled. Hemodynamic changes induced by right handgrip were recorded between days 7 and 10 of the menstrual cycle in premenopausal women. The same recordings were performed in postmenopausal women, before and after receiving transdermal estrogen replacement therapy for 8 days. Handgrip was performed at 50% of maximal voluntary contraction and maintained until exhaustion. Arterial pressure and blood velocity were recorded in the resting hand with photoplethysmographic and Doppler techniques. Indices of arterial elasticity and resistance were calculated. In postmenopausal women, these indices increased during effort only slightly less after therapy than before, if the mean values and statistical significance were considered, but the most evident effect of therapy was a decrease in interindividual differences in the effort induced changes. This means that, after therapy, increases in arterial resistance and elasticity indices were appreciably prevented mainly in those postmenopausal women who, before therapy, showed the greatest increases. Differences due to therapy were negligible in postmenopausal women in whom, before estrogen replacement, increases in elasticity and resistance indices during effort were similar to those obtained in premenopausal women. After therapy, no differences were found in resting conditions in any of the investigated cardiovascular parameters. Estrogen replacement did not appreciably affect changes in some arterial afterload-related indexes during handgrip, if the average values were considered in a group of postmenopausal women, but uneven and unpredictable peaks in individual responses were cut off, with a better predictability of the responses to sustained muscular contractions, as well as of the related risk factors.

Systolic and diastolic changes in human coronary blood flow during Valsalva manoeuvre

Valsalva manoeuvre is reported to be sometimes successful for the relief of angina pectoris. The present study investigated how haemodynamic changes produced by Valsalva manoeuvre can interact to improve the relationship between cardiac work and coronary blood flow. Ten male subjects aged 53 +/- 12 years (SD) were considered. Blood velocity in the internal mammary artery, previously anastomosed to the left descending coronary artery, was studied with Doppler technique. The subjects performed Valsalva manoeuvres by expiring into a tube connected to a mercury manometer, to develop a pressure of 40 mmHg. The arterial blood pressure curve was continuously monitored with a Finapres device from a finger of the left hand. During expiratory effort, an increase in heart rate and a decrease in arterial pulse pressure were followed by a more delayed and progressive increase in mean and diastolic pressures. Systolic blood velocity markedly decreased along with the reduction in pulse pressure and increase in heart rate. By contrast, diastolic and mean coronary blood velocities did not show any significant change. Since it is known that the Valsalva manoeuvre strongly reduces stroke volume and cardiac output, it is likely that a reduction in cardiac work also takes place. Since in diastole, i.e. when the myocardial wall is better perfused, coronary blood velocity did not show any significant reduction, it is likely that unchanged perfusion in the presence of reduced cardiac work is responsible for the relief from angina sometimes observed during Valsalva manoeuvre. It is also likely that the increase in heart rate prevents the diastolic and mean blood coronary velocity from decreasing during the expiratory strain, when an increased sympathetic discharge could cause vasoconstriction through the stimulation of the coronary alpha-receptors.

[First aid for multiple trauma patients: investigative survey in the Firenze-Bologna area]

Overall mortality ascribable to multiple traumas, that in Italy is responsible for about 8,000 death/year, is strictly dependent on the function of the so called Trauma Care System. This study reports on an epidemiological survey conducted in the urban area of Florence along a 23-month period (from Jan 97 to Nov 99), with the aim to identify the typology of traumas and the first aid care delivered to the person until hospital admission. These data were compared to those collected in the urban area of Bologna because the composition of the first-aid team is different, being nurses, in Bologna, an integral component of the first aid system. On a total of 118 multiple traumas, 17% was represented by isolated head trauma, while in 72% involvement of other organs was present in addition to the head; 11% of cases were abdominal or thoracic traumas, 1% of lower extremities. In 46% the cause of trauma was a car accident. The complexity of care delivered to the person with trauma was less in the Florence survey, as indicated by the immobilization of patients, performed in only 11% of cases as compared to 47% in Bologna, by the application of the cervical collar, applied in 12% versus 62% of traumas. Although the two samples are not strictly comparable, these data suggest that the presence of nurses in the Trauma Care System can be one of the elements of improvement of the quality of delivered care.

[Written information: evaluation of an informative leaflet for patients undergoing colonoscopy]

Client teaching and information on medical procedures and care organisation is recognised as one of the most important tasks for the nurse. The information must be complete, detailed, and personalized according to the client culture and learning capacity. To address these points, an information booklet has been designed to inform clients undergoing colonoscopy in the gastroenterology unit of Azienda Ospedaliera Careggi, Florence. The booklet, together with a multiple choice questionnaire aimed at evaluating clients' satisfaction with the information provided, was distributed to 100 clients undergoing a colonoscopy over a two-month period in 1998. The results of the survey suggest that the booklet has been instrumental in client learning about the procedure, as shown by the high positive satisfaction response provided to the questionnaire. Moreover, contents provided are clear and easy to understand. Clients would like to have specifically detailed information on the way the exam is performed, on its duration (22%) and on the disinfection procedures (21%). At present, all the patients booked for colonoscopy receive the booklet in their homes.

Changes of smoking habits and beliefs during nurse training: a longitudinal study

This prospective cohort study has been performed to evaluate the changes in student nurses smoking habits and beliefs during their training. The source of information was an anonymous questionnaire about tobacco smoking, administered to students who entered the first year of School of Nursing in Florence in 1991-1992, 1992-1993 and 1993-1994. Five hundred and thirty-six (95%) of these student nurses completed the questionnaire. Five hundred and one (93%) of these 536 respondents completed the questionnaire again at the end of the third (final) year of training. Student nurses who smoked increased the average number of cigarettes smoked per day (p < 0.01) and the degree of dependence to nicotine (p < 0.01). Tobacco smoking remained widespread and the percentage of ex-smokers who started smoking again increased (p < 0.05). The knowledge about the health hazards due to tobacco smoking remained generic and the prevalence of current smokers among student nurses and health care workers was overestimated. We conclude that Nursing School does not succeed in reducing the smoking habits of students. Effective antitobacco strategies and smoking cessation services still need be organized in Italy.