Retained sponges in abdomen: an analysis of the judgments of the Italian Supreme Court

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

Defining, Measuring and Preventing the Diagnosis of Cancer as an Emergency: A Critical Review of Current Evidence

Background: Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumor, patient and health-care factors, often in combination. Methods: We searched the literature to identify all population-based studies that examined emergency presentation as a diagnosis or independent variable. Results: Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. Conclusion: In this review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this underresearched aspect of cancer diagnosis.

Comparison of outcomes following intersphincteric resection vs low anterior resection for low rectal cancer: a systematic review

BACKGROUND

Low Rectal Anterior Resection (LAR) is challenging when anal canal mucosa and/or internal sphincter are involved by very low tumors. In these cases, Intersphincteric resection (ISR) with the removal of the internal sphincter is designed to increase the distal margin of resection, thus preserving the external sphincter and pubo-rectalis muscle complex. Aim is to compare results after ISR with those of LAR, including subgroup analysis of open, laparoscopic and robotic ISR.

METHODS

Studies published from January 1991 to January 2017 describing ISR and comparing results with LAR in adults were included irrespective of the technique. Tumor and surgical characteristics, clinical, functional and oncological results were collected.

RESULTS

25 non-randomized studies were included. Postoperative mortality ranged between 0% and 2.3%. The hospital stay ranged from 5 days to 40 days, lower in robotic ISR group if compared with laparoscopic ISR. Patients avoiding permanent stoma with ISR accept a lower continence level as satisfactory. Furthermore, anorectal function after ISR often tends to improve. ISR and LAR presented not statistically significant differences. Oncological outcomes were not statistically different Morbidity, blood loss and need for blood transfusions were lower in the laparoscopic ISR if compared with open approach.

CONCLUSIONS

Morbidity could more frequently affect open ISR if compared with laparoscopic ISR. Functional outcomes were influenced by neoadjuvant CRT, but not by the surgical approach of reconstruction, while were positively influenced by partial ISR with respect to total ISR.

A rare case of perforation of the subhepatic appendix by a toothpick in a patient with intestinal malrotation: laparoscopic approach

Foreign body ingestion is not an uncommon problem in clinical practice. While most ingested foreign bodies pass uneventfully through the gastrointestinal tract, sharp foreign bodies such as toothpicks should cause intestinal perforation. We reported the case of a perforation of the appendix caused by a toothpick, which also pierced the liver without hepatic damages, in a male with an intestinal malrotation and subhepatic appendix. The patient was admitted to our hospital for abdominal pain in the right upper quadrant. An abdominal computed tomography scan revealed the anomalous position of the first portion of the large intestine with inflamed appendix. A laparoscopic appendicectomy and the exploration of the abdominal cavity was performed using minimally invasive technique.

Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England

BACKGROUND

More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes.

METHODS

Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period.

RESULTS

Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis.

CONCLUSIONS

Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.

Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors

BACKGROUND

Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms.

METHODS

We conducted a bibliographic research using the National Library of Medicine's PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests.

RESULTS

One RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (p < 0.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, p = 0.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups.

CONCLUSIONS

Although the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.

Emotional responses to the experience of cancer 'alarm' symptoms

OBJECTIVE

To qualitatively explore associations between emotional responses to experience of cancer 'alarm' symptoms and help-seeking in a community sample of adults.

METHOD

Interviewees (n = 62) were recruited from a community sample (n = 2042) of adults aged ≥50 years, who had completed a health survey that included a list of cancer alarm symptoms. Participants who had reported an alarm symptom both at baseline and 3-month follow-up (n = 271), and who had consented to contact (n = 215), constituted the pool for invitations to interview.

RESULTS

Over a third of participants (37%) described an emotional response to their symptom experience. In all these cases, there was evidence of awareness of the risk of cancer. Emotional responses were usually either classified as mild ('worry') or severe ('fear'). Worry was often described in the context of a desire to seek medical help, either to rule out cancer or to minimise patient delay. In contrast, the 'fear' group described associations with death, the perceived incurability of cancer, and the consequence of a cancer diagnosis. Where the emotional reaction was fear, medical contact was seen as something to be avoided either because it had no value or because it was preferable not to be told a diagnosis.

CONCLUSION

In this community sample, worry about the possibility of cancer was associated with help-seeking, either for reassurance or as part of a 'sensible' strategy to deal with the risk. In contrast, fear was associated with avoiding help-seeking or even thinking about cancer, which could lead to prolonged help-seeking intervals.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Participation, satisfaction and knowledge level of patients with cutaneous psoriasis or psoriatic arthritis

There have been few studies about the participation in health care and the satisfaction of patients with psoriasis and with psoriatic arthritis. The objective of this study was to examine the attitudes of and satisfaction with decision-making of patients with psoriasis. The study was based on a self-completed questionnaire, given after a routine medical visit to a consecutive sample of 240 patients with psoriasis [207 with cutaneous psoriasis (CP) and 33 with psoriatic arthritis (PA)]. Of the patients with CP and PA, only about a third (27.3% and 28.1%, respectively) preferred to leave decisions entirely to their doctor, whereas the majority (72.7% and 71.9%, respectively) wanted to be involved in decision-making. However, the level of knowledge about the disease was not as high, with 17.0% and 21.4% of patient with CP and PA, respectively, having a good level of knowledge about psoriasis treatment. Participation, knowledge and overall satisfaction were not significantly different between patients with CP and those with PA. Information on treatment side-effects (OR = 5.11; 95% CI 2.5-15.0; P < 0.001) and information on treatment options (OR = 3.15; 95% CI 1.4-7.1; P = 0.006) were significantly associated with overall patient satisfaction.

[Psychological wellbeing in the hospital administrative personnel]

Job satisfaction and psychological well being of health care workers significantly influence the quality of care. The aim of this study was to evaluate job satisfaction and psychological well-being in the administrative personnel of a large hospital in Rome-Italy. The personnel self-completed two anonymous questionnaires: the General Health Questionnaire (GHQ-12) for minor psychiatric non psychotic diseases and a validated job satisfaction questionnaire. Descriptive analysis and multiple logistic regression analysis were performed. Response rate was 65%. 74 were the questionnaires analyzed. 37.8% of respondents showed a high likelihood to develop symptoms of depression/anxiety (OR = 3.57; 95% CI 1.17-10.85). Major determinants of job dissatisfaction were the lower autonomy and poor communication in the working Unit. Factors associated with overall dissatisfaction were: insufficient training opportunities (p = 0.033), low autonomy (p = 0.023), poor communication between hospital Units (p = 0.009), unclear aims of their working Unit (p = 0.029), low agreement between personal expectations and required competence (p < 0.001). Among administrative staff job dissatisfaction was associated with high likelihood of depression/anxiety, low autonomy and poor communication, independently of sex, age, years of employment. Possible targets to improve satisfaction of administrative personnel were identified.

Efforts to link declarations to actions: Italian experiences of shared decision making in clinical settings

The Italian National Health Plan 2006-08 acknowledges the importance of patient/citizen participation, highlighting that health services have to involve patients by means of a shared decision-making (SDM) approach. The present study aims at examining the implementation of SDM in clinical settings in Italy, describing some experiences, practical difficulties and potential solutions. We found that the majority of patients want to participate in decision-making, but substantial knowledge gaps represent a barrier. Small proportions of patients express opinions and questions during the medical encounter, with a lack of facilitating questions by physicians, indicating a limited degree of involvement. The project Partecip a Salute is an initiative aiming at involving citizens, patient associations and scientific-medical professionals in the health and clinical research debate. The literature review on Italian SDM experiences has shown a limited number of publications, with the majority being commentaries or letters. In conclusion, in order to put SDM into practice more organizational and educational efforts are needed directed to both health professionals and patients/consumers. Documenting and sharing experiences is a fundamental prerequisite for progressing in the field.

Sentinel lymph node biopsy for high risk cutaneous squamous cell carcinoma: Case series and review of the literature

AIMS

Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer. The metastatic potential is generally low. However, there are subgroups of patients at higher risk, for whom sentinel lymph node biopsy (SLNB) might be useful. SLNB might allow the timely inclusion of high risk patients in more aggressive treatment protocols, sparing at the same time node-negative patients the morbidity of potentially unnecessary therapy. Our aim was to introduce the concept of SLNB for patients with high risk cutaneous SCC.

PATIENTS AND METHODS

We examined a consecutive series of high risk cutaneous SCC patients undergoing SLNB at our large dermatological hospital, and performed a literature review and pooled analysis of all published cases of SLNB for cutaneous SCC.

RESULTS

Among the 22 clinically node-negative patients undergoing SLNB at our hospital, one patient (4.5%) showed a histologically positive sentinel node and developed recurrences during follow-up. Sentinel node-negative patients showed no metastases at a median follow-up of 17 months (range: 6-64). The incidence of positive sentinel nodes in previous reports ranged between 12.5% and 44.4%. Pooling together patients from the present and previous studies (total 83 patients), we calculated an Odds Ratio of 2.76 (95% CI 1.2-6.5; p=0.02) of finding positive sentinel nodes for an increase in tumor size from <2 cm to 2.1-3 cm to >3 cm.

CONCLUSIONS

Our case series and the pooled analysis support the concept that SLNB can be performed for high risk cutaneous SCC. Prospective multicenter studies are needed to examine the role, utility and cost-effectiveness of SLNB for this population.

Effects of patient satisfaction with care on health-related quality of life: a prospective study

OBJECTIVES

To evaluate the effect of patient satisfaction on health-related quality of life among dermatological outpatients, independently of patients' sociodemographic, and clinical characteristics.

DESIGN

Prospective cohort study. Satisfaction was evaluated with a standardized questionnaire three days after the visit by telephone interview. Quality of life and psychiatric disorders were measured with validated instruments (Skindex-29 and Ghq-12) before the dermatological visit and after four weeks. At the four week interview also self-reported medication adherence was assessed.

SETTING

Outpatient clinics of a large dermatological hospital in Rome, Italy.

PATIENTS

A consecutive sample of 1389 outpatients was approached, and 52% agreed to participate. Inclusion criteria were met by 424 patients, and 396 (93%) of them completed the study.

MAIN OUTCOME MEASURES

Improvement in health related quality of life.

RESULTS

At multivariate analysis satisfied patients have approximately twice the odds for an improved quality of life on the emotions scale (OR = 1.99; 95%CI 1.1 to 3.7; P = 0.03) and on the functioning scale (OR = 2.2; 95%CI 1.1 to 4.7; P = 0.03). Patients with psychiatric disorders at baseline were less likely to have an improved quality of life on the functioning scale (OR = 0.3; 95%CI 0.2 to 0.8; P = 0.01).

CONCLUSIONS

This is the first prospective study showing that patient satisfaction and psychiatric disorders have a significant effect on quality of life improvement among dermatological patients, independently of patient characteristics. Particular attention should be devoted to improving physicians' interpersonal skills, the major component of patient satisfaction.

[Job satisfaction, burnout and stress amongst nursing staff: a survey in two hospitals in Rome]

The job satisfaction and psychological well-being of health care workers may significantly influence the quality of care they provide. The aim of this study was to assess burnout and psychiatric disorders, such as anxiety and depression, as well as evaluate job satisfaction among nurses working at the IDI-Sanità in Rome. Nurses (n = 545) were invited to answer an anonymous, self-administered questionnaire, which consisted of the Maslach Burnout Inventory (MBI), the General Health Questionnaire (GHQ-12), and a validated questionnaire to examine job satisfaction. Descriptive analyses and multiple logistic regression analysis were performed. The section designed to evaluate job satisfaction was specifically examined by means of principal component factor analysis. Two hundred and forty-two nurses answered the questionnaire (response rate: 44%). Emotional exhaustion was observed in 38% of respondents. No significant difference was detected between mean values ( standard deviation) at each of the three MBI subscales and Italian normative data. About 33% of respondents showed a GHQ-12 score typical for disorders such as anxiety or depression. High levels of job satisfaction were found to be associated to a lower likelihood both of emotional exhaustion at MBI and psychiatric morbidity at GHQ-12. Factor analysis on items investigating job satisfaction identified 4 factors that globally accounted for 61% of the total variance. The factors obtained could represent possible targets for action aimed at improving nurse satisfaction.

Burnout and job satisfaction comparing healthcare staff of a dermatological hospital and a general hospital

BACKGROUND

Psychological distress among healthcare professionals can have negative effects on the well-being of the professionals and also on the quality of care they provide to patients.

OBJECTIVES

To evaluate burnout and job satisfaction of dermatologists and nurses working with dermatological patients compared with physicians and nurses of other specialties.

METHODS

A self-completed anonymous questionnaire was distributed to the personnel of two hospitals in Rome, Italy: a dermatological hospital (IDI) and a general hospital (GH), belonging to the same non-profit organization. Standardized instruments were used to assess burnout (Maslach Burnout Inventory) and job satisfaction. Multiple logistic regression was used to examine the association between burnout and working in dermatology vs. other specialties, job satisfaction, years of employment and respondents' sex and age.

RESULTS

We distributed 929 questionnaires to clinical and non-clinical staff of IDI and 494 questionnaires to the GH staff (response rates: 53% at IDI and 50% at the GH). Among respondents there were 67 physicians and 59 nurses at IDI and 70 physicians and 148 nurses at the GH. Subsequent analyses refer only to this clinical subsample. Factor analysis showed that among physicians and nurses the two main factors explaining job satisfaction were respondents 'satisfaction with the management of their unit' and 'opportunities for personal growth'. Among nurses the likelihood of burnout decreased significantly with higher levels of job satisfaction [odds ratio (OR) = 0.78; 95% confidence interval (95% CI) 0.7-0.9] and working in dermatology compared with other specialties (OR = 0.46; 95% CI 0.2-0.9). Among physicians a lower likelihood of burnout was associated with job satisfaction (OR = 0.66; 95% CI 0.5-0.8) and older age (OR = 0.28; 95% CI 0.1-0.8).

CONCLUSIONS

Among both physicians and nurses, job satisfaction was associated with a lower likelihood of burnout, independently of clinical specialty and other factors. Burnout was similar for dermatologists and other specialists. Nurses of the GH compared with those working in dermatology had a higher probability of burnout and were significantly less satisfied with the management of their units and with opportunities for personal growth.

[Satisfaction and critical aspects of inpatients care among patients with psoriasis]

OBJECTIVES

To evaluate satisfaction with care for psoriatic inpatients. Identify areas in need of interventions and actions to improve the satisfaction with care.

METHODS

We analyzed 133 patients with psoriasis and 335 patients affected by other dermatological diseases in their first access at the hospital. Six determinants of satisfaction with care were investigated with a self administered questionnaire. Moreover the overall satisfaction was documented. Descriptive analysis and a multiple logistic regression analysis correcting for confounding factors were performed. Focus groups were conducted with patients to further investigate about specific aspects of relationships between patients and personnel.

RESULTS

Psoriatic inpatients were less satisfied than other dermatological inpatients regarding Coordination of care, Information and education, Emotional support. Emotional support was the determinant with the smallest percentage of satisfied patients. Focus groups confirmed what was identified with the questionnaire and suggested necessary interventions.

CONCLUSIONS

It is necessary to improve the communication skills of health personnel. Information for patients need to be enhanced and the management of psoriatic patients has to be improved.

Treatment outcome and incidence of psychiatric disorders in dermatological out-patients

OBJECTIVE

Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease.

METHODS

The 12-item General Health Questionnaire (GHQ-12) was used to identify subjects free from psychiatric morbidity at their first dermatological visit. The GHQ-12 was administered again after 1 month during a computer-assisted telephone interview.

RESULTS

A total of 277 subjects was included in the study. At the follow-up interview, 21 (7.6%) were found to have significant psychiatric morbidity. Only lack of improvement was associated with increased incidence of psychiatric morbidity (13.6%), with an odds ratio of 3.1 (95% confidence interval 1.2-7.8), after adjustment for gender, age, educational level and clinical severity.

CONCLUSIONS

Physicians should devote special attention to the risk of psychiatric complications in patients who have not improved with treatment.

Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body

Psychiatric disorders are frequent among patients with skin diseases. We aimed at identifying factors associated with psychiatric morbidity in dermatological outpatients. All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given the 12-item General Health Questionnaire. The dermatologists indicated the diagnosis and location of skin lesions and rated the disease severity. A total of 1389 patients were asked to take part in the study. Of the 722 who accepted, 389 had a complete set of data and were included in the analysis. To verify the representativeness of our sample, we used the administrative registries to compare participants with the total population of patients who attended the clinics during the same period, and we examined the distribution of missing data. There was a tendency towards a younger age in the sample studied, but no evidence of substantial selection bias. The prevalence of psychiatric morbidity was 20.6%. We found higher probability of psychiatric disorders in women, controlling for age, clinical severity and localization of lesions. In women, but not in men, the prevalence of psychiatric morbidity was higher in patients with lesions on the face or hands. Given that the identification and appropriate management of psychiatric morbidity are important, it seems that the dermatologist should be particularly alert to the possibility of a concurrent psychiatric disorder in women with lesions on the face or hands.

Factors associated with patient satisfaction with care among dermatological outpatients

BACKGROUND

It has been shown that poor patient satisfaction can lead to poor adherence to treatment with consequently poor health outcomes. In order to improve the quality of care perceived by the patient and thus the health outcome, it is important to understand which are the main factors influencing patient satisfaction.

OBJECTIVES

To examine factors associated with patient satisfaction with care among dermatological out-patients.

METHODS

This longitudinal study is based on a sample of dermatology out-patients. The independent effects on patient's satisfaction of patient characteristics (sociodemographic characteristics, disease severity, quality of life) and of specific aspects of provided health care (the time the physician spent with patients, physician's interpersonal skills, etc.) were examined by multiple logistic regression.

RESULTS

A total of 1389 out-patients were selected at random and invited to participate. Of the 722 patients who agreed to participate, 424 fulfilled the inclusion criteria and 396 of these patients (93.4%) completed the study. Overall satisfaction was reported by 60.0% of patients. The likelihood of overall satisfaction was found to be significantly and independently increased by the physician's ability to give explanations and to show empathy for the patient's condition, and by the older age of patients. The likelihood of satisfaction also increased with increasing disease severity, but decreased with symptom-related poor quality of life. The lowest level of satisfaction was found among patients whose symptom-related quality of life was worse than the clinical severity rated by the dermatologist.

CONCLUSIONS

Improving the physician's interpersonal skills can increase patient satisfaction, which is likely to have a positive effect on treatment adherence and health outcomes. Dermatologists succeeded better in establishing a good relationship with clinically more severely affected patients than with patients who were clinically mildly affected despite their quality of life being impaired. Thus, the inclusion of a patient-rated quality of life can be a useful measure in dermatology, as it enables clinicians to perceive the patients' perception of their health status.

Factors associated with HIV testing: results from an Italian General Population Survey

BACKGROUND

HIV testing, with appropriate counseling, can help prevent the spread of HIV infection. This study is the first national survey in Italy that examines factors associated with serotesting among Italian heterosexuals and is part of a European Concerted Action.

METHODS

In 1998, a cross-sectional telephone survey was conducted on a random sample (n = 2,603) of the Italian population ages 18-49 years. Associations between HIV testing and risky sexual behaviors (multiple sexual partners in the past 5 years, intercourse with prostitutes, not always using condoms with a new sexual partner) and sociodemographic variables are examined separately for men and women using multiple logistic regression.

RESULTS

The prevalence of having ever been tested for HIV, whether voluntarily or not, among heterosexual men and women is 27.0 and 32.8%, respectively. Voluntary testing is reported by 8.4% of heterosexual men and 6.1% of heterosexual women. Multivariate analysis shows that having multiple sexual partners significantly increases the odds of testing (Men: OR = 2.10; 95% CI: 1.3-3.4. Women: OR = 3.03; 95% CI: 1.7-5.4). Multiple logistic regression, controlling for risky behavior, shows also that persons ages 30-39 years have significantly higher probability of being tested than younger subjects (Men: OR = 3.30; 95% CI: 1.4-7.9. Women: OR = 2.61; 95% CI:1.1-6.4). Better educated women tend to have a higher probability of testing, but this increase is not significant at the 5% level.

CONCLUSIONS

The prevalence of voluntary serotesting in Italy is lower than in other countries. Risky sexual behavior is associated with higher odds of testing; however, a high proportion of at-risk heterosexuals never sought testing. Particular attention should be dedicated to younger persons and to less educated women.

The use of relaxation techniques in the perioperative management of proctological patients: preliminary results

Relaxation techniques positively affect the psychosomatic pattern of patients undergoing surgical treatment. Among these techniques guided imaging (GI) has been reported to improve outcome following colorectal surgery. This study assessed the effects of GI on the postoperative course in proctological patients. We carried out a prospective randomized trial in a group of patients operated on for anorectal diseases in our coloproctology unit. Patients were randomized into group 1 (n = 43) with standard care and group 2 (n = 43) with relaxation techniques; they listened to a GI tape with music and relaxing text before, during, and after surgery. The following parameters were evaluated by a questionnaire (a) postoperative pain measured by visual analogue score, (b) the quality of sleep measured by a similar score, and (c) the nature of first micturition, evaluated as normal or difficult. Groups were similar in age and sex distribution, type of disease, and operation performed. The pain score was 3.2 +/- 1.4 in GI patients and 4.1 +/- 2.1 in controls (P = 0.07). The quality of sleep score was 4.8 +/- 2.9 in GI patients and 6.4 +/- 2.7 in controls (P = 0.01). The first micturition was painful in 10.3% of GI patients and in 27.3% of controls (P = 0.09). Perioperative relaxation techniques thus showed a trend to reducing pain following anorectal surgery and significantly improving the quality of sleep; a decrease in anxiety and a consequent muscle relaxation may be involved. Therefore GI, a low cost and noninvasive procedure, can be recommended as an helpful tool in this type of surgery.

Teratogenic effects of antiepileptic drugs: use of an International Database on Malformations and Drug Exposure (MADRE)

PURPOSE

The study goal was to assess teratogenic effects of antiepileptic drugs (AEDs) through the use of a surveillance system (MADRE) of infants with malformations.

METHODS

Information on all malformed infants (1990-1996) with maternal first-trimester drug exposure was collected by the International Clearinghouse for Birth Defects and Monitoring Systems (ICBDMS). Cases were defined as infants presenting with a specific malformation, and controls were defined as infants presenting with any other birth defect. Exposure was defined by the use of AEDs during the first trimester of pregnancy. The association of AEDs with malformations was then estimated by calculating the odds ratios with 95% confidence intervals and testing their homogeneity among registries.

RESULTS

Among 8005 cases of malformations, 299 infants were exposed in utero to AEDs. Of those exposed to monotherapy, 65 were exposed to phenobarbital, 10 to methylphenobarbital, 80 to valproic acid, 46 to carbamazepine, 24 to phenytoin, and 16 to other AEDs. Associations were found for spina bifida with valproic acid. Infants exposed to phenobarbital and to methylphenobarbital showed an increased risk of oral clefts. Cardiac malformations were found to be associated with phenobarbital, methylphenobarbital, valproic acid, and carbamazepine. Hypospadias was associated with valproic acid. Porencephaly and other specified anomalies of brain, anomalies of face, coarctation of aorta, and limb reduction defects were found to be associated with valproic acid.

CONCLUSIONS

Using the MADRE system, we confirmed known teratogenic effects of AEDs. We also found increased risks for malformations that had never been reported associated with AEDs or for which the association was suggested by case reports.

Psychologic aspects in proctalgia

PURPOSE

One of the main problems in coloproctology is chronic idiopathic anal pain. The aim of this study was to investigate the psychosomatic components of proctalgia to identify which, if any, component is associated with this pain and to what extent.

METHODS

Twenty patients with proctalgia were observed (mean age, 46 years). Psychologic consultations were required by the surgeons, because of persistent symptoms, to allow a better understanding of the problem and a more integrated therapy. The psychologic investigation consisted of three interviews and administration of the following tests: Institute for Personality and Ability Testing Anxiety Scale Questionnaire (1-10), Rorschach test (Klopfer and Davidson method), and Draw-A-Person test by Karen Machover. This sample was compared with a control group composed of 40 healthy subjects, homogeneous in age, social and working conditions, and investigation procedures.

RESULTS

Patients showed depression and anxiety according to standard validated questions (Institute for Personality and Ability Testing Anxiety Scale Questionnaire) and personality disorders; they had a strong tendency to use primitive defense mechanisms and showed a lack of personality formation.

CONCLUSIONS

Psychologic investigation allows a progressive clarification of all the components of anal pain. This might be useful not only for research purposes but also for a more effective approach to these patients.

[Prevention focused on sexual behavior]

In Italy, studies on the sexual behaviour of young persons are rare, especially those conducted among samples that are representative of the same-age general population. This report presents the preliminary results of a knowledge, attitudes and practices survey on sexual behaviour among a representative sample of individuals 18-26 years of age. The study was begun in 1994, and as of 30 June 1997, 8533 (32%) of the 26,536 questionnaires sent so far have been completed: 3947 (46%) by males and 4586 (54%) by females. 70% of the males and 64% of the females reported that they are sexually active; the median age at first sexual experience is 18 years for both genders. The proportion of respondents who use condoms with occasional sexual partners is low, and only half of the respondents demonstrated an adequate level of knowledge regarding the transmission of HIV.

[Sexual behavior of Italian youths in connection to AIDS risk]

The objective of this survey is to evaluate knowledge and sexual behaviour among young Italians (19 to 24 years). The project, began in 1993, is being carried out through an anonymous postal questionnaire, sent to a representative sample of the young Italian population (a total of 52,000 people from 363 Italian towns). In the present intermediate evaluation, we have analysed 6929 of the 18,132 questionnaires sent till now, with all Italian regions being proportionally included. Our data show that, after sexual activity has been started, it hardly seems to be limited to monogamy or to be always regulated by AIDS-preventing practices. Data show that the age of the first sexual intercourse is increasing (after age 18) and that condoms are used more frequently, particularly in occasional sex.

Prevention and treatment of low-grade B-cell primary gastric lymphoma by anti-H. pylori therapy

Mucosa-associated lymphoid tissue (MALT) showing a follicular structure can develop in the gastric mucosa as a response to Helicobacter pylori infection. We emphasize the importance of anti-H. pylori antibiotic therapy in the elimination of acquired MALT. Of the 200 patients studied, acquired MALT was found in 70 of the 151 H. pylori-positive patients, whereas it was present in only five of the 49 H. pylori-negative patients. Thirty-eight H. pylori-positive and MALT-positive patients were treated with antibiotic therapy and reevaluated after 6 months: 21 patients were H. pylori negative/MALT negative, 12 were H. pylori positive/MALT positive, four were H. pylori negative/MALT positive, one was H. pylori positive/MALT negative. In the control group (n = 20), H. pylori and acquired MALT were still present at follow-up. One patient with histological and immunohistochemical evidence of low-grade B-cell gastric MALT lymphoma underwent antibiotic treatment and was reexamined after 8, 12, and 24 weeks: histological examination of biopsy samples showed regression of the MALT lymphoma in tandem with the disappearance of H. pylori colonization. Our data confirm the correlation between H. pylori infection and acquired MALT, as documented by the ability of antibiotic therapy to induce the disappearance of acquired MALT and regression of MALT lymphoma. Considering the potential evolution of MALT into low-grade B-cell MALT lymphoma, H. pylori eradication should play a role in the prevention of this tumor.

Immunologic changes in circulating leukocytes in the presence of atherosclerotic disease

To assess the numeric and functional changes in circulating white blood cells in the presence of severe atherosclerosis, 25 subjects with marked, angiographically assessed, atherosclerotic lesions and 29 selected controls were studied. Of the differential leukocyte counts, only monocyte count was significantly higher in the atherosclerotic than in the control subjects (449.0 +/- 115.6 (1 S.D.) vs. 344.1 +/- 138.8/mmc; P = 0.0016). By flow-cytometry no significant differences concerning monocyte surface antigens were found, except a feeble decrease in beta 2-microglobulin in the atherosclerotic subjects. As to lymphocytes, an increase in the CD8 population (33.4 +/- 6.8 vs 28.6 +/- 6.5%; P = 0.0144) and decreases in class I HLA antigen (96.6 +/- 7.3 vs 99.4 +/- 0.7%; P = 0.0049), beta 2-microglobulin (97.9 +/- 2.1 vs 99.3 +/- 1.0%; P = 0.0055) and especially in vivo DNA synthesis (3.8 +/- 1.2 vs 5.3 +/- 2.1%; P = 0.0102) percent expressions were found in the atherosclerotic patients with respect to the controls. This study shows that circulating monocytes are increased in atherosclerotic disease, possibly due to their participation in the phagocytosis of lipids in the arterial wall, with no further immunologic involvement. Conversely, the replicative activity of T lymphocytes is decreased, which might be a consequence of or a factor predisposing to atherosclerosis.

[Treatment of pulmonary embolism. Current status and future prospects]

Although still severe, the prognosis of pulmonary embolism has recently improved due to considerable progress in the therapeutic field. This paper concerns the various therapeutic tools, both pharmacologic and surgical, which are already available or under evaluation. Despite the introduction of thrombolytic drugs, heparin remains an indispensable drug. The rationale for its use comes from the need of preventing further clot formation, while endogenous fibrinolysis or thrombolytic drugs are dissolving the already existing clots. Thrombolytic drugs, such as streptokinase, urokinase or rt-PA, have changed the therapeutic strategy of pulmonary embolism, due to their ability to accelerate the normal fibrinolytic mechanisms and to facilitate pulmonary reperfusion. This often allows an early disappearance of symptoms and a reduced incidence of invalidating complications involving the respiratory function. rt-PA seems to be most effective and fast in inducing reperfusion (angiographic signs of clot dissolution are obtained in 82% of the patients within 2 hours). The administration of rt-PA by intravenous bolus has recently been proposed, which would induce an even faster thrombolysis and fewer hemorrhagic complications. The role of surgical therapy has declined after the diffusion of thrombolytic drugs, being reserved only for the most serious cases. When anticoagulation is counter-indicated or not effective, the prevention of embolic relapses can be achieved by percutaneous insertion of caval filters of different types. Some new catheters provided with rotating metallic tips, which allow the mechanical fragmentation of the emboli, are presently under evaluation. Although some improvements are needed, this technique is expected to become soon of general use, especially in cases in which thrombolytic therapy is counter-indicated.

Increased serum IgA levels in subjects with previous myocardial infarction or other major ischemic events

To ascertain whether the increase in serum IgA, which has been found to be associated with the presence of severe atherosclerotic disease, precedes or follows the occurrence of major ischemic events (MIE), we studied the serum levels of IgA as well as IgG and IgM in 145 subjects with acute or previous ischemic events and 34 controls. The subjects with previous myocardial infarction had higher IgA levels with respect to the controls, the patients with angina pectoris and those with acute myocardial infarction, while no significant differences concerning IgG and IgM were found. In the subjects with previous extracoronary events, immunoglobulin levels tended to be even higher. Overall, 30% of the subjects with previous MIE and only 3% of the controls had IgA levels over 4.5 g/l (p = 0.0018). This study indicates that total serum IgA is a marker of previous major ischemic events (protracted immune response to denatured proteins?), rather than a factor predisposing to atherosclerosis development.

[Association of serum C3 and essential hypertension]

This study was performed to assess the possible involvement of humoral immunity in essential hypertension, independently of the presence of atherosclerotic disease, which in turn may be associated with immunologic changes. Sixty-five patients without demonstrated atherosclerotic disease were selected according to clinical and arteriographic criteria, including 23 hypertensive subjects (all pharmacologically treated) and 42 controls. Mean ages (58.7 +/- 8.3(1 S.D.) years in the controls and 57.7 +/- 7.9 years in the hypertensive subjects) and sex distribution were similar in the 2 groups. Of the main risk factors, atherosclerosis, smoking, diabetes, total cholesterol and HDL-cholesterol were equivalent, while triglycerides were higher in the hypertensive subjects than in the controls (142.6 +/- 52.7 vs. 112.6 +/- 67.7 mg/dl; p = 0.0065). In these subjects' sera the immunoglobulins IgG, IgA and IgM, and the third and fourth complement components (C3 and C4) were measured. Of these variables, only C3 was higher in the hypertensive subjects than in the controls (124.3 +/- 29.3 vs. 107.8 +/- 18.4 mg/dl; p = 0.0183). Furthermore, C3 was significantly correlated with triglycerides (tau = 0.3613; p < 0.0001), but the association with hypertension was confirmed only for C3, and not for triglycerides, by multiple logistic regression (p = 0.0142). The increase in serum C3 suggests the possible implication of humoral immunity in the pathogenesis or progression of essential hypertension.

[Increased serum levels of IgA and C4 in atherosclerosis: the absence of a correlation with the arteriographic picture]

We have previously shown that an increase in serum IgA and C4 is often detectable in presence of diffuse atherosclerotic disease. The present study was performed to verify such results in a different and larger sample of subjects, and to ascertain whether the above immunologic variables are correlated with the severity of atherosclerotic disease. Seventy-three atherosclerotic subjects with at least 1 significant (> 75%) stenosis in a major arterial branch were selected according to the reports of arterial panangiographies performed previously. Among them, 36 subjects (24 men and 12 women, mean age 63 +/- 7 years) were singled out, who matched by age and sex 36 control subjects (mean age 63 +/- 7 years). In all of these subjects the following serum immunologic and lipid variables were measured: IgG, IgA, IgM, IgE, C3, C4, total cholesterol, HDL-cholesterol and triglycerides. With respect to the controls, the 36 matched atherosclerotic subjects had higher levels of IgA (263.0 +/- 119.8 vs 334.3 +/- 130.5 mg/dl; p = 0.0126), C4 (25.7 +/- 5.8 vs 30.4 +/- 9.1 mg/dl; p = 0.0297) and triglycerides (153.1 +/- 77.3 vs 209.7 +/- 141.3; p = 0.0500). No correlation was found between the number of arterial stenoses (range 1-8, mean 2.9 +/- 1.5) and any of the immunologic or lipid parameters in all the 73 atherosclerotic subjects. Only the daily cigarette consumption was correlated with the disease extension (tau = 0.1984; p = 0.0392).(ABSTRACT TRUNCATED AT 250 WORDS)