Factors associated with hospitalization in a pediatric population of rural Tanzania: findings from a retrospective cohort study

BACKGROUND

Despite pediatric acute illnesses being leading causes of death and disability among children, acute and critical care services are not universally available in low-middle income countries, such as Tanzania, even if in this country significant progress has been made in child survival, over the last 20 years. In these countries, the hospital emergency departments may represent the only or the main point of access to health-care services. Thus, the hospitalization rates may reflect both the health system organization and the patients' health status. The purpose of the study is to describe the characteristics of clinical presentations to a pediatric Outpatient Department (OPD) in Tanzania and to identify the predictive factors for hospitalization.

METHODS

Retrospective cohort study based on 4,324 accesses in the OPD at Tosamaganga Voluntary Agency Hospital (Tanzania). Data were collected for all 2,810 children (aged 0-13) who accessed the OPD services, within the period 1 January - 30 September 2022. The association between the hospitalization (main outcome) and potential confounding covariates (demographic, socio-contextual and clinical factors) was evaluated using univariate and multivariate logistic regression models.

RESULTS

Five hundred three (11.6%) of OPD accesses were hospitalized and 17 (0.4%) died during hospitalization. A higher (p < 0.001) risk of hospitalization was observed for children without health insurance (OR = 3.26), coming from more distant districts (OR = 2.83), not visited by a pediatric trained staff (OR = 3.58), and who accessed for the following conditions: burn/wound (OR = 70.63), cardiovascular (OR = 27.36), constitutional/malnutrition (OR = 62.71), fever (OR = 9.79), gastrointestinal (OR = 8.01), respiratory (OR = 12.86), ingestion/inhalation (OR = 17.00), injury (OR = 6.84).

CONCLUSIONS

The higher risk of hospitalization for children without health insurance, and living far from the district capital underline the necessity to promote the implementation of primary care, particularly in small villages, and the establishment of an efficient emergency call and transport system. The observation of lower hospitalization risk for children attended by a pediatric trained staff confirm the necessity of preventing admissions for conditions that could be managed in other health settings, if timely evaluated.

Evaluating Healthcare Performance in Low- and Middle-Income Countries: A Pilot Study on Selected Settings in Ethiopia, Tanzania, and Uganda

The literature reports some experiences regarding the design of integrated healthcare Performance Evaluation Systems (PES) applied in Low- and Middle-income Countries (LMIC). This study describes the design of an integrated and bottom-up PES aimed at evaluating healthcare services delivery in rural settings. The analysis involved four hospitals and their relative health districts in Ethiopia, Tanzania, and Uganda. The evaluation process was undertaken for those indicators that could be evaluated using the same reference standard. The evaluation scores were determined through the international standards identified in the literature or through benchmarking assessment. Both administrative and health data were extracted from the hospitals' registers and District Health Information Systems (DHIS) from 2017 to 2020. We defined 128 indicators: 88 were calculated at the hospital level and 40 at the health district level. The evaluation process was undertaken for 48 indicators. The evaluated indicators are represented using effective graphical tools. In settings characterised by multiple healthcare providers, this framework may contribute to achieving good governance through performance evaluation, benchmarking, and accountability. It may promote evidence-based decision-making in the planning and allocation of resources, thus ultimately fostering quality improvement processes and practices, both at the hospital and health district level.

An integrated care pathway for maternal and childcare: evidence from Ethiopia, Tanzania, and Uganda

 

Performance monitoring and evaluation are key to quality improvement in maternal and child healthcare in Sub-Saharan Africa. This study presents the experience of designing and implementing bottom-up and integrated performance evaluation tools for care pathway to monitor and manage maternity healthcare services. The research project involved four health districts and relative reference hospitals, supported by the NGO Doctors with Africa CUAMM in Ethiopia, Tanzania, and Uganda. The maternal and childcare pathway developed consists of 23 indicators, calculated at hospital and district level, relating to pregnancy, childbirth and first year of life phases. The authors developed staves and performance maps, as graphical representation tools, to display longitudinally integrated health services provision performance along the continuum of care. Substantial variation was observed between the phases of each maternal and childcare pathway and across the care pathways of the different analysed settings. The most impressive results across the four settings are: 1) regarding pregnancy phase, that women tend to attend more than four antenatal classes, still with a quite high drop-out rate, and are largely tested for syphilis, 2) with respect to childbirth, that there are varying percentage levels in terms of C-sections, episiotomies and peri/intra-partum asphyxia cases, and 3) as it regards first year of life, there emerges scope for improvement considering the vaccination coverages attained for pentavalent, measles and polio vaccinations. Thanks to the collaboration with local managers and health professionals, the maternal and childcare pathway allowed to monitor the changes in the quality of maternity services provided within the analysed contexts. The benchmarking approach encouraged local professionals to learn from other settings. The use of such tool allowed the development of targeted quality improvement actions, shared among all involved stakeholders.

Key messages

• In collaboration with local professionals, we designed and implemented an integrated pathway for maternal and childcare, covering the phases of pregnancy, childbirth and first year of life.

• Benchmarking performance results encouraged collaboration among professionals and allowed the identification of actions to improve the provision of maternal and childcare services.

An integrated hospital-district evaluation for communicable diseases in low/middle-income countries

Background

The last two decades saw an extensive effort to design and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low/middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative tool to assess the performance of health services provision for communicable diseases in three African countries.

Methods

A total of 42 indicators, 14 per each communicable disease care pathway (Tuberculosis, Gastroenteritis, and HIV/AIDS), were developed. A sub-set of 23 indicators was included in the evaluation process. The indicators assessed four care phases: prevention, diagnosis, treatment, and outcome. All indicators were calculated for the period 2017-2019, while performance evaluation was performed for 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda.

Results

Substantial variability was observed over time and across the four different districts. In the TB pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase.

Conclusions

The bottom-up approach and stakeholders’ engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation and accountability in settings characterised by multiple healthcare service providers.

Key messages

• A successful experience in developing and implementing a communicable diseases performance evaluation systems in three sub-Saharan African countries using a bottom-up approach.

• The communicable diseases performance evaluation tool helped the data sharing between local healthcare providers and the development of competencies in data collection, analysis and interpretation.

An integrated hospital-district performance evaluation for communicable diseases in low-and middle-income countries: Evidence from a pilot in three sub-Saharan countries

Introduction

The last two decades saw an extensive effort to design, develop and implement integrated and multidimensional healthcare evaluation systems in high-income countries. However, in low- and middle-income countries, few experiences of such systems implementation have been reported in the scientific literature. We developed and piloted an innovative evaluation tool to assess the performance of health services provision for communicable diseases in three sub-Saharan African countries.

Material and methods

A total of 42 indicators, 14 per each communicable disease care pathway, were developed. A sub-set of 23 indicators was included in the evaluation process. The communicable diseases care pathways were developed for Tuberculosis, Gastroenteritis, and HIV/AIDS, including indicators grouped in four care phases: prevention (or screening), diagnosis, treatment, and outcome. All indicators were calculated for the period 2017–2019, while performance evaluation was performed for the year 2019. The analysis involved four health districts and their relative hospitals in Ethiopia, Tanzania, and Uganda.

Results

Substantial variability was observed over time and across the four different districts. In the Tuberculosis pathway, the majority of indicators scored below the standards and below-average performance was mainly reported for prevention and diagnosis phases. Along the Gastroenteritis pathway, excellent performance was instead evaluated for most indicators and the highest scores were reported in prevention and treatment phases. The HIV/AIDS pathway indicators related to screening and outcome phases were below the average score, while good or excellent performance was registered within the treatment phase.

Conclusions

The bottom-up approach and stakeholders’ engagement increased local ownership of the process and the likelihood that findings will inform health services performance and quality of care. Despite the intrinsic limitations of data sources, this framework may contribute to promoting good governance, performance evaluation, outcomes measurement and accountability in settings characterised by multiple healthcare service providers.

The contribution of benchmarking to quality improvement in healthcare. A systematic literature review

BACKGROUND

Benchmarking has been recognised as a valuable method to help identify strengths and weaknesses at all levels of the healthcare system. Despite a growing interest in the practice and study of benchmarking, its contribution to quality of care have not been well elucidated. As such, we conducted a systematic literature review with the aim of synthesizing the evidence regarding the relationship between benchmarking and quality improvement. We also sought to provide evidence on the associated strategies that can be used to further stimulate quality improvement.

METHODS

We searched three databases (PubMed, Web of Science and Scopus) for articles studying the impact of benchmarking on quality of care (processes and outcomes). Following assessment of the articles for inclusion, we conducted data analysis, quality assessment and critical synthesis according to the PRISMA guidelines for systematic literature review.

RESULTS

A total of 17 articles were identified. All studies reported a positive association between the use of benchmarking and quality improvement in terms of processes (N = 10), outcomes (N = 13) or both (N = 7). In the majority of studies (N = 12), at least one intervention, complementary to benchmarking, was undertaken to stimulate quality improvement. The interventions ranged from meetings between participants to quality improvement plans and financial incentives. A combination of multiple interventions was present in over half of the studies (N = 10).

CONCLUSIONS

The results generated from this review suggest that the practice of benchmarking in healthcare is a growing field, and more research is needed to better understand its effects on quality improvement. Furthermore, our findings indicate that benchmarking may stimulate quality improvement, and that interventions, complementary to benchmarking, seem to reinforce this improvement. Although this study points towards the benefit of combining performance measurement with interventions in terms of quality, future research should further analyse the impact of these interventions individually.

The Impact of New Surgical Techniques on Geographical Unwarranted Variation: The Case of Benign Hysterectomy

Since the 1980s, the international literature has reported variations for healthcare services, especially for elective ones. Variations are positive if they reflect patient preferences, while if they do not, they are unwarranted, and thus avoidable. Benign hysterectomy is among the most frequent elective surgical procedures in developed countries, and, in recent years, it has been increasingly delivered through minimally invasive surgical techniques, namely laparoscopic or robotic. The question therefore arises over what the impact of these new surgical techniques on avoidable variation is. In this study we analyze the extent of unwarranted geographical variation of treatment rates and of the adoption of minimally invasive procedures for benign hysterectomy in an Italian regional healthcare system. We assess the impact of the surgical approach on the provision of benign hysterectomy, in terms of efficiency (by measuring the average length of stay) and efficacy (by measuring the post-operative complications). Geographical variation was observed among regional health districts for treatment rates and waiting times. At a provider level, we found differences for the minimally invasive approach. We found a positive and significant association between rates and the percentage of minimally invasive procedures. Providers that frequently adopt minimally invasive procedures have shorter average length of stay, and when they also perform open hysterectomies, fewer complications.

Unintended consequences of expenditure targets on resource allocation in health systems

In recent decades, several countries have reformed their health care systems leading to the devolution of power to a lower governance level and, subsequently, to re-centralisation. Due to the ambiguous results of these policies and the start of the financial crisis of 2008, a wide number of national governments implemented cutback initiatives aimed at controlling health expenditure. The literature shows that the introduction of such initiatives may have produced unintended consequences on health systems' performance. In order to better understand the power relations and the resulting decision-making processes between national governments and local authorities, it is important to focus on the effects of such expenditure control mechanisms on the inputs of the health systems, i.e. the production factors. This research aims at investigating the effects of a cutback initiative intended to control personnel costs in a federal Beveridge health system through the analysis of resource allocation at the devolved level. The paper is based on a quantitative analysis of data resulting from the financial statements published by the 21 Italian regional health systems from 2012 to 2017. The results show that, although the Italian regional health systems managed to reduce personnel costs - i.e. hitting the target - the control of the total cost dynamic was not fully addressed. Overall, the initiative implemented by the national government had the effect of limiting the decision-making autonomy of regional authorities, pushing them toward shifting resource allocation from personnel to the purchase of services.

Lymphocyte Subsets Assayed by Numerical Tests in CAPD

Peripheral and peritoneal lumphocytes were assayed by numerical tests in adults on peritoneal dialysis. T lymphocytes were classified by monoclonal antibodies (OKT3, OKT4, OKT8) and B lymphocytes by the presence of surface immunoglobulins, using the immunofluorescence technique.

Peripheral T cells showed no significant change from the normal, except for T suppressor cells which increased in patients with 2 or more peritonitis episodes.

Examination of peritoneal lymphocytes showed a significant reduction in S-IgA lymphocytes (B cells bearing IgA receptors) and an increase in T-suppressor cells (OKT8+) in patients who developed peritonitis in the follow-up study. The implications of these results are discussed with particular reference to susceptibility to peritonitis.

Injury to the Common Peroneal Nerve during Surgery of the Lesser Saphenous Vein

Objective:

To evaluate the incidence and associated problems of common peroneal nerve (CPN) injury, which can occur during short saphenous vein (SSV) surgery.

Design:

A retrospective cohort study.

Setting:

Section of Vascular Surgery in a University Hospital.

Patients:

In a consecutive series of 88 patients (31 male, 57 female, ages ranging from 35 to 68 years, mean 49), 104 lower extremities were operated on for SSV insufficiency.

Interventions:

Each patient was assessed by clinical examination, duplex scanning and in some cases by venography (ascending venography and/or varicography). Surgery was carried out via a longitudinal or transverse approach in the popliteal region or the posterior aspect of the thigh.

Main outcome measures:

Haemodynamic criteria, cosmetic outcome and complications of the surgical procedures due to SSV insufficiency were considered. In particular, we focused on neurological complications.

Results:

Abnormality of foot dorsiflexion was observed in two out of 104 (2%) cases. This complication was caused by injury to the CPN. Recovery had occurred 1 year later.

Conclusions:

Two factors seem to be essential in preventing this neurological complication: (a) good knowledge of surgical anatomy and (b) a cautious, accurate surgical technique. The incidence of this complication has been underestimated, but its importance and medico-legal implications must be emphasised.

Cerebral vasoreactivity does not predict cerebral ischaemia during carotid endarterectomy

AIM

Assessment of cerebrovasoreactivity (CVR), obtained by transcranial Doppler (TCD) and the acetazolamide test to predict cases requiring selective carotid shunting on the basis of neurologic monitoring.

METHODS

A consecutive series of 87 carotid endarterectomy (CEA) cases was studied. Before surgery CVR was evaluated by measuring the mean velocity of the middle cerebral artery (mvMCA) using TCD at the basal condition and at 30 min after intravenous administration of acetazolamide (1 g). Carotid shunting was performed using neurologic monitoring under local anesthesia. Receiver operating characteristic (ROC) curve was calculated for sensitivity and specificity for various CVR cut offs.

RESULTS

The ROC curve demonstrated that there was no single CVR cut off with both sensitivity and specificity above 80%.

CONCLUSION

The present study, which employed neurologic monitoring as the method of comparison, did not prove that CVR, as calculated by TCD and the acetazolamide test, is a valid preoperative test for predicting cerebral ischaemia caused by carotid clamping.

Stump pressure and transcranial Doppler for predicting shunting in carotid endarterectomy

OBJECTIVES

to compare stump pressure (SP) and transcranial Doppler (TCD) with neurologic monitoring during carotid endarterectomy (CEA).

MATERIALS

one hundred and forty-seven CEAs performed under local anaesthesia.

METHODS

neurologic monitoring and SP were performed in all cases, while mean velocity of the middle cerebral artery (mvMCA) by TCD was done in 140/147 (95%) cases. Shunts were applied in all cases on the basis of neurologic monitoring. The following haemodynamic criteria have been compared to neurologic monitoring: (a) <25 mmHg SP; (b) <50 mmHg SP; (c) < or =10 cm/s mvMCA after carotid occlusion; (d) > or =70 decrease of mvMCA after carotid occlusion. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each haemodynamic criterion.

RESULTS

shunt was used in 18/147 (12.2%) cases. With regards to <25 mmHg SP, < or =50 mmHg SP, < or =10 cm/s mvMCA after carotid occlusion, and > or =70 decrease of mvMCA after carotid occlusion, sensitivity resulted 33, 89, 80 and 80%, respectively. Specificity resulted 96, 82, 97 and 96%, respectively. Positive predictive value resulted 55, 41, 75 and 71%, respectively. Negative predictive value 91, 98, 98 and 98%, respectively. Accuracy resulted 88, 76, 89 and 94%, respectively.

CONCLUSIONS

none of the haemodynamic criteria by SP and TCD resulted absolutely reliable in predicting the need for carotid shunt.

Cerebral haemodynamic aspects of severe carotid stenosis: asymptomatic vs symptomatic

OBJECTIVES

to compare cerebral haemodynamics in patients with asymptomatic and symptomatic severe (> or =70%) internal carotid artery (ICA) stenosis.

METHODS

we assessed 195 consecutive patients, 116 with asymptomatic carotid stenosis (ACS) and 79 with symptomatic carotid stenosis (SCS). Using transcranial Doppler we assessed cerebral vasoreactivity (CVR) following acetazolamide test, the middle cerebral artery flow velocity ratio after/before carotid clamping (mv-MCA ratio), and the carotid back pressure (CBP) during crossclamping.

RESULTS

no significant differences between the two groups were demonstrated regarding CVR (47 vs 39%), mv-MCA ratio (50 vs 52%), or CBP (36 vs 44 mmHg). However, in patients with contralateral ICA occlusion all three variables were significantly lower as compared to patients with patent contralateral ICA. Also patients who needed a shunt during surgery had significantly lower values of mv-MCA ratio and CBP. Patients who suffered peri-operative neurologic deficits (n=6; 3%) did not differ from patients who had an uneventful course.

CONCLUSIONS

clinical state of ICA stenosis is independent of cerebral haemodynamics. Occluded contralateral ICA is more important for predicting cerebral ischaemia caused by carotid clamping. Finally, none of the haemodynamic parameters showed predictive value for peri-operative neurologic morbidity.

Can cerebral vasoreactivity predict cerebral tolerance to carotid clamping during carotid endarterectomy?

Cerebral vasoreactivity (CVR) was evaluated as a preoperative test in predicting cerebral tolerance to carotid clamping.A consecutive series of 115 carotid endarterectomy (CEA) cases were studied. Before surgical operation CVR was evaluated, by measuring the mean velocity of the middle cerebral artery (mv-MCA) using transcranial Doppler (TCD) at the basal condition and 20 min after intravenous administration of acetazolamide (1 g). CEA was performed under general anesthesia. TCD was used during surgery to evaluate mv-MCA and to calculate mv-MCA clamping/mv-MCA pre-clamping x100 ratio (mv-MCA%), which was used as the parameter to validate CVR.CVR did not correlate with mv-MCA% (r=0.22). There was no significant difference (P=0.09) between mean values of the non shunted subgroup and the shunted one.CVR does not seem to be suitable for evaluating cerebral tolerance to carotid clamping.

External carotid artery shunting during carotid endarterectomy: an alternative for cerebral protection?

OBJECTIVES

to assess the application of external carotid artery (ECA) shunting in cerebral protection during carotid endarterectomy (CEA).

DESIGN

prospective study.

MATERIALS AND METHODS

the study comprised 137 consecutive patients who underwent CEA under locoregional anaesthesia. Transcranial Doppler was used to monitor the mean velocity of the middle cerebral artery (mv-MCA): (1) before carotid clamping; (2) after clamping both the common and external carotid arteries; (3) after clamping the internal carotid artery alone ("ECA test"). The decision to shunt was based on the occurrence of neurological deficit during carotid clamping. If the ECA test revealed mv-MCA approaching the pre-clamping values ECA shunting was used, whereas the remaining patients in need of a shunt had a standard internal carotid artery (ICA) shunt.

RESULTS

shunting was necessary in 12/137 cases (9%). The ECA test indicated that in four cases - 3% of the whole series or 33% of the shunted cases. In these four patients ECA shunting reversed the neurological deficit, and CEA was successfully performed without any complications.

CONCLUSIONS

ECA shunting could be considered as an alternative to standard ICA shunting. Suitable cases can be identified on the basis of the ECA test.

Impact of co-amoxiclav on polymorphonuclear granulocytes from chronic hemodialysis patients

Phagocyte-dependent host defenses are frequently impaired in maintenance hemodialysis patients who show an increased susceptibility to infections. In these individuals, the course of infections can be more aggressive than in normal hosts, and the antibiotic of choice should have a high antimicrobial effect without impairing host defenses. Hence, in uremic patients, the antibiotic enhancement of phagocyte functions may be of potential clinical importance in the outcome of bacterial infections. Because we demonstrated previously that co-amoxiclav had beneficial properties that result in enhancement of the microbicidal functions of human polymorphonuclear cells (PMNs) from healthy subjects, we investigated the influence of this combination on the activities of PMNs from chronic hemodialysis patients against Klebsiella pneumoniae, a human pathogen that can pose severe problems in patients whose immunity is impaired. PMNs from chronic dialysis patients showed a diminished in vitro phagocytic efficiency with a reduced phagocytosis and bactericidal activity towards intracellular K. pneumoniae compared with that seen in PMNs from healthy subjects. When co-amoxiclav was added to PMNs from chronic hemodialysis patients, it was able to restore the depressed primary functions of PMNs, resulting in a significant high increase in both phagocytosis or killing activity. A similar pattern was detected with PMNs collected from hemodialysis patients treated with co-amoxiclav. The results of the present study provide evidence that co-amoxiclav is able to induce stimulation of depressed phagocytic response of PMNs from patients on chronic hemodialysis, restoring their primary functions both in vitro and in vivo.

Predictive value of transcutaneous oximetry for selection of the amputation level

BACKGROUND

Transcutaneous oximetry was studied to select the correct amputation level for limb ischemic necrosis with possible identification of threshold value.

METHODS

The method was evaluated in 30 cases (20 patients, 5 males and 15 females, of ages ranging from 61 to 93, average 73.1+/-8.5) where patients underwent amputation because of severe leg ischemia. Surgical operations were: minor amputation (toe or transmetatarsal) in 23 cases, below knee amputation in 7. Oxygen tension was measured at the dorsum foot and at the third superior of the anteromedial calf aspect.

RESULTS

Results were classified as success (primary or delayed healing) or failure (necrosis at the surgical wound). Amputation was successful in 17/30 cases with oxygen tension of 0-65 mmHg (mean 32.5+/-16.1) and failed in 13/30 with oxygen tension of 0-57 mmHg (mean 7.8+/-17.3). The difference was statistically significant (p=0.0004). Sensitivity of the method resulted 88.2%, specificity 84.6%, diagnostic accuracy 86.7%, positive predictive value 88.2% and negative predictive value 84.6%. A threshold of 20 mmHg was identified: 15/17 successful cases showed values greater than 20 mmHg, while 11/13 failed cases presented values lower than the threshold.

CONCLUSIONS

Following our observations and according to some reported studies, we believe transcutaneous oximetry to be the best method for selection of amputation level This is a simple, noninvasive and accurate method, which has showed itself superior to other techniques (i.e., Doppler and radioisotope).

[Surgical management of asymptomatic carotid artery stenosis. Authors' experience, problems and prospectives]

BACKGROUND

Some trials have demonstrated effectiveness of carotid endarterectomy (CEA) for preventing stroke in patients with severe symptomatic carotid stenosis. Although some researches, indication to surgery for asymptomatic carotid stenosis is debated up today. Based on personal experience and literature, the main problems of CEA for asymptomatic stenosis are discussed.

METHODS

DESIGN

Retrospective study.

SETTING

Section of Vascular Surgery, University Department.

PATIENTS

CEA was performed in a consecutive series of 63 cases with asymptomatic stenosis (59 patients, 40 males and 19 females, ages ranging from 46 to 80 years, mean 67.9).

INTERVENTIONS

CEA was performed under general anesthesia, with primary closure of arteriotomy in 37 cases and patch angioplasty using PTFE in 24, using eversion technique in 2 cases. Pruitt-Inahara shunt was used in 10/63 cases (15.9%), according to the mean velocity of the middle cerebral artery at carotid clamping/mean velocity of the middle cerebral artery pre-clamping ratio x 100 equal to or lesser than 15%, evaluated with transcranial Doppler, or stump pressure lesser than 50 mmHg, when transcranial Doppler examination was not possible.

MEASURES

Operative mortality and postoperative morbidity.

RESULTS

Operative mortality plus postoperative stroke were 1.6% (1/63). Operative mortality was precisely 0.0%. Postoperative complications were two: one was a neurologic deficit (monoparesis of the arm) and the other was myocardial ischemia.

CONCLUSIONS

Four main problems have been shown in CEA for asymptomatic stenosis: 1. Identification of asymptomatic stenosis: 2. Assessment of risk for stroke: 3. Role of CEA: 4. Questions about surgical treatment. For the first problem, it is important to consider possible indicators for carotid stenosis (contralateral carotid stenosis, coronary artery disease, aortic aneurysm, peripheral arterial disease, etc.). With regard to the second problem, it is important to know the natural history of the carotid stenosis, which shows a stroke rate of 1-2% per year. Regarding the third problem, the role of CEA is conditioned by: trials, patient conditions, lesion characteristics and ability of the surgeon. Further studies should identify some groups of patients (with severe carotid stenosis, dyshomogeneous plaque, progression of plaque, etc.), who can profit from CEA. Finally (fourth problem), CEA for asymptomatic carotid stenosis carries all common problems of carotid surgery (preoperative assessment, evaluation of cerebral ischemia due to carotid clamping, shunt, closure of arteriotomy, etc.). Some of these problems can receive ultimate solutions from some studies in next years.

[Iliac vein insufficiency syndrome. Clinical contribution]

BACKGROUND

Definition of essential findings in chronic venous insufficiency without valvular incompetence of the greater and/or lesser saphenous vein and due to reflux in the system of the internal iliac vein.

METHODS

DESIGN

a retrospective study.

SETTING

Section of Vascular Surgery in a University Hospital.

PATIENTS

Five patients, all females, ages ranging from 24 to 62 years, (6 lower extremities) with internal iliac venous insufficiency syndrome were identified.

INTERVENTIONS

Each case was assessed with clinical examination, Doppler CW and venography. Moreover, all cases were surgically treated using the technique of varicose vein avulsion.

MEASURES

Venographic picture and results of surgical treatment were evaluated.

RESULTS

Reflux in the system of the internal iliac vein was demonstrated in all cases. Connections between this vein and subcutaneous varicose veins network were identified using venography. Surgical treatment has given good results in 5 lower extremities followed-up from 6 months to 3 years, while recurrent varicose veins were observed in 1 leg after 6 months.

CONCLUSIONS

Syndrome of internal iliac vein insufficiency requires more attention than in the past. As to diagnostic evaluation, venography (particularly varicography) plays an essential role. The best treatment is stab avulsion of varicose vein, if pelvic congestion syndrome is excluded.

[Surgery of recurrent varices of the minor saphenous vein]

BACKGROUND

Investigation of the diagnostic and technical problems of redo surgery of the lesser saphenous vein for primary varicose veins.

METHODS

DESIGN

a retrospective study.

SETTING

Section of Vascular Surgery in a University Hospital.

PATIENTS

Fifteen lower extremities were operated upon (13 patients, 3 males and 10 females, ages ranging from 43 to 65 years with a mean of 53.2).

INTERVENTIONS

Each case was assessed by clinical examination, duplex scanning and venography (ascending venography and/or varicography). Surgical procedure was carried out via a longitudinal approach over the popliteal region or the posterior aspect of the thigh. Each case presented with a stump of the lesser saphenous vein.

MEASURES

Hemodynamic (correction of reflux of the lesser saphenous vein) and clinical (improvement of clinical state in the operated lower limb and complications) results were evaluated.

RESULTS

Reflux at the ostium of the lesser saphenous vein was corrected in 15/15 (100%) cases. Clinical result was good in 15/15 (100%) cases. Postoperative edema was observed in 7/15 (46.7%) cases. Lesion of the common peroneal nerve with paresis of the foot dorsal flexion was found in 1/15 (6.7%) cases. Hypertrophic scar was observed in 4/15 (26.7%) cases.

CONCLUSIONS

Redo surgery of the lesser saphenous vein is requested less frequently than other surgical procedures for superficial venous diseases. This surgery requires two essential features: a) accurate diagnosis of the lesser saphenous vein insufficiency; b) adequate surgical technique. For the former purpose, venography is a fundamental method of assessment. Surgical technique should be cautious and gentle. A longitudinal approach leads to a wide exposure of the structures in the popliteal fossa.

Advantages of the lateral approach for re-exploration of the sapheno-femoral junction for recurrent varicose veins

Re-exploration of the sapheno-femoral junction for recurrent varicose veins presents many problems. The lateral approach to the sapheno-femoral junction via a groin incision as previously described was performed in 109 lower limbs. The operative mortality rate was 0%. Functional outcome was good in 106 cases (97.2%) and only in three (2.8%) did recurrent varicose veins occur in the upper thigh. Complications were mainly lymphorrhoea (six cases, 5.5%). Cosmetic results were also satisfactory. This surgical procedure allows an easy and safe approach to the sapheno-femoral junction and avoids damage to femoral vessels. Recurrence was rare and caused by incompetent communicating veins in the upper thigh. These characteristics make the lateral approach the preferred technique for re-exploration of the sapheno-femoral junction.

[Automated peritoneal dialysis (APD). Experience in 42 patients]

Automated peritoneal dialysis (APD) is currently considered as one of the most attractive home treatments for uremic patients. However, relevant costs and the presence of a dialysis machine prevent a wider diffusion of this technique. In this work we discuss the results obtained in 42 patients (12 females, 30 males) treated by two dialysis units of the Piedmont Region. Patients' characteristics. Eighty-three percent of the females and 66.5% of the males are under 65 years of age; glomerulo-nephritis and nephroangiosclerosis account for the most frequent renal diseases (28.5 each); a high risk condition is recorded in 52.5% of cases. Twenty-two patients were transferred to APD from CAPD (patient's request in 59% of cases, clinical problems in the remaining). RESULTS. Forty-five percent of cases are working full or part-time, 12% are not caring for self. Peritonitis rate accounts for 1 episode every 42 patient-months. Biochemical control is satisfactorily achieved (mean values: urea 137.8 mg/dl, creatinine 11 mg/dl, calcium 10.2 mg/dl, phosphate 5.7 mg/dl, albumin 4.3 g/dl, cholesterol 234 mg/dl, triglycerides 195 mg/dl). Technical assistance was requested on average once every 16 months of treatment. CONCLUSION. Negative drawbacks of APD, mainly related to elevated costs and technical complexity, are fully counterbalanced by satisfactory social and clinical rehabilitation, wider indications to peritoneal dialysis with respect to CAPD, lower rates of peritonitis and limited technical needs.

[Surgical interventions in dialysis patients in Piedmont: data from the Regional Registry. Working Group of the Piedmont Registry of Dialysis and Transplantation]

In this work surgical events in a large population of chronic dialysis patients are analysed. Data are obtained from the Regional (Piedmont) Registry of Dialysis and Transplantation (RPDT), that has collected information since 1981 about all chronic dialysis patients in the Region. Since 1984, causes of admission to-hospital are registered. Surgical causes of hospitalization, for purposes not related to uremia, were 538 (20% of all surgical admissions). In patients younger than 65 years, these hospitalizations account for about 6% of the cases, whereas in patients older than 65 they are less than 5%. As expected, a higher number of surgical operations is observed in diabetics, while on the contrary the lowest is performed in nephroangiosclerosis patients. Cardiovascular and bowel diseases represent almost 50% of all surgical needs. Postoperative mortality was 5.8% within 45 days from admission. Cardiac and infectious diseases and cachexia represent the more frequent causes of death. In 27 out of 28 cases at least one high risk condition was present.

Death in conditions of cachexia: the price for the dialysis treatment of the elderly?

Death in conditions of cachexia is increasing in potential dialysis patients, as treated cohorts are aging, the mean age of new patients increased and access to treatment is unlimited. The present study analyzes the clinical features of 417 deaths in conditions of cachexia recorded in 1981 to 1990 in the Dialysis and Transplantation Registry of a northern Italian region, Piedmont (about 4,400,000 inhabitants, 20 dialysis centers; 4,734 patients on file at December 31, 1990; yearly information on 100% of the cases). Death in conditions of cachexia increased from 105 cases in the first four years taken into account (1981 to 1984), to 107 in the last two years (1989 to 1990). Prevalence is higher in the elderly (85% of the death over age 60). Most patients (90.5%) were at high clinical risk. To assess whether the frequency of this diagnosis reflected the wide acceptance of elderly patients for dialysis and was a marked of vascular disease, a specific inquiry was conducted about 107 cachectic deaths recorded from 1989 to 1990: 82.5% of the patients had diffused vascular disease, 11.5% were already cachectic when dialysis was initiated, and 66% were in cachexia at least six months before death. Since mean age of patients dying in condition of cachexia increased from 68.8 in the period of 1981 to 1984 to 70.3 years in 1989 to 1990, and mean time on dialysis from 2.8 years in 1981 to 1984 to 70.3 years in 1989 to 1990, the higher prevalence is not likely to be due to lack of care of elderly patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphocyte subsets assayed by numerical tests in CAPD

Peripheral and peritoneal lymphocytes were assayed by numerical tests in adults on peritoneal dialysis. T lymphocytes were classified by monoclonal antibodies (OKT3, OKT4, OKT8) and B lymphocytes by the presence of surface immunoglobulins, using the immunofluorescence technique. Peripheral T cells showed no significant change from the normal, except for T suppressor cells which increased in patients with 2 or more peritonitis episodes. Examination of peritoneal lymphocytes showed a significant reduction in S-IgA lymphocytes (B cells bearing IgA receptors) and an increase in T-suppressor cells (OKT8+) in patients who developed peritonitis in the follow-up study. The implications of these results are discussed with particular reference to susceptibility to peritonitis.

The influence of blood transfusion on cellular immunity

To evaluate the effect of transfusion on immunity, we studied some immunological parameters in 14 uremic patients treated with 3 blood transfusions (5 with HLA-compatible and 9 with random transfusions). Before transfusions 8/14 patients were DNCB-negative; both spontaneous and active E-rosettes were below normal range. The parameters of humoral immunity (S-Ig, C3, C4, IC, CRP) were normal. After both the first and second transfusions an increase in T- and B-lymphocytes was found. The third transfusion led to a more pronounced and prolonged immunosuppression in patients treated with compatible transfusions than in those treated with random transfusions. Our findings suggest that blood transfusion--HLA-compatible transfusion in particular--results in an impairment of the lymphocyte role.

[Regular dialytic treatment in the Piedmont region. Results and prospects]

The Piedmont planning for the prevention and treatment of chronic uremia started in 1976, with the purpose to extending full treatment of the whole region, through the development of home and self care dialysis and intensive use of hospital short dialysis. Hospital dialysis would be reserved either for new treatments or complicated or uncooperative patients. Thank to an intensive exploitation of the existing hospital centers, a 68.7% increment in the number of treated patients was achieved and costs were kept down to a limited acceptable range. With the development of home and self care dialysis, 27% of the patients were located in out-of-hospital centers, and 17% at home. The Piedmont planning concerned itself with the patients' data collected by the Regional Registry under the following items: a) characteristics of dialysis population; b) the present modes of treatment; c) the number of patients apt to varying treatments and renal transplantation; d) the epidemiology of uremia causing nephropathies. At the present time results are only preliminary. Nevertheless, the first observations showed a long and difficult work with good possibilities of success for computerized facilities in the field of dialysis, particularly in respect to regional areas which in the reformed Health Service are now considered to be operating as autonomous.

[Hemofiltration: present and future]

Four thousand hemofiltrations have been performed in 22 patients with low tolerance to conventional hemodialysis (20 cases), and severe arterial hypertension (2 cases). In comparison with hemodialysis, hemofiltration had a low incidence of intradialytic collapses, vomit and cramps, and allowed a better state of well-being during interdialytic periods. In hypertensive patients hemofiltration has accomplished a better control of arterial pressure and pharmacotherapy has been reduced. In this study, we report the data concerning metabolism, electrolytes, acid-base balance during our experience utilizing bicarbonate in the replacement fluid. Our experience further supports the impression that hemofiltration may have some advantages in patients with low tolerance to conventional dialysis and/or severe dislipemia and hypertension. The possibility to reduce dialysis duration to 3 hrs, stimulates further application of this new treatment in a wider number of patients on RDT.

[Use of corticotherapy in the treatment of idiopathic glomerulonephritis]

Corticosteroids have multiform effects on traffic and functional capabilities of inflammatory or immunologically reactive cells, on various soluble factors, vascular and tissue responses. There is a different sensitivity of various populations and subpopulations of cells to the corticosteroid modulation. These mechanisms are still under discussion, but the final effects appear to support the use of corticosteroids in a number of idiopathic glomerulonephritis (GN). In the minimal change GN the 10 years after onset survival was not significantly increased by introducing corticosteroids, but the prompt disappearance of proteinuria (80% of adults by 8 weeks in our own series) supported their use. The problem of corticosteroid treatment in the focal sclerosing GN is complicated by the probable coexistence of two histologically undistinguishable forms (one of the these nonsteroid sensitive). In our own series the corticosteroid response, although transient, was present in 44% of 16 patients. We obtained a high number of total remissions (57%) and partial remissions (14%), in membranous GN, where the conflicting data of the literature suggest differences in the criteria of selection and admission of patients to corticosteroid treatment, calling attention to further controlled trials. In rapidly progressive GN the combined use of corticosteroids, immuno suppressants and heparin has elicited a stabilization or improvement of renal function in 40% of the treated patients. By the same treatment we observed a total remission in 19% and a partial remission in 62% of severely nephrotic patients with histological appearance of membranoproliferative GN characterized by massive subendothelial deposits of the early complement fractions (C1, C4). Although it is impossible to draw firm conclusions both on pathogenesis of idiopathic GN or on the biochemical, cellular and tissue effects of corticosteroid, these drugs appear sometimes effective in clinical practice.