How much general practitioners empathize with patients?

Introduction

Thanks to the privileged relationship that the general practitioner establishes with patients, he well knows their personal background and assesses the disorders as a whole, without focusing only on unique pathology. The aim of the work were: I) to assess the level of concordance between the health profile (HP) of the patient measured by the doctor and that measured by the patient, and II) to and assess which variables influence the perception.

Methods

A cross-sectional study was conducted between Aug 2019-Jan 2020 in a primary care setting. To assess health-related quality of life we administered the EuroQol 5d-5L to patients (EQ-p). Simultaneously, we asked the doctors to fill in the questionnaire 'from the patient's point of view' (EQ-d), also based on data collected in the computerized clinical diary. Data was collected anonymously and the statistical analysis was carried out using Stata 14 (Cohen's kappa; Fisher test).

Results

The sample consisted of 223 patients (46% men). The mean age was 56.5±19.6 (min 18-max95). The mean BMI was 25.5±5 (28% overweight; 18% obese). Significant differences by gender were found in Pain and Anxiety/Depression dimensions (44% of men had not pain vs 33% of women (p = 0.03) and 56% of men had no Anxiety/Depression vs 36% of women (p < 0.01)). These differences were not detected by doctors; As regards the concordance between EQ-p and EQ-d, it was moderate for Mobility (k = 0.45; p < 0.01) and Self-Care (k = 0.46; p < 0.01). The agreement was fair for usual activities (k = 0.39; p < 0.01) and it was poor for Pain/Discomfort (k = 0.14; p < 0.01), Anxiety/Depression (K = 0.19; p < 0.01) and EQ Index (k = 0.11 p < 0.01).

Conclusions

Our analysis shows a greater concordance especially for the dimensions that appear more objective (Mobility and self-care) than the subjective ones (Pain, Anxiety). The physicians do not seem to take into account the differences in perception between men and women when they empathize with patients.

Key messages

The general practitioner knows the personal history of his patients and assesses the disorders as a whole, without focusing only on the specific pathology. In the exercise of the identification, he seems to understand mainly dimensions that appear more objective without grasping the differences in perception between men and women.

Papular-purpuric "gloves and socks" syndrome

Papular-purpuric "gloves and socks" syndrome (PPGSS), is an acute dermatosis characterized by a papular-purpuric edematous rash in a distinct ''gloves and socks'' distribution often accompanied by fever, asthenia and lymphadenophaties. It is mainly caused by parvovirus B19 (B19V) but other viruses and drugs such as trimethoprim/sulfametaxol or chemotherapics may be involved. We describe a case of PPGSS with a serologically proven B19V infection in a 42-year-old Italian kindergarten teacher suffering from acute bacterial pharyngitis Immunoglobulin M by enzyme-linked immunosorbent assay (ELISA) to parvovirus B19 were positive. Histological examination showed dermal-ipodermal inflammation with evidence of leukocytoclastic vasculitis principally interesting the small venules The cutaneous rash resolved after 2 weeks. We reported our case to support that PPGSS is an immunomediated disease and that B19V morbidity varies with the immunologic and hematologic status of the host. In addition, a patient with PPGSS might be infectious at the moment of diagnosis, with significant implication for susceptible contacts.

Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group

BACKGROUND

In Italy, antiretroviral combination therapy was adopted in mid-1995 and protease inhibitors in mid-1996.

OBJECTIVE

To conduct a prospective, population-based, observational study to evaluate the effect of these therapies on the survival of persons with AIDS (PWA).

METHODS

PWA living in the Tuscany region diagnosed between 1985 and 31 March 1997 (National AIDS Registry) were studied. Information on antiretroviral drugs, prophylactic treatment, CD4 cell count, and AIDS-defining illnesses was collected for PWA still alive at 1 January 1996 and those diagnosed thereafter (analysis cut-off date, 30 November 1997). Kaplan-Meier curves were calculated by year of diagnosis. A Cox model was then used to estimate the adjusted (by sex, age, HIV exposure category, CD4 cell count, type and number of AIDS-defining illnesses) relative hazard (RH) of death by year of diagnosis and calendar date (considered as a time-dependent variable). Similar analyses were repeated for PWA diagnosed after 1989, having been stratified by disease-specific AIDS condition. A final analysis was performed for PWA still alive at 1 January 1996 or diagnosed thereafter for estimating the effect of single, double and triple combination therapy (time-dependent variables), having adjusted for the above variables and for prophylactic treatment.

RESULTS

A total of 1683 (79.5%) out of 2118 PWA died before 1 December 1997. Use of more potent combination therapies, including protease inhibitors, greatly increased during 1997. Median survival was 2.9, 12.3, 13.4, 11.4 and 17.6 months for diagnoses before 1987, in 1987-1990, 1991-1993, 1994 and 1995, respectively; an estimated 62% of those diagnosed in 1996-1997 had survived 15 months after diagnosis. The Cox model showed a trend of decrease of RH for calendar time starting in the first half of 1996, compared with 1994. When stratifying by specific AIDS-defining disease there was no statistically significant evidence that the improved overall survival was due to increased survival only for certain diseases. The final multivariate analysis for the 771 PWA still alive at 1 January 1996 or diagnosed thereafter estimated significant RH < 1.0 for double and triple therapy (RH, 0.61 and 0.36, respectively) compared with no therapy.

CONCLUSIONS

A significant reduction in risk of death after AIDS was observed from the second half of 1996, apparently due to the widespread use of antiretroviral combination therapies.

[The quantification of tuberculous disease in an Italian area and the estimation of underreporting by means of record linkage]

The description and interpretation of tuberculosis spatial and temporal variations in Italy is rather difficult because of well-grounded suspicions of disease underestimation, related with the bad working of the compulsory notification system. In this study, the record-linkage technique was used to estimate the proportion of TB undernotification in an Italian area, in order to give a first quantitative estimate of tuberculosis at a geographical level. The area considered was the Local Health Agency of Florence (population in 1994: 803,588) in 1995. Information for record-linkage was taken from: the Regional TB Archive, Hospital Discharge files, Laboratories, Pathology Departments, the Regional AIDS Registry, the Regional Mortality Registry. The linkage among the different sources was based on first and last name, date and place of birth, or only on first and last name for the laboratories. Prevalent cases and relapses were excluded through comparison with various historical archives. Most cases signalled only in hospital discharges were re-evaluated through original medical records. In such a way, the original sample was reduced from 690 to 182 cases incident in 1995, diagnosed in the area considered, and mostly resident in the same area. Among these cases, 98 (53.8%) were unknown to the compulsory notification system. The most of them come from hospital departments (27 cases) and from laboratories (47 cases). Fourty-nine of the unknown cases concerned pulmonary TB. The notification rate in the area moves then from 10.5/1000 to 22.7/1000.

Optomechanics with LEGO

The basic elements of a fairly complete optomechanical kit based on the use of LEGO are presented. Taking advantage of the great variety of standard LEGO elements, and adding a few custom components made of Plexiglas, we show how most of the mechanical parts of an optical setup can be built with little effort and at an extremely reduced cost. Several systems and experiments are presented, mainly in the fields of optical filtering and interferometry, to show that the proposed mounts are excellent for didactic purposes and often perfectly suitable even in applied research.

High suicide mortality soon after diagnosis among cancer patients in central Italy

A high suicide mortality risk has been documented among a population-based cohort of 27 123 cancer patients resident in central Italy where the general suicide rate is low. Forty-one suicides were observed (SMR = 2.36) which were only 0.2% of all deaths. However, the highest risk (SMR = 27.7) during the first 6 months after diagnosis, represents a greater contrast with the general population than has been observed in other studies.

Incidence of second primary cancers in three Italian population-based cancer registries

This is the first population-based study carried out in a southern European region to evaluate the risk of a cohort of cancer patients for developing further cancers. The Tuscany Tumour Registry, the Ragusa Cancer Registry and the Cancer Registry of Romagna, three of the 14 population-based cancer registries active in Italy, were involved in the present study. Overall, 19,252 incident cases of cancer of the female breast, and of the colon, rectum, lung and stomach were followed-up for 48 358.3 person-years. Only second metachronous cancers were considered. Controlateral breast cancers were analysed separately. Multiple primaries (MPs) were defined according to the IACR-IACR rules. The observed (O) numbers of MPs were compared with those expected (E) from age-, sex- and registry-specific incidence rates. Overall, 463 MPs were diagnosed (O/E = 0.87, P < 0.001). The O/E ratios for cancers of the colon (O/E = 0.66), rectum (O/E = 0.72) and all sites combined (O/E = 0.78) in males were significantly lower than expected. The deficit of observed MPs was significant during the first period (2-12 months) and increased over time. Patients over 65 years of age had a significant lower risk of MP, whereas young cancer patients had significantly higher risks for all cancers and for female breast cancer. Male lung cancer patients had a significantly reduced O/E ratio for stomach cancer (O/E = 0.21). Rectal cancer patients had reduced risks of developing stomach cancer and tumours of all sites combined and a 3-fold increased risk of kidney cancers. Colon cancer patients had an overall reduction in risk of MPs, but female colon cancer patients had a significantly increased risk for tumours of the ovary and small intestine; no significant results were found for primary stomach cancers. Female breast cancer patients had a significantly increased risk of rectal cancer (O/E = 1.97), and when synchronous and bilateral breast cancers were considered, significant overall increases in risk were seen for all cancer sites (O/E = 1.6) and for rectal (O/E = 2), and especially for breast cancers (O/E = 3). The cohort analysed had a lower risk of developing further independent tumours than the general population. Several artefacts may have biased these results: the exclusion of synchronous cancers greatly reduced the overall MP risk, and the age-related differences may have been due to reduced medical surveillance and diagnostic aggressiveness. We have confirmed the increased risk for kidney cancers in rectal cancer patients and the association between cancers of the colon and ovary. The significantly increased risk for rectal cancer in female breast cancer patients is probably due to hormonal and dietary factors. For female breast cancer patients, controlateral breast cancer represented the highest risk. The increased risk of cancer of the small intestine in patients with colon cancer may be due to overdiagnosis within increased medical surveillance.

Survival after AIDS diagnosis in Tuscany (Italy), 1985-1992

The study evaluated the overall survival after AIDS diagnosis of 1,014 patients reported to the Italian AIDS Registry as resident in Tuscany, stratified by age, gender, year of diagnosis, HIV transmission category, initial AIDS-defining disease and CD4+ cells count. The study was a population-based survival analysis, carried out through Kaplan-Meier method (mean survival times-MST-, 1, 2 and 3-year observed survival) and Cox models (crude and adjusted relative risk-RR). The MST was 12.4 months for all cases, increasing from 4-7 months in 1985-1987 to 14 months in 1991-1992. The observed survival was 51.4% at the first year of follow-up, 28.4% at the second year and 14.5% at the third year. The multivariate analysis showed an independent prognostic effect of age, year of diagnosis, initial AIDS-defining disease and CD4+ cells count. The prognosis was worse in cases aged over 44 (reference: 25-29), diagnosed before 1988 (reference: 1991) and with wasting syndrome, toxoplasmosis, HIV encephalopathy or multiple diseases (reference: PCP alone); and better in cases with more than 100 CD4+ cells/mm3 (reference: < or = 50 cells/mm3). The differences in gender and among HIV transmission categories disappeared after age-adjustment. The study confirmed, in an European population-based series, the poor long-term AIDS prognosis and, once AIDS has became clinically manifest, the prognostic value of some clinical and demographic variables.

The effect of the 1993 European revision of the AIDS case definition in Italy: implications for modelling the HIV epidemic

OBJECTIVES

To evaluate the effect of the 1993 European AIDS definition on reducing pre-AIDS mortality and to what degree an earlier diagnosis can be made.

DESIGN

Prospective observational study.

METHODS

All patients diagnosed between January 1993 and December 1994 and reported to the National AIDS Registry from four Italian regions, who met only the new criteria for the 1993 case definition (AIDS-1993) were studied. Follow-up of patients who did not eventually meet the 1987 definition (AIDS-1987), or had not died from other causes (pre-AIDS-1987 death), was censored at the last available clinical visit before 1 April 1996. We analysed the data using Kaplan-Meier non-parametric survival analysis and Cox proportional hazards model.

RESULTS

A total of 74 (4.1%) individuals met only the new criteria. Of these, 49 (62.2%) were men, 42 (56.8%) had pulmonary tuberculosis, 22 (29.7%) had recurrent bacterial pneumonia, and 10 (13.5%) had cervical cancer. During follow-up, 35 (45.3%) individuals developed an AIDS-1987 disease, and 10 (13.5%) died without fulfilling the AIDS-1987 definition. Pre-AIDS-1987 death accounted for 22.2% (10 out of 45) of the subsequent outcomes observed prior to 1 April 1996. Using Kaplan-Meier technique, we estimated that after 9.8 months 50% of these individuals were diagnosed with AIDS-1987 disease, or died without such a diagnosis. Individuals with lower CD4+ count at the time of the AIDS-1993 diagnosis progressed more rapidly to AIDS-1987 than those with a higher count. In contrast, pre-AIDS-1987 mortality was strongly associated with injecting drug use, whereas no association was found with CD4+ count.

CONCLUSIONS

Approximately 50% of individuals with one of the three new AIDS-defining diseases will develop an AIDS-1987 disease or will die within 1 year. Time from AIDS-1993 to AIDS-1987 disease is strongly associated with CD4+ count at diagnosis. AIDS_1993 diagnosis reduced the pre-AIDS-1987 mortality in injecting drug users. Furthermore, approximately 20% of individuals diagnosed with AIDS-1993 disease are expected to die without developing an AIDS-1987 disease. These data should be useful for correcting the AIDS incidence curve in Europe for the effect of the changes in the AIDS definition.

Completeness of AIDS reporting and quality of AIDS death certification in Tuscany (Italy): a linkage study between surveillance system of cases and death certificates

In Italy, the AIDS cases defined according to the CDC criteria are reported to the National AIDS Registry (RAIDS, compulsory surveillance system). The aim of the present study is to evaluate the completeness of AIDS cases reported and the quality of AIDS death certification in an Italian Region (Tuscany, about 3,500,000 inhabitants). The 737 AIDS cases reported to RAIDS as residents in Tuscany (1987-91) were cross-linked (key link: name and date of birth) with the data of the Mortality Registration system of the Region (RMR). For the residents in Tuscany decreased with a 279.1 death diagnosis (the code for AIDS deaths stated by the Italian Census Bureau) and not reported to RAIDS as AIDS cases, the clinical records were reviewed to check whether the diagnosis fitted the 1987-CDC diagnostic criteria. This study shows that there is a high completeness (97-98%) of the AIDS cases resident in Tuscany, reported to the RAIDS. The quality of RAIDS data is not as good with regard to life status assessment (23% of under-reporting of death). In Tuscany, the death certification for AIDS (code 279.1 of ICD IX) has a sensitivity of 88% and a specificity around 100% in comparison to RAIDS. About 50% of 'false negatives' in death certification are due to causes of death presumably unrelated to HIV infection. The evaluation of the quality of AIDS surveillance and mortality data is important in the assessment of the impact for AIDS epidemic in a target population.