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Comparabilità e valutazione dei servizi sanitari

  • Nerina Agabiti1

  1. Dipartimento di epidemiologia del servizio sanitario regionale, Lazio
Nera Agabiti -

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Ricerca bibliografica periodo dal 01 settembre al 15 novembre 2013

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Database: Pubmed/MEDline
Stringa: (((“Quality Indicators, Health Care"[Mesh] OR "Quality Assurance, Health Care"[Mesh] OR "Outcome Assessment (Health Care)" [Mesh:NoExp] OR Outcome* [tiab] OR “quality indicators” [tiab], OR appropriateness [tiab] OR indicator* [TIAB] OR procedure [TIAB] OR efficacy[tiab] OR effectiveness[tiab]) AND ("hospitals"[MeSH] OR hospital[tiab] OR mortality[tw] OR patient* [tiab]) AND (italy[mesh] OR ital* [tiab] OR ita [la] OR ital* [ad]) AND (“2013/09/01”[PDat] : “2013/11/15”[PDat])) NOT ((animals [mesh] NOT humans [mesh]) OR "Genetics"[Mesh] OR "Neurophysiology"[Mesh] "Drug Therapy"[Mesh] OR "Naturopathy"[Mesh] OR "drug therapy "[Subheading] OR Editorial[ptyp] OR "Case Reports "[Publication Type] OR Letter[ptyp] OR Clinical Trial, Phase I[ptyp] OR Clinical Trial, Phase II[ptyp]))

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1. Bianchi PP, Luca F, Petz W, Valvo M, Cenciarelli S, Zuccaro M, Biffi R. The role of the robotic technique in minimally invasive surgery in rectal cancer. Ecancermedicalscience. 2013 Sep 26;7:357.
Unit of Minimally Invasive Surgery, European Institute of Oncology, 20141 Milano, Italy. Abstract
Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors' centre.
2. Presutti DG, D'Ascenzo F, Omedè P, Biondi-Zoccai G, Moretti C, Bollati M, Sciuto F, Lee MS, Moreno R, Bikkina M, Di Cuia M, Resmini C, Gaita F, Sheiban I. Percutaneous coronary intervention in nonagenarian: a meta-analysis of observational studies. J Cardiovasc Med (Hagerstown). 2013 Nov;14(11):773-9. doi: 10.2459/JCM.0b013e3283619410.
aDivision of Cardiology, Department of Internal Medicine, Turin, Italy bDepartment of Cardiology, St.Joseph's Regional Medical Center, Paterson, New Jersey cDivision of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, California, USA dDivision of Interventional Cardiology, Instituto Cardiovascular, Hospital La Paz, Paseo La Castellana, Madrid, Spain eDepartment of Medico-Surgical Sciences, Biotechnologies Sapienza University of Rome, Italy fInvasive Cardiology, Campus Middelheim, Antwerpen, Belgium gMeta-analysis and Evidence based medicine Training in Cardiology, Italy. Abstract
BACKGROUND: Developed countries are facing a sustained increase in life expectancy. Along with all social and cultural implications of increase lifespan, very elderly patients are undergoing percutaneous coronary intervention (PCI) with increasing frequency. However, there is limited evidence to guide clinicians in evaluating pros and cons of PCI in this very frail patient population. We, thus, aimed to perform a systematic review and meta-analysis of clinical studies reporting on PCI with stenting in nonagenarians. METHODS: Studies reporting on five or more nonagenarians undergoing PCI were systematically searched in PubMed (last updated on November 2011). Baseline and clinical characteristics, in-hospital and long-term outcomes were systematically appraised. End points of interest were in-hospital and long-term follow-up incidence of death and Major Adverse Cardiac Events (MACE; i.e. the composite of death from all causes, myocardial infarction or repeat revascularization). Events were pooled with a random-effect model, generating summary estimates of incidence rates [95% confidence intervals (CI)]. RESULTS: A total of 10 studies were included, reporting on a total of 575 nonagenarians undergoing PCI with stenting who represented 1.99% (1.34-2.5) of those undergoing revascularization in the cath lab in a mean period of 5 (3-7) years. Twenty-three percent (13-45) of patients presented with STEMI (ST Segment Elevation Myocardial Infarction), 10% (7-12) with cardiogenic shock and in 78% (64-88) of cases a multivessel disease was diagnosed. Meta-analytic pooling of event rates showed an in-hospital death risk of 12.61% (9.71-15.50) with MACE in 16.41% (13.36-19.47). After a follow-up ranging from 6 to 29 months (median 12), the risk of long-term death was 31.00% (17.10-45.52), with MACE in 37.00% (19.56-55.95; all CI 95%). CONCLUSION: Our meta-analysis, pooling the largest cohort ever of nonagenarians undergoing PCI with stents, confirms the feasibility of percutaneous coronary stenting even in this very frail patient subset, despite the expected severe event attrition during follow-up. Thus, nonagenarians with an acceptable risk profile, recent clinical instability and/or disabling symptoms should not be denied the possibility of percutaneous coronary revascularization.
3. Esposito M, Gisondi P, Cassano N, Ferrucci G, Del Giglio M, Loconsole F, Giunta A, Vena GA, Chimenti S, Girolomoni G. Survival rate of antitumour necrosis factor-α treatments for psoriasis in routine dermatological practice: a multicentre observational study. Br J Dermatol. 2013 Sep;169(3):666-72. doi: 10.1111/bjd.12422.
Department of Dermatology, University of Rome Tor Vergata, Viale Oxford, 81 - 00133, Rome, Italy. Abstract
BACKGROUND: Adherence is an overall marker of treatment success, and it depends on multiple factors including efficacy and safety. Despite the wide use of tumour necrosis factor (TNF)-α blockers in the treatment of plaque-type psoriasis, few data regarding treatment adherence in routine clinical practice are available. OBJECTIVES: To estimate the long-term survival rate of anti-TNF-α therapy in a cohort of patients with psoriasis in routine clinical practice; to evaluate the reasons for and predictors of treatment discontinuation. METHODS: The Outcome and Survival rate Concerning Anti-TNF Routine treatment (OSCAR) study was based on a retrospective analysis to estimate the long-term survival rate of the first anti-TNF-α treatment in patients with psoriasis, from three Italian academic referral centres. Adult patients (n = 650) with plaque psoriasis treated with a first course of adalimumab, etanercept or infliximab for ≥ 3 months were included. RESULTS: Global adherence to anti-TNF-α treatments after 28•9 ± 15•4 months (867 ± 462 days) of observation was 72•6%. Etanercept showed a longer survival (mean 51•4 months, 1565 days; P < 0•001) compared with infliximab (36•8 months, 1120 days) and adalimumab (34•7 months, 1056 days). Treatment discontinuation due to primary and secondary inefficacy was observed in 5•2% and 14•5% of patients, respectively, whereas discontinuation due to adverse events was reported in 29 subjects (4•5%). Independent predictors of treatment withdrawal were female gender [hazards ratio (HR) 1•3], treatment with adalimumab or infliximab compared with etanercept (HR 2•7 and 1•7, respectively), and the concomitant use of traditional systemic treatment, as a rescue therapy, compared with monotherapy (HR 1•9). CONCLUSIONS: Overall survival of anti-TNF-α agents in psoriasis is elevated, with drug discontinuation mostly due to inefficacy. Etanercept showed a longer adherence compared with adalimumab and infliximab.
4. Romeo F, Acconcia MC, Sergi D, Romeo A, Gensini GF, Chiarotti F, Caretta Q. Lack of intra-aortic balloon pump effectiveness in high-risk percutaneous coronary interventions without cardiogenic shock: a comprehensive meta-analysis of randomised trials and observational studies. Int J Cardiol. 2013 Sep 1;167(5):1783-93. doi: 10.1016/j.ijcard.2012.12.027. Epub 2013 Jan 5.
Department of Cardiovascular Disease, University of Rome, Tor Vergata, Rome, Italy. Abstract
BACKGROUND: Although controversial, using prophylactic intra-aortic balloon pump (IABP) in patients undergoing high-risk percutaneous coronary intervention (PCI) has been reported to be effective by numerous registry studies. However, conflicting findings were observed in observational studies (Obs.) and randomised controlled trials (RCTs). OBJECTIVE: The purpose of this meta-analysis was to assess the impact of IABP on in-hospital deaths, major adverse cardiovascular events (MACCE), access-site complications and stroke in high-risk PCI cases from Obs. and RCTs published from 1st January, 1990 to 31st March, 2012 and indexed in PubMed. METHODS AND RESULTS: We retrieved 1125 studies from the database; 11 studies compared the effects of IABP support, i.e., prophylactic administration (P-IABP) vs. no support (No-IABP), in high-risk patients undergoing PCI. These studies were included in the meta-analysis. We then calculated risk ratios (RRs) and risk differences (RDs) between the two groups of patients (P-IABP vs. No-IABP). We did not observe significant in-hospital mortality, MACCE, access-site complications or stroke differences in the RRs and RDs of the two groups. CONCLUSIONS: The results suggest that PCI plus P-IABP support does not result in reduced in-hospital mortality or MACCE nor in significant higher access-site complications or stroke incidence compared with PCI alone in patients at high risk for peri-procedural PCI complications.
5. Proclemer A, Muser D, Campana A, Zoni-Berisso M, Zecchin M, Locatelli A, Brieda M, Gramegna L, Santarone M, Chiodi L, Mazzone P, Rebellato L, Facchin D. Indication to cardioverter-defibrillator therapy and outcome in real world primary prevention. Data from the IRIDE [Italian registry of prophylactic implantation of defibrillators] study. Int J Cardiol. 2013 Sep 30;168(2):1416-21. doi: 10.1016/j.ijcard.2012.12.042. Epub 2012 Dec 31.
Azienda Ospedaliero Universitaria "S. Maria della Misericordia" and IRCAB Foundation, SOC Cardiologia, Udine, Italy. Electronic address: proclemer.alessandro@aoud.sanita.fvg.it. Abstract
AIMS: Several trials demonstrated the life saving role of implantable cardioverter-defibrillators (ICD) in primary prevention of sudden cardiac death (SCD). The aim was to evaluate the clinical characteristics and 4-year outcome of consecutive patients treated in clinical practice by prophylactic ICD implantation on the basis of class I recommendations and up-to-date ICD programming. METHODS AND RESULTS: IRIDE multi-center, prospective and observational study enrolled 604 consecutive patients (mean age: 66 ± 10 years) treated by ICD between 01/01/2006 and 30/06/2010. Main characteristics were similarly distributed among the inclusion criteria of MADIT II (24%), SCD-HeFT (24%), COMPANION (26%) and MADIT-CRT (18%) trials, while a small number of patients met the MUSTT and MADIT (7%) inclusion criteria. Single-chamber ICDs were implanted in 168 (28%) patients, dual-chamber in 167 (28%) and biventricular in 269 (43%) patients. ATP programming was activated in 546 (90%) patients. Overall survival and rate of appropriate ICD intervention by ATP and/or shock at 12-24-36-48 months of follow-up were 94%, 89%, 80%, 75% and 16%, 28%, 37% and 50%, respectively. No difference in mortality rate between the groups who received or did not receive appropriate ICD interventions was demonstrated (p=ns). CONCLUSIONS: The IRIDE study confirms the effectiveness in real world practice of ICD implantation in patients at risk of SCD. The life saving role of ICD therapy increases as the duration of follow-up is prolonged and the survival benefit is similar in patients who received or did not receive appropriate device treatment, thus suggesting a beneficial effect of up-to-date device programming.

Breve commento a cura di Nerina Agabiti
Esistono poche evidenze sull’efficacia nella pratica clinica dell’impianto di defibrillatore cardiaco in prevenzione primaria in pazienti con grave patologia cardiaca a rischio di morte improvvisa. Lo studio condotto da Proclemer et al (studio IRIDE), che ha l’obiettivo di valutare le caratteristiche cliniche e gli esiti clinici a lungo termine in pazienti (follow up di 4 anni) sottoposti all’intervento di impianto di defibrillatore cardiaco a scopo profilattico, contribuisce alle conoscenze sul tema. Si tratta di uno studio osservazionale prosepettico multicentrico in cui sono stati arruolati 604 pazienti (età media 66 ani) in 10 ospedali italiani sottoposti all’intervento nel perdio 2006- 2010. I criteri di inclusione della casistica sono molto simili a quelli dei principali trials sul tema. La maggior parte dei pazienti hanno ricevuto l’impianto biventricolare. L’attivazione del sistema anti-aritmia (“antitachycardia pacing”, ATP) è avvenuto le 90% dei casi. La sopravvivenza complessiva e l’appropriato intervento del defibrillatore (ATP o shock)a 12, 24, 36 e 48 medi è stata pari a 94%, 89%, 80%, 75% e 16%, 28%, 37% e 50% rispettivamente. Non è stata osservata una differenza significativa nella mortalità tra i pazienti che hanno o non hanno ricevuto l’appropriato intervento anti-aritmico. Lo studio conferma l’efficacia nella pratica clinica del defribrillatore cardiaco impiantato in pazienti con rischio di morte improvvisa. Il beneficio aumenta con l’aumentare della durata del follow up.

6. Romagnoli E, De Vita M, Burzotta F, Cortese B, Biondi-Zoccai G, Summaria F, Patrizi R, Lanzillo C, Lucci V, Cavazza C, Tarantino F, Sangiorgi GM, Lioy E, Crea F, Rao SV, Trani C. Radial versus femoral approach comparison in percutaneous coronary intervention with intraaortic balloon pump support: The RADIAL PUMP UP Registry. Am Heart J. 2013 Dec;166(6):1019-26. doi: 10.1016/j.ahj.2013.09.009. Epub 2013 Oct 10.
Policlinico Casilino, Rome, Italy; SS. Filippo e Nicola Hospital, Avezzano, Italy. Electronic address: enromagnoli@gmail.com. Abstract
BACKGROUND: The role of intraaortic balloon pump (IABP) during percutaneous coronary intervention (PCI) in high-risk acute patients remains debated. Device-related complications and the more complex patient management could explain such lack of clinical benefit. We aimed to assess the impact of transradial versus transfemoral access for PCI requiring IABP support on vascular complications and clinical outcome. METHODS: We retrospectively analyzed 321 consecutive patients receiving IABP support during transfemoral (n = 209) or transradial (n = 112) PCI. Thirty-day net adverse clinical events (NACEs) (composite of postprocedural bleeding, cardiac death, myocardial infarction, target lesion revascularization, and stroke) were the primary end point, with access-related bleeding and hospital stay as secondary end points. RESULTS: Cardiogenic shock and hemodynamic instability were the most common indications for IABP support. Cumulative 30-day NACE rate was 50.2%, whereas an access site-related bleeding occurred in 14.3%. Patients undergoing transfemoral PCI had a higher unadjusted rate of NACEs when compared with the transradial group (57.4% vs 36.6%, P < .01), mainly due more access-related bleedings (18.7% vs 6.3%, P < .01). Such increased risk of NACEs was confirmed after propensity score adjustment (hazard ratio 0.57 [0.4-0.9], P = .007), whereas hospital stay appeared comparable in the 2 groups. CONCLUSIONS: In this observational registry, high-risk patients undergoing PCI and requiring IABP support appeared to have fewer NACEs if transradial access was used instead of transfemoral, mainly due to fewer access-related bleedings. Given the inherent limitations of this retrospective work, including the inability to adjust for unknown confounders, further controlled studies are warranted to confirm or refute these findings.
7. Ielasi A, Latib A, Tespili M. Current and new-generation transcatheter aortic valve devices: an update on emerging technologies. Expert Rev Cardiovasc Ther. 2013 Oct;11(10):1393-405. doi: 10.1586/14779072.2013.837702.
Cardiology Division, Azienda Ospedaliera "Bolognini", Seriate (BG), Italy. Abstract
Transcatheter aortic valve implantation (TAVI) has become an accepted treatment option for patients with symptomatic severe aortic stenosis who are at high risk for traditional surgical aortic valve replacement. In particular, TAVI has been shown to reduce mortality in a randomized comparison with medical treatment and to be non-inferior to surgical aortic valve replacement in 'high-risk operable' patients. From its early stages it became apparent that TAVI has tremendous potential and thus considerable efforts were made to design new devices and advance valve technology in order to improve outcomes and increase TAVI applications in complex anatomies and in patients with multiple co-morbidities. In this review, we present the advances in transcatheter aortic valve technology and discuss the current evidence on the new-generation TAVI devices.
8. De Bellis UG, Legnani C, Calori GM. Acute total hip replacement for acetabular fractures: A systematic review of the literature. Injury. 2013 Sep 20. pii: S0020-1383(13)00427-0. doi: 10.1016/j.injury.2013.09.018. [Epub ahead of print]
U.O.S.D. Servizio di Traumatologia d'Urgenza, Istituto Ortopedico G. Pini, Milano, Italy. Electronic address: umbertogiovanni.debellis@gpini.it. Abstract
INTRODUCTION: Immediate total hip replacement (THR) in patients with acetabular fractures is controversial because of concerns about high complication rates. The current article is a systematic review of the literature on the use of acute THR for the treatment of acetabular fractures. MATERIALS AND METHODS: This systematic review included studies published in English between 1992 and 2012 of subjects with acetabular fracture undergoing immediate THR. Outcomes of interest included indications; clinical assessment, including walking ability; comparison with control group; associated procedures, and rate of complications, such as loosening or revision surgery. RESULTS: This review identified six studies, of which only one included a control group. Acute THR was associated with satisfying outcomes with regard to clinical assessment and walking ability. The comparative study assessed the difference between acute THR and delayed THR in acetabular fractures: improved outcomes were observed in the delayed THR group, although the differences between the two groups were not statistically significant. DISCUSSION: According to data reported in the literature, acute primary THR can be successful in patients with poor bone quality, combined acetabular and femoral neck fractures, or pathological fractures and concurrent osteoarthritis of the hip. Relative indications include old age, delayed presentation, substantial medical comorbidities, and pathologic obesity. Clinical outcomes with acute THR were similar to those with delayed THR. Although the results reported in the six studies reviewed here were satisfying overall, there is limited evidence in this area in the existing literature and future prospective investigations are required. CONCLUSION: Data reported in the literature indicate that immediate THR can be successful in appropriately selected elderly patients or patients with extensive osteoporosis, combined acetabular and femoral neck fractures or pathological fractures. There is currently a limited evidence base for THR in patients with acetabular fractures; therefore, physicians' practice and expertise are the most useful tools in clinical practice.

Breve commento a cura di Nerina Agabiti
Esiste ancora controversia sull’efficacia del trattamento chirurgico di sostituzione protesica dell’anca per la frattura acetabolare, tenuto conto dell’alto rischio di complicanze. De Belli et la propongono una revisione della letteratura scientifica sul tema. Gli studi inclusi si riferiscono al periodo 1992-2012, sono in lingua inglese, il focus è sull’intervento immediato dopo frattura acetabolare, gli esiti includono la capacità funzionale (recupero deambulazione) e le complicanze (tra cui la revisione chirurgica). Gli Autori valutano sei studi dei quali solo uno include un gruppo di controllo. L’intervento di sostituzione protesica dell’anca immediatamente dopo l’evento di frattura acetabolare sembra essere di successo particolarmente in pazienti con qualità ossea modesta, frattura combinata del femore e dell’acetabolo, frattura patologica o concomitante osteoartrite dell’anca. Limitano la probabilità dell’intervento nel’immediato periodo dopo la frattura l‘età avanzata, la presentazione ritardata, la presenza di comorbidità, l’obesità patologica. Tuttavia, gli esiti clinici – come riportato negli studi esaminati - non sembrano diversi se l’intervento è fatto nell’immediato periodo dopo la frattura o se viene differito. Gli Autori concludono che in questa area esiste ancora molto spazio per ulteriori studi ed evidenze.

9. Anzini M, Merlo M, Sabbadini G, Barbati G, Finocchiaro G, Pinamonti B, Salvi A, Perkan A, Di Lenarda A, Bussani R, Bartunek J, Sinagra G. Long-term evolution and prognostic stratification of biopsy-proven active myocarditis. Circulation. 2013 Nov 26;128(22):2384-94. doi: 10.1161/CIRCULATIONAHA.113.003092. Epub 2013 Oct 1.
Cardiovascular Department, "Ospedali Riuniti di Trieste" and University of Trieste, Trieste, Italy (M.A., M.M., G.S., G.B., G.F., B.P., A.S., A.P., G.S.); Cardiovascular Centre, Azienda per Servizi Sanitari no. 1 Triestina, Trieste, Italy (A.D.L.); Institute of Pathological Anatomy and Histology, "Ospedali Riuniti di Trieste" and University of Trieste, Trieste, Italy (R.B.); and Cardiovascular Centre Aalst, OLV Clinic, Aalst, Belgium (J.B.). Abstract
BACKGROUND: Active myocarditis is characterized by large heterogeneity of clinical presentation and evolution. This study describes the characteristics and the long-term evolution of a large sample of patients with biopsy-proven active myocarditis, looking for accessible and valid early predictors of long-term prognosis. METHODS AND RESULTS: From 1981 to 2009, 82 patients with biopsy-proven active myocarditis were consecutively enrolled and followed-up for 147±107 months. All patients underwent clinical and echocardiographic evaluation at baseline and at 6 months. At this time, improvement/normality of left ventricular ejection fraction (LVEF), defined as a LVEF increase > 20 percentage points or presence of LVEF≥50%, was assessed. At baseline, left ventricular dysfunction (LVEF<50%) and left atrium enlargement were independently associated with long-term heart transplantation-free survival, regardless of the clinical pattern of disease onset. At 6 months, improvement/normality of LVEF was observed in 53% of patients. Persistence of New York Heart Association III to IV classes, left atrium enlargement, and improvement/normality of LVEF at 6 months emerged as independent predictors of long-term outcome. Notably, the short-term reevaluation showed a significant incremental prognostic value in comparison with the baseline evaluation (baseline model versus 6 months model: area under the curve 0.79 versus 0.90, P=0.03). CONCLUSIONS: Baseline left ventricular function is a marker for prognosis regardless of the clinical pattern of disease onset, and its reassessment at 6 months appears useful for assessing longer-term outcome.
10. Migliorini A, Valenti R, Parodi G, Marcucci R, Abbate R, Carrabba N, Gensini GF, Antoniucci D. Comparison of the degree of platelet aggregation inhibition with prasugrel versus clopidogrel and clinical outcomes in patients with unprotected left main disease treated with everolimus-eluting stents. Am J Cardiol. 2013 Dec 15;112(12):1843-8. doi: 10.1016/j.amjcard.2013.08.009. Epub 2013 Sep 21.
Department of Cardiology, Careggi Hospital, Florence, Italy. Abstract
The everolimus-eluting stent (EES) performs better than the first generation drug-eluting stent. Prasugrel compared with clopidogrel in acute coronary syndromes treated invasively is associated with improved clinical outcome and decreased risk of stent thrombosis. The aim of the study was to compare the clinical outcome and degree of platelet aggregation inhibition of patients treated with EES for unprotected left main disease (ULMD) and receiving clopidogrel or prasugrel. Patients receiving an EES for ULMD and with low residual platelet reactivity on clopidogrel or prasugrel treatment were included in the analysis. The primary end point of the study was the composite of cardiac mortality and myocardial infarction at 1 year. The secondary end point was the degree of platelet aggregation inhibition as assessed by light transmittance aggregometry. From January 2009 to December 2011, 252 patients with low residual platelet reactivity on thienopyridine treatment were treated with EES for ULMD. Of these, 104 patients received clopidogrel and 148 received prasugrel. The primary end point rate was lower in the prasugrel group compared with clopidogrel group: 1.3% and 9.6%, respectively (p = 0.002). Residual platelet reactivity was less in the prasugrel group compared with clopidogrel group (adenosine diphosphate 10 μmol/L 37 ± 17% and 45 ± 15%, respectively, p <0.001). At multivariate analysis, prasugrel treatment was related to the primary end point (hazard ratio 0.17; 95% confidence interval 0.04 to 0.77, p = 0.022). In conclusion, in patients treated with EES for ULMD, prasugrel compared with clopidogrel is associated with increased platelet aggregation inhibition and a better clinical outcome.
11. Offidani E, Guidi J, Tomba E, Fava GA. Efficacy and tolerability of benzodiazepines versus antidepressants in anxiety disorders: a systematic review and meta-analysis. Psychother Psychosom. 2013;82(6):355-62. doi: 10.1159/000353198. Epub 2013 Sep 20.
Affective Disorder Program, Department of Psychology, University of Bologna, Bologna, Italy. Comment in Psychother Psychosom. 2013;82(6):351-2. Abstract
BACKGROUND: Placebo-controlled trials showed that both benzodiazepines (BDZ) and antidepressant drugs (AD) are effective in treating anxiety disorders. However, in the last years a progressive shift in the prescribing pattern from BDZ to newer AD has taken place. The aim of this systematic review and meta-analysis is to analyze whether controlled comparisons support such a shift. METHODS: CINHAL, the Cochrane Library, MEDLINE, PubMed and Web of Science were searched from inception up to December 2012. A total of 22 studies met the criteria for inclusion. They were mostly concerned with tricyclic antidepressants (TCA; 18/22) and involved different anxiety disorders. In order to reduce clinical heterogeneity, only the 10 investigations that dealt with the comparison between TCA and BDZ in panic disorder were submitted to meta-analysis, whereas the remaining papers were individually summarized and critically examined. RESULTS: According to the systematic review, no consistent evidence emerged supporting the advantage of using TCA over BDZ in treating generalized anxiety disorder (GAD), complex phobias and mixed anxiety-depressive disorders. Indeed, BDZ showed fewer treatment withdrawals and adverse events than AD. In panic disorder with and without agoraphobia our meta-analysis found BDZ treatments more effective in reducing the number of panic attacks than TCA (risk ratio, RR = 1.13; 95% CI = 1.01-1.27). Furthermore, BDZ medications were significantly better tolerated than TCA drugs, causing less discontinuation (RR = 0.40; 95% CI = 0.20-0.57) and side effects (RR = 0.41; 95% CI = 0.34-0.50). As to newer AD, BDZ trials resulted in comparable or greater improvements and fewer adverse events in patients suffering from GAD or panic disorder. CONCLUSIONS: The change in the prescribing pattern favoring newer AD over BDZ in the treatment of anxiety disorders has occurred without supporting evidence. Indeed, the role and usefulness of BDZ need to be reappraised.
12. Minervini A, Siena G, Antonelli A, Bianchi G, Bocciardi AM, Cosciani Cunico S, Ficarra V, Fiori C, Fusco F, Mari A, Martorana G, Medica M, Mirone V, Morgia G, Porpiglia F, Rocco F, Rovereto B, Schiavina R, Simeone C, Terrone C, Volpe A, Carini M, Serni S; and Members of the RECORd Project-LUNA Foundation. Open versus laparoscopic partial nephrectomy for clinical T1a renal masses: a matched-pair comparison of 280 patients with TRIFECTA outcomes (RECORd Project). World J Urol. 2013 Sep 7. [Epub ahead of print]
Clinica Urologica I, AOUC, Università di Firenze, Florence, Italy. Abstract
AIM OF THE STUDY: To report a matched-pair comparative analysis between open (OPN) and laparoscopic partial nephrectomy (LPN) for clinical (c) T1a renal masses from a large prospective multicenter dataset. MATERIALS AND METHODS: The RECORd Project includes all patients who underwent OPN and LPN for kidney cancer between January 2009 and January 2011 at 19 Italian centers. Open and laparoscopic groups were compared regarding clinical, surgical, pathologic, functional results and TRIFECTA outcome. Multivariable logistic regression models were used to analyze predictors of WIT >25 min, surgical complications (SC) and the achievement of the TRIFECTA outcome. RESULTS: Overall, 301 patients had OPN and 149 LPN. Groups were matched 1:1 (140 matched pairs) for clinical diameter, tumor location and type of indication. Laparoscopic partial nephrectomy was associated with a significantly mean longer WIT (19.9 vs. 15.1 min; p < 0.001), and it was an independent predictor of a WIT >25 min (RR 6.29, p < 0.0001). The TRIFECTA was achieved in 78.6 and 74.3 % after OPN and LPN (p = ns), respectively, and the surgical approach was not a predictor of a negative TRIFECTA and SC at multivariable analysis. At 6-month follow-up, no significant differences were observed between the OPN and LPN group both in estimated glomerular filtration rate (eGFR) (∆GFR 1.1 vs. 4.1 mL/min) and in new-onset stage III-V chronic kidney disease (CKD) rate (0 vs. 0.7 %). CONCLUSION: No significant difference in achieving the TRIFECTA outcome was reported after OPN and LPN. LPN was associated with a significantly longer WIT. However, eGFR at 6-month follow-up did not differ significantly between the two surgical approaches.
13. Ghezzi F, Fanfani F, Malzoni M, Uccella S, Fagotti A, Cosentino F, Cromi A, Scambia G. Minilaparoscopic radical hysterectomy for cervical cancer: multi-institutional experience in comparison with conventional laparoscopy. Eur J Surg Oncol. 2013 Oct;39(10):1094-100. doi: 10.1016/j.ejso.2013.07.096. Epub 2013 Aug 12.
Gynecologic Oncology Unit, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy. Electronic address: fabio.ghezzi@uninsubria.it. Abstract
OBJECTIVE: To analyze the preliminary experience of three gynecologic oncology services with minilaparoscopic radical hysterectomy (mLRH) for the treatment of cervical cancer and to compare perioperative outcomes with those of conventional laparoscopic surgery (LRH). METHODS: Prospectively collected data on consecutive cervical cancer patients undergoing radical hysterectomy with a laparoscopic approach were analyzed retrospectively. Perioperative outcomes of women undergoing mLRH were compared to data from control patients who had undergone LRH with 5-mm instruments. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching. RESULTS: The study cohort consisted of 257 patients, 35 undergoing mLRH and 222 undergoing LRH. The two groups were comparable in terms of demographic and tumor characteristics. No significant differences were observed between groups in terms of operative time, blood loss, lymph node yield, amount of parametrial or vaginal cuff tissue removed, and percentage of intra- or postoperative complications, both in the entire cohort and in the PS matched group. No conversions were needed from mLRH to standard laparoscopy or from minilaparoscopy to open surgery. Conversion from standard laparoscopy to open surgery was necessary in 2 patients. A shorter hospital stay was observed among women who had mLRH than in those undergoing LRH [2 (1-10) vs 4 (1-14) days, p = 0.005]. This difference remained significant after PS matching. CONCLUSION: Our preliminary study suggests that in experienced hands minilaparoscopy is a feasible and safe technique for radical hysterectomy and yields results that are equivalent to those of LRH.
14. Romagnoli S, Zacchetti S, Perazzo P, Verde F, Banfi G, Viganò M. Simultaneous bilateral total hip arthroplasties do not lead to higher complication or allogeneic transfusion rates compared to unilateral procedures. Int Orthop. 2013 Nov;37(11):2125-30. doi: 10.1007/s00264-013-2015-1. Epub 2013 Jul 24.
IRCCS Galeazzi Orthopaedic Institute, via R. Galeazzi 4, 20161, Milan, Italy. Abstract
PURPOSE: About 20 % of patients undergoing a primary total hip arthroplasty could undergo a second contralateral procedure within five years. The possibility to perform simultaneous bilateral hip replacements instead of two-stage surgery could reduce hospitalisation time and patient management costs, but concerns exist because of risks related to massive blood loss and possible increase in complication rates. The purpose of this study is to assess the veracity of these concerns. METHODS: Parameters like blood loss, transfused blood units, total hospital length of stay (surgical and rehabilitation) and presence of in-hospital complications were collected from surgery reports of two different groups of patients. The first group comprised patients undergoing simultaneous bilateral total hip arthroplasty (n = 63), while the second group consisted of patients undergoing unilateral surgery (n = 97). Occurrence of complications within six post-operative months was assessed by phone interview. RESULTS: No differences were observed in complication, revision and mortality rates between the study groups. On the contrary, blood loss was significantly higher in the bilateral group, but the application of appropriate transfusion protocols reduced the use of allogeneic blood transfusion to the levels recorded for unilateral patients. Moreover, the difference in length of hospital stay (about two days) between the two groups was not clinically relevant. CONCLUSIONS: Our data show that simultaneous bilateral procedures do not lead to higher complication or allogeneic transfusion rates in comparison to unilateral hip replacement, and that, in cases of bilateral disease, they could significantly reduce the total length of hospital stay and, therefore, patient management costs.
15. Visca M, Donatini A, Gini R, Federico B, Damiani G, Francesconi P, Grilli L, Rampichini C, Lapini G, Zocchetti C, Di Stanislao F, Brambilla A, Moirano F, Bellentani D. Group versus single handed primary care: A performance evaluation of the care delivered to chronic patients by Italian GPs. Health Policy. 2013 Nov;113(1-2):188-98. doi: 10.1016/j.healthpol.2013.05.016. Epub 2013 Jun 22.
Agenas - Agenzia Nazionale per i Servizi Sanitari Regionali, Via Puglie, 23, 00187 Roma, Italy. Electronic address: visca@agenas.it. Abstract
OBJECTIVES: In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome. METHODS: Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice. RESULTS: No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065). CONCLUSIONS: No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.

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