rubrica

Comparabilità e valutazione dei servizi sanitari

  • Nerina Agabiti1

  • Marina Davoli1

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

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Ricerca bibliografica periodo dal 2 ottobre 2011 al 1 gennaio 2012

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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 (“2011/10/02”[PDAT] : “2012/01/01”[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]))
1. Brausi M, Witjes JA, Lamm D, Persad R, Palou J, Colombel M, Buckley R, Soloway M, Akaza H, Böhle A. A review of current guidelines and best practice recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group. J Urol. 2011 Dec;186(6):2158-67. Epub 2011 Oct 19.
Department of Urology, AUSL Modena, Modena, Italy. brausi@interfree.it

Abstract
PURPOSE: Although the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines all provide an excellent evidence-based framework for the management of nonmuscle invasive bladder cancer, these guidelines vary with respect to important issues such as risk level definitions and management strategies for these risk categories. Therefore, we built on the existing framework provided by current guidelines, and provide consensus on the definitions of low, intermediate and high risk nonmuscle invasive bladder cancer, as well as practical recommendations for the treatment of patients in each of these risk categories.
MATERIALS AND METHODS: An international committee of experts on bladder cancer management identified and analyzed the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines as well as the published English language literature related to the treatment and management of nonmuscle invasive bladder cancer available as of April 2010.
RESULTS: Based on review of the current guidelines and literature, the International Bladder Cancer Group developed practical recommendations for the management of nonmuscle invasive bladder cancer.
CONCLUSIONS: Complete transurethral bladder tumor resection is recommended for all patients with nonmuscle invasive bladder cancer. For low risk disease a single, immediate chemotherapeutic instillation after transurethral bladder tumor resection is recommended. For intermediate or high risk disease there is no significant benefit from an immediate, postoperative chemotherapeutic instillation. For intermediate risk disease intravesical bacillus Calmette-Guérin with maintenance or intravesical chemotherapy is recommended. For high risk disease bacillus Calmette-Guérin induction plus maintenance is recommended. The appropriate management of recurrence depends on the patient level of risk as well as previous treatment, while the management of treatment failure depends on the type of failure as well as the level of risk for recurrence and disease progression.

2. D'Onofrio A, Fusari M, Abbiate N, Zanchettin C, Bianco R, Fabbri A, Salvador L, Polesel E, Biglioli P, Gerosa G. Transapical aortic valve implantation in high-risk patients with severe aortic valve stenosis. Ann Thorac Surg. 2011 Nov;92(5):1671-7. Epub 2011 Oct 31.
Division of Cardiac Surgery, University of Padova, Padova, Italy. adonofrio@hotmail.it

Abstract
BACKGROUND: Transapical aortic valve implantation (TA-TAVI) represents an alternative in patients with symptomatic severe aortic valve stenosis (SSAVS) who cannot be operated on or have a high surgical risk. The aim of this prospective multicenter observational study was to assess early and 2-year clinical and hemodynamic outcomes after TA-TAVI.
METHODS: From May 2008 to September 2010, 179 patients with inoperable conditions or high-risk patients underwent TA-TAVI at 4 institutions. Indications for TA-TAVI were SSAVS and logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) greater than 20% or porcelain aorta in patients with severe aortoiliac disease. Patients underwent clinical and echocardiographic follow-up visits at hospital discharge, 3 and 6 months after TA-TAVI, and every 6 months thereafter. The impact of the learning curve for the centers and of intraoperative complications on patient outcomes was also evaluated.
RESULTS: Mean age was 81 ± 6 years. Mean logistic EuroSCORE was 22% ± 12%. Transapical delivery was successful in all patients. Seventeen severe intraoperative complications occurred in 13 (7.3%) patients. Thirty-day mortality was 3.9% (7 patients). Mean follow-up was 9.2 ± 6.5 months. Late mortality occurred in 9 patients. Two-year survival was 88% ± 3%. An intraoperative severe complication was identified as the only significant independent predictor of 1-year mortality. A significant benefit was found when comparing 2-year survival of the second versus the first 50% patients at each center (93% ± 2% versus 84% ± 3 %; p = 0.046). A significant reduction of both mean and peak gradients from the preoperative to the postoperative period, which remained stable during follow-up, was found.
CONCLUSIONS: TA-TAVI provides excellent early and 2-year results in terms of survival, valve-related adverse events, and hemodynamic performance. Survival after TA-TAVI is affected by the center learning curve and by the occurrence of an intraoperative complication.

Breve commento a cura di N. Agabiti
L’impianto di valvola aortica per via transcatetere (TAVI) è stata introdotta recentemente come alternativa alla chirurgia tradizionale di sostituzione valvolare in pazienti con grave stenosi valvolare aortica che non possono essere operati o sono ad alto rischio operatorio.
L’interessante lavoro di D’Onofrio et al pubblicato su Ann Thorac Surg riporta i risultati di uno studio multicentrico prospettico mirato a valutare gli esiti clinici ed emodinamici della TAVI a 2 anni dall’intervento. Nel periodo 2008-2010 sono stati studiati 179 pazienti (età media 81 anni) in 4 centri italiani (Padova, Milano, Venezia-Mestre, Vicenza) i quali sono stati valutati con esami clinici e strumentali prima dell’intervento secondo un protocollo standardizzato e poi sottoposti a TAVI usando anestesia generale e intubazione endotracheale. Il follow up clinico-funzionale è stato fatto alla dimissione e poi ogni 6 mesi. L’intervento ha avuto successo in tutti i casi. Nel 7.3% dei casi si sono verificate gravi complicanze intraoperatorie e 7 pazienti sono deceduti a 30 giorni (3.9%). La sopravvivenza a 2 anni è dell’88%+3%. L’incidenza di complicanze intraoperatorie è il solo significativo determinante della mortalità a 1 anno. E’ stato anche osservata una “curva di apprendimento” del centro ovvero migliori esiti con l’aumentare dell’esperienza chirurgica. Gli autori sottolineano il successo ed i benefici di questa tecnica dedicata a pazienti ad alto rischio, anche se nuove evidenze sono necessarie per valutare i risultati nel lungo termine.

3. Marchetti C, Pisano C, Mangili G, Lorusso D, Panici PB, Silvestro G, Candiani M, Greggi S, Perniola G, Di Maio M, Pignata S. Use of adjuvant therapy in patients with FIGO stage III endometrial carcinoma: a multicenter retrospective study. Oncology. 2011;81(2):104-12. Epub 2011 Oct 4.
Dipartimento di Scienze Ginecologico-Ostetriche e Scienze Urologiche, Università di Roma Sapienza, Roma, Italy.

Abstract
OBJECTIVES: Adjuvant treatment for stage III endometrial cancer is not yet defined. Previous experiences support the usefulness of combined chemotherapy and radiotherapy. The aim of this retrospective study was to describe the outcome in a cohort of patients with stage III endometrial cancer treated with chemotherapy and/or radiotherapy.
METHODS: A multicenter retrospective analysis of patients with stage III endometrial cancer from 1998 to 2009 was conducted. The impact on relapse-free survival of clinical and pathological variables and adjuvant treatment received was analyzed by univariate and multivariate analysis.
RESULTS: Eighty-two patients were considered. Median age was 62 years (range 38-82). Seventy-eight (95%) patients received an adjuvant treatment: chemotherapy (41; 50%), radiotherapy (18; 22%), or combined chemo-radiotherapy (19; 23%). Four patients were excluded from analysis because they were not treated with any adjuvant therapy. At univariate analysis, tumor grade (G3 vs. G1-G2; p = 0.003) was associated with risk of recurrence; similarly, patients treated with radiotherapy alone (p = 0.031, hazard ratio 0.19, 95% CI 0.04-0.86) or chemotherapy alone (p = 0.053, hazard ratio 0.54, 95% CI 0.29-1.01) had a significantly higher risk for relapse, compared to those treated with the multimodality approach. Relapse-free survival at 3 years was 86.5, 65.8 and 44.1%, with the multimodality approach, chemotherapy and radiotherapy, respectively. At multivariable analysis, age and grading were independently associated with recurrence-free survival. Hazard ratio for relapse-free survival was 0.14 (95% CI 0.02-1.04) and 0.20 (95% CI 0.04-1.11) for multimodality treatment compared to chemotherapy alone and radiotherapy alone, respectively.
CONCLUSIONS: Age and grading are independent prognostic factors. A combined approach with radiotherapy and chemotherapy may induce an advantage in relapse-free survival compared to radiotherapy or chemotherapy alone. Prospective clinical trials are needed to verify this clinical hypothesis.

4. Al-Lamee R, Ielasi A, Latib A, Godino C, Mussardo M, Arioli F, Figin F, Piraino D, Carlino M, Montorfano M, Chieffo A, Colombo A. Comparison of long-term clinical and angiographic outcomes following implantation of bare metal stents and drug-eluting stents in aorto-ostial lesions. Am J Cardiol. 2011 Oct 15;108(8):1055-60. Epub 2011 Jul 24.
Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.

Abstract
Percutaneous coronary intervention (PCI) to aorto-ostial (AO) lesions is technically demanding and associated with high revascularization rates. The aim of this study was to assess outcomes after bare metal stent (BMS) compared to drug-eluting stent (DES) implantation after PCI to AO lesions. A retrospective cohort analysis was conducted of all consecutive patients who underwent PCI to AO lesions at 2 centers. Angiographic and clinical outcomes in 230 patients with DES from September 2000 to December 2009 were compared to a historical control group of 116 patients with BMS. Comparison of the baseline demographics showed more diabetics (32% vs 16%, p = 0.001), lower ejection fractions (52.3 ± 9.7% vs 55.0 ± 11.5%, p = 0.022), longer stents (17.55 ± 7.76 vs 14.37 ± 5.60 mm, p <0.001), and smaller final stent minimum luminal diameters (3.43 ± 0.53 vs 3.66 ± 0.63 mm, p = 0.001) in the DES versus BMS group. Angiographic follow-up (DES 68%, BMS 66%) showed lower restenosis rates with DES (20% vs 47%, p <0.001). At clinical follow-up, target lesion revascularization rates were lowest with DES (12% vs 27%, p = 0.001). Cox regression analysis with propensity score adjustment for baseline differences suggested that DES were associated with a reduction in target lesion revascularization (hazard ratios 0.28, 95% confidence interval 0.15 to 0.52, p <0.001) and major adverse cardiac events (hazard ratio 0.50, 95% confidence interval 0.32 to 0.79, p = 0.003). There was a nonsignificantly higher incidence of Academic Research Consortium definite and probable stent thrombosis with DES (n = 9 [4%] vs n = 1 [1%], p = 0.131). In conclusion, despite differences in baseline characteristics favoring the BMS group, PCI with DES in AO lesions was associated with improved outcomes, with lower restenosis, revascularization, and major adverse cardiac event rates.

5. De Felice F, Fiorilli R, Parma A, Musto C, Nazzaro MS, Confessore P, Scappaticci M, Cifarelli A, Violini R. Comparison of one-year outcome of patients aged <75 years versus ≥75 years undergoing "rescue" percutaneous coronary intervention. Am J Cardiol. 2011 Oct 15;108(8):1075-80. Epub 2011 Jul 24.
UO Cardiologia Interventistica Azienda ASL S. Camillo Forlanini Circonvallazione Gianicolense, Roma, Italia. f.defelice@lycos.com

Abstract
The influence of age on the clinical results after rescue angioplasty (percutaneous coronary intervention [PCI]) has been poorly investigated. In the present study, we evaluated the outcome of 514 consecutive patients undergoing rescue PCI who were divided into 2 groups according to age: <75 years (n = 469) and ≥75 years (n = 45). The primary end point of the study was the incidence of death at 1 year of follow-up. The secondary end point was the 1-year incidence of major cardiac adverse events (MACE) defined as a composite of death, recurrent acute myocardial infarction, and target vessel revascularization. The predictors of death and MACE at 1 year were also investigated. At 1 year of follow-up, the <75-year-old group had a significantly lower incidence of death (7% vs 24%, p = 0.0001) and MACE (14% vs 28%, p = 0.01) compared to the ≥75-year-old group. The Cox proportional hazards model identified age (adjusted hazard ratio 0.2665, 95% confidence interval 0.1285 to 0.5524, p = 0.0004), cardiogenic shock (hazard ratio 0.1057, 95% confidence interval 0.0528 to 0.2117, p <0.000001), Thrombolysis In Myocardial Infarction flow grade 2 to 3 after PCI versus 0 to 1 (hazard ratio 3.8380, 95% confidence interval 1.7781 to 8.2843, p = 0.0006), multi- versus single-vessel disease (hazard ratio 0.3716, 95% confidence interval 0.1896 to 0.7284, p = 0.0039) as independent predictors of survival at 1 year of follow-up. In conclusion, at 1 year of follow-up after rescue PCI, the patients aged ≥75 years had a greater incidence of death and MACE compared to patients aged <75 years. Age, cardiogenic shock, Thrombolysis In Myocardial Infarction flow grade 0-1 after PCI, and multivessel coronary disease were predictors of survival and freedom from MACE at 1 year of follow-up.

6. Mani K, Lees T, Beiles B, Jensen LP, Venermo M, Simo G, Palombo D, Halbakken E, Troëng T, Wigger P, Björck M. Treatment of abdominal aortic aneurysm in nine countries 2005-2009: a vascunet report. Eur J Vasc Endovasc Surg. 2011 Nov;42(5):598-607. Epub 2011 Jul 19.
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK. kevin.mani@surgsci.uu.se

Abstract
OBJECTIVES: To study contemporary treatment and outcome of abdominal aortic aneurysm (AAA) repair in nine countries.
DESIGN AND METHODS: Data on primary AAA repairs 2005-2009 were amalgamated from national and regional vascular registries in Australia, Denmark, Finland, Hungary, Italy, Norway, Sweden, Switzerland and the UK. Primary outcome was in-hospital or 30-day mortality. Multivariate logistic regression was used to assess case-mix.
RESULTS: 31,427 intact AAA repairs were identified, mean age 72.6 years (95% CI 72.5-72.7). The rate of octogenarians and use of endovascular repair (EVAR) increased over time (p < 0.001). EVAR varied between countries from 14.7% (Finland) to 56.0% (Australia). Overall perioperative mortality after intact AAA repair was 2.8% (2.6-3.0) and was stable over time. The perioperative mortality rate varied from 1.6% (1.3-1.8) in Italy to 4.1% (2.4-7.0) in Finland. Increasing age, open repair and presence of comorbidities were associated with outcome. 7040 ruptured AAA repairs were identified, mean age 73.8 (73.6-74.0). The overall perioperative mortality was 31.6% (30.6-32.8), and decreased over time (p = 0.004).
CONCLUSIONS: The rate of AAA repair in octogenarians as well as EVAR increased over time. Perioperative outcome after intact AAA repair was stable over time, but improved after ruptured repair. Geographical differences in treatment of AAA remain.

Breve commento a cura di N. Agabiti
Negli ultimi anni è radicalmente cambiata la terapia dell’aneurisma dell’aorta addominale addominale (AAA), come risulta da numerosi randomized clinical trials (RCTs). Nello studio condotto da Mani et al – nell’ambito del “Vascunet Collaboration” supportato dalla European Society for Vascular Surgery - si è voluto valutare come sono cambiati nel tempo, in nove paesi, gli approcci chirurgici per questa condizione e gli esiti. I dati su interventi primari di riparazione dell’aneurisma dell’aorta addominale (AAA repair) sono stati ottenuti da registri nazionali e regionali nei seguenti paesi: Australia, Danimarca, Finlandia, Ungaria, Italia, Norvegia, Svezia, Svizzera e Inghilterra, e sono relativi al periodo 2005-2009. Sono stati studiati oltre 31.000 di interventi in elezione (età media 72.5 anni). Si è osservato un forte incremento nel tempo della chirurgia di tipo “endovascolare” ed, in generale, dell’offerta di chirurgia in pazienti con oltre 80 anni. La tecnica “endovascolare” tuttavia mostra un’ampia variabilità di uso (range: Finlandia 14.7%, Australia 56.0%). La mortalità periopeartoria overall è 2.8% ed è stabile nel tempo, con l’Italia che presenta il valore significativamente più basso (1.6%). La mortalità è influenzata dall’età, la tecnica a cielo aperto (open surgery) e la presenza di comorbidità. Molto più alta è la mortalità successiva all’intervento per i casi (oltre 7000, età media 73.8 anni) di riparazione dell’aneurisma dell’aorta addominale rotto (ruptured AAA repair) che arriva al 31.6% nell’intera popolazione. Per tale esito si osserva una significativa riduzione nel tempo. Nonostante si sia registrata una riduzione della variabilità tra paesi rispetto a precedenti rapporti del “Vascunet Collaboration”, esistono ancora delle differenze tra paesi nella selezione dei pazienti e negli esiti che meritano ulteriori approfondimenti. Il lavoro è pregevole per lo sforzo di valutare comparativamente tra periodi e tra paesi l’impatto nella pratica clinica di una chirurgia impegnativa come la chirurgia vascolare addominale.

7. Fancellu A, Rosman AS, Sanna V, Nigri GR, Zorcolo L, Pisano M, Melis M. Meta-analysis of trials comparing minimally-invasive and open liver resections for hepatocellular carcinoma. J Surg Res. 2011 Nov;171(1):e33-45. Epub 2011 Aug 5.
Department of Surgery-Institute of Clinica Chirurgica, University of Sassari, SS, Italy. afancel@uniss.it

Abstract
BACKGROUND: Recent literature suggests that minimally-invasive hepatectomy (MIH) for hepatocellular carcinoma (HCC) is associated with better perioperative results and similar oncologic outcomes compared to open hepatectomy (OH). However, previous reports have been limited by small sample size and single-institution design.
METHODS: To overcome these limitations, we performed a meta-analysis of studies comparing MIH and OH in patients with HCC using a random-effects model.
RESULTS: Nine eligible studies were identified that included 227 patients undergoing MIH and 363 undergoing OH. Patients were similar respect to age, gender, rates of cirrhosis, hepatitis C infection, tumour size, and American Society of Anesthesiology classification. The MIH group had lower rates of hepatitis B infection. There were no differences in type of resection (anatomic or non-anatomic), use of Pringle's maneuver, and operative time. Patients undergoing MIH had less blood loss [difference -217 mL; 95% confidence interval (CI), -314 to -121], lower rates of transfusion [odds ratio (OR), 0.38; 95% CI, 0.24 to 0.59], shorter postoperative stay (difference -5 days; 95% CI, -7.84 to -2.25), lower rates of positive margins (OR, 0.30; 95% CI, 0.12 to 0.69) and perioperative complications (OR, 0.45; 95% CI, 0.31 to 0.66). Survival outcomes were similar in the two groups.
CONCLUSIONS: Although patient selection might have influenced some of the observed outcomes, MIH was associated with decreased blood loss, transfusions, rates of positive resection margins, overall and specific morbidity, and hospital stay. Survival outcomes did not differ between MIH and OH, although further studies are needed to evaluate the impact of MIH on long-term results.

8. Zinzani PL PET in T-Cell Lymphoma. Curr Hematol Malig Rep. 2011 Dec;6(4):241-4. doi: 10.1007/s11899-011-0098-6.
Istituto di Ematologia "L. e A. Seràgnoli", Bologna, Italy. pierluigi.zinzani@unibo.it

Abstract
Most non-Hodgkin lymphomas (NHL) are of B-cell origin; only about 10% are T-cell or NK-cell lymphomas. The clinical features of T/NK-cell lymphomas differ from those of B-cell lymphomas: advanced stage and extranodal disease are more common and the prognosis is worse. Several studies have confirmed that 2-[fluorine-18]fluoro-2-deoxy-D-glucose (18FDG) uptake varies among different subtypes of lymphoma, a disparity that can be explained by the differences in histology, proliferation of tumor cells, and the ratio of viable tumor and reactive cells in the environment. These observations are based on investigation of B-cell lymphomas. Positron emission tomography (PET)/computed tomography (CT) was found to be useful both at staging and at measuring the therapeutic outcome after two to three cycles of chemotherapy (interim PET/CT). Several meta-analyses have confirmed the role of PET in evaluating the viability of the residual tumor mass after treatment. 18FDG-PET has been proved to have an excellent negative predictive value. Conversely, only a few studies have investigated the role of FDG-PET in T/NK-cell lymphomas. This paper summarizes the current information regarding the potential use of PET/CT in patients with T-cell lymphoma.

9. Pavoni V, Gianesello L, Paparella L, Buoninsegni LT, Mori E, Gori G. Outcome and quality of life of elderly critically ill patients: An Italian prospective observational study. Arch Gerontol Geriatr. 2011 Dec 17. [Epub ahead of print]
Department of Critical Medical-Surgical Area, Section of Anesthesia and Intensive Care, Largo Palagi, 1 Firenze, Italy.

Abstract
The demand of critical care admissions to intensive care unit (ICU) is projected to rise in the next decade. The aim of this study was to evaluate short and long-term mortality and quality of life (QoL) of elderly patients (80 years and older) admitted to two ICUs for medical conditions, abdominal surgery (planned and unplanned) and orthopedic surgery for hip fractures, over a 6-year period. Three months and one year after ICU discharge, patients or family members were contacted by telephone to obtain follow-up information using the EuroQoL questionnaire. The data were compared with an age-matched of the Italian population. Two hundred eighty-eight patients were included in the study. ICU mortality of medical (14.8%) and unplanned surgical patients (26.4%) was higher than that of planned surgical (5.0%) and orthopedic patients (2.5%), as was hospital mortality (27.7% vs. 50.0% vs. 5.0% vs. 14.3%). Three months and 12 months mortality rates after ICU discharge were 40.7% and 61.1% in medical patients, 70.5% and 76.4% in unplanned surgical patients, 20.0% and 30.0% in planned surgical patients, 36.2% and 46.2% in orthopedic patients. QoL measures revealed that, one year after ICU discharge, medical and orthopedic patients had significantly more severe problems vis-à-vis mobility, self-care and activity than abdominal surgical patients and control population. Type of admission was the independent risk factor associated with ICU and long-term mortality, whereas age 90 year and older was associated with long-term mortality. Orthopedic surgery for hip fractures seems to influence QoL similar to medical diseases.

10. Benedetti Panici P, Perniola G, Pernice M, Antonilli M, Achilli C, Di Donato V, Bellati F. Laparoscopically guided minilaparotomy: a minimally invasive approach for the treatment of gynaecologic diseases in morbidly obese patients. Eur J Obstet Gynecol Reprod Biol. 2011 Nov 30. [Epub ahead of print]
Department of Obstetrics and Gynaecology, University of Rome "Sapienza", Via del Policlinico, 155 - 00187 Rome, Italy.

Abstract
OBJECTIVE: Obese patients are at greater risk of gynaecologic surgery. Laparotomy is generally performed, even though this approach is regarded as highly invasive, whereas laparoscopy, though minimally invasive, is relatively contraindicated because of the high conversion rates to laparotomy. In light of this, we propose laparoscopically guided transverse minilaparotomy (LGTM) as a minimally invasive alternative technique. The rationale of diagnostic laparoscopy is to evaluate the feasibility of a minimally invasive approach. We have evaluated the feasibility and compared the outcomes with a historical group treated with laparotomy (LPTM), in morbidly obese patients (MOP) subjected to gynaecologic surgery.
STUDY DESIGN: From November 2004, MOPs with body mass index (BMI) ≥40kg/m(2) and admitted for gynaecologic surgery (early stage endometrial cancer and benign disease) were enrolled in this observational study and submitted to LGTM. Patients with a uterine size greater than the umbilical transverse line and with indication for vaginal surgery were excluded operative data and outcome were prospectively recorded.
RESULTS: LGTM was feasible in 34 cases (87%) out of 39. In two women, the procedure was aborted due to intraperitoneal and ovarian malignant disease spread diagnosed at laparoscopy. In three cases, conversion was necessary due to severe adhesions in one case; laparoscopically unrecognized disease spread in the parametria in the second, and in the remaining case a right common iliac vein injury during lymphadenectomy. When compared to LPTM, haemoglobin drop and postoperative stay were significantly reduced with LGTM. Complications were higher in the control group: due to a significantly higher incidence of wound dehiscence (OR 0.27, 95% CI 0.05-1.32, p<0.05).
CONCLUSIONS: LGTM is feasible in the vast majority of MOPs and achieves significantly better results when compared to the standard approach.

11. Vuylsteke A, Vincent JL, Payen de La Garanderie D, Anderson FA, Emery L, Wyman A, Rushton-Smith S, Gore JM; the Euro-STAT Investigators. Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT). Crit Care. 2011 Nov 16;15(6):R271. [Epub ahead of print]
Department of Anaesthesia & Intensive Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK. a.vuylsteke@nhs.net.

Abstract
INTRODUCTION: Although effective strategies are available for the management of chronic hypertension, less is known about treating patients with acute, severe elevations in blood pressure. Using data from the European registry for Studying the Treatment of Acute hyperTension (Euro-STAT), we sought to evaluate 'real-life' management practices and outcomes in patients who received intravenous antihypertensive therapy to treat an episode of acute hypertension.
METHODS: Euro-STAT is a European, hospital-based, observational study of consecutive adult patients treated with intravenous antihypertensive therapy while in the emergency department, perioperative unit or ICU. Enrolment took place between 1 July and 15 October 2009 in 11 hospitals in 7 European countries (Austria, Belgium, Germany, Italy, Spain, Sweden and the United Kingdom).
RESULTS: The study population was composed of 791 consecutive patients (median age 69 years, 37% women). Median arterial blood pressure before treatment was 166 mmHg systolic blood pressure (IQR 141 to 190 mmHg) and 80 mmHg diastolic blood pressure (IQR 68 to 95). Nitroglycerine was the most commonly used antihypertensive treatment overall (40% of patients), followed by urapidil (21%), clonidine (16%) and furosemide (8%). Treatment was associated with hypotension in almost 10% of patients. Overall 30-day mortality was 4%, and new or worsening end-organ damage occurred in 19% of patients.
CONCLUSIONS: High blood pressure requiring intravenous therapy is currently managed with a variety of agents in Europe, with those most commonly used being nitroglycerine, urapidil and clonidine. Patients with acute hypertension have substantial concomitant morbidity and mortality, and intravenous antihypertensive treatment is associated with hypotension in almost 10% of cases.

12. Garbossa D, Panciani PP, Fornaro R, Crobeddu E, Marengo N, Fronda C, Ducati A, Bergui M, Fontanella M. Subarachnoid hemorrhage in elderly: advantages of the endovascular treatment. Geriatr Gerontol Int. 2012 Jan;12(1):46-9.
Divisions of Neurosurgery Neuroradiology, Department of Neuroscience, University of Turin, Turin, Italy.

Abstract
Subarachnoid hemorrhage (SAH) from aneurysm rupture accounts for Aim: approximately 3% of all strokes. A significant improvement in surgery and endovascular procedures has reduced mortality and morbidity. Nowadays, endovascular treatment is a viable alternative to conservative treatment in elderly patients. We designed a retrospective observational study on all endovascular procedures carried out in our department in order to evaluate the A total of outcome in elderly patients compared with a younger cohort. Methods: 378 patients with aneurysmal SAH were treated with detachable platinum coils in years and 68 our department (1994-2009). Of these, 310 patients were aged 20-69 years. Data were stratified according to Hunt-Hess (H-H) grade were aged over 70 years. The final outcome was evaluated at admission. The mean follow up was 4.8 We observed a favorable through the Glasgow Outcome Scale (GOS). Results: outcome (GOS 5-4) in both groups of patients admitted with moderately good clinical conditions (H-H 1-3), with no statistically significant difference. In  contrast, in the case of H-H grade at admission>3, we observed a statistically  We consider the significant poor outcome in elderly patients. Conclusions: endovascular treatment as first choice for elderly patients presenting with a good H-H grade at admission. Quick functional recovery and reduced hospitalization time were observed. Unlike young patients, a chance of recovery in elderly patients with H-H 4-5 is more difficult to achieve. Therefore, a conservative approach should be considered. Geriatr Gerontol Int 2012; 12: 46-49.

13. Colivicchi F, Tubaro M, Santini M. Clinical implications of switching from intensive to moderate statin therapy after acute coronary syndromes. Int J Cardiol. 2011 Oct 6;152(1):56-60. Epub 2010 Aug 1.
Cardiology Division, Cardiovascular Department, “San Filippo Neri” Hospital, Rome, Italy. f.colivicchi@sanfilipponeri.roma.it

Abstract
BACKGROUND AND AIMS: Intensive statin therapy represents an effective option after acute coronary syndromes (ACS). Despite evidence, switching to less effective statins frequently occurs in practice. Aim of this observational study was to assess the impact of switching from intensive to moderate statin therapy on clinical outcomes after ACS.
METHODS AND RESULTS: A cohort of 1321 consecutive ACS patients (886 men, age 71 ± .8 years) discharged on atorvastatin 80 mg/d in a 6.5 year period was followed for 12 months after discharge. During follow-up, 557 patients (42%) were switched by primary care physicians to moderate statin therapy, either for side effects (56%) or for safety concerns (44%). No major adverse reaction was reported. Increasing age (HR 1.52 per 10-year increase, 95% CI 1.23-1.78, p=0.01), and female gender (HR 1.11, 95% CI 1.06-1.23, p=0.02) were associated with a higher probability of switch. Patients following a cardiac rehabilitation program (HR 0.64 95% CI 0.49-0.86, p=0.02) and diabetic subjects (HR 0.81, 95% CI 0.67-0.92, p=0.02) were more likely to continue atorvastatin 80 mg/d. During follow-up, a major adverse clinical event occurred in 331 patients (one-year probability 0.25, 95% CI 0.22-0.27). Multivariate analysis with Cox proportional hazards method, including statin switching as a time-dependent covariate, demonstrated that, after adjustment for demographic and clinical variables, reduction from intensive to moderate statin therapy was an independent predictor of adverse clinical outcomes (HR 2.7, 95% CI 1.7-5.1, p=0.004).
CONCLUSION: Switching from intensive to moderate statin therapy after ACS is associated with an increased incidence of adverse clinical events.

14. Frazzoni M, Conigliaro R, Colli G, Melotti G. Conventional versus robot-assisted laparoscopic Nissen fundoplication: a comparison of postoperative acid reflux parameters. Surg Endosc. 2011 Dec 17. [Epub ahead of print]
Fisiopatologia Digestiva, Nuovo Ospedale S. Agostino, Viale Giardini 1355, 41100, Modena, Italy, m.frazzoni@ausl.mo.it.

Abstract
BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is a technically demanding surgical procedure designed to cure gastroesophageal reflux disease (GERD). It represents an alternative to life-long medical therapy and the only recommended treatment modality to overcome refractoriness to proton pump inhibitor (PPI) therapy. The recent development of robotic systems prompted evaluation of their use in antireflux surgery. Between 1997 and 2000, in a PPI-responsive series we found postoperative normalization of esophageal acid exposure time (EAET) in most but not all cases. Between 2007 and 2009, in a PPI-refractory series we found postoperative normalization of EAET in all cases. We decided to analyze retrospectively our prospectively collected data to evaluate whether differences other than the conventional or robot-assisted technique could justify postoperative differences in acid reflux parameters.
METHODS: Baseline demographic, endoscopic, and manometric parameters were compared between the two series of patients, as well as postoperative manometric and acid reflux parameters.
RESULTS: There were no significant differences in the baseline demographic, endoscopic, and manometric characteristics between the two groups of patients. The median lower esophageal sphincter tone increased significantly, and the median EAET decreased significantly after conventional as well as after robot-assisted LNF. The median postoperative EAET was significantly lower in the robot-assisted (0.2%) than in the conventional LNF group (1%; P = 0.001). Abnormal EAET values were found in 6 of 44 (14%) and in 0 of 44 cases after conventional and robot-assisted LNF, respectively (P = 0.026).
CONCLUSIONS: Robot-assisted LNF provided a significant gain in postoperative acid reflux parameters compared with the conventional technique. In a challenging clinical setting, such as PPI-refractoriness, in which the efficacy of endoscopic or pharmacological treatment modalities is only moderate, even a small therapeutic gain can be clinically relevant. In centers where robot-assisted LNF is available, it should be preferred to conventional LNF in PPI-refractory GERD.

15. De Nunzio C, Aronson W, Freedland SJ, Giovannucci E, Parsons JK. The Correlation Between Metabolic Syndrome and Prostatic Diseases. Eur Urol. 2011 Nov 15. [Epub ahead of print]
Department of Urology, Sant'Andrea Hospital, University "La Sapienza," Rome, Italy.

Abstract
CONTEXT: Metabolic syndrome (MetS), a cluster of several metabolic abnormalities with a high socioeconomic cost, is considered a worldwide epidemic. Recent epidemiologic and clinical data suggest that MetS is involved in the pathogenesis and progression of prostatic diseases such as benign prostatic hyperplasia (BPH) and prostate cancer (PCa).
OBJECTIVE: This review evaluates the available evidence of the role of MetS in BPH and PCa development and progression and discusses possible clinical implications for the management, prevention, and treatment of these diseases.
EVIDENCE ACQUISITION: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published between 1995 and September 2011 was performed by combining the following Patient population, Intervention, Comparison, Outcome (PICO) terms: male, metabolic syndrome, prostate, benign prostatic hyperplasia, prostate cancer, prevention, diagnosis, treatment, and prognosis. Additional references were obtained from the reference list of full-text manuscripts.
EVIDENCE SYNTHESIS: MetS is a complex, highly prevalent disorder and a worldwide epidemic. Central obesity, insulin resistance, dyslipidemia, and hypertension are the main components of MetS. Notwithstanding all the attempts made to correctly define MetS, a major problem related to most definitions remains the applicability to different populations and ethnic groups. Although there is growing evidence of the association of MetS with the initiation and clinical progression of BPH and PCa, molecular mechanisms and effects on treatment efficacy remain unclear. Further research is required to better understand the role of MetS in BPH and PCa.
CONCLUSIONS: Data from the peer-reviewed literature suggest an association of MetS with BPH and PCa, although the evidence for a causal relationship remains missing. MetS should be considered a new domain in basic and clinical research in patients with prostatic disorders.

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