The effect of community nurse on mortality and hospi- talization in a group of over-75 older adults: a nested case-control study.

Background: Bio-psycho-social frailty can negatively affect the health status of an ageing population. The integration between community nurses and social services can emphasize community care and prevent the onset of both health and social negative outcomes in the older population. The aim of the paper is to explore the causal association through the analysis of the hospitalization and mortality rate after a pro-active social service integrated by the community nurse. Study Design: A nested case-control study comparing groups of older adults has been carried out. Methods. The paper compares data stem from a cohort followed up by the University of Rome "Tor Vergata" with data from the "Long Live the Elderly!" program (LLE) cohort. Results: One-year standardized mortality rate was 6.5%, 4.7% and 7.5% in the control group, the LLE group and the LLE group integrated by the community nurse (LLE-CN), respectively. One-year hospitalization rate was 15.4%, 15.5% and 10.8% in the control group, the LLE group and the LLE-CN group, respectively. Conclusions: According to our results a social service with a pro-active approach, integrated by the community nurse, appears to be able to reduce mortality and hospitalization in a group of older adults aged>75. The multidimensional assessment of frailty stands for the first step of a new organization of community services.

[Hospital anxiety and depression]. / Ansia e depressione nelle ospedalizzazioni.

OBJECTIVE: The study investigate the presence of depressive disorders in patient who are taken in general hospital, to prevent and reduce the risk of developing a psychological pathology (anxious-depressive symptoms). METHODS: We used two tests: 1. General Health Questionnaire (GHQ-12) by Goldberg, a self-report questionnaire, consisting of 12 items, used to estimate the probability of detecting non-psychotic mental disorders and problems in every day's activity. 2. Personal Health Questionnaire (PHQ), a self-report questionnaire, consisting of 10 items. It is a new tool for detecting individuals with ICD-10 depressive disorders, used to estimate the probability to individuate the presence of major depression symptoms, and minor depression symptoms. Tests have been administered to 140 subjects (males' experimental group, 32 subjects; males' control group, 20 subjects; females' experimental group 58 subjects; females' control group, 30 subjects) from eight departments of university hospital, medical faculty, and social services. RESULTS: It can be noted that with GHQ-12, the presence of non-psychotic mental disorders does not come out: just the females' group, experimental and control, shows some problems with insomnia and stress. On the other hand, with PHQ, the presence of no great entity depressive symptoms comes out for all groups. In the experimental groups the quantity of depressive symptoms is greater than in the control groups. CONCLUSIONS: We have find the presence of a number of depressive symptoms into a hospitalized population. It is known that detecting such symptoms is important for protection and care of depressive disorders in hospitalized and non-hospitalized populations.

Tonsillolith. Case report and review of the literature.

Large oropharyngeal concretions--giant tonsillolith--are not very common. Over the last few years only some 50 cases have been reported in the literature. Many tonsilloliths, especially small concretions, are asymptomatic; large concretions, on the contrary, may produce several symptoms. The case is described of a 56-year-old female complaining of dysphagia, odynophagia, sore throat, right otalgia and swelling in right tonsillar fossa. Routine panoramic radiography revealed a radio-opaque area in right tonsil region. Computed tomography of oropharynx was performed and axial slices revealed a calcified cylindrical lesion in posterior pharyngeal region, between palatoglossus and palatopharyngeus muscles. The tonsillolith was easily excised under local anaesthesia. The post-operative course was good with no recurrence. Microscopic examination of the specimen revealed necrotic debris, "ghost" cells, calcifications and inflammatory cells, confirming the diagnosis of tonsillolith. Authors stress that large tonsillar concretions are uncommon, and may be difficult to diagnose since the tonsillolith can also be mistaken for other anatomic and pathologic structures in the oropharyngeal area.

Irbesartan effects on renal function in patients with renal impairment and hypertension: a drug-withdrawal study.

The blood-pressure lowering activity, tolerability, and safety of irbesartan was evaluated in 52 hypertensive patients with chronic renal insufficiency. After a 3-week placebo period, once-daily irbesartan was administered for 12 weeks at a daily dose of 150 mg titrated to 300 mg. A second, non-angiotensin-converting enzyme inhibitor, antihypertensive drug was added after 8 weeks as needed. Twenty-four-hour creatinine clearance was determined and renal clearance studies of inulin and para-aminohippurate were done in a subset of 11 patients. Trough sitting blood pressures were reduced at the end of the first week in all groups. At weeks 4, 8, and 12 the reductions in systolic blood pressure/diastolic blood pressure averaged -11.9/-8.7, -10.8/-9.4, and -14.7/-12.1 mm Hg in patients with mild renal insufficiency and -7.7/-6.3, -13.1/-11.8, and -14.1/-10.6 mm Hg in patients with moderate-to-severe renal insufficiency. Creatinine clearance, glomerular filtration rate, and effective renal plasma flow were stable. Irbesartan was withdrawn in only five patients because of adverse clinical or laboratory experience. Hyperkalemia (>6 mEq/l) requiring discontinuation of irbesartan occurred in only one patient. Once-daily irbesartan given as monotherapy at dose of 150-300 mg or in combination with other antihypertensive drugs is effective in reducing blood pressure in hypertensive patients with chronic renal disease. Irbesartan regimens are well tolerated in all groups. In addition, the blood pressure-lowering effect of irbesartan is accompanied by a significant reduction in proteinuria in patients with chronic renal insufficiency.

Effects of enalapril and isradipine alone and in combination on blood pressure, renal function and echocardiographic parameters in mild hypertension.

AIMS AND METHODS: A study was carried out to evaluate the influence of antihypertensive treatment with combined low doses of enalapril plus isradipine (5+5 mg daily) compared with those of either drug at a higher dose level (10 mg daily) by double-blind, three-way crossover study (balanced Latin square design) in 102 subjects (mean age 51.9 +/- 7.42 years) with essential hypertension. Left ventricular mass and function were evaluated by M-B mode echocardiography, renal function by glomerular filtration rate (GFR) and by serum and 24-h urinary Na+ and K+ during wash-out period and after 24 weeks of treatment. RESULTS: The supine blood pressure for subjects given placebo was 171/103 mmHg. After 24 weeks of treatment, systolic and diastolic supine blood pressure were significantly lower with 5 mg isradipine plus 5 mg enalapril (134/84 mmHg) than with 10 mg enalapril (137/84 mmHg) or with 10 mg isradipine (144/85 mmHg). Left ventricular posterior wall and septal thickness were significantly and similarly reduced in all groups. Left ventricular systolic and diastolic end diameters were not significantly changed. Left ventricular mass (LVM) was significantly reduced in E plus I group and enalapril group. GFR was not significantly altered. The 24-h urinary Na+ significantly increased with enalapril, more so than isradipine. The combination was tolerated better than either monotherapy. We observed no clinically significant changes in laboratory variables including blood lipoproteins. CONCLUSIONS: The combination of isradipine plus enalapril reduced blood pressure more effectively and was better tolerated than other drug alone. All three groups showed similar changes in echocardiographic indices and no change in renal function.

Seroreactivity to Chlamydia trachomatis Hsp10 correlates with severity of human genital tract disease.

We have identified the chlamydial heat shock protein Hsp10 as a potential correlate to the immunopathogenic process in women with tubal factor infertility (TFI). The human serologic response to chlamydial Hsp10, Hsp60, and major outer membrane protein (MOMP) was measured by enzyme-linked immunosorbent assay. Three populations of women were studied: uninfected controls (CU), acutely infected (AI) women, and women with TFI. Sera from women in the AI and TFI groups both recognized Hsp10 more frequently and at a higher overall level than sera from healthy uninfected controls. Moreover, the infertile women had significantly greater Hsp10 seroreactivity than acutely infected women, indicating a concomitant increase of Hsp10 recognition in populations with increasing levels of disease severity. Hsp60 reactivity showed a similar correlation in these populations, while MOMP reactivity peaked at the same level in both AI and TFI populations but did not increase with disease severity. Test populations were standardized by level of reactivity to formalin-fixed Chlamydia trachomatis elementary bodies (EBs) to address whether these associations were reflections of increased overall chlamydial exposure rather than a property specific to Hsp10. Associations between Hsp10 seropositivity and TFI were greater in the EB(+) subgroup while associations among the EB(-) subgroup were diminished. When restricted to the EB(+) subgroups, Hsp60 and MOMP responses in the TFI population did not increase significantly over the level of AI group responses. Thus, among women with similar exposure to chlamydiae, the serologic response to Hsp10 exhibited a stronger correlation with TFI than did the response to Hsp60 or MOMP. These findings support the hypothesis that the serological response to C. trachomatis heat shock proteins is associated with the severity of disease and identifies Hsp10 as an antigen recognized by a significant proportion of women with TFI.

[The surgical approach to non-neoplastic abdominal pathology in the geriatric patient]. / L'approccio chirurgico alla patologia addominale non neoplastica nel paziente geriatrico.

BACKGROUND: The authors evaluate the most suitable approach to be used in elderly patients suffering from non-neoplastic abdominal pathology. METHODS: A retrospective evaluation was made of cases observed over the past two years. Follow-up continued for at least three months after treatment. SETTING: General Surgery 1, Department of Surgical and Anatomic Disciplines, Policlinico, University of Palermo. PATIENTS: A total of 92 patients were treated aged between 65 and 94 years old (mean age 79.5). The most frequently observed pathologies were cholelithiasis and hernia, treated both electively and in emergency. OPERATIONS: 76 patients were treated electively and 16 underwent emergency surgery. Parameters examined: The authors evaluated postoperative progress, morbidity and mortality. RESULTS: Morbidity was equal to 6.5%. Death occurred in three patients, one of whom had been operated a month earlier. CONCLUSIONS: Surgery is considered appropriate in the elderly patient provided an adequate pre-, intra- and postoperative approach is used. The preoperative phase should include a multidisciplinary evaluation to assess surgical risk (ASA and APACHE). During surgery, the most beneficial solution should be found which takes account of the patient's life expectancy; whenever possible, is it advantageous to resort to video-laparoscopy owing to the diagnostic accuracy of this method, as well as the capacity to adjust subsequent surgery whether it is performed using video-assisted laparoscopy or targeted mini-laparotomy. This causes less surgical aggression and therefore a more comfortable postoperative recovery. During the latter phase, vital and biohumoral parameters should be accurately monitored to ensure the prompt recognition of organic collapse and/or metabolic disorders consequent to surgical stress.

[Cervico-mediastinal goiter. Our experience]. / Gozzo cervico-mediastinico. Nostra esperienza.

BACKGROUND: Personal experience about substernal goiter is reported. Stressing laid on the importance of definition: a goiter that is totally or in the most part below the superior thoracic outlet, with normal vascularization. DESIGN: retrospective evaluation of patients observed in the last six years. SETTING: General Surgery I, Policlinico, University of Palermo. SUBJECTS: four hundred ninety-six thyroidectomies have been performed, 32 patients (6.5%) were found to have substernal goiters. The age was between 42 and 86 years (middle age 59). Male/female = 1/1.9. Asymptomatics were 8 (25%). More frequent symptoms were airway compression (34%), hoarseness (9%), pain (9%), thyrotoxicosis (9%) and dysphagia (3%). INTERVENTIONS: total thyroidectomies have been always performed. MAIN OUTCOME MEASURES: the incidence, symptoms, short and long term complication have been valued. RESULTS: There were no postoperative bleeding or lesion of recurrent nerves or definitive hypoparathyroidism. Postoperative hypocalcemia was observed in 9 patients (28%). Only one temporary hypoparathyroidism (two months) was observed. In 2 patients the histologic examination revealed a papillar carcinoma. There were no intraoperative deaths. CONCLUSIONS: In personal experience the presence of substernal goiter is an indication for total thyroidectomy. The reasons for treating substernal goiter surgically are the following: no effective medical treatment is available; respiratory compromise, thyrotoxicosis, dysphagia, or malignancy can develop in long-standing goiters; surgery, in skilled hands, presents minimal morbidity.

[Video laparoscopic appendectomy. Our experience]. / Appendicectomia videolaparoscopica. Nostra esperienza.

OBJECTIVE: Personal experience with the use of VL in the treatment of acute appendicitis (AA) is reported. The main advantage of this method is its high diagnostic reliability. SETTING: Chirurgia Generale I. Dipartimento di Discipline Chirurgiche e Anatomiche. Policlinico Università Palermo. SUBJECTS: The VL method has been used in 36 patients with diagnosis of suspect acute appendicitis. INTERVENTIONS: In the cases in which the diagnosis has been confirmed, a VL appendectomy with endoabdominal technique according to Semm has been performed in 23 cases, and an assisted VL appendectomy, trough a minimal and guided laparotomy, in 8 cases. In order to avoid vascular and visceral injuries, an "open" laparoscopy technique is always used. RESULTS: The diagnosis has been confirmed in 31 cases, 21 women and 10 men. The diagnosis has not been confirmed in 5 cases, a man of 74 years with sigmoidal diverticulitis and 4 women with terminal ileitis in a case, torsion of right ovarian cyst in another and, finally, pelvic inflammatory disease in 2. CONCLUSIONS: From this brief experience it is evident the diagnostic advantage of VL particularly in the female and in elderly patients. Other advantages of this method are the excellent aesthetic result, light postoperative pain, the rapid functional resumption, the small impact of adherences, wound infection, and incisional hernia, and the lower cost, when staplers are not used. The disadvantages are the extension of the operative time, using the "open" laparoscopy technique, and the difficulty to find Meckel diverticulum.

Investigations of the mechanism by which mammalian cell growth is inhibited by N1N12-bis(ethyl)spermine.

N1N12-Bis(ethyl)spermine (BESM) and related compounds are powerful inhibitors of cell growth that may have potential as anti-neoplastic agents [Bergeron, Neims, McManis, Hawthorne, Vinson, Bortell and Ingeno (1988) J. Med. Chem. 31, 1183-1190]. The mechanism by which these compounds bring about their effects was investigated by using variant cell lines in which processes thought to be altered by these agents are perturbed. Comparisons between the response of these cells and of their parental equivalents to BESM, N1N11-bis(ethyl)norspermine, N1N14-bis(ethyl)homospermine and N1N8-bis(ethyl)spermidine were then made. It was found that D-R cells, an L1210-derived line that over-expresses ornithine decarboxylase, were not resistant to these compounds. This indicates that the decrease in ornithine decarboxylase is not critical for the action of the compounds on cell growth. Furthermore, although polyamine levels were decreased in the D-R cells, the content was not totally depleted, indicating that such depletion is also not essential for the anti-proliferative effect. Two cell lines lacking mitochondrial DNA (human 143B206 cells and chicken DU3 cells) did not differ in sensitivity to BESM from their parental 143BTK- and DU24 cells. Furthermore, the inhibition of respiration in L1210 cells in response to BESM developed more slowly than the inhibition of growth. Thus it appears that the inhibitions of mitochondrial DNA synthesis and of mitochondrial respiration are also not primary factors in the anti-proliferative effects of these polyamine analogues. The inhibition of growth did, however, correlate with the intracellular accumulation of the analogues. It appears that the bis(ethyl)polyamine derivatives act by binding to intracellular target molecules and preventing macromolecular synthesis. The decline in normal polyamines may facilitate such binding, but is not essential for growth arrest.

Retroperitoneal infectious myositis.

A case of retroperitoneal infectious myositis is described. The symptoms of infectious myositis may be confused with those of other more frequent soft tissue pathologies (haematoma and sarcomata). This infection is more frequent in countries with a tropical climate. The most frequent aetiological agent is Staphylococcus aureus. This paper reports on the diagnostic and therapeutic problems of this disease as recently observed at the Division of Surgical Oncology of the National Cancer Institute in Genoa.

[Clinico-statistical study on the anti-inflammatory activity of proglumetacin. Proglumetacin: at last a complete anti-inflammatory agent?]. / Studio clinico-statistico sull'attività antiinfiammatoria della proglumetacina. La proglumetacina: finalmente un antiinfiammatorio completo?

Fifty outpatients suffering from rheumatoid disorders were treated with proglumetacin. Efficacy was classified as "good" or "very good" in 80% of cases. Besides this considerable efficacy, a tolerance classified as "good" or "very good" was observed in 86% of patients.