Effect of an educational program in primary care: the case of lipid control in cardio-cerebrovascular prevention.

Lowering blood cholesterol levels reduces the risk of coronary heart disease. However, the effect of interventions depends on the patients' adherence to treatment. Primary care plays an important role in the detection, treatment and monitoring of disease, therefore different educational programs (EP) have been implemented to improve disease management in general practice. The present study is aimed to assess whether a general practitioner auditing and feedback EP may improve dyslipidaemia management in a primary care setting and to evaluate patients' adherence to prescribed lipid-lowering treatment. The quality of cardiovascular and cerebrovascular disease prevention before and after the implementation of an EP offered to 25 general practitioners (GPs), was evaluated. Clinical and prescription data on patients receiving at least one lipid-lowering treatment was collected. To evaluate the quality of the healthcare service provided, clinical and biochemical outcomes, and drug-utilization, process indicators were set up. Adherence was evaluated before and after the EP as the "Medication Possession Ratio" (MPR). A correlation analysis was carried out to estimate the effect of the MPR in achieving pre-defined clinical end-points. Prescription data for lipid-lowering drugs was collected in a sample of 839 patients. While no differences in the achievement of blood lipid targets were observed, a slight but significant improvement of the MPR was registered after the EP (MPR >0.8=64.2% vs 60.6%, p=0.0426). Moreover, high levels of statin adherence were associated with the achievement of total blood cholesterol target (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.7-6.7) or LDL therapeutic goal (OR=3.3 for MPR >0.8 vs MPR <0.5, 95% CI:1.5-7.2). The EP partially improved the defined clinical targets; probably, a more patient-based approach could be more appropriate to achieve the defined target. Further studies are needed to identify how healthcare services can be improved.

Combined heart and kidney transplantation: long-term analysis of renal function and major adverse events at 20 years.

BACKGROUND: Combined heart-kidney transplantation (HKTx) is an accepted therapeutic option for patients with end-stage heart disease associated with severely impaired renal function. We report our long-term follow-up with this combined procedure. PATIENTS AND METHODS: Between April 1989 to November 2009, nine patients underwent combined simultaneous (HKTx) at our center. Seven patients were males (mean age 45.2 +/- 10.12 years); seven patients were on dialysis at the time of transplantation. RESULTS: Surgical procedures were uneventful in all patients. One patient died in the intensive care unit 41 days after transplantation. During long-term follow-up, three patients died: one due to infection and multiorgan failure 148 months after HKTx, one due to a lung neoplasm after 6 years, and one, a cerebral stroke at 34 months after transplantation. Only one patient experience renal allograft failure secondary to hypertension and cyclosporine nephrotoxicity at 10 years after HKTx with the need for renal replacement therapy. Last estimated glomerular filtration rates of all other patients was 61.3 +/- 17.4 mL/min. CONCLUSIONS: In selected patients, with coexisting end-stage cardiac and renal failure, combined HKTx with an allograft from the same donor proved to give satisfactory short- and long-term results, with a low incidence of both cardiac and renal allograft complications.

Long-lasting improvement of myocardial perfusion and chronic refractory angina after autologous intramyocardial PBSC transplantation.

We report the case of a 60-year-old man with patent coronary by-pass grafts on the left anterior descending and circumflex coronary arteries, who experienced recurrent Canadian class IV angina refractory to medical and interventional treatments for a dominant right coronary artery occlusion. He underwent autologous PBSC transplant into the inferior ventricular wall through a minimally invasive approach as a stand-alone therapy, in an attempt to induce therapeutic angiogenesis. Six months after the operation, angina significantly ameliorated; scintigraphy and coronary angiography showed a marked improvement in perfusion of the target injection area. These benefits had persisted at 25 months after stem cell transplant.

The patient with medication overuse: clinical management problems.

Patients with chronic headache arise many problems in clinical management, often strictly related to medication overuse. IHS classification did not clear the different clinical presentation and a chapter dedicated to this problem is lacking. This condition is very frequently associated with psychiatric illness, so that the clinical features become more complex over the years. Most of patients share a past clinical condition of episodic migraine; this aspect is very important facing the therapeutical phase, because after discontinuing medication overuse, if present, the treatment must be direct toward this disease. To treat a patient with analgesic, or ergotamine, or triptan abuse, require much caution because stopping the drug may arise new problems, such as different headache, abstinence syndrome, epileptic seizures etc. We review the different possibility that we have to manage the overuser patient.

Frontal impairment in subcortical ischemic vascular dementia in comparison to Alzheimer's disease.

We compared the performance of patients with Alzheimer's disease to that of patients with subcortical vascular dementia (s-IVD) in a set of tasks assessing categorization abilities, sustained and selective attention, and set-shifting and set-maintaining skills. Only the measures of naming and categorization abilities on the Test of Classification and Recall of Pictures (TCRP) proved useful in differentiating AD from s-IVD patients. s-IVD patients showed worse performance than AD on the TCRP categorization measures, while both AD and s-IVD patients were equally impaired in other tasks assessing executive functions (EF). With respect to the naming task, s-IVD patients made significantly more perseverative and unrelated errors than AD patients. Moreover, in the s-IVD group, we found a strong correlation between categorization ability and an attentional test score (Attentional Matrices), while no such correlation emerged in the AD group. These results suggest a dissociated impairment of EF in the 2 dementia groups. In our view, the lack of inhibition and the inability to manipulate complex information are responsible for a greater executive dysfunction in s-IVD patients in comparison with AD patients. The capacity to build up strategies appears more preserved in AD patients, whose impaired performance in executive tasks seems to be related to an impairment of attentional shifting and working memory.

Off-pump redo coronary artery bypass grafting: technical aspects and early results.

BACKGROUND: Redo coronary artery bypass grafting (CABG) represents an high-risk surgical procedure, because of an increased incidence of perioperative death, myocardial infarction and stroke. Theoretically, the avoidance of cardiopulmonary bypass may reduce surgical traumatism and ameliorate early results. MATERIALS AND METHODS: From January 1995 to May 2001, we performed 123 redo CABGs, of which 53 (44%) off-pump. Off-pump procedure represented respectively 90% of redo CABG in the period 2000-2001 versus 30% in the 1995-1999 period. The mean age was 66.4 years, males were 39 (73%). The mean 2D-echo ejection fraction was 56% and in 9 cases (17%) was less than 40%. Three operations (5.6%) were performed on an urgent base. The access was median sternotomy in all cases. The mean number of grafts per patient was 1.9 (1.7 in the period 1995-99 vs. 2.3 in the period 2000-01, p=0.01). In 20 cases (38%) we grafted the circumflex artery branches (19% in the period 1995-99 vs. 55.5% in the period 2000-01, p=0.015). Improvements in surgical techniques were achieved over time. The current operative strategy includes the use of deep traction stitches in the posterior pericardium and wall stabilizers to expose target vessels, coronary intraluminal shunts during construction of the anastomoses and continuous trans-esophageal echocardiographic monitoring. Urgent conversion to on-pump procedure was not required in any case. RESULTS: We recorded no in-hospital death, one perioperative myocardial infarction (1.9%), one fifth postoperative day-stroke (1.9%) and 9 atrial fibrillations (17%). Mediastinal re-exploration for bleeding was performed in no one patient; 13 patients (24.5%) required postoperative blood transfusion. The mean length of postoperative stay was 7.5 days, ranging from 6 to 18 days. CONCLUSIONS: In our experience off-pump redo CABG is a safe and effective alternative to on-pump procedure and now off-pump is our first choice-technique in redo CABG. A complete revascularization is technically feasible with a low incidence of perioperative complications.

[Myocarcial revascularisation without extracorporeal circulation: current indications, surgical technique and results]. / La rivascolarizzazione coronarica senza circolazione extracorporea. Indicazioni attuali, tecnica chirurgica e risultati.

BACKGROUND: This study was undertaken to assess our experience of the evolution, over time, of beating heart surgery in the Cardiologic Center Foundation Monzino. METHODS: From March 1995 to June 2000, 506 patients underwent myocardial revascularization on beating heart: 313 until May 1999, and 193 between June 1999 and June 2000, after the advent of coronary artery stabilizers and shunts, to keep the surgical field bloodless, with minimal motion and continuous myocardial perfusion. Surgical accesss was via a median sternotomy for 408 cases and via a left anterior thoracotomy for 98 cases. RESULTS: The indications by choice increased, from I to II period, from 61% to 83% with special situations in which patients had three-vessel coronary artery disease raised from 33% to 50%, concerning also bypass grafts performed on circumflex artery and right coronary increased. Postoperative mortality in hospital decreased from 1.3% to 0.5% and perioperative IMA (acute myocardial infarction) from 3.8% to 0.5% in patients undertaken to median thoracotomy. Hospital stay decreased from 8 to 7 days about [no significant differences with patients who underwent CPB (cardiopulmonary bypass)]; in patients who underwent to MTS (left anterior minithoracotomy) there was no deaths, IMA decreased from 3.9% to 0% and hospital stay from 6 to 5 days. Grafts patency increased from 92.3% to 100%. CONCLUSIONS: To perform completed revascularisations is possible now even on the beating heart, and also to make precise anastomosis as on pump CABG, in a reproducible and easy way. The beating heart procedure, that is also more economical, might be expanded to all patients, not only high risk patients.

Researching a differential impairment of frontal functions and explicit memory in early Parkinson's disease.

An impairment at tasks sensitive to frontal lobe damage has been repeatedly reported in Parkinson's disease, but the exact nature of these deficits has not yet been clarified. Similarly, deficits of visuo-spatial functions have been frequently observed, but it is still debated whether verbal and visuo-spatial memory can be differentially affected. In this study we have compared the performance of 20 mild Parkinson's disease patients (I-II Hoehn and Yahr stage) and 18 matched normal controls, at tasks assessing frontal functions and explicit memory. We detected a selective deficit in set shifting and maintaining, without impairment in categorization and set formation. The lack of a selective increase in perseverative errors might indicate that perseverations either measure something different from set shifting or that they do not represent an index sensitive enough to set shifting impairment. Parkinson's disease patients were also significantly impaired at Raven's Progressive Matrices, a task assessing both frontal and visuo-spatial aspects. However, they did not show any differential impairment of visuo-spatial memory. Indeed, despite a trend of lower performance in visuo-spatial learning, memory performance of Parkinson's disease patients was significantly different from that of controls only at a free recall test which involved both verbal and visuo-spatial memory. We suggest the exploration of set shifting and maintaining to detect 'frontal' deficits in mild Parkinson's disease. We argue that Raven's Progressive Matrices is a valuable task for detecting subclinical cognitive deficits in Parkinson's disease, even if it does not show a specific profile of impairment in these patients. According to our results, a differential evaluation of verbal vs. visuo-spatial memory is not necessary in clinical practice, whilst free recall confirms its usefulness to detect subclinical impairments of memory functions.

The radial artery: which place in coronary operation?

Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts, compared with internal mammary artery grafts. Recently, the use of the radial artery as a coronary artery bypass graft has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent report of encouraging 5-year patency rates, supports its continued use as a bypass graft. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.

[Coronary surgery without extracorporeal circulation: the short-term results in high-risk patients]. / Chirurgia coronarica senza circolazione extracorporea: risultati a breve termine nei pazienti ad alto rischio.

BACKGROUND: This study was conducted to assess the impact of coronary bypass surgery (CABG) without cardiopulmonary bypass (CPB) on high-risk patients. METHODS: From February 1997 to July 1998, 71 patients considered at high-risk underwent a CABG off-pump. Using the "Higgins score", eleven preoperative risk factors were identified and stratified in this group of patients. Among 1271 patients who underwent CABG with CPB in the same period, using a computer-based matched comparison, a second identical group of patients was selected according to the 11 risk variables and the number with coronary disease, so that complete preoperative matching included the year of operation, score index and coronary target. Moreover, among seven other preoperative variables that were not included in the matching comparison, the two groups differed only in mean age (64 +/- 10.9 vs 61.6 +/- 7.3 in groups off and on-pump, respectively, p < 0.05). Postoperative outcome and complications and blood requirement were compared. Myocardial cell injury and left ventricular performance were also assessed in the two groups. RESULTS: The global incidence of neurologic complications in the off-pump group was significantly lower (9.8 vs 0%, in on and off-pump groups, respectively; p = 0.02). Patients undergoing CABG off-pump required blood far less often (% of transfused patients: 26.7% for the patients with CPB and 11.2% for the patients without CPB; p = 0.032). Three patients from the on-pump group (4.2%) had a perioperative myocardial infarction (AMI), versus 0% of the off-pump cases (p = ns). Postoperative atrial fibrillation accounted for 14.1% in off-pump patients and 30.9% in on-pump patients (p = 0.027). One patient in both groups (1.4%) suffered from postoperative heart failure. Mean ventilation time and ICU stay did not differ significantly between the two groups. However, hospital discharge occurred earlier in the off-pump group (9.3 +/- 3 vs 12.6 +/- 8, p = 0.007). In-hospital death occurred in one case from the on-pump group (1.4%) versus 0% of patients operated off-pump. CPK-MB release in patients without perioperative AMI was significantly lower in off-pump patients 6 and 12 hours after the operation (36.6 +/- 17 IU/l vs 69.8 +/- 23 IU/l after 6 hours, p < 0.05; and 36.7 +/- 19 IU/l vs 67.3 +/- 26 IU/l after 12 hours, p < 0.05, in off and on-pump groups, respectively) and LVSWI turned out to be better in off-pump patients 6 hours postoperatively (34.2 +/- 2 g*m/m2 vs 27.2 +/- 3 g*m/m2, p < 0.01). CONCLUSIONS: CABG without CPB seems to be a promising technique for high-risk patients. It offers better neurologic and cardiac protection, shortens postoperative hospital stay and reduces the need for blood transfusion.

Non-Alzheimer forms of cortical degeneration: frequency in clinical practice and clinical report of six cases.

Recent clinical and neuropathological studies suggest the possibility of distinguishing some forms of cortical degeneration from Alzheimer's disease. We report data on the frequency of non-Alzheimer forms of cerebral atrophy that were diagnosed on the basis of clinical criteria. Six examples of these neurological disorders are described: two patients with Lewy body disease; two patients with frontal lobe type dementia, one of whom had associated features of motor neuron disease; a patient with primary progressive aphasia; and a patient with a familial dementia that was probably an atypical form of Pick's disease.