[Performance indicators: INCA (cardiovascular indicators) project]. / Indicatori di performance: progetto INCA (INdicatori CArdiovascolari).

The objective of INCA project was the development and implementation of Acute Myocardial Infarction (AMI type ST elevation) process and outcome indicators for the regional cardiology units, testing the possibility of using regional healthcare information data to evaluate the quality of provided healthcare within the regional healthcare accreditation process. The project is introduced by an overview of major concepts of evaluating and managing quality of healthcare. We performed a literature review of structure, process and outcome indicators in cardiology and of accreditation standards for cardiology at national and international level. Through consensus procedures and according to international evidence based literature a set of 18 process and outcome indicators for AMI was defined. A specific procedure for data collection has been developed. Education and training of participants on procedures, quality and accreditation was achieved. Expected verifiable end-points have been achieved over a three months period of data collecting throughout 21 cardiology units, differentiated for level of complexity and location, for a total of 409 clinical observed cases of AMI. Analysis of data was followed by the diffusion of results. Successful data collection of clinical performance indicators on a regional basis was achieved. Participants have been trained to quality sciences. Results will be useful to evaluate and design implementation strategies of regional accreditation of health care services within a shared framework. Benchmarking within Regional hospital cardiology care services will be developed following self evaluation and continuous quality improvement cycle activities.

[Public health: from the past toward new frontiers]. / Sanità Pubblica: dal passato alle nuove frontiere.

The Authors analyse and discuss the contents of some recent international meetings devoted to Public Health, namely the 10th Congress of the WFPHA, the 12th British annual Forum of Public Health and the 12th Conference of the EUPHA. Their efforts to evaluate health services comes off enriched with new scenarios of integration and convergence. Objectives of global interest in the world cannot be faced by individual countries alone: on the contrary, the whole scientific community of public health operators must be involved. The cultural, social and economic development is the unavoidable condition to increase the health level of the populations. No health organization with the characteristics of excellence can exist without a comparable, balanced development regarding the society and its economy. With such considerations in mind, the European Commission in 1997 has began to develop the Health Monitoring Programme, with the aim to build a system for monitoring health in the UE. Within this Programme, the Study ECHI 1 (European Community Health Indicators 1) has been published, which includes 4 large groups of indicators (demographic and socioeconomic indicators, health indicators, determinants of health/disease indicators, health services indicators); such a study was performed with the cooperation of OCSE and WHO/Euro researchers. The following ECHI 2 research did not change the supporting philosophy of ECHI 1. We are trying to evaluate whether the intervention of health operators and health structures could influence - increasing or decreasing - the phenomena described and measured by the indicators, inviting the readers to start a debate with us.

Culture and urban mental health.

The previous panoramic view provides sufficient evidence that cultural understanding of urban realities and expressions of their impact on mental health are necessary for a successful approach to mental health in cities. The issues go beyond understanding how urban realties and cultural issues differ in New York from Jakarta; every city has a variety of unwritten cultural norms that permeate every aspect of its mental health. Unless these norms are understood within the dynamic structure of city living, any attempt to intervene on mental health programs will be doomed to failure. Understanding the cultural blueprint of a city, however, is only the first step, as we need to shed our cultural assumptions while we consider contextual socioeconomic and political factors for each city. Finally we need to adapt our western view of cultural values and how citizens function or do not function within the urban environments. Because each city in is its own culturally specific entity, the three steps outlined previously can help create an accurate portrait of what is needed to implement culturally sensitive changes. A paradigm shift, laid on a bicurcated foundation, on the one hand a locally attuned awareness of urban cultural dimensions and on the other educational programs based on extensive knowledge of worldwide problems such as stigma, gender-specific issues, disability, and the plight of vulnerable populations can potentially have far reaching implications on mental health policy changes addressing the cultural needs of cities. Urban mental health is poised to be one of the central issues for the next few decades, because of the size of the world urban population and because of the protean nature of its problems. Cultural factors interplay with urban dynamics in a unique, at times creative, other times destructive, fashion. Under conditions of socioeconomic disadvantage vulnerable individuals who lack adaptive mechanisms may become mentally ill or experience an exacerbation of their mental illness. Understanding how cultural dynamics articulate with adaptation to urban life may greatly enhance our ability to properly assess and treat mental disorders in cities. In the assessment and treatment of patients living in urban areas contextual cultural factors rather than being merely complementary assume a preeminent if not crucial role.

Painful sensory symptoms in neuroleptic-induced extrapyramidal syndromes.

OBJECTIVE: The authors tested the hypothesis that neuroleptic-induced extrapyramidal syndromes are associated with painful sensations objectively conforming to the characteristics of primary sensory symptoms as reported in idiopathic and postencephalitic parkinsonism. METHOD: The frequency of subjective painful sensory symptoms and their relation to neuroleptic-induced extrapyramidal syndromes were examined in a consecutive series of 107 psychiatric patients newly admitted to acute care units at a teaching hospital. Patients without illnesses or conditions likely to be associated with pain were included in the study if they had a diagnosis other than organic mental syndromes and were receiving psychotropic medications as prescribed by their treating physicians. Structured interviews with a modified version of the McGill Pain Questionnaire to assess sensory complaints and neurological examinations for neuroleptic-induced extrapyramidal syndromes (parkinsonism and akathisia) were conducted independently by two raters blind to each other's findings and patients' medication status. RESULTS: Fourteen (23%) of 60 patients receiving neuroleptics reported experiences of spontaneous pain subjectively attributed to pharmacological treatment, compared with only one (2%) of 47 patients receiving psychotropic medications other than neuroleptics. There was no difference between these two groups in subjective complaints of paresthesia (8% versus 9%). Twelve (55%) of the 22 patients with neuroleptic-induced extrapyramidal syndromes reported pain, compared with only two (5%) of the 38 patients who received neuroleptics but did not experience extrapyramidal syndromes. CONCLUSIONS: Although consonant with the study hypothesis, these results should be regarded as preliminary and interpreted conservatively in the light of the methodological limitations of the study.

Cigarette smoking and neuroleptic-induced parkinsonism.

Several studies have reported an apparent protective effect of cigarette smoking for the risk of idiopathic Parkinson's disease (IPD). These observations are supported by neurochemical studies demonstrating enhancement of central dopaminergic neurotransmission by nicotine. We studied the prevalence and severity of neuroleptic-induced parkinsonism (NIP) in relation to cigarette smoking in a homogeneous sample of 130 psychiatric inpatients receiving long-term neuroleptic treatment. Despite the fact that smokers had significantly higher dosage of neuroleptics during the month prior to evaluation and longer exposure to medication, they presented with significantly less prevalence and severity of NIP than nonsmokers. These findings suggest that the inverse association between smoking and IPD may apply to NIP.

Subjective awareness of abnormal involuntary movements in chronic schizophrenic patients.

The authors examined the effects of verbal and visual feedback on subjective awareness of involuntary movements in 20 chronic schizophrenic patients. At initial evaluation only 25% of the patients were fully aware of their movement disorder. Both verbal and visual feedback resulted in significant immediate enhancement of awareness. However, assessment of awareness 2 weeks later showed a return to prefeedback baseline levels. Lack of awareness of involuntary movements was associated with a lack of awareness of psychiatric disorder, and both were associated with a longer duration of illness.

Anomalous dominance and persistent tardive dyskinesia.

We examined handedness and cerebral hemispheric asymmetries on computed tomography (CT) scan in a sample of schizophrenic patients who were rated also for the presence or absence of persistent tardive dyskinesia (TD). Patients with TD showed a more standard dominance pattern, with dextral hand preference and normal occipital asymmetry. Anomalous dominance was associated with a marked underrepresentation of TD. Stepwise discriminant analyses indicated that the statistical prediction of TD was enhanced by the inclusion of dominance measures. Schizophrenic patients with strong standard dominance patterns may be more susceptible to developing TD, or conversely, anomalous dominance may confer protection against TD.

Persistent tardive dyskinesia in bipolar patients.

The prevalence and outcome of persistent tardive dyskinesia (TD) was studied in 131 bipolar patients. There were 34 cases of persistent TD in the subgroup (n = 96) with a history of neuroleptic treatment (prevalence, 35.4%; 95% confidence interval, 25% to 45%); there were no cases of persistent TD in the subgroup (n = 35) without such treatment history. Except in one patient, signs of TD persisted in spite of lithium carbonate treatment in 23 patients (median duration, 16 months; range, five to 24 months), of whom 15 remained off of a neuroleptic regimen during the study period for a median duration of 14 months (range, four to 24 months). Using multiple regression analysis, two variables were found to predict the presence of persistent TD and account for 36% of the variance: longer cumulative duration of maintenance neuroleptic treatment and shorter duration of previous lithium carbonate treatment. There appears to be a significant risk of persistent TD among neuroleptic-treated bipolar patients. High-risk subgroups within this category need to be identified.

Phencyclidine in an East Harlem psychiatric population.

The use of phencyclidine (PCP) was investigated in the psychiatric population of an East Harlem, New York, hospital. Sixty-eight consecutive PCP-user admissions were interviewed through a 77-item questionnaire. The patient population served by the facility was 48 percent Hispanic and 32 percent black. The sample of PCP users was 86 percent black. This suggests that, in this area, either more blacks use PCP, or nonblack PCP users seek psychiatric help less frequently than black users. This study emphasizes the many problems affecting the sample population and shows evidence that a large portion of the sample is at risk to develop psychiatric symptoms.