Communicating medical information: a little lesson from Italian patients.

OBJECTIVE: To construct and validate a questionnaire that could be used to investigate the clarity of the medical information received by patients and their satisfaction with it, as well as their knowledge and opinions concerning advance directives and their associated variables. METHODS: We administered a 30-item questionnaire to 157 adult patients affected by progressive neurological, oncological and nephrological diseases. RESULTS: The results indicate the good reliability and structure of the questionnaire, which identifies three factors: "information and knowledge" (alpha .91), "need for physical and mental support" (alpha .89), and "determination and decision-making capacity" (alpha .75). The amount of time dedicated to medical communication proved to be one of the variables determining the patients' knowledge of their disease and their capacity to express their needs, neither of which changed over time. The oldest patient, a man in the most advanced phase of disease, was the most fragile in expressing his needs and making decisions. Advance directives, living wills, active/passive euthanasia and therapeutic obstinacy' at most only marginally reach the cognitive and emotional sphere of the patients. CONCLUSION: Patients' needs unequivocally lead us back to the primary matrices of medical act: paying attention to patients, offering adequate time, listening to him/her concerns and asking when no question emerges. This so obvious evidence does not match with the increasingly techno-oriented attitude of health professional, who also have to guarantee more productivity in less time. The quality of medical information received by patients impacts their decision making process, particularly in the oldest people. In Italy, as well as in other countries, it is necessary to pay more attention to this issue, keeping in mind that nobody can really choose without knowing exactly what it is going to happen.

[Prognostic evaluation of silent ischemia during exercise in patient with recent infarction. Italian multicenter study. SMISS Group]. / Evaluation du pronostic de l'ischémie silencieuse à l'effort chez des patients avec infarctus récent. Etude italienne multicentrique. Groupe SMISS.

AIM: The aim of the Multicenter Silent Ischemia Study (SMISS), co-ordinated by the Italian Working Group on Cardiac Rehabilitation, was to evaluate prospectively, the prognostic significance of silent myocardial ischemia during exercise testing in patients with proven ischemic cardiac disease. METHODS: Over a period of six months 4389 consecutive patients performing a maximal symptom-limited exercise testing, after drug withdrawal, were enrolled in the 73 ergometric laboratories. All patients were followed up after 12 months, at which time electrocardiogram, examination and clinical history were reassessed. Here we report the results of 1111 patients group with the recent myocardial infarction (inferior 3 months). The follow-up was completed in 1031 (93%) patients. RESULTS: The results of exercise testing were normal in 666 (64.6%) patients; angina alone in 33 (3.2%) patients; silent ischemia in 234 (22.7%) patients; symptomatic ischemia in 98 (9.5%) patients. In 270 patients (26.1%) new events occurred: angina (19.7%); myocardial infarction (3.1%; PTCA (4%); CABG (6%); cardiac death (1.4%). The total events were more common in the patients with exercise induced angina (48.5%) and in those who had exercise induced-symptomatic ischemia (48%), in respect of patients with silent ischemia (29.5%) and of those who had normal testing (20.7%) (p = 0.0001). Myocardial infarction rate was higher in patients with symptomatic ischemia (7.1%) that for those of all other groups (silent ischemia: 1.3%, angina: 3%, normal 3.2%) (p = 0.05). Moreover, the patients with symptomatic ischemia had higher incidence of CABG (p = 0.0001). The mortality rate was low among all patients and did not show differences among the groups. Only among the 31 patients (3%) with blood pressure fall was mortality higher that in patients with a normal blood pressure increase. By multivariate logistic analysis the angina induced by exercise maintained its prognostic significance for all the events, but also other variables were significant: poor exercise tolerance and, between clinical variables angina before myocardial infarction. CONCLUSION: The results showed, in patients who underwent to exercise testing after drug withdrawal, a low incidence of cardiac death and of myocardial infarction on 12 month follow-up; the patients with induced-exercise symptomatic schema had a greater risk for all cardiac events, except for death.

The natural history and the effects of gabapentin in amyotrophic lateral sclerosis.

Glutamate excitotoxicity seems to play an important role in the aetiopathogenesis and progression of Amyotrophic Lateral Sclerosis (ALS). Gabapentin is a modulator of the glutamatergic system and has been shown to prolong survival in the transgenic model of familial ALS. It has also been demonstrated to slow the decline of arm strength in human sporadic cases. The aim of our study was to assess the effects of different dosages and duration of treatment of gabapentin on the natural history and survival of ALS patients. A total of 110 patients affected by definite ALS entered the study. After a 6-12 month period of observation, patients were randomly assigned to receive oral gabapentin 500 mg/day (Group A) or 1000 mg/day (Group B) for 6 months. In addition a group of patients received gabapentin 500 mg/day for 6 months and 1000 mg/day for a further 6 months (Group C). A group of 121 patients referred to our Institute, who received only symptomatic treatment, was considered as the control group (Group D). Each patient was seen at entry and every 3 months. All average slopes were negative but the comparison of all slopes showed a trend toward a slower rate of decline of muscle strength loss in all treated groups of patients compared with the control group. The differences were statistically significant. Analysis between the pretreatment and treatment period showed a statistically significant decrease of the decline of muscle strength and Norris score during the treatment period. Survival analysis showed a significantly longer survival in treated patients of Groups B and C. Our study suggests that gabapentin may be an effective drug for ALS; hence a controlled trial involving a sufficient large number of patients is warranted.

ECG-manifest and ECG-silent dipyridamole technetium-99m sestamibi SPET perfusion defects in patients with ischaemic heart disease.

At dipyridamole myocardial scintigraphy, perfusion defects are seldom backed up by significant ECG changes. This would suggest myocardial blood flow heterogeneity, rather than true ischaemia, as the cause of the scintigraphic abnormalities. Electrocardiographic surface mapping has been documented to be more accurate than standard 12-lead ECG in the detection of provoked ischaemia. Thus, to investigate the relationship between ECG changes and perfusion abnormalities, body surface maps were recorded during dipyridamole infusion in 55 subjects (11 normals and 44 patients with ischaemic heart disease) undergoing dipyridamole technetium-99m sestamibi single-photon emission tomography (SPET). All had a normal resting ECG. The extent and severity of the sestamibi defect were quantified. New negative areas in the isointegral maps and rest-dipyridamole map differences >2 SD from normal limits were considered abnormal. After dipyridamole in normals, neither perfusion defects nor >/=1 mm ST segment depression on 12-lead ECG nor new negative areas in isointegral maps occurred. In patients, dipyridamole induced new perfusion defects in 35 (80%) but ST segment depression in only 18 (41%, P<0.001). Of the 35 patients with perfusion defects, 17 (49%, group 1) showed ST segment depression, while the other 18 (51%, group 2) did not. Abnormal body surface maps were found in 100% of group 1 and 88% of group 2 patients (NS). In group 1, the provoked hypoperfusion was of greater extent (P=0.007) and severity (P=0.01) and the onset of map abnormalities was significantly earlier (P<0. 001) than in group 2; time to map abnormalities was also significantly shorter than time to ST segment depression (P=0.01). In the 35 patients with complete scintigraphic, body map and angiographic data, the severity of reversible perfusion defect proved to be the strongest correlate of ST segment depression upon logistic regression analysis. Thus, sestamibi SPET abnormalities after dipyridamole are almost always associated with electrical changes on body surface maps, suggesting myocardial ischaemia as their cause. The much less common 12-lead ECG changes are slower to appear and reflect a more severe hypoperfusion.