Three-Dimensional Evaluation of Soft Tissue Malar Modifications after Zygomatic Valgization Osteotomy via Geometrical Descriptors.

Patients with severe facial deformities present serious dysfunctionalities along with an unsatisfactory aesthetic facial appearance. Several methods have been proposed to specifically plan the interventions on the patient's needs, but none of these seem to achieve a sufficient level of accuracy in predicting the resulting facial appearance. In this context, a deep knowledge of what occurs in the face after bony movements in specific surgeries would give the possibility to develop more reliable systems. This study aims to propose a novel 3D approach for the evaluation of soft tissue zygomatic modifications after zygomatic osteotomy; geometrical descriptors usually involved in face analysis tasks, i.e., face recognition and facial expression recognition, are here applied to soft tissue malar region to detect changes in surface shape. As ground truth for zygomatic changes, a zygomatic openness angular measure is adopted. The results show a high sensibility of geometrical descriptors in detecting shape modification of the facial surface, outperforming the results obtained from the angular evaluation.

Sudden infant death syndrome: the role of multidisciplinary teams. Experience of the SIDS-ALTE Center of Liguria Region.

The aim of this paper was to highlight the importance of a multidisciplinary and multiprofessional management of SIDS for a complete approach to this tragic event. Both biomedical and psychosocial aspects are evaluated, focusing on the impact of SIDS diagnosis on the family. The paper describes the organization of our team, composed of a network of specialists involved in both prevention and management of SIDS. A protocol is proposed to improve SIDS diagnosis and management. In our team, the clinical pediatrician is the coordinator of specialists and the mediator between the family and the other specialists, thanks to his direct relationship with parents.

Thirty-day readmission rates after PCI in a metropolitan center in Europe: incidence and impact on prognosis.

INTRODUCTION: Thirty-day readmission rates after percutaneous coronary intervention (PCI) have been related to adverse prognosis, and represent one of the most investigated indicators of quality of care. These data, however, derive from non-European centers evaluating all-cause readmissions, without stratification for diagnosis. METHODS: All consecutive patients undergoing PCI at our center from January 2009 to December 2011 were enrolled. Thirty-day readmissions related to postinfarction angina, myocardial infarction, unstable angina or heart failure were defined as acute coronary syndrome (ACS) or heart failure rehospitalizations. Major cardiac adverse event (MACE) was the primary outcome, and its single components (death, myocardial infarction and repeated revascularization) the secondary ones. RESULTS: A total of 1192 patients were included; among them, 53 (4.7%) were readmitted within 30 days, and 25 (2.1%) were classified as ACS/heart failure related. During hospitalization, patients with ACS/heart failure readmissions were more likely to suffer a periprocedural myocardial infarction (22 vs. 4%; P = 0.012), and to undergo PCI at 30 days (52 vs. 0.5%; P < 0.001). Logistic regression analysis indicated that periprocedural myocardial infarction represented the only independent predictor of an ACS/heart failure readmission [odds ratio (OR) 4.5; 1.1-16.8; P = 0.047]. After a median follow-up of 787 days (434-1027; first and third quartiles), patients with a 30-day ACS/heart failure readmission experienced higher rates of MACE, all-cause death and myocardial infarction (64 vs. 21%, P < 0.001; 28 vs. 6%, P = 0.017; and 20 vs. 2.7%, P < 0.001, respectively). Cox multivariate analysis indicated that ACS/heart failure 30-day readmissions were independently related to an increased risk of all-cause death (OR 3.3; 1.1-8.8; P = 0.02), differently from 30-day non-ACS/heart failure readmissions (OR 3.1; 0.7-12.9; P = 0.12). CONCLUSION: Thirty-day readmissions after PCI in an Italian center are infrequent, and only those patients with ACS/heart failure show a detrimental impact on prognosis who have periprocedural myocardial infarction as the only independent predictor.

Studying factors related to pressure ulcers prevention: a marginal scale model for modelling heterogeneity among hospitals.

RATIONALE, AIMS AND OBJECTIVES: The purpose of this study was to analyse risk factors associated with the presence of pressure ulcer development in patients referred to several Italian hospitals, taking properly into account the within-hospital outcome correlation. METHODS: We analysed data from a prevalence survey coordinated by the European Pressure Ulcer Advisory Panel on 12,000 hospitalized patients in Italy, collecting information on patient's risk, presence of ulcers and prevention measures. The article describes the bases which generalized estimating equations rely on as well as their statistical properties. The article compares different model specifications in the light of background knowledge of the survey data and model assumptions, and discusses the potential for this modelling approach to apply in similar statistical situations. RESULTS: In accordance with existing literature, factors associated with pressure ulcers in hospitalized patients were identified as Braden scale, age and assistance-connected aspects. Between-hospital variability seemed to be explained by the adopted degree of prevention (use of preventive equipment combined with a repositioning strategy). CONCLUSIONS: Modelling the covariance matrix or the scale argument of the correlated binary responses (presence/absence of pressure ulcers) by using moment estimators based on generalized estimating equations prevents optimistic inference and provides an important insight into the role of structural differences among hospitals.

An economic evaluation of water birth: the cost-effectiveness of mother well-being.

PURPOSE: To assess the cost-effectiveness of water compared with normal land delivery. METHODS: A retrospective controlled study was conducted over a two-year period in a Northern Italian hospital. The cohort included all the 110 women who completed a water birth and 110 women who had a land birth during the same period. The two groups were compared with respect to labour duration, perineal tear and newborn's health status. The economic evaluation adopted a cost-effectiveness approach in relation to presence/absence of perineal tears. RESULTS: In the water delivery group 58 women (52.7%) experienced at least one perineal tear versus 80 (72.7%) in the traditional delivery group. The mean duration of labour was similar in the two groups. Neonatal well-being, expressed as Apgar score, did not differ significantly among the two groups at the first minute (9.48 vs. 9.28) and was slightly higher at 5 minutes in the water delivery group (9.95 vs. 9.84; P = 0.0269). Water delivery was found to be both more costly [ΔC = €279; 95% confidence interval (CI): 262-296] and more effective in terms of avoided perineal tears. The incremental health care cost per avoided perineal tear because of water delivery was estimated of €1395.7 (95% CI: 1049.2-3608.5). CONCLUSION: Water birth, as compared with traditional delivery, allows for an increase in maternal well-being and is cost-effective.

Impact of advanced exercise ECG analysis on cost of coronary artery disease management.

BACKGROUND: Conventional analysis of exercise electrocardiogram (EX-ECG) has limited accuracy. This study aims to evaluate the potential impact of improving EX-ECG accuracy on costs of diagnosis and number of misdiagnoses of coronary artery disease (CAD). METHODS: A decision-tree model was simulated including sequential application of diagnostic procedures for suspected CAD. The model was structured in two main branches (presence or absence of CAD). A probabilistic sensitivity analysis was then performed for several combinations of improvement in test sensitivity and specificity. RESULTS: A clear trend in cost reduction was observed at improving EX-ECG specificity (about 8-8.5 million dollars, corresponding to a 5.6-7.6% reduction according to the prevalence level). Wrong diagnoses counted for 9-13% of test. Improvements in test parameters lead to reductions in wrong diagnoses, especially when increasing specificity (8.8-12.5%). CONCLUSIONS: A proper improvement in EX-ECG sensitivity and specificity would have a relevant impact on the costs of CAD management, while reducing the number of misdiagnoses.

Predictors of treatment failures during chemotherapy: A prospective study on 110 older cancer patients.

Several instruments have been proposed to improve treatment decisions in elderly cancer patients, but evidence of their impact in clinical practice is limited. The aim of this study was to analyze the role of clinical and functional factors in predicting serious adverse events, including death, severe toxicity or treatment interruption, during chemotherapy in elderly cancer patients. The survey evaluated elderly with lung or colon or breast cancer treated with chemotherapy, followed by S. Giovanni Battista Hospital. We enrolled 110 consecutive patients older than 70 years of age with lung (n=45), colon (n=50) and breast (n=15) cancer between October 2004 and October 2005. Overall, 73/110 patients (66.4%) experienced adverse events as death (n=14), grades III and IV toxicity (n=40), or treatment interruption for other reasons (n=19). The variables with stronger predictivity were advanced stage, toxicity of treatment, level of comorbidity and Karnofsky performance status (KPS). instrumental activities of daily living (IADL) index and age itself were not independent predictors. In conclusion our results confirm the need of a careful selection of elderly patients suitable for chemotherapy, giving more weight to comorbidity and KPS scores than to age itself. The potential role of other functional evaluations need to be further assessed in randomized controlled trials.

Information on center characteristics as costs' determinants in multicenter clinical trials: is modeling center effect worth the effort?

OBJECTIVES: Several methodological problems arise when health outcomes and resource utilization are collected at different sites. To avoid misleading conclusions in multi-center economic evaluations the center effect needs to be taken into adequate consideration. The aim of this article is to compare several models, which make use of a different amount of information about the enrolling center. METHODS: To model the association of total medical costs with the levels of two sets of covariates, one at patient and one at center level, we considered four statistical models, based on the Gamma model in the class of the Generalized Linear Models with a log link, which use different amount of information on the enrolling centers. Models were applied to Cost of Strategies after Myocardial Infarction data, an international randomized trial on costs of uncomplicated acute myocardial infarction (AMI). RESULTS: The simple center effect adjustment based on a single random effect results in a more conservative estimation of the parameters as compared with approaches which make use of deeper information on the centers characteristics. CONCLUSIONS: This study shows, with reference to a real multicenter trial, that center information cannot be neglected and should be collected and inserted in the analysis, better in combination with one or more random effect, taking into account in this way also the heterogeneity among centers because of unobserved centers characteristics.

[Methodological aspects in valuing loss of production and informal care in cost-of-illness studies]. / Indicazioni metodologiche per la valorizzazione economica della perdita di produttività e dell'informal care nella stima dei costi di malattia.

Estimating costs of illness in social terms requires the consideration of the loss of production costs due to absence from work. Costs related to informal care should also be counted. Costs due to the loss of production are valued through the human capital method and the frictional costs method. Opportunity cost and proxy good methods are utilized for the informal care. Our study highlights practical issues about the use of a variety of methods and points out their main limits.

Guidelines for preoperative assessment: impact on clinical practice and costs.

OBJECTIVE: To describe preoperative evaluation in the San Giovanni Battista Hospital in Turin and to forecast the economic impact when preoperative assessment guidelines are implemented. DESIGN: We enrolled, in a month, 702 consecutive patients, excluding cardiac, thoracic, neuro- and vascular surgery, as well as emergency operations. Preoperative assessment data were collected individually, followed by simulating various applications of guidelines based on: (i) preoperative tests relying on full medical history and physical examination to discriminate preoperative risk patients; (ii) organization of a preoperative evaluation unit and tests before patient hospitalization. MAIN MEASURES: Mean number of tests prescribed, preoperative assessment cost per patient. RESULTS: The application of preoperative guidelines would decrease the mean number of tests prescribed from 20 laboratory and 1.9 instrumental to, respectively, 3 and 1.4 per patient. Tests deemed inappropriate by guidelines did not add any relevant clinical information to our study. Economic analysis estimates a reduction of 63% in cost per patient for preoperative tests by introducing guideline criteria (from 69 euros to 26 euros). As regards the cost per patient for preoperative evaluation and hospital stay (115 euros considering only variable costs, 580 euros including all costs), the application of the guidelines would reduce costs by 41-52% according to different cost evaluation approaches for hospital stay. CONCLUSION: Preoperative guidelines fully introduced in practice could notably increase efficiency without affecting the quality of care.