[Italian validation of the Prolonged Grief Disorder Questionnaire (PG-12)]. / Validazione italiana del Questionario Prolonged Grief Disorder (PG-12).

Death or severe invalidity (e.g. vegetative state) of a family member causes deep emotional distress to the caregiver. In most cases elaboration of mourning at the loss unfolds in physiological times and modes, enabling the caregiver to react to the separation and resume their own daily life. In some cases, however, there is an incapacity to react and caregivers remain imprisoned in a condition they are unable to elaborate consisting of memories, regrets and a sense of guilt, that leads to their self isolation and prevents them from leading a full life as prior to the grief-causing event. This condition, not always classifiable as a major depressive disorder, is, according to a recent debate, more adequately described as the "Prolonged Grief Disorder". The Prolonged Grief Disorder is a new diagnostic category, currently under examination in America for inclusion in the DSM V in order to give clinicians a picture that better describes the condition of these caregivers. The PG-12 is a questionnaire that is easy and quick to administer and score which can guide the clinician in the diagnosis of this condition. The present paper presents the methodology followed for the translation into Italian of this instrument and the data that emerged concerning its validity and applicability. 45 caregivers of vegetative state patients were enrolled. The PG-12 Italian version showed good internal consistency (Cronbach alpha = 0.88) and a mono factorial structure.

[Vegetative state and over-treatment: what families think of it]. / Stato vegetativo e accanimento terapeutico: cosa ne pensano i familiari.

With the notable advances made in all branches of medicine doctors are now increasingly faced with issues no longer of a purely clinical nature but of an ethical and moral nature. Chronic diseases, terminal conditions, and the vegetative state are just some of the many examples of clinical conditions that impose on health professionals the need to reflect (and make decisions?) on ethical matters. The instruments that medicine places in the hands of the health professional must lead them to reflect not only on the clinical validity of a choice but also on how opportune it is to undertake a given intervention, on the proportionality of the intervention. There is an increasing need to calibrate interventions between 'opportune' and 'excessive'. To do this, technical expertise is not sufficient; other factors come into play that are more personal and difficult to standardize concerning the meaning itself of life and its quality. Alongside the technical-scientific opinions of the medical professional, the voice of family members must also be taken into account. A voice whose tone is deepened by the burden of caring, by the painful situation they are experiencing, by the difficulty of understanding a technical language they are not conversant with. The present study is a preliminary investigation carried out on 32 family caregivers of patients in minimally responsive or vegetative states in either long-term hospital structures or home care. Family caregivers were investigated concerning their understanding of the concept of over-treatment and which aspects of the patient's daily life could, in their opinion, be considered as over-treatment. Findings show that the concept of over-treatment is not well understood by families, even if almost all subjects declared to be contrary to over-treatment. Considering the health interventions in detail, however, family caregivers were of the opinion that all possible medical acts were opportune and necessary, even when they appear to be particularly invasive interventions, such as defibrillation manoeuvres.

[Severe and prolonged post-dural puncture headache: from pathological basis to therapeutic role and correct timing for epidural blood patch]. / Cefalea da deliquorazione grave e protratta: dal riconoscimento del substrato organico al ruolo terapeutico e alla corretta temporizzazione del blood patch peridurale.

Believed to be due to unbalance between cerebrospinal fluid (CSF) production rate and its loss through the spinal dural puncture hole, post-dural puncture headache (PDPH) is often considered as a physiological syndrome, usually reversible without pathological sequelae after dural hole's closure. The clinical case here presented (incapacitating headache associated with diagnostic dural puncture in a leukaemic young female patient who underwent bone marrow transplantation) shows potentially fatal pathological sequelae following prolonged headache (untreated, due to the severe postransplant immunodeficiency and coagulopathy). The observed RMI lesions suggest interesting conclusions about the clinical indications and correct timing of autologous epidural blood patch (EBP). We also suggest the ways to preventing rebound intracranial hypertension following autologous epidural blood patch in patients suffering from incapacitating and prolonged headache.

[Determination of the best amino acid input after orthotopic liver transplantation]. / Determinazione dell'apporto aminoacidico ottimale dopo trapianto ortotopico di fegato.

Ten-three patients were investigated during the early postoperative phase after orthotopic liver transplantation to assess the adequacy of the amino acid (AA) supply during both parenteral (days 1-5) and enteral (days 6-9) nutrition. Plasma AA profile was determined preoperatively, on day 4 and 5 during TPN and on day 8 and 9 during EN, urea production rate was measured every day. Calories input was 28 kcal.kg-.day as glucose, nitrogen intake was 0.25 g.kg- day, supplying individual AA on the basis of previous studies. Urea nitrogen production during TPN (9-11 gN/m2.day) outlines the ability of the transplanted liver to manage the overall nitrogen load. Individual AA plasma profile was considered the expression of an adequate input when comprised between 1 and 1.5 times the normal value, in this respect we obtained adequate levels of all essential AAs. Particularly phenylalanine, methionine and branched chain AA, critical during liver failure, were kept in this range by supplying 68, 48 and 500 mg.kg-1.day. According to AA profile the supply of cystine and tyrosine (conditionally essential AAs), and of histidine, taurine, proline and serine could be safely increased. Not given dispensable AAs (glutamine, asparagine, citrulline and alfa amino butyric) showed a plasma level below the norm and should be added to the diet.

[Changes in the plasma amino acid profile in critically ill patients during total parenteral therapy]. / Variazioni del profilo aminoacidico plasmatico in pazienti critici durante terapia parenterale totale.

The aim of this study was to evaluate the kinetics of arterial plasma amino acid profile during the first 48 h of clinical TPN in order to assess the time necessary to reach the steady-state condition during infusion. Each patient was treated with one of three different amino acid solutions yielding, in the same nitrogen intake, different intakes of individual amino acids. We found four different kinetics for the administered amino acids: an increase of plasma levels immediately after the start of the TPN with no variations during the steady period; the same trend with the steady-state obtained after 6-24 h of TPN infusion; no influence at all; a decrease of fasting plasma levels with the steady-state attained variably during the study period. Each given amino acid showed a different trend partly depending on the supply, suggesting that the steady-state was reached sooner for most amino acids, when the supply was larger. With lower intakes, plasma levels were unaffected or decreased. We conclude that in critically ill patients at least 24 h are needed to obtain stable arterial plasma amino acid concentration during TPN with adequate intakes of amino acid. Knowledge offers the possibility for a quick and accurate assessment of the adequacy of a given preparation (tailored for critically ill patients), it reduces the time span of the study and, as a consequence, the influence of varied metabolic conditions.

[Kinetic study during amino acid infusion in catabolic patients. Comparison between two solutions]. / Studio cinetico durante infusione aminoacidica in pazienti catabolici. Confronto tra due soluzioni.

The equilibrium kinetic of two different amino acid solutions was investigated in ten catabolic patients (Parentamin, Pierrel; HBC, Baxter). Plasma amino acid pattern was determined on arterial samples before TPN and several times over 48 hours of TPN. Nitrogen balance was measured from 24 hours urine collection. Three different cinetic trends were found: a fast modification (diminution or increase), a slow adaptation, or no modification of plasmatic levels, however each amino acid reached a steady state plateau. The adequacy of the infusion of each amino acid was evaluated comparing its steady-state plasma level to the after lunch level in healthy man. This made possible to approximate metabolic needs of each of the infused amino acids and to identify the inadequacy of some metabolic pathways to synthetized non essential amino acids lacking in solutions. This made possible to identify amino acids infused in excess or in defect, and those infused in dose adapt to the metabolic needs of such patients.