Quality in emergency departments: a study on 3,285,440 admissions.

INTRODUCTION: A multi-centre study has been conducted, during 2005, by means of a questionnaire posted on the Italian Society of Emergency Medicine (SIMEU) web page. Our intention was to carry out an organisational and functional analysis of Italian Emergency Departments (ED) in order to pick out some macro-indicators of the activities performed. Participation was good, in that 69 ED (3,285,440 admissions to emergency services) responded to the questionnaire. METHODS: The study was based on 18 questions: 3 regarding the personnel of the ED, 2 regarding organisational and functional aspects, 5 on the activity of the ED, 7 on triage and 1 on the assessment of the quality perceived by the users of the ED. RESULTS AND CONCLUSION: The replies revealed that 91.30% of the ED were equipped with data-processing software, which, in 96.83% of cases, tracked the entire itinerary of the patient. About 48,000 patients/year used the ED: 76.72% were discharged and 18.31% were hospitalised. Observation Units were active in 81.16% of the ED examined. Triage programmes were in place in 92.75% of ED: in 75.81% of these, triage was performed throughout the entire itinerary of the patient; in 16.13% it was performed only symptom-based, and in 8.06% only on-call. Of the patients arriving at the ED, 24.19% were assigned a non-urgent triage code, 60.01% a urgent code, 14.30% a emergent code and 1.49% a life-threatening code. Waiting times were: 52.39 min for non-urgent patients, 40.26 min for urgent, 12.08 for emergent, and 1.19 for life-threatening patients.

Recurrent thromboembolism as a hallmark of Cushing's syndrome.

The present report describes a 54-year-old woman with a history of recurrent thromboembolic events. The clinical and physical examination led to suspect Cushing's syndrome. Screening tests (urinary free cortisol excretion and 1 mg dexamethasone) were inconclusive, but a detailed endocrine work up confirmed the presence of ACTH-dependent hypercortisolism. The patient was cured by the removal of a ACTH-secreting microadenoma by transsphenoidal route. The present case provides a clinical demonstration of a previous experimental evidence that a hypercoagulable state is present in Cushing's syndrome.

[Hypothyroidism with pseudo-ischemic and hypertensive clinical presentation: physiopathological and diagnostic considerations]. / Ipotiroidismo a presentazione clinica pseudo-ischemica ed ipertensiva: considerazioni fisiopatologiche e diagnostiche.

Serious primary hypothyroidism, disclosed fortuitously through routine thyroid function test derangements, was found in a 40-year-old woman admitted to the hospital with a tentative diagnosis of ischemic heart disease. The clinical picture and electrocardiographic alterations of pseudo-ischemic heart disease associated with hypertension, particularly diastolic, may be the only significant manifestations of hypothyroidism. Substitutive hormone replacement therapy enables a good prognosis for children and young adults. A diagnosis of hypothyroidism should be considered during the initial evaluation of pseudo-ischemic, hypertensive and hypercholesterolemic patients, even when no other signs or clinical symptoms of hormonal deficiency are evident. Particular attention should be paid to female patients, as they are much more frequently affected by thyroid pathologies.

Testicular feminization syndrome diagnosed in an elderly patient at surgery. A case report.

A case of Morris' syndrome in which the diagnosis has been realized only in old age is reported. A 69 year-old patient, with female external genitalia and secondary sexual characteristics, was referred to us with a diagnosis of a mass in the right inguinal region. Her personal history was based on a primary amenorrhoea, which was unsuccessfully investigated since she was adolescent. At the age of 63, during surgery for a left inguinal hernia realized in another hospital, a testis-like mass with the spermatic cord was casually found. During our hospitalization, a surgical removal of the right inguinal mass was performed, and the histologic examination showed the presence of a dominant sclerohyalin testicular tissue without evidence of seminal epithelium and sparse focuses of Leydig cells hyperplasia. Besides, the determination of gonadotropins and sex hormones yielded an increased production of LH, FSH, estradiol, testosterone and androstenedione. A cytogenetic analysis showed a 46, XY karyotype. The diagnosis realized only in old age has compelled the patient to live all her life, from sexual maturity, with indecision and doubt, and without a clinical explanation of fundamental utility even from the psychological point of view. Finally, in our patient the absence of cytologic aspect of malignant transformation in the removed testes in a six years period, seem fortuitous. It is always necessary to consider Morris' syndrome among the possible diseases causing primary amenorrhoea in the clinical evaluation of young phenotypic female patients.

[A case of disseminated bone tuberculosis in an aged patient]. / Un caso di tubercolosi ossea disseminata in una paziente anziana.

It is described the case of a 75-year-old woman admitted to the hospital for physical degeneration, serious decline in mental status and swelling in the pre-sternal region. The diagnosis of a severe, destructive and infrequent form of disseminated bone tuberculosis was made. This case underscores the risk of tuberculosis to which the elderly, in particular, are subject. Moreover, the lack of specificity of symptoms and laboratory findings and the presence of concomitant chronic pathologies can mask the clinical picture, rendering the hypothesis of tuberculosis highly improbable. Computed tomography studies of this patient also disclosed the seldom encountered finding of severe bone destruction, particularly of the vertebrae and sternum, caused by infiltration of caseating granulomas.

[Spontaneous dissection of the left vertebral artery in a young woman. A report and the diagnostic considerations of a case]. / Dissezione spontanea dell'arteria vertebrale sinistra in una giovane donna. Descrizione e considerazioni diagnostiche su un caso.

A case of spontaneous left vertebral artery dissection occurred in a 45-year-old woman is reported. The most important epidemiological, etiological, anatomopathological and clinical features of this disease are described. The authors, starting from the case observed, point out the usefulness of noninvasive diagnostic techniques such as duplex scanning, color duplex scanning and magnetic resonance angiography for the detection, monitoring, and follow-up of this pathological condition.

[A case of adrenal adenoma with radiologic "cystic" appearance associated with hypophyseal adenoma]. / Un caso di adenoma surrenalico di aspetto radiologico "cistico" associato ad adenoma ipofisario.

Expansive lesions of the adrenal glands without signs of hormonal hypersecretion are usually discovered "incidentally", and are therefore called "incidentalomas". Since the silent adrenal masses constitute a heterogeneous group of lesions, the most important issue raised by the identification of these masses is their possible malignant potential. Therefore, the age and sex of the patients, the size of the mass, its imaging characteristic and its histologic features are the most important factors in the assessment of nonfunctioning adrenal masses. We report here the case of a women, aged 43 years mild hypertension, harbouring a great adrenal mass of 8 cm diameter, with cystic appearance at CT scan and ultrasonography, it did not show any uptake after 75Se-Seleniumcholesterol or 131I-Metaiodobenzyl-guanidine. The patient was also affected by mild hyperprolactinemia caused a small pituitary adenoma. After selective venography, she underwent the surgical removal of the left adrenal gland with its mass, which showed a hystological picture of adrenal adenoma. The postoperative course was clinically normal. The interest of this case resides: in the dimensions of the adrenal tumor (the presence of adenomas greater than 6 cm diameter is extremely rare); in the radiographic findings, showing a cystic appearance, probably related to a fluid component, in the association of adrenal and pituitary adenoma, as a possible variant of multiple endocrine neoplasia (MEN) of type I.(ABSTRACT TRUNCATED AT 250 WORDS)

[Adrenal myelolipoma. Historical, etiopathogenetic, pathologic, clinical, epidemiologic and radiologic features. A case report]. / Il mielolipoma del surrene. Aspetti storici, eziopatogenetici, anatomopatologici, clinico-epidemiologici e radiologici. Presentazione di un caso clinico.

Adrenal myelolipoma is a rare, benign, non-functional tumor composed of fat and brown erythropoietic marrow in varying proportions. It is a rare clinical entity. Usually asymptomatic, in the majority of cases it is found incidentally at autopsy. The authors discuss the historical, etiopathogenetic, anatomo-pathological, clinical-epidemiological and radiological features. They also describe a case of myelolipoma of the right adrenal gland come to their observation.

GH response to GHRH before and after meals at different hours of the day in obese patients.

In normal subjects several factors are involved in the regulation of the GH response to GHRH, such as nutritional status, metabolic fuels and neurotransmitters. We previously have shown a paradoxical increase in the GH response to GHRH after meals in obese patients, in contrast to the blunted GH response observed after feeding in normal subjects. We have further investigated this phenomenon, studying the GH response to GHRH before and after meal at three different hours during the day in 10 obese patients, aged 18-35 yr, in comparison to that in eight normal women, aged 20-35 yr. GHRH was injected in a fasting state or 1 hr after a standard meal (800 KCal). In obese subjects, after food ingestion the peak GH response to GHRH was increased at 0900h and 1300h and was significant when the patients were tested after lunch (1300h). On the contrary, in the evening the GH response to GHRH remained unchanged, both before and after feeding. These data point to an altered sensitivity of GH secretion to metabolic signals in patients with obesity.

[Role of endogenous opioids in the modulation of hypophyseal hormone secretion]. / Ruolo degli oppioidi endogeni nella modulazione della secrezione ormonale ipofisaria.

The aim of the present study is to review current knowledge of the endogenous opiates in order to identify both their basic features and their receptors' properties, including the biological effects of their stimulation, and finally their endocrine actions. Since the identification of methionine-enkephalin and leucin-enkephalin, many opioid peptides with higher molecular weight have been characterized, and their origin from specific precursor has been recognized: proopiomelanocortin, preproenkephalin A, preproenkephalin B. In particular we have analyzed the pharmacological properties and the biological effects of beta-endorphin and met -and leu-enkephalins, the most diffuse of opioids. The use of naloxone has permitted the study of endogenous opioid tone and its effects on the release of the pituitary hormones. The present study reports a summary of data in the literature and personal observation indicating that the peripheral sexual steroids are the most important modulators of naloxone effects on endogenous opioid tone. Finally, the paper reports preliminary observations indicating that during naloxone infusion, females with hypothalamic amenorrhoea show a hormonal profile which differs from normal subjects.

[Antihypertensive efficacy and effects on quality of life of captopril in mild-to-moderate arterial hypertension]. / Efficacia anti-ipertensiva ed effetto sulla "qualità di vita" del captopril nell'ipertensione arteriosa di grado lieve-moderato.

The anti-hypertensive effectiveness and effect on the "quality of life" of captopril administered for 90 days to 17 patients suffering from mild-to-moderate arterial hypertension and already under anti-hypertensive treatment have been assessed. At the end of treatment with captopril, 76% of the patients attained normal pressure values. A diuretic was added in 7 patients. Average A.P. fell from 183 +/- 24/110 +/- 9 mmHg to 147 +/- 11/92 +/- 5 mmHg (p less than 0.001) without significant changes in heart rate. "Quality of life" was assessed on the basis of a questionnaire at the start and finish of treatment and it was reported improved after treatment with captopril compared to the previous pharmacological treatment. This improvement was particularly felt with respect to sense of wellbeing and capacity to perform working and recreation activity, and there was a reduction in physical disturbances.

[Hereditary xanthinuria. A clinical case report]. / Xantinuria ereditaria. Descrizione di un caso clinico.

A case of hereditary xanthinuria in a 68-year-old man with congestive heart failure and alcoholic liver disease is presented. Urolithiasis and muscular symptoms were absent, and the metabolic error was revealed by hypouricemia, hypouricosuria and excess of xanthine and hypoxanthine excretion in urine. Xanthine oxidase (EC 1.2.3.2) activity in liver tissue was absent, confirming the diagnosis of xanthinuria.

[Growth hormone-releasing hormone. The physiopathologic aspects and its diagnostic-therapeutic use]. / Growth hormone releasing hormone. Aspetti fisiopatologici ed impiego diagnostico-terapeutico.

The object of the present study is to review all that in the last years has been discovered about growth hormone-releasing hormone (GHRH), in order to point out both its physiopathological characteristics and its possible diagnostic and therapeutic use. In the first section are summarily reviewed the different studies that culminated in 1982 with the identification of three GRF: GRF(1-37)-OH, GRF(1-40)-OH and GRF(1-44)-NH2, the last of which, by immunohistochemical methods, resulted to be similar to the hypothalamic hGHRH. Then we describe the anatomic distribution of GHRH in man, and its mechanism of action at both receptor and postreceptor levels. On the other hand, the control of the GHRH secretion by peptidergic hypothalamic neurons occurs through four principal monoaminergic systems such as dopaminergic, noradrenergic, adrenergic and serotoninergic ones, and also by cholinergic fibers and by endogenous opiates, all acting to cause the release, into the hypothalamo-hypophyseal portal circulation, of GHRH. In the second section is attracted attention on the GHRH as a diagnostic agent in the two diseases that represent the main alterations of the GH secretion: acromegaly and short stature. According to the different studies considered, it may be concluded that GHRH testing has limited diagnostic usefulness in the clinical evaluation of acromegaly, but allows to discriminate acromegalic patients with ectopic production of GHRH from those with pituitary tumors. For what concerns short stature, the results of observation realized both in adult subjects and in children, all with GH deficiency, by exogenous administration of GHRH, have pointed out that the majority of the GH deficiency patients have hypothalamic disregulation, and not a pure pituitary deficiency as it has been supposed before GHRH discovery. In the third section is attracted attention on the GHRH as a therapeutic agent. Its possible use in the therapy of the children with GH deficiency is of considerable interest, above all in relation to the hypothalamic pathogenesis of their short stature.

Periovulatory plasma prolactin response to synthetic growth hormone-releasing hormone in normal women.

Following the demonstration of a positive prolactin (PRL) response to growth hormone-releasing hormone (GHRH) in acromegalic and anorexic women, we have injected GHRH (50 micrograms intravenously as a bolus) in normal women during various phases of their menstrual cycle in order to establish whether a positive response was present also in normal subjects. Synthetic GHRH 1-44 elicited a significant increase in circulating PRL levels in eight women studied during the periovulatory phase of the menstrual cycle. In contrast, no significant changes in circulating PRL levels after GHRH administration were found in nine women during the midfollicular phase or in five women during the midluteal phase. A temporal correlation between the midcycle gonadotropin peak and the positive response to GHRH has been observed. Synthetic GHRH elicited the expected increase in GH levels during all phases of the cycle studied. Our data demonstrate that GHRH is capable of stimulating a PRL response in normal subjects and raise the possibility that PRL secretion is regulated by several hormones of hypothalamic origin.