Feasibility study for the introduction of a new treatment method for benign thyroid nodules in a teaching and research hospital.

RATIONALE, AIMS AND OBJECTIVES: Numerous scientific publications have confirmed that percutaneous laser thermal ablation (LTA) represents a possible therapeutic option in selected patients with benign thyroid nodules. A study was carried out to evaluate the feasibility of adopting the LTA technique to treat benign thyroid nodules in a teaching and research hospital in northern Italy. METHODS: A cost analysis from a company's perspective determined the impact of adoption of the new technique on the overall Hospital budget, considering currently available equipment, infrastructure and personnel, equipment costs and treatment tariffs. RESULTS: The cost analysis shows that, strictly from an economic point of view, any provision of the LTA technique will result as a loss on the Hospital's balance sheet. However, it does not estimate the extent of the impact on the overall budget because it did not evaluate the savings that such a technique would make with respect to alternative therapeutic treatments. Therefore, the Hospital policy management decided to extend the current agreement with a private authorized health care structure that already carries out LTA. Also, although difficult to express in economic terms, this new technique would undoubtedly raise the profile and enhance the reputation of the Hospital. CONCLUSIONS: Using the new technique in these patients could cut costs for the entire regional health care system, widen the experience of the Hospital's endocrinology team and offer the potential for the procedure also to be provided by operators on a freelance basis within the Hospital.

[New role for hospital department directors in a Milan hospital, Italy]. / Nuovo ruolo del dipartimento nell'ospedale per aree omogenee.

In Italy, the hospital departmental model was introduced over 30 years ago with the aim of fostering collaboration between wards and promoting the appropriate use of resources. However, these objectives have not been consistently met. For this reason, the Strategic Direction of the hospital "Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico" in Milan has proposed a new model in which department directors are given a more active role in hospital management and actively participate in decision-making processes.

[A new Emergency Department case management model for nonurgent patients]. / Un nuovo modello di gestione dei pazienti "non urgenti" in Pronto Soccorso.

Emergency Department visits for nonurgent conditions are very widespread and new strategies to provide timely and appropriate medical care for these patients are required. The "Fondazione IRCCS Ca 'Grande" Hospital in Milan, in collaboration with the local health authorities have evaluated a new case management model in which patients classed as nonurgent at triage are diverted to a "continuity of care" outpatient office within the emergency department. This model, based on the integration of hospital and community-based primary healthcare, was effective and led to a significant reduction in waiting times in the ED and to a more appropriate use of resources.

Prevalence and correlates of echocardiographic left atrial enlargement in hypertensive outpatients in clinical practice.

Prevalence of left atrial enlargement (LAE) in hypertension has been mostly assessed in population-based samples and selected hypertensive groups. A few data are available in clinical practice. We examined LAE prevalence and severity in a cohort of hypertensive patients referred by general practitioners to a routine echocardiographic examination. A total of 2170 hypertensive individuals (mean age 62 years, 53% men) referred by practitioners to 17 outpatient echocardiographic laboratories across Italy for detection of hypertensive cardiac disease were included in the study. LAE was defined as: A) absolute LA diameter >4.0 cm in men and >3.8 cm in women; B) LA diameter normalized to body surface area (BSA) >2.3 cm/m(2) in both sexes. Left atrial enlargement was graded as mild, moderate, and severe according to Lang's report. Patients with LAE were 38% by criterion A, and 20% by criterion B. A moderate/severe increase in LA size was present in 34% (A) and 32% (B) of patients with LAE. Severe LAE was 3.3-fold (A) and 2.6-fold (B) more frequent in women than in men. Left ventricular mass was the strongest correlate of absolute LA diameter as well as of normalized LA diameter, after age. Left atrial enlargement defined either by absolute or normalized LA diameter is a frequent cardiac phenotype in hypertensive patients referred to echo-labs in clinical practice. This cardiac parameter is closely related to LV mass and its severity is highly prevalent in women.

Self-reported weight and height: implications for left ventricular hypertrophy detection. An Italian multi-center study.

We examined the difference between self-reported and measured body size values and their impact on detection of left ventricular hypertrophy (LVH) by echocardiographic LV mass indexation. A total of 1963 subjects referred by their practitioners for routine echocardiographic examination to nine outpatient echocardiographic laboratories across Italy were included in the study. Left ventricular hypertrophy was defined according to two gender- specific criteria as: A) Left ventricular mass (LVM) index ≥49 g/h(2.7) in men and ≥45 g/h(2.7) in women; B) LVM index ≥125 g/m(2) in men and ≥110 g/m(2) in women. Prevalence of LVH was calculated by indexing LVM to both self-reported and measured anthropometric values. In the whole population, LVH tended to be underestimated by self-reported values by 5.4% according to criterion A (48.5% vs. 53.9%, p < 0.001) and by 1.2% according to criterion B (29.6% vs. 30.8%, p < 0.01); similar findings were observed in the hypertensive subgroup encompassing one-half of the sample. Underestimation of LVH was more pronounced in older patients than in younger patients: 8.6% vs. 3.2% (p < 0.001) by criterion A, 3.1% vs. 0.1% (p < 0.001) by criterion B, in women than in men (8.6% vs. 3.3% (p < 0.001) by criterion A and 1.8% vs. 0.5% (p < 0.01) by criterion B. In a sample of outpatients attending echocardiographic laboratories, LVH is misclassified when left ventricular mass is normalized to self-reported weight and height. The error is related to the clinical characteristics of patients and is more pronounced when LVM is normalized to height(2.7).

Prevalence and severity of echocardiographic left ventricular hypertrophy in hypertensive patients in clinical practice.

BACKGROUND AND AIM: The prevalence of left ventricular hypertrophy (LVH) in human hypertension has been mostly documented in population-based samples and selected hypertensive cohorts. Rather scant data are available from clinical practice. Thus, we examined the prevalence of LVH in a large group of hypertensive patients referred by general practitioners to a routine echocardiographic examination. METHODS: A total of 2249 hypertensive subjects (mean age 62 years, 52.3% men, 84.5% treated) referred by their practitioners to 17 outpatient echocardiographic laboratories across Italy for detection of hypertensive early cardiac damage were included in the study. LVH was defined as left ventricular mass (A) ≥ 225/163 g, (B) ≥ 116/96 g/m(2), (C) ≥ 49/45 g/m(2.7) in men/women, respectively; LVH was graded as mild, moderate and severe according to Lang's report. RESULTS: Overall, patients with LVH were 58%, 58% and 65% by criteria A, B and C, respectively. LVH was mild in 33% (A), 36% (B) and 29% (C), moderate in 31% (A), 28% (B) and 27% (C), and severe in 36% (A), 36% (B) and 44% (C). CONCLUSIONS: Data provided by this multicentre nationwide survey support the view that, despite therapeutic interventions, LVH remains a highly frequent phenotype in human hypertension and that severe LVH is present in a large fraction of hypertensives.

[A new setting of opportunistic cardiovascular screening: from blood donation to preventive cardiology. Preliminary results of the Cardiorisk program]. / Un nuovo modello di screening cardiovascolare di opportunità: dalla donazione di sangue alla cardiologia preventiva. Primi risultati del programma Cardiorisk.

BACKGROUND: Cardiovascular diseases remain the leading cause of mortality and disability in developed countries. Therefore, it is necessary to increase a policy of primary prevention. The most recent European guidelines recommend the use of the absolute risk profile as a tool to identify high-risk individuals, but also underline the need for interventions on the whole population. They also mentioned the concept of opportunistic screening for cardio- and cerebrovascular risk factors. METHODS: From September 2004 to December 2008, 13 619 consecutive blood donors were evaluated to determine the absolute risk profile by using the CUORE Project score. Inclusion criteria were age between 35 and 69 years, no evidence of cardiovascular disease, 12 h fasting, and informed consent. All blood donors underwent physical examination and blood tests. The absolute risk profile system includes 8 variables: age, gender, diabetes, smoking habit, systolic blood pressure, total and HDL cholesterol, and antihypertensive therapy. The population was classified into five risk categories (<5%; 5-10%; 10-15%; 15-20%; > or =20%). The results were analyzed according to age and gender. RESULTS: The mean risk score was 2.9 +/- 3 in men and 0.8 +/- 1.04 in women. Furthermore, the proportion of subjects at low risk was high even in the most advanced age groups in both sexes, differently from the general population. In particular, in young and female subjects the risk score did not exceed 20%. The proportion of men at high risk increased in adulthood, varying between 0.5% in the 50-59 age range to 4% in subjects > or =60 years. CONCLUSIONS: Our results demonstrate the feasibility of a primary cardiovascular prevention program in a new opportunistic setting, not assessed previously. The implementation of this program is a valuable tool not only to identify high-risk subjects but also to maintain a favorable risk profile in low-risk subjects over time.

Does echocardiography play a role in the clinical diagnosis of congenital absence of pericardium? A case presentation and a systematic review.

Congenital absence of pericardium is an uncommon cardiac defect with variable clinical presentations. The detection of this malformation is clinically relevant because of potential complications such as fatal myocardial strangulation, myocardial ischemia and sudden death. Physical examination, chest radiograph and ECG are not helpful for the diagnosis. Echocardiography may accurately identify abnormalities in myocardial wall motion and in cardiac silhouette that may strongly suggest the diagnosis that is confirmed by magnetic resonance imaging (MRI) or computed tomography scan. A case presentation and a review of the literature with emphasis on the role of echocardiography are presented.

Cross-sectional epidemiological study to evaluate the cardiovascular profile of a cohort of blood donors.

BACKGROUND: Cardiovascular diseases are among the most frequent causes of mortality and morbidity in industrialised countries. The identification of subjects at high risk of cardiovascular diseases is one of the main aims of individual primary prevention programmes and is the essential background for instituting interventions aimed at reducing modifiable risk factors, from lifestyle changes to pharmacological interventions. DONORS AND METHOD: In order to evaluate the absolute global risk of cardiovascular disease in the population of blood donors of the Transfusion and Immunohaematology Centre of the Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena of Milan, we used the absolute global cardiovascular risk (CVR) score of the Progetto Cuore. Between September 2004 and June 2006, 11,093 blood donors were evaluated for their suitability for donating blood. The criteria for inclusion in the calculation of the individual values of the absolute global CVR score were: age between 35 and 65 years old, fasted for at least 12 hours, and no previous reported or diagnosed cardiovascular episodes. Each donor was also asked to provide written informed consent to participation in the study. THE POPULATION OF BLOOD DONORS WAS DIVIDED INTO FOUR GROUPS ACCORDING TO THEIR CVR SCORE: CVR < 3%, CVR between 3% and 10%, CVR between 10% and 20%; CVR above 20%. The characteristics of the population were analysed subdividing the subjects according to age and gender. RESULTS: Although most of the blood donors belonged to the group with low CVR, it was nevertheless possible to identify a group of donors with high CVR. CONCLUSIONS: It is to be hoped that CVR is calculated ever more widely in the population of blood donors in order to identify individuals at high CVR and also with the aim of reducing the levels of risk factors in the population with low or moderate CVR.

In patients with severe systolic dysfunction, only brain natriuretic peptide is related to diastolic restrictive pattern.

BACKGROUND: In patients with severe systolic dysfunction the relationship between diastolic dysfunction and plasma levels of atrial and brain natriuretic peptide (ANP, BNP), catecholamines, renin, and aldosterone in patients with chronic heart failure (CHF) has never been investigated. OBJECTIVES: The aim of this study was to evaluate in clinically stable patients with severe systolic dysfunction whether the presence of diastolic restrictive pattern modifies neurohormonal plasma levels. METHODS: Of 82 consecutive patients with stable CHF, 36 were in sinus rhythm, had an adequate ultrasound window and an ejection fraction <30%, and gave their written consent. Plasma levels of ANP, BNP, aldosterone, renin, epinephrine, and norepinephrine were assessed, and the diastolic function was evaluated by Doppler transmitral flow velocity curves. RESULTS: Except for aldosterone, plasma levels of the other hormones were above normal range in most patients. Patients with restrictive pattern (22%) had BNP plasma levels significantly higher than patients with nonrestrictive pattern (78%): 251 +/- 196 versus 44 +/- 35 ng/L (P=.02). A BNP value of 72.6 ng/L had a sensitivity of 88%, with a specificity of 89% for detecting restrictive pattern in our population. CONCLUSION: In clinically stable patients with CHF and severe systolic dysfunction, BNP is the only neurohormone sensitive to the concomitant presence of a restrictive pattern.