Neurological recovery after out-of-hospital cardiac arrest: hospital admission predictors and one-year survival in an urban cardiac network experience.

AIM: The aim of the study was to detect early predictors of neurological recovery and evaluate one year survival related to neurological status at discharge in patients (pts) admitted after out of hospital cardiac arrest (OHCA). METHODS: Sixty-three consecutive pts with OHCA from any cardiac cause, admitted to our cardiac intensive care unit, were classified according to survival and cerebral performance category (CPC) scale from 1 to 4 at hospital discharge. Pre-hospital and emergency room (ER) variables were analyzed to identify early predictors of neurological recovery as defined CPC=1-2. RESULTS: Overall in-hospital survival was 60%. Sixty-eight and 32% of survivors were classified as CPC 1-2 and CPC 3-4 respectively. During one year follow-up 96% of patients classified as CPC 1-2 survived and 100% of CPC 3-4 died. Emergency crew witnessing, performance of cardio pulmonary resuscitation (CPR) by witnesses, the call for chest pain, no history of heart disease and a Glasgow coma scale (GCS) of ≥9 on arrival to the ER, were more frequent in patients classified as CPC 1-2 and times from "OHCA to return of spontaneous circulation (ROSC)", from "emergency medical system (EMS) arrival to ROSC" and "first DC shock to ROSC" were also significantly shorter in these patients. The time of first DC shock to ROSC in pts who presented with rhythm in ventricular fibrillation and the time from OHCA to ROSC in pts with witnessed OHCA were an independent predictors of neurological recovery. CONCLUSION: Forty-one percent of pts admitted to our tertiary centre after OHCA were discharged with CPC 1-2 and at one year follow-up 96% of these were alive, while all pts classified as CPC 3-4 died. Easily documented information such as the time from OHCA to ROSC and the time of first shock to ROSC are early independent predictors of neurological recovery.

Predicting haemorrhage in pre-hospital traumatic patients: evaluation of the novel heart-to-arm time index.

BACKGROUND: Early recognition of hypovolaemia in trauma patients is very important. However, the most often used clinical signs, such as hypotension and tachycardia, lack specificity and sensitivity. METHODS: We propose a non-invasive index of hypovolaemia, the heart to arm time (iHAT), based on a modified pulse transit time indexed to heart rate. Pulse transit time is the sum of pre-ejection period and vascular transit time. Following pre-load reductions due to hypovolaemia, ventricular diastolic filling time increases causing an increase in pre-ejection-period, pulse transit time, and hence iHAT. One hundred and four consecutive patients with suspected major trauma were enrolled. The primary aim was to evaluate the use of the iHAT for detecting haemorrhage in major trauma. The secondary end point was to compare the specificity and sensitivity of iHAT compared to commonly used indexes. RESULTS: iHAT was calculated in 84 subjects, 11 of whom were haemorrhagic. iHAT discriminated haemorrhagic from non-haemorrhagic group (46.8% vs. 66.9%, P < 0.0001). The cut-off for iHAT with the best compromise between sensitivity (90.9%) and specificity (100%) was reached at the 58.78% level. Comparing haemorrhagic and non-haemorrhagic patients, the area under the ROC curve was 0.952 for iHAT, 0.835 for heart rate, and 0.911 for systolic blood pressure, showing no significant differences. CONCLUSIONS: iHAT is a non-invasive index that can identify haemorrhage in trauma patients with high sensitivity and specificity. These data should be considered as an exploration, but any conclusion should be validated in a new set of consecutive patients.

[Implementation of parliamentary act D. Lgs 25/02 and definition of "moderate risk"]. / Applicazione del D.Lgs 25/02 e definizione di "rischio moderato".

This paper describes the position of the Joint Working Group of the Italian Association of Industrial Hygienists (AIDII), the Italian Society of Occupational Health and Industrial Hygiene (SIMLII) and the Italian Society of Toxicology (SITOX) on "Analysis of Parliamentary Act D.Lgs 25/02 and role of the Scientific Societies in the definition of Limit Values". The positive aspects of the new law which implements the European Directive 98/24 are discussed, including the abolition of the rigid periodicity of medical examinations as stated by the old rule D.P.R. 303/56. The Authors also address various parts of the law which appear to be unclear and controversial and highlight the expected difficulties arising for the employers and the safety and health professionals during the application of this new piece of legislation. Moreover, a number of discrepancies are noted between the new Italian law and the original Directive or other current Italian rules such as i. the translation of the term "slight risk", as from the original Directive, into "moderate risk", and the resulting non compulsoriness of health surveillance and biological monitoring of the workers in presence of a "moderate risk", ii. the concurrent exclusion, under the same circumstances, of the occupational physician from risk assessment procedures and iii. the upward modification of the previously established (D.Lgs 277/91) occupational exposure limits for lead. Moreover, the Authors examine and criticize--both in semantic and in toxicological terms--a recent proposal for the definition of "moderate risk" made by an ad hoc Consulting Committee of the Labour Ministry, in which the term "moderate" has been interpreted either as "low" or as "irrelevant for health effects", clearly two very different meanings. Besides, it would be inappropriate to define the conditions of a moderate risk based only on the level of exposure to the chemical (expressed as a fraction of the corresponding limit value), without considering the two other components of risk assessment for that chemical (hazard and susceptibility). Even worse would be the use of simplified models based on "algorithms", which might be useful in a preliminary phase of risk assessment, but easily could lead to an under- or over-estimation of risk, particularly when used by non professionals. In conclusion, the Working Group recommend that the new law be amended in order to clarify its most controversial aspects, whose misinterpretation could severely jeopardize the protection of the workers' safety and health at work.

[The role and chronobiometric study of ambulatory arterial pressure monitoring in hypertensive patients with a recent cerebral ischemia episode]. / Ruolo e studio cronobiometrico del monitoraggio ambulatoriale della pressione arteriosa in pazienti ipertesi con recente episodio ischemico cerebrale.

Essential hypertensive patients with a history of recent TIA syndrome were investigated by ambulatory blood pressure monitoring (ABPM). The aim of this trial was to verify the presence of false normotensive patients in order to optimize the secondary prevention of hypertensive cerebrovascular damage (ischemic or hemorrhagic stroke). This study was carried out on 51 patients (26 M and 25 F, mean age = 58 +/- 14 yrs) and 225 clinically healthy control subjects (113 M and 112 F, mean age = 55 +/- 12 yrs), who underwent an ABPM. The BP time series were analyzed by chronobiometric procedures. The comparison of the individual BP within-day values to the reference limit revealed a highly significant proportion of these patients (90%) whose hypertension was not well controlled. Their BP series showed supranormal values ranging from 39% to 56% of all the readings, with a pressure excess ranging from 8.35 h to 11.34 h. The high incidence of not adequately treated patients with a history of recent TIA syndrome confirms that their hypertension should be controlled by means of the ABPM. These results suggest that the chronomodulation of the antihypertensive treatment might be the better management of BP regimen in these patients for the secondary prevention of cerebrovascular damage.

[Primary gastric lymphoma. 14 clinical cases]. / Linfoma gastrico primitivo. 14 casi clinici.

Fourteen patients affected by primary gastric lymphoma were observed retrospectively to verify the results of surgical and adjuvant chemotherapy. After a 85% preoperative diagnostic specificity, 79% of patients were subjected to surgical therapy by subtotal gastrectomy (93%) and by total gastrectomy (7%), and 64% of patients were subjected to adjuvant chemotherapy in conformity with CHOP and CVP. Classified by the Working formulation, 57% of cases presented a high grade of malignancy, 29% a low grade and 14% an intermediate grade. Classified by Ann Arbor with Mushoff's modification, 43% of patients were assigned to stage IIE1, 36% to stage IE, 14% to stage IIE2 and 7% to stage IIIE. Operative mortality was null. The overall median survival have been of 21 months, while surgical and chemotherapeutical median survival reached 32 months. The 5-year actuarial survival was: 10% (overall), 14% (treated patients), 50% (low grade), 33% (stage IE). With negative influence by istology and staging.

[The Campodimele study: 24-hour blood pressure in rural life style subjects]. / Studio di Campodimele: la pressione arteriosa di 24 ore in soggetti con stile di vita rurale.

The present paper is aimed at investigating the daily blood pressure in subjects with a rural style of life with the purpose of detecting whether or not the blood pressure regimen is influenced as expected because of the stress less prominent in the non-urban areas. Control data were obtained by the study of age- and sex-matching subjects with a metropolitan style of life. The results indicate the blood pressure has a lower daily level in rural subjects as compared to urban subjects. The daily baric impact is also lower, suggesting that the blood pressure regimen is really less pronounced in those who live according to a rural style of life. Such a lower magnitude allows us to experimentally suggest that the rural life is concrete in protecting the hemodynamic system from the higher level of blood pressure which are observable in subjects who live according to a metropolitan style of life. Interestingly, the expected phase anticipation in blood pressure circadian rhythm of rural subjects was not detected, as the wake up time was not so anticipated to act as a synchronizer.

Inadequacy of combined 5-Fluorouracil, very-high-dose leucovorin, mitomycin-C and Cisplatin as 2nd-line therapy for advanced colon-cancer.

Fourteen patients with metastatic colon cancer which had progressed under fluoro-folates chemotherapy were treated with MM-C (10 mg/m(2) on day 1), 5-FU (370 mg/m(2) for 5 consecutive days), l-LV (500 mg/m(2) for 5 consecutive days) and CDDP (70 mg/m(2) on day 4), every 29th day till further disease progression. Neither CR nor PR were observed; 3 patients only had stable disease, while the extant 11 patients progressed. Resulting toxicity was severe. Since no antitumor effects were evidenced in the first 14 patients, the study was discontinued according to commonly accepted criteria.

Cobalt exposure in wet grinding of hard metal tools for wood manufacture.

The authors examined exposure to cobalt during the wet grinding of hard metal tools (Widia tools) used in the wood industry, usually in small specialized workshop which can produce exposure to cobalt > TLV-TWA (50 micrograms/m3) if carried out with no protective devices. Local exhausts near the grinding wheel can reduce the exposure to cobalt by as much as 20 times. Nevertheless, some technical problems often hamper the effectiveness of these protective devices, so that the plant situation, examined by the forecasting OTL test as proposed by Tuggle (Am. Ind. Hyg. Assoc. J., 43 (1982) 338), does not appear to be completely acceptable. Other technical solutions are therefore necessary for a complete control of the exposure to cobalt. A more effective water stream, a greater air velocity near the grinding wheel and a protective shield between the wheel and the worker are some suggestions.

Plasma selenium levels of the general population of an area in northern Italy.

Plasma selenium (Se) levels of 293 subjects (160 males and 133 females) living in Desio (a small town near Milan) were determined. Analyses were performed by graphite-furnace atomic absorption spectrophotometry with Zeeman background correction. Plasma samples were not subjected to any treatment before analysis and serum samples containing a certified Se content were used as reference materials to control the quality of the analytical determinations. Plasma Se levels were found to be distributed normally with an average value of 118.8 micrograms/l and a S.D. of 27.2 (95% of the subjects lie between 64.4 and 173.2 micrograms/l). No statistically significant difference was found between males and females, and no correlation was found between plasma Se levels and age or smoking habits.

A new tool for sampling airborne isocyanates.

A new sampling system is presented that uses solid sorbent media contained in a tube for the determination of airborne isocyanates (2.4-2.6 toluene diisocyanate, hexamethylene diisocyanate, and 4.4' diaminodiphenylmethane diisocyanate). The method is compared with the National Institute for Occupational Safety and Health (NIOSH) Method P&CAM 5505 (Revision #1). Experimental tests yielded results that were highly concordant with the NIOSH method.

Behaviour of urinary nickel in low-level occupational exposure.

The study tested the feasibility of using urinary nickel (Ni-U) as a biological indicator to assess exposure to soluble nickel compounds in electroplating departments at concentrations well below the current TLV-TWA. Two groups of workers were studied: Group A, consisting of 13 subjects and Group B consisting of 10 subjects, with an average weekly nickel exposure of nickel in air (Ni-A) greater than or equal to 10 micrograms/m3 (Group A) and less than 10 micrograms/m3 (Group B). Air samples and urine specimens were taken on 4 consecutive days from Monday to Thursday. The mean Ni-U levels in both groups were significantly higher than in the reference group. The Ni-U levels in end-of-shift spot samples showed a tendency to increase over the week; this trend was more marked in Group A. Closer correlations between Ni-A and Ni-U were found using the postshift Ni-U values of Thursday: the test was well correlated both with the Ni-A levels of the same day and with the mean levels of the previous days. The results suggest that Ni-U is a sufficiently sensitive indicator for use in monitoring low-level occupational exposure, especially if Ni-A concentrations are above 10 micrograms/m3.

Behaviour of biological indicators of cadmium in relation to occupational exposure.

Cadmium in blood (CdB), cadmium in urine (CdU) and beta 2-microglobulins (beta 2MU) were determined in 83 male workers exposed to cadmium fumes. CdU was measured both on 24-h urine samples and on spot samples. The behaviour of the biological indicators of cadmium was assessed in relation to degree of current exposure, length of exposure and cumulative exposure (computed as concentration of cadmium at the workplace multiplied by duration of exposure). CdB values were significantly higher in the subgroups of subjects with higher current cadmium exposure and in the subgroups of subjects with greater cumulative exposure, but the test levels were not influenced by duration of exposure. CdU levels were significantly higher in the subgroup of subjects with greater cumulative exposure, but were less influenced by current exposure or duration of exposure. Considering the entire population, a rather close correlation (r = 0.69) was observed between CdB and CdU. When the population was divided according to level of current exposure, a close relationship was observed between the two indicators in all subgroups; nevertheless, for identical CdU values, the CdB values were higher in the subjects with heavier current exposure. Even if in all Cd workers the beta 2MU levels were in the range of reference values, the highest beta 2MU levels were found in the subjects with CdU greater than 10 micrograms/l. The data confirm that CdU is prevalently influenced by the body burden of metal, but they also suggest that the CdB levels are not influenced solely by the intensity of current exposure but also depend to a considerable degree on the body burden.

Problems concerning the usefulness of adjustment of urinary cadmium for creatinine and specific gravity.

A previous study concluded that there are some doubts as to the validity of creatinine as a parameter for adjusting the values of biological indicators determined on spot samples of urine, since it is subject to marked inter- and intraindividual variations. Furthermore, since there was only a moderate correlation between creatinine levels and specific density, it can be assumed that these two parameters cannot be used indifferently for adjustment. Nevertheless, it seemed advisable to verify whether correction of cadmium values determined from spot samples offers any practical advantages. For this purpose, 105 subjects with occupational exposure to cadmium were examined. They collected their 24-h urine and spot samples separately at 8.00 h. There was a close correlation between CdU/spot samples and CdU/24 h. The correlation index was very similar both for CdU/spot values expressed in microgram/l and for values adjusted according to creatinine or 1024 specific gravity. These results show that no particular advantages are offered by adjusting CdU according to creatinine or specific gravity.