[Italian guidelines in accordance with the new National Guidelines System: critical issues and perspectives.] / Le linee guida italiane secondo il nuovo SNLG: criticità e prospettive.

Law No. 24/2017 on professional responsibility has assigned a fundamental role to the guidelines, giving the Istituto Superiore di Sanità, through the new Centro Nazionale per l'Eccellenza Clinica, la Qualità e la Sicurezza delle Cure (CNEC), the role of methodological guarantor and of national governance of the guidelines production process. In a scenario marked by the increasing use of defensive medicine, the adherence to guidelines recognized as reliable by an institutional body can lead to the desired reduction of the malpractice claim, as well as to considerable clinical advantages, with the improvement of the quality of healthcare and of health outcomes and the reduction of unjustified variability of clinical practices in the national territory. If the opportunity that the new National Guidelines System (SNLG) offers is great and must be seized, at the same time the connection between guidelines and health responsibility presents some critical issues. In this context, it is of utmost importance to promote an efficient production mechanism of good quality national guidelines, informed by the best evidence available and responding to the population health needs, based on the criteria of relevance and clinical, economic and social impact, as well as to make the SNLG the pivotal instrument to achieve that alignment of clinical efficacy, professional and organizational appropriateness, fairness, security and humanization of care that can guarantee the sustainability of our National Health Service and its capacity to face the difficult challenges of the future.

[Sex differences in incidence of mortality after acute myocardial infarction]. / Diversa incidenza della mortalità nei pazienti dei due sessi dopo infarto miocardico acuto.

BACKGROUND: Previous studies have indicated that the mortality after acute myocardial infarction (AMI) is higher among women than among men. However, whether this difference is attributable to the older age of the women studied or to the presence of other unfavorable prognostic factors remains unclear. METHODS: This retrospective study compares the clinical features, management and 30-day outcome in men and women from a consecutive, unselected series of 878 patients with AMI (225 women, 25.7%) who were admitted to the coronary care unit. The studied variables included demographic, history and risk factors, the ECG at the time of admission and treatment assignment. The analysis, both unadjusted as well as adjusted, was performed using multiple logistic regression. RESULTS: The overall mortality rate during hospitalization was 24.4% for women and 13.2% for men (p < 0.0001). Women were, on average, significantly older than men (71.6 vs 62.3 years, p < 0.0001), had a higher prevalence of hypertension (58.2 vs 41.5%, p < 0.0001) and diabetes mellitus (33.7 vs 19.6%, p < 0.0001), were less frequently smokers (22.2 vs 52.3%, p < 0.0001) and waited longer resorting to the coronary care unit following the onset of symptoms (p < 0.005). Thrombolytic therapy was prescribed less often in women (19.1 vs 40.7%, p < 0.0001). Women had more mechanical complications than men (acute pulmonary edema, p < 0.0001; cardiogenic shock, p < 0.03). No significant difference was found between sexes regarding previous coronary events, the size and type of infarction, the ECG at the time of admission and arrhythmic or ischemic complications. After adjustment, female gender was not an independent predictor of mortality, following AMI. Mortality rates after AMI remained significantly higher for women than for men only among patients who had not received thrombolysis (odds ratio 1.90, 95% confidence interval 1.08-3.34, p < 0.03). CONCLUSIONS: Much of the increased post-AMI mortality observed in women could be attributed to age, risk factors, comorbidity and other baseline characteristics. Female gender seems to be independently associated with a higher risk of death after AMI only among patients to whom thrombolytic therapy is not prescribed.