Gloso-faringo-laringo-esofagitis cáustica fatal por ingestión de desatascador líquido comercial (hidróxido sódico al 47, 8%) / Fatal caustic pharyngo-laryngo-esophagitis by ingestion of commercial unblocker liquid (NaOH 47, 8%)

No disponible

No disponible

Evaluación médico-legal de las prótesis intracardíacas en la autopsia: III. Stents intracoronarios / Evalutaion of intracardiac devices at autopsy: III. Coronary Stents. Medico legal implications

No disponible

Evaluación médico-legal de las prótesis intracardíacas en la autopsia: II. Prótesis valvulares / Evaluation of intracardiac devices at autopsy: II. Prosthetic heart valves. Medico legal implications

No disponible

Epidemiologic study of use of resources in patients with unstable angina: the EARISA registry. On behalf on the EARISA Investigators (Epidemiologia dell'Assorbimento di Risorse nell'Ischemia, Scompenso e Angina).

AIM: The EARISA Registry was designed to describe diagnostic and therapeutic resources used in Italian cardiology centers for patients with the epidemiologically most relevant cardiac diseases. This article focuses on patients with unstable angina; characteristics associated with invasive procedures were specifically analyzed. METHODS AND RESULTS: Information was collected over a 2-week period on 1420 patients with unstable angina discharged from 308 cardiology centers. The mean length of stay was 9 +/- 6 days; 51% of patients were admitted to a coronary care unit (mean length of stay, 4 +/- 3 days). Noninvasive procedures included echocardiography (64%), Holter monitoring (25%), exercise stress testing (24%), and echocardiographic stress testing or nuclear imaging (7%). Invasive procedures were coronary angiography (39%) and percutaneous transluminal coronary angioplasty or coronary artery bypass grafting (13%). Unstable angina had a greater impact on invasive procedures than acute myocardial infarction. Variables independently associated with a higher rate of coronary angiographic procedures were younger age, higher technologic level of the hospital, and need for intravenous therapy. CONCLUSION: In Italy, approximately half the patients with unstable angina are admitted to hospitals without catheterization laboratories or cardiac surgery facilities. This fact supports the concept that treatments that can be administered in all types of hospitals are more likely to affect the outcome of patients with unstable angina. Overall, the rates of coronary angiography and revascularization procedures appeared low, and the setting where cardiologists practice, rather than patient characteristics, is the major determinant of the care given to patients with unstable angina.

Hemorragia subaracnoidea fatal en mujer de 49 años / Fatal subarachnoid haemorrhage in a woman 49 years old

Las hemorragias intracraneales espontáneas (no traumáticas) pueden ocurrir en el encéfalo (hemorragias intracerebrales) o en el espacio subaracnoideo (hemorragia subaracnoidea). Las causas más frecuentes de una hemorragia subaracnoidea espontánea son, por orden de frecuencia: a) la ruptura de un aneurisma sacular (65 por ciento), b) la ruptura de una malformación arteriovenosa (5 por ciento), c) la extensión de una hemorragia cerebral hacia los ventrículos y al espacio subaracnoideo (5 por ciento). Los aneurismas saculares pueden ser únicos o múltiples. El 90 por ciento de ellos se localizan en el territorio de distribución de las carótidas internas; el 10 por ciento restante, en el árbol arterial vértebro-basilar. Un 10-15 por ciento de los pacientes presentan aneurismas múltiples que se asocian con: a) coartación de aorta, b) estenosis de la arteria renal y c) Enfermedad Poliquística Renal del Adulto Autosómica Dominante. Etiopatogénicamente, la hipertensión arterial juega un importante papel en su aparición; no obstante, en la EPRAD (PKD, del inglés polycystic kidney disease) existen mutaciones en tres genes: el gen PKD I (cro-mosoma 16) (85 por ciento de los casos), el PKD2 (10 por ciento de las familias) y el PKD3. Estos genes codifican las proteínas Policistina 1 y 2, cuyas funciones tienen que ver con los mecanismos de interacción célula-célula y célula-matriz extracelular. Presentamos un caso de muerte súbita, de una mujer de 49 años, debida a hemorragia subaracnoidea fatal. La autopsia demostró la presencia de una Enfermedad Poliquística Renal del Adulto Autosómica Dominante y múltiples aneurismas saculares en el polígono de Willis (AU)

Ruptura cardíaca yatrógena, en mujer joven, secundaria a maniobras de resucitacion cardiopulmonar postinfarto de miocardio / Iatrogenic myocardial rupture following cardiopulmonary resuscitation after myocardial infarct in a young woman

Las lesiones yatrógenas provocadas por las maniobras de Resucitación Cardiopulmonar (RCP), de tipo básicas y/o avanzadas constituyen un hallazgo muy frecuente en Patología forense. La mayoría de las veces son inesperadas y, a veces sorprendentes en el transcurso de una Autopsia Médico-Forense. La diferenciación entre la patología yatrógena y aquella otra secundaria a secuelas de enfermedades naturales, o de traumatismos sufridos por el paciente antes de la muerte constituye un capitulo especialmente importante de la Patología Médico-Legal y de la Medicina Forense, debido a que los hallazgos patológicos y el establecimiento de sus relaciones de causalidad pueden afectar al diagnóstico certero de la manera de la muerte. Los autores describen el caso de una mujer, de 35 de años, que sufrió una parada cardiaca por un infarto agudo de miocardio ocurrido unas 6-7 horas antes. La paciente fue sometida a maniobras de resucitación básicas, durante 2 horas, por el Servio Médico de Urgencias de la localidad. Posteriormente, el 061 realizo maniobras de R.C.P avanzadas, durante 30 minutos más, hasta que la paciente fue exitus. En la autopsia se demostró líquido pericárdico teñido de sangre y una rotura lineal, de unos 3 cm de longitud en la cara anterior ventricular izquierda próxima al ápex, que no presentaba características macroscópicas vitales. Microscópicamente se demostró una trombosis de la arteria coronaria descendente anterior y un área de isquemia miocádica aguda, en el territorio ventricular vásculo-dependiente, en las cercanías de la rotura. Los bordes de la herida no presentaban características de vitalidad, tales como hemorragiá, fibrina, etc. La rotura fue atribuída a las prolongadas maniobras de resucitación sufridas por la paciente (2 horas y 30 minutos). Se revisa la literatura referente a las lesiones yatrogénicas - especialmente las cardiacas - dependientes de maniobras de RCP estándar, así corno aquellas otras inducidas por los dispositivos más modernos de RCP (Bomba Cardiaca de Compresión-Descompresión Activa) que se están utilizando en algunos países (AU)

Air pollution and cause-specific mortality in Milan, Italy, 1980-1989.

In several studies, investigators have reported associations among air pollution, weather, and daily deaths, usually from all causes. In the current study, we focused on the difference in lag time between exposure to total suspended particulates or extreme weather and cause-specific mortality in an effort to understand the potential underlying mechanism. We used a robust Poisson regression in a generalized additive model to investigate the association between air pollution and daily mortality. We used a loess smooth function to model season, weather, and humidity; indicator variables for hot days were also used. To examine the relationship in a currently meaningful range, we excluded all days with a total suspended particulate concentration higher than 200 microg/m3. We found a significant association on the concurrent day, both for respiratory infection deaths (11% increase/100 microg/m3 increase in total suspended particulate; 95% confidence interval = 5, 17) and for heart-failure deaths (7% increase; 95% confidence interval = 3, 11). The associations with myocardial infarction (i.e., 10% increase; 95% confidence interval = 3, 18) and chronic obstructive pulmonary disease (12% increase, 95% confidence interval = 6, 17) were found for the means of 3 and 4 d prior to death. We observed an effect of cold weather at lag 1 for respiratory infections and an effect of hot weather at lag 0 for heart failure and myocardial infarctions. The association for all causes and cause-specific deaths was almost identical to that noted previously in Philadelphia, Pennsylvania. Smoothed functions of total suspended particulates suggested a higher slope at lower concentrations, and this finding may account for differences noted between European and U.S. studies. Given that both the dependence between weather and daily mortality and the lag between exposure and death varies by cause of death, analyses by specific causes of death would be very useful in the future.

Variation in hospital use and avoidable patient morbidity.

OBJECTIVES: To determine whether geographical areas with relatively low overall hospitalization rates have higher population-based rates of admission of patients with advanced stages of disease. METHODS: Age- and sex-standardized hospital admission rate were calculated for the residents of the 80 Local Health Units in Lombardia, Italy. Using the Disease Staging classification, advanced stage admissions were identified for six common medical and surgical conditions, which it was presumed would reflect untimely hospital admission. Standardized rates of advanced stage admissions were compared in areas with overall high hospitalization rates (high-use areas). RESULTS: Hospitalization at advanced stages of disease in the low-use areas were significantly higher for the six conditions combined (55.9 vs 43.0 per 100,000; P = 0.005), and for external hernia, appendicitis and uterine fibroma, but not for bacterial pneumonia, diverticular disease and peptic ulcer. For the six study conditions combined, residents of overall low-use area were 30% more likely to be admitted with advanced stages of disease. CONCLUSION: Low overall hospitalization rates were found to be associated with greater severity of illness at hospitalization and potentially avoidable morbidity for some conditions. Policies aimed at curbing unnecessary hospital admission should consider preserving access for appropriate treatment.

[Evaluation of activity in intensive care. A comparison of administrative and epidemiologic data]. / Valutazione delle attività delle terapie intensive. Un confronto tra dati amministrativi ed epidemiologici.

This paper reports on results of a formal comparison of data excerpted from 3 different data sources regarding patients cared for in Italian Intensive Care Units (ICU) in 1992. The analysis was carried out in order to assess whether the administrative data routinely collected for reimbursement and policy issues are valid when compared with data from epidemiologic studies. First, using data from the Central Service for Health Planning (SCPS) a general description of the whole national scenario is shown. All the Italian data from 265 Italian hospitals having at least one ICU were analyzed. In these hospitals there were 2,357 ICU beds (4.3 beds/1000 inhabitants, with large regional variability). About 100,000 cases were identified (1% of all the hospital admissions received ICU care at some moment during the stay), with an overall hospital mortality rate of 17%. This estimate was largely different from those obtained from GiViTI data base (5100 patients from a national sample of 114 ICUs), where mortality rates were always higher (25 and 30%, for ICU and hospital mortality). Second, a more detailed analyses and comparison was carried out in the subsample of cases admitted in the Hospitals of the Regione Lombardia. In this case, beside the data from SCPS (No = 20580) and from GiViTI (No = 1121), the Regional data-base formed by all the discharge from 41 hospitals having at least one ICU were available (NO = 16674), allowing a formal comparison between estimates obtained from 3 different sources. In this sub-sample, although administrative data showed a good capability and satisfactory accuracy to describe the volume and socio-demographic and clinical characteristics of the cases when compared with GiViTI estimates, still a systematic underestimate of the overall ICU and hospital mortality was present. Moreover, an unexpected high rate of cases were apparently discharged alive from ICU (16.5 versus 32.6% in GiViTI). Tentative explanations and implications of these phenomena are discussed in the text. Finally, in the Lombardia sub-sample a formal description of the case-mix using the Diagnosis Related Group (DRG) system was carried out in order to identify strengths and limitations of this approach when adopted in the ICU setting. Overall, when data are analyzed according to the kind of Major Diagnostic Category (MDC), 75% of all cases were concentrated in 5 alone, with very peculiar concentration in some specific categories. For example, 45% of all the hospital admissions related to the multiple trauma were actually admitted in the ICU setting. At DRG level, fifty of the 493 DRGs available explained 65% of all the cases, showing an unexpected capability of this system to detect the ICU case-mix. The most represented surgical DRG was the number 107 (Coronary Arterial Bypass Graft, without catheterization) and the corresponding medical was the 28 (Cerebro Vascular Accident, excluding TIA).

Diet and cancers of the larynx and hypopharynx: the IARC multi-center study in southwestern Europe.

The main causes of cancer of the larynx and hypopharynx are smoking cigarettes and drinking alcohol. However, for these as well as for other cancers of the upper aerodigestive tract, some dietary components, mainly low consumption of fruit and vegetables, have been observed to be associated with increased cancer risk. We report results from a multicenter case-control study carried out in six regions of Europe located in northern Spain, northern Italy, Switzerland, and France. A total of 1,147 males with cancer (cases) and 3,057 population controls were interviewed on usual diet, lifelong drinking and smoking habits, and occupational history. Cancer cases had histologically verified epidermoid carcinomas. The cancers were classified in two anatomic sub-entities: the epilarynx (hypopharynx and upper part of the larynx), which enters into contact with the bolus and the air; and the endolarynx, through which air and tobacco smoke pass, but not the bolus. A previous report from this study found that alcohol drinking presents a greater risk factor for cancer of the epilarynx than for cancer of the endolarynx. The main results regarding diet indicate that high intake of fruit, vegetables, vegetable oil, fish, and low intake of butter and preserved meats were associated with reduced risk of both epilaryngeal and endolaryngeal cancers, after adjustment for alcohol, tobacco, socioeconomic status, and non-alcohol energy intake. Among nutrients, a reduced risk was found for high intake of vitamins C and E and for a high polyunsaturated/saturated fatty acids (P/S) ratio. While these variables are relevant in scoring nutritional behaviour, it remains unresolved whether the biologic properties of these nutrients play a role in the apparent protective effect.

[Air pollution and daily mortality among Milan residents, 1980-89. Preliminary results]. / Inquinamento atmosferico e mortalità giornaliera nei residenti a Milano, 1980-89. Risultati preliminari.

Short term effects of air pollutant levels on daily mortality were studied, using time series approach, in Milan from the year 1980 to 1989. The Poisson regression with autocorrelated residuals was applied. This paper reports preliminary results of the analyses on the association between total daily number of deaths and the 24h mean concentrations, on the same day, for two air pollutants: sulphur dioxide and total suspended particulate. A positive and curvilinear relation (with a logarithmic shape) has been found between total daily mortality and concentration levels for each pollutant. This result confirm a steeper increase in mortality at low concentrations, lower than the international standards in use at the moment.

Variation in use of breast-conserving surgery in Lombardia, Italy.

The extent of variation in the use of breast-conserving surgery was analyzed using the 1990 and 1991 hospital discharge data of Lombardia, Italy. The proportion of patients undergoing breast-conserving surgery for unilateral breast cancer was estimated for each of the 10 geographic areas (9 provinces plus metropolitan Milano) in which the region is divided. Overall, the rate of use was 41% of 3,225 patients in 1990, and 45% of 3,736 patients in 1991. In both study years, patient age was strongly correlated with the likelihood of undergoing conservative surgery, with younger women more frequently treated with this approach. In each province, patients treated at centers located in the main city had a greater probability (OR, 1.54; 95% CI, 1.37-1.69) of having conservative surgery. This procedure was also more often used in private hospitals (OR, 1.59; 95% CI, 1.20-2.08) where care is paid at the point of consumption by patients, directly or through their private insurance. The observed variation in the use of the conservative procedure across the 10 regional areas was greater than that expected by chance alone (p < .0001), with rates ranging from 29% to 60%. This pattern persisted even after adjusting for the relevant patient and hospital characteristics. Despite the relatively large body of scientific evidence, it appears that the surgical management of breast cancer is more dependent on physicians' attitudes in each geographic area than on individual patients' characteristics.

Cost containment: Europe. Italy.

Through prepaid compulsory insurance managed by the central government, Italy's National Health Service (NHS) provides full coverage, free accessibility, and no or limited copayment by individuals when receiving health services. Although Italy spends less than other countries on health care (< 8% of the country's gross national product), the present NHS faces considerable difficulties, and its performance regarding quality, outcome, and spending has come under question. ICUs account for < 2% of total hospital beds, and the proportion of ICU patients is < 2.5% of all hospital patients (2.5% of all Italian hospital patients receive ICU care at some time during their hospital stay). Information from administrative databases and epidemiologic studies gives an interesting national picture of the situation in Italy regarding admission criteria case mix, and outcomes when compared with data from other countries. Important changes in the financial and institutional framework of the NHS are underway, yielding an unpredictable scenario for the future. Innovations focus mostly on cost containment and quality initiatives. These innovations will likely produce a new health service in which regions will have a more important role than in the past. Actions planned in a large Italian region by the local government are used as an example to explain the potential impact of this new trend on critical care medicine.

[The public-private mix in hospital care in the Lombardy region]. / Il mix pubblico-privato nella assistenza ospedaliera in Regione Lombardia.

OBJECTIVES: 1) to compare complexity and severity of the case-mix in the public and private sector, overall and across individual hospitals, and to examine their relative efficiency, by contrasting DRG and/or stage specific average length of stay (ALOS); 2) to assess the impact of a new contractual scheme based on a preassigned number of beddays for a restricted list of specific conditions. DATA SOURCES: Discharge data on 940.670 admissions to 101 public hospitals and 185.161 admissions to 55 private hospitals in the Regione Lombardia in 1990, assigned to HCFA-DRGs, 8th version and to stages and substages of principal and unrelated diagnostic categories, based on Disease Staging. RESULT: The spread of the case-mix is higher in the private sector, which also shows a higher concentration of admissions across hospital for specific medical and surgical conditions. The proportion of more advanced stages of disease is higher in the public sector, for most of the most frequent diagnostic categories. Obstetric care, including abortion, is the largest single public sector activity, while it is virtually not existent in the private sector. Elective surgical procedures, including ENT, cataract and varicose veins surgery make up a substantial proportion of the private hospitals' case load. DRGs-specific ALOS is longer in public hospitals for the most frequent surgical DRGs, mainly due to their preoperative LOS. The net impact of the proposed contractual scheme will save substantial proportion of beddays for most of the conditions considered, except cataract and varicose veins surgery.

Identification of the cohort of type 1 diabetes presenting in Lombardy in 1983-84: a validated assessment.

An incidence register for Type 1 diabetes was started in Lombardy in 1983-84 for people under 35 years of age. The main information source was the Regional Health Service record system, which provides anonymous reports on all patients discharged from public and private hospitals. Great care was taken to assure the quality of the data in the register. The clinical diagnosis was validated by examining the case notes. Completeness of the register was assessed using multiple independent sources of case ascertainment such as the list of the Youth Diabetics Association, the files of three hospital endocrinology centres, and the registry of conscripts rejected because of diabetes. The estimated age-adjusted (world standard) annual incidence rate was 6.04 per 100,000 in the group 0-18 years and 5.96 per 100,000 in the age group 0-14 years. Females had peak incidence at 11 years of age, males had peak incidence 2 years later. These results confirm the low occurrence of Type 1 diabetes in northern Italy. A seasonal variation in onset of Type 1 diabetes was seen.

Effect of information campaign by the mass media on hysterectomy rates.

The annual frequency of hysterectomy was monitored in the Canton Ticino, Switzerland, from 1977 to 1986. From February to October, 1984, there was a public information campaign in the mass media about rates of and need for hysterectomy. After the start of the campaign and during the following year the annual rate of operations per 100,000 women of all ages dropped by 25.8%, whereas in the reference area (Canton Bern), where no information was given to the public, hysterectomy rates increased by 1%. In the same period the hysterectomy rate per 100,000 women aged 35-49 declined by 33.2%, and the number of hysterectomies performed annually per gynaecologist decreased by 33.3%. In Canton Bern these rates were unchanged. The decline began 2 months after the start of the information campaign. The reduction in the number of hysterectomies was greater (p less than 0.001) in non-teaching hospitals (31.9%) than in teaching hospitals (18.1%). Information on regional rates and on the need for hysterectomy given through the mass media to the general population can change professional practices.

Correcting spontaneous abortion rates for the presence of induced abortion.

This paper introduces a method for correcting spontaneous abortion rates by taking into consideration the fact that a number of spontaneous abortions are "prevented" by induced abortions. This correction may be important in settings of high induced abortion incidence. The method is then applied to the data of the Italian region of Lombardy. The results obtained are compared to those obtained with previous correction methods, and it is concluded that the present method is useful and appropriate when data on induced and spontaneous abortions are available by gestational age.