Comparabilità e valutazione dei servizi sanitari

  • Nerina Agabiti1

  1. Dipartimento di epidemiologia del servizio sanitario regionale, Lazio
Nera Agabiti -

Ricerca bibliografica periodo dal 1 aprile al 15 giugno 2013

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Stringa: (((“Quality Indicators, Health Care"[Mesh] OR "Quality Assurance, Health Care"[Mesh] OR "Outcome Assessment (Health Care)" [Mesh:NoExp] OR Outcome* [tiab] OR “quality indicators” [tiab], OR appropriateness [tiab] OR indicator* [TIAB] OR procedure [TIAB] OR efficacy[tiab] OR effectiveness[tiab]) AND ("hospitals"[MeSH] OR hospital[tiab] OR mortality[tw] OR patient* [tiab]) AND (italy[mesh] OR ital* [tiab] OR ita [la] OR ital* [ad]) AND (“2013/04/01”[PDat] : “2013/06/15”[PDat])) NOT ((animals [mesh] NOT humans [mesh]) OR "Genetics"[Mesh] OR "Neurophysiology"[Mesh] "Drug Therapy"[Mesh] OR "Naturopathy"[Mesh] OR "drug therapy "[Subheading] OR Editorial[ptyp] OR "Case Reports "[Publication Type] OR Letter[ptyp] OR Clinical Trial, Phase I[ptyp] OR Clinical Trial, Phase II[ptyp]))

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1. Iacono C, Verlato G, Ruzzenente A, Campagnaro T, Bacchelli C, Valdegamberi A, Bortolasi L, Guglielmi A. Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy. Br J Surg. 2013 Jun;100(7):873-85. doi: 10.1002/bjs.9136.
Department of Surgery, Unit of Hepato-Biliary-Pancreatic Surgery, Verona, Italy.

BACKGROUND: Central pancreatectomy (CP) is a parenchyma-sparing surgical procedure that enables the removal of benign and/or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this review was to evaluate the short- and long-term surgical results of CP from all published studies, and the results of comparative studies of CP versus distal pancreatectomy (DP). METHODS: Eligible studies published between 1988 and 2010 were reviewed systematically. Comparisons between CP and DP were pooled and analysed by meta-analytical techniques using random- or fixed-effects models, as appropriate. RESULTS: Ninety-four studies, involving 963 patients undergoing CP, were identified. Postoperative morbidity and pancreatic fistula rates were 45•3 and 40•9 per cent respectively. Endocrine and exocrine pancreatic insufficiency was reported in 5•0 and 9•9 per cent of patients. The overall mortality rate was 0•8 per cent. Compared with DP, CP had a higher postoperative morbidity rate and a higher incidence of pancreatic fistula, but a lower risk of endocrine insufficiency (relative risk (RR) 0•22, 95 per cent confidence interval 0•14 to 0•35; P < 0•001). The risk of exocrine failure was also lower after CP, although this was not significant (RR 0•59, 0•32 to 1•07; P = 0•082). CONCLUSION: CP is a safe procedure with good long-term functional reserve. In situations where DP represents an alternative, CP is associated with a slightly higher risk of early complications.

2. Romeo F, Acconcia MC, Sergi D, Romeo A, Muscoli S, Valente S, Gensini GF, Chiarotti F, Caretta Q. The outcome of intra-aortic balloon pump support in acute myocardial infarction complicated by cardiogenic shock according to the type of revascularization: a comprehensive meta-analysis. Am Heart J. 2013 May;165(5):679-92. doi: 10.1016/j.ahj.2013.02.020. Epub 2013 Mar 26
Department of Cardiovascular Disease, University of Rome-Tor Vergata, Rome, Italy.

AIMS: Despite the recommendations of the current guidelines, scientific evidence continue to challenge the effectiveness of intra-aortic balloon pump (IABP) in acute myocardial infarction (AMI) complicated by cardiogenic shock. Moreover, 2 recent meta-analyses showed contrasting results. The aim of this study is to test the effect of IABP according to the type of therapeutic treatment of AMI: percutaneous coronary intervention (PCI), thrombolytic therapy (TT), or medical therapy without reperfusion. Articles published from January 1, 1986, to December 31, 2012, were collected and analyzed by meta-analysis. METHODS AND RESULTS: We evaluated the IABP impact on inhospital mortality, on safety end points (stroke, severe bleeding) and long-term survival, using risk ratio (RR) and risk difference (RD) estimates. We found that the risk of death was (i) not significantly different between the IABP and control groups (RR 0.95, P = .52; RD -0.04, P = .28), (ii) significantly reduced in the TT subgroup (RR 0.77, P < .0001; RD -0.16, P < .0001), and (iii) significantly increased in the PCI subgroup (RR 1.18, P = .01; RD 0.07, P = .01). There were no significant differences in secondary end points (P, not significant). In addition, we compared the meta-analyses collected over the same search period. CONCLUSION: The results show that IABP support is significantly effective in TT reperfusion but is associated with a significant increase of the inhospital mortality with primary PCI. The comparison of the meta-analyses demonstrates the key role of analysing primary clinical treatments to avoid systematic errors.

3. De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, Diaz de la Llera LS, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW; DESERT Cooperation. Meta-analysis comparing efficacy and safety of first generation drug-eluting stents to bare-metal stents in patients with diabetes mellitus undergoing primary percutaneous coronary intervention. Am J Cardiol. 2013 May 1;111(9):1295-304. doi: 10.1016/j.amjcard.2013.01.281. Epub 2013 Mar 12.
Division of Cardiology, Ospedale Maggiore Della Carità, Eastern Piedmont University, Novara, Italy.

Several concerns have emerged regarding the higher risk for stent thrombosis (ST) after drug-eluting stent (DES) implantation, especially in the setting of ST-segment elevation myocardial infarction (STEMI). Few data have been reported so far in patients with diabetes mellitus, which is associated with high rates of target vessel revascularization after bare-metal stent (BMS) implantation but also higher rates of ST after DES implantation. Therefore, the aim of this study was to perform a meta-analysis of individual patients' data to evaluate the long-term safety and effectiveness of DES compared with BMS in patients with diabetes who undergo primary percutaneous coronary intervention for STEMI. Published reports were scanned by formal searches of electronic databases (MEDLINE and CENTRAL). All completed randomized trials of DES for STEMI were examined. No language restrictions were enforced. Individual patients' data were obtained from 11 of 13 trials, including a total of 972 patients with diabetes (616 [63.4%] randomized to DES and 356 [36.6%] to BMS). At long-term follow-up (median 1,095 days, interquartile range 1,087 to 1,460), DES significantly reduced the occurrence of target vessel revascularization (hazard ratio 0.42, 95% confidence interval 0.29 to 0.59, p <0.0001), without any significant difference in terms of mortality, late reinfarction, and ST (>1 year) with DES. In conclusion, this meta-analysis, based on individual patients' data from 11 randomized trials, showed that among patients with diabetes with STEMIs who undergo primary percutaneous coronary intervention, sirolimus-eluting stents and paclitaxel-eluting stents, compared with BMS, are associated with a significant reduction in target vessel revascularization at long-term follow-up, without any apparent concern in terms of mortality, despite the trend toward higher rates of reinfarction and ST.

4. Pacelli F, Cusumano G, Rosa F, Marrelli D, Dicosmo M, Cipollari C, Marchet A, Scaringi S, Rausei S, di Leo A, Roviello F, de Manzoni G, Nitti D, Tonelli F, Doglietto GB; Italian Research Group for Gastric Cancer (IRGGC). Multivisceral resection for locally advanced gastric cancer: an italian multicenter observational study. JAMA Surg. 2013 Apr 1;148(4):353-60. doi: 10.1001/2013.jamasurg.309.
IMPORTANCE The role of multivisceral resection, in the setting of locally advanced gastric cancer, is still debated. Previous studies have reported a higher risk for perioperative morbidity and mortality, with limited objective benefit in terms of survival. Conversely, recent studies have shown the feasibility of enlarged resections and the potential advantage of extended resection for clinical stage T4b gastric adenocarcinoma with good long-term results. OBJECTIVE To analyze the role of multivisceral resection for locally advanced gastric cancer with particular attention to the brief and long-term results and to the prognostic value of clinical and pathologic factors. DESIGN Prospective multicenter study using data from between January 1, 1995, and December 31, 2008. SETTINGS Seven Italian surgery centers. PATIENTS A total of 2208 patients underwent curative resections for gastric carcinoma at the centers. Among them, 206 patients presented with a clinical T4b carcinoma. One hundred twelve underwent a combined resection of the adjacent organs with a gastrectomy owing to suspicion or direct invasion of these organs by the gastric cancer. MAIN OUTCOMES AND MEASURES Clinical and pathologic variables were prospectively collected and the feasibility and efficacy of multivisceral resection for locally advanced clinical T4b gastric cancer were assessed. RESULTS Postoperative mortality and complication rates of patients who underwent a gastrectomy with a combined resection of the involved organs were 3.6% and 33.9%, respectively. Pathologic factors revealed that the nodal involvement was present in about 89.3% of patients and the mean (SD) number of pathologic lymph nodes was 14.8 (16.6). The overall 5-year survival rate was 27.2%. The completeness of resection and lymph node invasion represent independent prognostic parameters at multivariate analysis. CONCLUSIONS AND RELEVANCE Our study indicates that patients undergoing extended resections experience acceptable postoperative morbidity and mortality rates, and an en bloc multivisceral resection should be performed in patients when a complete resection can be realistically obtained and when lymph node metastasis is not evident.
5. Marfella R, Sasso FC, Siniscalchi M, Cirillo M, Paolisso P, Sardu C, Barbieri M, Rizzo MR, Mauro C, Paolisso G. Brief episodes of silent atrial fibrillation were associated with an increased risk of silent cerebral infarct and stroke in type 2 diabetic patients. J Am Coll Cardiol. 2013 May 15. pii: S0735-1097(13)01881-0. doi: 10.1016/j.jacc.2013.02.091. [Epub ahead of print]
Department of Geriatrics and Metabolic Diseases Second University of Naples, Italy. Electronic address:

OBJECTIVE: We evaluated whether subclinical episodes of atrial fibrillation (AF) were associated with an increased risk of silent cerebral infarct (SCI) and stroke in diabetic patients younger than 60 years who did not have other clinical evidence of AF and cerebrovascular disease at baseline. BACKGROUND: In type 2 diabetic patients, one quarter of strokes are of unknown cause, and subclinical episodes AF may be a common etiologic factor. METHODS: Longitudinal, observational study was performed on 464 type 2 diabetic patients younger than 60 years and matched them to patients without diabetes. Patients underwent to quarterly 48-hour ECG Holter monitoring (48HM) to detect brief subclinical episodes of AF (AF durations <48 hours.) and followed them for 37 months. The outcomes were a SCI, assessed by brain MRI, and stroke events during the follow-up. RESULTS: Prevalence of subclinical episodes of AF was significantly greater among patients with diabetes compared with matched healthy subjects (9% vs. 1.6%, P<0.0001). During an average duration of 37 months, 43 stroke events occurred in diabetic population, whereas no events occurred in healthy subjects. Diabetic patients with silent episodes of AF (SAFE-group, n=176) had higher baseline prevalence of SCI (61% versus 29%, P<0.01) and higher stroke events (17.3% versus 5.9%, P<0.01) during the follow-up period than the others (non-SAFE-group, n=288). Episode of silent AF was an independent determinant of SCI (OR 4.441, P<0.001 C.I=2.42 to 8.16) and independent predictors for the occurrence of stroke in diabetic patients (HR, 4.6; P<0.01 C.I 2.7-9.1). CONCLUSION: Subclinical episodes of AF occurred frequently in type 2 diabetic patients and were associated with a significantly increased risk of SCI and stroke.

6. Fortuna D, Nicolini F, Guastaroba P, De Palma R, Di Bartolomeo S, Saia F, Pacini D, Grilli R; RERIC (Regional Registry of Cardiac Surgery); REAL (Regional Registry of Coronary Angioplasties) Investigators. Coronary artery bypass grafting vs percutaneous coronary intervention in a 'real-world' setting: a comparative effectiveness study based on propensity score-matched cohorts. Eur J Cardiothorac Surg. 2013 Jul;44(1):e16-24. doi: 10.1093/ejcts/ezt197. Epub 2013 Apr 28.
Regional Agency for Health and Social Care of Emilia-Romagna, Bologna, Italy.

OBJECTIVES: Most studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) showed that fewer patients who had undergone CABG required repeat revascularizations , but no difference in survival, with the exception of some subgroups of patients. However, long-term real-world evidence on patients in whom both procedures are technically feasible is yet not available. The aim of this study was to compare 5-year rates of death, myocardial infarction (MI), target vessel revascularization (TVR) and stroke in a large cohort of patients with left main coronary artery (LMCA) or multivessel disease, treated with CABG or PCI (with or without DES) or PCI with DES only. METHODS: Two propensity score (PS)-matched cohorts of patients undergoing revascularization procedures at the regional public and private centres of Emilia-Romagna over the period July 2002-December 2008 were used to compare long-term outcomes of PCI (6246 patients) and CABG (5504 patients). RESULTS: PCI was associated with higher risk of death (HR = 1.6; 95% CI 1.4-1.8, P < 0.0001), MI (HR = 3.3; 95% CI 2.7-4.0, P < 0.0001) and TVR (HR = 4.5; 95% CI 3.8-5.2, P < 0.0001) at 5 years. No significant difference was shown for stroke (HR = 1.1; 95% CI 0.9-1.4, P = 0.43). CABG benefit was more evident in the risk of death in patients with two-vessel disease plus LMCA and in those with three-vessel disease, LVEF <35%, congestive heart failure and diabetes. Adjusted comparison with PS between PCI with DES only and CABG confirmed significant differences in favour of CABG for mortality, MI and TVR rates. Competing risk analysis showed that the difference in the mortality rate was due to higher rate of MI in PCI. CONCLUSIONS: In the 'real-world' setting of this study, CABG was associated with significantly lower rates of death, MI and TVR in patients with LMCA or multivessel disease, so it remains the standard of care, particularly for patients with more extensive coronary disease and diabetes.

Breve commento a cura di Nerina Agabiti
L’efficacia comparativa dei diversi trattamenti chirurgici dei pazienti con cardiopatia ischemica è ancora oggetto di ampio dibattito. Molti studi osservazionali hanno dimostrato che il “bypass aortocoronarico” (CABG) e l’ “Angioplastica Coronarica (PCI) con drug-eluting stent (DES)” sono equivalenti in termini di mortalità e morbosità. Altre evidenze da registri indicano un maggiore tasso di mortalità dopo PCI, ma in genere i follow up non sono più lunghi di 3 anni. Nei trials clinici randomizzati i follow up sono più lunghi ma non si hanno sufficienti dati sul PCI-DES. Quindi, esiste tuttora una lacuna conoscitiva, soprattutto mancano dati dalla reale pratica clinica. Questo studio osservazionale ha utilizzato i dati del Registro Regionale delle Angioplastiche Coronariche dell’Emilia Romagna (REAL Registry) e ha studiato 11750 pazienti, 6246 co PCI e 5504 con CABG operati nel periodo 2002-2008 e seguito con un follow up fino al dicembre 2010. Con opportuni metodi statistici le due coorti con diverso trattamento sono state confrontate (propensity-score matched cohorts). La PCI (con e senza DES) è risultata associata a maggiore rischio di morte (Hadard ratio, HR 1.6), di infarto del miocardio (HR=3.3), rivascolarizzazione successiva (HR=4.5), mentre nessuna differenza è stata osservata per incidenza di ictus cerebrale. Il vantaggio del CABG sulla PCI è più evidente, relativamente al rischio di morte, in pazienti con coronaropatia di 2 vasi (two-vessel disease) in aggiunta a patologia della arteria principale coronarica, e in quelli con coronaropatia di 3 vasi coronarici (three-vessel disease), frazione di eiezione < 35%, scompenso cardiaco e diabete. L’analisi dei rischi competitivi mostra che la differenza nei tassi di mortalità è principalmente dovuta alla maggiore incidenza di infarto del miocardio nei pazienti sottposti a PCI rispetto a CABG. In questo interessante lavoro, con il pregio di un ampia base dati da un contesto osservazionale e di un lungo follow up, gli Autori confermano che il CABG in pazienti con patologia coronarica estesa e con concomitante diabete continua ad essere lo standard di cura.

7. Bugiardini R, Manfrini O, Majstorovic Stakic M, Cenko E, Boytsov S, Merkely B, Becker D, Dilić M, Vasiljević Z, Koller A, Badimon L. Exploring In-hospital Death from Myocardial Infarction in Eastern Europe; From the International Registry of Acute Coronary Syndromes in Transitional Countries (ISACS-TC); on the behalf of the Working Group on Coronary Pathophysiology & Microcirculation of the European Society of Cardiology. Curr Vasc Pharmacol. 2013 Apr 22. [Epub ahead of print]
Olivia Manfrini, MD. Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, University of Bologna. Via Massarenti 9 (Padiglione 11), 40138 Bologna, Italy.

Introduction: The aim of the current study was to investigate the outcomes of coronary reperfusion therapies and ST-segment elevation myocardial infarction (STEMI) in patients of eastern countries with economies in transition. Methods and Results: We received STEMI registry data from 4 countries: Bosnia and Herzegovina, Hungary, Russian Federation, and Serbia. The overall population consisted of 23,486 consecutive patients admitted to hospitals from January 1st to December 31st 2009. Registry data and statistics from the Organization for Economic Cooperation and Development (OECD) countries for the same period were used for comparison (2009-2010). In-hospital mortality was between 4% and 5% in the Western countries. In comparison mortality data was significantly larger in Serbia (10.8%) and Bosnia and Herzegovina (11.2%), intermediate in Russian Federation (7.2%) and similar in Hungary (5.0%). The rates of primary percutaneous coronary intervention (primary PCI) were very low in Bosnia and Herzegovina (18.3%), low in Russian Federation (20.6%) and Serbia (22%), and high in Hungary (70%). Major risk factors for death appear to be lack of reperfusion therapy, longer time delay from symptoms onset to hospital presentation as well as the higher percentage of patients with clinical presentation in Killip class III/IV. Conclusion: In-hospital STEMI case-fatality rates ranges widely in the former Eastern Bloc countries. Beyond the quality of care provided in hospitals, differences in time delay from symptoms onset to hospital admission may strongly influence STEMI patients' outcome.

*Department of Ophthalmology, Jacobs Retina Center at Shiley Eye Center, University of California San Diego, La Jolla, California; †U.O. Oculistica, Dipartimento di Scienze Cliniche e di Comunità, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; and ‡Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California.

PURPOSE:: To evaluate the safety of oral fluorescein angiography (FA) and to compare its efficacy in detection of macular edema (ME) with spectral-domain optical coherence tomography (SD-OCT). METHODS:: Results of imaging studies for 1,928 eyes of 1,019 patients who had simultaneously undergone both oral FA and SD-OCT by a confocal laser ophthalmoscope were reviewed. Sensitivity in detecting ME, discrepancy rate, and "kappa" agreement were determined for both the techniques and with eyes stratified by disease diagnosis. RESULTS:: No allergic reactions occurred after oral FA. Mild gastric discomfort was noted in <1% of the patients; 1,840 eyes (95.4%) showed concordance between the two techniques, and kappa agreement was 90.3%. For ME, oral FA showed an overall sensitivity of 0.97 and SD-OCT of 0.91. Equivalent sensitivity was found in cases of wet age-related macular degeneration (0.99). Oral FA was more sensitive than SD-OCT in cases of retinovascular diseases. The SD-OCT showed higher sensitivity in cases of macular holes. Detection of ME by SD-OCT was significantly higher in cases of intense leakage on oral FA (P < 0.001). CONCLUSION:: Oral FA proved to be a safe and an adequate technique to evaluate ME. It is more sensitive than SD-OCT in detection of ME in cases of retinovascular diseases but can fail to detect ME in cases of macular holes. A noninvasive examination with simultaneous oral FA and SD-OCT may be considered to obtain a comprehensive evaluation of the presence of ME from different pathologies.

9. Avesani R, Roncari L, Khansefid M, Formisano R, Boldrini P, Zampolini M, Ferro S, De Tanti A, Dambruoso F. The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients. Eur J Phys Rehabil Med. 2013 Apr 5. [Epub ahead of print]
Department of Rehabilitation Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy -

Background: The lack of knowledge about epidemiological and clinical data of patients with Acquired Brain Injury (ABI) admitted to Rehabilitation facilities in Italy led to the creation, in June 2008, of a data collection on-line registry. Aim: To collect epidemiological and clinical data and to evaluate functional outcome of patients with severe traumatic and non-traumatic ABI admitted to Rehabilitation facilities in Italy between June 2008 and December 2011 and to compare data of patients with ABI of different aetiologies. Design: Observational retrospective study. Setting: The study involved 29 Italian Rehabilitation facilities. Population: The study enrolled 1469 patients with severe traumatic (TBI) and non-traumatic ABI (NTBI). Methods: Data collected included demographic (number of patients with TBI and NTBI, gender, age) and clinical characteristics (provenience, number of days elapsed between onset and rehabilitation admission, rehabilitation length of stay, discharge destination, death and vegetative state diagnosis, presence of percutaneous endoscopic gastrostomy, tracheostomy, pressure sores and paraosteoarthropathies). Functional outcome was evaluated using the Disability Rating Scale. Results: Of the whole population studied, 44.31% and 55.69% patients had suffered a TBI and a NTBI, respectively. In the NTBI group 40.09% had a cerebrovascular injury, 12.04% an anoxic brain damage, 3.6% had a brain injury of other causes. The mean age was 43.67 and 56.68 for subjects with TBI and NTBI, respectively. Patients with TBI showed a lower onset-admission interval (OAI), compared with NTBI group; no difference in rehabilitation length of stay (LOS) was recorded between groups. Patients with TBI presented a lower DRS score at admission and discharge and returned home more frequently than NTBI group. Conclusions: The creation of a National registry allows the collection of data about patients with ABI in order to study the clinical course, the functional outcome and to establish a basis for comparison with other data sources. Clinical Rehabilitation Impact: Data collection could be useful in the evaluation and planning of rehabilitation pathways, and to assess the allocation of healthcare and rehabilitative resources.

10. Gizzo S, Saccardi C, Patrelli TS, Di Gangi S, Breda E, Fagherazzi S, Noventa M, D'Antona D, Nardelli GB. Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature. Fertil Steril. 2013 Jun;99(7):2097-107. doi: 10.1016/j.fertnstert.2013.02.013. Epub 2013 Mar 15.
Department of Woman and Child Health, University of Padua, Padua, Italy. Electronic address:

OBJECTIVE: To investigate the most appropriate surgical technique for optimizing hemostasis and preservation of subsequent fertility after postpartum hemorrhage (PPH). DESIGN: Systematic review of the literature. SETTING: Not applicable. PATIENT(S): None. INTERVENTION(S): Review of MEDLINE, EMBASE, ScienceDirect, and the Cochrane Library. MAIN OUTCOME MEASURE(S): Comparison of the effectiveness of conservative surgical techniques, separately or together, with respect to success rate (ability to stop bleeding and preserve the uterus), fertility rate (subsequent pregnancies or the return of regular menstrual cycles), complication rate of the procedure, and the outcomes of subsequent pregnancies in terms of type of delivery and eventual delivery complications. RESULT(S): Compressive sutures and vessel embolization may be considered life-saving procedures by achieving the best hemostatic efficacy. Data on restoration of menses and pregnancy rates after these procedures are limited by short-term follow-up and by the paucity of studies, especially for vascular ligation. CONCLUSION(S): Pelvic vessel embolization and compressive sutures are associated with high rates of restoration of regular menses and successive pregnancies, even if the former is burdened by an increased rate of placental disorders and fetal growth restriction and the latter by an increased risk of cesarean deliveries and PPH recurrence. Randomized trials would be desirable to define the best management of PPH.

11. Murzi M, Cerillo AG, Miceli A, Bevilacqua S, Kallushi E, Farneti P, Solinas M, Glauber M. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg. 2013 Jun;43(6):e167-72. doi: 10.1093/ejcts/ezt043. Epub 2013 Feb 12.
Fondazione Toscana Gabriele Monasterio, G. Pasquinucci Heart Hospital, Massa, Italy.

OBJECTIVES: Recent studies have suggested an increased risk of stroke in patients undergoing minimally invasive mitral-valve surgery with retrograde perfusion when compared with antegrade perfusion. The aim of the present study was therefore to evaluate the impact on early outcome of retrograde arterial perfusion (RAP) strategy vs antegrade arterial perfusion strategy in a consecutive large cohort of patients who underwent minimally invasive mitral-valve surgery through a right minithoracotomy. METHODS: Between 2003 and 2012, 1280 consecutive patients underwent first-time minimally invasive mitral-valve surgery at our institution. A total of 167 (13%) of these patients received a retrograde perfusion, while 1113 (87%) received antegrade perfusion. Logistic analysis was used to evaluate outcomes and risk factors for stroke. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving retrograde perfusion and was included along with the comparison variable in the multivariable analyses of outcome. RESULTS: The overall frequency of in-hospital mortality was 1.1% (14/1280) and postoperative stroke was 1.6% (21/1280). After adjusting for the propensity score, RAP was associated with a higher incidence of stroke (5 vs 1%; P = 0.002), postoperative delirium (14 vs 5%, P = 0.001) and aortic dissection (1.7 vs 0%; P = 0.01). Multivariable regression analysis revealed that the use of retrograde perfusion was an independent risk factor for stroke [odds ratio (OR) 4.28; P = 0.02] and postoperative delirium (OR 3.51; P = 0.001). CONCLUSIONS: Minimally invasive mitral valve procedure can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications and aortic dissection when compared with antegrade perfusion. Central aortic cannulation allows the avoidance of complications associated with retrograde perfusion while extending the suitability of minimally invasive mitral procedures also to those patients who have an absolute contraindication to femoral artery cannulation.

12. D'Annibale A, Pernazza G, Monsellato I, Pende V, Lucandri G, Mazzocchi P, Alfano G. Total mesorectal excision: a comparison of oncological and functional outcomes between robotic and laparoscopic surgery for rectal cancer. Surg Endosc. 2013 Jun;27(6):1887-95. doi: 10.1007/s00464-012-2731-4. Epub 2013 Jan 5.
Minimally Invasive and Robotic Surgery Unit, San Giovanni Addolorata Hospital, Via dell'Amba Aradam 9, Rome, Italy.

BACKGROUND: Long-term data from the CLASICC study demonstrated the oncologic equivalence of laparoscopic and open rectal cancer surgery despite an increased circumferential resection margin involvement in the laparoscopic group in the initial report. Moreover, laparoscopic total mesorectal excision (TME) may be associated with increased rates of male sexual dysfunction compared to conventional open TME. Robotic surgery could potentially obtain better results than laparoscopy. The aim of this study was to compare the clinical and functional outcomes of robotic and laparoscopic surgery in a single-center experience. METHODS: This study was based on 100 patients who underwent minimally invasive anterior rectal resection with TME. Fifty consecutive robotic rectal anterior resections with TME (R-TME) were compared to the first 50 consecutive laparoscopic rectal resections with TME (L-TME). RESULTS: Median operative time was 270 min in R-TME and 275 min in L-TME. No conversions occurred in the R-TME group whereas six conversions occurred in the L-TME group. The mean number of harvested lymph nodes was 16.5 ± 7.1 for R-TME and 13.8 ± 6.7 for L-TME. The circumferential margin (CRM) was <2 mm in six L-TME patients, whereas no one in R-TME group had a CRM <2 mm. The International Prostate Symptom Score (IPSS) scores were significantly increased 1 month after surgery in both the L-TME and R-TME groups, but they normalized 1 year after surgery. Erectile function worsened significantly 1 month after surgery in both the groups but it was restored completely 1 year after surgery in the R-TME group and partially in the L-TME group. CONCLUSIONS: Robotic TME is oncologically safe and adequate for rectal cancer treatment, showing better results than laparoscopic TME in terms of CRM, conversions, and hospital length of stay. Better recovery in voiding and sexual function is achieved with the robotic technique.

13. Fumagalli Romario U, Puccetti F, Elmore U, Massaron S, Rosati R Self-gripping mesh versus staple fixation in laparoscopic inguinal hernia repair: a prospective comparison. Surg Endosc. 2013 May;27(5):1798-802. doi: 10.1007/s00464-012-2683-8. Epub 2013 Jan 5..
General and Minimally Invasive Surgery, Istituto Clinico Humanitas IRCCS, Via Manzoni, 56, 20089 Rozzano, Milan, Italy.

BACKGROUND: Transabdominal preperitoneal (TAPP) repair is widely used to treat bilateral or recurrent inguinal hernias. Recently a self-gripping mesh has been introduced into clinical practice. This mesh does not need staple fixation and thus might reduce the incidence of chronic pain. This prospective study aimed to compare two groups of patients with bilateral (BIH) or monolateral (MIH) primary or recurrent inguinal hernia treated with TAPP using either a self-gripping polyester and polylactic acid mesh (SGM) or a polypropylene and poliglecaprone mesh fixed with four titanium staples [standard technique (ST)]. METHODS: In this study, 96 patients (mean age, 58 years) with BIH (73 patients with primary and recurrent hernia) or MIH (22 patients with recurrent hernia) underwent a TAPP repair. For 49 patients, the repairs used SGM, and for 46 patients, ST was used. The patients were clinically evaluated 1 week and then 30 days postoperatively. After at least 6 months, a phone interview was conducted. The short-form McGill Pain Questionnaire was administered to all the patients at the 6-month follow-up visit. RESULTS: The mean length of the procedure was 83 min in the SGM group and 77.5 min in the ST group. The mean follow-up period was 13.8 months (range 1.3-42.0 months) for the SGM group and 18.2 months (range 1.9-27.1 months) for the ST group. The recurrence rate at the last follow-up visit was 0 % in the SGM group and 2.2 % (1 patient) in the ST group. The incidence of mild chronic pain at the 6-month follow-up visit was 4.1 % in the SGM group and 9.1 % in the ST group, and the incidence of moderate or severe pain was respectively 2.1 and 6.8 %. CONCLUSIONS: The study population was not large enough to obtain statistically significant results. However, the use of SGM for TAPP repairs appeared to give good results in terms of chronic pain, and the incidence of recurrences was not higher than with ST. In our unit, SGM during TAPP repair of inguinal hernias has become the standard.

14. Quaranta L, Biagioli E, Riva I, Rulli E, Poli D, Katsanos A, Floriani I. Prostaglandin analogs and timolol-fixed versus unfixed combinations or monotherapy for open-angle glaucoma: a systematic review and meta-analysis. J Ocul Pharmacol Ther. 2013 May;29(4):382-9. doi: 10.1089/jop.2012.0186. Epub 2012 Dec 11.
Ophthalmology Department, University of Brescia, Brescia, Italy.

PURPOSE: To estimate the intraocular pressure (IOP)-lowering effect of prostaglandin analogs (PGAs) administered in combination with β-blockers. METHODS: We searched the Medline and Embase databases for randomized trials comparing topical therapies with PGAs and timolol administered as monotherapy (Mt), or in fixed (FC) or unfixed combinations (UC) to patients with glaucoma or ocular hypertension. The efficacy endpoint was the mean difference (MeD) in the reduction in IOP from baseline; the tolerability endpoint was the incidence of hyperemia. RESULTS: The 18 eligible trials involved 23 comparisons of FC versus Mt, and 5 of FC versus UC. The FCs were less efficacious than UCs (MeD: 0.69, 95% CI: 0.29 to 1.08). In comparison with timolol Mt, the latanoprost/timolol FC led to a greater IOP reduction (MeD: -2.74, 95% CI: -3.24 to -2.23) than the bimatoprost/timolol FC (MeD: -1.49, 95% CI: -1.86 to -1.12) or the travoprost/timolol FC (MeD: -1.93, 95%CI: -2.98 to -0.88). The FCs led to a lower hyperemia risk than UCs [relative risk (RR): 0.70, 95% CI: 0.43 to 1.14] and PGA Mt (RR: 0.61, 95% CI: 0.53 to 0.70). CONCLUSIONS: FCs are more efficacious than their individual components, but less efficacious than their respective UCs. FCs lead to a lower hyperemia risk than UCs and their respective PGA Mts.

15. Ortolani P, Solinas E, Guastaroba P, Marino M, Casella G, Manari A, Piovaccari G, Ottani F, Varani E, Campo G, Marzocchi A, Merlini PA, Caminiti C, De Palma R, Ardissino D. Relevance of gender in patients with acute myocardial infarction undergoing coronary interventions. J Cardiovasc Med (Hagerstown). 2013 Jun;14(6):421-9. doi: 10.2459/JCM.0b013e328357bb04.
Istituto di Cardiologia, Università di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy.

AIMS: To evaluate whether gender differences in terms of up to 4-year outcome still persist within patients with acute myocardial infarction (AMI) who uniformly underwent coronary revascularization, we performed a gender comparison in a large contemporary multicentre percutaneous intervention (PCI) registry. MATERIALS AND METHODS: We retrospectively analyzed data from 18,351 patients with AMI, who underwent percutaneous coronary interventions (5093 women and 13,258 men) in the Emilia Romagna region of Italy between July 2002 and December 2007. Median follow-up was 1174 days. RESULTS: After propensity score adjustment, differences in gender-related mortality were not temporarily homogeneous: 30-day adjusted mortality was higher in women than in men [hazard ratio (HR): 1.40, P < 0.0001], whereas thereafter female gender showed a significantly lower mortality risk (HR: 0.84, P = 0.01). Notably, younger women (<50 years old) both in the acute and postacute period had more than 3.6 higher risk of mortality when compared with men, whereas older women, particularly after the first 30-day post AMI, had similar (50-80 years old) or even better (≥ 80 years old) survival compared with men. Finally 1-month adjusted risk of heart failure and post PCI vascular complications requiring surgical treatment was higher in women while there was no detectable difference in terms of early and late AMI/unstable angina, stroke and angiographic stent thrombosis. CONCLUSION: In a contemporary large real-world AMI population treated with PCI, we found gender-related temporal and age-dependent adjusted differences in mortality. Our data suggest the hypothesis that biological gender-related differences could, in part, explain these findings.

Breve commento a cura di Nerina Agabiti
Dati di letteratura dimostrano che le donne hanno una prognosi peggiore dopo infarto del miocardio rispetto agli uomini, ma non è chiaro ancora il meccanismo. Lo studio osservazionale condotto da Fortuna et al utilizza i dati del Registro Regionale delle Angioplastiche Coronariche dell’Emilia Romagna (REAL Registry) che coinvolge tutti i 15 entri centri di emodinamica interventistica della Regione e raccoglie informazioni dettagliate sui pazienti, sulle procedure e sulle terapie. La popolazione in studio di 18.351 pazienti (72% uomini) con angioplastica coronarica è stata arruolata nel periodo 2002-2007 ed il follow up è durato fino al dicembre 2008. Le analisi statistiche hanno utilizzato procedure sofisticate tra cui il propensity score adjustment per tener conto delle potenziali variabili di confondimento (caratteristiche cliniche, angiografiche, procedurali, etc..). La mortalità a 30 giorni è risultata significativamente più alta nelle donne (7.1% vs 3.7%, adjusted hazard ratio 1.40), mentre nel periodo successivo (dal 31° giorno fino a 4 anni di follow up) il rischio di morte è minore tra le donne (adjusted HR=0.84). Le donne con età < 50 anni hanno un rischio di morte molto maggiore (3.6 volte) rispetto agli uomini della stessa categoria di età, mentre nella categoria di età oltre i 50 anni non si osserva più tale differenziale. Inoltre, il rischio di scompenso cardiaco e di complicanze vascolari post- angioplastica è più alto tra le donne. Questo studio ossrvazionale con amiai base di dati raccolti dalla reale pratica clinica aggiunge conoscenza sui possibili motivi del differenziale tra generi negli esiti del post-infarto suggerendo che parte di questo differenziale è dovuto a motivi biologici.

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