Giuseppe Verlato

Survival and Disease Complications in Thalassemia Major

Abstract: We studied survival and disease complications in 1,146 patients with thalassemia major, born from January 1, 1960 to December 31, 1987. At last follow‐up, in March 1997, probability of survival to age 20 years was 89% and to age 25 years was 82% for patients born in the years 1970‐1974. Patients who died had a serum ferritin level, measured the year before death, significantly higher than those who survived. Diabetes was present in 5.4% of the patients; heart failure in 6.4%; arrhythmias in 5.0%, thrombosis in 1.1%, hypothyroidism in 11.6%, HIV infection in 1.8%. Hypogonadism was diagnosed in 55% of 578 patients who had reached pubertal age: 83.5% of hypogonadic females and 78.6% of males were receiving substitutive hormonal therapy. In conclusion, the survival of patients with thalassemia major is good and improving, but the prevalence of severe complications is still high.

The Coexistence of Asthma and Chronic Obstructive Pulmonary Disease (COPD): Prevalence and Risk Factors in Young, Middle-aged and Elderly People from the General Population

Background The joint distribution of asthma and chronic obstructive pulmonary disease (COPD) has not been well described. This study aims at determining the prevalence of self-reported physician diagnoses of asthma, COPD and of the asthma-COPD overlap syndrome and to assess whether these conditions share a common set of risk factors. Methods A screening questionnaire on respiratory symptoms, diagnoses and risk factors was administered by mail or phone to random samples of the general Italian population aged 20–44 (n = 5163) 45–64 (n = 2167) and 65–84 (n = 1030) in the frame of the multicentre Gene Environment Interactions in Respiratory Diseases (GEIRD) study. Results A physician diagnosis of asthma or COPD (emphysema/chronic bronchitis/COPD) was reported by 13% and 21% of subjects aged <65 and 65–84 years respectively. Aging was associated with a marked decrease in the prevalence of diagnosed asthma (from 8.2% to 1.6%) and with a marked increase in the prevalence of diagnosed COPD (from 3.3% to 13.3%). The prevalence of the overlap of asthma and COPD was 1.6% (1.3%–2.0%), 2.1% (1.5%–2.8%) and 4.5% (3.2%–5.9%) in the 20–44, 45–64 and 65–84 age groups. Subjects with both asthma and COPD diagnoses were more likely to have respiratory symptoms, physical impairment, and to report hospital admissions compared to asthma or COPD alone (p<0.01). Age, sex, education and smoking showed different and sometimes opposite associations with the three conditions. Conclusion Asthma and COPD are common in the general population, and they coexist in a substantial proportion of subjects. The asthma-COPD overlap syndrome represents an important clinical phenotype that deserves more medical attention and further research.

LAPAROSCOPIC CHOLECYSTECTOMY FOR SEVERE ACUTE CHOLECYSTITIS. A META-ANALYSIS OF RESULTS

ObjectiveThe aim of this review was to evaluate surgical outcomes of laparoscopic cholecystectomy for gangrenous and empyematous acute cholecystitis defined as severe acute cholecystitis.BackgroundIt is not known to what extent surgical outcomes of laparoscopic cholecystectomy for severe acute cholecystitis differ from those for the nonsevere acute form, making it questionable whether urgent laparoscopic cholecystectomy is the best approach even in severe acute cases.MethodsLiterature searches were conducted to identify: (1) comparative studies which reported laparoscopic surgical outcomes separately for severe acute and nonsevere acute cholecystitis; (2) studies comparing such an approach with open cholecystectomy, subtotal laparoscopic cholecystectomy or cholecystostomy in severe acute cholecystitis. Results were pooled by standard meta-analytic techniques.ResultsSeven studies with a total of 1,408 patients undergoing laparoscopic cholecystectomy were found. The risks of conversion (RR 3.2, 95% CI 2.5 to 4.2) and overall postoperative complications (RR 1.6, 95% CI 1.2–2.2) were significantly higher in severe acute cholecystitis with respect to the nonsevere acute forms. However, no difference was detected as regards to local postoperative complications. No studies comparing open cholecystectomy or cholecystostomy with urgent laparoscopy were found.ConclusionA lower feasibility of laparoscopic cholecystectomy has been found for severe cholecystitis. A lower threshold of conversion is recommended since this may allow to reduce local postoperative complications. Literature data lack valuable comparative studies with other treatment modalities, which therefore need to be investigated.

Ondansetron versus metoclopramide in the treatment of postoperative nausea and vomiting

In this prospective, randomized, double-blind study, we compared the efficacy and safety of ondansetron and metoclopramide in the treatment of postoperative nausea and vomiting (PONV). One hundred seventyfive patients with PONV during recovery from anesthesia for gynecological laparoscopy were treated intravenously with either ondansetron 4 mg (58 patients), metoclopramide 10 mg (57 patients), or placebo (60 patients). Early antiemetic efficacy (abolition of vomiting within 10 min and of nausea within 30 min from the administration of the study drugs with no further vomiting or nausea episodes during the first hour) was obtained in 54 of 58 patients (93.1%) in the ondansetron group, in 38 of 57 patients (66.7%) in the metoclopramide group, and in 21 of 60 patients (35%) in the placebo group (P < 0.001). This difference was still significant when controlling for age, body weight, history of motion sickness, previous PONV episodes, duration of anesthesia, and intraoperative fentanyl consumption using a logistic model. Early antiemetic efficacy was inversely related to the amount of fentanyl administered during anesthesia, regardless of treatment. According to the Kaplan-Meier method, the probability of remaining PONV-free for 48 h after a successful treatment was 0.59 (95% confidence interval 0.45-0.71) in the ondansetron group, 0.45 (0.29-0.60) in the metoclopramide group, and 0.33 (0.15-0.53) in the placebo group (P = 0.003). In conclusion, ondansetron 4 mg is more effective than metoclopramide 10 mg and placebo in the treatment of established PONV. (Anesth Analg 1997;85:395-9)

Clinician versus nurse symptom reporting using the National Cancer Institute—Common Terminology Criteria for Adverse Events during chemotherapy: results of a comparison based on patient’s self-reported questionnaire

BACKGROUND Monitoring adverse events during chemotherapy by clinicians is a standard practice but clinicians may report fewer side-effects or lower symptom severity than patients. Our aim was to compare symptoms self-reported by patients with symptoms registered by clinicians and nurses, to assess validity of a nurse reporting. METHODS From April to August 2007, a double-blind questionnaire with 13 common items graduated according to the National Cancer Institutes Common Terminology Criteria for Adverse Events was completed by clinicians and nurses for outpatients undergoing chemotherapy at our Medical Oncology Day Hospital Unit. Patients completed a modified questionnaire with simplified terms. They were requested to specify seriousness of symptoms with a subjective scale varying from 1 to 4. Every patient-nurse-clinician questionnaire was registered for the statistical analysis. Agreement was evaluated by Cohens kappa coefficient. RESULTS Eighty-five paired questionnaires were completed. Patients, nurses and clinicians agreed on most symptoms and toxicity grade. Agreements between patients and nurses were stronger than those between patients and physicians for the six most common symptoms: asthenia (kappa 75% versus 37%), constipation (83% versus 45%), neuropathy (82% versus 55%), mucositis (78% versus 46%) and diarrhoea (90% versus 77%). These differences mainly reflected differences in the proportion of positive agreement: nurses were more able to detect symptoms self-reported by patients than physicians. The only exception was nausea, as kappa coefficient was very good for both health professionals (91% versus 89%). When considering the different grade of toxicity by the weighted kappa coefficient, we scored again the highest agreement between patient and nurse, with weighted kappa ranging from 55% (asthenia) to 86% (diarrhoea), and the lowest agreement between patient and physician, with weighted kappa ranging from 32% (asthenia) to 74% (nausea). The agreement between physician and nurse slightly improved, with weighted kappa ranging from 41% (constipation) to 77% (nausea). CONCLUSION Our results support the validity of nurse toxicity reporting and that the nurse staff could be successfully employed in collecting toxicity data because of a greater ability to elicit information from patients than the medical staff.

Systematic review of central pancreatectomy and meta-analysis of central versus distal pancreatectomy.

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).

Indexes of Surgical Quality in Gastric Cancer Surgery: Experience of an Italian Network

BackgroundShort-term results of gastric cancer surgery vary remarkably worldwide, and international surgical quality criteria are urgently needed. To contribute to defining these criteria, we reviewed short-term results of gastrectomy for gastric cancer in three centers of the Italian Research Group for Gastric Cancer, with an average of 24.7, 29.5, and 18 gastrectomies per year.MethodsBetween 1988 and 2002, 1,032 patients underwent gastrectomy for gastric cancer in Verona, Siena, and Padua. D1, D2, and D3 lymphadenectomy were performed, respectively, in 228, 584, and 220 cases.ResultsThe median number of retrieved lymph nodes was 14 (interquartile range 9–18.75) after D1, 29 (21–38) after D2, and 46.5 (37–57) after D3. Fewer than 15 nodes were retrieved in 54.5%, 6.2%, and 1.4% of cases undergoing, respectively, D1, D2, and D3. Adjacent organ removal was rare during D1 (splenectomy: 6.1%, splenopancreasectomy: 1.8%), and quite common during D3 (11.4%, 11.4%). Forty patients (3.9%) died postoperatively. Neither postoperative morbidity nor mortality was significantly associated with extension of lymphadenectomy.ConclusionWe conclude that at least D2 lymphadenectomy is necessary to achieve adequate disease staging (≥15 nodes retrieved). Spleen and pancreas tail are more frequently removed during D3, but this removal is not associated with higher postoperative morbidity or mortality.

Domestic use of hypochlorite bleach, atopic sensitization, and respiratory symptoms in adults

BACKGROUND Professional use of hypochlorite (bleach) has been associated with respiratory symptoms. Bleach is capable of inactivating allergens, and there are indications that its domestic use may reduce the risk of allergies in children. OBJECTIVE To study the associations between household use of bleach and atopic sensitization, allergic diseases, and respiratory health status in adults. METHODS We identified 3626 participants of the European Community Respiratory Health Survey II in 10 countries who did the cleaning in their homes and for whom data on specific serum IgE to 4 environmental allergens were available. Frequency of bleach use and information on respiratory symptoms were obtained in face-to-face interviews. House dust mite and cat allergens in mattress dust were measured in a subsample. Associations between the frequency of bleach use and health outcomes were evaluated by using multivariable mixed logistic regression analyses. RESULTS The use of bleach was associated with less atopic sensitization (odds ratio [OR], 0.75; 95% CI, 0.63-0.89). This association was apparent for specific IgE to both indoor (cat) and outdoor (grass) allergens, and was consistent in various subgroups, including those without any history of respiratory problems (OR, 0.85). Dose-response relationships (P < .05) were apparent for the frequency of bleach use and sensitization rates. Lower respiratory tract symptoms, but not allergic symptoms, were more prevalent among those using bleach 4 or more days per week (OR, 1.24-1.49). The use of bleach was not associated with indoor allergen concentrations. CONCLUSION People who clean their homes with hypochlorite bleach are less likely to be atopic but more likely to have respiratory symptoms.

Variability of body weight, pulse pressure and glycaemia strongly predict total mortality in elderly type 2 diabetic patients. The Verona Diabetes Study.

Ageing is characterized by a decreased functional reserve, a concept defined as homeostenosis. We assessed the impact of long‐term exposure to the average value (mean) or to the variability (coefficient of variation) of fasting glycaemia, body mass index (BMI) and pulse pressure on total mortality in a cohort of type 2 diabetic patients.

Comparison of old and new TNM systems for nodal staging in adenocarcinoma of the gastro-oesophageal junction†

Adenocarcinoma of the gastro‐oesophageal junction is considered a distinct clinical entity, although the current pathological tumour node metastasis (pTNM) classification does not consider this tumour specifically. A prospective study was undertaken to determine the prognostic importance of lymph node involvement in adenocarcinoma of the gastro‐oesophageal junction, analysing both a number‐ and site‐based classification, in order to develop a clinically useful nodal staging system.