RESUMEN

BACKGROUND: New challenges in the medical field of the third millennium emphasise the "humanization of medicine" leading to a redefinition of doctors' values, limits and roles. The study aims to assess whether there are different personality dimensions of physicians in relation to their perception of professional values and public expectations. METHODS: A questionnaire on the perception of professional values and the opinion on work in the medical field, work relationships and public expectations was administered to 374 doctors attending Continuing Medical Education courses. RESULTS: Two personality dimensions were identified: the first dimension (which we termed "Performance Attainment") is associated preeminently with values of competence, advocacy, confidentiality, spirit of enquiry, integrity, responsibility and commitment; the second dimension (which we called "Personal Involvement") focuses on concern and compassion. The doctors that have more difficulty accepting judgements on their activity are those who think that "Performance attainment" is less important (ß = 6.01; p-value = 0.007). Instead, the doctors who believe "public expectation of the health system" is not high enough, tend to think that "Performance Attainment" is more important (ß = -6.08; p-value = 0.024). The less importance is given to the values of "Personal Involvement", the less is the doctor's perception of having a leading role in respect to other health professionals (ß = -2.37; p-value = 0.018). CONCLUSIONS: Our results demonstrate that there are two different attitudes in terms of recognition and selection of the essential values to better practice the medical profession. Whether the doctors attach more importance to one dimension or the other, they do not differ in our analysis for how they answered the questions about relationships with patients, colleagues or family commitments in the questionnaire, even if they work in different areas. This suggests that in our research there is no single personal attitude that characterizes "a good doctor".

Asunto(s)

Actitud del Personal de Salud/etnología , Médicos/psicología , Profesionalismo/tendencias , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Percepción , Personalidad , Relaciones Médico-Paciente/ética , Encuestas y Cuestionarios

RESUMEN

We present the case of a woman with a severe clinical history of antiphospholipid syndrome and persistent positivity for lupus anticoagulant, IgG anticardiolipin and IgG anti-ß2Glycoprotein I antibodies. An acute clinical onset characterized by severe abdominal pain immediately followed by circulatory shock and histological colonic small vessel thrombosis pattern pointed to a diagnosis of ischemic colitis. The subsequent rapid onset of pulmonary alveolitis and heart failure associated to subendocardial hypoperfusion led to a diagnosis of definite catastrophic antiphospholipid syndrome (CAPS). Conventional triple therapy together with a broad-spectrum preventive antibiotic therapy were quickly initiated, and the outcome was favorable. We evaluated the patients with ischemic colitis in CAPS described in the literature between 1992 and May 2019 and our CAPS case. In accordance with the "two-hit" hypothesis and on the basis of the patients' data, we would like to speculate that the colonic wall necrosis related to ischemic colitis damaged the intestinal barrier causing loss of resistance to bacteria and leading to endotoxemia and bacteremia with bacteria translocation through the circulatory stream to the lungs and heart. The bacteria acted as the priming factor which favored the binding of ß2Glycoprotein I to the endothelium vessels in the colon, lungs, and heart following activation of anti-ß2Glycoprotein I antibodies which attached to the domain I of ß2Glycoprotein I. This was followed by complement activation which triggered the thrombotic and cytokine storm. If further clinical studies confirm this hypothesis, the treatment of CAPS could be more targeted and effective.

Asunto(s)

Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/terapia , Colitis Isquémica/complicaciones , Anticuerpos Antifosfolípidos/sangre , Síndrome Antifosfolípido/patología , Femenino , Humanos , Inhibidor de Coagulación del Lupus/sangre , Persona de Mediana Edad , Recurrencia , Factores de Riesgo , beta 2 Glicoproteína I/antagonistas & inhibidores , beta 2 Glicoproteína I/inmunología

RESUMEN

BACKGROUND: Chronic mesenteric ischaemia (CMI) has a long asymptomatic period, but little is known about the clinical implications of this phase of the disease, particularly in the elderly, who are most exposed to the condition. AIMS: The aim of the present observational study was to survey the in-hospital clinical course of elderly patients during the non-specific phase of the disease due to occlusion of at least one splanchnic artery. METHODS: For a median of 29 months, we followed up 85 patients aged 65 and over who, for various clinical reasons, had undergone computed tomographic and magnetic resonance angiography during 2010 at Padua Teaching Hospital, assessing economic impact and reasons for admission. RESULTS: Thirty-four of these patients had at least one occluded artery, and 68 % of them had at least one hospital admission. Elderly CMI patients were characterised by a higher number of admissions (median 2 vs 1 p = 0.05) and a higher cost (6044 vs 1733 Euros p = 0.04), but did not present typical gastrointestinal symptoms. The higher number of hospital admissions was not due to specific clinical risks (admitting wards: general medicine: 32 vs 29 %, p = 0.77; general surgery 8 vs 14 %, p = 0.73; vascular surgery: 26.5 vs 20 %, p = 0.46). CONCLUSIONS: In the asymptomatic phase of CMI, hospitalised elderly patients with at least one occluded splanchnic artery can be subject to a more challenging in-hospital clinical course.

Asunto(s)

Isquemia Mesentérica , Anciano , Angiografía por Tomografía Computarizada/métodos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Italia , Estudios Longitudinales , Angiografía por Resonancia Magnética/métodos , Masculino , Isquemia Mesentérica/diagnóstico , Isquemia Mesentérica/fisiopatología , Evaluación de Procesos y Resultados en Atención de Salud , Circulación Esplácnica

RESUMEN

BACKGROUND/AIM: Increased demand for colon cancer screening procedures can significantly impact on routine colonoscopy management at dedicated facilities, prompting a review of the factors that can negatively affect workflow. Although potential adverse effects and impact on costs of deep sedation have been documented elsewhere, this study focuses on variables that can influence performance of colonoscopy in deep sedation and interfere with normal procedure scheduling in settings where the presence of an anesthesiologist is mandatory. PATIENTS AND METHODS: We performed a cross-sectional study of the activities of a colonoscopy screening unit, applying Bayesian Network (BN) analysis, designed to assess interdependencies among variables that can affect a process in complex, multidimensional systems. The study was performed at a teaching hospital where endoscopists and anesthesiologists of varying work experience operate on a rota basis. During a six-month period, we analyzed 1485 consecutive colonoscopies performed under deep propofol sedation, administered by an anesthesiologist via hand-controlled syringe. The BN was constructed with the variables: Gender, age, ASA status, bowel preparation, baseline blood pressure, endoscopist's experience, anesthesiologist's experience, presence of polypectomy, and the target node, "challenging procedure." This previously undefined category refers to any events disrupting the scheduled rota. RESULT AND CONCLUSION: Two distinct networks were identified. One deals mainly with relationships among the variables, patients' demographic and clinical characteristics (procedures with polypectomy, ASA and baseline blood pressure). The other explains relationships among the variables, "challenging procedure," bowel preparation, and endoscopist's experience. The factors associated with the anesthesiologist's activity do not influence challenging colonoscopies.

Asunto(s)

Neoplasias del Colon/diagnóstico por imagen , Colonoscopía/métodos , Sedación Profunda/métodos , Propofol/administración & dosificación , Anciano , Teorema de Bayes , Neoplasias del Colon/diagnóstico , Estudios Transversales , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad

RESUMEN

BACKGROUND: The interest of the case lies in an unexpected delayed bleeding following an endoscopic procedure in a patient with post-polycythemia myelofibrosis. The case gives the opportunity to discuss the medical management and monitoring of patients with myeloproliferative disorders undergoing minimally invasive surgery interventions. CASE PRESENTATION: A 75 years old woman affected by post-polycythemia myelofibrosis underwent endoscopy polypectomy followed by a delayed major local bleeding. At the time of the endoscopy followed by bleeding, the platelet count was 837 × 109/L, haemoglobin 113 g/L, PCV 35,2% and WBC 20.22 × 106/L. No antithrombotic prophylaxis with low molecular weight heparin was used. Antiplatelet drug was withdraw seven days before endoscopy and restarted one week after the procedure. Polyp size was 11 x 19 mm and it was located on right side of the colon. CONCLUSION: There are some patients in whom current guidelines do not apply and our case stress the importance of myeloproliferative neoplasms as a risk factor for complications of endoscopic polypectomy. The delayed haemorrhage we observed suggest to strictly control the patient for a period longer than only one week also in case of antithrombotic treatment with antiplatelet drugs.

Asunto(s)

Enfermedades del Colon/etiología , Pólipos del Colon/complicaciones , Pólipos del Colon/cirugía , Endoscopía Gastrointestinal/efectos adversos , Hemorragia Gastrointestinal/etiología , Policitemia/complicaciones , Complicaciones Posoperatorias/etiología , Mielofibrosis Primaria/complicaciones , Anciano , Femenino , Humanos , Índice de Severidad de la Enfermedad

RESUMEN

OBJECTIVES: The aim of this study was to assess the decision-making capacity of elderly patients hospitalized in a geriatric surgery division, and the clinician's ability to assess that capacity. SUBJECTS AND METHODS: The study was conducted on patients (aged >66 years) undergoing surgical procedures. Exclusion criteria were a diagnosis of psychogeriatric disorders interfering with decision-making capacity; hearing or visual impairment; and inability to communicate. Patients previously declared legally incompetent were also excluded. The methodological approach consisted of additional interviews to collect data on patients' awareness of the reasons for their hospitalization, their informed consent, and their ability to sign a consent form. The interview was integrated with a clinical-behavioral assessment by means of the Mini-Mental State Examination and the Clock Drawing Test. Data were collected anonymously. RESULTS: The inclusion criteria were met by 123 patients, with a mean age ± SD of 77.65 ± 7.91 years (range 67-98). Their mean (±SD) Mini-Mental State Examination and the Clock Drawing Test scores were 24.53 ± 4.29 and 5.36 ± 2.41, respectively. Mild-to-severe cognitive impairment was identified in 39 patients (31.7%). The consent form was signed by 111 patients (90.25%), including 33 patients (29.72%) with mild-severe cognitive impairment; 18 patients (16.21%) were unaware of the reason for their admission to hospital. DISCUSSION: Many factors may interfere with elderly patients' ability to give their valid consent to treatment, and this study reveals that clinicians may overestimate their patients' decision-making capacity. Physicians should be aware of this problem, and intellectual capacity assessments and/or enhanced consent procedures should be considered when treating elderly patients.

Asunto(s)

Consentimiento Informado , Competencia Mental , Procedimientos Quirúrgicos Operativos , Anciano , Anciano de 80 o más Años , Disfunción Cognitiva/diagnóstico , Femenino , Hospitalización , Humanos , Consentimiento Informado/ética , Consentimiento Informado/legislación & jurisprudencia , Responsabilidad Legal , Masculino

RESUMEN

BACKGROUND: Body mass index (BMI) is considered a short-term mortality predictor, but a consensus has not been reached on its role and that of other nutritional parameters in predicting long-term mortality in nursing home residents. OBJECTIVES: To correlate BMI, Mini Nutritional Assessment scores, and serum albumin levels with the 5-year mortality rate in institutionalized elderly subjects. METHODS: A total of 181 nursing home residents aged ≥ 70 years were included in a 5-year longitudinal study. Data were collected on all participants' nutritional, health, cognitive, and functional status by means of a comprehensive geriatric assessment. Data on the participants' vital status were obtained 5 years after beginning the study, and a survival analysis was conducted using Kaplan-Meier curves and multivariate Cox proportional hazards models. RESULTS: The 5-year mortality rate was 63%. The deceased subjects (n = 115) had a lower BMI (24.7 ± 4.6 vs 26.6 ± 5.0 kg/m(2); P = .03) and Mini Nutritional Assessment score (18.6 ± 3.7 vs 20.1 ± 3.6; P = .02) than those still alive. Serum albumin levels did not differ between the two groups. Among the three indicators of nutritional status considered in this study, only BMI ≥ 30 kg/m(2) was significantly associated with a lower mortality risk at 5 years (hazard ratio = 0.432; 95% CI 0.20-0.70; P = .04), the risk for death being greater the lower the BMI class (log-rank test: P < .001). CONCLUSIONS: Our findings suggest that BMI is the best of the three parameters considered as a nutritional predictor of nursing home residents' mortality in the longer term, and indicate that a lower mortality risk coincides with a higher BMI.

Asunto(s)

Índice de Masa Corporal , Causas de Muerte , Casas de Salud/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Estudios de Seguimiento , Evaluación Geriátrica , Humanos , Modelos Lineales , Estudios Longitudinales , Masculino , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Índice de Severidad de la Enfermedad

RESUMEN

Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in "bridging" and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in "incurable" conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.

RESUMEN

BACKGROUND: The case presented by the authors gives the opportunity to discuss the medico-legal issues related to lack of prevention of falls in elderly hospitalized patients. CASE PRESENTATION: A 101 year old Caucasian female was admitted to a surgery division for evaluation of abdominal pain of uncertain origin. During hospitalization, after bilateral bed rails were raised, she fell and reported a femoral fracture. Before surgical treatment of the fracture, scheduled for the day after injury, the patient reported a slight reduction in hemoglobin. She received blood transfusion but her general condition suddenly worsened; heart failure was observed and pulseless electrical activity was documented. The patient died 1 day after the fall. Patient relatives requested a judicial evaluation of the case.The case was studied with a methodological approach based on the following steps: 1) examination of clinical records; 2) autopsy; 3) evaluation of clinicians' behavior, in the light of necroscopic findings and a review of the literature. CONCLUSIONS: The case shows that an accurate evaluation of clinical and environmental risk factors should be always performed at the moment of admission also in surgery divisions. A multidisciplinary approach is always recommended also with the involvement of the family members. In some cases, as in this one a fall of the patient is expectable but not always avoidable. Physical restraint use should be avoided when not necessary and used only if there are no practical alternatives.

Asunto(s)

Accidentes por Caídas , Seguridad del Paciente , Accidentes por Caídas/prevención & control , Anciano de 80 o más Años , Resultado Fatal , Femenino , Geriatría/legislación & jurisprudencia , Geriatría/normas , Hospitalización , Humanos , Italia , Responsabilidad Legal , Seguridad del Paciente/legislación & jurisprudencia , Seguridad del Paciente/normas

RESUMEN

BACKGROUND: Differences in health-related quality of life perception in patients with chronic disease may depend on pre-existing differences in personality profile. The purpose of the study was to investigate in a cohort of female patients with chronic diseases the relationship between the Quality of Life perception and the potential presence of depressive symptoms. PATIENTS AND METHODS: Female patients with chronic diseases were enrolled in the study. Exclusion criteria were diagnosis of psychopathological condition, treatment with psychoactive substances.Methodological approach was based on administration of the following test. Short Form health survey SF-36, Symptom Check List SCL-90-R, Satisfaction Profile test (SAT-P) and Beck Depression Inventory-II (BDI-II). The Pearson correlation coefficient was used to evaluate the relationship between depressive symptoms and Quality of life as assessed by psychometric test. RESULTS: 57 patients, aged 52(± 3,4), responded to inclusion criteria. 57% of patients had a diagnosis of functional dyspepsia or gastro-oesophageal reflux not complicated, and the remaining 43% musculoskeletal diseases. The statistical analysis showed an inverse correlation between the variable Bodily Pain of the SF-36 and the variable Depression scales of the SCL-90-R.In a second phase another sample of female patients was enrolled in the study. 64 patients, aged 49(± 3,2), responded to inclusion criteria.Another significant negative correlation was found between the Somatic-Affective factor of the BDI-II and the scale Physical Functioning of the SAT-P. DISCUSSIONS: In female patients with chronic disease depressive symptoms resulted influenced by pain and vice versa. The treatment of depressive symptoms could improve the quality of life of patients.

Asunto(s)

Dolor Crónico/psicología , Depresión/etiología , Dispepsia/psicología , Reflujo Gastroesofágico/psicología , Enfermedades Musculoesqueléticas/psicología , Calidad de Vida/psicología , Enfermedad Crónica , Dolor Crónico/etiología , Estudios de Cohortes , Dispepsia/complicaciones , Femenino , Reflujo Gastroesofágico/complicaciones , Humanos , Modelos Lineales , Persona de Mediana Edad , Enfermedades Musculoesqueléticas/complicaciones , Pruebas Psicológicas , Encuestas y Cuestionarios

RESUMEN

BACKGROUND: To determine whether patients with no alarm signs who ask the endoscopist to shorten their waiting time due to test result anxiety, represent a risk category for a major organic pathology. METHODS: At our open-access endoscopy service, we set up an expedite list for six months for outpatients who complained that the waiting time for gastroscopy was too long. Over this period we studied 373 gastroscopy patients. In addition to personal details, we collected information on the presence of Hp infection and compliance with dyspepsia guideline indications for gastroscopy. RESULTS: Average waiting time was 38.2 days (SD 12.7). The 66 patients who considered the waiting time too long underwent gastroscopy within 15 days. We made 5 diagnoses of esophageal and gastric tumour and gastric ulcer (7.6%) among the expedite list patients and 14 (4.6%) among those on the normal list (p=0.31). On including duodenal peptic disease in the analysis, the total prevalence rate rose to 19.7% in the short-wait group and to 10.4% (p=0.036) in the longer-wait group. DISCUSSION AND CONCLUSIONS: Our data suggests that asking to be fast-tracked does not have prognostic impact on the diagnosis of a major (gastric ulcer and cancer) pathology.

Asunto(s)

Ansiedad/etiología , Dispepsia/etiología , Neoplasias Esofágicas/diagnóstico , Gastroscopía/psicología , Neoplasias Gástricas/diagnóstico , Úlcera Gástrica/diagnóstico , Listas de Espera , Adulto , Anciano , Úlcera Duodenal/complicaciones , Úlcera Duodenal/diagnóstico , Úlcera Duodenal/psicología , Dispepsia/psicología , Neoplasias Esofágicas/complicaciones , Neoplasias Esofágicas/psicología , Femenino , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/diagnóstico , Reflujo Gastroesofágico/psicología , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Neoplasias Gástricas/complicaciones , Neoplasias Gástricas/psicología , Úlcera Gástrica/complicaciones , Úlcera Gástrica/psicología

RESUMEN

BACKGROUND: The gastro-esophageal reflux disease (GERD) is one of the most frequent disease of the upper gastro-entheric tract. Surgical treatment is reserved to selected patients, affected by severe forms of disease and/or without compliance to medical therapy.In 95%-60% of the patients submitted to surgical antireflux intervention, a notable improvement of the quality of life is observed.Functional evaluations performed on pre and post--surgical pHmetric and manometric examination have provided new acquisitions about improvements in the restoration of anatomical and functional integrity of the esophagus-gastric antireflux barrier. METHODS: 45 elderly patients with GERD were recruited in a 27 months period. All patients were subjected to laparoscopic Nissen-Rossetti 360° fundoplication. The subjects had a pre-surgical evaluation with:• 24 hours pHmetry,• esophageal manometry,The same evaluation was repeated 1 month and 6 months after surgical intervention. RESULTS: In our series all patients get benefit from surgical treatment, with an improvement of pHmetric and manometric parameters and a regression of complications of GERD such as Barrett's metaplasia. In 8.33% of patients a PPI therapy was necessary, after the surgical intervention, to control symptoms. CONCLUSIONS: The role of surgery in GERD concerns selected patients. Nissen-Rossetti mini-invasive approach is performed with an acceptable percentage of complications (3%-10%). This technique is associated with a good control of GERD symptoms in a short and middle term and with an improvement of functional parameters, such as pHmetric and manometric.

Asunto(s)

Fundoplicación/métodos , Reflujo Gastroesofágico/cirugía , Laparoscopía/métodos , Anciano , Anciano de 80 o más Años , Monitorización del pH Esofágico , Femenino , Estudios de Seguimiento , Reflujo Gastroesofágico/diagnóstico , Humanos , Masculino , Manometría , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Cholecystectomy, gold standard treatment for gallbladder lithiasis, is closely associated with increased bile reflux into the stomach as amply demonstrated by experimental studies. The high prevalence of gallstones in the population and the consequent widespread use of surgical removal of the gallbladder require an assessment of the relationship between cholecystectomy and gastric mucosal disorders.Morphological evaluations performed on serial pre and post - surgical biopsies have provided new acquisitions about gastric damage induced by bile in the organ. METHODS: 62 elderly patients with gallstone related disease were recruited in a 30 months period. All patients were subjected to the most appropriate treatment (Laparoscopic cholecystectomy). The subjects had a pre-surgical evaluation with:• dyspeptic symptoms questionnaire,• gastric endoscopy with body, antrum, and fundus random biopsies,• histo-pathological analysis of samples and elaboration of bile reflux index (BRI).The same evaluation was repeated at a 6 months follow-up. RESULTS: In our series the duodeno-gastric reflux and the consensual biliary gastritis, assessed histologically with the BRI, was found in 58% of the patients after 6 months from cholecystectomy. The demonstrated bile reflux had no effect on H. pylori's gastric colonization nor on the induction of gastric precancerous lesions. CONCLUSIONS: Cholecystectomy, gold standard treatment for gallstone-related diseases, is practiced in a high percentage of patients with this condition. Such procedure, considered by many harmless, was, in our study, associated with a significant risk of developing biliary gastritis after 6 months during the postoperative period.

Asunto(s)

Colecistectomía Laparoscópica , Reflujo Duodenogástrico/etiología , Cálculos Biliares/cirugía , Gastritis/etiología , Complicaciones Posoperatorias , Anciano , Anciano de 80 o más Años , Reflujo Duodenogástrico/diagnóstico , Reflujo Duodenogástrico/epidemiología , Femenino , Estudios de Seguimiento , Gastritis/diagnóstico , Gastritis/epidemiología , Infecciones por Helicobacter/diagnóstico , Infecciones por Helicobacter/epidemiología , Infecciones por Helicobacter/etiología , Helicobacter pylori/aislamiento & purificación , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Lesiones Precancerosas/diagnóstico , Lesiones Precancerosas/epidemiología , Lesiones Precancerosas/etiología , Estudios Prospectivos , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiología , Neoplasias Gástricas/etiología

RESUMEN

A 71 years old Italian man had type 3 gastric cancer of the greater curvature. Total gastrectomy with splenectomy and D2 lymph node dissection were performed. After discharge chemotherapy ELF regimen was administered for 6 months. After 16 months from the operation a local recurrence was discovered by CT scan. Surgical en-bloc resection was performed removing pancreatic tail, splenic colic flexure and a portion of left diaphragm. Histological examination confirmed local recurrence of gastric adenocarcinoma infiltrating pancreas, colon and diaphragm with lymph node metastasis.

Asunto(s)

Adenocarcinoma/cirugía , Gastrectomía , Recurrencia Local de Neoplasia/diagnóstico por imagen , Neoplasias Gástricas/cirugía , Tomografía Computarizada por Rayos X , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/patología , Anciano , Antineoplásicos/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia Adyuvante , Etopósido/uso terapéutico , Fluorouracilo/uso terapéutico , Humanos , Levoleucovorina/uso terapéutico , Masculino , Recurrencia Local de Neoplasia/patología , Neoplasias Gástricas/diagnóstico por imagen , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/patología

RESUMEN

BACKGROUND: To study the relationship between endoscopic practice and adverse events during colonoscopy under standard deep sedation induced and monitored by an anesthetist. METHODS: We investigated the routine activity of an endoscopy center at the Padova University teaching hospital. We considered not only endoscopic and cardiorespiratory complications, but also the need to use high-dose propofol to complete the procedure, and the inability to complete the procedure. Variables relating to the patient's clinical conditions, bowel preparation, the endoscopist's and the anesthetist's experience, and the duration of the procedure were input in the model. RESULTS: 617 procedures under deep sedation were performed with a 5% rate of adverse events. The average dose of propofol used was 2.6 ± 1.2 mg/kg. In all, 14 endoscopists and 42 anesthetists were involved in the procedures. The logistic regression analysis identified female gender (OR=2.3), having the colonoscopy performed by a less experienced endoscopist (OR=1.9), inadequate bowel preparation (OR=3.2) and a procedure lasting longer than 17.5 minutes (OR=1.6) as the main risk factors for complications. An ASA score of 2 carried a 50% risk reduction (OR=0.5). DISCUSSION AND CONCLUSIONS: Our model showed that none of the variables relating to anesthesiological issues influenced which procedures would prove difficult.

Asunto(s)

Colonoscopía , Sedación Profunda , Hipnóticos y Sedantes , Propofol , Anciano , Competencia Clínica , Colonoscopía/efectos adversos , Colonoscopía/métodos , Sedación Profunda/efectos adversos , Femenino , Humanos , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/efectos adversos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Evaluación de Procesos y Resultados en Atención de Salud , Propofol/administración & dosificación , Propofol/efectos adversos , Factores de Riesgo , Factores Sexuales , Factores de Tiempo

RESUMEN

BACKGROUND: Diverticular Disease (DD) is a common condition in Italy and in other western countries. There is not much data concerning DD's impact on budget and activity in hospitals. METHODS: The aim is to detect the clinical workload and the financial impact of diverticular disease in hospitals.Retrospective observational study of all patients treated for diverticular disease during the period of seven years in AOU Federico II. Analysis of inpatient and outpatient investigations, treatment, hospitalization and financial refunds. RESULTS: A total of 738 patients were treated and 840 hospital discharge records were registered. There were a total number of 4101 hospitalization days and 753 outpatient accesses. The investigations generated were 416 endoscopies, 197 abdominal CT scans, 177 abdominal ultrasound scans, 109 X-rays tests. A total of 193 surgical operations were performed. The total cost of this activity was € 1.656.802 or 0.2% of the total budget of the hospital. € 1.346.218, were attributable to the department of general surgery, 0.9% of the department's budget . CONCLUSIONS: The limited impact of diverticular disease on the budget and activity of AOU Federico II of Naples is mainly due to the absence of an emergency department.

Asunto(s)

Atención Ambulatoria/economía , Colectomía/economía , Colostomía/economía , Técnicas de Diagnóstico del Sistema Digestivo/economía , Diverticulosis del Colon/economía , Costos de Hospital/estadística & datos numéricos , Hospitalización/economía , Atención Ambulatoria/estadística & datos numéricos , Colectomía/estadística & datos numéricos , Colostomía/estadística & datos numéricos , Técnicas de Diagnóstico del Sistema Digestivo/estadística & datos numéricos , Diverticulosis del Colon/diagnóstico , Diverticulosis del Colon/cirugía , Hospitalización/estadística & datos numéricos , Humanos , Italia , Estudios Retrospectivos

RESUMEN

BACKGROUND AND AIMS: Chronic mesenteric ischemia in older patients is a challenge for the physician because it coincides with a vague and non-specific clinical presentation with abdominal pain. It can frequently cause diagnostic errors and lead to legal consequences. The aim of this work was to evaluate the literature on chronic mesenteric ischemia and focus on the limited data concerning the geriatric population. METHODS: This research focused on observational studies, randomized controlled trials, and clinical reports (excluding case reports and reviews) dealing with patients at least 65 years old with a clinical or instrumental diagnosis of chronic intestinal ischemia, published between 2000 and 2010. The search was conducted in PubMed using the following key words: chronic ischemic splanchnic disease, chronic mesenteric ischemia, angina abdominis, chronic abdominal angina, intestinal ischemia. RESULTS: We selected 925 articles with the key words as follows: chronic mesenteric ischemia in 355 cases; chronic ischemic splanchnic disease in 46; angina abdominis in 4; abdominal angina in 242; and chronic intestinal ischemia in 278. We then excluded articles judged scarcely pertinent, case reports, reviews, works concentrating only on diagnostic, methodological, instrumental and surgical approaches, and articles based on animal or experimental models. This selection left us with 13 articles (after excluding duplicates), only three of which were considered valid for our purposes. CONCLUSIONS: Our review indicates that there is a shortage of useful literature on chronic intestinal ischemic disease diagnosed in the older adults, and the appropriate geriatric management of these patients is consequently not well established.

Asunto(s)

Isquemia/diagnóstico , Enfermedades Vasculares/diagnóstico , Dolor Abdominal/fisiopatología , Anciano , Errores Diagnósticos , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Isquemia Mesentérica , Persona de Mediana Edad , Ultrasonografía , Enfermedades Vasculares/diagnóstico por imagen , Enfermedades Vasculares/fisiopatología

RESUMEN

This work investigates the prognostic role of advanced age as a risk factor for recurrence in a population of patients undergoing surgery for N0 stage colon cancer, and also evaluates whether that role is affected by tumor location. A population of 129 consecutive patients who underwent radical surgery for N0 stage colon cancer was selected. Patients were subdivided into three age groups: <65, 65-80 and >80. The only correlation found in the examined population between age and clinical-pathological features was between advanced age (>80) and tumor location in the right side of the colon. Overall survival (OS) and disease- free survival (DFS) were significantly lower in patients over 80 than in the other two classes. Two multivariate analyses were carried out: when tumor location was not considered, age >80 represented a negative prognostic factor for risk of recurrence, regardless of the other factors examined. This role was also confirmed when tumor location was considered. As hypothesized by several authors, the role of advanced age which emerges from this study is mainly due to the increased fragility of elderly patients caused by multiple pathophysiological factors, but it does not necessarily represent an absolute contraindication to surgery. The role played by tumor location remains controversial, as more and more studies show that right colon cancer (RCC) is a biological entity distinct from left colon cancer (LCC). Further studies are required to examine right and left colon cancers as two separate diseases.

Asunto(s)

Neoplasias del Colon/patología , Recurrencia Local de Neoplasia/patología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Neoplasias del Colon/cirugía , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Factores de Riesgo

RESUMEN

Complications after surgical treatment of diverticulitis are not very frequent, in view of the total number of patients affected by this pathology, but they do become significant in absolute terms because of the high prevalence of the disease itself. Surgeons continue to debate which option is better: Hartmann resection or combined resection and anastomosis. Since age is a crucial factor when surgery is being considered, we evaluated the outcome of surgical treatment for diverticulitis in patients treated in our unit over a six-month period, in view of the number of elderly patients generally admitted. Between January 2001 and June 2012, 77 patients underwent surgery for diverticular disease in the Geriatric Surgery Unit of the Department of Surgical and Gastroenterological Sciences, University of Padova Hospital. Gastrointestinal resection and anastomosis were performed in 75 patients (97%), resulting in an overall complication rate of 37% and a mortality rate of 1%. This surgical strategy was chosen because, when it is performed by experienced surgeons, it offers the same results in terms of mortality and morbidity as Hartmann resection, while presenting significant advantages as regards the patient's quality of life. Various factors such as the timing of surgery, severity of the disease defined according to the Hinchey classification, patient's clinical condition, and surgeon's experience and expertise can all influence the surgical choice. Several studies in the literature confirm that combined resection and anastomosis is safe and efficacious, but more research is needed to confirm these data.

Asunto(s)

Anastomosis Quirúrgica/métodos , Diverticulitis/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/efectos adversos , Humanos , Persona de Mediana Edad , Resultado del Tratamiento

RESUMEN

Colonoscopy in the elderly is a reliable practice of great diagnostic and management value. However, patient's age has long been considered to affect the success of the procedure, achieved when the cecum is intubated, there is a good view of the colon if preparation has been properly carried out, and the examination does not cause excessive discomfort or complications. Substantial improvements have been made to the latter two aspects, due to more widespread use of deep sedation with propofol and cardiocirculatory monitoring during the procedure. The aim of our work was to assess whether, in the everyday practice of an open-access, digestive endoscopy teaching center, staffed by various providers delivering screening for polyposis, age is still a limitation to the success of the procedure and whether appropriate measures have been taken to improve colonoscopy in geriatric patients. We analysed 1480 consecutive colonoscopies, of which 319 were performed in patients aged over 73 years. The examination was significantly less successful in this group of patients (88.1 vs 94.4, p=0.0001), but there were no major technical or use-related complications connected with administration of propofol for sedation purposes, despite lower doses to the elderly (2.2 ± 1.1 mg/kg total dose, mean 151 ± 72.4 mg vs 2.9 ± 1.3 mg/kg total dose, mean 199 ± 77.9 mg in younger patients, p<0.001). More experienced technical staff were not allocated to these colonoscopies (for endoscopic or anesthesiological purposes) and, according to the results of multivariate stepwise logistic regression analysis, inadequate preparation was the main factor affecting the success of the procedure in elderly patients (OR 5.9, 95% CI 2.25-15.72; p=0.0003). Only body weight over 60 kg facilitated it (weight ≥ 60 kg, OR 0.46, 95% CI 0.26-0.83). In colonoscopy in the elderly, safety appears to be the primary concern and, good outcomes can be achieved, but sometimes at the expense of diagnostic accuracy. This could probably be improved through better pre- and post-procedure care, not currently differentiated between young and elderly patients.

Asunto(s)

Colonoscopía/métodos , Factores de Edad , Anciano , Colonoscopía/efectos adversos , Colonoscopía/educación , Colonoscopía/estadística & datos numéricos , Sedación Profunda/efectos adversos , Sedación Profunda/métodos , Sedación Profunda/estadística & datos numéricos , Humanos , Hipnóticos y Sedantes/administración & dosificación , Propofol/administración & dosificación