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Performance monitoring and evaluation are key to quality improvement in maternal and child healthcare in Sub-Saharan Africa. This study presents the experience of designing and implementing bottom-up and integrated performance evaluation tools for care pathway to monitor and manage maternity healthcare services. The research project involved four health districts and relative reference hospitals, supported by the NGO Doctors with Africa CUAMM in Ethiopia, Tanzania, and Uganda. The maternal and childcare pathway developed consists of 23 indicators, calculated at hospital and district level, relating to pregnancy, childbirth and first year of life phases. The authors developed staves and performance maps, as graphical representation tools, to display longitudinally integrated health services provision performance along the continuum of care. Substantial variation was observed between the phases of each maternal and childcare pathway and across the care pathways of the different analysed settings. The most impressive results across the four settings are: 1) regarding pregnancy phase, that women tend to attend more than four antenatal classes, still with a quite high drop-out rate, and are largely tested for syphilis, 2) with respect to childbirth, that there are varying percentage levels in terms of C-sections, episiotomies and peri/intra-partum asphyxia cases, and 3) as it regards first year of life, there emerges scope for improvement considering the vaccination coverages attained for pentavalent, measles and polio vaccinations. Thanks to the collaboration with local managers and health professionals, the maternal and childcare pathway allowed to monitor the changes in the quality of maternity services provided within the analysed contexts. The benchmarking approach encouraged local professionals to learn from other settings. The use of such tool allowed the development of targeted quality improvement actions, shared among all involved stakeholders. Key messages • In collaboration with local professionals, we designed and implemented an integrated pathway for maternal and childcare, covering the phases of pregnancy, childbirth and first year of life. • Benchmarking performance results encouraged collaboration among professionals and allowed the identification of actions to improve the provision of maternal and childcare services.

Objectives: to compare stump pressure (SP) and transcranial Doppler (TCD) with neurologic monitoring during carotid endarterectomy (CEA). Materials: one hundred and forty-seven CEAs performed under local anaesthesia. Methods: neurologic monitoring and SP were performed in all cases, while mean velocity of the middle cerebral artery (mvMCA) by TCD was done in 140/147 (95%) cases. Shunts were applied in all cases on the basis of neurologic monitoring. The following haemodynamic criteria have been compared to neurologic monitoring: (a)

Objectives: to compare cerebral haemodynamics in patients with asymptomatic and symptomatic severe (≥70%) internal carotid artery (ICA) stenosis. Methods: we assessed 195 consecutive patients, 116 with asymptomatic carotid stenosis (ACS) and 79 with symptomatic carotid stenosis (SCS). Using transcranial Doppler we assessed cerebral vasoreactivity (CVR) following acetazolamide test, the middle cerebral artery flow velocity ratio after/before carotid clamping (mv-MCA ratio), and the carotid back pressure (CBP) during crossclamping. Results: no significant differences between the two groups were demonstrated regarding CVR (47 vs 39%), mv-MCA ratio (50 vs 52%), or CBP (36 vs 44 mmHg). However, in patients with contralateral ICA occlusion all three variables were significantly lower as compared to patients with patent contralateral ICA. Also patients who needed a shunt during surgery had significantly lower values of mv-MCA ratio and CBP. Patients who suffered peri-operative neurologic deficits (n=6; 3%) did not differ from patients who had an uneventful course. Conclusions: clinical state of ICA stenosis is independent of cerebral haemodynamics. Occluded contralateral ICA is more important for predicting cerebral ischaemia caused by carotid clamping. Finally, none of the haemodynamic parameters showed predictive value for peri-operative neurologic morbidity.

Solid Phase Micro Extraction (SPME) involves exposing a fused silica fiber coated with stationary phase to a contaminated water sample. The organic analytes become partitioned between the stationary phase and the water and when equilibrium is reached the fiber is removed from the solution and the analytes are thermally desorbed in the injector of a gas chromatograph. The fiber is contained in a syringe to facilitate handling. Factors which affect linear range, limit of detection, and total analysis time are discussed with regard to the development of a method for analysis of volatile compounds in environmental water samples. The sensitivity of the method was determined by the thickness of the film of stationary phase; the equilibration time, however, increased with the film thickness, although it can be minimized by use of a cross-shaped stirrer bar. Increasing the thickness of stationary phase in the analytical column enables the cryofocusing temperature to be increased from −40 to −15°C. With an ion trap mass spectrometer, detection limits required by the US Environmental Protection Agency are met for all compounds except chloromethane and chloroethane. The method has been applied to environmental water samples.

Assessment of cerebrovasoreactivity (CVR), obtained by transcranial Doppler (TCD) and the acetazolamide test to predict cases requiring selective carotid shunting on the basis of neurologic monitoring.A consecutive series of 87 carotid endarterectomy (CEA) cases was studied. Before surgery CVR was evaluated by measuring the mean velocity of the middle cerebral artery (mvMCA) using TCD at the basal condition and at 30 min after intravenous administration of acetazolamide (1 g). Carotid shunting was performed using neurologic monitoring under local anesthesia. Receiver operating characteristic (ROC) curve was calculated for sensitivity and specificity for various CVR cut offs.The ROC curve demonstrated that there was no single CVR cut off with both sensitivity and specificity above 80%.The present study, which employed neurologic monitoring as the method of comparison, did not prove that CVR, as calculated by TCD and the acetazolamide test, is a valid preoperative test for predicting cerebral ischaemia caused by carotid clamping.

Cerebral vasoreactivity (CVR) was evaluated as a preoperative test in predicting cerebral tolerance to carotid clamping. A consecutive series of 115 carotid endarterectomy (CEA) cases were studied. Before surgical operation CVR was evaluated, by measuring the mean velocity of the middle cerebral artery (mv-MCA) using transcranial Doppler (TCD) at the basal condition and 20 min after intravenous administration of acetazolamide (1 g). CEA was performed under general anesthesia. TCD was used during surgery to evaluate mv-MCA and to calculate mv-MCA clamping/mv-MCA pre-clamping x100 ratio (mv-MCA%), which was used as the parameter to validate CVR. CVR did not correlate with mv-MCA% ( r = 0.22). There was no significant difference ( P= 0.09) between mean values of the non shunted subgroup and the shunted one. CVR does not seem to be suitable for evaluating cerebral tolerance to carotid clamping.

Phagocyte-dependent host defenses are frequently impaired in maintenance hemodialysis patients who show an increased susceptibility to infections. In these individuals, the course of infections can be more aggressive than in normal hosts, and the antibiotic of choice should have a high antimicrobial effect without impairing host defenses. Hence, in uremic patients, the antibiotic enhancement of phagocyte functions may be of potential clinical importance in the outcome of bacterial infections. Because we demonstrated previously that co-amoxiclav had beneficial properties that result in enhancement of the microbicidal functions of human polymorphonuclear cells (PMNs) from healthy subjects, we investigated the influence of this combination on the activities of PMNs from chronic hemodialysis patients against Klebsiella pneumoniae , a human pathogen that can pose severe problems in patients whose immunity is impaired. PMNs from chronic dialysis patients showed a diminished in vitro phagocytic efficiency with a reduced phagocytosis and bactericidal activity towards intracellular K. pneumoniae compared with that seen in PMNs from healthy subjects. When co-amoxiclav was added to PMNs from chronic hemodialysis patients, it was able to restore the depressed primary functions of PMNs, resulting in a significant high increase in both phagocytosis or killing activity. A similar pattern was detected with PMNs collected from hemodialysis patients treated with co-amoxiclav. The results of the present study provide evidence that co-amoxiclav is able to induce stimulation of depressed phagocytic response of PMNs from patients on chronic hemodialysis, restoring their primary functions both in vitro and in vivo.

Transcutaneous oximetry was studied to select the correct amputation level for limb ischemic necrosis with possible identification of threshold value.The method was evaluated in 30 cases (20 patients, 5 males and 15 females, of ages ranging from 61 to 93, average 73.1+/-8.5) where patients underwent amputation because of severe leg ischemia. Surgical operations were: minor amputation (toe or transmetatarsal) in 23 cases, below knee amputation in 7. Oxygen tension was measured at the dorsum foot and at the third superior of the anteromedial calf aspect.Results were classified as success (primary or delayed healing) or failure (necrosis at the surgical wound). Amputation was successful in 17/30 cases with oxygen tension of 0-65 mmHg (mean 32.5+/-16.1) and failed in 13/30 with oxygen tension of 0-57 mmHg (mean 7.8+/-17.3). The difference was statistically significant (p=0.0004). Sensitivity of the method resulted 88.2%, specificity 84.6%, diagnostic accuracy 86.7%, positive predictive value 88.2% and negative predictive value 84.6%. A threshold of 20 mmHg was identified: 15/17 successful cases showed values greater than 20 mmHg, while 11/13 failed cases presented values lower than the threshold.Following our observations and according to some reported studies, we believe transcutaneous oximetry to be the best method for selection of amputation level This is a simple, noninvasive and accurate method, which has showed itself superior to other techniques (i.e., Doppler and radioisotope).

Some trials have demonstrated effectiveness of carotid endarterectomy (CEA) for preventing stroke in patients with severe symptomatic carotid stenosis. Although some researches, indication to surgery for asymptomatic carotid stenosis is debated up today. Based on personal experience and literature, the main problems of CEA for asymptomatic stenosis are discussed.Retrospective study.Section of Vascular Surgery, University Department.CEA was performed in a consecutive series of 63 cases with asymptomatic stenosis (59 patients, 40 males and 19 females, ages ranging from 46 to 80 years, mean 67.9).CEA was performed under general anesthesia, with primary closure of arteriotomy in 37 cases and patch angioplasty using PTFE in 24, using eversion technique in 2 cases. Pruitt-Inahara shunt was used in 10/63 cases (15.9%), according to the mean velocity of the middle cerebral artery at carotid clamping/mean velocity of the middle cerebral artery pre-clamping ratio x 100 equal to or lesser than 15%, evaluated with transcranial Doppler, or stump pressure lesser than 50 mmHg, when transcranial Doppler examination was not possible.Operative mortality and postoperative morbidity.Operative mortality plus postoperative stroke were 1.6% (1/63). Operative mortality was precisely 0.0%. Postoperative complications were two: one was a neurologic deficit (monoparesis of the arm) and the other was myocardial ischemia.Four main problems have been shown in CEA for asymptomatic stenosis: 1. Identification of asymptomatic stenosis: 2. Assessment of risk for stroke: 3. Role of CEA: 4. Questions about surgical treatment. For the first problem, it is important to consider possible indicators for carotid stenosis (contralateral carotid stenosis, coronary artery disease, aortic aneurysm, peripheral arterial disease, etc.). With regard to the second problem, it is important to know the natural history of the carotid stenosis, which shows a stroke rate of 1-2% per year. Regarding the third problem, the role of CEA is conditioned by: trials, patient conditions, lesion characteristics and ability of the surgeon. Further studies should identify some groups of patients (with severe carotid stenosis, dyshomogeneous plaque, progression of plaque, etc.), who can profit from CEA. Finally (fourth problem), CEA for asymptomatic carotid stenosis carries all common problems of carotid surgery (preoperative assessment, evaluation of cerebral ischemia due to carotid clamping, shunt, closure of arteriotomy, etc.). Some of these problems can receive ultimate solutions from some studies in next years.

Definition of essential findings in chronic venous insufficiency without valvular incompetence of the greater and/or lesser saphenous vein and due to reflux in the system of the internal iliac vein.a retrospective study.Section of Vascular Surgery in a University Hospital.Five patients, all females, ages ranging from 24 to 62 years, (6 lower extremities) with internal iliac venous insufficiency syndrome were identified.Each case was assessed with clinical examination, Doppler CW and venography. Moreover, all cases were surgically treated using the technique of varicose vein avulsion.Venographic picture and results of surgical treatment were evaluated.Reflux in the system of the internal iliac vein was demonstrated in all cases. Connections between this vein and subcutaneous varicose veins network were identified using venography. Surgical treatment has given good results in 5 lower extremities followed-up from 6 months to 3 years, while recurrent varicose veins were observed in 1 leg after 6 months.Syndrome of internal iliac vein insufficiency requires more attention than in the past. As to diagnostic evaluation, venography (particularly varicography) plays an essential role. The best treatment is stab avulsion of varicose vein, if pelvic congestion syndrome is excluded.

Treatment of primary varicose veins with valvular incompetence of the sapheno-femoral junction has received a lot of attention in recent years. There are many options for the treatment of this venous disease. Stripping of the greater saphenous vein is the standard procedure and the effectiveness of this has been widely stressed.

Re-exploration of the sapheno-femoral junction for recurrent varicose veins presents many problems. The lateral approach to the sapheno-femoral junction via a groin incision as previously described was performed in 109 lower limbs. The operative mortality rate was 0%. Functional outcome was good in 106 cases (97.2%) and only in three (2.8%) did recurrent varicose veins occur in the upper thigh. Complications were mainly lymphorrhoea (six cases, 5.5%). Cosmetic results were also satisfactory. This surgical procedure allows an easy and safe approach to the sapheno-femoral junction and avoids damage to femoral vessels. Recurrence was rare and caused by incompetent communicating veins in the upper thigh. These characteristics make the lateral approach the preferred technique for re-exploration of the sapheno-femoral junction.

Automated peritoneal dialysis (APD) is currently considered as one of the most attractive home treatments for uremic patients. However, relevant costs and the presence of a dialysis machine prevent a wider diffusion of this technique. In this work we discuss the results obtained in 42 patients (12 females, 30 males) treated by two dialysis units of the Piedmont Region. Patients' characteristics. Eighty-three percent of the females and 66.5% of the males are under 65 years of age; glomerulo-nephritis and nephroangiosclerosis account for the most frequent renal diseases (28.5 each); a high risk condition is recorded in 52.5% of cases. Twenty-two patients were transferred to APD from CAPD (patient's request in 59% of cases, clinical problems in the remaining). RESULTS. Forty-five percent of cases are working full or part-time, 12% are not caring for self. Peritonitis rate accounts for 1 episode every 42 patient-months. Biochemical control is satisfactorily achieved (mean values: urea 137.8 mg/dl, creatinine 11 mg/dl, calcium 10.2 mg/dl, phosphate 5.7 mg/dl, albumin 4.3 g/dl, cholesterol 234 mg/dl, triglycerides 195 mg/dl). Technical assistance was requested on average once every 16 months of treatment. CONCLUSION. Negative drawbacks of APD, mainly related to elevated costs and technical complexity, are fully counterbalanced by satisfactory social and clinical rehabilitation, wider indications to peritoneal dialysis with respect to CAPD, lower rates of peritonitis and limited technical needs.

In this work surgical events in a large population of chronic dialysis patients are analysed. Data are obtained from the Regional (Piedmont) Registry of Dialysis and Transplantation (RPDT), that has collected information since 1981 about all chronic dialysis patients in the Region. Since 1984, causes of admission to-hospital are registered. Surgical causes of hospitalization, for purposes not related to uremia, were 538 (20% of all surgical admissions). In patients younger than 65 years, these hospitalizations account for about 6% of the cases, whereas in patients older than 65 they are less than 5%. As expected, a higher number of surgical operations is observed in diabetics, while on the contrary the lowest is performed in nephroangiosclerosis patients. Cardiovascular and bowel diseases represent almost 50% of all surgical needs. Postoperative mortality was 5.8% within 45 days from admission. Cardiac and infectious diseases and cachexia represent the more frequent causes of death. In 27 out of 28 cases at least one high risk condition was present.

Death in conditions of cachexia is increasing in potential dialysis patients, as treated cohorts are aging, the mean age of new patients increased and access to treatment is unlimited. The present study analyzes the clinical features of 417 deaths in conditions of cachexia recorded in 1981 to 1990 in the Dialysis and Transplantation Registry of a northern Italian region, Piedmont (about 4,400,000 inhabitants, 20 dialysis centers; 4,734 patients on file at December 31, 1990; yearly information on 100% of the cases). Death in conditions of cachexia increased from 105 cases in the first four years taken into account (1981 to 1984), to 107 in the last two years (1989 to 1990). Prevalence is higher in the elderly (85% of the death over age 60). Most patients (90.5%) were at high clinical risk. To assess whether the frequency of this diagnosis reflected the wide acceptance of elderly patients for dialysis and was a marked of vascular disease, a specific inquiry was conducted about 107 cachectic deaths recorded from 1989 to 1990: 82.5% of the patients had diffused vascular disease, 11.5% were already cachectic when dialysis was initiated, and 66% were in cachexia at least six months before death. Since mean age of patients dying in condition of cachexia increased from 68.8 in the period of 1981 to 1984 to 70.3 years in 1989 to 1990, and mean time on dialysis from 2.8 years in 1981 to 1984 to 70.3 years in 1989 to 1990, the higher prevalence is not likely to be due to lack of care of elderly patients.(ABSTRACT TRUNCATED AT 250 WORDS)

A derangement of magnesium homeostasis with hypermagnesemia and increased intraerythrocyte Mg content [Mgi] has been described in uremic patients, and could play a pathogenetic role in both alterations of bone metabolism and vascular reactivity, observed in these patients. Recently Féray and Garay described in human erythrocytes a transport system which catalyzes outward Mg movements in the presence of external Na. These fluxes may be responsible for maintaining and regulating a low [Mgi]. The aim of this study was to evaluate in 16 normal subjects and 14 uremic patients undergoing CAPD: [Mgi] and rate of Na-dependent and Na-independent Mg efflux in Mg-loaded erythrocytes, in order to maximally stimulate Mg efflux. Mean plasma and intraerythrocyte Mg concentrations were significantly higher in CAPD than in normal subjects (1.09 +/- 0.20 vs 0.86 +/- 0.004 mmol/l, p less than 0.001 and 2.57 +/- 0.38 vs 1.96 +/- 0.18 mmol/l RBC, p less than 0.001). After an in-vitro Mg load, the intraerythrocyte Mg concentration and Na-independent Mg efflux were similar in both groups (17.5 +/- 1.4 vs 18.2 +/- 4.1 mmol/l RBC and 152 +/- 20 vs 126 +/- 19 mumol/l RBC/h). However, the Vmax of erythrocyte Na-stimulated Mg efflux was significantly higher in CAPD patients than in normal subjects (357 +/- 48 vs 229 +/- 88 mumol/l RBC/h, p less than 0.02). [Mgi] and the rate of Na-dependent Mg efflux were inversely related in CAPD patients (r = -0.76; p less than 0.002). These results indicate that uremic CAPD patients have a [Mgi] and Vmax of erythrocyte Na-dependent Mg efflux higher than normal subjects; this could reflect a compensatory, although insufficient, mechanism against high levels of intraerythrocyte Mg concentration, as suggested by the correlation between [Mgi] and the rate of Na-dependent Mg efflux.

A method for sampling volatile chlorinated hydrocarbons in either gaseous or aqueous samples using solid-phase microextraction (SPME) is presented. In the liquid phase, method limits of detection of 1–130 ng l–1 can be achieved with an electron-capture detector. The method is linear over at least 2–4 orders of magnitude and has a relative standard deviation of 1–5%. In the gaseous phase, the method has limits of detection in the parts per trillion (v/v) range when used with an electron-capture detector. The linear range is at least two orders of magnitude and the relative standard deviation is 1–7%. Sample preparation times range from 10 min for gaseous samples to 20 min for liquid samples. The method is comparable to US Environmental Protection Agency (EPA) methods 502.2 and TO-14. The precision of the technique is relatively independent of the number of injections made per container. Samples can be stored for up to 20 min on the fibre if they are capped and refrigerated. The amount absorbed by the fibre decreases with increasing temperature and increasing humidity.

A technique for water sample analysis is presented which uses chemically modified fused silica optical fibers as micro solid phase extractors. The small size of the fibers (100 µm o. d. ) allows for direct introduction into the on column injector port of a high resolution gas chromatograph (GC), where the analytes are thermally desorbed. This eliminates the need for solvents and syringes which are used in liquid-liquid or solid phase extraction techniques. Thus, this method lowers cost and analysis time per sample, as well as eliminates possible sources of error. Results show that the efficiency and selectivity of this technique are dependent upon the thickness and polarity of the stationary phase. Initial results indicate that the limit of detection for 2-naphthol and FID detection is approximately 5 ng/g with a linear response range of 5 orders of magnitude.

To evaluate the effect of transfusion on immunity, we studied some immunological parameters in 14 uremic patients treated with 3 blood transfusions (5 with HLA-compatible and 9 with random transfusions). Before transfusions 8/14 patients were DNCB-negative; both spontaneous and active E-rosettes were below normal range. The parameters of humoral immunity (S-Ig, C3, C4, IC, CRP) were normal. After both the first and second transfusions an increase in T- and B-lymphocytes was found. The third transfusion led to a more pronounced and prolonged immunosuppression in patients treated with compatible transfusions than in those treated with random transfusions. Our findings suggest that blood transfusion--HLA-compatible transfusion in particular--results in an impairment of the lymphocyte role.

Plasma fibronectin concentrations in CAPD patients were found not to be different from healthy controls. During peritonitis plasma fibronectin concentration was lowered and the plasma fibronectin/ peritoneal fibronectin ratio increased. In two patients with recurrent peritonitis the plasma fibronectin/peritoneal fibronectin ratio remained very low. Since fibronectin is an important opsonic protein for staphylococcal destruction, its low concentration in some patients with frequent peritonitis suggests a causal role in these patients.

Only recently the relationship between trauma and acute renal failure has been described on a rational basis. Shock is commonly a major pathogenetic factor in tubulo-interstitial damage often associated with other causes, such as toxic agents, toxins, immunologic and coagulation mechanisms. The Authors consider the various patterns of acute renal failure such as the "functional, tubulo-interstitial, cortical necrosis" and analyze the different etiopathogenesis. Finally they report the mortality rate of acute renal failure in S. Giovanni Hospital of Turin from 1969 to 1979.

Four thousand hemofiltrations have been performed in 22 patients with low tolerance to conventional hemodialysis (20 cases), and severe arterial hypertension (2 cases). In comparison with hemodialysis, hemofiltration had a low incidence of intradialytic collapses, vomit and cramps, and allowed a better state of well-being during interdialytic periods. In hypertensive patients hemofiltration has accomplished a better control of arterial pressure and pharmacotherapy has been reduced. In this study, we report the data concerning metabolism, electrolytes, acid-base balance during our experience utilizing bicarbonate in the replacement fluid. Our experience further supports the impression that hemofiltration may have some advantages in patients with low tolerance to conventional dialysis and/or severe dislipemia and hypertension. The possibility to reduce dialysis duration to 3 hrs, stimulates further application of this new treatment in a wider number of patients on RDT.

To evaluate the effect of transfusion on immunity, 14 uraemic patients treated with 3 blood transfusions from a single donor, at weekly intervals, were studied: in 5 cases HLA-A,B were compatible, in 9 cases they were not. As markers of cellular and humoral immunity DNCB, PPD skin tests, spontaneous and active E-rosettes, EAC-rosettes, surface membrane immunoglobulins, C3, C4, C3d, serum immunoglobulins, circulating immune complexes and C-reactive protein were investigated. This protocol was applied before transfusions, 1 week after each transfusion (day +7, +14, +21) and 20 weeks later (day +80). Before transfusions 8/14 patients were DNCB negative; both spontaneous and active E-rosettes were below normal range. The other parameters were normal. On day +7 T and B lymphocytes were increased, while the other parameters were unmodified. On day +21 there was a significant reduction (p less than 0.5) in T lymphocytes in patients treated with compatible transfusions. On day +80 3/3 DNCB positive patients, treated with compatible transfusions, became negative and 1/3 DNCB positive patients, treated with random transfusions, also became negative. Three/fourteen patients showed a decrease in B lymphocytes. The other results were unchanged. Our preliminary results suggest that transfusions, either from an HLA compatible donor or not, can impair lymphocyte function.