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In 2012, testing of the Chronic Related Groups model, an innovative chronic care organisational model, was launched in the Lombardy Region (Italy). In this model, chronic care patients are cared for by healthcare providers who must identify in advance a quota of resources necessary and then ensure continuity of care to patients by providing, with the predefined quota, all outpatient services required for good clinical management of the patient's illness (e.g. outpatient consultations, therapy, home hospitalisation, prosthetics). Two hundred seven primary care physicians and 22,500 patients with chronic illnesses were enrolled to pilot test the model in Bergamo (Italy). The vast participation will allow appropriate testing of the model and identification of advantages and critical clinical and organizational issues that need to be improved. The expected results could profoundly change the current structure of primary care.

Purpose: To evaluate the sensitivity of the mammographic screening programme and the causes of diagnostic fault in cases surfacing as interval cancers., Materials and Methods: Interval cancers (CI) were identified by linkage of the screening database for the years 2000-2002 to the database of hospital discharge records (HDR) for breast cancer during 2000-2002. Linkage between screening attenders during 2000-2001 and HDR (biennial follow-up for year 2000, one year follow-up for year 2001) was used to calculate the proportional rate of observed/expected IC. The observed/ expected rate was compared with international standards and literature data. Screening mammograms followed by IC, randomly admixtured with negative controls, underwent blind review by an independent radiologist, using the recommended classification criteria to evaluate causes of error (occult, minimal signs, screening error)., Results: The analysis of HDR during 2000-2002 allowed us to identify 31 out of 89 expected IC. Proportional observed/expected IC rate in the first or second year of screening interval was 26 or 67%, respectively. Screening mammograms for radiological review were available in 38 of 61 total IC: 20 cases (52.6%) were classified as occult, whereas minimal signs or screening errors were 2 (5.2%) or 16 (42.1%), respectively. Diagnostic suspicion had been reported at screening in 7 of 16 cases classified as screening error, but were not diagnosed at the subsequent diagnostic assessment., Conclusions: Proportional IC rate was higher than reported in the literature or currently recommended (<30% in the 1st, <50% in the 2nd year). The analysis of error causes shows an excess of screening errors with respect to current recommendations (<20% of IC should be classified as screening error at review), but also an excess of IC suspected at screening but misdiagnosed at assessment (7/38=18.4 %). Overall the analysis revealed a reduced sensitivity of the screening programme, as often observed in service screening as compared to excellence centres, and suggests proper action to improve diagnostic accuracy. Analysis and critical review of IC is an early indicator of screening efficacy which is not currently used in Italian screening programmes. Using HDR for this purpose may have limited drawbacks, but gives the advantage of earlier identification of IC as compared to cancer registries and is the most reliable source of information in areas lacking a cancer registry. The present study methodology might be currently applied in screening programmes.

This study examines the early data of a breast cancer screening campaign (Progetto Donna) set up by the Milan Health Unit 1 in 1999. The authors have focused on some basic organizational aspects of such campaign and the patients' high response to the project showed a good efficiency of this initiative, aimed at informing and awakening people. The high rate of suspiciously positive results checked in several Hospitals, led to a careful assessment of the quality and the standards of radiology services.

The development and the validation of the Pavia Physical Performance Scale (PPPS) is here presented. PPPS is a new instrument evaluating the physical performance of pacemaker implanted patients. Data comes from a cross-over clinical trial on the efficacy of two functions of the pacemaker device. Primary end-point is the improvement of the physical performance together with the quality of life. We used data of 168 patients actually enrolled and interviewed with the Pavia Physical Performance Scale. We first selected 30 Likert-type items; then we applied a statistical methodology of Homogeneity Analysis (HOMALS). We verified the homogeneity of the scale and the internal consistency (Cronbach's alpha = 0.92). With the same methodology, we developed the final version of PPPS. The final version lists 20 items; based on the results of the psychometric analysis, we turned the Likert-type scoring into a binary scoring (1 = no limitation of physical activity, 0 = limitation or never tried). The external validity, trough an Analysis of Variance of PPPS mean scores within New York Heart Association classes (NYHA), has been performed. We found a negative linear trend of PPPS scores and NYHA classes. That means an association between high PPPS scores (good physical performance) and low NYHA classes (also good physical capacity). The Pavia Physical Performance Scale (PPPS) could be proposed as a valid and consistent scale aimed to evaluate physical performance in pacemaker implanted patients. We suggest to use it in the clinical practice in addition to more traditional techniques.

Venous thrombosis is a well-known complication of permanent cardiac pacemaker implantation, particularly, chronic occlusion of the subclavian vein is reported to occur in 20-33% of the cases where the percutaneous approach is performed. We examined 135 asymptomatic patients with digital venography to asses the frequency of venous thromboses causing stenosis and occlusion of the subclavian or anonymous arteries in pacemaker carriers. We considered both one- (44) and two-chamber (91) pacemakers and investigated a possible statistically significant difference between them: we found 21 venous thromboses (15%), seven of them in one-chamber pacemakers (15.9%) and 14 two-chambers pacemakers (15.3%). None of our 94 male and 41 female patients was on anticoagulants or had any evidence of coagulation disorders. Venography was performed 39.3 months (mean) after pacemaker implantation (range: 3-120 months). We conclude that digital venography is a simple and relatively noninvasive method permitting better depiction of subclavian, anonymous and caval veins than Doppler US and also showing some vascular abnormalities which may complicate pacemaker implantation.

Background and Methods: We analyzed the complications of 1729 pacemakers implants (from October 1980 to December 1992) divided according to the way of leads insertion. The approaches from the subclavian vein was used in 1220 cases, the cephalic vein was used in 431 implants and the external jugular vein in 78., Results: Major complications were: pocket bleeding (108 cases), pocket erosion (15 cases), infection (2 cases), lead fracture (5 cases), lead dislodgement (20 cases), pneumothorax (4 cases, only for subclavian puncture). There were no significative differences in the complications between the three approaches. On the other hand, the subclavian puncture reduces the time of the procedure, is less traumatic and allows to insert and to position several leads., Conclusions: We suggest to use the subclavian vein approach as first choice to implant one or more leads, being this way safe and fast.

The purpose of this study was to evaluate the hemodynamic benefits of atrioventricular (A-V) sequential pacing. 30 pts implanted with DDD pacemakers underwent M-mode, B-mode and Doppler echocardiography. In each patient, left ventricular (LV) stroke volume was assessed by measuring the time-velocity integral of mitral inflow in the following modes and rates: VOO at 70 ppm or at the minimum stimulation rate and at 120 ppm; DOO at the same rates with different A-V delay (100, 150, 200, 250 and, whenever possible, 300 msec). The increase in stroke volume obtained with dual chamber pacing at the optimal A-V delay was 45 +/- 25% at 75 ppm and 29 +/- 14% at 120 ppm (p less than 0.05 75 vs 120 ppm). This increase was significantly higher in pts with than in pts without LV hypertrophy (respectively: 51.9 +/- 20.4 vs 36.9 +/- 20.8% at 75 ppm, p less than 0.05 and 33 +/- 13.4 vs 25.4 +/- 14.5% at 120 ppm, p = 0.08). Concerning the A-V delay, we noted that at 75 ppm stroke volume was significantly higher in DOO than in VOO with any A-V delay ranging +/- 100 msec from the optimal one; at 120 ppm the hemodynamic benefit of DOO pacing was observed only when the programmed A-V delay was the optimal one or very near to it. In conclusion, atrio-ventricular sequential pacing allows a significant increase in LV stroke volume over single chamber ventricular pacing both at 75 and 120 ppm. Programming the optimal A-V delay is absolutely necessary to obtain this hemodynamic benefit at the higher stimulation rate.

Five patients affected by angina pectoris showed a spontaneous attack of myocardial ischemia in the course of coronary arteriography examination. During the ischemic episode it was shown a severe coronary arterial spasm promptly relieved by nitroglycerin. In these patients the administration of ergonovine maleate induced the same clinical, electrocardiographic and coronariographic patterns of spontaneous ischemic episodes. These data support the hypotesis that the ergonovine maleate administration is a suitable test for detection of the vasospastic pathogenesis in acute myocardial ischemia.

Left ventricular contractile function was evaluated in twenty patients with coronary artery disease before and during handgrip by use of Vpm, VCEIO and Vmax (obtained with a simplified calculation) from high-fidelity pressure measurements. In eight patients the response to handgrip was characterized by an increase of the contractile indices accompanied by small changes of left ventricular end-diastolic pressure (not exceeding + 4 mm Hg) and was considered normal. Twelve patients who showed abnormal or pathologic reaction to isometric exercise repeated handgrip after administration of 0.4 mg of spray nitroglycerin. Thus eight patients normalized their response to exercise, while in four we observed again a pathologic reaction to handgrip. It is concluded that is a useful and simple manoeuvre for a better evaluation of left centricular function in patients with coronary artery disease; the repetition of the test after administration of nitroglycerin can be useful in identifying those patients with greatest contractile reserve.

Screening of patients with precordial symptoms is a mayor social problem. Holter monitoring is easy to use because it ambulatory, non invasive, can be repeated without harm, has no contraindications and permits prolonged monitoring. Therefore, it seemed necessary to determine the "role" of this test. We examined all of the Holter monitorings performed in Dynamic electrocardiographic laboratory of the S. Matteo Polyclinic from 1983 to 1986. 480 of the 3365 patients visited, presented precordial symptoms. 162 patients (group A) had established ischemic heart disease (old myocardial infarction and/or coronary arteriography). 318 patients (group B) had no definite diagnosis. 71 subjects from group A and 140 from group B presented a typical symptomatology. Group A showed a 31.48% positivity during the test with 165 ischemic attacks. Group B had 25.15% positivity with 397 ischemic attacks. 51 symptomatic attacks (30%) were recorded for group B. Therefore, there was a mayor incidence of silent ischemic heart disease in both groups. Results obtained comparing Holter monitoring to the bicycle ergometry exercise test and to functional test, were comparable in 56.91% (sensibility 41.71% and specificity 78.62%) in the first case and 61.38% (sensibility 42.50% and sensitivity 73.77%) in the latter. In conclusion, we believe that Holter monitoring is useful in mass screening because it permits monitoring of most ischemic attacks, whether under stress or at rest, symptomatic or silent.

Four cases of subjects with implanted pacemakers are reported. The patients temporarily presented suspected symptoms of altered activity of the pacemakers. On the other hand usual tests demonstrated a regular activity of the pacemakers. The dynamic electrocardiography, by a regular registration during 24/48 hours and during usual working, documented; once a partial hole in the circuits of the generator, twice a partial break of the catheter, once a displacement. It is underlined the importance of dynamic electrocardiography to identify temporarily altered activity of pacemakers, undiagnosticable by disposable usual tests.

In 6 patients affected by spontaneous angina with S-T elevation and coronariographic findings of obstruction, intravenous administration of ergonovine maleate determined the same clinical and ECG patterns of spontaneous episodes. The coronary arteriography during pain showed a marked spasm with occlusion of a large coronary vessel in four patients. In 2 patients with atypical chest pain and normal coronariogram, E.M. did not induce pain, ECG abnormality or coronariographic alterations. The role of spasm in spontaneous angina is discussed.

The effects of atrial pacing (A.P.) on the myocardial balance of inorganic phosphate (Pi) were studied in 11 patients with coronary atherosclerosis and pacing-induced angina (Group C) and in 5 normal subjects (Group N). During A.P. in group C 64% of patients had myocardial loss of Pi, statistically significant (p less than 0,025) always with concomitant reduced myocardial extraction or production of lactate, but only 70% of patients with reduced myocardial extraction or production of lactate had myocardial loss of Pi. In only 1 p. of group N myocardial loss of Pi with normal lactate extraction was observed. These data show that during pacing-induced ischemia there is a negative myocardial balance of Pi, that can be used as a metabolic indicator of ischemia, but less reliable than lactate reduced extraction or production.

Based on classifications proposed by Anglosaxon and French authors who were the first to become interested in the so-called cardiomyopathies of unknown origins, 41 cases clinically classified as hypotrophic-hypokinetic (congestive) cardiomyopathies are presented. After a period of clinical observation, 21 cases were studied hemodynamically, with ventriculography and coronaryarteriography, with phonocardiography (35 cases) and follow-up from some months to 6 years. Post mortem studies were performed in 6 patients, five of whom died of congestive heart failure or thromboembolism and one of sudden death. It was concluded that these entities are hypotrophic-hypokinetic cardiomyopathies with a clinical pattern of congestive heart failure and with unknown aethiologic factors. Treatment as far as indications and efficacy are discussed.