Resource allocation criteria in a hospital

INTRODUCTION

Allocate fixed resources among competing users is a challenge in terms of hospital management in order to obtain the best performance considering strategic objectives. In order to address this need, a system of evaluation in an important research and teaching hospital was designed. This study describes resource allocation criteria in a hospital focusing on the evaluation system and its developed application methodology.

METHODS

The indicator system allows the strategic management to rapidly detect the priorities in the evaluations of the Strategic, Organizational, Managerial, Economic, Research and Qualitative conditions of each unit. The chosen indicators are expressed with three numerical values, (1 indicating critical status, 2 acceptable conditions and 3 a good operational situation).

RESULTS AND DISCUSSION

The adopted evaluation system considered different thematic areas: Strategic, Organizational, Managerial, Economic, Research and Qualitative. In order to define each area, 3 fields of evaluation have been chosen. The indicators have been structured according to a pyramid system allowing creating a single indicator for each area for each unit. Furthermore, a single indicator has been fixed in order to facilitate a first consideration on whether to carry out or not closer examinations of the most critical units. This manuscript describes an attempt to define objective criteria for the allocation of scarce resources in order to achieve the hospital's strategic objectives. The indicators identified allow to obtain an overall score for each unit, which allows the management to prioritize the needs.

[Reorganize hospitals to improve efficiency and quality]

The current economic difficulties and the changed epidemiological picture, characterized by an increase in life expectancy, which shows in the elderly, chronically ill and disabled the main, both health and social, care needs,r equires a remark on the hospital network and organization. Today, most of the application assistance is usually at low intensity of care, whereas the acute event is shrinking. The prevalence of hospital admissions concern the elderly, who get into acute events but on a substrate of chronicity and co-morbidity conditions. There must be a new model of hospital network, with the possibility of converting some hospital centres for medium intensity care and selecting few centres for high intensity care, where concentrating the more expensive technology and the skill and expertise of the professional. The -suggestion is a renewed health planning that detects:- hospitals for widespread disease, equipped with emergency war for minor codes-hospital at high intensity of care for emergency-urgency- hospital for particular fields of medical speciality and research.

A multistate epidemic outbreak of Salmonella Goldcoast infection in humans, June 2009 to March 2010: the investigation in Italy

After an urgent inquiry into a suspected international outbreak of Salmonella Goldcoast infection was launched by Hungary in October 2009 a nation-wide multidisciplinary investigation was carried out in Italy. The aims were to verify whether the higher than expected number of cases of S. Goldcoast infection that had occurred in Italy in the previous months were linked to the outbreak in Hungary and to determine their origin. Between June 2009 and March 2010, 79 confirmed cases of S. Goldcoast infection were identified. Of these, 17 were part of three different point-source outbreaks probably associated with the consumption of salami. Eating salami was also reported by 20 of the 39 sporadic cases that could be interviewed. Fifteen strains of S. Goldcoast isolated from the cases were typed by pulsed-field gel electrophoresis. They shared more than 90% homology with the Hungarian epidemic strain and were also highly similar to S. Goldcoast strains that had been isolated in Italy from pigs and pork-containing food items in 2009 and 2010. Although the origin of the outbreak and the common source linking the Hungarian and the Italian cases could not be definitively identified, our results suggest a possible zoonotic connection of the outbreak cases with the pork production chain.

Epidemiological and clinical characteristics and behaviours of individuals with newly diagnosed HIV infection: a multicentre study in north Italy

INTRODUCTION

We aimed to investigate socio-demographic, clinical and epidemiological characteristics and behaviours of subjects with new HIV diagnosis.

METHODS

We carried out a multi-centre cross-sectional study comprising 17 infectious diseases units in the Lombardy Region, North Italy. All subjects with a first positive test for HIV infection examined in 2008-09 were interviewed using a structured questionnaire.

RESULTS

472 patients were enrolled (mean age 39.8 years, standard deviation [SD] 11.5), mostly males (78%), and born in Italy (77%). The most common routes of HIV transmission were heterosexual intercourse (49%) and sex among men who have sex with men (MSM) (40%). Never/sometimes use of a condom with occasional partners was associated with male gender, heterosexual transmission route, and with >10 sexual partners in their lifetime. 47% had previous HIV negative tests. Having had more than 2 previous HIV negative tests was associated with younger age, MSM transmission route, CD4+ lymphocyte count >350/microl and self-perception of risk.

DISCUSSION

This study shows that there is a large portion of the adult population, especially heterosexual men aged 45 years and over, who are at high risk of acquiring and transmitting HIV infection and undergoing the HIV diagnostic test late, due to risk behaviours combined with a low perception of being at risk. Compared to people infected by heterosexual contacts, MSM show a greater awareness of being at risk of infection, but this knowledge has a low impact in reducing at-risk behaviours.

Surveillance of acute infectious gastroenteritis (1992–2009) and food-borne disease outbreaks (1996–2009) in Italy, with a focus on the Piedmont and Lombardy regions

We describe trends in the occurrence of acute infectious gastroenteritis (1992 to 2009) and food-borne disease outbreaks (1996 to 2009) in Italy. In 2002, the Piedmont region implemented a surveillance system for early detection and control of food-borne disease outbreaks; in 2004, the Lombardy region implemented a system for surveillance of all notifiable human infectious diseases. Both systems are internet based. We compared the regional figures with the national mean using official notification data provided by the National Infectious Diseases Notification System (SIMI) and the National Institute of Statistics (ISTAT), in order to provide additional information about the epidemiology of these diseases in Italy. When compared with the national mean, data from the two regional systems showed a significant increase in notification rates of non-typhoid salmonellosis and infectious diarrhoea other than non-typhoid salmonellosis, but for food-borne disease outbreaks, the increase was not statistically significant. Although the two regional systems have different objectives and structures, they showed improved sensitivity regarding notification of cases of acute infectious gastroenteritis and, to a lesser extent, food-borne disease outbreaks, and thus provide a more complete picture of the epidemiology of these diseases in Italy.

Surveillance of acute infectious gastroenteritis (1992-2009) and food-borne disease outbreaks (1996-2009) in Italy, with a focus on the Piedmont and Lombardy regions

We describe trends in the occurrence of acute infectious gastroenteritis (1992 to 2009) and food-borne disease outbreaks (1996 to 2009) in Italy. In 2002, the Piedmont region implemented a surveillance system for early detection and control of food-borne disease outbreaks; in 2004, the Lombardy region implemented a system for surveillance of all notifiable human infectious diseases. Both systems are internet based. We compared the regional figures with the national mean using official notification data provided by the National Infectious Diseases Notification System (SIMI) and the National Institute of Statistics (ISTAT), in order to provide additional information about the epidemiology of these diseases in Italy. When compared with the national mean, data from the two regional systems showed a significant increase in notification rates of non-typhoid salmonellosis and infectious diarrhea other than non-typhoid salmonellosis, but for foodborne disease outbreaks, the increase was not statistically significant. Although the two regional systems have different objectives and structures, they showed improved sensitivity regarding notification of cases of acute infectious gastroenteritis and, to a lesser extent, food-borne disease outbreaks, and thus provide a more complete picture of the epidemiology of these diseases in Italy.

Autologus platelet gel for the management of persistent alveolar fistula after lung resection

Postoperative alveolar fistula (AF) associated with pleural cavity (PC) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study was to assess the efficacy of the use of the autologous platelet gel for the treatment of AF and PC. We treated a patient with post lung resection persistent alveolar fistula using a autologous platelet gel, a cellular compose produces at the Division of Immunohaematoligy and Trasfusion. The platelet gel-PRP (Platelet-Rich Plasma) is a biological material made of autologous platelets, extracted from a small amount of the patient's blood, centrifuged at 1100 g for 9 min. The PRP obtained was activated by addition of autologous thrombin and calcium chloride to form a matrix of fibrin (PRFM) thick. The patient presented important air leak after middle lobe wedge resection for solitary lung lesion with standard open decortication for important pleural adhesions post pleuritis. On postoperative day XIII the patient developed a thoracic empyema and consequently underwent a antibiotic pleural irrigation through the chest drainage based on the microbiological analysis of the pleural fluid. After a week we obtained the resolution of the empyema but a residual space remained and air leak persisted. We treated the patient with autologous platelet gel. We administer 7.5 mL of the autologous platelet gel across the chest drainage ever 72 hours for 3 times. After the third application we had the closure of the cavity and the cessation of air leak. Autologous platelet gel is easy to use, safe and inexpensive. It can be considered a valid therapeutic option in selected patients with a alveolar fistula and a lung partial re-expansion. The product consist of a significant amount of cellular components with healing anti-inflammatory an proregenerative properities that permit the body to heal tissue wounds faster and more efficiently. A sterile pleural cavity is fundamental conditions for the final success of the procedure.

[Investigation of potential risk factors for Salmonella enterica subsp enterica serotype Napoli: a nested case-control study in Lombardia region]

Enter-net surveillance system has detected the re-emergence of Salmonella enterica subsp enterica serotype Napoli (S. Napoli) since 2002. Preliminary data show that food vehicle could not be the only one implicated in the transmission of this serotype. A nested case-control study has been conducted using data form a prospective cohort: for each salmonellosis notification in Lombardia from May 2004 to December 2005 an ad hoc epidemiological investigation has been performed. Cases have been defined as subjects affected by salmonellosis with a positive faecal sample for Salmonella serotype Napoli and controls as subjects affected by salmonellosis with a positive faecal sample for Salmonella serotype not Napoli. Among 2185 salmonellosis notifications collected by 12 of 15 Local Health Authorities, we identified 67 cases and 867 controls. Infection due to S. Napoli were significantly more common among subjects with exposure to surface water (adjusted Odds Ratio (OR) = 3,82; 95% Confidence Interval (C.I.)=1,03-14,19), to domestic animals (adjusted OR = 3,22; 95% C.I. = 1,28-8,10) and among person who practice activities connected to surface water (adjusted OR 3,88; 95% C.I.=1,15-13,05) compared to subjects not exposed to these factors. Hyperendemia of S. Napoli could be attributable to an animal reservoir not yet identified: surface water contamination may be a direct (waterborne infection) or indirect (foodborne infection) vehicle for transmission of S. Napoli. behaviour. Regarding the relations of the neuroendocrine parameters and driving behaviour, positive correlations were observed between dopamine levels and frequency of driving violations while a negative relationship was found between adrenaline levels and frequency of driving errors. In conclusion the identification of psycho-physiological variables related to driving risky behaviour might be a useful instrument to design traffic safety programs tailored to high risk subjects.

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

West Nile virus transmission with human cases in Italy, August - September 2009

In 2009, to date 16 human cases of West Nile neuroinvasive disease (WNND) have been reported in Italy, in three regions: Veneto, Emilia-Romagna and Lombardia. The number of cases is higher compared with last year when nine cases were identified (eight cases of WNND and one case of West Nile fever) and the geographical distribution indicates spread from east to west.

An outbreak of viral gastroenteritis linked to municipal water supply, Lombardy, Italy, June 2009

We report an outbreak of viral gastroenteritis linked to municipal drinking water in a town in northern Italy in June 2009. Over one month we identified 299 probable cases of whom 30 were confirmed for at least one of the following viruses: norovirus, rotavirus, enterovirus or astrovirus. Water samples and filters from the water system also tested positive for norovirus and enterovirus. Control measures included treating the water system with chlorine dioxide and filters with peracetic acid, while providing temporary alternative sources of drinking water to the population.

[Law simplification: the Lombardy Region experience]

Lombardy Region, adopted its own rules to reorganize and to relaunch health prevention activities. Particularly, the started way foresees for the useless activity divestment, not backed by scientific evidences and of no effect to preserve public health. In this optics, the run is inserted that foresees the planning of the activity of official control, based on the acquisition of the epidemiological and the productive, economic and social territorial context data, so to be able to point out interventions priorities and to graduate health risks. Similarly the integration among different operators, belonging to different Services and Departments too, it's considered necessary, passing from the planning of independent Plans of sector to Plans bringing common and joined objectives, in a business logic. The change of perspective, needs a suitable monitoring of the obtained results aiming to start deepened evaluations to implement or to reassess the regional strategic lines.

Impairment of endothelial cell differentiation from bone marrow-derived mesenchymal stem cells: new insight into the pathogenesis of systemic sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is a disorder characterized by vascular damage and fibrosis of the skin and internal organs. Despite marked tissue hypoxia, there is no evidence of compensatory angiogenesis. The ability of mesenchymal stem cells (MSCs) to differentiate into endothelial cells was recently demonstrated. The aim of this study was to determine whether impaired differentiation of MSCs into endothelial cells in SSc might contribute to disease pathogenesis by decreasing endothelial repair.

METHODS

MSCs obtained from 7 SSc patients and 15 healthy controls were characterized. The number of colony-forming unit-fibroblastoid colonies was determined. After culture in endothelial-specific medium, the endothelial-like MSC (EL-MSC) phenotype was assessed according to the surface expression of vascular endothelial growth factor receptors (VEGFRs). Senescence, chemoinvasion, and capillary morphogenesis studies were also performed.

RESULTS

MSCs from SSc patients displayed the same phenotype and clonogenic activity as those from controls. In SSc MSCs, a decreased percentage of VEGFR-2+, CXCR4+, VEGFR-2+/CXCR4+ cells and early senescence was detected. After culturing, SSc EL-MSCs showed increased expression of VEGFR-1, VEGFR-2, and CXCR4, did not express CD31 or annexin V, and showed significantly decreased migration after specific stimuli. Moreover, the addition of VEGF and stromal cell-derived factor 1 to cultured SSc EL-MSCs increased their angiogenic potential less than that in controls.

CONCLUSION

Our data strongly suggest that endothelial repair may be affected in SSc. The possibility that endothelial progenitor cells could be used to increase vessel growth in chronic ischemic tissues may open up new avenues in the treatment of vascular damage caused by SSc.

Glucagon-like peptide-1 accelerates the onset of insulin action on glucose disappearance in mice

Glucagon-like peptide-1 (GLP-1) plays a significant role in glucose homeostasis through its incretin effect on insulin secretion. However, GLP-1 also exhibits extrapancreatic actions, and in particular its possible influences on insulin sensitivity are controversial. To study the dynamic action of GLP-1 on insulin sensitivity, we applied advanced statistical modeling methods to study glucose disappearance in mice that underwent intravenous glucose tolerance test with administration of GLP-1 at various dose levels. In particular, the minimal model of glucose disappearance was exploited within a population estimation framework for accurate detection of relationships between glucose disappearance parameters and GLP-1. Minimal model parameters were estimated from glucose and insulin data collected in 209 anesthetized normal mice after intravenous injection of glucose (1 g/kg) alone or with GLP-1 (0.03-100 nmol/kg). Insulin secretion markedly increased, as expected, with increasing GLP-1 dose. However, minimal model-derived indexes, i.e., insulin sensitivity and glucose effectiveness, did not significantly change with GLP-1 dose. Instead, fractional turnover rate of insulin action [P2 = 0.0207 +/- 24.3% (min) at zero GLP-1 dose] increased steadily with administered GLP-1 dose, with significant differences at 10.4 nmol/kg (P2 = 0.040 +/- 15.5%, P = 0.0046) and 31.2 nmol/kg (P2 = 0.050 +/- 29.2%, P = 0.01). These results show that GLP-1 influences the dynamics of insulin action by accelerating insulin action following glucose challenge. This is a novel mechanism contributing to the glucose-lowering action of GLP-1.

Lipid microdomains contribute to apoptosis-associated modifications of mitochondria in T cells

Plasma membrane lipid microdomains have been considered as a sort of 'closed chamber', where several subcellular activities, including CD95/Fas-mediated proapoptotic signaling, take place. In this work we detected GD3 and GM3 gangliosides in isolated mitochondria from lymphoblastoid CEM cells. Moreover, we demonstrated the presence of microdomains in mitochondria by immunogold transmission electron microscopy. We also showed that GD3, the voltage-dependent anion channel-1 (VDAC-1) and the fission protein hFis1 are structural components of a multimolecular signaling complex, in which Bcl-2 family proteins (t-Bid and Bax) are recruited. The disruption of lipid microdomains in isolated mitochondria by methyl-beta-cyclodextrin prevented mitochondria depolarization induced by GD3 or t-Bid. Thus, mitochondrion appears as a subcompartmentalized organelle, in which microdomains may act as controllers of their apoptogenic programs, including fission-associated morphogenetic changes, megapore formation and function. These results disclose a new scenario in which mitochondria-associated lipid microdomains can act as regulators and catalysts of cell fate.