Quality sharing between the national health service and citizens: a diagnostic and therapeutic planning experience at the "S. Maria" Hospital in Terni

The Diagnostic and Therapeutic Programs are instruments of clinical management. The authors report on their experience with the construction of a Diagnostic and Therapeutic Program in the field of breast cancer. This is the result of collaboration between the Breast Unit, an administrative team and a computer team at the "S. Maria" Hospital in Terni. The implementation of the guidelines in the hospital setting makes it possible to systematise the clinical activities, to quantify the economic impact for each disease, and to plan any changes in the use of resources. The application of this method, moreover, makes it possible to develop a common language between medical and nursing staff which can be easily understood by the patients and to inform patients adequately with regard to the diagnostic and therapeutic program they will have to comply with for their respective conditions.     

Granulomatous mastitis: diagnostic and therapeutic problems. Case report and review of the literature

The granulomatous mastitis is uncommon inflammatory disease of the breast of unknown etiology. The diagnosis is obtained only through hystopathology. We report a case of woman, 41 years old, showing lesions of the breast, that caused strong pain with ulcerations sero-haematic secretion and axillary omolateral lymphadenopathy. The diagnostic workup (sonography, mammography, multiples FNAB of single lesions, the culture of cells and hormonal profile) showed an inflammatory aspecific lesions with presence of atipic cells in nipple's secretion and in FNAB of periareola lesion. We performed an excisional biopsy. The hystopathologic diagnosis showed a granulomatous mastitis, confirming the validity of our diagnostic and therapeutic choices. The excisional biopsy has allowed to avoid an overtreatment and obtain a good aesthetic result.     

Usage of antimicrobial agents in a private primary healthcare setting in South Africa

Objective The aim of this study was to investigate the prescribing of antimicrobials in a private primary healthcare setting in South Africa. Setting A group of private primary healthcare clinics in South Africa. Method A retrospective, drug utilisation study was conducted on nine clinics that were randomly selected from 33 clinics situated in different geographical areas of South Africa, and whose data were electronically available. Data were obtained from the central database of the private primary healthcare provider and extracted for the period January 1, to December 31, 2001. Key findings The study population consisted of the total patient population (n = 83 655) who visited the clinics during this one‐year period. The total number of medicine items prescribed was 515 976 at a total cost of R1 716 319 ($17 163). Of these, antimicrobials represented 18.69% (n = 96 421) of all medicine items prescribed at a cost of R1 045 108 ($10 451) (60.89%). Antimicrobials were prescribed during 72.72% of consultations at the nine clinics during the one‐year period. The antimicrobials most frequently prescribed were penicillins (38.17%) followed by sulphonamides (22.49%), antiprotozoals (9.88%) and tetracyclines (9.34%). The most common diagnoses for which antimicrobials were prescribed were viral influenza, upper respiratory tract infections, hypertension, acute bronchitis, and common cold. Conclusions The high percentage of antimicrobial prescribing obtained in this study could indicate excessive use of antimicrobials in the private primary healthcare setting. The prescribing of antimicrobials in respiratory tract infections could indicate overuse and inappropriate use of these agents. This could have an effect on the health of the patients needing care, and the general budget for healthcare services. It is recommended that further investigations on the prescribing protocols of antimicrobial usage be done.     

Comparison of search strategies and quality of medical information of the Internet: a study relating to ankle sprain

OBJECTIVES: to evaluate the quality of web sites on ankle sprain diagnosis and treatment and to assess the impact of Internet search expertise on quality of retrieved information. METHOD: two internet search strategies were conducted - one developed by an experienced information officer (expert's search) and the other based on the search terms used by orthopaedic medical staff (doctors' search). RESULTS: the expert's search revealed 32 web sites, of which nine were relevant, whereas the doctors' search revealed 61 web sites of which 27 were relevant. Of the relevant web sites in the expert's search, one complied with all quality criteria, whereas none of the web sites in the doctors' search complied with all criteria (11 vs. 0%, P=0.25). The web sites identified by expert's search had higher credibility (median scores 70 vs. 44, P=0.01) and accuracy of content (median scores 50 vs. 35, P=0.24). CONCLUSION: the quality of medical information on the internet is generally poor and information experts can capture higher quality web sites compared with doctors.     

FLT3 receptor expression on the surface of normal and malignant human hematopoietic cells

FLT3 ligand is a hematopoietic growth factor that plays a key role in growth of primitive hematopoietic cells. FLT3 receptor mRNA is found in early hematopoietic progenitors and in human myeloid leukemia blasts. Much less is known about the surface expression of FLT3 receptor on human hematopoietic cells. Using human 125I-FLT3 ligand, we have identified and characterized surface FLT3 receptors on normal and malignant human hematopoietic cells and cell lines. Our results showed that surface display of FLT3 receptor was greatest in fresh myeloid leukemia blast cells and myeloid leukemia cell lines. Erythroleukemic and megakaryocytic leukemia cell lines (n = 5) bound little to no 125I- FLT3 ligand. Scatchard analysis of 125I-FLT3 ligand binding data shows that three myeloid leukemia cell lines, ML-1, AML-193, and HL-60, as well as normal human marrow mononuclear cells, exhibit high affinity FLT3 receptors. Crosslinking of 125I-FLT3 ligand to FLT3 receptors on the surface of ML-1 myeloid leukemia cells indicates that the FLT3 ligand. The rates of FLT3 ligand internalization and degradation were determined by binding 125I-FLT3 ligand to ML-1 cells and acid stripping to distinguish surface bound from internalized ligand. Internalized 125I-FLT3 ligand was detected within 5 minutes after binding to ML-1 cells. In addition, we evaluated the effect of FLT3 ligand on megakaryocytic colony growth and nuclear endoreduplication, alone or in the presence of thrombopoietin. FLT3 ligand did not promote colony forming unit megakaryocyte (CFU-Meg) colony growth or megakaryocyte nuclear maturation, nor did FLT3 ligand augment the effects of thrombopoietin on these measures of megakaryopoiesis. These data indicate that the FLT3 receptor shares several characteristics with the c-kit receptor including dimerization and rapid internalization. However, the more restricted cellular distribution of the FLT3 receptor may target the effects of FLT3 ligand to primitive hematopoietic cells and to myeloid and lymphoid progenitor cells, in contrast to the pleiotropic effects of the c-kit receptor ligand, stem cell factor.     

Stem cell factor modulates avidity of alpha 4 beta 1 and alpha 5 beta 1 integrins expressed on hematopoietic cell lines

Interactions between hematopoietic cells and bone marrow (BM) stroma, composed of extracellular matrix and stromal cells, are crucial for hematopoiesis. Integrins facilitate these interactions by mediating adherence of hematopoiesis. Integrins facilitate these interactions by mediating adherence of hematopoietic cells to both the extracellular matrix and stromal cells. Marrow stromal cells secrete a variety of growth factors, including stem cell factor (SCF). Because treatment with SCF in vivo mobilizes primitive hematopoietic cells from the BM, we investigated the effect of the growth factor SCF of hematopoietic cell adhesion. These studies show that SCF modulates adhesive function in a dose- and time-dependent manner, but does not modulate expression of the integrins alpha 4 beta 1 and alpha 5 beta 1 in the SCF- responsive cell line MO7E. Treatment of MO7E cells with SCF (200 ng/mL) produced a transient increase in adherence to cytokine-activated human umbilical vein endothelial cells (HUVECs) or to vascular cell adhesion molecule 1 (VCAM-1)-transfected Chinese hamster ovary (CHO) cells with peak adhesion at 30 minutes and return to baseline by 60 to 90 minutes. This increase in adhesion was paralleled by increased binding of the beta 1 activation-dependent monoclonal antibody (MoAb) 15/7, as determined by flow cytometry. However, prolonged incubation of MO7E with SCF induced a marked decrease in integrin-mediated adherence, with maximal inhibition by 24 hours. No change in expression of integrins, as determined by flow cytometry, was observed with short- or long-term incubation with SCF. SCF-treated cells were still able to respond to phorbol esters and to the activating beta 1 MoAb 8A2 with increased adherence, but not to the level seen in control cells. This suggests that a subpopulation of expressed alpha 4 beta 1 and alpha 5 beta 1 integrins is disengaged by prolonged incubation with SCF.     

Protein A adsorption of acute myelogenous leukemia serum induces in vitro blast lysis

We studied cytotoxic activity of acute myelogenous leukemia (AML) sera for AML blasts before and after immunoadsorption with Staphylococcus aureus, Cowan I (SAC), which contains protein A. We found in vitro that incubation with treated AML sera reduced viability to 42.7% of control (p less than 0.01) for autologous and 21.0% of control (p less than 0.01) for allogeneic blasts. Normal peripheral blood cells were not killed by treated AML sera. Wood 46 strain of Staphylococcus aureus, which does not contain protein A, did not significantly reduce AML blast viability (94.8%, p greater than 0.4), while Sepharose-bound protein A reduced viability to 63.8% (p less than 0.01). Cytotoxicity does not appear to be complement-mediated, byt cytotoxic activity is trypsin-sensitive and is contained in the immunoglobulin fraction. This model for study of the tumoricidal action of protein A adsorption should be useful for predicting utility of plasma adsorption as a therapeutic adjunct in the future.