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Biomedical subjects

E Paci

Publications and source records attributed to E Paci.

At least 55 records · Page 3Linked to original sources
PubMed1999

Terminal cancer patients and timing of referral to palliative care: a multicenter prospective cohort study. Italian Cooperative Research Group on Palliative Medicine.

This study describes the characteristics of a representative sample of terminally ill cancer patients at admission to Italian palliative care programs, the rate and reasons for discontinuation of care, and survival after enrollment. All Italian palliative care units (PCUs) specifically committed to palliative care were asked to consecutively register all new patients (n = 3901) between January and June, 1995. Fifty-eight of the 62 PCUs contacted by the Steering Committee completed the study. A random sample of 589 evaluable patients was prospectively selected from the 2667 eligible patients. Patients were mostly referred by a general practitioner (31.2%) or a specialist (42.1%). Most patients (84.7%) were followed until death. Seventy-seven discontinued care because of hospital admission (6.6%), change of residence (3.9%), refusal (1.7%), or improvement (0.8%). Median survival was 37.9 days; 14.3% of the patients died within 7 days, and 15.3% lived longer than 180 days. A statistically significant association between survival and gender, cancer type, setting of the first visit, and type of unit was observed. In Italy, as in other countries with different health systems, referral of cancer patients to palliative care tends to occur late in the course of the disease. This study suggests that the process of enrollment and the duration of patients' survival in palliative care, when studied in large unselected populations, can provide important information relevant to the care of terminally ill patients.

Adolescent↗
PubMed1999

Recent trends of in situ carcinoma of the breast and mammographic screening in the Florence area, Italy.

OBJECTIVES: The study analyzes the relationship between the incidence trends of breast carcinoma in situ (CIS) and the spread of mammography screening in the Italian area of Florence (about 608,000 female residents). SETTING: In this area, since the seventies, a mammographic screening by personal invitation was performed by the Center for Cancer Prevention (CSPO) in some rural municipalities. After 1990, the municipality of Florence and other municipalities were involved in the screening. METHODS: The study included all cases of female breast carcinomas in situ reported to the population-based Tuscany Cancer Registry between 1985 and 1995. On the basis of information from the CSPO files, the cases were categorized into: "screen-detected", "self-referrals", and "other" (CSPO cases diagnosed in symptomatic women or at periodic check up after breast cancer plus hospital cases). RESULTS: Overall, 332 women with breast carcinoma in situ (CIS) were registered between 1985 and 1995. The CIS incidence rate increased from 2.39/100,000 women in 1985-87 to 6.22/100,000 in 1994-95. The largest increase was observed for the ductal carcinoma in situ (2.9 times) and in women aged 50-69 years (3.8 times). In this age group, cases diagnosed at the screening by personal invitation accounted for 69% of the rise in CIS incidence. The proportion of mastectomy lowered from 41% before 1990 to 25% after 1990. CONCLUSION: In the Florence area the CIS incidence trend, showing a marked increase beginning in 1991, was mainly explained by the spread of the mammographic screening by personal invitation. The period during which mammographic screening became widespread coincided with a change in the treatment policy of breast cancer, with a high proportion of breast conserving surgery also for CIS. Therefore, the rise in CIS incidence rates correlated with the widespread use of mammographic screening did not substantially increase the number of women treated by mastectomy.

Adult↗
PubMed1999

Informed consent and patient participation in the medical encounter: a list of questions for an informed choice about the type of anaesthesia.

The present study was undertaken to evaluate the impact of a new procedure for eliciting informed consent by patients undergoing minor surgical procedures, in which the choice between general anaesthesia (GA) and regional anaesthesia (RA) was possible. In this prospective study, two randomly selected groups of patients were compared: study group (SG), 52 patients, received from the nurse before the preoperative interview, a list of seven questions, which they were invited to ask the anaesthetist; while the control group (CG), 73 patients, did not receive any suggested questions. There were two end points: the proportion that chose RA and the number of questions actually addressed to the doctor at the preanaesthetic interview. Psychological aspects were taken into account by collecting the Hospital Anxiety and Depression (HAD) scale before the preanaesthetic interview. Satisfaction with the interview was recorded using a telephone questionnaire 2 weeks after the operation. The results from the two groups were compared by calculating the odds ratio according to Mantel-Haenszel and by logistic analysis. Altogether, 71.2% of the patients chose RA without any difference between the groups. The average number of questions asked by each SG patient was higher than for the CG (1.67 vs. 0.96). The satisfaction level was similar in the two groups. Our list of questions was designed to facilitate patient autonomy. It offered an aid to those requesting more information and assisted communication. The method did not change the proportion who chose a specific kind of anaesthesia, but does seem to improve patient participation in the decision-making process.

Adult↗
PubMed1999

Early diagnosis, place of diagnosis and persistent differences at 10 years in breast cancer survival. Hospitals and breast clinic cases prognosis.

In the Province of Florence (central Italy), the Center for Cancer Prevention (CSPO) runs a breast clinic for early diagnosis of breast cancer at which women can present as self-referrals or be referred by a general practitioner. About 55% of breast cancers incident in the area were diagnosed at CSPO. This paper evaluates the differences observed in 10-year observed and relative survival between hospitals and breast clinic cases. A population-based data set of 1182 invasive cases diagnosed in the years 1985 and 1986 (Tuscany Cancer Registry) was analyzed. Cox models were used to evaluate the effects of place of diagnosis on observed survival. In comparison to hospital cases, breast clinic cases showed a significantly higher frequency of localized cancer (55% vs 37%) and a better relative survival, persistent at 10 years of follow-up (69% vs 58%). The better survival of breast clinic cases persisted after age adjustment (hospitals cases; RR = 0.71, 95% CI: 0.60-0.84) and after age + diffusion of disease adjustment (RR = 0.79, 95% CI: 0.66-0.93). For regionally diffused cancers, breast clinic cases showed a 10-year survival significantly better than hospital cases. In conclusion, even if some bias (i.e. lead-time and length bias) could affect the comparison, breast clinic cases showed a better survival persistent until 10 years after diagnosis. An earlier stage distribution explained, at least partly, the different prognosis.

Adult↗
PubMed1999

Breast cancer screening in 21 countries: delivery of services, notification of results and outcomes ascertainment.

Following clinical trial evidence of mammography screening's efficacy and effectiveness, data are needed from organized population-based programmes to determine whether screening in these programmes results in breast cancer mortality reductions comparable to those demonstrated in controlled settings. The International Breast Cancer Screening Network (IBSN) conducted two international programme assessments: in 1990 among nine countries and in 1995 among 22 countries, obtaining information on the organization and process for screening within breast cancer screening programmes. This manuscript describes procedures for recruitment, service delivery, interpretation and communication of results, case ascertainment, and quality assurance. Practices in more established programmes are compared with pilot programmes. Each IBSN country defined a unique programme of population-based breast cancer screening. Some programmes were sub-national rather than national in scope, while others were in pilot stages of development. Screening took place in dedicated centres in established programmes and in both dedicated and general radiology centres in pilot programmes. Although most countries used personal invitation systems to recruit women to screening, other recruitment mechanisms were used. Most countries used two-view mammography in their screening programmes. About half had implemented independent double reading of mammograms, considering it a key component of high-quality mammography screening. In conclusion, diversity exists in the organization and delivery of screening mammography internationally. Quality assurance activities are a priority and are being evaluated in the IBSN.

Australia↗
PubMed1999

Home palliative care for terminal cancer patients: a survey on the final week of life.

As part of a large multicentre study on palliative care units in Italy, carried out between 1 January and 30 June 1995, we describe the place, circumstances and 'quality of death' of patients admitted to home palliative care. Data presented refer to 401 patients (67% of the 601 patients randomly selected for evaluation). Of these 401 patients 303 (76%) died at home. According to the Support Team Assessment Schedule (STAS) pain was fairly well controlled during the final week of life, while the control of other symptoms appeared to be less satisfactory. Invasive procedures were undertaken on 56% of patients, while in hospital the percentage increased to 75%. Twenty-five per cent of patients were totally pharmacologically sedated during the final 12 h of life. Neither the number of symptoms nor other factors were apparently associated with the decision to sedate the patient. The wide variations in the frequency of sedation among centres suggest that the choice to sedate the patient may reflect the provider's behaviour or services' policy rather than the patients' preference or needs. The definition of common criteria and guidelines for sedation of patients should be one of the topics for discussion among palliative care teams.

Adult↗
PubMed1998

Osteoporosis in juvenile systemic lupus erythematosus: a longitudinal study on the effect of steroids on bone mineral density.

Peak bone mass is an important determinant of future bone mass and of the risk of osteoporosis and subsequent fractures. Although some information concerning bone mineral density (BMD) in adults affected with systemic lupus erythematosus (SLE) is available, few data on children and adolescents have been reported. Many variables, such as duration and activity of the disease, reduced sun exposure, and steroid therapy have been suggested as risk factors in the pathogenesis of osteoporosis in SLE. In this study, we longitudinally evaluated, by dual energy X-ray absorptiometry (DEXA), the BMD of 20 young patients affected with juvenile SLE (JSLE), in order to establish the degree of osteoporosis and the influence of steroid treatment, among other clinical variables. At baseline, the mean BMD in JSLE patients was 0.978 g/cm2 and in controls 1.038 g/cm2 (P = 0.31). At 1 year (time 2), this value became 0.947 g/cm2 in JSLE children; the mean individual difference was 0.28 g/cm2 (3.4%). Only in those patients aged 19-25 years BMD was significantly lower than in controls, both at baseline and at time 2. Considering the steroid treatment, no significant difference between the two groups was found either at baseline or at time 2; however, the mean yearly BMD loss in the steroid patients was 0.031 g/cm2 (3.5%) vs. 0.005 g/cm2 (0.5%) in those who had not taken steroids. A significantly inverse correlation between BMD and the cumulative dosage of corticosteroids has been detected. BMD produced a significantly inverse correlation to the cumulative dosage of corticosteroids; no significant correlation has been found between BMD and disease activity or duration.

Absorptiometry, Photon↗
PubMed1998

Quality-of-life evaluation: when do terminal cancer patients and health-care providers agree?

A multicenter study involving six palliative care units in Italy was carried out on 159 terminal cancer patients seen at home or in hospital. The physician or the nurse completed independently from the patient the Therapy Impact Questionnaire (TIQ), a questionnaire devised for quality-of-life evaluation in terminal cancer patients. The patient's assessment was used as the valid reference measurement to compare with the health-care workers' evaluation to assess the validity of the latter. The results showed that percentages of agreement were higher for physical than for psychological and cognitive symptoms, and that there was a greater agreement on the absence rather than on the presence of a problem. None of the characteristics of the patient nor of the proxy showed any statistically significant relationship with the two disagreement indexes. The results suggest that caution is needed in the use of health-care workers as alternative sources of information regarding patients' quality of life.

Evaluation Studies as Topic↗
PubMed1998

Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening.

BACKGROUND: Currently there are at least 22 countries worldwide where national, regional or pilot population-based breast cancer screening programmes have been established. A collaborative effort has been undertaken by the International Breast Cancer Screening Network (IBSN), an international voluntary collaborative effort administered from the National Cancer Institute in the US for the purposes of producing international data on the policies, funding and administration, and results of population-based breast cancer screening. METHODS: Two surveys conducted by the IBSN in 1990 and 1995 describe the status of population-based breast cancer screening in countries which had or planned to establish breast cancer screening programmes in their countries. The 1990 survey was sent to ten countries in the IBSN and was completed by nine countries. The 1995 survey was sent to and completed by the 13 countries in the organization at that time and an additional nine countries in the European Network. RESULTS: The programmes vary in how they have been organized and have changed from 1990 to 1995. The most notable change is the increase in the number of countries that have established or plan to establish organized breast cancer screening programmes. A second major change is in guidelines for the lower age limit for mammography screening and the use of the clinical breast examination and breast self-examination as additional detection methods. CONCLUSION: As high quality population-based breast cancer screening programmes are implemented in more countries, they will offer an unprecedented opportunity to assess the level of coverage of the population for initial and repeat screening, evaluation of performance, and, in the longer term, outcome of screening in terms of reduction in the incidence of late-stage disease and in mortality.

Adult↗
PubMed1997

Limitations of magnetic resonance imaging in measurement of hepatic iron.

To evaluate the usefulness of magnetic resonance imaging for the quantitative determination of hepatic iron, we examined 43 patients with thalassemia major and assessed the influence of pathologic changes in the liver on the precision of estimates of the hepatic iron concentration. Tissue signal intensities were measured from magnetic resonance T1-weighted images derived from gradient-echo (GE) pulse sequences and the ratio of the signal intensity of liver to muscle calculated. By excluding patients (n = 9) having a signal intensity ratio (SIR) less than or equal to 0.2, a linear relationship with hepatic iron was found and subsequent analyses were limited to these 34 patients. In 27 patients with hepatic fibrosis, an overall correlation of -0.848 was found between hepatic iron and SIR. By contrast, in the seven patients with no fibrosis, the correlation coefficient (-0.993) was significantly greater (P < .0001). Despite the differences in correlation, the regression line between hepatic iron and SIR for the patients with no fibrosis did not differ significantly with respect to either slope or intercept from that of the patients with fibrosis. Thus, the presence of fibrosis did not seem to affect the pattern of the relationship between hepatic iron and the SIR, but rather to increase the variability of the relationship. Clinically, the presence of fibrosis makes estimates of hepatic iron derived from magnetic resonance imaging so variable as to be of little practical use in the management of transfusional iron overload.

Adolescent↗
PubMed1997

Effect of faecal occult blood testing on colorectal mortality: results of a population-based case-control study in the district of Florence, Italy.

The aim of our case-control study was to estimate the effect on mortality from colorectal cancer (CRC) of a population-based screening with a faecal occult blood test started in 1982 in a rural area of the district of Florence. We examined the relationship between mortality and the interval since the most recent screening. The cases in the study were 206 individuals who had died from CRC after the age of 41 years. Five controls were selected randomly from the list of individuals alive at the time of diagnosis of the corresponding case and were matched by sex, age and place and length of residence. After adjustment for potentially confounding factors, the odds ratio (OR) for death from CRC for screened persons vs. those not screened was 0.60 [95% confidence interval (CI), 0.4-0.9]. The OR was lowest in the first 3 years after the most recent test (OR = 0.54; 95% CI, 0.3-0.9) and increased towards unity subsequently. Our results suggest that screening for CRC by biennial faecal occult blood testing can reduce mortality from the disease.

Aged↗
PubMed1997

Disclosure practices and cultural narratives: understanding concealment and silence around cancer in Tuscany, Italy.

Disclosure practices are embedded in and enact personal, professional, and societal narratives. These narratives are not given but contested and evolving. The medical arena constitutes an important social space in which this contestation, reproduction and change take place. More specifically, based on ethnographic and cultural survey data, we describe and interpret the cultural sense of "not telling" about cancer within the local world of Tuscany, Italy. We locate the traditional practice of non-disclosure of cancer diagnoses within a larger cultural narrative we call "social-embeddeness", a narrative of social unity and hierarchy, of protection from or adaptation to the inevitable necessities of life, in part by using narrative itself to construct a sense of group protection. This narrative is being challenged, as it confronts other medical and societal narratives, such as one originating from the United States and embedded in health care practices like open disclosure, informed consent, Advanced Directives, and the Patient Self-Determination Act, what we call the "autonomy-control narrative". Explicit disclosure to a patient about his or her illness and the future plays an important role in actualizing this narrative, in helping in the quest to control one's destiny, eliminate uncertainty and necessity, and foster a person's identity as singular and sovereign over him/herself. The concept "narrative" highlights the ideology and intent of people's practices, not just "outcome", and helps us understand contradictions in various disclosure contexts as partly due to multiple cultural narratives in play. Considering some of the practices and understandings embedded within and reproduced by the larger cultural narratives also allows us to track the dynamics of history and individual biography, to locate and compare approaches to disclosure across time and space, and to avoid the pitfalls of cultural determinism and cultural stereotypes.

Bioethics↗
PubMed1997

Outcome evaluation in a home palliative care service.

The complexity of assessing the impact of palliative care is much greater than in other fields of medicine, due to the shortcomings of traditional outcome indicators. We conducted a prospective study to describe the patient's quality of life at the outset and during palliative care at home and to define some potential indicators of palliative care outcomes with the aim of assessing the quality of home care as provided by a palliative care unit. Seventy-three patients who received care at home were assessed. The median survival in palliative home care was 29 days. To evaluate the degree of symptom distress, we used an Italian version of the Symptom Distress Scale. Assessing the quality-of-life pattern over time, we observed that palliative care was effective in mitigating pain and, at least in part, in stimulating appetite, curbing nausea, and controlling psychological aspects. The subscales referring to social and functional aspects steadily worsened. The difficulties encountered (the high percentage of missing data, the considerable number of patients treated for less than 10 days, etc.) should be a warning against using only one assessment instrument. It is worthwhile defining the various potential outcomes of palliative care even though all results will not always be measurable in every patients. Only a global assessment, a "multiple outcomes approach," based on different indicators, would allow for evaluation of the outcome of the care process.

Adult↗