In campo sanitario il costo di un test diagnostico non deve essere valutato in termini assoluti, bensì in termini relativi di costo-efficacia: un test anche di costo elevato può risultare di buon valore se il beneficio è di gran lunga superiore ai potenziali rischi, così come un test apparentemente economico può risultare dannoso se il beneficio è di gran lunga inferiore ai rischi.
L'editoriale illustra i criteri utilizzati dall’American College of Physicians per razionalizzare e ottimizzare l’uso dei test diagnostici e di screening evitandone un sovrautilizzo o ancor peggio un cattivo utilizzo e riporta le conclusioni più significative del gruppo di studio statunitense.

(1) Centro Studi Fondazione FADOI

The introduction of antiretroviral therapy (ART) has substantially modified the clinical history and epidemiology of HIV infection with an important decline in infective causes of death and an increase in non-infective comorbidities particularly in cardiovascular complications.
HIV infection has been related to an increased cardiovascular risk due to the presence of three factors: classic cardiovascular risk factors (shared with the general population), HIV infection itself (indirectly due to the inflammation and directly due to viral molecule) and ART-related chronic metabolic alterations.
We describe a peculiar case of metabolic alteration in an HIV infected patient on ART with particular attention to the diagnosis and therapeutic aspects.
Giving the higher cardiovascular risk of this specific population it is advisable that the clinician performs a frequent re-assessment of risk factors and cardiovascular organ damage. An early detection of metabolic alteration must lead to an aggressive specific therapy; this must be done by taking care of the HIV-infected subject fragility and the interactions with ART.


(1) Centro Ipertensione Arteriosa, Clinica Medica, Ospedale San Gerardo, Monza
(2) Dipartimento di Medicina Clinica e Prevenzione, Università degli studi di Milano-Bicocca e Cardiologia IV, Ospedale Niguarda, Milano

The differential diagnosis of an episode of transient loss of consciousness can be sometimes very tricking, in particular when symptoms peculiar of syncope are mixed with focal neurological symptoms. We report the case of a 54-year-old woman who suddenly claimed, during a polygraphic recording (electroencephalography/electrocardiogram), a feeling of fear and tachycardia followed by loss of consciousness and then a tonic posturing of the left limbs. Polygraphic recording showed a critical electroencephalographic pattern starting from left temporo-zygomatic channels followed after few seconds by a sudden slowing of cortical background activity associated with an episode of asystole, as witnessed simultaneously by electrocardiogram. Muscular activity covered electroencephalographic activity of following minutes. This case provides an opportunity to highlight the existence of rare conditions such as ictal arrhythmias which should be considered in the differential diagnosis of episodes of transient loss of consciousness in particular when dysautonomic and neurological symptoms are intermingled. Autonomic symptoms (vomiting, tachycardia, cyanosis, bradycardia and asystole) may be also more frequent in idiopathic (more rarely symptomatic) epilepsies of childhood (Panayiotopoulos syndrome).

(1) Neurologia Clinica, Università Campus Biomedico di Roma

Bacterial biofilms play a role in upper respiratory tract diseases, including acute and chronic middle ear diseases, and are involved in chronic infections and resistance to antibiotic treatment. In particular, the nasopharynx and the surrounding tissues act as important reservoirs of resistant bacterial biofilms, which have been detected in biopsies taken from adenoid and/or middle ear mucosa of children with chronic middle ear effusion.
Here we describe the management of a child with congenital immunodeficiency and a chronic middle ear effusion, resistant to traditional medical treatment and presumably due to nasopharyngeal colonization by bacterial biofilms, which has been successfully treated by means of medicated nasal douches delivering antibiotic and a biofilm-destroying compound.

(1) Dipartimento di Scienze Chirurgiche Specialistiche, Università degli Studi di Milano, Fondazione IRCCS Ospedale Maggiore Policlinico, Milano

The hypertensive patient is the most stable phenotype in psychosomatic medicine. Hypertensive patients represent a vulnerable population that deserves special attention from health care providers and systems, and psychosomatic medicine may be an important tool in the management of high blood pressure. Depression, anxiety disorders and personality features are often associated with elevated blood pressure (BP) and they may have a role in the development of mild highrenin essential hypertension. Besides, “white coat” hypertension and “masked” hypertension demonstrate how clinic blood pressure could be strongly related to trait anxiety. Hypertension is largely asymptomatic, and patients often have little understanding of the importance of achieving BP control. Medication adverse effects may become an important factor in poor adherence to the treatment and the antidepressant use increases the risk of hypertension. So, the challenge in the management of hypertensive patients is the adherence to non-pharmacological and behavioural treatments for hypertension.

(1) Dipartimento di Medicina e Oncologia Sperimentale, Centro Ipertensione, Università di Torino, Ospedale “San Giovanni Battista”, Torino

La Redazione di CMI – Clinical Management Issues desidera ringraziare tutti i referee che, con il loro supporto e con la loro fattiva collaborazione, hanno contribuito a migliorare il rigore scientifico, la precisione e l’accuratezza dei contenuti della rivista.