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Valle R.,Ospedale Civile
Contributions to Nephrology | Year: 2010

The key management goals for the stabilization of patients admitted for acutely decompensated heart failure (ADHF) include relief of congestion and restoration of hemodynamic stability. Nevertheless, in spite of clinical improvement, many patients are discharged with hemodynamic congestion. In response to volume expansion, the heart secretes the brain natriuretic peptide (BNP) with a biological action that counter-regulates the activation of the renin-angiotensin-aldosterone system. Since BNP is released by increased volume load and wall stretch, and declines after treatment with drugs of proven efficacy, on the basis of an improvement in filling pressures the level of BNP has been proposed as a 'measure' of congestion. The BNP level of a patient who is admitted with ADHF comprises two components: a baseline, euvolemic 'dry' BNP level and a level induced by volume or pressure overload ('wet' BNP level). So, the prognostic value of BNP during hospitalization depends on the time of measurement: from the lowest on admission when congestion is present (wet BNP) to the highest on clinical and instrumental stability (dry BNP), following the achievement of normohydration, as determined by fluid volume measurement. Euvolemia can be set as the primary goal of treatment for ADHF with dry BNP concentration as a target for discharge other than improvement of symptoms, because high BNP levels predict rehospitalization and death. Discharge criteria utilizing both BNP and hydration status measurement which account for the heterogeneity of the patient population and incorporate different strategies of care should be developed. This could in the next future offer an aid in monitoring heart failure patients or actively guiding optimal titration of therapy. Copyright © 2010 S. Karger AG, Basel.


Angeli F.,Teaching Hospital Sm Della Misericordia | Verdecchia P.,Hospital of Assisi | Savonitto S.,IRCCS Arcispedale S. Maria Nuova | Morici N.,Hospital Niguarda Ca Granda | And 2 more authors.
Catheterization and Cardiovascular Interventions | Year: 2014

Background It is unclear whether the benefits of an early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) equally apply to younger and older individuals. Elderly patients are generally less likely to undergo EIS when compared with younger patients. Objectives We conducted a meta-analysis to compare the benefit of an EIS versus a selectively invasive strategy (SIS) in patients with NSTEACS. We tested the hypothesis that the magnitude of benefit of an EIS over a SIS mainly applies to older individuals. Methods We extracted data from randomized controlled trials (RCTs) identified through search methodology filters the primary outcome of the analysis was the composite of all-cause death and myocardial infarction (MI). Secondary outcomes were death and MI taken alone and re-hospitalization. Results Nine trials (n = 9,400 patients) were eligible the incidence of the composite end-point of MI and all-cause death was 16.0% with the EIS and 18.3% with the SIS (OR: 0.85, 95% CI: 0.76-0.95) the incidence of MI was 8.4% with the EIS and 10.9% with the SIS (OR: 0.75, 95% CI: 0.66-0.87). Similar results were obtained for rehospitalization (OR: 0.71, 95% CI: 0.55-0.90) the incidence of all-cause death did not differ between the two groups the EIS reduced the composite end-point and re-hospitalization to a greater extent in elderly than in younger patients (P for interaction = 0.044 and <0.0001, respectively) these findings were confirmed in meta-regression analyses. Conclusions In patients with NSTEACS, a routine EIS reduces the risk of rehospitalization and the composite end point of recurrent MI and death to a greater extent in elderly than in younger individuals. © 2013 Wiley Periodicals, Inc. Copyright © 2013 Wiley Periodicals, Inc.


Ronco C.,St Bortolo Hospital | Kaushik M.,St Bortolo Hospital | Valle R.,Ospedale Civile | Aspromonte N.,San Filippo Neri Hospital | Peacock W.F.,Cleveland Clinic
Seminars in Nephrology | Year: 2012

Cardio-Renal syndrome may occur as a result of either primarily renal or cardiac dysfunction. This complex interaction requires a tailored approach to manage the underlying pathophysiology while optimizing the patient's symptoms and thus providing the best outcomes. Patients often are admitted to the hospital for signs and symptoms of congestion and fluid overload is the most frequent cause of subsequent re-admission. Fluid management is of paramount importance in the strategy of treatment for heart failure patients. Adequate fluid status should be obtained but a target value should be set according to objective indicators and biomarkers. Once the fluid excess is identified, a careful prescription of fluid removal by diuretics or extracorporeal therapies must be made. While delivering these therapies, adequate monitoring should be performed to prevent unwanted effects such as worsening of renal function or other complications. There is a very narrow window of optimal hydration for heart failure patients. Overhydration can result in myocardial stretching and potential decompensation. Inappropriate dehydration or relative reduction of circulating blood volume may result in distant organ damage caused by inadequate perfusion. We suggest consideration of the "5B" approach. This stands for balance of fluids (reflected by body weight), blood pressure, biomarkers, bioimpedance vector analysis, and blood volume. Addressing these parameters ensures that the most important issues affecting symptoms and outcomes are addressed. Furthermore, the patient is receiving the best possible care while avoiding unwanted side effects of the treatment. © 2012 Elsevier Inc.


Castricini R.,Ospedale Civile | Longo U.G.,Biomedical University of Rome | De Benedetto M.,Villa Maria Cecilia Hospital GVM Care and Research | Panfoli N.,Ospedale Civile | And 4 more authors.
American Journal of Sports Medicine | Year: 2011

Background: After reinsertion on the humerus, the rotator cuff has limited ability to heal. Growth factor augmentation has been proposed to enhance healing in such procedure. Purpose: This study was conducted to assess the efficacy and safety of growth factor augmentation during rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Eighty-eight patients with a rotator cuff tear were randomly assigned by a computer-generated sequence to receive arthroscopic rotator cuff repair without (n = 45) or with (n = 43) augmentation with autologous platelet-rich fibrin matrix (PRFM). The primary end point was the postoperative difference in the Constant score between the 2 groups. The secondary end point was the integrity of the repaired rotator cuff, as evaluated by magnetic resonance imaging. Analysis was on an intention-to-treat basis. Results: All the patients completed follow-up at 16 months. There was no statistically significant difference in total Constant score when comparing the results of arthroscopic repair of the 2 groups (95% confidence interval, -3.43 to 3.9) (P =.44). There was no statistically significant difference in magnetic resonance imaging tendon score when comparing arthroscopic repair with or without PRFM (P =.07). Conclusion: Our study does not support the use of autologous PRFM for augmentation of a double-row repair of a small or medium rotator cuff tear to improve the healing of the rotator cuff. Our results are applicable to small and medium rotator cuff tears; it is possible that PRFM may be beneficial for large and massive rotator cuff tears. Also, given the heterogeneity of PRFM preparation products available on the market, it is possible that other preparations may be more effective. © 2011 The Author(s).


Tamburino C.,Ferrarotto Hospital | Tamburino C.,ETNA Foundation | Capodanno D.,Ferrarotto Hospital | Capodanno D.,ETNA Foundation | And 14 more authors.
Circulation | Year: 2011

Background- There is a lack of information on the incidence and predictors of early mortality at 30 days and late mortality between 30 days and 1 year after transcatheter aortic valve implantation (TAVI) with the self-expanding CoreValve Revalving prosthesis. Methods and Results- A total of 663 consecutive patients (mean age 81.0±7.3 years) underwent TAVI with the third generation 18-Fr CoreValve device in 14 centers. Procedural success and intraprocedural mortality were 98% and 0.9%, respectively. The cumulative incidences of mortality were 5.4% at 30 days, 12.2% at 6 months, and 15.0% at 1 year. The incidence density of mortality was 12.3 per 100 person-year of observation. Clinical and hemodynamic benefits observed acutely after TAVI were sustained at 1 year. Paravalvular leakages were trace to mild in the majority of cases. Conversion to open heart surgery (odds ratio [OR] 38.68), cardiac tamponade (OR 10.97), major access site complications (OR 8.47), left ventricular ejection fraction <40% (OR 3.51), prior balloon valvuloplasty (OR 2.87), and diabetes mellitus (OR 2.66) were independent predictors of mortality at 30 days, whereas prior stroke (hazard ratio [HR] 5.47), postprocedural paravalvular leak2+ (HR 3.79), prior acute pulmonary edema (HR 2.70), and chronic kidney disease (HR 2.53) were independent predictors of mortality between 30 days and 1 year. Conclusions- Benefit of TAVI with the CoreValve Revalving System is maintained over time up to 1 year, with acceptable mortality rates at various time points. Although procedural complications are strongly associated with early mortality at 30 days, comorbidities and postprocedural paravalvular aortic regurgitation2+ mainly impact late outcomes between 30 days and 1 year. © 2011 American Heart Association. All rights reserved.


Vettoretto N.,M Mellini Hospital | Agresta F.,Ospedale Civile
Techniques in Coloproctology | Year: 2011

Laparoscopic appendectomy was first performed more than 25 years ago. We performed a systematic literature search on laparoscopic appendectomy and selected related topics. The technique should be considered the gold standard for surgical removal of the appendix in women of childbearing age (level of evidence Ia). There is minor but consistent evidence that it should also be advocated for men (level of evidence III), obese (level of evidence III), and elderly (level of evidence IIb) patients, while there is some evidence of unfavorable results on pregnant women (level of evidence IIb). Studies reporting higher incidence of intra-abdominal abscesses after laparoscopic appendectomy are difficult to interpret due to a lack of standardization of the operative technique and lack of uniformity related to the different grades of disease (ranging from uninflamed appendix to diffuse peritonitis, gangrene, or perforation of the organ). As far as surgical technique, the three-port procedure is superior to needleoscopy and single port access (level of evidence Ia). Costly high-tech instruments for dissection are mostly unnecessary (level Ib). Mechanical closure of the stump might prove safer (level Ib). The quantity of peritoneal lavage fluid is generally scanty (level III), and abdominal drains are not useful (level Ia). Fast-track protocols should be implemented (level Ic). Training and technical standardization are the key to devising future trials on this topic. © 2010 Springer-Verlag.


Dallocchio C.,Ospedale Civile | Arbasino C.,Ospedale Civile | Klersy C.,Fondazione IRCCS Policlinico San Matteo | Marchioni E.,CNR Institute of Neurological Sciences
Movement Disorders | Year: 2010

Psychogenic movement disorders (PMD) are a diagnostic fascinating challenge in both neurologic and psychiatric setting. Many factors influence response to treatment, but few treatment strategies are available. Physical activity proves to be effective in the treatment of depression, anxiety, and other psychiatric disorders, but the effects of regular walking exercise on patients with PMD have never been investigated in a single-blind study. Sixteen outpatients [13 women; mean age 33.0 years (range 22-51)] with primarily mild-to-moderate PMD completed a thrice-weekly, 12-weeks mild walking program. Assessments included DSM-IV interview, the Psychogenic Movement Disorder Rating Scale (PMDRS), Beck Anxiety Inventory (BAI), Hamilton Depression Scale (HDS), V02 Max, and body mass index (BMI). Changes in total score on the PMDRS were the primary endpoint. A comparison of all measures taken at study onset and after completing the exercise program indicates statistically significant improvements. We observed a relevant improvement in 10 of 16 patients (62%). The mean difference for the primary outcome (PMDRS total) corresponded to about 70%. Compliance was good, and there were no adverse effects. This study provides preliminary evidence for regular low-medium intensity exercise as a safe, adequate, and pleasing intervention for PMD. Furthermore, well-designed studies appear justified to confirm these findings. © 2010 Movement Disorder Society.


Savonitto S.,Ospedale Niguarda Ca Granda | Caracciolo M.,Ospedale Niguarda Ca Granda | Cattaneo M.,University of Milan | De Servi S.,Ospedale Civile
Journal of Thrombosis and Haemostasis | Year: 2011

About 5% of patients undergoing coronary stenting need to undergo surgery within the next year. The risk of perioperative cardiac ischemic events, particularly stent thrombosis (ST), is high in these patients, because surgery has a prothrombotic effect and antiplatelet therapy is often withdrawn in order to avoid bleeding. The clinical and angiographic predictors of ST are well known, and the proximity to an acute coronary syndrome adds to the risk. The current guidelines recommend delaying non-urgent surgery for at least 6 weeks after the placement of a bare metal stent and for 6-12 months after the placement of a drug-eluting stent, when the risk of ST is reduced. However, in the absence of formal evidence, these recommendations provide little support with regard to managing urgent operations. When surgery cannot be postponed, stratifying the risk of surgical bleeding and cardiac ischemic events is crucial in order to manage perioperative antiplatelet therapy in individual cases. Dual antiplatelet therapy should not be withdrawn for minor surgery or most gastrointestinal endoscopic procedures. Aspirin can be safely continued perioperatively in the case of most major surgery, and provides coronary protection. In the case of interventions at high risk for both bleeding and ischemic events, when clopidogrel withdrawal is required in order to reduce perioperative bleeding, perioperative treatment with the short-acting intravenous glycoprotein IIb-IIIa inhibitor tirofiban is safe in terms of bleeding, and provides strong antithrombotic protection. Such surgical interventions should be performed at hospitals capable of performing an immediate percutaneous coronary intervention at any time in the case of acute myocardial ischemia. © 2011 International Society on Thrombosis and Haemostasis.


The therapeutic role of mediastinal radiotherapy and stem cell transplantation (SCT) in lymphoblastic lymphoma (LL) remains controversial. In a risk-oriented design, we adopted a flexible treatment program in which (1) patients with persistent mediastinal abnormality, evaluated by post-induction computed chest tomography, received mediastinal irradiation; and (2) those with persistence of minimal residual disease (MRD), evaluated by MRD analysis of the bone marrow, underwent SCT. Twenty-eight out of 30 patients (T-lineage, n = 24; B-lineage, n = 6) achieved a complete response. Of 21 patients with mediastinal mass, 13 (62%) achieved a complete response after chemotherapy alone, while 6 (28.5%) required additional irradiation. Eleven patients were evaluated for MRD: 6 were negative and 5 positive. On the basis of MRD findings and clinical risk characteristics, 14 patients underwent SCT, 13 received maintenance chemotherapy, and 1 had local radiotherapy. Five patients relapsed. Among the 14 non-irradiated patients with T-LL, the mediastinal recurrence rate was only 7%. After a median follow-up of 3.9 years, 21 patients who responded were alive without recurrence (75%). The projected 5-year survival, disease-free survival, and relapse rate were 72%, 77%, and 18%, respectively. This program induced high remission and survival rates, indicating the feasibility and the benefits potentially associated with a selective, response-oriented policy of mediastinal irradiation and a concurrent MRD-based strategy to assign adult LL patients to SCT.


Agresta F.,Ospedale Civile | Bedin N.,Ospedale Civile
Updates in Surgery | Year: 2012

Laparoscopy has rapidly emerged as the preferred surgical approach in a number of different diseases because it ensures correct diagnoses and appropriate treatment. The use of mini-instruments (5 mm or less in diameter) and, when possible, the reduction of the number of trocars used might be its natural evolution. Laparoscopic cholecystectomy is a gold standard technique. The aim of the present work is to illustrate the results of the prospective experience of minilaparoscopic cholecystectomy (5 mm MLC) performed at our institution. Between August 2005 and July 2010 a total of 932 patients (mean age 45 years) underwent a laparoscopic cholecystectomy. Amongst them, 887 (95.1%) were operated on with a 5 mm-three trocar approach and in the remaining 45 cases (4.8%) a 3 mm trocar was used. The primary endpoint was the feasibility rate of the techniques. Secondary endpoints were safety and the impact of the techniques on duration of laparoscopy. In two cases conversion to laparotomy was necessary. We needed to add a fourth-5 mm trocar in the 10.7% of the cases (95 patients) in the 5 mm MLC. There were two cases of redo-laparoscopy in this group due to bile leakage from the cystic duct in one case, and to bleeding from the gallbladder bed in the other. Minor occurrence ranged as high as 2.1% in the 5 mm-MLC group, while it was nil in the 3 mm-MLC patients. The present experience shows that the 5 mm-three trocars MLC is a safe, easy, effective and reproducible approach to gallbladder diseases. Such features make the technique a challenging alternative to conventional laparoscopy both in the acute and the scheduled setting. We consider the 3 mm-MLC approach suitable only in selected cases, young and thin patients, due to the fragility of the smaller instruments. © 2011 Springer-Verlag.

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