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Semeraro F.,Ospedale Maggiore | Frisoli A.,Sant'Anna School of Advanced Studies | Loconsole C.,Sant'Anna School of Advanced Studies | Banno F.,Sant'Anna School of Advanced Studies | And 4 more authors.
Resuscitation | Year: 2013

Introduction: Outcome after cardiac arrest is dependent on the quality of chest compressions (CC). A great number of devices have been developed to provide guidance during CPR. The present study evaluates a new CPR feedback system (Mini-VREM: Mini-Virtual Reality Enhanced Mannequin) designed to improve CC during training. Methods: Mini-VREM system consists of a Kinect® (Microsoft, Redmond, WA, USA) motion sensing device and specifically developed software to provide audio-visual feedback. Mini-VREM was connected to a commercially available mannequin (Laerdal Medical, Stavanger, Norway). Eighty trainees (healthcare professionals and lay people) volunteered in this randomised crossover pilot study. All subjects performed a 2min CC trial, 1h pause and a second 2min CC trial. The first group (FB/NFB, n=40) performed CC with Mini-VREM feedback (FB) followed by CC without feedback (NFB). The second group (NFB/FB, n=40) performed vice versa. Primary endpoints: adequate compression (compression rate between 100 and 120min-1 and compression depth between 50 and 60mm); compressions rate within 100-120min-1; compressions depth within 50-60mm. Results: When compared to the performance without feedback, with Mini-VREM feedback compressions were more adequate (FB 35.78% vs. NFB 7.27%, p< 0.001) and more compressions achieved target rate (FB 72.04% vs. 31.42%, p< 0.001) and target depth (FB 47.34% vs. 24.87%, p= 0.002). The participants perceived the system to be easy to use with effective feedback. Conclusions: The Mini-VREM system was able to improve significantly the CC performance by healthcare professionals and by lay people in a simulated CA scenario, in terms of compression rate and depth. © 2012 Elsevier Ireland Ltd.


Fabrizi F.,Ospedale Maggiore | Aghemo A.,Maggiore Hospital and IRCCS Foundation | Messa P.,Ospedale Maggiore
Kidney and Blood Pressure Research | Year: 2013

Hepatorenal syndrome is a complication of end stage liver disease. It is a unique form of functional renal failure related to kidney vasoconstriction in the absence of underlying kidney pathology. Hepatorenal syndrome is classified into 2 types: type-1 HRS shows a rapid and progressive decline in renal function with a very poor prognosis (median survival of about 2 weeks); type-2 HRS has a more stable kidney failure, with a median survival of 6 months; its main clinical manifestation is refractory ascites. The most appropriate therapy for HRS is liver transplantation but only a minority of HRS patients undergo the procedure due to the high mortality; survival among liver transplant recipients is lower in HRS than among their counterparts without HRS. A large body of evidence, based on observational studies and randomized controlled trials, has been accumulated in the last decade showing that terlipressin represents a milestone in the management of HRS. According to our meta-analysis of randomized trials comparing terlipressin vs. placebo (five trials, n=243 patients), the pooled rate of patients who reversed HRS by terlipressin was 8.09 (95% CI, 3.52; 18.59) (P<0.001). Among vasoconstrictors, terlipressin (a V1 vasopressin agonist) is the most widely used; however, noradrenaline is another good choice. Vasoconstrictor drugs alone or with albumin reduce mortality compared with no intervention or albumin (RR of mortality, 0.82; 95% Confidence Intervals, 0.70; 0.96) (P<0.01). Two series of patients with HRS recurrence after the first treatment have recently shown that long-term therapy with terlipressin and albumin is beneficial as a bridge to liver transplant. Nevertheless, recovery of renal function can be achieved in less than 50% of patients with HRS after terlipressin use and the recovery of renal function may also be partial in patients who are defined full responders. Renal replacement therapy should not be considered a first-line therapy for HRS Clinical trials are under way in order to assess efficacy and safety of novel therapeutic agents for the treatment of type-1 and type-2 HRS. © 2014 S. Karger AG, Basel.


Diener H.-C.,University of Duisburg - Essen | Connolly S.J.,Hamilton Health Sciences | Ezekowitz M.D.,Lankenau Institute for Medical Research and the Heart Center | Wallentin L.,Uppsala University | And 5 more authors.
The Lancet Neurology | Year: 2010

Background: In the Randomised Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial, dabigatran reduced occurrence of both stroke and haemorrhage compared with warfarin in patients who had atrial fibrillation and were at increased risk of stroke. We aimed to assess the effects of dabigatran compared with warfarin in the subgroup of patients with previous stroke or transient ischaemic attack. Methods: In the RE-LY trial, 18 113 patients from 967 centres in 44 countries were randomly assigned to 110 mg or 150 mg dabigatran twice daily or to warfarin dose adjusted to international normalised ratio 2·0 to 3·0. Median follow-up was 2·0 years (IQR 1·14-2·86), and the primary outcome was stroke or systemic embolism. The primary safety outcome was major haemorrhage. Patients and investigators were aware of whether patients received warfarin or dabigatran, but not of dabigatran dose, and event adjudicators were masked to treatment. In a predefined analysis, we investigated the outcomes of the RE-LY trial in subgroups of patients with or without previous stroke or transient ischaemic attack. RE-LY is registered with ClinicalTrials.gov, NCT00262600. Findings: Within the subgroup of patients with previous stroke or transient ischaemic attack, 1195 patients were from the 110 mg dabigatran group, 1233 from the 150 mg dabigatran group, and 1195 from the warfarin group. Stroke or systemic embolism occurred in 65 patients (2·78% per year) on warfarin compared with 55 (2·32% per year) on 110 mg dabigatran (relative risk 0·84, 95% CI 0·58-1·20) and 51 (2·07% per year) on 150 mg dabigatran (0·75, 0·52-1·08). The rate of major bleeding was significantly lower in patients on 110 mg dabigatran (RR 0·66, 95% CI 0·48-0·90) and similar in those on 150 mg dabigatran (RR 1·01; 95% CI 0·77-1·34) compared with those on warfarin. The effects of both doses of dabigatran compared with warfarin were not significantly different between patients with previous stroke or transient ischaemic attack and those without for any of the outcomes from RE-LY apart from vascular death (110 mg group compared with warfarin group, interaction p=0·038). Interpretation: In patients with previous stroke or transient ischaemic attack, the effects of 110 mg dabigatran and 150 mg dabigatran on stroke or systemic embolism were similar to those of warfarin. Most effects of both dabigatran doses were consistent in patients with versus those without previous stroke or transient ischaemic attack. Funding: Boehringer Ingelheim. © 2010 Elsevier Ltd.


Coccolini F.,Papa Giovanni XXIII Hospital | Coccolini F.,University of Lyon | Cotte E.,University of Lyon | Glehen O.,University of Lyon | And 5 more authors.
European Journal of Surgical Oncology | Year: 2014

Introduction An important component of treatment failure in gastric cancer (GC) is cancer dissemination within the peritoneal cavity and nodal metastasis. Intraperitoneal chemotherapy (IPC) is considered to give a fundamental contribute in treating advanced GC. The purpose of the study is to investigate the effects of IPC in patients with advanced GC. Material and methods A systematic review with meta-analysis of randomized controlled trials (RCTs) of IPC + surgery vs. control in patients with advanced GC was performed. Results Twenty prospective RCTs have been included (2145 patients: 1152 into surgery + IPC arm and 993 into control arm). Surgery + IPC improves: 1, 2 and 3-year mortality (OR = 0.31, 0.27, 0.29 respectively), 2 and 3-year mortality in patients with loco-regional nodal metastasis (OR = 0.28, 0.16 respectively), 1 and 2-year mortality rate in patients with serosal infiltration (OR = 0.33, 0.27 respectively). Morbidity rate was increased by surgery + IPC (OR = 1.82). The overall recurrence and the peritoneal recurrence rates were improved by surgery + IPC (OR = 0.46 and 0.47 respectively). There was no statistically significant difference in lymph-nodal recurrence rate. The rate of haematogenous metastasis was improved by surgery + IPC (OR = 0.63). Conclusions 1, 2 and 3-year overall survival is incremented by the IPC. No differences have been found at 5-year in overall survival rate. 2 and 3-year mortality rates in patients with nodal invasion and 1 and 2-year mortality rates in patients with serosal infiltration are improved by the use of IPC. IPC has positive effect on peritoneal recurrence and distant metastasis. Morbidity rate is incremented by IPC. Loco-regional lymph-nodes invasion in patients affected by advanced gastric cancer is not a contraindication to IPC. © 2013 Elsevier Ltd. All rights reserved.


Maugeri N.,Vita-Salute San Raffaele University | Campana L.,Vita-Salute San Raffaele University | Gavina M.,San Raffaele Scientific Institute | Covino C.,San Raffaele Scientific Institute | And 9 more authors.
Journal of Thrombosis and Haemostasis | Year: 2014

Increasing evidence implicates both platelets and neutrophils in the formation, stabilization, and growth of peripheral and coronary thrombi. Neutrophil extracellular traps (NETs) play a key role. The early events in the deregulated cross-talk between platelets and neutrophils are poorly characterized. Objectives: To identify at the molecular level the mechanism through which platelets induce the generation of NETs in sterile conditions. Patients/Methods: The presence of NETs was determined in 26 thrombi from patients with acute myocardial infarction by immunohistochemistry and immunofluorescence and markers of NETs assessed in the plasma. In vitro NET generation was studied in static and in physiological flow conditions. Results: Coronary thrombi mainly consist of activated platelets, neutrophils, and NETs in close proximity of platelets. Activated platelets commit neutrophils to NET generation. The event abates in the presence of competitive antagonists of the high mobility group box 1 (HMGB1) protein. Hmgb1-/- platelets fail to elicit NETs, whereas the HMGB1 alone commits neutrophils to NET generation. Integrity of the HMGB1 receptor, Receptor for Advanced Glycation End products (RAGE), is required for NET formation, as assessed using pharmacologic and genetic tools. Exposure to HMGB1 prevents depletion of mitochondrial potential, induces autophagosome formation, and prolongs neutrophil survival. These metabolic effects are caused by the activation of autophagy. Blockade of the autophagic flux reverts platelet HMGB1-elicited NET generation. Conclusions: Activated platelets present HMGB1 to neutrophils and commit them to autophagy and NET generation. This chain of events may be responsible for some types of thromboinflammatory lesions and indicates novel paths for molecular intervention. © 2014 International Society on Thrombosis and Haemostasis.


Semeraro F.,Ospedale Maggiore | Taggi F.,Ospedale Maggiore | Tammaro G.,Ospedale Maggiore | Imbriaco G.,Ospedale Maggiore | And 2 more authors.
Resuscitation | Year: 2011

Objectives: The present study evaluates a new CPR feedback application for the iPhone (iCPR) designed to improve chest compression performance tested in a cardiac arrest simulation to evaluate performance and acceptance by healthcare professionals and lay people. Methods: We built an application specifically dedicated to self-directed CPR training through a tutorial that includes a simple feedback module to guide training in order to improve the quality of chest compressions. We tested it in a sample of 50 users to evaluate the effect of iCPR on performance and it is acceptance. The participants were randomly assigned to one of the study groups and were asked to perform a trial of 2. min of chest compressions (CC), to answer a predefined set of questions and then to perform two more minutes of CC. The first group performing the sequence of CC with iCPR - questions - CC without feedback, and the second the sequence CC without feedback - questions CC with iCPR. Results: The mean compression rate was 101±2.8min-1 when CC were performed with iCPR and 107.8±20.5min-1 when performed without iCPR (p<0.01). Overall, the participants considered iCPR useful to maintain CC at the desired rate of 100 compressions per minute. Conclusions: The iCPR feedback tool was able to significantly improve the performance of chest compressions in terms of the compression rate in a simulated cardiac arrest scenario. The participants also believed that iCPR helped them to achieve the correct chest compression rate and most users found this device easy to use. © 2010 Elsevier Ireland Ltd.


Vacchi-Suzzi M.,Ospedale Maggiore | Bocciolini C.,Ospedale Maggiore | Bertarelli C.,Maggiore Hospital | Dall'Olio D.,Ospedale Maggiore
Annals of Otology, Rhinology and Laryngology | Year: 2010

Objectives: The study was performed to evaluate the prognostic relevance of cell proliferation associated with Ki-67/Mib-1 immunostaining in malignant tumors of the major salivary glands. Methods: Cell proliferation was evaluated by Mib-1 antibody against Ki-67 antigen in 41 patients with cancer of the parotid or submandibular glands, including 14 acinic cell carcinomas, 12 ductal carcinomas, 7 mucoepidermoid carcinomas, 5 carcinomas ex pleomorphic adenoma, 1 adenoid cystic carcinoma, 1 undifferentiated carcinoma, and 1 polymorphous low-grade adenocarcinoma. Results: Patients with Ki-67 values of more than 15% and those with Ki-67 values of 15% or less differed both in disease-free survival (p < 0.001) and in overall survival (p < 0.001). We evaluated the association between Ki-67 and time to recurrence in correlation to age, sex, ductal histotype, and N stage; the Cox regression model was significant (p = 0.013). In the group of patients with T1 and T2 cancers, those with Ki-67 values of 15% or less had better survival rates than did those with Ki-67 values of more than 15% (p = 0.004). In the group of patients with N0 cancers, those with Ki-67 values of 15% or less had a better survival than did those with Ki-67 values of more than 15% (p < 0.001). Conclusions: To our knowledge, this is the first study to stratify different risk classes in early T1-T2 or N0 malignant tumors of the major salivary glands that identified aggressive lesions with elevated Ki-67 expression at an initial stage. © 2010 Annals Publishing Company. All rights reserved.


Faldini C.,University of Bologna | Pagkrati S.,Ospedale Maggiore | Leonetti D.,University of Bologna | Miscione M.T.,University of Bologna | Giannini S.,University of Bologna
Clinical Orthopaedics and Related Research | Year: 2011

Background: The Cloward anterior interbody fusion is commonly performed for cervical disc herniation or spondylosis. In followup studies, various authors have noted clinically relevant adjacent-level degeneration. However, factors associated with adjacent-level degeneration are not well known. Questions/purposes: We asked whether the postoperative sagittal segmental alignment of the fused vertebrae could be used as a predictor of adjacent-level degeneration. Methods: We retrospectively studied 107 patients, aged 35 to 55 years, with one-level cervical disc disease between C4 and C7 operated on from 1985 to 1995 by discectomy and one-level anterior cervical fusion according to the Cloward procedure. In standard radiographs of the cervical spine in lateral view, the alignment of the involved intervertebral space (sagittal segmental alignment) and the sagittal alignment of the cervical spine were measured and the adjacent-level degeneration was assessed using the Kellgren and Lawrence criteria. The minimum followup was 10 years (mean, 16 years; range, 10-23 years). Results: Preoperatively, mean sagittal segmental alignment was 0.6° ± 2.0° and sagittal alignment of the cervical spine was 17.0° ± 4.9°. At last followup, the mean sagittal segmental alignment was 1.8° ± 4.1° and mean sagittal alignment of the cervical spine was 19.7° ± 6.6°. Adjacent-level degeneration was present in 60% of cases with postoperative sagittal segmental alignment of 0° or less and in 27% of cases with postoperative sagittal segmental alignment of more than 0°. Conclusions: To prevent adjacent-level degeneration, we recommend proper lordotic sagittal segmental alignment when anterior interbody fusion of the cervical spine is indicated. Level of Evidence Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. © The Association of Bone and Joint Surgeons® 2010.


De Iure F.,Segreteria di Ortopedia Ospedale Maggiore | Bosco G.,Ospedale Maggiore | Cappuccio M.,Ospedale Maggiore | Paderni S.,Ospedale Maggiore | Amendola L.,Ospedale Maggiore
European Spine Journal | Year: 2012

Purpose Pre-curved peek rods to support posterior lumbar fusion have been available in the market since 4 years. Potential advantages using this new technology are increased load sharing on the anterior column promoting interbody fusion, reduced stress on bone-screw interface decreasing the rate of screw mobilization and, in the long term, reduced incidence of adjacent level disc degeneration. Methods: The authors retrospectively reviewed 30 cases in which posterior fusion was supported by peek rods, analyzing early complications, rate of fusion and clinical outcome. Results: At an average follow-up of 18 months, both clinical and radiographic results were satisfactory with only one case requiring surgical revision for a mechanical complication. Conclusions: The semi-rigid systems can now be considered a viable option in the lumbar degenerative disease, although clinical evaluations are necessary in the longer term. © Springer-Verlag 2012.


Sofia S.,Ospedale Maggiore
Journal of Ultrasound | Year: 2013

Objectives: The aim of this review article is to present the current views and visions of the role of ultrasound (US) in the management of patients with multiple trauma. The article is divided into two parts. Part 1 (US findings and techniques) will mainly deal with the technical aspects of US imaging in trauma patients and is written also for educational purposes. Part 2 (pathophysiology and US imaging in trauma patients) will deal with integration of US in the clinical and pathophysiological management of multiple trauma patients. Methods: A non-systematic review of the literature through PubMed search (restricted to the last 10 years) of original articles and review articles. Results: 80 publications were selected for Part 1. Of these 80 articles, the author selected 50 according to personal criteria on the basis of their innovative or original contents (48 original articles and 2 literature review articles); 19 articles were furthermore extracted from the references of the selected publications. The information extracted from these 69 publications was organized into sections dealing with different fields of applications of US imaging in multiple trauma patients. Conclusions: US imaging in trauma has evolved from the initial use, i.e., early diagnosis of peritoneal effusion (focused abdominal sonography for trauma), to a wider use known as resuscitative ultrasonography, and is today considered as an extension of physical examination to implement a more effective approach to clinical problems and increase the timeliness and safety of interventions. © 2013 Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).

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