Telemedicine Has a Social Impact: An Italian National Study for the Evaluation of the Cost-Opportunity for Patients and Caregivers and the Measurement of Carbon Emission Savings

Background: Owing to COVID-19, all stakeholders have recognized the advantages of telehealth and they were available for its permanent implementation, both from the normative and economic point of view. It is, therefore, necessary to understand what were the real benefits created in society through telehealth. Objective: Develop a method to identify a social impact of telemedicine in Italy, considering the reduction on the patient moves with a consequent travel cost, time (opportunity costs), and carbon emission savings. Methods: Since March 2020, we have conducted a quality improvement study in 17 centers, collecting sociodemographic variables. To assess the social impact, we transform the data into outcome measures. The protocol used "Telemedicina Subito" allows the rapid implementation of telemedicine, using operating manual, structured according Health Technology Assessment approach. Results: We collected data related to 2,091 televisits, analyzing three different perspectives. First, one patient with a televisit had a saving equal to the median of EUR 97.16 (interquartile range [IQR]: 64.29-159.69), USD 113.88; considering that the median cost for the visit in presence was EUR 105.91 (p-value <0.05) and after the use of telehealth had a median of EUR 0 (mean: EUR 14.70; p-value <0.05). Second, informal caregivers have a median savings of EUR 65.06 (IQR: 55.52-89.21), USD 76.26. Finally, for one single telemedicine visits we can contribute with a median carbon emission savings of ∼13 kg (IQR: 6-24). Conclusions: The evaluation of the social impact on telemedicine facilitated the creation of an important framework for decision-makers.

From the lockdown to the new normal: individual mobility and local labor market characteristics following the COVID-19 pandemic in Italy

Italy was among the first countries to introduce drastic measures to reduce individual mobility in order to slow the diffusion of COVID-19. The first measures imposed by the central authorities on March 8, 2020, were unanticipated and highly localized, focusing on 26 provinces. Additional nationwide measures were imposed after one day, and were removed only after June 3. Looking at these watershed moments of the pandemic, this paper explores the impact of the adoption of localized restrictions on changes in individual mobility in Italy using a spatial discontinuity approach. Results show that these measures lowered individual mobility by 7 percentage points on top of the reduction in mobility recorded in the adjacent untreated areas. The study also fills a gap in the literature in that it looks at the changes in mobility after the nationwide restrictions were lifted and shows how the recovery in mobility patterns is related to various characteristics of local labour markets. Areas with a higher proportion of professions exposed to diseases, more suitable for flexible work arrangements, and with a higher share of fixed-term contracts before the pandemic are characterised by a smaller increase in mobility after re-opening.

Robots and risk of COVID-19 workplace contagion: Evidence from Italy

This work investigates the cross-industry relationship between robot adoption and the risk of contracting COVID-19 in the workplace in Italy. Using a novel dataset on the risk of workplace contagion, we show that industries employing more robots tend to exhibit lower risks, thereby providing some empirical support for the widely held, but so far untested, hypothesis that robots can help mitigate the risk of contagion among workers by reducing the need for physical interactions. While we acknowledge the relevance of robots in the fight against COVID-19 and their possible role in enhancing the resilience of economic systems against future pandemics, we also thoroughly discuss a series of potential trade-offs between workplace safety and employment conditions that could arise (especially in the short run) due to a substantial increase in the rate of robot adoption.

Robots and risk of COVID-19 workplace contagion: Evidence from Italy

This work investigates the cross-industry relationship between robot adoption and the risk of contracting COVID-19 in the workplace in Italy. Using a novel dataset on the risk of workplace contagion, we show that industries employing more robots tend to exhibit lower risks, thereby providing some empirical support for the widely held, but so far untested, hypothesis that robots can help mitigate the risk of contagion among workers by reducing the need for physical interactions. While we acknowledge the relevance of robots in the fight against COVID-19 and their possible role in enhancing the resilience of economic systems against future pandemics, we also thoroughly discuss a series of potential trade-offs between workplace safety and employment conditions that could arise (especially in the short run) due to a substantial increase in the rate of robot adoption.

The COVID-19 Pandemic as an Opportunity to Improve Health Care Through a Nurse-Coordinated Multidisciplinary Model in a Headache Specialist Center: The Implementation of a Telemedicine Protocol

Background: Due to coronavirus disease-19 (COVID-19) pandemic, Italian outpatient clinics were suspended in March-April 2020 and subsequently slowed down. Telemedicine was shown to be useful in headache clinics, despite absence of a detailed protocol for its development. Objective: To describe the implementation of a structured telemedicine protocol during COVID-19 pandemic. Materials and Methods: Since May 2020, we performed a quality improvement study in a Headache Specialist Center in central Italy. We involved patients who had in-person follow-up visits scheduled during suspension and initial reopening of clinics. Patients had two appointments with a nurse specialized in headache care and a headache physician, respectively, using Microsoft Teams^®. The service is still active. We collected sociodemographic and clinical characteristics of patients, technical details of telemedicine visits, patient feedback, medical judgment about complexity of clinical decisions, and need for in-person re-evaluation. We also performed a Strengths-Weaknesses-Opportunities-Threats analysis to provide a realistic picture of the service. Results: We performed 207 telemedicine visits involving 100 patients with a median age of 44 (interquartile range [IQR]: 35-56) years; 76.0% were women and lived at a median of 68 (IQR: 24-109) km from the Center. Thirty-nine (39.0%) were visited for migraine without aura. Patients mostly used a computer (68.1% visits) with high audio-video quality in 93.2% of visits. First and second appointments lasted in median 20 (IQR: 14-25) minutes and 9 (IQR: 7-13) minutes, respectively. Interacting with patients was very easy in 66.7% of visits. Patients reported no difficulty in sharing documents and high satisfaction in 78.6% and 93.5% of visits, respectively. Perceived complexity of clinical decisions was generally low (86.5%), whereas 8.2% of cases required in-person re-evaluation. Conclusions: Telemedicine facilitated follow-ups, ensuring multidisciplinary care and high patient satisfaction, justifying its wider adoption in headache care.

Evaluation of filter paper as a means to transport inactivated bacteria for identification using the MALDI-TOF MS system

A novel approach to transport inactivated bacteria in filter paper for identification in the MALDI-TOF MS was evaluated. Seventy four bacterial isolates were evaluated and the approach presented sensitivity of 97.3% and specificity of 100%. Inactivated bacteria in filter paper are a safer alternative to transport bacteria for MALDI-TOF MS identification.

Restoration of Ultrafiltration Capacity of Peritoneal Membrane in Patients on CAPD

Among 55 uremic patients who entered our CAPD program, 7 of them showed a reduction or loss of the ultrafiltration capacity (UF) of the peritoneal membrane (PM). They have been treated with high dose of Furosemide (F) to force residual urine output. Four appeared «responders» to drug administration with a significant increase in urine volume, Na excretion and, within a week period gained their dry body weight (BW).

In the remaining 3 patients drug therapy resulted ineffective, and fluid removal was obtained by hemofiltration (HF).

In both groups we noted an increase in the UF capacity of PM when their dry BW was obtained either by pharmacological or technical approach.

These results support the assumption that the overhydration status of the PM plays a major role in maintaining the UF process.

Spontaneous Plasma Exchange by Gravity

Lysagth et al have reported a semplified model of spontaneous plasmapheresis by placing between an A-V shunt a conventional plasmafilter. On the basis of this experience we tried to make a further semplification of this apparatus using a single venous puncture, obtaining by gravity sufficient transmembrane pressure for plasma separation. By alternatively lowering and elevating the system, plasma is separated from the blood and packed red cells are reinfused after a new pass through the filter with FFP or plasma substitutes.

Determinants of virtual water flows in the Mediterranean

The aim of the paper is to investigate the main determinants of the bilateral virtual water (water used in the production of a commodity or service) flows associated with international trade in agricultural goods across the Mediterranean basin. We consider the bilateral gross flows of virtual water in the area and study what export-specific and import-specific factors are significantly associated with virtual water flows. We follow a sequential approach. Through a gravity model of trade, we obtain a "refined" version of the variable we aim to explain, one that is free of the amount of flows due to pair-specific factors affecting bilateral trade flows and that fully reflects the impact of country-specific determinants of virtual water trade. A number of country-specific potential explanatory variables, ranging from water endowments to trade barriers, from per capita GDP to irrigation prices, is presented and tested. To identify the variables that help to explain the bilateral flows of virtual water, we adopt a model selection procedure based on model averaging. Our findings confirm one of the main controversial results in the literature: larger water endowments do not necessarily lead to a larger 'export' of virtual water, as one could expect. We also find some evidence that higher water irrigation prices reduce (increase) virtual water 'exports' ('imports').

A phase II study on the efficacy and safety of procedural analgesia with fentanyl buccal tablet in cancer patients for the placement of indwelling central venous access systems

Background

Pain in cancer patients is often related to oncologic therapies and diagnostic procedures. The placement of fully implantable venous access systems is a very common procedure in oncology patients. Local anaesthesia is the method most commonly used to overcome pain related to this surgical procedure, but the local anaesthetic may be unable to completely eradicate all pain. This study investigates the effectiveness and safety of fentanyl buccal tablet (FBT), administered by OraVescent® technology, in reducing procedural pain related to the placement of indwelling central venous access systems (Ports) in opioid-naïve cancer patients.

Methods

Inpatients who required an indwelling vascular access (Port) were preoperatively assessed with a self-assessment questionnaire on anxiety and pain. A 100 μg FBT was administered 10 min before preparation of the operating field. A self-assessment scale for pain experienced during the procedure was administered at the end of the procedure. Vital signs and the presence of any side effects or bothersome symptoms were monitored during the procedure, at the end, and 4 h later.

Results

From October 2012 to June 2014, 65 patients were enrolled in the study. A total of 61 (93.9 %) patients perceived no or a little pain during the procedure. Four patients (6.2 %) reported a lot of pain. No patient reported very severe pain. This data is significant in terms of the lower than expected presence of pain (Fisher test p = 0.0018) as assessed in our previous experience without procedural analgesia. The most common side effects of FBT was drowsiness, experienced by 28 patients at the end of the procedure (43.1 %), significantly reduced (p < 0.01) to 8 patients after 4 h (12.5 %). Nausea was present in 6 cases at the end of the procedure (9.2 %) and in 7 cases 4 h later (10.9 %). Vomiting was present in 3 cases at the end (4.7 %) and in 2 other patients after 4 h (7.8 %). No significant change of vital parameters was observed between the baseline and the subsequent measurements in all patients studied.

Conclusions

The significant improvement in the number of patients experiencing little or no pain, accompanied by a lower number of non-severe side effects, suggests that FBT is a valid, practical and safe method of procedural analgesia. It will be necessary to perform further studies, taking into account the need for standard antiemetic pre-medication to minimise the incidence of nausea and vomiting.

The refusal of food in childhood: From our clinical experience to an evaluation of recent diagnostic classifications

The aim of this study, which was carried out because of the importance of eating disorders (EDs) acquired by the young and the need to organise resources and interventions for patients and their families, was to quantify the increased incidence of EDs arising early in life in order to identify the nosographic classification that best reflects the complexity of the symptoms. Between 2003 and 2008, we assessed 128 subjects aged less than 14 years and observed a constant increase in ED-related problems. Our analysis shows the importance of representative classification criteria suitable for young patients in order to improve diagnosis and therapeutic planning. The need for a specific classification for early childhood is underlined by the fact that comorbidities and overlapping patterns often complicate adequate assessment.

Online Convective Therapies: Results from a Hemofiltration Trial

With the introduction of the on-line preparation of dialysis fluids, the hemofiltration technique, which has never had a widespread diffusion in its old version with the infusion bags, has gained a new interest. We planned a prospective, randomized, 3-year-long study comparing survival and morbidity in ultrapure bicarbonate dialysis (BD) with on-line predilution hemofiltration (HF). Since comorbidity is one of the main factors limiting survival, the study was addressed to patients with a severe degree of comorbidity. The paper presents the preliminary results of the trial. Sixty-four patients were enrolled and randomized to either BD (N = 32) or HF (N = 32). Mean age and dialysis vintage were comparable. Twenty patients died during the study, 12 in BD and 8 in HF. The relative risk of death was 11% higher in patients treated with BD compared to those in the HF group (p < 0.005). The number of hospitalisation events per single patient was lower, even though not significantly, in HF compared to BD (1.94 + 1.26 in HF vs 2.48 + 1.98 in BD, p = NS). As concerns biochemistry, apart from beta-2-microglobulin, any other substantial difference was not found during the study, though the small solute concentration was generally a little more elevated in HF than in BD. Dialysis hypotension showed a trend to decrease in both the dialysis modalities up to near half of the trial, then, during the last year, it remained quite stable in HF, while, on the contrary, it increased in the BD group. By the end of the protocol, patients in HF showed a 2.5% incidence of acute dialysis hypotension, while patients in BD had 23%.

Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions

BACKGROUND

The success of the neurolytic celiac plexus block, despite different approaches and methods used, depends on adequate spread of the injectate in the celiac area. This retrospective study was conducted to evaluate the patterns of alcohol spread and pain relief in patients with cancer or therapy-related anatomic distortion of the celiac area.

METHODS

From 177 cancer patients who underwent computed tomography (CT)-guided single-needle neurolytic celiac plexus block via an anterior approach, a radiologist, blind to the aim of the study, retrospectively selected 105 patients with abnormal anatomy of the celiac area as judged by CT images obtained before the block. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Results were expressed as the number of quadrants into which contrast spread, ie., four, three, two, or one quadrants with contrast. The patterns of contrast spread according to the number of quadrants with anatomic distortion were analyzed. Patient assessment by visual analog scale was reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was considered long-lasting. Pain relief at 30 days after block was analyzed according to the number of quadrants with contrast.

RESULTS

Overall, four, three, two, and one quadrants with contrast were observed in 9 (8%), 21 (20%), 49 (47%), and 26 (25%) patients, respectively. An inverse correlation was observed between the number of quadrants with anatomic distortion and the number of quadrants with contrast (P < 0.001). Long-lasting pain relief was noticed in nine of nine patients (100%; 95% confidence interval, 66-100) with contrast in four-quadrants, and in 10 of 21 patients (48%; 95% confidence interval, 26-70) with contrast in 3 quadrants (P < 0.01). None of the 75 patients with contrast in two quadrants or one quadrant experienced long-lasting pain relief.

CONCLUSIONS

These findings suggest that, using the single-needle anterior approach, the neurolytic spread in the celiac area is highly hampered by the regional anatomic alterations. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia, and that this picture may be obtained in a very limited fraction of patients with regional anatomic alterations.

Pharmacokinetic and pharmacodynamic effects of high-dose continuous intravenous verapamil infusion: clinical experience in the intensive care unit

OBJECTIVE

Our study aimed at evaluating the pharmacokinetic, cardiovascular, and metabolic effects of high-dose verapamil continuous intravenous infusion in cancer patients.

DESIGN

Prospective clinical and pharmacokinetic study.

SETTING

Intensive care unit of a Cancer Research Institute.

PATIENTS

Nine patients (age range 31 to 57 yrs) with progressive cancer disease and without cardiovascular, renal, or hepatic dysfunctions.

INTERVENTIONS

After a loading dose (0.15 mg/kg followed by 12 hrs of continuous intravenous infusion at 0.20 mg/kg/hr), the infusion rate of verapamil was increased every 24 hrs (0.25, 0.30, 0.35, and 0.40 mg/kg/hr). The highest rate was maintained for 48 hrs. Doxorubicin was given from the 60 th to the 108 th hr. Hydrochlorothiazide (25 mg/day) and potassium (36 mmol/day) were given orally. Altogether, 17 courses were completed.

MEASUREMENTS AND MAIN RESULTS

Steady state concentration (C(SS) and systemic clearance of verapamil and nor-verapamil (active metabolite) for each infusion rate were calculated. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), PR, QT and QTc intervals, and left ventricular ejection fraction (LVEF) were measured, as well as daily body weight, blood glucose and potassium. C(SS) of verapamil and nor-verapamil increased more than proportionally to the infusion rate (p<.001). Systemic clearance of verapamil decreased over the range of the infusion rate (p<.005). MAP and HR decreased at the 12th hr (p<.001) and then plateaued. CVP increased (p<.01). The relationship between MAP, HR, CVP, and verapamil plasma concentrations was significant (r2 = .25, .14, and .35, respectively; p<.0001). LVEF did not change. Six patients (11 courses) developed junctional rhythm. Three patients (six courses) showed a PR interval increase (p<.05). Patients with junctional rhythm had higher Css of verapamil (p<.009). Overall, QT and QTc intervals increased (p<.01). A linear relationship was observed between verapamil plasma concentrations and QT intervals (r2 = .09, p<.01). Cardiovascular side effects did not determine treatment withdrawal in any patient. Body weight, blood glucose, and potassium did not show significant changes.

CONCLUSIONS

Our data suggest a capacity-limited clearance of high-dose verapamil. In the absence of heart disease, following a step by step increase of the dosage, the high plasma verapamil concentrations (617 to 2970 ng/mL) produce frequent but well tolerated hemodynamic and electrocardiogram changes.

Glycosaminoglycans prevent the functional and morphological peritoneal derangement in an experimental model of peritoneal fibrosis

Chronic peritoneal dialysis results in fibrosis of the peritoneal membrane, which leads to progressive reduction in dialytic efficacy. It was recently shown that the intraperitoneal administration of glycosaminoglycans (GAGs) improves the efficiency of peritoneal dialysis in CAPD patients. To verify whether the favorable effects of GAGs are purely functional or involve a morphological amelioration of the peritoneal membrane structure, a study was carried out in an animal model of plasticizer-induced peritoneal fibrosis. Rats, in which chronic renal failure had been induced by subtotal nephrectomy, received either placebo, plasticizers (i.p.), or GAGs (s.c.), or plasticizers (i.p.) and GAGs (s.c.). Urea dialysate-to-plasma equilibrium, urea and albumin peritoneal clearance, and glucose reabsorption were determined. The peritoneal membrane was evaluated morphometrically and histologically. In plasticizer-treated animals, peritoneal function tests and morphology were dramatically deranged. On the contrary, the subcutaneous administration of GAGs in plasticizer-treated rats maintained the peritoneal physiology and normal structure. The subcutaneous administration of GAGs protects peritoneal functions by affecting the remodeling of the peritoneum, rather than by a purely functional or simple mechanical effect.

Single-needle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions?

BACKGROUND

The "single-needle" celiac plexus block is becoming a popular technique. Despite different approaches and methods used to place the needle, the success of the block depends on adequate spread of the injectate in the celiac area. In the present retrospective study, the influence of needle tip position in relation to the celiac artery on injectate spread was evaluated.

METHODS

Among 138 cancer patients subjected, via an anterior approach, to computed tomography (CT)-guided single-needle neurolytic celiac plexus block, a radiologist, blinded to the aim of the study, retrospectively selected 53 cases with normal anatomy of the celiac area as judged by CT. The decision was based on images obtained before the block. Patients were then classified into either group A (29 patients), in whom the needle tip was caudad to the celiac artery, and group B (24 patients), in whom it was cephalad. To evaluate CT patterns of neurolytic (mixed with contrast) spread, the celiac area was divided on the frontal plane into four quadrants: upper right and left and lower right and left, as related to the celiac artery. Patient assessments by visual analog scale were reviewed to evaluate the degree of pain relief. Pain relief 30 days after block was judged as long-lasting. The patterns of contrast spread in relation to the needle position and pain relief according to the number of quadrants with contrast were analyzed.

RESULTS

The percentage of cases with four quadrants with contrast was higher when the needle tip was cephalad (58%, group B) than when it was caudad (14%, group A) to the celiac artery (P < 0.01). The percentage of patients with four and three quadrants with contrast was also higher in group B at 79% than in group A at 38% (P < 0.01). A significant difference in long-lasting pain relief was observed between patients with four quadrants with contrast (18 of 18, 100%; 95% confidence interval [CI], 81-100%) and patients with three quadrants with contrast (5 of 12, 42%; 95% CI, 15-72%) (P < 0.01). No patients showing two or one quadrant with contrast had long-lasting pain relief.

CONCLUSIONS

These findings suggest that, when the celiac area is free from anatomic distortions, and the single-needle neurolytic celiac plexus block technique is used, the needle tip should be positioned cephalad to the celiac artery to achieve a wider neurolytic spread. It also appears that only a complete (four quadrants) neurolytic spread in the celiac area can guarantee long-lasting analgesia.

Low-dosage ibopamine treatment in progressive renal failure: a long-term multicentre trial

A multicentre trial (11 nephrology centres) was carried out to test the effects of ibopamine, an orally active dopamine-like drug, on the progression of chronic renal failure. For a 2-year period 189 chronic renal failure patients (serum creatinine level 1.5-4.0 mg/dl) were observed. They were homogeneous for basic nephropathy, degree of residual renal function, blood pressure, and proteinuria. The patients were randomly divided into two groups: 96 took ibopamine at a dosage of 100 mg/day (group A) and 93 served as controls (group B). All were on a low-protein diet (mean 0.8 g/kg body weight). By the end of the observation period, the rate of decrease of the renal function indexes in time proved significantly slower (1.8 times) in group A than in group B. The survival curves for renal function (pre-established end points were creatinine level increases equal to or > 20% and equal to or > 40% of the basal values) proved significantly better (p < 0.02 and p < 0.002 respectively) in group A than in group B. The mean plasma creatinine values rose by 17% in group A and by 36% in group B. The creatinine clearance decreased by 5% in treated patients and by 14% in the controls. Statistical analysis ruled out any possible centre effect. The trial suggests that low-dosage ibopamine administration may be used as a valid and safe pharmacological adjunct for retarding the progression of renal failure in patients with mild or moderate chronic renal impairment.

Nonsteroidal antiinflammatory drugs for cancer pain: comparison between misoprostol and ranitidine in prevention of upper gastrointestinal damage

PURPOSE

The prophylactic strategy of nonsteroidal antiinflammatory drug (NSAID)-induced upper gastrointestinal (UGI) damage has largely been studied in arthritic patients, but not in cancer patients. The efficacy of misoprostol and ranitidine in the prevention of gastroduodenal damage in patients taking diclofenac for their cancer pain has been compared in this study.

PATIENTS AND METHODS

Patients who needed high-dose (200 to 300 mg/d) diclofenac for cancer pain and without mucosal lesions at baseline gastroduodenal endoscopy were randomized to receive misoprostol (200 micrograms twice daily; M group) or ranitidine (150 mg twice daily; R group). UGI endoscopy was repeated after 4 weeks.

RESULTS

Twenty-three patients treated with misoprostol and 26 treated with ranitidine concluded the study. The M group showed a significantly (P < .02) lower incidence of gastroduodenal lesions (two patients; 8.7%) than the R group (10 patients; 38.5%). Gastric ulcers occurred in one (4%) misoprostol-treated patient and in six (23%) ranitidine-treated patients. Six of seven patients with ulcers were asymptomatic. Seventy-one percent and 86% of ulcers occurred in patients older than 60 years and in those who received greater than 3.1 mg/kg of diclofenac, respectively.

CONCLUSION

Misoprostol was significantly more effective than ranitidine in the prevention of gastroduodenal lesions in cancer patients receiving diclofenac.

Use of glycosaminoglycans to increase efficiency of long-term continuous peritoneal dialysis

Long-term continuous ambulatory peritoneal dialysis (CAPD) frequently induces progressive structural changes in the peritoneal membrane, leading to dialysis failure. Because heparin and glycosaminoglycans favourably remodel anatomical barriers exposed to injury, we studied the effect of intraperitoneal administration of glycosaminoglycans on peritoneal dialysis efficiency. 16 CAPD patients received glycosaminoglycans for 30 days followed by a 30-day wash-out. Glycosaminoglycans in urea and creatinine dialysate-to-plasma ratios significantly increased (means 0.86 and 0.78 at baseline, 0.92 and 0.82 at 30 days, respectively). Peritoneal protein loss was reduced, and serum albumin concentration increased. We now need to assess whether glycosaminoglycans can postpone dialysis failure in the long term.

Aortic valve prosthesis and late survival of successfully repaired type A dissection

Seventy-two operative survivors of acute type A dissection between 1973 and 1993 had a complete follow up with a 16 years actuarial survival of 57% and a reoperation free actuarial survival of 34%. Follow up was 100% complete and covered a total of 500.6 patients-years with a median of seven years. Distal tear location (proximal, medium or distal aortic arch) with retrograde dissection toward the aortic valve was the single most important predictor of late mortality with a relative risk of 4.4 (70%CL 2.4-8.2) (p = 0.016). Mortality rate of patients with an aortic valve prosthesis was 6.2%/patient-year vs. 1.7/patient-year without aortic valve prosthesis, with a relative risk of 3.4 (70%CL 2.0-5.8) (p = 0.02). This finding could be due to confounding of variables related both to death and need of aortic valve replacement. Therefore a multivariate proportional hazard analysis, with mandatory inclusion of possible confounders, was done. It showed that patients with aortic valvular prosthesis had eight times higher risk (70% CL 2.7-24.2); prosthetic aortic valves and conservative aortic root procedures had an unconfounded relative risk of 14 times higher (70%CL 3.4-58.7) (P = 0.06), whereas patients with a composite conduit had a six times higher risk (70%CL 2.0-19.9) (p = 0.11). These findings support the attitude favoring a selective approach to aortic root repair and oppose standardized use of aortic valve prosthesis or composite conduit in acute type A dissection.

Antithrombin III deficiency as a risk factor for catheter-related central vein thrombosis in cancer patients

The fibrin sleeve of venous catheters (VC) and parietal thrombi represent frequent and dangerous side-effects of central venous catheterization (CVC), due to the risk of embolism. Reduced levels of coagulation clotting factors inhibitors (such as Antithrombin III) are known to be associated with increased thrombogenic risk. The aim of this study was to evaluate the role of Antithrombin III (AT III) deficiency as a risk factor for thrombosis in cancer patients undergoing CVC. The study groups included patients with a reduced AT III activity (< 70%, 20 consecutive patients) and with normal AT III values (> 70%, 20 randomly selected patients), requiring a VC for chemotherapy and/or total parenteral nutrition. The study protocol included evaluation of Hb, PLTs, PT (INR), aPTT, Fibrinogen and AT III at days 0, 1, 3 and 8 after CVC and upon VC removal. Peripheral and pullout phlebographies were performed in all patients on catheter withdrawal. A quantitative scale was developed to evaluate both VC and parietal thrombus degree in each catheter-containing venous segment (subclavian, innominate, superior vena cava); the sum of the mean values was defined as overall thrombus. The average VC dwelling time was similar in both groups. There were no significant differences in Hb, PLTs, PT (INR), aPTT, Fibrinogen and in the remaining parameters of the study between the two groups. The group with AT III deficiency presented a higher degree of both parietal (p < 0.05) and overall thrombus (p < 0.02). Data showed a higher severity of CVC-related thrombosis in patients with AT III deficiency than in the control group. Further studies are needed to evaluate whether the therapeutically-induced normalization of AT III levels can reduce the thrombosis degree.

Emergency surgical treatment of ruptured incompetent mitral valve after percutaneous valvuloplasty

Of 263 consecutive patients undergoing mitral balloon valvulotomy at the Cardiac Catheterization Unit of Padua University Hospital, six (2.3%) required surgical treatment within 24 hours. The indication for surgery was unstable hemodynamic status due to acute mitral insufficiency caused by the percutaneous balloon valvulotomy. The purpose of this study was to evaluate whether the failure of percutaneous mitral balloon valvulotomy, in this subset of patients, was related to technical problems or was the direct consequence of unfavourable pathologic conditions. Additionally, we evaluated the operative results and clinical outcome of these six patients. The patients were all female with a mean age of 55.7 +/- 14 years (range 38-75 years). Previous surgical commissurotomy was performed in three. The anatomical lesions responsible for the massive regurgitation were tear of the anterior leaflet in two patients and tear of the posterior leaflet in four; rupture of the papillary muscle and/or chordae tendineae were present in five. All patients underwent mitral valve replacement. The elapsed time between the onset of mitral regurgitation and surgery ranged from two to 24 hours (mean 10 +/- 11 hours). There were two hospital deaths (33.3 +/- 21.1%): all surviving patients are alive and clinically well. In conclusion, massive mitral regurgitation following percutaneous mitral dilatation appears to be related to unfavourable pathology of the mitral valve rather than to technical errors. Therefore, careful patient selection is mandatory in order to achieve optimal results. In our experience, adequate and aggressive medical therapy provided sufficient time to prepare for the surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Discrete subaortic stenosis. Operative age and gradient as predictors of late aortic valve incompetence

Between January 1969 and May 1990, 100 patients were operated on for discrete subaortic stenosis. Three patients died in the perioperative period. Patients with intrinsic lesions, prosthetic replacement, or extensive operative remodeling of the aortic valve were excluded from the analysis. The 67 remaining patients had a median follow-up of 62 months. Preoperatively, 8 patients had aortic valve competence, 51 had mild incompetence, and 8 patients moderate aortic valve incompetence. At follow-up mild incompetence persisted in 27 and moderate incompetence in 6 patients. In 1 patient it worsened from no incompetence to mild and in another patient from mild to moderate. The probability of aortic incompetence at follow-up was significantly and simultaneously related (multivariate ordinal logistic model) to (1) older age at operation (logarithm of months, p = 0.007), (2) higher preoperative gradient (third power of milligrams of mercury, p = 0.0004), (3) preoperative cardiomegaly (p = 0.04), and (4) surgical myectomy (p = 0.002). There was an interaction between age and gradient (p = 0.03). Two nomograms are proposed as a generalizable aid to decision making. The data support the policy of early repair of subaortic stenosis.

Combined hemodialysis-hemoperfusion in the treatment of secondary hyperparathyroidism of uremic patients

Hyperparathyroidism and its related symptoms such as bone pain, soft-tissue calcifications and pruritus often get worse during dialysis treatment. We have treated 12 cases among 170 patients on regular dialysis by using coated charcoal (150 g/cartridge) in combination with standard hemodialysis. During a 6-month treatment period, without changing medical therapy and diet regime, the patients reported a marked relief from pruritus. Parathyroid hormone (PTH) levels changed from 552 +/- 86 to 364 +/- 62 pg/ml (p less than 0.001) compared to the pretreatment period, Plasma PO4(3-) changed in the same period from 6.9 +/- 1.8 to 4.6 +/- 1.5 mg/dl (p less than 0.005). The results obtained indicate a relationship between PTH, serum plasma PO4(3-) levels and pruritus. The mechanism which may be involved is that hemoperfusion removes PTH excess by absorption. Our treatment reducing PTH levels resulted in a marked relief from pruritus and other symptoms, suggesting that patients in this condition, before undergoing surgical parathyroidectomy, may be usefully treated with this therapeutic modality.

Mitral valve disruption following percutaneous balloon valvuloplasty

Two cases of massive mitral regurgitation due to mitral valve disruption following percutaneous balloon valvuloplasty are reported. This severe complication occurred in two elderly women with recurrent mitral stenosis after previous surgical commissurotomy. Due to their unstable hemodynamic and clinical condition, both patients underwent emergency valve replacement. At surgery, the commissures appeared fused and heavily calcified; the chordae tendineae thickened, shortened, and fused; and the leaflets presented a large tear with sheared edges. Because the technical aspects of both procedures were unremarkable, the anatomic features of the mitral valve seemed to affect the occurrence of severe mitral regurgitation. Percutaneous balloon valvuloplasty should be therefore applied carefully to patients with prior surgical valvotomy, in whom the structural alterations of the mitral apparatus may predispose to severe valvular damage.

[Morphine in the inferior cerebellar cisterna for oncologic pain in the ORL area]

The study aimed to assess whether the infusion of microdoses of morphine in the cisterna magna, close to the sensitive nuclei of the cranial nerves (V-VII-IX-X) involved in painful syndromes of the head and neck, is able to control severe oncological pain in this region which does not respond to traditional pain killing treatment or neurolesive practices. Cisternal catheters were inserted in eight patients with cancer of the head and neck. The intensity of pain was assessed using VAS and the quality of analgesia obtained using cisternal morphine was judged to be: excellent, good, inadequate or null. Treatment lasted a mean of 121 days. Good or excellent analgesia was achieved in 7 patients using a mean daily dose of 1.5 mg morphine during the initial stage and 4.8 mg during the final stage; in one patient with a large component of "deafferent pain", good pain relief was obtained by associating cisternal morphine with chlorimipramin per os. The side-effects observed were almost always short-term and easily resolved. Morphine treatment was begun in the hospital and in all cases continued at home. This efficacious pain killing method should be given adequate attention in the global strategies used to treat oncological pain in the head and neck region.

On-line bioelectric impedance during haemodialysis: monitoring of body fluids and cell membrane status

We have measured by a computed integrated system (BIA 109, RJL AKERN) the changes of bio-impedance (BI) deriving from a tetrapolar system working on 800 microA, 50 kHz current, in 23 haemodialysed patients. Resistance (R) and reactance (Xc) have been continuously monitored during haemodialysis in each patient. Resistance was strictly inversely correlated to the decrease of body weight (r = 0.82). Also, Xc increased almost constantly. In most of the patients the increase of Xc was proportionally greater than R, resulting in an increase of phase angle (PA). However, Xc showed a transient decrease in response to seven severe symptomatic hypotensive episodes, whereas R maintained the increasing trend, causing a sharp reduction of phase angle. As Xc is an expression of storage of electrical charge by the cells acting as condensers, and phase angle quantifies the active capacitive component in relation to passive electrical resistance, these parameters may be important to evaluate cell membrane function. In fact, the univocal increase of R, Xc and phase angle observed during normal unevenful haemodialysis probably indicates improvement of cellular activities due to the depurative treatment. On the contrary, the transient reduction of Xc and phase angle observed during hypotensive crises may be an expression of cellular distress because of a too rapid ultrafiltration.

Early and late survival of repaired type A aortic dissection

From 1 January 1977 to 31 December 1988, 119 patients were operated upon for type A aortic dissection. The maximum follow-up was 11.7 years (median 5.6 years); follow-up was 100% complete. Actuarial survival was 47.3% +/- 5%. The death risk decreased rapidly to a constant rate of 0.0027 events/month after 3 months. There were 41 early deaths, mostly due to haemorrhage, brain damage and low output syndrome. A significantly higher probability of early death was observed in patients with preoperative myocardial ischaemia or infarction (P less than 0.0001) or preoperative cerebral symptoms (P = 0.0002). Extended dissection increased the risk proportionally to the length of the aorta involved (P = 0.0002). Typical dissection originating from an intimal tear in the ascending aorta had a significantly lower operative risk than atypical dissection with an intimal tear not localized in the aortic root (P = 0.0006). Of the 14 late deaths, 2 were unrelated to dissection, 2 were of unknown origin and 4 were sudden. Stroke was the cause of 2 and congestive heart failure the cause of 4 deaths. The probability of late death was higher in patients with perioperative brain damage (P = 0.003) and in patients with preoperative shock (P = 0.0025). It was significantly lower in patients with dissection of hypertensive aetiology (P = 0.002). There were 13 reoperations on 12 patients. Early reoperations were due to rupture of the distal aortic anastomosis. Late reoperations were mostly due to dehiscence of aortic valvular prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Source and route of microbial colonisation of parenteral nutrition catheters

To assess the effectiveness of tunnelling the polyurethane venous catheter for parenteral nutrition in reducing the frequency of catheter microbial colonisation, and to investigate the routes taken by microorganisms colonising the central venous catheter, 109 patients were randomised to traditional subclavian catheterisation (58, group A) or to subcutaneous catheter tunnelling (51, group B). Samples were taken from patients and their nurse attendants to identify their indigenous flora. Cultures were also done of swabs from the catheter insertion site, blood, nutrient solution, segment of the catheter, and washings of the catheter hub. Intravascular segment colonisation was commoner in group A (18/58) than in group B patients (4/51), and bacterial migration from insertion site to intravascular segment was also commoner among group A (9/58) than among group B patients (1/51). Catheter hub contamination was responsible in 10 out of 22 cases of microbial colonisation; in 6 of these 10 the bacterium isolated was present on the skin of nurses who changed the bag. Contamination of the insertion site skin and of the CVC hub were equally responsible for the microbial colonisation of the intravenous segment of the catheter.

Effect of phthalate acid esters on transport in toad bladder membrane

Sclerosing peritonitis is a serious complication in patients on long-term peritoneal dialysis; it markedly decreases transport of water and solute across the peritoneal membrane. Although the precise mechanism is unknown, organic compounds (i.e., plasticizers) from plastic tubing and dialysis bags have been suggested to be a cause of the syndrome. The effects of three such compounds on water and sodium transport in vitro were studied in the toad bladder. The compounds studied were didodecylphthalate, dioctylphthalate, and benzylbutylphthalate. After 4 hr incubation in vitro, dioctylphthalate and benzylbutylphthalate significantly inhibited vasopressin-stimulated water flow in toad bladder. Basal water flow was not affected by any of the three compounds. Sodium transport, as measured using short-circuit current, was decreased to an equivalent degree by all compounds; inhibition of short-circuit current was dose dependent and was approximately 30% at 10(-3) M. The onset of action was between 3.5 and 4 hr, and the effect on short-circuit current was not reversible. These results demonstrate that the plasticizers (to which patients of all sorts are commonly exposed) inhibit transport across living membranes. In the toad bladder these compounds decrease sodium transport and maximal water flow. Although other evidence suggests that the cumulative toxic effects of these compounds may play a causal role in sclerosing peritonitis in patients on peritoneal dialysis, our study suggests that chronic exposure to the phthalate acid esters in patients with normal renal function may result in sodium wastage, polyuria, and a concentrating defect resistant to AVP.

[Results of emergency aortocoronary bypass in complicated coronary angioplasty]

Sixteen out of 293 (5.4%) procedures for percutaneous transluminal coronary angioplasty, performed between 1985 and 1988, were complicated by acute closure and required emergency revascularization surgery. The injured vessel was the left anterior descending artery in 14 cases and the right coronary artery in 2 cases. All patients had persistent chest pain associated with ST-segment elevation in 14 cases and ST-segment depression in 2 cases. Two patients developed cardiogenic shock and were in cardiac arrest at the beginning of operation; one of these died immediately after the operation. Thus the overall mortality rate was 6.2%. Enzyme evidence of myocardial infarction (CPK-MB greater than 40 UI/I) occurred postoperatively in 8 patients (50%), but only the 6 patients (37.5%) with electrocardiographic evidence of myocardial necrosis (new Q-waves or loss of R-wave voltage) showed akinesis of the myocardium perfused by the occluded vessel at the echocardiographic examination performed two weeks after the operation. The occurrence of myocardial infarction was correlated with the degree of preoperative ischemia and hemodynamic deterioration. A collateral flow was present in 3 cases and none of these showed evidence of myocardial necrosis after the operation. Our results show that emergency bypass surgery for failed coronary angioplasty is less satisfactory than elective surgery, and has a higher mortality and myocardial infarction rate. Thus, the risk of emergency operation for complicated dilation must be considered when selecting of candidates for coronary angioplasty.

Tricuspid atresia versus other complex lesions. Comparison of results with a modified Fontan procedure

Several modifications of the Fontan principle are currently applied to the treatment of tricuspid atresia with low mortality. The use of these modifications in other malformations has most frequently been associated with less satisfactory results. At our institution, from June 1977 to October 1986, 35 consecutive patients, whose ages ranged from 8 months to 20 years (median age 3.4 years), underwent a modified Fontan procedure. Twenty patients with a median age of 3.2 years (group I) having tricuspid atresia (16 patients) or hypoplastic right heart syndrome (four patients) were treated by means of a right atrium-pulmonary artery anastomosis (12 patients) or right atrium-subpulmonary chamber connection (eight patients). Fifteen patients (group II) with a median age of 3.6 years, having a single left ventricle (10 patients), left atrioventricular valve hypoplasia or atresia (three patients), or double-outlet right ventricle (two patients), underwent right atrium-pulmonary artery anastomosis, together with a repositioning of the atrial septum to the right of the right atrioventricular valve, which thus left intact the inlet to the ventricle(s). The operative mortality rate was 25% in group I and 0% in group II. One patient in group I and one in group II died late postoperatively. All the 28 survivors are free of symptoms 3 months to 9 years after correction. According to our results, low risk can be associated with modified Fontan procedures in the treatment of complex heart malformations other than tricuspid or pulmonary atresia. Preserving the integrity of the entire inlet to the ventricle(s) by repositioning the interatrial septum, as done in group II malformations, might be helpful in improving the quality of the repair.

Determinants of late survival of 105 patients operated for dissection of the aorta

In the surgery of aortic dissection, only a small section of aorta compared to the extent of the aortic damage, is usually replaced. The disease is not cured by surgery and needs continuous postoperative surveillance and medical therapy. We report the follow-up of 105 patients who were operated upon between January 1970 and April 1986 and discharged from hospital. Overall actuarial survival was 90% at 5 years, 52% at 10 years and 39% at 15 years. There were 20 deaths, mostly (85%) related to cardiovascular causes. Survival times were correlated, using multivariate methods, with several pre-, peri- and postoperative variables to identify significant risk factors and to calculate actuarial survivals. We found that postoperative low output syndrome (p = 0.007) and stroke (p = 0.04) adversely affected survival and that previous aortic disease or operation (p = 0.004) was associated with an increased rate of dissection-related complications. On the contrary, preoperative hypertension was related to a significantly better survival (p = 0.01) and survival free of dissection-related complications (p = 0.001). When dissection was related to hypertension, adequate postoperative medical treatment neutralized the progression of the aortic damage and its consequences. When dissection was not due to hypertension, the observed survival was unsatisfactory, probably because of a more fragile aorta and inadequate medical follow-up therapy.

Removal of phosphate (Pi) by either bicarbonate dialysis or biofiltration in uremics

The kinetics of extra and intracellular red blood cell (RBC) Pi and its removal by different therapeutic modalities were evaluated in 30 uremic patients over a 6 mo. period. Acetate hemodialysis alone, combined with hemoperfusion, or associated once a week with plasma-perfusion sessions using an activated bauxite cartridge, bicarbonate dialysis either in single pass or in recirculating system (40 L) and biofiltration, were the depurative treatments employed. The treatments with acetate buffer showed a temporary intracellular shift of Pi at the end of the sessions with post-dialytic plasma Pi rebound. This was not evident with bicarbonate buffer and biofiltration where acidosis was corrected better, and similarly during plasma perfusion treatment because blood pH remained unchanged. These findings may explain the better plasma Pi level at the end of our study with these later therapeutic models compared to acetate dialysis alone or combined with hemoperfusion. In these conditions Pi removal is limited by the correction of acidosis which implies acetate metabolism with ATP activation leading to a transient Pi intracellular influx and a subsequent efflux into the extracellular compartment.