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Biomedical subjects

A Gallino

Publications and source records attributed to A Gallino.

At least 19 recordsLinked to original sources
PubMed2005

Venous thromboembolism prophylaxis in acutely ill medical patients: definite need for improvement.

AIM OF THE STUDY: To examine the frequency and adequacy of thromboprophylaxis in acutely ill medical patients hospitalized in eight Swiss medical hospitals. METHODS: A cross-sectional study of 1372 patients from eight Swiss hospitals was carried out. After exclusion of patients (275) given therapeutic anticoagulation, 1097 patients were audited. The adequacy of thromboprophylaxis was assessed by comparison with predefined explicit criteria. RESULTS: Of 1097 patients, 542 (49.4%) received thromboprophylaxis. According to the explicit criteria, 644 (58.7%) should have been on prophylaxis (P < 0.001, when compared with the rate observed). The rate of prevention differed widely between hospitals (from 29.4 to 88.6%) with no difference between teaching and nonteaching hospitals. According to the explicit criteria, a substantial proportion (44.9%) of the patients who should have been treated were not. Conversely, 41.3% of the patients were unnecessarily treated. CONCLUSIONS: Even though the appropriateness of the explicit criteria used could be challenged, our data suggest that the current practice is associated with important uncertainty leading to both overuse and underuse of thromboprophylaxis in patients hospitalized in medical wards. More efforts are urgently needed to develop new or endorse existing explicit, evidence-based criteria and guidelines for thromboprophylaxis in this population of patients.

Acute Disease↗
PubMed2004

Extrahepatic arterioportal fistula: three-dimensional reconstruction of computerized tomodensitometric scan for diagnosis and morphologic assessment.

Arterioportal fistulae (APFs) are rare. An asymptomatic APF was suspected by computed tomography. Multiplanar, maximum intensity projection, and surface shaded display reconstructions showed its anatomy. To our knowledge, this is the first report using such reconstructions to analyze the architecture of an extrahepatic APF. Complete assessment of APF can be achieved noninvasively, and initial endovascular treatment can be planned.

Arteriovenous Fistula↗
PubMed2003

Alloimmunity and nonimmunologic risk factors in cardiac allograft vasculopathy.

Graft vasculopathy is an accelerated form of coronary artery disease that occurs in transplanted hearts. Despite major advances in immunosuppression, the prevalence of the disease has remained substantially unchanged during the last two decades. According to the 'response to injury' paradigm, graft vasculopathy is the result of a continuous inflammatory response to tissue injury initiated by both alloantigen-dependent and independent stress responses. Experimental evidence suggests that these responses may become self-sustaining, as allograft re-transplantation into the donor strain at a later stage fails to prevent disease progression. Histological evidence of endothelitis and arteritis, in association with intima fibrosis and atherosclerosis, reflects the central role of alloimmunity and inflammation in the development of arterial lesions. Experimental results in gene-targeted mouse models indicate that cellular and humoral immune responses are both involved in the pathogenesis of graft vasculopathy. Circulating antibodies against donor endothelium are found in a significant number of patients, but their pathogenic role is still controversial. Alloantigen-independent factors include donor-transmitted coronary artery disease, surgical trauma, ischaemia-reperfusion injury, viral infections, hyperlipidaemia, hypertension, and glucose intolerance. Recent therapeutic advances include the use of novel immunosuppressive agents such as sirolimus (rapamycin), HMG-CoA reductase inhibitors, calcium channel blockers, and angiotensin converting enzyme inhibitors. Optimal treatment of cardiovascular risk factors remains of paramount importance.

Antibody Formation↗
PubMed2002

Telemedicine for cardiac surgery candidates.

BACKGROUND: Cardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms. METHODS: Coronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images. RESULTS: In 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P<0.01. CONCLUSION: Initial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located centers.

Cardiac Surgical Procedures↗
PubMed2002

Routine use of intravascular ultrasound for endovascular aneurysm repair: angiography is not necessary.

INTRODUCTION: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography. MATERIALS/METHODS: eighty consecutive patients (median age 69 years (range 25-90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference. RESULTS: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190 ml (range: 20-350) for angiography versus 0 ml for IVUS (p<0.01). Median X-ray exposure time 24 min (range 9-65 min) versus 8 min (range 0-60 min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures. CONCLUSIONS: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.

Adult↗
PubMed2000

Systematic, immediate in-hospital initiation of lipid-lowering drugs during acute coronary events improves lipid control.

Background: Patients who have had a coronary heart attack often go completely untreated for hypercholesterolemia. We investigated whether immediate initiation of lipid-lowering drugs during hospitalization for acute coronary events increases the proportion of correctly treated patients compared to referred treatment as recommended by current guidelines. Methods: This prospective, multicenter study randomized 57 hypercholesterolemic patients hospitalized for acute coronary events to immediate in-hospital initiation or to referred initiation of lipid-lowering drugs by primary care physicians 3 months after unsuccessful nutritional intervention. Results: After 6 months, 53 patients were available for follow-up. More patients in the immediate initiation group (26/30 patients, 87%) were treated with lipid-lowering drugs than in the referred initiation-group (13/23 patients, 57%, P=0.03). Twenty-seven patients (87%) in the immediate initiation group versus 17 patients (65%) in the referred initiation group had a 10% or greater decrease in total cholesterol or a 15% or greater decrease in LDL-cholesterol (P=0.18). Although statistically not significant, there was a trend to improved lipid values in the immediate initiation group compared to the referred initiation group (TC, -21.1 vs. -13.8% (P=0.08); LDL-C, -28.2 vs. -18.9% (P=0.13); HDL-C, +10.8 vs. +5% (P=0.44); TC/HDL-C ratio, -24.7 vs. -15.1% (P=0.22)), and the LDL-C/HDL-C ratio was -34.1 vs. -19.1% (P=0.04, P=NS after Bonferroni correction). Conclusion: The immediate initiation of lipid-lowering drugs in hypercholesterolemic patients hospitalized for acute coronary events increases the rate of correctly treated patients and has the potential to improve lipid control.

Journal Article↗
PubMed1999

[Treatment of endovascular aneurysms: the indications widen].

Recently, the material available for endovascular aneurysm repair (covered stents and application systems), real time medical imaging and operator experience have significantly improved. Hence, more and more complex vascular lesions, well beyond the original indications, can now be treated by endovascular surgery. Since 1996 our group has implanted 55 endovascular systems in the clinical setting: 45/55 (80%) for classical indications and 11/55 (20%) for extended indications. In the latter group four different endoprosthetic systems were used according to either their performance and availability or the type of lesion to be treated. For the 11 patients undergoing endovascular procedures with extended indications, 6/11 had thoracic aortic lesions (55%) and 5/11 (45%) had aorto-iliac lesions requiring either progressive embolisation of the internal iliac arteries or suprarenal anchorage. For these extended indications hospital mortality was 0/11 (0%). One patient died after hospital discharge. 1/11 patients (9%) had to be converted to open surgery during the interval between iliac embolisation and endovascular repair. There has been no conversion to open surgery during or after the endovascular procedures. Two major endoleaks were detected (2/11: 18%). One has been corrected by an additional covered stent and endovascular repair is planned for the other one. Spontaneously regressive functional hypoperfusion has been observed in 4/5 patients with progressive internal iliac embolisation. There was no irreversible renal insufficiency. Early results of endovascular aneurysm repair for extended indications are promising. Although the long-term outcome is unknown, it can already be said that traditional open surgery can be avoided for a considerable amount of time in an increasing number of patients.

Aneurysm↗
PubMed1999

The high-dose sequential (Milan) chemotherapy/PBSC transplantation regimen for patients with lymphoma is not cardiotoxic.

BACKGROUND: The high-dose sequential (HDS) regimen developed in Milan for high-grade lymphomas is very active, but its toxicities are still partly unknown. We evaluated prospectively by doppler-echocardiography the cardiotoxicity of this treatment. PATIENTS AND METHODS: Over seven weeks, 20 patients received a sequence of cyclophosphamide, methotrexate, etoposide, mitoxantrone and melphalan, each at its maximum tolerable dose, and the latter in conjunction with autologous peripheral stem-cell transplantation. Echocardiography was performed at baseline, before administration of mitoxantrone and 2, 6 and 12 months after transplantation. The following parameters of the left ventricular systolic and diastolic functions were determined: end diastolic (LVD) and end systolic (LVS) dimensions, the ejection fraction (EF), and the Doppler derived diastolic parameters: peak velocity of the early (E) and late (A) transmitral flow, the E:A ratio, deceleration time of the E wave (DT) and isovolumetric relaxation time (IVRT). A group of 20 normal volunteers served as control. RESULTS: At baseline, in comparison to controls, the patients had altered diastolic function (diminished E:A ratio) and, although still within the normal range, a slightly reduced systolic function (EF). During treatment or in the course of follow-up none of the patients showed clinical signs or symptoms of cardiac failure, nor significant changes of systolic or diastolic parameters, apart from a transient increase in the E:A ratio after the first three chemotherapy cycles (from 1.14 to 1.37, P < 0.05). The EF remained constant during, and up to six months after, transplantation, decreasing only slightly after one year (from 62% to 59%, P < 0.05). Using analysis of covariance we showed that the major determinants of baseline cardiac function and of its evolution over time were patient age and gender, with previous treatment with anthracyclines having a minor role. CONCLUSIONS: The HDS chemotherapy regimen produced no significant sign of cardiotoxicity up to one year after transplantation in patients with normal baseline cardiac function and no history of cardiac disease, pretreated with up to 550 mg/m2 of doxorubicin.

Adult↗
PubMed1998

Serious interaction between mibefradil and tacrolimus.

BACKGROUND/AIMS: Tacrolimus is metabolized by cytochrome P450 3A4 and 2D6 and has a narrow therapeutic range. We report a serious kinetic interaction between tacrolimus and mibefradil, a potent cytochrome P450 inhibitor. CASE REPORT: A 62-year-old women who had undergone liver transplantation was treated with tacrolimus for immunosuppression. For control of blood pressure, the patient was treated with nifedipine. She developed ankle edema, and nifedipine was replaced by mibefradil. Four days later, she presented with mental confusion, renal failure, and hyperglycemia, compatible with tacrolimus toxicity. In agreement with this assumption, the tacrolimus blood concentration was 100 ng/ml. Mibefradil and tacrolimus were both stopped, and the patient recovered within 1 week. Eight days after stopping mibefradil, tacrolimus was restarted at the same dosage and the subsequent plasma concentrations remained in the therapeutic range. CONCLUSIONS: Mibefradil increases the tacrolimus blood concentration by inhibiting its metabolism and should, therefore, not be used in patients treated with tacrolimus.

Benzimidazoles↗
PubMed1998

Spiral computed tomography: a novel diagnostic approach for investigation of the extracranial cerebral arteries and its complementary role in duplex ultrasonography.

BACKGROUND: For the detection of atherosclerotic lesions of the extracranial cerebral arteries, duplex ultrasonography (US) is an established operator-dependent method, whereas arteriography is associated with the not-insignificant risk of embolic complications. Spiral CT is a promising novel diagnostic tool that allows noninvasive, operator-independent diagnosis of obstruction of extracranial cerebral arteries. The aim of our prospective study was to evaluate in a clinical setting the complementary role of duplex US and spiral CT. METHODS AND RESULTS: We compared the results obtained independently by spiral CT and duplex US in 59 consecutive patients with clinical suspicion of an obstructive lesion affecting the carotid arteries. We analyzed a total of 354 segments from the extracranial carotid arteries, including the common, internal, and external carotid arteries. A total of 4 complete occlusions, 38 severe stenoses (70% to 99%), and 32 moderate stenoses (30% to 69%) were concordantly identified by means of duplex US and spiral CT. In 5 cases in which duplex US did not allow sufficient evaluation of the carotid artery because of a poor US window or severe calcification, spiral CT allowed identification and correct measurement of the stenotic lesion. The comparison of the percentage of stenosis with both methods was good (r=0.91, P=0.024). CONCLUSIONS: Our results indicate that spiral CT of the extracranial cerebral arteries is a promising noninvasive complementary and non-operator-dependent examination. Its application is particularly attractive in cases in which duplex US is not reliable (ie, severe kinking, severe calcification, short neck, and high bifurcation) and particularly when an overall view of the vascular field is required.

Aged↗
PubMed1998

Prognosis of medically treated patients referred for cardiac transplantation.

OBJECTIVES: To assess prognosis and factors influencing survival of transplant candidates in whom continued medial therapy was recommended in comparison to that of immediately listed patients. METHODS: Retrospective analysis of clinical, echocardiographic and hemodynamic data as related to survival or listing for transplantation of medically treated transplant candidates. PATIENTS: 160 patients considered 'too well' for cardiac transplantation and 133 patients immediately listed for transplantation. RESULTS: Forty-one of the medically treated patients deteriorated clinically and were listed after 10.7+/-12.3 months after initial evaluation. Mid-term prognosis (2 years) of patients never listed was comparable to that of immediately listed patients (74% vs. 70%) but long-term prognosis (5 years) was worse (41% vs. 54%, p<0.001). Cardiothoracic ratio and pulmonary capillary wedge pressure were independent predictors of survival (multivariate analysis) in patients whose NYHA class and physical working capacity improved and cardiothoracic ratio decreased significantly after adjustment of medical therapy. CONCLUSIONS: Mid-term prognosis of selected patients considered 'too well' for transplantation is comparable to patients immediately listed. Lower left ventricular filling pressures, smaller hearts on chest X-ray on initial evaluation, and improvement of symptoms during follow up may identify a subgroup of patients who do well on optimized therapy.

Actuarial Analysis↗
PubMed1998

Intracavitary chemotherapy with thiotepa in malignant pericardial effusions: an active and well-tolerated regimen.

PURPOSE: Malignant pericardial effusion, although highly variable, is an uncommon complication of cancer. It is often associated with symptoms like dyspnea, chest pain, and cough, which may be severe and disabling. We analyzed the results of our current treatment policy to evaluate the effectiveness and tolerance of a new approach for this disorder. PATIENTS AND METHODS: Patients with malignant pericardial effusions were treated with intracavitary thiotepa (15 mg on days 1, 3, and 5) through an indwelling pericardial cannula after extraction of as much pericardial fluid as possible on day 0. Responses were assessed by clinical examination, computed tomographic (CT) scan, and echocardiography before treatment, 1 month after treatment, and every 2 months thereafter. Twenty-three patients with malignant symptomatic pericardial effusion were treated and all were assessable for effectiveness and tolerance of the procedure. RESULTS: Nine patients with breast cancer, 11 with lung cancer, two with an unknown primary tumor, and one with metastatic melanoma were treated. In all but three patients, systemic medical treatment was started after completion of intracavitary therapy. Nineteen patients responded to treatment (83%; 95% confidence interval, 61% to 95%) with a rapid improvement of symptoms. The median time to pericardial effusion progression was 8.9 months (range, 1 to 26). No significant side effects were registered, except one patient who had transient grade III thrombocytopenia and leukopenia and one patient who had grade I leukopenia. CONCLUSION: A short course of intracavitary treatment with thiotepa is highly effective and well tolerated in the treatment of malignant pericardial effusion.

Adult↗
PubMed1997

Reduced coronary flow reserve during exercise in cardiac transplant recipients.

BACKGROUND: Coronary flow reserve (CFR) is reduced in a majority of patients after heart transplantation (HTx). Pharmacological interventions, however, provide only limited information on CFR under physiological conditions. Thus, CFR during exercise was evaluated in the present study. METHODS AND RESULTS: Coronary angiography was performed at rest and during supine bicycle exercise in 35 patients early (2 to 3 months; n = 10) or late (1 to 6 years; mean, 2.5 years; n = 25) after HTx and in 8 controls (C). CFR was determined by parametric imaging after administration of 10 mg intracoronary papaverine, during exercise, and after 1.6 mg sublingual nitroglycerin. Epicardial coronary artery size was measured by quantitative coronary angiography. CFR after papaverine was normal early (3.6 +/- 0.5 versus C, 3.6 +/- 0.7; P = NS) and late (3.8 +/- 1.3 P = NS) after HTx. During exercise, CFR was normal early (3.1 +/- 0.6 versus C, 3.9 +/- 0.9; P = NS) but decreased late (2.3 +/- 0.6; P < .01) after HTx. The increase in coronary cross-sectional area during exercise was also diminished late after HTx (14 +/- 10% versus C, 22 +/- 10%; P < .05). Both exercise-induced CFR (r = -.39, P < .05) and coronary vasodilation (r = -.44, P < .01) were inversely correlated with time after HTx. CONCLUSIONS: CFR during exercise is normal early but reduced late after HTx, whereas CFR after papaverine administration is maintained. This difference between physiological and pharmacological vasodilation suggests progressive endothelial dysfunction after HTx.

Adult↗