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Biomedical subjects

A Pacitti

Publications and source records attributed to A Pacitti.

At least 19 recordsLinked to original sources
PubMed2006

The catheter as Ariadne's thread to follow the path of Peritoneal Dialysis (PD) through the long-term experience of a Center.

In our institution, the first patient was treated by HD in 1955. In the middle of the '60s, the PD technique, revised by Maxwell (1), was implemented. The access to peritoneum was obtained by repeated puncturing of the abdomen, the catheter being removed after each session. In 1966, our first results on one year of PD were published (20 patients treated, 13 affected by ARF and 7 by CRF, for a total number of 150 sessions). Since 1967, the procedure of the repeated punturing was improved by the Seldinger technique. The efficiency of the PD intermittent treatment was increased with the "fast shift" schedule and PD automation was pursued with the project of a cycler (1968). The first CRF patients were treated by fast shift PD. In the late intermittent PD phase, the adoption of permanent catheters, destined to endure in our practice, the rigid and the soft indwelling for long-term treatments, allowed us to launch programs of home and nocturnal PD. With the incoming CAPD age, the greatest care was directed to the role of the catheter. The adoption of the surgical insertion by paramedian approach through rectus muscle, minimized, in our experience, the early complications. With the reduction of peritonitis rate, the later catheter complications increased in terms of patient discomfort, hospitalization and technique survival. On those grounds, in our institution a prospective trial on a ten year period was undertaken to compare, in terms of late complications rate, new versions of the classic Tenckhoff straight catheter (ST). The surgical insertion method was adopted for all the types, for a total of 196 catheters in 163 CRF patients. The tip displacement rate (12.2% with ST) decreased, albeit non significantly, with Swan Neck (7.9%), but was markedly and significantly reduced (1.0%) with the Self-Locating (SL) catheter experience. The surgical insertion of SL was comparable to that of ST. For those reasons, in recent years, in our institution the SL catheter became the first choice catheters for CRF patients.

Catheterization↗
PubMed2004

EPO or not-EPO? An evidence based informed consent.

BACKGROUND: Informed consent is crucial in therapeutic choices; however, the forms presented to patients are often locally developed and information may not be homogeneous. OBJECTIVE: To prepare an evidence-based model for informed consent, applied in the case of erythropoietin therapy (EPO) as a teaching tool for medical students. METHODS: Methodological tools of Evidence-Based Medicine (EBM) were developed within the EBM Course in the Medical School of Torino, Italy, as problem solving and patient information tools (5th year students work in small groups under the supervision of statisticians, epidemiologists and experts of internal medicine--nephrology in this case). RESULTS: Methodological and ethical problems were identified: in the pre-dialysis field, evidence from randomized clinical trials (RCT) is scant; how to use evidence gathered in dialysis? How to deal with implementation? How with the mass media? Do we need to discuss the drug choice with the patients? How to deal with rare and severe side effects?). The "evidence" was searched for on Medline/Embase, by using key-words and free terms. About 680 papers were retrieved and screened. Forms available on the Internet were retrieved and a general scheme was drawn: it included 5 areas: title, aim and targets (patients and family physicians); search strategies and updating; pros and cons of therapy; alternative options; open questions. CONCLUSIONS: EBM may offer valuable tools for systematically approaching patient information; the inclusion of this kind of exercise in the Medical School EBM courses may help enhance the awareness of future physicians of the correct communication with patients.

Aged↗
PubMed2003

Twenty years of renal replacement therapy in a type 1 diabetic patient: advantages of a multiple choice dialysis system.

The prognosis of diabetic patients on renal replacement therapy (RRT) is usually poor. We report on the type 1 diabetic woman with the longest RRT follow-up in our area: over 20 years, half on dialysis, half with a renal graft. CS started RRT at age 27 on peritoneal dialysis (3 years), continued until an underdialysis syndrome developed, was switched to acetate dialysis and, because of poor tolerance, to hemofiltration which with good clinical results, allowing her to become the first Italian patient on home hemofiltration, which continued for 5 years. A cadaver graft lasted for the subsequent decade, despite several complications; afterwards she resumed bicarbonate dialysis, choosing a frequent home hemodialysis schedule. Despite several vascular access problems, her clinical conditions were good enough to candidate her for a second renal transplant, performed 3 years ago. This history of active self-care may draw attention to the advantages of a multiple choice dialysis network.

Catheters, Indwelling↗
PubMed2002

Patient knowledge and interest on dialysis efficiency: a survey.

BACKGROUND: Therapeutic compliance is fundamental on dialysis; however following a therapy requires a prior understanding of it. Aim of the study was to assess the need and interest for information on dialysis efficiency and to prepare a dedicated teaching tool. METHODS: 72 patients, on hemodialysis in two limited-care satellite units, were given a questionnaire testing knowledge and interest on dialysis efficiency. In a subsequent second phase, following patients' suggestions, a cartoon book was prepared and opinions recorded. RESULTS: 63 patients' returned the questionnaire. 79.4% had basic knowledge on routine blood tests, 30.1% were aware of their specific meaning. All patients asked for further information, preferring books to other media. The book "Kt/V as cartoon" was distributed; 71.2% read it, 93% scored it as good-very good. In the Unit employing flexible dialysis schedules, 22/42 patients increased dialysis time. CONCLUSIONS: Despite insufficient knowledge on dialysis efficiency, patient interest is high. An educational program is feasible and may also give practical results, such as self-increase in dialysis time.

Adult↗
PubMed2002

[Daily dialysis: evaluation of the first year of experience at home and in a limited care center].

BACKGROUND: Among self dialysis treatments, daily dialysis is encountering a growing interest. Aim of this study was to evaluate results of the first year of daily dialysis in our Center. METHODS: Since November 1998, twelve patients started daily dialysis. One patient started RRT on daily dialysis; one patient was in training; 8 were on home dialysis, 3 in the limited care center. Selection of patients was performed according to wide acceptance criteria as for age (range 33-61 years), dialysis follow-up (range 1-23 years), comorbidity (=/>1 comorbid factor present in 8). Dialysis schedule consisted of 6 sessions per week (2-3 hours), blood flow 250-320 ml/min, individualized dialysate. Occasional shift to 3-4 times per week were allowed for logistic or working reasons. RESULTS: Results were analyzed taking into account patient satisfaction and main clinical parameters. In 9/12 the choice of treatment resulted from both clinical reasons and patient preferences, while in 3 was due to clinical indications (1/3 dropped out). The main reasons of choice were logistic or research of the best treatment. The most common fears regarded fistula and needle puncturing. Despite the time unconvenience, the rapidly regained well being was the reason for choosing this treatment. Also in this relatively short follow-up the favorable results reported as for weight gain, blood pressure control and metabolic pattern are confirmed. The few side effects were multifactorial (fistula thrombosis after blood pressure normalization, 2 recurrences of atrial fibrillation). CONCLUSIONS: In conclusion, daily dialysis resulted also in our centre as a promising alternative even in difficult patients.

Adult↗
PubMed2001

Daily dialysis Kt/V and flexible schedules: is it possible to control efficiency, when and how?

BACKGROUND: Daily hemodialysis is a promising treatment schedule but uniform criteria for defining efficiency are lacking. METHODS: On our daily dialysis (DD) schedule, duration is flexible (2-3 hours, patients are free to add up to 30 min/session), Qb 250-350 mL/min; dialyser 1.6-1.8 m2. Study was performed on 12 pts on DD for > or = 2 months, with > or = 4 Kt/V on subsequent days, tested in the same laboratory. GOAL: To evaluate variability and identify a simple method for weekly calculation, Kt/V was assessed for 133 sessions. RESULTS: On flexible DD, variability of Kt/V-session is high (relative error 4.9%-22%). On flexible schedules, within the time range chosen (2-3 hours) variability of average hourly Kt/V is lower (standard deviation: min (0.014; max (0.052 hour, relative error 4.9%-10%) allowing calculation of weekly Kt/V (averaging 3 sessions: relative error < 6%) suitable for clinical practice. CONCLUSIONS: Flexible schedules, allowing patients to increase treatment time, are an interesting clinical option, but a challenge for Kt/V assessment.

Adult↗
PubMed2001

Limits of aortic stop flow infusion chemotherapy in the treatment of advanced cancer.

BACKGROUND: Advanced and relapsed tumors remain a challenging disease with a poor and dismal prognosis. Our choice for inoperable tumors consists in a percutaneous treatment strategy involving intra-arterial chemotherapy and hemofiltration, with previous blood stop-flow, which allows high doses of Cisplatin-cisplatinum, cis-diammine-dichloroplatinum (CDDP) and Mitomycin C (MMC) in the tumor-bearing area with minimal systemic toxicity. METHODS: We analyse the morbidity and mortality associated with stop-flow in 20 patients with unresectable and/or metastatic thoraco- abdominal tumors, non responders to prior systemic chemotherapy. RESULTS: In our experience, the rate of major side effects of the procedure was 31% with a mortality of 5%. The side effects were related to the radiological procedure and to the chemotherapic treatment. A 74-year-old patient died for acute kidney toxicity within 15 days after the procedure. The other transient toxicity symptoms recorded were: nausea, vomiting, increasing of creatinine levels, diplopia and appearance of necrotic ulcer associated to chemotherapic drugs. Concerning the complications related to the radiological technique, the main problem was the rupture of the balloon stop-flow catheter in four patients. CONCLUSIONS: Stop-flow is a new procedure that could develop in the future, thanks to the possibility of obtaining a higher dose intensity of chemotherapic drugs in districts or organs affected by advanced tumors, with less systemic side effects. Unfortunately, the uncertain results in terms of increasing survival and the default of effective devices are to be resolved for a wider application of the procedure.

Adult↗
PubMed2000

[Relationship between risk profiles, prognosis, and outcome of patients with acute renal failure treated with dialysis].

BACKGROUND: The paradox of the increased mortality in the patients with acute renal failure (ARF) although submitted to better cares and newer renal replacement therapies (RRT) has recently prompted to the use of quantitative individual severity scores (ISS) calculating for each patient an individual death probability (DP) in correlation with the risk covariates found before the start of RRT; beside the clinical use, the ISS allow an evaluation of the effect of strategies and modalities of treatments as quantitative additive factors eventually added or subtracted to the base-line individual background of risk. The ideal index should be chosen on the basis of its precocity (origin just at the start of therapy), sensitivity (true positive against false positive results), universality (independence from the development set) and discriminative power (the capability to discern patients potentially treatable from those with an unchangeable prognosis). Indexes already validated in their development set should be used and studied into a different set ("evaluation set"). METHODS: The aim of this study has been: to evaluate a literature index (ATN-ISS, Liaño, developed prospectively in a remote set) in the local (A) environment on 340 patients with ARF successively treated with dialysis (mostly hemo-filtration) studied retrospectively along a 4 year period in our regional hospital and compare its performances with a local index (PDTOR) developed by logistic analysis in the same pool; the fitness of both tests to the real outcome has been evaluated by the Limeshow test and by ROC curves; to compare both indexes in a remote environment (B) of a dialytic pool of 345 patients extracted by a group of 25721 patients treated by 25 Italian ICU (Archidia Study group). The responses of the two indexes have been compared even with the index (SAPSII) prospectively generated at the admittance in the ICU by the Archidia Group. RESULTS: In the local set (A) TOR-ISS fits well with the outcomes (Limeshow test C2 = N.S.) as expected being evaluated in its own "development" set, while ATN-ISS significantly underestimates deaths, perhaps working on a retrospectively built data-base, that could contain fewer risk elements than necessary. (B) In the remote set, ATN-ISS fits very well, while TOR-ISS significantly overestimates expected deaths, for its retrospective origin or for a real lower death incidence compared to that of its development set. SAPSII shows no correlation at all with the outcome because its calculation is often well before (10 days on average) than the actual start of dialytic treatment. CONCLUSIONS: In conclusion ATN-ISS, an index built prospectively on a large cohort of patients, fits correctly in a remote prospectively built evaluation set. Retrospective built indexes or data-base don't allow a correct ISS evaluation while ICU indexes (SAPSII, APACHE), generated at the admittance in the ICU should not be used for ARF patients submitted to dialysis.

Acute Kidney Injury↗
PubMed2000

[Research potential of a regional registry].

BACKGROUND: The need for data bank gathering information in dialysis patients is as old as dialysis. Dialysis Registries presently active are characterized by different policies of data gathering (large vs small number of information) and of use (research vs economical or clinical purposes). Aim of the work was a discussion on the use of a Regional Registry (RPDT, Regional Registry of Dialysis and Transplantation of Piedmont, Italy), gathering since 1981 a wide set of information (about 80 items) on all patients treated in a relatively small area (about 4,300,000 inhabitants). METHODS: Two researches were selected: the first includes patients treated for > or = 20 years by RRT. Cases were identified on the basis of RPDT data and an inquiry regarding all patients was performed, with specific interest on comorbidity. The second includes diabetic patients on regular RRT, a sample of which was further analyzed in high detail. RESULTS AND CONCLUSIONS: While a Regional Registry, even gathering a wide set of data is unable to answer to the most qualitative questions, such as quality of life, its archives are a powerful tool to identify cases. Furthermore, ad hoc inquiries may represent a way to control quality of data or to test new fields to be studied. In the case of patients with long RRT follow-up, comorbidity questions were tested before being included on RPDT. In the case of a sample of diabetic patients, type of diabetes and cause of ESRD were controlled. This biunivocal relationship between clinical work-up and epidemiological archives may often interest future perspectives.

Adult↗
PubMed1998

[Complex vascular access].

Availability of a proper vascular access is a basic condition for a proper extracorporeal replacement in end-stage chronic renal failure. However, biological factors, management and other problems, may variously condition their middle-long term survival. Therefore, personal experience of over 25 years has been critically reviewed in order to obtain useful information. In particular "hard" situations necessitating complex procedures have been examined but, if possible, preserving the peripherical vascular features.

Animals↗
PubMed1996

Elderly patients on dialysis: epidemiology of an epidemic.

The increase in the incidence of elderly patients starting dialysis has been as sharp, during the 1980s-1990s, as an epidemic (+70%, +150% in different settings). According to this study, performed in Piemonte, northern Italy, the process is still ongoing. During the period 1981-93, according to the Regional Registry of Dialysis and Transplantation (RPDT: data on 100% of centres and patients), the cohort on treatment increased by 79.5% and the annual incidence by 48.3%; the increase is limited to older people and is greater in males. Nephroangiosclerosis/ischaemic renal disease and diabetes mellitus are the main diagnoses. Since the increase of elderly patients is still ongoing, forecasts are difficult; according to a computer simulation, a plateau of patients on treatment is reached only if incidence is stabilized, While it is impossible to exclude a decrease in hidden selection or an increase in referral, complex modifications at the overall population level are presumably at the basis or the increase of elderly patients on dialysis. Despite the increase in average age, however, survival improved throughout the period; this confirms the interest towards the open dialysis system adopted in Piemonte, which is characterized by easy shifts among treatments and by the widespread use of high tolerance techniques.

Adult↗
PubMed1995

Prescription and surveillance of the acetate-free biofiltration sessions: the bicarbonate cycle.

A computerized system, structured by 4 different models concerning urea depuration, and bicarbonate and sodium handling in acetate-free hemodiafiltration has been conceived for integrated use covering each step of the therapeutic cycle, from a) the prescription of the session to b) its delivery, up to c) the dose-response analysis: the system, now fully developed for the bicarbonate cycle, covers both working areas; the medical one, with a program implemented on a Personal Computer, called Skipper which deals with steps a) and c), and the nursing area, with a program built into the dialytic equipment software. The Skipper program supports the prescription step (a) testing the session schedule by bicarbonate, sodium and urea kinetics. The dialytic equipment, (step(b)) using a different program, on the basis of the scheduled parameters memorizes the end-session plasma bicarbonate level and reacts to any modifications of the parameters regarding blood flow and fluid reinfusion flow suggesting opposite changes in order to reach the scheduled results. Finally (step (c)), the Skipper system statistically evaluates the observed end session bicarbonate plasma level with an expected value with upper and lower confidence bounds obtained by a multiple regression analysis performed on a large population of patients.

Acetates↗
PubMed1994

High level expression and purification of the enzymatically active cytoplasmic region of human CD45 phosphatase from yeast.

The cytoplasmic region of human CD45 corresponding to residues 584-1281 was inserted downstream of the alcohol dehydrogenase promoter and transfected into a haploid strain of yeast. Expression of recombinant CD45 in yeast reached as high as 5% of the soluble protein. Following removal of cellular debris by centrifugation and an ammonium sulfate precipitation step, the enzyme was purified using phenyl-Sepharose chromatography, preparative gel filtration, Mono Q anion exchange chromatography and a final analytical gel filtration step. Enzymatically active material with a purity of > or = 98% was obtained with a yield approaching 50%. The final product gave a Km of 5.5 mM and a Vmax of 87.5 U/mg with p-nitrophenylphosphate and a Km and Vmax of 0.167 mM and 185 U/mg, respectively, with a phosphotyrosine peptide. The native enzyme purified from Jurkat cells showed comparable Kms with both substrates to the recombinant enzyme but displayed substantially lower Vmax values for both substrates.

Amino Acid Sequence↗
PubMed1993

Beta-2-microglobulin serum profiles in different settings of mass transport and fluid pyrogen content.

Different beta 2-microglobulin (beta 2m) serum profiles have been related to dialytic membranes, mass transport and/or patient immune stimulation. Eight patients were followed by cycles of four sessions: hemodialysis (HD), hemodiafiltration (HDF), acetate-free HDF (AFH), hemofiltration (HF) by filters on synthetic membranes (polysulphone = 4; methylmethacrylate = 4); pre- (A) and post- (B) measurements in the fourth session, and at the start of the next one (C), beta 2m lipopolysaccharide content of the fluids (LPS), and monocytes in vitro and spontaneous production of interleukins (IL); IL-1-IL-6 and tumor necrosis factor (TNF) were measured. In HD, beta 2m (mg/liter), corrected for ECV distribution, did not change (A = 36.5 +/- 10, B = 37 +/- 9, C = 36.4 +/- 9.7). In HDF, lower basal beta 2m (P < 0.001; A = 26.5 +/- 9) still decreased (B = 9.13 +/- 6.2), boosting subsequently to C = 21.6 +/- 14, as in AFH (A = 24.5 +/- 7, B = 11.2 +/- 2, C = 25.3 +/- 9) and in HF (A = 26.6 +/- 7; B = 8.5 +/- 4; C = 25.6 +/- 11). LPS (EU/ml) decreased (P < 0.001) from HD fluids (0.41 +/- 0.1) to HDF (0.28 +/- 0.1), AFH (0.15 +/- 0.1) and HF (0.04 +/- 0.05) but IL-1 and IL-6 were found in greater concentrations in HDF and AFH versus HD and HF, probably due to back-filtration. Beta 2m in different modes of dialytic treatments seem better correlated with the amount of convective transport rather than with the selected markers of immune stimulation.

Adult↗
PubMed1992

Atrial natriuretic factor and concomitant hormonal, hemodynamic and renal function changes after slow continuous ultrafiltration.

We treated a patient with refractory biventricular heart failure, dilutional hyponatremia and prerenal azotemia, by means of ultrafiltration. After ultrafiltration, gas exchange and cardiac output improved, with concomitant reduction of systemic and pulmonary vascular resistances. Despite a decrease of right atrial and wedge pressure, atrial natriuretic factor rose and plasma renin activity decreased.

Atrial Natriuretic Factor↗
PubMed1991

Concomitant iron and aluminum mass transfer following deferoxamine infusion during hemofiltration.

Variable tissue overloading can alter the removal rate of iron and aluminum from uremics. Owing to its higher affinity to deferoxamine (DFO) and higher plasma concentrations, Fe could impair Al removal in cases of simultaneous body burden. Fe and Al plasma kinetics and mass transfer were therefore studied in 12 uremic patients with different Fe and Al status: six with normal ferritin levels (less than 400 micrograms/L [ng/mL]), and Al 1.4 to 4.7 mumol/L (40 to 131 micrograms/L) (group A); six with increased ferritin (greater than 2,000 micrograms/L), and Al 1.7 to 17 mumol/L (47 to 476 micrograms/L) (group B). DFO (40 and 80 mg/kg in a random sequence) was administered once a week during the first hour of the first hemofiltration (HF). The results show that in both groups and with both DFO doses, maximum Fe and Al mass transfer was achieved in the first and second HF, respectively. The 80-mg/kg dose of DFO significantly raised Al mass transfer in both groups, whereas Fe mass transfer was only slightly affected. Even though plasma Fe levels were almost always higher than Al, Al mass transfer eventually exceeded that of Fe, in both Fe-normal and Fe-overload patients. The bias towards Al in mass transfer was enhanced in both groups in the second HF, and at the higher DFO doses. Thus, DFO once a week reduced Fe loss to less than 30 mumol/wk in patients with normal ferritin levels. In both Fe and Al overloaded patients, Al can be removed, and Al mass transfer may often exceed Fe mass transfer, depending on the degree of tissue burden, the time from DFO infusion, and the DFO dose.

Adult↗