Biomedical subjects

Giuseppe Micieli

Publications and source records attributed to Giuseppe Micieli.

17 recordsLinked to original sources

PubMed2006

Impaired blood pressure increase in acute cardioembolic stroke.

BACKGROUND AND PURPOSE: Studies on the prognostic significance of blood pressure (BP) increases during the acute phase of ischemic stroke give contradictory results. The aim of this study was to evaluate BP response during the acute phase in different ischemic stroke subtypes, and to assess the prognostic value, considering long-term outcome, of different BP patterns recorded. METHODS: We included 110 ischemic stroke patients hospitalized within 6 h of the onset of symptoms. All the patients underwent 24-h monitoring on hospital admission and on day 7 after stroke. For statistical analysis the whole population was divided into cardioembolic (CE), atherothrombotic (AT) and lacunar (LAC) groups, according to TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. RESULTS: In both the whole population and in all subgroups systolic and diastolic BP were higher at admission than during monitoring on day 7, the lowest values being recorded in the CE subgroup. CE stroke was significantly related to lower BP (systolic and diastolic) values (P = 0.01) during the acute phase and CE patients were characterized by poorer outcome. A history of diabetes was a predictor of higher systolic and diastolic BP on the first day of monitoring; higher systolic and diastolic BP values were related to a history of hypertension and with male gender, respectively. Predictors of death by 6-months were atrial fibrillation, age and history of hypertension (P < 0.05) while higher systolic BP in the acute phase seems to represent a protective factor. CONCLUSION: CE stroke shows a lack of BP response during the acute phase of ischemic stroke. This phenomenon is associated with a poor long-term outcome and seems not be related with cardiac co-morbidity.

Adult↗

PubMed2005

Cardiovascular risk calculators: understanding differences and realising economic implications.

In recent years, the concept of "global cardiovascular risk assessment" has grown in interest for its role in primary prevention of cardiovascular diseases. Interventions for reducing the risk of relapse for persons with cardiovascular past history are well agreed-on. But for persons without such a history, the risk of a first attack varies greatly and this variability implies a range in the intensity of interventions. In several countries, guidelines for general practitioners have been diffused about pharmaceutical prescriptions in the different risk classes. In particular, in Italy, a governmental drug management commission has established that Statins, the most used cholesterol lowering medicines, can be refunded by the National Healthcare System only if they are prescribed to hyper-cholesterol patients with a global risk greater than 20%. The question is: how to calculate the risk? We performed a review of both the web and the literature and we found a lot of different "risk calculators". By means of a simulation study, we showed that these tools, when used for the same person, may lead to very different results. We estimated the economic impact of using one or another calculator.

Aged↗

PubMed2005

Cerebral venous thrombosis and demyelinating diseases: report of a case in a clinically isolated syndrome suggestive of multiple sclerosis onset and review of the literature.

Cerebral venous thrombosis (CVT) has been described in several cases of clinically definite multiple sclerosis (MS). In the majority of these, lumbar puncture followed by intravenous corticosteroid treatment was suspected as the cause. We report what is, to our knowledge, the first case of a patient with a multifocal clinically isolated syndrome suggestive of MS onset, who developed multiple CVT after lumbar puncture and during high-dose i.v. corticosteroid treatment We conclude that the sequence 'lumbar puncture followed by corticosteroid treatment' may be a contributory risk factor for the development of CVT when associated with other risk factors.

Adrenal Cortex Hormones↗

PubMed2004

Relation of apolipoprotein(a) size to alzheimer's disease and vascular dementia.

Lipoprotein(a) [Lp(a)] level is a newly established vascular risk factor which has been suggested to play a role in dementia. However, the majority of Lp(a) cell-to-cell interactions are mediated by its specific apolipoprotein(a) [apo(a)] moiety. This suggests that the size polymorphism of apo(a) may be of importance in conveying the Lp(a)-related risk. Specifically, we postulated that variation in apo(a) isoform size may lead to increased risk of vascular dementia (VaD), Alzheimer's disease (AD), stroke, or all three of them. Under a case-control design we compared Lp(a) plasma levels and the distribution of apo(a) phenotypes in groups of subjects consisting of 50 VaD patients, 162 sporadic AD patients, 95 non-demented stroke patients (NDS), and 105 normal controls. The prevalence of small-sized apo(a) isoforms in the VaD group was significantly higher than that in the stroke and normal control groups, with an odds ratio of 5.29 (95% CI 2.24-12.49, p = 0.0001) for the development of VaD for individuals with at least one apo(a) isoform of low molecular weight (LMW). Furthermore, the possession of at least one small-sized apo(a) isoform significantly increased the risk of AD to 1.92 (95% CI 1.02-3.61, p = 0.0434). Our results demonstrate that possession of at least one LMW apo(a) isoform is significantly associated with dementia and specifically offer new evidence of a strong association between the lipoprotein system and post-stroke dementia.

Aged↗

PubMed2004

Economic benefit from clinical practice guideline compliance in stroke patient management.

BACKGROUND AND PURPOSE: In a previous study we showed that compliance with evidence-based guidelines improves the health outcome of stroke patients in terms of both survival and residual disability. In this analysis, we shall investigate the impact of such guidelines on healthcare costs during the acute/sub-acute hospitalisation phase. METHOD: we considered the direct costs from the hospital's point of view, where funding is provided by the National Healthcare System. We did not consider production loss or intangible costs related to the decreased quality of life. Data was collected on both costs and guideline compliance prospectively, and the relationship between them was studied through a multivariate statistical model. RESULTS: Patients treated according to guidelines result in lower costs; on average they have a shorter length of stay in hospital (10.8 versus 12.9 days), leading to a significant difference in the consumption of hospital resources. On a level of statistical analysis, guideline compliance is a significant independent indicator of cost, together with the patient's initial disability and neurological deficit.

Aged↗

PubMed2004

Non-compliance with guidelines: motivations and consequences in a case study.

Guidelines are often based on a mixture of evidence-based and consensus-based recommendations. It is not straightforward that providing a series of "good" recommendations result in a guideline that is easily applicable, and it is not straightforward that acting according to such recommendations leads to an effective and efficient clinical practice. In this paper we summarize our experience in evaluating both the usability and the impact of a guideline for the acute/subacute stroke management. A computerised version of the guideline has been implemented and linked to the electronic patient record. We collected data on 386 patients. Our analysis highlighted a number of non-compliances. Some of them can be easily justified, while others depend only on physician resistance to behavioural changes and on cultural biases. From our results, health outcomes and costs are related to guideline compliance: a unit increase in the number of non-compliance results in a 7% increase of mortality at six months. Patients treated according to guidelines showed a 13% increase in treatment effectiveness at discharge, and an average cost of 2929 Euros vs 3694 Euros for the others.

Costs and Cost Analysis↗

PubMed2003

Association between small apolipoprotein(a) isoforms and frontotemporal dementia in humans.

Apolipoprotein(a) [apo(a)] is a genetically polymorphic glycoprotein that has several similarities to apolipoprotein E. However, its role as a risk factor for frontotemporal dementia (FTD) remains to be elucidated. We therefore investigated the effect of an apo(a) polymorphism on the incidence of FTD in a sample of Caucasian Italian patients. From the entire group of FTD patients (n=54), 55.6% of the subjects had at least one apo(a) low molecular weight (MW) isoform, compared to 29.9% of non-demented controls (n=77). The difference between the two groups was statistically significant (odds ratio 2.93, 95% confidence interval 1.42-6.06, P=0.003). The FTD group was further divided into sporadic (n=26) and familial (n=28) cases. Even after such dichotomization, both sporadic and familial FTD patients showed a significantly higher prevalence of low MW apo(a) isoforms than the cognitively healthy controls (P=0.011 and P=0.025, respectively). Our data suggest a role of apo(a) phenotypes of low MW in mediating susceptibility to FTD.

Aged↗

PubMed2003

Role of monitoring in management of acute ischemic stroke patients.

BACKGROUND AND PURPOSE: Although several studies have demonstrated the effectiveness of specialist Stroke Unit (SU) care of stroke patients, there is still disagreement over how these units are best organized. We sought to clarify the role of continuous monitoring of physiological parameters in acute ischemic stroke. METHODS: We conducted a prospective study of 268 first-ever ischemic stroke patients admitted to our Cerebrovascular Department and allocated, according to the availability of beds, to the SU or Cerebrovascular Unit (CU). Statistical analysis compared mortality and outcome at discharge, medical and neurological complications, and length of hospitalization in the 2 care settings. RESULTS: Two hundred sixty-eight patients were enrolled. A good outcome at discharge, observed in 114 SU patients (85%) and 78 CU patients (58%) (odds ratio, 2.63; 95% CI, 1.4 to 4.8; P<0.02), was found, on multivariate analysis, to be significantly related to type of care (SU versus CU). A significantly greater proportion of SU patients showed adverse changes in monitored parameters, which required acute medical treatment (SU: 64%; CU: 19%; P<0.0001). The mean duration of these complications was significantly shorter in the SU patients (SU: 1.0 day; CU: 2.4 days; P<0.02), and the outcome in patients experiencing complications covered by the monitoring protocol was significantly better in the SU (66%) than in the CU (35%) group (P<0.0001). CONCLUSIONS: Admission of acute stroke patients to a monitoring SU may positively influence their outcome at discharge. Confirmation of our findings in larger trials will indicate the need for a revision of the minimum requirements of SUs, with the addition of monitoring as a new requirement.

Acute Disease↗

PubMed2003

Familial hemiplegic migraine type 2 is linked to 0.9Mb region on chromosome 1q23.

Familial hemiplegic migraine (FHM) is a rare autosomal dominant disorder characterized by episodes of transient hemiparesis followed by headache. Two chromosomal loci are associated to FHM: FHM1 on chromosome 19 and FHM2 on chromosome 1q21-23. Mutations of the alpha-1A subunit of the voltage gated calcium channel (CACNA1A) are responsible for FHM1. FHM2 critical region spans 28 cM, hence hampering the identification of the responsible gene. Here, we report the FHM2 locus refining by linkage analysis on two large Italian families affected by pure FHM. The new critical region covers a small area of 0.9Mb in 1q23 and renders feasible a positional candidate approach. By mutation analysis, we excluded the calsequestrin and two potassium channel genes mapping within the narrowed FHM2 locus.

Adolescent↗

PubMed2003

Assessment of regional acute stroke unit care in Italy: the PROSIT study.

BACKGROUND/OBJECTIVES: The aim of this study was to survey acute in-hospital stroke services in seven Italian regions. METHODS: Regional hospital discharge registers were searched to identify hospital services that record at least 50 acute stroke discharges per year and the doctors in charge of these services were interviewed. RESULTS: Only 31 (7%) out of 447 services could be classified as stroke units (SUs). Of these, only 9 (29%) were found to have vital function monitoring systems available for all patients. The most striking differences between SUs and mixed stroke services emerged when comparing staff/patient ratios in the two types of unit. CONCLUSIONS: There are still not enough SUs in Italy, and fewer than 10% of stroke patients can be admitted to such units.

Cerebral Angiography↗

PubMed2003

Cardiovascular risk calculators: understanding differences and realising economic implications.

In recent years, the concept of "global cardiovascular risk assessment" has grown in interest for its role in primary prevention of cerebro-cardiovascular diseases. Interventions for reducing the risk of relapse for persons with past history of these diseases are well agreed-on. On the contrary, the risk status of persons without such a history varies greatly, and this variability implies a range in the intensity of interventions. In several countries, guidelines for general practitioners have been diffused about pharmaceutical prescriptions in presence of various risk degrees. In particular, in Italy, a governmental drug management commission has established that statins, the most used cholesterol lowering medicines, can be refunded by the National Healthcare System only if prescribed to hyper-cholesterol patients with a global risk greater than 20%. The question is: how to calculate the risk? We performed a review of both the web and the literature and we found a lot of different "risk calculators". By means of a simulation study, we showed that these tools, when applied to the same person, may lead to very different results. We estimated the economic impact of using one or another calculator.

Algorithms↗

PubMed2003

Web-based data and knowledge sharing between stroke units and general practitioners.

We describe a telemedicine application for emergency management in Stroke Units, where prompt decisions must be taken, often knowing neither the clinical history nor the stroke symptoms onset modality. We have designed and implemented an Information and Communication Technology architecture for the situation in which a general practitioner is called for a suspected stroke and provides for the admission to a Stroke Unit. By means of a palmtop and a wireless Internet connection, he can send to the Stroke Unit the demographic data, the list of the patient's problems, current and/or recent therapies, and a guideline-based stroke-specific form with the objective examination results. In this way, the Stroke Unit team is alerted and informed before the patient arrival, and can manage the urgency at the best. The proposal involved 20 general practitioners and one Stroke Unit in the Lombardia Region, Italy.

Computer Systems↗

PubMed2002

Guideline compliance improves stroke outcome: a preliminary study in 4 districts in the Italian region of Lombardia.

BACKGROUND AND PURPOSE: Guidelines for medical practice in stroke have been proposed in different countries, but their impact on stroke outcome has not been verified to date. The aim of this study was to evaluate the impact of the American Heart Association guidelines for acute stroke and for transient ischemic attack on first-ever stroke patients. METHODS: Three hundred eighty-six first-ever ischemic stroke patients were admitted to the study. Those observed within 6 hours from stroke onset were eligible for the acute clinical phase of the study, while all were admitted to the early clinical phase. The follow-up lasted 6 months. Primary end points were survival and the effectiveness of treatment on disability, measured as the proportion of potential improvement in the Barthel Index score achieved during treatment. A rating of noncompliance with the guideline recommendations was calculated for each patient, and its association with the end points was investigated. The Kaplan-Meier method and log-rank test were used to estimate and compare survival curves between groups; Cox proportional hazards model and logistic regression were used to identify risk factors for mortality; and correlation tests and regression analysis were used to evaluate the influence of guideline compliance on disability. Both univariate and multivariate statistical analyses were performed. RESULTS: Survival and treatment effectiveness were directly correlated with guideline compliance. The relative risk of death for patients with a noncompliance rating > or =5 was 2.26 with respect to patients with a noncompliance rating <5 (95% CI, 1.51 to 4.67; P<0.0007). In this latter group, at 6 months we detected a 15% decrease in mortality (95% CI, 9.1% to 17.5%). Treatment effectiveness showed a Spearman's rank correlation with the noncompliance rating of -0.3 (P<0.001). At discharge we observed a 13% increase in treatment effectiveness, while no significant differences were detectable at 3 and 6 months. These associations were confirmed by the multivariate analysis, in which we included, together with the noncompliance rating, all the variables previously identified as independent predictors of mortality and disability. CONCLUSIONS: This study demonstrates an association between adherence to guidelines and stroke outcome, and it can be viewed as a study that prepares the way for a randomized controlled trial in this area. It also emphasizes the need to develop personnel and structures devoted to stroke care because an evidence-based clinical approach could significantly reduce the risk of death.

Aged↗

PubMed1991

Impairment of corneal pain perception in cluster headache.

Despite many studies, the mechanisms underlying the pathogenesis of pain in cluster headache (CH) still remain obscure. An involvement of substance P (SP) containing neurons of the Gasserian ganglion and/or of the spinal trigeminal nucleus has recently been suggested, e.g., by impairment of inhibitory descending pathways on trigeminal nociceptive neurons. The electrically elicited corneal reflex was studied in 21 CH patients (15 in active phase, 6 in remission). This method allows simultaneous measurements of the trigemino-facial reflex and corneal pain perception. A significant reduction of pain thresholds (more evident on the pain side) was observed in CH during the active phase, while normal values were recorded during the remission phase. Ten out of 15 patients in the active phase showed a significantly reduced corneal pain threshold on the pain side, while tactile sensibility was normal. Moreover, latency, amplitude and duration of the corneal reflex were normal for both painful and painless stimulations during both phases. The threshold of the nociceptive muscular response in the active phase was significantly reduced, suggesting that the excitability of trigeminal nociceptive neurons or of the motor neurons is increased in CH. The results agree with the hypothesis that a reversible impairment of several integrative functions, including the activity of trigeminal pain control system, exists in CH during the active phase.

Adult↗

PubMed1984

Progressive impairment of CSF beta-EP levels in migraine sufferers.

Common migraine (CM) is an evolutive disease characterized by a progressive increase in the number of attacks and a consequent reduction in the free periods, eventually reaching a state of continuous migraine with interparoxysmal headache (MIH). To evaluate the role of central pro-opiocortin-related peptides in the pathogenesis of the disease, cerebrospinal fluid (CSF) levels of beta-lipotropin (beta-LPH), beta-endorphin (beta-EP) and ACTH were measured in two groups of migraine sufferers with increasing severity of the disease (CM and MIH), and in healthy controls. ACTH values were similar in the 3 groups, while beta-LPH levels were significantly lower (P less than 0.005) in patients affected by MIH (10.4 +/- 8.6 fmol/ml) than in patients with CM (35.7 +/- 8.3) and in controls (32.9 +/- 15.33). beta-EP levels were closely correlated with the severity of the disease: they decreased significantly from those found in healthy controls (86.1 +/- 37 fmol/ml) to those of CM sufferers (38.5 +/- 3.5; P less than 0.005) and showed a further significant fall (P less than 0.01) to the lowest levels which were found in MIH patients (14.8 +/- 9.8). These data showing that the progressive evolution of migraine is concomitant with a progressive impairment in the CSF levels of beta-EP, sustain the concept that non-organic central pain is related to a reduced activity of the neurons responsible for the CSF content of beta-EP.

Adolescent↗

PubMedDate not supplied

Cerebral haemodynamic response to acute intracranial hypertension induced by head-down tilt.

The aim of this study was to evaluate, in a context of general inhibition of the sympathetic nervous system, the cerebral haemodynamic response to -30 degrees head-down tilt (HDT), a manoeuvre that produces an increase in intracranial arterial pressure. Nineteen healthy subjects were studied according to the following protocol: 10 min lying in supine position, 10 min HDT, 10 min recovery. Inhibition of the sympathetic system was confirmed by the decrease in heart rate (-3.6 bpm) and arterial blood pressure (-5.9 mmHg, p<0.05) in the late phase of the test. Blood velocity and blood pusatility index initially increased (+3.2 cm s(-1) and +9% respectively, p<0.01) then returned towards baseline before the end of HDT, while the cerebrovascular resistance index (=arterial blood pressure/blood velocity) dropped significantly and remained below control level (-7%, p<0.01) throughout the test. The changes in both these indices were opposite to those reported in several sympathetic activation tests, such as the handgrip and cold pressor tests. Conversely, arterial pressure at cranial level increased during HDT (as it also does during sympathetic activation tests), due to the development of a hydrostatic pressure gradient between heart and brain levels. Therefore, the effects observed on the pulsatility and resistance indices are not secondary to the increase in intracranial arterial pressure. It is suggested that the changes in these cerebrovascular indices are mediated by a reduction of sympathetic tone that presumably involves the cerebral as well as the peripheral vascular bed.

Adaptation, Physiological↗

PubMedDate not supplied

[Depression and stroke: an up-to-date review].

AIMS: To define the epidemiological and clinical characteristics of Post Stroke Depression (PSD) and to evaluate treatment options. METHODS: Systematic search using Medline electronic database limited to studies published from year 2000 to 2004, was carried out. Manual search was also performed. RESULTS: Depression after stroke is a common event. The same, stroke incidence in depressed patients is more frequent than by chance. Risk of underdiagnosing a patient with former stroke is high. Disability after stroke is frequent, with compromission of quality of life of patients and relatives. Antidepressants are efficacious in PSD treatment, even if complete remission is difficult to obtain. CONCLUSIONS: There is enough evidence concerning epidemiology, pathogenesis, clinical and therapy to justify psychiatrists' interest on relationship between stroke and depression.

Major Depressive Disorder↗