Variable threshold of exertional angina: a clue to a vasospastic component.
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Angina Pectoris↗
Biomedical subjects
C Brunelli
Publications and source records attributed to C Brunelli.
Sequence of events in angina at rest: primary reduction in coronary flow.
To investigate the events that lead to acute myocardial ischemia we monitored continuously the ECG, the left ventricular (four patients) or aortic (two patients) pressure and the great cardiac vein oxygen saturation (CSO2S) by a fiberoptic catheter in six patients with frequent anginal attacks at rest. We recorded 137 transient ischemic episodes (10 with chest pain) characterized by ST-segment elevation in 28 episodes, depression in three episodes and by pseudonormalization of previously inverted or flat T waves in 106 episodes. The onset of electrocardiographic and hemodynamic changes was preceded by a large drop in CSO2S in all 135 episodes with ST-T changes in the anterior leads but not in two episodes with ST elevation on inferior leads. The fall in CSO2S, consistently followed by signs of left ventricular function impairment and never preceded by any detectable increase in the hemodynamic determinants of myocardial oxygen consumption, probably reflects a reduction in regional perfusion. Thus, a reduction in coronary flow may cause transient ischemia in patients with angina at rest. These episodes may be associated with variable, often minor electrocardiographic changes and occasionally with anginal pain.
Adult↗
[Myocardial extraction of oxygen and left ventricular function in angina at rest].
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Adult↗
Evaluation of quality of life in patients with malignant dysphagia.
BACKGROUND: In the last 10 years of clinical research there has been increasing interest in the evaluation of quality of life. Several generic and specific instruments have been developed for this purpose. EORTC QLQ C-30 is a cancer-specific questionnaire translated into various languages and validated in several European countries including Italy, where the impact of malignant disease on different areas of quality of life is poorly documented. METHODS: The EORTC QLQ C-30 was administered to 109 patients referred to the endoscopy division of the Istituto Nazionale Tumori, Milan, for endoscopic palliative treatment of malignant dysphagia to test its characteristics in terms of acceptability and clinical validity. RESULTS: In this group of patients the impact of advanced esophageal cancer was highly evident for Emotional and Physical Functioning, Fatigue and Global QoL scales. Dysphagia is a serious problem for many patients; there is a correlation between grade of dysphagia and four QoL dimensions. CONCLUSIONS: QoL assessment is an important tool to evaluate the adequate management of patients with esophageal cancer. The EORTC QLQ-C30 questionnaire proved to be valid and reliable also in this population.
Aged↗
Pain experienced by patients hospitalized at the National Cancer Institute of Milan: research project "towards a pain-free hospital".
According to the data of the literature, the prevalence of pain in cancer patients at various stages of the disease and the settings of care range from 38 to 51%, with an increase of up to 74% in the advanced and terminal stages. Despite published World Health Organization (WHO) guidelines for pain management, 42 to 51% of cancer patients receive inadequate analgesia and 30% receive no analgesics at all. A 3-year Research Project "Towards a Pain-free Hospital", which began one year ago, is ongoing at the National Cancer Institute of Milan. The research is organized in three subsequent steps. In the 1st one, a series of patient- and staff-oriented evaluation tools are used to assess the level of appropriateness of pain communication, assessment, management and control of the in-patients. The 2nd step will implement a number of continuing educational interventions aimed at improving patient awareness and staff knowledge of the appropriate pain assessment and management in order to respond to the patient's pain problem. In the 3rd step, all the assessment tools used in step one will be applied again to establish the prevalence of pain, the causes and intensity and patient satisfaction with pain management and to evaluate the impact of the interventions performed during the 2nd step regarding the overall ability of our hospital to tackle pain emergency in the hospitalized cancer population. The results relative to the 1st step are herein reported, in particular as regards the study on prevalence, causes, severity of pain, the interference of pain with sleep, mood and concentration, the use of pain medications and the relief obtained, the structural validity and internal consistency of the assessment tool used. A total of 258 patients hospitalized for at least 24 h were interviewed by 9 physicians using a brief structured questionnaire prepared ad hoc: 51.5% of the patients presented pain during the previous 24 h caused by surgery (49.6%) or by the tumor mass itself (29.3%). Out of the 133 patients with pain, a high degree (much or very much) of pain at rest was present in 27.1% and pain on movement in 30.8%; 31.6% did not take any analgesic treatment, and 14.3% of the latter reported a high degree of pain at rest and 21.4% on movement. Pain interfered with sleep from much to very much in 28.8% and with irritability and nervousness in 15.9% of the patients. In the 91 patients taking analgesics, 57.2% reported a high degree of pain relief. A high degree of pain and interference, however, was associated with low relief levels. The assessment tool used was shown to have a good structural validity and internal consistency (Chrombach alpha index of interference scale = 0.73). Although the Milan Cancer Institute has the longest tradition in Italy of pain assessment by means of validated tools and pain management according to the WHO guidelines and educational efforts in this field, the results of the study clearly show that it is necessary to persevere with continuing educational and informative programs in order to reduce the frequency and severity of pain and thus improve the quality of life of in-patients.
Adult↗
[Quality of life at the end of life. Analysis of the quality of life of oncologic patients treated with palliative care. Results of a multicenter observational study (staging)].
Outcome in palliative care can be defined as patients' quality of life, quality of death and satisfaction with care. In an Italian multicentre prospectic study ('Staging') the quality of life of 571 palliative care patients with advanced cancer disease was assessed since the beginning of palliative care till the end of the study. We analyzed the tissue of quality of life missing data and the possibility to input the missing quality of life evaluation through the quality of life evaluation made by a proxy (doctor, nurse). The greatest functional impairment and an increasing level of some symptoms (fatigue, general malaise, emotional status) were observed during the last two weeks of life, whereas for other symptoms (gastro-intestinal, pain) some degree of control was possible. The quality of life analysis for palliative care patients should consider the different response of different quality of life components to the palliative care intervention.
Aged↗
Ultrasound biomicroscopy and corneal endothelium in Nd:YAG-laser iridotomy.
BACKGROUND AND OBJECTIVE: Thirty eyes affected by angle-closure glaucoma that had undergone YAG-laser iridotomy were studied to evaluate variations of central anterior chamber depth, width of the angle, and loss of endothelial cells after laser treatment. PATIENTS AND METHODS: These parameters were determined before and after iridotomy: endothelial cell count using a "non-contact" specular biomicroscope, and anterior chamber depth and angle width using ultrasound biomicroscopy (UBM). The width of the iridotomy and the distance of the iridotomy from the scleral spur and from the corneal endothelium were also measured by UBM, after laser treatment. RESULTS: Results confirmed that, after iridotomy, there is not a significant variation in the central depth of the anterior chamber: it goes from 2.02 mm pre-laser to 2.07 +/- 0.38 mm post-laser. There is, however, a statistically significant increase in the angle (P < .001), which goes from 10.69 +/- 8.88 degrees (0.109 +/- 0.07 mm) to 21.03 +/- 11.28 degrees (0.183 +/- 0.09 mm). The mean dimension of the iridotomies was 0.46 +/- 0.13 mm. The mean endothelial cell count was 55.8 +/- 4.08 cells per linear millimeter before laser treatment and 47.01 +/- 5.39 cells per linear millimeter afterward (P <.001). CONCLUSION: This study confirms that YAG-laser iridotomy leads to a reduction in the average endothelial cell density. The loss of these cells is inversely proportional to the distance of the iridotomy from the endothelium and the scleral spur.
Anterior Chamber↗