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Biomedical subjects

G Giunti

Publications and source records attributed to G Giunti.

At least 19 recordsLinked to original sources
PubMed2005

Rehospitalization following compensable work-related tetraplegia.

DESIGN: Descriptive study. OBJECTIVES: To document the characteristics of rehospitalization following work-related tetraplegia, investigate risk factors for rehospitalization and identify opportunities for rehospitalization prevention. SETTING: Workers' compensation administrative database with national coverage. METHODS: The administrative database of a large workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In all, 61 cases were identified where detailed rehospitalization information was available. Medical payment data were extracted, rehospitalization reasons were coded, and rates, costs and length of stay were calculated. RESULTS: In all, 62% of cases were rehospitalized at some time during the period for which data were available. The average number of days the study group spent rehospitalized per year was 9.2 and the average annual cost was 14,197 US dollars. The most common reasons for rehospitalization were dermatological (23%), orthopedic (18%) and urological (14%). It was found that as many as 74% of the total number of days persons spent rehospitalized, 64% of the monies spent on rehospitalization, and 47% of rehospitalizations could have been prevented. CONCLUSIONS: Consistent with earlier research, the ability to identify risk factors for rehospitalization was limited. However, the current study does highlight the extent to which rehospitalizations disrupt the lives of people with work-related tetraplegia and that a substantial proportion of rehospitalizations can be avoided. SPONSORSHIP: The research was supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research National Model SCI Systems (Grant no. H133N00024).

Adult↗
PubMed2004

Work-related tetraplegia: cause of injury and annual medical costs.

STUDY DESIGN: Descriptive study. OBJECTIVE: To describe the demographics, cause of injury, and annual-paid medical costs for the 5 years following injury for cases of work-related tetraplegia. SETTING: A single United States workers' compensation (WC) claims database. METHODS: Tetraplegia cases with initial date of injury from 1 January 1989 to 31 December 1999 were selected by cross-referencing word search terms pertaining to body part injured and nature of injury. The main outcome measures were injury causes and annual-paid medical payments (adjusted to year 2000 medical consumer price index) of work-related tetraplegia by injury group for each year postinjury over a 5-year time period. RESULTS: A total of 62 claimants with work-related tetraplegia injured between 1 January 1989 and 31 December 1999. The vast majority of those identified were male claimants (92%) and more than a quarter worked in the construction industry (26%). Other highly represented industries included transportation and retail (15% each), manufacturing (13%), and agriculture and utility (11% each). The majority of injuries were the result of falls (36%) and vehicular accidents (34%). The mean Year 1 cost was US dollars 560524 for those with a high-level tetraplegia (C2-4 ASIA A-C), US dollars 431033 for a low-level injury (C5-8 ASIA A-C), and US dollars 178041 for those with an ASIA D tetraplegia injury. The mean cost of subsequent years (Years 2-5) was US dollars 130992 for a high-level, US dollars 129250 for a low-level, and Us dollars 34352 for an ASIA D tetraplegia injury. CONCLUSIONS: Mean costs for Year 1 postinjury in WC cases are similar to previously published estimates. Comparing the current results with those of previous spinal cord injury cost studies suggests that those with work-related tetraplegia may receive more injury-related paid medical benefits after the first year postinjury than cases who do not receive WC-supported benefits. SPONSORSHIP: Supported, in part, by a grant from the National Institute on Disability and Rehabilitation Research (NIDDR) (Grant # H133N00024).

Accidents, Occupational↗
PubMed2004

Services provided following compensable work-related tetraplegia.

DESIGN: Descriptive study. OBJECTIVE: To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI). SETTING: Workers' compensation claims database. METHODS: The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories. RESULTS: Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications/supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher. CONCLUSIONS: Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.

Accidents, Occupational↗
PubMed2002

Emergency management of spontaneous coronary artery dissection.

Six cases of spontaneous coronary arteries dissection are reported. In one patient, triple vessel spontaneous coronary artery dissection was identified. Another patient presented spontaneous left main coronary artery dissection. In one case we found the spontaneous dissection of the left anterior descending artery associated with distal aortic arch dissection. These conditions are very rare and may present a surgical dilemma. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention is safe and effective. Early recognition of left main coronary artery dissection or three-vessel dissection is essential because urgent coronary artery bypass grafting may be life saving.

Adult↗
PubMed2001

Restoration of patency after apparent occlusion of the lambda-graft's right branch.

The "string sign" is a physiological and reversible response of the internal mammary artery (IMA) anastomosed to a moderately stenotic coronary artery. We describe a patient who presented postoperatively with a string sign phenomenon of the right branch of the lambda-composite graft. The graft regained full patency 32 months after the surgical procedure with progression of the native coronary artery stenotic lesion. This case demonstrates that under specific conditions, such as the progression of native coronary artery disease, a no-flow composite graft employing IMAs can only regain patency and functional status in the same way as in situ IMAs. These findings confirm that the IMA remains the conduit of choice not only for its long-term patency, but also for its physiological adaptation characteristics.

Adaptation, Physiological↗
PubMed2001

Lambda graft with the radial artery or free left internal mammary artery anastomosed to the right internal mammary artery: flow dynamics.

BACKGROUND: The aim of this study was to evaluate the outcome and flow dynamics of the lambda graft configuration, relative to a second arterial graft. METHODS: From 1998 to 2000, 47 patients (mean age 55.5 +/- 4.7 years) with triple-vessel disease underwent arterial revascularization using the lambda graft. The in situ left internal mammary artery (LIMA) and right internal mammary artery (RIMA) were anastomosed to the left anterior descending (LAD) and obtuse marginal arteries, respectively. In 21 patients (group I) presenting proximal or middle-third LAD or right coronary (RC) arterial stenoses, the lambda graft was constructed by anastomosing the distal LIMA, as a free LIMA graft, to the RC and proximally to the in situ RIMA. In the other 26 patients (group II) presenting with middle-distal third LAD or RC arterial stenoses, the radial artery (RA) was used to construct the lambda graft. All patients underwent transthoracic echo color Doppler before and after an adenosine test at 1 week and 3 months after operation. RESULTS: There were no hospital deaths. Overall, 47 lambda grafts were constructed. There was no difference between baseline and maximal flows and coronary flow reserve (CFR) between groups. CFR at IMA stems increased in both groups within 3 months versus 1 week [(LIMA)CFR = 2 +/- 0.3 vs 2.3 +/- 0.3 (p = 0.002) and (RIMA)CFR = 2.2 +/- 0.4 vs 2.5 +/- 0.3 (p = 0.009) in group I, and (LIMA)CFR = 2.12 +/- 0.33 vs 2.4 +/- 0.35 (p = 0.005) and (RIMA)CFR = 2.17 +/- 0.32 vs 2.52 +/- 0.26 (p = 0.001) in group II]. At 3 months versus 1 week, the (RIMA)diameter(i) (mm) at rest was 1.69 +/- 0.32 versus 1.48 +/- 0.2 (p = 0.015) in group I and 1.66 +/- 0.3 versus 1.47 + 0.2 (p = 0.01) in group II. At 6 +/- 2.4 months, all patients were free of angina. CONCLUSIONS: These data, almost identical for free LIMA and RA to RIMA using the lambda graft, demonstrate that RIMA flow reserve is adequate for multiple coronary anastomoses irrespective of the second arterial graft.

Arteries↗
PubMed2001

Beating heart myocardial revascularization on extracorporeal circulation in patients with end-stage coronary artery disease.

OBJECTIVES: To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement. METHODS: Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2. RESULTS: Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns). CONCLUSION: In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.

Aged↗
PubMed2001

Respiratory dysfunction after coronary artery bypass grafting employing bilateral internal mammary arteries: the influence of intact pleura.

OBJECTIVE: To evaluate the role of intact pleurae regarding the postoperative respiratory functional status in patients undergoing coronary revascularization employing both internal mammary arteries (IMAs), according to the pedunculated or skeletonized technique (SKT) with opened or intact pleurae. MATERIALS AND METHODS: Using both IMAs, 299 patients underwent elective coronary revascularization. They were randomized and divided into group I (n=82, undergoing IMA harvesting according to the SKT without opening the pleurae); group II (n=186, undergoing IMA harvesting according the pedunculated technique with open pleurae); and group III (n=31, undergoing IMA harvesting according the SKT with incidentally opened pleurae). There were no differences regarding the preoperative patient characteristics and the anaesthetic and surgical management. RESULTS: There were two deaths in group I versus seven in group II and one in group III (P=ns). The number of total arterial myocardial revascularization and arterial composite grafts was significantly higher in groups I and III than in group II, (P<0.001 and P<0.005, respectively). The incidence of postoperative complications was similar between groups. Blood loss of >1000 ml was significantly higher in group II than group I (P<0.028); but the incidence of re-thoracotomy and blood transfusion was similar between groups. The mechanical ventilation time was significantly higher in groups II and III versus group I (P<0.018 and P<0.02, respectively). The incidence of prolonged ventilation (>24 h), pleural effusion, thoracocentesis and atelectasis, resulted in being significantly higher in group II than group I. The incidence of thoracocentesis was significantly higher in group III than group I. The pain score and analgesic requirements at 1-12 h after awakening were significantly higher in groups II and III versus group I, becoming similar after the chest tubes were removed. PaO(2) was significantly higher, and PaCO(2) and FiO(2) were significantly lower in group I than groups II and III at 1 and 4 h before extubation and at 1 and 4 h after extubation. PaO(2) and PaCO(2) became similar between groups at the 5th postoperative day. CONCLUSIONS: According to our results, we may conclude that pleural integrity has beneficial effects on the respiratory functional status after coronary revascularization using both IMAs. A meticulous and more careful IMA harvesting approach significantly reduces the postoperative morbidity regarding the pulmonary functional status, and as a consequence, reduces the hospital costs.

Blood Loss, Surgical↗
PubMed2001

Urgent surgical revascularization of unstable angina. Influence of double mammary arteries.

OBJECTIVE: Aim of this study was to evaluate retrospectively: (1) the outcome in patients with unstable angina (UA) refractory to the medical therapy undergoing urgent-emergent CABG; (2) the influence of both IMAs employment. PATIENTS AND METHODS: Between January 1995 and July 2000, 576 (28.5%) consecutive patients with UA underwent CABG procedure. 182 (31.6%, Group I) patients, presenting unstable hemodynamic or angina pectoris refractory to the maximal medical therapy, underwent urgent/emergent CABG. 397 (68.4%, Group II) patients, after the maximal medical therapy did not present angina's episodes or ECG alterations and underwent elective CABG procedure. Preoperative data were similar in the two groups. Both IMAs were used in 68 (37.4%) patients of I and 152 (38%) of II (P>0.05) to left side revascularization. RESULTS: CAD extension was greater in Group I: 45 (24.7%) patients presented ischemia in >1 area vs 53 (13.5%) in II (P<0.001). Incidence of anteroseptal ischemia resulted significantly higher in I (P=0.017); left main coronary artery stenosis was present in 68 (37%) patients in I vs 108 (27%) in II (P=0.01). LV function resulted significantly depressed in I, demonstrated by a significantly lower LVEF (P<0.001), higher NYHA class (P<0.001) and preoperative incidence of IABP (P<0.001). Intraoperative data analysis did not reveal any difference between groups. Hospital mortality was 13 (7%) and 21 (5.3%) patients in I and II respectively (P=ns). Multivariate analysis of all preoperative and intraoperative variables revealed the age >65 years (P=0.01), congestive heart failure (P<0.001), LVEF<35% (P=0.03), >1 ischemic area (P=0.02) as strong predictors for poor overall survival, and LIMA (P=0.006) and both IMAs (P=0.001) as strong predictors for good overall survival. Actuarial survival at 1, 3 and 5 years resulted to be 98.5, 96.5 and 90% in I and 99, 96 and 92% in II (P=ns). CONCLUSION: CABG has been associated with acceptable outcome in patients with UA which should be applied soonest possible in patients refractory to medical treatment. Total coronary revascularization and employment of both IMAs for left myocardial side are associated with low operative risk and incidence of complications, permit to have acceptable short and long-term outcome in this pool of patients.

Aged↗
PubMed2001

Ischemic mitral valve regurgitation grade II-III: correction in patients with impaired left ventricular function undergoing simultaneous coronary revascularization.

BACKGROUND AND AIM OF THE STUDY: Mitral valve regurgitation (MVR), occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction, is predictive of poor outcome. The study aim was to assess the feasibility of mitral valve surgery concomitant with coronary artery bypass grafting (CABG) in patients with ischemic MVR grade II-III and impaired LV function. METHODS: Between January 1996 and July 2000, 99 patients with grade II and III ischemic MVR and LV ejection fraction (LVEF) 17-30% underwent either combined mitral valve surgery and CABG (group I, n = 49) or isolated CABG (group II, n = 50). LVEF (%), LV end-diastolic diameter (LVEDD; mm), LV end-diastolic pressure (LVEDP; mmHg), LV end-systolic diameter (LVESD; mm) respectively were 27.5+/-5, 67.7+/-7, 27.7+/-4 and 51.4+/-7 in group I versus 27.8+/-4, 67.5+/-6, 27.5+/-5 and 51.2+/-6 in group II. In group I, mitral valve repair was performed in 43 patients (88%) and replacement in six (12%). RESULTS: Preoperative data analysis showed no difference between groups. Five patients (10%) died in group I, compared with six (12%) in group II (p = NS). Within six months of surgery, LV function and geometry improved significantly in group I versus group II (LVEF, p <0.001; LVEDD, p = 0.002; LVESD, p = 0.003, LVEDP, p <0.001); only mild improvements were seen in group II. The regurgitation fraction decreased significantly in group I patients after surgery (p <0.001). Cardiac index increased significantly in groups I and II (p <0.001 and p = 0.03, respectively). In group I at follow up, four of six patients undergoing mitral valve replacement died, compared with five of 43 patients (11.5%) undergoing mitral valve repair (p = 0.007). At three years, the overall survival in group II was significantly lower than in group I (p <0.009). CONCLUSION: Both MV repair and replacement preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcome in terms of morbidity and survival. Surgical correction of grade II-III MVR in patients with impaired LV function should be taken into consideration as it provides better survival and improves LV function.

Actuarial Analysis↗
PubMed2000

Right Y-graft, a new surgical technique using mammary arteries for total myocardial revascularization.

BACKGROUND: We report a new technique that consists of a right Y-graft using only skeletonized internal mammary arteries (IMA) for total arterial myocardial revascularization. METHODS: This technique consists of anastomosing the in situ left IMA (LIMA) and right IMA (RIMA) to the left anterior descending and obtuse marginal artery, via the transverse sinus, respectively. The distal free LIMA was anastomosed to the right coronary artery and afterwards in a Y fashion to the RIMA stem. Eleven patients with triple-vessel disease underwent coronary artery bypass grafting using this technique. Postoperatively and at follow-up all patients underwent color Doppler contrast-enhanced transthoracic echocardiography (TTE) before and after an adenosine provocation test. RESULTS: Overall, 33 IMA-coronary anastomoses were made and 11 right Y-grafts were constructed. At 1 week after operation color Doppler contrast-enhanced TTE before and after the adenosine provocation test, respectively, showed an increase in LIMA stem diameter of 0.31 mm and in mean flow 62 mL/min. Coronary flow reserve (CFR) was 2+/-0.3. The increase in RIMA stem diameter was 0.2 mm and in mean flow was 121.7 mL/min. Coronary flow reserve was 2.5+/-0.4. Only 1 patient demonstrated an anomalous Doppler pattern, suggesting a partial Y-graft closure. CONCLUSIONS: Such a technique permits total myocardial revascularization using only mammary arteries and left ventricular perfusion from both IMAs simultaneously. The color Doppler contrast-enhanced TTE is a rapid, accurate, and noninvasive test allowing a good assessment of IMA patency.

Adenosine↗
PubMed1998

Abdominal aortic aneurysms in heart transplanted patients.

OBJECTIVE: In the AA's opinion, the dilatation of the abdominal aorta is not a contraindication to heart transplantation. METHODS AND MATERIALS: From July 1994 to February 1998, 3 out of 80 heart transplanted patients, required a replacement of their abdominal aorta because of an infrarenal aortic aneurysm. The first patient (62 years old) did not have an aneurysm by time of heart transplantation: his aneurysm (5.1 cm wide) was resected 2 years later. The other two patients (m, 44 years old; m, 60 years old) had a dilatation of 3.1 and 3.5 cm of the abdominal aorta by time of cardiac transplantation: 15 months later, the aneurysms measured 5.8 and 7 cm, respectively, and had been resected. Two resections were performed through a retroperitoneal approach. RESULTS: All 3 patients had uneventful postoperative course. CONCLUSION: Before heart transplantation the aorta must be screened for dilatation or aneurysm, which can be enlarged by operation. Such lesions can be operated on, with low risks, and should not be a contraindication to heart transplantation.

Adult↗
PubMed1997

Characterization of the hyperpolarization-activated current, I(f), in ventricular myocytes from human failing heart.

BACKGROUND: Disease-associated electrophysiological alterations may contribute to the increased predisposition to arrhythmias of the hypertrophied or failing myocardium. An I(f)-like current is expressed in rat left ventricular myocytes (LVMs), its amplitude being linearly related to the severity of cardiac hypertrophy. Here, we report the occurrence and electrophysiological properties of I(f) in human LVMs. METHODS AND RESULTS: LVMs were isolated from hearts of three male patients undergoing cardiac transplantation for terminal heart failure due to ischemic dilated cardiomyopathy. The patch-clamp technique was used to record I(f), ie, a barium-insensitive, cesium-sensitive, time-dependent increasing inward current elicited on hyperpolarization. Membrane capacitance was 244 +/- 27 pF (n = 25). I(f) occurred in all cells tested; its density measured at -120 mV was 2.1 +/- 0.3 pA/pF. Activation curves of I(f) (n = 24) were fitted by a Boltzmann function; the threshold was -55 mV; midpoint, -70.9 +/- 2.1 mV; slope, -5.4 +/- 0.3 mV; and maximal specific conductance, 19.6 +/- 2.5 pS/pF. I(f) blockade by extracellular cesium was voltage dependent. Reducing extracellular potassium concentration from 25 to 5.4 mmol/L caused a shift of the reversal potential from -12.7 +/- 0.5 to -24.8 +/- 2.1 mV and a 64% decrease of current conductance. CONCLUSIONS: I(f) is present in human LVMs. Its electrophysiological characteristics resemble those previously described in hypertrophied rat LVMs and suggest that I(f) could be an arrhythmogenic mechanism in patients with severe heart failure.

Cardiac Output, Low↗