Biomedical subjects

Giuseppe Giordano

Publications and source records attributed to Giuseppe Giordano.

11 recordsLinked to original sources

PubMed2006

Appropriateness of learning curve for carotid artery stenting: an analysis of periprocedural complications.

OBJECTIVES: Cerebral embolism is the first cause of neurologic complications of carotid artery stenting (CAS). A large debate has been raised to identify the caseload necessary for an appropriate learning curve before systematic use of CAS. This study examined (1) the timing of periprocedural complications during CAS and how these complications vary over time to identify factors that contribute to neurologic morbidity and (2) a sufficient number of procedures for adequate training. METHODS: During 2001 to 2006, 627 CAS procedures with cerebral protection devices (CPD) were performed in a single vascular surgery center by a team including a vascular surgeon and an interventional radiologist. These represented 38% of a total of 1598 carotid revascularizations performed in the same interval. CAS procedures were divided into two groups according to time interval: the first period, 2001 to 2003, included 195 CAS procedures, and the second period, 2004 to 2006, included 432 CAS procedures. During each CAS procedure, five major steps were considered: phase 1, or the catheterization phase, included the passage of the aortic arch, catheterization of the target vessel, and introduction of a guiding catheter or sheath. Phase 2, or the crossing stenosis phase, included the placement of a CPD. Phase 3, or the stent ballooning phase, included predilation (when indicated), stent implantation, postdilation, and recovery of the protection system. Phase 4, or the early postinterventional phase, included the first 24 hours after leaving the catheterization table. Phase 5, or the late postinterventional phase, included the interval from the first postoperative day to 30 days. RESULTS: At 30 days, 10 major strokes (2 of which were fatal) and 1 cardiac death occurred, for an overall major stroke/death rate of 1.75%. Furthermore, 18 minor strokes (2.9%) were recorded. By analyzing the occurrence of major strokes according to the three intraprocedural phases, four occurred in phase 1 and six in phase 3. All strokes but one were ischemic; six were ipsilateral, three were contralateral, and one was posterior. Minor strokes occurred prevalently after the procedure (11 in phase 4, 5 in phase 5, and 1 for phases 1 and 3). Comparing the first with the second interval of the study period, the 30-day major stroke and death rate decreased from 3.1% to 0.9% (P = .047), and the 30-day any stroke and death rate decreased from 8.2% to 2.7% (P = .005). According to multivariate analysis, study interval (hazard ratio, 3.68; 95% confidence interval, 1.49-9.01; P = .005) and age (hazard ratio, 1.06; 95% confidence interval, 1.00-1.12; P = .05) were significant predictors of stroke. CONCLUSIONS: A large proportion of major strokes (4/10) from CAS cannot be prevented by using CPD, because these strokes occur during catheterization (phase 1). This finding, together with the significant decrease in the overall stroke/death rate between the first and the last interval of the study period, enhances the importance of an appropriate learning curve that involves a caseload larger than that generally accepted for credentialing. The noticeable number of postprocedural cerebral embolizations leading to minor strokes and occurring in the early and late postinterventional phases (16/18) is likely due to factors less strictly related to the learning-curve effect, such as stent design and medical therapy. Moreover, expertise in selecting material and design of the stents according to different vessel morphology, in association with correct medical treatment, may be useful in reducing the number of minor strokes that occur in the later postinterventional phases of CAS.

Age Distribution↗

PubMed2006

Outcome of carotid stenting versus endarterectomy: a case-control study.

BACKGROUND AND PURPOSE: To compare perioperative and midterm results of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in similar cohorts of patients, a retrospectively matched case-control study was performed. METHODS: Three hundred and one case subjects undergoing CAS with cerebral protection and 301 concurrent matched-controls undergoing CEA were examined. Matching was by sex, age (+/-2 years), symptoms and coronary disease. RESULTS: The 30-day disabling stroke/death rate was 2.6% in the CAS group versus 1.3% in the CEA group (odds ratio [OR] 2; 95% CI, 0.54 to 9.35; P=0.4). CAS patients had a significantly higher risk of periprocedural stroke (7.9% versus 2.3%; OR, 5.2; 95% CI, 1.7 to 18; P=0.001) than CEA patients. However, there was a decreasing trend in 30-day neurological event rates for the last 201 CAS matched cases: 5.4% versus 1.9% (OR 2.8; 95% CI, 0.8 to 10.2; P=0.1). Fifty percent of CAS disabling strokes occurred during cannulation of epiaortic vessels before placement of cerebral protection. Conditional multivariate analysis revealed CAS as a predictor of 30-day stroke (hazard ratios [HR] 3.9; 95% CI, 1.6 to 9.4; P=0.002) but not of 30-day disabling stroke/death (HR 3.6; 95% CI, 0.93 to 13.9; P=0.06). Restenosis free intervals at 36 months were 93.6% versus 92.1% for CAS and CEA, respectively, (P=0.6). CONCLUSIONS: When comparing CAS with CEA, the risk of any neurological events is still higher, particularly during catheterism and ballooning. The effect of the learning curve related to technical expertise and patient selection may influence the outcome of CAS versus CEA. In the midterm the restenosis rate of CAS compares favorably to CEA.

Aged↗

PubMed2006

Method for the quantification of underivatized amino acids on dry blood spots from newborn screening by HPLC-ESI-MS/MS.

In our study we have developed an HPLC-ESI-MS/MS method for qualitative and quantitative analysis of underivatized amino acids on dry blood spots. The sensitive and specific instrumental performances permitted the chromatographic separation of 40 amino acids and their isomers within 10 min. The method has been set up for cases of suspected metabolic diseases revealed by newborn screening. What is new is that it is applied on the same blood spots used for newborn screening, instead of plasma, in order to avoid involvement of doctors, increased anxiety for parents, stress for patients for plasma collection, long time of waiting and further costs for analysis.

Amino Acids↗

PubMed2006

Identification of an unusual naturally occurring apolar fatty acid amide in mammalian brain and a method for its quantitative determination.

Fatty acid amides (FAAs), such as the N-acylamides, N-acylethanolamides, N-acyldopamines and N-acylamino acids, are now emerging as an important new class of lipid-signalling molecules. This paper provides evidence, based on high-performance liquid chromatography/electrospray ionisation mass spectrometry (HPLC/ESI-MS/MS), gas chromatography/mass spectrometry (GC/MS) and 1H-NMR, of the occurrence in mouse and bovine brain extracts of a compound characterised by a mass spectrum attributable to a FAA not previously described, namely, the isopropyl-amide of stearic acid (SIPA). A highly sensitive GC/MS method was developed for quantification of naturally occurring SIPA and, also, for purposes of comparison, that of palmitoylethanolamide (PEA), a structurally related compound commonly determined in animal tissues. The results obtained show that SIPA levels in mouse brain are 8-10-fold higher than those of PEA. Moreover, SIPA was found in human neuroblastoma cell (SHSY-5Y) extracts, at significantly higher levels following exposure of the cells to the mitochondrial inhibitor rotenone. All this evidence not only shows surprisingly that SIPA may be found naturally in mammalian biological extracts despite the unusual functional group (i.e. isopropylamide) implicated, but also raises many important questions concerning its biological origin.

Animals↗

PubMed2004

Eversion versus conventional endarterectomy.

Changes in surgical techniques may affect outcomes of carotid endarterectomy (CEA). Numerous studies have attempted to determine whether eversion CEA is safer and more effective than conventional CEA. Randomized controlled trials comparing eversion to conventional technique for CEA have been identified and systematically analyzed by the Cochrane Stroke Review Group database. Outcomes included stroke and death, carotid restenosis/occlusion, and local complications. There is evidence that eversion CEA is an effective surgical option comparable to conventional CEA. In literature no differences were found between eversion CEA and conventional CEA with respect to operative morbidity and mortality. Evidence-based data indicated that eversion CEA had a lower restenosis rate than conventional CEA with primary closure techniques, however, no differences in late stroke-free survival rate and superior long-term durability when compared to patch closure were found. Recent studies, as well as our single center experience, indicate that shunt use in eversion CEA is feasible with comparable complication rate versus use of shunt in conventional CEA, although it may require specific experience with the technique.

Aged↗

PubMed2003

Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable stent-grafts.

OBJECTIVE: Several studies have suggested that proximal aortic neck dilatation (AND) is a frequent event after balloon-expandable endografting. Yet few data are available on AND after repair with self-expandable stent grafts. To investigate incidence, predictive factors, and clinical consequences of AND, computed tomography (CT) scans obtained at intervals during follow-up of 230 patients who had undergone endoluminal abdominal aortic aneurysm (AAA) repair with self-expandable stents were reviewed. SUBJECTS: Between April 1997 and March 2001, 318 patients underwent endoluminal AAA repair with a self-expandable endograft at our unit. CT scans obtained at 1 and 12 months after surgery and yearly thereafter were prospectively stored in a computer imaging data base. Two hundred thirty patients were available for minimum 1-year assessment. Two vascular surgeons with tested interobserver agreement reviewed 686 CT scans. Diameter of the proximal aortic neck was measured as the minor axis of the first CT section that contained at least half of the proximal portion of the endograft. For endografts with suprarenal attachment the first scan below the lowest renal artery was considered. Diameter change of 3 mm or more between the CT scan at 1 month and subsequent evaluations was defined as AND. Nine possible independent predictors of AND were analyzed with Cox regression analysis. RESULTS: Median follow-up was 24 months (range, 12-54 months). In 2 patients, AAA ruptured during follow-up. CT scans for 65 patients (28%) showed AND. Thirteen patients with AND (5.6%) underwent repeat intervention, including positioning of the proximal cuff in 8 patients and late conversion to open repair in five patients. Of the nine variables examined with multivariate analysis, only 3, ie, presence of neck circumferential thrombus (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.26-5.01; P =.008), preoperative proximal neck diameter (HR, 1.21; 95% CI, 1.07-135; P =.001), and preoperative AAA diameter (HR, 1.03; 95% CI, 1.00-1.06; P =.046) were positive independent predictors of AND, whereas the other 6, ie, neck angulation more than 60 degrees, neck length, suprarenal fixation, oversizing more than 15%, endoleak at 30 days, and increased AAA diameter during follow-up, showed no significant correlation. Probability of AND at 48 months was 59 +/- 6.1 at analysis with the Kaplan-Meier method. CONCLUSIONS: AND is a frequent sequela of endoluminal repair in the mid-term. Severe AND developed in a small percentage of our patients, compromising integrity of AAA repair. Patients with large aneurysms and aortic necks and patients with aortic neck circumferential thrombus are at high risk for aortic neck enlargement after endoluminal repair of AAA.

Aortic Aneurysm, Abdominal↗

PubMed2002

Protein turnover, lipolysis, and endogenous hormonal secretion in critically ill children.

OBJECTIVES: The catabolic state is a major contributor to morbidity and mortality of critical illness and may be related to endocrine changes. We studied whether protein and lipid turnover correlate with insulin and growth and thyroid hormone plasma levels in critically ill infants. DESIGN: Prospective clinical study. SETTING: Pediatric intensive care unit. PATIENTS: Twelve critically ill children and ten age-matched controls. MEASUREMENTS: We measured lipolysis and protein turnover by infusing albumin-bound uniformly 13C palmitic acid and 2H3-leucine for 3 hrs and 2H5-glycerol for 5 hrs to critically ill infants. Simultaneously, we measured serum growth hormones, insulin, C-peptide, thyroid-stimulating hormone, T4, T3, albumin, retinol binding protein (RBP), and prealbumin. Hormone and serum protein levels were also measured in six children when recovered from critical illness. Ten healthy age-matched children served as controls for hormone serum levels comparison. RESULTS: Palmitic acid and glycerol turnover were 5.6 +/- 2.2 micromol/kg/min and 12.2 +/- 7.3 micromol/kg/min, respectively, whereas alpha-ketoisocaproic turnover was 4.9 +/- 2.8 micromol/kg/min. Alpha-ketoisocaproic turnover positively correlated (R = 0.7, p = .03) with duration of pediatric intensive care unit admission and with prealbumin and RBP serum levels (R = 0.9, p = .001). Insulin-like growth factor binding protein (IGFBP)-2 was significantly higher and IGFBP-3 was significantly lower in critically ill children (p = .03 and p = .04 vs. recovery phase, respectively). No other hormonal differences were found. Serum albumin was significantly lower in sick children. We found a significant correlation between prealbumin and RBP and IGFBP-3 (R = 0.6, p = 0.03 and R = 0.6, p = .04, respectively). Alpha-ketoisocaproic turnover positively correlated with IGFBP-1 (R = 0.79, p = .01) and did not correlate with insulin-like growth factor I (R = -0.5, p = .15 [not significant]) No other correlations were found. Lipid turnover measurements did not correlate with any endogenous hormone levels or with duration of critical illness. CONCLUSION: Protein turnover but not lipolysis correlated with a persisting critically ill condition, serum prealbumin, RBP, and plasma IGFBP-1.

C-Peptide↗

PubMedDate not supplied

[Unusual case of malignant pleomorphic fibrohistiocytoma of the abdominal wall].

The authors report their experience with a case of a voluminous malignant pleomorphic histiocytoma of the anterior abdominal wall occurring in an 81-year-old female patient. She presented with a one-year history of a non-painful, poorly mobile tumefaction which had grown in size over the 2 months prior to admission. A preoperative CT scan confirmed the presence of a 10-cm mass located in the anterior abdominal wall. The patient underwent resection of the tumour and was discharged on postoperative day 15. A 12-month follow-up has so far revealed no evidence of recurrence. The authors go on to examine the diagnostic and therapeutic treatments of these rare neoplasms with reference to the international scientific literature. They confirm the validity of radiotherapy but stress the elective role of surgical treatment.

Abdominal Wall↗

PubMedDate not supplied

[Prosthetic treatment in inoperable cancers of the oesophagus and cardia: a report of 7 cases].

The Authors report their personal experience with 9 patients affected by cardial cancer and 4 with medio-distal oesophageal cancer, treated at the Department of Surgical Sciences of the University of Foggia. Of the 9 patients with cardial cancers, 4 were submitted to total gastrectomy; while the other 5, who had clearly inoperable forms, were fitted with a self-expanding metal prosthesis (Ultraflex). Of the 4 cases with medio-distal oesophageal cancers, which were considered beyond any kind of surgical treatment, 2 (with stenosing forms) were fitted with the self-expanding prosthesis (Ultraflex), while the other 2 (with friable, bleeding tissue) were treated by laser therapy with all the drawbacks such treatment entails. After application of stents, dysphagia decreases and on the whole we obtain real functional success and a better quality of life. Furthermore, the percentage of acute complications such as profuse bleeding, perforation of the pharynx or migration of the prosthesis and late complications such as obstruction by food, neoplastic obstruction, or haemorrhage is marginal. Finally, the ease of application and the economic saving achieved (due to reduction in hospitalisation time and charges) confer undeniable additional advantages on the procedure.

Carcinoma↗

PubMedDate not supplied

[Esophago-pharyngeal diverticulum: a case report].

The Authors report a case of Zenker's diverticulum seen and treated at the University Department of Surgical Sciences of the University of Foggia. The treatment of this condition is invariably surgical and consists in a diverticulectomy combined with a lengthwise extramucosal myotomy. This latter technical adjunct, however, would not appear to be accepted by all Authors. Other techniques have been proposed for the treatment of this condition, but no confirmation of their efficacy exists in the literature. Mortality fluctuates in the various case series, from 0.45% to 8.1%, and the morbidity varies from 5.3% to 40%. The risk of postoperative complications is always present, but can be reduced if the patient undergoes a thorough preoperative investigation.

Aged↗

PubMedDate not supplied

[Ramirez abdominoplasty for large incisional hernia: personal experience].

The Authors report their experience with the surgical treatment of incisional hernias over the period from July 2000 to June 2004 in the Division of General Surgery of the Department of Surgical Sciences of the University of Foggia where 22 patients were operated on. Nine of them had an incisional hernia of considerable size, while in the other 13 patients the hernia was less voluminous. The authors emphasise the essential role of synthetic prostheses (polypropylene) which now replace and supersede the reabsorbable ones which have fallen into disuse due to the lack of guarantees regarding their strength over lengthy periods. An interdisciplinary approach is now mandatory for a pathology which requires the contribution of many different healthcare operatives such as cardiologists, respiratory physiopathologists, physiokinesitherapists, endocrinologists and resuscitators who all share in the work of the surgeon who represents the last link in the chain and has the technical task of resolving the basic pathology. The technique adopted for the larger incisional hernias was a Ramirez abdominoplasty, the first step of which consists in a very meticulous separation of the different structures of the abdominal wall followed by synthesis of the different anatomical layers with the application of polypropylene meshes. Our results in terms of intra- and postoperative mortality, complicating diseases and hospitalisation are compared with those reported in other studies using the Rives technique.

Abdominal Wall↗