New surgical procedures: can we minimise the learning curve?
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Adolescent↗
Biomedical subjects
M Pozzi
Publications and source records attributed to M Pozzi.
Tetralogy of Fallot: what operation, at which age.
BACKGROUND: The optimal management of tetralogy of Fallot is still under debate, particularly with respect to surgical approach and the age of operation. In recent times a transatrial-transpulmonary approach and primary repair in younger patients is favoured. The purpose of the present study was to analyze the result of our current surgical management by assessing the perioperative and intermediate term follow up in order to define the optimal strategy and timing of operation for our institution. METHODS: One hundred and thirty two patients with tetralogy of Fallot who underwent definitive repair between May 1993 and December 1998 were analyzed by reviewing their medical records and follow-up. Median age was 15. 5 (2.3-68.6) months and median weight was 8.8 (5-16) kg. Ten (7.57%) patients were under 6 months, 38 (28.78%) were between 6 and 12 months, 36 (27.27%) were between 12 and 18 months, 23 (17.42%) were between 18 and 24 months and 25 (18.93%) were more than 24 months age. During the study period there was a move to earlier surgery and differing methods of repair depending on the anatomy observed. Follow up was conducted by the referring cardiologist. Median follow up was 35.48 (8.07-74.93) months. RESULTS: Forty-two (31.8%) patients required a palliative procedure before total correction due to unfavourable anatomy. Subpulmonary infundibular obstruction with a fibrous component increased significantly with age (P<0.05). Operations were entirely transatrial in 14 (10.6%), transatrial and transpulmonary in 69 (52.2%), transatrial and transventricularly in 42 (31.8%) and a homograft conduit was used in seven (5.3%) patients. Younger patients had narrower pulmonary valves and required a transannular patch more frequently. All patients were in sinus rhythm, 28 (21.1%) showing right bundle branch block. Median hospital stay was 8 (5-54) days. No patient required reintervention during follow up and there was no early or late mortality. CONCLUSION: Correction of tetralogy of Fallot at younger age does not increase morbidity or mortality and has potential advantages. A surgical technique adapted to the anatomy of the right ventricular outflow tract, achieves the best results.
Age Factors↗
Cytogenetic and ultrastructural study of a pineocytoma case report.
The authors report a case of pineocytoma in a 44-year-old woman suffering from headache, vomiting and Parinaud syndrome. At histopathological examination the neoplasm showed a ill-defined lobulate pattern with some small pineocytomatous rosettes. The electron-microscopy revealed cells of moderate size and oval nuclei with smooth nuclear envelopes; well-developed organelles were found in the, abundant cytoplasm. The chromosome analysis revealed this kariotype: 58-59, XXX, -4, -5, -13, - 14, -15, + 19. This is the first report of a pineocytoma with ultrastructural and cytogenetic study; it confirms the literature findings of the electron-microscopy, whereas there is partial accordance with the previous cytogenetic studies.
Adult↗
Enoximone pharmacokinetics in infants.
Enoximone and enoximone sulphoxide concentrations were measured in plasma of 20 infants, median age 6.0 (range 0.6-49.7) weeks, during and after prolonged continuous infusions. Patients were given enoximone 1 mg kg-1 and an infusion at 10 micrograms kg-1 min-1 just before being weaned from cardiopulmonary bypass (CPB). The infusion was stopped when clinically indicated, after a median 97 (range 24-572) h. Arterial blood samples were taken 30 min and 12 h after CPB, every 24 h during the infusion, and then 2, 4, 8, 12 and 24 h after the infusion was stopped. Pharmacokinetic non-compartmental analysis was performed using TOPFIT software. Fourteen patients who retained normal hepatic function had a median (95% confidence intervals) clearance of 9.7 (6.3-14.1) ml min-1 kg-1, elimination half-life of 5.2 (2.4-6.8) h and a volume of distribution of 3.6 (2.0-5.7) litre kg-1. The six patients with significant hepatic dysfunction had a lower clearance, 5.7 (2.4-14.5) ml min-1 kg-1, and significantly longer elimination half-life, 7.6 (6.5-10.9) h (P = 0.02). Enoximone sulphoxide elimination half-life was significantly prolonged in three patients with renal dysfunction, 16.2 (10.5-17.7) h versus 6.9 (6.1-9.4) h (P = 0.03). These results confirm that enoximone pharmacokinetics in infants is similar to that found in adults. The infusion rate of enoximone should be reduced if hepatic or renal dysfunction supervenes.
Enoximone↗
A placebo-controlled study of the effects of dopexamine on gastric mucosal perfusion in infants undergoing hypothermic cardiopulmonary bypass.
We used a laser Doppler probe to measure gastric mucosal blood flow (flux) and a paediatric tonometer to intermittently calculate gastric-arterial PCO2 difference (PrCO2-PaCO2 gap) in 50 infants aged 0.3-52 weeks who required hypothermic cardiopulmonary bypass (CPB). During CPB, patients in group 2 (n = 25) were given dopexamine 1.0 mg kg-1 over 5 min, followed by an infusion of 2 micrograms kg-1 min-1. Patients in group 1 (n = 25) received an equal volume of saline. Drug allocation was random and blinded. Measurements of flux, PrCO2-PaCO2 gap and mean femoral arterial pressure (MAP) were made over 5 min during steady state before and after cooling on CPB to 18-24 degrees C. MAP and blood lactate concentrations were similar in both groups throughout CPB. Mean flux decreased from 182 (SD 60) at the beginning of CPB to 158 (51) after rewarming on CPB in group 1, whereas it increased from 180 (56) to 196 (49) in group 2. This post-rewarm flux was significantly greater in group 2 than in group 1 (P = 0.01). Similarly, mean PrCO2-PaCO2 gap increased significantly from 3.6 (6.3) to 8.2 (6.7) in group 1 (P = 0.01) compared with a significant decrease from 5.8 (5.5) to 2.1 (5.5) in group 2 (P = 0.02). Mean PrCO2-PaCO2 gap after rewarming in group 2 was significantly higher than that in group 1 (P = 0.001). These data indicate that dopexamine may be useful in maintaining normal gut perfusion in infants requiring hypothermic CPB.
Adrenergic beta-Agonists↗
Depression during interferon therapy for chronic viral hepatitis: early identification of patients at risk by means of a computerized test.
OBJECTIVES: At the doses used for the treatment of chronic viral hepatitis, interferon (IFN)-related side-effects are usually modest, even though in some cases they require the interruption of therapy. Neuropsychiatric disturbances that range from modest depression and irritability to forms of manic-depressive psychosis and attempted or successful suicides are among the most important side-effects. The aim of our study was to determine whether the Minnesota Multiphasic Personality Inventory (MMPI) is a sensitive and reliable test for the early identification of patients at risk of depression before IFN therapy is commenced, and whether it could be useful for the monitoring of these patients during treatment. METHODS: We prospectively studied 67 patients with chronic active liver diseases, consecutively enrolled in open studies and treated with r-IFNalpha2. Before starting therapy and after 3 months of treatment, all patients underwent a clinical neurological evaluation and MMPI. RESULTS: At baseline, the correlation between the clinical evaluation and the score of the depression scale of the MMPI was statistically significant (P< 0.0001). Nine of 14 (64.3%) patients with a baseline score > or = 60/100 showed a depressive mood after 3 months of therapy. Five of 44 patients (11.3%) with a baseline score < 60/100 showed a depression of medium level after 3 months of treatment. This difference was highly significant (P< 0.0001). CONCLUSIONS: According to our results, the MMPI is a reliable and sensitive test for the early identification of patients at risk of depression before and during IFN therapy for chronic viral liver diseases.
Adult↗
Intraaortic balloon pumping in children.
BACKGROUND: Intraaortic balloon pump (IABP) usage in young children remains a rarity because, first, there is a widespread misconception that the greater elasticity of the aorta in children may prevent effective augmentation, and second, children in low cardiac output states are more likely to have associated right ventricular failure and pulmonary problems. We report our experience with the use of IABP in children undergoing cardiac surgery in whom mechanical support was necessary for the treatment of refractory cardiac failure. METHODS: Over a 3-year period, 14 children were identified as requiring IABP support after cardiac surgery. Their median age was 3 years (range 7 days to 13 years) and their median weight was 13.3 kg (range 3.5-51 kg). Indications for IABP use were: failure to wean from cardiopulmonary bypass (5 patients), sudden deterioration in intensive therapy unit (ITU) (3 patients), progressive deterioration in ITU (4 patients), and prophylactic therapy for known poor preoperative ventricular function (2 patients). RESULTS: Ten of 14 patients (71%) were successfully weaned from the IABP, of whom 8 became long-term survivors (57%). Among the survivors, the mean duration of IABP usage was 127 h (range 12-260 h), while for those who died while on IABP, the mean duration was 15 h (range 8-24 h). The most major IABP-related complication encountered was mesenteric ischemia, which had a fatal outcome. CONCLUSIONS: IABP therapy, used as an adjunct to conventional medical treatment, can give properly selected young children in refractory low cardiac output states after heart surgery a greater than 50% chance of long-term survival.
Cardiopulmonary Bypass↗
Early effects of total paracentesis and albumin infusion on muscle sympathetic nerve activity in cirrhotic patients with tense ascites.
BACKGROUND/AIMS: Cirrhotic patients with ascites are characterized by a marked activation of the sympathetic and the renin-angiotensin-aldosterone system. Total paracentesis is associated with a short-lived suppression of the renin-angiotensin-aldosterone system. Little information exists as to whether this favourable effect is parallelled by sympathoinhibition. METHODS: In 16 Child C cirrhotic patients (age: 57.1+/-6.2 years, mean+/-SEM) with tense ascites we assessed the time course of the effects of total paracentesis followed by intravenous albumin (6-8 g/l of ascites) on beat-to-beat mean arterial pressure (Finapres), heart rate, plasma norepinephrine, epinephrine (high performance liquid chromatography) and muscle sympathetic nerve activity (microneurography, peroneal nerve). Measurements were obtained under baseline conditions, during staged removal of ascitic fluid (250 ml/min) and 24 h later. The patient remained supine throughout the study period. RESULTS: Total paracentesis (10.6+/-1.3 l) induced a decrease in mean arterial pressure (from 95.0+/-2.6 mmHg to 88.2+/-3.2 mmHg, p<0.01), in heart rate (from 82.5+/-3.3 beats/min to 77.1+/-2.8 beats/min, p<0.01) and a reduction in plasma norepinephrine values (from 782+/-133 pg/ml to 624+/-103 pg/ml, p<0.01), which were substantially maintained 24 h later. In eight patients muscle sympathetic nerve activity did not change during paracentesis (from 65+/-7.1 bursts/min to 65+/-7.4 bursts/min, p=NS), but a marked reduction was observed 24 h later (48.4+/-5.6 bursts/min, p<0.01). CONCLUSIONS: These data provide the first evidence that total paracentesis exerts an acute marked sympathoinhibitory effect. Whether this is a long-lasting phenomenon and to what extent plasma expansion with albumin contributes to this effects need to be further addressed.
Adult↗
[HPV infection as a disease of couples. Prevalence of the infection in the male partner].
BACKGROUND: The role of males who are sexual partners of females with genital human papillomavirus (HPV) infection and premalignant lesions is explored in the present study. METHODS: In a period of 6 years, 845 females with genital premalignant and HPV-associated lesions were examined and treated at the Sexual Transmitted Disease Center of S. Gallicano Hospital. The male partners of were asked to attend this Center, and 163 (70%) of them responded. All participants underwent sexual anamnesis, genital inspection and colposcopic examination. RESULTS: Macroscopic lesions were found in 7.4% of the males enrolled. The colposcopic prevalence of HPV infection among the male partners was 21.8% 3 months later among 28 negative patients to the first colposcopic control, 2 were found positive. CONCLUSIONS: These data confirm that the colposcopic evaluation of male partners during an HPV infection of the couple is to be considered for the therapeutic assessment and evolution control of the infection in each couple.
Colposcopy↗
Age as a risk factor in cervicofacial reconstruction.
The Authors report their experience from January 1980 to January 1998 with 392 reconstructive flaps for the oncological reconstruction of the cervicofacial district. One hundred and forty-two were conventional flaps, 187 were myocutaneous or pedicled muscular ones and 63 were microvascular. Ninety percent of the patients had Stage IV disease, 80% were tumors involving the oral cavity structures, 40% of the patients had received preoperative radiotherapy; 35% of the cases were recurrences. The complications related to the surgery were evaluated for each type of flap, comparing them to the same flaps employed in patients > 70. Complications were divided into major and minor that were observed at an overall rate of 22%. With the use of conventional flaps, there was an 11.3% rate of minor complications and a 5.6% rate of major ones. Examining the 187 myocutaneous or pedicled muscular flaps, 21% of the overall 27% were minor and 6% were major complications. Of the remaining 63 free flaps, minor complications were observed in 4.7% and major complications in 14.2% of cases. Thirty-four of the 392 flaps, 24 of which were myocutaneous or pedicled muscular and 10 free flaps, were utilized in elderly patients and compared with the 216 of the same type, in patients < 70. A comparative analysis shows that there was a major complication rate of 11.7% in the flaps employed on the elderly patients as opposed to 7.9% for those employed in the younger patients. In terms of minor complications, a 20.5% complication rate was observed for those > 70 as opposed to 16.7% for patients < 70. A more detailed analysis of these data, enabled to postulate that the smaller group of flaps used in elderly patients is statistically influenced by the "dilution" of the complication rate in favour of the larger group of younger patients. Furthermore, by appropriately correcting the risk factors due to concomitant diseases that were not related to surgery in the older patients, a realignment of the results may be seen. Therefore, a careful preoperative study must be carried out in the elderly patients with cervicofacial tumors who are eligible for surgery to establish and possibly treat the concomitant disease responsible for the increased peri- and postoperative morbidity. In conclusion, complications in elderly patients are correlated to the state of co-morbidity and neither to age nor to the duration of the operation. Responsiveness may therefore be obtained also in elderly patients employing sophisticated techniques such as microvascular flaps.
Aged↗
The Ross procedure in children under ten years of age.
BACKGROUND AND AIMS OF THE STUDY: The potential advantages of the Ross procedure in children under 10 years of age have yet to be validated. Concerns remain regarding progressive dilatation of the pulmonary autograft and potential homograft stenosis. We present our experience in this age population. METHODS: A retrospective analysis of aortic root replacement using the Ross procedure in 11 young children (nine males, two females; median age 84 months; range 3 months to 10 years) between January 1996 and January 1999 was performed jointly in two pediatric surgical centers. RESULTS: There were no operative deaths. Mean hospital stay was 12 +/- 4 days, and mean follow up 14.5 +/- 8 months. The event-free survival (death, reoperation, endocarditis, arrhythmia) was 100%. Currently, nine children are in NYHA functional class I, and two in class II. The autograft and homograft were evaluated by serial echocardiography. There was no sign of progressive dilatation of the autograft. Aortic regurgitation was trivial in four children and mild in seven. No growth of the autograft was noted; this was consistent with minimal somatic growth. Homograft peak gradients remained low during the follow up. CONCLUSIONS: Although the pulmonary autograft procedure is more complex than other types of aortic valve replacement, it can be safely applied in children. Early follow up indicates satisfactory performance of the autograft. If dilatation will not occur, pulmonary root autograft may be an attractive substitute for diseased aortic valves in children.
Aortic Valve↗
Vulvar squamous carcinoma: prognostic role of DNA content.
DNA nuclear content was evaluated on 46 paraffin-embedded blocks of vulvar cancer by means of flow cytometry. Fifteen of 44 evaluable samples (34%) were found to have an aneuploid DNA pattern. Aneuplody showed a statistically significant relationship with tumor grading (P = 0.0004) and defined a subset of patients who have pathological characteristics of high risk, such as advanced stage of disease, deepest stromal invasion, or positive inguinal nodes. However, when a multivariate regression model was used, ploidy status did not have any prognostic role, while FIGO staging system was confirmed to be the strongest independent prognostic factor (P = 0.009). The integration of a panel of cell kinetic parameters with traditional features is worth investigating on a larger population.
Adult↗
Intraaortic balloon pump after treatment of anomalous origin of left coronary artery.
The same system of intraaortic balloon pumping has been used in 2 infants after surgical repair of anomalous origin of the left coronary artery from the main pulmonary artery. Intraaortic balloon pumping was started in the first patient on the second postoperative day, whereas in the second patient it was started before the patient was weaned from cardiopulmonary bypass. Both patients survived. In the first patient intraaortic balloon pumping improved the low cardiac output, which had failed to respond to maximal inotropic support, whereas in the second it maintained hemodynamic stability.
Cardiac Output, Low↗
HCV genotypes in Northern Italy: a survey of 1368 histologically proven chronic hepatitis C patients.
BACKGROUND/AIMS: Hepatitis C virus (HCV) easily undergoes genomic changes, thus accounting for the presence of different genotypes, with different geographic distributions and different outcomes of chronic hepatitis. Type 1b is frequently found in advanced diseases; however, since this genotype is the most prevalent in older patients, the association with advanced age and severity of the disease is confounding. The aim of this study was to assess changes in the prevalence of HCV genotypes by surveying a large population of chronic hepatitis C patients in Northern Italy, and to assess if the high prevalence of genotype 1b in older patients with advanced diseases simply reflects the duration of HCV infection, rather than intrinsic biological properties of HCV. METHODS: We studied 1368 HCV-RNA positive patients, with histologically proven chronic hepatitis. Drug addiction, blood transfusions and sporadically acquired infections represented the risk factors. RESULTS: Genotype 1b, the most prevalent isolate, and genotype 2a were associated with older age, cirrhosis, sporadically-acquired infections and blood transfusion, while types 1a, 3a, and 4 were associated with younger age, chronic persistent hepatitis and drug addiction. Patients with a history of transfusions were divided into four groups depending on the period of transfusion. The prevalence of genotype 1b decreased with time. Type 3a appeared only after 1979. CONCLUSION: The severity of chronic hepatitis C could be related more to the duration of the infection rather than to the intrinsic pathogenicity of HCV genotypes.
Adolescent↗
HCV genotypes and breakthrough in patients treated with recombinant alpha interferon.
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Adolescent↗
Persistent damage to Enterocytozoon bieneusi, with persistent symptomatic relief, after combined furazolidone and albendazole in AIDS patients.
AIM: To investigate morphological changes in Enterocytozoon bieneusi and the duration of symptomatic relief after combination treatment with furazolidone and albendazole in AIDS patients. METHODS: Four severely immunocompromised AIDS patients with symptomatic E bieneusi infection of the gut received an 18 day course of combined furazolidone and albendazole (500 + 800 mg daily). All patients were monitored for parasite shedding in stool by light microscopy at the end of treatment and monthly during follow up. At the end of treatment, duodenal biopsy specimens obtained from three patients were studied by transmission electron microscopy by two pathologists blind to the patients' treatment or clinical outcome. Duodenal biopsy specimens obtained from one of the patients two months after completion of treatment were also studied electronmicroscopically. RESULTS: All patients had long lasting symptomatic relief, with a major decrease--or transient absence--of spore shedding in stools from completion of treatment. After treatment, changes in faecal spores were persistently found by light microscopy in all cases, and there was evidence of both a substantial decrease in the parasite load and ultrastructural damage in the parasite in all biopsy specimens. The treatment was well tolerated, and no patient had clinical or parasitological relapse during follow up (up to 15 months). CONCLUSIONS: The long lasting symptomatic relief observed in all four treated patients correlated with the persistent decrease in parasite load both in tissue and in stool, and with the morphological changes observed in the life cycle of the protozoan. These data suggest that combined treatment with furazolidone and albendazole is active against E bieneusi and may result in lasting remission even in severely immunocompromised patients.
AIDS-Related Opportunistic Infections↗
Chronic cryptosporidiosis in patients with AIDS: stable remission and possible eradication after long-term, low dose azithromycin.
AIMS: To investigate the effectiveness of long term, low dose azithromycin treatment for chronic cryptosporidiosis in patients with AIDS. METHODS: Azithromycin was administered as initial daily treatment to 13 patients with AIDS: 6 patients received 500 mg for 30 to 40 days (mean 35); 3 patients received 1000 mg for 21 to 50 days (mean 37); and 4 patients received 1500 mg for 20 days. Nine of the 13 patients were also given low dose maintenance treatment with different schedules of azithromycin for 30 to 360 days (mean 129). Patients were monitored, during and after treatment, for parasite shedding in stool and for daily stool frequency and body weight. All but one patient had severe immunodeficiency. RESULTS: Long term, low dose maintenance treatment was associated with major clinical and parasitological benefits: there was probable eradication of infection in 2 patients, and 7 patients showed a complete response with persistent high decrease (5 patients) or clearance (2 patients) of parasite in stool. The drug was well tolerated, and there was no relapse either during treatment or during follow up (up to 21 months). These results were more impressive than those observed after the short term initial course of azithromycin, which was unable at any tested dose to achieve parasite clearance in stool (except in the patient with less advanced immunodeficiency) or to prevent relapse in 3 patients who discontinued treatment. Reversible side effects occurred with the 1500 mg daily dose. CONCLUSIONS: Long term, low dose azithromycin is well tolerated and may induce stable remission of chronic cryptosporidiosis in patients with AIDS. It may lead to probable eradication of the infection in some patients, even those with severe immunodeficiency.
AIDS-Related Opportunistic Infections↗
Thromboembolism leading to myocardial ischaemia in a patient requiring a fenestrated Fontan operation.
We report a case of air/thromboembolism of the left anterior descending coronary artery complicating a fenestrated Fontan procedure treated with aprotinin. The patient was successfully treated by saphenous vein grafting to the left anterior descending coronary artery and reconversion of the Fontan circulation to the original cavo-pulmonary connection.
Coronary Artery Bypass↗