Myocardial damage following cardiac surgery: comparison between single-dose Celsior cardioplegic solution and cold blood multi-dose cardioplegia.

Myocardial protection during cardiac surgery can be accomplished by different cardioplegic solutions. The aim of this study was to assess myocardial damage after heart valve surgery performed with myocardial protection of a single dose of Celsior cardioplegia or with repeated cold blood cardioplegia. After the stratification of 139 valvular patients by means of matching according to cross-clamp and cardiopulmonary bypass time, 32 patients were retained for comparison (16 patients received Celsior and 16 patients received cold blood cardioplegia). Creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) release were evaluated until six days after the operation. Pre-operative characteristics were similar in both groups. In the Celsior group, CK-MB and cTnI values were significantly higher from the first up to the sixth post-operative day. Peak cTnI values were 19.4 ± 13.4 and 9.7 ± 7 ng/mL (p=0.01) in the Celsior and the Cold Blood group, respectively. Peak CK-MB values were 79.6 ± 58.8 and 45.9 ± 20.6 U/L (p=0.07) in the Celsior and the Cold Blood group, respectively. Cold blood cardioplegia reduces perioperative myocardial damage compared to the Celsior solution in elective cardiac valve operations.

Transapical beating heart mitral valve repair versus conventional surgery: a propensity-matched study.

OBJECTIVES: Transapical Neochordae implantation (NC) allows beating heart mitral valve repair in patients with degenerative mitral regurgitation. The aim of this single-centre, retrospective study was to compare outcomes of NC versus conventional surgical (CS) mitral valve repair. METHODS: Data of patients who underwent isolated mitral valve repair with NC or CS from January 2010 to December 2018 were collected. A propensity score matching analysis was performed to reduce confounding due to baseline differences between groups. The primary end point was overall all-cause mortality; secondary end points were freedom from reoperation, freedom from moderate (2+) and from severe (3+) mitral regurgitation (MR) and New York Heart Association functional class in the overall population and in patients with isolated P2 prolapse (type A anatomy). RESULTS: Propensity analysis selected 88 matched pairs. There was no 30-day mortality in the 2 groups. Kaplan-Meier analysis showed similar 5-year survival in the 2 groups. Patients undergoing NC showed worse freedom from moderate MR (≥2+) (57.6% vs 84.6%; P < 0.001) and from severe MR (3+) at 5-year follow-up: 78.1% vs 89.7% (P = 0.032). In patients with type A anatomy, freedom from moderate MR and from severe MR was similar between groups (moderate: 63.9% vs 74.6%; P = 0.21; severe: 79.3% vs 79%; P = 0.77 in NC and FS, respectively). Freedom from reoperation was lower in the NC group: 78.9% vs 92% (P = 0.022) but, in type A patients, it was similar: 79.7% and 85% (P = 0.75) in the NC and CS group, respectively. More than 90% of patients of both groups were in New York Heart Association class I and II at follow-up. CONCLUSIONS: Transapical beating-heart mitral chordae implantation can be considered as an alternative treatment to CS, especially in patients with isolated P2 prolapse.

Myocardial protection during aortic surgery: comparison between Bretschneider-HTK and cold blood cardioplegia.

The ideal cardioplegic strategy in thoracic aorta operations requiring long cardiopulmonary bypass and cross-clamp time has not been established. Suboptimal myocardial protection may lead to myocardial damage and possible post-operative complications. We evaluate post-operative cardiac Troponin I (cTnI) release, low cardiac output syndrome (LCOS) and mortality, using a cold crystalloid single-dose intracellular or cold blood multidose cardioplegia in 112 elective or emergent thoracic aorta operation patients. Fifty-four patients (HTK group) received Custodiol® cardioplegic solution and 58 received cold blood cardioplegia (CB group). Cross-clamp time, cardiopulmonary bypass (CPB) time and cTnI peak release were similar in both groups. No differences were found for atrial and ventricular arrhythmias, inotropic support, LCOS and in-hospital mortality. Two-way ANOVA analysis revealed an interactive effect on cTnI peak (p=0.012) of cardioplegic solution type across the cross-clamp time quintile. In the fifth quintile, cross-clamp time patient (>160 min) cTnI peak value was higher in CB patients (p=0.044). HTK and CB cardioplegic solutions assure similar myocardial protection in patients undergoing thoracic aorta operations. In long cross-clamp times, the lower post-operative cTnI release detected using HTK may be indicative of a better myocardial protection in these extreme conditions.

Symptomatic carotid stenosis. Diagnosis and treatment guidelines. Juridical and medico-legal approach.

An increasing body of health care regulations and the growing concern of physicians and patients about health care services have sharpened the debate surrounding the concept of quality in medicine. Once unknown terms such as audit, peer review, accreditation, ISO 9000, quality assurance (QA), continuous quality improvement (CQI) and risk management have become more familiar but also less clear. Following recent reports, medical error has been cited as a result of a health care system that has not yet fully embraced the tenets of quality management. A clearer explanation of definitions, knowledge and procedures is therefore needed. In Italy, the general debate on surgical risk led to a proposal to implement control systems that would monitor the work of each team member in the operating room, from the patient's arrival to transfer to the floor. But to understand the dynamics of doubtful cases, we need to start from new concepts that release the surgeon from the role of ''high priest in the surgery temple.'' Such concepts would underpin a process analysis of how much is effectively done and by whom. This means, on one hand, developing a greater awareness of one's role and competences, and on the other, delineating the stages within which each health care professional is expected to operate. Entering into the debate are the guidelines scientific societies have drawn up to rationalise and improve health care delivery through recommendations directed at optimizing the efficacy and efficiency of surgical intervention as the result of scientific evaluation and clinical observation. However, the critics in question do not always allow the surgeon to work under a medico-legal ''guarantee'' that covers his medical conduct. Further-more, they can be a double-edged sword in court if not adequately considered and critically evaluated with regard to a specific case, the object of censure and charge. In fact, they can be ''exploited'' as an instrument of accusation or defence in an arena where the mass media rush to blame the surgeon but later forget to duly report the acquittal of charges held against the surgeon. The present article examines the light and dark sides of guidelines, taking as an example those profiled by the Italian Society of Vascular and Endovascular Surgery and based on international guidelines for the treatment of symptomatic carotid stenosis.

Cogeneration from thermal treatment of selected municipal solid wastes. A stoichiometric model building for the case study on Palermo.

This paper aims to calculate the energetic and environmental effects of an integrated solid waste management system in Palermo, Italy. In particular, the thermal treatment of Municipal Solid Waste (MSW) with energy recovery is assessed. The current characterization at the local scale is taken into account. Two different options of collection are taken into account: (1) unselected wastes; and (2) sorted collection, according to the current Italian regulation. Combustion process is analyzed and the following features are calculated: (1) stoichiometric content of air and air excess; and (2) temperature and enthalpy of flue gases. Energy recovery is performed in the hypothesis of Hirn cycle both with steam condensation to produce only power, and with bleeding cycle for the combined production of power and thermal energy. Total electric efficiency is assumed as representative index of the technological level of the assessed plant. Results show that the thermal treatment of selected MSW, associated with a cogenerative recovery of energy, represents a relevant sustainable strategy of waste valorization as an alternative to fossil fuels.

Diabetes and pregnancy: prophylaxis of genital infections.

Diabetic pregnant women have many potential reasons to have genital infections such as poor metabolic control and impairement of leucocyte function. Relative immune deficiency exists in pregnancy. This study was designed to test the hypotheses that pregnant patients with insulin-dependent diabetes have a higher rate of ante partum genital infections when compared with a pair-matched control population. Two groups of pregnant women consisting of 23 patients with and 23 without diabetes mellitus, underwent colposcopy and cytology between 16th and 24th week of gestation to detect the presence of human papilloma virus (HPV), Gardnerella vaginalis, Candida albicans and aspecific infections. No significant differences were observed between the two groups.

Preterm labour and neonatal parameters.

OBJECTIVES: Our objective was to identify those neonatal factors associated with survival in preterm infants. MATERIAL AND METHODS: We examined a population of 457 preterm newborns delivered between 1 January-31 December 1990, with birthweight between < 1000 gr and > 2000 gr, in respect to umbilical pH values, plasmatic glucose values, 5-minute Apgar score and gestational age. Data were abstracted from the maternal intrapartum records and the neonatal records, with specific attention to neonatal parameters. RESULTS: A positive correlation between birthweight and 5-minute Apgar score, between birthweight, pH and glucose values was noted. No such relationship existed between pH values and 5-minute Apgar score. Within birthweight groups the distribution of neonatal mortality rate was 85.18% in ELBW (Extremely Low Birth Weight) and only 5.26% in LBW (Low Birth Weight). CONCLUSION: The importance of the echographic estimate of the fetal weight must be emphasized, since a birthweight of 1500 gr represents the cut-off for the neonatal morbidity and mortality, and also an accurate clinical evaluation of the risk of preterm labour or pathologies in order to improve the estimate of childbirth timing.

Prognostic value of biophysical profile score in post-date pregnancy.

OBJECTIVES: This study was undertaken to assess the ability of each individual biophysical profile score variable and combination of variables, to predict fetal distress or imminent labor in the post data pregnancy. MATERIALS AND METHODS: From June 1992 to August 1993, Biophysical Profile Scoring (BPS) was performed on 182 pregnant women. Thirty one patients delivered between 42 and 43 weeks of gestation, while the other 151 pregnant women delivered between 38 and 41+6 days. Monitoring procedures were based on the evaluation of fetal heart rates by Non Stress Test and four ultrasound parameters: Fetal Tone; Gross Body Movements; Fetal breathing movements; Evaluation of amniotic fluid volume. RESULTS: In this analysis the BPS showed a high specificity (82.7%) with a negative predictive value of 100%. The mean value of the last BPS among the 151 term patients was significantly higher if compared with the 31 post term pregnant women (6.73 and 6.12 respectively with p < 0.05). The predictive value of Fetal Breathing Movements (FBM) for the onset of imminent labor was confirmed. CONCLUSION: BPS, as measured in this study, has proved to be a very accurate method of determination of fetal well-being. Although these results will be further verified by other studies, BPS should come into general use to help reach the correct diagnosis and treatment of post date pregnancy.

Treatment of female hyperandrogenism: estroprogestinic therapy at low dose in an inversal sequential scheme.

OBJECTIVE: to investigate the effects of treatment with low dose of cyproterone acetate and ethynyl-estradiol on chemical and hormonal parameters in female hyperandrogenism. DESIGN: twenty patients, affected by clinical manifestations of hyperandrogenism, were studied basally and during treatment with 10 mg of cyproterone acetate associated with ethynyl-estradiol (20 m g) in an inversal sequential scheme for six months. Safety parameters were assessed throughout the study. Hirsutism was graded by Ferriman and Gallway score, and hormonal parameters were evaluated basally and after six months of therapy. RESULTS: after six months of therapy all patients showed a significant decrease of clinical and biochemical signs of hyperandrogenism, and normalization of ovarian parameters in seventeen women affected by PCOS. CONCLUSIONS: this treatment is an effective and well tolerated therapy. It is reasonable to consider this treatment as a safe procedure especially in view of a long-term administration.

Endocrine function in four anencephalic infants.

Endocrine studies of 4 anencephalic infants were carried out. No hypothalamic or hypophyseal structures could be found in any of them macroscopically, but we cannot say that there were no functioning pituitary cells which might have been seen microscopically. A combined LH-RH and TRH test was performed in the 6th h of life, followed by an intravenous glucose tolerance test 1 h later. Our data suggest that: (1) adenohypophyseal tissue, present in anencephaly even in the absence of a hypothalamus, is able to synthesize PRL and TSH autonomously and, under specific stimulation, PRL, TSH, and ACTH can be released while FSH and LH-HCG are not, hGH secretion is doubtful; (2) the circulating hGH and TSH surges that normally occur after delivery are hypothalamus-dependent and do not occur in anencephalics; (3) the thyroid and adrenals are able to synthesize hormones when specifically stimulated, even in the absence of the hypothalamus, and (4) beta-pancreatic function is not markedly impaired in anencephaly.

Endocrine involvement in children with beta-thalassaemia major. Transverse and longitudinal studies. I. Pituitary-thyroidal axis function and its correlation with serum ferritin levels.

Thyroid function was investigated by a TRH test in 24 clinically prepubertal children, 3-15 years old with beta-thalassaemia major; in 7 of them the test was repeated once and in 2 twice at intervals of at least 12 months. Basal T4, T3, TBG and TSH levels and the TSH levels during a TRH test were determined and correlated with age and serum ferritin levels. Basal serum T4, T3 and TBG levels were lower and serum TSH levels were higher during the test and in the basal state in thalassaemia major children than in control children. These results show a compensated sub-clinical primary hypothyroidism. The transversal study did not show any significant correlation between the hormonal parameters studied and chronological age or serum ferritin levels. In contrast, the longitudinal study showed a significant correlation between pituitary-thyroidal axis function and siderosis (positive correlations between the variations of TSH levels as delta, peak, 30 and 45 min values and the variations of serum ferritin levels). The thyroid impairment seems not to be correlated with serum ferritin levels in the transversal study because of the presence of an individual different sensitivity of the gland to the iron overload. The ferritin dependence of this impairment is shown only by longitudinal studies where individual differences in sensitivity of the gland are absent.(ABSTRACT TRUNCATED AT 250 WORDS)