Salvatore Mario Romano

Assessment of cardiac output from systemic arterial pressure in humans.

ObjectiveTo evaluate the reliability, by comparison with established techniques, of a new method to assess cardiac output, called pressure recording analytical method (PRAM), deriving from the analysis of the arterial pressure profile in the time domain the arterial-pressure-blood flow relationship. DesignCriterion standard. SettingHemodynamics laboratory at an university medical center. PatientsTwenty-two hemodynamically stable cardiac patients scheduled for diagnostic right and left heart catheterization. InterventionsNone. Measurements and Main ResultsCardiac index was simultaneously estimated by direct-oxygen Fick method, thermodilution, and PRAM applied to pressure signals recorded either invasively from an aortic catheter (PRAMa) or noninvasively at the finger (PRAMf) by photoplethysmography. Cardiac index values obtained by established techniques were significantly correlated with those estimated by PRAM: Fick method vs. PRAMa, r = .88, vs. PRAMf, r = .94; thermodilution vs. PRAMa, r = .77, vs. PRAMf, r = .77. The Bland-Altman analysis showed agreement between the Fick method and PRAM, with all data points comprised within the limits of agreement (±2sd) (mean difference ± sd:- 0.012 ± 0.187 L·min−1·m−2 for PRAMa; 0.024 ± 0.167 L·min−1·m−2 for PRAMf). Agreement was also found between thermodilution and PRAM, with all but one data point lying within the limits of agreement (mean difference ± sd: −0.154 ± 0.348 L·min−1·m−2 for PRAMa; −0.108 ± 0.348 L·min−1·m−2 for PRAMf). ConclusionsIn the range evaluated (cardiac index from 1.65 to 3.91 L·min−1·m−2 by the Fick method), PRAM provides reliable invasive and noninvasive estimates of cardiac output in hemodynamically stable cardiac patients. PRAM may prove clinically useful for the beat-to-beat monitoring of cardiac output.

Altered platelet function associated with the bronchial hyperresponsiveness accompanying nocturnal asthma

BACKGROUND Nocturnal awakening is a common feature of bronchial asthma, and yet the mechanisms underlying this phenomenon are poorly understood. We investigated whether nocturnal awakening is associated with changes in platelet function with the use of a variety of markers of platelet activation. METHODS Ten patients with a history of nocturnal asthma and 10 age- and sex-matched healthy control subjects were studied at 10:00 PM, 4:00 AM, and 10:00 AM on 2 consecutive days. The following parameters were tested: forced expiratory volume in 1 second (FEV1), log dose of methacholine inducing a 20% fall in FEV1, platelet count and volume, platelet aggregation induced by collagen or activating factor, and plasma and intraplatelet levels of beta-thromboglobulin and platelet factor 4. RESULTS We have demonstrated that altered platelet function and platelet activation occurs at 4:00 AM in patients with nocturnal asthma and is associated with the maximum increases in bronchial reactivity. Such changes were not observed in 10 control subjects. Platelet dysfunction has been detected as a reduced aggregatory response of platelets to collagen and platelet activating factor such that up to 5 times more platelet activating factor and 1.5 times more collagen were required to elicit a threshold aggregatory response in asthmatic subjects when compared with control subjects; this difference was evident at all time points tested. Furthermore, at 4:00 AM there were significantly lower levels of intraplatelet beta-thromboglobulin corresponding to the maximum reduction in peak expiratory flow and to the maximal increase in bronchial responses to inhaled methacholine. CONCLUSIONS These results suggest that platelet activation accompanies nocturnal asthma and further suggest that platelets may play a role in this common clinical condition.

Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study

To evaluate the clinical, biohumoral, and haemodynamic effects of ultrafiltration vs. intravenous diuretics in patients with decompensated heart failure (HF). Signs and symptoms of volume overload are often present in these patients and standard therapy consists primarily of intravenous diuretics. Increasing evidence suggests that ultrafiltration can be an effective alternative treatment.

Randomized trial of adjuvant chemotherapy versus control after curative resection for gastric cancer: 5-year follow-up

Adjuvant chemotherapy of gastric cancer after curative resection is still subject to discussion. In this study 137 patients with gastric adenocarcinoma, all with positive nodes, were randomized after curative resection so that 69 received epidoxorubicin (EPI), leucovorin (LV) and 5-fluorouracil (5-FU) on days 1–3 every 3 weeks for 7 months, whereas the remaining 68 did not. After a follow-up period of 5 years, 21 of the 69 treated patients (30%) and nine controls (13%) were still alive; median survival time was 18 months for the controls and 31 months for the patients treated with adjuvant chemotherapy (P< 0.01).

Adjuvant chemotherapy after gastric resection in node-positive cancer patients : a multicentre randomised study

After curative resection for gastric adenocarcinoma, 103 patients, all with positive nodes, were randomised so that 48 received adjuvant chemotherapy of epidoxorubicin (EPI) 75 mg m-2 on day 1, leucovorin (LV) 200 mg m-2 on days 1-3 and 5-fluorouracil (5-FU) 450 mg m-2 on days 1-3, every 21 days for 7 months, whereas the remaining 55 did not. During the first year of observation, 21 control patients (38%) and five treated patients had recurrences. After a follow-up period of 36 months, 12 of the treated patients (25%) and only seven controls (13%) were still alive. At that point, the median survival was 13.6 months for the 55 untreated patients and 20.4 months for the 48 treated patients, a significant difference. We found a survival advantage for patients treated with the EPI-LV-5-FU regimen and a consistent delay in the appearance of recurrent or metastatic cancer. Acute toxicity was mild and treatment was well accepted by all patients. There was no long-term toxicity or any cardiac toxicity. We conclude that this particular chemotherapy, administered shortly after gastric resection, improves survival rate in node-positive gastric cancer patients, even although final assessment of this particular adjuvant approach must await completion of the trial.

Assessment of cardiac output in children: A comparison between the pressure recording analytical method and Doppler echocardiography*

Objective: To assess cardiac output in pediatric patients with the pressure recording analytical method (PRAM) and the Doppler echocardiography method. PRAM derives cardiac output from beat-by-beat analysis of the arterial pressure profile (systolic and diastolic phase) in the time domain. Design: A prospective observational study. Setting: Pediatric intensive care unit at a tertiary care children’s hospital. Patients: Forty-eight patients between the ages of 1 month and 18 yrs. Interventions: Femoral or radial artery catheterization and mechanical ventilation. Measurements and Main Results: Cardiac output was simultaneously estimated by Doppler echocardiography and PRAM. Cardiac output values obtained by Doppler echocardiography (2.7 ± 1.6 L/min, range 0.92–8.20) were significantly correlated with those estimated by PRAM (2.6 ± 1.7 L/min, range 0.89–7.48; r2 = .99, p < .01). The mean difference between the two estimates was 0.12 ± 0.27 L·min−1 (95% confidence interval, −0.54 to 0.77 L·min−1). Conclusions: In the range of ages evaluated, PRAM provides reliable estimates of cardiac output when compared with noninvasive techniques.

Evidence for bone mass and body fat distribution relationship in postmenopausal obese women

The measurement of bone mass, a reliable predictor of osteoporotic fractures, in obese subjects has yielded conflicting results and bone mass has been reported to be elevated, normal or decreased. These observations indicate that factors other than body weight may be involved in the less risk for osteoporosis in obese subjects. In order to clarify the role of body fat distribution on bone density we studied sixty postmenopausal overweight/obese women with Body Mass Index (BMI) over 25 kg/m(2). Thirty five age-matched, nonobese postmenopausal women, served as controls. Bone mineral density (BMD) was measured at the proximal and ultradistal non dominant forearm using a double energy X-ray absorption (DEXA) apparatus. The waist/hip circumferences ratio (WHR) was used, in obese group, as an anthropometric estimation of the abdominal (WHR>0.85) to lower-extremity (WHR>0.85) fat proportion. The results were analyzed by Student t-test, ANOVA, and multiple linear regression analysis. No difference was found in BMD between obese group and controls, but a highly significant (P<0.001) positive correlation has been documented between proximal and ultradistal radius bone mineral density and waist/hip ratio in the obese group. Instead not significant correlation was found with BMI. Regional fat topography may influence the bone mass independently of total adiposity and visceral fat was the primary parameter accounting for higher bone mineral density values. These finding suggest that women with android-like obesity are protected from osteoporosis.

Circadian mesor-hyperprolactinemia in fibrocystic mastopathy

Abstract Prolactin, assayed in serum obtained at six consecutive 4-hourly intervals from 22 women with fibrocystic mastopathy and 18 clinically healthy women (controls), undergoes a statistically significant circadian rhythm demonstrated by population-mean cosinor. In the group with fibrocystic mastopathy, as compared to the controls, the circadian amplitude is only slightly higher when summarized in original values and slightly lower in relative terms—as per cent of rhythm-adjusted mean or mesor. These differences are not statistically significant (P > 0.05). Nearly identical in the two groups is the rhythms timing, assessed by fitting a 24-hour cosine curve to the data to obtain an acrophase estimate. For the group with fibrocystic mastopathy and the controls, the point estimates of the acrophase are nearly the same at −18 ° and −26 ° from local midnight (01 12 and 01 44 , since 360 ° = 24 hours) with the 95 per cent confidence intervals extending from +4 ° (−356 °) to −38 ° and from −6 ° to −47 °, respectively. A mesor test establishes a mesor-hyperprolactinemia in patients with fibrocystic mastopathy who, as a group, represent a population differing from the clinically healthy control subjects (P

Dynamic response of liquid-filled catheter systems for measurement of blood pressure: precision of measurements and reliability of the Pressure Recording Analytical Method with different disposable systems ☆

PURPOSE We aimed to compare the effects of a blood pressure transducer system specifically manufactured to limit underdamping artifacts with those of a standard system on hemodynamic parameter estimation and accuracy. MATERIALS AND METHODS Forty-three consecutive patients undergoing vascular surgery at the University of Florence, Italy, were included. Arterial blood pressure signal was simultaneously registered with 2 MostCare monitors, connected to the artery either by a standard transducer or a specific transducer manufactured to avoid underdamping artifacts (Resonance Over-Shoot Eliminator [R.O.S.E.]; Becton Dickinson, Becton Drive, NJ). Patients were divided into 2 groups: absence (C group) or presence (R group) of underdamping/resonance artifacts of blood pressure signal. Systolic blood pressure, cardiac index, maximal pressure/time ratio (dP/dt(MAX)), and cardiac cycle efficiency were recorded every 30 seconds for 30 minutes. A total of 2675 measurements were performed with 34.9% incidence of underdamping/resonance artifacts. RESULTS All hemodynamic parameters showed clinically acceptable differences in the C group; in contrast, the results differed greatly in the R group between standard and R.O.S.E. transducer (systolic blood pressure bias, 16.7 mm Hg; cardiac index bias, 0.24 L min(-1) m(-2); dP/dt(MAX) bias, 0.92 mm Hg/ms; cardiac cycle efficiency bias, 0.018 units). CONCLUSIONS Underdamping/resonance artifacts frequently affect blood pressure measurement in operating rooms and intensive care units and cause severe overestimation of systolic blood pressure and incorrect estimation of hemodynamic parameters when the pulse contour method is used.

Accuracy of invasive arterial pressure monitoring in cardiovascular patients: an observational study

IntroductionCritically ill patients and patients undergoing high-risk and major surgery, are instrumented with intra-arterial catheters and invasive blood pressure is considered the “gold standard” for arterial pressure monitoring. Nonetheless, artifacts due to inappropriate dynamic response of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values. We sought to analyze the incidence and causes of resonance/underdamping phenomena in patients undergoing major vascular and cardiac surgery.MethodsArterial pressures were measured invasively and, according to the fast-flush Gardner’s test, each patient was attributed to one of two groups depending on the presence (R-group) or absence (NR-group) of resonance/underdamping. Invasive pressure values were then compared with the non-invasive ones.ResultsA total of 11,610 pulses and 1,200 non-invasive blood pressure measurements were analyzed in 300 patients. Ninety-two out of 300 (30.7%) underdamping/resonance arterial signals were found. In these cases (R-group) systolic invasive blood pressure (IBP) average overestimation of non-invasive blood pressure (NIBP) was 28.5 (15.9) mmHg (P <0.0001) while in the NR-group the overestimation was 4.1(5.3) mmHg (P <0.0001). The mean IBP-NIBP difference in diastolic pressure in the R-group was −2.2 (10.6) mmHg and, in the NR-group −1.1 (5.8) mmHg. The mean arterial pressure difference was 7.4 (11.2) mmHg in the R-group and 2.3 (6.4) mmHg in the NR-group. A multivariate logistic regression identified five parameters independently associated with underdamping/resonance: polydistrectual arteriopathy (P =0.0023; OR = 2.82), history of arterial hypertension (P =0.0214; OR = 2.09), chronic obstructive pulmonary disease (P =0.198; OR = 2.61), arterial catheter diameter (20 vs. 18 gauge) (P <0.0001; OR = 0.35) and sedation (P =0.0131; OR = 0.5). The ROC curve for the maximal pressure–time ratio, showed an optimum selected cut-off point of 1.67 mmHg/msec with a specificity of 97% (95% CI: 95.13 to 99.47%) and a sensitivity of 77% (95% CI: 67.25 to 85.28%) and an area under the ROC curve by extended trapezoidal rule of 0.88.ConclusionPhysicians should be aware of the possibility that IBP can be inaccurate in a consistent number of patients due to underdamping/resonance phenomena. NIBP measurement may help to confirm/exclude the presence of this artifact avoiding inappropriate treatments.