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Search Results: 1 - 10 of 1656 matches for " Eugenio Picano "
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The Risks of Inappropriateness in Cardiac Imaging
Eugenio Picano
International Journal of Environmental Research and Public Health , 2009, DOI: 10.3390/ijerph6051649
Abstract: The immense clinical and scientific benefits of cardiovascular imaging are well-established, but are also true that 30 to 50% of all examinations are partially or totally inappropriate. Marketing messages, high patient demand and defensive medicine, lead to the vicious circle of the so-called Ulysses syndrome. Mr. Ulysses, a typical middle-aged “worried-well” asymptomatic subject with an A-type coronary personality, a heavy (opium) smoker, leading a stressful life, would be advised to have a cardiological check-up after 10 years of war. After a long journey across imaging laboratories, he will have stress echo, myocardial perfusion scintigraphy, PET-CT, 64-slice CT, and adenosine-MRI performed, with a cumulative cost of >100 times a simple exercise-electrocardiography test and a cumulative radiation dose of >4,000 chest x-rays, with a cancer risk of 1 in 100. Ulysses is tired of useless examinations, exorbitant costs. unaffordable even by the richest society, and unacceptable risks.
Economic and biological costs of cardiac imaging
Eugenio Picano
Cardiovascular Ultrasound , 2005, DOI: 10.1186/1476-7120-3-13
Abstract: A Renaissance of cardiac imaging occurred in the 1980s [1]. New technologies allowed the non-invasive description of cardiac function, perfusion, and metabolism in a polychrome, three-dimensional, overwhelming fashion. Almost unlimited resources were devoted to patient care in the economic framework of the affluent society. At the beginning of the 1990s, The Renaissance made its transition into the splendid decadence of the Baroque. The increasing technological burden in clinical cardiology paradoxically did not bring a parallel increase in the quality of care but rather an increase in cost. The economic climate had changed; the illusion of unlimited economic resources had come to an end [2]. Keeping in mind that each test represents a cost, often a risk, and always a diagnostic hypothesis, we can agree that every unnecessary and unjustifiable test is one test too many. Small individual costs, risks, and wastes multiplied by billions of examinations per year represent an important population [3], society [4] and environmental [5] burden. Unfortunately, the appropriateness of cardiac imaging is usually extra-ordinarily low and there is little awareness among patients and physicians of the elementary physical basis, differential costs, radiological doses, and long term risks of different imaging modalities [6]. It is also well known that – in the words of Bernard Lown – "technology in medicine is frequently untested scientifically, often applied without data relating to cost benefit, and driven by market forces rather than by patient needs." Bernard Lown, 2004 [7]."Ten years ago, medical imaging wasn't even in the radar screen for most health insurers. In 2004, it' s one of the highest cost items in a health plan's medical budget, and also one of the fastest growing". (Atlantic info service newsletter, 2004) [8]. As an example, in U.S. during the year 2002, 7.8 million cardiac perfusion scans were performed, with a growth of 40% in the last 3 years [9]. Still in U.S.,
Anniversary Editorial: One year of Cardiovascular Ultrasound
Eugenio Picano
Cardiovascular Ultrasound , 2004, DOI: 10.1186/1476-7120-2-3
Abstract: Cardiovascular Ultrasound is an Open Access, peer-reviewed online journal covering clinical, technological, experimental, biological, and molecular aspects of ultrasound applications in cardiovascular physiology and disease.Cardiovascular Ultrasound is aimed at providing a suitable tribune for the most current, clinically and biologically relevant, and high quality research in the field of ultrasound of heart and vessels. The journal publishes peer-reviewed original research, updated reviews, case reports on challenging and/or unusual diagnostic aspects, and expert opinions on new techniques and technologies. Other feature of interest to the cardiologist, the sonographer and allied scientists is the "natural born digital" nature of the journal, with the possibility to publish colour illustrations and video clips with no extra costs. This feature is especially attractive in a field so dynamic (both in a conceptual and in a cinematic sense) as ultrasound. The possibility to go immediately to Pubmed, and the publication of video-clips, will tremendously increase the scientific impact of your material. Cardiovascular Ultrasound might become a good first choice for much of your "hot material", when time is not an independent variable.The cardiovascular ultrasound community needs an Open Access forum in which to publish peer-reviewed articles with speed (in revision and publication), and versatility (in arguments, ranging from biology to engineering to clinical echocardiography). Cardiovascular Ultrasound aims to be that forum.Manuscripts must be submitted to Cardiovascular Ultrasound electronically using the online submission system. Full details of how to submit a manuscript are given in the instructions for authors. Cardiovascular Ultrasound reviews all the material it receives. About 10 % of articles are rejected after review in-house. The usual reasons for rejection at this stage are insufficient originality or serious scientific flaws. We aim to reach a decision on
The Radiation Issue in Cardiology: the time for action is now
Eugenio Picano, Eliseo Vano
Cardiovascular Ultrasound , 2011, DOI: 10.1186/1476-7120-9-35
Abstract: Almost 10 years ago, the "radiation issue" was raised, which refers to the need to include long-term cancer risks due to ionizing radiation in the risk-benefit assessment of diagnostic or therapeutic testing. This issue is obviously relevant from the individual patient's [1], societal [2] and bioethical [3] perspective, and clearly stemmed from standard radioprotection knowledge already at that time well-embedded in Euratom law [4] and European Commission medical imaging guidelines [5]. It was initially raised in the critical area of non-invasive diagnosis of coronary artery disease, where the dose of 10 million stress imaging future procedures per year, the high dose of perfusion imaging and the availability of competitive non-ionizing techniques pose special problems of avoidable long-term cancer risk [1,6]. However, at that time this position was largely perceived by peers as being motivated by an attempt of non-radiologist imaging specialists to expand or defend their own imaging market shares [7]. In the last 10 years, things have changed. For a long time ignored by the mainstream imaging and cardiology community, the "linear-no threshold" model in radioprotection assumes that no safe dose exists; the risk increases linearly with increasing radiation dose; all doses add up in determining cancer risk. This model was more generally accepted as epidemiological evidence matured, and was re-endorsed by concordant statements of the US National Academy of Sciences Biological Effects of Ionizing Radiation Committee (2006), International Commission on Radiological Protection (2007), and United Nations Scientific Committee on the Effects of Atomic Energy (2008) [8-10]. Conversely, the hormesis model assuming that low doses of radiation were less harmful and possibly even beneficial was abandoned [8-10] although there are currently no data showing that high dose medical studies have actually increased the incidence of cancer and the full validation of the linear no-thresh
The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis
Eugenio Picano, Sabrina Molinaro, Emilio Pasanisi
Cardiovascular Ultrasound , 2008, DOI: 10.1186/1476-7120-6-30
Abstract: To evaluate the diagnostic accuracy of dobutamine versus dipyridamole stress echocardiography through an evidence-based approach.From PubMed search, we identified all papers with coronary angiographic verification and head-to-head comparison of dobutamine stress echo (40 mcg/kg/min ± atropine) versus dipyridamole stress echo performed with state-of-the art protocols (either 0.84 mg/kg in 10' plus atropine, or 0.84 mg/kg in 6' without atropine). A total of 5 papers have been found. Pooled weight meta-analysis was performed.the 5 analyzed papers recruited 435 patients, 299 with and 136 without angiographically assessed coronary artery disease (quantitatively assessed stenosis > 50%). Dipyridamole and dobutamine showed similar accuracy (87%, 95% confidence intervals, CI, 83–90, vs. 84%, CI, 80–88, p = 0.48), sensitivity (85%, CI 80–89, vs. 86%, CI 78–91, p = 0.81) and specificity (89%, CI 82–94 vs. 86%, CI 75–89, p = 0.15).When state-of-the art protocols are considered, dipyridamole and dobutamine stress echo have similar accuracy, specificity and – most importantly – sensitivity for detection of CAD. European recommendations concluding that "dobutamine and vasodilators (at appropriately high doses) are equally potent ischemic stressors for inducing wall motion abnormalities in presence of a critical coronary artery stenosis" are evidence-based.Pharmacological stress echocardiography is widely used for the diagnosis of coronary artery disease [1,2], and the two most employed pharmacological stresses are dipyridamole and dobutamine, first proposed more than 20 years ago [3,4]. The latest 2006 European Society of Cardiology (ESC) guidelines for stable angina conclude that "the two tests have very similar applications and the choice as to which is employed depends largely on local facilities and expertise" [5]. This statement was corroborated by a meta-analysis of the published literature, included in the guidelines, and showing comparable accuracy, sensitivity and specif
Temporal Trends in Radiation Dose Associated with Coronary Computed Tomography Angiography  [PDF]
Paolo Marraccini, Alessandro Mazzarisi, Clara Carpeggiani, Mathis Schluter, Marco Brambilla, Massimiliano Bianchi, Lorenzo Faggioni, Giuseppe Coppini, Carlo Bartolozzi, Eugenio Picano
Open Journal of Radiology (OJRad) , 2014, DOI: 10.4236/ojrad.2014.41013
Abstract:

Background: In 2010, the International Atomic Energy Agency launched the “3A’s campaign” as an effective tool for primary cancer prevention. In 2011, the American Association of Physicists in Medicine recommended the size specific dose estimate (SSDE). Objectives: To audit doses of Coronary CT Angiography (Coronary CTA) in tertiary care referral center. Methods: We reviewed 998 consecutive Coronary CTA (from 2007 to 2012). Doses (CTDIvol mGy), DLP (mGy*cm), effective dose (DLP*0.014, mSv) were on-line archived. SSDE was estimated retrospectively. Appropriateness score was evaluated for exams performed from the 2010. Results: Overall median dose per Coronary CTA was 49.7 mGy for CTDIvol, 55.5 mGy for SSDE, 994.96 mGy*cm for DLP, 13.9 mSv for effective dose. Median DLP decreased over time (1452.94 in 2007, 1605.56 in 2008, 1113.49 in 2009, 759.99 in 2010, 448.61 in 2011 and 497.88 mGy*cm in 2012, p < 0.0001). SSDE was proportional to the size dependent factor (SDF); in patients with SDF > 1 (88%) CTDIvol underestimated SSDE (48.49 vs 57.19 mGy), whilst in patients with SDF < 1 (12%) CTDIvol overestimated SSDE (56.46 vs 50.3 mGy). Scans were appropriate in 58%, uncertain in 24%, and inappropriate in 18% of cases. Doses were similar in appropriate, uncertain or inappropriate examinations and in excellent-to-good (81%) vs. sufficient-to-poor (19%) image quality exams. Conclusions: Coronary CTA reference doses can be very misleading. SSDE can allow individual technique optimization. The dose is similar in appropriate and inappropriate examinations, and unrelated to image quality. The rate of inappropriate examinations is still too high even after dissemination of guidelines.

Trends of Increasing Medical Radiation Exposure in a Population Hospitalized for Cardiovascular Disease (1970–2009)
Clara Carpeggiani, Patrizia Landi, Claudio Michelassi, Paolo Marraccini, Eugenio Picano
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0050168
Abstract: Background High radiation doses employed in cardiac imaging may increase cancer frequency in exposed patients after decades. The aim of this study was to evaluate the relative trends in medical radiation exposure in a population hospitalized for cardiovascular disease. Methods and Results An observational single-center study was conducted to examine 16,431 consecutive patients with heart disease admitted to the Italian National Research Council Institute of Clinical Physiology between January 1970 and December 2009. In all patients, the cumulative estimated effective dose was obtained from data mining of electronic records of hospital admissions, adopting the effective dose typical values of the American Heart Association 2009 statement and Mettler’s 2008 catalog of doses. Cumulative estimated effective dose per patient in the last 5 years was 22 (12–42) mSv (median, 25th–75th percentiles), with higher values in ischemic heart disease (IHD), 37 (20–59) vs non-IHD, 13 (8–22) mSv, p<0.001. Trends in radiation exposure showed a steady increase in IHD and a flat trend in non-IHD patients, with variation from 1970–74 to 2005–2009 of +155% for IHD (p<0.001) and ?1% in non-IHD (NS). The relative contribution of different imaging techniques was remodeled over time, with nuclear cardiology dominating in 1970s (23% of individual exposure) and invasive fluoroscopy in the last decade (90% of individual exposure). Conclusion A progressive increase in cumulative estimated effective dose is observed in hospitalized IHD patients. The growing medical radiation exposure may encourage a more careful justification policy regarding ionizing imaging in cardiology patients applying the two main principles of radiation protection: appropriate justification for ordering and performing each procedure, and careful optimization of the radiation dose used during each procedure.
WEB downloadable software for training in cardiovascular hemodynamics in the (3-D) stress echo lab
Tonino Bombardini, Davide Cini, Giorgio Arpesella, Eugenio Picano
Cardiovascular Ultrasound , 2010, DOI: 10.1186/1476-7120-8-48
Abstract: Aims of this paper are: 1) to propose a simple method to assess a set of parameters allowing a complete characterization of cardiovascular hemodynamics in the stress echo lab, from basic measurements to calculations 2) to propose a simple, web-based software program, to learn and training calculations as a phantom of the everyday activity in the busy stress echo lab 3) to show examples of software testing in a way that proves its value.The informatics infrastructure is available on the web, linking to http://cctrainer.ifc.cnr.it webciteRecent technological development and engineering refinements have allowed the application of real-time three-dimensional (RT3D) echocardiography in the routine clinical setting [1]. Because full-volume datasets obtained with RT3 D echocardiography incorporate information on the entire left ventricle in four volumetric datasets, RT3 D echocardiography has the potential to overcome many of the limitations encountered with two-dimensional echocardiography, mostly by eliminating the need for geometric modelling and the errors caused by the use of foreshortened views [2]. Three-dimensional (3D) volumetric imaging has potential advantages in stress echocardiography, including the ability to provides an accurate assessment of stroke volume, allowing derivation of a set of hemodynamic measures usually difficult or impossible to obtain with two-dimensional (2D) echocardiography [3-6]. However calculations are time-consuming and difficult to plan in the busy stress echo lab, and generally cardiologists are not well-trained in these calculations. Therefore we present a WEB based software program for calculation training in the 3 D stress echo lab. The "algorithms", "testing" and "implementation" of this new computational method will be described. The informatics infrastructure is available on the web, linking to http://cctrainer.ifc.cnr.it webcite.Once the electronic rest and stress data set is filled, the CCtrainer program will show that echo-m
Recruitment of aged donor heart with pharmacological stress echo. A case report
Giorgio Arpesella, Sonia Gherardi, Tonino Bombardini, Eugenio Picano
Cardiovascular Ultrasound , 2006, DOI: 10.1186/1476-7120-4-3
Abstract: To counteract heart donor shortage, we should screen aged potential donor hearts for initial cardiomyopathy and functionally significant coronary artery disease.Donors with a history of cardiac disease are generally excluded. Coronary angiography is recommended for most male donors older than 45 years and female donors older than 50 years to evaluate coronary artery stenoses. A simpler way to screen aged potential donor hearts for initial cardiomyopathy and functionally significant coronary artery disease should be stress echocardiography.A marginal donor (A 57 year old woman meeting legal requirements for brain death) underwent a transesophageal (TE) Dipyridamole stress echo (6 minutes accelerated protocol) to rule out moderate or severe heart and coronary artery disease. Wall motion was normal at baseline and at peak stress (WMSI = 1 at baseline and peak stress, without signs of stress inducible ischemia). The pressure/volume ratio was 9.6 mmHg/ml/m2 at baseline, increasing to 14 mmHg/ml/m2 at peak stress, demonstrating absence of latent myocardial dysfunction.The marginal donor heart was transplanted to a recipient "marginal" for co-morbidity ( a 63 year old man with multiple myeloma and cardiac amyloidosis , chronic severe heart failure, NYHA class IV).Postoperative treatment and early immunosuppressant regimen were performed according to standard protocols.The transplanted heart was assessed normal for dimensions and ventricular function at transthoracic (TT) echocardiography on post-transplant day 7.Coronary artery disease was ruled out at coronary angiography one month after transplant; left ventriculography showed normal global and segmental LV function of the transplanted heart.For the first time stress echo was successfully used in the critical theater of screening potential donor hearts. This method is enormously more feasible, less expensive, and more environmentally sustainable than any possible alternative strategy based on stress scintigraphy perfusio
Abnormal shortened diastolic time length at increasing heart rates in patients with abnormal exercise-induced increase in pulmonary artery pressure
Tonino Bombardini, Rosa Sicari, Elisabetta Bianchini, Eugenio Picano
Cardiovascular Ultrasound , 2011, DOI: 10.1186/1476-7120-9-36
Abstract: At baseline, PASP was 30 ± 5 mmHg in patients and 25 ± 4 in controls. At peak stress the PASP was normal in 95 patients (Group 1); 14 patients (Group 2) showed an abnormal increase in PASP (from 35 ± 4 to 62 ± 12 mmHg; P < 0.01). At 100 bpm, an abnormal (< 1) diastolic/systolic time ratio was found in 0/16 (0%) controls, in 12/93 (13%) Group 1 and 7/14 (50%) Group 2 patients (p < 0.05 between groups).The first and second heart sound vibrations non-invasively monitored by a force sensor are useful for continuously assessing diastolic time during exercise. Exercise-induced abnormal PASP was associated with reduced diastolic time at heart rates beyond 100 beats per minute.Pulmonary hypertension is frequent in patients with heart failure, contributes to exercise intolerance and is associated with a worse outcome [1]. The degree of pulmonary hypertension is not independently related to the severity of left ventricular systolic dysfunction but is frequently associated with left ventricular diastolic filling abnormalities and with the quantified degree of functional mitral regurgitation [2]. It has been shown that dynamic mitral regurgitation and limited contractile reserve correlate with pulmonary pressure at exercise [3]. However, no study related the diastolic time duration during exercise with the pulmonary pressure at exercise [4,5]. Ideally, the non-invasive, imaging-independent, objective assessment of diastolic and systolic times at rest and during stress in patients with abnormal exercise-induced increase in pulmonary artery pressure would greatly enhance its practical appeal [6]. A new cutaneous force-frequency relation recording system has recently been validated in the stress echo lab, based on heart sound amplitude and timing variations at increasing heart rates [7,8]. Expert monitoring of the heart - via a chest wall accelerometer - can reliably and non-invasively sense the contractile force and the filling function of the heart [7,8]. The aim of this study w
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