Update on iodine-refractory differentiated thyroid carcinoma

Radioiodine therapy represents a fundamental pillar in the routine adjuvant therapy of patients with high-risk differentiated thyroid carcinoma. However, a non-negligible percentage of these patients will develop iodine refractoriness, showing a worse prognosis, as well a lower survival, which demonstrates a clear need to explore different therapeutic approaches. Iodine refractory patient treatment continues to be a challenge, currently having different novel therapeutic options that should be known by the different specialties related to differentiated thyroid carcinoma (DTC). The aim of this work is to review iodine refractory thyroid carcinoma treatment, focusing especially on the definition of iodine refractoriness, highlighting its importance due to its high mortality, and introducing the different therapeutic options available for these patients.

C26 COMPLETE REVASCULARISATION IMPROVES SURVIVAL OF PATIENTS RESUSCITATED AFTER AN OUT–OF–HOSPITAL CARDIAC ARREST

Background

Sudden cardiac death is a major issue in industrialised countries and survival of patients after out–of–hospital cardiac arrest (OHCA) remains low. Acute myocardial infarction (AMI) is the principal cause of OHCA and myocardial revascularisation plays a positive role on survival. In this setting little is known about the role of complete (CR) versus culprit–only revascularisation (IR) on survival.

Purpose

The aim of this study was to assess whether CR could lead to a better one–year survival as compared to IR. Methods. Among patients prospectively enrolled in the Lombardia CARe OHCA registry from January 1 2015 to May 1 2021, who underwent a coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo were enrolled in this study. CAGs were retrospectively reviewed by two interventional cardiologists. Prehospital and survival data were retrieved from the registry.

Results

We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; shockable presenting rhythm 84.1%; AMI at post ROSC ECG 67.9%; ejection fraction 37% (30–45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with multi–vessel disease, 82 (69%) received IR whereas 37 (31%) received CR [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5–10) days]. This latter group showed significantly higher one–year survival (54.9% vs 16.2%, p < 0.001). At univariable logistic regression only a shockable presenting rhythm and the presence of chronic total occlusion (CTO) were significantly associated with the probability of receiving a CR [OR 5.1 (95%CI 1.1–22), p = 0.03; OR 0.37 (95%CI 0.16–0.85), p = 0.02 respectively]. However, at multivariable regression analysis only CTO was significantly associated with the probability of receiving a CR [OR 0.36 (95%CI 0.15–0.9), p = 0.007]. At Cox multivariable regression model cardiac arrest duration (longer that the median value of 24 min) and CR were independently associated with the probability of death [HR 3.6 (95%CI 1.9–6.9), p < 0.001; HR 0.2 (95%CI 0.1–0.9), p = 0.02]. Similarly, cardiac arrest duration, CR and a shockable presenting rhythm were associated with the probability of death or poor neurologic outcome [HR 3.3 (95%CI 1.8–6), p < 0.001; HR 0.5 (95%CI 0.3–0.9), p = 0.03 and HR 0.2 (95%CI 0.1–0.5), p < 0.001].

Conclusions

Complete revascularisation is independently associated with a better one–year survival in patients resuscitated from an out–of–hospital cardiac arrest.

Barriers associated with emergency medical service activation in Italian patients with ST-segment elevation acute coronary syndromes

Background

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation include patients with any acute coronary syndrome (ACS) without representation of southern European populations. However, barriers are influenced by the ACS type and by socio-demographic and racial factors.

Purpose

We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy.

Methods

A prospective, single-center, survey-based study, including all the patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 1st June 2018 to 31st May 2020.

Results

The questionnaire was filled out by 293 patients. The majority of the participants were males (74%), married (70.4%), with a high-school degree (38.4%) and with a median age of 62 years. Chest pain as a possible symptom related to a cardiovascular attack is known by most of the respondents (89%), and left arm pain/shake by 53.7% of them, whilst the other possible signs and symptoms (i.e. dyspnea, asthenia, sweating, nausea, vomiting, dizziness) were unknown to the majority of the participants. Only 191 (65.2%) of the participants activated the EMS after symptoms onset. The main reasons for not calling EMS were the perception that symptoms were not related to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). The median time to first medical contact was 60 minutes, and it was significantly higher in the patients who did not called EMS compared to those who did (180 [60–420] mins vs 35 [15–120] mins, p<0.001). The patients who called a private doctor after symptoms onset did not called EMS more frequently than those who did not (5.9% vs 8.2%, p=0.3). Moreover, 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred and the main reasons for this were that they think to be faster than EMS (57.1%) and to live close to the hospital (17.9%). Analyzing predictors of EMS activation, only prior history of cardiovascular disease has been demonstrated to be a predictor of calling the EMS in case of symptoms suspected for STEACS.

Conclusions

Our study, from the southern Europe, showed that a substantial percentage of patients with symptoms suspected for STEACS preferred private vehicle rather than activating the EMS. Our results highlight the need for information campaigns targeted to both the general population and medical doctors, stressing that the EMS is faster than a private vehicle to direct the patient to the right hospital and increasing the awareness of the people on the type of possible heart attack symptoms, which seem to be the most neglected issues by patients who did not call the EMS.

Funding Acknowledgement

Type of funding sources: None.

Sentinel lymph node biopsy procedure in squamous vulvar cancer. 10 years follow-up analysis

AIM

Application of sentinel lymph node biopsy (SLNB) procedure in early-stage vulvar cancer and analysis of results, recurrences and complications.

MATERIAL AND METHODS

40 patients with vulvar cancer and SLNB between 2008 and 2018 were retrospectively reviewed. During the surgical procedure the inguinofemoral lymph nodes were checked with a gamma probe to identify the sentinel nodes that were removed and referred for intraoperative pathological assessment. Subsequently, long-term patient follow-up was performed with analysis of complications, relapse and mortality.

RESULTS

40 patients (mean age: 72 years [47-86], the overall detection rate per patient was 95% and a total of 129 Sentinel Lymph Nodes (SLNs) were removed (3.22 SLN/patient). In 3 out of 25 patients with lateral tumour lesions drainage was bilateral and in 2 out of 15 with midline lesions drainage was unilateral. On lymphoscintigraphy, 16 out of 40 had bilateral drainage and 24 unilateral. A total of 119 SLN- and 10 SLN+ were obtained, in 8 out of 10 an inguinofemoral lymphadenectomy was performed. In the SLN- group, one case of lymphatic blockage and one false negative were included. In 12 out of 40 patients there were post-surgical complications, 4 of them lymphoedemas. In the median follow-up (40 months), 6 out of 10 with SLN+ (40% mortality) and 7 out of 30 SLN- (16% mortality) had recurrences.

CONCLUSIONS

SLNB in vulvar cancer is the technique of choice for correct staging and locoregional therapy. Correct clinical lymph node staging is important before surgery in order to avoid potential blockage drainages which could induce a false negative SLN.

P5539Genetic heterogeneity of spontaneous coronary artery dissection (SCAD)

Introduction

SCAD is a rare coronary event that may cause acute coronary syndromes (ACS). SCAD predominantly occurs in apparently healthy, young to middle aged women (up to 95% of cases). The known causes include: heritable connective tissue diseases, fibromuscular dysplasia, arteritis, contraceptives, cocaine abuse and chest trauma. A variable proportion of patients manifests progression to longer segments of the same vessel or recurrence of dissection in other coronary arteries. SCAD can be the first manifestation of a previously unrecognised systemic disease.

Methods

In 2010 we started collecting consecutive SCAD, as first clinical manifestation, in patients addressed to our attention for investigation of genetic or non genetic causes, after successful management of the acute phase and exclusion of systemic inflammatory and autoimmune diseases. All patients underwent genetic visit and counselling, collection of clinical reports and imaging records, clinical cardiologic evaluation with pan-angio CT scan, biochemical testing including coagulation-related tests, and and genetic testing of genes causing connective tissue diseases. Parallel clinical family screening and genetic testing were systematically performed.

Results

The series is constituted of 35 patients (28F and 7M) (age at onset, mean ± SD, 44±7.6 years) with ACS-SCAD (20 STEMI and 15 NSTEMI) and 9 second dissections in a different coronary artery. Two sisters had ACS-SCAD caused by dissection of the same coronary artery.

We identified pathologic mutations (n=19/35, 54%) in COL3A1 (n=3), FBN1 (n=1), FBN1+TGFBR1 (n=1), TGFBR1 (n=2), TGFBR2 (n=1), MYLK (n=1), SMAD3 (n=1), COL5A1 (n=1 homozygous), COL5A2 (n=1), MYH11 (n=1), TGFB2 (n=1), ABCC6 (1 homozygous), ELN (2 homozygous sisters and 1 heterozygous unrelated patient), NOTCH1 (n=1). In 8 (23%) patients we identified VUS classified as C3 because previously unreported and predicted as uncertain on the basis of in silico analyses. In the remaining 8 patients we only identified C2 variants. A second SCAD (14 days to 78 months after the first event) occurred in 9 patients (9/35, 25%) (COL3A1 (n=2), FBN1 (n=1), FBN1+TGFBR1 (n=1), MYLK (n=1), COL5A2 (n=1), NOTCH1 (n=1) COL5A2 (n=1) and 1 with a C2 variant in COL3A1. Two patients with thrombocytosis were carriers of the somatic JAK2 V617F mutation. Extra-coronary arterial dilations/aneurysms occurred in 13 families; in the follow-up 2 patients demonstrate dissection in non-coronary arteries.

Conclusions

Our series, with the potential bias of a referral centre for inherited cardiovascular disease, demonstrated that SCAD is the possible first manifestation of a genetic disorder and that neither disease gene or mutation predicts the risk of a second coronary event. SCAD is a potentially fatal coronary event associated with ACS, warning for familial disease and unpredictable risk of recurrence.

P970DK-crush is the best treatment strategy to reduce stent oriented clinical outcome, results from a network meta-analysis of twenty-six randomized clinical trials comparing different stent techniques

Background

Coronary bifurcation disease (CBD) accounts for approximately 20% of all and is associated with worse short- and long- term clinical outcomes. Provisional stenting (PS) is the preferred choice, however, this approach may not be suitable in all CBD anatomies, therefore several elective two-stents techniques have been described, however there is lack of randomized evidence to guide interventionalist across different stent techniques. Objectives. To identify the best percutaneous coronary interventions (PCI) technique for CBD.

Methods

We systematically review randomized clinical (RCTs) of patients receiving CBD PCI with either PS or six type of elective two-stent techniques (DK-crush, TAP, culotte, dedicated bifurcation stents, crushing, T-stenting) and compare device oriented clinical events (DOCE) in a network meta-analysis. DOCE was defined as composite of cardiac death, target-vessel myocardial infarction, stent thrombosis, target lesion revascularization OR target vessel revascularisation.

Results

We included 26 RCTs leading to a pooled population of 10339 patients-years with 1229 DOCE. Compared to PS, the DK-crush technique had a lower DOCE with RR=0.62, [0.42–0.92]. Figure. DK-crush had the highest likelihood (model likelihood=90.2%, SUCRA=98.0%) of being the best treatment to reduce DOCE.

Figure 1

Conclusions

In the management CBD, when a two-stent technique is required as upfront strategy, the DK- Crush technique should be privileged as it showed to reduce stent-related clinical outcomes (DOCE) when compared to other bifurcation techniques.

The-374T/A Variant of the Rage Gene Promoter is Associated with Clinical Restenosis after Coronary Stent Placement

Upregulation of the receptor for advanced glycation end products (RAGE) may play a crucial role in neointimal formation upon vessel injury. The −374T/A variant of the RAGE gene promoter, which has been associated with an altered expression of the cell-surface receptor, could exert a protective effect toward the development of vascular disease. The aim of this study is to determine the impact of this common genetic variant in the occurrence of clinical in-stent restenosis after coronary stent implantation. The −374T/A polymorphism of the RAGE gene promoter was evaluated by PCR-RFLPs in 267 patients with coronary artery disease who underwent coronary stent implantation and a subsequent coronary angiography 6–9 months later for suspected restenosis. In-stent restenosis was assessed by means of quantitative angiography. Carriers of the-374AA genotype showed a significantly reduced risk of developing restenosis after percutaneous transluminal intervention than non-carriers. To determine whether the protective effect of the homozygous AA genotype toward clinical restenosis was independent of potential confounders, we performed multivariable logistic regression analysis. After allowance for clinical and biochemical risk factors and stent length, the AA genotype remained significantly associated with a reduced prevalence of in-stent restenosis. No relation was evident between the RAGE genotype and established cardiovascular risk factors. In conclusion, the −374AA genotype of the RAGE gene promoter could be associated with a reduced risk of in-stent restenosis after coronary stent implantation.

Decline in macrolide resistance rates among Streptococcus pyogenes causing pharyngitis in children isolated in Italy

Macrolides are often used to treat group A streptococcus (GAS) infections, but their resistance rates reached high proportions worldwide. The aim of the present study was to give an update on the characteristics and contemporary prevalence of macrolide-resistant pharyngeal GAS in Central Italy. A total of 592 isolates causing pharyngitis in children were collected in the period 2012–2013. Clonality was assessed by emm typing and pulsed-field gel electrophoresis (PFGE) for all macrolide-resistant strains and for selected susceptible isolates. Genetic determinants of resistance were screened by polymerase chain reaction (PCR). Forty-four GAS were erythromycin-resistant (7.4 %). Among them, 52.3 % and 50 % were clindamycin- and tetracycline-resistant, respectively. erm(B)-positive isolates (52.3 %) expressed the constitutive cMLS_B phenotype. mef(A) and its associated M phenotype were recorded in 40.9 % of the cases. The remaining erm(A)-positive isolates expressed the iMLS_B phenotype. Seventeen tetracycline-resistant isolates carried tet(M) and five isolates carried tet(O). Twenty-five emm types were found among all strains, with the predominance of emm types 12, 89, 1, and 4. Eleven emm types and 12 PFGE clusters characterized macrolide-resistant strains, with almost two-thirds belonging to emm12, emm4, and emm11. Macrolide-susceptible and -resistant emm types 12, 89, 11, and 4 shared related PFGE profiles. There was a dramatic decline in macrolide resistance in Central Italy among pharyngeal GAS isolates in 2012–2013 when compared to previous studies from the same region (p < 0.05), although macrolide consumption remained stable over the past 15 years. We observed a decrease in the proportion of macrolide-resistant strains within emm types commonly associated with macrolide resistance in the past, namely emm12, 1, and 89.

Characterization of levofloxacin non-susceptible clinical Streptococcus pyogenes isolated in the central part of Italy

We investigated the prevalence, genetics, and clonality of fluoroquinolone non-susceptible isolates of Streptococcus pyogenes in the central part of Italy. S. pyogenes strains (n = 197) were isolated during 2012 from patients with tonsillopharyngitis, skin, wound or invasive infections and screened for fluoroquinolone non-susceptibility (resistance to norfloxacin and levofloxacin minimum inhibitory concentration (MIC) = 2 mg/L) following EUCAST guidelines. First-step topoisomerase parC and gyrA substitutions were investigated using sequencing analysis. Clonality was determined by pulsed field gel electrophoresis (PFGE; SmaI digestion) and by emm typing. The fluoroquinolone non-susceptible phenotype was identified in 18 isolates (9.1 %) and correlated with mutations in parC, but not in gyrA, the most frequent leading to substitution of the serine at position 79 with an alanine. Most of the fluoroquinolone non-susceptible isolates belonged to the emm-type 6, even if other emm-types were also represented (emm75, emm89, and emm2). A significant level of association was measured between PFGE and both emm type and substitutions in parC. The prevalence of fluoroquinolone non-susceptible Streptococcus pyogenes isolates in Italy is of concern and, although the well-known emm type 6 is dominant, other types are appearing and spreading.

Enzyme replacement therapy in adult-onset glycogenosis II: is quantitative muscle MRI helpful?

Although it has been shown that muscle magnetic resonance imaging (MRI) improves the phenotypic characterization of patients with neuromuscular disorders and allows accurate quantification of muscle and adipose tissue distribution, to date quantitative MRI has not been used to assess the therapeutic response in clinical trials of neuromuscular diseases. We discuss quantitative MRI findings after a 6-month course of enzyme replacement therapy administered to nine patients with adult-onset glycogenosis II.

Characterization of a Staphylococcus Aureus Strain Showing High Levels of Biofilm Formation Isolated from a Vascular Graft: Case Report

A methicillin-susceptible Staphylococcus aureus strain, SA-DZ1, was isolated from an infected bypass crossover graft. Its general microbiological features were reminiscent of those previously described for the wound Wiley strain. Removal of the prosthetic device was necessary to resolve the infection. SA-DZ1 grown under different conditions showed a very strong and distinctive biofilm-producing phenotype, which was also visualized by confocal laser scanning microscopy. The biofilm extracellular matrix was essentially polysaccharidic, as determined by differential growth and physicochemical tests. By Multi Locus Sequence Typing (MLST), SA-DZ1 was classified as st94, a single locus variant of st8. Several other genetic traits assayed by PCR, such as agr-type and the presence of gene encoding proteins involved in adhesion and virulence (e.g. ica operon), confirmed the identifying features of this clinical isolate.

Plaque composition in plexogenic and thromboembolic pulmonary hypertension: the critical role of thrombotic material in pultaceous core formation

BACKGROUND

Patients with pulmonary hypertension develop intimal plaques in large pulmonary arteries.

OBJECTIVE

To test the hypothesis that the composition of such plaques differs depending on whether the aetiology of the disease is thromboembolic or hypertensive.

DESIGN

Chronic thromboembolic and plexogenic pulmonary hypertension (primary and secondary (Eisenmenger syndrome)) were investigated. These are spontaneous human models and were used to examine the independent role of thrombus and hypertension in plaque composition.

SETTING

A national tertiary referral centre for lung transplantation and pulmonary thromboendoarterectomy.

PATIENTS

Thirty nine patients with chronic thromboembolic pulmonary hypertension who had undergone thromboendoarterectomy (n = 32) or lung transplantation (n = 7), 28 with plexogenic diseases (nine primary and 19 Eisenmenger), and three with Eisenmenger syndrome complicated by thromboembolic events.

INTERVENTIONS

The lung and thromboendoarterectomy samples were sectioned, stained with Movat pentachrome, and immunostained with antibodies for fibrin, platelets, inflammatory cells, smooth muscle cells, and erythrocyte membrane glycophorin A.

MAIN OUTCOME MEASURE

Composition of the plaques affecting large pulmonary arteries.

RESULTS

Two types of intimal lesion were distinguished in chronic thromboembolic pulmonary hypertension: fibrous plaques with angioneogenesis; and core-rich atherosclerotic plaques with pultaceous cores largely consisting of glycophorin immunoreactive material, with cholesterol clefts (61.5%), CD68 positive macrophages (84.6%), T lymphocytes (87%), and calcification (46.1%). The samples from the patients with Eisenmenger syndrome and thromboembolic complications had similar characteristics, whereas those from patients with uncomplicated primary pulmonary hypertension had core-free fibrous plaques, spotted with macrophages and T lymphocytes.

CONCLUSIONS

Chronic thromboembolic pulmonary hypertension is associated with atherosclerotic plaques with glycophorin-rich pultaceous cores, and plexogenic pulmonary hypertension with fibrous plaques. Thromboembolic material thus plays a critical role in the formation of pultaceous cores, of which erythrocyte membrane derived glycophorin is a major component.

Complete or incomplete percutaneous coronary revascularization in patients with unstable angina in stent era: Are early and one-year results different?

The aim of our study was to evaluate the impact of a strategy of incomplete revascularization by PTCA, with or without stent implantation, on clinical outcome of 208 consecutive patients (171 men) with unstable angina and multivessel coronary artery disease. Mean age of the group was 63.8 +/- 10.3 years (range, 31-91). Complete and incomplete revascularization was achieved in 49 and 159 patients, respectively. A total of 226 stents were implanted in 172 patients (1.31 +/- 0.65 stent per patient), equally distributed between the two groups. Left ventricular ejection fraction < 40% and total chronic coronary occlusions were significantly more frequent in patients with incomplete revascularization than in those with complete (P = 0.014 and 0.001, respectively). In-hospital MACE occurred in 10% and 7.5% of patients with complete and incomplete revascularization, respectively (P = NS). By multivariate analysis, multiple stent implantation (OR, 5.44; 95% CI, 1.21-24.3), presence of thrombus in the treated lesion (OR, 6.3; 95% CI, 1.53-25.9), Braunwald class III (OR, 4.74; 95% CI, 1.08-20.8), and ad hoc PTCA (OR 4.51; 95% CI, 1.11-18.3) were significantly related to in-hospital outcome. At 1-year follow-up, 11.3% and 11.5% of patients with complete and incomplete revascularization, respectively, had MACE. In all patients, diabetes (OR, 3.40; 95% CI, 1.09-10.58) and presence of thrombus in the treated lesion (OR, 3.48; 95% CI, 1.12-10.84) were significant predictors of 1-year outcome by multivariate analysis. These results indicate that the strategy of incomplete revascularization in unstable angina patients with multivessel coronary disease does not expose them to a higher risk of death or other major ischemic events in comparison to those undergoing complete revascularization.

[ANMCO genetic area. Significance of family history in cardiology--Part III]

This is a proposal for collecting the family history throughout a guided form to be given to the patient when awaiting for ambulatory examination or hospital admission, before meeting the cardiologist. In this form, the patient is asked to make an effort in order to focus on his family history (diseases, signs, symptoms, medications, etc.) at least for parents, sibs, and off-springs. A nurse should be committed to give the form to the patient, making him sure that the incomplete filling does not limit the quality of the diagnostic and therapeutic work-up. Thanks to the guided form, the patient concentrates the attention on his family history, eventually consulting the relatives before being examined. The form opens stating that all data are potentially helpful, but none is essential for diagnosis and treatment. This new approach to the family history could support clinicians in having helpful news, only deepening information that seems to be more relevant for the diagnosis.

[The Genetic Area of the ANMCO. Family history in modern cardiology: cardiomyopathies -- Part II]

The family history plays an important role in the cardiomyopathy setting. Cardiomyopathies are defined as familial when at least two members of the family are proven as affected. Given that the definition of familial cardiomyopathy has to be evidence-based, the familial forms have to be identified and documented. Detailed family pedigrees are obtained by interviewing patients and relatives and examining all clinical and pathological reports. Then, the clinical non-invasive screening of relatives is proposed, and performed in all informed and consenting relatives. All patients diagnosed with cardiomyopathy are potentially affected by familial forms, until relatives are proven to be unaffected. A few exceptions could be for syndromic disorders for which the phenotypes provide certainty elements/signs analogous to those observed in the proband. Key points for family history interpretation are the phenotype at onset, the time of onset, the presence/absence of coronary risk factors (such as diabetes and hypertension) and concomitant diseases. Special attention has to be paid to neuromuscular disorders that represent a wide heterogeneous issue in which cardiac involvement (cardiomyopathy, arrhythmias and conduction defects) could be the first manifestation of the disease. Based on rigorous investigation, the information derived for each family will provide useful data for present and future management of the family members, and for future research in the field of cardiomyopathies.

[The genetic area of the Italian Association of Hospital Cardiologists. The family history in modern cardiology--part I]

The family history constitutes the first step in the cardiologist's clinical approach to the patient and is highly informative both for monogenic and multifactorial disorders. A detailed interview is a time-consuming activity: in their daily practice, cardiologists may have 10, 20 or more interviews to complete. The patient tends to concentrate his attention on his own clinical history, rather than on that of his family, and explaining the importance of the role of a well analyzed family history in the modern cardiology can be difficult and may further increase the loss of time. However, the information about a given phenotype revealed by a detailed and non-confounding family history is essential to define the inheritance of monogenic diseases, to calculate the penetrance, even when the disease genes are unknown, or to evaluate "clinically cryptic" risks in multifactorial diseases. The Genetic Area of the Italian Association of Hospital Cardiologists proposes a novel approach to the family history of the patients: a guide form to be filled in by the patient whilst awaiting for clinical evaluation or immediately after admission to the cardiology department. The proposal will be articulated in three parts: one dedicated to general considerations on the confounding or incomplete evaluation of potentially useful data from the family history, one specifically dedicated to cardiomyopathies, and one containing a model of the form to be eventually adopted by the cardiological scientific societies.

Evidence-based diagnosis of familial non-X-linked dilated cardiomyopathy. Prevalence, inheritance and characteristics

AIMS

To assess the prevalence of familial non-X-linked dilated cardiomyopathy, to diagnose early asymptomatic cases evaluate inheritance and characterize clinical phenotypes.

METHODS AND RESULTS

We screened 472 relatives of 104 consecutive patients diagnosed with dilated cardiomyopathy; males with X-linked dilated cardiomyopathy were excluded based on systematic immunohistochemical and molecular analysis. Relatives underwent clinical examination, electrocardiography, echocardiography and serum creatine-phosphokinase determination. Twenty-six index patients (25%) had familial disease: four youths (< or = 20 years) had rapidly progressive outcome and underwent emergency transplantation. In a sib-pair, the onset was with atrioventricular block. Inheritance was autosomal dominant in 15, undetermined in seven (four sib-pairs); mitochondrial DNA pathological mutations were found in four. The screening identified 23 newly diagnosed relatives in the familial group. Transplantation (P = 0.04) and atrial fibrillation (P = 0.04) were more frequent, and left bundle branch block (P = 0.04) less frequent in index patients with familial than in those with non-familial disease. Several non-affected relatives had instrumental abnormalities potentially useful as pre-clinical markers: their prevalence was similar in both groups.

CONCLUSIONS

The prevalence of familial, non X-linked dilated cardiomyopathy was 25%. The immediate benefits of screening family members of index patients was early diagnosis in unaware symptomless affected relatives.

Coronary angioplasty in patients with unstable angina: clinical, electrocardiographic and angiographic predictors of in-hospital outcome. R.OS.A.I. Study Group

BACKGROUND

In unstable angina early coronary arteriography is frequently performed, often followed by percutaneous revascularization with liberal use of stents. We intended to study the in-hospital outcome of patients receiving this treatment.

METHODS

From April 1997 to April 1998, patients submitted to coronary arteriography due to unstable angina, and with no previous myocardial revascularization, were included in a multicenter registry.

RESULTS

Out of 987 patients enrolled at 14 centers, 876 (89%) had percutaneous or surgical revascularization. Coronary angioplasty was performed in 571 patients (58%); 281 (49%) had Braunwald class IIIB or C angina. Refractory or prolonged chest pain, or both, were present in 133, 217 and 85 patients, respectively, and multivessel disease in 245 patients (43%). Stenting was performed in 486/571 cases (85%), abciximab was administered to 42 patients, and ticlopidine and/or aspirin to all. A procedural success was obtained in 96.9 % of cases. In-hospital major adverse cardiac events occurred in 29/571 patients (5.1%). Pain-related ST segment depression (44% of cases) was not predictive of outcome after coronary angioplasty. In multivariate analysis prolonged plus refractory angina (p = 0.02), an ejection fraction < 0.4 (p = 0.04), multivessel disease (p = 0.01) and--with the strongest predictive value--ad hoc angioplasty (p = 0.007) and use of > 1 stent (p = 0.0008) were all independent predictors of in-hospital adverse outcome.

CONCLUSIONS

Coronary angioplasty with a liberal use of stents yields a high rate of procedural success, with few in-hospital major cardiac events also in "high risk" patients.

Tissue factor in human coronary atherosclerotic plaques

The rupture or fissuring of a coronary atherosclerotic plaque and subsequent thrombosis is considered the key event in the pathogenesis of unstable angina and myocardial infarction. Although plaque disruption frequently occurs during the evolution of atherosclerosis, only a minority of ruptured plaques develop thrombosis. The content and procoagulant activity of tissue factor in human coronary atherosclerotic plaques varies widely, and different studies confirm that it is higher in the plaques extracted from patients with unstable angina, myocardial infarction or histologic/angiographic evidence of coronary thrombosis than in those taken from patients with stable angina or uncomplicated coronary lesions. Variations in tissue factor content and activity may be responsible for the different thrombotic responses to human coronary atherosclerotic plaque rupture.

One-year outcome in multivessel coronary disease patients undergoing coronary stenting

The purpose of this study was to assess 1-year clinical outcome of patients with multivessel coronary artery disease (CAD) who underwent coronary stenting and were prospectively enrolled in the Registro Impianto Stent Endocoronarico (RISE). Of 939 consecutive patients included in the registry, 377 patients with angiographic evidence of multivessel CAD had a 1-year clinical follow-up. All patients underwent PTCA and single or multiple stenting in at least one vessel. Angiographic optimization was usually performed by using high-pressure balloon dilation. After the procedure, continuation of aspirin (at least 250 mg/day) was recommended, whereas the use of anticoagulation or ticlopidine was determined by the physician in charge of the patient in the various centers. Major adverse cardiac events were defined as death, Q-wave or non-Q-wave myocardial infarction and target vessel revascularization. Mean age of patients (311 men, 66 women) was 60 +/- 10 years. Globally, there were 596 stents implanted (72% Palmaz-Schatz stents) in 434 vessels. In about 75% of the procedures, an inflation pressure > 12 atm was used. Angiographic success rate was 98.5%. After stenting, 77% of patients received antiplatelet treatment with ticlopidine and aspirin. During hospitalization, there were 34 major adverse cardiac events in 24 patients. At 1-year follow-up, 309 patients were alive and event-free; cumulative incidence of death, myocardial infarction, and repeat revascularization were 2.9%, 4.7%, and 10.8%, respectively. By Cox regression analysis, multiple stents implantation (HR 1.72, 95% CI 1-2.97), left anterior descending artery revascularization (HR 1.86, 95% CI 1.01-3.42), use of inflation pressure > 12 atm (HR 0.93, 95% CI 0.89-0.97), ticlopidine therapy (HR 0.41, 95% CI 0.23-0.74), and stent length (HR 1.03, 95% CI 1.01-1.05) were associated with 1-year major cardiac events. In patients with multivessel CAD undergoing stent implantation in at least one vessel, 1-year follow-up is favorable and the need for repeat revascularization procedures, based on clinical data, is lower than previously reported for conventional PTCA. Cathet. Cardiovasc. Intervent. 48:343-349, 1999.

Prospective, randomized, double-blind trial comparing teicoplanin and cefazolin as antibiotic prophylaxis in prosthetic vascular surgery

To compare efficacy, tolerability, and cost of antibiotic prophylaxis with teicoplanin and cefazolin in clean prosthetic vascular surgery, a randomized, prospective, double-blind study was performed at the Vascular Surgery Unit of a tertiary-care university hospital. Two-hundred thirty-eight consecutive patients undergoing elective, clean, abdominal or lower-limb prosthetic vascular surgery were allocated to receive a single intravenous dose of teicoplanin (400 mg) or cefazolin (2 g) at the induction of anesthesia. Surgical-site infections occurred in 5.9% of teicoplanin recipients (4.2% wound infection, 1.7% graft infection) and 1.7% of cefazolin recipients (1.7% wound infection, 0% graft infection) (P=0.195). Other postoperative infections occurred in 10% of teicoplanin recipients (pneumonia 7%, urinary tract infection 3%) and 12% of cefazolin recipients (pneumonia 7%, urinary tract infection 2.5%, bloodstream infections 2.5%). Overall mortality rate was 3.4% in teicoplanin recipients (4 patients) and 2.5% in cefazolin recipients (3 patients). Infective deaths occurred in one patient for each group. The two prophylactic regimens were well tolerated. Cost savings of US $52,510 favoring cefazolin were related to the lower acquisition cost (US $1034 vs US $4740) and to the shorter duration of the hospital stay (1762 days vs 1928 days). Cefazolin can still be regarded as the drug of choice for prophylaxis in clean vascular surgery.

[In vitro study of the antifungal activity of two chlorine derivatives to be used in antisepsis]

The activity of two chlorine derivates, sodium hypochlorite in water solution with NaCl (product A) and electrolytic chloroxidant (product B) has been tested in vitro against potentially human pathogenic fungi (Aspergillus niger, Aspergillus fumigatus, Microsporum gypseum, Candida albicans, Cryptococcus neoformans, Trichophyton mentagrophytes, Microsporum canis, Epidermophyton floccosum, Trichophyton rubrum, Sporotrix schenkii). For A. niger, the relation of the two compounds has also been considered between mycelial and sporidial forms. Dilutions used ranged from 0.15 to 10% (corresponding to 17.2-1150 ppm of active principle for product A, and to 18.3-1220 ppm of active principle for product B). These were applied for different times in order to assess the minimal inhibitory concentration (M.I.C.) and to evaluate the survival time of the microorganisms tested, which were strains from the collection of the Institute of Mycology, (Faculty of Agrarian Science, Perugia) and recently isolated ones from animal and vegetable tissues, cultivated on Sabouraud medium. The cell suspension to be tested was obtained on nutrient broth in shaken flasks (120 rpm) at 28 degrees C for 48 h, and was separated by centrifugation and 10000 rpm at 5 degrees C for 20 min, repeatedly washed with sterile physiologic saline and resuspended in sterile water where it was submitted to delicate pressure in order to fragment the mycelium. Activity tests were carried out on Sabouraud broth and Sabouraud agar with controls for every case without the active principle. Aliquots of the suspensions (microrganism++ + disinfectant) were transferred at regular intervals (1, 3, 5 and 10 minutes) to the two substrates in liquid and solid state, and the growth of microorganisms was followed at 28 degrees C for 48-72 h in the case of yeasts, and for up to 21 days in the case of sower growing fungi. The cell content of the different suspensions was found to range from 10(4) to 10(9) UFC/ml. The active chlorine contents of the two compounds was evaluated by iodometry simultaneously with the pH of the different solutions. Useful data were obtained from the comparison of the two systems of activity assessment of the fluid and agarized substrate. It was thus found that the two compounds were equally active against the species tested. Some of these (A. fumigatus, M. gypseum, A. niger, C. albicans, C. neoformans) were less sensitive to the compounds examined (doses for cell inactivation 0.62-2.5% for product A, and O.15-1.25% for product B) where at any rate product B was more active.(ABSTRACT TRUNCATED AT 400 WORDS)

Inhibition of beta-lactamase production in gram-positive and gram-negative strains by sub-inhibitory concentrations of nalidixic acid

We found it of interest to try to determine a microbiological parameter for the effects that sub-inhibitory doses of a chemotherapeutic agent may have on bacteria. To this end, the antibacterial activity of nalidixic acid was analyzed and our attention was directed to evidence of the production of beta-lactamase by 60 strains. The tests carried out showed that sub-inhibitory concentrations of nalidixic acid, from 2 to 64 times lower than the MIC (minimum inhibitory concentrations), were able to inhibit production of penicillinases in the 14 strains of Staphylococcus spp. tested, while only in 7 of the 21 strains of Gram-negative bacteria. Strains from our collection of beta-lactamase producing bacteria were analyzed, and our results confirmed that nalidixic acid inhibits plasmidic and chromosomic beta-lactamases.

Identification, clinical distribution, and susceptibility to methicillin and 18 additional antibiotics of clinical Staphylococcus isolates: nationwide investigation in Italy

A multicentric study of clinical Staphylococcus isolates was performed by seven operative units working in different areas of Italy. Over a 6-month period, a total of 3,226 staphylococci, isolated from in- and outpatients, were identified and tested for antimicrobial susceptibility by a protocol agreed upon by all units. On the basis of their bacteriolytic-activity patterns and other conventional tests, the isolates were identified by lyogroups , which closely correlate with human Staphylococcus species. Lyogroup I (Staphylococcus aureus) and lyogroup III (Staphylococcus capitis) were the most and the least frequently isolated staphylococci, respectively. Significant differences depending on strain origin from in- or outpatients were only observed with lyogroup IV (i.e., novobiocin- resistant staphylococci), whose isolation from outpatients was three times greater than from inpatients. Lyogroup I was predominant among isolates from most clinical sources. Lyogroup IV predominated in strains isolated from the urinary tract; lyogroup V (Staphylococcus epidermidis) predominated in strains from blood, cerebrospinal fluid, and indwelling artificial devices; and lyogroup VI ( Staphylococcus hominis, Staphylococcus haemolyticus, and Staphylococcus warneri ) predominated in strains from bile and the male genital tract. The incidence of methicillin resistance within the different lyogroups varied from unit to unit, suggesting epidemiological differences among different hospitals and different geographical areas. On the whole, methicillin resistance was more frequent in coagulase-negative staphylococci than in S. aureus and ranged from 19% for lyogroups I and III to 30% for lyogroup II (Staphylococcus simulans). Laboratory testing with 18 additional antibiotics suggested the occurrence of some specific differences in susceptibility among the different lyogroups . The rate of organisms resistant to the various antibiotics was greater among methicillin-resistant than among methicillin -susceptible staphylococci; particularly marked differences occurred with cephalosporins, rifampin, gentamicin, and tobramycin. The results suggested an increasing spread in Italy, during the last few years, of staphylococcal resistance to methicillin and to many other antibiotics. Some questions about the actual reliability of laboratory tests for the determination of staphylococcal susceptibility to methicillin and other beta-lactam antibiotics were raised by parallel test performances in which both unsupplemented and 5% NaCl-supplemented Mueller-Hinton agars were used. The presence of NaCl heightened, on the whole, the number of resistant strains detected; however, a few isolates resistant in the unsupplemented medium and susceptible in the salt-supplemented medium were also encountered. This was true not only for methicillin but also for all other beta-lactam antibiotics tested except cefamandole. With cefamandole, the presence of 5% NaCl reduced the number of resistant strains detected.

[Analysis of the system of evaluation of a medical career in Chile]

For the purpose of measuring the extent to which the modern university accomplishes its purposes, the authors have devised an evaluation methodology inspired by the work of the most modern international specialists in the subject. They have applied their methodology first to the system for evaluating medical programs in general and then to a specific medical program regarded as representative of medical training in Chile. Surveys of faculty and students led them to the conclusion that in actual evaluative practice there have been wide deviations from the ideal model, and that the evaluation system could be improved to become an essential component of the process of informing and training the student and to provide feedback to th teaching-learning process.