Multimodality Imaging Approach for Planning and Guiding Direct Transcatheter Tricuspid Valve Annuloplasty

Interest in transcatheter treatment of tricuspid regurgitation (TR) has grown significantly in recent years due to increasing evidence correlating TR severity with mortality and to limited availability of surgical options often considered high-risk in these patients. Although edge-to-edge repair is currently the main transcatheter therapeutic strategy, tricuspid valve direct annuloplasty can also be performed safely and effectively to reduce TR and improve heart failure symptoms and quality of life. In the annuloplasty procedure, an adjustable band is implanted around the tricuspid annulus to reduce valvular size and improve TR. Patient selection and careful preoperative imaging, including transthoracic echocardiography, transesophageal echocardiography, and computed tomography, are critical for procedural success and proper device implantation. Compared to edge-to-edge repair, perioperative imaging with transesophageal echocardiography and fluoroscopy is particularly challenging. Alignment and insertion of the anchors are demanding but essential to achieve good results and avoid damaging the surrounding structures. The presence of shadowing artifacts due to cardiac devices makes the acquisition of good-quality images even more challenging. In this review, we discuss the current role of multimodality imaging in planning direct transcatheter tricuspid valve annuloplasty and describe all procedural steps focusing on echocardiographic monitoring.

The Positive Impact of Early Frailty Levels on Mortality in Elderly Patients with Severe Aortic Stenosis Undergoing Transcatheter/Surgical Aortic Valve Replacement

Background: Frailty is highly common in older patients (pts) undergoing transcatheter aortic valve replacement (TAVR), and it is associated with poor outcomes. The selection of patients who can benefit from this procedure is necessary and challenging. The aim of the present study is to evaluate outcomes in older severe aortic valve stenosis (AS) pts, selected by a multidisciplinary approach for surgical, clinical, and geriatric risk and referred to treatment, according to frailty levels. Methods: A total of 109 pts (83 ± 5 years; females, 68%) with AS were classified by Fried's score in pre-frail, early frail, and frail and underwent surgical aortic valve replacement SAVR/TAVR, balloon aortic valvuloplasty, or medical therapy. We evaluated geriatric, clinical, and surgical features and detected periprocedural complications. The outcome was all-cause mortality. Results: Increasing frailty was associated with the worst clinical, surgical, geriatric conditions. By using Kaplan-Meier analysis, the survival rate was higher in pre-frail and TAVR groups (p < 0.001) (median follow-up = 20 months). By using the Cox regression model, frailty (p = 0.004), heart failure (p = 0.007), EF% (p = 0.043), albumin (p = 0.018) were associated with all-cause mortality. Conclusions: According to tailored frailty management, elderly AS pts with early frailty levels seem to be the most suitable candidates for TAVR/SAVR for positive outcomes because advanced frailty would make each treatment futile or palliative.

Prognostic role of CRP-independent inflammatory patterns in patients undergoing primary percutaneous interventions

BACKGROUND

Despite the key pathophysiological role of inflammation in the development of coronary artery disease (CAD), the evaluation of inflammatory status has not been clearly established in patients presenting with acute coronary syndrome (ACS). The aim of this study is to evaluate the prevalence of CRP-independent inflammatory patterns in patients referred for primary percutaneous coronary intervention (pPCI) and to determine their one-year relationship with adverse clinical outcomes.

METHODS

We carried out a single-centre, observational study consecutively enrolling all patients presenting at a large-volume PCI hub with a diagnosis of ST-segment elevation myocardial infarction (STEMI) and treated with pPCI. Systemic Immune-Inflammatory Index (SII) was calculated at admission and at discharge. According to different SII trajectories patients were divided into four patterns: "persistent-low", "down-sloping", "up-sloping" and "persistent-high" pattern. The primary endpoint was a composite of all-cause of death and myocardial infarction (MI) at a one-year follow-up.

RESULTS

Among the total 2353 subjects enrolled, 44% of them belonged to "persistent-low", 31% to "down-sloping", 4% to "up-sloping" and 21% to "persistent-high" pattern. The primary endpoint was observed in 8% of patients with a "persistent-low", 12% with a "down-sloping", 27% with a "up-sloping", and 25% with a persistent-high pattern (p=0.001). After multivariate analysis, "up-sloping" [OR: 3.2 (1.59-3.93); p=0.001] and "persistent-high" [OR: 4.1 (3.03-4.65); p=0.001] patterns emerged as independent predictors of one-year adverse events.

CONCLUSIONS

"Persistent-high" and "up-sloping" CRP-independent inflammatory patterns in patients undergoing primary PCI are associated with an increased risk of adverse events at one-year follow-up. The prognostic value of these inflammatory patterns might be helpful to individualise potential therapeutic targets.

Additional value of T1 and T2 mapping techniques for early detection of myocardial involvement in scleroderma

BACKGROUND

We evaluated the prevalence of myocardial involvement by native T1 and T2 mapping, the diagnostic performance of mapping in addition to conventional Lake Louise Criteria (LLC), as well as correlations between mapping findings and clinical or conventional cardiovascular magnetic resonance (CMR) parameters in systemic sclerosis (SSc) patients.

METHODS

Fifty-five SSc patients (52.31 ± 13.24 years, 81.8% female) and 55 age- and sex-matched healthy subjects underwent clinical, bio-humoral assessment, and CMR. The imaging protocol included: T2-weighted, early post-contrast cine sequences, native T1 and T2 mapping by a segmental approach, and late gadolinium enhancement (LGE) technique.

RESULTS

Global myocardial T1 and T2 values were significantly higher in SSc patients than in healthy subjects. An increase in native T1 and/or T2 was present in the 62.1% of patients with normal conventional CMR techniques (negative LGE and T2-weighted images). Respectively, 13.5% and 59.6% of patients fulfilled original and updated LLC (overall agreement = 53.9%). Compared with patients with normal native T1, patients with increased T1 (40.0%) featured significantly higher left ventricular end-diastolic volume index and cardiac index, biventricular stroke volume indexes, and global heart T2 values, and more frequently had a history of digital ulcers. Biochemical and functional CMR parameters were comparable between patients with normal and increased T2 (61.8%).

CONCLUSION

T1 and T2 mapping are sensitive parameters that should be included in the routine clinical assessment of SSc patients for detecting early/subclinical myocardial involvement.

Combining echo-derived haemodynamic phenotypes and myocardial strain for risk stratification of chronic heart failure with reduced ejection fraction

AIMS

Echocardiography has shown to categorize heart failure (HF) patients according to haemodynamic profiles. Whether left ventricular (LV) global longitudinal strain (LV-GLS) could integrate echo-derived haemodynamic profiles to risk stratify chronic HF patients is still unknown.

METHODS AND RESULTS

Chronic HF outpatients with LV ejection fraction (LV-EF) <50% (n = 351) and LV-GLS assessment were evaluated and divided according to four haemodynamic phenotypes based on LV stroke volume index (SVI), LV filling pressure (LVFP), and right ventricular (RV) function: normal output-normal LVFP (NO-NP), normal output-high LVFP (NO-HP), low output-no RV dysfunction (LO-NRVD), and low output-RV dysfunction (LO-RVD). RV function was defined using the tricuspid annular plane systolic excursion and RV free-wall longitudinal strain. The median follow-up duration was 3.3 years. The combination of all-cause mortality and HF hospitalization was the primary endpoint. Secondary endpoints were all-cause mortality and cardiovascular mortality. The prevalence of NO-NP, NO-HP, LO-NRVD, and LO-RVD were 38%, 22%, 30%, and 10%, respectively. The haemodynamic model independently predicted primary and secondary outcomes, with incremental prognostic information over LV-EF (all P-values <0.001 for C-statistics). When univariate Cox regression analysis was performed to assess the prognostic stratification capability of LV-GLS in different haemodynamic subgroups, we observed a reduction in LV-GLS hazard ratios from the NO-NP to the LO-RVD for every endpoint.

CONCLUSION

There was a continuum in LV-GLS impairment across the spectrum of haemodynamic phenotypes and its prognostic value resulted variable depending on the types of chronic HF patients. The highest prognostic information added by LV-GLS was in patients with normal SVI.

Preliminary assessment of persistent organic pollutants (POPs) in tissues of Risso's dolphin (Grampus griseus) specimens stranded along the Italian coasts

Ecotoxicological and pathological research on Grampus griseus (Cuvier, 1812) (Risso's dolphins) is scarce both globally and in the Mediterranean Sea. This species has been classified as "Vulnerable" by the International Union for Conservation of Nature (IUCN) in the Mediterranean Sea. To evaluate the presence of "persistent organic pollutants" (POPs), especially organochlorine compounds (OCs), in the animals, chemical analyses were performed on tissues and organs of Risso's dolphin stranded along the Italian coasts between 1998 and 2021. Toxic contaminants such as hexachlorobenzene (HCB), polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane and its metabolites (DDTs) were examined in the blubber, liver, muscle, and brain of 20 animals, and data was correlated with sex, age, and stranding locations.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Echocardiographically defined haemodynamic categorization predicts prognosis in ambulatory heart failure patients treated with sacubitril/valsartan

AIM

Echo-derived haemodynamic classification, based on forward-flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan.

METHODS AND RESULTS

In our multicentre, open-label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m2 ) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e': ≥ or <15): Profile-A: normal-flow, normal-pressure; Profile-B: low-flow, normal-pressure; Profile-C: normal-flow, high-pressure; Profile-D: low-flow, high-pressure. Patients were started on sacubitril/valsartan and followed-up for 12.3 months (median). Rates of the composite of death/HF-hospitalization were assessed by multivariable Cox proportional-hazards models. Twelve sites enrolled 727 patients (64 ± 12 year old; LVEF: 29.8 ± 6.2%). Profile-D had more comorbidities and worse renal and LV function. Target dose of sacubitril/valsartan (97/103 mg BID) was more likely reached in Profile-A (34%) than other profiles (B: 32%, C: 24%, D: 28%, P < 0.001). Event-rate (per 100 patients per year) progressively increased from Profile-A to Profile-D (12.0%, 16.4%, 22.9%, and 35.2%, respectively, P < 0.0001). By covariate-adjusted Cox model, profiles with low forward-flow (B and D) remained associated with poor outcome (P < 0.01). Adding this categorization to MAGGIC-score and natriuretic peptides, provided significant continuous net reclassification improvement (0.329; P < 0.001). Intermediate and high-dose sacubitril/valsartan reduced the event's risk independently of haemodynamic profile.

CONCLUSIONS

Echocardiographically-derived haemodynamic classification identifies ambulatory HFrEF patients with different risk profiles. In real-world HFrEF outpatients, sacubitril/valsartan is effective in improving outcome across different haemodynamic profiles.

Benefit from sacubitril/valsartan is associated with hemodynamic improvement in heart failure with reduced ejection fraction: An echocardiographic study

BACKGROUND

Sacubitril/valsartan improves outcome in patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (EF, HFrEF). However, little is known about possible mechanisms underlying this favourable effect.

PURPOSE

To assess changes in echocardiographically-derived hemodynamic profiles induced by sacubitril/valsartan and their impact on outcome.

METHODS

In this multicenter, open-label study, 727 HFrEF outpatients underwent comprehensive echocardiography at baseline (before starting sacubitril/valsartan) and after 12 months. Estimated LV filling pressure (E/e') and cardiac index (CI, l/min/m²) were combined to determine 4 hemodynamic profiles: profile-A (normal-flow/normal-pressure); profile-B (low-flow/normal-pressure); profile-C: (normal-flow/high-pressure); profile-D: (low-flow/high-pressure). Changes among categories were recorded, and their associations with rates of the composite of death/HF-hospitalization were assessed by multivariable Cox analysis.

RESULTS

At baseline, 29% had profile-A, 15% had profile-B, 32% profile-C, and 24% profile-D. After 12 months, the hemodynamic profile improved in 53% of patients (all profile-A achievers, or profile-D patients achieving either C or B profile), while it remained unchanged in 39% patients and worsened in 9%. Prevalence of improved profile progressively increased with increasing dose of sacubitril/valsartan (P < 0.0001). After the second echocardiography, patients were followed up 12.6 ± 7.6 months: event-rate was lower in patients with improved profile (12.3%, 95%CI: 9.4-16.1) compared to patients in whom hemodynamic profile remained unchanged (29.9%, 24.0-37.3) or worsened (31.2%, 20.7-46.9, P < 0.0001). Improved hemodynamic profile was associated with favourable outcome independent of LVEF and other covariates (HR 0.65, 95%CI: 0.45-0.95, P < 0.05).

CONCLUSION

In HFrEF patients, the beneficial prognostic effects of sacubitril/valsartan are associated with improvement in hemodynamic conditions.

Improved diastolic dysfunction is associated with higher forward flow and better prognosis in chronic heart failure

The benefit of repeat assessment of left ventricular (LV) systolic and diastolic function in heart failure (HF) remains uncertain. We assessed the prognostic value of repeat echocardiographic assessment of LV filling pressure (LVFP) and its interaction with cardiac index (CI) in ambulatory patients with chronic HF and reduced ejection fraction (HFrEF). We enrolled 357 patients (age 68 ± 11 years; 22% female) with chronic HFrEF. Patients underwent a clinical and echocardiographic examination at baseline. LVFP as assessed by the 2016 Guidelines and Doppler-derived CI were estimated. After the second echocardiographic examination, patients were followed for a median time of 30 months. The study endpoint included all-cause death and hospitalization for worsening HF. Patients who normalized LVFP or showed persistently normal LVFP at the follow-up examination had a significantly lower mortality rate than those with worsening or persistently raised LVFP (p < 0.0001). After stratification by CI, patients with elevated LVFP and CI < 2.0 l/min/m2 had a further worse outcome than those with elevated LVFP and CI ≥ 2.0 l/min/m2 (p < 0.0001). Multivariate survival analysis confirmed an independent prognostic impact of changes in LVFP, incremental to that of established clinical, laboratory and echocardiographic predictors. Repeat assessment of LVFP and CI significantly improved risk stratification of chronic HFrEF outpatients compared to baseline evaluation.

Left atrial structural and mechanical remodelling in heart failure with reduced ejection fraction

Aims

In patients with heart failure with reduced ejection fraction (HFrEF), an association between left atrial (LA) dilatation and dysfunction is expected, but the degree of coexistence of the two abnormalities and their relative prognostic role is not known.

Methods and results

A total of 626 HFrEF patients formed the study population. All of them underwent a comprehensive echocardiographic evaluation. LA maximal volume was indexed to body surface area (LAVi); LA function was assessed using strain analysis during the reservoir phase: peak atrial longitudinal strain (PALS) analysis. Study primary endpoint was overall mortality or hospitalization for worsening heart failure. Four groups of patients were included in this study according to LAVi (≤34 or >34 mL/m²) and PALS (≤23% or >23%); 61 (10%) patients had normal LA volume and function (Group 1), 58 (9%) had LA dilatation but normal function (Group 2), 100 (16%) had normal volume but abnormal function (Group 3), and 407 (65%) had enlarged left atrium and abnormal function (Group 4). PALS was associated with primary endpoint in patients with both normal‐size [Groups 1 and 3: hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.88–0.96; P = 0.0006] and dilated left atria (Groups 2 and 4: HR 0.93, 95% CI 0.91–0.96; P < 0.0001). In contrast, LAVi was associated with the primary endpoint in patients with abnormal LA function (Groups 3 and 4: HR 1.018, 95% CI 1.011–1.024; P < 0.00001) but not in those with normal PALS (Groups 1 and 2: HR 1.023, 95% CI 0.99–1.057; P = 0.1).

Conclusions

Left atrial dilatation and dysfunction frequently but not invariably coexist. PALS emerged as a significant prognostic parameter in HFrEF even in the absence of LA dilation.

Impact of the first Covid-19 pandemic wave on first episode psychosis in Milan, italy

The ongoing Corona Virus Disease 2019 (COVID-19) pandemic appears to increase risk for mental illness, either directly due to inflammation caused by the virus or indirectly due to related psychosocial stress, resulting in the development of both anxious-depressive and psychotic symptoms. The purpose of the present study was to assess the frequency and characteristics of all patients with First Episodes Psychosis (FEP) without COVID-19 infection hospitalized in the first four months since lockdown in Milan. We recruited sixty-two patients hospitalized between March 8 to July 8, 2020 versus those first  hospitalized in the same period in 2019. The two subgroups were compared for sociodemographic variables and clinical characteristics of the episodes. Patients with FEP in 2020 were significantly older than patients with FEP in 2021, and presented with significantly less substances abuse. Interestingly, patients presenting with FEP in 2020 were significantly older than patients with FEP in 2019. These data are compatible with the greater vulnerability to stressful factors during the pandemic, as well as with the greater concern regarding a possible COVID-19 infection producing brain damage causing the FEP.

PEG-crosslinked-chitosan hydrogel films for in situ delivery of Opuntia ficus-indica extract

In the present study, chitosan-based wound dressings loaded with the extract of Opuntia ficus-indica (OPU) were prepared. OPU is known for its capability to accelerate skin injury repair. Chitosan (Ch) was crosslinked with a low molecular weight diepoxy-poly(ethylene glycol) (diePEG), and hydrogel films with different Ch/PEG composition and OPU content were prepared by casting. The occurrence of crosslinking reaction was confirmed by FTIR spectroscopy. FTIR and DSC analysis suggested that ionic interactions occur between chitosan and OPU. Tensile tests evidenced that the crosslinking caused a decrease of Young's modulus, which approaches the value of the human skin modulus. Swelling characteristics, water vapor transmission rate, and release kinetics demonstrated that these films are adequate for the proposed application. Finally, a scratch test on a keratinocytes monolayer showed that the rate of cell migration in the presence of OPU-loaded samples is about 3-fold higher compared to unloaded films, confirming the repairing activity of OPU.

Assessment of the causes of Hg bioaccumulation in the fish of a Mediterranean lagoon subject to environmental management interventions

In a Mediterranean lagoon characterized by high levels of Hg in the sediment, Hg content in commercial fish species was determined, and, in order to establish Hg concentration in the water column, Diffusive Gradient in Thin films technique (DGT) was used. The results allowed to state (1) the disturbance of the surface sediment and its resuspension in the water column did not cause detectable increase in Hg releases, (2) the East basin acted more than the West one in contamination of fish species, (3) the small-sized sea-breams (<400 g) were more contaminated than larger sizes ones (>400 g). We concluded: (1) fish contamination may also depend on direct contact with releases of the contaminant and small, gregarious and less sedentary subjects are more likely to incur releases of Hg; (2) Hg releases can be greater in areas with a relatively low sedimentary organic matter load compared to areas subjected to high density macroalgal mat, regardless of the amount of Hg present in the sediments; (3) wind transport of plant masses in low energy storage areas, may constitute an increase factor of Hg in the sediment. A critical review of the results was made in comparison with the available literature reports and some hypotheses were proposed regarding the possible dynamics and availability of the contaminant.

Zygomatic implants supported rehabilitations in atrophic maxilla: sinus complications, radiological, periodontal and prosthodontic evaluations: a one year follow up retrospective longitudinal study

The rehabilitation of maxillary bone atrophy represents one of the main challenges of modern oral implantology. The use of zygomatic implants in the prosthetic rehabilitation of the patient affected by severe maxillary bone atrophy is another therapeutic alternative, not exempt from complications. The present study included 19 patients with edentulous maxillae who were treated between 2013 to 2015 with at least two zygomatic implants at the Department of Maxillofacial Surgery, Verona, Italy. The purpose of this retrospective longitudinal study was to evaluate sinus complications and radiological, periodontal and prosthetic evaluations of zygomatic implants technique in severe atrophic. Implant-prosthetic rehabilitation of the upper jaw edentulous severely atrophic using zygomatic implants represents one safe and repeatable technique. In terms of implant survival from our study showed an implant CRS (common reporting standard) of 98.5% and a prosthetic CRS 100% with a mean follow-up period of 19.2 months (range). Both recorded data are superimposed on major reported studies in literature.

Left atrial remodeling in heart failure: coexistence and additive prognostic power of atrial dilation and dysfunction

Background

Heart failure (HF) is associated with volumetric and functional changes of left atrium (LA).

Purpose

It is still unclear whether the two atrial abnormalities necessarily coexist and if they have additive prognostic implications.

Methods

690 patients with HF due to reduced left ventricular ejection fraction (EF) formed the study population. Each patients underwent comprehensive echocardiographic evaluation; atrial function was assessed by means of strain analysis during reservoir (PALS). End-point of the study was overall survival free of hospitalization.

Results

Patients were divided in 4 groups according to left atrial size (34 ml/mq) and function (PALS 20%). 64 patients (10%) were characterized by completely normal left atrium (group 1), 150 (25%) by dilated LA by normal PALS (group 2), 130 (20%) by normal LA volume but abnormal PALS (group 3) and 200 patients with dilated LA and decreased PALS (group 4). Clinical and echocardiographic characteristics of the groups are presented in the table. Decreased PALS was associated with worse survival both in patients with normal and abnormal LA volume (p&lt;0.0001 for each group).

Conclusions

Increased volume and decreased function of LA frequently but not necessarily coexist. LA functional impairment affects prognosis independently of LA volume.

Funding Acknowledgement

Type of funding source: None

Echocardiography of right ventricular-arterial coupling predicts survival of elderly patients with heart failure and reduced to mid-range ejection fraction

Echocardiography of right ventricular (RV)-arterial coupling obtained by the estimation of the ratio of the longitudinal annular systolic excursion of the tricuspid annular plane and pulmonary artery systolic pressure (TAPSE/PASP) has been found to be a remarkable prognostic indicator in patients with HF. Our aim was to evaluate the impact of TAPSE, PASP and their ratio in the prognostic stratification of outpatients with HF aged ≥70 years and reduced to mid-range ejection fraction (EF). A complete echocardiographic examination was performed in 400 outpatients with chronic HF and left ventricular (LV) EF ≤50% who averaged 77 years in age. During a median follow-up period of 25 months (interquartile range: 8-46), there were 135 cardiovascular deaths. Two different Cox regression models were evaluated, one including TAPSE and PASP, separately, and the other with TAPSE/PASP. In the first model, LV end-systolic volume index, age, no angiotensin converting enzyme (ACE) inhibitor use, TAPSE, PASP and gender were found to be independently associated with the outcome after adjustment for demographics, clinical, biochemical, echocardiographic data. In the second model, TAPSE/PASP resulted the most important independent predictor of outcome (hazard ratio [HR]:0.07, p<0.0001) followed by LV end-systolic volume index, no ACE inhibitor use, age and gender. The use of the variable TASPE/PASP improved the predictive value of the new multivariable model (area under the curve [AUC] of 0.74 vs AUC of 0.71; p<0.05). TASPE/PASP improved the net reclassification (NRI = 14.7%; p<0.01) and the integrated discrimination (IDI = 0.04; p<0.01). In conclusion, the study findings showed that assessment of RV-arterial coupling by TAPSE/PASP was of major importance to assess the prognosis of patients with chronic HF and LV EF ≤50% aged ≥70 years.

Effects of sacubitril/valsartan on B-type natriuretic peptide circulating levels and loop diuretic dose in a case series of stabilized heart failure patients with left ventricular ejection fraction ≤35

Sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor, was shown to improve outcome in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). There are reasons for believing that the concept that the lower the B-type natriuretic peptide (BNP) circulating level the better the prognosis may no longer be correct in patients treated with sacubitril/valsartan, since sacubitril may interfere with BNP clearance. We reported a case series of ten patients with stable chronic HF and LVEF ≤35% (mean age: 64 ± 8 years; 30% female), referred to our outpatient HF clinic, treated with sacubitril/valsartan, in whom the global amelioration of NYHA class and LVEF was coupled with a clinically significant decrease in BNP levels and a reduction of loop diuretic dose. Average sacubitril/valsartan daily dose was 220 mg. The median duration of treatment was 15 months (range: 6-21 months). Seventy percent of patients exhibited an improvement in exercise tolerance, as indicated by the change in NYHA class. There was also an improvement in LVEF from 28 ± 5% to 39 ± 7%. Clinically significant reductions in BNP levels were evident, with a median change from 181 pg/ml to 70 pg/ml. Furosemide daily dose decreased from a median of 43.3 mg to 12.5 mg. This case series suggests that BNP may still be valuable for the assessment of ambulatory HF patients, after the optimization of sacubitril/valsartan therapy.

The assessment of pressure-volume relationship during exercise stress echocardiography predicts left ventricular remodeling and eccentric hypertrophy in patients with chronic heart failure

BACKGROUND

The contractile response of patients with heart failure (HF) may be assessed by exercise stress echocardiography (ESE)-derived indexes. We sought to test whether ESE parameters are useful to identify the risk of adverse left ventricular (LV) remodeling in patients with chronic HF and reduced or mildly reduced LV ejection fraction (EF).

METHODS

We enrolled 155 stabilized patients (age: 62 ± 11 years, 17% female, coronary artery disease 47%) with chronic HF, LV EF ≤50% and LV end-diastolic volume index > 75 ml/m2. All patients underwent a symptom-limited graded bicycle semi-supine ESE, with evaluation of peak stress LV EF, end-systolic pressure-volume relation (ESPVR, i.e. LV elastance) and cardiac power output to LV mass (CPOM). A complete echocardiographic study was performed at baseline and after 6 ± 3 months. Adverse LV remodeling was defined as the association of eccentric LV hypertrophy (LV mass: ≥115 g/m2 for male and ≥ 95 g/m2 for women, and relative wall thickness < 0.32) with an increase in LV end-systolic volume index ≥10% at six months.

RESULTS

Adverse LV remodeling was detected in 34 (22%) patients. After adjustment for clinical, biochemical and echocardiographic data, peak ESPVR resulted in the most powerful independent predictor of adverse LV remodeling (OR: 12.5 [95% CI 4.5-33]; p < 0.0001) followed by ischemic aetiology (OR: 2.64 [95% 1.04-6.73]; p = 0.04).

CONCLUSION

In patients with HF and reduced or mildly reduced EF, a compromised ESE-derived peak ESPVR, that reflects impaired LV contractility, resulted to be the most powerful predictor of adverse LV remodeling.

Robust, reproducible, recyclable SERS substrates: monolayers of gold nanostars grafted on glass and coated with a thin silica layer

We prepared and characterized recyclable surface enhanced Raman spectroscopy (SERS) active glass chips. Gold nanostars were grafted on properly functionalized glasses by means of electrostatic interactions and then they were coated with a silica layer of controllable thickness in the nanometer range. The SERS activity of the obtained substrates were tested in terms of reproducibility and homogeneity intra-samples and inter-samples from different batches using the Raman reporter as the model compound rhodamine 6G. The uncoated substrates were used as reference to evaluate the effect of silica spacers on SERS enhancement factors (EFs). The chemical route to obtain silica-coated SERS chips is described in detail, and the morphology and the optical response of substrates have been characterized. We demonstrate that SERS substrates coated with 1 nm silica conserve a good EF, and that the coating confers to the SERS platform an extreme robustness leading to reusability of the substrates.

Prevalence and determinants of left ventricular diastolic dysfunction in obese subjects and the role of left ventricular global longitudinal strain and mass normalized to height

BACKGROUND

Left ventricular (LV) diastolic dysfunction (DD) is a frequent finding in obesity and may predispose to the development of heart failure (HF). However, no data are available on the prevalence of DD after the introduction of the 2016 Recommendations of the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

METHODS AND RESULTS

To assess the impact of the new Recommendations on the prevalence of DD and on their clinical and echocardiographic correlates in obesity, a prospective study was performed in 588 subjects with an ejection fraction (EF) ≥50% and no history of HF either obese (n = 402; mean age: 47 ± 12 years; women 71%; body mass index [BMI]: 44 ± 8 kg/m² ), overweight (n = 86; BMI: 28 ± 1 kg/m² ), or with a normal weight (n = 100; BMI: 22 ± 2 kg/m² ). All subjects underwent an echocardiographic and Doppler study, including the assessment of global longitudinal strain (GLS). DD occurred in 19% of obese patients, 12% of overweight subjects, and 2% of normal weight subjects. We used multivariable logistic analysis to assess the risk of DD. In patients with BMI ≥30 kg/m² , LV mass normalized to height (2.7) (OR: 1.04, P = .0028), and GLS (OR: 0.85, P = .0032) were associated with an increased risk of DD followed by EF (OR: 0.91, P = .045), diabetes (OR: 1.91, P = .065), and systolic blood pressure (OR: 1.02, P = .076).

CONCLUSION

These results show that DD is highly prevalent among obese subjects and impairment of longitudinal systolic mechanics, as reflected by GLS reduction, and LV mass normalized to height are major independent predictors of DD in this patients' population.

Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients

Recent European Society of Cardiology and American Heart Association/American College of Cardiology Guidelines did not recommend biomarker-guided therapy in the management of heart failure (HF) patients. Combination of echo- and B-type natriuretic peptide (BNP) may be an alternative approach in guiding ambulatory HF management. Our aim was to determine whether a therapy guided by echo markers of left ventricular filling pressure (LVFP), lung ultrasound (LUS) assessment of B-lines, and BNP improves outcomes of HF patients. Consecutive outpatients with LV ejection fraction (EF) ≤ 50% have been prospectively enrolled. In Group I (n=224), follow-up was guided by echo and BNP with the goal of achieving E-wave deceleration time (EDT) ≥ 150 ms, tissue Doppler index E/e' < 13, B-line numbers < 15, and BNP ≤ 125 pg/ml or decrease >30%; in Group II (n=293), follow-up was clinically guided, while the remaining 277 patients (Group III) did not receive any dedicated follow-up. At 60 months, survival was 88% in Group I compared to 75% in Group II and 54% in Group III (χ ² 53.5; p < 0.0001). Survival curves exhibited statistically significant differences using Mantel-Cox analysis. The number needed to treat to spare one death was 7.9 (Group I versus Group II) and 3.8 (Group I versus Group III). At multivariate Cox regression analyses, major predictors of all-cause mortality were follow-up E/e' (HR: 1.05; p=0.0038) and BNP >125 pg/ml or decrease ≤30% (HR: 4.90; p=0.0054), while BNP > 125 pg/ml or decrease ≤30% and B-line numbers ≥15 were associated with the combined end point of death and HF hospitalization. Evidence-based HF treatment guided by serum biomarkers and ultrasound with the goal of reducing elevated BNP and LVFP, and resolving pulmonary congestion was associated with better clinical outcomes and can be valuable in guiding ambulatory HF management.

Seed mediated growth of silver nanoplates on glass: exploiting the bimodal antibacterial effect by near IR photo-thermal action and Ag+ release

Silver nanoplates synthesized with the desired features directly on glass show a bimodal antibacterial action: Ag⁺ release and NIR laser switchable hyperthermia.

Melatonin reduces the need for sedation in ICU patients: a randomized controlled trial

BACKGROUND

Critically ill patients suffer from physiological sleep deprivation and have reduced blood melatonin levels. This study was designed to determine whether nocturnal melatonin supplementation would reduce the need for sedation in patients with critical illness.

METHODS

A single-center, double-blind randomized placebo-controlled trial was carried out from July 2007 to December 2009, in a mixed medical-surgical Intensive Care Unit of a University hospital, without any form of external funding. Of 1158 patients admitted to ICU and treated with conscious enteral sedation, 82 critically-ill with mechanical ventilation >48 hours and Simplified Acute Physiology Score II>32 points were randomized 1:1 to receive, at eight p.m. and midnight, melatonin (3+3mg) or placebo, from the third ICU day until ICU discharge. Primary outcome was total amount of enteral hydroxyzine administered.

RESULTS

Melatonin treated patients received lower amount of enteral hydroxyzine. Other neurological indicators (amount of some neuroactive drugs, pain, agitation, anxiety, sleep observed by nurses, need for restraints, need for extra sedation, nurse evaluation of sedation adequacy) seemed improved, with reduced cost for neuroactive drugs. Post-traumatic stress disorder prevalence did not differ between groups, nor did ICU or hospital mortality. Study limitations include the differences between groups before intervention, the small sample size, and the single-center observation.

CONCLUSION

Long-term enteral melatonin supplementation may result in a decreased need for sedation, with improved neurological indicators and cost reduction. Further multicenter evaluations are required to confirm these results with different sedation protocols.

Inclusion of all permanent mandibular molars and all maxillary second and third molars: a case report and review of the literature

Simultaneous impactions of first, second, and third permanent molars on both mandibular sides together with the all maxillary second and third molars is a clinical situation never reported before in the literature and it might be a difficult challenge for maxillofacial surgeons and dentists. Early diagnosis and treatment of eruption disturbances contributes to optimal outcomes. This article reports the treatment of an adult with severe impaction of all mandibular first, second, and third molars together with all maxillary second and third molars, which limits the masticatory function and dental arch integrity. The impacted molars were surgically removed as the patients declined orthodontic treatment. The combined surgical-orthodontic approach represents a challenging treatment and the optimal one as it eliminates the need for prosthetic rehabilitation and implant replacement of the impacted molars, when accepted.

Blood levels of interleukins in patients with ameloblastoma

The aim of study was to determine and compare serum concentrations of interleukin 1 beta (IL-1β), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) in patients with oral ameloblastoma and healthy controls. Sixteen patients with ameloblastoma and 16 healthy controls were enrolled in this study. Cytokine concentrations were measured by chemiluminescent enzyme linked immunoassay. Serum concentrations of IL-1β were below level of detection in all but four participants. No significant differences between the groups were observed in serum concentrations of IL-6. Serum TNF-α was significantly higher in control subjects than in ameloblastoma patients. Patients diagnosed with ameloblastoma have relatively normal levels of inflammatory cytokines in their blood and thus cannot be used as indicators of disease severity or for monitoring the treatment outcomes.

Salivary levels of IgA in healthy subjects undergoing active orthodontic treatment

It has been reported that the immune system undergoes changes due to various factors, inflammation, surgery, medication, age and gender. The aim of this study was to investigate therapy-dependent changes of salivary IgA among healthy subjects undergoing active orthodontic treatment. The levels of IgA were determined at the beginning, and after 1,4, 8,16 weeks and 32 weaks of active orthodontic treatment. A total of 100 healthy individuals (aged 15-42 years) were enrolled in the study. Two milliliters of saliva were collected from all participants, and salivary IgA levels were measured by the ELISA technique. Mean salivary IgA levels were significantly higher in subjects after 1 week as compared to subjects at the beginning of orthodontic treatment (P < 0.01).. The mean levels of salivary IgA were significantly higher after 4 and 8 weeks of therapy than those observed in the control group (P < 0.00001 and P < 0.05, respectively) and reached the highest level at 16 weeks and then remained stable during treatment. Gender had no effect on the salivary levels of IgA as any significant differences were observed between men and women. The results highlight the importance of the salivary defense mechanism, translated through the increase in the levels of IgA, once orthodontic treatment is started.

The benefits of Quercitin for dentistry and maxillofacial surgery: a systematic review

Quercetin (3,3',4',5,7-pentahydroxyflavone) is the major bioflavonoid in the human diet and belongs to an extensive class of polyphenolic flavonoid compounds almost ubiquitous in plants and plant food sources. The estimated average daily dietary intake of quercetin by an individual in the United States is 25 mg. In recent years, research about quercetin has evolved from animal studies to in vitro and in vivo studies and to human clinical studies and trials in order to establish its real properties and effects. In oral medicine, quercetin has been extensively studied, as a real increase in major diseases like cancers, periodontal disease, oral lesions, tooth decay and infections have been reported worldwide by health providers.It has been thus established that quercetin exhibits beneficial effects on oral health with its broad pharmacological properties, as preventive and therapeutic agent in dental caries with anti-inflammatory effect against oral pathogens, as well as an antioxidant and anti-cancer agent .The aim of the review is to present evidence-based aspect of treatment with quercetin in order to validate its tremendous role in dentistry and maxillofacial surgery.

Salivary calcium levels during orthodontic treatment

Saliva contains many defense factors and plays a key role in oral metabolism. Salivary calcium, due to its affinity to be readily taken up by plaque, is an important factor not only with regard to the onset of periodontitis but also significantly with regard to dental health. The aim of this study was to estimate the salivary concentration of calcium, in a group of adults undergoing active orthodontic treatment. The levels of salivary calcium were determined at the beginning, and after 16 weeks of active orthodontic treatment. A total of 40 healthy individuals with a mean age of 23.9 years were enrolled in the study group, while 40 subjects served as controls. Two milliliters of saliva were collected from all participants, and salivary calcium levels were measured by biochemical assay. Mean salivary calcium levels were significantly higher in subjects after 16 weeks as compared to subjects at the beginning of orthodontic treatment and to the control group (p= 0.001). A significant association between higher salivary calcium levels and orthodontic treatment has been established, therefore, monitoring salivary calcium levels might be a useful tool to establish periodontal health status during active orthodontic treatment along with other inflammatory parameters.

Bimaxillary distraction osteogenesis used for treatment of crowding in non-growing individuals. Case report

Dental crowding is frequently associated with transverse jaw discrepancies, resulting in a less-than-ideal position of the teeth in the basal bone. The classic aproach for correcting bimaxillary crowding are extractions or arch expansion. Rapid maxilla-mandibular expansion was used to treat transverse discrepancies in growing patients, but with aging, the upper and lower jaw bones become increasingly resistant to expansion. The surgically assisted rapid maxillary expansion (SARME) and the mandibular midsymphyseal distraction osteogenesis procedure overcome this age limitation and are of great importance for the treatment of transverse discrepancies in adults. The aim of this paper is to report a case with a severe transverse deficiency treated with SARME, mandibular midsymphyseal distraction together with orthodontic treatment in an adult patient. The case highlights the esthetic advantages of increasing the transversal dimension of both jaws in patients with severe crowding associated with constricted dental arches and recommends the maxillo-mandibular transverse distraction osteogenesis as an and effective form of surgical treatment for patients with malocclusions or dentofacial deformities featuring severe transverse discrepancies, combined with a carefully monitored orthodontic treatment.

Dental white spots associated with bulimia nervosa in orthodontic patients

Bulimia nervosa is an eating disorder characterized by consuming a large amount of food in a short amount of time followed by an attempt to rid oneself of the food consumed (purging), typically by vomiting, taking a laxative, diuretic, or stimulant, and/or excessive exercise, because of an extensive concern for body weight. The frequent contact between teeth and gastric acid, in particular, may cause: severe dental erosion, perimolysis, or the erosion of tooth enamel and swollen salivary glands. Constant vomiting can lead to gastroesophageal reflux. The aim of this article is to report two cases of patients with severe dental demineralization associated with bulimia nervosa during orthodontic treatment. Diagnosis and prevention aspects are highlighted and discussed.

Non-traumatic unilateral bifid mandibular condyle and multiple inclusions: a case report

Simultaneous impactions of first, second, and third permanent molars on both mandibular sides together with the all maxillary second and third molars is a clinical situation never reported before in the literature and it might be a difficult challenge for maxillofacial surgeons and dentists. Early diagnosis and treatment of eruption disturbances contributes to optimal outcomes. This article reports the treatment of an adult with severe impaction of all mandibular first, second, and third molars together with all maxillary second and third molars, which limits the masticatory function and dental arch integrity. The impacted molars were surgically removed as the patients declined orthodontic treatment. The combined surgical-orthodontic approach represents a challenging treatment and the optimal one as it eliminates the need for prosthetic rehabilitation and implant replacement of the impacted molars, when accepted.

Mesenchymal stem cells from patients to assay bone graft substitutes

Bio-engineered scaffolds used in orthopedic clinical applications induce different tissue responses after implantation. In this study, non-stoichiometric Mg(2+) ions and stoichiometric apatites, which are used in orthopedic surgery as bone substitutes, have been assayed in vitro with human adult mesenchymal stem cells (hMSC) to evaluate cytocompatibility and osteoconductivity. hMSCs from the bone marrow aspirates of orthopedic patients were isolated and analyzed by flow cytometry for the surface markers Stro1, CD29, CD44, CD71, CD73, CD90, CD105 (positive) and CD45, CD235 (negative). The hMSC were analyzed for self-renewal capacity and for differentiation potential. The hMSC, which were grown on different biomaterials, were analyzed for (i) cytotoxicity by AlamarBlue metabolic assay, (ii) osteoconductivity by ELISA for activated focal adhesion kinase, (iii) cytoskeleton organization by fluorescence microscopy, and (iv) cell morphology which was investigated by scan electron microscopy (SEM). Results indicate that isolated cell populations agree with minimal criteria for defining hMSC cultures. Non-stoichiometric Mg(2+) and stoichiometric apatites, in granular form, represent a more favorable environment for mesenchymal stem cell adhesion and growth compared to the non-stoichiometric Mg(2+) apatite, in nano-structured paste form. This study indicates that different forms of biomaterials modulate osteoconductivity and cellular growth by differential activation focal adhesion kinase.

Fighting for territories: time-lapse analysis of dental pulp and dental follicle stem cells in co-culture reveals specific migratory capabilities

Stem cell migration is a critical step during the repair of damaged tissues. In order to achieve appropriate cell-based therapies for tooth and periodontal ligament repair it is necessary first to understand the dynamics of tissue-specific stem cell populations such as dental pulp stem cells (DPSC) and dental follicle stem cells (DFSC). Using time-lapse imaging, we analysed migratory and proliferative capabilities of these two human stem cell lines in vitro. When cultured alone, both DPSC and DFSC exhibited low and irregular migration profiles. In co-cultures, DFSC, but not DPSC, spectacularly increased their migration activity and velocity. DFSC rapidly surrounded the DPSC, thus resembling the in vivo developmental process, where follicle cells encircle both dental epithelium and pulp. Cell morphology was dependent on the culture conditions (mono-culture or co-culture) and changed over time. Regulatory genes involved in dental cell migration and differentiation such as TWIST1, MSX1, RUNX2, SFRP1 and ADAM28, were also evaluated in co-cultures. MSX1 up-regulation indicates that DPSC and DFSC retain their odontogenic potential. However, DPSC lose their capacity to differentiate into odontoblasts in the presence of DFSC, as suggested by RUNX2 up-regulation and TWIST1 down-regulation. In contrast, the unchanged levels of SFRP1 expression suggest that DFSC retain their potential to form periodontal tissues even in the presence of DPSC. These findings demonstrate that stem cells behave differently according to their environment, retain their genetic memory, and compete with each other to acquire the appropriate territory. Understanding the mechanisms involved in stem cell migration may lead to new therapeutic approaches for tooth repair.