Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

[Management of patent foramen ovale in non-cardiac surgery]

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Ischemia With No Obstructive Coronary Artery Disease: Are Misdiagnosis and Undertreatment Always Behind the Corner?

Ischemia with no obstructive coronary artery disease (INOCA) is not an uncommon diagnosis in patients presenting with chest pain who undergo clinically indicated coronary angiography. However, the symptoms reported by patients with INOCA may be heterogeneous, leading to misdiagnosis and undertreatment. Herein we report 3 clinical cases of INOCA misdiagnosis and describe how the cases were reinvestigated following the appropriate diagnostic pathway. (Level of Difficulty: Advanced.).

293 IMPACT OF FEMALE GENDER ON ACUTE AND MID-TERM MORTALITY IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION DURING THE PANDEMIC ERA

Background

There is still much controversy concerning the impact of gender on mortality during ST-segment elevation myocardial infarction (STEMI). The COVID-19 pandemic deeply affected the clinical history of these patients, both in terms of presentation time and management. The aim of our study was to evaluate the impact of female gender on acute and mid-term mortality in STEMI patients hospitalized during the pandemic period.

Materials and Methods

Our study focuses on STEMI patients hospitalized during the darkest period of the pandemic. We retrospectively analyzed consecutive STEMI patients hospitalized from 15 March 2020 to 15 March 2021 in our Hub centre in Milan, Lombardy. All clinical, demographic, and procedural characteristics were collected in a dedicated database. Patient follow-up was carried out through clinical visits, telephone calls and remote monitoring through the “Lombardia Regional Registry”.

Results

From a total of 283 patients, women represented 26.8% of the population, with a mean age of 72 - 11.2 years vs. 64.7 - 12.6 years in men. Anterior STEMI was the most represented with a mildly reduced ejection fraction (EF 48.3 _ 11.8%) similar between genders. Coronary angiography showed more extensive disease in man, while women presented with a higher Killip class at admission and a more pronounced anemic status. In-hospital and 1-year mortality of the whole cohort were 11.4% and 7.5%, respectively, with no significant differences between genders (14.5% women vs. 10.6% men, p = ns; 9.2% women vs. 7% man, p = ns). EF resulted in being the only independent predictor of mortality in the short-term and at 1-year follow up in both genders. In the acute phase, the only other independent predictor of mortality was COVID-19 infection, secondary to the higher rate of respiratory omplications, without any difference in terms of major adverse cardiac events. The impact of COVID-19 infection on mortality was completely lost at 1-year follow up.

Conclusions

Our study has shown that female gender in STEMI patients does not represent an independent predictor of mortality both in the short- and in the mid-term follow up. Concomitant COVID-19 infection significantly influenced in-hospital mortality due to the higher rate of respiratory complications in both genders. The impact of COVID-19 on mortality was completely lost at follow-up, where age and a reduced EF remained the only independent predictors, regardless of gender.

Age-Related Mortality in STEMI Patients: Insight from One Year of HUB Centre Experience during the Pandemic

Background: Old patients have a poor prognosis when affected by ST elevation myocardial infarction (STEMI). The aim of our study was to evaluate the impact of age on acute and mid-term mortality in STEMI patients over one year in the pandemic period. Methods: we collected data on 283 STEMI patients divided into three groups according to age (not old, “Not-O”, ≤74 y/o; old, “O”, 75−84 y/o; very old, “Very-O”, ≥85 y/o). Results: the three groups did not differ in their clinical or procedural characteristics. The Very-O patients had a significantly increased incidence of in-hospital MACE (35%), mortality (30.0%), and percentage of cardiac death (25.0%). The only two independent predictors of in-hospital mortality were the ejection fraction (EF) [OR:0.902 (95% CI) 0.868−0.938; p < 0.0001] and COVID-19 infection [OR:3.177 (95% CI) 1.212−8.331; p = 0.019]. At follow-up (430 +/− days), the survival rates were decreased significatively among the age groups (Not-O 2.9% vs. O 14.8% vs. Very-O 28.6%; p < 0.0001), and the only two independent predictors of the follow-up mortality were the EF [OR:0.935 (95% CI) 0.891−0.982; p = 0.007] and age [OR:1.06 (95% CI) 1.018−1.110; p = 0.019]. Conclusions: in very old patients, all the accessory procedures that may be performed should be accurately and independently weighed up in terms of the risk−benefit balance and the real impact on the quality of life because of the poor mid-term prognosis.

Intravascular imaging for left main stem assessment: An update on the most recent clinical data

Left main (LM) stem has different structural and anatomical characteristics compared to all of the other segments of the coronary tree, thus its management through percutaneous coronary intervention (PCI) is a challenge and is associated with worse clinical outcome and higher need for revascularization as compared to other lesion settings. Intravascular imaging, by means of intravascular ultrasound (IVUS) or optical coherence tomography (OCT), is an important tool for LM PCI guidance, aiming at improving the immediate performance and the long term outcome of this procedure. Following current guidelines and recent scientific findings, IVUS becomes important to firstly assess, and finally evaluate the result of LM stenting, according to the experience and preferences of the operator. The role of OCT still remains to be defined, but recent data is shedding light also on this imaging technique. The aim of this review is to highlight the latest scientific advancements regarding intravascular imaging in LM coronary artery disease.

Optical Coherence Tomography and Coronary Dissection: Precious Tool or Useless Surplus?

Spontaneous coronary artery dissection (SCAD) is a rare clinical condition, but frequently manifested as acute myocardial infarction. In this particular setting, in recent years, optical coherence tomography (OCT) has been established as a possible diagnostic method due to the high spatial resolution (10–20 μm), which can visualize the different layers of coronary vessels. OCT can better analyze the “binary” or double lumen morphology, typical of this entity. Furthermore, it can identify the entrance breach and the circumferential and longitudinal extension of the lesion. However, we have to emphasize that this technique is not free from complications. OCT could further aggravate a dissection or exacerbate a new intimal tear. Therefore, the use of OCT in the evaluation of SCAD should be defined by balancing the diagnostic benefits versus procedural risks. Moreover, we underline that as SCAD is a rare condition and OCT is a recently introduced technique in clinical practice, limited data is available in literature.

Impact of RAAS Inhibitors on Clinical Outcome and Mortality in Patients With STEMI During the COVID-19 Era: A Multicenter Observational Study

Conflicting results are available regarding the influence of ACEi/ARBs on the risk of COVID-19 infection, while less is known about their impact on the clinical outcome of patients with STEMI diagnosed with COVID-19. Our aim was to evaluate the impact of ACEi/ARBs therapy on in-hospital mortality and clinical outcomes of patients with STEMI during the COVID-19 pandemic. We retrospectively analyzed consecutive patients with STEMI hospitalized from February 20 to May 10, 2020 in four Hospitals in Lombardy. SARS-COV-2 diagnosis was performed by nasopharyngeal swab test. Procedural outcome, respiratory complications, and in-hospital mortality were reported. Univariate and multivariate analyses were performed by logistic regressions. Our population was represented by 182 patients with STEMI, 76.9% of which were males, and mean age was 67 ± 12.5. Hypertension was reported in 53.3%, and 29.1% was treated with ACEi/ARBs. COVID-19 diagnosis was confirmed in 17.1% of the patients. In-hospital mortality (13.2%) was significantly higher in patients with COVID-19 (31 vs. 10%, p = 0.003), even if ejection fraction [OR 0.93 (95% CI) 0.87-0.99; p = 0.03] and respiratory complications [OR 9.39 (95% CI) 1.91-45.9; p = 0.006] were the only two independent predictors. The incidence of COVID-19 infection was not influenced by ACEi/ARBs (16.5 in naïve vs. 18.8%) whose presence on admission did not correlate with respiratory complications or mortality both in the case of discontinuation and maintenance. In conclusion, in a high-risk population, such as that of patients with STEMI, the potential benefit of ACEi/ARB discontinuation in patients with COVID-19 is overcome by its detrimental effect. Intensive care, additional preventive respiratory investigations, regardless of swab test result, should be suggested for all patients admitted for STEMI during the pandemic.

99 New onset atrial fibrillation in STEMI patients: main prognostic factors and clinical outcome

The treatment of patients with known atrial fibrillation (AF) undergoing percutaneous coronary intervention has clear indications in the actual guidelines. Remarkable lack of evidence regarding new-onset AF (NOAF) in particular during STEMI is the reason for this study. We retrospectively analysed 1455 consecutive STEMI patients. The primary outcomes are in-hospital, 1-year and long-term follow-up mortality. Cerebral ischaemic events and major bleedings were considered clinical endpoints at 1 year. NOAF was detected in 102 subjects, 62.7% males, mean age 74.8 ± 10.6 years. Mean left ventricular ejection fraction (LVEF) was 43.5 ± 12.1% and left atrial enlargement (58 ± 20.9 ml) was observed. Anterior STEMI accounted for the majority (46%). NOAF has been predominantly recorded in the acute phase (mean duration of 8.1 ± 12.5 h). CHA2DS2-VASc score &gt;2 was recorded in 83% of cases, while HAS-BLED score of 2 or 3 was the most represented. All patients acutely received enoxaparin, but only 21.6% were discharged on oral anticoagulation (OAC). In-hospital mortality was 14.2%, while 1-year and long-term mortality were 17.2% and 32.1%, respectively. We identified age as an independent predictor of short- and long-term mortality, while LVEF was the only other independent predictor for in-hospital mortality and arrhythmia duration for 1-year mortality. After 1-year of follow-up we recorded three ischaemic events and no major bleeding. In conclusion, STEMI patients who present NOAF are a very high-risk population with increased short- and long-term mortality. Our data suggest that the indication for OAC should be always driven by CHA2DS2-VASC and HAS-BLEED score, even in patients with a single episode indeed. 99 Figure 1Kaplan-Meier curve representing the long-term survival of the entire population from hospital admission up to the maximum follow-up time was performed

New onset atrial fibrillation in STEMI patients: main prognostic factors and clinical outcome

Background

New onset atrial fibrillation (NOAF) is not a so rare condition among patients hospitalized for ST-segment elevation myocardial infarction (STEMI). Several studies showed that NOAF during an acute coronary syndrome (ACS) leads to increased mortality, both at short and long term. The indications for the treatment of patients with known AF undergoing percutaneous coronary interventions (PCI) are clear, while less is available about the management of NOAF during ACS and in particular during STEMI. The purpose of this study is therefore to evaluate mortality and clinical outcome of this high risk subgroup of patients.

Methods

We analysed 1455 consecutive patients undergoing coronary angiography and/or PCI for STEMI. CHA2DS2-VASc and HAS-BLED scores were calculated for all patients. In-hospital, 1-year and long-term follow up mortality was evaluated for all patients. Cerebral ischemic and hemorrhagic events were also evaluated as clinical endpoints at 1 year.

Results

NOAF was detected in 102 subjects, 62.7% males, with a mean age of 74.8±10.6 years. We found a high prevalence of main cardiovascular risk factors such as hypertension, dyslipidemia, smoke and renal failure. Mean ejection fraction (EF) was 43.5±12.1% and the mean atrial volume was increased (58±20.9 ml). The most represented type of MI at admission was anterior STEMI (46%). NOAF occurred mainly in the peri-acute phase and had a very variable duration (8.1±12.5 min). During hospitalization all patients were treated with Enoxaparin, but only 25.2% of them were discharged with long term oral anticoagulation (16.7% warfarin, 4.9% direct oral anticoagulant). The majority of patients had a CHA2DS2-VASc score &gt;2 and a HAS-BLED score of 2 or 3. In-hospital mortality was 14.2%, while 1-year mortality was 17.2% and long term mortality 32.1% (median follow-up time 1820 days, range 341 to 3985). Through a logistic regression analysis we identified age as an independent predictor of mortality both at short and long term follow up, while EF was the only independent predictor for in-hospital mortality and arrhythmia duration for 1-year mortality. At 1-year follow up we recorded three ischemic strokes, while no bleeding complications.

Conclusions

STEMI patients who develop NOAF are a very high-risk population and are characterized by increased short and long term mortality. NOAF should be diagnosed and treated as soon as possible with a correct indication to long term OAC based on the ratio between ischemic and hemorrhagic risk.

Funding Acknowledgement

Type of funding sources: None.

Long term results of a phase II trial of hypofractionated adjuvant radiotherapy for early-stage breast cancer with volumetric modulated arc therapy and simultaneous integrated boost

PURPOSE

to report toxicity and cosmetic outcome with a median follow-up of 6 years of a phase II trial of hypofractionated radiotherapy with volumetric modulated arc therapy (VMAT) and simultaneous integrated boost (SIB) for early-stage breast cancer after conservative surgery.

MATERIALS AND METHODS

From August 2010 to September 2014, patients requiring adjuvant radiotherapy for early-stage breast cancer were treated according to a phase I-II protocol with SIB to 40.5 and 48 Gy to the breast and the boost region, respectively, with VMAT technique. The primary endpoint evaluated the treatment feasibility regarding adherence to required dose constraints for target, heart and lungs. Acute and late toxicity, local and distant control were secondary endpoints.

RESULTS

450 patients were included in the trial and analysed after a median follow-up of 6 years. Acute toxicity was already presented in a previous paper. Regarding late toxicity, 93% of patients had no skin alteration at five years, while 5.3% and 1.3% did record G1 and G2 residual toxicity, respectively. Cosmetic outcome was scored good or excellent in almost all cases (97.2%), fair only in 2.3% of patients. Residual tenderness in the irradiated breast was reported by 10% of patients. Cosmesis and breast pain improved during follow-up. Two cases of G2 pneumonitis and two cases of ischemic cardiopathy were registered during follow-up. Five cases presented local recurrence in the homolateral breast, four patients had a new primary cancer in the contralateral breast, while distant metastasis developed in 7 patients.

CONCLUSION

After more than six years, hypofractionated VMAT with SIB for adjuvant radiotherapy in early-stage breast cancer patients remains a safe and effective approach. Mature data on skin toxicity and cosmetic outcome are encouraging. However, longer follow-up is required to evaluate local control, cardiac toxicity and secondary carcinogenesis.

Long-term outcomes after pancreatoduodenectomy for ampullary cancer: The influence of the histological subtypes and comparison with the other periampullary neoplasms

BACKGROUND

Ampullary carcinoma (AC) is histologically classified as intestinal (In-AC), pancreaticobiliary (Pb-AC) or mixed-AC. The prognostic role of AC subtypes has been debated and remains unclear. The aims of this study were to evaluate outcomes after pancreatoduodenectomy (PD) for each subtype of AC and to compare these with pancreatic ductal adenocarcinoma [PDAC] and distal cholangiocarcinoma [DCC].

METHODS

PDs performed for AC between 2010 and 2018 were retrospectively evaluated. Histological subtype was obtained for all patients. One-year, 3-year and 5-year disease-free-survival (DFS) and overall survival (OS) rates were calculated. Kaplan-Meier survival analysis was performed to compare Pb-AC, In-AC and mixed-AC. Comparison with PDs performed for PDAC and DCC during the same period was also performed.

RESULTS

A total of 97 patients undergoing PD for AC were evaluated: 34 (35.1%) In-AC, 54 (55.7%) Pb-AC and 9 mixed-AC (9.3%). DFS and OS rates for Pb-AC were significantly lower compared to In-AC (p < 0.05 and p < 0.01), but similar to mixed-AC (p = 0.3 and p = 0.4). Adjuvant therapy was not associated with increased survival, regardless of the histological subtype (p > 0.05). During the same period, 337 and 53 PDs for PDAC and DCC, respectively, were performed. In-AC was associated with significantly better outcomes compared to PDAC and DCC (p < 0.001); DFS and OS rates for Pb-AC and mixed AC were significantly higher compared to PDAC (p < 0.001), but similar to DCC (p > 0.05).

CONCLUSIONS

Pb-AC has significantly worse survival compared to In-AC. Moreover, mixed-AC should be considered as Pb-AC. Pb-AC and mixed-AC seem to have better prognosis compared to PDAC, but similar to DCC.

Incremental Value of Renal Dysfunction Addition to the CHA2DS2-Vasc Score for Mortality Prediction in Patients with Acute Coronary Syndrome

INTRODUCTION

This study analyzes the usefulness of the CHA2DS2-VASc score for mortality prediction in patients with acute coronary syndromes (ACSs) and evaluates if the addition of renal functional status could improve its predictive accuracy.

METHODS

CHA2DS2-VASc score was calculated by using both the original scoring system and adding renal functional status using 3 alternative renal dysfunction definitions (CHA2DS2-VASc-R1: eGFR <60 mL/min/1.73 mq = 1 point; CHA2DS2-VASc-R2: eGFR <60 mL/min/1.73 mq = 2 points; and CHA2DS2-VASc-R3: eGFR <60 mL/min/1.73 mq = 1 point, <30 mL/min/1.73 mq = 2 points). Inhospital mortality (IHM) and post-discharge mortality (PDM) were recorded, and discrimination of the various risk models was evaluated. Finally, the net reclassification index (NRI) was calculated to compare the mortality risk classification of the modified risk models with that of the original score.

RESULTS

Nine hundred and eight ACS patients (median age 68 years, 30% female, 51% ST-elevation) composed the study population. Of the 871 patients discharged, 865 (99%) completed a 12-month follow-up. The IHM rate was 4.1%. The CHA2DS2-VASc score demonstrated a good discriminative performance for IHM (C-statistic 0.75). Although all the eGFR-modified risk models showed higher C-statistics than the original model, a statistically significant difference was observed only for CHA2DS2-VASc-R3. The PDM rate was 4.5%. The CHA2DS2-VASc C-statistic for PDM was 0.75, and all the modified risk models showed significantly higher C-statistics values than the original model. The NRI analysis showed similar results.

CONCLUSIONS

CHA2DS2-VASc score demonstrated a good predictive accuracy for IHM and PDM in ACS patients. The addition of renal dysfunction to the original score has the potential to improve identification of patients at the risk of death.

Access-site hematoma in distal and conventional transradial access: a randomized trial

BACKGROUND

Distal transradial access (dTRA) has been recently proposed as an innovative access for coronary procedures and a valuable alternative to conventional transradial access (cTRA). The aim of this study was to assess the safety of dTRA versus cTRA in patients undergoing percutaneous coronary angiography and intervention.

METHODS

In this single-center randomized trial, consecutive patients admitted for stable cardiac condition or acute coronary syndrome (ACS) were assigned to dTRA or cTRA. The primary endpoint was an early discharge after transradial stenting of coronary arteries (EASY) grade ≥II access-site hematoma (ASH). Vascular access failure, radial artery occlusion (RAO) at hospital discharge , 30-day rates of death, myocardial infarction, stroke and bleeding not related to coronary artery bypass grafting were considered as secondary endpoints.

RESULTS

A total of 204 patients were included and randomized to dTRA (n=100) or cTRA (n=104). The two populations were similar, except for a higher percentage of ACS in the dTRA than in the cTRA group (38% versus 24%, P=0.022). The rate of EASY grade ≥II ASH was lower in dTRA than in cTRA patients, but the difference was not statistically significant (4% versus 8.4%, respectively, P=0.25). Vascular access failure was more frequent in dTRA patients than in cTRA patients (34% versus 8.7%, P<0.0001). We detected no case of RAO at hospital discharge and similar rates of 30-day adverse events in both groups.

CONCLUSIONS

DTRA is safe and feasible. When compared to cTRA, dTRA is technically more demanding and limited by more frequent crossover to an alternative vascular access.

Arrhythmic event prediction in patients with heart failure and reduced ejection fraction

AIMS

Implantable cardioverter defibrillator (ICD) is an effective treatment to reduce mortality in patients with symptomatic heart failure and left ventricular ejection fraction (LVEF) 35% or less. LVEF presents a low sensitivity for predicting arrhythmic events. Aim of this study was to identify predictors of sustained ventricular arrhythmias (SVAs), overall and according to the cause of heart failure.

METHODS

Single-center, retrospective, cohort study of 193 patients (51 nonischemic and 142 ischemic) with chronic heart failure and LVEF less than 35% who had received ICD for primary prevention of sudden cardiac death. We collected clinical data, echocardiographic parameters and SVAs detected by the ICD.

RESULTS

During a median follow-up of 1440 days, 32 (16.2%) patients had SVAs. SVAs incidence was similar in patients with nonischemic (15.6%) and ischemic cause of heart failure (16.9%). Hypertension, diabetes, chronic renal failure, atrial fibrillation, chronic obstructive pulmonary disease, New York Heart Association class at least III were predictors at univariate analysis of SVAs. A clinical score, assigning one point to each of these variables, was associated with a significantly increased risk of SVAs [odds ratio for each point increase = 1.92, 95% confidence interval 1.40-2.65, P < 0.0001, area under the curve (AUC) 0.73], with 72% sensitivity and 60% specificity for a cutoff at least three and remained significant in nonischemic (AUC 0.84) and ischemic (AUC 0.68) patients.

CONCLUSION

Our study shows the benefit of ICD implantation in primary prevention and its independency of cause. A simple clinical score, based on comorbidities, identifies patients with more benefits from ICD implantation.

How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism

BACKGROUND

Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism.

CASE REPORT

A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection.

CONCLUSION

Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

Impact of COVID-19 on STEMI: Second youth for fibrinolysis or time to centralized approach?

On March 11th 2020 the World Health Organization declared the pandemic infection of SARS-CoV-2 (COVID-19) and Italy was one of the most affected country. The regional Emergency Medical System (EMS) founded itself facing an exponential increase in hospitalizations with a consequent organizational system crisis. Experts from Cina, UK and US suggested to reconsider thrombolysis as the best treatment in term of balance between time consumption and operators safety for ST-segment elevation myocardial infarction (STEMI) patients respect to primary PCI (pPCI). The system reorganization consisted in a centralization of all the emergency nets: from 55 hospitals with cardiac catheterization laboratories distributed within our region offering a 24/7 service we passed to 13 Hub and 42 Spoke centres. Dedicated in-hospital paths for patients COVID positive or suspected (pCOV+) and COVID negative (pCOV-) were instituted. We analysed all consecutive patients undergoing emergency coronary angiogram from March 14 to April 14, 2020 at San Carlo Hospital in Milan comparing the two different in-hospital paths. We collected 30 STEMI patients. Eighteen patients (60%) were treated in pCOV-, while twelve patients (40%) in pCOV+. No significant differences were found among the two groups regarding key time points of STEMI care and interestingly we didn't find any treatment delay in pCOV+. In conclusion, a focused overhaul of the EMS may allow to maintain pPCI as the treatment of choice for patients and operators.

[Customer satisfaction in home care: methodological issues based on a survey carried out in Lazio]

Home care customer satisfaction has been, until now, rarely evaluated. After illustrating the main italian regional surveys on this issue, the article presents a customer satisfaction survey carried out in the district of Civitavecchia (Local Health Unit 'Rome F'), Lazio, regarding 30 home care beneficiaries. Methodological aspects emerging from the survey are basically focused on: advantages and disadvantages of quantitative and qualitative approaches (possibly associated each other); main criteria of eligibility of people selected for interviewing, both patients or caregivers; conditions that maximize answers reliability, including training on interviewers. Authors highlight opportunity of using such kind of survey, integrated with other different tools, into a systemic vision, for promoting management changes coming from suggested problems, aimed at total quality management.

Utility of pedometer step recommendations for predicting overweight in children

OBJECTIVE

The purpose of this study was to examine the utility of pedometer-based physical activity recommendations in predicting childhood adiposity.

DESIGN

Subjects (n=608) (9.6 years) were from two Midwestern USA communities. Physical activity was assessed by a pedometer. The percentage of subjects meeting physical activity recommendations was determined using published recommendations. Overweight and obesity were determined based on reference values for the body mass index (BMI) developed by the International Obesity Task Force. An elevated waist circumference (WC) was determined based on age- and sex-specific reference values >75th percentile.

RESULTS

Children who did not meet the pedometer recommendations were about two times more likely to be overweight/obese and have an elevated WC compared with those meeting recommendations. The BMI and WC were significantly different across pedometer step count groups in males and females.

CONCLUSION

Subjects not meeting the recommendations for steps per day were more likely to be classified with the overweight phenotype than those meeting the recommendation. A dose-response relationship between pedometer steps per day and adiposity is also apparent.

Nickel ions release in patients with fixed orthodontic appliances

AIM

The extent to which orthodontic appliances can cause contact allergies due to nickel release is a controversial matter. Since the data provided by literature are contrasting, the Authors think that it is important to analyse nickel ions released in organic tissues by means of a plasma spectrometer.

METHODS

About 100 intact hairs were taken from 15 patients wearing fixed orthodontic appliances. The hairs had been washed 12 to 24 h before, in order to limit environmental contamination. The same procedure was carried out on a control group corresponding in sex, age and abode. The samples of hair were taken from at least 3 different scalp sites: frontal, vertex and occipital areas.

RESULTS

According to the spectrophotometric analysis of the hair, there were no differences in nickel concentrations between the test group (0.50 mg/g on average) and control group (0.64 mg/g) (*P<0.005). The mean value was reduced even further if minimum and maximum values were excluded (test group 0.46 mg/g, control group 0.52 mg/g). Even though there was a slight difference (0.14 mg/g), it showed that more nickel concentration was found in the control sample (without orthodontic appliances) to a maximum of 2.20 mg/g. This suggests that environmental contamination, in particular diet, has an influence on ion concentration. Other studies also confirm that gut absorption of nickel released in the mouth by orthodontic appliances is much lower than the absorption of nickel release through diet.

CONCLUSIONS

It can be assumed that orthodontic appliances do not release significant values of nickel to be a risk factor to the patient's health.

[The quality of medical records: a retrospective study in Lazio Region, Italy]

INTRODUCTION

Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice.

PURPOSE

We performed a retrospective study in order to assess the quality of medical records in the Lazio region.

METHODS

From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires.

RESULTS

A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate.

CONCLUSIONS

Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Urinary leukotriene E(4) excretion during the first month of life and subsequent bronchopulmonary dysplasia in premature infants

BACKGROUND

Inflammation plays an important role in the pathogenesis of bronchopulmonary dysplasia (BPD), but the exact nature of this inflammatory process is incompletely understood. Older infants with established BPD have higher levels of urinary leukotriene E(4) (LTE(4)) compared to healthy infants of the same age. This suggests that cysteinyl leukotrienes may play a role in the abnormalities seen in BPD.

OBJECTIVES

To measure urinary LTE(4) levels during the first month of life in premature infants, and to determine whether there are significant differences in premature infants who develop BPD, as compared to those who do not develop BPD.

DESIGN

Prospective, blinded, controlled study.

SETTING

Neonatal ICUs of a tertiary-care university hospital.

METHODS

Thirty-seven premature infants (< 33 weeks of gestational age) were enrolled prospectively at birth. Urinary LTE(4) levels were measured blinded, using a standard radioimmunoassay technique at 2 days, 7 days, and 28 days of life. At 1 month of age, infants were classified as with or without BPD, based on need for supplemental oxygen, and characteristic chest radiographs. Clinical features and urinary LTE(4) were compared between the two groups.

RESULTS

Mean +/- SD gestational age was 29 +/- 2.6 weeks. None of the infants had a family history of asthma. Thirteen of 37 infants were classified as having BPD at 28 days after birth. Mean gestational age in infants who developed BPD was 27 +/- 2.4 weeks, compared to 30 +/- 2 weeks in infants who did not develop BPD (p < 0.05). In infants with BPD, mean urinary LTE(4) levels of urinary creatinine were 1,762 +/- 2,003 pg/mg, 1,236 +/- 992 pg/mg, and 5,541 +/- 5,146 pg/mg at days 2, 7, and 28, respectively, compared to 1,304 +/- 1,195 pg/mg, 1,158 +/- 1,133 pg/mg, and 2,800 +/- 2,080 pg/mg in infants without BPD. LTE(4) levels at 2 days, 7 days, and 28 days did not correlate with the subsequent development of BPD. LTE(4) levels at day 28 were significantly higher than LTE(4) levels at day 2 and day 7 in both groups, even after correcting for gestational age or birth weight (p < 0.05). There was significant inverse correlation between LTE(4) levels at day 2 with gestational age and birth weight (p < 0.05). All 13 infants with BPD received steroid pulses, compared to 3 of 26 infants without BPD. Gestational age and use of postnatal steroid pulses, diuretics, and theophylline (for apnea of prematurity) were significantly associated with each other and with the subsequent development of BPD.

CONCLUSION

Urinary LTE(4) levels measured on the second day of life in very-low-birth-weight infants inversely correlate with gestational age and birth weight. Urinary LTE(4) levels may reflect lung injury and/or inflammation in premature infants, not necessarily related to BPD as it is presently defined.

Intermittent doxercalciferol (1alpha-hydroxyvitamin D(2)) therapy for secondary hyperparathyroidism

Hypercalcemia and hyperphosphatemia frequently necessitate vitamin D withdrawal in hemodialysis patients with secondary hyperparathyroidism. In short-term trials, doxercalciferol (1alpha-hydroxyvitamin D(2) [1alphaD(2)]) suppressed intact parathyroid hormone (iPTH) effectively with minimal increases in serum calcium and phosphorus (P) levels. This modified, double-blinded, controlled trial examined the efficacy and safety of 1alphaD(2) use in 138 hemodialysis patients with moderate to severe secondary hyperparathyroidism by using novel dose titration; 99 patients completed the study. Hemodialysis patients with secondary hyperparathyroidism were enrolled onto this study, consisting of washout (8 weeks), open-label 1alphaD(2) treatment (16 weeks), and randomized, double-blinded treatment with 1alphaD(2) or placebo (8 weeks). Oral 1alphaD(2) was administered at each hemodialysis session, with doses titrated to achieve target iPTH levels of 150 to 300 pg/mL. Baseline iPTH levels (897 +/- 52 [SE] pg/mL) decreased by 20% +/- 3.4% by week 1 (P: < 0.001) and by 55% +/- 2.9% at week 16; iPTH levels returned to baseline during placebo treatment but remained suppressed with 1alphaD(2) treatment. In 80% of the patients, iPTH level decreased by 70%, reaching the target level in 83% of the patients. Grouping patients by entry iPTH level (<600, 600 to 1,200, and >1,200 pg/mL) showed rapid iPTH suppression in the group with the lowest level; greater doses and longer treatment were required in the group with the highest level. During open-label treatment, serum calcium and P levels were 9.2 +/- 0.84 (SD) to 9.7 +/- 1.05 mg/dL and 5.4 +/- 1.10 to 5.9 +/- 1.55 mg/dL, respectively. During double-blinded treatment, serum calcium levels were slightly greater with 1alphaD(2) than placebo, but P levels did not differ. During double-blinded treatment, 3.26% and 0.46% of serum calcium measurements exceeded 11.2 mg/dL with 1alphaD(2) and placebo, respectively (P: < 0.01); median level was 11.6 mg/dL during hypercalcemia. Intermittent oral 1alphaD(2) therapy effectively suppresses iPTH in hemodialysis patients with secondary hyperparathyroidism, with acceptable mild hypercalcemia and hyperphosphatemia.

Clinical use of nebulized budesonide inhalation suspension in a child with asthma

Childhood asthma contributes to significant morbidity among patients and significantly impacts the quality of life and daily routines of their caregivers. The parents or caregivers assume responsibility for tasks that children are too young to perform; this often includes daily administration of controller medications and nightly administration of reliever medications. Most young children do not have the coordination or understanding to effectively use pressurized metered-dose inhalers or inhalation-driven devices; thus nebulizer therapy often is preferred for children younger than 4 years of age. Budesonide inhalation suspension will be the first inhaled corticosteroid available for children younger than 4 years of age and the first inhaled corticosteroid for delivery by nebulization in the United States. This is a case report of a 3-year-old boy who received budesonide inhalation suspension as part of several double-blind and open-label studies evaluating the drug. Before study entry, the boy was experiencing more breakthrough wheezing episodes at night than the parents were used to, resulting in an increase in nighttime awakenings that required nebulizer therapy. These nighttime awakenings had a substantial impact on the quality of life of the entire family and interfered with the parents' ability to function at work. Even though they wanted to have more children, this situation discouraged them from doing so. Budesonide inhalation suspension improved overall asthma control and was well tolerated. The boy had a decrease in nighttime symptoms and an increase in both height and weight percentiles for his age. Importantly, use of budesonide inhalation suspension in this boy eased the management of severe asthma and improved the quality of life of the entire family. The parents subsequently decided to have a second child. Budesonide inhalation suspension represents a major breakthrough for infants and young children by providing a formulation that, on approval, can be delivered reliably by nebulizer for effective maintenance treatment of persistent asthma.

Increased interleukin-6 levels in nasal lavage samples following experimental influenza A virus infection

Interleukin-6 (IL-6) is a pleotropic cytokine implicated in the pathogenesis of local inflammation during viral upper respiratory infections. This study determined if experimental influenza A virus infection causes local IL-6 production. Seventeen healthy, adult subjects were intranasally inoculated, by course drops, with a safety-tested strain of influenza A/Kawasaki/86 (H1N1) virus. Nasal lavage samples were collected, symptoms were recorded, and expelled nasal secretions were weighed once before and then daily for 8 days after the virus inoculation. Lavage samples were submitted for virus culture and were examined for IL-6 and IL-4 by enzyme-linked immunosorbent assay. The IL-6, but not IL-4, levels were significantly increased in the nasal lavage samples of the 12 subjects who shed virus but not in those of the 5 subjects who did not shed virus. Moreover, the elevations in IL-6 levels were related temporally to the development of nasal symptoms and secretions but not to systemic symptoms. These results suggest a role for locally produced IL-6 in the pathogenesis and expressed symptomatology of influenza A virus infection.

Outcome of patients who refused out-of-hospital medical assistance

Activation of the emergency medical services (EMS) system does not always result in transport of a patient to the hospital. This study assessed the outcomes of patients who refused medical assistance in the field, to determine if refusal of medical assistance (RMA) is associated with poor outcomes. Four high-volume suburban volunteer ambulance corps participated in the study. Consecutive patients who refused medical assistance were prospectively enrolled. Medical and identifying data were collected for each patient. Telephone follow-up was conducted to determine the patient's condition and if the patient sought further care after RMA. Primary endpoints were whether the patient sought further care, was admitted to a hospital, or died subsequent to RMA. Follow-up was successfully obtained for 199 of 321 patients enrolled (62%). Of these 199 patients, 95 (48%) sought further medical care within 1 week for the same complaint, with 13 being admitted to the hospital. Six of the 13 admitted patients had chief complaints of a cardiac or respiratory nature. One patient died during hospital admission. Even if none of the patients lost to follow-up had sought further care, a substantial number of patients who refuse out-of-hospital medical assistance seek further care. Some of these patients require hospital admission, especially those with cardiac or respiratory complaints. Efforts to minimize RMA should be especially focused on patients with such complaints.

[The treatment of benign laryngeal pathologies using CO2 laser in direct microlaryngoscopy with propofol-induced endovenous anesthesia in spontaneous respiration without intubation]

Direct microlaryngoscopy is an endoscopic technique with considerable diagnostic and surgical potentialities, which are increased when carbon-dioxide Laser is used, but often limited by the anaesthesiologic methods employed. In fact, the traditional anaesthesiologic technique, which uses small bore oral-tracheal tubes and provides good ventilation, has significant disadvantages: the tube often impedes surgical activity especially in the posterior regions of the larynx; stenoses of the larynx impede oral-thacheal intubation and thus require pre-operatory thacheotomy; administration of succinylcholine often induces diffused myalgia in the following 12-24 hours; administration of traditional narcotics always requires hospitalization. Jet-ventilation used by the Freach School as an alterative, while offering a more ample operatory space, is also accompanied by many disadvantages: vocal cords vibration; spray expulsion of smoke, blood, etc.; as with the traditional method, it cannot be employed in cases of laryngeal stenoses; succinylcholine often induces diffused myalgia; it cannot be used on out-patients. Introduction of Propofol, a new endovenous anaesthetic, the anaesthetologic pratice has permitted total endovenous anaesthesia to be achieved, in spontaneous respiration, without intubation. This method is indicated even in cases where the previously mentioned approaches are shown to be inadequate or impracticable. Narcosis with Propofol was used in 70 patients with benign laryngeal pathologies, belonging to the ASA risk classes I-II who underwent surgery via CO2 Laser during Microlaryngoscopy. The pharmacologic protocol of this narcosis require intravenous premedication with atropine and phentanyl, induction and continuation with Propofol and pharyngolaryngeal local anaesthesia with lidocaine spray. The advantages offered by this method are considerable: a completely free operative space; the possibility of being used in cases of laryngeal stenosis; a rapid return to consciousness; the absence of myalgia after surgery; the possibility of treating the disease on an out-patient basis. The absence of significant complications and the good results obtained lead us to propose this anaesthesiologic method as a valid alternative to anaesthesia by the traditional oral-tracheal intubation and to Jet ventilation.