P207 KOUNIS SYNDROME TYPE 2: A COLD CASE

Case Report

A 61–year–old man, smoker and family history of cardiovascular diseases, started oral antibiotic therapy with amoxicillin / clavulanic acid following the appearance of a dental abscess. About 30 minutes after taking the antibiotic, he complained of widespread erythema in the limbs, followed by intense itching and dyspnea. Upon arrival of the medical staff, IV cortisone and antihistamine therapy was performed with gradual and progressive resolution of the symptoms. Despite the doctors’ invitation, the patient refused access to the emergency room for fear of a possible hospital infection with SARS–CoV–2. Almost two months later, due to the onset of exertional dyspnea, he is persuaded to go to the hospital for further tests. The ECG showed signs of diffuse anterolateral necrosis (Figure 1). Echocardiography showed severe left ventricular dysfunction (FE 35%) with extensive akinesia of the mid–distal SIV, apex, and anterior mid–distal wall. Myocardiocytolysis indices were negative and allergy tests positive for beta–lactam antibiotics. Subsequently he underwent coronary angiography which showed proximal occlusion of an intermediate branch (Figure 2) treated with angioplasty and drug stent release. Cardiac MRI was then performed with evidence of a large area of ischemic necrosis (subendocardial / transmural) of the antero–septal, anterior and anterolateral wall with FE 35% (Figure 3).

Comment

Kounis syndrome is a clinical emergency characterized by the appearance of an acute coronary syndrome during an anaphylactic–type reaction. A correct diagnosis is of fundamental importance to limit the extent of myocardial damage as much as possible. In Kounis type 2, the mediators of the allergic reaction can cause not only vasospasm but also the activation of metalloproteases that induce the degradation of collagen with consequent rupture of pre–existing atheromatous plaques, as in our patient. Failure to perform an ECG during first aid leaves doubts about the possible allergic genesis of the episode, which however cannot be excluded with certainty. We have decided to report this clinical case to emphasize the importance of always taking into consideration the possibility of being compared with a case of Kounis when assisting a patient with an anaphylactic type reaction.

P189 DOAC: WHEN DRUG INTERACTIONS MAKE A DIFFERENCE

Introduction

Direct oral anticoagulants (DOACs), as substrates of cytochrome P450 and / or P–glycoprotein (P–gp), are susceptible to drug–drug interactions (DDI) by both inducers and inhibitors. Awareness of this aspect is essential when choosing a DOAC, to avoid exposing the patient to an increased risk of bleeding or cardioembolicism.

Description

We report the clinical case of a 41–year–old woman with a history of iron deficiency anemia and primary hypertrophic cardiomyopathy (HCM), who came to our emergency room for an episode of atrial fibrillation with high ventricular rate (HR 140 bpm), datable (<48h) and haemodynamically well tolerated. She was therefore subjected to pharmacological cardioversion with amiodarone, which was found to be effective. Subsequently, she was subjected to interrogation of the defibrillator (ICD), of which the patient was a carrier in primary prevention, with the finding of numerous episodes of AF, lasting up to several hours, paucisymptomatic. An antiarrhythmic prophylaxis with amiodarone and anticoagulant therapy with edoxaban was therefore recommended at discharge. In the following two months, in conjunction with the menstrual cycle, the patient had access to emergency room for metrorrhagia with the need for blood transfusion due to severe anemia (Hb 6 gr / dl). The gynecological tests were negative and she was entrusted to the cardiologist for the management of the therapy. Reassessed on an outpatient basis, given the impossibility of changing antiarrhythmic drugs, as amiodarone is the only molecule recommended for rhythm control in patients with this type of cardiomyopathy, and given the possible interaction between edoxaban and amiodarone (+ 40% plasma DOAC levels ), it was decided to shift to another DOAC: rivaroxaban 20 mg (less interference). In the following twelve months the patient no longer had acute anemia phenomena, the hemoglobin values remained stable and upon interrogation of the ICD device there were no arrhythmic events.

Comment

We have described this case to underline how the possible pharmacokinetic interactions between DOACs and antiarrhythmic drugs are of fundamental importance in daily clinical practice, especially when there are non–reversible causes that increase the risk of bleeding. In this case, the therapy shift vs a DOAC with a documented lower DDI interaction was found to be conclusive.

EXPANDING THE SPECTRUM OF GORHAM STOUT DISEASE EXPLORING A SINGLE CENTER PEDIATRIC CASE SERIES

Gorham-Stout Disease (GSD), also named vanishing bone disease, is an ultrarare condition characterized by progressive osteolysis with intraosseous lymphatic vessel proliferation and bone cortical loss. So far, about 300 cases have been reported. It may occur at any age but more commonly affects children and young adults. The aim of this study is to retrospectively review our internal patient series and to hypothesize a diagnostic-therapeutic protocol for earlier diagnosis and treatment. Clinical datasets from our center were examined to identify all GSD patients for collection and analysis. We identified 9 pediatric cases and performed a retrospective case-series review to examine and document both diagnosis and treatment. We found that delay in diagnosis after first symptoms played a critical role in determining morbidity and that multidisciplinary care is key for proper diagnosis and treatment. Our study provides additional insight to improve the critical challenge of early diagnosis and highlights a multidisciplinary treatment approach for the most appropriate management of patients with rare GSD disease. Although GSD is an ultrarare disease, physicians should keep in mind the main clinical features since neglected cases may result in potentially fatal complications.

Expanding the spectrum of Gorham Stout disease exploring a single center pediatric case series

Gorham-Stout Disease (GSD), also named vanishing bone disease, is an ultrarare condition characterized by progressive osteolysis with intraosseous lymphatic vessel proliferation and bone cortical loss. So far, about 300 cases have been reported. It may occur at any age but more commonly affects children and young adults. The aim of this study is to retrospectively review our internal patient series and to hypothesize a diagnostic-therapeutic protocol for earlier diagnosis and treatment. Clinical datasets from our center were examined to identify all GSD patients for collection and analysis. We identified 9 pediatric cases and performed a retrospective case-series review to examine and document both diagnosis and treatment. We found that delay in diagnosis after first symptoms played a critical role in determining morbidity and that multidisciplinary care is key for proper diagnosis and treatment. Our study provides additional insight to improve the critical challenge of early diagnosis and highlights a multidisciplinary treatment approach for the most appropriate management of patients with rare GSD disease. Although GSD is an ultrarare disease, physicians should keep in mind the main clinical features since neglected cases may result in potentially fatal complications.

Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder

Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring. In our opinion, surgery for small glanular venous malformations is indicated within puberty to prevent traumatic bleeding and psychological impact.

Real-life Performance of Edoxaban in Elderly Patients With Atrial Fibrillation: a Multicenter Propensity Score-Matched Cohort Study

PURPOSE

The purpose of the current study was to compare the efficacy and safety of edoxaban versus vitamin K antagonist (VKA) therapy among a cohort of elderly patients (ie, those aged ≥75 years) with atrial fibrillation (AF) in a real-life setting.

METHODS

A propensity score-matched cohort observational study was performed comparing the safety and efficacy of edoxaban versus VKA therapy among a cohort of elderly (aged ≥75 years) patients with AF in a real-life setting. Follow-up data were obtained through outpatient visits at 1, 3, and every 6 months. The primary safety outcome was major bleeding. The primary efficacy outcome was the composite of stroke, transient ischemic attack, and systemic embolism.

FINDINGS

A total of 130 patients receiving edoxaban 60 mg (EDO) treatment were compared with the same number of VKA recipients. The mean follow-up was 16 (2.6) months. The cumulative incidence of thromboembolic events in the EDO and VKA groups was 1.5% (2 of 130) and 2.3% (3 of 130), respectively (P < 0.6). The cumulative incidence of major bleeding events was 1.5% (2 of 130) in the EDO group and 3.1% (4 of 130) in the VKA group (P < 0.4). The total anticoagulant therapy discontinuation rate was 2.3% (3 of 130) in the EDO group and 4.6% (6 of 130) in the VKA group (P < 0.3). A nonsignificant trend in improved adherence was observed between the EDO and VKA groups (81% vs 78%; P = 0.6).

IMPLICATIONS

Edoxaban therapy showed a good real-life performance among elderly patients (aged ≥75 years) with AF.

NSAIDs and heart failure: A dangerous relationship

One of the potential cardiotoxic action of anti-inflammatory drugs is the occurrence of heart failure (HF), due to their effects on fluid retention and blood pressure. The risk of hospitalization for HF is roughly doubled for both Coxibs, cyclooxygenase-1 (COX-1) and cyclooxygenase- 2 (COX-2) inhibitors, and all the conventional nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are also associated with a risk of vascular thrombosis, which for NSAIDs is different in relation to their different ability to inhibit COX-1 and COX-2. The cardiovascular toxicity of these drugs in the direction of HF follow different pathways respect to their related vascular thrombosis toxicity and involves, in particular, the renal prostaglandins, PGE2 and prostacyclin, mostly synthesized by COX-2. In the kidneys the PGs perform a direct vasodilatory action, e.g. by means of non-contrasting angiotensin mechanisms, and for this reason nimesulide effects on renal microcirculation are independent from the prevalence of intrarenal renin angiotensin aldosterone system (RAAS) activity. Conversely, nimesulide reduces sodium tubular urinary flow only in presence of intrarenal RAAS.

Electrochemotherapy of unresectable cutaneous tumours with reduced dosages of intravenous bleomycin: analysis of 57 patients from the International Network for Sharing Practices of Electrochemotherapy registry

BACKGROUND

Electrochemotherapy (ECT) is currently used to treat unresectable superficial tumours of different histotypes through the combination of cytotoxic chemotherapy and local application of electric pulses. In 2006, a collaborative project defined the ESOPE (European Standard Operating Procedures of Electrochemotherapy) guidelines to standardize the procedure. The International Network for Sharing Practices of Electrochemotherapy (InspECT) aims to refine the ESOPE and improve clinical practice. Limiting patient exposure to systemic chemotherapy would be advisable to ameliorate ECT safety profile.

OBJECTIVE

The aim of this study was to evaluate the efficacy and toxicity of ECT with reduced chemotherapy dosages.

METHODS

In a retrospective analysis of a prospectively maintained database (InspECT registry), we evaluated the outcome of patients who received ECT with reduced dosages of bleomycin (7500, 10 000 or 13 500 IU/m² , instead of the standard dose of 15 000 IU/m² ). Tumour response in melanoma patients was compared with melanoma patients of the InspECT registry who received the standard dose of bleomycin.

RESULTS

We identified 57 patients with 147 tumours (melanoma, 38.6%; squamous cell carcinoma, 22.8%; basal cell carcinoma, 17.5%; breast cancer 7%; Kaposi sarcoma 7%; other histotypes, 7.1%). Per-tumour complete response (CR) rate at 60 days was 70.1% (partial, 16.3%); per-patient CR was 57.9% (partial, 21.1%). Local pain was the most frequently reported side-effect (n = 22 patients [39%]), mostly mild; two patients experienced flu-like symptoms, one patient nausea. We observed the same CR rate (55%) in patients with melanoma treated by reduced or conventional bleomycin dosages (P = 1.00).

CONCLUSIONS

Electrochemotherapy performed with reduced bleomycin dosages could be as effective as with currently recommended dose. Patients with impaired renal function or candidate to multiple ECT cycles could benefit from a reduced dose protocol. Our findings need prospective confirmation before being adopted in clinical practice.

Efficacy of electrochemotherapy in ulcerated basal cell carcinoma

Basal cell carcinoma is the most common cutaneous malignant tumor, accounting for up to 80% of non melanoma skin cancers. Surgery, radiotherapy and chemotherapy have been for long time the main options for its treatment. Electrochemotherapy (ECT) is a novel local treatment successfully used in primary skin tumors. We report a case of a man affected by ulcerated basal cell carcinoma treated with ECT. In our case ECT was successful in the management of extensive basal cell carcinoma in clinical conditions whereas other approaches, would have been dangerous and inappropriate. To our knowledge, ECT must be considered as an alternative of traditional techniques when they are contraindicated in relation to the appearance of the lesions or the patient medical history.

The role of surface fluxes in the development of a tropical-like cyclone in southern Italy

Abstract. Numerical simulations of a tropical-like cyclone in southern Italy have been performed with two different modelling systems (BOLAM-MOLOCH and WRF) with the aim of discussing the role of the surface fluxes in the development of the vortex and evaluating their intensity during the mature stage of the cyclone. Although significant differences emerge in their intensity, both the modelling systems agree in showing that the surface fluxes are more important than the latent heat release associated with convection in the initial phase of the vortex lifecycle, while they are less relevant (although more intense) when the minimum assumes the characteristic of a tropical cyclone.

Long-Term Results of Hybrid Therapy in Patients with Atrial Fibrillation Who Develop Atrial Flutter During Flecainide Infusion

The flecainide infusion test has been proposed to screen candidates for hybrid pharmacological and ablation therapy. We report the long-term follow-up of 154 consecutive patients with paroxysmal or persistent atrial fibrillation (AF) who developed atrial flutter (AFL) during flecainide infusion (IC AFL), treated with inferior vena cava-tricuspid annulus isthmus catheter ablation and oral flecainide (hybrid therapy). Over a mean of 54.1 +/- 13.1 months 82 patients (53%) remained free of AF and AFL. Flecainide was discontinued because of adverse effects in 6 patients (4%). A history of persistent AF, and the documentation of >/=1 spontaneous AFL episode before the flecainide test were independent predictors of successful hybrid therapy. In patients with paroxysmal AF without documented spontaneous AFL, the long-term efficacy of hybrid therapy was 38.5% (P = 0.03). The flecainide infusion test reliably detects candidates for hybrid therapy. The efficacy of this therapy is maintained over the long-term with a high patient compliance.

["The memory effect" in healthy heart and transplanted heart. "Cor se ipse alit, se ipse movet, se ipse reget"]

The heart's memory, interpreted as information residue between a cardiac cycle and the subsequent one, is a very definite phenomenon (short- term memory) both in healthy subjects and in heart transplanted recipients. This "memory effect", we have observed by the autocorrelation and by the spectrum analysis of the values expressing the heartbeat acceleration variability (tachogram 24 h). The "memory effect" cannot be absolutely put down in heart transplanted recipients to interference or to the activity of the central and/or peripheral nervous system, because the heart transplanted is a denervated heart by definition. Moreover, an immediate regulating effect of hormonic factors in the short-term heartbeat regulation is not completely plausible. As already known, the heart transplanted responds to the emergency situation autonomously and autochthonously in proportion to the signals reaching it directly from the circle (vascular resistance, blood pressure, etc.). This implies the existence of functional memory that is likely to be inborn in the conduction system of the heart. Looking at the results of our research we can conclude: "cor se ipse alit, se ipse movet, se ipse reget" (it autonomously models itself to all the different modifications in the circle, it feeds itself as the organ propelling blood circulation and, if necessary, it carries on its kinetic activity autonomously).

Pretreatment with verapamil in patients with persistent or chronic atrial fibrillation who underwent electrical cardioversion

OBJECTIVES

To evaluate, in a prospective and randomized fashion, the efficacy of a pretreatment with verapamil (V) in reducing recurrences of atrial fibrillation (AF) after electrical cardioversion (C).

BACKGROUND

The increased vulnerability for AF recurrence is probably due to AF-induced changes in the electrophysiologic properties of the atria. This electrical remodeling seems to be due to intracellular calcium overload.

METHODS

One hundred seven patients with persistent or chronic AF underwent external and/or internal C. All patients received oral propafenone (P) (900 mg/day) three days before and during the entire period of follow-up (three months). In the first group, patients received only the P. In the second group, in adjunct to P, oral V (240 mg/day) was initiated three days before C and continued during the follow-up. Finally, in the third group, oral V was administered three days before and continued only for three days after electrical C.

RESULTS

During the three months of follow-up, 23 patients (23.7%) had AF recurrence. Mantel-Haenszel cumulative chi-square reached a significant level only when comparing AF free survival curves of group I versus group II and group III (chi-square = 5.2 and 4, respectively; p < 0.05). Significantly, 15 (65.2%) AF relapses occurred during the first week after cardioversion with a higher incidence in group I (10/33 patients, 30.3%) than group II (2/34 patients, 5.9%; p = 0.01) and group III (3/30 patients, 10%; p = 0.04).

CONCLUSIONS

Six days of oral V administration centered on the C day, combined with P, significantly reduce the incidence of early recurrences of AF compared with P alone.

[The predictive value of junctional beats during the radiofrequency transcatheter ablation of the slow pathway of the nodal reentry circuit]

BACKGROUND

Junctional beats (JB) are often recorded during slow pathway (SP) radiofrequency (RF) ablation in patients with atrioventricular nodal reentrant tachycardia (AVNRT). Neither the correlation between JBs and SP potentials nor the role of mechanically-evoked JBs has been clarified yet.

METHODS

Two hundred-eleven consecutive patients, with common AVNRT, underwent RF transcatheter ablation guided by Jackman SP potential searching. If we were unable to record an SP potential or if 4 RF pulses delivered on ideal ablation sites were ineffective, the ablation was carried out on anatomical landmarks. Light pressure was applied with the ablation catheter to each ablation site before RF delivery in order to evaluate the inducibility of JBs.

RESULTS

Transcatheter ablation was performed successfully in 209/211 (99%) patients. In 17 (8.1%) patients, no SP potential was recorded. JBs were observed more often delivering RF in the mid-septal region, whereas SP potentials were more often recorded at the base of the Koch triangle. The success rate (successful pulses/overall pulses) was higher in the mid-septal (58.6% in M1, 77.8% in M2) than in the postero-septal region (4% in PSC, 16.8% in P1). JBs showed a higher specificity (73.2 vs 5.3%), positive (55.5 vs 24.6%) and negative predictive value (97.3 vs 63.8%) than SP potential in identifying the successful ablation site. Mechanical JBs were evoked in 23 patients on 29 ablation sites, and 18/29 (62.1%) of them were successful ablation sites.

CONCLUSIONS

The recording of JBs during or before RF ablation is a useful parameter to guide SP ablation in patients with AVNRT. Although the underlying mechanism has not been clarified yet, their preferential occurrence in the mid-septal region suggests that they might be due to thermal stimulation of compact atrioventricular node.

[Ablation of paroxysmal tachycardia in Wolff-Parkinson-White syndrome]

Surgical or catheter ablation of accessory pathways by means of high energy shock has been substantial associated with morbidity and mortality. On the contrary radiofrequency current, an alternative energy source for ablation, has a low incidence of complications and a very high success rate. Aim of this study was to relate about the results using catheter ablation of accessory pathways by radiofrequency current in our Electrophysiologic laboratory. Radiofrequency current (20-40 W) was delivered between a large-tip catheter electrode positioned against the mitral or tricuspid anulus and a standard adhesive electrosurgical dispersive pad applied to the left chest wall. When possible radiofrequency delivery was guided by catheter recordings of accessory pathway activation. Ablation was attempted in 181 patients with 191 accessory pathways. We obtained successful ablation of 187/191 accessory pathways and accessory pathway conduction was eliminated in 177/181 patients. During a mean follow-up of 14 +/- 10 months preexcitation returned in 7 patients (3.9%). All underwent a second successful ablation. In 1 patient, during the procedure, we observed a transient ischemic attack, with no complications. In accordance to other reports we conclude that radiofrequency ablation is highly effective in ablating accessory pathways, with low morbidity and no mortality.

[The psychodynamic basis of diver training]

The techniques employed in teaching diving and especially diving safety, were studied. Since it was felt that most accidents are not merely fortuitous but also derive from unconscious urges towards risk-taking, an attempt was made to understand the psychodynamics of the question. The study also investigated the effectiveness of the teaching method as a means not only of transmitting intrinsically useful skills and knowledge, but also as a psychotherapeutic technique aiding the diver to control any self-destructive aggressive urges.

[Psychodynamic aspects of sports diving]

Individual and group discussions with divers and instructors were used to discover the psychodynamic bases of the diver's psychology. The clearly narcisistic compensation mechanisms, based essentially on so-called "cross-identification" appear to explain the apparently contradictory personality traits revealed by both psychodiagnostic techniques and phenomenological analysis. The recognition of cross identification as the basis of the narcisism-masochism collusion appears to be a useful addition to the field of accident prevention.

[Environmental lead pollution. An epidemiologic study in road gasoline station workers (author's transl)]

Erythrocyte ALA-D and urinary coproporphyrins were investigated in 29 road gasoline station workers in order to detect a possible abnormal lead absorption. The ALA-D test represents the most sensitive laboratory device to detect both abnormal lead absorption and possible initial lesions due to lead poisoning. Using the above mentioned laboratory tests evidence of abnormal lead absorption was found in five of the examined subjects. Some remarks on prevention of possible lead intoxication are done.