Simultaneous stereo-EEG and high-density scalp EEG recordings to study the effects of intracerebral stimulation parameters

BACKGROUND

Cortico-cortical evoked potentials (CCEPs) recorded by stereo-electroencephalography (SEEG) are a valuable tool to investigate brain reactivity and effective connectivity. However, invasive recordings are spatially sparse since they depend on clinical needs. This sparsity hampers systematic comparisons across-subjects, the detection of the whole-brain effects of intracortical stimulation, as well as their relationships to the EEG responses evoked by non-invasive stimuli.

OBJECTIVE

To demonstrate that CCEPs recorded by high-density electroencephalography (hd-EEG) provide additional information with respect SEEG alone and to provide an open, curated dataset to allow for further exploration of their potential.

METHODS

The dataset encompasses SEEG and hd-EEG recordings simultaneously acquired during Single Pulse Electrical Stimulation (SPES) in drug-resistant epileptic patients (N = 36) in whom stimulations were delivered with different physical, geometrical, and topological parameters. Differences in CCEPs were assessed by amplitude, latency, and spectral measures.

RESULTS

While invasively and non-invasively recorded CCEPs were generally correlated, differences in pulse duration, angle and stimulated cortical area were better captured by hd-EEG. Further, intracranial stimulation evoked site-specific hd-EEG responses that reproduced the spectral features of EEG responses to transcranial magnetic stimulation (TMS). Notably, SPES, albeit unperceived by subjects, elicited scalp responses that were up to one order of magnitude larger than the responses typically evoked by sensory stimulation in awake humans.

CONCLUSIONS

CCEPs can be simultaneously recorded with SEEG and hd-EEG and the latter provides a reliable descriptor of the effects of SPES as well as a common reference to compare the whole-brain effects of intracortical stimulation to those of non-invasive transcranial or sensory stimulations in humans.

Excimer laser technology in percutaneous coronary interventions: Cardiovascular laser society's position paper

Excimer Laser Coronary Atherectomy (ELCA) is a well-established therapy that emerged for the treatment of peripheral vascular atherosclerosis in the late 1980s, at a time when catheters and materials were rudimentary and associated with the most serious complications. Refinements in catheter technology and the introduction of improved laser techniques have led to their effective use for the treatment of a wide spectrum of complex coronary lesions, such as thrombotic lesions, severe calcific lesions, non-crossable or non-expandable lesions, chronic occlusions, and stent under-expansion. The gradual introduction of high-energy strategies combined with the contrast infusion technique has enabled us to treat an increasing number of complex cases with a low rate of periprocedural complications. Currently, the use of the ELCA has also been demonstrated to be effective in acute coronary syndrome (ACS), especially in the context of large thrombotic lesions.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery

Objective

To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID‐19) status.

Methods

From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID‐19 status, 1306 (96.5%) were negative to SARS‐CoV‐2 (COVID‐N), and 48 (3.5%) were positive to SARS‐CoV‐2 (COVID‐P); among the COVID‐P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non‐CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID‐N (10.4% vs. 2.5%, p = .01).

Results

Overall in‐hospital mortality was 1.6% (22 cases), being significantly higher in COVID‐P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID‐P condition as a predictor of in‐hospital mortality together with emergency status. In the COVID‐P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in‐hospital mortality.

Conclusion

As expected, SARS‐CoV‐2 infection, either before or soon after cardiac surgery significantly increases in‐hospital mortality. Moreover, among COVID‐19‐positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

How to cope in heterogeneous coastal environments: Spatio-temporally endogenous circadian rhythm of valve gaping by mussels

Transitional coastal zones are subject to high degrees of temporal fluctuation in environmental conditions, with these patterns varying in space. Gaining an in depth understanding of how sessile organisms cope with and respond to such environmental changes at multiple scales is needed to i) advance fundamental knowledge, ii) predict how organisms may react to stressors and iii) support the management of halieutic resources in transitional coastal areas. We addressed this question using mussels (Mytilus galloprovincialis) as model system. Valve-gaping sensor were deployed at multiple sites within the southern Venice Lagoon over a period of 6 months, to investigate the existence of periodicity in valve-gaping and its relationship with environmental variables, such as temperature and chlorophyll-a. Gaping behaviour was found to have periodic rhythms, of ~12 h and ~ 24 h, which were most pronounced in the inner part of lagoon part and were strongest during summer months. In autumn, the dual periodicity became weaker and mostly the 12 h remained. Gaping was closely linked with tide, but the relationship in terms of phasing varied upon location. Surprisingly, no clear direct relationships were found with chlorophyll-a, but food delivery may be mediated by tide itself. The results highlight the heterogeneity of behaviour and the endogenic nature of circadian rhythms in space and time. These findings have important implications for management of transitional areas where tidal alteration may have impacts on key behaviours, and emphasize the importance of characterizing their rhythms before using these as stress indicator. Moreover, the described tidal relationships should be included in growth models of bivalves in these systems.

Focal lesions induce large-scale percolation of sleep-like intracerebral activity in awake humans

Focal cortical lesions are known to result in large-scale functional alterations involving distant areas; however, little is known about the electrophysiological mechanisms underlying these network effects. Here, we addressed this issue by analysing the short and long distance intracranial effects of controlled structural lesions in humans. The changes in Stereo-Electroencephalographic (SEEG) activity after Radiofrequency-Thermocoagulation (RFTC) recorded in 21 epileptic subjects were assessed with respect to baseline resting wakefulness and sleep activity. In addition, Cortico-Cortical Evoked Potentials (CCEPs) recorded before the lesion were employed to interpret these changes with respect to individual long-range connectivity patterns. We found that small structural ablations lead to the generation and large-scale propagation of sleep-like slow waves within the awake brain. These slow waves match those recorded in the same subjects during sleep, are prevalent in perilesional areas, but can percolate up to distances of 60 mm through specific long-range connections, as predicted by CCEPs. Given the known impact of slow waves on information processing and cortical plasticity, demonstrating their intrusion and percolation within the awake brain add key elements to our understanding of network dysfunction after cortical injuries.

The rise of organ donation after circulatory death: a narrative review

Solid organ transplantation saves and transforms lives. The original type of organ donation from deceased patients was controlled donation after circulatory death, previously referred to as non-heart beating organ donation. The rise of donation after circulatory death in the UK came about through advances in critical care and transplant medicine and support from several key organisations in developing a robust ethical, legal and professional framework. The transplant waiting list reached a historic peak in 2009-2010 of 8000 patients, but fell by 25% to 6000 in 2017-2018. There has also been a steady rise in the number of deceased donors and the number of donations after circulatory death. The contribution of donation after circulatory death to the total number of donations rose steadily between 2000 and 2012 and has remained about 40% since. Although the situation has improved for patients waiting for a transplant, deaths and long waits remain common. Changes to legislative, technical and peri-mortem procedures may greatly change future practices in donation after circulatory death in the UK.

Intercepting Parkinson disease non-motor subtypes: A proof-of-principle study in a clinical setting

The construct of non-motor symptoms (NMS) subtyping in Parkinson Disease (PD) is emerging as a line of research in the light of its potential role in etiopathological interpretation of PD heterogeneity. Different approaches of NMS subtyping have been proposed: an anatomical model suggests that NMS aggregate according to the underpinning pathology; other researchers find aggregation of NMS according to the motor phenotype; the contribution of genetic background to NMS has also been assessed, primarily focusing on cognitive impairment. We have analyzed NMS burden assessed through an extensive clinical and neuropsychological battery in 137 consecutive non-demented PD patients genotyped for MAPT haplotypes (H1/H1 vs H2 carriers) in order to explore the applicability of the "anatomo-clinical", "motor" or "genetic" models for subtyping PD in a clinical setting; a subsequent independent analysis was conducted to verify a possible cluster distribution of NMS. No clear-cut NMS profiles according to the previously described models emerged: in our population, the autonomic dysfunctions and depressive symptoms represent the leading determinant of NMS clusters, which seems to better fit with the hypothesis of a "neurotransmitter-based" model. Selective preferential neurotransmitter network dysfunctions may account for heterogeneity of PD and could address translational research.

Functional Clustering approach for the analysis of Stereo-EEG activity patterns in correspondence of epileptic seizures

In this study, a functional clustering approach is proposed and tested for the identification of brain functional networks emerging during sleep-related seizures. Stereo-EEG signals recorded in patients with Type II Focal Cortical Dysplasia (FCD type II), were analyzed. This novel approach is able to identify the network configuration changes in pre-ictal and early ictal periods, by grouping Stereo-EEG signals on the basis of the Cluster Index, after wavelet multiscale decomposition. Results showed that the proposed method is able to detect clusters of interacting leads, mainly overlapped on the Epileptogenic Zone (EZ) identified by a clinical expert, with distinctive configurations related to analyzed frequency ranges. This suggested the presence of coupling activities between the elements of the epileptic system at different frequency scales.

Adaptation and psychometric properties of the Italian version of the Non-Motor Symptoms Questionnaire for Parkinson's disease

Although non-motor symptoms (NMS) of Parkinson's disease (PD) are very common also in early stages of the disease, they are still under-recognized. Screening tools for non-motor symptoms, such as non-motor symptoms questionnaire (NMSQuest), help clinicians to recognize NMS and to evaluate if patients could require further assessment or specific treatments. To validate an adapted Italian version of NMSQuest and study its psychometric properties, Italian PD patients self-completed Italian NMSQuest, and then underwent a standard clinical evaluation including motor assessment (by Hoehn and Yahr staging, unified Parkinson's disease rating scale part III) and non-motor assessment (by Montreal cognitive assessment, Beck depression inventory, neuropsychiatric inventory, Epworth sleepiness scale, scale for outcomes in Parkinson's disease-Autonomic and movement disorder society-sponsored revision of the unified Parkinson's disease rating scale part I). Somatic comorbidities were quantified using the modified cumulative illness rating scale (CIRS). Seventy-one subjects were assessed (mean age years 69.8 ± 9.6 SD; 31% women; mean duration of disease 6.3 ± 4.6 years; H&Y median 2). Italian NMSQuest showed adequate satisfactory clinimetrics in terms of data quality, precision, acceptability, internal consistency and reliability. A significant correlation was found between NMSQuest and most of non-motor assessment scales, while no significant correlation appeared with motor severity as well as with age of patients, disease duration, levodopa equivalent daily dose, L-DOPA/dopamine agonists assumption and CIRS total score. The Italian version of the NMSQuest resulted as a reliable instrument for screening NMS in Italian PD patients.

Validation of viscoelastic coagulation tests during cardiopulmonary bypass

BACKGROUND

Viscoelastic point-of-care tests such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are increasingly used to guide hemostatic therapy after cardiac surgery. The aim of this study was to assess their clinical utility during cardiopulmonary bypass to predict postbypass coagulation status and to guide therapy.

METHODS

In this prospective study, TEG and ROTEM tests were performed in 52 adult patients undergoing elective cardiac surgery at two time points: near the end of cardiopulmonary bypass and after heparin reversal with protamine. The 95% confidence intervals of the mean difference were compared with a prespecified clinically relevant limit of ± 20% of the value after protamine.

RESULTS

Both viscoelastic fibrinogen assays were well within the prespecified clinically relevant limit (≥ 79% of patients). The laboratory Clauss fibrinogen was much lower during cardiopulmonary bypass than after protamine (mean difference 1.2 g L(-1) , 95% CI 1.03-1.4, which was outside a clinically acceptable difference. For intrinsically activated tests, clotting times (CT) were different and outside the prespecified limit on TEG (mean difference -1.2 min, 95% CI -1.8 to -0.6) but not on ROTEM (mean difference 2.3 sec, 95% CI -8.6 to 13.2), while clot strength was well within the clinical limit on both devices (≥ 94% of patients). For extrinsically activated tests, clot strength on both TEG and ROTEM was within the pre-specified limit in 98% of patients.

CONCLUSIONS

Results from TEG and ROTEM tests performed toward the end of cardiopulmonary bypass are similar to results after reversal of heparin. Amplitudes indicating clot strength were the most stable parameters across all tests, whereas CT showed more variability. In contrast, laboratory testing of fibrinogen using the Clauss assay was essentially invalid during cardiopulmonary bypass.

Potential impact of the 70-gene signature in the choice of adjuvant systemic treatment for ER positive, HER2 negative tumors: a single institution experience

PURPOSE

We investigated in a single institution series of 124 women with operable breast cancer whether tumor clinicopathological features could predict the 70-gene signature (Mammaprint, MP) results, and whether MP results could help to make decisions for the use of chemotherapy (CT) in patients (pts) with ER positive breast cancer beyond recommendations of international guidelines.

RESULTS

Among the 68 ER/PgR positive, HER2 negative tumors, Ki-67 ≥ 20% was the only significant predictor of a high risk-MP among standard clinicopathological features. In candidates for endocrine therapy with undetermined benefit from CT according to international guidelines, MP results would have led to different treatment decisions in 13/46 (28%) and in 20/68 (29%) pts according to NCCN and St. Gallen recommendations, respectively.

CONCLUSIONS

Ki-67 independently predicted high risk-MP in ER/PgR positive, HER2 negative tumors. MP results would have led to discordant treatment recommendations in about 30% of cases, generally increasing indication rate for CT. The results of large randomized trials are warranted in order to understand whether we should rely on multigene assays rather than on standard clinicopathological features for treatment decisions.

The future of primary paediatric care in Europe: reflections and Report of the EPA/UNEPSA Committee

BACKGROUND

Changes in the scope of the field of paediatrics and the variability in primary paediatric care (PPC) and practice throughout Europe motivated the European Paediatric Association and Union of National European Paediatric Societies and Associations (EPA/UNEPSA) to establish a working group to discuss definitions of paediatric coverage in terms of age limits, find common denominators in the provision of PPC and examine the challenges and goals of 21st century paediatrics relevant to the continent. These issues were presented at the 2008 Europaediatrics in Istanbul, where a consensus declaration was drawn up and accepted by the EPA/UNEPSA Executive Committee.

AIM

To present an outline of the essential elements of the 2008 EPA/UNEPSA Executive Committee consensus declaration.

CONCLUSION

The definition of basic characteristics and the establishment of requirements for optimal PPC and practice are important steps in overcoming the differences among European countries and pave the way for an acceptable formulation of standardized high-quality paediatric medical care in Europe.

Intensive versus conventional insulinotherapy after elective and on-pump myocardial revascularization: a prospective and randomized study

OBJECTIVES

Strict glycemic control is increasingly recognized as an important goal in a broad spectrum of critically ill patients. We analyzed the inflammatory and clinical response of patients submitted to intensive or conventional insulinotherapy in a specific clinical context.

MATERIALS AND METHODS

We analyzed a prospective and randomized collected database of an Intensive Care Unit (ICU) in a University Hospital. The database comprised a total of 50 patients aged 30 to 80 (ASA II-III) who underwent elective and on-pump myocardial revascularization from September 2006 to June 2008. On ICU admission, patients were randomly assigned to Group 1 (intensive insulinotherapy) or Group 2 (conventional insulinotherapy). Data collected included glucose and lactate blood levels, haemodynamic parameters, cytokines (TNFalpha, IL-6, IL-8, IL-10), C-Reactive Protein, white blood cells and platelets blood levels, body temperature, Sequential Organ Failure Assessment (SOFA) score, Infection Probability Score (IPS) and ICU length of stay (LOS). Within-between group analysis, one-way ANOVA and unpaired t-test were used when appropriate.

RESULTS

Pre- and perioperative variables were comparable between the two groups (p=NS for all measurements). Glucose and lactate blood levels were lower in Group 1 (p less than 0.0001). Stroke Volume Index was higher in Group 1 (p less than 0.05). Moreover, we observed statistically significant differences between groups in terms of inflammatory parameters and severity scores. No difference was observed in ICU LOS.

CONCLUSIONS

Intensive insulinotherapy after elective on-pump myocardial revascularization significantly modulates the inflammatory response. Different inflammatory patterns could correlate with different clinical response as suggested by SOFA and IP score analysis.

Dipeptide transport in the intestinal mucosa of developing rabbits

Influxes of glycyl-L-proline (a dipeptide which is not hydrolysed in the membrane and is transported intact across the brush border) and of glycyl-L phenylalanine (a dipeptide which has affinity for the peptide transport system and is hydrolysed at the brush border membrane) have been studied in the small intestine of fetal, newborn and suckling rabbits. For glycyl-L-phenylalanine, transport as the intact dipeptide and 'membrane hydrolysis + amino acid transport' have been measured separately by using glycyl-L-proline and L-leucine as selective inhibitors of each pathway. For comparison, uptake of free glycine and of free phenylalanine has also been studied. The intestine of newborn rabbits is shown to have a translocation process for intact dipeptides which is saturable with a low Kt and stimulated by sodium ions, and which is not shared by free amino acids. This process resembles that described in adult animals, except that the maximal velocity is much higher in newborns. The developmental pattern of this uptake process for dipeptides differs markedly from that of free glycine, thus providing a new type of evidence for the distinction between amino acid and dipeptide transport processes. The developmental pattern of the free phenylalanine uptake process also differs from the development of the 'superficial hydrolysis + amino acid transport' component of glycl-L-phenylalanine uptake. These data suggest that the advantage of mucosal uptake of peptides, compared to the uptake of free amino acids, is much greater in the early stages of postnatal life than in the adult.

Delayed initiation of subcutaneous insulin therapy after failure of oral glucose-lowering agents in patients with Type 2 diabetes: a population-based analysis in the UK

AIMS

The aim of this retrospective cohort study was to estimate the time to insulin initiation in patients with Type 2 diabetes inadequately controlled on oral glucose-lowering agents (OGLAs).

METHODS

Insulin-naïve patients failing on OGLAs were identified from The Health Improvement Network database, which collects records from general practices throughout the UK. Patients were included if they were aged > or = 40 years, had concomitant prescriptions for > or = 2 OGLAs, and > or = 1 year of available records prior to the first occurrence of HbA(1c) > or = 8.0% after > or = 90 days of OGLA polytherapy at > or = 50% of maximum recommended dosages.

RESULTS

A total of 2501 eligible patients with Type 2 diabetes who had an HbA(1c) above the OGLA failure threshold of > or = 8.0% were identified (54.0% male; 30.9% aged 60-69 years). It was estimated that if all the eligible patients were followed for 5 years, 25% would initiate insulin within 1.8 years of OGLA failure (95% CI 1.6-2.0), and 50% within 4.9 years (95% CI 4.6-5.8). The presence of diabetes-related complications had no substantial impact on the time to insulin initiation.

CONCLUSIONS

This study found that 25% of patients with Type 2 diabetes had insulin initiation delayed for at least 1.8 years, and 50% of patients delayed starting insulin for almost 5 years after failure of glycaemic control with OGLA polytherapy, even in the presence of diabetes-related complications. Interventions that reduce this delay to insulin initiation are required to help achieve and maintain recommended glycaemic targets in patients with Type 2 diabetes.

Diagnosed diabetic retinopathy in France, Italy, Spain, and the United Kingdom

AIM

The objective of this study was to describe the proportion and characteristics of patients diagnosed with diabetic retinopathy (DR) in France, Italy, Spain, and the United Kingdom (UK).

METHODS

To estimate the proportion of patients with type 1 and type 2 diabetes diagnosed with DR, we conducted a cross-sectional survey of general practitioners in each country using physician records. In addition, diabetes specialists were recruited in Italy and Spain. We extracted data from the medical notes of a sample of DR patients to characterize DR severity and clinical characteristics.

RESULTS

The average number of physicians per country was 41 (range: 34-49). The proportion of diagnosed DR ranged from 10.3% (95% CI, 6.7-14.0%) in Spain to 19.6% (95% CI, 16.0-23.1%) in the UK. Of 752 DR patients studied, 53.9% were male; mean age (+/-SD) was 64.2+/-12.8 years. Consistently across countries, mild non-proliferative DR was the most common severity level of diagnosed DR. Proliferative DR (PDR) ranged from 19.7% (France) to 31.5% (UK). Diabetic macular oedema was reported in approximately 10% of patients. Hypertension (73.1%), dyslipidemia (63.2%), and neuropathy (52.1%) were the most common co-morbidities.

CONCLUSIONS

Country-specific prevalence of diagnosed DR may reflect clinical management of diabetes, healthcare systems, or record-keeping accuracy. Across countries, up to 30% of DR patients had a diagnosis of PDR, which could suggest that patients are diagnosed only when their disease is advanced.

CT features of solitary fibrous tumour of the pleura: experience in 26 patients

PURPOSE

The purpose of this study was to identify the typical computed tomography (CT) features of solitary fibrous tumours of the pleura (SFTP) and determine which findings would allow confirmation of the pleural origin or benign behaviour of the tumour.

MATERIALS AND METHODS

Twenty-six preoperative CT studies of the chest (23 enhanced and 14 unenhanced) were retrospectively reviewed.

RESULTS

Up to 50% of SFTP were larger than 10 cm. At unenhanced CT, they showed homogeneous attenuation in 5 cases (35.7%) and inhomogeneous attenuation in 9 (64.3%). At contrast-enhanced CT, they were inhomogeneous in 21 cases (91.3%), with geographic pattern (61.9% of cases), serpiginous linear areas of enhancement (intralesional vessels) (23.8%), rounded (52.4%) or linear (33.3%) areas of low attenuation (necrosis).

CONCLUSIONS

Depending on location, size and histological features, SFTP may produce a large spectrum of findings. Typical CT features of small SFTP were well-defined margins and smooth contours, homogeneous attenuation and right or obtuse angles with the pleura. Larger lesions were characterised by well-defined margins and lobulated contours, geographic pattern in enhanced CT scans, acute angles or smooth tapering margins with the pleura.

Micrometastasis in sentinel (SLN) and non-sentinel lymph nodes of breast cancer: An update including clinico-pathologic impact and survival

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Aims: To assess the rate of positive axillary clearance when the SLN biopsy contains micro-metastatic disease and to evaluate the survival impact of local lymph nodes with micro-metastases. Materials and Methods: From 1997 to 2005 2,750 consecutive patients (pts) underwent breast surgery with SLN biopsy or axillary dissection. Of these, 87 pts had lymph node micro-metastases assessed with haematoxylin and eosin or cytokeratine staining and defined according to the current TNM classification. Lymph node micro-metastases were found after axillary dissection in 27 pts and after SLN biopsy in 60 cases; 55 (63.2%) were micro-metastases 0.2–1 mm, 22 (25.3%) measured 1–2 mm, 7 were isolated tumor cells and in 3 cases size was not available; micro-metastases were located within lymph node sinuses in 43 and in nodal parenchyma in 37 cases. Age: median 53 years (range 34–78), surgery: 77 (88.5%) conservative and 10 radical mastectomy; histotype: 79 (90.8%) ductal, 4 lobular, 2 tubular and 2 other histotypes. T stage: pT1a/pT1b in 16 (18.4%), pT1c in 54 (62.1%) and pT2 in 17 (19.5%) pts; grading 3 in 24 pts (27.6%); 76 pts (87.3%) had positive Er/Pgr; vascular invasion: present in 30 pts (34.5%); HER-2/neu overexpression in 16 (18.4%) pts; 64 pts (73.6%) received adjuvant chemotherapy (49 AC, 11 CMF ev, and 4 FEC); 69 pts (79.3%) had radiotherapy and hormonal therapy. Results: Among 60 pts with SLN micro-metastases, 8 (13%) had further axillary involvement; in 5/8 cases size of micro-metastases was >1 mm, in 7/8 cases micro-metastases were located in the nodal parenchyma. These 8 pts were not considered for survival analysis. Of the remaining 79 patients with micro-metastases, survival data were as follow: at median follow-up time of 32 months (range 2–158) 69 pts were alive without any evidence of disease, 4 pts died of disease and 6 pts were alive with disease. Three years DFS was 87.75% and OS 95.57%. Conclusions: Further axillary involvement was found in 13% of pts with micrometastases in the SLN biopsy supporting complete nodal dissection in all pts.Our preliminary results show that even minimal nodal involvement could correlate to worse prognosis and may require adjuvant treatment.

No significant financial relationships to disclose.

Family history, diabetes and extension of coronary atherosclerosis are strong predictors of adverse events after PTCA: A one-year follow-up study

BACKGROUND AND AIM

In this study we addressed some open questions in patients with coronary artery disease (CAD). First, we analysed which of the traditional risk factors was associated with the spreading of coronary stenosis and second, we aimed to identify if any variable was predictive of post-percutaneous transluminal coronary angioplasty (PTCA) clinical events.

METHODS AND RESULTS

We collected a consecutive series of patients with CAD (n=301) and in the subgroup of patients undergoing PTCA (n=135) we performed a prospective one-year follow-up study recording cardiovascular morbidity and total mortality. According to the extension of coronary atherosclerosis, we found a significant relationship with the prevalence of diabetes in men and with plasma HDL-cholesterol concentrations in women. The follow-up was completed in 95% of patients; we did not document any death whereas clinical events were registered in 16% of patients. At univariate analysis, we found that patients with clinical events had a higher prevalence of family history of CAD (43% vs 14%, p<0.005), diabetes (52% vs 21%, p<0.005) and multivessel disease (52% vs 35%, p<0.05). Multivariate analysis (logistic regression) confirmed that family history of CAD (OR 4.6, 95% CI 1.7-12.8, p<0.005), diabetes (OR 4.0, 95% CI 1.5-10.6, p<0.01) and multivessel disease (OR 2.8, 95% CI 1.1-7.4, p<0.05) were the only variables predictive of clinical events.

CONCLUSIONS

In this study, factors associated with the spreading of coronary stenosis were different according to the gender. Moreover, the presence of diabetes and multivessel disease had a negative impact on the long-term prognosis of patients undergoing PTCA. In addition, the family history of CAD represented in our study a strong predictor of clinical events. We suggest that in the management of post-PTCA patients, the role of individual baseline clinical characteristics must be taken into account and that subjects with a family history of premature CAD, diabetes and a wide extension of coronary disease represent those with the highest risk.