The conditioning regimens with different alkylators at different doses can influence the outcome of allogeneic stem cell transplantation (SCT), but conclusive data are missing.
With the aim to ...analyze real-life allogeneic SCTs performed in Italy between 2006 and 2017 in elderly patients (aged >60 y) with acute myeloid leukemia or myelodysplastic syndrome, we collected 780 first transplants data. For analysis purposes, patients were grouped according to the type of alkylator included in the conditioning (busulfan BU-based; n = 618; 79%; treosulfan TREO-based; n=162; 21%).
No significant differences were observed in nonrelapse mortality, cumulative incidence of relapse, and overall survival, although in the TREO-based group, we observed a greater proportion of elderly patients (
< 0.001); more active diseases at the time of SCT (
< 0.001); a higher prevalence of patients with either hematopoietic cell transplantation-comorbidity index ≥3 (
< 0.001) or a good Karnofsky performance status (
= 0.025); increased use of peripheral blood stem cells as graft sources (
< 0.001); and greater use of reduced intensity conditioning regimens (
= 0.013) and of haploidentical donors (
< 0.001). Moreover, the 2-y cumulative incidence of relapse with myeloablative doses of BU was significantly lower than that registered with reduced intensity conditioning (21% versus 31%;
= 0.0003). This was not observed in the TREO-based group.
Despite a higher number of risk factors in the TREO group, no significant differences were observed in nonrelapse mortality, cumulative incidence of relapse, and overall survival according to the type of alkylator, suggesting that TREO has no advantage over BU in terms of efficacy and toxicity in acute myeloid leukemia and myelodysplastic syndrome.
...the hemodynamic pattern was likely different. ...patients with HF with elevated AHI and several CSAs have the same cardiac output and circulatory delay as patients who do not show these findings ...(1). ...changes in AHI are unlikely related to changes in pulmonary receptor stimulation.
Background Despite the widespread use of transcatheter aortic valve implantation (TAVI), the role of sex on outcome after TAVI or surgical aortic valve replacement (AVR) has been poorly investigated. ...We investigated the impact of sex on outcome after TAVI or AVR. Methods There were 2108 patients undergoing TAVI or AVR who were enrolled in the Italian Observational Multicenter Registry (OBSERVANT). Thirty-day mortality, major periprocedural morbidity, and transprosthetic gradients were stratified by sex according to interventions. Results Female AVR patients showed a worse risk profile compared with male AVR patients, given the higher mean age, prevalence of frailty score of 2 or higher, New York Heart Association class of 3 or higher, lower body weight, and preoperative hemoglobin level ( P ≤ .02). Similarly, female TAVI patients had a different risk profile than male TAVI patients, given a higher age and a lower body weight and preoperative hemoglobin level ( P ≤ .005), but with a similar New York Heart Association class, frailty score, EuroSCORE ( P = NS), a better left ventricular ejection fraction and a lower prevalence of left ventricular ejection fraction less than 30%, porcelain aorta, renal dysfunction, chronic obstructive pulmonary disease, arteriopathy, and previous cardiovascular surgery or percutaneous coronary intervention ( P ≤ .01). Women showed a smaller aortic annulus than men in both populations ( P < .001). Female sex was an independent predictor in the AVR population for risk-adjusted 30-day mortality (odds ratio OR, 2.34; P = .043) and transfusions (OR, 1.47; P = .003), but not for risk-adjusted acute myocardial infarction, stroke, vascular complications, permanent atrioventricular block ( P = NS). Female sex was an independent predictor in the TAVI population for risk-adjusted major vascular complications (OR, 2.92; P = .018) and transfusions (OR, 1.93; P = .003), but proved protective against moderate to severe postprocedural aortic insufficiency ( P = .018). Conclusions Female sex is a risk factor for mortality after aortic valve replacement, for major vascular complications after TAVI, and for transfusions after both approaches.
The aim of this study was to investigate the effects of transcatheter aortic valve implantation (TAVI) on left ventricular (LV) hypertrophy and diastolic function in patients with severe aortic valve ...stenosis (AVS). There are few and conflicting data on LV mass remodeling and LV diastolic function after TAVI.
Echocardiography and clinical assessment were performed at baseline and at 6 months in high-risk patients affected by severe AVS who underwent TAVI.
One hundred thirty-five patients successfully underwent TAVI. Peak transvalvular aortic pressure gradient and mean transvalvular aortic pressure gradient were reduced from 87 ± 25 to 18 ± 7 mm Hg and from 54 ± 14 to 9 ± 4 mm Hg, respectively (P < .001), accompanied by significant clinical improvement. The mean LV ejection fraction improved from 50 ± 13% to 54 ± 11% during follow-up (P = .009). At 6-month follow-up, interventricular septal wall thickness regressed from 14 ± 2 to 12 ± 1 mm and posterior wall thickness from 13 ± 3 to 11 ± 2 mm (P < .001). LV mass and LV mass index decreased from 332 ± 106 to 228 ± 58 g (P < .001) and from 191 ± 58 to 132 ± 30 g/m(2) (P < .001), respectively. Ninety-seven patients (72%) showed improvements in LV diastolic filling pattern. The mean e' value increased from 4.1 ± 1.7 to 5.6 ± 2.2 cm/sec, and the mean E/e' ratio decreased from 24 ± 7 to 17 ± 6 (P < .001) after TAVI.
Significant LV mass reverse remodeling associated with improvement in LV systolic and diastolic function was found in patients with severe AVS 6 months after TAVI. These changes may have relevant clinical prognostic value.
Background We investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery ...bypass and to preoperatively recognize patients who are unlikely to benefit from this approach. Methods Among 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months interquartile range, 5–6 months; late: median, 33 months interquartile range, 17–51 months). Results Subjects with late regurgitation had preoperatively more symmetric tethering ( P < .001), more accentuated anterior mitral leaflet tethering ( P < .001), and more restricted anterior leaflet excursion ( P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased ( P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge ( P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5° or greater ( P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater ( P < .001), an anterior leaflet excursion angle of 35° or less ( P = .001), and a coaptation height of 11 mm or greater ( P = .04) to be predictors of recurrent mitral regurgitation. Conclusions Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.
The presence of a high number of positive SARS-CoV-2 patients is found daily in the emergency room database, finding evidence of infection also in trauma and burns. Surgical debridement remains the ...gold standard for eschar removal, but it does not come without complications such as bleeding and high heat loss. In recent years, there has been an increase in the use of enzymatic debridement techniques, replacing surgical escharotomy. Early eschar removal is proven to be important; it has been proved that an early and effective burn treatment in COVID-19 patients can reduce other infection. Five clinical cases of patients arrived at our COVID-19 Major Burns Intensive Care Unit. On admission, burns extension and depth were assessed by an expert burn surgeon. We evaluated eschar removal modality, adverse events, and potential side effects. Enzymatic debridement was efficient in all patients treated with complete eschar removal, and no serious adverse events. All patients were treated within 24 hours of arrival at our facility with Nexobrid by specialized personnel in deep sedation and with O
support using a face mask or nasal goggles. The use of enzymatic debridement in COVID-19-positive burn patients within dedicated pathways through nonsurgical treatment optimizes the treatment time. We believe that the use of enzymatic debridement could be a valid therapeutic option in burn patients, even with SARS-CoV-2 infection, and its use, when indicated, is safe and effective for the patient and optimizes the use of instrumental and human resources in a pandemic emergency.
Data are limited about the relative efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) for the treatment of unprotected left main coronary artery (ULMCA) stenosis. The survey ...promoted by the Italian Society of Invasive Cardiology on ULMCA stenosis was an observational study involving 19 high-volume Italian centers of patients with ULMCA stenosis treated using percutaneous coronary intervention (PCI). From January 2002 to December 2006, of 1,453 patients identified with ULMCA stenosis treated with PCI, 1,111 were treated with DESs and 342 were treated with BMSs. During a 2-year follow-up, risk-adjusted survival free from cardiac death was significantly higher in patients treated with DESs than in those treated with BMSs. The propensity-adjusted hazard ratio for risk of 2-year cardiac mortality after DES versus BMS implantation was 0.49 (95% confidence interval 0.32 to 0.77). The benefit of DESs in reducing cardiac mortality was obtained in the period from 3 to 6 months and maintained up to 2 years. In conclusion, for patients with ULMCA stenosis undergoing PCI, DES implantation was associated with higher adjusted rates of 2-year survival free from cardiac death. The benefit of DESs in reducing cardiac mortality was obtained in the period in which clinical manifestations of restenosis usually peak.
Reciprocal ST-segment downsloping on electrocardiogram is a frequent finding during ST-elevated myocardial infarction (STEMI), but its etiology is still disputed. We sought to evaluate the relation ...between reciprocal ST-segment downsloping during STEMI and major cardiac perfusion and functional parameters. One hundred eighty-five patients with STEMI underwent emergency coronary angiography. The presence of reciprocal ST-segment downsloping was assessed. At coronary angiography, the corrected TIMI frame count (cTFC) was computed both on culprit and remote vessels and the occurrence of “no/slow reflow” phenomenon after percutaneous coronary intervention (PCI) identified. The left ventricular wall motion score index ratio (discharge/admission values) at echocardiography and the slope of high-sensitivity troponin elimination were computed as measures of effective myocardial reperfusion. Reciprocal ST-segment downsloping was revealed in 91 patients (49%). They presented higher cTFC values on remote vessels than patients without reciprocal electrocardiographic abnormalities (44 ± 18 vs 37 ± 15 cineframes × second−1 , p = 0.004). The presence of remote ST-segment downsloping was also associated with a higher prevalence of “no/slow reflow” phenomenon (59% vs 40%, p = 0.013) as well as more abnormal values of wall motion score index ratio (p = 0.042) and high-sensitivity troponin slope (p = 0.012). At multivariate analyses, a higher cTFC on remote vessels predicted the occurrence of reciprocal ST-segment changes (p = 0.018) and the development of “no/slow reflow” phenomenon after PCI (p = 0.005). In conclusion, the presence of reciprocal ST-segment downsloping during STEMI clusters with significant perfusion and cardiac functional abnormalities, predicting the development of “no reflow” phenomenon after PCI.
Background Identification of the clinical behavior of atypical Spitzoid tumors with conflicting histopathologic features remains controversial. Objective We sought to assess whether molecular ...findings may be helpful in the diagnostic and prognostic assessment of atypical Spitzoid tumors. Methods A total of 38 controversial, atypical Spitzoid lesions (≥1 mm in thickness) were analyzed for clinicopathological features, chromosomal alterations by fluorescence in situ hybridization (FISH) analysis (RREB1/MYB/CCND1/CEP6), BRAFV600E mutation by allele-specific real-time polymerase chain reaction confirmed by sequencing, and H-RAS gene mutation by direct sequencing. Results Atypical Spitzoid lesions developed in 21 female and 17 male patients (mean age 22 years). Nine patients underwent sentinel lymph node biopsy and a sentinel lymph node micrometastasis was detected in 4 of these 9 cases. Four additional patients, who did not receive a sentinel lymph node biopsy, experienced bulky lymph node metastases and one experienced visceral metastases and death. Lesions from patients with lymph node involvement showed more deep mitoses ( P < .01), less inflammation ( P = .05), and more plasma cells ( P = .04). FISH analysis demonstrated the presence of chromosomal alterations in 6 of 25 cases. Correlation with follow-up data showed that the only case with fatal outcome showed multiple chromosomal alterations by FISH analysis. BRAFV600E mutation was detected in 12 of 16 cases (75%) and H-RAS mutation on exon 3 was found in 3 of 11 cases (27%). Limitations Our results require validation in a larger series with longer follow-up information. Conclusions FISH assay may be of help in the prognostic evaluation of atypical Spitzoid tumors. Diagnostic significance of BRAFV600E and H-RAS mutations in this setting remains unclear.
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