Background
The venous access for the insertion of permanent leads of cardiac implantable electronic devices is often achieved by venous cutdown of the cephalic vein, or by “blind” puncture of the ...subclavian vein using anatomical landmarks, or by fluoroscopy‐assisted methods.
Methods
We have retrospectively analyzed our clinical experience to verify the feasibility, the safety, and efficacy of the adoption of ultrasound‐guided puncture/cannulation of the axillary vein for this purpose.
Results
Nine hundred eighty‐seven leads were placed during 548 consecutive procedures, accessing the axillary vein in the infraclavicular area using real‐time ultrasound guidance. Venipuncture was successful in 99.8% of cases. The access time was 11 seconds (range 4‐580). We recorded three cases of pneumothorax (0.5%), but no hemothorax and no hemo‐mediastinum. The incidence of local hematoma was 2.1% (12 cases). No injury to the brachial plexus or to the phrenic nerve was recorded. In a follow‐up of 33 months (range 16‐39), we observed no cases of “subclavian crush syndrome” (damage of the leads at the level of the thoracic inlet), and the rate of pocket infection/infective endocarditis was 0.7%.
Conclusion
In our experience, ultrasound‐guided puncture/cannulation of the axillary vein for implantation of permanent leads is feasible, effective, and safe. It might be considered as a first option for this procedure.
Currently, several therapies are available for metastatic castration-resistant prostate cancer (mCRPC) but no specific clinical factors to personalize treatment. We first sought the prognostic value ...of duration on androgen-deprivation therapy (ADT) for hormone-sensitive prostate cancer (HSPC) in patients receiving androgen-receptor-signaling inhibitors (ARSI) for mCRPC.
A multicenter cohort of mCRPC patients who started ARSI between July 2011 and October 2021 was identified. Based on their initial disease burden and duration on ADT for HSPC, primary progressive (PP) men were classified into four groups: low/intermediate-risk localized disease (LOC) and high-risk localized/locally advanced disease (LAD) and short-term (ST) < 24 vs. long-term (LT) ADT ≥ 24 months, whereas de novo (DN) mHSPC were subdivided into short-time vs. long-time to CRPC.
We included 919 mCRPC patients with a median age of 77 years interquartile range (IQR) = 71-82). Median ADT duration in HSPC was 24 months (IQR = 14-40). Median follow-up was 91 months (IQR = 62-138), median OS and PFS from ARSI start were 20 (IQR 10-32) and 10 months (IQR = 5-19), respectively. In PP developing metastatic disease (n = 655, 71.3%), LOC and LAD with ST ADT had a greater than almost double-risk of death compared to LT ADT (LOC/ST: hazard ratio HR = 2.01; 95% CI 1.54-2.64; LAD/ST: HR = 1.73; 95% CI 1.34-2.24; p < 0.001). In the multivariate analysis including age, prognostic cohort, Gleason, ECOG, radical radiotherapy and prostatectomy, groups with ST ADT were associated with worse OS compared to LT ADT (LOC/ST: HR = 1.84; 95% CI 1.38-2.45; p < 0.001; LAD/ST: HR = 1.59; 95% CI 1.21-2.10; p < 0.001), along with ECOG > 2 (HR = 1.55; 95% CI 1.06-2.26; p = 0.03). There were also similar results of PFS. Moreover, long-time to CRPC in patients with history of DN mHSPC (n = 264, 28.7%) resulted in a better OS/PFS (HR = 0.76, 95% CI 0.56-1.02, p = 0.064 and HR = 0.74, 95% CI 0.55-0.99, p = 0.042, respectively).
Our study showed that duration on ADT for mHSPC was significantly associated with survival in mCRPC undergoing ARSI. These findings suggest a possible connection between initial management of prostate tumour and a better prognostication in mCRPC. Prospective trials are warranted.
The anti-viral T cell response is believed to play a central role in the pathogenesis of hepatitis C virus infection. Since chronic evolution occurs in > 50% of HCV infections, the sequential ...analysis of the T cell response from the early clinical stages of disease may contribute to define the features of the T cell response associated with recovery or chronic viral persistence. For this purpose, 21 subjects with acute hepatitis C virus infection were sequentially followed for an average time of 44 wk. Twelve patients normalized transaminase values that remained normal throughout the follow-up period; all but two cleared hepatitis C virus-RNA from serum. The remaining nine patients showed persistent viremia and elevated transaminases. Analysis of the peripheral blood T cell proliferative response to core, E1, E2, NS3, NS4, and NS5 recombinant antigens and synthetic peptides showed that responses to all hepatitis C virus antigens, except E1, were significantly more vigorous and more frequently detectable in patients who normalized transaminase levels than in those who did not. By sequential evaluation of the T cell response, a difference between the two groups of patients was already detectable at the very early stages of acute infection and then maintained throughout the follow-up period. The results suggest that the vigor of the T cell response during the early stages of infection may be a critical determinant of disease resolution and control of infection.
The HLA class II–restricted T‐cell response to hepatitis C virus (HCV) antigens is believed to influence the final outcome of hepatitis C, because it is vigorous in patients who recover from acute ...hepatitis C, but it is weak in those who develop a chronic infection. For this reason, exogenous stimulation of T‐cell responses in chronic HCV infection may represent a strategy to cure patients with chronic hepatitis C by approximating the vigor of their T‐cell reactivity to that of patients who succeed in recovering from hepatitis. It may also be a preventive approach to avoid spread of the virus by facilitating the development of a vigorous protective response at the very early stages of infection. T‐cell–based vaccines composed of immunodominant, promiscuous, and conserved T‐cell epitopes may represent a powerful tool to achieve optimal stimulation of the T‐cell reactivity. To identify HLA class II–restricted T‐cell epitopes useful for this purpose, 22 subjects with acute HCV infection were studied and followed for an average time of 29 months. Eight of them recovered from hepatitis, and 14 developed a chronic infection. Overlapping 20‐mer peptides covering the entire core and NS4 antigens and a panel of peptides representing highly conserved regions of core, NS3, NS4, and NS5 were used. By direct peripheral blood T‐cell stimulation and by fine‐specificity analysis of HCV‐specific T‐cell lines and clones, highly immunogenic T‐cell epitopes were identified within core, NS3, and NS4. All these epitopes are immunodominant and highly conserved among the known HCV isolates. Moreover, they are promiscuous, because they can be presented to T cells by different HLA class II molecules. Immunodominance, sequence conservation, and promiscuity make these epitopes ideal components of preventive or therapeutic T‐cell–based vaccines against HCV.
The Schmorl node represents displacement of intervertebral disc tissue into the vertebral body. Both Schmorl nodes and degenerative disc disease are common in the human spine. We performed a ...retrospective study, for the period from January 2003 to February 2005, evaluating 23 patients affected by painful Schmorl nodes, who underwent in our department percutaneous transpedicular injection of polymethylmethacrylate (vertebroplasty) in order to solve their back pain not responsive to medical and physical management. Eighteen patients reported improvement of the back pain and no one reported a worsening of symptoms. Improvement was swift and persistent in reducing symptoms. Painful Schmorl nodes, refractory to medical or physical therapy, should be considered as a new indication within those vertebral lesions adequately treatable utilizing Vertebroplasty procedure.
Electrophysiologic intracardiac and noninvasive transesophageal testing, used to evaluate parameters of anterograde conduction across the accessory pathway, the refractory period and shortest atrial ...cycle length with 1:1 conduction over the pathway, were compared to assess the reliability of the noninvasive technique in identifying patients with Wolff-Parkinson-White syndrome, at risk of rapid ventricular response during atrial fibrillation when this arrhythmia is not inducible. Sixteen patients with Wolff-Parkinson-White syndrome were submitted both to invasive and transesophageal atrial stimulation. We evaluated both the functional and effective refractory periods of the accessory pathway, using the same drive cycle length, and the shortest cycle length with 1:1 atrioventricular conduction over the accessory pathway. There were no differences between the parameters obtained by intracardiac atrial stimulation and by transesophageal atrial stimulation. The two approaches correlated well: mean functional refractory periods of the accessory pathway were 285 +/- 42 msec and 289 +/- 32 msec, respectively (NS, r = 0.88); mean effective refractory periods of the accessory pathway were 267 +/- 41 msec and 271 +/- 32 msec, respectively (NS, r = 0.89); mean shortest cycle lengths with 1:1 conduction over the accessory pathway were 255 +/- 48 msec and 255 +/- 44 msec, respectively (NS, r = 0.94). These data demonstrate the reliability of transesophageal atrial stimulation in estimating the parameters for anterograde conduction across an accessory pathway. These results, and the already documented ability of transesophageal atrial stimulation to induce atrial fibrillation, suggest this noninvasive technique should be taken as a first approach in screening patients with Wolff-Parkinson-White syndrome.
The natural evolution of ventricular arrhythmias complicating a first episode of acute myocardial infarction has been studied in a group of 56 consecutive patients, who were admitted to the Coronary ...Care Unit within three hours of the onset of symptoms, and in whom drug administration (digitalis, antiarrhythmics, diuretics and heparin) was limited. Ventricular arrhythmias have been evaluated by means of Holter monitoring performed during the first 24 hours, the second 24 hours, the eighth day, the 18th day and two years after discharge when antiarrhythmic drugs has been discontinued for at least five half-lives. The overall incidence and prevalence of ventricular arrhythmias showed a steady and statistically significant reduction from the first to the eighth day, and a not statistically significant increase from the eighth to the 18th day. The latter increase was still present at the two-year follow-up. The one-by-one behaviour analysis of discharged patients delineated three different patterns: patients who presented a steady reduction in ventricular arrhythmias from the first to the 18th day (44%); patients who showed an almost constant incidence of ventricular arrhythmias during all phases of acute myocardial infarction (24%); and patients who presented both a decrease and an increase in their ventricular arrhythmias (31%). The follow-up at two years showed that the majority of patients, especially those discharged in a high Lown class, had the same arrhythmias as at their follow-up on the 18th day. Correlation of ventricular arrhythmias with the extent of the infarcted area demonstrated that only the peak and mean values of lactic dehydrogenase correlated with the severity of ventricular arrhythmias.
This study was performed to evaluate whether transoesophageal atrial pacing could also stop ventricular tachycardias with low rates and no haemodynamic impairment. Prior to resorting to ventricular ...endocardial pacing, seven male patients, aged between 15 and 73 years, were treated by transoesophageal atrial pacing for 10 spontaneous episodes of sustained ventricular tachycardia at rates between 105 and 160 beats per minute, without haemodynamic impairment. When atrial pacing did not allow ventricular capture, atropine sulphate was administered. Transoesophageal atrial pacing led to ventricular capture in seven episodes, which made overdriving possible, and blocked six episodes of ventricular tachycardia. In no case did transoesophageal atrial pacing lead to an acceleration of ventricular tachycardia or to degeneration into ventricular fibrillation. Transoesophageal atrial pacing can block low-rate sustained ventricular tachycardias (less than or equal to 150 beats per minute). For low-rate sustained ventricular tachycardias without haemodynamic impairment, transoesophageal atrial pacing can thus be used as the method of choice thanks to its good ratio of risk to efficiency.
PDF
