The optimal management and short- and long-term prognoses of spontaneous coronary artery dissection (SCAD) remain not well defined. The aim of this observational multicenter study was to assess ...long-term clinical outcomes in patients with SCAD. In-hospital and long-term outcomes were assessed in 134 patients with documented SCAD, as well as the clinical impact and predictors of a conservative rather than a revascularization strategy of treatment. The mean age was 52 ± 11, years and 81% of patients were female. SCAD presented as an acute coronary syndromes in 93% of patients. A conservative strategy was performed in 58% of patients and revascularization in 42%. On multivariate analysis, distal versus proximal or mid location of dissection (odds ratio 9.27) and basal Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 versus 0 or 1 (odds ratio 0.20) were independent predictors of conservative versus revascularization strategy. A conservative strategy was associated with better in-hospital outcomes compared with revascularization (rates of major adverse cardiac events 3.8% and 16.1%, respectively, p = 0.028); however, no significant differences were observed in the long-term outcomes. In conclusion, in this large observational study of patients with SCAD, angiographic features significantly influenced the treatment strategy, providing an excellent short- and long-term prognosis.
Patients with acute coronary syndrome (ACS) and nonobstructive coronary artery disease (CAD) have a substantial risk of subsequent coronary events within 1 year. The aim of the present study was to ...evaluate the prevalence, long-term outcomes, and adherence to oral antiplatelet therapy in patients with ACS and nonobstructive CAD compared with patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Nonobstructive CAD was defined as an angiographic finding of <50% diameter stenosis in any major epicardial artery. These patients were further stratified into 2 groups: those with normal coronary arteries (0% angiographic stenosis) and those with mild CAD (0% to 50% angiographic stenosis). Major adverse cardiac events, defined as death, myocardial infarction, ACS leading to hospitalization, and nonfatal stroke, were recorded and compared with a historical control group of patients with ACS and obstructive CAD who had undergone percutaneous coronary intervention. Of 2,438 consecutive patients with ACS undergoing coronary angiography, 318 (13%) had nonobstructive CAD. Of the 318 with nonobstructive CAD, 160 had normal coronary arteries and 158 had mild CAD. Patients with obstructive CAD had experienced greater rates of major adverse cardiac events at 26 ± 16 months (16.6% vs 9.1%, p = 0.001), driven by a greater rate of myocardial infarction compared with those without (5.3% vs 0%, p <0.001). However, the rate of death, ACS leading to hospitalization, and stroke was similar. After adjusting for baseline characteristics, no difference was found in the risk of major adverse cardiac events across the groups. Only 50% of patients with nonobstructive CAD were prescribed dual antiplatelet therapy. In conclusion, patients with ACS and nonobstructive CAD remain at high risk of long-term recurrent ischemic events.
The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have ...posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process (1 pretransplant assessments and waiting list registration, 2 time on the waiting list, and 3 time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue.
We searched
and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs.
Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC.
The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.
The aim of this study was to test the safety and efficacy of a novel rapid desensitization procedure in patients with acetylsalicylic acid sensitivity and coronary artery disease who underwent ...cardiac catheterization and coronary stent implantation. Aspirin plays a key role in the secondary prevention of atherothrombotic events and thrombotic complications after stent implantation. Aspirin sensitivity not only limits patients to benefit from the long-term use of this antiplatelet agent but is also often an impediment to the implantation of bare-metal and drug-eluting coronary stents. Of 1,014 patients admitted for cardiac catheterization, 26 (2.6%) had histories of aspirin sensitivity characterized by respiratory or cutaneous manifestations (none had previous anaphylactic reactions); of these, 61.5% presented with acute coronary syndromes. All patients underwent a novel rapid desensitization challenge procedure before cardiac catheterization, except for those presenting with ST-elevation myocardial infarctions (n = 4), who underwent desensitization before hospital discharge. The desensitization procedure involved the oral administration of 6 sequential doses of aspirin (1, 5, 10, 20, 40, and 100 mg) over 5.5 hours without the use of corticosteroids or antihistamines. Patients were followed for 1 year to assess compliance with aspirin therapy and adverse events. The desensitization procedure was successful in 23 patients (88.5%). Percutaneous coronary intervention with stent implantation was performed in 22 patients (1.8 stents/patient). Drug-eluting stents were used in all patients except those who underwent primary percutaneous coronary intervention (n = 3), in whom bare-metal stents were used. Multivessel percutaneous coronary intervention was performed in 30.7% of patients. At follow-up, all patients who successfully responded to the desensitization procedure tolerated aspirin well, without developing allergic reactions. Aspirin was withdrawn in only 1 patient, because of a peptic ulcer. In conclusion, rapid desensitization is safe and highly effective in patients with aspirin sensitivity and coronary artery disease who undergo coronary stent implantation, including those who receive drug-eluting stents.
Pulmonary embolism can be a catastrophic event that can result in early death or serious hemodynamic dysfunction. The dehydration, immobility, and infections occurring in acute stroke patients puts ...these patients at risk of developing deep vein thrombosis and pulmonary embolism. Recombinant tissue-type plasminogen activator (rt-PA) is the established therapy for acute ischemic stroke, and its prompt administration results in a better outcome in stroke patients. We describe a 73-year-old man who arrived at the emergency room within 2 hours of acute onset of left hemiparesis who was treated with rt-PA and suffered a pulmonary embolism 3 days after acute stroke therapy. rt-PA is also a current therapy for pulmonary embolism, but an ischemic stroke in the previous 3 months is an absolute contraindication to thrombolysis because of the high risk of intracranial hemorrhage. We discuss clinical and therapeutic decisions and review the current literature.
Objective Results of recent studies suggest a link between neuronal excitatory or inhibitory unbalance and depression. To investigate this relation, we studied the rest activity and the cortical ...excitability of the cerebral areas dedicated to hand control in 12 patients with depression. Methods Brain activity was recorded from the Rolandic region in both hemispheres of 12 depression patients and 11 control subjects by means of magnetoencephalography. We studied cortical excitability by focusing on the M20 and M30 components of the magnetic fields evoked by a stimulation of the median nerve. Results Parietal rest rhythms showed greater total power in patients than in control subjects. In particular, the patient's parietal alpha was higher in the right than in the left hemisphere. Primary sensory cortex excitability, expressed by the M20, appeared significantly reduced in patients with depression, but was still higher in the right than in the left hemisphere. The M30 also appeared reduced, and this reduction was significantly correlated with both depression severity and global illness. Conclusions The patients studied were not completely drug free. For this reason, it is impossible to rule out the possibility that our results are an effect of drug assumption. Nevertheless, since all patients were well below the drugs' steady state levels when the data were recorded, the behaviour of M20 and M30 and their relation with the patients' clinical pictures suggest that an unbalance of the excitatory or inhibitory cortical activity, and especially a potentiation of the parietal afferent to the motor cortex, may be significant hallmarks of depression.
Estimates of atmospheric inputs to the Mediterranean and some coastal areas are reviewed, and uncertainities in these estimates considered. Both the magnitude and the mineralogical composition of ...atmospheric dust inputs indicate that eolian deposition is an important (50%) or even dominant (>80%) contribution to sediments in the offshore waters of the entire Mediterranean basin. Model data for trace metals and nutrients indicate that the atmosphere delivers more than half the lead and nitrogen, one-third of total phosphorus, and 10% of the zinc entering the entire basin. Measured data in sub-basins, such as the north-western Mediterranean and northern Adriatic indicate an even greater proportions of atmospheric versus riverine inputs. When dissolved fluxes are compared (the form most likely to impinge on surface water biogeochemical cycles), the atmosphere is found to be 5 to 50 times more important than rivers for dissolved zinc and 15 to 30 times more important for lead fluxes. Neglecting co-limitation by other nutrients, new production supported by atmospheric nitrogen deposition ranges from 2-4 g C/m super(2)/yr, whereas atmospheric phosphorus deposition appears to support less than 1 g C/m super(2)/yr. In spite of the apparently small contribution of atmospheric deposition to overall production in the basin it has been suggested that certain episodic phytoplankton blooms are triggered by atmospheric deposition of N, P or Fe. Future studies are needed to clarify the extent and causal links between these episodic blooms and atmospheric/oceanographic forcing functions. A scientific program aimed at elucidating the possible biogeochemical effects of Saharan outbreaks in the Mediterranean through direct sampling of the ocean and atmosphere before and after such events is therefore highly recommended.
Do recency processes associated with repetitive sensorimotor events modulate the magnitude and functional coupling of brain rhythmicity in human temporal cortex? Intracranial stereo ...electroencephalographic activity (SEEG; 256 Hz sampling rate) was recorded from hippocampus, and inferior (BA20) and middle (BA21) temporal cortex in four epilepsy patients. The repetitive events were represented by predicted imperative somatosensory stimuli (CNV paradigm) triggering hand movements (‘repetitive visuomotor’) or counting (‘repetitive counting’). The non‐repetitive events were ‘rare’ (P3 paradigm) somatosensory stimuli triggering hand movements (‘non‐repetitive visuomotor’) or counting (‘non‐repetitive counting’). Brain rhythmicity was indexed by event‐related desynchronization/synchronization (ERD/ERS) of SEEG data, whereas the functional coupling was evaluated by spectral SEEG coherence between pairs of the mentioned areas. The frequency bands of interest were theta (4–8 Hz), alpha (8–12 Hz), beta (14–30 Hz), and gamma (32–46 Hz). Compared to the non‐repetitive events, the ‘repetitive visuomotor’ events showed a significant beta and gamma ERS in the hippocampus and a significant theta ERD in the inferior temporal cortex. Furthermore, the ‘repetitive visuomotor’ events induced a task‐specific significant gamma coherence among the examined areas. These results suggest that recency processes do modulate the magnitude and functional coupling of brain rhythmicity (especially gamma) in the human temporal cortex.
In order to define the most suitable instrumental protocol for the diagnosis of multiple sclerosis (MS), 41 patients with definite (D = 14), probable (P = 14) and suspected (S = 13) MS were examined ...with CSF immunology, brain MRI and multimodal evoked potentials. The central motor tracts were also tested. The following alteration rates were found: MRI = 78%, CSF = 63.6%, VEP = 70.0%, median nerve SEP = 50%, peroneal nerve SEP = 68.0%, BAEPs = 35.7%, motor-evoked potentials (MEPs) = 74.0%. Altogether, EPs were abnormal in 90% of cases. Normal MRI with altered EPs were found in 22% of cases, whilst a normal EP battery with defective CSF or MRI findings were found in 7%. Twenty-six out of 27 patients with P or S forms were reclassified into a D one when considering EPs and MRI features.
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