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The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced., info:eu-repo/semantics/published

Background Tailoring Dual Antiplatelet Therapy (DAPT) to each patient bleeding and ischemic risk profile is a majopr challenge in everyday clinical practice. As the elderlies were underrepresented in validation cohorts of bleeding risk scores, their generalizability in this context is uncertain. Purpose We sought to assess the clinical utility of the PRECISE-DAPT and PARIS bleeding risk scores to elderly patients suffering from ACS and undergoing invasive management. Methods Our external validation cohort included 1,883 patients older >74 years admitted for ACS and treated with PCI from 3 multicenter, randomized trials. Bleeding risk scores were calculated on a patient-level and subjects were stratified into risk categories according to each risk score definition. Results After a median follow-up of 365 days, patients in the high-risk categories according to the PRECISE-DAPT score experienced a higher rate of BARC 3–5 bleedings (log rank p=0.002) while this was not observed for those in the high-risk category according to the PARIS risk score (log rank p=0.3). Both scores had a moderate discriminative power (c-statistics 0.70 and 0.64, respectively) and calibration was accurate for both risk scores (all χ2>0.05), but PARIS risk score was associated to a greater overestimation of the risk (mean D observed-predicted probability = −0.65 for PRECISE DAPT and −4.62 for PARIS, p=0.02; Figure 1). Decision curve analysis was in favor of the PRECISE-DAPT score up to a risk threshold of 2%. A sensitivity showed that calibration and discrimination power was moderate for both risk scores also after including BARC 2 events. Conclusion In the setting of older adults managed invasively for ACS both the PARIS and the PRECISE-DAPT scores were moderately accurate in predicting bleeding risk. However, the use of the PRECISE-DAPT is associated with better performance and a higher net benefit. Figure 1 Funding Acknowledgement Type of funding source: None

Background pacemaker induced cardiomyopathy or transient impairment of the left ventricle (LV) function could be common collateral effects of the prolonged right ventricle (RV) pacing in patients with a pacemaker (PM) and pre-existing intra-ventricular conduction disturbances. However, the impact of RV pacing-site on RV performance of patients with right bundle branch block(RBBB) is still under-investigated. Purpose to study the effects of RV pacing in the mid-septal versus apical site on the morpho-functional performance of RV in patients undergoing permanent PM implantation. Methods We prospectively enrolled consecutive patients with a pre-existent complete RBBB and undergoing dual-chamber PM implantation in our institution. We randomized the patients 1:1 to receive the RV catheter fixed either in the apex or in the mid-septal position. Patients with LV systolic dysfunction (LVEF Results a total of 22 patients were randomized in the study, 11 (50%) received RV catheter positioned in the apex and 11 (50%) in the mid-septum, respectively. No baseline differences were recorded between the two groups in clinical characteristics, ECG and echocardiographic parameters. At 2 months follow up, there were no statistically significant difference in the % of RV pacing between the two groups. Nonetheless, RV mid-septal group showed significantly shorter duration of the stimulated QRS (146 ± 12 msec vs. 161 ± 20 msec, p = 0.05), significantly reductions in the RV dimensions (pre: 42 ± 8 mm vs. post: 37 ± 7 mm, p = 0.05) telediastolic area (pre: 12 ± 3 cm2/m2 vs post: 9 ± 4 cm2/ m2, p = 0.02) telediastolic volume (pre: 55 ± 16 ml/m2 vs post: 50 ± 17 ml/m2, p = 0.02) and a significant improvement of RV ejection fraction (pre: 54 ± 9% vs post: 57 ± 11%, p = 0.02) than patients in the RV-apical group. Moreover, patients in the RV-apical group showed significant lowering in the GLS of the LV (pre: -16 ± 3% vs post: -11.7 ± 3%, p Conclusions In this study, mid-septal pacing seems associated with a better morpho-functional RV performance than apical pacing in patients with pre-existent RBBB undergoing permanent PM implantation.

Background: The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe. Methods: A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14). Results: A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries. Conclusion: More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

One of the biggest obstetric challenges is the diagnosis and management of a short cervix as cervical length has an inverse relationship with risk of preterm birth. A cervical cerclage is a surgical procedure to reduce the risk of preterm birth and can be placed in an elective or emergency setting. This is a retrospective review of cervical cerclages inserted at an outer metropolitan hospital from February 2014 to May 2017. Since the introduction of the service, a total of 43 patients were identified as requiring a cervical cerclage. Four of these patients were transferred to tertiary hospitals. Of the 39 cerclages inserted, 26 were elective and 13 were emergency, placed at a mean gestation of 15.6 and 19.6 weeks. In total, there were 35 live births, 2 stillbirths, and 2 neonatal deaths. The maternal demographics (age, gravidity, parity, and preterm risk factors) were not statistically significant between the two groups. The mean pregnancy prolongation and birthweight was greater in the elective than the emergency group (21.4 versus 14.1 weeks; 3148.2 versus 2447.2 grams). There was no obvious pattern with which patients received antibiotics pre-, intra-, or postoperatively or received a vaginal swab. This audit identified the need for improvements to guidelines to standardise the use of antibiotics and progesterone in women with a cervical cerclage.

BACKGROUND: Due to the failure of the "old Mason loop," the mini-gastric bypass (MGB) has been viewed with skepticism. During the past 12 years, a growing number of authors from around the world have continued to report excellent short- and long-term results with MGB. METHODS: One university center, three regional hospitals, and two private hospitals participated in this study. From July 2006 to December 2012, 475 men (48.8 %) and 499 women (51.2 %) underwent 974 laparoscopic MGBs. The mean age of these patients was 39.4, and their preoperative body mass index was 48 ± 4.58 kg/m2. Type 2 diabetes mellitus (T2DM) affected 224 (22.9 %) of the 974 patients, whereas 291 of the 974 patients (29.8 %) presented with hypertension. The preoperative gastrointestinal status was explored in all the patients through esophagogastroduodenoscopia. The major end points of the study were definitions of both MGB safety and efficacy in the long term as well as the endoscopic changes in symptomatic patients eventually produced by surgery. RESULTS: The rate of conversion to open surgery was 1.2 % (12/974), and the mortality rate was 0.2 % (2/974). The perioperative morbidity rate was 5.5 % (54/974), with 20 (2 %) of the 974 patients requiring an early surgical revision. The mean hospital length of stay was 4.0 ± 1.7 days. At this writing, 818 patients are being followed up. Late complications have affected 74 (9 %) of the 818 patients. The majority of these complications (66/74, 89.1 %) have occurred within 1 year after surgery. Bile reflux gastritis was symptomatic, with endoscopic findings reported for 8 (0.9 %) and acid peptic ulcers for 14 (1.7 %) of the 818 patients. A late revision surgery was required for 7 (0.8 %) of the 818 patients. No patient required revision surgery due to biliary gastritis. At 60 months, the percentage of excess weight loss was 77 ± 5.1 %, the T2DM remission was 84.4 %, and the resolution of hypertension was 87.5 %. CONCLUSIONS: Despite initial skepticism, this study, together with many other large-scale, long-term similar studies from around the world (e.g., Taiwan, United States, France, Spain, India, Lebanon) demonstrated the MGB to be a short, simple, low-risk, effective, and durable bariatric procedure.

Aims Left ventricular (LV) diastolic filling is characterized by the formation of a vortex that supports an efficient transit into systolic ejection. Aim of this study was to assess the intraventricular (IV) blood flow dynamics among patients with ST elevated myocardial infarction (STEMI) at different degrees of LV dysfunction, in the attempt to find novel indicators of LV pump efficiency. Methods and results Sixty-four subjects, 34 consecutive STEMI patients and 30 healthy controls, underwent before hospital discharge 2D speckle tracking echocardiography toassess global longitudinalstrain (GLS), and echo-particle image velocimetryanalysis to assess flow energetic parameters. Left ventricular volumes ejection fraction (LVEF) and global wall motion score index (GWMSI) were evaluated by 3D echocardiography. ST elevated myocardial infarction patients were subdivided into three groups according to LVEF. Energy dissipation, vorticity fluctuation, and kinetic energy fluctuation indexes, which characterize the degree of disturbance in the flow, exhibit a biphasic behaviour in STEMI patients when compared with controls, with the highest values in patients with still preserved LV function and progressive lower values with LV function worsening. Significant linear correlations were found between energy dissipation index and both LVEF and GLS (r ¼ 0.57, P , 0.001 and r ¼ 20.61, P ¼ 0.001, respectively). Kinetic energy fluctuation index significantly correlates with both LVEF (r ¼ 0.75, P , 0.001) and GLS (20.58, P ¼ 0.002). Finally, a significant correlation was observed between GWMSI and energy dissipation index (20.56, P ¼ 0.008). Conclusions The present study describes, for the first time, the progression of IV flow energetic properties in patients with acute myocardial infarction at different stages of LV dysfunction when compared with healthy controls. Further data are needed to assess the role of these parameters in the development and maintenance of LV dysfunction.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers

Background The prevalence of thyroid disease in patients with cardiac disease can be as high as 11.2%. Combined thyroid and cardiovascular surgery has rarely been reported. Methods Ten patients (6 female, 4 male, age range 51-73 years) had total thyroidectomy and cardiac surgery in the same procedure in our surgical department. Six patients had coronary artery disease; four patients had valvulopathy. The thyroid goiter was retrosternal in 6 patients. Results Mean stay in the intensive care unit was 46.4 hours; the postoperative course was complicated by transient right laryngeal nerve palsy in one case and by transient hypocalcemia in the patients in whom a parathyroid autotransplantation was performed (n = 3). There was one case of hemodynamic compromise needing vasoactive drug support; the mean hospital stay was 8.4 days. Conclusions Our experience and our review of the literature suggest that a single-stage procedure is safe and feasible and must be preferred to different operations as it has an acceptable peri-operative and anesthesiological risk.

The adipofascial flap, introduced by Lin in 1994, has many advantages compared to fasciocutaneous or free flaps. Its dissection is relatively easy and fast with low donor-site morbidity, and it does not alter the shape of the leg. The aim of this dissection study is to evaluate the anatomic localization of the most distal perforator of the posterior tibial vessels to provide an anatomical rationale for the safe harvesting of distally based medial adipofascial flaps of the leg.30 Lower limbs from 15 cadavers were used for this study. The most distal perforator from posterior tibial perforator artery, accompanied by at least one vein, was identified and its distance from the medial malleolus was noted.A distal perforator was found in all specimens; the mean caliber was 0.77 mm. In all cases, the perforator artery passed in the septum between flexor hallucis longus m. and flexor digitorum longus m. and was accompanied by two veins. In our series, the distance between the lowest perforator and the medial malleolus ranged from 3.5 to 8.2 cm. The median was 6.75 cm, the 5th percentile 4 cm and the 95th percentile 8.1 cm. The mean distance of the perforator from the medial tibial border was 1.23 cm. The mean ratio between the distance of perforator from the medial malleolus and the total leg length was 21%.Compared to all previous researches, our study has found more distal perforators from posterior tibial perforator artery. This fact may have important clinical consequences, because the anteromedial adipofascial flap would cover more distal soft tissue defects. Moreover, our data suggest some safety parameters to make the rising of a medial adipofascial leg flap safer in surgical practice.

To evaluate prospectively the impact on left ventricular (LV) remodelling of an intracoronary aspiration thrombectomy device as adjunctive therapy in primary percutaneous coronary intervention (PCI) in patients with anterior ST elevation myocardial infarction (STEMI).76 consecutive patients with anterior STEMI (65.3 (11.2) years, 48 men) were randomly assigned to intracoronary thrombectomy and stent placement (n = 38) or to conventional stenting (n = 38) of the infarct related artery. Each patient underwent transthoracic echocardiography immediately after PCI and at six months. At the time of echocardiographic control, major adverse cardiovascular events (MACE) in terms of death, new onset of myocardial infarction, and hospitalisation for heart failure were also evaluated.After a successful primary PCI, patients in the thrombectomy group achieved a higher rate of post-procedure myocardial blush grade 3 (36.8% v 13.1%, p = 0.03) and effective ST segment resolution at 90 minutes (81.6% v 55.3%, p = 0.02). Six months after the index intervention, 19 patients (26.8%) developed LV dilatation, defined as an increase in end diastolic volume (EDV)or= 20%: 15 in the conventional group and four in the thrombectomy group (p = 0.006). Accordingly, at six months patients treated conventionally had significantly higher end systolic volumes (82 (7.7) ml v 75.3 (4.9) ml, p0.0001) and EDV (152.5 (18.1) ml v 138.1 (10.7) ml, p0.0001) than patients treated with thrombectomy. No differences in cumulative MACE were observed (10.5% in the conventional group v 8.6% in the thrombectomy group, not significant).Compared with conventional stenting, adjunctive aspiration thrombectomy in successful primary PCI seems to be associated with a significantly lower incidence of LV remodelling at six months in patients with anterior STEMI.

Neuroendocrine tumors (NETs) can be sporadic or they can arise in complex hereditary syndromes. Patients with hereditary NETs can be identified before the development of tumors by performing genetic screenings. The aim of the study was to evaluate the clinical and prognostic impact of a preclinical genetic screening in subjects with hereditary NET syndromes. 46 subjects referred for hereditary NET syndrome [22 MEN1, 12 MEN2, 12 Familial Paragangliomatosis (FPGL)] were enrolled and divided in 2 groups (group A, 20 subjects with clinical appearance of NET before the genetic diagnosis; group B, 26 subjects with genetic diagnosis of hereditary NET syndromes before the clinical appearance of NETs). The main outcome measures were severity of disease, prognosis, and survival. The rate of surgery for MEN1-, MEN2-, FPGL4-related tumors was 90% in group A and 35% in group B (p

Antiplatelet therapy is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS). Over the last years, several studies have evaluated old and new oral or intravenous antiplatelet agents in ACS patients. In particular, research was focused on assessing superiority of two novel platelet adenosine diphosphate (ADP) P2Y12 receptor antagonists (i.e. prasugrel and ticagrelor) over clopidogrel. Several large randomized controlled trials have been undertaken in this setting and a wide variety of pre-specified and post hoc analyses are available that evaluated the potential benefits of novel antiplatelet therapies in different subsets of patients with ACS. The aim of this document is to review recent data on the use of current antiplatelet agents for in-hospital treatment of ACS patients. For each drug or class of drugs, strong evidence and/or areas of uncertainty that warrant further research are highlighted by examining 10 subgroups of patients with ACS.

The placenta is the primary site of nutrient and gas exchange between mother and foetus. During human placental development, proliferation, differentiation and apoptosis occur at different stages. In order to clarify some of the molecular mechanisms underlying these events, we investigated the pattern of expression of two members of the Bcl-2 family in human placenta samples and compared them to the level of apoptosis detected by the TUNEL method. In particular, we evaluated the expression of Bcl-2 and Bax and their ratio during the first and third trimester. We found that Bcl-2 was generally expressed at low levels during the entire gestational period. On the other hand, Bax was low during the first trimester but increased towards the end of gestation. In accordance with the change of ratio of these two molecules, the increase of apoptotic cells was observable in the third trimester. These data indicate that Bcl-2 and Bax are spatio-temporally regulated during placental development and that the different expression of the above mentioned genes is at least in part responsible for the delicate balance between cell proliferation and programmed cell death in the human placenta during pregnancy.

Advagraf is a new modified-release once-daily formulation of tacrolimus. The aim of this study was to define the efficacy and safety of switching from Prograf to Advagraf immunosuppression in kidney transplant recipients. The switched dose ratio of Prograf to Advagraf was 1:1. Forty-one patients (34 men and 7 women) were switched at 36.6 ± 16.1 months after kidney transplantation. All patients maintained stable renal function and the conversion. In 16 subjects it was possible to withdraw steroid administration after obtaining adequate Advagraf blood levels, among whom 14 remained steroid free. Adverse events, including dizziness and tinnitus, were reported in 1 patient, who was reverted to Prograf. One patient who was receiving triple therapy with low tacrolimus blood levels experienced are acute rejection episode. The switch to Advagraf was safe and efficacious in kidney transplant recipients with or without steroid administration. Moreover, interruption of steroid was possible and well tolerated after achieving adequate stable blood levels with Advagraf.

Background The use of kidneys from older donors has become generally accepted and increasingly common, despite the knowledge that donor age is a well-known risk factor for graft failure. Aim To review our experience with the utilization of kidneys from donors older than 60 years. Patients and methods Among two hundred eight patients, 32 (group A) received an organ obtained from a donor older than 60 years. The organs were age-matched with a maximum gap of 20 years between donors and recipients. Organs from older donors were assigned to recipients presenting a body mass index lower than that of the donor. The Primary end point was patient and graft survival. Secondary endpoints were incidences of delayed graft function and of acute rejection episodes as well as renal function at 3 months and yearly. Results The two groups were comparable in terms of demographic features, indications for transplantation, comorbidities, as well as cold and warm ischemia times. The Mean lengths of follow up were 31.4 ± 20.3 months and 30.3 ± 20.1 months, respectively. Graft and patient survivals were comparable. Mean creatinine values at the study intervals were significantly lower among group B who received grafts from younger donors. The incidence of delayed graft function and acute rejection episodes were similar: 15.6% (5/32) versus 20.5% (36/176; P = 0.35) and 15.6% (5/32) and 12.1% (21/167; P = 0.136) in groups A and B, respectively. Conclusions Donor age older than 60 years showed a negative impact on kidney function. Though, given the escalating disparity between organ supply and demand, this precious source of organs cannot be neglected. We need better ways to use the available organs.

Objective To analyze the risk reduction of cardiopulmonary bypass complications between on-pump and off-pump coronary artery bypass grafting in high-risk patients. Methods This multicenter, prospective, randomized, parallel trial enrolled patients for elective or urgent isolated coronary artery bypass grafting with an additive European System for Cardiac Operative Risk Evaluation of 6 or more. The patients in cardiogenic shock were excluded. The composite primary end point included operative mortality, myocardial infarction, stroke, renal failure, reoperation for bleeding and adult respiratory distress syndrome within 30 days after surgery. The total sample size was 693 patients, according to a scheduled interim analysis at 400 patients enrolled (α-spending = 0.029, Pocock method). Results A total of 411 patients were included in the interim analysis. Randomization assigned 203 patients to on-pump and 208 patients to off-pump treatment. Of the 411 patients, 24 crossed over; thus, 195 patients were actually treated on-pump and 216 off-pump. According to the intention to treat analysis, the rate of the composite primary end point was significantly lower (unadjusted P = .009, adjusted P = .010) in the off-pump group (5.8% vs 13.3%). The risk of experiencing the primary end point was significantly greater for the on-pump group (unadjusted odds ratio, 2.51; 95% confidence interval, 1.23–5.10; P = .011; adjusted odds ratio, 3.07; 95% confidence interval, 1.32–7.14; P = .009). Conclusions Off-pump coronary artery bypass grafting reduces early mortality and morbidity in high-risk patients.

Introduction Malignancies are a well-known complication of immunosuppressive therapy among renal transplant recipients, representing an important cause of long-term morbidity and mortality. Rapamycin has been shown to limit the proliferation of a number of malignant cell lines in vivo and in vitro. Methods Fifteen patients developed the following malignancies at a mean of 90.3 months (range = 10–252) after kidney transplantation: metastatic gastric cancer ( n = 1), metastatic colon cancer ( n = 1), bilateral nephrourothelioma ( n = 1), skin cancer ( n = 2), Kaposi's sarcoma ( n = 2), posttransplant lymphoproliferative disorder (PTLD; n = 4), renal cell carcinoma T1 ( n = 1), MALT lymphoma ( n = 1), intramucous colon carcinoma ( n = 1), liposarcoma of the spermatic cord ( n = 1). After the diagnosis of malignancy, the patients were switched from calcineurin inhibitor-based immunosuppression to rapamycin (monotherapy, n = 3), or associated with steroids ( n = 6) or with mycophenolate mofetil ( n = 6). Results Both patients with metastatic cancer underwent chemotherapy but succumbed after 6 and 13 months. Two patients with PTLD who underwent chemotherapy died after 12 and 36 months. At a mean follow-up of 32.7 months (range = 7–56), the remaining 11 patients are cancer-free. Two patients lost their grafts after 24 and 36 months after the switch due to chronic rejection. Renal graft function remained stable in all other patients from diagnosis throughout follow-up. Conclusion Our observations suggested that rapamycin-based immunosuppression offers the possibility for regression of nonmetastatic tumors. Nevertheless, it is difficult to assess whether tumor regression was due to rapamycin treatment or to the reduced immunosuppression.

Introduction Breast fibroadenomas may result from exposure to cyclosporine (CsA). The aim of this prospective study was to assess the reversibility of breast fibroadenomas following conversion from CsA to tacrolimus among a small cohort of female renal transplant recipients. Methods Following renal transplantation, fibroadenomas either developed or progressed in eight Caucasian female patients with CsA-based immunosuppression. These patients were enrolled in a pilot study assessing whether conversion from a CsA-based to a tacrolimus-based regimen prevented progression of breast disease or reversed existing lumps. Patients underwent a baseline visit in which we assessed the clinical history, number and dimension of fibroadenomas, graft function and hormonal profile (FSH prolactin, estradiol and progesterone). Twenty-one lumps were described in six patients; in addition, two patients had “grapes of fibroadenomas,” of nondefinable numbers. Results Patients underwent conversion to tacrolimus after a mean of 63.8 ± 37.4 months after renal transplantation. Of the 21 clearly described lumps complete reversibility was observed for eight fibroadenomas. Other fibroadenomas either decreased in size or remained stable without further progression. These changes were reported within 1 year following conversion to tacrolimus. Conclusion A switch from CsA to tacrolimus was effective to prevent the progression of fibroadenomas. In female renal transplant recipients with CsA-based immunosuppression suffering from breast fibroadenomas, early CsA withdrawal may avoid the need for breast surgery.

In 3231 prosthetic valves implanted between January 1975 and November 1990, we observed 61 cases of prosthetic obstruction of biological origin with clinical and laboratory findings of severe functional impairment which required surgery as emergency treatment. The hospital mortality was 19.67% (12/61). The obstruction was due to a primary thrombosis in all 5 bioprostheses which were not anticoagulated and in 11/56 (19.64%) mechanical prostheses of which 3 were not anticoagulated and 4 were not properly anticoagulated. The obstruction was due to fibrous tissue overgrowth in the other 45 mechanical prostheses (80.35%) with secondary thrombosis in 34 cases (60.71%) and no thrombosis in 11 (19.64%); 71.11% of these prostheses were adequately anticoagulated. Of the 61 obstructed prostheses, 53 were mitral and 8 were aortic. No tricuspid obstruction was observed. A statistical assessment by multiple correspondence, cluster and chi square analysis was performed in two groups of patients with different models of mechanical mitral prostheses. The 5-year actuarial incidence of obstruction was 6.08%. Significant risk factors were: tilting disc prostheses, prostheses without pyrocarbon coating, large prostheses, tilting disc prostheses with a small orifice posteriorly oriented, atrial fibrillation, enlarged left atrium, time from implant greater than 4 years, age between 40 and 50 years. In our opinion, prosthetic obstruction may be referred to a primary thrombosis only in cases where it may be prevented by adequate anticoagulation. In most cases, the obstruction is produced by periprosthetic fibroblastic proliferation which may develop in spite of adequate anticoagulation in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this report is to describe the endovascular exclusion of an internal iliac artery (IIA) aneurysm in emergency setting, long after abdominal aortic aneurysm surgical repair. An 85-year-old male presented with a contained rupture of a huge IIA aneurysm, ten years after aortoiliac bifurcated grafting. Because of poor clinical conditions an emergency endovascular treatment was planned. A stent-graft was positioned from the proximal right branch of the bifurcated surgical prosthesis to the distal external iliac artery, covering the hypogastric aneurysm neck. One month after the procedure, CT scan demonstrated the complete exclusion of the aneurysm. Endovascular treatment of IIA aneurysms is an excellent option to reduce perioperative morbidity and mortality in high risk patients, particularly in an emergency setting.

Atrial infarction is rarely diagnosed, usually being recognised only when associated with ventricular infarction. The most common ECG sign of atrial infarction is elevation or depression of the P–Ta segment, reflected by the P–R segment; this pattern, however, is usually mild (

T lymphocytes play an important role in the induction and progression of acute coronary syndromes (ACS). To gain insight into how different T cell subsets can influence ACS, we analyzed the frequencies of circulating CD4+T cells producing either pro-inflammatory interferon(IFN)-γ or anti-inflammatory interleukin (IL)-10 in subjects presenting with ST-elevation myocardial infarction (STEMI). The effect of coronary bare metal (BS) and paclitaxel-eluting stent (PES) on the balance between CD4+IFN-γ+ and CD4+IL-10+ lymphocytes was also investigated. Peripheral blood mononuclear cells (PBMC) were isolated from 38 consecutive patients with STEMI before and 48 hrs or 6 days after implantation of either BS or PES. Twenty patients with no history of coronary artery disease were included as basal controls. PBMC were stimulated in vitro with anti-CD3/anti-CD28 monoclonal antibodies, and CD4+IFN-γ+ or CD4+IL-10+ T cells were detected by flow cytometry intracellular staining. The frequency of peripheral CD4+IL-10+ T cells was significantly higher in STEMI patients as compared with controls. Conversely, the frequency of CD4+IFN-γ+ T lymphocytes did not differ between STEMI and subjects without history of coronary artery disease. Six days after the revascularization procedure, the percentage of CD4+IL-10+ T cells was significantly decreased in BS but not in the PES group, whereas the relative percentage of CD4+IFN-γ+ T lymphocytes were diminished in both groups as compared with baseline levels. Our data indicate that STEMI is associated with a peripheral expansion of CD4+IL-10+T lymphocytes, and that primary coronary revascularization with implantation of either BS or PES is followed by a reduction in circulating CD4+IFN-γ+ T lymphocytes. PES implantation, however, appears to inhibit the relative decrease of the IL-10 producing lymphocyte as observed in BS implanted patients, shifting the balance between pro-inflammatory and anti-inflammatory T cell populations in favor of the latter.

Introduction Basiliximab use with delayed entry of Tacrolimus (TAC) as renal sparing agent may help reduce renal impairment in liver transplant (LT) recipients. We aimed to evaluate factors affecting renal dysfunction and the effect of basiliximab post-LT. Method All consecutive LT patients (1/2006–1/2014) with a follow up >3months and eGFR 2 at day 1 post-LT were analysed for factors known to affect renal dysfunction: biochemical/clinical data, donor age, cold/warm ischemia time, mean trough TAC levels up to days 7, 15, 30 post-LT, basiliximab use, initial/maintenance immunosuppression, acute cellular rejection (ACR), diabetes mellitus (DM) pre and post-LT, systemic hypertension, days on filtration post-LT. Renal impairment was defined as mild: eGFR 60–89 and moderate/severe: eGFR Results 126 patients given basiliximab were compared with 189 consecutive patients with eGFR 5 ng/ml vs 41%(38/92) with TAC Logistic regression analysis showed that factors associated with moderate-severe renal impairment (eGFR 50years (p 5 ng/ml at week 1 post-LT(p = 0.003, OR=0.4, 95% CI=0.3–0.7) and mean CNI levels >7 ng/ml up to 15 days post-LT(p = 0.019 OR=0.85, 95% CI=0.75–0.97). The same factors were associated with mild renal impairment (eGFR 7 ng/ml at days 15 post-LT (p = 0.003 OR=1,9 95% CI=1.2–2.9) and use of steroids >3months post-LT(p = 0.006, OR=0.7, 95% CI=0.5–0.9). Conclusion Basiliximab use allows reduced TAC trough levels with less episodes of ACR compared with the control group. However, TAC trough levels Disclosure of interest None Declared.

The hemolytic uremic syndrome (HUS) is a severe disease characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. We herein report our experience with a 43-year-old female patient who underwent a second cadaveric kidney transplantation in February 2005, for adult-onset HUS. The first renal transplantation, which was performed in 1996, required removal after 3 weeks for probable recurrence of HUS. The immunosuppressive regimen for the second transplant included basiliximab, tacrolimus, mycophenolate mofetil, and steroids. On postoperative day (POD) 7, she received steroid treatment for an acute rejection episode with improved renal function. On POD 19 due to worsening renal function, a graft biopsy showed HUS recurrence, thus we instituted hemodialysis and then plasmapheresis treatments. At two months after transplantation, the patient continued under plasmapheresis treatment due to clinical evidence of HUS. On POD 80, cytomegalovirus infection was diagnosed and intravenous gancyclovir treatment started for 3 weeks. After 110 days from transplant, a deterioration in renal function was evident: the graft was swollen and painful with Doppler ultrasound showing patency of both the renal artery and vein but, low blood flow. After 2 weeks of hemodialysis, the patient underwent transplantectomy. In adult-onset HUS the recurrence rate reduces graft survival, particularly among patients undergoing second transplantation.

The aim of the study was to evaluate safety and efficacy of everolimus with cyclosporine (CsA) in de novo renal transplant recipients. The immunosuppressive regimen, including basiliximab, everolimus (3 mg), and low-dose CsA, was administered to 17 patients, of whom 15 were part of a multicenter randomized study that stipulated cessation of steroids at 7 days posttransplantation in 5 recipients. Five patients underwent dialysis after transplantation for delayed graft function (DGF; 29%), all of whom showed a good recovery within 3 weeks. The mean follow-up was 45.7 months (SD +/- 13). The 1-year graft survival was 100%. We observed one acute rejection episode. No patient experienced a cytomegalovirus infection. Increased cholesterol and triglyceride levels were reported in almost all patients. Severe arthralgia (n = 3) was treated by everolimus dose reduction to maintain trough levels at 3 ng/mL. We noted a high rate of switch to mycophenolate mofetil (MMF) throughout follow-up (n = 7), due to everolimus-induced side effects. However, we did not observe normalization of lipids after the switch: patients always required stain treatment, resulting in slightly lower serum cholesterol and triglycerides. Everolimus plus CsA was effective to prevent acute rejection after kidney transplantation. To manage the induced side effects of the drugs C(2) monitoring is mandatory, targeting 350 ng/mL during 1 year and 200 to 250 ng/mL thereafter. Careful reduction of everolimus trough levels to 3 ng/mL is recommended for patients with arthralgia.

A 37-year-old male liver transplant recipient developed hemorrhagic shock from massive rectal bleeding a few hours after a protocol liver biopsy. Conservative treatment was not possible and the patient underwent a radiological investigation of the celiac and mesenteric arterial trunks, which showed active bleeding from a branch of the middle colic artery. Embolization with Tabotamp (Ethicon, Neuchatel, CH Switzerland) particles led to successful hemostasis. We thus discuss the possible mechanisms of injury. To our knowledge, no other cases of major rectal bleeding following percutaneous liver biopsy have been reported in the literature. We emphasize the need for Doppler ultrasound assistance, in terms of either preoperative examination with or without marking or guidance. The latter is the safest and most reliable technique, given the low risk of puncture of other organs and the low probability of obtaining an inadequate sample.

Diabetes is a source of significant morbidity and mortality resulting from long-term micro- and macrovascular complications after coronary angioplasty in patients with ACS. Optimal pre-procedural glycaemic control and inhibition of intimal hyperplasia would reduce or impede re-stenosis, resulting in better clinical results.

to determine variables favouring good surgical outcome in posterior epilepsies. Fourteen patients submitted to epilepsy surgery were included in the study. The epileptogenic zone was located in temporo–parieto–occipital areas as assessed by both invasive and non-invasive pre–surgical evaluation. Several variables (age at first seizure; age at surgery; disease duration; type, frequency and clinical semiology of seizures; presence of lesion; scalp ictal and interictal EEG; localization and extension of epileptogenic zone; completeness of surgical resection) were compared (Fisher’s exact test) with freedom from seizures to determine whether surgical outcome (Engel’s classification) could be related to any of them. Seven patients were seizure free (Ia) and very satisfying results were obtained for 3 patients (2 Ib, 1 Ic). New post–surgical visual deficits occurred only in 3 patients. Surgical outcome was related significantly to two variables: scalp ictal EEG (focal versus non–focal; p: 0.014) and completeness of surgical resection of epileptogenic zone (p: 0.0023). A significant trend towards a better outcome for focal interictal intracranial activity versus a nonfocal one (p: 0.07) was found. The correlation between completeness of epileptogenic zone resection and surgical outcome suggests that a presurgical protocol, allowing a precise definition of the area of resection, could help in obtaining more satisfying results in posterior epilepsies.

Nephrotoxicity caused by calcineurin inhibitors can lead to either delayed graft function or long-term decline of renal function after kidney transplantation. Therefore, recipients of renal transplants from marginal donors require non-nephrotoxic immunosuppression. Eighteen patients received kidney transplants from marginal donors, with a calcineurin inhibitor-free immunosuppressive regimen, based on basiliximab, mycophenolate mofetil, steroids, and sirolimus. Renal graft biopsy was performed in all cases before surgery. Mean follow-up was 11.8 months. We report immediate renal function in 9 patients, delayed graft function in 5 and acute tubular necrosis in 4 patients. One patient was successfully treated for biopsy-proven acute rejection. Hypercholesterolemia and hypertriglyceridemia were the most common adverse effects (n = 13) associated with arthralgia (n = 2) and thrombocytopenia (n = 2). Five patients underwent a switch to tacrolimus, due to sirolimus-induced side effects. Immunosuppression without the use of calcineurin inhibitors is a safe and effective regimen in kidney transplantation, although sirolimus-related side effects still represent a morbidity factor in these patients.

Sudden cardiac death is a dramatic, undesirable event that can often result from cardiomyopathies. To investigate the validity of the QTdispersion (QTd) in revealing regional heterogeneity of repolarisation, with consequent possibility of sudden death,1 we evaluated ECGs of patients affected by Becker muscular dystrophy (BMD). This is an X linked recessive muscular dystrophy caused by dystrophin anomalies in striated muscles with myocardial involvement2–4 and consequent dilated cardiomyopathy, ventricular arrhythmias and, in 30% of cases, sudden cardiac death.5,6 The study was retrospective using the clinically validated database of ECGs and echocardiograms (echo recorded together with the ECG) from 30 BMD patients (mean (SD) age 25 (10) years) with variable stages of myocardial involvement, and 26 healthy, age matched controls. All subjects underwent a physical examination, blood analyses, and M mode and two dimensional echocardiography. The diagnosis of the type of muscular dystrophy in Becker patients was confirmed by DNA analysis (polymerase chain reaction) and by reduced dystrophin labelling from the immunohistochemical examination of biopsy samples. We excluded the ECGs from subjects with ST-T anomalies on the 12 lead ECG, and with sustained ventricular arrhythmias at 24 hour Holter monitoring, electrolyte …

Objective: Assessment of endovascular stent-graft treatment for diseases of the descending thoracic aorta as a valid and effective alternative to surgery. Methods: From March 1999 to August 2000, a total of 16 patients underwent deployment of endovascular stentgrafts in the descending thoracic aorta. Patients were divided into three groups according to the type of lesion. Group AOna 8U included five patients with atherosclerotic aneurysm and three with chronic post-traumatic pseudoaneurysm. Patients with acute post-traumatic pseudoaneurysmOna 3U and type B aortic dissectionOna 5U were included in Groups B and C, respectively. All patients underwent 5-mm chest spiral angio-computerized tomography (CT) scan and angiography as preoperative assessment. The deployed stent-graft systems were Talente-Medtronic and Excluder w -Gore. Results: A total of 20 stent-grafts were placed. Two patients required deployment of two grafts, while three grafts were juxtaposed in a third patient in order to treat larger lesions. There was no mortality related to the procedure, although one patient (6.2%) died because of multiorgan failure 24 h post-operatively. The placement of the graft was successful in all cases except one affected with type B dissection and characterized by a very large intimal flap, which was eventually fenestrated by graft guidewire. Therefore, an optimal sealing of the grafts was achieved in 15 patients. However, in one patient the descending aorta had to be surgically replaced because of the calcified pseudoaneurysm still compressing the trachea and left bronchus. Two patients required a left carotid-subclavian bypass in order to achieve a sufficient neck for the proximal placement of the graft. No spinal cord injuries were observed. At the follow-up, performed with chest spiral angio-CT scan within 72 h and scheduled at 6 and 12 months and once a year, no stent-graft related complications have been detected. Conclusions: Endoluminal stent-graft treatment may represent a valid option in well-selected cases of descending thoracic aorta diseases. A longer follow-up in a larger series of patients is desirable to confirm these initial positive results. q 2001 Elsevier Science B.V. All rights reserved.

Objective: Cardiopulmonary bypass (CPB) is associated with abnormalities of lung function characterized by an increase in static elastance of the respiratory system. We examined the following: a) the effects of CPB on the total inspiratory volume-pressure (V-P) relationship of the respiratory system; b) the relative contribution of the chest wall and lung to the impairment of respiratory system mechanics; and c) the time-course of such impairment. Design: Prospective, interventional study. Setting: Surgical and medical intensive care units in a teaching hospital. Patients: Eight adult patients scheduled for elective open heart surgery to correct valvular dysfunction. Interventations: V-P curves (interrupter technique) of the respiratory system were partitioned between the chest wall and lung by measurements of esophageal pressure. Measurements were obtained before stemotomy (control), immediately after, 4 hrs after, and 7 hrs after separation from CPB. Measurements and Main Results : Control V-P relationships of the respiratory system and lung showed lower inflection points (P flex ) at pressure values of 5.9 ± 2.3 and 4.3 ± 2.5 cm H 2 O, respectively. Immediately after and 4 hrs after separation from CPB, both curves had sigmoid shapes because of lower P flex and formation of upper inflection (UIP) points. The pressures corresponding to the P flex increased significantly (p

Introduction. Malignancies are a well-known complication of immunosuppressive therapy among renal transplant recipients, representing an important cause of long-term morbidity and mortality. Rapamycin has been shown to limit the proliferation of a number of malignant cell lines in vivo and in vitro. Methods. Eight patients developed the following malignancies after kidney transplantation (mean 102.6 months; range 12 to 252): metastatic gastric cancer (n 1), metastatic colon cancer (n 1), bilateral nephrourothelioma (n 1), skin cancer (n 1), Kaposi’s sarcoma (n 2), posttransplant lymphoproliferative disorder (PTLD) (n 2). After the diagnosis of malignancy, the patients were switched from calcineurin inhibitor-based immunosuppression to rapamycin (monotherapy, n 2), associated with steroids (n 4) or mycophenolate mofetil (n 2). Results. Both patients with metastatic cancer underwent chemotherapy and then succummbed after 6 and 13 months. After a mean follow-up of 20.3 months (range 2 to 47), the remaining six patients are free from cancer disease. Renal graft function was unchanged from diagnosis throughout the follow-up. Conclusion. Our observations suggested that rapamycin-based immunosuppression offered the possibility of regression of nonmetastatic tumors. Nevertheless, it is difficult to assess whether tumor regression was attributed to Rapamycin treatment or to the reduced immunosuppression.