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Background The short- and long-term prognosis of Takotsubo syndrome (TTS) presenting with right ventricular (RV) involvement remains poorly understood. Research Question What is the incidence and clinical outcome of RV involvement in TTS? Study Design and Methods This study analyzed 839 consecutive patients with TTS (758 female subjects and 81 male subjects) in a multicenter registry. RV involvement was defined as wall motion abnormality of the RV free wall, with or without apical involvement. The median long-term follow-up was 2.1 years (interquartile range, 0.3-4.5 years). The primary outcome was in-hospital and out-of-hospital all-cause mortality. The secondary end point was a composite of in-hospital death, thromboembolic events, cardiogenic shock, pulmonary edema, and malignant arrhythmias. Results The incidence of RV involvement in TTS was 11% (n = 93). More often patients with RV involvement were male compared with patients without RV involvement (P = .02). There was a slight difference in the left ventricular ejection fraction measured in patients with RV involvement vs those patients with isolated left ventricular TTS (38 ± 10% vs 40 ± 10%; P = .03). No major differences in terms of comorbidities were observed between groups except regarding a history of cancer, which was significantly more prevalent in patients with TTS presenting with RV involvement (P = .03). Physical stressors were more prevalent in the RV group (P Interpretation RV involvement defines a high-risk cohort of patients with TTS. Clinical Trial Registration ClinicalTrials.gov ; No.: NCT04361994 ; URL: www.clinicaltrials.gov .

Objectives The management of chronic migraine (CM) with Medication Overuse Headache (MOH) consists of withdrawal therapy, education on medications’ use and prescription of prophylaxis. Little attention has been given to patients who fail in achieving a successful short‐term outcome after withdrawal: we aim to describe predictors of failure. Methods Patients with CM and MOH were enrolled at the Neurological Institute C. Besta of Milano, and included if they completed the three months follow‐up. Withdrawal failure was defined as the situation in which patients either did not revert from chronic to episodic migraine (EM), were still overusing acute medications, or both did not revert to EM and kept overusing acute medications. Predictors of failure were addressed with a logistic regression, and for all variables, the longitudinal course in the two groups was described. Results In 39, out of 137 patients, withdrawal was unsuccessful: the predictors included day‐hospital‐based withdrawal (OR: 2.37; 95% CI: 1.06–5.29), emergency room (ER) access before withdrawal (OR: 2.81; 95% CI: 1.13–6.94) and baseline headache frequency >69 days/three months (OR: 2.97; 95% CI: 1.32–6.65). Patients who failed withdrawal did not improve on medications intake, use of prophylactic and non‐pharmacological treatments, symptoms of anxiety and depression. Conclusions Patients who were treated in day‐hospital, those who recently attended ER for headache, and those with more than 69 headache/3 months, as well as to those with relevant symptoms of anxiety and depression who did not improve should be closely monitored to reduce likelihood of non‐improvement after structured withdrawal.

Objective: This article reviews current headache disability measures and clinical need, as well as presenting the rationale for a new measure addressing work-related disability in migraine patients and the steps devoted to this aim. Background: Episodic and chronic migraine (EM and CM) constitute an enormous economic burden to societies, and the vast majority of this burden is attributable to indirect costs, ie those associated with productivity loss. A measure of work-related disability is therefore needed to quantify the impact of EM and CM on patients' ability to carry out work tasks. Methods: We briefly present the advantages and disadvantages of the disability measures that have been most commonly used for this purpose and the rationale for developing a new measure. Results: The entire process of development of HEADWORK, a questionnaire designed to assess work-related disability, is presented together with short-term sensitivity to change. Conclusions: Current headache disability measures need improvement. HEADWORK is a valid, reliable, and sensitive questionnaire to address the amount and severity of work-related difficulties and of the factors contributing to such difficulties. HEADWORK is suitable for daily clinical practice, epidemiological research and for clinical trials, and potentially to define work-related disability weights for the calculation of migraine indirect costs.

Introduction Skin tags are benign lesions, that often represent only an aesthetic problem; if subjected to trauma, they can occasionally bleed with possible infection and pain. When they occur in the preauricular region, attention should be paid to the diagnosis and approach; in fact, controversy exists in the differential diagnosis between hair follicle nevi, accessory tragus, and skin tag. Misdiagnosis and failure of treatment can lead to serious consequences, such as chondritis. Materials and Methods In our retrospective study, we evaluated 19 newborns affected by single, unilateral skin tag in the preauricular region. Each patient underwent a careful clinical examination; lesions without a pilosebaceous unit and with a thin, soft pedicle were treated in the nursery with Ligaclip (Johnson & Johnson). Results Skin tag falls between day 7 and 10. We had no cases of edema, cellulitis, clip loss, or bleeding. Scarring results were extremely satisfactory at 3-month follow-up. Conclusion We believe that after a careful clinical examination, cases of skin tags in the preauricular area can be selected and treated with Ligaclip. This procedure can be considered rapid, safe, economical, and simple in the newborn patients.

One important complication related to takotsubo syndrome (TTS) is adverse rhythm disorders. Our study was conducted to determine the incidence and management of adverse rhythm disorders in TTS and its long-term prognostic impact. We analyzed 906 TTS patients from 9 European centers. Patients were divided into the adverse rhythm disorders group (encompassing ventricular tachycardia, ventricular fibrillation, torsade de pointes, and asystole or complete atrioventricular block) and non-adverse rhythm disorders group. In our study cohort, we identified 67 (7.4%) patients with presence of adverse rhythm disorders. TTS patients were followed up over a period of 2.8 years. In the adverse rhythm disorders group, 18% of patients presented adverse rhythm disorders before hospital admission. Asystole and/or AV block were significantly more presented before admission (13 patients versus 8 patients; p < 0.01), whereas ventricular tachyarrhythmias were more presented in-hospital (4 patients versus 42 patients; p < 0.01). Adverse rhythm disorders patients suffered more frequently from cardiogenic shock (31% versus 7.6%, p < 0.01) and in-hospital death (10.9% versus 3.6%; p < 0.01). Furthermore, the long-term survival was significantly impaired in adverse rhythm disorders patients as compared with non-adverse rhythm disorders patients; (log-rank p < 0.01). Using multivariate Cox regression analysis, cardiogenic shock (HR 2.86, 95% CI 1.1-6.9; p = 0.02) was identified as independent predictors of adverse rhythm disorders. The short- and long-term mortality rate of TTS patients presenting with adverse rhythm disorders was significantly higher than in TTS patients presenting without it. Therefore, TTS patients with adverse rhythm disorders should be carefully monitored during hospital stay and at long-term follow-up.

Background An intramedullary augmentation technique using a titanium cage with different types of hardware can be considered a new option in the management of proximal humeral fractures. This study aimed to report the perioperative, early, and late complications of proximal humeral fractures using the intramedullary augmentation technique. Methods From 2005 to 2017, 142 displaced proximal humeral fractures were treated in the same unit by the aforementioned technique. Perioperative, early, and late complications were evaluated in all patients. Clinical evaluation was performed according to the Constant and Disabilities of the Arm, Shoulder and Hand scores. Only 115 patient records could be considered to have long-term follow-up (7-12 years). Results Extra-articular migrations of K-wires, plate cutout, and screw penetration were not observed. A transitory axillary nerve palsy with inferior humeral head subluxation was observed in 41 patients (29.8%). Of the 142 patients, 2 (1.4%) manifested early signs of infection, and 1 underwent a reoperation after 30 days. Complete bone healing was obtained at a mean of 3.5 months in 140 of 142 shoulders (98.6%). We achieved long-term follow-up on only 115 patients because 14 had died, 6 lived abroad, and 7 could not participate due to illness. The results were good or excellent in 99 patients (86%), fair in 12 (10.4%), and poor in 4 (3.4%). K-wires were removed in 15 of 79 patients (11.5%). Nonunion or malunion occurred in 1 patient (0.8%). Asymptomatic avascular necrosis developed in 8 patients (6.9%) after 5 years, and secondary glenohumeral osteoarthritis occurred in 6 (5.2%). Conclusions Intraoperative and postoperative analyses with short-, medium-, and long-term outcomes show that the intramedullary augmentation technique improves fracture treatment with significantly good anatomic reconstruction in complex and unstable cases. The bone healing rate is significantly high, and the technique is associated with a significantly low percentage of complications.

Background Several hematological indices including subtypes of leukocytes populations have been associated with cardiovascular outcome. Takotsubo syndrome (TTS) is a form of acute heart failure syndrome featured by several in‐hospital complications (IHCs). Hypothesis Hematological indices at admission may predict IHCs in TTS patients. Methods One hundred and sixty consecutive patients with TTS were enrolled in a multicenter prospective registry. Clinical data, admission hemogram, and IHCs were recorded. Results Incidence of IHCs was 37%, including pulmonary edema 9%, cardiogenic shock 9%, need of invasive ventilation 10%, death 8%, stroke 2.5%, and left ventricular thrombi 6%. Patients with IHCs were older, more frequently male, with physical stressor‐induced TTS, lower left ventricular ejection fraction at admission. Neutrophil/lymphocyte ratio (NLr) (12 ± 12 vs 7 ± 8, P = .002) and white blood cells/mean platelet volume ratio (1.2 ± 0.5 vs 1.0 ± 0.5, P = .03) at admission were significantly higher in patients with IHCs. NLr values were predictor of IHCs (Odds ratios [OR] 1.07, 95% CI 1.03‐1.11, P

Outflow tract (OT) premature ventricular contractions (PVCs) are commonly found in clinical practice; in most cases, PVCs are benign and observed in structurally normal hearts, not requiring any therapeutic intervention. In this study, we therefore sought to evaluate with cardiac magnetic resonance (CMR) patients with PVC and apparently normal heart at echocardiographic examination, in order to identify possible substrates linked with higher prevalence of arrhythmias or structural heart disease. Thirty-three consecutive patients with frequent PVCs originating from the ventricular OT (right and left) were enrolled in the study and assessed by echocardiography and CMR. All patients had normal baseline electrocardiogram. CMR showed structural changes in 5 patients out of 33; in 3 cases, areas of fibrosis limited in one case to the middle basal segments of the interventricular septum and in two patients to the middle basal segments of the inferior-lateral wall were found. In 2 other cases, however, late gadolinium enhancement showed significant anomalies characterized in one patient by extensive areas of subepicardial fibrosis of the left ventricle, suitable with arrhythmogenic left dominant dysplasia; in another patient, a marked trabeculation of left ventricular medium apical segments suitable with non-compaction myocardium was present. CMR may identify cases of structural heart disease in subjects with OT PVCs and apparently normal electrocardiogram and echocardiogram examinations. A preliminary screening with CMR may be considered before any further invasive electrophysiology assessment and therapeutic planning.

Background Phimosis is the inability to retract the preputium downward over the glans penis. Despite the various techniques of preputial plasty described in literature, the most performed surgical treatment is still the conventional circumcision. Methods In this paper we retrospectively reviewed data of a homogeneous population of 36 consecutive adult patients who underwent phimosis correction by circumcsion with dissection of the Deep Fascia. Patients were followed up by one independent plastic surgeon that measured penis length and circumference in nonerected state preoperatively and at 6 month time postoperatively. Results The Wilcoxon Signed Rank Test showed a significant (p Conclusions In conclusion, the ancillary technique we described leads to an increase of penis size, is safe and easy to perform and does not increase significantly operative time nor complication rate to the conventional procedure.

Purpose: To evaluate the clinical and radiologic outcomes of patients undergoing arthroscopic glenoid bone allograft combined with subscapularis upper-third tenodesis for anterior shoulder instability associated with clinically relevant bone loss and hyperlaxity. Methods: Between January 2016 and December 2017, patients with recurrent anterior shoulder instability associated with bone loss and hyperlaxity were selected and treated with arthroscopic iliac crest bone graft combined with subscapularis upper-third tenodesis. The selection criteria were as follows: more than 5 dislocations; positive apprehension, anterior drawer, and Coudane-Walch test results; glenoid bone defect between 15% and 30% and humeral bone defect with an engaging Hill-Sachs lesion; and no previous shoulder surgery. All patients were followed up with the Constant score, University of California-Los Angeles (UCLA) rating, Rowe score, and visual analog scale evaluation. Assessments were performed with plain radiographs and a PICO computed tomography scan before surgery and at 2 years of follow-up. Results: Nineteen patients were included in the study, with a mean follow-up duration of 34.6 months (range, 24-48 months). In 17 patients (89%), excellent clinical results were recorded according to the Rowe score. The Constant score improved from 82.9 (standard deviation [SD], 5.2) to 88.9 (SD, 4.3) (P = .002); Rowe score, from 25.3 (SD, 5.3) to 89.1 (SD, 21.8) (P < .001); UCLA score, from 23.7 (SD, 3) to 31.5 (SD, 4.8) (P < .001); and visual analog scale score, from 3.2 to 1.3 (P < .001). Patients met the minimal clinically important difference 94.7%, 89.5%, and 47.3% of the time for the Rowe score, UCLA score, and Constant score, respectively. Bone graft resorption was observed in all patients: partial in 9 and complete in 10. We recorded 2 recurrent traumatic dislocations (11%), with no case of persistent anterior apprehension or other complication. Conclusions: An arthroscopic glenoid bone graft combined with subscapularis upper-third tenodesis may be a valid surgical option to treat recurrent anterior instability associated with both bone loss and hyperlaxity. Level of evidence: Level IV, case series.

Background: Endoscopic carpal tunnel surgery (ECTR) is a procedure that gained wide popularity resulting in reduced scar length and faster recovery. Different studies focused on how the type of skin closure affected the quality and the appearance of the final scar in carpal surgery release. In this study, we investigated the efficiency of a well-established primary skin closure method using Steri-Strips that, to date, has never been described in ECTR. Methods: We retrospectively reviewed data of 47 consecutive patients who underwent unilateral endoscopic carpal tunnel release at our clinic. All patients underwent the same surgical procedure performed by two different surgeons that differed only in the final skin closure: one used only Steri-Strips (group A), while the other used continuous absorbable subcuticular 4/0 monofilament polyglytone 6211 sutures (group B). Data collected included photographs at 10days and three months after surgery and the visual analogue scale (VAS) for pain evaluation, while the measure for the scar evaluation was the Stony Brook Scar Evaluation Scale. We also performed the Wilcoxon rank test to assess if there was a statistically significant difference between the two groups in terms of pain and scar quality. Results: A total of 47 patients were included in this study. According to skin closure technique performed, the patients were categorised into two groups, A and B. Group A comprised 26 patients in which only Steri-Strips were used for the final skin closure; group B included 21 patients in which the closure was performed through 4/0 polyglytone. Data obtained from the VAS and from the Stony Brook Scar Evaluation Scale showed no significant difference between the two groups (p > 0.05). Data obtained from the evaluation of the visual analogue scale showed no significant differences in the median scores and similar postoperative pain between the two groups for all the 7 days of data recorded (p > 0.05). Conclusions: Skin closure with Steri-Strips is a safe, secure and cheap method that leads to excellent aesthetic results. It is both a first choice and a valid alternative to intradermal suture for wound closure after endoscopic carpal tunnel release. Level of evidence: Level IV, therapeutic study.

Background/Aims: Cherry angiomas (CAs) are one of the most common vascular manifestations of the skin. By and large, these benign lesions often only represent an aesthetic problem. In the literature, few authors have focused on the pathogenesis of these lesions, and some risk factors have been identified, such as the presence of cutaneous and nonskin neoplasias. In this study, the correlation between the distribution of CAs and breast cancer was investigated. Methods: We carried out a study whereby 50 women with unilateral breast cancer and the presence of CAs on the anterior thoracic wall were evaluated, with a particular focus on the difference in the number of CAs between the two haemithoraces. The data was elaborated using the Wilcoxon signed-rank test in order to evaluate whether there was a statistical significance in the distribution of CAs. Results: In 31 patients we found that the number of CAs was greater on the cancerous breast than on the contralateral one (p value

The surgical treatment of comminuted distal humeral articular fractures (DHF) is challenging and is jeopardized by the high rate of complications. The study aims to describe the application of osteochondral allograft (OCA) transplantation for the treatment of complex DHF assisted with a 3D printed specific instrumentation. Retrospective study. Inclusion criteria were the presence of an articular multi-fragmented DHF treated with frozen OCA. Clinical, self-reported and radiographic outcomes were collected every 6 months. CT were performed at 2 years FU. Four patients were included. At a mean follow-up of 37.3 months (24–49) MEPS, DASH and VAS were 90 (80–100), 11.8 (0–25) and 1 (0–3) points, respectively. Not significant complication or reoperation was recorded. Graft healing was observed in 3 cases. In all cases, we observed arthritic progression after 2 years of follow-up. OCA transplantation can be considered a reliable and safe procedure in patients affected by a complex DHF. Level V. Technical Notes.

Takotsubo syndrome (TTS) can be induced by a large variety of physical/emotional triggers; several cases, however, are related to either an overt or occult malignancy, as shown in retrospective studies and case reports. The aim of this study was therefore to evaluate the clinical outcome of patients with TTS and cancer in a meta-analysis study. In June 2018, a Pubmed systematic research was conducted for studies assessing outcome in patients with TTS and cancer. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for adverse events at follow-up. After paper retrieval, four studies were included in the meta-analysis, with a total of 123,563 patients. The prevalence of current or previous malignancy among patients admitted with TTS was 6.7% (8258 patients). When compared to control patients, patients with cancer showed an increased risk of clinical events (RR 3.24, 95% CI 3.04–3.45, p

Highlights • A biopsy of any suspicious breast skin lesion after radiotherapy is recommended. • Patients with clinical anomalies post-breast cancer surgery and RT need attention. • The Angiosarcoma was cured due to surgery and high-dose neoadjuvant chemotherapy. • A correct 6 month follow-up is needed: check-ups, chest X-rays and ultrasound. • The survival of the patient suggests possible ways to manage this rare tumour type., Introduction Radiation-induced breast angiosarcoma is a severe but rare late complication in the breast-preserving management of breast cancer through surgery and radiotherapy. Often the initial diagnosis is complex given its relatively anodyne nature and the fact that it usually presents in the form of typically multifocal reddish-purple papular skin lesions. Presentation of the case We describe the clinical and pathologic findings of a 79-year-old woman, who developed a radiation-induced breast angiosarcoma after around 8 years. She initially refused a mastectomy leading to an adaptation in the management of this cancer. Discussion The average latency of secondary angiosarcoma of the breast following radiation therapy is around six years. Breast angiosarcoma is typically considered to affect the dermis, and is therefore cutaneous in origin. An incisional biopsy of the discoloured skin and underlying mass is necessary. The treatment is surgical resection. The role of chemotherapy has not been clearly defined. Most data originate from retrospective case series studies suggesting that angiosarcomas are relatively sensitive to taxanes and anthracyclines. Conclusion The preferred treatment is always aggressive surgical removal and, as our atypical clinical case suggests, neoadjuvant chemotherapy in very high doses is also needed. A biopsy of any suspicious breast skin lesion after radiotherapy is recommended. Despite the treatment challenges, our case provides enlightening details on the management of such a rare cancer even when faced with unplanned events which do not always allow for a textbook approach.

In patients with short nipple to inframammary fold (N-IMF) distance, as in tuberous breast, the cohesivity and gel distribution of shaped implants work as a controlled tissue expander, progressively adapting the tissues to the implant's shape. This phenomenon translates into a gradual increase of the N-IMF distance over time, but the true extent to which this occurs has not been quantified to date. This study aims to quantify the postoperative variation of the N-IMF distance in tuberous breast treated with shaped cohesive silicone breast implants.We did a retrospective review of a prospective maintained database of all consecutive patients with bilateral Groulleau I and II tuberous breasts who underwent primary breast augmentation between April 2017 and May 2018 at our institution. To quantify the lower mammary pole's morphological changes, we evaluated the N-IMF distance under maximal stretch as an endpoint. We recorded this value at time 0 (preoperative), immediate post-op (equivalent to the distance planned preoperatively) and at month 1, month 6 and 1-year post-op. Then we calculated the average N-IMF distance variation of our sample of patients with a 99% interval of confidence for each breast obtained. Comparisons were performed using the Sign test and the Mann-Whitney U test.The average implant weight was 353g (range 290-450; SD ±46.147). Of the 54 breasts analyzed, the immediate post-op N-IMF distance was on average 2.43 cm longer than the preop IMF with a 99% confidence interval between 2.01 and 2.86 and SD of ±1.22. The mean difference between the preop N-IMF distance and after 1, 6 and 12 months was respectively 2.78 cm (SD,1.56) (99% CI, 2.24-3.34), 3.08 cm (SD, 1.57) (99% CI, 2.53-3.64), and 3.36 (1.55) (99% CI, 2.82-3.91) Comparing immediate postoperative nipple to inframammary fold distance (N-IMF) to the 1, 6 and 12 months N-IMF values, an average of 4.23% (CI 1.3-7.16), 7.74% (CI 4.25-11.23) and 10.84% (CI 7.21-14.49) of skin length, was gained respectively. According to implants' weight, subgroup analysis showed that implants400 g were associated with significantly higher N-IMF distance increase (p0.05) compared to implants400 g.Our findings suggest that a significant progressive postoperative increase in N-IMF distance should be expected in all cases of tuberous breast augmentation with anatomical implants over a 1 year period. This aspect may have an important implication on the IMF incision and the new fold position preoperative planning. LEVEL OF EVIDENCE IV.

Headache disorders are prevalent and disabling conditions impacting on people of all ages, including children and adolescents with substantial impact on their school activities and leisure time. Our study aims to report specific information on headaches in children and adolescents based on the Global Burden of Disease (GBD) study, that provides estimates for incidence, prevalence, fatal and non-fatal outcomes. We relied on 2007 and 2017 GBD estimates for prevalence and Years Lived with Disability (YLDs) at the global level and in WHO regions. The results show that, migraine and tension-type headache (TTH) together account for 37.5% of all-cause prevalence and for 7% of all-cause YLDs. Over the past decade, prevalence rates showed a mild increase of TTH in all ages and of migraine alone for adolescents. The YLDs increased among females of all ages with some regional differences that might be connected to the unequal availability of effective acute and prophylactic treatments across world regions. GBD data support the need to promote public health policies and strategies including diagnosis, pharmacological and non-pharmacological treatments that are expected to help reduce the disability and burden associated to migraine and TTH among children and adolescents.

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IMPORTANCE Takotsubo syndrome (TTS) is an acute, reversible heart failure syndrome featured by significant rates of in-hospital complications. There is a lack of data for risk stratification during hospitalization. OBJECTIVE To derive a simple clinical score for risk prediction of in-hospital complications among patients with TTS. DESIGN, SETTING, AND PARTICIPANTS In this prognostic study, 1007 consecutive patients were enrolled in the German and Italian Stress Cardiomyopathy (GEIST) registry from July 1, 2007, through December 31, 2017, and identified as the derivation cohort; 946 patients were enrolled in the Spanish Registry for Takotsubo Cardiomyopathy (RETAKO) as the external score validation. An admission risk score was developed using a stepwise multivariable regression analysis from 2 registries. Data analysis was performed from March 1, 2018, through July 31, 2018. MAIN OUTCOMES AND MEASURES In-hospital complications were defined as death, pulmonary edema, need for invasive ventilation, and cardiogenic shock. Four variables were identified as independent predictors of in-hospital complications and were used for the score: male sex, history of neurologic disorder, right ventricular involvement, and left ventricular ejection fraction (LVEF). RESULTS Of the 1007 patients enrolled in the GEIST registry, 107 (10.6%) were male, with mean (SD) age of 69.8 (11.4) years. Overall rate of in-hospital complications was 23.3% (235 of 1007) (death, 4.0%; pulmonary edema, 5.8%; invasive ventilation, 6.4%; and cardiogenic shock, 9.1%). The GEIST prognosis score was derived by providing 20 points each for male sex and history of neurologic disorders and 30 points for right ventricular involvement and then subtracting the value in percent of LVEF (decimal values between 0.15 and 0.70). Score accuracy on area under the receiver operating characteristic curve analysis was 0.71, with a negative predictive power of 87% with scores less than 20. External validation in the RETAKO population (124 [13.1%] male; mean [SD] age, 69.5 [14.9] years) revealed an area under the curve of 0.73 (P = .46 vs GEIST derivation cohort). Stratification into 3 risk groups (40 points) classified 316 patients (40.9%) as having low risk; 342 (44.3%) as having intermediate risk, and 114 (14.8%) as having high risk of complications. The observed in-hospital complication rates were 12.7% for low-risk patients, 23.4% for intermediate-risk patients, and 58.8% for high-risk patients (P < .001 for trend). After 2.6 years of follow-up, patients with in-hospital complications had significantly higher rates of mortality than those without complications (40% vs 10%, P = .01). CONCLUSIONS AND RELEVANCE The GEIST prognostic score may be useful in early risk stratification for TTS. High-risk patients with TTS may require an intensive care unit stay, and low-risk patients with TTS could be discharged within a few days. In-hospital complications in patients with TTS may be associated with increased risk of long-term mortality.

Background Current literature only reports variable information from single‐center studies on the recurrence rate, the complications, and the outcome of patients with Takotsubo syndrome ( TTS) experiencing recurrent TTS . Therefore, a detailed description of clinical characteristics, predictors, and the prognostic impact of patients with TTS and recurrences in a multicenter registry is needed. Methods and Results We analyzed 749 patients with TTS from 9 European centers being part of the international, multicenter GEIST (German Italian Stress Cardiomyopathy) Registry. Patients were divided into the recurrence group and the nonrecurrence group. The recurrence rate at a median follow‐up of 830 days (interquartile range, 118–1701 days) was 4%. Most recurrences were documented in the first 5 years after the index TTS episode. Up to 2 TTS recurrences were documented in 2 of 30 patients (6%). A variable ballooning pattern (n=6, 0.8%) with, in particular, involvement of the right ventricular occurred in 3 cases (0.4%) at the recurrence event. Except for the higher presence of arterial hypertension (86.7% versus 68.3%; P =0.03) in the recurrence group, no other baseline characteristics were different between groups. Observation of TTS complications during follow‐up, including stroke, thromboembolic events, in‐hospital death, and cardiogenic shock, revealed no significant differences between groups ( P >0.05), except the higher presence of pulmonary edema in the recurrence group versus the nonrecurrence group (13.3% versus 4.9%; P =0.04). Conclusions The incidence of TTS recurrence is estimated to be 4% in this multicenter TTS registry. A variable TTS pattern at recurrence is common in up to 20% of recurrence cases.

Introduction Left ventricular (LV) non-compaction (LVNC) is a rare cardiomyopathy characterised by a two-layered LV myocardium with prominent trabeculae separated by deep recesses perfused from the LV cavity. Myocardial work analysis (MWA) is a novel echocardiographic method that calculates pressure-strain loops from longitudinal strain and bedside blood pressure measurement. Our study investigates the MWA features of LVNC patients and their association with outcomes. Methods We compared 40 LVNC with preserved LVEF (≥50%) (pEF-LVNC) and 40 LVNC patients with reduced LVEF ( Results Clinical characteristics, conventional echocardiography, and strain analysis results are detailed in Table 1 and Figure 1. Myocardial work index was significantly reduced in rEF-LVNC (1088 [138–1211 mm.Hg%]) and pEF-LVNC (1394 [1138–1501 mm.Hg%]) in comparison to control (1827 [1758–1981 mm.Hg%]), but there was no difference between the two LVNC groups. Global constructive work (GCW) was significantly lower in rEF-LVNC (1094 [947–1281 mm.Hg%]) than in pEF-LVNC (1730 [1368–1691 mm.Hg%]) (p=0.001), while both LVNC groups were lower than control (2201 [1965–2406 mm.Hg%]) (pEF-LVNC p=0.001, rEF-LVNC p Conclusion MWA is a promising parameter for risk assessment of LVNC patients especially because it is less load-dependent and, unlike LVEF, incorporates left ventricular haemodynamics. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): 2018 research grant from the Swiss Heart Foundation

In recent decades, the number of people living with one or more chronic diseases has increased dramatically, affecting all sectors of society, particularly the labour market. Such an increase of people with chronic diseases combined with the aging of working population affects income levels and job opportunities, careers, social inclusion and working conditions. Both legislation and company regulations should take into account the difficulties that workers experiencing chronic diseases may face in order to be able to formulate innovative and person-centred responses to effectively manage this workforce while simultaneously ensuring employee wellbeing and continued employer productivity. The European Joint Action &ldquo, CHRODIS PLUS: Implementing good practices for Chronic Diseases&rdquo, supports European Union Member States in the implementation of new and innovative policies and practices for health promotion, diseases prevention and for promoting participation of people with chronic diseases in labour market. Therefore, a Toolbox for employment and chronic conditions has been developed and its aim is to improve work access and participation of people with chronic diseases and to support employers in implementing health promotion and chronic disease prevention activities in the workplace. The Toolbox consists of two independent instruments: the Training tool for managers and the Toolkit for workplaces that have been tested in different medium and large companies and working sectors in several European countries.

Background It is common clinical experience that, after structured withdrawal, some patients with chronic migraine and medication overuse headache (CM with MOH) are more prone than others to relapse and to be in need of further structured treatments. Our aim was to explore similarities and differences between frequent relapsers (FRs) and non-frequent relapsers (NFRs) by considering their point of view, perceptions, and perspective of their subjective experience with relapse into CM with MOH. Methods Patients were consecutively recruited on occasion of a structured withdrawal treatment and were interviewed individually about their headache experience and their perspectives on relapse into CM with MOH. We considered FR those patients requiring 2 or more structured withdrawals for MOH within 3 years. A narrative approach with no preconceived coding schemes was employed. To facilitate coding, categorization and organization of data the software QRS NVivo 11.0 was used: themes were defined as common to FR and NFR, or peculiar (by frequency or content) to one of the 2 groups. Results Sixteen patients (13 women; mean age of 53) were interviewed: 7 were classified as FRs. A total of 22 themes emerged from 552 single quotations (the 10 most relevant covered 82% of the entire body of quotations). Four themes were commonly reported by both FR and NFR patients, and 6 were peculiar to one group only. Common aspects included issues connected to the dilemma between disclosing, concealing and the feelings of isolation around MOH, the idea of being addicted to medication, presence of anxiety, and the attempt to use non-pharmacological therapies as an alternative to medication. Peculiar aspects included causal attribution (FRs attributed headache to uncontrollable factors); future expectations at the time point of withdrawal (FRs were generally resigned); high-performance functioning (FRs believed they are "forced" to reach high levels of performance as a consequence of others' inability); coping strategies (FRs tended to "passively accept" problems and showed avoidance-related behaviors). Moreover, FRs were less frequently aware of their problems and described more frequently depressive symptoms. Conclusions Our results highlight that some differences between FR and NFR patients with CM and MOH exist. Frequent relapsers among patients with CM and MOH reported some important peculiarities of the lived experience of having chronic migraine; clinicians should recognize these psychosocial aspects such as social relationships, future expectations, the experience of illness, medication management, and how the withdrawal experience is regarded, as they may be associated with frequent relapse into MOH.

Acute patellar dislocation is a common knee injury that occurs most often in adolescents, frequently associated with sport and physical activities. Two-thirds of acute patellar dislocations occur in young active patients less than 20 years old. Non-contact knee sprain in flexion and valgus is the leading mechanism for patellar dislocation, accounting for as many as 93% of all cases. The strong displacement of the patella tears the medial stabilizing structures, and mostly the medial patellofemoral ligament (MPFL), which is almost always injured in acute patellar dislocation, most frequently at its femoral attachment. Plain X-ray and CT are mandatory to diagnose bony risk factors for patellar dislocation and plan correction. MRI gives the best information on cartilage and capsulo-ligamentous status for treatment planning: free bodies or osteochondral fracture should be treated surgically. Acute patellar dislocation is associated with a high rate of recurrent patellar instability, instability symptoms and, eventually, patellofemoral osteoarthritis. A consensus on its management is still lacking. Though most authors have reported good results with conservative treatment, a surgical approach would be necessary in the presence of severe cartilage damage or a relevant disruption of the medial stabilizers with instability and subluxation of the patella.

Background Potential predictors of clinical complications of Takotsubo syndrome (TTS) are poorly known. Persistent ST-segment elevation (PSTE) may have an impact on outcome similar as previously reported in acute coronary syndrome. The aim of this study was to assess the prevalence and prognostic relevance of PSTE in patients with TTS. Methods Two-hundred-sixty-nine consecutive patients were enrolled in an international multicenter registry. PSTE was defined as the documentation of ST-elevation at least for the first 48h of hospitalization. Long-term mortality was evaluated in median 1.9years after the acute event. Results PSTE was found in 52 TTS patients (19%). Patients with PSTE were characterized by higher admission levels of troponin-I (23±12 vs 8±49ng/L, p p =0.02) and a higher rate of in-hospital complications (31% vs 17% p =0.03). At multivariate analysis including PSTE, age, male sex, admission ejection fraction, PSTE (odds ratio [OR] 4.2; 95% confidence interval [CI] 1.4–13; p =0.01), age (OR 1.05; 95%CI 1.00–1.10; p =0.03) and admission ejection fraction (OR 0.93; 95%CI 0.87–0.99; p =0.02) were independent predictors of in-hospital complications. At long-term follow-up no significant differences in terms of mortality were observed between patients with and without PSTE (19% vs 15%; p =0.5). However, PSTE was a predictor of major cardiac adverse events (MACE) at follow-up (HR 2.32, 95% CI 1.02–5.31, p 0.045). Conclusions In TTS patients, PSTE is a common finding, represents an independent predictor of in-hospital complications and could be associated with MACE at follow-up.

In this single-arm pilot open-label study we examined the effect of a mindfulness-based intervention on reduction of headache frequency after 12 months in adolescents aged 12–18 with chronic or high-frequency migraine without aura. Adolescents were recruited at the headache center of the C. Besta Neurological Institute and followed-up for 12 months. The mindfulness-based intervention was delivered in small groups and consisted of six weekly group sessions of guided meditation, and one booster session 15 days after. Patients filled in questionnaires assessing headache frequency (primary endpoint), medication intake, disability, anxiety, depression, catastrophizing, and caregivers’ burden. Within-person ANOVA was used to address variation of endpoints over time. Thirty-five out of 37 patients completed the study for primary endpoints, and 33 for secondary endpoints. Headache frequency dropped from 21.3 (95% CI 18.5, 24.1) to 9.6 (95% CI 6.1, 13.1) days per month at 12 months (F = 30.5, p &lt, 0.001), 23 patients out of 35 (65.7%) achieved a headache frequency reduction greater than or equal to 50%. Significant improvements were also reported for medication intake (F = 18.7, p &lt, 0.001), disability (F = 3.8, p = 0.027), trait anxiety (F = 5.1, p = 0.009), symptoms of depression (F = 9.5, p &lt, 0.001), and catastrophizing (F = 23.6, p &lt, 0.001). In conclusions, our study shows a reduction of headache attacks in adolescents who follow a mindfulness-based program, suggesting benefit of this nonpharmacological approach.

Background.: Scleroderma is traditionally classified into two forms with different clinical expression: localized and diffused. An early variant has been described that is distinguished in three different “subsets” characterized by the constant presence of Raynaud phenomenon associated or not with anatomic alterations in the microcirculation detectable by nailfold videocapillaroscopy and/or the presence of autoantibodies (anti centromere or anti topoisomerase I): subset (1): autoantibodies plus microcirculation alterations; subset (2): autoantibodies, in the absence of microcirculation alterations; subset (3): microcirculation alterations, in the absence of autoantibodies. Methods.: Our study was conducted on a group of 89 subjects with a positive history for Raynaud’s phenomenon enrolled at the Interdisciplinary Interdepartmental Reference Center for Early Diagnosis of Scleroderma Ulcers (CRIIS) of “Sandro Pertini” hospital in Rome, with the aim of defining the subset to which they belonged basing on the positivity to nailfold videocapillaroscopy and/or the presence of specific autoantibody markers. Results and conclusions.: We identified: 25 patients with anti-CENP B antibodies, two of which were also positive for anti-SSA antibodies; 7 with anti-Topoisomerase I antibodies, of which one was also positive for anti-SS-A and another for both anti-Ro60 and anti-snRNP. These patients were classified as subset 1 or 2. Three patients were positive for anti-PM/Scl-100 antibodies in addition to other autoantibody markers: one resulted also positive for anti-snRNP, the others for both anti-SS-A and anti-Ro52.

Background Prolonged QT corrected (QTc) intervals are associated with adverse cardiovascular outcomes both in healthy and high-risk populations. Our objective was to evaluate the QTc intervals during a takotsubo cardiomyopathy (TTC) episodes and their potential prognostic role. Hypothesis Dynamic changes of QTc interval during hospitalization for TTC could be associated with outcome at follow-up. Methods Fifty-two consecutive patients hospitalized for TTC were enrolled. Twelve-lead electrocardiogram (ECG) was performed within 3 h after admission and repeated after 3, 5, and 7 days. Patients were classified in 2 groups: group 1 presented the maximal QTc interval length at admission and group 2 developed maximal QTc interval length after admission. Results Mean admission QTc interval was 493 ± 71 ms and mean QTc peak interval was 550 ± 76 ms (P

Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is frequently associated with mutations in genes coding for desmosomal proteins. In this study, we investigated the association of genetic status with ARVC progression as defined by echocardiographic parameters. Methods We tested 62 ARVC patients for their genetic profile. Accordingly, they were grouped in mutation positive (48 (77%) patients; median age 48.5 years; 33 (69%) males), and mutation negative (14 (23%) patients; median age 45 years; 10 (71%) males). Prevalent mutations were Desmoglein-2 (DSG2) in 16 (26%), Desmoplakin (DSP) in 14 (23%), and Plakophilin-2 (PKP2) in 9 (15%) patients. Results At baseline, there were no significant differences in clinical characteristics between the two groups. Patients were followed-up for a median time period of 1420 days, and there was no significant difference in the duration of follow-up between the two groups (p=0.05). In the mutation positive group, there was a significant increase in right ventricular end-diastolic area (p=0.002), right atrial short (p=0.008) and long (p=0.002) diameter, left atrial diameter (p=0.014), and a decrease in left ventricular ejection fraction (p=0.014) during follow up. Right ventricular functial parameters did not change significantly (tricuspid annular plane systolic excursion: p=0.24; fractional area change: p=0.088). In the mutation negative group, none of the aforementioned echocardiographic findings exhibited any significant difference during follow-up: right ventricular end-diastolic area (p=0.1); right atrial short (p=0.7) and long (p=0.9) diameter, left atrial diameter (p=0.6), and left ventricular ejection fraction (p=0.3). Similarly, right ventricular functional parameters did not change significantly (tricuspid annular plane systolic excursion: p=0.77; fractional area change: p=0.80. Results are summarized in the figure. Change in echocardiographic findings. Conclusions There is a strong association between echocardiographic progression of ARVC phenotype and the presence of a pathogenic mutation. Such mutations should be searched in all patients with an ARVC phenotype, and mutation positive individuals should be followed-up in shorter intervals.

The distal humeral fractures and nonunion are still considered a challenge for the orthopedic surgeon, and their treatment is difficult and controversial. In these cases, total elbow arthroplasty (TEA) has emerged as an alternative to open reduction and internal fixation (ORIF). The following chapter aims to give an overview of the total elbow arthroplasty from the therapeutic strategy to the surgical procedures. In acute elbow fractures and nonunion, linked implants are used to ensure joint stability, even in the presence of severe bone loss or ligamentous insufficiency. The critical points are to give the right indication of TEA and to follow a clear and precise surgical protocol. The preoperative assessment and planning, the patient positioning, and the choice of surgical approaches are fundamental aspects of the procedure. The surgical technique is aimed to reach proper bone preparation and the correct setting of the implant. The most frequent complications are related to the deep periprosthetic infection, the risk of ulnar neuropathy, the extensor mechanism dysfunction, and the mechanical failure like aseptic loosening, polyethylene wear, osteolysis, component fracture, and disengagement.

Significant side effects or drug interactions can make pharmacological management of headache disorders very difficult. Non-conventional and non-pharmacological treatments are becoming increasingly used to overcome these issues. In particular, non-invasive neuromodulation, nutraceuticals, and behavioral approaches are well tolerated and indicated for specific patient categories such as adolescents and pregnant women. This paper aims to present the main approaches reported in the literature in the management of headache disorders. We therefore reviewed the available literature published between 2010 and 2020 and performed a narrative presentation for each of the three categories (non-invasive neuromodulation, nutraceuticals, and behavioral therapies). Regarding non-invasive neuromodulation, we selected transcranial magnetic stimulation, supraorbital nerve stimulation, transcranial direct current stimulation, non-invasive vagal nerve stimulation, and caloric vestibular stimulation. For nutraceuticals, we selected Feverfew, Butterbur, Riboflavin, Magnesium, and Coenzyme Q10. Finally, for behavioral approaches, we selected biofeedback, cognitive behavioral therapy, relaxation techniques, mindfulness-based therapy, and acceptance and commitment therapy. These approaches are increasingly seen as a valid treatment option in headache management, especially for patients with medication overuse or contraindications to drug treatment. However, further investigations are needed to consider the effectiveness of these approaches also with respect to the long-term effects.

Highlights • A subtle case report of primary Hodgkin’s disease of the breast. • Definition and staging of primary lymphomas of the breast. • A comprehensive review of the Literature about this kind of disease., Introduction According to literature, primary Hodgkin’s lymphomas of the breast represent one of the rarer entity in the primary breast lymphoma (PBL) scenario. This is the reason why these tumors are insidious in mammary oncology. Presentation of the case We report a case of HL primitive breast in an elderly patient in whom radiology suspected an advanced breast cancer with ipsilateral axillary involvement and in which the fine-needle aspiration came back not significant. Discussion Eighteen cases of primary Hodgkin’s lymphoma of the breast has been described in Literature in a very large period of time: from 1928 to 2016. The nodular sclerosis type is the most frequent histological variant. Conclusion Their rarity together with the fact that radiological investigations are not significant for the purpose of an exact diagnosis, make these lesions extremely difficult to identify.

Background: Tuberous breast deformity is a congenital anomaly affecting young women. Several surgical techniques have been developed, but in many cases, they have not led to the expected results or have led to significant complications. The purpose of our study is to evaluate the efficacy of treating tuberous breast deformity with an innovative “star-like” incision technique. Methods: Between 2009 and 2013, 25 patients with a tuberous breast deformity underwent surgery at our department. All patients were managed with a star-like incision of the gland and the placement of a subfascial silicone gel implant in a single-stage surgical procedure. An areolar reduction was also performed. Results: Our results, with a maximum follow-up of 4 years, were satisfying. There were no surgical or later complications. The new breasts had a natural shape, correct symmetry, a normal-sized areola, reduced evidence of the “double-bubble" deformity, good mammary projection, and resolved ptosis. Conclusion: Advantages of the star-like incision technique include lower breast pole restructuring in the volume, length, and shape, suitable breast implant coverage, and proper correction of areola size and herniation. The technique is safe and achieves satisfactory, long-lasting results. Level of Evidence: Level IV, descriptive study. Tuberous breast deformity is a congenital anomaly affecting young women. Several surgical techniques have been developed, but in many cases, they have not led to the expected results or have led to significant complications. The purpose of our study is to evaluate the efficacy of treating tuberous breast deformity with an innovative "star-like" incision technique.Between 2009 and 2013, 25 patients with a tuberous breast deformity underwent surgery at our department. All patients were managed with a star-like incision of the gland and the placement of a subfascial silicone gel implant in a single-stage surgical procedure. An areolar reduction was also performed.Our results, with a maximum follow-up of 4 years, were satisfying. There were no surgical or later complications. The new breasts had a natural shape, correct symmetry, a normal-sized areola, reduced evidence of the "double-bubble" deformity, good mammary projection, and resolved ptosis.Advantages of the star-like incision technique include lower breast pole restructuring in the volume, length, and shape, suitable breast implant coverage, and proper correction of areola size and herniation. The technique is safe and achieves satisfactory, long-lasting results.Level of Evidence: Level IV, descriptive study.

Background. Thrombotic microangiopathies (TMA) are relatively rare but severe disorders characterised by non-immune haemolytic anaemia, thrombocytopaenia and organ failure. In patients with metastatic cancer, sporadic forms of TMA can be triggered by chemotherapeutic agents or can occur as complication of malignancy itself or of infections. Case report. Hereby, we report a case of a patient diagnosed with metastatic colorectal cancer who experienced an atypical haemolytic-uraemic syndrome (aHUS) during chemotherapy treatment with FOLFOX6 scheme. The use of eculizumab led to prompt recovery of laboratory parameters that was maintained despite treatment discontinuation due to appearance of pneumonia infectious. Additionally, genetic analyses revealed the presence in heterozygosis of CFH gene polymorphisms associated with aHUS. Conclusion. This case emphasises the importance of considering TMA as a possible diagnosis in patients with cancer presenting with haemolytic non-immune mediate anaemia and thrombocytopaenia associated with worsening of renal function. Prompt diagnosis is crucial for the requirement of its specific treatment that can impact on long-term outcome and prognosis.

Background: Reverse total shoulder arthroplasty (RTSA) has been indicated primarily for patients aged older than 65 years with symptomatic rotator cuff deficiency, poor function, and pain. However, conditions that benefit from RTSA are not restricted to an elderly population. This study evaluates a consecutive series of RTSA patients aged younger than 50 years.

Previous studies have reported slightly higher stroke rates in Takotsubo Syndrome compared to acute myocardial infarction. Our goal was to evaluate the temporal course of stroke rates and left ventricular recovery in patients with Takotsubo Syndrome.We retrospectively examined the clinical and imaging data of 72 patients with Takotsubo Syndrome. The data collected came from January 2005 to March 2017. Left ventricular performance was evaluated by cardiovascular magnetic resonance imaging (MRI) in all patients during the acute phase of Takotsubo Syndrome and in a follow-up scan 2 months later. Acute stroke and major adverse clinical events, such as myocardial infarction or recurrence of Takotsubo Syndrome and death, were also determined for each patient at 30 days and 12 months after initial presentation.The MRI scans performed during the acute phase of Takotsubo Syndrome demonstrated apical ballooning with anterior wall motion dysfunction in 65 (90%) patients. Imaging performed 2 months later demonstrated resolution of this in 97% of those patients. Median left ventricular ejection fraction also significantly increased between both scans (49.5% vs. 64.0%, P 0.001). We observed 9 (12%) events in the study population within 12 months of the initial diagnosis of Takotsubo Syndrome. Stroke had an event rate of 2.8% after 30 days and 4.2% after 12 months.Apical ballooning was found in the majority of our Takotsubo Syndrome patients on the MRI scans performed at presentation. This finding was subsequently associated with higher than expected stroke rates within 30 days of diagnosis and with rapid recovery of left ventricular function within 2 months of diagnosis. This suggests that rapid improvement in left ventricular morphology and function may facilitate the formation of cardiac emboli and consequently increase stroke rates in Takotsubo Syndrome. Although no guidelines currently exist for the treatment of Takotsubo Syndrome, these results may point to a potential role for temporary oral anticoagulation in high-risk patients. Future studies should examine if stroke rates after Takotsubo Syndrome have been underestimated.

Background: Research addressing the impact of a large number of factors on unemployment is scarce. We aimed to comprehensively identify factors related to unemployment in a sample of persons aged 18–64 from Finland, Poland and Spain. Methods: In this cross-sectional study, factors from different areas were considered: socio-demographic indicators, health habits, chronic conditions, health state markers, vision and hearing indicators, and social networks and built environment scores. Results: Complete data were available for 5003 participants, mean age 48.1 (SD 11.5), 45.4% males. The most important factors connected to unemployment were health status indicators such as physical disability (OR = 2.944), self-rated health (OR = 2.629), inpatient care (OR = 1.980), and difficulties with getting to the toilet (OR = 2.040), while the most relevant factor related to employment were moderate alcohol consumption (OR = 0.732 for non-heavy drinkers; OR = 0.573 for infrequent heavy drinkers), and being married (OR = 0.734), or having been married (OR = 0.584). Other factors that played a significant role included presence of depression (OR = 1.384) and difficulties with near vision (OR = 1.584) and conversation hearing (OR = 1.597). Conclusions: Our results highlight the importance of selected factors related to unemployment, and suggest public health indications that could support concrete actions on modifiable factors, such as those aimed to promote physical activity and healthy behaviors, tackling depression or promoting education, in particular for the younger.

Background and aims Systemic inflammatory activation can be observed in both Takotsubo cardiomyopathy (TTC) and acute coronary syndrome (ACS). The aim of this study was therefore to compare circulating cytokine levels during the acute and subacute phase of TTC and ACS. Methods One hundred thirty-six consecutive patients were enrolled in the study; after a propensity score matching, 32 TTC patients were compared with 32 subjects with ACS. Clinical baseline features and circulating levels of interleukin(IL)-1β, IL-1α, IL-2, IL-4, IL-6, IL-8, IL-10, IFN-γ, MCP1, EGF, VEGF, TNFα were obtained at admission (t0) and after 120 h (t1). Results At t0, several circulating IL levels were higher in subjects with TTC (IL-2 2 vs. 0.5 pg/ml, IL-4 1.5 vs. 0.82 pg/ml, IL-10 3.34 vs. 1.62 pg/ml, TNF-α 5 vs. 2.3 pg/ml, IFN-γ 0.92 vs. 0.32 pg/ml, EGF 84.8 vs. 10.7 pg/ml, p At t1, IL-2 and EGF levels were still higher in patients with TTC vs. those with ACS (IL-2 4.6 vs. 0.72 pg/ml, p = 0.01; EGF 36.3 vs. 18.5 pg/ml, p = 0.03), while IL-6 serum levels were higher in ACS patients (19.6 vs. 7.35 pg/ml, p = 0.02). Conclusions Different inflammatory patterns can be observed during the acute and subacute phase of TTC when compared to ACS. Increased levels of anti-inflammatory interleukins can be found during the acute phase of TTC while ACS is featured by higher levels of IL-6 during the acute and sub-acute phase.

BACKGROUND: Persistent ST‐segment elevation in acute coronary syndrome is associated with both short and long‐term complications. By contrast, there is limited information about ST‐elevation and its evolution during takotsubo (stress) cardiomyopathy (TTC). AIM: To evaluate whether persistent downsloping ST‐elevation in the early stages of TTC might correlate with short and long‐term clinical events. METHODS: One‐hundred fifty‐eight consecutive subjects with TTC were prospectively enrolled and assessed by electrocardiogram. Patients were classified in two groups according to the presence of downsloping ST‐elevation ≥5 mm lasting at least 24 hr (“lambda‐wave” ST‐elevation group vs. without downsloping ST‐elevation) in at least one/two contiguous leads. RESULTS: Five (3.2%) patients, all female with a mean left ventricular ejection fraction 32 ± 5%, were included in the lambda‐wave ST‐elevation group. These patients were characterized by a higher prevalence of physical stressor (100% vs. 49%, p = 0.04) and higher admission and peak levels of troponin‐I levels during hospitalization. Peak of ST‐elevation in the lambda‐wave ST‐elevation group was reached 6 hr after admission and gradually decreased after 24 hr. In‐hospital complications were observed in all the patients presenting lambda ST‐elevation (100% vs. 23%, p = 0.03, OR: 29.1, p = 0.04); one patient presented endoventricular thrombosis and two died of cardiogenic shock. At long‐term follow‐up (mean 443 days), adverse events were observed in 80% of patients with lambda‐wave ST‐elevation (RR of adverse events at follow‐up 32, p

Background Left ventricular ( LV ) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome. Methods and Results We enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST ‐elevation (56% versus 16%; P P =0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST ‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P =0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P =0.99). Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.