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Objective: The prevalence of colonization with multidrug-resistant organisms (MDRO) has increased over the last decade, reaching levels as high as 23% in certain patient populations. Active surveillance cultures (ASC) represent a valuable tool to identify patients colonized with MDRO to apply preventive measures, reduce transmission, and guide empiric antimicrobial therapy. There is a paucity of data evaluating the impact of admission ASCs to predict future infection. The aim of this study was to evaluate the concordance between ASCs results and the development of clinical infection by the same microorganism identified in the surveillance swab ("swab-related infection"), in hospitalized septic patients, and to evaluate the presence of specific risk factors associated with the development of a swab-related infection., Methods: All adults admitted to the Diagnostic and Therapeutic Medicine Department of the University Hospital Campus Bio-Medico of Rome with a diagnosis of infection or any other medical reason with admission surveillance swabs (rectal or nasal) between January 2018 and February 2021 were included in the study. A retrospective chart review was conducted to identify patients that developed infections with concordant MDROs identified on ASC, and the risk factors for swab-related infection. Secondary outcomes were need of intensive care unit transfer, length of stay, sepsis or septic shock development, and all-cause mortality., Results: A total of 528 patients were included in the study, of which 97 (18.3%) had a positive surveillance swab. Among patients with positive surveillance swabs, 18 (18.5%) developed an infection with the same microorganism recovered from the swab, 57 (58.8%) developed an infection with a different microorganism than that recovered from the surveillance swab, and 22 (22.7%) did not develop an infection during hospitalization. The number of colonized sites, an interventional procedure within the previous 3 months, a Systemic Inflammatory Response Syndrome (SIRS) score ≥ 2, and a quick Sequential Organ Failure Assessment (q-SOFA) score ≥ 2 were associated with a significantly higher risk of developing a swab-related infection. SIRS and q-SOFA scores ≥ 2 and procalcitonin ≥ 0.43 ng/ml help for identifying patients with a swab-related infection., Conclusion: Patients with positive surveillance swabs were at increased risk for development of infections by the same MDRO identified in surveillance swabs (swab-related infection). This study is the first to show that the positivity of surveillance swabs, in combination with anamnestic data, PCT values, and SIRS or q-SOFA scores, serves as a valuable tool to help clinicians predict patients at higher risk for swab-related infection development and guide the administration of appropriate empiric antimicrobial therapy in septic patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Spoto, Daniel Markley, Valeriani, Abbate, Argemi, Markley, Fogolari, Locorriere, Anguissola, Battifoglia, Costantino, Ciccozzi, Bustos Guillén and Angeletti.)

Rationale: Marfan syndrome is a rare cause of heart failure due to primary or secondary cardiomyopathy. Recently, sacubitril/valsartan-an angiotensin receptor blocker-neprilysin inhibitor-has been added in clinical practice as a standard therapy for heart failure. To our knowledge, there are no data on sacubitril/valsartan's effects on cardiovascular outcomes in patients with Marfan syndrome., Patient Concerns: A 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray., Diagnoses: Recurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy., Interventions and Outcomes: Sacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up., Lessons: Sacubitril/valsartan should be effective on pathophysiologic mechanisms and cardiovascular outcomes of Marfan syndrome-related cardiovascular complications.

Background: Acute pericarditis may occur frequently after viral infections. To our knowledge, influenza B virus infection complicated by pericarditis without myocardial involvement has never been reported. We report the first case of life-threatening pericarditis caused by influenza B virus infection., Case Presentation: A 48-years-old woman with trisomy 21 and ostium primum atrial septal defect was transferred from Cardiology to our Internal Medicine Department for severe pericardial effusion unresponsive to ibuprofen and colchicine. Based on the recent patient history of flu-like syndrome, and presence of pleuro-pericardial effusion, a viral etiology was suspected. Laboratory evaluation and molecular assay of tracheal aspirate identified influenza B virus. Therefore, the ongoing metilprednisolone and colchicine therapy was implemented with oseltamivir with progressive patient improvement and no evidence of pericardial effusion recurrence during follow-up., Conclusions: Especially in autumn and winter periods, clinicians should include Influenza B virus infection on differential diagnosis of pericarditis with large pericardial effusion.

Background: A number of recent studies underline the importance of vitamin D in the pathogenesis of Type 1 diabetes (T1D)., Aims: The aim of this study was to investigate whether supplementation with the active form of vitamin D (calcitriol) in subjects with recent-onset T1D protects residual pancreatic beta-cell function and improves glycaemic control (HbA(1c) and insulin requirement)., Methods: In this open-label randomized trial, 70 subjects with recent-onset T1D, mean age 13.6 years +/- 7.6 sd were randomized to calcitriol (0.25 microg on alternate days) or nicotinamide (25 mg/kg daily) and followed up for 1 year. Intensive insulin therapy was implemented with three daily injections of regular insulin + NPH insulin at bedtime., Results: No significant differences were observed between calcitriol and nicotinamide groups in respect of baseline/stimulated C-peptide or HbA1c 1 year after diagnosis, but the insulin dose at 3 and 6 months was significantly reduced in the calcitriol group., Conclusions: At the dosage used, calcitriol has a modest effect on residual pancreatic beta-cell function and only temporarily reduces the insulin dose.

Inflammation and endothelial dysfunction play important roles in the pathophysiology of congestive heart failure (CHF), and the peptide bradykinin, generated during inflammation, may act as a defence mechanism by inducing vasodilation. Plasma bradykinin levels are increased in experimental heart failure but low in patients with advanced chronic CHF despite treatment with angiotensin-converting enzyme (ACE) inhibitors. It is not currently known how bradykinin behaves in less severe phases of CHF controlled by long-term ACE inhibitor treatment. We studied 10 male patients with clinically stable chronic CHF [New York Heart Association (NYHA) class II] on long-term ACE inhibitor treatment and 10 normal sex- and age-matched control subjects. High performance liquid chromatography/radioimmunoassay methods were used to evaluate plasma levels of bradykinin in relation to an array of parameters of endothelial function, coagulation and inflammation before and after stimuli of forearm arterial occlusion and physical exercise. CHF patients had higher levels of bradykinin (P = 0.008), activated factor XII (P = 0.049), interleukin-6 (P = 0.050) and tumour necrosis factor receptor II (sTNFRII) (P = 0.026) than controls. Arterial occlusion and exercise significantly increased bradykinin and von Willebrand factor levels in controls but not in CHF patients. The increase in brachial artery diameter after arterial occlusion was less in CHF patients (P = 0.036) and inversely related to baseline plasma levels of bradykinin (r = -0.855, P = 0.002) and sTNFRII (r = -0.780, P = 0.008). NYHA class II CHF patients during long-term treatment with ACE inhibitors have increased bradykinin levels and signs of inflammation. They are unable to respond adequately to stimuli of ischaemia and physical exercise which both require vasodilation.

Background: The recovery of left ventricular function (LVF) after revascularization takes time. alpha-Adrenergic blockade acutely improves coronary blood flow and LVF, whereas the effects of more prolonged alpha-adrenergic blockade on LVF recovery after stenting are unknown., Methods: In 32 patients (age 58 +/- 12 y) with an 82% +/- 6% stenosis, ejection fraction (EF) and systolic thickening (%Th) were measured by transthoracic echocardiography before and 30 minutes to 2 hours after revascularization. In a double-blinded protocol, either 200 microg/kg urapidil or placebo was given intravenously, and LVF was measured 10 minutes later. Two hours later, oral treatment with 30 mg/d drug or placebo was started, and LVF measured again after 24 hours and 3 months., Results: Before revascularization, EF was 49.4% +/- 8.5% (+/-SD) and 51.3% +/- 8.8% in the urapidil-treated and the placebo groups, respectively. Thirty minutes to 2 hours after coronary stenting, EF was unchanged. After intravenous drug administration, EF increased to 56.5% +/- 9.7%). At 24 hours and 3 months after revascularization, EF became 59.5% +/- 7.9% and 59.6% +/- 8.2% in the urapidil-treated group, respectively, whereas EF in the placebo group did not change (50.4% +/- 5.7% and 49.7% +/- 4.9%, respectively). Revascularization did not acutely improve %Th. Intravenous urapidil improved %Th from 31.4% +/- 17.6% to 44.2% +/- 11.6%, whereas there was no change in the placebo group. At 3 months, %Th was 49.5% +/- 12.9% in the urapidil-treated group and 39.7% +/- 8.9% in the placebo group., Conclusions: These data suggest that long-term alpha-adrenergic blockade might improve LVF at midterm after coronary revascularization.

One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anastomosis. Furthermore, the possibility of improving the suture with additional stitches is often technically demanding. We, therefore, describe a new surgical technique for the proximal anastomosis, positioning the prosthesis within the left ventricle. We present our series of 6 patients treated with this new technique. The immediate results confirmed the efficacy, speed, and simplicity of the technique. During long-term follow-up no patient showed significant residual aortic valve incompetence.

Background: AMI reperfusion by thrombolysis does not improve TIMI flow and LV function. The role of infarct-related artery (IRA) stenosis and superimposed changes in coronary vasomotor tone in maintaining LV dysfunction must be elucidated., Methods and Results: Forty patients underwent diagnostic angiography 24 hours after thrombolysis. Seventy-two hours after thrombolysis, the culprit lesion was dilated with coronary stenting. During angioplasty, LV function was monitored by transesophageal echocardiography. Percent regional systolic thickening was quantitatively assessed before PTCA, soon after stenting, 15 minutes after stenting, and after phentolamine 12 microg/kg IC (n=10), the alpha1-blocker urapidil 600 microg/kg IV (n=10), or saline (n=10). Ten patients pretreated with beta-blockers received urapidil 10 mg IC. Coronary stenting significantly improved thickening in IRA-dependent and in non-IRA-dependent myocardium (from 27+/-15% to 38+/-16% and from 40+/-15% to 45+/-15%, respectively). Simultaneously, TIMI frame count decreased from 39+/-11 and 40+/-11 in the IRA and non-IRA, respectively, to 23+/-10 and 25+/-7 (P<0.05). Fifteen minutes after stenting, thickening worsened in both IRA- and non-IRA-dependent myocardium (to 19+/-14% and 28+/-14%, P<0.05), and TIMI frame count returned, in both the IRA and non-IRA, to the values obtained before stenting. Phentolamine and urapidil increased thickening to 36+/-17% and 41+/-14% in IRA and to 48+/-11% and 49+/-17% in non-IRA myocardium respectively, and TIMI frame count decreased to 16+/-6 and to 17+/-5, respectively. Changes were attenuated with beta-blocker pretreatment., Conclusions: Our finding that alpha-adrenergic blockade attenuates vasoconstriction and postischemic LV dysfunction supports the hypothesis of an important role of neural mechanisms in this phenomenon.

Objectives: We sought to evaluate the efficacy of alpha-adrenergic blocking agents in counteracting left ventricular (LV) dysfunction occurring after transient ischemia in humans., Background: The mechanisms underlying postischemic LV dysfunction are largely unknown., Methods: Percutaneous transluminal coronary angioplasty (PTCA) provides a clinical model of ischemia and reperfusion. In 50 patients undergoing coronary stenting for 77+/-5% stenosis, LV function was monitored by transesophageal echocardiography during and 30-min after PTCA. Fifteen minutes after stenting, 15 patients received 12 microg/kg body weight of the alpha-blocker phentolamine intracoronarily, 15 patients received 600 microg/kg of the alpha1-blocker urapidil intravenously, 10 patients received the combination of phentolamine and 1.2 mg of propranolol intracoronarily, and 10 patients received saline., Results: Fifteen minutes after successful coronary dilation, significant contractile dysfunction occurred in previously ischemic and nonischemic myocardium. LV dysfunction was accompanied by an increase in coronary resistance and diffuse vasoconstriction. Alpha-blockers counteracted LV dysfunction and coronary resistance and the increase in vasoconstriction. Phentolamine and urapidil increased global LV shortening from 34+/-9% to 45+/-8% and to 49+/-8%, respectively (p < 0.05). After the administration of propranolol combined with phentolamine, LV dysfunction remained unchanged (34+/-6%), as in control subjects., Conclusions: LV dysfunction occurs after PTCA, as described in animal models after ischemia. Alpha-blockers abolished LV, macrocirculatory and microcirculatory dysfunction, whereas the alpha-blocker effect was prevented by combining alpha- and beta-blockers. The evidence of diffuse rather than regional dysfunction, together with the opposite effects of alpha- and beta-blockade, supports the hypothesis of neural mechanisms eliciting postischemic LV dysfunction.

Calcium antagonist pretreatment and intracoronary high doses of nitrates (9 mg of isosorbide dinitrate) do not counteract coronary vasoconstriction occurring after rotational atherectomy. In 30 patients undergoing Rotablator atherectomy, intracoronary injection of the alpha 1-sympathetic blocker urapidil abolished or prevented significant vasoconstriction occurring 15 minutes after the procedure despite repeated injections of nitrates.

Objective: To verify the applicability and the clinical significance of left ventricular wall stress determinations by intraoperative transesophageal echocardiography (TEE) during resections of abdominal aortic aneurysms., Designs: Prospective comparison of changes in left ventricular wall stress between two groups of patients with and without coronary artery disease., Setting: Operatory room of Universitary Institute., Patients: Twenty-three patients with abdominal aortic aneurysms; 8 had clinically evident coronary artery disease (CAD+); 15 patients did not have clinical or electrocardiographic evidence of coronary artery disease (CAD-)., Interventions: Resection of the aortic aneurysm and insertion of a synthetic prosthesis., Measurements and Main Results: During operation transesophageal monitoring of left ventricular volumes and wall stress was performed during induction of anesthesia (T1), for two minutes after aortic clamping (T2), at the end of the proximal anastomosis (T3), for two minutes after aortic declamping (T4) and at the end of the procedure (T5). Circumpherential stress at end systole (sES) and end diastole (sED) was more sensitive than hemodynamic and volumetric parameters in detecting changes i function of the ischemic myocardium. In detail we observed: a significant increase of sES in CAD+versus CAD- at T2: 98 (sd 18) vs 83 (sd 14) 10(3) dyne/cm2. a significant increase of sED in CAD + versus CAD- at T2: 28.5 (sd 6) vs 22 (sd 4.5) 10(3) dyne/cm3. a similar trend of sES and sED at T4: 73 (sd 20.5) vs 46 (sd 15) 10(3) dyne/cm2 and 31 (sd 12) vs 16 (sd 7.7) 10(3) dyne/cm2 respectively. a significant increase of sED in CAD + at T5 (about 20' after T4): 26.5 (sd 9.5) vs 16 (sd 5.2) 10(3) dyne/cm2 which is expression of a persistent reduction of ventricular compliance in the ischemic patients., Conclusions: Wall stress modifies MVO2 and subsequently is sensitive in detecting changes in myocardial performance. TEE could valuably integrate routine hemodynamic monitoring of patients with coronary heart disease who undergo surgical resection of abdominal aortic aneurysms.

The paper reports a consecutive series of 523 patients undergoing abdominal aortic aneurysm surgery, paying particular attention to the cardiological risk factor. Coronary disease was present in 167 (31.9%) cases and the overall mortality rate was 1.7%: 5 cases (3%) in the group of coronary disease patients; 4 cases (1.2%) in the group of noncoronary disease patients. All fatal cardiac complications during the postoperative period occurred in those patients who presented coronary cardiopathies before surgery. The preoperative cardiological risk was therefore much greater and more significant in this group of patients. This risk factor should therefore be assessed prior to the operation in order to prepare the necessary medical or even surgical therapeutic measures.

A rare case of arteriovenous fistula between an internal mammary artery and a pulmonary artery is presented. The clinical history of recurrent bronchitis and dyspnoea during exercise, the presence of right parasternal murmur with normal heart size and normal blood gases justified the execution of an arteriovenous thoracic angiography which revealed the presence of a cirsoid aneurysm supplied by the internal and external mammary arteries. Diagnostic investigation and surgical indication in patients with the rare fistulous communication between the internal mammary artery and the systemic or pulmonary circulation are analysed.

Shock therapy is a problem which readily leads to considerations of a practical nature. Routine clinical experience is the basis for all evaluations of results. Drugs, doses, therapeutical tactics are of value only in so far as experience has successfully made use of them.

A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.

Tumors of the heart are relatively rare events and fibromas represent no more than 5% of these. A central source of peripheral embolization suggests the possibility to kept in mind in the absence of other causes and is therefore worthy of closer investigation.

The Authors describe a case in which an anterior mediastinal tumor manifested as a cardiovascular disease. Phonocardiographic findings and their modifications induced by respiratory manoeuvres are presented and discussed. Particular enphasis is given to the disappearance, with deep inspiration, of the pulmonary ejection murmur associated with the simultaneous paradoxical behaviour of pulmonary component of the second sound. The Authors suggest that such findings can be indicative of pulmonary outflow obstruction by an external mass.