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Accelerated partial breast irradiation (APBI), including intraoperative radiation therapy (IORT), is an evidence-based treatment option in patients undergoing breast conserving surgery (BCS) for early-stage breast cancer. However, literature regarding reirradiation for patients with ipsilateral breast tumor recurrences (IBTR) is limited. This prospective study assessed the feasibility and efficacy of using APBI in patients who had prior whole breast irradiation.This was a single institution, prospective study of patients who were previously treated with BCS and adjuvant whole breast radiation. At the time of enrollment, all had unifocal IBTR, histologically confirmed invasive ductal carcinoma with negative margins after repeat BCS. Patients received either IORT in a single fraction at time of BCS or MammoSite brachytherapy twice daily over 5 days. Follow-up data and patient surveys were collected at 1, 3, 6, 9, and 12 months, then annually for at least a 5-year period.From 2008 to 2014, 13 patients were enrolled. Median time to recurrence after initial course of radiation was 12.5 years. Median follow-up after retreatment was 7.8 years. One patient in the IORT group had a subsequent tumor bed recurrence, yielding a local control of 92%. One patient had distant recurrence. At baseline, 680 reported excellent-good cosmesis compared with 42% at 5 years. All patients indicated total satisfaction with overall treatment experience.APBI using IORT was well tolerated with excellent local control and may be a reasonable alternative to mastectomy for IBTR. Further study is needed to determine the most suitable candidates for this approach.

Funding Acknowledgements Type of funding sources: None. Background transvenous (TV) pacemakers are negatively associated with local and systemic device-related infections, often requiring transvenous lead extraction (TLE). Moreover, patients reimplanted with a TV device following TLE, exhibit substantial mortality and reinfection rates during the subsequent follow-up (FU). In this setting, leadless pacemakers (LPMs) are appealing as a first choice for TLE patients requiring a pacemaker reimplantation. To date, limited data on real-world safety and efficacy of LPMs in patients who underwent TLE are available. Purpose The present study aims to assess long-term safety and efficacy of LPM implantation in patients who previously underwent TLE of a transvenous pacemaker, compared to LPM de novo implant patients. Methods Consecutive patients who underwent LPM implantation in 12 centers joining the International LEAdless PacemakEr (i-LEAPER) registry were enrolled. Patients receiving LPM following TLE (n=184) were compared with patients with de novo implant (n=995). The primary endpoint was LPM-related major complications rate at implant and during FU. Additionally, differences in electrical performance were assessed between the two groups. Completion of 12-months FU was obtained in all patients. Results 1179 patients were enrolled in this study and followed for a median of 12 [IQR 11-14] months. Baseline clinical characteristics resulted balanced among the two groups, apart from a higher prevalence of heart failure among recipients of LPM following TLE (16.8% vs. 9.4%, p=0.013). As reported in the Table, LPM related major complications and all-cause mortality did not differ among the two groups (1.6% TLE group vs. 2.2% de novo group, p=0.785, and 5.4% TLE group vs. 7.8% de novo group, p=0.288, respectively). Pacing threshold (PT) resulted higher in the TLE group throughout the FU (Figure-Panel A). Higher PTs were recorded in LPMs implanted at same location from where the previous transvenous lead was removed, as far as 12-months postimplant (Figure-Panel B), with a higher proportion of patients with high PT (>1 to 2V @0.24ms) in the first group at implant, 1-month, and 12-month FU (Figure-Panel C). Conclusion In this real-world registry, LPMs showed a satisfactory safety and efficacy profile after TLE. In the post-TLE cohort, better electrical parameters were obtained when LPMs were implanted at a different location from where the previous transvenous lead was extracted.

Background A previous randomized study (PRAETORIAN) demonstrated that the subcutaneous implantable cardioverter–defibrillator (S-ICD) was noninferior to transvenous ICD with respect to device-related complications and inappropriate shocks. However, that was performed prior to the widespread adoption of pulse generator implantation in the intermuscular (IM) space instead of the traditional subcutaneous (SC) pocket. Purpose To compare survival from device-related complications and inappropriate shocks between patients who underwent S-ICD implantation with the generator positioned in an IM position in comparison with a SC pocket. Methods We analyzed 1577 consecutive patients who had undergone S-ICD implantation from 2013 to 2021 and were followed up until December 2021. SC patients were propensity-matched with patients of the IM group, and their outcomes were compared. Results SC implantations were performed in 367 (23%) patients. These patients were propensity-matched with 367 IM patients. Intra-procedural complications were reported in 9 (2.5%) patients in the SC Group and 7 (1.9%) in the IM Group. During a median follow-up of 29 months, device-related complications were reported in 55 (7.5%) patients and inappropriate shocks were reported in 54 (7.4%) patients. The risk of the composite primary endpoint was lower in the matched IM Group than in the SC Group (unadjusted hazard ratio 0.67, 95% CI 0.45–0.99, p=0.042), while the risk of appropriate shocks was similar between groups (unadjusted hazard ratio 0.99, 95% CI 0.60–1.64, p=0.976). There was no significant interaction between generator positioning and variables such as gender, age, body mass index, ejection fraction and generation of the device. Conclusions In this experience, IM S-ICD generator positioning was superior to SC positioning in reducing device-related complications and inappropriate shocks. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Background Experience with the subcutaneous implantable cardioverter-defibrillator (S-ICD) is expanding rapidly. However, few data on generator replacement exist. Purpose The aim of this analysis was to describe the procedural characteristics of the pulse generator replacement in the current Italian practice and to provide a preliminary insight in the possible acute complications associated with first elective S-ICD generator replacements. Methods We analyzed 106 consecutive patients enrolled in the Rhythm Detect registry who underwent elective replacement of the S-ICD generator from September 2019 to July 2021. Procedures were accomplished according to the local clinical practice. A chest X-ray was performed, and the PRAETORIAN score was assessed and compared with the one measured after the first implantation. Results All replacements were performed in electrophysiology laboratories, 50% in day-hospital regimen, by 1 or 2 expert operators. Procedures were performed using local (87%) or general anaesthesia (13%). The median procedure duration was 40 (30-45) min. The previous S-ICD generator was in a subcutaneous pocket in 58 (55%) patients, and in an intermuscular pocket in the remaining patients. The PRAETORIAN score of the previous system was low ( Conclusions S-ICD replacements seem easy to perform with no peri-procedural complications. The adoption of an intermuscular pocket is associated with optimal positioning according to the PREATORIAN score, and seems preferred also in many cases of generators previously placed subcutaneously. In the Italian clinical practice conversion testing is rarely performed at device replacement.

Introduction: Disease modifying treatments are commonly used in the treatment of multiple sclerosis. As different opportunistic infections have been reported, concerns are also raised regarding the risk of invasive fungal infections. Areas covered: Both clinical trials and observational studies on safety and efficacy of diseases modifying treatment for multiple sclerosis were reviewed and data regarding the occurrence of invasive fungal infections were reported. Papers evaluating the following drugs were reviewed: rituximab, ocrelizumab, alemtuzumab, fingolimod, natalizumab, dimethyl fumarate, interferon, glatiramer acetate, cladribine, teriflunomide. Expert opinion: Overall, the occurrence of invasive fungal infections was low, with most infective events reported among patients treated with monoclonal antibodies and fingolimod. Aspergillosis and cryptococcal meningitidis were the most representative fungal infections. Although not common, these infections may be difficult to diagnose and their fatality rate is often high. For this reason, screening protocols for fungal infections must be implemented in the clinical practice when managing patients with MS.

Background Several studies suggest that an alteration of monocyte metabolism might be implicated in inflammatory diseases. Enhanced glycolysis might be a hallmark of pro-inflammatory monocyte subsets. Improved glycolysis enables the immune cells to generate sufficient ATP and biosynthetic intermediates to carry out its particular effector functions. For macrophages this includes phagocytosis and inflammatory cytokine production. Pyruvate Kinase isozyme M2 (PKM-2) catalyzes the final step of glycolysis producing pyruvate and ATP. Latest studies have shown that a member of Jumonji family (JMJD8) acts as a positive regulator in TNF-induced NF-kB signaling leading to pro-inflammatory pathways in macrophages and is involved in angiogenesis and cellular metabolism through interacting with PKM-2 in endothelial cells. Purpose The aims of the study are to assess the expression of the glycolytic key enzyme PKM-2 in CD14+ monocytes obtained from patients with non-ST-elevation myocardial infarction (NSTEMI) or with stable angina (SA). Furthermore, the expression of JMJD8 was evaluated. Methods 30 patients with NSTEMI and 30 patients with SA were enrolled. Peripheral blood mononuclear cells were obtained from whole blood samples. For cytoplasmatic protein identification, cells were fixed and permeabilized and then incubated with fluorochrome-conjugated mAbs anti-CD14, anti-PKM-2 and anti-JMJD8. For analysis we used Two-tailed Mann-Whitney non parametric Comparison test. Results CD14+ monocytes from NSTEMI patients showed reduced expression of the key glycolytic enzyme PKM-2 as compared to CD14+ monocytes from SA patients (p=0.02) (Figure 1). JMJD8 expression in NSTEMI patients is increased compared with SA patients (p=0.02) (Figure 2). Conclusion This study introduces a role for immune-metabolism in the immunity dysregulation described in ACS patients and provides novel insights into the mechanisms responsible for coronary instability. Taking their potential interaction into account, our data suggest that in acute setting glycolysis key enzyme PKM2 expression is downregulated. Besides, JMJD8 protein levels increase in NSTEMI patients acting as potential limiting factor of PKM2 function. Moreover, our data propose the potential roles of immune-metabolism to detect novel therapeutic targets, associated with an accurate patient stratification based on immune-metabolic profiles, for prevention and treatment of atherosclerosis, in the perspective of a personalized medicine approach. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Fondazione Policlinico A. Gemelli

Funding Acknowledgements This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Background/Introduction: The benefits of cardiac resynchronization therapy with defibrillator (CRT-D) in heart failure are well established. However, a gap of evidence is still present for patients with permanent atrial fibrillation (perm-AF) Purpose To investigate outcomes of CRT-D patients with perm-AF in terms of appropriate shock for ventricular arrhythmia and all-cause mortality in a long-term time horizon. Methods We used the Home Monitoring Expert Alliance (HMEA) database, a nationwide data repository of daily remote monitoring transmissions. The episodes with delivered shock were adjudicated by a board of 3 electrophysiologists. Results Among 1226 CRT-D patients (mean age 71.2 ± 10.0 years; 75.5% males), 276 (22.5%) had perm-AF at device implantation. These patients had more frequently rate responsive function (19.7% vs 64.1%) and higher basic rate (median value 60 bpm vs 70 bpm) as compared to all other patients (p At 5-year appropriate shock incidence was 34.2% (95% confidence interval [CI], 25.1%-45.3%) for perm-AF and 19.9% (15.6%-25.1%) for all other patients. All-cause mortality was 27.7% (17.7%-41.8%) for perm-AF and 15.6% (12.2%-19.9%) for all other patients. The age- and sex-adjusted hazard ratio between perm-AF and all other patients was 1.81 (95% CI: 1.25-2.64, p = 0.002) for appropriate shock and 0.92 (95% CI: 0.57-1.50, p = 0.748) for all-cause mortality. Conclusion Although a higher incidence of appropriate shock, perm-AF at the time of CRT-D implantation was not associated with increased long-term mortality, Abstract Figure. Appropriate shock and mortality

Emerging evidence supports the hypothesis that pathogenic protein aggregates associated with neurodegenerative diseases spread from cell to cell through the brain in a manner akin to infectious prions. Here, we show that mutant huntingtin (mHtt) aggregates associated with Huntington disease transfer anterogradely from presynaptic to postsynaptic neurons in the adult Drosophila olfactory system. Trans-synaptic transmission of mHtt aggregates is inversely correlated with neuronal activity and blocked by inhibiting caspases in presynaptic neurons, implicating synaptic dysfunction and cell death in aggregate spreading. Remarkably, mHtt aggregate transmission across synapses requires the glial scavenger receptor Draper and involves a transient visit to the glial cytoplasm, indicating that phagocytic glia act as obligatory intermediates in aggregate spreading between synaptically-connected neurons. These findings expand our understanding of phagocytic glia as double-edged players in neurodegeneration—by clearing neurotoxic protein aggregates, but also providing an opportunity for prion-like seeds to evade phagolysosomal degradation and propagate further in the brain.

Drugs that affect lipid metabolism are used with the aim to decrease negative outcomes such as cardiovascular-related morbidity and mortality. Six classes of lipid-lowering medications exist, and each has a variety of actual or potential side effects associated with their use. These medications are discussed in the following chapter with a focus on side effects as described in current literature. Evidence presented should be used in context and may aid clinical decision-making through identification of appropriate monitoring for actual or potential side effects of lipid-lowering medications.

Background: The aim of the study was to examine the efficacy of a vocational training program on renewable energy sources in reducing disabilities of people with chronic psychosis (CP). The innovative element was that the project could produce major advantages regarding the economic needs of the whole area involved. Methods: Experimental Cohort, 26 subjects with CP (EC); Control Cohort1, 130 subjects with CP following pharmacotherapy plus other rehabilitation activities (CIC); Control Cohort2, 101 subjects with CP following the usual treatment (pharmacotherapy) (CUC). Study tool: Health of the Nation Outcome Scales (HoNOS). Assessment made at the start of the study (T0) and after three months (T1). Statistical analysis made by MANOVA. Results: Improvement in HoNOS total score in both groups (F=7.574, p=0.000) with non-significant differences between groups over time (F=1.336, p=0.252) was found comparing EC vs. CIC. Greater improvement in EC vs. CIC was shown in the HoNOS “impairment" scale (F=4.910, p=0.028). EC vs. CUC: both groups improved in HoNOS total score (F=9.440, p=0.000) but the improvement was greater in EC (F = 2.273, P=0.048). Conclusions: Work inclusion, as well as other rehabilitation treatments, reduces the social needs of people with chronic psychosis. Work inclusion in a project with real relevance for the area where these people live, produces more improvement of cognitive, physical and somatic disabilities, probably related to a better outcome in self-efficacy.

The acid-insoluble salivary proteome obtained by addition of TFA to whole human saliva from adults, preterm and at-term newborns has been analysed by 2-DE in order to evidence differences among the three groups, and integrate data previously obtained on the acid-soluble fraction. 2-DE spots differentially expressed among the three groups were submitted to in-gel tryptic digestion and the peptide mixtures analysed by high resolution HPLC-ESI-MS/MS. By this strategy, we identified 3 over-expressed proteins in at-term newborns with respect to preterm newborns and adults (BPI fold-containing family A member 1, annexin A1, and keratin type 1 cytoskeletal 13), and several over-expressed proteins in adults (fatty acid-binding protein, S100 A6, S100 A7, S100 A9, prolactin-inducible protein, Ig kappa chain, cystatin SN, cystatin S/SA and ?-amylase 1). Four spots, already detected but not characterized by other authors in human saliva 2-DE, were attributed to different protein species of S100 A9 (long-type and long-type monophosphorylated, short-type and short-type monophosphorylated) by MS/MS analysis of tryptic peptides and sequential staining of 2-DE gels with Pro-Q Diamond, for specific detection of phosphoproteins, and total protein SYPRO Ruby stain.

In the last years, increasing interest has grown on the synthesis of light-weight, miniaturized surfaces for light manipulation based on metamaterials. These surfaces can be easily integrated in photonic systems and they can be used as high numerical aperture lenses, light-deflection surfaces and polarization-dependent surfaces. All-dielectric nanoresonator metasurfaces are particularly promising to synthesize light manipulating devices. By simply adjusting the geometric parameters (height and diameter) of the dielectric particles, it is possible to tune the spectral positions of the electric and magnetic resonant modes. The overlap of these resonances allows to design metasurfaces exhibiting a transmission coefficient with unit-amplitude and arbitrary, spatially-variant phase distribution. Moreover, resorting to asymmetric cross-section resonators, it is possible to define metasurfaces with high-efficiency of cross-polarization. In this work, we exploit both properties of dielectric nanoresonators to design a high numerical aperture micro-lens and a thin linear-to-circular polarizer, both working in the visible range. Numerical simulations of the performances of the devices are reported.

In this paper, the design principles and the sensitivity analysis needed for the realization of a high numerical aperture metasurface micro-lens are presented. The metasurface micro-lens is realized defining a surface with spatially-variant dielectric resonators embedded in a dielectric bulk. The designed micro-lens achieves a numerical aperture of 0.86 at the visible wavelength of 635 nm with miniaturized dimensions (total active area on the order of tens of square micrometers). These features makes the design extremely interesting for integrated photonic applications.

Statistics provides essential tool in Bioinformatics to interpret the results of a database search or for the management of enormous amounts of information provided from genomics, proteomics and metabolomics. The goal of this project was the development of a software tool that would be as simple as possible to demonstrate the use of the Bioinformatics statistics. Computer Simulation Methods (CSMs) developed using Microsoft Excel were chosen for their broad range of applications, immediate and easy formula calculation, immediate testing and easy graphics representation, and of general use and acceptance by the scientific community. The result of these endeavours is a set of utilities which can be accessed from the following URL: http://gmein.uib.es/bioinformatica/statistics. When tested on students with previous coursework with traditional statistical teaching methods, the general opinion/overall consensus was that Web-based instruction had numerous advantages, but traditional methods with manual calculations were also needed for their theory and practice. Once having mastered the basic statistical formulas, Excel spreadsheets and graphics were shown to be very useful for trying many parameters in a rapid fashion without having to perform tedious calculations. CSMs will be of great importance for the formation of the students and professionals in the field of bioinformatics, and for upcoming applications of self-learning and continuous formation.

Traditional karyotyping and molecular cytogenetic techniques were used to study the chromosomes of Champsocephalus gunnari from the Indian Sector of the Antarctic Ocean. C. gunnari has 24 pairs of chromosomes, giving a diploid number of 48. Most are acrocentric, six are metacentric and submetacentric and the level of divergence from the supposed ancestral notothenioid karyotype remains low. The chromosomal features of this icefish do not differ very much from those of the other channichthyids, the karyotypic macrostructure being kept stable in these fishes. Although providing relevant basic biological information, traditional cytogenetics do not allow a significant comparative analysis between species in this notothenioid family. Molecular cytogenetic techniques such as in situ hybridization have been successfully used on C. gunnari, opening new opportunities for a deeper characterization of Antarctic fish chromosomes. The in situ location of specific DNA sequences could provide valuable new information for phylogenetic reconstruction, and shed light on the relationship between chromosome change and the evolutionary process.

Objective: The authors sought to evaluate psychiatric comorbidity, subjective quality of life, and impact of psychopathology on quality of life measures in a clinical sample of patients attending a center for the diagnosis and treatment of obesity compared to a matched sample of non-obese subjects. Methods: Two hundred ninety-three consecutive obese patients (48 males, 245 females, mean age 45.41 α 13.55 yrs; mean BMI 35.60 α 6.20) were compared with a control group made of 293 non obese subjects (48 males, 245 females, mean age 45.66 α 13.86 yrs; mean BMI 21.8 α 2.06); all subjects were interviewed by means of SCID I and SCID II and completed the WHO-QoL-Bref, a self-administered instrument for evaluation of subjective quality of life. Results: Obesity was associated with a significant lifetime major risk both for axis I (OR = 3.47, p = 0.000) and axis II disorders (OR = 2.27, p = 0.000); obesity was also associated with significantly lower measures of subjective quality of life on physical, social, and psychological domains; comorbidity with axis I/II disorders was associated with lower QoL measures on WHO-QoL-Bref, in particular among obese patients. Conclusions: Obesity is significantly associated with a significant major risk of psychiatric comorbidity and poor quality of life; comorbid mental disorders play a significant role in worsening quality of life of obese patients; a multimodal approach to the treatment of obesity, including psychiatric evaluation and intervention, is needed to improve quality of life of patients.

The aim of this study was two-fold: to make available to the medical community a fast, efficient tool for troubleshooting PCR problems, and to demonstrate that hypermedia allow one to approach this kind of problem in a new, more useful way. The Web provides access to an enormous amount of information in the medical area, and in particular enables troubleshooting of new techniques in the medical laboratory. Currently it is possible to find textual information but it is not always easy to find hypermedia information. In many cases authors change only the means of dissemination of a book or paper to the Web, but do not adapt the information to the features of this new medium. The prototype of our hypermedia application was developed using Director and Flash programs (Macromedia), the application was developed from a decision tree built as a result of information compiled from expert PCR users and the existing literature. It was implemented on a website using Dreamweaver (Macromedia). The usefulness and possibilities of this application have been tested with physicians, medical laboratory technicians, and health science students, and have been proven to be more effective than traditional methods, both in education processes and in helping researchers and medical laboratory technicians in their daily work. The advance and popularization of the Internet in the medical profession requires information on the Web to adapt to the advantages offered by hypermedia. This new step must be taken, and the Web must offer medical users not only a different medium of information distribution but also a new way of handling and obtaining information.

A case of superior vena cava thrombosis secondary to the thoracic outlet syndrome is reported. The diagnosis was revealed by CT-scan and confirmed by phlebography performed to insert a catheter for intrathrombotic infusion of urokinase. The thrombolytic treatment was followed by complete clot lysis. A hyperabduction manoeuvre confirmed costoclavicular compression as the cause of the subclavian-axillary vein thrombosis for which the patient underwent first rib resection. Axillary-subclavian vein thrombosis (or Paget-von Schroetter syndrome) is a relatively frequent complication of the thoracic outlet syndrome often treated with anticoagulants on the basis of a duplex examination. Involvement of the superior vena cava is not readily detected by duplex ultrasound so a partial thrombosis, with a possible fatal outcome could remain undiagnosed. Full investigation by phlebography or CT-scan is therefore recommended. In addition, transcatheter thrombolytic therapy has a lower incidence of follow-up complications than heparin.

Only 1% of the world’s modern fish species live in antarctic waters, but the antarctic fish fauna display a number of different and unique features for large marine ecosystems.1,2 Most of the antarctic fishes possess so many physiological and biochemical peculiarities that they have been considered an extreme in the spectrum of animal diversification and adaptation.3 A well-known example are the icefish (family Channichthyidae), which are unique among vertebrates because they lack hemoglobin and oxygen is transported by the plasma.4 From an evolutionary perspective, the hemoglobin loss was possible due to greater adaptability of a reduced blood viscosity coupled with an increased oxygen solubility in cold antarctic waters. Another remarkable molecular adaptation is the presence of glycoproteins in body fluids that prevents freezing in these fishes and allows them to survive at subzero temperatures.5 The antarctic fish evolved the antifreeze protein at an estimated time of about 14 million years ago.6 From this time, the presence of small ice crystals, thick ice on the surface and on the bottom was no longer an obstacle for their survival and success during the severe cooling of the Southern Ocean.

Hypoplasia of the distal abdominal aorta, first described by Quain in 1847, is rarely associated with atherosclerotic occlusive disease. The condition usually occurs early in life; the principal clinical features are hypertension and arterial insufficiency of the lower extremities which is often well tolerated. Some 20 patients had operations for abdominal aortic hypoplasia; 16 underwent prosthetic reconstruction and four had aortoiliac endarterectomy with angioplasty. Reconstructive techniques were influenced by narrow renal arteries and by the presence of extensive atheroma. The long-term prognosis is often poor, especially in patients with extensive disease.

Surgical treatment for graft thrombosis is often difficult and its outcome is complicated by a high incidence of rethrombosis. The records of 803 patients (1261 limbs) treated with aortofemoral bypass graft for peripheral vascular disease were reviewed. Among these, 71 patients (63 men and eight women with a mean age of 60.2 years) needed an overall number of 125 reoperations. The mean follow-up was 6.3 years. Smoking was significantly higher in these patients compared with those who were not reoperated on. Intimal hyperplasia was the most common lesion responsible for graft thrombosis. Before 'redo' surgery 20 patients with recent thrombosis received thrombolytic treatment; one was subsequently treated with percutaneous transluminal angioplasty and the others underwent reoperation. The best patency rates were achieved with reconstruction of the distal anastomosis with a graft interposition or with a patch angioplasty. Isolated thrombectomy was complicated by early rethrombosis in 53.3% of cases. The overall amputation rate was 14%, the operative mortality rate 5.6%, and the incidence of complications 16.8%. At follow-up a cumulative secondary patency rate of 81.7% at 5 years (74.5% at 10 years), a limb salvage rate of 80.5%, and a survival rate of 89.2% at 10 years were recorded. It is concluded that the only indications for redo surgery following graft thrombosis are severe limb ischaemia or disabling claudication.

was higher in the NRG (p 0.70 was the more accurate RT-MCE value to predict LV regional recovery with positive predictive value of 70% and negative predictive value of 56% (p

The natural history of carotid lesions has generally been evaluated in anedoctal series or in clinical trials. The purpose of this study was to evaluate clinical and pathological modifications linked to an increasing waiting list in our region and the related medico-legal implications.Neurological symptoms that occurred during the waiting period were evaluated in 282 out of 491 patients placed on the waiting list for a carotid stenosis less than 80% or without an unstable plaque. The other 202 patients cancelled their booking. Progression of carotid disease was evaluated by duplex scanning in 116 patients who had a duplex evaluation in our Department both at booking and at the time of operation.The incidence of stroke in a mean waiting period of 8.9 months was 2.6% in symptomatic patients and 1.5% in asymptomatic, respectively; 39 (13.8%) patients experienced an ipsilateral TIA and 4.2% a carotid thrombosis (25% of which symptomatic). The crude mortality-rate was 2.4% with a 1% of related deaths. The cumulative actuarial hard end points rate (stroke, carotid thrombosis and related death) was 7.8% at 12 months and 19.8% at 18 months.This study gives us data about the natural history of carotid stenosis in our country. The high morbidity and mortality-rate related to this lesion and particularly their occurrence within the first 3 months stress the urgency of treatment, and of the planning of specialized Departments in relation to the real incidence of the pathology in order to avoid medico-legal consequences.

The authors report their experience in studying patients undergoing carotid endarterectomy with simple photon emission computed tomography (SPECT). This technique made it possible to identify areas of preoperative cerebral hypoperfusion in 54.8% of the patients which had a good correlation with neurological symptoms. To distinguish gradual changes in the ischemic lesions, a method of assessing the surface of the hypoperfused areas was adopted. In addition, SPECT made it possible to detect a greater number of hypoperfused areas even in sites other than those revealed by CT. Moreover, there was good correlations between the SPECT data and the grade and site of the carotid lesion and the data provided by some intraoperative monitoring procedures. The Authors therefore propose the use of SPECT in the evaluation of patients with cerebrovascular insufficiency following a carotid disease.

The records of 920 patients who underwent carotid endarterectomy by the same surgeon (M. D'A) between 1976 and 1989 were reviewed. Particular attention was paid to both the neurological and general complications and to how and when the neurological symptoms appeared. Among these patients, a cumulative stroke plus death rate of 3.1% was observed. Complications were classified as clamping ischemia (2.2%), postoperative embolism (1.5%), postoperative thrombosis (2.4%), and cerebral haemorrhage (0.3%). Two patients (0.2%) died from myocardial infarction. In 3.5% of patients, neurological symptoms were transient. The incidence of clamping ischemia was higher when 40 mmHg was considered as the safety limit of the back-pressure; this incidence fell by raising this limit to 50 mmHg, and introducing, in recent years, SEPs monitoring. Intraoperative monitoring of SEPs, in fact, reduced the neurological complications to 1.4%, while intraoperative angiography reduced the need for intraoperative reoperation from 10% to 2%. The use of antiplatelet drugs and an accurate surgical technique are useful steps in the prevention of postoperative embolism or thrombosis.

The results of carotid endarterectomy in 521 patients were analyzed to verify whether the early and late outcome in young patients is worse than in older patients, such as the results observed in peripheral arterial reconstruction in young adults. The patients were subdivided into 3 groups: 105 under 55 years, 397 aged between 56 and 74 years and 19 over 75 years. Young patients presented less risk factors and associated diseases than older ones, with the exception of smoking-habit; on the other hand, they presented a higher incidence of early post-operative thrombosis, myocardial infarction and of recurrent stenosis at follow-up. This trend has already been observed in other series. Young age and smoking habit have also been significantly related with recurrent carotid stenosis. In spite of these complications, carotid endarterectomy is indicated in severe stenosis or complicated carotid plaques, in young adults, because of a low operative mortality and a better trend in the follow-up period; however, the pre-operative evaluation needs a more accurate study and, when possible, the normalization of metabolic risk factors and the elimination of smoking.