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Purpose Weight stigma is the negative weight related attitudes and beliefs towards individuals because of their overweight or obesity. Subjects with obesity are often victim of weight-related stigma resulting in a significant negative social consequence. As obesity epidemic is growing so fast, there is urgency to act on weight-stigma related social consequences being potentially serious and pervasive. This study investigated experiences, interpersonal sources, and context of weight stigma in Italy in a sample of adult subjects with obesity. Methods An online questionnaire was distributed to respondents via a snowball sampling method among subjects with obesity belonging to Italian Associations for people living with obesity aged 18 years and above. Results Four hundred and three respondents (47.18 ± 9.44 years; body mass index (BMI) 33.2 ± 8.48 kg/m2) participated to the study. Most respondents were females (94.8%). The age first dieted was 15.82 ± 7.12 years. The mean period of obesity was 27.49 ± 11.41 years. Frequency analyses reported that stigmatizing situations were experienced by 98% of participants: 94.82% during adulthood, 89.88% during adolescence and 75.39% during childhood. Verbal mistreatments (92.43%) was the most reported stigmatizing situation, strangers (92.43%) were the most common interpersonal sources of stigma and public settings (88.08%) were the most common location of stigma. Conclusions Identifying strategies acting on the identified weight stigma targets could contribute to reduce weight stigma and thus to result in important implications for obesity treatment in Italy.

Introduction In Prader–Willi syndrome (PWS) adult patients, sleep-breathing disorders, especially obstructive sleep apnoea syndrome (OSAS), are very common, whose missed or delayed diagnosis can contribute to further increase cardiovascular morbidity and mortality. Purpose The aim of this cross-sectional study was to evaluate differences in sleep-breathing parameters obtained by overnight cardiorespiratory polygraphy in 13 adult PWS patients and 13 individuals with non-syndromic obesity as controls matched by age, sex, and BMI. Methods In all subjects’ anthropometric parameters, body composition using bioimpedance analysis and overnight cardiorespiratory monitoring parameters were obtained. Results Ten (76.9%) PWS patients were diagnosed with OSAS, most notably nine (69.2%) and one PWS (7.7%) with mild and severe OSAS, respectively. Compared with the control group, PWS patients had evidence of higher apnoea–hypopnea index (AHI) (p = 0.04) and oxyhaemoglobin desaturation index (ODI) (p = 0.009). However, no differences were found between the two groups regarding OSAS categories or diagnosis of nocturnal respiratory failure. In the PWS group, there were no significant correlations among AHI, ODI and hypoxemia index (T90) and anthropometric measurements, fat mass (FM), and FM percentage (%). Conversely, in the control group, the sleep-related respiratory indices evaluated correlated positively with BMI, waist circumference, FM and FM%. Conclusions This study confirmed that AHI and ODI indices were worse in PWS than in age, sex and BMI-matched controls. The lack of their significant association with the anthropometric parameters and FM supported the existence of PWS-related mechanisms in OSAS pathophysiology that are independent of visceral obesity and FM.

Funding Acknowledgements Type of funding sources: None. Background Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). A multicentric American case series suggested a greater efficacy of the bilateral (BCSD), compared to the left-side only procedure (LCSD), albeit with a potential impact on chronotropism. The impact of CSD on the risk of electrical storms (ES) in CMP has never been evaluated. Purpose To describe our multicenter experience with CSD in CMP patients with refractory VAs, with a specific focus on ES incidence. Methods Thirty patients with CMP and refractory VAs underwent either LCSD or BCSD between April 2016 and June 2022. Among them, one patient received first LCSD and then right-side CSD due to ES recurrence after LCSD: to properly assess the risk of ES after LCSD and BCSD he was included in both groups, leading to 5 cases of LCSD and 26 cases of BCSD. All patients had a Video-Assisted Thoracoscopic Surgery, in 8 cases with the robotic technique. The main reason (3/5 cases, 60%) to perform LCSD instead of BCSD since the beginning was sinus bradycardia in single ICD lead recipients. Results 87% of pts were male, mean age was 56 ± 16 yrs and mean LVEF 31± 12%; most (n=26, 85%) suffered non-ischemic CMP and 37% were in NYHA class ≥3. Main indications for CSD were refractory polymorphic/fast VAs in 60% of pts and refractory monomorphic VAs in the rest. Except for 5 patients (17%) with previous thyrotoxicosis, the majority were either on amiodarone (n=19, 63%) or on sotalol (n=3, 10%) and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow-up (FU) after CSD was 16 months (IQR 6-42 months). No major complications occurred. Eleven patients (37%) either died during FU (n=8, 27%), mostly due to end-stage heart failure, or underwent heart transplant (n=3, 10%). After CSD, the percentage of patients with ES decreased from 77% to 40% (p Conclusions Our case series of CSD in CMP represents the largest reported in Europe and the first one to evaluate the impact of CSD on electrical storms. The occurrence of electrical storms was more than halved by BCSD confirming the powerful protective effect also on this ominous phenomenon. The greater antiarrhythmic benefit observed among patients with better functional class suggests the opportunity to perform this procedure earlier on in the trajectory of patients with progressive heart failure.

Funding Acknowledgements Type of funding sources: None. Background Acute Physiologic and Chronic Health Evaluation (APACHE), Sequential (sepsis-related) Organ Failure Assessment (SOFA) and Simplified Acute Physiologic Score-2 (SAPS-2) are common predictive scoring systems in the intensive care unit (ICU) used all around the world to predict outcomes in general or specific population (eg. sepsis and septic shock). However, these scores were found to have mixed performance in several subgroups of critically ill patients. Purpose Few and conflicting data are available on patients admitted in the ICU after an out-of-hospital cardiac arrest (OHCA) regarding these prognostic scores. We sought to evaluate the performance of these scores obtained on admission in predicting good neurological outcome at ICU discharge. Methods We enrolled 171 consecutive patients admitted to ICU at our center after being resuscitated from an OHCA from September 2017 to April 2021. APACHE, SOFA and SAPS-2 were available for 133 patients [77% male, mean age 60 (18-90) years, 54% with first shockable rhythm, median number of shocks delivered 1 (0-14), median value of adrenaline administered 3 mg (0-12), 26% received amiodarone, median cardiac arrest duration 38 min (IQR 22-74)]. Worst values collected during the first 24 hours were considered for APACHE and SAPS-2 calculations, whereas SOFA was assessed at 24 hours from admission. The median values of each one of the three scores of patients with and without good neurological outcome (cognitive performance category 1-2) at ICU discharge were compared with Mann-Whitney U-test. For each one of the scores the Receiver Operating Characteristic (ROC) curve was analysed and the corresponding area under the curve AUC with its 95%CI was calculated, with the endpoint of survival with good neurological outcome at ICU discharge. Results patients with good neurological outcome had lower values of APACHE [22 (IQR 19-25) vs 24 (IQR 21-28)(p=0.01], SOFA [9 (IQR 7-10) vs 10 (IQR 8-12)(p Conclusion SAPS-2 score discriminates survival with good neurological outcome at ICU discharge significantly better than APACHE and SOFA in patients resuscitated from an OHCA and admitted to the ICU. These results could help clinicians in identifying which patients yield a better prognosis after 24 hours of clinical observation in the ICU and could therefore be safely and rapidly discharged to the ward.

Funding Acknowledgements Type of funding sources: None. Background Since its proposal, Vasoactive Inotropic Score (VIS) was applied in different setting of acute critical care (e.g. pediatric population or post-cardiac surgery). It reflects the pharmacological support of the cardiovascular system and higher VIS values in the first 24 hours from ICU admission predict worse outcomes, both in pediatric and adult population. Few data are available regarding patients admitted for an Out of Hospital Cardiac Arrest (OHCA). The aim of this work is to investigate the prognostic role of VIS score in this population. Methods We enrolled 171 consecutive patients who were resuscitated after an OHCA and admitted to ICU at our center from September 2017 to April 2021. VIS score on admission was available for 144 patients. We divided the population in two groups (high vs low VIS score) according to VIS score median values. For every patient neurological outcome at discharge and survival at one year were available. Results Median VIS score was 10 so we considered low values ≤ 10 (group 1) and high values > 10 (group 2). There were 73 patients in low VIS group (Group 1) and 71 in high VIS group (Group 2). No differences were found in the two groups regarding sex (75% males vs 74%, p=0.88), age [64 (49-70) vs 61 (52-74), p=0.5], SAPS II score at admission [63.61 (53-70) vs 65.46 (61-86), p=0.54], shockable rhythm as first rhythm (60.2% vs 51.51%, p=0.3) and number of shocks delivered [median value 1 (0-13) vs 1 (0-14), p=0.84]. On the contrary, patients with lower VIS values had a shorter arrest duration [26 mins (19-40) vs 41 mins (27-74), p=0.0002] and less adrenaline delivered [2 mg (0-6) vs 3 mg (0 -12), p=0.0012]. Moreover, patients with lower VIS score values on admission showed a better neurological outcome (defined as a CPC < 2) at ICU discharge (44% vs 21%, p=0.08). In addition, patients in group 1 showed a lower mortality rate as compared to group 2 [60% (44/73) vs 76% (54/71),p=0.0048]. Conclusion in adult patients resuscitated from an out-of-hospital cardiac arrest and admitted to an ICU, lower values of VIS score were associated with higher survival at 1 year. Moreover patients with low VIS showed better neurological outcome at ICU discharge. This could be explained by the fact that VIS express the need for cardiovascular support and is lower in patients with a more stable hemodynamic status after OHCA, reflecting a less compromised clinical condition.

Funding Acknowledgements Type of funding sources: None. Background Global hypoperfusion causes tissue hypoxia, resulting in overproduction of lactate because of impaired mitochondrial oxidation, causing lactic acidosis (LA). Base excess (BE) is defined as the amount of acid or base required to return the pH to 7.4 in the setting of a normal Paco2 and is therefore related to the degree of acid production following injury. Purpose Our hypothesis was that lactate levels, BE levels and occurrence of LA on admission could help in early risk stratification in patients admitted to the ICU after an out-of-hospital cardiac arrest (OHCA). Methods we enrolled 171 consecutive patients resuscitated from an OHCA and admitted to ICU at our center from September 2017 to April 2021. Blood gas analysis on admission was available for 140 patients [77%male, mean age 60 (18-90) years, 54% with first shockable rhythm, median number of shocks delivered 1 (0-14), median dose of adrenaline administered 3 mg (0-12), 26% received amiodarone, median cardiac arrest duration 38 min (IQR 22-74 min)]. Patients with low lactate levels were compared with patients with high lactate levels (cutoff 2 mmol/l as per standard practice), patients with low BE levels were compared with patients with high BE levels (cutoff -8.5 mmol/l, median value) and patients with LA were compared with patients without LA (defined as pH 2mmol/). Survival with good neurological outcome (CPC 1-2) at ICU discharge and 30-day survival were investigated for each group with chi-squared test. Then, one-year survival was investigated for each group with Kaplan-Meier analysis. Results Patients with low BE (< -8.5 mmol/l) had a significantly lower survival with good neurological outcome at ICU discharge (p=0.0017), lower survival at 30 days (p < 0.0001) and 365 days (p - 8.5 mmol/l). Low lactate levels (< 2 mmol/L) were associated with higher survival with good neurological outcome at ICU discharge (p< 0.0001), higher survival at 30 days (p < 0.0001) and 365 days (p = 0.0002) compared to higher lactate levels (> 2 mmol/l). The occurrence of LA on admission was significantly associated with lower survival with good neurological outcome at ICU discharge (p=0.001), lower 30-days survival (p=0.001) and 365-days survival (p Conclusion high blood lactate levels, low base excess and lactic acidosis predict short-term and long-term survival in patients admitted to the ICU after an OHCA. These results could help clinician in the identification of populations with different risk profile with the first blood gas analysis obtained at ICU admission.

Funding Acknowledgements Type of funding sources: None. Backround Regional and general hypoperfusion cause hypoxia, resulting in excess production of lactate secondary to reduced mitochondrial oxidation. Peripheral perfusion index (PI) is the fraction of the pulsatile blood flow to the non-pulsatile blood in peripheral tissue obtained by standard pulse-oximetry. Recent literature has highlighted its association with both survival and ECG reliability in patients resuscitated from an out-of-hospital cardiac arrest (OHCA). Purpose We raised the hypothesis that the mean value of PI over 30-minutes monitoring (MPI30) after ROSC in patients resuscitated from an OHCA is associated with the probability of detecting a lactic acidosis (LA) at the first arterial blood gas analysis available after ICU admission. Materials and Methods This was a retrospective study, obtaining data from our cardiac arrest registry. Among 172 post-ROSC patients admitted to the ICU (between 1st January 2017 and May 2021) post-ROSC MPI30 was available in 76 patients: 54 (72%) males; median age 70 years (IQR 59-77). PI was automatically and continuously measured by the manual monitor/defibrillator (Corpuls by GS Elektromedizinische Geräte G. Stemple GmbH, Germany) once the pulse oximeter was placed, then registered in the report. The population was divided in quartiles according to MPI30 values, then the incidence along the quartiles were compared with chi-squared test. The association between MPI30 and LA incidence was investigated both with univariate and multivariate logistic regression. Results LA was documented in 57% of the study population. We found a significant trend toward reduction of incidence of LA along the four quartiles (p=0.0386). Univariate logistic regression showed a statistically significant association between MPI30 and LA on admission [OR 0.62 (95%CI 0.44-0.89), p=0.005] which was confirmed after correction for age and sex [OR 0.63 (95%CI 0.43-0.91), p=0.009]. Conclusions Low perfusion as measured by MPI30 after ROSC predicts a higher incidence of lactic acidosis in patients on admission to the ICU. Our results could help clinicians in identifying patients at risk for metabolic derangements even before a blood gas analysis is obtained.

Funding Acknowledgements Type of funding sources: None. Introduction The optimal energy level for shock in biphasic waveform defibrillation represents a significant knowledge gap. Different energy regimens have been trialed; however, a selection criterion which may help in adopting one approach over another has never been identified. Choosing the maximum energy may be an option but current-induced myocardial damage should not be neglected and an effort to tailor energy delivery is desirable. Purpose To assess whether amplitude spectral area (AMSA) of VF can guide the dose-regimens of defibrillation in out-of-hospital cardiac arrest (OHCA) patients. Methods This is a multicenter study based on the data from some of the largest OHCA registers in Europe, which enrolled 830 OHCA patients who received at least one shock during advanced resuscitation. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 and LIFEPAK 12/15 monitors/defibrillators and by using a 2-second-pre-shock ECG interval. Results Among 830 OHCAs, 2135 shocks were delivered from a minimum energy level of 150 J to a maximum of 360 J. The AMSA values of efficacious shocks delivered at 150 J were higher compared to those of efficacious shock at 360 J [13.1 (IQR 10.2-17.1) vs 11.8 (IQR 8.3-15.2) HzxmV; p Conclusion This is the first study to identify a datapoint to guide decision-making with regards to defibrillation with lower energy levels. AMSA could indeed guide the selection of energy levels in order to optimize efficaciousness in restoring a perfusing rhythm while minimizing the contribution to myocardial dysfunction.

Despite Polycystic Ovary Syndrome (PCOS) is a very prevalent disorder among women of reproductive age, there is widespread agreement that until now, no pharmacological options are available to tackle the entire spectrum of clinical manifestations encountered in the clinical practice. Obesity and insulin resistance, which commonly characterized this syndrome, prompted the design of studies investigating the effects of glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RA) in PCOS. Indeed, a very impressive number of randomized controlled clinical trials (RCTs) and systematic reviews provided robust evidence on the effectiveness of GLP-1RA in PCOS as a new, appealing approach, producing both satisfactory and permanent weight loss, and improvement of insulin resistance at the same time. However, most of the subjects included in the RCTs are PCOS patients with obesity/overweight, whereas a portion of PCOS women, which can even reach 50%, might present a lean phenotype. Moreover, some benefits on clinical and metabolic features of PCOS may not have fully emerged due to the low or medium doses employed in the vast majority of the current studies. Thus, pitfalls in the methodology of these studies have led sometimes to misleading results. In addition, some aspects of GLP-1 beyond weight loss, such as preclinical evidence on GLP-1 effects in directly modulating the hypothalamus–pituitary–gonadal axis, or the effects of GLP-1RA on clinical and biochemical expression of hyperandrogenism, still deserve a greater insight, especially in light of a possible therapeutic use in PCOS women independently of obesity. Aim of this review is to further unravel the possible role of GLP-1 in PCOS pathogenesis, tempting to provide additional supports to the rationale of treatment with GLP-1RA in the management of PCOS also independent of weight loss. For this purpose, the outcomes of RCTs investigating in PCOS the anthropometric and metabolic changes have been treated separately to better underpin the effects of GLP-1 RA, in particular liraglutide, beyond weight loss.

Background The hypothalamic–pituitary–adrenal (HPA) axis is a neuroendocrine system involved in controlling stress responses in humans under physiological and pathological conditions; cortisol is the main hormone produced by the HPA axis. It is known that calorie restriction acts as a stressor and can lead to an increase in cortisol production. Renin–angiotensin–aldosterone system (RAAS) is a complex endocrine network regulating blood pressure and hydrosaline metabolism, whose final hormonal effector is aldosterone. RAAS activation is linked to cardiometabolic diseases, such as heart failure and obesity. Obesity has become a leading worldwide pandemic, associated with serious health outcomes. Calorie restriction represents a pivotal strategy to tackle obesity. On the other hand, it is well known that an increased activity of the HPA may favour visceral adipose tissue expansion, which may jeopardize a successful diet-induced weight loss. Very low-calorie ketogenic diet (VLCKD) is a normoprotein diet with a drastic reduction of the carbohydrate content and total calorie intake. Thanks to its sustained protein content, VLCKD is extremely effective to reduce adipose tissue while preserving lean body mass and resting metabolic rate. Purpose The purpose of this narrative review is to gain more insights on the effects of VLCKD on the HPA axis and RAAS, in different phases of weight loss and in different clinical settings.

Introduction In case of cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), the optimal energy level for defibrillation is that which achieves defibrillation and minimize the current–induced myocardial damage. Therefore, it would be reasonable to reduce the energy level as well as the number of shocks. ECG–based VF waveform analysis features such as amplitude spectral area (AMSA) have been recently introduced as predictors of shock success but their predictivity for shock success with low energy level is not known. We aimed to assess whether AMSA of VF is able to predict the efficacy of low energy level for defibrillation in out–of–hospital cardiac arrest (OHCA) patients. Methods All the OHCAs with at least one shockable rhythm occurred from January 2015 to December 2020 in the province of Pavia, Italy, were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators and by using a 2–second–pre–shock ECG interval. Results Among 4619 OHCA, AMSA values and energy for defibrillation were documented in 791 shocks, of which 45% received a shock at low energy (150J). The rate of efficacy between the two groups did not differ significantly (44% vs 38%, p=0.102), however in patients efficaciously treated with low energy, AMSA was higher compared to those efficaciously treated with high energy [13.2 mV·Hz (12.5–14.2) vs 10.8 (10.1–11.5), p Conclusion Amplitude spectral area of VF is a predictor of shock success at low energy. This could be useful to optimize the choice of energy limiting the current related myocardial injury.

Introduction Ventricular fibrillation (VF) Amplitude Spectral Area (AMSA) is a well-established predictor of successful defibrillation and return of spontaneous circulation (ROSC). Attending to the limited evidence on the topic, gender seems to affect AMSA, and higher values have been reported in females. The aim of this work was to investigate the effect of gender in AMSA values for patients suffering out-of-hospital cardiac arrest (OHCA). Methods We enrolled 4619 consecutive OHCA patients from January 2015 to December 2020 in the LombardiaCare Registry. We considered only those subjects with attempted cardio-pulmonary resuscitation (697 patients) and at least one shock delivered. A total of 250 patients were considered (40 F/ 210 M) with 830 shocks (100 F/ 730 M). AMSA values were computed for the ventricular fibrillation in the 2-s pre-shock interval of the ECG recorded by the Corpuls3 defibrillator (Corpuls, Kaufering, Germany). Results Female patients were older than male [median (IQR): 70.5 (62–72) vs 67 (55–75) years, p=0.01], with cardiac arrest more frequently at home (84% vs 76%, p=0.003), fewer shocks [2 (1–4) vs 4 (2–7), p=0.004] and higher percentage of success (53% vs 40%, p=0.009). On the contrary, cardiac arrest duration [ 58.7 (31–69) vs 57.6 (41.4–77.3) min, p=0.366] and the rate of ROSC (32% vs 33%, p=0.88) were similar in both groups. Higher AMSA values were found in female patients [10.3 Hz-mV (6.6–13.5) vs 7.9 Hz-mV (5.2–12.1), p=0.0007]. At a multivariable analysis, after correction for witnessed status, bystanders CPR, amiodarone administration, age and call-to shock time, male sex was found to be independently associated with the probability of having low values of AMSA, below the median value of 8.3 Hz-mV [OR 2.15 (95% CI1.35–3.43), p=0.001]. Despite gender stratification ROC curve analysis confirmed AMSA as a predictor of shock success [AUC-F: 0.75 (95% CI 0.65–0.83), p Conclusion Female sex is related to higher AMSA values. As AMSA reflects the energetical status and the ATP levels in the myocardial cells during cardiac arrest, this difference may be due to lower incidence and lower severity of cardiac ischemic disease in women. AMSA remains a valid predictor of both shock success and ROSC for female and male patients. Further investigations are needed to support and comprehend these conclusions. Funding Acknowledgement Type of funding sources: None.

Background Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). Purpose The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance and reliability in real-world clinical practice. Methods We analyzed ECG and angiographic data from 408 consecutive STEMI patients submitted to primary percutaneous coronary intervention, dividing the overall population into derivation (306 patients) and validation (102 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance and reliability in the validation cohort. Results In the derivation cohort, the algorithm correctly predicted the IRA in 91% of cases and both the IRA and its occlusion level (proximal vs. mid-distal) in 73% of cases. When applied to the validation cohort, the algorithm resulted in 90% and 69% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (p=0.026 vs. best cardiologist and p Conclusions Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients. Funding Acknowledgement Type of funding sources: None.

Background Brugada Syndrome (BrS) is an inherited disorder associated with an increased risk of sudden cardiac death (SCD) and is diagnosed by the presence of a Brugada type I ECG pattern, either spontaneous or drug-induced. A spontaneous ECG pattern is one of the two main risk factors for SCD, along with syncope. However, there is still no clear evidence on how and how often to screen patients with drug-induced BrS to detect a spontaneous ECG pattern, therefore allowing to reassess their arrhythmic risk. Purpose To determine how many subjects develop a spontaneous ECG pattern among a pool of patients with low risk BrS (drug-induced pattern without history of syncope at the time of diagnosis) observed through systematic ECG Holter monitoring. Methods We retrospectively collected data for all patients with low risk BrS treated at our center for at least 12 months between 2016 and 2021. Each patient was tested yearly with at least one 12-lead 24-hour ECG Holter monitoring with high precordial leads (V1-V2, V3-V4, V5-V6 respectively in 2nd, 3rd and 4th intercostal space parasternal left and right). In case of spontaneous pattern detection at two recordings, patients underwent electrophysiological study (EPS) and in case of inducible ventricular arrhythmias, implantable cardiac defibrillator (ICD) placement. Results We included 63 patients with low risk BrS. During a median follow-up of 48 months: 1 patient died for SCD (1.6%), 1 experienced syncope (1.6%) and 19 exhibited a spontaneous ECG pattern (30.2%). Of these 19 patients: 18 were males and 5 had a mutation of SCN5A; the average age at the time of spontaneous pattern detection was 48.1±11.5 years. The average number of ECG holters/per patient/per year was 1.1±0.6, the average number of ECG Holters until the detection of a spontaneous pattern was 3.3±1.8, whilst the average number of months in between the diagnosis and the detection of a spontaneous pattern was 43.2±41.1. After the observation of a spontaneous pattern: 6 patients were excluded from further investigation (as they had already undergone EPS or refused), 1 was directly treated with ICD and 12 underwent EPS, 4 of whom consequently underwent ICD placement. Among these 5 patients who underwent ICD placement – 7.9% of the original 63 patients – we observed 1 appropriate ICD intervention (antitachycardia pacing), 1 inappropriate ICD shock and 1 ICD related complication. Conclusions In our population of patients with low risk BrS the detection of a spontaneous ECG pattern is the most common determinant of risk reclassification. Systematic ECG Holter monitoring disclosed the presence of a spontaneous ECG pattern in a relevant number of subjects, allowing to reassess their arrhythmic risk and indication for ICD placement. Our study stresses the importance of periodic evaluation of low risk BrS patients with ECG Holter monitoring and the need for further investigation to define the optimal monitoring strategy. Funding Acknowledgement Type of funding sources: None.

Background The use of antiarrhythmic drug therapy is usually recommended in addition to defibrillation in shockable cardiac arrest. The role of the amplitude spectral area (AMSA) of ventricular fibrillation as a predictor of defibrillation efficacy has been established, but little is known about how amiodarone could affect AMSA values. Purpose The aim of our study was to evaluate whether the administration of amiodarone during resuscitation could affect AMSA and to verify if AMSA preserves its predictive role of shock success in OHCA patients treated with amiodarone. Material All the OHCAs with an attempted resuscitation and at least one shockable rhythm which occurred from January 2015 to December 2020 in the province of Pavia were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators (Corpuls, Kaufering, Germany) used in the field and by considering a pre-shock interval of 2 seconds. Results Of 4619 OHCAs, 697 underwent attempted CPR with at least one shock delivered. Of these, AMSA was available on 250 patients (male 84%, median age 67 years), for a total of 830 shocks, of which 534 (64%) shocks were in patients receiving amiodarone. The success rate of each single shock was similar in the two groups (amiodarone 42% vs no amiodarone 41%, p=0.68). The AMSA median values were significantly lower in the amiodarone group as compared to the non-amiodarone group when shocks were delivered to patients older than 67 years old [median difference: 1.55 mV Hz (95% CI 0.6–2.5), p=0.0013] or receiving bystander CPR [median difference 0.9 mV Hz (95% CI 0.1–1.8), p=0.03] or after more than 33 minutes from the emergency call to each single shock [median difference: 0.91 mV Hz (95% CI 1.9–0.01), p=0.047]. AMSA value lower than the median (8.3 Hz mV) was associated with a lower probability of shock success (19% vs 64%, p Conclusions Amiodarone administration is independently associated with lower values of AMSA. This could justify the lack of benefit from amiodarone administration in term of defibrillation success which would be expected by the administration of an antiarrhythmic drug during the resuscitation. Moreover, AMSA maintains its predictive value for shock success and ROSC rate in patients receiving amiodarone as well as in the general population. Funding Acknowledgement Type of funding sources: None.

Background The autonomic system plays a pivotal role in ventricular arrhythmogenesis. Percutaneous stellate ganglion block (PSGB) is a technique known since many years for analgesic purposes, which has recently proven its antiarrhythmic effect suitable for an emergency setting. However, evidences are limited and heterogeneous. Purpose To assess the efficacy and safety of PSGB performed with an anterior paratracheal approach using anatomical landmarks in consecutive patients with electrical storm refractory to conventional treatment. Methods Patients with electrical storm were consecutively enrolled from November 2017 to January 2022. Left PSGB (PLSGB) was performed after failure of at least one intravenous antiarrhythmic drug. Its repetition or a continuous infusion of the local anaesthetic were considered in selected cases. Clinical data, the characteristics of the block and the occurrence of complications were collected. The efficacy was evaluated by comparing the number of arrhythmias treated with ATP or DC-shocks by external or internal defibrillator in the hour before the block with that in the hour after the procedure. Per-patient efficacy was assessed by comparing the number of ATP/shocks in the 24 hours before the procedure with that in the 24 hours after the last procedure. Results 28 patients were enrolled: 78% male, mean age 65.4±14.2 years; 9 with dilated cardiomyopathy, 8 with chronic ischemic heart disease, 7 with ST-elevation myocardial infarction, 2 with non-ST-elevation myocardial infarction, 1 with arrhythmogenic right ventricular dysplasia and 1 with drug intoxication; the average ejection fraction was 24.2±15%. A total of 44 PLSGBs were performed: 18 for ventricular tachycardia (VT), 11 for ventricular fibrillation (VF) and 15 for both VT and VF episodes; 7 on intubated patients, 3 in extracorporeal circulation, 7 in cardiogenic/septic shock, 22 on patients on single antiplatelet therapy, 7 on dual antiplatelet therapy, 25 on anticoagulant therapy. PLSGBs were performed during intravenous infusion of antiarrhythmics (amiodarone in 24, lidocaine in 27 procedures). The local anaesthetic used was lidocaine 200 mg in 16/44 PLSGB, bupivacaine 50 mg in 4/44 and both in 24/44. The per-procedure analysis showed a significant reduction of the number of ATP/shocks in the hour after PLSGB compared with the hour before [0 (0–0) vs 5 (1–8) p Conclusions This is the largest case series so far in which PLSGB has proven to be highly effective and safe in the treatment of challenging patients with refractory electrical storm. Its safety and the exiguity of the equipment required for the anatomical approach make PLSGB a technique that can be easily performed by cardiologists at the bedside. Funding Acknowledgement Type of funding sources: None.

Introduction In case of cardiac arrest due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), the optimal energy should be the lowest energy effective to achieve defibrillation minimizing the current-induced myocardial damage. Therefore, it would be ideal to minimize the energy level as well as the number of shocks during resuscitation. ECG-based VF waveform analysis features such as amplitude spectral area have been recently introduced as predictors of shock success, but their predictivity for shock success with low energy level is not known. Purpose To assess whether amplitude spectral area (AMSA) of VF is able to predict the efficacy of low energy level defibrillation in out-of-hospital cardiac arrest (OHCA) patients. Methods All the OHCAs with at least one shockable rhythm that occurred from January 2015 to December 2020 were considered. AMSA values were calculated by retrospectively analyzing the data collected by the Corpuls 3 monitors/defibrillators and by using a 2-second-pre-shock ECG interval. Results Among 4619 OHCAs, resuscitation was attempted in 2982 (64%) and at least one shock was delivered in 697 (15%). AMSA values and defibrillation energy were available for 791 shocks, of which 45% received shock at low energy (>150J) and 55% at high energy (>150J). The rate of efficacy between the two groups was similar (44% vs 38%, p=0.102). However, in patients efficaciously treated with shock at low energy, AMSA was higher compared to those treated with shock at high energy [13.2 mV Hz (IQR 10.2–17) vs 10.8 mV Hz (IQR 8–13.8), p Conclusion Ventricular fibrillation amplitude spectral area is a predictor of shock success at a low energy level. This could be useful to optimize both time and dose-energy to patients, yielding the highest chance for successful defibrillation while reducing the number of futile shocks and thus limiting the total current myocardial energy as well as CPR interruptions. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Clinical presentation and outcome of out-of-hospital cardiac arrest (OHCA) presenting with shockable rhythm may vary between males and females. Very limited data exist on gender-related differences in OHCAs with refractory ventricular arrhythmias (VA) and, in particular, on distribution and prevalence of coronary artery disease (CAD). Purpose The aim of this study was to characterize gender-related outcome, prevalence and severity of CAD in OHCA victims presenting with shockable rhythm and refractory VA. Methods All OHCAs presenting with shockable rhythm occurred between 2015 and 2019 in the province of Pavia (Italy) and in the Canton Ticino (Switzerland) were included. Results Out of 3592 OHCAs, 685 presented with shockable rhythm and, of them, 212 had a refractory VA. Overall, male gender was independently associated with a lower probability of survival both at hospital admission and at 30-days (OR 0.63, 95% CI 0.58-0.67, p Conclusions Male gender is more frequently associated with refractory VA, lower probability of survival and higher prevalence and severity of CAD. CAD severity, however, does not significantly affect refractory VA presentation.

Funding Acknowledgements Type of funding sources: None. Introduction Previous studies have reported a significant decrease in ventricular sensing amplitude during follow-up in patients with arrhythmogenic cardiomyopathy (ACM) implanted with trans-venous implantable cardioverter defibrillator (ICD). No data are yet available on sensing amplitudes values over time for subcutaneous ICD (S-ICD). Low QRS voltage on surface ECG is one of the diagnostic clues in ACM. This, together with the progressive nature of the disease and the not-negligible incidence of inappropriate shocks due to oversensing, raise safety concerns on the use of S-ICD in this population. Aim The aim of this study was to evaluate the trend of QRS amplitude on subcutaneous ECG (S-ECG) over time in patients with ACM implanted with S-ICD. Methods We conducted a retrospective analysis on a cohort of consecutive patients with ACM implanted with S-ICD in two tertiary centers, prospectively enrolled in the home-monitoring program. The S-ECGs recorded by the S-ICD at the time of first and last data transmission were analyzed. The voltage amplitude was estimated for each QRS complex available, and the values obtained were compared between the two time points (i.e. baseline and last follow-up available). The primary endpoint of our study was the proportion of patients in which the decrease of QRS amplitude during follow-up was statistically significant. Results Eleven patients (1 female, 9%) were enrolled in this study. The mean age was 43±10 years. An exclusive right ventricular involvement was reported in 5 patients (46%), 2 patients (18%) had an exclusive left ventricular, and 4 (36%) a biventricular involvement. Three patients (27%) were implanted in secondary prevention. During a median follow-up of 9 months (IQR 6-17), 6 patients (55%, 95%CI 24-84%) experienced a statistically significant reduction in the S-ECG QRS amplitude (Figure A). Considering these 6 patients, the mean absolute reduction was -0.46±0.32 mV corresponding to a relative reduction of -19%±11%. Moreover, we found a statistically significant correlation between follow-up duration and QRS amplitude relative reduction (r=-0.89, p=0.018, Figure B). No patients experienced inappropriate shocks. Conclusions In a cohort of ACM patients implanted with S-ICD the majority of patients experienced a significant reduction in the amplitude of QRS voltage during follow-up, confirming a potential safety concern on the use of S-ICD in this population. Further studies are needed to investigate this issue.

Funding Acknowledgements Type of funding sources: None. Background Sudden cardiac death is a major issue in industrialised countries and survival of patients who suffered from an out-of-hospital cardiac arrest (OHCA) remains awfully low. An acute myocardial infarction is the principal cause of OHCA and myocardial revascularisation plays a positive role in survival. In this particular setting little is known about the role of complete versus culprit-only revascularisation on survival. Purpose The aim of the present study was to assess whether a complete revascularisation could lead to a better one-year survival as compared to culprit-only revascularisation. Methods All the patients prospectively enrolled in the OHCA registry of the Lombardy region (Lombardia CARe) from January 1, 2015 to May 1, 2021 in the province of Pavia who underwent a coronary angiography at our Polyclinic were enrolled in the study. All the coronary angiographies were retrospectively reviewed by two interventional cardiologists and angiographic features were inserted in the database. Prehospital data and survival were retrieved from the registry according to the Utstein style. Results We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; presenting shockable rhythm 84.1%; acute myocardial infarction at post ROSC ECG 67.9%; ejection fraction 37% (30-45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with a multi-vessel disease 82 (69%) received an incomplete revascularisation whereas 37 (31%) were completely revascularised [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5-10) days]. This latter group showed a significantly higher one-year survival (54.9% vs 16.2%, p Conclusions A complete revascularisation is independently associated with a better one-year survival in patients resuscitated from an out-of-hospital cardiac arrest.

Introduction Previous studies have reported a significant decrease in ventricular sensing amplitude during follow–up in patients with arrhythmogenic cardiomyopathy (ACM) implanted with trans–venous implantable cardioverter defibrillator (ICD). No data are yet available on sensing amplitude values over time for subcutaneous ICD (S–ICD). Low QRS voltage on surface ECG is one of the diagnostic clues in ACM. This, together with the progressive nature of the disease and the not–negligible incidence of inappropriate shocks due to oversensing, raise safety concerns on the use of S–ICD in this population. The aim of this study was to evaluate the trend of QRS amplitude on subcutaneous ECG (S–ECG) over time in patients with ACM implanted with S–ICD. Methods We conducted a retrospective analysis on a cohort of consecutive patients with ACM implanted with S–ICD in two Italian tertiary centers, prospectively enrolled in the home–monitoring program. The S–ECGs recorded at the time of first and last data transmission were analyzed. The voltage amplitude was estimated for each QRS complex available, and the values obtained were compared between the two time points (i.e. baseline and last follow–up available). The primary endpoint of our study was the proportion of patients in which the decrease of QRS amplitude during follow–up was statistically significant. Results Eleven patients (1 female, 9%) were enrolled in this study. The mean age was 43±10 years. An exclusive right ventricular involvement was reported in 5 patients (46%), 2 patients (18%) had an exclusive left ventricular, and 4 (36%) a biventricular involvement. Three patients (27%) were implanted in secondary prevention. During a median follow–up of 9 months (IQR 6–17), 6 patients (55%, 95%CI 24–84%) experienced a statistically significant reduction in the S–ECG QRS amplitude (Fig. A). Considering these 6 patients, the mean absolute reduction was –0.46±0.32 mV corresponding to a relative reduction of –19%±11%. Moreover, we found a statistically significant correlation between follow–up duration and QRS amplitude relative reduction (r=–0.89, p = 0.018, Fig. B). No patients experienced inappropriate shocks. Conclusions In a cohort of ACM patients implanted with S–ICD the majority of patients experienced a significant reduction in the amplitude of QRS voltage during follow–up, confirming a potential safety concern on the use of S–ICD in this population. Further studies are needed to investigate this issue.

Background Sudden cardiac death is a major issue in industrialised countries and survival of patients after out–of–hospital cardiac arrest (OHCA) remains low. Acute myocardial infarction (AMI) is the principal cause of OHCA and myocardial revascularisation plays a positive role on survival. In this setting little is known about the role of complete (CR) versus culprit–only revascularisation (IR) on survival. Purpose The aim of this study was to assess whether CR could lead to a better one–year survival as compared to IR. Methods. Among patients prospectively enrolled in the Lombardia CARe OHCA registry from January 1 2015 to May 1 2021, who underwent a coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo were enrolled in this study. CAGs were retrospectively reviewed by two interventional cardiologists. Prehospital and survival data were retrieved from the registry. Results We enrolled 239 patients [mean age 63.7±12.4 years; male 79.9%; shockable presenting rhythm 84.1%; AMI at post ROSC ECG 67.9%; ejection fraction 37% (30–45), circulatory support with ECMO 10.9%]. Among the 119 (50%) patients with multi–vessel disease, 82 (69%) received IR whereas 37 (31%) received CR [8 during the first procedure, 29 in a second procedure with a median time after OHCA of 5 (2.5–10) days]. This latter group showed significantly higher one–year survival (54.9% vs 16.2%, p Conclusions Complete revascularisation is independently associated with a better one–year survival in patients resuscitated from an out–of–hospital cardiac arrest.

Introduction Cardiac arrests in sports can involve professional athletes, amateurs, but also spectators of sports competitions. Sports facilities are the only ones for which the current law provides for the presence of an automatic external defibrillator (AED) and trained personnel, unlike other public places (schools, work, street, station, general public buildings) where it is only recommended. Objective To compare patient characteristics, presentation rhythm, bystander cardiopulmonary resuscitation (CPR), AED use before emergency medical services (EMS) arrival, and return of spontaneous circulation (ROSC) longer than 30 seconds in the Utstein category of out–of–hospital cardiac arrests (OHCAs) in sports compared to events in other public places. Materials and Methods We considered all the OHCAs occurred from 01/01/2015 to 31/12/2020 in the provinces of Pavia, Lodi, Cremona, Mantua and Varese (2400000 inhabitants), excluding the OHCAs occurred at home, in long–term care facilities and witnessed by the EMS. Results During the study period, 22 OHCAs occurred in sports and 552 in other public places (school, work, street, station, public buildings). The age is similar in the two groups [sport 59 years (IQR 53.5–66.7) vs other 63 years (IQR 51–75), p = 0.2]. In sports, there is a trend in favor of shockable rhythms (13/22=59% vs 185/552=33%, p = 0.1). The percentage of CPR performed by bystanders in sports is significantly higher than in other public places (20/22=91% vs 299/552=54%, p = 0.003), as the bystander AED use (11/22=50% vs 64/552=12%, p Conclusions During sports competitions there is a greater ability to intervene in case of cardiac arrest, which determines a higher probability of obtaining ROSC, although in terms of age or presentation rhythm the patients are comparable to OHCA victims in other places public. These results suggest the need for an AED and trained personnel in other public places as well.

Background Once the return of spontaneous circulation (ROSC) after an out–of–hospital cardiac arrest (OHCA) is achieved in patients with an ST–elevation myocardial infarction, the acquisition of a 12–lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients. Methods We analysed all the post–ROSC ECGs collected from January 2015 to December 2018 in three European centres (Pavia, Lugano and Vienna). For every ECG, the main features were analysed and filed in the database together with the pre–hospital data collected for every patient according to the Utstein style. Results We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53–70 years); 121 from Pavia (32.7%), 38 from Lugano (10.3%) and 211 from Vienna (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95% IC 1.1–2.4), p = 0.007], QRS wider than 120 msec [HR 1.87 (95% IC 1.3–2.7), p Conclusions Our study confirms the central role of ECG in STEMI patients resuscitated after an OHCA and proves that post–ROSC ECG features can be used for both the selection of patients who may benefit from urgent coronary angiography as well as for prognostic stratifications.

Funding Acknowledgements Type of funding sources: None. Background Once the return of spontaneous circulation (ROSC) after an out-of-hospital cardiac arrest (OHCA) is achieved the acquisition of a 12-lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients. Purpose The aim of the present study is to assess whether ECG features could be associated with survival to hospital discharge. Methods We analysed all the post-ROSC ECGs collected from January 2015 to December 2018 in three European centres. For every ECG, the main features were analysed and filed in the database together with the pre-hospital data collected for every patient according to the Utstein style. Every ECG was evaluated by two independent cardiologists and in case of doubt a third one was asked to solve the dispute. Results We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53-70 years); 121 from center 1 (32.7%), 38 from center 2 (10.3%) and 211 from center 3 (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95%CI 1.1-2.4), p=0.007], QRS wider than 120 msec [HR 1.87 (95%CI 1.3-2.7), p Conclusions Our study proves that after an out-of-hospital cardiac arrest, post-ROSC ECG features can be used for prognostic stratification in addition to the selection of patients who may benefit from urgent coronary angiography.

Introduction According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival > 1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of out–of–hospital cardiac arrest (OHCA) survivors with major neurological outcomes. Cerebral Performance Category (CPC) is the most widespread scale to define the neurological and functional outcome of OHCA survivors, but it is not known if it can be used to guide ICD implantation. Objective To evaluate whether the presence of a bad neurological outcome (CPC > 2) at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD in OHCA survivors. Materials and Methods. We considered all the patients who had a cardiac arrest from 01/10/2014 to 30/09/2019 presenting a CPC> 2 at discharge. The territory included was that of the Province of Pavia (550000 inhabitants) from 2014 to 2018 and of the Provinces of Pavia, Lodi, Cremona and Mantua (1550000 inhabitants) from 2019. We assessed the survival and the neurological status variation at 1–year. Results In the study period, CPR was attempted in 2998 confirmed OHCAs. 227 patients (7.6%) were discharged alive and in 218 of these, CPC was available. 51 patients (23.4%) had a CPC>2 at discharge (22 CPC = 3, 24 CPC = 4 and 5 CPC = A). 1–year follow–up was available in 200 patients: among 158 alive, 12 (7.6%) had CPC>2 (7 CPC = 3 and 5 CPC = 4). 1–year survival of patients with CPC>2 at discharge was significantly lower those discharged with CPC≤2 (39.6% vs 91.6% p 2 survived at 1 year: a good cerebral performance was recovered in 6 patients (31.6%), while CPC>2 persisted in 11 (58%) and the CPC value was unknown in 2 of them. Conclusions Our results highlight that 1–year survival is quite low in patients with CPC>2 at discharge and that an improvement in cerebral performance occurs only in a minority of them. This evidence suggests the need for clinical re–evaluation after the event in order to carefully evaluate whether to implant an ICD in this kind of patients.

Background Cardiac Sympathetic Denervation (CSD) has been recently proposed for the treatment of refractory ventricular arrhythmias (VAs) in patients with cardiomyopathy (CMP). Long–term outcome and predictors of recurrences after the procedure are still poorly defined. Aim: To describe our multicenter Italian experience with CSD in CMP patients with refractory VAs. Methods 32 patients with CMP and refractory VAs underwent either left CSD (n=4) or BCSD (n=28). All patients had a Video Assisted Thoracoscopic Surgery, in 8 cases with the robotic technique. The main reason (3/4 cases, 75%) to perform LCSD instead of BCSD was sinus bradycardia in single ICD lead recipients. Results 84% of patients were male, mean age was 55 ± 16 yrs and mean LVEF was 32± 12%; most (n=26, 81%) had non–ischemic CMP (including 3 with hypertrophic CMP and 2 with cardiolaminopathy) and 34% were in NYHA class ≥3. Main indications for CSD were refractory polymorphic/fast VAs (>200 bpm) in 56% of pts and refractory monomorphic VAs in the rest. Except for 5 patients (15%) with previous thyrotoxicosis, the majority were either on amiodarone (n=20, 63%) or on sotalol (n=3, 9%) and 53% had previously undergone ≥1 catheter ablation for VAs. The median follow–up (FU) after CSD was 16 months (IQR 5–45 months). No major complications occurred. Eleven patients (34%) either died during FU (n=8, 25%), mostly due to end–stage heart failure, or underwent heart transplant (n=3, 9%). After CSD, the percentage of patients with ES decreased from 78% to 40% (p Conclusions Our case series of CSD in CMP represents the largest reported in Europe and the one with the longest follow–up. The occurrence of electrical storms was almost halved by CSD, and most patients had a reduction in ICD shocks at 6 months larger than 75%. Patients with better functional class, better LVEF and faster VAs benefited more from CSD, suggesting the opportunity of an earlier referral of these patients.

Background Neuromodulation by percutaneous stellate ganglion block (PSGB) with local anaesthetic has proved its antiarrhythmic effect suitable for an emergency setting. Purpose To assess the efficacy and safety of PSGB performed with an anterior anatomical approach in patients with refractory electrical storm refractory. Methods Patients with electrical storm at the Policlinico S.Matteo of Pavia were enrolled from November 2017 to January 2022. Left PSGB (PLSGB) was performed after failure of at least one intravenous antiarrhythmic drug. Its repetition or a continuous infusion of the local anaesthetic were considered in selected cases. Clinical data, characteristics of the block and complications were collected. The efficacy was evaluated by comparing the number of arrhythmias treated with ATP or DC–shocks by external or internal defibrillator 1 hour before the block with 1 hour after the block. Per–patient efficacy was assessed by comparing the number of ATP/shocks in the 12 hours before the first procedure with that in the 12 hours after the last one. Results 37 patients were enrolled: 76% male, mean age 65 years; 11 with dilated cardiomyopathy, 18 with chronic ischemic heart disease, 11 with STEMI, 3 with NSTEMI, 1 with ARVC and 1 with drug intoxication. A total of 62 PLSGBs were performed: 19 for VT, 26 for VF and 17 for both VT and VF episodes; 15 on intubated patients, 4 in extracorporeal circulation, 7 in cardiogenic/septic shock, 28 on patients on single antiplatelet therapy, 11 on dual antiplatelet therapy, 33 on anticoagulant therapy. PLSGBs were performed during intravenous infusion of antiarrhythmics (amiodarone in 30, lidocaine in 37 procedures). The local anaesthetic used was lidocaine in 27/62 PLSGB, bupivacaine in 6/62 and both in 29/62. The per–procedure analysis showed a significant reduction of the number of ATP/shocks in the hour after PLSGB compared with the hour before [0 (0–0) vs 5 (1–8) p Conclusions This is the case series with the highest number of PLSGB for antiarrhythmic purposes in literature and it confirms its efficacy and safety in refractory electrical storm. The exiguity of the equipment required makes the anatomical approach suitable to be easily performed by cardiologists.

Septic pulmonary embolism (SPE) is an uncommon disease in which a microorganism- containing thrombus causes an inflammatory reaction and a mechanical obstruction in the vascular system of the lungs. Usually it is associated with tricuspid valve vegetation, septic thrombophlebitis or infected venous catheters. We present a rare and fatal case of massive septic pulmonary thromboembolism occurred in a diabetic woman, who complained in previous days dyspnoea, abdominal pain and nausea. Autopsy findings showed evidence of an erosive cystitis, while lungs examination showed total occlusion of pulmonary circulation system due to thrombo-embolic clots. In literature cases report about an association between septic pulmonary thromboembolism and erosive cystitis haven't been reported. So, we here show the first reported fatal case of a septic pulmonary thromboembolism as a lethal evolution of an erosive cystitis.

The objective of this study is to investigate bone metabolism, density, and quality in patients with diabetes type 2 using DEXA and spinal deformity index (SDI), a surrogate index of bone quality. Fifty-six patients with type 2 diabetes were studied; exclusion criteria were diseases and medications that affect bone and mineral metabolism. Mean age was 65 ± 7 years. Mean diabetes duration was 10 ± 7 years and mean HbA1C was 6.6 ± 0.5 %. BMI was 30 ± 4. Fifty-six sex, age, and BMI matched served as controls. All subjects underwent a clinical and biochemical examination. Spinal and femoral neck BMD were measured by DEXA, and a spine radiography was performed to assess vertebral fractures and to calculate SDI. Mean serum 25-OH vitamin D levels were 19.6 ± 3.7 ng/ml in patients and 30 ± 14 ng/ml in controls (p < 0.01). PTH serum levels were 47.9 ± 40 pg/ml in patients versus 37 ± 5.3 pg/ml in controls (p < 0.01). At lumbar spine there was a significant difference between patients and controls only for T-score (p =

There is currently still no consensus regarding the best technique for implanting prolonged-venous-access devices (PVAD). One hundred ninety-six patients underwent surgical PVAD positioning using an all-surgical cutdown approach to the cephalic vein (CV). When surgical cannulation proved impossible, the patient was converted to percutaneous positioning. A retrospective analysis was performed on the difference between these two techniques. Among the 196 patients who underwent the surgical insertion of a PVAD, 23 (11.7%) were converted to percutaneous cannulation. For the surgical cannulation group, the median operating time was 35 minutes vs the 52.5 minutes needed for the percutaneous cannulation group. The median time of fluoroscopy amounted to eight seconds for the surgical cannulation group vs 18 seconds for the percutaneous cannulation group. Complications were observed in 23/196 patients (11.7%): 9/23 patients (39.1%) developed infections. Deep venous thrombosis was observed in 4/23 patients (17.4%). Pneumothorax and arterial hematoma developed in 5/23 patients (21.7%), all cases of percutaneous placement. PVAD malfunction was observed in 3/23 patients (13.0%). We concluded that surgical cutdown is faster than the percutaneous approach and safer for both patient and surgeon, involving a shorter time of exposure to radiation and reducing the risk of infection.

Introduction Ten years after the introduction of stapled haemorrhoidopexy few studies have stratified patients by degree of haemorrhoidal disease when analysing results. Objective The aim of this study was prospectively to evaluate 116 patients who underwent stapled anopexy conducted by the same surgeon for III or IV degree haemorrhoidal prolapse. Materials and methods One hundred and sixteen consecutive patients affected by symptomatic haemorrhoids of III or IV degree underwent stapled anopexy using the technique described by Longo in the period January 2001 to October 2003. Mean follow-up was 28.1 months. Fischer's exact test was used for statistical analysis. Results, in terms of morbidity and recurrence rates, were stratified according to degree of haemorrhoidal disease. Results There was no statistically significant difference between the results for third degree compared with fourth degree prolapse although there was a trend towards increased incidence of postoperative bleeding and recurrence. Conclusion Third degree haemorrhoidal prolapse remains the best indication for stapled haemorrhoidopexy. This procedure may also be indicated in fourth degree haemorrhoidal prolapse. Patients with fourth degree haemorrhoids may be subjected to this procedure following adequate discussion of the outcome.

Hyperechoic pseudotumors usually are considered "spared areas" in a fatty liver; they frequently are detected at the fourth hepatic segment close to the portal vein. Over a 3 year period, we observed 14 patients with a hyperechoic pseudotumor in otherwise normal livers; all of these lesions resembled a hyperechoic pseudotumor of the fourth segment with respect to site and morphology. In all cases echographic findings did not significantly change during the follow-up period ranging from 4 to 12 months. Computed tomographic examination was normal in two cases, whereas in the remaining 12 cases the hyperechoic lesion was appreciable as a hypodense area on both direct and dynamic scans; the contrast enhancement was never typical for a malignancy of a hemangioma. Six patients also underwent a color Doppler and power Doppler examination, which never demonstrated intralesional or perilesional abnormalities in the vascular signals. Three patients, who underwent surgery for adenocarcinoma of the large bowel, had intraoperative sonography and sonographically guided biopsy; a hepatic steatosis was diagnosed at histologic examination in all cases. The uniqueness of the cases presented here lies on the finding of focal steatosis at a site where, according to the most credible hypothesis, intracellular deposition of triglycerides is less likely because of possible variation of the regional portal circulation. From a practical point of view it should be emphasized that, in addition to the more frequent hypoechoic pseudolesions, hyperechoic pseudonodular images just anterior to the portal vein can be observed in normal livers; in our experience these lesions should be interpreted as a focal steatosis in an atypical site.

Bariatric surgery is nowadays an effective therapeutic option for morbid obesity. Endocrinologists may thus have a growing opportunity to diagnose and treat obese patients eligible for surgery in pre- and post-operative phase. This requires a better understanding of endocrine changes caused by either obesity or weight loss surgery. Despite the large number of studies available in literature, only limited well-designed clinical trials have been performed so far to investigate changes of endocrine axes following bariatric procedures. There are still areas of unclear results such as female and male fertility, however, weight loss after bariatric surgery is considered to be associated with favorable effects on most endocrine axes. The aim of this clinical review is to overview the available literature on the effects of weight loss after bariatric surgery on the endocrine systems to suggest the most appropriate pre- and post-operative management of obese patients undergoing bariatric surgery in terms of "endocrine" health.

Apart from waist circumference, other adiposity measures, such as subscapular skin fold (SST), arouse growing interest due to their relationship to metabolic complications and cardiovascular risk. The IGF-I system is deregulated in obese subjects in proportion to their degree of visceral adiposity.To examine the association among IGF-I, IGF-binding protein (BP)-1 and -3 levels and different measures of adiposity in a sample of adult male population in Southern Italy.A complete database for this analysis was available for 229 (age range 50-82 yr) participating at 2002-2004 Olivetti Heart Study follow-up.After adjustment for age, IGF-I was inversely associated with body mass index (BMI) and waist circumference (p0.05). IGFBP-1 was inversely associated with BMI, waist circumference, SST, homeostasis model assessment (HOMA) index, fat mass. HOMA index, age, and SST significantly predicted the IGFBP-1 plasma levels, with 24% of IGFBP-1 variability explained at a linear regression analysis.IGFBP-1 inversely correlated to adiposity and HOMA index. Among adiposity indexes, SST was the best predictor of IGFBP-1 levels. The evaluation of some components of the IGF system, and simple measures of body adiposity, such as SST, may represent a further tool to better evidence phenotype profiles associated to the pathogenetic mechanism of cardiovascular risk factor clustering in male adults.

Introduction. The stapled transanal rectal resection (STARR) procedure is safe and effective. Objective of the Study. To compare STARR performed with PPH-01 (STARR) and CCS 30 (Transtar). Materials and Methods. Sixty-four patients underwent STARR for obstructed defecation syndrome (32 STARR and 32 Transtar) and were observed from January 2007 to June 2009. Patients were studied by visit with questionnaires, colonoscopy or barium enema, defecography, and anorectal manometry. Postoperatively they were assessed through visit and questionnaires. Results. All patients improved symptoms without statistical differences. The obstructed defecation syndrome score changed from 13 to 1.8 at 6 months and to 1 at 1 year in the STARR group ( P < .05), and the score changed from 15 to 2 at 6 months and to 1 at 1 year in the Transtar group ( P < .05). There were no intraoperative complications in the STARR group, but there were 2 dehiscences of suture in the Transtar group. There were no differences with regard to complications. Conclusion. Transtar is a more complex technique with more severe complications. A major resection is not always more effective.

To evaluate skeletal muscle biopsy from asymptomatic patients affected with newly diagnosed colorectal cancer and to identify pathological features which may be indicative of tumor-associated muscle disorders, potentially leading to cachexia.Patients affected with newly diagnosed colorectal cancer at clinical onset of disease underwent biopsy of the rectus abdominis muscle during elective laparoscopic tumor resection, before chemotherapeutic treatment. Morphometric analyses, ATPase histochemistry and immunohistochemical studies using antibodies directed to N-CAM and to MHC-emb, two sound makers of muscle denervation and injury-induced muscle regeneration, were performed on intraoperative muscle biopsies from ten patients. Muscle biopsies from rectus abdominis of seven subjects affected with non-neoplastic condition, which underwent laparoscopic surgery, were used as controls.In patients' biopsies, we observed a surprisingly high percentage of myofibers with internalized or central nuclei compared to controls (9.15 +/- 8.9 versus 0.6 +/- 0.9, p0.0003). In addition, in the 30% of patients, small myofibers expressing the MHC-emb have been identified (0.4 +/- 0.5 positive fibers/mm(2)), while in 50% of patients, larger fibers positive for N-CAM have also been detected (0.7 +/- 1.1 positive fibers/mm(2)), suggesting that investigated muscle biopsies exhibit other evidence of muscle fiber injury/regeneration and/or denervation. Among the 10,000 analysed myofibers in control biopsies, no MHC-emb and N-CAM-positive muscle fibers have been detected. Thus, patients affected with newly diagnosed colorectal cancer at clinical onset of disease display early signs of a subclinical myopathy.Factors and mechanisms of this cancer-associated myopathy are yet unknown. The facts that the great majority of the abnormally nucleated myofibers are of the fast type and that regenerating myofibers are present, suggest a myogenic response to the colorectal cancer and not to the laparoscopic modalities of the biopsy harvesting. Follow-up of the patients will elucidate the clinical relevance of our observation, and further studies investigating the molecular mechanism underlying this early cancer-associated myopathy will hopefully provide some pathogenetic clues leading to the identification of potential specific targets for therapeutic intervention to prevent tumor cachexia.

Objective To evaluate the clinical course of extensive anal condylomatosis in relation to treatment modalities, patient comorbidity and immune function, and associated papillomavirus (HPV) sequences. Method Clinical data, treatment modalities and follow-up were recorded and analysed in relation to host and viral type. Histology, immunohistochemistry and molecular analyses for HPV search and typing were performed on formalin-fixed paraffin-embedded samples. Results Sixteen patients [14 males, median age 41.8 years (range 19–66)] affected by extensive anal condylomatosis [10 Buschke-Lowenstein Tumors (BLT) and 6 condylomatosis] treated in three different Italian institutions were included. There was associated preoperative anal intraepithelial neoplasia grade 3 (AIN3) in one and invasive carcinoma in three patients. After radical resection (n = 16) recurrence occurred in 4/10 (40%) BLT patients. Malignancy before or after treatment developed in 5/16 (31.25%) patients. HPV sequences were present in all the samples of 15 evaluable patients (types 6 or 11, 9 patients; type 16, 6 patients). A statistically significant association was found between presence of HPV type 16 and both malignancy and recurrence. Viral variant L83V was present in 3/4 HPV 16 positive recurrent cases. Conclusion Radical resection resulted in a favourable clinical course. Typing of HPV sequences in the management of patients affected by extensive anal condylomatosis may be useful.

Background Elderly population in Western countries is rapidly increasing. Literature suggests that radical colorectal resection in the elderly can be safely undertaken with good short and long term results; however results of specific rectal laparoscopic resections are not well defined and so quality of life. The aim of this study was to assess long-term outcome; risk factors and health related quality of life (HRQoL) in elective rectal cancer laparoscopic resection in patients older than 65 years.

Purpose To evaluate morphological features of hyper and hypo autofluorescence areas using Spectral Domain OCT technology. Methods 16 patients ( 10 male , 6 females ) with first diagnosis of age related maculopathy and dry AMD have been enrolled.Visual acuity test ( Snellen chart ) and Amsler’ grid test have been performed. Patients underwent to fundus autofluorescence ( FAF ) study (cSLO HRA 2 Laser source 488 nm , Barrier filter 500 nm, Heidelberg , Germany ) and Specral Domain OCT evaluation ( SD OCT OTI , Canada ). The FAF abnormalities have been compared to OCT images using gray scale and colour inversion system. Abnormalities in outer limiting membrane ( OLM ) profile , photoreceptor inner-outer segment junction and RPE layer have been recorded for each patient. Results OCT did not show any morphological changes in areas of hyperautofluorescence . In cases of hypoautofluorescence , main OCT changes were : abnormal profile of the OLM with continuous gaps , disruption of the IS/OS junction with focal breaks and granular destructuration of the RPE layer .No alterations inside neurosensory retina or modifications of retinal thickness and volume have been recorded. Conclusion Abnormal FAF is mainly derived from RPE lipofuscin . Excessive accumulation of lipofuscin has been associated with degeneration of RPE cells and photoreceptors. SD-OCT is able to show retinal morphological changes associated to abnormal FAF improving our knowledge in pathophisiologic pathways.

Purpose To evaluate the clinical findings, visual outcomes, and confocal microscopic corneal features after DSAEK in Fuchs endothelial dystrophy. Methods A 70-year-woman patient with pseudophakia and Fuchs endothelial dystrophy underwent small-incision DSAEK surgery. Best spectacle corrected visual acuity (BSCVA) was 1.30 (20/400) logMAR (Snellen) before treatment. Confocal scanning microscope (ConfoScan 4, Nidek Technologies, Padova, Italy) was performed before surgery procedure, after 7 days, at 1 and 6 months after DSAEK. Images of corneal structures, including endothelium, donor and recipient stroma were obtained. Endothelium density was evaluated using manual count and 40x probe. Results BSCVA improved at 0.3 (20/40) log MAR (Snellen) at 6 months. No astigmatism change was recorded at the end of follow-up. Endothelial cell density was about 850 cells/mm2 after 6 months surgery procedure. Interface and donor stroma reflectivity were highest at 7 days showing progressive decrease over time. Conclusion The DSAEK procedure represents a promising alternative to conventional penetrating keratoplasty (PK) for patients with Fuchs’ dystrophy. Confocal microscopy is able to detect precise evaluation of corneal features, interface morphologic characteristics and reflectivity to improve therapeutic choice and to understand the pathophysiology of visual recovery.

Purpose To evaluate safety and local effects of -in the end of trabeculectomy Avastin injection on filtering bleb vascularisation and bleb failing trend. Methods 1 male patients 65yo with a clinical history of pharmacologically uncontrolled primary open angle glaucoma in right eye (IOP 36 mmHg,CCT=525 µ)underwent to trabeculectomy without use of antiproliferative agents. A traditional surgical approach with a 12 o’clock scleral wedge(4 x 4 mm) and a double Nylon 10/0 made sclerocorneal suture using modified Meduri’s technique was performed.At the end of the surgery ,0.05 ml of bevacizumab ( Avastin 25 mg/ml , Roche) were injected in the subconjutival space above the sclera wedge.The IOP and bleb vascularisation have been recordered in the post op each day during the first week and one time a week in the following three months.A digital camera mounted on slit lamp was used for images acquisition. Results IOP was stable on 9 mmHg during the first three weeks , increasing to 16 mmHg during the follow up and stable until the end of the study despite removing Meduri’ sclerocorneal sutures . No complications were seen in the anterior chamber . Filtering bleb did not show any sign of inflammation or swelling with a “ quite “ vascularisation as clinical marker during the follow up . Conclusion Our short experience demonstrates the safety of subconjuntival injection of Avastin and effects on bleb’s vascularisation regardless of incidence of bleb failure.Further investigations in multicentric randomized studies on larger sample size are necessary to confirm current results .