Valutazione dello scompenso cardiaco nel Dipartimento d'Urgenza: luci ed ombre

I mutamenti sociodemografici ed i progressi della medicina hanno profondamente cambiato lo scenario dei bisogni assistenziali, nel nostro come in altri paesi occidentali, spostando l’asse delle cure dalle patologie acute a malattie croniche che, spesso coesistenti fra loro, colpiscono una popolazione sempre più anziana ed assorbono una proporzione sempre maggiore della spesa sanitaria. La cronicità è quindi il nuovo scenario con cui i professionisti e le istituzioni devono confrontarsi per sviluppare risposte assistenziali efficaci e sostenibili. Pertanto appare chiaro il progressivo emergere di condizioni morbose di tipo cronico-degenerativo tipiche dell’età adulta e anziana quali malattie cardiovascolari, neoplasie, diabete mellito, broncopneumopatie croniche ostruttive, osteoartropatie degenerative. Lo scompenso cardiaco, in tale contesto, rappresenta una delle patologie croniche a più alto impatto sulla sopravvivenza, sulla qualità e sulla durata di vita dei pazienti e sull’assorbimento di risorse. Inoltre, nei prossimi anni il numero di soggetti affetti da tale malattia è destinato ad aumentare per la stretta relazione intercorrente tra età e scompenso cardiaco e per i notevoli progressi che si sono verificati nel trattamento di varie forme di cardiopatia acuta (in particolare la cardiopatia ischemica) con un grande miglioramento della prognosi “quoad vitam”. Anche riguardo allo scompenso cardiaco le conoscenze sulla diagnosi e sul suo trattamento sono aumentate con un positivo impatto sulla prognosi, ovvero un aumento della sopravvivenza che comporterà un aumento della prevalenza di questa condizione. Il percorso di cura dei soggetti con scompenso cardiaco acuto inizia oggi nell’area dell’Emergenza-Urgenza. In Italia i dati epidemiologici disponibili oggi fanno riferimento a conclusione del percorso alla Scheda di Dimissione Ospedaliera (SDO) non considerando che segni e sintomi di presentazione sono più evidenti nella fase di accesso all’ospedale, quindi nel dipartimento d’emergenza, area dove i sintomi e le complicanze possono essere trattate e risolte tempestivamente con evidenti ricadute sulla prognosi. In questa situazione il medico d’urgenza rappresenta una figura strategica: prende decisioni sul primo trattamento, decide poi se il paziente debba essere dimesso dopo un trattamento iniziale oppure ricoverato e in quale area (Osservazione Breve Intensiva, Degenza ordinaria, monitoraggio continuo con telemetria, trattamento in terapia intensiva). La maggior parte delle casistiche degli studi clinici non considerano l’arruolamento dal momento dell’accesso nei Dipartimenti d’Emergenza, ma individuano pazienti nelle fasi successive del percorso, operando quindi una selezione dei casi. Tale selezione tuttavia racchiude una gamma molto eterogenea di soggetti presenti nella pratica clinica, sia per eziologia, fattori precipitanti, comorbidità, severità ed espressione dei segni e sintomi di presentazione. Nonostante la maggior parte dei casi presentino all’accesso aspetti di criticità da ore e/o giorni, <20% di questi verrà ricoverato in terapia intensiva, e <4% necessiterà di supperto ventilatorio o emodinamico per shock cardiogeno. Poiché la maggior parte dei casi risponderà alla terapia convenzionale, una buona parte sarà ricoverato in aree di degenza ordinaria, o in area medica non specialistica. L’obiettivo dello studio è individuare le caratteristiche cliniche ed epidemiologiche dei pazienti che ricorrono al Pronto Soccorso per scompenso cardiaco acuto di nuova insorgenza o per riacutizzazione di uno scompenso cardiaco noto. Attraverso il software gestionale del Pronto Soccorso della A.O.U.P. (First-Aid®) sono stati individuati i pazienti afferiti al Pronto Soccorso nel periodo 1 gennaio 2011 – 31 dicembre 2011. Il criterio scelto è stato la selezione come prima o seconda diagnosi di scompenso cardiaco mediante l’ICD9 428. Il numero di pazienti selezionato secondo i criteri sopra definiti è risultato di 442 pazienti distinti in 186 maschi e 256 femmine ovvero il 42% gli uomini e il 58% le donne. L’età media complessiva è di 81,16 anni con una netta prevalenza nei pazienti ultrasettantacinquenni In ben 320 pazienti, ovvero nel 73% dei casi, la causa dello scompenso acuto non è identificabile. Quando invece è possibile risalire alla causa che ha determinato l’accesso in PS, nel 10% si tratta di aritmie, nel 7% di scarso controllo dei valori pressori mentre per il restante 10% riconosciamo come cause l’IRC (4%), la febbre (3%), la mancata adesione alla terapia (2%) ed infine la SCA (1%). Nell’ambito delle comorbidità sottolineiamo come l’ipertensione arteriosa (63%), l’IRC (43%), le aritmie (41%), l’anemia (40%) e il diabete mellito (31%) rappresentino le patologie associate di maggior prevalenza. Nella rilevazione dei dati relativi alla terapia farmacologica domiciliare i diuretici dell’ansa rappresentano i farmaci maggiormente utilizzati (62%), seguiti da ACE-inibitori/sartani (49%), antiaggreganti (48%), beta-bloccanti (33%), anticoagulanti orali (21%), nitrati (19%), antialdosteronici (19%) e digitale (14%). Tra le indagini ematochimiche, il 99% ha effettuato il dosaggio della sodiemia, il 93% ha effettuato il dosaggio del BNP e l'84% ha eseguito il dosaggio della Troponina. Per quanto riguarda la terapia somministrata in urgenza in PS i farmaci che risultano principalmente somministrati sono rappresentati dai diuretici dell’ansa (65%), seguiti da ossigeno in maschera (46%), NIMV (25%) e nitrati (23%). Dall'analisi dei nostri dati possiamo concludere che anche nella popolazione considerata le comorbidità condizionano fortemente la gestione in Pronto Soccorso e la necessità di ospedalizzazione. La complessità di tali malati si riflette anche nell'ambiente scelto per il ricovero (solo 22% in ambiente cardiologico). Non possiamo esprimere giudizi sui costi derivanti da questo tipo di gestione ma è ipotizzabile, trattandosi di pazienti ad elevato tasso di comorbidità, che una gestione domiciliare attenta di tali condizioni potrebbe incidere favorevolmente sulle riacutizzazioni e quindi sulle ospedalizzazioni. Nella fase di inquadramento diagnostico in PS il paziente riceve indagini diagnostiche appropriate e correttamente interpretate. Anche la tempestività degli interventi risulta adeguata e il tasso di mortalità acuta sembra confermarlo. Dai dati considerati e con i limiti dell'indagine retrospettiva sembra carente la fase di inquadramento anamnestico (mancata individuazione delle cause precipitanti) e quella del riconoscimento etiologico (ecocardiogramma effettuato nel 11% dei pazienti). Per il primo punto si potrebbe pensare ad un'azione di sensibilizzazione dei professionisti riguardo all'utilità di questo dato per la gestione del paziente, per il secondo punto è auspicabile un intervento formativo per perfezionare le competenze dei medici d'Urgenza in relazione a questa patologia

Characterization of the Volatile Profile of Cultivated and Wild-Type Italian Celery (Apium graveolens L.) Varieties by HS-SPME/GC-MS

Celery (Apium graveolens L.) is a vegetable belonging to the Apiaceae family that is widely used for its distinct flavor and contains a variety of bioactive metabolites with healthy properties. Some celery ecotypes cultivated in specific territories of Italy have recently attracted the attention of consumers and scientists because of their peculiar sensorial and nutritional properties. In this work, the volatile profiles of white celery "Sedano Bianco di Sperlonga" Protected Geographical Indication (PGI) ecotype, black celery "Sedano Nero di Torricella Peligna" and wild-type celery were investigated using head-space solid-phase microextraction combined with gas-chromatography/mass spectrometry (HS-SPME/GC-MS) and compared to that of the common ribbed celery. Exploratory multivariate statistical analyses were conducted using principal component analysis (PCA) on HS-SPME/GC-MS patterns, separately collected from celery leaves and petioles, to assess similarity/dissimilarity in the flavor composition of the investigated varieties. PCA revealed a clear differentiation of wild-type celery from the cultivated varieties. Among the cultivated varieties, black celery "Sedano Nero di Torricella Peligna" exhibited a significantly different composition in volatile profile in both leaves and petioles compared to the white celery and the prevalent commercial variety. The chemical components of aroma, potentially useful for the classification of celery according to the variety/origin, were identified

High innate attractiveness to black targets in the blue blowfly, Calliphora vomitoria (L.) (Diptera: Calliphoridae)

Calliphora vomitoria is a myiasis-causing fly in many animal species including humans. The control of blowflies is still anchored on the use of chemicals. However, mass trapping and lure-and-kill techniques represent a promising alternative to pesticides. Visual and olfactory cues are the main stimuli routing the fly's landing behavior. Notably, color attractiveness has been barely explored in flies of medical and veterinary importance, with special reference to blowflies. In this study, we investigated the innate color preferences in C. vomitoria adults, testing binary combinations of painted targets under laboratory conditions. The identity of tested species C. vomitoria was confirmed by DNA sequencing (18S and cox1 genes). C. vomitoria flies showed a significant preference for black colored targets in all tested binary color combinations, after 5, 15, 30 and 60 min of exposure. Black targets were significantly preferred over blue, red, yellow and white ones. Spectral characteristics of all tested color combinations were quantified and the innate attraction of blowflies towards black targets was discussed in relation to their behavioral ecology. To the best of our knowledge, this is the first report on innate color preferences in the Calliphora genus. Our findings can be useful to develop new, cheap and reliable monitoring traps as well as â\u80\u9clure and killâ\u80\u9d tools to control blowfly pests

La credibilità del richiedente asilo, l'ascolto come mezzo di prova

Collocazione delle procedure di riconoscimento di forme di protezione internazionale nel più ampio alveo del diritto d'asilo (così come riconosciuto dall'art. 10 co. 3 Cost.); l'ascolto delle storie dei migranti come mezzo di prova; la ri-soggettivazione vittimaria; lo straniero, il nemico, l'ospite, come figure dell'alterità; il diritto ospitale; il problema della oggettività e della verificabilità del narrato

Phase-contrast breast CT: the effect of propagation distance

X-ray phase imaging has the potential to dramatically improve soft tissue contrast sensitivity, which is a crucial requirement in many diagnostic applications such as breast imaging. In this context, a program devoted to perform in-vivo phase-contrast synchrotron radiation breast computed tomography is ongoing at the Elettra facility (Trieste, Italy). The used phase-contrast technique is the propagation-based configuration, which requires a spatially coherent source and a sufficient object-to-detector distance. In this work the effect of this distance on image quality is quantitatively investigated scanning a large breast surgical specimen at 3 object-to-detector distances (1.6, 3, 9 m) and comparing the images both before and after applying the phase-retrieval procedure. The sample is imaged at 30 keV with a 60 \ub5m pixel pitch CdTe single-photon-counting detector, positioned at a fixed distance of 31.6~m from the source. The detector fluence is kept constant for all acquisitions. The study shows that, at the largest distance, a 20-fold SNR increase can be obtained by applying the phase-retrieval procedure. Moreover, it is shown that, for phase-retrieved images, changing the object-to-detector distance does not affect spatial resolution while boosting SNR (4-fold increase going from the shortest to the largest distance). The experimental results are supported by a theoretical model proposed by other authors, whose salient results are presented in this paper

Effectiveness, safety, and tolerability of delayed dexamethasone, rituximab, and cyclophosphamide as first-line treatment in patients with Waldenström macroglobulinemia: data from the Sicilian Myeloma Network

BackgroundWaldenström macroglobulinemia (WM) is a rare and indolent B-cell lymphoproliferative disorder with greater incidence in elderly patients where a precise algorithm of initial therapy is still not clear. Immunochemotherapy regimen consisting of dexamethasone, rituximab, and oral cyclophosphamide (DRC) is considered a suitable first-line treatment because of its safety, efficacy, and manageability.Patients and methodsWe retrospectively describe the results of 36 consecutive treatment-naïve patients with WM who were treated from June 2013 until June 2021 with the DRC regimen every 4 weeks instead of 3 weeks, for six cycles. The median age was 69 years (range, 42–85 years), with one-third being older than 75 years. Most patients had features of advanced disease, with nearly 60% being high risk. Median IgM level prior to treatment initiation was 2.9 g/dL.ResultsOverall response rate was 80% after a median time of two cycles, with 67% of patients achieving at least partial response. After a median follow-up of 59 months, the median overall survival (OS) was not reached and the median time to next treatment (TTNT) was 48 months (95% CI 25–87 months). Approximately 70% of the evaluable study population had a 3-year survival without additional treatment, while 75% had a 3-year OS rate. The treatment was well-tolerated with only two patients (6%) recorded to have grade 3 pneumonia and no grade 3 hematological toxicity maybe due to the regular use of growth factors for red and white blood cells. Baseline albumin level and achievement of at least minimal or partial response had a significant impact on TTNT, while baseline hemoglobin and IgA level affected outcome in terms of OS (p &lt; 0.05).ConclusionThis is the first real-life experience describing the use of the DRC regimen in treatment-naive patients with WM with administration of therapy every 4 weeks instead of 3 weeks showing apparent comparable efficacy, along with good tolerability and safety, especially in terms of hematological toxicity, independently from comorbidity burden

A Small Molecule SMAC Mimic LBW242 Potentiates TRAIL- and Anticancer Drug-Mediated Cell Death of Ovarian Cancer Cells

BACKGROUND: Ovarian cancer remains a leading cause of death in women and development of new therapies is essential. Second mitochondria derived activator of caspase (SMAC) has been described to sensitize for apoptosis. We have explored the pro-apoptotic activity of LBW242, a mimic of SMAC/DIABLO, on ovarian cancer cell lines (A2780 cells and its chemoresistant derivative A2780/ADR, SKOV3 and HEY cells) and in primary ovarian cancer cells. The effects of LBW242 on ovarian cancer cell lines and primary ovarian cancer cells was determined by cell proliferation, apoptosis and biochemical assays. PRINCIPAL FINDINGS: LBW242 added alone elicited only a moderate pro-apoptotic effect; however, it strongly synergizes with tumor necrosis factor-related apoptosis inducing ligand (TRAIL) or anticancer drugs in inducing apoptosis of both ovarian cancer cell lines and primary ovarian cancer cells. Mechanistic studies show that LBW242-induced apoptosis in ovarian cancer cells is associated with activation of caspase-8. In line with this mechanism, c-FLIP overexpression inhibits LBW242-mediated apoptosis. CONCLUSION: LBW242 sensitizes ovarian cancer cells to the antitumor effects of TRAIL and anticancer drugs commonly used in clinic. These observations suggest that the SMAC/DIABLO mimic LBW242 could be of value for the development of experimental strategies for treatment of ovarian cancer

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

Background and objective: Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF. Methods: We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death. Results: We considered 2,343 elderly hospitalized patients (median age 81&nbsp;years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009). Conclusion: In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population

Endovascular Abdominal Aortic Aneurysm Repair With Ovation Alto Stent Graft: Protocol for the ALTAIR (ALTo endogrAft Italian Registry) Study

Background: Since 2010, the Ovation Abdominal Stent Graft System has offered an innovative sealing option for abdominal aortic aneurysm (AAA) by including a sealing ring filled with polymer 13 mm from the renal arteries. In August 2020, the redesigned Ovation Alto, with a sealing ring 6 mm closer to the top of the fabric, received CE Mark approval. Objective: This registry study aims to evaluate intraoperative, perioperative, and postoperative results in patients treated by the Alto stent graft (Endologix Inc.) for elective AAA repair in a multicentric consecutive experience. Methods: All consecutive eligible patients submitted to endovascular aneurysm repair (EVAR) by Alto Endovascular AAA implantation will be included in this analysis. Patients will be submitted to EVAR procedures based on their own preferences, anatomical features, and operators experience. An estimated number of 300 patients submitted to EVAR with Alto stent graft should be enrolled. It is estimated that the inclusion period will be 24 months. The follow-up period is set to be 5 years. Full data sets and cross-sectional images of contrast-enhanced computed tomography scan performed before EVAR, at the first postoperative month, at 24 or 36 months, and at 5-year follow-up interval will be reported in the central database for a centralized core laboratory review of morphological changes. The primary endpoint of the study is to evaluate the technical and clinical success of EVAR with the Alto stent graft in short- (90-day), mid- (1-year), and long-term (5-year) follow-up periods. The following secondary endpoints will be also addressed: operative time; intraoperative radiation exposure; contrast medium usage; AAA sac shrinkage at 12-month and 5-year follow-up; any potential role of patients' baseline characteristics, valuated on preoperative computed tomography angiographic study, and of device configuration (number of component) in the primary endpoint. Results: The study is currently in the recruitment phase and the final patient is expected to be treated by the end of 2023 and then followed up for 5 years. A total of 300 patients will be recruited. Analyses will focus on primary and secondary endpoints. Updated results will be shared at 1- and 3-5-year follow-ups. Conclusions: The results from this registry study could validate the safety and effectiveness of the new design of the Ovation Alto Stent Graft. The technical modifications to the endograft could allow for accommodation of a more comprehensive range of anatomies on-label