Utility of the Implantable Loop Recorder: Current Status

Of similar size to a pacemaker, implantable loop recorders (ILRs) are implanted subcutaneously in the left precordial region. The ILRs are equipped with a memory loop and, once activated by the patient by means of a magnet, record a 1-lead electrocardiographic trace, both retrospectively and prospectively, for several minutes.ILRs have a monitoring capability of up to 36 months and are explanted once the diagnosis has been made or the battery has run down. The current indication of ILRs as diagnostic tools is rapresented by the evaluation of transitory symptoms of possible arrhythmic origin, such as syncope and palpitations. Moreover, the theoretical capability of the new generation ILRs to record any kind of arrhythmic events automatically (from atrial fibrillation, to atrial flutter/tachycardia, from ventricular tachycardia to bradyarrhytmic events) suggests the possibility to use these devices also in the longterm evaluation of the total (symptomatic and asymptomatic) arrhythmic burden of patients at risk of arrhythmic events

Acute hemichorea as unusual first multiple sclerosis presentation

Patient 1 was a 39-year-old woman with an unremarkable medical history who developed acute involuntary right arm and leg movements. Neurologic examination revealed moderate dysarthria and subcontinuous, choreic movements in her right limbs, prevailing in the arm, which worsened during postural tasks. She occasionally had ballistic movements in her right limbs and abnormal dystonic postures. Continuous peribuccal and tongue involuntary movements were noted. Moreover, bilateral upper limb ataxia, gait and trunk ataxia, and brisk right tendon reflexes were found. There was no strength or sensory loss (video 1 at Neurology.org/cp). Brain MRI revealed a tumefactive, T2/fluid-attenuated inversion recovery (FLAIR) hyperintense, T1 hypointense contrast-enhancing demyelinating lesion in the left cerebral peduncle, extending to the substantia nigra and subthalamic nucleus (STN) (figure, A-C). Multiple hyperintense T2/FLAIR, T1 hypointense, non-contrast-enhancing demyelinating lesions in the hemispheric and periventricular deep white matter, brainstem, and cerebellar hemispheres were also found. All serologic tests were within normal limits. Isoelectric focusing (IEF) revealed 9 CSF oligoclonal bands (OCBs). A diagnosis of multiple sclerosis (MS) was made and the patient was treated with high-dose methylprednisolone with improvement of symptoms

Exercise-based cardiac rehabilitation in cardiac resynchronization therapy recipients: A primer for practicing clinicians

Cardiac resynchronization therapy (CRT) is a therapeutic option of increasing importance for chronic heart failure (CHF) and criteria for implantation now concern a large amount of patient populations. As a consequence, subjects with ongoing CRT (or immediately after CRT implantation) are more often referred to Cardiac Rehabilitation (CR) programmes, and it has been recently estimated that about one third of CHF patients attending CR in Italy currently have this kind of device. The presence of CRT represents a modulating factor for exercise prescription and monitoring, since CRT patients may be considered per se as a target group for CR. Exercise therapy (ET) increases benefits from CRT on functional capacity, and recent evidence suggests an adjuvant role of ET in improving cardiovascular prognosis also. Both aerobic endurance and resistance training activities may involve CHF patients with CRT, while the potential role of aerobic interval training needs more studies and evidence. Prescription of an ET program should be associated with information regarding device programming and possible limiting factors associated with pacing therapy, tailoring of the basic principles of ET (in terms of type of exercise, intensity and program duration) in this patient group is mandatory

Weather-Related Flood and Landslide Damage: A Risk Index for Italian Regions

The frequency of natural hazards has been increasing in the last decades in Europe and specifically in Mediterranean regions due to climate change. For example heavy precipitation events can lead to disasters through the interaction with exposed and vulnerable people and natural systems. It is therefore necessary a prevention planning to preserve human health and to reduce economic losses. Prevention should mainly be carried out with more adequate land management, also supported by the development of an appropriate risk prediction tool based on weather forecasts. The main aim of this study is to investigate the relationship between weather types (WTs) and the frequency of floods and landslides that have caused damage to properties, personal injuries, or deaths in the Italian regions over recent decades. In particular, a specific risk index (WT-FLARI) for each WT was developed at national and regional scale. This study has identified a specific risk index associated with each weather type, calibrated for each Italian region and applicable to both annual and seasonal levels. The risk index represents the seasonal and annual vulnerability of each Italian region and indicates that additional preventive actions are necessary for some regions. The results of this study represent a good starting point towards the development of a tool to support policy-makers, local authorities and health agencies in planning actions, mainly in the medium to long term, aimed at the weather damage reduction that represents an important issue of the World Meteorological Organization mission

The peculiar challenge of bringing CAR-T cells into the brain: Perspectives in the clinical application to the treatment of pediatric central nervous system tumors

Childhood malignant brain tumors remain a significant cause of death in the pediatric population, despite the use of aggressive multimodal treatments. New therapeutic approaches are urgently needed for these patients in order to improve prognosis, while reducing side effects and long-term sequelae of the treatment. Immunotherapy is an attractive option and, in particular, the use of gene-modified T cells expressing a chimeric antigen receptor (CAR-T cells) represents a promising approach. Major hurdles in the clinical application of this approach in neuro-oncology, however, exist. The peculiar location of brain tumors leads to both a difficulty of access to the tumor mass, shielded by the blood-brain barrier (BBB), and to an increased risk of potentially life-threatening neurotoxicity, due to the primary location of the disease in the CNS and the low intracranial volume reserve. There are no unequivocal data on the best way of CAR-T cell administration. Multiple trials exploring the use of CD19 CAR-T cells for hematologic malignancies proved that genetically engineered T cells can cross the BBB, suggesting that systemically administered CAR-T cell can be used in the neuro-oncology setting. Intrathecal and intra-tumoral delivery can be easily managed with local implantable devices, suitable also for a more precise neuro-monitoring. The identification of specific approaches of neuro-monitoring is of utmost importance in these patients. In the present review, we highlight the most relevant potential challenges associated with the application of CAR-T cell therapy in pediatric brain cancers, focusing on the evaluation of the best route of delivery, the peculiar risk of neurotoxicity and the related neuro-monitoring