Unusual focal keratin expression in plexiform angiomyxoid myofibroblastic tumor: A case report and review of the literature

Background: Plexiform angiomyxoid myofibroblastic tumor (PAMT), also known as plexiform fibromyxoma, is a rare distinctive benign intramural tumor, typical of gastric antrum, commonly causing mucosal ulceration with upper gastrointestinal bleeding and anemia, effectively treated by complete surgical resection usually accomplished by distal gastrectomy. Methods and Results: We herein report a 47-year-old man presenting with a syncopal episode, regurgitation and epigastric discomfort, bearing a gastric antral myxoid plexiform tumor positive for \u3b1-smooth muscle actin, vimentin and, partially, for caldesmon, desmin, and CD10; CD117, DOG1, CD34, S100, CAM5.2, CK20, CK7, EMA, p53, CDX2, chromogranin A, synaptophysin, anaplastic lymphoma kinase, Melan-A, and HMB-45 were all negative. All these features are typical of PAMT. Of note, focal positivity for AE1/AE3 and pan-CK KL1 was also present. Conclusions: The finding of a focal keratin expression in PAMT contributes to enlarge the immunophenotypic spectrum of this tumor type and is relevant for avoiding presurgical misdiagnoses which could ultimately lead to inappropriate overtreatment of patients with PAMT

Prediction of early recurrent thromboembolic event and major bleeding in patients with acute stroke and atrial fibrillation by a risk stratification schema: the ALESSA score study

Background and Purposes—This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation. Methods—The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00–1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08–2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30–1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632–0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493–0.678; P=0.10) for major bleedings. Results—The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529–0.763; P=0.009) for ischemic outcome events and 0.407 (0.275–0.540; P=0.14) for hemorrhagic outcome events. Conclusions—In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings

Izu-Bonin-Mariana Rear Arc: The Missing Half of the Subduction Factory

4GT) lies in the western part of the Izu fore-arc basin, ~60 km east of the arc-front volcano Aogashima, ~170 km west of the axis of the Izu-Bonin Trench, 1.5 km west of Ocean Drilling Program (ODP) Site 792, and at 1776 meters below sea level (mbsl). It was drilled as a 150 m deep geotechnical test hole for potential future deep drilling (5500 meters below seafloor [mbsf]) at proposed Site IBM-4 using the D/V Chikyu. Core from Site U1436 yielded a rich record of Late Pleistocene explosive volcanism, including distinctive black glassy mafic ash layers that may record large-volume eruptions on the Izu arc front. Because of the importance of this discovery, Site U1436 was drilled in three additional holes (U1436B, U1436C, and U1436D), as part of a contingency operation, in an attempt to get better recovery on the black glassy mafic ash layers and enclosing sediments and to better constrain the thickness of the mafic ash layers. IODP Site U1437 is located in the Izu rear arc, ~330 km west of the axis of the IzuBonin Trench and ~90 km west of the arc-front volcanoes Myojinsho and Myojin Knoll, at 2117 mbsl. The primary scientific objective for Site U1437 was to characterize “the missing half of the subduction factory”; this was because numerous ODP/Integrated Ocean Drilling Program sites had been drilled in the arc to fore-arc region (i.e., ODP Site 782A Leg 126), but this was the first site to be drilled in the rear part of the Izu arc. A complete view of the arc system is needed to understand the formation of oceanic arc crust and its evolution into continental crust. Site U1437 on the rear arc had excellent core recovery in Holes U1437B and U1437D, and we succeeded in hanging the longest casing ever in the history of R/V JOIDES Resolution scientific drilling (1085.6 m) in Hole U1437E and cored to 1806.5 mbsf

Timing of initiation of oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation comparing posterior and anterior circulation strokes

Background: The aim of this study in patients with acute posterior ischemic stroke (PS) and atrial fibrillation (AF) were to evaluate the risks of recurrent ischemic event and severe bleeding and these risks in relation with oral anticoagulant therapy (OAT) and its timing. Methods: Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of: stroke recurrence, TIA, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. Results: A total of 2,470 patients were available for the analysis: 473 (19.1%) with PS and 1,997 (80.9%) AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80). Conclusions: Patients with posterior or anterior stroke and AF appear to have similar risks of ischemic or hemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT

Hemorrhagic transformation in acute ischemic stroke patients and atrial fibrillation: time to initiation of anticoagulants and outcome

Background: In patients with acute ischemic stroke and atrial fibrillation, early anticoagulation prevents ischemic recurrence but with the risk of hemorrhagic transformation (HT). The aims of this study were to evaluate in consecutive patients with acute stroke and atrial fibrillation (1) the incidence of early HT, (2) the time to initiation of anticoagulation in patients with HT, (3) the association of HT with ischemic recurrences, and (4) the association of HT with clinical outcome at 90 days. Methods and Results: HT was diagnosed by a second brain computed tomographic scan performed 24 to 72 hours after stroke onset. The incidence of ischemic recurrences as well as mortality or disability (modified Rankin Scale scores >2) were evaluated at 90 days. Ischemic recurrences were the composite of ischemic stroke, transient ischemic attack, or systemic embolism. Among the 2183 patients included in the study, 241 (11.0%) had HT. Patients with and without HT initiated anticoagulant therapy after a mean 23.3 and 11.6 days, respectively, from index stroke. At 90 days, 4.6% (95% confidence interval, 2.3–8.0) of the patients with HT had ischemic recurrences compared with 4.9% (95% confidence interval, 4.0–6.0) of those without HT; 53.1% of patients with HT were deceased or disabled compared with 35.8% of those without HT. On multivariable analysis, HT was associated with mortality or disability (odds ratio, 1.71; 95% confidence interval, 1.24–2.35). Conclusions: In patients with HT, anticoagulation was initiated about 12 days later than patients without HT. This delay was not associated with increased detection of ischemic recurrence. HT was associated with increased mortality or disability

The risk of stroke recurrence in patients with atrial fibrillation and reduced ejection fraction

Abstract Background: Atrial fibrillation (AF) and congestive heart failure often coexist due to their shared risk factors leading to potential worse outcome, particularly cerebrovascular events. The aims of this study were to calculate the rates of ischemic and severe bleeding events in ischemic stroke patients having both AF and reduced ejection fraction (rEF) (⩽40%), compared to ischemic stroke patients with AF but without rEF. Methods: We performed a retrospective analysis that drew data from prospective studies. The primary outcome was the composite of either ischemic (stroke or systemic embolism), or hemorrhagic events (symptomatic intracranial bleeding and severe extracranial bleeding). Results: The cohort for this analysis comprised 3477 patients with ischemic stroke and AF, of which, 643 (18.3%) had also rEF. After a mean follow-up of 7.5 ± 9.1 months, 375 (10.8%) patients had 382 recorded outcome events, for an annual rate of 18.0%. While the number of primary outcome events in patients with rEF was 86 (13.4%), compared to 289 (10.2%) for the patients without rEF; on multivariable analysis rEF was not associated with the primary outcome (OR 1.25; 95% CI 0.84–1.88). At the end of follow-up, 321 (49.9%) patients with rEF were deceased or disabled (mRS ⩾3), compared with 1145 (40.4%) of those without rEF; on multivariable analysis, rEF was correlated with mortality or disability (OR 1.35; 95% CI 1.03–1.77). Conclusions: In patients with ischemic stroke and AF, the presence of rEF was not associated with the composite outcome of ischemic or hemorrhagic events over short-term follow-up but was associated with increased mortality or disability

Anticoagulation After Stroke in Patients With Atrial Fibrillation : To Bridge or Not With Low-Molecular-Weight Heparin?

Background and Purpose- Bridging therapy with low-molecular-weight heparin reportedly leads to a worse outcome for acute cardioembolic stroke patients because of a higher incidence of intracerebral bleeding. However, this practice is common in clinical settings. This observational study aimed to compare (1) the clinical profiles of patients receiving and not receiving bridging therapy, (2) overall group outcomes, and (3) outcomes according to the type of anticoagulant prescribed. Methods- We analyzed data of patients from the prospective RAF and RAF-NOACs studies. The primary outcome was defined as the composite of ischemic stroke, transient ischemic attack, systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding observed at 90 days after the acute stroke. Results- Of 1810 patients who initiated oral anticoagulant therapy, 371 (20%) underwent bridging therapy with full-dose low-molecular-weight heparin. Older age and the presence of leukoaraiosis were inversely correlated with the use of bridging therapy. Forty-two bridged patients (11.3%) reached the combined outcome versus 72 (5.0%) of the nonbridged patients (P=0.0001). At multivariable analysis, bridging therapy was associated with the composite end point (odds ratio, 2.3; 95% CI, 1.4-3.7; P Conclusions- Our findings suggest that patients receiving low-molecular-weight heparin have a higher risk of early ischemic recurrence and hemorrhagic transformation compared with nonbridged patients.Peer reviewe

Analisi strutturale ed assetto tettonico del Gruppo dei Monti Leoni (Toscana Meridionale)

Il rilevamento geologico e l’analisi strutturale alla meso e microscala, hanno permesso di definire l’assetto tettonico e l’analisi strutturale del Gruppo dei M. Leoni Toscana meridionale). Il Gruppo dei M. Leoni è costituito dalla sovrapposizione di più unità tettoniche. Nei settori centro-settentrionali dell’area studiata affiorano l’Unità Monticano-Roccastrada, la sovrastante Falda Toscana e l’Unità di Canetolo. Quest’ultima giace, mediante faglie normali ad alto angolo, sulle altre due unità. Nella porzione meridionale della zona rilevata, in corrispondenza del Poggio di Moscona, affiora, al di sotto della Falda Toscana, una ulteriore unità tettonica: il Complesso Calcareo con Ofioliti. Nell’Unità Monticano-Roccastrdada e nella Falda Toscana, è stata riconosciuta una tettonica polifasica, caratterizzata dalla presenza di tre fasi deformative duttili principali (D1, D2 e D3). La fase tettonica D1 rappresenta l’evento deformativo principale, e determina la formazione di pieghe (F1) isoclinali coricate, con vergenza orientale, a cui si associano laminazione dei fianchi e lo sviluppo di una foliazione di piano assiale (S1). Le fasi tettoniche D” e D3 portano rispettivamente alla formazione di blande pieghe chilometriche a piano assiale verticale (F2), non associate allo sviluppo di alcuna foliazione, ed alla crenulazione delle precedenti superfici tettoniche e stratigrafiche. Le pieghe F3 mostrano vergenze sia verso E che verso W, e sono associate allo sviluppo di una superficie di crenulazione parallela al loro piano assiale (S3). Il rilevamento geologico e le analisi condotte sull’indice di cristallinità dell’illite nel Verrucano dell’Unità Monticano-Roccastrada, permettono di escludere, nel Gruppo dei M. Leoni, lo sviluppo dei fenomeni di raddoppio tettonico alla scala regionale osservati, poco più a nord, nelle Dorsale Monticano.Roccastrada. Una fase tettonica estensionale a carattere fragile si sovrappone alle strutture plicative formate precedentemente, determinando lo sviluppo di una configurazione ad horst e graben. Questa fase tettonica è responsabile delle frequenti riduzioni delle successioni meso-cenozoiche toscane, e della giacitura diretta dell’Unità di Canetolo sull’Unità Monticano-Roccastrada e sulla Falda Toscana. Mentre la Falda Toscana è caratterizzata da un metamorfismo polifasico, caratterizzato da una prima fase di alta pressione, seguita da una fase di retrocessione in facies scisti verdi, che oblitera più o meno intensamente le paragenesi precedentemente sviluppate. Le differenze di pressione esistenti tra l’Unità Monticano-Roccastrada e la Falda Toscana inducono a prevedere, almeno per le prime fasi collisionali, un’evoluzione tettonico-strutturale indipendente per queste due unità. Durante la fase D1, mentre l’Unità Monticano-Roccastrada raggiunge profondità più elevate, tali da poter permettere lo sviluppo di processi metamorfici di alta pressione, la Falda Toscana viene deformata a livelli strutturali superficiali, sviluppando paragenesi di bassissimo grado metamorfico. Con la successiva fase di esumazione, l’Unità Monticano-Roccastrada risale verso livelli strutturali più superficiali, interponendosi tra le unità tettoniche più esterne, al letto, e la Falda Toscana al tetto. Il Complesso Calcareo con Ofioliti mostra strette analogie con le unità di Cala Grande e di Cala Piatti del M.Argentario. Nel CCO è stato riconosciuto un metamorfismo polifasico, caratterizzato da un evento di alta pressione, a cui segue una fase di retrocessione in facies scisti verdi. Sembra, quindi, piuttosto verosimile che, duramte la subduzione, anche questo complesso tettonico, sia stato trascinato a profondità elevate, tali da consentire lo sviluppo delle associazioni mineralogiche di alta pressione, e successivamente risalito verso livelli strutturali superficiali, in seguito all’attivazione di processi di riesumazione

[Viaje a Listra de San Pablo y San Bernabé] : [San Pablo y San Bernabé reciben ofrendas y sacrificios al ser confundidos con dioses] / Raffaelle Sanzio invento, Vincenzo Pasqualoni disegno, Michelangelo Martini incise

La estampa es copia de uno de los Cartones sobre los Hechos de los Apostoles que Rafael pintó para decorar los vanos de la Capilla SixtinaSin fech

Bajocian transgressive-regressive sequences of the Tecocoyunca Group, southern Mexico, with maximum flooding surfaces marked by Thalassinoides

Bajocian (Middle Jurassic) transgressive-regressive sequences (TRS), outcropping in the Rosario Nuevo Creek (Tezoatlán Basin, Tecocoyunca Group) in Oaxaca State, Mexico, represent one of the Jurassic phases of opening and widening of a trans-Pangaean marine corridor (called also the Hispanic Corridor) and show a retrogradational-progradational set of sedimentary successions with decipherable and diverse facies. Two TRSs have been distinguished. The lower one starts with fluvio-deltaic sandstones including pedogenic horizons. Drowning of the deltaic plain and gradual rising of the water table is marked by change in vegetation: from large trees to low-rise vegetation with characteristic clumps of dense roots cemented by siderite. The delta plain succession is topped by a thin coal seam, followed by a transgressive surface. Ensuing laminated mudstones of restricted marine origin pass into open marine deposits, represented by bioturbated heterolithic strata with ammonites followed by nearshore sandstones, deposited in a storm-dominated basin. A similar succession, although without the deltaic part, is repeated in the next TRS. Of note are two thin (15-20 cm) continuous beds with Thalassinoides isp. networks, present within open marine deposits. Although large Thalassinoides networks are mostly known from shallow-marine and coastal environments, the case from Mexico represents less common occurrences from a deeper marine (offshore) setting, associated with maximum flooding surfaces, sediment starvation and firmgrounds (Glossifungites ichnofacies). Occurrences of Thalassinoides meshes, precisely marking maximum flooding surfaces, are helpful in defining the hierarchy of sequence stratigraphic cycles