Acute mechanical circulatory support for cardiogenic shock: the “door to support” time [version 1; referees: 3 approved]

Cardiogenic shock (CS) remains a major cause of in-hospital mortality in the setting of acute myocardial infarction. CS begins as a hemodynamic problem with impaired cardiac output leading to reduced systemic perfusion, increased residual volume within the left and right ventricles, and increased cardiac filling pressures. A critical step towards the development of future algorithms is a clear understanding of the treatment objectives for CS. In this review, we introduce the “door to support” time as an emerging target of therapy to improve outcomes associated with CS, define four key treatment objectives in the management of CS, discuss the importance of early hemodynamic assessment and appropriate selection of acute mechanical circulatory support (AMCS) devices for CS, and introduce a classification scheme that identifies subtypes of CS based on cardiac filling pressures

TEVAR for Iatrogenic Injury of the Distal Aortic Arch after Pacemaker Implantation

Introduction We report the endovascular treatment of aortic arch injury due to direct puncture during pacemaker implantation. Report After pacemaker implantation a 74-year-old woman showed a progressive decrease in haematocrit with elevation of cardiac troponin-I. Coronary angiography revealed the malposition of the catheters introduced through the aortic wall. The atrial lead was placed in the left circumflex coronary artery. Computed tomography scan confirmed distal aortic arch perforation. A Medtronic-Valiant stent–graft was implanted in the distal aortic arch while the two catheters were removed. A new VVI pacemaker was implanted and, 3 days later, the patient underwent percutaneous coronary intervention (PCI) on the dissected left circumflex artery. Four days later the patient was discharged. One-year computed tomography scan showed successful repair of the injured aorta. Discussion Endovascular stent grafting has emerged as a less invasive therapeutic alternative to treat traumatic or iatrogenic injuries of the distal aortic arch

Left atrial trajectory impairment in hypertrophic cardiomyopathy disclosed by geometric morphometrics and parallel transport

The analysis of full Left Atrium (LA) deformation and whole LA deformational trajectory in time has been poorly investigated and, to the best of our knowledge, seldom discussed in patients with Hypertrophic Cardiomyopathy. Therefore, we considered 22 patients with Hypertrophic Cardiomyopathy (HCM) and 46 healthy subjects, investigated them by three-dimensional Speckle Tracking Echocardiography, and studied the derived landmark clouds via Geometric Morphometrics with Parallel Transport. Trajectory shape and trajectory size were different in Controls versus HCM and their classification powers had high AUC (Area Under the Receiving Operator Characteristic Curve) and accuracy. The two trajectories were much different at the transition between LA conduit and booster pump functions. Full shape and deformation analyses with trajectory analysis enabled a straightforward perception of pathophysiological consequences of HCM condition on LA functioning. It might be worthwhile to apply these techniques to look for novel pathophysiological approaches that may better define atrio-ventricular interaction

Self-concept evaluation and migraine without aura in childhood

Introduction: Self-esteem is related to the broadly understood concept of self-schemas and is a crucial mechanism for a correct psychological development in children and adolescents. The impact of the many psychological difficulties linked to the migraine without aura (MoA) and recurrent headache attacks, such as anger and separation anxiety, on self-esteem has not yet been well investigated. The aims of the present study were to assess self-esteem levels in an objective way and to verify their possible relationship and correlation with the frequency and intensity of migraine attacks, in a population of children and adolescents affected by MoA. Methods: The study population was comprised of 185 children (88 males [M], 97 females [F]) aged between 6 and 12 years (mean 9.04 ± 2.41 years) referred consecutively for MoA to the Center for Childhood Headache, Clinic of Child and Adolescent Neuropsychiatry, Second University of Naples and of 203 healthy controls (95 M, 108 F) with mean age 9.16 ± 2.37 years, recruited from schools in Campania. The monthly headache frequency and the mean headache duration were assessed from daily headache diaries kept by all the children, and MoA intensity was assessed on a VAS (visual analog scale). To further evaluate their level of self-concept, all subjects filled out the Multidimensional Self-Concept Scale (MSCS). Results: The two study groups were comparable for age (P = 0.621), sex (P = 0.960), and z-score BMI (P = 0.102). The MoA group showed a significant reduction in the MSCS total score (P , 0.001) and in the Social (P , 0.001), Affect (P , 0.001), Family (P , 0.001), and Physical (P , 0.001) domains of the MSCS compared with the control group. The Pearson’s correlation analysis showed a significantly negative relationship between MoA clinical characteristics and MSCS scores, and similarly the frequency of attacks was significantly negatively related with the Social (r = −0.3176; P , 0.001), Competence (r = −0.2349; P = 0.001), Physical (r = −0.2378; P = 0.001), and total (r = −0.2825; P , 0.001) scores of the MSCS. On the other hand, the MoA duration was significantly negatively related with the Social (r = −0.1878; P = 0.01), Competence (r = −0.2270; P = 0.002), Physical (r = −0.1976; P = 0.007), and total (r = −0.1903; P = 0.009) scores of the MSCS. Conclusion: Our study first identified differences in self-esteem levels, with an objective tool, in children affected by MoA compared with controls, suggesting the need for evaluation of self-esteem for better psychological pediatric management of children with migraine

Executive dysfunction in children affected by obstructive sleep apnea syndrome: an observational study

Introduction: The role of sleep in cognitive processes can be considered clear and well established. Different reports have disclosed the association between sleep and cognition in adults and in children, as well as the impact of disturbed sleep on various aspects of neuropsychological functioning and behavior in children and adolescents. Behavioral and cognitive dysfunctions can also be considered as related to alterations in the executive functions (EF) system. In particular, the EF concept refers to self-regulatory cognitive processes that are associated with monitoring and controlling both thought and goal directed behaviors. The aim of the present study is to assess the impact of the obstructive sleep apnea syndrome (OSAS) on EF in a large sample of school aged children. Materials and methods: The study population comprised 79 children (51 males and 28 females) aged 7–12 years (mean 9.14 ± 2.36 years) with OSAS and 92 healthy children (63 males and 29 females, mean age 9.08 ± 2.44 years). To identify the severity of OSAS, an overnight respiratory evaluation was performed. All subjects filled out the Italian version of the Modified Card Sorting Test to screen EFs. Moreover, to check the degree of subjective perceived daytime sleepiness, all subjects were administered the Pediatric Daytime Sleepiness Scale (PDSS). Results: No significant differences between the two study groups were found for age (P = 0.871), gender (P = 0.704), z-score of body mass index (P = 0.656), total intelligence quotient (P = 0.358), and PDSS scores (P = 0.232). The OSAS children showed a significantly higher rate of total errors (P , 0.001), perseverative errors (P , 0.001), nonperseverative errors (P , 0.001), percentage of total errors (P , 0.001), percentage of perseverative errors (P , 0.001), and percentage of nonperseverative errors (P , 0.001). On the other hand, OSAS children showed a significant reduction in the number of completed categories (P = 0.036), total correct sorts (P = 0.001), and categorizing efficiency (P , 0.001). The Pearson’s correlation analysis revealed a significant positive relationship between all error parameters and apnea-hypopnea index, oxygen desaturation index, and percentage of mean desaturation of O2 with a specular negative relationship between the error parameters and the mean oxygen saturation values, such as a significant negative relationship between apnea-hypopnea index, oxygen desaturation index, percent of mean desaturation of O2, and the number of completed categories. Conclusion: Our study identified differences in the executive functioning of children affected by OSAS and is the first to identify a correlation between alteration in respiratory nocturnal parameters and EF that has not yet been reported in developmental age. These findings can be considered as the strength and novelty of the present report in a large pediatric population

Semantic Segmentation to Extract Coronary Arteries in Invasive Coronary Angiograms

Accurate semantic segmentation of each coronary artery using invasive coronary angiography (ICA) is important for stenosis assessment and coronary artery disease (CAD) diagnosis. In this paper, we propose a multi-step semantic segmentation algorithm based on analyzing arterial sements extraced from ICAs. The proposed algorithm firstly extracts the entire arterial binary mask (binary vascular tree) using a deep learning-based method. Then we extract the centerline of the binary vascular tree and separate it into different arterial segments. Finally, by extracting the underlyingarterial topology, position, and pixel features, we construct a powerful coronary artery segment classifier based on a support vector machine. Each arterial segment is classified into the left coronary artery (LCA), left anterior descending (LAD), and other types of arterial segments. The proposed method was tested on a dataset with 225 ICAs and achieved a mean accuracy of 70.33% for the multi-class artery classification and a mean intersection over union of 0.6868 for semantic segmentation of arteries. The experimental results show the effectiveness of the proposed algorithm, which provides impressive performance for analyzing the individual arteries in ICAs

Semantic Segmentation to Extract Coronary Arteries in Invasive Coronary Angiograms

Accurate semantic segmentation of each coronary artery using invasive coronary angiography (ICA) is important for stenosis assessment and coronary artery disease (CAD) diagnosis. In this paper, we propose a multi-step semantic segmentation algorithm based on analyzing arterial sements extraced from ICAs. The proposed algorithm firstly extracts the entire arterial binary mask (binary vascular tree) using a deep learning-based method. Then we extract the centerline of the binary vascular tree and separate it into different arterial segments. Finally, by extracting the underlyingarterial topology, position, and pixel features, we construct a powerful coronary artery segment classifier based on a support vector machine. Each arterial segment is classified into the left coronary artery (LCA), left anterior descending (LAD), and other types of arterial segments. The proposed method was tested on a dataset with 225 ICAs and achieved a mean accuracy of 70.33% for the multi-class artery classification and a mean intersection over union of 0.6868 for semantic segmentation of arteries. The experimental results show the effectiveness of the proposed algorithm, which provides impressive performance for analyzing the individual arteries in ICAs

Ethical Issues in the Use of Suboptimal Kidneys for Transplants: an Italian Point of View

The shortage of organs leads to the need for utilizing suboptimal kidneys for transplantation. The distinction between optimal, marginal, and suboptimal kidneys leads surgeons to face not only technical problems but also ethical and legal issues related to clinical advantages offered by the transplant of a nonstandard kidney and the acquisition of consent. Between 1999 and 2015, we performed 658 transplants, 49 (7.5%) using suboptimal kidneys. All patients were alive and with vital graft throughout follow-up. We did not encounter any major surgical complications. From a technical point of view, our experience and literature review confirm that transplant of suboptimal kidney leads to good clinical results but exposes patients to a increased risks of surgical complications. Therefore, these interventions must take place in hospitals fully prepared for this type of surgery and performed by experienced transplant surgeons with proper matching between organ and recipient. Considering the insufficient resources available, from an ethical and legal point of view, doctors play an essential role in optimizing the use of these kidneys by avoiding wastage of organs, ensuring that transplants are done in suitable patients, and that patients are fully informed and aware of the risks and benefits associated with the specific suboptimal kidney being transplanted. We believe that, in highly specialized centers, the number of suboptimal kidney transplants should be increased, as their use has shown good clinical results and carries fewer ethical issues compared with marginal kidneys. Further, suboptimal kidneys may also be proposed for use in young patients with end-stage renal disease

Long-term outcomes of pediatric infections: from traditional infectious diseases to long covid

: There is limited evidence available on the long-term impact of SARS-CoV-2 infection in children. In this article, the authors analyze the recent evidence on pediatric long covid and lessons learnt from a pediatric post-covid unit in Rome, Italy. To gain a better understanding of the concerns raised by parents and physicians in relation to the potential long-term consequences of this novel infection, it is important to recognize that long-term effect of a post-infectious disease is not a new phenomenon

Biopsy confirmation of metastatic sites in breast cancer patients:clinical impact and future perspectives

Determination of hormone receptor (estrogen receptor and progesterone receptor) and human epidermal growth factor receptor 2 status in the primary tumor is clinically relevant to define breast cancer subtypes, clinical outcome,and the choice of therapy. Retrospective and prospective studies suggest that there is substantial discordance in receptor status between primary and recurrent breast cancer. Despite this evidence and current recommendations,the acquisition of tissue from metastatic deposits is not routine practice. As a consequence, therapeutic decisions for treatment in the metastatic setting are based on the features of the primary tumor. Reasons for this attitude include the invasiveness of the procedure and the unreliable outcome of biopsy, in particular for biopsies of lesions at complex visceral sites. Improvements in interventional radiology techniques mean that most metastatic sites are now accessible by minimally invasive methods, including surgery. In our opinion, since biopsies are diagnostic and changes in biological features between the primary and secondary tumors can occur, the routine biopsy of metastatic disease needs to be performed. In this review, we discuss the rationale for biopsy of suspected breast cancer metastases, review issues and caveats surrounding discordance of biomarker status between primary and metastatic tumors, and provide insights for deciding when to perform biopsy of suspected metastases and which one (s) to biopsy. We also speculate on the future translational implications for biopsy of suspected metastatic lesions in the context of clinical trials and the establishment of bio-banks of biopsy material taken from metastatic sites. We believe that such bio-banks will be important for exploring mechanisms of metastasis. In the future,advances in targeted therapy will depend on the availability of metastatic tissue