Aetiology of intracerebral haemorrage

Spontaneous non traumatic intracerebral haemorrhage (ICH) is usually caused by many different interacting factors, such as the use of alcohol or fibrinolitic drugs, congenital aneurysm, brain tumors, and blood dyscrasia. Age and hypertension-related small vessel diseases, and cerebral amyloid angiopathy are the most common forms of vascular damage which can lead to ICH. Furthermore, a group of inherited cerebral small vessel diseases linked to ICH have been reported recently and the number of these forms is increasing. The presence of leukoaraiosis, lacunar infarcts and microbleeds has been suggested to indicate a higher risk for cerebral hemorrhage. In recent years, MRI and neuroimaging techniques contributed to the understanding and the diagnosis of this disease

Accurate Estimation of Start-Up Pulsating Torque of Direct On Line Synchronous Motors Driving Compressor Trains

Case StudiesIn a compressor train driven by fixed speed synchronous motor (>17MW) was discovered a potential torsional problem on the input shaft of the hydraulic variable speed gear during the start-up phase when only low speed shaft line is engaged. It was due to high motor excitation torque crossing the 1st torsional critical speed during startup causing a very limited numbers of train startups (1400) versus project requirements (5000). Supported by API 617 (8th edition), the motor excitation air-gap torque during startup has been analyzed considering electrical system characteristics that influence the effective voltage drop at motor terminals. A more realistic analysis of the excitation confirmed the correctness of the shaft line design avoiding any redesign and impacts in the projects execution

Accurate Estimation of Start-Up Pulsating Torque of Direct On Line Synchronous Motors Driving Compressor Trains

Case StudiesIn a compressor train driven by fixed speed synchronous motor (>17MW) was discovered a potential torsional problem on the input shaft of the hydraulic variable speed gear during the start-up phase when only low speed shaft line is engaged. It was due to high motor excitation torque crossing the 1st torsional critical speed during startup causing a very limited numbers of train startups (1400) versus project requirements (5000). Supported by API 617 (8th edition), the motor excitation air-gap torque during startup has been analyzed considering electrical system characteristics that influence the effective voltage drop at motor terminals. A more realistic analysis of the excitation confirmed the correctness of the shaft line design avoiding any redesign and impacts in the projects execution

Importance of Structural Modal Analysis in 2 Poles Induction Motors for LNG Application

Case StudyCase Study 18: High vibrations due to 2X electrical frequency excitation on bearing housings and frame occurred on a 20MW 2-Pole Induction Motors during acceptance tests in manufacturer workshop in stand alone configuration. Modal Analysis results in Factory Acceptance Tests (FAT) configuration were confirmed by Operating Deflection Shape (ODS) and Experimental Modal Analysis (EMA - Hammer test) leading to supports redesign. To mitigate the risk of high vibration in string test bench and customer site, validating also the present motor design, a further Modal Analysis were executed using the experimental data collected during the FAT to drive mode selection

Anticoagulation in the early phase of non-valvular atrial fibrillation-related acute ischemic stroke: where do we stand?

The balance between the risk of early stroke recurrence and hemorrhagic transformation represents the cornerstone of practical management of non-valvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS). Patients who receive antithrombotic therapy as secondary prevention in the early phase of NVAF-related AIS have a better prognosis compared with patients who do not receive antithrombotic treatment. Recently, the RAF study showed that the best efficacy/safety profile was associated with anticoagulation started between 4 and 14 days from stroke onset. Based on the RAF study, the 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines suggest starting anticoagulants between 4 and 14 days from stroke onset with a class of recommendation IIa. Strong evidence for the use of direct oral anticoagulants (DOACs) in the early phase of NVAF-related AIS is lacking, because this kind of patients were excluded from phase III randomized clinical trials (RCT) and ad hoc RCTs are ongoing. However, the real life evidence suggests that early starting time of DOACs in patients with NVAF-related AIS is safe and associated with low recurrence risk and all-cause mortality. In the present review the Authors provide an update on anticoagulation in the early phase of NVAF-related AIS with focus on DOACs

Comparison and combination of a hemodynamics/biomarkers-based model with simplified PESI score for prognostic stratification of acute pulmonary embolism: findings from a real world study

Background: Prognostic stratification is of utmost importance for management of acute Pulmonary Embolism (PE) in clinical practice. Many prognostic models have been proposed, but which is the best prognosticator in real life remains unclear. The aim of our study was to compare and combine the predictive values of the hemodynamics/biomarkers based prognostic model proposed by European Society of Cardiology (ESC) in 2008 and simplified PESI score (sPESI).Methods: Data records of 452 patients discharged for acute PE from Internal Medicine wards of Tuscany (Italy) were analysed. The ESC model and sPESI were retrospectively calculated and compared by using Areas under Receiver Operating Characteristics (ROC) Curves (AUCs) and finally the combination of the two models was tested in hemodinamically stable patients. All cause and PE-related in-hospital mortality and fatal or major bleedings were the analyzed endpointsResults: All cause in-hospital mortality was 25% (16.6% PE related) in high risk, 8.7% (4.7%) in intermediate risk and 3.8% (1.2%) in low risk patients according to ESC model. All cause in-hospital mortality was 10.95% (5.75% PE related) in patients with sPESI score ≥1 and 0% (0%) in sPESI score 0. Predictive performance of sPESI was not significantly different compared with 2008 ESC model both for all cause (AUC sPESI 0.711, 95% CI: 0.661-0.758 versus ESC 0.619, 95% CI: 0.567-0.670, difference between AUCs 0.0916, p=0.084) and for PE-related mortality (AUC sPESI 0.764, 95% CI: 0.717-0.808 versus ESC 0.650, 95% CI: 0.598-0.700, difference between AUCs 0.114, p=0.11). Fatal or major bleedings occurred in 4.30% of high risk, 1.60% of intermediate risk and 2.50% of low risk patients according to 2008 ESC model, whereas these occurred in 1.80% of high risk and 1.45% of low risk patients according to sPESI, respectively. Predictive performance for fatal or major bleeding between two models was not significantly different (AUC sPESI 0.658, 95% CI: 0.606-0.707 versus ESC 0.512, 95% CI: 0.459-0.565, difference between AUCs 0.145, p=0.34). In hemodynamically stable patients, the combined endpoint in-hospital PE-related mortality and/or fatal or major bleeding (adverse events) occurred in 0% of patients with low risk ESC model and sPESI score 0, whilst it occurred in 5.5% of patients with low-risk ESC model but sPESI ≥1. In intermediate risk patients according to ESC model, adverse events occurred in 3.6% of patients with sPESI score 0 and 6.65% of patients with sPESI score ≥1.Conclusions: In real world, predictive performance of sPESI and the hemodynamic/biomarkers-based ESC model as prognosticator of in-hospital mortality and bleedings is similar. Combination of sPESI 0 with low risk ESC model may identify patients with very low risk of adverse events and candidate for early hospital discharge or home treatment.

Cryptogenic stroke

Although in the last few years emerging conventional and unconventional radiological and laboratory techniques have shed light on different pathophysiologic causes of stroke, nowadays almost 25% of ischemic strokes results of undetermined etiology. Different diagnostic criteria have been developed to define cryptogenic stroke and to establish its prevalence in stroke units. Different studies tried to unravel mechanisms of cryptogenic stroke and to evaluate adequate primary and secondary preventive measures, but standardized diagnostic and therapeutic strategies are still missing. In this review we report the most relevant updated notions in cryptogenic stroke providing an overview of the definition, the recommendations for diagnostic evaluation and the updated treatment strategies for secondary prevention

Complexity in internal medicine wards: A novel screening method and implications for management

AbstractRationaleComplexity is increasingly recognized as a critical variable in health care. However, there is still lack of practical tools to assess it and tackle the challenges that stem from it, particularly within hospitals.Aims and objectiveTo validate a simple novel screening method based on both objective and subjective criteria to identify patients with clinically complex hospitalization events. To evaluate the prevalence of patients with complex events, identify their features, and compare them with those of the other patients and to those of patients with multimorbidities.MethodWe monitored the level of complexity of the hospitalization events of 240 patients admitted to an internal medicine ward in Tuscany over the course of 56 days. We compared the demographic features, the length of stay, and the prognosis of patients with and without complex events.ResultsSixty‐nine patients (28.8% of the sample) had a complex episode during their stay, and 115 (47.9%) had phases of low complexity. Patients with complex episodes were younger and more comorbid than patients without. They stayed longer in‐hospital (+4.5 days; 95% CI: 2.5‐6.5) and had higher mortality (OR: 24.93; 95% CI: 6.97‐171.63) and a lower probability of home discharge (OR: 0.25; 95% CI: 0.13‐0.48).ConclusionsThe results show that using a simple screening method is possible to identify complex patients within IM wards and that every day, about one‐third of the patients are complex. The results are discussed in implications for the dynamic management of patients with complex and simple phases during hospitalization

Direct Oral Anticoagulants in Patients Undergoing Urgent Reperfusion for Nonvalvular Atrial Fibrillation-Related Ischemic Stroke: A Brief Report on Literature Evidence

Introduction. The optimal timing for starting anticoagulation in the early phase of nonvalvular atrial fibrillation (NVAF)-related acute ischemic stroke (AIS) remains a challenge, especially in patients undergoing urgent reperfusion by systemic thrombolysis or mechanical thrombectomy. The aim of our study was to review the literature evidence reporting on safety of direct oral anticoagulants (DOACs) starting in the early phase of NVAF-related AIS undergoing systemic thrombolysis and/or mechanical thrombectomy. Materials and Methods. We reviewed the PubMed databases searching articles reporting on efficacy and safety of DOACs starting time within two weeks from AIS onset in patients undergoing systemic thrombolysis and/or mechanical thrombectomy. Results. Three studies were selected, overall including one hundred and six patients (62 females, 58.4%). Median National Institute of Health Stroke Scale (NIHSS) score at hospital admission ranged from 9 to 13 points. Median DOACs starting time ranged from 2 to 6 days. Median CHA2DS2-VASC score ranged from 4 to 6 points. Follow-up was limited to 14 days in one study, 30 days in another, and 90 days in a third one. Overall, stroke recurrence and/or intracranial bleeding occurred in two patients (1.9%) and no patient died at follow-up. Conclusion. Small sample size real life studies seem to demonstrate that the introduction of DOACs in the early phase of NVAF-related AIS undergoing urgent reperfusion is efficacious and safe. Prospective RCTs are necessary to confirm these findings