Regolazione del mercato energetico e tutela dell’ambiente: il caso dell’efficienza energetica.

L’integrazione degli interessi ambientali ed energetici nel settore dell’efficienza energetica. L’assetto istituzionale ed amministrativo dell’efficienza energetica. Il ruolo dell’AEEGSI dinanzi alla sfida della sostenibilità del mercato energetico. Le linee evolutive della regolazione indipendente. L’impatto della nuova regolazione environment oriented.L’integrazione degli interessi ambientali ed energetici nel settore dell’efficienza energetica. L’assetto istituzionale ed amministrativo dell’efficienza energetica. Il ruolo dell’AEEGSI dinanzi alla sfida della sostenibilità del mercato energetico. Le linee evolutive della regolazione indipendente. L’impatto della nuova regolazione environment oriented.LUISS PhD Thesi

Regolazione del mercato energetico e tutela dell\u2019ambiente: il caso dell\u2019efficienza energetica.

L\u2019integrazione degli interessi ambientali ed energetici nel settore dell\u2019efficienza energetica. L\u2019assetto istituzionale ed amministrativo dell\u2019efficienza energetica. Il ruolo dell\u2019AEEGSI dinanzi alla sfida della sostenibilit\ue0 del mercato energetico. Le linee evolutive della regolazione indipendente. L\u2019impatto della nuova regolazione environment oriented

Dynamic modulation of coronary arterio-venous communications

A 62 year-old man with multiple coronary risk factors – including uncontrolled hypertension, smoking habit, abdominal obesity and family history of ischemic heart disease – was admitted to our Emergency Department for a prolonged episode of chest pain occurring at rest. He had no relevant past medical history except recently diagnosed chronic obstructive pulmonary disease; however, in the last year he suffered from sporadic episodes of effort angina (Canadian Class II–III) with spontaneous regression after few minutes of rest. During the last week he experienced worsening angina, with daily episodes of chest pain, mainly occurring during mild exertion but with some episodes occurring even at rest in the last two days. On admission the patient was symptomatic for angina. Physical examination was unremarkable, except for rhonchi and wheezing sounds in the chest, the blood pressure was 200/95 mmHg and the ECG revealed sinus tachycardia with ST segment elevation and QS waves in V1–V4 leads. Pharmacological treatment was immediately started with loading doses of Aspirin and Clopidogrel, iv. morphine, i.v. nitroglycerin and i.v. beta-blockers, with partial pain resolution. Cath lab team was promptly alerted for urgent coronary angiography. In the meantime, a trans-thoracic echocardiogram was performed, showing a hypertrophic and mildly dilated left ventricle with regional wall motion abnormalities in the left anterior descending (LAD) coronary artery territory: apical and mid septal akinesia, anterior wall hypokinesia. The estimated left ventricular ejection fraction was 35–40%. No other relevant findings. Fifteen minutes after the admission the patient was still mildly symptomatic for angina and ST segment elevation was still present on the ECG, although reduced, thus the patient was transferred directly to the cath lab to undergo coronary angiography. The selective right coronary angiography revealed significant stenosis of the posterolateral branch of the right coronary artery (RCA) and, more importantly, the presence of collaterals to the LAD and three artero-venous fistulae, which allowed the RCA to communicate with the pulmonary artery, the coronary sinus and a posterolateral branch of the cardiac venous system (Fig. 1A ). Prior to the selective angiography of the left coronary artery, the patient's chest pain resolved together with the concomitant resolution of the ST segment elevation. The left coronary angiography (Fig. 2C ) was performed and showed the presence of significant proximal LAD stenosis, likely representing the culprit lesion, which appeared spontaneously reperfused. Angiography also revealed sub-occlusion of the first diagonal and significant stenosis of the first obtuse marginal (OM) branch. Due to these findings, a new right coronary angiography was performed, which documented the disappearance of both arterial and venous communications (Fig. 1 B). Because of the spontaneous reperfusion of the culprit lesion, together with the total regression of symptoms and ST segment elevation, urgent revascularization was not deemed necessary. Furthermore, considering the presence of multivessel disease, a joint clinical case meeting with cardiac surgeons and invasive cardiologists was arranged and a staged PCI was felt to be the best treatment option and thus was scheduled the following day. A successful revascularization procedure was performed with the implantation of two everolimus eluting stents (EES), 2.75×23 mm on LAD and 2.75×32 mm on OM, and a POBA of the first diagonal branch with a 2.5×25 mm balloon. The patient was discharged with the indication to complete the percutaneous revascularization later. The pre-discharge echocardiogram confirmed global left ventricular dysfunction (LVEF 35–40%) with the above described regional wall motion abnormalities. One month later the revascularization was completed with an elective PCI of the posterolateral branch of the RCA with the implantation of another EES 2.75×16 mm and the angiography confirmed the complete disappearance of collateral circulation and arterio-venous fistulae (Fig. 2 D,E)

Lemierre's syndrome complicated by cerebral venous sinus thrombosis: A life threatening and rare disease successfully treated with empiric antimicrobial therapy and conservative approach

Lemierre's syndrome (LS) is a "forgotten" condition characterized by septic thrombophlebitis of the jugular vein that follows an otolaryngological infection. Fusobacterium necrophorum is the aetiological agent responsible for the syndrome in adolescents and young adults whereas in older people even common bacteria are involved. Complications arise from spreading of septic emboli distally, i.e. to the brain, lungs, bones and internal organs everywhere in the body. We report a middle-aged woman who presented with headache and bilateral sixth cranial nerve palsy following a sphenoidal sinusitis and left mastoiditis. Imaging revealed thrombotic involvement of the left internal jugular vein as well as of several cerebral venous sinuses thrombosis (CVT). Currently, precise management protocols of LS with CVT complication do not exist although a combination of macrolides and second or third-generation cephalosporins, as well as anti-coagulants represent the mainstream of therapeutics. Surgical drainage is associated to remove septic foci but is burdened by severe complications and side effects. Complete recovery was achieved following pharmacological treatment in our patient. This report adds further evidence that LS complicated by CVT may be effectively treated adopting a conservative approach thus avoiding surgical drainage and severe complications

Fractional flow reserve in acute coronary syndromes and in stable ischemic heart disease: clinical implications

Background: Fractional Flow Reserve (FFR) in Stable Ischemic Heart Disease (SIHD) is universally accepted, while in Acute Coronary Syndromes (ACS) is less established. Aims of this retrospective study were: to compare in patients undergoing FFR assessment the prognostic impact of ACS vs SIHD, to evaluate the clinical relevance of the modality of utilization and timing of FFR assessment and to assess the different outcomes associated with an FFR> or 640.80. Methods: Major cardiac adverse events were assessed at a follow up of 16.4 \ub1 10.5 months in 543 patients with SIHD and 231 with ACS needing functional evaluation. FFR was used for lesions of ambiguous significance in the absence of a clear culprit vessel (first intention, FI) and for incidental lesions in the presence of a clear culprit vessel (second intention, SI). The decision to perform FFR and the identification of the stenosis needing functional assessment were left to the operator's discretion. Revascularization was performed when FFR was 640.80. Results: SIHD and ACS patients were not significantly different for principal clinical characteristics. ACS patients had significantly more events than SIHD, due to an excess of death and myocardial infarction. This was confirmed when FFR was used as FI, in particular if FFR was >0.80. On the contrary, when FFR was used as SI, event rates were similar between ACS and SIHD patients, regardless of FFR value. Conclusions: Our study shows that using FFR the risk of recurrent events in ACS is significantly higher than in SIHD. This different outcome is confined to those patients in whom FFR is utilized for lesions of ambiguous significance in the absence of a clear culprit vessel