Early evaluation of coronary microcirculation by echocardiography with contrast medium in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty.

AIM: In about 30% of patients with ST elevated myocardial infarction (STEMI), in which a TIMI 3 flow is obtained in the infarct related artery (IRA) after primary percutaneous transluminal coronary angioplasty (PTCA), it's not possible to obtain a good perfusion of coronary microcirculation (no reflow). Aim of the study is to estimate the prognostic value of microcirculation study by echocardiography with contrast medium (MCE) within 48 h from procedure and to point out if there're clinical or procedural factors correlated with no reflow. METHODS: From February 2002 to June 2003 we have analyzed the integrity of microcirculation by MCE in patients with STEMI treated with PTCA. We have included in this study 62 patients with anterior myocardial infarction (MI) (first event), within 12 h from symptoms onset, with great echocardiographic window and TIMI 3 flow in the IRA after PTCA, excluding shock. We have obtained the evaluation of myocardial perfusion by MCE within 48 h from the treatment. We have used Sonovue as contrast medium, infused through peripheral vein. In each patient we have measured: perfusion index (PI) (sum of single segments scores divided by total number of myocardial segments) and regional perfusion index (RPI) (number of normal perfused segments between the diskinetic ones divided by diskinetic segments). RPI varies from 0 to 1: when >0.5 it has been considered index of good perfusion. Ejection fraction (EF) and wall motion score index (WMSI) have been calculated within 48 h and at 6 weeks follow up. ST resolution (STR) has been evaluated at 90 min from procedure and it was considered significant when >70%. RESULTS: Patients have been divided into 2 groups by myocardial perfusion: group R (33 patients with RPI>0.5) and group NR (29 patients with RPI =/<0.5). The 2 groups were similar for age (group R: mean age 61 years old; group NR: mean age 64 years old, P=n.s.), glycoprotein inhibitors use (group R 90%, group NR 97%, P=n.s.), diabetes (group R 12%, group NR 17%, P=n.s.), hypertension (group R 22%, group NR 23%, P=n.s.), incomplete revascularization (group R 12%, group NR 10%, P=n.s.). Group NR has shown a major women percentage (33%) than group R (9%) P=0.026. In group R we have appreciated a trend to a major percentage of TIMI 2-3 flow preprocedure (66% vs 36%, P=n.s.), a shorter ischemic time (209 min vs 258 min, P=n.s.) and a major STR at 90 min (72% vs 53%, P=n.s.), not statistically significant. Echocardiographic analysis and MCE show a better myocardial perfusion in group R (RPI 0.7 vs 0.14 and PI 0.96 vs 0.86, P<0.0001); better left ventricular kinetics at 6 weeks follow up (EF 54.2% vs 50.8%, P=n.s. and WMSI 1.07 vs 1.2, P=0.014) but not in the acute phase (EF 46.8 vs 42.9 and WMSI 1.3 vs 1.34, P=n.s.) 30 days mortality is similar in the 2 groups (both 3%). CONCLUSIONS: Myocardial perfusion evaluation correlates with left ventricular contractility measured at 6 weeks from acute MI, but doesn't correlate with contractility in the acute phase or 30 days mortality.

[A 'lucky' patient]. / Un caso 'fortunato'

A 72-year-old male diabetic patient admitted to our operative unit of nephrology and dialysis underwent hemodialytic treatment because of rapidly progressive renal failure. A moderate hypertensive state was associated to nephrotic proteinuria and microematuria. Renal angiography showed a severe stenosis of the right renal artery and a smaller left kidney. Right renal artery stenting induced a significant reduction in serum creatinine (Cr) and the patient discontinued with the dialytic treatment.

[Nurses' professional responsibility]. / La responsabilità professionale dell'infermiere.

As managed care relevance is growing, several old issues related to personal institutional responsibility are increasing among practitioners. Therefore, as a professional figure a nurse bases his/her job on a mix of personal knowledge and skills along with training, and he/she is responsible for giving advice in line with professional care standards. In addition, he/she is in charge of the treatment pattern agreed with the patient. However, nursing is a much more complex job, which leads professional figures facing the controversial issue of combining institutional responsibility and nursing professional tasks and duties daily. As far as nursing institutional responsibility is concerned, different view points or approaches can be applied to investigate it. The most common one is the legal approach, yet this is not the most appropriate one. Therefore, our professional background is mainly based on a management prospective rather than a legal one; dealing with the issue legally would lead, essentially, to a summary of laws and regulations without any kind of argumentative discussion. Consequently, this study aimed to analyze nurses' institutional responsibility by approaching the issue from an innovative human resources management prospective; therefore, defining the gap between nursing institutional responsibility and its tasks.