Glomerular filtration rate: A prognostic marker in atrial fibrillation-A subanalysis of the AntiThrombotic Agents Atrial Fibrillation.

OBJECTIVE: An increased cardiovascular mortality and morbidity has been widely reported in patients with atrial fibrillation (AF). In this study, a subanalysis of the AntiThrombotic Agents Atrial Fibrillation (ATA-AF) is performed with the aim to evaluate estimated glomerular filtration rate (eGFR) as an independent prognostic marker of cardiovascular mortality and morbidity in patients with AF. METHODS AND RESULTS: The ATA-AF study enrolled 7148 patients with AF, in 360 Italian centers. The eGFR was calculated from data reported in patient notes or hospital database. This post-hoc analysis included 1097 AF patients with eGFR data available and 1-year clinical follow-up. The endpoint was assessed as cardiovascular mortality and/or hospital admission for cardiovascular causes at follow-up. Patients were also divided in two groups according to the eGFR (<60 and ≥60 mL/min/1.73 m2 ). The Kaplan-Meyer curve for the mentioned endpoint showed a higher endpoint incidence in the group of patient with eGFR below 60 mL/min/1.73 m2 (P < 0.001). Using multivariate analysis (Cox regression), a trend toward a higher rate of occurrence of the primary endpoint was observed for eGFR below 60 mL/min/1.73 m2 without reaching the conventional level of statistical significance (hazard ratio [HR] 1.40; 95% confidence interval [CI] 0.99-1.99; P = 0.0572). When eGFR was included in the analysis as continuous variable a significant correlation was observed with the combined endpoint at the Cox regression (HR 0.99, 95% CI 0.98-0.99, P = 0.04). CONCLUSION: The result of this post-hoc analysis indicates that an impaired eGFR is independently associated with worse prognosis among patients with AF.

Hemodynamic Surveillance of Ventricular Pacing Effectiveness with the Transvalvular Impedance Sensor.

The Transvalvular Impedance (TVI) is derived between atrial and ventricular pacing electrodes. A sharp TVI increase in systole is an ejection marker, allowing the hemodynamic surveillance of ventricular stimulation effectiveness in pacemaker patients. At routine follow-up checks, the ventricular threshold test was managed by the stimulator with the supervision of a physician, who monitored the surface ECG. When the energy scan resulted in capture loss, the TVI system must detect the failure and increase the output voltage. A TVI signal suitable to this purpose was present in 85% of the tested patients. A total of 230 capture failures, induced in 115 patients in both supine and sitting upright positions, were all promptly recognized by real-time TVI analysis (100% sensitivity). The procedure was never interrupted by the physician, as the automatic energy regulation ensured full patient's safety. The pulse energy was then set at 4 times the threshold to test the alarm specificity during daily activity (sitting, standing up, and walking). The median prevalence of false alarms was 0.336%. The study shows that TVI-based ejection assessment is a valuable approach to the verification of pacing reliability and the autoregulation of ventricular stimulation energy.

The effect of vaginally administered genistein in comparison with hyaluronic acid on atrophic epithelium in postmenopause.

PURPOSE: The quality of life in postmenopause is seriously affected by the symptoms related to vaginal atrophy. To evaluate in a 3-month, prospective, randomized, double blind, study whether vaginal suppositories containing genistein might improve genital symptoms, colposcopical and cytologic findings or modify DNA cytometric features in postmenopausal women affected by vaginal atrophy, in comparison with vaginal suppositories containing hyaluronic acid (HA). METHODS: A total of 62 postmenopausal women were randomly assigned to receive intravaginally 97 µg of genistein (group A, n = 31) or 5 mg of HA (group B, n = 31) daily for 15 days continuously/month for 3 months. Vaginal and cervical smear, colposcopy, vaginal biopsy were performed before and at the end of the study. Maturation value (MV) was calculated. Flow cytometric analysis of DNA ploidy (DI) and S-phase fraction (SPF) were performed. RESULTS: After 90 days of study, a significant improvement was obtained in genital symptoms, colposcopy scores and MV (p < 0.001) in both groups; the improvement obtained by genistein was more effective especially regarding genital score (p value between groups 0.001). No significant change was found in SPF value and DI. CONCLUSION: Both treatments improved genital symptoms, colposcopical features and MV, although genistein was more effective on genital score. Both treatments did not significantly influence flow cytometry parameters, although genistein showed slight decrease in DI, with a normalization of the aneuploid content present in some cases that could represent an additional application of intravaginal phytoestrogen therapy, providing an alternative therapy of vaginal atrophy in postmenopausal patients. The results of this investigation should be considered preliminary and need to be verified in larger, prospective studies.

A global approach to the management of EMR (electronic medical records) of patients with HIV/AIDS in sub-Saharan Africa: the experience of DREAM software.

BACKGROUND: The DREAM Project operates within the framework of the national health systems of several sub-Saharan African countries and aims to introduce the essential components of an integrated strategy for the prevention and treatment of HIV/AIDS. The project is intended to serve as a model for a wide-ranging scale-up in the response to the epidemic. This paper aims to show DREAM's challenges and the solutions adopted. One of the solutions is the efficient management of the clinical data regarding the treatment of the patients and epidemiological analyses. METHODS: Specific software for the management of the patients' EMR has been created within the DREAM programme in order to deal with the challenges deriving from the context in which DREAM operates. Setting up a computer infrastructure in health centres, providing a power supply, as well as managing the data and the project resources efficiently and reliably, are some of the questions that have been analysed in this study. RESULTS: Over the years this software has proved that it is able to respond to the need for efficient management of the clinical data and organization of the health centres. Today it is used in 10 countries in sub-Saharan Africa by thousands of professionals and by now it has reached its fourth version. The medical files of over 73,000 assisted patients are managed by this software and the data collected with it have become essential for the epidemiological research that is carried out to improve the effectiveness of the therapy. CONCLUSION: Sub-Saharan Africa is the region hardest hit by HIV and AIDS in the world. However, the resources and responses adopted so far, to confront the epidemic, have at times been rather minimalist. The DREAM project has faced the battle against the epidemic by equipping itself with qualitative standards comparable to Western ones. The experience of DREAM has revealed that it is indeed possible to guarantee levels of excellence in developing countries, also in the sphere of ICT (Information and Communication Technology), thus making the intervention even more effective and contributing to bridging the digital divide.

Tissue factor and monocyte chemoattractant protein-1 expression in hypertensive individuals with normal or increased carotid intima-media wall thickness.

BACKGROUND: People with hypertension display an inflammatory pattern that includes increased plasma concentrations of monocyte chemoattractant protein 1 (MCP-1) and C-reactive protein (CRP) and enhanced expression of tissue factor (TF) mRNA in blood monocytes. METHODS: In this study, we investigated the relationship between CRP concentrations and TF and MCP-1 mRNA expression in unstimulated and lipopolysaccharide (LPS)-stimulated monocytes isolated from hypertensives with or without an increase in carotid intima-media thickness (IMT). We also investigated the expression of TF and MCP-1 mRNA and MCP-1 protein after in vitro addition of CRP to monocytes. We measured CRP (by immunonephelometry) and monocyte expression of TF and MCP-1 (by real-time PCR) in 80 untreated hypertensive patients without clinical cardiovascular disease (CVD) or additional risk factors for CVD compared with 41 controls. Based on IMT measured by carotid Doppler ultrasonography, patients were classified into the categories of normal (< or =1 mm) or abnormal (>1 mm). TF and MCP-1 mRNA and MCP-1 protein (by Western blotting) were measured after in vitro addition of CRP to monocytes from 10 randomized controls as well as 10 hypertensives with IMT < or =1 mm and 10 with IMT >1 mm. RESULTS: CRP and TF and MCP-1 mRNA concentrations were significantly higher in IMT >1 mm hypertensives vs those with IMT < or =1 mm and controls. CRP had no effect on monocyte TF mRNA from either hypertensives or controls. CRP-stimulated monocytes from hypertensives, however, showed increased MCP-1 mRNA and protein expression compared with controls and LPS-stimulated cells. CONCLUSIONS: Our findings suggest that the inflammatory response of blood monocytes plays an important role in the development of atherosclerosis and hypertension.

[Hypothermia in the elderly: a shivering case]. / L'ipotermia nell'anziano: un caso da brividi.

Hypothermia is a medical emergency in patients with a body temperature lower than 35 degrees C (95 degrees F) due to prolonged exposure to ambient cold temperatures without appropriate protection. This condition has a 5-fold increased risk of death in the elderly. Usually, diagnosis is suggested by warning signs and symptoms like lethargy, weakness and loss of coordination, confusion and reduced respiratory or heart rate. We report the case of a 76-year-old woman who was referred to our center for symptomatic sinus bradycardia and with typical electrocardiographic abnormalities (Osborn wave) that suggested the diagnosis of severe hypothermia.

[Atrioventricular nodal reentrant tachycardia with 2:1 anterograde block]. / Tachicardia reciprocante nodale con blocco 2:1 della conduzione anterograda.

We describe the case of a patient who presented with narrow QRS tachycardia at a rate of 100 b/min. The R-R intervals were constant, and negative P waves were evident in the inferior leads, midway between two ventricular complexes. A few minutes later, the tachycardia rate suddenly increased to 190 b/min, and the electrocardiographic pattern became typical of atrioventricular nodal reentrant tachycardia. Intravenous verapamil succeeded in restoring sinus rhythm. These data suggested an atrioventricular nodal reentrant tachycardia that at the beginning was associated with a 2:1 anterograde block.

[Persistent left superior vena cava and absence of right superior vena cava]. / Persistenza della vena cava superiore sinistra ed assenza della vena cava superiore destra.

Persistence of left superior vena cava is a rare finding. The combination of persistent left superior vena cava and absent right superior vena cava with no other congenital cardiovascular abnormalities has been exceptionally reported. We describe a case of persistent left superior vena cava and absent right superior vena cava observed during pacemaker implantation and confirmed by transthoracic contrast echocardiography.