Health-Status Outcomes in Older Patients With Myocardial Infarction: Physiology-Guided Complete Revascularization Versus Culprit-Only Strategy.

BACKGROUND: The FIRE trial (Functional Assessment in Elderly Myocardial Infarction Patients With Multivessel Disease) enrolled 1445 older (aged ≥75 years) patients with myocardial infarction and multivessel disease in Italy, Spain, and Poland. Patients were randomized to physiology-guided complete revascularization or treatment of the only culprit lesion. Physiology-guided complete revascularization significantly reduced ischemic adverse events at 1 year. This prespecified analysis investigated the changes between the 2 study groups in angina status, quality of life, physical performance, and frailty. METHODS: Patients underwent validated scales at hospital discharge (baseline) and 1 year later. Angina status was evaluated using the Seattle Angina Questionnaire, health-related quality of life by EQ visual analog scale, physical performance by short physical performance battery, and frailty by the clinical frailty scale. Mixed models for repeated measures analysis were used to study the association between the treatment arms, time, and scales. RESULTS: Baseline and 1-year Seattle Angina Questionnaire, EQ visual analog scale, short physical performance battery, and clinical frailty scale were collected in around two-thirds of the entire FIRE study population. The mean age was 80.9±4.6 years (female sex, 35.9%). Overall, 35.3% were admitted for ST-segment-elevation myocardial infarction, whereas the others were admitted for non-ST-segment-elevation myocardial infarction. Physiology-guided complete revascularization, compared with culprit-only revascularization, was associated with greater improvement in terms of angina status (Seattle Angina Questionnaire summary score, 7.3 [95% CI, 6.1-8.6] points), health-related quality of life (EQ visual analog scale, 6.2 [95% CI, 4.4-8.1] points), and physical performance (short physical performance battery, 1.1 [95% CI, 0.9-1.3] points). After 1 year, patients randomized to culprit-only revascularization experienced a deterioration in frailty status (clinical frailty scale, 0.2 [95% CI, 0.1-0.3] points), which was not observed in patients randomized to physiology-guided complete revascularization. CONCLUSIONS: The present analysis suggested that a physiology-guided complete revascularization is associated with consistent benefits in terms of angina status, quality of life, physical performance, and the absence of further deterioration of the frailty status. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03772743.

QFR for the Revascularization of Nonculprit Vessels in MI Patients: Insights From the FIRE Trial.

BACKGROUND: The role of quantitative flow ratio (QFR) in the treatment of nonculprit vessels of patients with myocardial infarction (MI) is a topic of ongoing discussion. OBJECTIVES: This study aimed to investigate the predictive capability of QFR for adverse events and its noninferiority compared to wire-based functional assessment in nonculprit vessels of MI patients. METHODS: The FIRE (Functional Assessment in Elderly MI Patients With Multivessel Disease) trial randomized 1,445 older MI patients to culprit-only (n = 725) or physiology-guided complete revascularization (n = 720). In the culprit-only arm, angiographic projections of nonculprit vessels were prospectively collected, centrally reviewed for QFR computation, and associated with endpoints. In the complete revascularization arm, endpoints were compared between nonculprit vessels investigated with QFR or wire-based functional assessment. The primary endpoint was the vessel-oriented composite endpoint (VOCE) at 1 year. RESULTS: QFR was measured on 903 nonculprit vessels from 685 patients in the culprit-only arm. Overall, 366 (40.5%) nonculprit vessels showed a QFR value ≤0.80, with a significantly higher incidence of VOCEs (22.1% vs 7.1%; P < 0.001). QFR ≤0.80 emerged as an independent predictor of VOCEs (HR: 2.79; 95% CI: 1.64-4.75). In the complete arm, QFR was used in 320 (35.2%) nonculprit vessels to guide revascularization. When compared with propensity-matched nonculprit vessels in which treatment was guided by wire-based functional assessment, no significant difference was observed (HR: 0.57; 95% CI: 0.28-1.15) in VOCEs. CONCLUSIONS: This prespecified subanalysis of the FIRE trial provides evidence supporting the safety and efficacy of QFR-guided interventions for the treatment of nonculprit vessels in MI patients. (Functional Assessment in Elderly MI Patients With Multivessel Disease [FIRE]; NCT03772743).

Quantitative flow ratio-based outcomes in patients undergoing transcatheter aortic valve implantation quaestio study.

Background: Coronary artery disease (CAD) is common in patients with aortic valve stenosis (AS) ranging from 60% to 80%. The clinical and prognostic role of coronary artery lesions in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) remains unclear. The aim of the present observational study was to estimate long-term clinical outcomes by Quantitative Flow Ratio (QFR) characterization of CAD in a well-represented cohort of patients affected by severe AS treated by TAVI. Methods: A total of 439 invasive coronary angiographies of patients deemed eligible for TAVI by local Heart Teams with symptomatic severe AS were retrospectively screened for QFR analysis. The primary endpoint of the study was all-cause mortality. The secondary endpoint was a composite of cardiovascular mortality, stroke/transient ischemic attack (TIA), acute myocardial infarction (AMI), and any hospitalization after TAVI. Results: After exclusion of patients with no follow-up data, coronary angiography not feasible for QFR analysis and previous surgical myocardial revascularization (CABG) 48/239 (20.1%) patients had a QFR value lower or equal to 0.80 (QFR + value), while the remaining 191/239 (79.9%) did not present any vessel with a QFR positive value. In the adjusted Cox regression analysis, patients with positive QFR were independently associated with an increased risk of all-casual mortality (Model 1, HR 3.47, 95% CI, 2.35-5.12; Model 2, HR 5.01, 95% CI, 3.17-7.90). In the adjusted covariate analysis, QFR+ involving LAD (37/48, 77,1%) was associated with the higher risk of the composite outcome compared to patients without any positive value of QFR or non-LAD QFR positive value (11/48, 22.9%). Conclusions: Pre-TAVI QFR analysis can be used for a safe, simple, wireless functional assessment of CAD. QFR permits to identify patients at high risk of cardiovascular mortality or MACE, and it could be considered by local Heart Teams.

Protein-loosing enteropathy in sclerosing mesenteritis.

Sclerosing mesenteritis (SM) is a rare, idiopathic disorder of unknown aetiology that involves the adipose tissue of the mesentery, being characterized by chronic and non-specific fibrous inflammation. Patients usually present with non-specific clinical manifestations, such as abdominal pain and diarrhoea. The diagnosis of SM is difficult and it can be definitely established only by means of surgical or imaging-guided biopsy. Different therapeutic strategies have been used in case series with different rate of success. The disease is generally self-limiting, and the long-term prognosis is good, even if some cases of severe SM are reported in literature. Here, we report a fatal case of sclerosing mesenteritis associated to protein-losing enteropathy.

[Non-alcoholic hepatic steatosis: the role of policosanols in associated hyperlipidemia]. / La steatosi epatica non alcolica: il ruolo dei policosanoli nelle iperlipemie associate.

AIM: The purpose of this study was to evaluate the efficacy of policosanols in the treatment of associated hyperlipidemia in patients with non-alcoholic fatty liver disease (NAFLD). METHODS: We conducted a retrospective study on 52 patients with NAFLD. Pretreatment patients' data (total cholesterol, LDL cholesterol, triglycerides, ALT, and AST) were collected and analyzed. Furthermore, based on weight and height, we calculated the Body Mass Index (BMI) and, based on blood glucose and insulin levels, we estimated the Human Omeostatic Assesment Index (HOMA). After that, all patients were treated with a policosanols' supplement (Frilipid®) and a hypocaloric balanced diet, and then followed over time with quarterly inspections. We collected and analyzed data on three subsequent quarterly monitoring during treatment. RESULTS: The collected and analyzed data showed a significant reduction in total cholesterol, LDL cholesterol and HOMA index (P<0.002). It was also found a trend not statistically significant for a marked reduction in ALT, AST, triglycerides, and BMI. CONCLUSION: The use of policosanols is shown effective in the treatment of associated hyperlipidemia and insulin resistance in patients with fatty liver disease.

The role of neopterin in cardiovascular disease.

Inflammation plays a key role in the initiation and progression of atherosclerosis but also in the pathophysiology of atheromatous plaque disruption and the development of acute coronary syndromes. Neopterin is a marker of inflammation and of immune system activation, it is synthesized by macrophages, that, once activated, release this substance. Indeed, in clinical evaluation of patients, measurements of plasma levels of neopterin are usually used to evaluate progression of viral infections, renal transplant rejection, severe systemic inflammatory diseases, nephritic syndrome and several autoimmune diseases. This mediator is able to induce a pro-atherothrombotic phenotype in cells of the coronary circulation. Recent data indicate that serum levels of neopterin are elevated in patients with coronary and peripheral artery disease and seem to be a prognostic marker for major adverse cardiovascular events. In particular, neopterin levels predict future major cardiac and vascular adverse events in patients presenting with chronic coronary artery disease, with acute coronary syndromes, and in those with critical limb ischemia. This renders this molecule a useful marker of atherosclerotic plaque activity, permitting the identification of the subjects at highest risk for major adverse cardiovascular events. In line with the above mentioned evidences, patients with high neopterin levels may require aggressive risk factor modification and intensive medical treatment irrespective of the severity of their coronary artery disease. This data suggest a potential clinical use of neopterin as a marker for disease activity in patients with cardiovascular disease.

HMG-CoA reductase inhibitors reduce nicotine-induced expression of cellular adhesion molecules in cultured human coronary endothelial cells.

BACKGROUND: Smoking predisposes to the development of atherosclerosis and of its complications. The mechanisms responsible for these effects are not completely understood. We have investigated whether nicotine might promote a proatherosclerotic state in human coronary endothelial cells (HCAECs), studying the role of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors in preventing these phenomena. METHODS AND RESULTS: Real-time PCR showed that nicotine induced a dose-dependent increase in mRNA levels for vascular cellular adhesion molecule-1 (VCAM-1)/intercellular adhesion molecule-1 (ICAM-1). Fluorescent-activated cell sorting analysis showed that nicotine induced expression of functionally active VCAM-1/ICAM-1, since they increased leukocyte adherence to HCAECs. Oxygen free radicals, Rho A and nuclear factor kappaB (NF-kappaB) play a pivotal role in modulating these effects. Indeed, nicotine caused oxygen free radical production as well as activation of Rho A and NF-kappaB pathways, evaluated by malondialdehyde levels, pulldown assay and by electrophoretic mobility shift assay, respectively. Superoxide dimutase, Rho A (Y-27639) and NF-kappaB inhibitors (pyrrolidine dithiocarbamate ammonium, Bay 11-7082) suppressed nicotine effects on CAM expression. HMG-CoA reductase inhibitors prevented these nicotine-mediated effects by inhibiting free radical generation and by modulating activation of Rho A and NF-kappaB pathways. CONCLUSIONS: Nicotine promotes CAM expression on HCAECs, shifting them toward a proatherosclerotic state. These effects might explain, at least in part, the deleterious cardiovascular consequences of cigarette smoking. HMG-CoA reductase inhibitors play an important role in preventing these phenomena.

[Primary colonic lymphoma: report of two cases]. / Linfomi primitivi del colon: descrizione di due casi clinici.

Primary colonic lymphoma is a rare condition. It may be associated with immunosuppressed states and inflammatory bowel disease. The pattern of presentation is not specific, this leads to lengthy in diagnosis. Authors report two personal cases and discuss the problem of diagnosis. Surgery followed by adjuvant chemotherapy is the standard treatment. Using this approach 5-years survival ranges from 27-55%.

Acoso moral (mobbing): un nuevo riesgo en la medicina del trabajo / Moral harassment: a new risk in occupational medicine

Los riesgos psicosociales se están constituyendo en una de las principales causas de alteración de la salud en los puestos de trabajo. En los últimos años, el "riesgo relacional o interpersonal" - mobbing - se ha ido incrementando debido a los cambios macroeconómicos y por el cambio en la tipología del trabajo y en los riesgos laborales derivados. Cada trabajador, independientemente de las características de su propia personalidad y del propio carácter, puede ser objeto de acoso moral. Los primeros efectos derivados del mobbing son observables sobre la salud de la víctima que, casi siempre, después de un intervalo variable, se altera con manifestaciones en la esfera neuropsíquica, Las consecuancias sociales pueden ser devastadoras. El costo del mobbing no se limita a los aspectos individuales, sino que se refleja generalmente a nivel de la empresa. La gestión del fenómeno de mobbing es multidisciplinaria. A nivel asistencial, el rol del médico del trabajo, del psiquiatra y del psicólogo son interdependientes y deben por lo tanto ser integrados en una estructura funcional unitaria...(AU)

Acoso moral (mobbing): un nuevo riesgo en la medicina del trabajo / Moral harassment: a new risk in occupational medicine

Los riesgos psicosociales se están constituyendo en una de las principales causas de alteración de la salud en los puestos de trabajo. En los últimos años, el "riesgo relacional o interpersonal" - mobbing - se ha ido incrementando debido a los cambios macroeconómicos y por el cambio en la tipología del trabajo y en los riesgos laborales derivados. Cada trabajador, independientemente de las características de su propia personalidad y del propio carácter, puede ser objeto de acoso moral. Los primeros efectos derivados del mobbing son observables sobre la salud de la víctima que, casi siempre, después de un intervalo variable, se altera con manifestaciones en la esfera neuropsíquica, Las consecuancias sociales pueden ser devastadoras. El costo del mobbing no se limita a los aspectos individuales, sino que se refleja generalmente a nivel de la empresa. La gestión del fenómeno de mobbing es multidisciplinaria. A nivel asistencial, el rol del médico del trabajo, del psiquiatra y del psicólogo son interdependientes y deben por lo tanto ser integrados en una estructura funcional unitaria...

International traffic in coca through the early 20th century.

This paper compiles records of coca exported by the major producing sites, Peru, Bolivia, Java and Formosa, from the late 19th century through the first third of the 20th century. During most of this era coca was legally produced and responsive to market demands. World coca exports did not peak [corrected] until around 1920, followed by a steady decline over the next decade. This export pattern (if not the exact figures) suggests a period of rising cocaine consumption, peaking regionally first in North America, then in Europe and other parts of the world, followed [corrected] by a marked decrease in the drug's popularity and acceptance.

Cocaine's history, especially the American experience.

The history of cocaine in America can be traced to the late 19th century. After the discovery of its physiological and psychological effects, cocaine figured in consumables as diverse as hay fever remedies, local anaesthetics and soft drinks. The development of its different usages as well as eventual control of its use through restrictive legislation followed a different pattern in America from that in Europe. In the United States, national laws to control drugs faced constitutional obstacles until the era of World War I. Initially acclaimed as an ideal tonic, within two decades of its introduction in the mid 1880s cocaine was perceived as an extremely dangerous drug. By the 1930s cocaine had declined in use and in the 1960s, when it gradually emerged again, almost no public memory existed of the earlier 'epidemic'. Once again this substance evolved into a threatening and seductive hazard with some similarities to the earlier episode.