Transcatheter aortic valve implantation: current status and future perspectives.

In the 16 years since the first pioneering procedure, transcatheter aortic valve implantation (TAVI) has come of age and become a routine strategy for aortic valve replacement, increasingly performed under conscious sedation via transfemoral access. Simplification of the procedure, accumulation of clinical experience, and improvements in valve design and delivery systems have led to a dramatic reduction in complication rates. These advances have allowed transition to lower risk populations, and outcome data from the PARTNER 2A and SURTAVI trials have established a clear evidence base for use in intermediate risk patients. Ongoing studies with an expanding portfolio of devices seem destined to expand indications for TAVI towards lower risk, younger and asymptomatic populations. In this article, we outline recent advances, new devices and current guidelines informing the use of TAVI, and describe remaining uncertainties that need to be addressed.

[Tricuspid valve regurgitation : Indications and operative techniques]. / Trikuspidaklappenoperation : Indikationen und Techniken.

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or >21 mm/m2) is present. Functional TV regurgitation is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Valve replacement is rarely required. Tricuspid valve repair with ring annuloplasty is associated with better survival and a lower reoperation rate than suture annuloplasty. Long-term results are not available. The severity of the heart insufficiency and comorbidities (e.g. renal failure and liver dysfunction) are the essential determinants of operative mortality and long-term survival. Tricuspid valve reoperations are rarely necessary and associated with a considerable mortality.

Long-term results after transcatheter aortic valve implantation: what do we know today?

Transcatheter aortic valve implantation (TAVI) is evolving rapidly as a therapeutic option in patients deemed to be at high risk for surgical aortic valve replacement. Early outcome and survival of controlled feasibility trials and single- center experience with TAVI have been previously reported. Valve performance and hemodynamics seem to improve significantly after TAVI. Long-term outcome up to 3 years have been demonstrated in recent studies. Admittedly, the results are encouraging with a survival rate at 2 and 3 years ranging from 62 to 74% and from 56 to 61% respectively. The improvement in hemodynamical and clinical status sustained beyond the 3 years follows up. However, paravalvular leakage after TAVI remains an important issue in this rapidely evolving field.

Which way in? The necessity of multiple approaches to transcatheter valve therapy.

TAVI (transcatheter aortic valve implantation) is a less invasive treatment of the stenotic aortic valve while avoiding midline sternotomy and cardiopulmonary bypass. A crimped biological valve on a self-expanding or balloonexpandable stent is inserted antegradely or retrogradely under fluoroscopy, and deployed on the beating heart. Among the worldwide TAVI programs, many different concepts have been established for the choice of the access site. Whether retrograde or antegrade TAVI should be considered the superior approach is matter of an ongoing debate. The published literature demonstrates safety of all techniques if performed within a dedicated multidisciplinary team. Since there is no data providing evidence if one approach is superior to another, we conclude that an individualized patient-centered decision making process is most beneficial, taking advantage of the complementarity of the different access options. The aim of this article is to give an overview of the current practice of access techniques for transcatheter based valve treatment and to outline the respective special characteristics.

[Sexual dysfunctions in female with neurological disorders]. / Disfunzioni sessuali nella donna con patologia neurologica.

Female sexuality is a controversial issue due to its embarrassment and to paucity of literature publications. The neuroanatomy and neuromediators involved in female sexuality are important but not so fundamental as in men. There are three sexual female dysfunctions (SFD): primary, secondary, tertiary. In the primary one, the sexual dysfunction (SD) is correlated to the neurological disease, in the secondary the SD derives from the symptoms of the neurological disease, in the tertiary the SD is the psychological reaction to the effects of the disease. We analyse the FSD in neurological diseases, as the outcome of medulla trauma, multiple sclerosis, epilepsy, Alzheimer, Parkinson, diabetes, outcome of pelvic surgery. Female sexuality (FS) is difficult and complex compared to male sexuality. Women with medulla lesion feel some discomfort when having to go and speak to their doctor: they are afraid of pregnancy, sexual intercourses, bladder and rectal functions. In women with newly diagnosed multiple sclerosis, there is a tertiary sexual dysfunction. Medical therapy worsens female sexuality as in case of epilepsy. Emotional and behavioural disorders involve sexual dysfunctions in women with Alzheimer. In Parkinson, reduction of sexual desire involves break of sexual intercourses. SD are more frequent in complicated diabetes. In pelvic surgery, pelvic autonomic dysfunction and depression correlated to the oncology disease, contribute to the FSD. Sexual counselling, especially in young women with medulla lesion or multiple sclerosis, is the best therapy, and learning erotic extragenital areas able to make sensations similar to the orgasms.

Filariasis: an emergent cause of acute scrotal pain.

A 25-year-old man from Bangla Desh with acute right scrotal pain was subjected to scrotal surgical exploration because of the suspicion of testicular torsion. The testicle appeared normally positioned; an epididymal nodule was removed, and pathology showed the presence of the filaria worm. Filariasis is a tropical disease which has been estimated to affect 120 millions people throughout the world. Lymphadenitis and lymphangitis are the more common clinical settings; in men, there is a frequent scrotal involvement. In some cases, acute scrotal pain may lead to the suspicion of testicular torsion. The observation of patients with genital filariasis is likely to become more frequent in an era of massive immigration from different countries; nowadays, the disease should always be taken into consideration in the differential diagnosis in patients with acute scrotal pain coming from tropical areas.

Adherence to patient selection criteria in patients undergoing transcatheter aortic valve implantation with the 18F CoreValve ReValving System.

BACKGROUND: Anecdotal evidence suggests that transcatheter aortic valve implantation (TAVI) is being used beyond pre-market label indications. METHODS: To assess the frequency and outcomes associated with "off-label" use of TAVI, we conducted a retrospective study, examining adherence to patient selection criteria in 63 patients undergoing implantation with the 18F CoreValve ReValving System (CRS). Label status (on-label vs off-label) was determined by following (1) inclusion/exclusion criteria indicated in the 18F CRS safety and efficacy trial and (2) a patient selection matrix indicating anatomical boundaries to guide patient selection. Off-label use was defined as the presence of at least one exclusion criterion or "non-acceptable" criteria based on the patient selection matrix. RESULTS: Off-label implantation was identified in 42 patients (67%)-40% had one, 19% had two and 8% had three or more off-label criteria. Baseline demographics were similar between the groups except for a higher logistic EuroSCORE in the on-label group (19.8 (11.2) vs 14.5 (7.3), p = 0.029). There was no significant difference in the procedural success rates between the on-label and off-label groups (91% vs 95%, respectively, p = 0.47). The frequency of angiographic moderate-severe aortic regurgitation, post-implant dilatation or implantation of a second valve was also similar between the groups. At 30 days, the cumulative death rate was 10%; there were four deaths in the "on-label" and three deaths in the "off-label" group. CONCLUSION: In this study we found that "off-label" implantation of the CRS was common. Further studies are needed to evaluate the consequences of "label status" for patients undergoing TAVI.

Evaluation of the female sexual function after vaginal surgery using the FSFI (Female Sexual Function Index).

Urinary Incontinence (UI) and Pelvic Organ Prolapse (POP) have a detrimental effect on Female Sexual Function (FSF). We decided to focus on the effect of vaginal surgery for UI and/or POP on FSF. MATERIALS AND METHODS. 72 women (aged 42-80, mean age: 62) were given the FSFI questionnaire after undergoing the following operations: 54 Tension-Free Vaginal Slings (TFVS), 12 Kelly plications, 3 hysterectomies+Kelly, 2 Tension-Free Vaginal Slings+Kelly, 1 hysterectomy+ Kelly+posterior IVS. RESULTS. 35 women did not answer the questionnaire, 6 women were sexually inactive and answered only partially; 31 patients answered completely. Mean pre- and postoperative scores were, respectively, 25.26 and 25.22 (normal >26.55). 9 patients had a normal preoperative score, whereas 22 a pathological score. The FSFI score did not change postoperatively in 26 women; it worsened in 3 and improved in 2 women treated because of coital incontinence. CONCLUSIONS. Vaginal surgery for UI and/or POP does not seem to affect FSF in the great majority of cases; conditions may worsen or improve, the latter definitely resulting from the treatment of Coital Incontinence. The high number of patients not answering the questionnaire deserves further studies and it could be - at least partially - explained on the basis of psychological and/or cultural problems regarding the highly emotional issues of sex, incontinence and prolapse.

Development of a new geometric bicycle saddle for the maintenance of genital-perineal vascular perfusion.

OBJECTIVE: To identify a bicycle saddle model for cyclists who cover long distances, to minimally reduce the compression on the structures of the pelvic floor, thereby protecting blood perfusion of the penis and avoiding possible consequences on penile erection. MATERIALS AND METHODS: A comparison between a new geometric development of a bicycle saddle model (SMP) and one of the more frequently used models by professional cyclists was made. The measurement of the partial pressure of penile transcutaneous oxygen (PtcO(2)) in 29 healthy voluntary cyclists was recorded to investigate the differences of compression from two different saddles on the vascular structures of the perineum. The PtcO(2) was recorded at 3 and 10 minutes in conditions of static sitting. Then, the values of PtcO(2) were recorded for 15 minutes while the cyclists were in a 60-degree position and in stable hemodynamic conditions. RESULTS: A t-test was performed to measure the level of confidence. The clear superiority of the SMP saddle in preventing vascular compression of the perineal structures was demonstrated to be statistically significant. CONCLUSION: The experiment validated the effectiveness of the SMP saddle in limiting the compression on the pelvic floor. In addition, the SMP saddle introduces compatible seat dimensions that cyclists prefer to cover long distances.

[Evaluation of the immune status against poliomyelitis in a group of young immigrants]. / Valutazione dello stato immunitario verso la poliomielite in un campione di giovani immigrati.

The immunity state towards poliomyelitis has been evaluated in 506 young immigrants coming from European and extraeuropean countries without immunization history. Polioviruses 1, 2 and 3 antibodies were detected in 97% of the serum samples. 15 subjects did not have detectable antibodies at 1:2 dilution for one or two polioviruses. Out of these subjects, 6 (coming mostly from East European Region) were negative in the undiluted serum too. On the whole, GMTs for type 1 (43,29) and 2 (41,9) appeared higher than those for type 3 (33,6). Moreover there are differences among the origin countries; in fact, GMTs more elevated for type 1 and 3 (74,6 and 49,6 respectively) have been observed in the subjects coming from the African region, as well in those coming from the American region.

Prueba de susceptibilidad antimicrobiana de un material de obturación endodóntica / Antimicrobial susceptibility test of an endodontic filling material

Los estudios y ensayos de laboratorio "in vitro" realizados en el presente trabajo con P.L.R.M. (pasta lentamente reabsorbible de Maisto) confirman un efecto bacteriostático con todas las cepas de microorganismos estudiados: Fusobacterium periodonticum ATCC 33693 Prevotella Melaninogénica ATCC 439822 Porphyromonas endodontalis ATCC 35406 Staphylococcus sp., Streptococcus viridans y Streptococcus Grupo A, en períodos de 0 a 56 días y valores de 1g. hasta 0,5mg/ml

Prueba de susceptibilidad antimicrobiana de un material de obturación endodóntica / Antimicrobial susceptibility test of an endodontic filling material

Los estudios y ensayos de laboratorio "in vitro" realizados en el presente trabajo con P.L.R.M. (pasta lentamente reabsorbible de Maisto) confirman un efecto bacteriostático con todas las cepas de microorganismos estudiados: Fusobacterium periodonticum ATCC 33693 Prevotella Melaninogénica ATCC 439822 Porphyromonas endodontalis ATCC 35406 Staphylococcus sp., Streptococcus viridans y Streptococcus Grupo A, en períodos de 0 a 56 días y valores de 1g. hasta 0,5mg/ml (AU)

The substance abuse subtle screening inventory minimizes the need for toxicology screening of prenatal patients.

Multiple authors have reported attempts to effectively address the discovery of substance abuse in pregnancy using various mechanisms to encourage positive self-reports and urine toxicology to augment identification. In this study, we evaluated 1,251 patients with (a) self-report, (b) the Substance Abuse Subtle Screening Inventory (SASSI), and (c) urine toxicology screening to determine which modality or combination would yield the most cost-effective discovery. Combining the SASSI with the self-report was the most clinically effective and cost effective mode of discovery. This led to the development of a clinical protocol using the SASSI and self-report with limited use of urine toxicology for specific patient subgroups. Alcohol abuse, which is missed by toxicology and self-report, is detected by the SASSI.

Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort.

PURPOSE: Pathological predictors of outcome for patients undergoing radical cystectomy for bladder cancer are needed as few data are available in the literature. We retrospectively analyzed a homogeneous and contemporary series of patients treated with radical surgery as monotherapy for bladder cancer to identify the independent predictors of survival. MATERIALS AND METHODS: We evaluated 369 of 535 patients with bladder cancer treated with radical cystectomy, pelvic node dissection and urinary diversion by the same staff at a single institution between February 1982 and February 1994. Patients treated with radiation therapy and/or chemotherapy, and those who did not undergo formal pelvic node dissection were excluded from study. The end point of univariate and multivariate analyses was the overall 5-year survival. RESULTS: Univariate analysis revealed that tumor stage, nodal involvement, ureteral obstruction, and vascular, lymphatic and perineural invasion were prognostic predictors of survival (p <0.05). However, only tumor stage (p <0.0000) and nodal involvement (p <0.0000) were independent prognostic variables of survival on multivariate analysis. CONCLUSIONS: Tumor stage and nodal involvement are the only independent predictors of survival to be used to select the optimal therapy after radical cystectomy, stratify patients in controlled trials and evaluate new prognostic factors.

The Purpose-in-Life Test and religious denomination: Protestant and Catholic scores in an elderly population.

The Purpose-in-Life Test (PIL) was administered to a group of 118 elderly persons from three senior citizen centers. Data were obtained on religious denomination. Results suggested that whether a person was Protestant or Catholic had no significant effect on PIL scores, with mean scores almost identical. What seemed to be important was how meaningful spirituality was to the person. Those who scored high on an index of spirituality also scored high on the PIL.

The substance abuse subtle screening inventory is more cost effective and has better selectivity than urine toxicology for the detection of substance abuse in pregnancy.

OBJECTIVE: To compare the SASSI as a screen for substance abuse in pregnancy with the patient history and toxicology screening. STUDY DESIGN: On 560 patients the substance abuse history and urine toxicology was obtained at registration in the prenatal clinic. Each patient also completed the SASSI questionnaire. The SASSI was compared with each screen individually and the result of the SASSI and the patient's history were combined for comparison with the toxicology results. RESULTS: SASSI was found to be more selective as a screen for substance abuse than urine toxicology and it gave a profile of alcohol use which was absent on the toxicology screen. CONCLUSIONS: The SASSI is a more effective clinical tool for identifying substance abuse and more cost effective than toxicology screening.

Is stage pT4a (D1) reliable in assessing transitional cell carcinoma involvement of the prostate in patients with a concurrent bladder cancer? A necessary distinction for contiguous or noncontiguous involvement.

PURPOSE: A series of patients with concurrent transitional cell carcinoma involvement of the prostate and bladder is reviewed to define the impact of prostate involvement pathways and the degree of prostate invasion on survival rate. MATERIALS AND METHODS: A total of 72 patients who underwent radical cystectomy for pathological stage pT4a (D1) cancer was divided into contiguous--stage pT4a, transitional cell carcinoma of the bladder extended into the prostate through the bladder wall and noncontiguous--stage pT4a simultaneous transitional cell carcinoma of the prostate and bladder carcinoma that did not directly infiltrate into the prostate through the bladder wall. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement, stromal invasion and extracapsular extension. The survival rate was estimated by the Kaplan-Meier and Cox proportional hazards methods. Comparisons between curves were performed by univariate log rank and multivariate L-ratio tests. RESULTS: The overall 5-year survival rate for stage pT4a was 21.5% (median followup 64 months). Furthermore, 46% and 7% of patients in noncontiguous and contiguous pT4a groups, respectively, were estimated to be alive (p < 0.000). Those with positive nodes experienced a poor outcome in both groups. Of patients with noncontiguous pT4a stage 100% with urethral mucosal involvement, 50% with ductal/acinar involvement and 40% with stromal invasion were estimated to be alive. The major prognostic factors were bladder tumor stage, nodal involvement and degree of prostate invasion. CONCLUSIONS: The invasion pathways of the prostate in patients with transitional cell bladder carcinoma have a statistically significant prognostic role. Contiguous and noncontiguous involvements are 2 distinct clinicopathological features and they should not be included in the same stage. In the noncontiguous stage pT4a group bladder and prostate transitional cell carcinoma should be separately staged, and prostate involvement also should be staged according to invasion degree.

Dual diagnosis and adolescent psychiatric inpatients.

Recognition is growing that many individuals with mental health disorders also suffer from substance use disorders. Providers of adolescent mental health services are in need of prevalence data and instruments that can assist in screening for alcohol and other drug use problems. This study provides data on the concurrent validity of using the Substance Abuse Subtle Screening Inventory with mental health patients and data on the prevalence of substance use disorders in a sample of adolescent psychiatric inpatients.

Improving the efficacy of BCG immunotherapy by dose reduction.

Several clinical trials have shown intravesical bacillus Calmette-Guérin (BCG) to be effective in the prophylaxis of papillary tumour recurrences and in the therapy of bladder carcinoma in situ (CIS), as well as in delaying progression to muscle invasion. Nevertheless, the optimal regimen of BCG therapy for superficial bladder cancer has still to be defined. In a previous phase II trial, a low-dose regimen (BCG Pasteur strain, 75 mg) was able to achieve clinically significant response rates with a decrease in side-effects compared with other reported studies using standard-dose BCG. However, a phase III randomized trial--low dose versus standard dose (BCG Pasteur strain, 75 vs. 150 mg)--was considered necessary to clarify definitively the relationships between dose, efficacy and toxicity. The results of the interim analysis of 183 patients (performed in 1993) have shown response rates to be better in patients submitted to a low-dose BCG regimen (p = 0.0009) and a significant decrease in most of the common side-effects (cystitis, fever, haematuria; p < 0.05). Breaking down the results by stage, no differences in response rates were found in patients with stage TaM (70 vs. 62% in low-dose and standard-dose regimens, respectively, p = 0.5). In T1M and CIS stages, 82 and 0 (p = 0.07), and 64 and 0% (p = 0.0003) of patients were free of tumour following low-dose and standard-dose therapy, respectively. An additional 6-week course in patients who failed the induction course retrieved additional responses in both groups. No differences in progression rates were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Stereotactic fine-needle aspiration biopsy (FNAB) of nonpalpable breast lesions: cyto-histological correlations]. / Agoaspirazione (FNAB) mediante centratura stereotassica di lesioni mammarie non palpabili: correlazioni cito-istologiche.

There are not complete consensus if mammographically guided FNABs of nonpalpable breast lesions can replace open biopsy. To elucidate this problem, we have reviewed the efficacy of stereotactic FNAB in a series of 502 cases of nonpalpable lesions observed in a period from 1990 to 1994, with a immediate cytologic control of adequacy of material. In 144 patients of the lesion is achieved with 4% sterile coal localisation and an open biopsy of the area performed. In each case cytologic findings, with a brief description of probable histotype of the lesion, are correlate with surgical pathologic diagnosis, with a comparison between two time period (1990-92; 1993-94). In our study particularly ductal and lobular hyperplasia (with or without atypia) restrict the efficiency of the FNAB. In fact the specificity varies from 83.3% to 90.3%, the sensitivity from 78.7% to 77.8%, positive predictive value from 86.0% to 90.3%, negative predictive value from 75.6% to 70% and diagnostic accuracy from 80.0 to 82.4%, considering ductal and lobular hyperplasias as true negatives or true suspects. Cytologically we have 2 false positive in the first period of time, 3 false suspects in the second period of time and 7 false negatives. However benign/malign biopsy ratio is well (0.97). Moreover histopathologic informations of cytological diagnosis is variable according the histotype of the lesion. In conclusion our study confirm that FNAB is an reliable method that avoid unnecessary biopsy but is insufficiently sensitive to replace open biopsy of nonpalpable breast lesions, also with an immediate cytological control of adequacy of aspirate.