Surgery in MEN 2A Patients Older Than 5 Years with Micro-MTC: Outcome at Long-term Follow-up.

In multiple endocrine neoplasia syndrome type 2A (MEN 2A), early total thyroidectomy (TT; performed before the age of 5 years) is the best option to prevent medullary thyroid carcinoma (MTC) development, but the management of MEN 2A patients diagnosed after childhood is still under debate. Seventeen consecutive patients diagnosed with MEN 2A after the age of 5 years (mean age, 23.3 years) with a pathologic diagnosis of micro-MTC without nodal involvement were enrolled. All patients underwent TT with thymectomy and central compartment lymph node dissection. During surgery, parathyroid tissue removal occurred in 14 patients. No major postoperative complications nor persistent hypoparathyroidism was observed. After a mean follow-up of 16.6 years, no patient developed primary hyperparathyroidism or disease recurrence. Even if TT is recommended before the age of 5, when MEN 2A diagnosis is performed after this age in micro-MTC without nodal involvement, TT with thymectomy and central compartment lymphadenectomy can provide good oncologic and functional results.

Decreased usage and increased effectiveness of percutaneous coronary intervention in complex older patients with acute coronary syndromes.

BACKGROUND: Application of percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) is suboptimal in older frail individuals. This study was conducted to verify if background risk is a risk factor for underuse and diminished effectiveness of PCI in older patients. METHODS: An observational cohort study was conducted using data from the Acute Myocardial Infarction in Florence 2 registry, including all ACS hospitalised in 1 year in the area of Florence, Italy. Patients aged 75+ years were selected, whose background risk was stratified with the Silver Code (SC), a validated tool predicting mortality based upon administrative data. Multivariable OR for PCI application and HR for 1-year mortality by PCI usage were calculated. RESULTS: In 698 patients (358 women, mean age 83 years), of whom 176 had ST-segment elevation myocardial infarction (STEMI), for each point increase in SC score the odds for application of PCI decreased by 11%, whereas the hazard of 1-year mortality increased by 10%, adjusting for positive and negative predictors. PCI reduced 1-year mortality progressively more with increasing SC, with HR (95% CI) of 0.8 (0.19 to 1.21), 0.41 (0.18 to 0.45), 0.41 (0.23 to 0.74) and 0.26 (0.14 to 0.48) for SC of 0-3, 4-6, 7-10 and 11+. CONCLUSIONS: Application of PCI in older ACS patients decreased with increasing background risk. This therapeutic attitude could not be justified by decreasing effectiveness of PCI in more compromised patients: conversely, application of PCI was associated with a long-term survival advantage that increased progressively with background risk, as expressed by SC.

Upper Digestive Bleeding in Atrial Fibrillation: Evaluation of Gastroscopy Prior to Oral Anticoagulant Therapy (GOAT), Prospective, Randomized, Double Blind Study on a Community Population.

BACKGROUND: The aim of this study was to investigate the incidence of digestive hemorrhages in patients with non-valvular atrial fibrillation (NVAF), scheduled for oral anticoagulant therapy. METHODS: We conducted, over 24 months, a prospective, randomized, population-based observational study on consecutive patients with recurrent paroxysmal, persistent, or permanent NVAF, scheduled for oral anticoagulant therapy. The study initially included 268 patients with NVAF (162 males and 106 females) with a mean age of 74 years (range 42-86 years). Patients were split into two groups: those undergoing preventive Esophago-Gastro-Duodenoscopy (EGD) (Group A) and those who did not (Group B). All patients positive by EGD underwent medical treatment and subsequent 30-day endoscopic controls showed complete healing. The primary outcome of the study was to determine if previous EGD in patients with NVAF resulted in a low risk of bleeding during oral anticoagulant therapy. The two groups were comparable for most variables. RESULTS: Significant differences were found between groups for the incidence of antiarrhythmic drugs and for early hemorrhage (P <0.001). The incidences of early hemorrhages were significantly different between the two groups with 12 in group B (12%) and 2 in group A (1.7%). CONCLUSIONS: Preventive EGD can identify hidden digestive diseases, which may increase the incidence of early hemorrhages.

Clinostatic hypertension and orthostatic hypotension.

BACKGROUND: The association of clinostatic hypertension (CH) and orthostatic hypotension (OH) is described as the "Hyp-Hyp phenomenon," and it has been found in about 5.5% of hypertensive patients and in up to 50% of patients with OH. The importance of CH/OH in clinical practice is mainly due to the presence of troublesome symptoms, end-organ damage, and difficulties in its clinical management. HYPOTHESIS: The review focuses on the clinical problem of CH and review the international literature for the best management, including the diagnostic work-up and the taylored treatment for this kind of patients. METHODS: A systematic review of the literature was conducted through MEDLINE research to focus the main controversial issues about CH/OH. Included topics: (1) the diagnostic work-up, (2) the association with dysautonomic failure and syncope, and (3) the treatment options and prevention of end-organ damage. RESULTS: Current standard reference for OH diagnosis includes functional assessment of the cardiac vagal nervous system and the sympathetic adrenergic system. The association with dysautonomic failure and with syncope needs further investigation. Pharmacologic treatment of OH is aimed at controlling symptoms rather than restoring normotension. Midodrine is the only medication that has been put to multicenter placebo-controlled trial and subsequently approved by the U.S. Food and Drug Administration (FDA) for OH treatment. Short-acting oral antihypertensive agents at bedtime should be considered in patients with severe, sustained CH. CONCLUSIONS: Data obtained from the literature review showed that clinical diagnosis of the Hyp-Hyp phenomenon is relatively simple, but it remains more difficult to establish the causal disease. In our opinion, it is advisable to define simple diagnostic standards for the selection of patients at risk of dysautonomic impairment so that a subsequent highly specific diagnostic work-up could be initiated.