Optimisation of antithrombotic therapy in patients with acute coronary syndrome to reduce bleeding episodes.

AIM: The aim of the study was to evaluate the effectiveness of a multidisciplinary intervention to reduce the risk of bleeding associated with antithrombotic drugs in patients with acute coronary syndrome (ACS). METHODS: We designed a pre-post quasi-experimental intervention study using retrospective cohorts. The first cohort was analysed to detect correctable measures contributing to bleeding (PRE: January-July 2010). Second, a bundle of interventions was implemented and third, a second cohort of patients was evaluated to investigate the impact of our measures in bleeding reduction (POST: September 2011-February 2012). RESULTS: A total of 677 patients were included (377 in PRE and 300 in POST). The bundle of interventions was: Overdose avoidance measures: the percentage of patients overdosed was reduced by 66.3% (p < 0.001). Institutional protocol update to include the latest recommendations regarding bleeding prevention: In POST, the percentage of patients treated with fondaparinux increased (2.4% vs. 50.7%; p < 0.001). In PRE, 11 patients were treated with the combination of abciximab and bivalirudin; whereas in POST, only one patient received the combination (p = 0.016). Mandatory measurement of body weight: the percentage of patients with unknown body weight was reduced by 35% (p = 0.0001). In POST, the total bleeding rate was reduced by 29.2% (31.6% in PRE vs. 22.4%, p < 0.05, OR: 0.62; 95% CI: 0.44-0.88). It was necessary to implement the interventions in 11 patients to prevent one bleeding episode (95% CI: 7-39). CONCLUSION: The multidisciplinary programme has been effective in reducing bleeding episodes. The interventions were effective in reducing antithrombotic drugs overdosage, incorporating the use of fondaparinux to the NSTE-ACS therapeutic arsenal, limiting the use of bivalirudin with abciximab and obtaining body weight for most patients.

Risks and benefits of sharing patient information on social media: a digital dilemma.

Social media (SoMe) has witnessed remarkable growth and emerged as a dominant method of communication worldwide. Platforms such as Facebook, X (formerly Twitter), LinkedIn, Instagram, TikTok, and YouTube have become important tools of the digital native generation. In the field of medicine, particularly, cardiology, attitudes towards SoMe have shifted, and professionals increasingly utilize it to share scientific findings, network with experts, and enhance teaching and learning. Notably, SoMe is being leveraged for teaching purposes, including the sharing of challenging and intriguing cases. However, sharing patient data, including photos or images, online carries significant implications and risks, potentially compromising individual privacy both online and offline. Privacy and data protection are fundamental rights within European Union treaties, and the General Data Protection Regulation (GDPR) serves as the cornerstone of data protection legislation. The GDPR outlines crucial requirements, such as obtaining 'consent' and implementing 'anonymization', that must be met before sharing sensitive and patient-identifiable information. Additionally, it is vital to consider the patient's perspective and prioritize ethical and social considerations when addressing challenges associated with sharing patient information on SoMe platforms. Given the absence of a peer-review process and clear guidelines, we present an initial approach, a code of conduct, and recommendations for the ethical use of SoMe. In conclusion, this comprehensive review underscores the importance of a balanced approach that ensures patient privacy and upholds ethical standards while harnessing the immense potential of SoMe to advance cardiology practice and facilitate knowledge dissemination.

New-onset atrial fibrillation and prognosis in nonagenarians after acute myocardial infarction.

BACKGROUND: The influence of new-onset atrial fibrillation (AF) on the long-term prognosis of nonagenarians who survive acute myocardial infarction (AMI) has not been demonstrated. OBJECTIVE: Our aim was to study the association between new-onset AF and long-term prognosis of nonagenarians who survive AMI. METHODS: From a total of 96 patients aged ≥89 years admitted during a 5-year period, 64 (67 %) were discharged alive and are the focus of this study. RESULTS: Mean age was 91.0 ± 2.0 years, and 39 patients (61 %) were women. During admission, 9 patients (14 %) presented new-onset AF, 51 (80 %) did not present AF, and 4 (6 %) had chronic AF. During follow-up (mean 2.3 ± 2.6 years; 6.6 ± 3.6 years in survivors), 58 patients (91 %) died, including the 9 patients with new-onset AF. Cumulative survival at 6, 12, 18, 24, and 30 months was 68.3 %, 57.2 %, 49.2 %, 47.6 %, and 31.8 %, respectively. The only two independent predictors of mortality in the multivariate analysis were age (hazard ratio [HR] 1.14; 95 % confidence interval [CI] 1.01-1.28; p = 0.04) and new-onset AF (HR 2.3; 95 % CI 1.1-4.8; p = 0.02). CONCLUSION: New-onset AF is a marker of poor prognosis in nonagenarians who survive AMI.

Mapping of Anatomic Variants of the Proximal Vertebral Artery in Relation to Embryology.

BACKGROUND AND PURPOSE: Variations in the origins and courses of the vertebral arteries are relatively rare but may be clinically meaningful. We hypothesize a relationship between variant origins of the vertebral arteries and their levels of entry to the foramina transversaria. MATERIALS AND METHODS: In this retrospective study of CT angiograms, we document the frequency and types of vertebral artery variants, correlating origins with levels of entry to the foramina transversaria. RESULTS: Vertebral artery variants were observed in 18.7% of a sample of 460 CT angiograms of the neck. Right-sided variants were less common than left (44.2% versus 68.6%, with 12.8% bilateral) and more common than previously thought. The most common variant on both sides was a variant origin proximal to the normal vertebral artery origin and entry at C5. Most right vertebral arteries originating within 2 cm of the origin of the right subclavian artery and left vertebral arteries originating between the left common carotid and subclavian arteries were "high-entry" variants. Most "low-entry" variants, entering at C7, took origin from the arch just distal to the left subclavian artery or at a common origin with the costocervical trunk. Multiple origins or accessory vertebral arteries were also described, and each moiety followed the same rules described for single origins. A map of vertebral artery origins mirrored the map of aortic arch embryology. CONCLUSIONS: Vertebral artery variants follow certain well-defined patterns that correlate with the embryology of the aortic arch and great vessels.

Repeated inhalation of crack-cocaine affects spermatogenesis in young and adult mice.

To investigate the effects of repeated crack-cocaine inhalation on spermatogenesis of pubertal and mature Balb/c mice, ten young (Y(ex)) and ten adult (A(ex)) Balb/c mice were exposed to the smoke from 5 g of crack with 57.7% of pure cocaine in an inhalation chamber, 5 days/week for 2 months. The young (Y(c)) and adult (A(c)) control animals (n = 10) were kept in a specially built and controlled animal house facility. The morphologic analysis of both testes of all animals included the analysis of quantitative and qualitative histologic parameters to assess the effect of crack-cocaine on spermatogenesis and Leydig cells. Apoptosis was determined by immunolabeling with caspase-3 antibodies. Compared to the Y(c) animals, Y(ex) animals showed a significant reduction in the number of stage VII tubules per testis (p = 0.02), Sertoli cells (p < 0.001) and elongated spermatids (p = 0.001). Comparisons between the Y(ex) and A(ex) groups identified a significant reduction in the number of Sertoli cells (p < 0.001) and round spermatids (p < 0.001) in the Y(ex) group and a significant increase in apoptotic Leydig cells (p = 0.04) in the A(ex) group. The experimental results indicate that crack-cocaine smoke inhalation induced spermatogenesis disruption in chronically exposed mice, particularly in pubertal mice.

Structural alterations in adult rat carotid bodies exposed to hyperbaric oxygenation.

UNLABELLED: Inhibition of carotid body (CB) function is the main mechanism involved in the attenuation of respiratory drive observed during hyperoxia. However, only a few studies at 5.0 atmospheres absolutes (ATA) have analyzed carotid body structure or function in hyperbaric oxygenation (HBO2) situations. We hypothesized that rats will present CB structural alterations when exposed to different lower hyperbaric oxygen doses enough to alter their chemosensory response to hypoxia. METHODS: Twenty-one adult male Wistar rats, divided into three groups, were maintained in room air or exposed to O2 at 2.4 or 3.0 ATA for six hours. Histological, ultrastructural and immunohistochemical analyses for neuronal nitric oxide synthase (nNOS) and F2-isoprostane were performed in the excised CBs. RESULTS: Histological analyses revealed signs of intracellular edema in animals exposed to both conditions, but this was more marked in the 3.0 ATA group, which showed ultrastructural alterations at the mitochondrial level. There was a significant increase in the volume density of intraglomic-congested capillaries in the 3.0 ATA group associated with an arteriolar vasoconstriction. In the 2.4 ATA group, there was a relative increase of glomic light cells and a decrease of glomic progenitor cells. Additionally, there was a stronger immunoreactivity for F2-isoprostane in the 3.0 ATA O2-exposed carotid bodies. The glomic cells stained positive for nNOS, but no difference was observed between the groups. Our results show that high O2 exposures may induce structural alterations in glomic cells with signs of lipid peroxidation. We further suggest that deviation of blood flow toward intraglomic capillaries occurs in hyperbaric hyperoxia.

Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association.

Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.

Prevalence of peripheral arterial disease and prior stroke in octogenarians with symptomatic severe aortic stenosis or severe coronary artery disease: influence in management and outcome.

AIM: Severe aortic stenosis (SAS) and severe coronary artery disease (SCAD) are the most frequent reasons to perform cardiac surgery in octogenarians. Non-coronary vascular disease is frequently present in these patients. METHODS: We assessed the prevalence and impact of previous stroke (PS) and peripheral arterial disease (PAD) on the management and outcome of 130 consecutive symptomatic patients (80 years old with SAS or SCAD. RESULTS: Mean age was 82.8+/-3.1 years. PS was present in 24 patients (18.5%) and PAD in 15 (11.5%). We found a non-significant trend to a higher prevalence of PAD in patients with SCAD than in patients with SAS (14.5% vs 6.4%, P=0.13), while no relevant differences were seen for PS prevalence (19.3% vs 17%, P=0.75). Patients with PS tended to be operated less frequently than patients without PS (20.8% vs 37.7%, P=0.08), while no relevant differences were seen for patients with and without PAD (26.7% vs 35.7%, P=0.5). Thirty-nine patients (30%) died during follow-up, mean of 1.1(0.7 years (median 1 years; 100% complete). There was a trend to a worse prognosis in patients with PAD (adjusted hazard ratio [HR] 2.2; 95% confidence interval [CI] 0.96-4.8; P=0.06), while PS showed no independent influence on survival (adjusted HR 1.3, 95% CI 0.6-2.8, P=0.53). CONCLUSIONS: PS and PAD are frequently present in octogenarians with SAS or SCAD. Patients with PS show a similar long-term mortality, but tend to be operated less frequently. On the other hand, PAD did not influence the decision of surgical treatment, but is associated with a lower survival rate.

Assessment of the knowledge and perception of support of patients with heart failure SOPICA study IN SPAIN.

OBJECTIVE: To understand the perceptions of patients with heart failure (HF) concerning their disease, treatment and support, as well as the specialists who provide care after a decompensation, and to determine whether there is a relationship between the type of specialist involved in the follow-up and the medium-term prognosis. METHODS: A multicentre, prospective cohort study consecutively included patients with acute HF in the emergency department. The patients were interviewed by telephone 91-180days after their emergency department visit. We investigated the relationship between the type of specialist who performed the follow-up and the emergency department visits or hospitalisations using Cox regression models, with progressive adjustment by groups of potential confounders of these relationships. RESULTS: We interviewed 785 patients. Thirty-three percent (95%CI: 30%-36%) considered their disease mild, 64% (60%-67%) required help from third parties for daily activities, 65% (61%-68%) had no recent therapeutic changes, and 69% (67%-72%) received the same treatment in the exacerbations. The perceived support varied significantly depending on the factor under consideration (from greater to lesser: family, hospital, emergency department, health centre, religion and patient associations; p<.05 in all comparisons). Thirty-nine percent (36%-43%) of the patients with decompensations consulted directly with the emergency department, with no prior changes in treatment. At discharge, general practitioners (74%, 71%-77%) and cardiologists (74%, 70%-77%) were the most involved in the follow-up, although the specialty was not related to the prognosis. CONCLUSION: There are various aspects of the perception of patients with HF concerning their disease that are susceptible to future interventions. Patient follow-up involves various specialties, but all achieve similar results in the medium term.

Effects of dobutamine on Doppler echocardiographic indexes of aortic stenosis.

OBJECTIVES: This study sought to assess the diagnostic implications of the flow dependence of Doppler echocardiographic indexes of aortic valve stenosis. BACKGROUND: Although valve area has been shown to change with alterations in flow rate, the diagnostic consequences of this phenomenon remain unknown. Valve resistance has been suggested as a more stable index for evaluating aortic stenosis. METHODS: A low dose dobutamine protocol was performed in 35 patients with aortic stenosis. Hemodynamic indexes were obtained by Doppler echocardiography at baseline and at each dobutamine dose. RESULTS: As a result of the shortening of the systolic ejection period, flow increased from (mean +/- SD) 164 +/- 48 to 229 +/- 102 ml/s (p < 0.0001). At peak flow, valve area increased by 28% (from 0.5 +/- 0.2 to 0.6 +/- 0.3 cm2, p < 0.0001), whereas valve resistance decreased by 4% (from 498 +/- 252 to 459 +/- 222 dynes.s.cm-5, p = 0.04). This observed change in resistance was smaller than that for valve area (p < 0.01). The flow dependence of valve area varied among individual patients (p < 0.0001). Multivariate analysis identified calcific degenerative etiology (beta 0.29, p = 0.002), left ventricular velocity of fiber shortening (beta 0.22, p = 0.01), baseline flow (beta -0.28, p = 0.04) and amount of flow increased induced by dobutamine (beta 0.90, p < 0.0001) as factors related to valve area flow dependence. CONCLUSIONS: Although all Doppler echocardiographic indexes of aortic stenosis are affected by flow, valve resistance is more stable than valve area under dobutamine-induced hemodynamic changes. Baseline valve area may be unreliable in patients with calcific degenerative aortic stenosis and low output states.

Human Mesenchymal Stromal Cells Transplantation May Enhance or Inhibit 4T1 Murine Breast Adenocarcinoma through Different Approaches.

The use of Mesenchymal Stromal Cells (MSCs) aiming to treat cancer has shown very contradictory results. In an attempt to clarify the contradictory results reported in the literature and the possible role of human fallopian tube Mesenchymal Stromal Cells (htMSCs) against breast cancer, the aim of this study was to evaluate the clinical effect of htMSCs in murine mammary adenocarcinoma using two different approaches: (1) coinjections of htMSCs and 4T1 murine tumor cell lineage and (2) injections of htMSCs in mice at the initial stage of mammary adenocarcinoma development. Coinjected animals had a more severe course of the disease and a reduced survival, while tumor-bearing animals treated with 2 intraperitoneal injections of 10(6) htMSCs showed significantly reduced tumor growth and increased lifespan as compared with control animals. Coculture of htMSCs and 4T1 tumor cells revealed an increase in IL-8 and MCP-1 and decreased VEGF production. For the first time, we show that MSCs isolated from a single source and donor when injected in the same animal model and tumor can lead to opposite results depending on the experimental protocol. Also, our results demonstrated that htMSCs can have an inhibitory effect on the development of murine mammary adenocarcinoma.

Blood strontium concentration related to the length of the agonal period in seawater drowning cases.

The levels of ventricular blood strontium (Sr) from 70 seawater drowning victims were compared with their diagnosis of drowning based mainly on certain criteria selected from their autopsy report. From this comparison, intervals of either the difference of Sr concentration between the left and the right ventricle blood (LVSr-RVSr) or the Sr concentration in the left ventricle blood (LVSr), appear to be related to different time-lapses of the agonal period of drowning. In the aim to diagnose drownings, intervals of both LVSr-RVSr and LVSr were proposed to characterize three different agonal periods in seawater drowning cases: instantaneous death (ID), fast vital-submersion drowning (FVSD) and common vital-submersion drowning (CVSD).

Pulmonary embolism after pacemaker implantation.

One day after implantation of a permanent pacemaker in an 82-year-old man, transthoracic echocardiography showed a mass in the right ventricle and a small pericardial effusion. Transesophageal echocardiography revealed a mass attached to the pacemaker lead. Subcutaneous administration of enoxaparin was begun, and the patient remained free of symptoms for the duration of his hospital stay Follow-up echocardiography performed before discharge failed to show the right ventricular mass, but a lung perfusion scan revealed multiple bilateral perfusion defects consistent with pulmonary emboli. The patient was discharged on a regimen of enoxaparin for another 30 days. Two years later, he remained asymptomatic.

[Clinical prediction of the early prognosis in acute myocardial infarct]. / Predicción clínica del pronóstico precoz en el infarto agudo de miocardio.

Several clinical factors can influence the pathophysiology, clinical course and prognosis of acute myocardial by different means. Some of them may be easily detected through the history, physical examination or ECG in an early phase. The knowledge of these factors may help the therapeutic decision making of patients with myocardial infarction. The influence for the main clinical factors (age, sex, risk factors, cardiologic antecedents and evolutive findings) on the short-term prognosis of acute myocardial infarction is reviewed. An analysis of the likely mechanisms of the influence of these factors on infarct prognosis is also performed.

[Usefulness of carotid sinus massage for Doppler quantification of mitral stenosis in sinus rhythm]. / Utilidad del masaje del seno carotídeo en la cuantificación por técnica Doppler de la estenosis mitral en ritmo sinusal.

The quantification of mitral stenosis by pressure half-time method may be difficult in sinus rhythm with short deceleration slopes. To evaluate the usefulness of carotid sinus massage (CSM) for measuring mitral valve area by pressure half-time, 80 consecutive patients with mitral stenosis in sinus rhythm underwent a echo-Doppler study at basal heart rate and during right CSM. In both situations we measured: heart rate, mitral area by pressure half-time and E-F interval (time from E peak velocity to onset of atrial contraction). In 38 consecutive patients we also determined the mitral area by planimetry. The study group was divided into patients with basal E-F interval < or = 150 ms and a HR > or = 75 bpm (group A, 28 patients [35%]) and those with a basal E-F interval > 150 ms who showed a heart rate < 75 bpm (group B, 52 patients). In the group A, the values obtained at basal heart rate vs after CSM were: heart rate, 86 +/- 9 vs 61.6 +/- 10.5 lpm; E-F interval, 109 +/- 33 vs 372 +/- 136 ms; mitral area, 1.88 +/- 0.5 vs 1.23 +/- 0.29 cm2 (p < 0.001). In the group B, these values were: 69.7 +/- 6.6 vs 53 +/- 11 bpm, 253 +/- 60 vs 510 +/- 212 ms y 1.34 +/- 0.3 vs 1.18 +/- 0.32 cm2, respectively (p < 0.01). Mean differences in Doppler mitral areas between both situations for groups A and B were: 0.63 +/- 0.3 cm2 and 0.17 +/- 0.1 cm2, respectively (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Transesophageal echocardiography in mitral prosthesis dysfunction: usefulness and limitations in the evaluation of mitral insufficiency]. / Ecocardiografía transesofágica en la disfunción protésica mitral: utilidad y limitaciones en la valoración de la insuficiencia mitral.

This study was performed to test the usefulness of transesophageal echocardiography in the diagnosis and assessment of pathological mitral regurgitation in patients with mitral valve prostheses. Doppler color flow imaging by transesophageal echocardiography was compared to the transthoracic echocardiography and angiographic and surgical assessment. We analyzed the influence of the spatial configuration of the jet on the semiquantitative assessment of mitral regurgitation. We studied 71 patients with prostheses in mitral position which were submitted for transesophageal echocardiography examination. 51 of these patients were found to have a pathological prosthetic regurgitation that was confirmed in 21 cases by left ventriculography and in 4 during cardiac surgery. Transesophageal echocardiography Doppler color flow imaging identified a regurgitant jet in 31 patients (60.7%). There was complete agreement with the quantitative assessment of regurgitation by angiography or surgery in 36% of the cases. All patients with prosthetic insufficiency observed by angiography or during cardiac surgery were confirmed by transesophageal echocardiography. Complete agreement in grade of severity by transthoracic echocardiography was found in 84% of cases. There was a difference in grade of severity of mitral regurgitation in only 4 patients. Regurgitant jets were classified by transesophageal echocardiography color Doppler in two groups: free jets and impinging wall jets. 21 cases presented a free jet and 31 excentrically directed impinging wall jet of mitral regurgitation. There was complete agreement with hemodynamic assessment of severity in all patients with regurgitant free jets (11/11). In presence of jet wall there was understimation of mitral regurgitation in 28.5% (4/13).(ABSTRACT TRUNCATED AT 250 WORDS)

[The mitral valve apparatus in hypertrophic myocardiopathy: observations by transesophageal echocardiography]. / El aparato valvular mitral en la miocardiopatía hipertrófica: observaciones por ecocardiografía transesofágica.

INTRODUCTION AND OBJECTIVES: We analyzed the characteristics of mitral valve apparatus by transesophageal echocardiography in a consecutive series of patients with hypertrophic cardiomyopathy. METHODS: We performed a transesophageal study in 60 patients; 35 of them had intraventricular obstruction at basal state. The following measurements and observations were made in the frontal long-axis transesophageal plane: a) length of both mitral leaflets and dimensions of left ventricular outflow tract that were compared with those obtained from 25 normal subjects; b) structure involved in the systolic anterior mitral motion; c) mechanism of mitral regurgitation, and d) sequence of systolic events. RESULTS: Compared with control subjects (anterior mitral leaflet: 2.86 +/- 0.3 cm, posterior mitral leaflet: 1.62 +/- 0.2 and 1.7 +/- 0.2 cm, respectively; the mitral leaflets were longer in patients with and without subaortic obstruction (anterior leaflet: 2.3 +/- 0.1; posterior leaflet: 1.07 both, p < 0.01). Systolic anterior motion was observed in 49 patients, with mitral leaflet-septal contact in 87% of patients with obstruction and in 11% of nonobstructive patients (p < 0.01). Structures participating in this phenomenon were: distal portion of the anterior mitral leaflet (77.5%), of both mitral leaflets (18.4%) and anomalous chordae (4.1%); in 5 patients the obstruction was located at a more distal level. Mitral regurgitation was observed in 43 patients; in 37 of them the jet was posteriorly directed in late systole. Patients with hypertrophic cardiomyopathy have longer mitral leaflets with frequent associated abnormalities suggesting that this disease is not confined to myocardium and that leaflet length is not the sole determinant of the obstruction; 2) in almost 80% of patients the systolic anterior motion was produced by the distal anterior mitral leaflet resulting in incomplete coaptation in mid-systole; 3) the sequence of systolic events was ejection/obstruction/leak.

[Bradycardia and asystolia secondary to epileptic crisis. Report of a case]. / Bradicardia y asistolia secundarias a crisis epiléptica. A propósito de un caso.

We report the case of a 21 year old man with bradycardia and asystolia after a seizure. No cardiac disease could be demonstrated, but electroencephalography after sleep deprivation showed the presence of a temporal irritative focus. The importance of differential diagnosis between cardiogenic syncope and loss of consciousness due to epilepsy is discussed.

[Spinal tumors in infancy. A report of 48 cases]. / Tumores espinales en la infancia. Presentación de 48 casos.

INTRODUCTION: Spinal tumours in infancy are an infrequent oncological disorder. The clinical features, usually of insidious onset, are alterations in gait and a painful spine. OBJECTIVE: To analyze the different histological types of spinal tumours seen in infancy and their form of presentation in our series. PATIENTS AND METHODS: We reviewed the clinical histories of 48 patients with intraspinal tumours, aged under 15 years, whose reports of histological diagnosis had been sent to our centre. RESULTS: Of the patients studied, 17 were girls (35.4%) and 31 boys (64.6%) with an average age of 7.7 years. The histological diagnoses made most frequently were astrocytomas (22.9%) and lipomas (18.8%) followed by metastases (12.5%), ependymomas (8.3%) and Edwing's sarcoma (8.3%). The clinical features were present prior to diagnosis for between 1 and 6 months in 13 patients, and for less than one month in 9 patients. The presenting symptoms were alterations in gait and back pain in most patients. Exploratory tests were related to the involvement of long vias and second motor-neurone lesions. The main topographical findings were: in the axial plane the lesions were extradural (23 patients) and in the sagittal plane there was dorsal involvement (34 patients). CONCLUSIONS: Insidious, progressive alterations in gait together with continuous, nocturnal back pain are valuable data when a serious spinal disorder is to be suspected. Early diagnosis should be based on neuroimaging tests, essentially MR, in the patients in whom spinal cord involvement is considered.

Kounis syndrome secondary to amoxicillin use in an asthmatic patient.

A sixty-four year old man with a past history of hypercholesterolemia, asthma, food allergy, epilepsy and myocardial infarction was admitted to the emergency department because of a generalized erythema, nausea, vomiting, and chest pain after taking an oral dose of amoxicillin. Electrocardiography showed ST segment elevation in anterior leads. After coronary angiography, type 2 variant of Kounis syndrome was diagnosed. We present the first case of oral amoxicillin induced Kounis syndrome in an asthmatic patient with severe anaphylactic shock. The present report also shows that atopic people expressing an amplified mast cell degranulation may have more serious hemodynamic decompensation during hypersensitivity reactions. Case selective mast cell surface membrane stabilization should be considered a potential therapeutic strategy for people with food induced allergy, for atopic patients and for patients who have already experienced a first Kounis syndrome.