Electrical storm treatment by percutaneous stellate ganglion block: the STAR study.

BACKGROUND AND AIMS: An electrical storm (ES) is a clinical emergency with a paucity of established treatment options. Despite initial encouraging reports about the safety and effectiveness of percutaneous stellate ganglion block (PSGB), many questions remained unsettled and evidence from a prospective multicentre study was still lacking. For these purposes, the STAR study was designed. METHODS: This is a multicentre observational study enrolling patients suffering from an ES refractory to standard treatment from 1 July 2017 to 30 June 2023. The primary outcome was the reduction of treated arrhythmic events by at least 50% comparing the 12 h following PSGB with the 12 h before the procedure. STAR operators were specifically trained to both the anterior anatomical and the lateral ultrasound-guided approach. RESULTS: A total of 131 patients from 19 centres were enrolled and underwent 184 PSGBs. Patients were mainly male (83.2%) with a median age of 68 (63.8-69.2) years and a depressed left ventricular ejection fraction (25.0 ± 12.3%). The primary outcome was reached in 92% of patients, and the median reduction of arrhythmic episodes between 12 h before and after PSGB was 100% (interquartile range -100% to -92.3%). Arrhythmic episodes requiring treatment were significantly reduced comparing 12 h before the first PSGB with 12 h after the last procedure [six (3-15.8) vs. 0 (0-1), P < .0001] and comparing 1 h before with 1 h after each procedure [2 (0-6) vs. 0 (0-0), P < .001]. One major complication occurred (0.5%). CONCLUSIONS: The findings of this large, prospective, multicentre study provide evidence in favour of the effectiveness and safety of PSGB for the treatment of refractory ES.

Ultrasound-Assisted, Catheter-Directed Thrombolysis for Acute Intermediate/High-Risk Pulmonary Embolism: Design of the Multicenter USAT IH-PE Registry and Preliminary Results.

Catheter-based revascularization procedures were developed as an alternative to systemic thrombolysis for patients with intermediate-high- and high-risk pulmonary embolisms. USAT IH-PE is a retrospective and prospective multicenter registry of such patients treated with ultrasound-facilitated, catheter-directed thrombolysis, whose preliminary results are presented in this study. The primary endpoint was the incidence of pulmonary hypertension (PH) at follow-up. Secondary endpoints were short- and mid-term changes in the echocardiographic parameters of right ventricle (RV) function, in-hospital and all-cause mortality, and procedure-related bleeding events. Between March 2018 and July 2023, 102 patients were included. The majority were at intermediate-high-risk PE (86%), were mostly female (57%), and had a mean age of 63.7 ± 14.5 years, and 28.4% had active cancer. Echocardiographic follow-up was available for 70 patients, and in only one, the diagnosis of PH was confirmed by right heart catheterization, resulting in an incidence of 1.43% (CI 95%, 0.036-7.7). RV echocardiographic parameters improved both at 24 h and at follow-up. In-hospital mortality was 3.9% (CI 95%, 1.08-9.74), while all-cause mortality was 11% (CI 95%, 5.4-19.2). Only 12% had bleeding complications, of whom 4.9% were BARC ≥ 3. Preliminary results from the USAT IH-PE registry showed a low incidence of PH, improvement in RV function, and a safe profile.

Hospital-Acquired Anemia in Patients with Acute Coronary Syndrome: Epidemiology and Potential Impact on Long-Term Outcome.

BACKGROUND: Anemia (either pre-existing or hospital-acquired) is considered an independent predictor of mortality in acute coronary syndromes. However, it is still not clear whether anemia should be considered as a marker of worse health status or a therapeutic target. We sought to investigate the relationship between hospital-acquired anemia and clinical and laboratory findings and to assess the association with mortality and major cardiovascular events at long-term follow-up. METHODS: Patients consecutively admitted at Niguarda Hospital between February 2014 and November 2020 for an acute coronary syndrome were included in this cohort analysis and classified as anemic at admission (group A), with normal hemoglobin at admission but developing anemia during hospitalization (hospital-acquired anemia) (group B); and with normal hemoglobin levels throughout admission (group C). RESULTS: Among 1294 patients included, group A included 353 (27%) patients, group B 468 (36%), and group C 473 patients (37%). In terms of cardiovascular burden and incidence of death, major cardiovascular events and bleeding at 4.9-year median follow-up, group B had an intermediate risk profile as compared with A and C. Baseline anemia was an independent predictor of death (hazard ratio 1.51; 95% confidence interval, 1.02-2.25; P = .04) along with frailty, Charlson comorbidity Index, estimated glomerular filtration rate, previous myocardial infarction, and left ventricular ejection fraction. Conversely, hospital-acquired anemia was not associated with increased mortality (hazard ratio 1.18; 95% confidence interval, 0.8-1.75; P = .4). CONCLUSIONS: Hospital-acquired anemia affects one-third of patients hospitalized for acute coronary syndrome and is associated with age, frailty, and comorbidity burden, but was not found to be an independent predictor of long-term mortality.

Left Ventricular Unloading in Acute on Chronic Heart Failure: From Statements to Clinical Practice.

Cardiogenic shock remains a deadly complication of acute on chronic decompensated heart failure (ADHF-CS). Despite its increasing prevalence, it is incompletely understood and therefore often misdiagnosed in the early phase. Precise diagnosis of the underlying cause of CS is fundamental for undertaking the correct therapeutic strategy. Temporary mechanical circulatory support (tMCS) is the mainstay of management: identifying and selecting optimal patients through understanding of the hemodynamics and a prompt profiling and timing, is key for success. A recent statement from the American Heart Association provided pragmatic suggestions on tMCS device selection, escalation, and weaning strategies. However, several areas of uncertainty still remain in clinical practice. Accordingly, we present an overview of the main pitfalls that can occur during patients' management with tMCS through a clinical case. This case illustrates the strict interdependency between left ventricular unloading and right ventricular dysfunction in the case of low filling pressures. Moreover, it further illustrates the pivotal role of stepwise escalation of therapy in a patient with an ADHF-CS and its peculiarities as compared to other forms of acute heart failure.

Percutaneous Coronary Revascularization after Out-of-Hospital Cardiac Arrest: A Review of the Literature and a Case Series.

Out-of-hospital cardiac arrest (OHCA) is still associated with high mortality and severe complications, despite major treatment advances in this field. Ischemic heart disease is a common cause of OHCA, and current guidelines clearly recommend performing immediate coronary angiography (CAG) in patients whose post-resuscitation electrocardiogram shows ST-segment elevation (STE). Contrarily, the optimal approach and the advantage of early revascularization in cases of no STE is less clear, and decisions are often based on the individual experience of the center. Numerous studies have been conducted on this topic and have provided contradictory evidence; however, more recently, results from several randomized clinical trials have suggested that performing early CAG has no impact on overall survival in patients without STE.

Effect of landiolol in patients with tachyarrhythmias and acute decompensated heart failure (ADHF): a case series.

Tachycardia and rapid tachyarrhythmias are common in acute clinical settings and may hasten the deterioration of haemodynamics in patients with acute decompensated heart failure (ADHF), treated with inotropes. The concomitant use of a short-acting ß1-selective beta-blocker, such as landiolol, could rapidly and safely restore an adequate heart rate without any negative inotropic effect. We present a case series of five patients with left ventricular dysfunction, admitted to our Intensive Cardiac Care Unit with ADHF deteriorated to cardiogenic shock, treated with a combination of landiolol and inotropes. Landiolol was effective in terms of rate control and haemodynamics optimization, enabling de-escalation of catecholamine dosing in all patients. The infusion was always well tolerated without hypotension. In conclusion, a continuous infusion of a low dose of landiolol (3-16 mcg/kg/min) to manage tachycardia and ventricular or supraventricular tachyarrhythmias in haemodynamically unstable patients may be considered.

Cardiovascular injuries and SARS-COV-2 infection: focus on elderly people.

The novel coronavirus disease (COVID-19) has hit the healthcare system worldwide. The risk of severe infection and mortality increases with advancing age, especially in subjects with comorbidities such as cardiovascular disease, hypertension, diabetes, obesity and cancer. Moreover, cardiovascular complications such as myocardial injury, heart failure and thromboembolism are frequently observed in COVID-19 cases, and several biomarkers (troponin, NTproBNP and D-Dimer) have been identified as prognostic indicators of disease severity and worst outcome. Currently, there is no specific therapy against SARS-CoV-2, although many medications are under investigation. The aim of this review will be to explore the intertwined relationship between COVID-19 disease and the cardiovascular system, focusing on elderly population. The available supportive treatments along with the related concerns in elderly patients, due to their comorbidities and polypharmacotherapy, will be explored.

Inflammation and Coronary Microvascular Dysfunction in Autoimmune Rheumatic Diseases.

Autoimmune rheumatic diseases (ARDs) form a heterogeneous group of disorders that include systemic lupus erythematosus (SLE), systemic sclerosis (SSc), rheumatoid arthritis (RA), idiopathic inflammatory myopathies (IIMs), and systemic vasculitis. Coronary microvascular dysfunction (CMD) is quite common in patients with ARDs and is linked to increased cardiovascular morbidity and mortality. Inflammation plays a crucial role in the pathogenesis of both accelerated atherosclerosis and CMD in ARDs, especially in patients affected by SLE and RA. In this regard, some studies have highlighted the efficacy of immunosuppressants and/or biologics in restoring CMD in these patients. By contrast, the role of inflammation in the pathogenesis of CMD-SSc appears to be much less relevant compared to endothelial dysfunction and microvascular ischemia, with calcium-channel blockers providing some benefits. Few studies have endeavored to assess the occurrence of CMD in IIMs and systemic vasculitis, thus warranting further investigations. The present review summarizes the current evidence on the occurrence of CMD in ARDs, focusing on the role of inflammation and possible therapeutic approaches.

Meta-Analysis of the Optimal Percutaneous Revascularization Strategy in Patients With Acute Myocardial Infarction, Cardiogenic Shock, and Multivessel Coronary Artery Disease.

The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients with multivessel (MV) coronary artery disease (CAD) who present with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has not been systematically addressed. Accordingly, we performed a study-level meta-analysis comparing 2 PCI strategies in these patients-infarct-related artery (IRA) only versus MV revascularization. Studies including patients with AMI and MV CAD complicated with CS who received primary PCI were searched from 2000 to 2016. The primary end points were in-hospital/30-day and mid- to long-term (≥6 month) mortality. Fixed and random effects models were used for analysis. Ten studies (9 prospective and 1 retrospective) involving 6,068 patients met our inclusion criteria. IRA-only PCI was the most frequently used revascularization strategy (4,872 patients, 80%), while MV PCI was performed in 1,196 patients (20%). The MV PCI strategy was associated with higher short-term mortality compared with the IRA-only PCI strategy (odds ratio 1.41, 95% confidence interval 1.15 to 1.71, p = 0.008). There was no difference in mid- to long-term mortality between MV PCI and IRA-only strategies (odds ratio 1.02, 95% confidence interval 0.65 to 1.58, p = 0.94). In conclusion, in patients with AMI and MV CAD complicated by CS, the IRA-only PCI strategy seems to be associated with lower short-term, but not mid- to long-term mortality compared with MV PCI. This finding is different from the revascularization strategy recommended by current professional guidelines and suggests the need for dedicated randomized clinical trials.

Cloning and functional expression of intracellular loop variants of the honey bee (Apis mellifera) RDL GABA receptor.

The insect GABA receptor, RDL (resistance to dieldrin), plays central roles in neuronal signalling and is the target of several classes of insecticides. To study the GABA receptor from an important pollinator species, we cloned Rdl cDNA from the honey bee, Apis mellifera. Three Rdl variants were identified, arising from differential use of splice acceptor sites in the large intracellular loop between transmembrane regions 3 and 4. These variants were renamed from previously, as Amel_RDLvar1, Amel_RDLvar2 and Amel_RDLvar3. When expressed in Xenopus laevis oocytes, the three variants showed no difference in sensitivity to the agonist, GABA, with EC50s of 29µM, 20µM and 29µM respectively. Also, the potencies of the antagonists, fipronil and imidacloprid, were similar on all three variants. Fipronil IC50 values were 0.18µM, 0.31µM and 0.20µM whereas 100µM imidacloprid reduced the GABA response by 17%, 24% and 31%. The possibility that differential splicing of the RDL intracellular loop may represent a species-specific mechanism leading to insensitivity to insecticides is discussed.

Plasma-induced graft-polymerization of polyethylene glycol acrylate on polypropylene films: chemical characterization and evaluation of the protein adsorption.

This work deals with the optimization of argon plasma-induced graft-polymerization of polyethylene glycol acrylate (PEGA) on polypropylene (PP) films in order to obtain surfaces with a reduced protein adsorption for possible biomedical applications. To this end, we examined the protein adsorption on the treated and untreated surfaces. The graft-polymerization process consisted of four steps: (a) plasma pre-activation of the PP substrates; (b) immersion in a PEGA solution; (c) argon plasma-induced graft-polymerization; (d) washing and drying of the samples. The efficiency of these processes was evaluated in terms of the amount of grafted polymer, coverage uniformity and substrates wettability. The process was monitored by contact angle measurements, attenuated total reflection Fourier transform infrared spectroscopy (ATR-FTIR), X-ray Photoelectron Spectroscopy (XPS) and atomic force microscopy (AFM) analyses. The stability of the obtained thin films was evaluated in water and in Phosphate Buffer Saline (PBS) at 37 degrees C. The adsorption of fibrinogen and green fluorescent protein (GFP)--taken as model proteins--on the differently prepared surfaces was evaluated through a fluorescence approach using laser scanning confocal microscopy with photon counting detection. After plasma treatments of short duration, the protein adsorption decreases by about 60-70% with respect to that of the untreated film, while long plasma exposure resulted in a higher protein adsorption, due to damaging of the grafted polymer.

Platinum, palladium and rhodium release from vehicle exhaust catalysts and road dust exposed to simulated lung fluids.

The risk associated with the inhalation of platinum group element (PGE) emissions from vehicle exhaust catalysts (VECs) has been investigated by extracting road dust and milled auto catalyst with simulated lung fluids. Gamble's solution (representative of the interstitial fluid of the deep lung) and artificial lysosomal fluid (ALF) (representative of the more acidic environment within the lung) were employed as extraction fluids. The highest PGE release was observed in ALF, implying that inhaled particles would have to be phagocytized before significant amounts of PGEs dissolve. The greatest percentage (up to 88%) of PGEs was released from road dust, possibly due to the presence of mobile PGE species formed in the roadside environment. Pt showed the highest absolute bioavailability, due to its greater concentration in the environmental samples. Pd and Rh had higher percentage of release, however, because of their more soluble nature. From the toxicological perspective, the results demonstrate potential health risks due to the likely formation of PGE-chloride complexes in the respiratory tract, such species having well-known toxic and allergenic effects on human beings and living organisms.

The estimation of the bioavailabilities of platinum, palladium and rhodium in vehicle exhaust catalysts and road dusts using a physiologically based extraction test.

Platinum group element (PGE) levels in the environment have increased following the introduction of vehicle exhaust catalysts (VECs). In order to evaluate the potential pathways of PGEs from VECs into humans, a physiologically based extraction test (PBET) was used to study the uptake of PGEs by the human digestive tract. The PBET assay was implemented in two phases, to first simulate the passage of ingested soil through the acid conditions of the stomach before it enters the near neutral conditions of the small intestine. The results showed that Pt, Pd and Rh did not undergo precipitation reaction when passing from the acid environment of the stomach to the neutral environment of the small intestine. The greatest fractions of bioavailable PGEs (up to 68%) were observed in road dust samples, possibly due to the presence of mobile PGE species formed in the roadside environment. Higher percentages of Pd and Rh were bioavailable than Pt, probably due to the differences in their mobilities and tendencies to form soluble complexes. Pt showed the highest absolute bioavailability however, due to its greater concentration in environmental samples. The solubilization of PGEs in the human digestive tract could involve the formation of PGE-chloride complexes, with perhaps increased health-hazard issues because of the known toxic and allergenic effects of these species.

Photochemical reduction of oxygen adsorbed to nanocrystalline TiO(2) films: a transient absorption and oxygen scavenging study of different TiO(2) preparations.

Transient absorption spectroscopy (TAS) has been used to study the interfacial electron-transfer reaction between photogenerated electrons in nanocrystalline titanium dioxide (TiO(2)) films and molecular oxygen. TiO(2) films from three different starting materials (TiO(2) anatase colloidal paste and commercial anatase/rutile powders Degussa TiO(2) P25 and VP TiO(2) P90) have been investigated in the presence of ethanol as a hole scavenger. Separate investigations on the photocatalytic oxygen consumption by the films have also been performed with an oxygen membrane polarographic detector. Results show that a correlation exists between the electron dynamics of oxygen consumption observed by TAS and the rate of oxygen consumption through the photocatalytic process. The highest activity and the fastest oxygen reduction dynamics were observed with films fabricated from anatase TiO(2) colloidal paste. The use of TAS as a tool for the prediction of the photocatalytic activities of the materials is discussed. TAS studies indicate that the rate of reduction of molecular oxygen is limited by interfacial electron-transfer kinetics rather than by the electron trapping/detrapping dynamics within the TiO(2) particles.

A practical approach to hyperglycemia management in the intensive care unit: evaluation of an intensive insulin infusion protocol.

STUDY OBJECTIVES: To evaluate the effectiveness and safety of maintaining a target blood glucose concentration of 91-130 mg/dl with a standardized, nurse-managed, intensive insulin infusion protocol outside a study setting, and to determine if a statistically significant favorable effect on morbidity and mortality was achieved. DESIGN: Retrospective, observational, chart review. SETTING: Medical and surgical intensive care units (ICUs) in a community teaching hospital. PATIENTS: One hundred forty-three adult patients who received insulin infusions managed at the discretion of the physician over a 1-year period before initiation of the protocol (control group), and 70 patients who received insulin infusions over a 6-month period with infusion dosages titrated by using the protocol (protocol group). MEASUREMENTS AND MAIN RESULTS: Episodes of hypoglycemia, time within target range, mean blood glucose concentration, frequency of measurement, length of ICU stay, duration of mechanical ventilation, and overall mortality were collected. Hypoglycemic episodes were not significantly different between the groups. Blood glucose concentrations were within target range in 34% of all measurements in the protocol group compared with 23% in the control group (p<0.001, relative risk [RR] 1.48, 95% confidence interval [CI] 1.38-1.58). Once target range was reached on one measurement, 43% of concentrations remained in target range in the protocol group compared with 29% in the control group (p<0.001, RR 1.47, 95% CI 1.38-1.56). Frequency of measurements was higher in the protocol group versus control group (p=0.01); however, clinical difference was minimal. Protocol group had lower overall mortality rate (27% [19/70] vs 32% [46/143], p=0.45), reduced mean ICU length of stay (16.7 +/- 10.6 vs 18.4 +/- 16.0 days, p=0.37), and less mechanical ventilation time (16.5 +/- 9.7 vs 17.0 +/- 15.0 days, p=0.79). CONCLUSION: The nurse-managed insulin infusion protocol improved glycemic control with minimal hypoglycemic episodes compared with baseline practice. A trend toward decreased mortality, ICU length of stay, sand days of mechanical ventilation was observed. When compared with other published protocols, our insulin protocol displays comparable effectiveness with the use of less-frequent blood glucose measurements.