Pulmonary embolism with floating thrombus in right atrium complicated by ischemic stroke during systemic fibrinolysis.

Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death in Europe. The presence of a floating thrombus in the right sections, is a life-threatening condition in which the most appropriate treatment is not well established. The management of this setting is still uncertain, particularly in cases of thrombosis straddling the patent foramen ovale (PFO). The stratification and treatment of PE do not consider the presence of intracardiac floating thrombosis. We describe the case of a female, 69-years-old, presenting to the emergency department because of sudden onset of dyspnea and pre-syncope. An echocardiogram was performed, showing a massive floating thrombus both in the right and left atrium, passing through a PFO. The patient underwent systemic thrombolysis with alteplase. After 1 h of infusion, sudden onset of left facio-brachio-crural hemiplegia occurred. An urgent cerebral angiographic computed tomography was performed with evidence of acute occlusion of the right M1 branch treated with mechanical thrombectomy. The presence of intracardiac thrombosis in both right and left cardiac chambers with involvement of the fossa ovalis added a further level of management complexity. To date, no clear therapeutic strategies are recommended in these clinical settings. Learning objective: •The presence of floating thrombosis in the right sections is a life-threatening condition and could be considered in the risk stratification of pulmonary embolism•The presence of intracardiac thrombosis straddling the foramen ovale is a condition that poses additional difficulties in choosing the correct therapeutic approach during massive pulmonary embolis.

The Role of Shame in Schizophrenia Delusion: The Interplay Between Cognitive-Perceptual and Emotional Traits.

ABSTRACT: Through a strictly dimensional approach, the present study aimed at evaluating the interplay between cognitive-perceptual disturbances and emotional dispositions, particularly shame proneness, in schizophrenia delusion. One hundred one outpatients with schizophrenia were administered the Peters et al. Delusions Inventory, the Referential Thinking Scale (REF), the Magical Ideation Scale (MIS), the Perceptual Aberration Scale (PAS), the Positive and Negative Affect Schedule and the Experiences of Shame Scale (ESS). The severity of delusional ideation was positively related to all the cognitive-perceptual scales (REF, MIS, and PAS) and to shame proneness (ESS). Referential thinking (REF) emerged as the strongest predictor of delusion severity. The experience of shame played a mediation role in the relationship between cognitive-perceptual traits and delusional severity. These data suggest that severity delusion in schizophrenia depends, at least in part, on a complex interplay between cognitive-perceptual disturbances and experiences of shame.

Digital dental workflow for a smile makeover restoration.

This article describes a novel concept for treatment planning and execution in the digital era. The aim of the presented workflow was to design, plan, communicate, perform, fabricate, deliver, and maintain a smile makeover restoration entirely through digital technology. The interdisciplinary treatment plan is described from the planning through the diagnostic mock-up to the final restoration. In digital designing, the dental morphology and tooth shape seen by the clinician and technician are interpreted by the computer as a 3D geometric mathematic model. Controlling the geometry provides freedom for the clinician to develop a restorative digital plan that can be followed throughout the patient's treatment. Moreover, new ceramic materials used with computer-assisted techniques have considerably broadened the choices for dental teams and have enhanced the results that can be achieved.

Prospective Study of Tricuspid Regurgitation Associated With Permanent Leads After Cardiac Rhythm Device Implantation.

BACKGROUND: Tricuspid regurgitation (TR) has been associated with cardiac rhythm device (CRD) implantation with intracardiac lead insertion. However, data on the incidence of postdevice TR are limited and largely from retrospective studies. We hypothesized that permanent lead implantation would be associated with an increase in TR. METHODS: We prospectively included consecutive patients with a clinical indication for CRD. Patients underwent transthoracic echocardiography 1 month before and 1 year after CRD implantation. RESULTS: A total of 328 patients were prospectively enrolled (69 ± 15 years, 38% female). Echocardiograms before and 1 year after CRD were available in 290 patients (15 died, 23 lost to follow-up). Compared with baseline, there was a significant change in TR grade 1 year after CRD insertion (no/trivial TR: 66% vs 29%; mild TR: 29% vs 61%; moderate TR: 3% vs 8%; severe TR 2% vs 2%; P < 0.001 for an increase in TR by at least 1 grade). Compared with baseline, there was a higher prevalence of moderate or severe TR in the 247 patients with CRD without cardiac resynchronization therapy (4% vs 10%, P = 0.004), but no progression in the 43 patients who received cardiac resynchronization therapy (14% vs 11%, P = 1). Multivariable analysis in the patients with less than moderate TR at baseline (n = 274) showed that only a history of atrial fibrillation was independently associated with progression to moderate or severe TR after correction for baseline TR grade (P = 0.013). CONCLUSIONS: One year after endocardial lead insertion, there was a 5% increase in the prevalence of moderate or severe TR, which may be clinically relevant.

Economic impact of remote monitoring after implantable defibrillators implantation in heart failure patients: an analysis from the EFFECT study.

AIMS: Heart failure (HF) patients with implantable cardioverter-defibrillators (ICD) require admissions for disease management and out-patient visits for disease management and assessment of device performance. These admissions place a significant burden on the National Health Service. Remote monitoring (RM) is an effective alternative to frequent hospital visits. The EFFECT study was a multicentre observational investigation aiming to evaluate the clinical effectiveness of RM compared with in-office visits standard management (SM). The present analysis is an economic evaluation of the results of the EFFECT trial. METHODS AND RESULTS: The present analysis considered the direct consumption of healthcare resources over 12-month follow-up. Standard tariffs were applied to hospitalizations, in-office visits and remote device interrogations. Economic comparisons were also carried out by means of propensity score (PS) analysis to take into account the lack of randomization in the study design. The analysis involved 858 patients with ICD or CRT-D. Of these, 401 (47%) were followed up via an SM approach, while 457 (53%) were assigned to RM. The rate of hospitalizations was 0.27/year in the SM group and 0.16/year in the RM group (risk reduction =0.59; P = 0.0004). In the non-adjusted analysis, the annual cost for each patient was €817 in the SM group and €604 in the RM group (P = 0.014). Propensity score analysis, in which 292 RM patients were matched with 292 SM patients, confirmed the results of the non-adjusted analysis (€872 in the SM group vs. €757 in the RM group; P < 0.0001). CONCLUSION: There is a reduction in direct healthcare costs of RM for HF patients with ICDs, particularly CRT-D, compared with standard monitoring. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov/Identifier, NCT01723865.

The P-wave terminal force in embolic strokes of undetermined source.

BACKGROUND: The Embolic Stroke of Undetermined Source (ESUS) is a recently developed clinical construct which describes stroke patients for whom the embolic source remains undetermined despite recommended investigations. The aim of the study was to characterize the ESUS population according to the abnormality in the P-wave terminal force in lead V1 (PTFV1). METHODS: We retrospectively identified consecutive patients hospitalized for acute ischemic stroke who met the ESUS diagnostic criteria. The PTFV1 was obtained from the admission 12-lead ECG. Increased PTFV1 was defined a value >5000µV·ms. Baseline and diagnostic work-up findings were compared between the PTFV1 patient groups. RESULTS: Among 109 patients with ESUS, 31 (28.4%) had evidence of increased PTFV1. The patients with the ECG-defined left atrial abnormality had higher rates of hypertension (77.4% versus 55.1%; p=0.031), history of prior stroke or TIA (35.5% versus 16.7%; p=0.032), and moderate to severe left atrial enlargement (29.0% versus 7.7%; p=0.004) and ventricular hypertrophy (35.5% versus 16.7%; p=0.032), whereas they were less likely to have patent foramen ovale (9.7% versus 28.2%, p=0.038) and unstable sub-stenotic atherosclerosis of aortic arch and cranial arteries (12.9% versus 32.1%, p=0.041). CONCLUSIONS: The abnormally increased PTFV1 was observed in about one third of patients with ESUS and it was inversely associated with artery-to artery and paradoxical potential sources of stroke. Left atrial cardiopathy could be involved in the ESUS pathogenesis and the ECG-defined abnormality could point towards the risk of cardiac embolism.

Prospective study of tricuspid valve regurgitation associated with permanent leads in patients undergoing cardiac rhythm device implantation: Background, rationale, and design.

Given the increasing numbers of cardiac device implantations worldwide, it is important to determine whether permanent endocardial leads across the tricuspid valve can promote tricuspid regurgitation (TR). Virtually all current data is retrospective, and indicates a signal of TR being increased after permanent lead implantation. However, the precise incidence of moderate or greater TR post-procedure, the exact mechanisms (mechanical, traumatic, functional), and the hemodynamic burden and clinical effects of this putative increase in TR, remain uncertain. We have therefore designed a multicenter, international, prospective study of 300 consecutive patients (recruitment completed, baseline data presented) who will undergo echocardiography and clinical assessment prior to, and at 1-year post device insertion. This prospective study will help determine whether cardiac device-associated TR is real, what are its potential mechanisms, and whether it has an important clinical impact on cardiac device patients.

Facial reactions in response to dynamic emotional stimuli in different modalities in patients suffering from schizophrenia: a behavioral and EMG study.

Emotional facial expression is an important low-level mechanism contributing to the experience of empathy, thereby lying at the core of social interaction. Schizophrenia is associated with pervasive social cognitive impairments, including emotional processing of facial expressions. In this study we test a novel paradigm in order to investigate the evaluation of the emotional content of perceived emotions presented through dynamic expressive stimuli, facial mimicry evoked by the same stimuli, and their functional relation. Fifteen healthy controls and 15 patients diagnosed with schizophrenia were presented with stimuli portraying positive (laugh), negative (cry) and neutral (control) emotional stimuli in visual, auditory modalities in isolation, and congruently or incongruently associated. Participants where requested to recognize and quantitatively rate the emotional value of the perceived stimuli, while electromyographic activity of Corrugator and Zygomaticus muscles was recorded. All participants correctly judged the perceived emotional stimuli and prioritized the visual over the auditory modality in identifying the emotion when they were incongruently associated (Audio-Visual Incongruent condition). The neutral emotional stimuli did not evoke any muscle responses and were judged by all participants as emotionally neutral. Control group responded with rapid and congruent mimicry to emotional stimuli, and in Incongruent condition muscle responses were driven by what participants saw rather than by what they heard. Patient group showed a similar pattern only with respect to negative stimuli, whereas showed a lack of or a non-specific Zygomaticus response when positive stimuli were presented. Finally, we found that only patients with reduced facial mimicry (Internalizers) judged both positive and negative emotions as significantly more neutral than controls. The relevance of these findings for studying emotional deficits in schizophrenia is discussed.