Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study

Background

Potent P2Y₁₂ inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type.

Electrocardiographic patterns during Holter monitoring in patients with first and second degree A-V block due to 'dual A-V nodal pathways'

The electrocardiographic patterns, observed during 24-h Holter monitoring, of 10 patients (mean age 35 +/- 22 years) with first and second degree A-V block due to dual A-V nodal pathways are reported. Recordings were selected according to the presence of: sudden and persistent prolongation of the PR interval: sudden normalization of the PR interval: 'atypical' Wenckebach sequences showing sudden and pronounced prolongation of any PR interval prior to the blocked P wave. Besides the already recognized pattern, new aspects were identified: (1) Wenckebach sequences in the slow and fast pathways characterized by a progressive increase in the PR interval until a blocked P wave occurred during long and short PR interval periods, respectively; (2) Wenckebach periods first in the slow and then in the fast pathway; (3) 2:1 A-V block with a normal PR interval in the conducted beat after a Wenckebach sequence in the slow pathway; (4) Wenckebach in the fast pathway and, subsequently, in the slow one characterized by a slight prolongation of the PR interval for some beats followed by a sudden and pronounced increase in the PR interval of one beat and a subsequent progressive slight PR prolongation until a blocked P wave occurred; (5) Wenckebach sequence in the fast pathway with subsequent conduction over the slow pathway without a blocked P wave; (6) blocked P waves during both long and short PR interval periods with slight prolongation of the preceding PR interval. The electrophysiological mechanisms involved in these electrocardiographic patterns together with the nature (anatomical or functional) of the intranodal pathways and the clinical significance of this type of block are discussed.     

Value of "protruding lips" sign in malignant bowel obstructions

ObjectiveThis study aims to evaluate the diagnostic accuracy of a new CT sign in order to define or exclude a malignant aetiology of bowel obstruction.Materials and methodsCT scans of 137 patients affected by bowel obstruction were reviewed. Colonic obstruction occurred in 47 (34%) cases, small bowel obstruction in 90 (66%). Neoplastic aetiology was found in 42 cases (31%), while in the remaining 95 (69%) obstruction was caused by non-neoplastic conditions. Definitive diagnosis was surgically confirmed in all patients. CT images were evaluated searching for bowel obstruction's signs and for the presence of the “protruding lips” sign on the proximal surface of stenosis, which is represented by the evidence of a protrusion within the dilated loop.ResultsThe sign was found in 31 (23%) cases, all of neoplastic origin. When malignant obstruction was diagnosed, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy values of the described sign were 74%, 100%, 100%, 90% and 92%, respectively.ConclusionsThe “protruding lips” sign represents an alteration to be searched when bowel obstruction is diagnosed by CT examination. Its evidence correlates to a malignant condition with a 100% probability and when it is not found, the probability of a non-neoplastic condition is 90%.     

Vitamin K status in cystic fibrosis

Appearance of PIVKA-II (protein induced by vitamin K absence-II) in serum is a biochemical sign of insufficient vitamin K-dependent carboxylation of prothrombin. Plasma concentrations of PIVKA-II and vitamin K1 were determined in 24 children with cystic fibrosis. Eight were supplemented with vitamin K1. The purpose of the study was to determine the occurrence of vitamin K deficiency in cystic fibrosis and to evaluate the effect of vitamin K supplementation. PIVKA-II was detectable in only one unsupplemented child. In this patient, the concentration of vitamin K1 was below the limit of detection of 60 ng/l. Vitamin K1 levels in the other unsupplemented children were normal (mean 476 ng/l = 1 mmol/l). The supplemented patients showed extremely high levels of vitamin K1 (mean 22445 ng/l = 50 nmol/l). In conclusion, vitamin K deficiency occurs infrequently in cystic fibrosis. Checking the coagulation system is advised, but routine vitamin K supplementation is not recommended. If additional vitamin K is needed, the starting dose should not exceed 1 mg daily.     

Pearson bone marrow-pancreas syndrome with insulin-dependent diabetes,progressive renal tubulopathy,organic aciduria and elevated fetal haemoglobin caused by deletion and duplication of mitochondrial DNA

We report a patient with a clinical picture consisting of small birth weight, connatal hypoplastic anaemia, vacuolised bone marrow precursors, failure to thrive, and, subsequently, by insulin-dependent diabetes, renal Fanconi syndrome, lactic acidosis, complex organic aciduria, and elevation of haemoglobin F and of adenosine deaminase activity. The clinical course was progressive and death occurred at age 19 months. A high proportion of mitochondrial (mt) DNA molecules with a deletion of nucleotides 9238 to 15575 were identified in several tissues; about half of the shortened mtDNA molecules were concatenated to form circular dimers. The clinical and laboratory findings support recent conclusions that Pearson syndrome is not confined to bone marrow and pancreas, as originally described, but is a multi-organ disorder associated with delctions in part of the mtDNA molecules. The tissue distribution and the relative proportions of the abnormal mtDNA molecules apparently determine the phenotype and clinical course.