Clinical relevance of homocysteine levels in patients receiving coronary stenting for unstable angina.

BACKGROUND: We prospectively investigated whether plasma homocysteine (HCY) concentrations are related to target lesion revascularization (TLR) rates in patients with unstable angina undergoing stenting. METHODS: We enrolled 196 consecutive patients with at least one successful coronary stent implantation for unstable angina. RESULTS: The mean vessel diameter was 3.1 +/- 0.5 mm. At follow-up (17.8 +/- 7.5 months), patients with higher HCY levels (> 17 micromol/l, 4th quartile) had similar TLR rates to the rest of the sample (11.1 vs 13.2%, p = 0.90). On the other hand, high HCY levels did seem to be associated with higher total (13.3 vs 0.7%, p = 0.001) and cardiac (6.7 vs 0%, p = 0.01) mortality rates. At multivariate analysis, only target vessel diameter independently predicted TLR, while both HCY levels and target vessel size predicted late total mortality. CONCLUSIONS: At least in patients with a mean vessel diameter > 3 mm, HCY levels cannot be taken as a prognostic indicator of in-stent restenosis for patients with unstable angina. However, in spite of successful percutaneous revascularization, HCY values do seem to strongly influence late mortality.     

Early predictors of smoking cessation after myocardial infarction

The determinants of long-term smoking cessation were evaluated in 80 patients who smoked cigarettes and survived a myocardial infarction. All patients underwent a program of rehabilitation and secondary prevention including in-hospital counseling and physician-guided reinforcing sessions at 1, 3, and 6 months after discharge. At 18 months of follow-up, 53 patients (66.3%) had quit smoking. Variables associated with smoking cessation were duration of hospital stay greater than or equal to 19 days (79 vs. 48%; p less than 0.005) and peak creatine phosphokinase (CPK) elevation greater than or equal to 500 U/l (76 vs. 54%; p less than 0.05). Males tended to quit in higher proportion than females (68 vs. 44%). Age, prior myocardial infarction, other cardiovascular risk factors, infarction location, Killip class at entry, and duration of stay in coronary care unit did not significantly affect the quitting rates. Logistic regression analysis singled out the duration of hospital stay as a significant predictor of smoking cessation (p less than 0.005). Early and intensive secondary prevention during the hospital stay is crucial in promoting sustained smoking cessation after myocardial infarction.     

Silent dysphagia in two patients with Steinert disease and recurrent respiratory exacerbations

We describe two cases of patients with Steinert’s dystrophy or myotonic dystrophy type 1 (DM1) who presented with frequent respiratory exacerbations and pneumonia. They did not report any risk factors for asthma, allergy, bronchopathy or dysphagia in their history. The Videofluoroscopic swallow study test allowed to highlight post-swallowing aspiration phenomena responsible for respiratory exacerbations.Key words: dysphagia, Steinert disease, respiratory exacerbation     

The attracting power of the gaze of politicians is modulated by the personality and ideological attitude of their voters: a functional magnetic resonance imaging study

Observing someone rapidly moving their eyes induces reflexive shifts of overt and covert attention in the onlooker. Previous studies have shown that this process can be modulated by the onlooker's personality, as well as by the social features of the person depicted in the cued face. Here, we investigated whether an individual's preference for social dominance orientation, in‐group perceived similarity (PS), and political affiliation of the cued‐face modulated neural activity within specific nodes of the social attention network. During functional magnetic resonance imaging, participants were requested to perform a gaze‐following task to investigate whether the directional gaze of various Italian political personages might influence the oculomotor behaviour of in‐group or out‐group voters. After scanning, we acquired measures of PS in personality traits with each political personage and preference for social dominance orientation. Behavioural data showed that higher gaze interference for in‐group than out‐group political personages was predicted by a higher preference for social hierarchy. Higher blood oxygenation level‐dependent activity in incongruent vs. congruent conditions was found in areas associated with orienting to socially salient events and monitoring response conflict, namely the left frontal eye field, right supramarginal gyrus, mid‐cingulate cortex and left anterior insula. Interestingly, higher ratings of PS with the in‐group and less preference for social hierarchy predicted increased activity in the left frontal eye field during distracting gaze movements of in‐group as compared with out‐group political personages. Our results suggest that neural activity in the social orienting circuit is modulated by higher‐order social dimensions, such as in‐group PS and individual differences in ideological attitudes.     

Asynclitism: a literature review of an often forgotten clinical condition

Asynclitism is defined as the “oblique malpresentation of the fetal head in labor”. Asynclitism is a clinical diagnosis that may be difficult to make; it may be found during vaginal examination. It is significant because it may cause failure of progress operative or cesarean delivery. We reviewed all literature for asynclitism by performing an extensive electronic search of studies from 1959 to 2013. All studies were first reviewed by a single author and discussed with co-authors. The following studies were identified: 8 book chapters, 14 studies on asynclitism alone and 10 papers on both fetal occiput posterior position and asynclitism. The fetal head in a laboring patient may be associated with some degree of asynclitism; this is seen as usual way of the fetal head to adjust to maternal pelvic diameters. However, marked asynclitism is often detected in presence of a co-existing fetal head malposition, especially the transverse and occipital posterior positions. Digital diagnosis of asynclitism is enhanced by intrapartum ultrasound with transabdominal or transperineal approach. The accurate diagnosis of asynclitism, in an objective way, may provide a better assessment of the fetal head position that will help in the correct application of vacuum and forceps, allowing the prevention of unnecessary cesarean deliveries.     

Antibody response to BK polyomavirus as a prognostic biomarker and potential therapeutic target in prostate cancer

Infectious agents, including the BK polyomavirus (BKPyV), have been proposed as important inflammatory pathogens in prostate cancer. Here, we evaluated whether the preoperative antibody response to BKPyV large T antigen (LTag) and viral capsid protein 1 (VP1) was associated with the risk of biochemical recurrence in 226 patients undergoing radical prostatectomy for primary prostate cancer. Essentially, the multivariate Cox regression analysis revealed that preoperative seropositivity to BKPyV LTag significantly reduced the risk of biochemical recurrence, independently of established predictors of biochemical recurrence such as tumor stage, Gleason score and surgical margin status. The predictive accuracy of the regression model was denotatively increased by the inclusion of the BKPyV LTag serostatus. In contrast, the VP1 serostatus was of no prognostic value. Finally, the BKPyV LTag serostatus was associated with a peculiar cytokine gene expression profile upon assessment of the cellular immune response elicited by LTag. Taken together, our findings suggest that the BKPyV LTag serology may serve as a prognostic factor in prostate cancer. If validated in additional studies, this biomarker may allow for better treatment decisions after radical prostatectomy. Finally, the favorable outcome of LTag seropositive patients may provide a potential opportunity for novel therapeutic approaches targeting a viral antigen.     

Left ventricular systolic and diastolic function after anthracycline chemotherapy in childhood

BACKGROUND: In childhood, late cardiotoxicity is characterized by inappropriately thin wall and consequent increased end-systolic wall stress, but the associations of impaired left ventricular geometry and function occurring under these circumstances need further investigation. HYPOTHESIS: The purpose of this study was to assess anthracycline late effects on the relationships occurring between increased end-systolic stress (ESS) and changes in both M-mode systolic measurements (i.e., endocardial and midwall fractional shortening) and Doppler diastolic indices in the pediatric age. METHODS: The population consisted of 101 children treated with anthracyclines for at least 12 months and 91 healthy children. Using M-mode echocardiography, end-systolic wall stress was calculated as index of afterload, and endocardial and midwall fractional shortening as systolic indices. Doppler transmitral measurements were made as diastolic indices. RESULTS: Patients treated with anthracyclines showed significantly lower relative wall thickness and left ventricular mass index, greater end-systolic wall stress, reduced endocardial and midwall fractional shortening and peak E/A ratio, prolonged deceleration, and isovolumic relaxation times. Direct relationships were found between end-systolic wall stress and both endocardial and midwall shortening. The use of midwall shortening in the relation showed a greater, but not significant increase (from 3 to 6%) in the proportion of patients with depressed systolic function than did endocardial shortening. In the anthracycline group, end-systolic wall stress was also inversely related to relative wall thickness and directly to isovolumic relaxation time. CONCLUSIONS: In childhood, reduced myocardial thickness and increased afterload explain much of systolic and diastolic dysfunction of late anthracycline toxicity. Midwall fractional shortening does not seem to add useful information for identifying subsets of children more prone to the development of heart failure.     

Long-term clinical and angiographic outcome of patients with occlusive in-stent restenosis treated with (32P) beta-brachytherapy.

The objective of this study was to determine the safety and efficacy of (32)P beta-brachytherapy in totally occlusive in-stent restenosis (ISR). Patients with occlusive ISR were generally excluded from the randomized clinical trials on intracoronary brachytherapy (utilizing either gamma- or beta-sources) that have shown reductions in restenosis rate and need for revascularization procedures. We analyzed short- and long-term effects of (32)P beta-brachytherapy (20 Gy) in 27 patients (28 lesions) with occlusive ISR and 84 (99 lesions) patients with nonocclusive high-risk ISR. The primary outcome measure was frequency of in-lesion angiographic binary restenosis at 7 months. Secondary endpoints were rates of major adverse cardiac events (MACE), target vessel revascularization (TVR), clinically driven TVR, and target lesion revascularization (TLR). (32)P beta-brachytherapy was feasible and safe and provided similar postprocedural angiographic results in the two clinically comparable groups. However, the 7-month binary restenosis rate was higher in the occlusive group, as were the MACE and late total occlusion rates. Multivariate logistic analysis of the overall population indicated occlusive pattern to be the only independent predictor of angiographic restenosis. In both groups, recurrent lesions most often showed a focal pattern with significant reduction of length. Although safe and effective in high-risk ISR, (32)P brachytherapy at 20 Gy does not appear to be sufficient to avoid long-term restenosis in patients with occlusive lesions. Further studies should determine the most suitable source and dosage of brachytherapy for patients with occlusive ISR.