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Background: In the last few years, advances have been made in the diagnosis and management of ST-segment elevation myocardial infarction (STEMI). Recent guidelines have been developed to improve outcome of STEMI patients by implementation of the recommendations into clinical practice. In order to assess the disease burden, the treatment modalities and the mid-term outcome of STEMI in the Umbria region, Italy, we performed a prospective observational study of all patients hospitalized with a diagnosis of STEMI from October 14, 2006 to April 14, 2008 (Umbria-STEMI registry)., Methods: All the medical emergency services (118) and all the emergency, internal medicine and cardiology departments were involved in the project. Three typologies of cardiology departments are operating in our region: a) intensive care units (ICUs) with percutaneous coronary intervention (PCI) facilities fully operating 24 h/day and 7 days/week (1 center), b) ICUs with PCI facilities operating 6 h/day and 5 days/week (2 centers); c) ICUs without PCI facilities (4 centers). The Umbria-STEMI health area includes about 850 000 inhabitants., Results: Overall, 868 patients (70% male, mean age 66.5 +/- 13.3 years) were enrolled. Patients with late presentation (> 12 h) or non-persistent ST-segment elevation (9.9%) were excluded. 86.7% of patients underwent reperfusion treatment: 45.9% with primary angioplasty and 40.8% with thrombolysis (64 of them had rescue angioplasty). Primary angioplasty was mainly performed in the hospital with PCI facilities operating 24 h/day. 104 patients with STEMI (13.3%) did not receive any type of coronary reperfusion therapy. In a logistic regression analysis, the direct admission to the hospital with fully operating PCI facilities was the strongest positive predictor of reperfusion therapy utilization, whereas the time delay, older age and TIMI risk index were negative predictors. The mean door-to-needle time for lytic therapy was 60 min, and the door-to-balloon time for primary angioplasty was 156 min. In-hospital mortality was 5.9%., Conclusions: The Umbria-STEMI registry disclosed several discrepancies between guidelines-recommended treatments and their utilization in daily practice. Efforts should be made to reduce the delay from symptom onset to intervention.

Infective endocarditis is a rare but serious disease. The incidence in western countries is 1.7-6.2 cases/100,000 per year. The mortality rate today is 20-40%. The Duke University incorporates echocardiographic findings as one of the major criteria in the diagnosis of infective endocarditis. In case of suspected infective endocarditis, echocardiography is used to: 1) detect and characterize endocarditic vegetations; 2) detect complications; 3) conduct follow-up after treatment. Sensitivity for detection of vegetations in native-valve endocarditis is < 65% by transthoracic echocardiography, whereas it is 82-100% by transesophageal echocardiography; in infective endocarditis on prosthetic valves, sensitivity is 16-36 and 82-96%, respectively. Echocardiographic studies have demonstrated that highly mobile vegetations with a diameter of > 10 mm are more likely to cause complications (embolism, heart failure, need for surgery, and death). Another important advantage offered by echocardiography is the ability to accurately detect cardiac complications of infective endocarditis: valvular regurgitation, valve rupture, periannular abscess, prosthetic dehiscence, rupture of cardiac fibrosa, septal abscess, hemopericardium, and myocardial infarction. The sensitivity of transthoracic echocardiography for the detection of periannular abscess is 28% whereas that of transesophageal echocardiography is 87%. Finally, echocardiography has an invaluable role in indicating if surgery is required in cases of infective endocarditis with severe complications.

It is not clear how acute infection is associated with a subsequent ischaemic brain infarction. Infection may, indeed, cause changes in blood fluidity. Abnormalities in blood flow, particularly in white blood cell rheology, are known to be precipitating factors for ischaemic events. Therefore, the rheological behaviour of the erythrocytes and of the main leucocyte subpopulations (granulocytes = G; mononuclear cells = MNL) were studied in 29 patients 30 days after the onset of acute bacterial infections. A group of 49 controls (matched for sex, body mass index and cardiovascular risk factors) was also evaluated. A significant impairment in the flow properties of the mononuclear leucocyte subpopulation was found in the patients as compared to control. These results indicate that disturbances in leucocyte rheology might be considered an additional risk factor for ischaemic brain infarction when this occurs shortly after febrile infection.