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Background: In the framework of 'Doing more does not mean doing better - Choosing Wisely Italy' health professionals, general population and healthcare advocacy associations are widely involved. PartecipaSalute-Mario Negri IRCCS and Altronconsumo organized a survey in order to assess the opinions and behaviors of people toward unnecessary tests and drugs., Methods: An online survey was distributed by Altroconsumo to a voluntary panel of 6304 Italian citizens covering the whole of the country and by PartecipaSalute-Mario Negri IRCCS through the PartecipaSalute website, e-mail lists, website articles, lay journals and Facebook., Results: In all 1006 people reached by Altroconsumo, and 355 volunteers of healthcare advocacy associations reached by PartecipaSalute responded. Respondents usually decides on their treatment together with the physician, respectively 50% for general population and 64% for volunteers of healthcare advocacy associations. The respondents are aware of the question of over-use of drugs and tests (80%), more often among the volunteers of healthcare advocacy associations (86%). Over-use is considered a problem mostly for economic reasons among the general population, while in the advocacy associations the risks for patients' health is considered more important., Conclusion: These findings suggest that patients do not always ask for more, especially if they receive an answer to their questions and clarifications about unnecessary treatments. There is a need for further understanding of the factors influencing decision-making aimed at achieving good care. Engaging the public and patients at all levels of healthcare is essential for a valuable use of health resources., (© The Author 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

Objective: Our study aimed to analyze the predictive value of intra-operative bypass graft flow measurements for long-term mortality., Methods: A total of 1593 consecutive coronary artery bypass graft (CABG) patients routinely underwent intra-operative bypass graft flow measurements with the transit-time flow meter (TTFM: Cardiomed(®)). The results of the flow measurements and the demographics were analyzed retrospectively., Results: The mean follow-up was 3.8 years (0.5-8.8 years) with no losses to follow-up. Overall mortality was 10.1%. The preoperative left ventricular ejection fraction (LVEF) (echocardiograph) was the highest independent predictor of long-term survival (hazard ratio 0.97, p = 0.004) in all groups. The univariate analysis for the CABG I group showed that besides LVEF, female gender (hazard ratio 3.6, p = 0.02) was also significant. For the CABG II group, additive EuroSCORE (European System for Cardiac Operative Risk) (ES) (hazard ratio 1.4, p = 0.0001) and age (hazard ratio 1.1, p = 0.001) were significant. In the CABG III group, ES (hazard ratio 1.2, p < 0.0001), age (hazard ratio 1.04, p = 0.001), IMA (hazard ratio 0.5, p < 0.0001) and concomitant aortic valve replacement (AVR) (hazard ratio 2.1, p = 0.03) were significant, in addition to the LVEF., Conclusion: With quality-controlled surgeons checked by intra-operative TTFM, accurate quantification of preoperative LVEF significantly predicts long-term outcome. Effective bypass graft flows failed to predict outcome in CABG patients, regardless of the degree of coronary artery disease (CAD) and concomitant AVR., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Aims: We compared pacing rate adaptation based on closed loop stimulation (CLS) or accelerometer sensor (AS) during acute mental and physical stress in the same patient., Methods and Results: One month after Protos (Biotronik, Germany) pacemaker implantation, 131 chronotropically incompetent patients were randomized to AS or CLS for 3 months with crossover. Arithmetic and 6 min walk tests were performed in the non-rate-adaptive mode and AS and CLS rate-adaptive modes, respectively. At the end, patients had to select the individually preferred pacemaker sensor. Heart rate during mental stress was higher (3.0 +/- 9.2 bpm) in the CLS than in the AS mode (P = 0.004). Benefit in the walking distance compared with non-rate-adaptive pacing was similar for the two modes: added 27 +/- 96 m (AS, P = 0.013) and 30 +/- 116 m (CLS, P = 0.025). At the end of the walk, heart rate was higher by 4.8 +/- 21.4 bpm in AS than in CLS (P = 0.049). Twice as many patients preferred CLS over AS (P < 0.01)., Conclusion: The arithmetic test was associated with a significantly higher heart rate for CLS than for AS, showing a greater sensitivity of CLS-based rate adaptation to mental stress. Performance during physical stress was comparable. Patients preferred CLS.

Objectives: In this single-center study we reviewed our experience with a significant number of cardiac myxoma cases occurring over the past two decades., Patients and Methods: Cardiac myxomas represented 86% of all surgically treated cardiac tumors at our center. Specifically, there were 49 consecutive patients, each with at least one myxoma. A detailed clinical, immunological, and echocardiographic long-term examination of 37 patients revealed one recurrent myxoma., Results: Most myxomas originated from the left atrium (87.7%), but also much less frequently from the mitral valve (6.1%), from the right atrium (4.1%), and from the left and right atria (2.0%). The myxomas produced a prolapse into the left ventricle in 40.8% of the patients, mitral stenosis in 10.2%, and threatened left ventricular outflow tract obstruction in 2.0%. Multiple myxomas were found in 20.4% of the patients. Cardiac signs appeared in 93.9% of the patients. Preoperative embolic events had occurred in 26.5%. Immunologic alterations were present in 87.5%. For resection, a bilateral atriotomy was used. An additional aortotomy was needed to expose one mitral valve myxoma. Postoperatively, 81.1% of the patients remained without cardiac symptoms. The early mortality rate was 2.0% and the late mortality rate was 6.1%. Long-term prognosis was excellent with an actuarial survival rate of 0.74. Specific immunologic alterations were found in 71.4% of the patients. The actuarial freedom from reoperation of the myxoma was 0.96. The rate of reoperations was low with 2.0% after 24 years., Conclusions: Myxomas were usually detected and operated on in symptomatic patients. A high index of suspicion seems important for early diagnosis. Immunologic findings may play an additional role in confirming the diagnosis and the recurrence of a myxoma. Immediate surgical treatment was indicated because of the high risk of embolization or of sudden cardiac death. Also, a familial genesis must be excluded in myxoma patients.

Objectives: Left ventricular hypertrophy in patients with critical aortic stenosis (AS) is an adaptive process that compensates for high intracavitary pressure and reduces systolic wall stress followed by an increase in myocardial masses. In the present prospective clinical trial, we investigated long-term compensatory changes in left ventricular geometry and function after aortic valve replacement using mechanical bileaflet prostheses with the main emphasis on the small-sized aortic annulus and valve prosthesis-patient mismatch., Methods: A total of 58 patients with critical AS were assigned to the following groups according to the predictive value of prosthetic valve area index (VAI): group EXMIS: 29 patients (VAI < or =0.99), expected mismatch; group NOMIS: 29 patients (VAI < or =0.99), no mismatch. At controls T(0) (before operation/operation (OP), T(1) and T(2) (4 and 20 months after OP) the left ventricular geometry was recorded by means of Imatron electron beam tomography and the transprosthetic velocities were measured by echocardiography., Results: Statistical analysis showed a consistent reduction in the absolute (P=0.04) and indexed (P=0.04) left ventricular myocardial mass for both cohorts; furthermore, there was a significant difference between EXMIS and NOMIS patients concerning the factors, time and mass reduction (P=0.005), because of distinct baselines. A logistic regression report revealed preoperative cardiac output, absolute left ventricular myocardial mass, perfusion, body surface area and the native valve orifice area as predicting coefficients and factors for a minimum mass reduction of 25%. We explain a mathematical formula that turned out to be the most sensitive for correctly classified factors., Conclusions: The left ventricular geometry and transprosthetic velocities resulted in the same postoperative recovery for both EXMIS and NOMIS patients. The presented data showed that valve prosthesis-patient mismatch had no influence in several stepwise logistic regression models. We conclude that modern mechanical bileaflet prostheses allow both acceptable hemodynamics and recovery of left ventricular hypertrophy, even in small aortic annuli.

Six years after the first aortic valve replacement with the Starr-Edwards Silastic ball prosthesis at Oregon Health Sciences University, the model 1260 was implanted in a 44-year-old patient at our department. During 24 years no signs of dysfunction, thromboembolism, thrombosis, periprosthetic leaks or hemolysis were observed. Material test showed no signs of fatigue. The dimension of the Silastic poppet was found to be one millimeter less than the original specifications of these poppets and there were some lipid infiltrations. Functionally the poppet was found to be nonvariant. Histologic findings detected focal hyalinization and giant cells without signs of acute inflammation or ulceration. With regard to its reliability and durability, the Starr-Edwards valve prosthesis should not be viewed with disfavor.

The present study aimed to establish the role of the metabolite norfluoxetine in the anorectic activity of fluoxetine, and to relate the anorectic doses (ED50) to the brain concentrations of the parent drug and its metabolite. Fluoxetine showed anorectic activity at increasing intraperitoneal doses (ED50 = 39.1, 34.7 and 21.7 mumol kg-1 in mouse, rat and guinea-pig, respectively) and norfluoxetine was slightly more active (24.3, 22.9 and 19.1 mumol kg-1, respectively) in all three species. In terms of maximum concentration (Cmax) and area under the curve (AUC) within the experimental period (0-90 min), brain concentrations varied widely and were poorly related to the dose; guinea-pig appeared to be much more sensitive to fluoxetine than was mouse or rat. Administered norfluoxetine was present in the brain of the three species in approximately the same order as fluoxetine, i.e. lower in guinea-pig than in mouse or rat. The Cmax and AUC of norfluoxetine after fluoxetine administration was 50-60% of the values after an equiactive dose of norfluoxetine in mouse and guinea-pig, and more than 80% in rat.