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Following the spread of the infection from the new SARS-CoV2 coronavirus in March 2020, several surgical societies have released their recommendations to manage the implications of the COVID-19 pandemic for the daily clinical practice. The recommendations on emergency surgery have fueled a debate among surgeons on an international level.We maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the COVID-19 era. Moreover, since laparoscopic cholecystectomy is not more likely to spread the COVID-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have.

Objectives Antimicrobial resistance (AMR) is one of the major health issues worldwide. Clinicians should play a central role to fight AMR, and medical training is a pivotal issue to combat it; therefore, assessing levels of knowledge, attitudes and practices among young doctors is essential for future antimicrobial stewardship (AMS) programmes. Methods A nationwide, cross-sectional, multicentre survey was conducted in Italy. A descriptive analysis of knowledge and attitudes was performed, along with a univariate and multivariate analysis of their determinants. Results Overall, 1179 young doctors accessed the survey and 1055 (89.5%) completed all sections. Regarding the knowledge section of the questionnaire, almost all participants declared to know the different species of bacteria proposed, however the percentage of participants who correctly responded to clinical quizzes was 23% for the question on vancomycin-resistant enterococci (VRE), 42% on carbapenem-resistant Enterobacteriaceae (CRE), 32% on extended-spectrum β-lactamase-producing enterobacteria (ESBL) and 27% on methicillin-resistantStaphylococcus aureus (MRSA). Similarly, 81% of participants disagreed in stating that AMR was adequately addressed during their medical training and 71% disagreed that they received the right example from their tutors. Finally, a high rate of agreement with the proposed actions to combat AMR was documented; in particular, the percentage agreement was 76% for respondents who agreed to be part of an active surveillance system or AMS programme. Conclusions Tackling AMR should be a priority for politicians and for all health workers. Inclusion of competencies in antibiotic use in all specialty curricula is urgently needed.

Backround: We aimed at assessing the prevalence of polypharmacy and potential drug-drug interactions (DDIs) with clinical relevance in elderly patient on Emilia Romagna area. Both outpatients and residents in nursing homes were assessed, with only partially overlapping strategies.Methods: We defined a list of 190 pairs of potentially interacting drugs, based on literature appraisal and availability of therapeutic alternatives. January-June 2018 data on drug use in patients over 65 years-old were collected from nine Local Health Authorities of Emilia Romagna: data on community-dwelling subjects were extracted from archives of reimbursed prescriptions, while drug use in a sample of nursing homes was recorded from clinical charts in one index day within the same semester. The frequency of polypharmacy (at least five or at least 10 concurrent drugs) and of each DDI was calculated.Results: In line with different rates of polypharmacy (80% vs 16%), the risk of exposure to at least one interaction was 53.7% in nursing homes and 26.4% in outpatients. Among DDIs, in nursing homes antidepressants—anxiolytics (11.9%) ranked first, followed by antidepressants—aspirin (7.4%). In outpatients, ACE-inhibitors—non-steroidal anti-inflammatory drugs (NSAIDs) reached 7.2% followed by the calcium channel blockers—α-blockers (2.4%).Discussion: Polypharmacy and risk of DDIs appeared very different in the two settings, due to both technical and clinical reasons. In order to reduce use of benzodiazepines, NSAIDs, antidepressants and relevant DDIs, 1) defining alternative options for pain relief in elderly outpatients, and 2) implementing non-pharmacological management of insomnia and anxiety in nursing homes should be prioritized.

Background Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X‐ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P, The COVID‐19 pandemic required reorganization of surgical services, affecting patients with common surgical diseases including acute appendicitis. No evidence is available on the topic. This study found global variation in screening policies, use of personal protective equipment and intraoperative directives. There has been increased adoption of non‐operative management and open appendicectomy. Hands off

Background and Objective Safinamide is a novel anti-parkinsonian drug with possible anti-dyskinetic properties. Parkinson's disease (PD) is a complex disease. The objective of this systematic review and meta-analysis is to evaluate the efficacy and safety of safinamide administration compared to placebo in PD patients on multiple outcomes. Methods PubMed, EMBASE, Cochrane CENTRAL, LILACS, and trial databases were searched up to 23 December 2020 for randomized controlled studies (RCTs) comparing safinamide to placebo, alone or as add-on therapy in PD. Data were extracted from literature and regulatory agencies. Primary outcomes were ON-time without troublesome dyskinesia, OFF-time, and Unified Parkinson’s Disease Rating Scale (UPDRS) section III (UPDRS-III). Secondary outcomes included any dyskinesia rating scale (DRS), ON-time with troublesome dyskinesia, UPDRS-II, and Parkinson’s Disease Questionnaire 39 (PDQ-39). In order to estimate mean difference (MD) and odds ratios with 95% confidence intervals (CI), generic inverse variance and Mantel–Haenszel methods were used for continuous and dichotomous variables, respectively. Analyses were performed grouping by PD with (PDwMF) or without (PDwoMF) motor fluctuations, safinamide dose, and concomitant dopaminergic treatment. Summary of findings with GRADE were performed. Results Six studies with a total of 2792 participants were identified. In PDwMF patients, safinamide 100 mg as add-on to levodopa (l-dopa) significantly increased ON-time without troublesome dyskinesia (MD = 0.95 h; 95% CI from 0.41 to 1.49), reduced OFF-time (MD = − 1.06 h; 95% CI from − 1.60 to − 0.51), and improved UPDRS-III (MD = − 2.77; 95% CI from − 4.27 to − 1.28) with moderate quality of evidence. Similar results were observed for the 50 mg dose. However, the quality of evidence was moderate only for ON-time without troublesome dyskinesia, whereas for OFF-time and UPDRS-III was low. In PDwoMF patients taking a single dopamine agonist, safinamide 100 mg resulted in little to no clinically significant improvement in UPDRS-III (MD = − 1.84; 95% CI from − 3.19 to − 0.49), with moderate quality of evidence. Conversely, in PDwoMF patients, the 200 mg and 50 mg doses showed nonsignificant improvement in UPDRS-III, with very low and moderate quality of evidence, respectively. In PDwMF patients taking safinamide 100 mg or 50 mg, nonsignificant differences were observed for ON-time with troublesome dyskinesia and DRS, with high and low quality of evidence, respectively. In the same patients, UPDRS-II was significantly improved at the 100 mg and 50 mg dose, with high and moderate quality of evidence. In PDwoMF, UPDRS-II showed a little yet significant difference only at 100 mg, with low quality of evidence. PDQ-39 resulted significantly improved only with the 100 mg dose in PDwMF, with low quality of evidence. Conclusion Overall, safinamide is effective in PDwMF patients taking l-dopa both at 100 and 50 mg daily. Evidence for efficacy in early PD is limited. Further trials are needed to better evaluate the anti-dyskinetic properties of safinamide. Supplementary Information The online version contains supplementary material available at 10.1007/s40261-021-01011-y.

Acute appendicitis remains a common reason for hospital admission. Reports have suggested a reduction in patients attending emergency departments during the acute phase of the SARSCoV- 2 pandemic. Moreover, a global surge in conservative management of acute appendicitis has recently been registered by the Appy Study of the Association of Italian Surgeons in Europe (ACIE)1. This is a treatment option that has been known for some years, although quite seldom used before the pandemic2–4. As most countries are experiencing new waves of the pandemic, the attitude of surgeons towards SARS-CoV-2 screening policies and personal protective equipment (PPE) used during the management of patients with acute appendicitis need to be established. According to a subanalysis of the ACIE Appy Study, half of surgeons globally were testing patients for SARS-CoV-2 only when symptomatic or there was suspicion of infection; approximately 12 per cent did not test patients at all (Fig. 1 and Table S1). There were regional differences. In Europe, respondents tested all patients (50.8 per cent) or those with suspected infection (43.9 per cent), with only 5.3 per cent not being tested at all. In the USA, the majority of participants only tested patients with a suspected infection (65.6 per cent). A similar picture of testing only those with a suspected infection was also reported from Latin America (57.2 per cent), Asia/Middle East (76.8 per cent), and Africa (41.7 per cent). Even more worrisome, 58.3 per cent of respondents from Africa and 27.6 per cent from Latin America were not testing patients at all before appendicectomy. Concerning the screening modality, most respondents used PCR alone or in combination with chest imaging. Serology was rarely used overall and never in Africa (Fig. 1 and Table S2 ). It is now accepted that chest imaging is not routinely required and that PCR is an accurate screening modality. Serology might, however, be useful to shed light on the disease course and previous exposure to the virus, but respondents from some countries still have restricted access to this test. In terms of PPE during appendicectomy, most African respondents did not use different PPE compared with the prepandemic period in patients who tested negative for COVID-19. More concerning is that 58.3 per cent did not use different PPE in untested patients. This differed from other regions where the rate of those not considering a change of PPE in untested patients did not exceed 22 per cent. One in 10 respondents from Latin America also reported that they were not using different PPE compared with the prepandemic phase in patients who tested positive for COVID-19. These data, and taking into account the high prevalence of acute appendicitis, leads to the conclusion that omission of routine patient screening may have contributed to local clusters among patients and threatened the safety of healthcare workers5. In this respect, it is likely that limited access to PPE explains the attitude of surgeons towards patients with unknown SARSCoV- 2 status or those infected, raising ethical concerns about the safety of surgical staff. It is of outmost importance that, even during challenging times and stress on economic stability, industrialized countries make efforts to sustain low-income countries and those with limited resources. This would ensure equal working conditions, safer treatment for patients with acute appendicitis, and better control of the pandemic

The statements produced by the Chairmen and Speakers of the 3rd International Symposium on Diverticular Disease, held in Madrid on April 11th-13th 2019, are reported. Topics such as current and evolving concepts on the pathogenesis, the course of the disease, the news in diagnosing, hot topics in medical and surgical treatments, and finally, critical issues on the disease were reviewed by the Chairmen who proposed 39 statements graded according to level of evidence and strength of recommendation. Each topic was explored focusing on the more relevant clinical questions. The vote was conducted on a 6-point scale and consensus was defined a priori as 67% agreement of the participants. The voting group consisted of 124 physicians from 18 countries, and agreement with all statements was provided. Comments were added explaining some controversial areas.

In this session different issues for the diagnosis of diverticular disease (DD) were considered including “Biomarkers”, “Computer tomography”, “Ultrasonography in detecting acute diverticulitis”, “Endoscopy” and “The DICA classification: a new predictive tool in managing diverticular disease”. Most patients affected by DD suffer from recurrent attacks of abdominal pain without evidence of an active inflammatory process, causing a difficult differential diagnosis with other intestinal conditions. Several biomarkers, serological, fecal, urinary and genetic were considered, but recent studies confirmed that only CRP and fecal calprotectin are matching with the criteria for an ideal biomarker for DD. Colonoscopy still remains the gold standard for the diagnosis of DD, playing a key role in many clinical settings, such as colonic diverticular bleeding, or to differentiate inflammatory bowel disease (IBD) and segmental colitis associated with diverticulosis (SCAD); Moreover, in 2015 has been developed the DICA (Diverticular Inflammation and Complication Assessment) endoscopic classification that considers 10 different parameters, each one with a score, and the sum of items scores represents the severity of the disease; in this way the endoscopic exam would be able to predict the outcome of DD for each patient. On the other hand, computer tomography (CT) is the gold standard for acute diverticulitis (AD) with an excellent sensitivity and specificity; recently, metanalysis of prospective studies have shown that intestinal ultrasonography (IUS) and CT have the same sensitivity for the diagnosis of an AD and the advantage is that IUS is less expensive, non-invasive and easily accessible.

Acute appendicitis (AA) is one of the most common causes of abdominal pain requiring surgical intervention. Approximately 20% of AA cases are characterized by complications such as gangrene, abscesses, perforation, or diffuse peritonitis, which increase patients' morbidity and mortality. Diagnosis of AA can be difficult, and evaluation of clinical signs, laboratory index and imaging should be part of the management of patients with suspicion of AA.This consensus statement was written in relation to the most recent evidence for diagnosis and treatment of AA, performing a literature review on the most largely adopted scientific sources. The members of the SPIGC (Italian Polispecialistic Society of Young Surgeons) worked jointly to draft it. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Chest Physicians (CHEST) for the strength of the recommendations.Fever and migratory pain tend to be present in patients with suspicion of AA. Laboratory and radiological examinations are commonly employed in the clinical practice, but today also scoring systems based on clinical signs and laboratory data have slowly been adopted for diagnostic purpose. The clinical presentation of AA in children, pregnant and elderly patients can be unusual, leading to more difficult and delayed diagnosis. Surgery is the best option in case of complicated AA, whereas it is not mandatory in case of uncomplicated AA. Laparoscopic surgical treatment is feasible and recommended. Postoperative antibiotic treatment is recommended only in patients with complicated AA.

BACKGROUND It is still unknown whether ERAS program is safe, feasible and effective in elderly patients undergoing laparoscopic colorectal surgery. In addition, the definition of the "old patient" in terms of age varies across the studies and different age cut-off, such as 65, 70, and 75 years have been used worldwide. METHODS All adult patients undergoing primary, elective colorectal laparoscopic surgery between January 2017 and December 2018 were considered eligible to follow the ERAS protocol according to the Enhanced Recovery After Surgery (ERAS) Society guidelines. Elderly were defined according three different cut-off values

Purpose Metastatic non-small-cell lung cancer (NSCLC), the leading cause of death from cancer worldwide, is a debilitating disease that results in a high burden of symptoms and poor quality of life; the estimated prognosis after the diagnosis has been established was less than 1 year until some years ago. At the present, the new targeted therapies and immunotherapy are changing the course of the disease. However, advanced NSCLC remains an incurable disease, with a poor prognosis for the majority of the affected patients, so that quality of life and relief from symptoms are primary objectives of treatment. Some evidences suggest that early palliative care (EPC) for these patients can improve quality of life and even survival. Design A systematic review of the studies evaluating the impact on objective and on patient-reported outcomes of the introduction of EPC in opposition to standard care (SC), for advanced lung cancer patients, was performed. Because of the small number of studies conducted in this area, retrospective studies were also considered for the review. Results Five studies were included because they matched the inclusion criteria previously defined as relevant for the study. The review found that both survival and quality of life were better for patients included in EPC groups. Conclusions While results of the studies included in this review are not always comparable because different methods and scales have been used, there is enough evidence for clinical oncologists to implement the use of EPC in clinical practice for advanced lung cancer patients.

Background The onset of depressive disorders in old age (≥65 years) involves very complex choices in the use of pharmacological treatments. Clinical case heterogeneity, aging-derived biological alterations determine a specific use of antidepressant drugs in elderly patients compared to adults and young ones. Besides these fragilities, poly-therapies characterise these patients due to the frequency of somatic pathologies, increasing the risk of pharmacological interactions. Purpose The aim of this study was to capture the local situation of the interaction between the SSRIs (ATC N06AB) and the anti-inflammatory and anti-rheumatic drugs NSAIDs (ATC M01A) in the elderly population, and subsequently define a therapeutic treatment with the specialists to promote the appropriateness of prescriptions. Material and methods We compiled and analysed reimbursed prescriptions dispensed to poly-treated (≥four drugs) elderly (>65 years) patients during the first semester of the years 2017 and 2018 related to the prescriptions of NSAIDs and SSRIs. On the basis of inappropriateness indicators previously published (Beer 2015, STOPP Criteria (2nd ed.)), together with the analysis of the most recent literature (review of 2016), we produced clinical governance documents useful in defining management/alternative to be proposed to the doctors to avoid or reduce the risks related to the interaction. Subsequently, clinical meetings were held, to promote the correct use of SSRIs in association with NSAIDs. Results In the two semesters analysed, patients aged ≥65 years and residing in Piacenza totalled 64 759 in 2017 and 64 932 in 2018. The population surveyed was 57% female and 43% male. The participants exposed to the interaction of interest were 868 for the year 2017 and 871 for the year 2018. Patients 76–80 years of age were the most involved group with, respectively, 19 635 participants in 2017 and 19 742 in 2018. Conclusion The study showed how the extent of the SSRIs-NSAIDs interaction is a problem not to be underestimated and represents a growing trend. The poor reporting of adverse events represents a further confirmation (only an ADR in the two-year period 2017–2018). In order to raise awareness of pharmacovigilance, monitoring of hospitalisations of the study population will be arranged in 2019. References and/or acknowledgements General practice. No conflict of interest.

In this session different issues for the surgical management of diverticular disease DD) were considered. The first session debated about the antibiotic treatment for acute uncomplicated diverticulitis (AUD), and supports their use selectively rather than routinely in patients with AUD. The second session discussed the best surgical treatment for those patients. Open approach is a valid choice especially in acute setting, while the laparoscopic approach should be individualised according to the level of skills of the surgeon and the risk factors of the patient (such as obesity and state of health at the time of the operation). The third session debated about the peritoneal lavage and drainage, which is still a safe surgical procedure. However, it requires longer follow-up and results of other trials to draw an adequate conclusion. The last session covers the current surgical certainties in managing complicated DD: 1. urgent colectomy has higher mortality in immune-compromised patients, while in elective surgery is comparable with other populations; 2. laparoscopic peritoneal lavage (LPL) should be the choice in young/fit patients; 3. elective resection is safer in an inflammation free interval; 4. laparoscopic resection shows advantages in several outcomes (such as post-operative morbidity and lower stoma and re-operation rate); 5. in Hinchey III/fecal peritonitis, primary sigmoid resection and anastomosis (open or laparoscopic) could be proposed in young/ fit patient; 6. in case of emergency surgery, Hartmann procedure (open or laparoscopic) must be considered in critically ill/unstable patient.

Worldwide, traditional treatments (including herbal medicines) and traditional practitioners are still the primary source of health for many millions of people. The World Health Organization (WHO) has called for the incorporation of traditional medicine in public health services. However, for most of the traditional practices, information about efficacy, safety and quality is poor, and the control on the proper utilisation of these practices is scarce or inexistent, so the evaluation of the results of treatment (efficacy) is quite difficult. Moreover, the established standards, certification requirements, competency testing (quality), or legal requirements for a business licence (regulation) are often absent. The global integration of traditional medicine in public health services envisioned by WHO depends on a coordinated approach by the following stakeholders: regulators, healthcare professionals/traditional practitioners, manufacturers and patients/public. In this chapter, we provide the reader with an overall picture of the challenges faced by each of the stakeholders and what are the current approaches to solve them. We deliberately will restrict the discussion to herbal medicines, specifically Phytotherapy, which is just one of the many types of traditional practices.

Aims Although anomalous origin of left (AOLCA) and right coronary artery (AORCA) from the wrong sinus may cause sudden death (SD) in athletes, early diagnosis and management of these anomalies are still challenging. We analysed clinical/instrumental profiles of athletes identified with AOLCA/AORCA focusing our attention on diagnosis, management and follow-up. Methods and results We report 23 athletes (17 males, mean age 27 ± 17 yrs.), 6 with AOLCA and 17 with AORCA. Diagnosis was made by trans-thoracic echocardiography (TTE) in 21/23(91%). Symptoms were present only in 10(41%). Only 3 had an abnormal rest-ECG and 9(39%) an abnormal stress test ECG (3 ST-depression, 4 ventricular arrhythmias, 1 supraventricular arrhythmias, 1 rate-dependent left-bundle-branch-block). Anatomy of the anomalous coronary artery showed no significant correlation with clinical presentation, except for a tendency to higher occurrence of proximal hypoplasia in symptomatic athletes (83% vs 40%, p = 0.09). All athletes were disqualified from competitive-sports and advised to avoid strenuous effort. Surgery was recommended to all athletes with AOLCA and 6 with AORCA, but only 6 underwent surgery. No major cardiac events or ischemic symptoms/signs occurred during a mean follow-up of 65 ± 70 months. Conclusions Early diagnosis of AOLCA/AORCA in athletes is feasible by TTE. Typical symptoms/signs of myocardial ischemia are present only in one third of cases thus underlying the need of a high index of clinical suspicion to achieve the diagnosis. After exercise restriction, none had major cardiac events or ischemia symptoms/signs recurrence. There was no correlation between anatomical characteristics and clinical presentation with the possible exception of coronary hypoplasia.

Background— Fractional flow reserve (FFR) specifically relates to the severity of a stenosis to the mass of tissue to be perfused. Accordingly, the larger the territory to be perfused, the greater the flow and the pressure gradient induced by maximal hyperemia. Although this notion may be considered intuitive, its unequivocal demonstration is still lacking. The aim of our study was to evaluate the influence of the amount of myocardium subtended to an intermediate stenosis on FFR, especially in relation to quantitative coronary angiography. Methods and Results— The severity of each lesion was assessed by FFR and 2-dimensional quantitative coronary angiography. The amount of jeopardized myocardium was evaluated using 3 validated scores specifically adapted to this aim: the Duke Jeopardy Score (DJS), the Myocardial Jeopardy Index (MJI), and the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Lesion Score (ALS). The presence of a concomitant collateralized chronic total occlusion was also reported. A total of 213 intermediate coronary stenoses in 184 patients were enrolled. FFR values were correlated to minimal lumen diameter ( r =0.34; P r =−0.28; P r =−0.28, P r =−0.40, P r =−0.34, P P P Conclusions— A larger amount of perfused myocardium subtended by a stenosis is associated with a higher probability that an angiographically intermediate coronary stenosis is functionally significant.

Objectives This study sought to compare increasing doses of intracoronary (IC) adenosine or IC sodium nitroprusside versus intravenous (IV) adenosine for fractional flow reserve (FFR) assessment. Background Maximal hyperemia is the critical prerequisite for FFR assessment. Despite IV adenosine currently representing the recommended approach, IC administration of adenosine or other coronary vasodilators constitutes a valuable alternative in everyday practice. However, it is surprisingly unclear which IC strategy allows the achievement of FFR values comparable to IV adenosine. Methods Fifty intermediate coronary stenoses (n = 45) undergoing FFR measurement were prospectively and consecutively enrolled. Hyperemia was sequentially induced by incremental boli of IC adenosine (ADN) (60 μg ADN60, 300 μg ADN300, 600 μg ADN600), by IC sodium nitroprusside (NTP) (0.6 μg/kg bolus) and by IV adenosine infusion (IVADN) (140 μg/kg/min). FFR values, symptoms, and development of atrioventricular block were recorded. Results Incremental doses of IC adenosine and NTP were well tolerated and associated with fewer symptoms than IVADN. Intracoronary adenosine doses (0.881 ± 0.067, 0.871 ± 0.068, and 0.868 ± 0.070 with ADN60, ADN300, and ADN600, respectively) and NTP (0.892 ± 0.072) induced a significant decrease of FFR compared with baseline levels (p Conclusions Intracoronary adenosine, at doses higher than currently suggested, allows obtaining FFR values similar to IV adenosine. Intravenous adenosine, which remains the gold standard, might thus be reserved for those lesions with equivocal FFR values after high (up to 600 μg) IC adenosine doses.

Objectives This study sought to compare the procedural performance and the acute angiographic result on side-branch ostium obtained using 2 different drug-eluting stents (DES) to treat patients with bifurcated coronary lesions. Background Drug-eluting stents are routinely used in percutaneous coronary interventions (PCI) of bifurcated coronary lesions. Different DES types have major technical differences that may influence the procedural and clinical performance in bifurcation PCI. Methods Consecutive patients with bifurcated lesions undergoing DES implantation using a systematic provisional-stenting strategy were randomized to sirolimus-eluting stent (SES) or everolimus-eluting stent (EES) before intervention. The procedural details for PCI were prospectively recorded to assess the occurrence of any trouble in the side-branch (SB) management (primary end point). Post-PCI angiographic result (primary end point: minimal lumen diameter at SB ostium) was evaluated offline by 3-dimensional reconstruction and quantitative coronary analysis. Clinical outcome was prospectively recorded up to 18 months to assess the occurrence of target bifurcation failure. Results A total of 150 patients were enrolled in the study (29% diabetics, 17% unprotected left main). The stent was successfully implanted according to randomization in all cases. Procedural performance was not significantly different between the 2 kinds of DES. Three-dimensional reconstruction and quantitative coronary analysis showed similar post-PCI results in the main vessel and better results in the SB with EES than with SES (minimal lumen diameter at SB ostium: 1.94 ± 0.72 mm vs. 1.64 ± 0.62 mm; p = 0.013). At 18 months, target bifurcation failure occurred in 7 (9.0%) of SES-treated patients versus 8 (10.7%) of EES patients (p = 0.57). Conclusions In patients with bifurcated lesions treated by provisional stenting technique, EES compared with SES is associated with similar procedural performance and better 3-dimensional reconstruction and quantitative coronary analysis result in the SB. Both DES are associated with low rates of major adverse events and angiographic failure. (Sirolimus Versus Everolimus-Eluting Stent Randomized Assessment in Bifurcated Lesions and Clinical Significance of Residual Side-Branch Stenosis [SEA-SIDE]; NCT00697372 )

Background Most of the studies assessing transradial approach for coronary angiography (CA) have been performed through right radial approach (RRA). Our aim was to evaluate the safety and efficacy of left radial approach (LRA) compared with RRA for coronary procedures. Methods From January 2009 to December 2009, in 2 hospitals, 1,540 patients were randomized to RRA (770 patients) or LRA (770 patients) for percutaneous coronary procedures. The primary end point was fluoroscopy time for CA and for percutaneous coronary intervention (PCI) evaluated independently. Prespecified subgroup analyses according to patient age and operator experience were planned. Results In 1,467 patients (732 RRA and 735 LRA), a CA (diagnostic group) was performed, and in 688 (344 each for RRA and LRA), a PCI. In the diagnostic group, LRA was associated with significantly lower fluoroscopy time (149 seconds, interquartile range [IQR] 95-270 seconds) and dose area product fluoroscopy (10.7 Gy cm 2 , IQR 6-20.5 Gy cm 2 ) compared with the RRA (168 seconds, IQR 110-277 seconds, P = .0025 and 12.1 Gy cm 2 , IQR 7-23.8 Gy cm 2 , P = .004, respectively). In the PCI group, there were no significant differences in fluoroscopy time (614 seconds, IQR 367-1,087 seconds for LRA and 695 seconds, IQR 415-1,235 seconds, P = .087 for RRA) and dose area product fluoroscopy (53.7 Gy cm 2 , IQR 29-101 Gy cm 2 for LRA and 63.1 Gy cm 2 , IQR 31-119 Gy cm 2 , P = .17 for RRA). According to subgroup analyses, the differences between LRA and RRA were confined to older patients (≥70 years old) and to operators in training. Conclusions Left radial approach for coronary diagnostic procedures is associated with lower fluoroscopy time and radiation dose adsorbed by patients compared with the RRA, particularly in older patients and for operators in training.

Introduccion y objetivos La clasificacion de Medina de las lesiones bifurcadas ha alcanzado gran difusion debido a su simplicidad. No hay datos sobre el uso de la clasificacion de Medina para orientar la tecnica de implantacion de stents que utilizar en las bifurcaciones. Metodos Se clasifico prospectivamente a pacientes consecutivos con lesiones bifurcadas (rama lateral ≥ 2,25 mm) utilizando la clasificacion de Medina. La estrategia estudiada consistio en implantar dos stents en las lesiones Medina 1,1,1 (grupo M3) e implantar un stent tan solo en el vaso principal en las lesiones con otras clasificaciones de Medina (grupo OM). Las variables de valoracion clinicas fueron los eventos cardiacos adversos mayores (MACE) y la revascularizacion de la lesion Diana (RLD) durante la hospitalizacion y en un seguimiento de 12 meses. Resultados Se incluyo en el estudio a un total de 120 pacientes. De ellos, 25 formaron el grupo M3 y 95 el grupo OM. Los dos grupos no diferian en lo relativo a las caracteristicas basales. La estrategia programada se aplico satisfactoriamente en el 97% de los casos del grupo OM, frente al 68% de los del grupo M3 (p Conclusiones Una estrategia intencionada de implantacion de un unico stent en pacientes con lesiones bifurcadas, sin lesiones de tipo Medina 1,1,1, se asocial a una tasa muy baja de necesidad de implantacion de un segundo stent. Ademas, la eleccion de un stent metalico sin recubrimiento predice la RLD y ello indica que deben emplearse de manera habitual stents liberadores de farmacos para tratar las lesiones bifurcadas, sea cual fuere su complejidad angiografica.

The Medina bifurcated lesion classification has been widely adopted because of its simplicity. However, no data are available on its use in helping select the best stenting technique for bifurcations.Consecutive patients with bifurcated lesions (side branchor=2.25 mm) were prospectively assessed using the Medina classification. The treatment strategy studied involved implanting two stents in lesions with a Medina classification of 1,1,1 (M3 group) and one stent in only the main vessel in lesions with other Medina classifications (OM group). Clinical endpoints were a major adverse cardiac event (MACE) and target lesion revascularization (TLR) during hospitalization and at 12-month follow-up.The study included 120 patients: 25 in the M3 group and 95 in the OM group. There was no difference in baseline characteristics between the groups. The treatment strategy was successfully implemented in 97% of the OM group and 68% of the M3 group (P.001). No death or TLR was recorded during hospitalization, though three myocardial infarctions occurred postoperatively (2.1% in the OM group vs 4.0% in the M3 group; P=.6). At 12 months, there was no difference in clinical outcome between the two groups (MACE: 12.6% in the OM group vs 8% in the M3 group; P=.4; TLR: 13.7% in the OM group vs 8% in the M3 group; P=.5). Multivariate analysis showed that bare metal stent implantation (only in patients receiving a single stent) was the only independent predictor of TLR.The planned treatment strategy of implanting a single stent in patients with bifurcated lesions not classified as Medina 1,1,1 lesions was associated with a very low rate of second stent implantation. Moreover, bare metal stent use was a predictor of TLR, suggesting that drug-eluting stents should be used routinely to treat bifurcated lesions regardless of their angiographic complexity.

Objectives: To investigate the outcome of patients undergoing percutaneous coronary interventions (PCI) with implantation of a new thin-strut cobalt-chromium bare-metal-stent (BMS) in the drug-eluting-stent (DES) era. Background: Despite the contemporary penetration of DES in the clinical practice, a relevant percentage of patients are still treated by BMS. Data on clinical outcome of novel BMSs are lacking. Methods: This is a single-centre-registry enrolling patients treated by Skylor™ stent implantation. During the study, the criteria for BMS selection adopted at our institution (“internal” criteria) were as follows: (1) limited compliance to prolonged double antiplatelet therapy, (2) ST-elevation myocardial infarction (STEMI) or saphenous vein grafts (SVG) interventions, and (3) in the absence of these conditions, noncomplex (no bifurcations, no chronic total occlusions) lesions considered at low restenosis risk on the basis of arbitrary angiographic criteria (short lesions, large vessels). Primary and secondary end-points were respectively major adverse cardiovascular events (MACE) and target vessel failure (TVF) up to 9-month. Results: A total of 150 patients were treated with Skylor™ stent on 169 lesions. At 9-month follow-up, MACE occurred in 12 patients (8.0%) and TVF in 21 lesions (12.4%). By multivariable analysis, the predictors of MACE were Euroscore≥9 and ejection fraction < 30% while the predictors of TVF were the absence of the angiographic criteria of low restenosis risk and ejection fraction < 30%. Conclusions: In the DES era, the use of a last-generation BMS in patients with limited compliance to double antiplatelet therapy, STEMI or SVG interventions, and noncomplex angiographic lesions may be associated with acceptable clinical outcome. © 2009 Wiley-Liss, Inc.

The role of oxidised low-density lipoprotein (ox-LDL) in plaque destabilisation is controversial; therefore we aimed at comparing plaque and plasma ox-LDL content in stable and unstable ischaemic syndromes. We also assessed the correlation between plaque or plasma ox-LDL and angiographic complex stenosis morphology.Ten consecutive patients with chronic stable angina (SA) and 10 consecutive patients with unstable angina (UA) were studied. Plaque sections obtained by directional coronary atherectomy were immunostained with the monoclonal antibody mAb-4E6, which recognises several oxidation epitopes on LDL (mAb-4E6 ox-LDL), and with the monoclonal antibody mAb-1H11 (mAb-1H11 ox-LDL), which recognises malondialdehyde-modified LDL. An mAb-4E6-based competition ELISA was used for quantification of ox-LDL in plasma. C-reactive protein serum levels were measured by a high-sensitivity nephelometric assay. An angiographic analysis was performed to assess severity and extent of coronary atherosclerotic disease and stenosis morphology.Percent plaque area occupied by mAb-4E6 ox-LDL or mAb-1H11 ox-LDL was similar in patients with SA or UA (22.4 +/- 13.1 vs. 21.1 +/- 19.7%, P = 0.8 and 19.3 +/- 10.4 vs. 16.8 +/- 16.9%, P = 0.6, respectively), whereas ox-LDL plasma levels were significantly higher in patients with UA than in patients with SA (2.4 +/- 1.1 vs. 0.9 +/- 0.6 mg/dl; P = 0.03). Furthermore, a significant correlation was found between plasma levels of ox-LDL and the number of angiographically complex lesions (P = 0.03) or C-reactive protein serum levels (P = 0.04).Neither plaque mAb-4E6 ox-LDL nor plaque mAb-1H11 ox-LDL seem to be a major trigger of coronary plaque instability. However, circulating ox-LDL might be involved in plaque vulnerability and coronary artery disease activity.

We noticed that some symbols were lacking in Table 5 and some of the Plant Family names were not currently accepted. We hereby present the Tables ​Tables11–9 with all symbols and botanical names re-checked. Table 1 Medicinal plant species listed in RENISUS with reported effects of on CYP1A2. Table 9 Medicinal plant species listed in RENISUS with reported effects of on P-glycoprotein activity. Table 2 Medicinal plant species listed in RENISUS with reported effects of on CYP2C9. Table 3 Medicinal plant species listed in RENISUS with reported effects of on CYP2C19. Table 4 Medicinal plant species listed in RENISUS with reported effects of on CYP2D6. Table 5 Medicinal plant species listed in RENISUS with reported effects of on CYP2E1. Table 6 Medicinal plant species listed in RENISUS with reported effects of on CYP3A. Table 7 Medicinal plant species listed in RENISUS with reported effects of on glutathione levels. Table 8 Medicinal plant species listed in RENISUS with reported effects of on UGT levels. Apologies for any inconvenience this may have caused.

Intracoronary infusion of serotonin has been reported to induce varying degrees of coronary vasoconstriction in different coronary syndromes, but it has never been studied in patients after myocardial infarction. In patients with recent myocardial infarction, we found a low incidence (11%) of serotonin-induced occlusive spasm only in the infarct-related artery (IRA), and a significantly higher vasoconstriction in the distal segment of the IRA than in the same segment of the non-IRA.

Objectives The aim of this study was to evaluate the use of a new manual thrombus-aspirating device in unselected patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing urgent percutaneous coronary intervention (PCI). Background Failure to achieve myocardial reperfusion often occurs during PCI in patients with STEMI. The use of thrombus-aspirating devices might improve myocardial reperfusion by reducing distal embolization. Methods We prospectively randomized before coronary angiography 100 consecutive patients with STEMI to either standard PCI or PCI with manual thrombus-aspiration. Primary end points of the study were post-procedural rates of myocardial blush grade (MBG) ≥2 and ST-segment resolution (STR) ≥70%. Analyses were planned by intention to treat. Results Ninety-nine patients entered the analyses. The rates of post-procedural MBG ≥2 and STR ≥70% were, respectively, 68.0% and 44.9% in the thrombus-aspiration group compared with 58.0% and 36.7% in the standard PCI group: odds ratio (OR) 2.6 (95% confidence interval [CI] 1.2 to 5.9), p = 0.020, and 2.4 (95% CI 1.1 to 5.3), p = 0.034, respectively. Moreover, the rate of patients achieving both the angiographic and electrocardiographic (ECG) criteria of optimal reperfusion was significantly higher in the thrombus-aspiration group compared with standard PCI: 46.0% versus 24.5%, OR 2.6 (95% CI 1.1 to 6.2), p = 0.025. In multivariate analysis, randomization to thrombus-aspiration was a significant independent predictor of achievement of MBG ≥2 and STR ≥70% (p = 0.013). Conclusions This prospective randomized study shows that manual thrombus-aspiration in unselected patients with STEMI undergoing primary or rescue PCI is clinically feasible and results in better angiographic and ECG myocardial reperfusion rates compared with those achieved by standard PCI.

A 31-year-old woman presenting with acute abdomen underwent an emergency Hartmann's procedure for fecal peritonitis due to perforated adenocarcinoma of the left colon. Shortly after a 7-month course of adjuvant chemotherapy, follow-up contrast-enhanced CT showed multiple peritoneal and hepatic nodules, showing focal intense and homogeneous FDG uptake on FDG-PET/CT, highly suspected for recurrence of disease. Excisional biopsy of the nodules revealed foreign body granulomas made up of alimentary materials surrounded by a fibrous wall. We report a unique case of a false-positive finding secondary to food residues mimicking metastatic disease on FDG-PET in a patient with colon cancer.

Background: No data are available on the early vasoreactive profile of skeletonized internal thoracic artery grafts. Methods: Fifteen patients undergoing primary isolated coronary artery bypass grafting were randomly assigned to receive a skeletonized or pedicled internal thoracic artery graft. On the second postoperative day all patients were subjected to follow-up angiography and endovascular infusion of serotonin, acetylcholine, and isosorbide dinitrate. Results: Internal thoracic artery grafts were widely patent in all cases. Mean diameters of the internal thoracic artery were 1.95 ± 0.17 mm in the pedicled group and 2.26 ± 0.40 mm in the skeletonized group. After serotonin challenge, mean internal thoracic artery diameters were reduced to 1.44 ± 0.34 mm and 1.64 ± 0.14 mm, respectively; acetylcholine challenge lead to a moderate degree of vasoconstriction (1.55 ± 0.59 mm in the pedicled group and 1.84 ± 0.15 mm in the skeletonized group). No statistically significant difference was evident between the two groups at any step. Conclusion: Skeletonization does not affect the early vasoreactive profile of internal thoracic artery grafts used for surgical myocardial revascularization. J Thorac Cardiovasc Surg 2003;125:638-41

Post-procedural renal microvascular perfusion measured using the Quantitative Blush Evaluator (QuBE) predicts improvement in renal function in patients undergoing percutaneous renal artery stenting Carlo Trani , Italo Porto ⁎, Francesco Burzotta , Giovanni Luigi De Maria , Antonio Maria Leone , Gianpaolo Niccoli , Mario Attilio Mazzari , Rocco Mongiardo , Leonardo Bolognese , Giovanni Schiavoni , Filippo Crea a

Background: The purpose of this study was to elucidate the midterm endothelium-dependent vasodilatory capacity of radial artery grafts anastomosed to the aorta, as well as their morphometric evolution with the time. Methods: Five years after surgery we evaluated the response of aorta-anastomosed radial artery grafts to the endovascular infusion of acetylcholine in 11 of the first 61 patients operated on at our institution, and we compared it to the response with that of internal thoracic artery grafts. Moreover, the first 20 patients who had a perfect radial artery graft on angiography at 1 year were restudied at 5 years and subjected to a comparative analysis of the diameters of the radial artery graft and the grafted coronary arteries. Results: At midterm angiography, dilation of the 2 types of grafts was similar in response to acetylcholine administration (radial artery, from 2.61 ± 0.39 to 2.90 ± 0.34 mm; internal thoracic artery, from 2.68 ± 0.21 to 2.93 ± 0.27 mm; P =.01 for both). The diameters of aorta-anastomosed radial artery grafts and grafted coronary arteries increased between both 1 and 5 years according to angiographic studies (radial artery grafts, from 2.08 ± 0.45 to 2.54 ± 0.53 mm; grafted coronary arteries, from 1.92 ± 0.47 to 2.18 ± 0.41 mm; P

Previous studies indicate that percutaneous transluminal coronary angioplasty (PTCA) is associated with platelet activation. It is not well-established whether enhanced platelet aggregability after PTCA is prevented by the association of ticlopidine with aspirin. The aim of this study was to evaluate whole blood platelet aggregability before and after elective PTCA in patients with chronic stable angina receiving ticlopidine and aspirin. We studied 16 patients referred for elective PTCA, treated for≥72 hours with oral aspirin and ticlopidine (group 1), and 10 patients referred for diagnostic coronary angiography, treated with oral aspirin alone (group 2). An intravenous bolus of heparin was administered at the start of PTCA. In both groups, platelet aggregability was assessed at baseline and 24 hours after the procedure, using the PFA 100® system. This method measures the time required for flowing whole blood to occlude a collagen and adenosine diphosphate (ADP)–coated ring, shorter times indicating greater aggregability. In both groups, platelet aggregability after the procedure was significantly increased compared with baseline: 104±30 seconds before versus 88±24 seconds at 24 hours in group 1 (p=0.03) and 84±16 seconds before versus 69±14 seconds at 24 hours in group 2 (p=0.004). Group 1 patients, compared with group 2, showed a trend toward reduced aggregability at baseline (p=0.06) and significantly lower aggregability 24 hours after the procedure (p=0.03). Ticlopidine and aspirin reduce whole-blood platelet aggregability compared with aspirin alone but fail to suppress the increased aggregability that occurs 24 hours after PTCA.

Heterotopic pancreas (HP) is defined as the presence of pancreatic tissue in an aberrant location, without any vascular or anatomical continuity with the normal pancreas. HP is a rare condition occurring in 0.11%‡0.21% at autopsy, with a male to female ratio of 3:1 and a peak age incidence between the 4th and 6th decades of life. Up to 90% of HPs are found in the upper gastrointestinal tract, involving the stomach, duodenum or jejunum. We report a case of HP presenting as a jejunal nodule found in a young girl during the staging of breast cancer.

Background Access-site vascular complications (ASVC) in patients undergoing trans-radial coronary procedures are rare but may have relevant clinical consequences. Data regarding the optimal management of radial-access-related ASVC are lacking. Methods During a period of 6years we prospectively collected ASVC. ASVC were defined as any complication requiring ultrasound examination or upper limb angiography. ASVC were categorized according to the timing of diagnosis: "very early" (in the cath lab), "early" (after cath lab discharge, but during the hospital stay) and "late" (after hospital discharge). The need of surgery (primary end-point) and the development of neurological hand deficit (secondary end-point) were assessed. Results Fifty-seven radial-artery related ASVC were collected. ASVC diagnosis was obtained by upper limb angiography in 25 patients (44%) and by Doppler in 32 patients (56%). Surgery was required in 6 cases (11%), the remaining patients receiving successful conservative management (which included prolonged local compression). Three patients (who received surgery) exhibited a mild neurological hand deficit in the follow-up. Need for surgery differed significantly according to timing of diagnosis as it occurred in 1 of 26 patients (3.8%) with "very early" diagnosis, in 1 of 21 patients (4.8%) with "early" diagnosis, and in 4 of 10 patients (40%) with "late" diagnosis ( p =0.026). Conclusions ASVC are diagnosed with different timing after trans-radial procedures. Conservative management including local compression allows successful management in the majority of ASVC. Prompt recognition is pivotal as late diagnosis is associated to the need for surgery.

Mast cells play a key role in inflammatory reactions triggered by tissue injury or immune perturbations. Little is known about endogenous molecules and mechanisms capable of modulating inappropriate mast cell activity. N-(2-Hydroxyethyl)hexadecanamide (palmitoylethanolamide), found in peripheral tissues, has been proposed to act as a local autacoid capable of negatively regulating mast cell activation and inflammation-hence the acronym Autacoid Local Inflammation Antagonism (ALIA). Recently, N-(2-hydroxyethyl)hexadecanamide (LG 2110/1) has been reported to down-modulate mast cell activation in vitro by behaving as an agonist at the peripheral cannabinoid CB2 receptor. Here, we have characterized and functionally correlated the anti-inflammatory actions of LG 2110/1 with its ability to control mast cell activation, when given orally in a battery of rodent models of inflammation. LG 2110/1 diminished, in a dose-dependent and correllated manner, the number of degranulated mast cells and plasma extravasation induced by substance P injection in the mouse ear pinna. In addition, LG 2110/1 reduced dose dependently plasma extravasation induced by passive cutaneous anaphylaxis reaction. In adult rats LG 2110/1 decreased, in a dose-dependent manner, carrageenan-induced hindpaw edema and hyperalgesia, but not phospholipase A2-induced hindpaw edema. Further, anti-edema effects were observed when utilizing dextran and formalin, known to also cause mast cell activation. Locally administered LG 2110/1 was likewise effective in minimizing dextran-induced hind paw edema. In contrast, equivalent amounts of palmitic acid plus ethanolamine were ineffective against plasma extravasation provoked by substance P. LG 2110/1 did not decrease plasma extravasation induced by the substance P fragment, substance P-(6-11), known to be inactive on mast cells. These results indicate that orally administered N-(2-hydroxyethyl)hexadecanamide is effective in: (a) directly down-modulating mast cell activation in vivo; (b) suppressing pathological consequences initiated by mast cell activation independently of the activating stimuli; (c) exerting an anti-inflammatory action distinguishable from that of classical steroidal and non-steroidal anti-inflammatory agents. These findings raise the possibility that N-(2-hydroxyethyl)hexadecanamide and related saturated N-acylamides ('ALIAmides') represent novel therapeutic agents useful in the management of inflammatory disease conditions.

AIMS Contrast-induced nephropathy (CIN) is a frequent and potentially harmful complication of percutaneous coronary interventions (PCI), especially in the setting of ST-elevation myocardial infarction (STEMI). We tested the efficacy of a sodium bicarbonate (SB)-based hydration in urgent PCI for STEMI. METHODS AND RESULTS From June 2009 to September 2010, 262 consecutive STEMI patients undergoing urgent PCI were prospectively enrolled and treated by SB-based hydration (154 mEq/L at 3 ml Kg-1 for one hour followed by 1 ml Kg-1 for six hours) (group A). As controls, 262 consecutive STEMI patients receiving 0.9% saline hydration (1 ml Kg-1 for 24 hours) before June 2009 were retrospectively enrolled (group B). Both groups received high-dose N-acetylcysteine (NAC). The primary endpoint was the composite of in-hospital death, need for dialysis and CIN (≥25% increase in serum creatinine at 48 hours). The two groups were comparable for baseline clinical and procedural characteristics, for Mehran risk score and baseline estimated glomerular filtration rate. The primary combined endpoint was significantly reduced in group A as compared to group B (9.2 vs. 18.7%, p=0.023) with a number needed to treat (NNT) of 11. Specifically, a significant reduction of both in-hospital death (2.3 vs. 6.1%, p=0.049, NNT 27) and CIN (8.0 vs. 14.1%, p=0.03, NNT 17) was observed, with no difference in the need for dialysis. CONCLUSIONS Our data indicate that hydration with sodium bicarbonate in addition to high-dose NAC in the setting of urgent PCI for STEMI is associated with a net clinical benefit.

Gastric adenocarcinoma is considered a disease of the elderly, with a peak incidence in the seventh and eighth decades of life. In the elderly, biochemical changes in tissues and in organ physiology, in association with Helicobacter pylori infection, lead to atrophic gastritis, with an increased risk of developing cancer. Gastric cancer in the elderly is often diagnosed at an advanced stage and is associated with a poor prognosis in terms of disease-free and overall survival. Surgical treatment of gastric cancer in these patients remains controversial due to the increased perioperative risk; instead, subtotal gastrectomy is preferred when feasible. Total gastrectomy with or without combined resections of adjacent organs is associated with higher rates of postoperative morbidity and mortality. For advanced cancer, palliative resection is preferable, whenever possible, to gastroenterostomy. Morbidity and mortality are higher in the elderly, probably related to the comorbidities in these patients. T stage, lymph node metastases, and depth of invasion of the primary tumor are recognized as independent prognostic factors in terms of overall survival. The impact of multimodality treatment in the elderly cannot be clearly evaluated; currently, adjuvant chemotherapy is recommended in otherwise healthy patients. In general, age alone has not been definitively confirmed as a negative prognostic factor in patients with gastric cancer and should not preclude gastric resection. After radical resection, elderly patients have the same chance of survival as middle-age patients.

Objectives To investigate a possible independent predictive role of systemic inflammation markers on renal function after renal artery stenting. Background An elevated baseline serum creatinine has previously been shown to be the strongest predictor of improved renal function after percutaneous renal artery stenting. The inflammatory system is implicated in every stage of chronic kidney disease, and we hypothesized an additional value of markers of systemic inflammation in predicting response after renal artery stenting. Methods This single center, prospective study includes 62 consecutive patients with chronic kidney disease at stage ≥3 or resistant hypertension who underwent stent placement for 74 angiographically significant atherosclerotic renal lesions. Inflammatory markers, including serum C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were determined prior to renal angioplasty and related to changes in renal function at follow-up. Results Six-month clinical follow up was completed in 57 patients. Overall, median serum creatinine concentration exhibited a non significant reduction from 1.40mg/dl (quartiles: 1.20, 1.75mg/dl) at baseline to 1.30mg/dl (quartiles: 1.1, 1.55mg/dl) at 6months (p=0.17). Significant multivariate independent predictors of decreased creatinine included higher baseline serum creatinine levels (adjusted OR per quartile increment, 2.5 [1.3 to 4.7], p=0.004) and lower C-reactive protein levels (adjusted OR per quartile increment 0.39 [0.19 to 0.82], p=0.013). Conclusions Patients with higher serum creatinine and lower CRP derive the most benefit from renal artery stenting.

Background Randomized trials have shown that transradial approach, compared with transfemoral, reduces vascular complications (VCs) of coronary procedures in selected patients. Yet, radial approach is associated to a variety of access-site VC as well as to a higher failure rate compared with femoral access. Methods At our institution, from May 2005 to May 2010, we prospectively assessed the occurrence and outcome of VC in consecutive patients undergoing transradial percutaneous coronary procedures performed by trained radial operators. The need of access crossover to complete the procedure was also prospectively investigated. Vascular complications were classified as "radial related" or "nonradial related" (in the case of access crossover). Vascular complications were also classified "major" if requiring surgery and/or blood transfusions or causing hemoglobin drop >3 g/dL. Results Ten thousand six hundred seventy-six procedures were performed using a right radial (87.5%), left radial (12.4%), or ulnar (0.1%) artery as primary access. A total of 53 VCs (0.5%) were observed: 44 (83%) radial related and 9 (17%) nonradial related. Major VCs occurred in 16 patients only (0.2%) and were radial related in 10 (62.5%) and nonradial related in 6 (37.5%) patients. Vascular complications rate was stable during the study and independent of operator's experience. Access crossover rate was 4.9%, differed according to the operator radial experience and significantly decreased over time. Conclusions The present study, conducted in a center with high volume of radial procedures, shows that transradial approach is associated with a very low rate of VC, which is stable over time. On the contrary, access crossover rate decreased over time and differed according to operator (radial) experience.

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Atraumatic splenic rupture (ASR) is a rare clinical entity. Several underlying benign and malignant conditions have been described as a leading cause. We report on a case of ASR in a 41-year-old man treated with laparoscopic splenectomy. Considering ASR as a life-threatening condition, a prompt diagnosis can be life saving.

The small bowel can be involved by several pathologic conditions whose diagnosis is often difficult. Current diagnostic tools include enteric NMR, double-balloon ileoscopy, and PillCam, all of which are helpful for decision-making in many cases.The prompt diagnosisof congenital malformations, inflammatory diseases, ischemia, diverticulosis, and neoplasms allows successful treatment. In considering the different modalities of resection and reconstruction, surgeons must also take into account the small bowel’s nutritional functions. The increasing use of a laparoscopic approach remains controversial despite reported successes. This chapter is a short but nonetheless thorough description of the surgical management of small-bowel diseases.

Drug-eluting stents (DES) have revolutionized the treatment of coronary bifurcation lesions. Among different DES types, sirolimus-eluting stents (SES) showed better outcomes than paclitaxel-eluting stents. Because novel sirolimus analogues have been implemented in DES, a prospective observational comparison was undertaken to compare major mammalian target of rapamycin inhibitor-eluting stents in the treatment of bifurcation lesions according to the provisional T-stenting and small protrusion (TAP) technique. Overall, 187 patients (165 men, 65 ± 10 years) were enrolled in the study: 80 patients received a SES, whereas zotarolimus-eluting stents (ZES) were implanted in 53 patients and everolimus-eluting stents (EvES) in 62 patients. Primary end-point of the study was the 12-month incidence of target bifurcation failure (TBF) defined as occurrence of cardiovascular death, nonfatal myocardial infarction (MI), and target vessel revascularization (TVR) or angiographic documentation of >50% restenosis on the main vessel or TIMI flow