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Therapeutic hypothermia has been shown to reduce brain damage due to postcardiac arrest syndrome. Actually, there is no agreement on which is the best device to perform therapeutic hypothermia. The 'ideal' device should not only 'cool' patient until 33-34°C as fast as possible, but also maintain the target temperature and reverse the therapeutic hypothermia. For out-of-hospital cardiac arrest, there are devices that allow starting of therapeutic hypothermia on the field (prehospital hypothermia). On hospital arrival, these prehospital devices can be quickly and easily replaced with other devices more suitable for the management of therapeutic hypothermia in ICUs (in-hospital hypothermia). Some studies have compared surface and endovascular devices and found no substantial differences in neurologic outcome or survival at hospital discharge. On a clinical ground, the knowledge of the technical aspects of therapeutic hypothermia (such as characteristics of devices) is mandatory for clinicians who have to perform therapeutic hypothermia in cardiac arrest patients because the timing of therapeutic hypothermia, the choice of the device for the single patients, and avoidance of temperature fluctuation have shown to affect outcome in these patients (also in terms of reducing the incidence of complications).

Background Pulmonary vascular dysfunction has been described in patients with acute respiratory distress syndrome (ARDS). Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a well-established treatment for these patients. We hypothesized that severe pulmonary vascular dysfunction and cor pulmonale identified by echocardiography before cannulation in these patients were associated with worse survival. Methods Echocardiography was used to identify pulmonary hypertension in 21 patients with refractory ARDS just before ECMO implantation. Survival was compared for those with and without cor pulmonale. Results In our series, the overall mortality rate was 57.1% (12/21). Echocardiographic exams were transthoracic in 5 patients (23.8%), transesophageal in 4 patients (19%), and both (transthoracic and transesophageal) in the remaining 12 patients (57.1%). In our series, six patients (28.5%) showed LV dysfunction. Acute cor pulmonale was detectable in 2 patients (9.5%), while the remaining 19 patients showed moderate pulmonary dysfunction. Survivors had a higher pre-cannulation LV ejection fraction (EF) (P = 0.02) and tricuspid annular plane excursion (P = 0.04), and lower peak systolic pulmonary artery pressures (P = 0.02). Conclusions In patients with refractory ARDS immediately before ECMO implantation, the prevalence of acute cor pulmonale is low (9.5%). Survival is associated with higher LVEF and lower systolic pulmonary arterial pressure. These findings support the idea that echocardiographic assessment of pulmonary artery pressure in patients with refractory ARDS before VV-ECMO implantation may have value for risk-stratification.

In clinical practice, acidotic patients with acute cardiogenic pulmonary edema (ACPE) are commonly considered more severe in comparison with nonacidotic patients, and data on the outcome of these patients treated with noninvasive pressure support ventilation (NIV) are lacking.The present investigation was aimed at assessing whether acidosis on admission (pH

Introduction Limited data are available on the natural history of high on treatment platelet reactivity (HPR) by arachidonic acid and ADP - markers of unfavorable prognosis in acute coronary syndrome patients -. Material and methods In a cohort of acute coronary syndrome male patients (n = 101), we evaluated the time-course of HPR by ADP (platelet aggregation by 10 μM ADP ≥ 70%) and arachidonic acid (platelet aggregation by 1 mmol arachidonic acid ≥ 20%) measuring platelet function in the acute phase (T0), at 6 months (T1) and 1 year (T2). Results We identified persistent (HPR at T0,T1 and T2), acute non persistent (HPR only at T0), and late (HPR only at T1 or T2). Patients with persistent HPR by ADP were more frequently with higher values of BMI. Patients carrying CYP2C19*2 variant were more prevalent in the group of persistent HPR (33%). Significant higher values of immature platelet fraction and high immature platelet fraction at 6 and 12 months and mean platelet volume were present in patients with late HPR. Immature platelet fraction was the only variable significantly associated with late HPR by ADP at multivariate analysis (OR = 1.6 (1.08-2.3), p = 0.016). Patients with persistent HPR by arachidonic acid were more frequently diabetics. Immature platelet fraction at 6 months and high immature platelet fraction at 6 and 12 months were the parameters associated with late HPR by AA (OR = 1.4 (1.0-1.9), p = 0.036; OR = 1.5 (1.08-2.4), p = 0.05; OR = 4.9 (1.3-18.8), p = 0.018, respectively). Conclusions About 25% of 101 patients has persistent HPR; they are more frequently diabetics, overweight or carriers of CYP2C19*2. The occurrence of an inflammatory state, indicated by the increase of immature platelet fraction, is associated with the occurrence of late HPR.

Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team’s judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome.

The aim of this study was to assess the incidence and prognostic role of echocardiographic abnormalities in consecutive patients with refractory acute respiratory distress syndrome (ARDS) before veno-venous extracorporeal membrane oxygenation (VV-ECMO).In this study 74 consecutive patients with refractory ARDS underwent echocardiography (transthoracic, transesophageal or both, according to the best acoustic window). Baseline characteristics were collected for all patients and the simplified acute physiology score was calculated. At echocardiography the following parameters were considered: left ventricle (LV) ejection fraction, right ventricle (RV) size and function (by means of tricuspid annular plane excursion [TAPSE]) and systolic pulmonary arterial pressure.At echocardiography, 25 patients showed normal findings (33.8%), 32 patients exhibited isolated pulmonary hypertension (43.2%) and the remaining 17 patients showed RV dilation and pulmonary hypertension (23%). A reduced LVEF (50%) was observed in 14 patients (18.9%), while RV dysfunction (as indicated by TAPSE16 mm) was documented in 21 patients (28.4%). The in-Intensive Care Unit [ICU] mortality rate was 41.8%. At stepwise regression analysis the following variables were independent predictor for in-ICU mortality (when adjusted for TAPSE16 mm): RV end diastolic area/LV end diastolic area (OR 0.21, 95%CI 0.062-0.709, P=0.012), Body Mass Index (BMI) (OR 0.87, 95%CI 0.802-0.958, P=0.004) CONCLUSIONS: In consecutive patients with refractory ARDS, echocardiographic alterations were common, mainly represented by systolic pulmonary hypertension associated or not with RV dilatation. Moreover, RV dilatation and BMI were independent predictors of in-ICU mortality. On clinical grounds, our findings strongly suggest that echocardiography helps to risk stratifying patients with refractory ARDS requiring VV-ECMO.

Eur J Clin Invest 2012; 42 (9): 927–932 Abstract Background To assess the effect of a personalized physical activity programme on weight and circulating (CPC) and endothelial progenitor cells (EPC) in overweight and obese subjects. Materials and methods Anthropometric measurements with body composition, cardiopulmonary test, maximal stress exercise test with maximal oxygen uptake (VO2max) and a series of biochemical analyses were taken before (T0) and after 3 months of physical activity (T1) in a total of 80 overweight and obese subjects. CPC and EPC were determined using flow cytometry and were defined as CD34+, CD133+ and CD34+/CD133+ for CPC and CD34+KDR+, CD133+KDR+ and CD34+CD133+KDR+ for EPC. Results At the end of the programme, we divided the population into two groups, compliant individuals (group A, n = 47) and noncompliant individuals (group B, n = 33). Group A reported significant reductions of weight by 3·1% (P

A pivotal role in treating decompensated heart failure (HF) is played by inotropes and calcium sensitizers such as levosimendan. In this study, the authors evaluated whether levosimendan could determine further clinical and hemodynamic benefits in 31 HF patients (New York Heart Association [NYHA] class III or IV), after successful treatment with diuretics (n=15) or ultrafiltration (n=16). Systolic, diastolic, dicrotic, and mean arterial pressures; systemic vascular resistance (SVR); some classic hemodynamic variables (cardiac output [CO], stroke volume [SV], dP ⁄dtmax); and indices of cardiovascular system performance (cardiac cycle efficiency [CCE], cardiac power output) have been assessed by the pressure recording analytical method (PRAM), a minimally invasive monitoring system, before levosimendan infusion, at the end of treatment (EoT), and 36 hours after EoT (post-36). A significant increase in CCE, CO, SV, and dP ⁄dtmax and a significant decrease in diastolic and dicrotic arterial pressures and in SVR have been observed at EoT and at post-36. After the addition of levosimendan, a further reduction in signs and symptoms of HF and NYHA class was observed. Five patients showed an opposite trend of several hemodynamic parameters without any significant clinical improvement (nonresponders). In conclusion, most HF patients treated with diuretics or ultrafiltration receive additional clinical and hemodynamic benefits from levosimendan. The characterization of nonresponders could help in optimizing its use. Congest Heart Fail. 2012;18:47‐53. � 2011 Wiley Periodicals, Inc. Standard therapy for patients with decompensated heart failure (HF) and overhydration is aimed at achieving euvolemia and consists primarily of intravenous diuretics and vasodilators. Patients unresponsive to diuretic therapy or with renal dysfunction can be treated with ultrafiltration and those with hypotension can also be treated with inotropic agents. However, classic inotropic drugs are associated with increased myocardial oxygen consumption, major risk of arrhythmias, and reduced short- and long-term survival. Therefore, attention has been focused on calcium-sensitizing agents, 1,2 a novel class of inotropic drugs, among which levosimendan is the most studied. This group of drugs is able to enhance cardiac performance without increasing intracellular calcium and cyclic adenosine monophosphate levels and, consequently, without the deleterious effects associated with classic inotropic drugs. However, the effective role of levosimendan in the treatment of decompensated congestive HF is yet to be clarified because it is an inotropic agent indicated only when systolic arterial pressure is 90 mm Hg. Therefore, this study was performed to evaluate whether patients with decompensated HF successfully treated with standard therapy, including continuous diuretic infusion or ultrafiltration, receive further clinical and hemodynamic benefits from the addition of levosimendan. Hemodynamic parameters were assessed in the present study with the pressure recording analytical method (PRAM), a minimally invasive monitoring system. 3,4

Objectives Previous investigations on microalbuminuria in acute myocardial infarction have been performed in heterogeneous populations of hypetensive/nonhypertensive, diabetic/nondiabetic patients, submitted to either thrombolysis or mechanical revascularization or not revascularized. Therefore, the aim of our investigation was to assess, in 242 consecutive hypertensive patients with ST elevation myocardial infarction without previously known diabetes, all submitted to mechanical revascularization, whether microalbuminuria, in the early phase, has a prognostic role for in-hospital mortality or complications (acute pulmonary edema and arrhythmias). Methods The study population was divided into two groups according to microalbuminuria excretion: group A (microalbuminuria within the normal range); group B (microalbuminuria above the normal range). Results The incidence of microalbuminuria was 52.1% (126/242). No significant difference was detectable in the incidence of in-hospital mortality and complications between the two groups. Patients with microalbuminuria exhibit a larger infarct size as indicated by higher values of troponin I. Microalbuminuria was associated with higher values of glucose and a higher prevalence of insulin resistance. Conclusion In ST elevation myocardial infarction hypertensive patients without previously known diabetes, all submitted to mechanical revascularization, microalbuminuria is a common finding but it does not yield prognostic information about in-hospital mortality or complications. Interestingly it was associated with acute glucose dysmetabolism (as inferred by hyperglycemia and the prevalence of insulin resistance), thus suggesting that it can be considered part of the acute metabolic response to the acute coronary event.

Background Guidelines recommend that blood pressure (BP) should be lowered in hypertensive patients to prevent cardiovascular accidents. Management of antihypertensive treatment by general practitioners is usually based on office measurements, which may not allow an assessment of BP control over 24 h, which requires ambulatory BP monitoring (ABPM) to be implemented. This is rarely done in general practice, and limited information is available on the consistency between the evaluations of the response to treatment provided by office measurement and by ABPM in this setting.Aim To assess concordance between office BP measurements and ABPM-based estimates of hypertension control in a general practice setting.Design of study Prospective, comparative between techniques.Setting General practice.Methods Seventy-eight general practices, representative of all Italian regions, participated in this study by recruiting sequential hypertensive adults on stabilized treatment, who were subdivided into even groups with office BP, respectively, controlled or noncontrolled by treatment. In each individual, ABPM was applied by the general practitioner after appropriate training, and 24-h ABP values were defined as controlled or not according to current guidelines. Concordance between office and ABPM evaluation of BP control was assessed with kappa statistics. Positive and negative predictive values of office measurement versus ABPM were estimated.Results Between July 2005 and November 2006, 190 general practitioners recruited 2059 hypertensive patients based on office BP measurements; in 1728 patients, a 24-h ABPM was performed, yielding 1524 recordings considered as valid for further analysis. The agreement between the assessment of BP control by office measurement and by ABPM was poor (kappa=0.120), with office measurements showing a satisfactory positive predictive value (0.842) and a poor negative predictive value (0.278); the situation was worse in patients with three or more among the following features: male sex, age of at least 65 years, alcohol consumption, diabetes, and obesity (negative predictive value=0.149).Conclusion In general practice, the agreement between assessment of BP control by treatment provided by office and ambulatory BP measurements is better in patients of 'uncontrolled' office BP than in 'controlled' office BP patients. This emphasizes the need for the larger use of out-of-office BP monitoring in a general practice setting, in particular, in patients considered as 'controlled' during consultation. J Hypertens 28:910-917 (C) 2010 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

OBJECTIVE The 6-min walk test (6mWT) is widely used to assess physical performance in cardiac rehabilitation settings. Factors affecting the walked distance before starting physical training have been described, whereas information on factors affecting the increase of the walked distance after physical training is still scant. The aim of this study was to verify, in a large sample of elderly patients soon after cardiac surgery, the role of left-ventricular function (LVF) in increases in distances walked after an intensive rehabilitation program. DESIGN We enrolled 459 patients (300 males and 159 females, mean [+/-SD] age 70 +/- 11 yrs). According to the echographic ejection fraction, patients were classed into two categories, LVF > or = 40% and LVF < 40%. All patients performed the 6mWT at the beginning and end of the rehabilitation program. RESULTS Longer walked distances before and after the rehabilitation program were significantly associated with preserved or moderately depressed LVF, whereas greater relative increases of the distance walked after the rehabilitation program were significantly associated with poor LVF (P < 0.001 for all). CONCLUSIONS Among elderly patients admitted as inpatients to an intensive rehabilitation program soon after cardiac surgery, those with poor LVF are most likely to respond more favorably to physical training. Therefore, instead of considering poor LVF a risk for starting physical training in these patients, it should be considered a strong indication, to avoid further physical deconditioning and disability.

Hyperglycemia was reported to enhance angiotensin (Ang) II generation in rat cardiomyocytes, and Ang II inhibition reduces cardiovascular morbidity and mortality in diabetic patients. In diabetic patients, the enhanced activation of intracellular pathways related with myocyte hypertrophy and gene expression might enhance the progression of cardiac damage. Therefore, we investigated the effects of glucose on Ang II–mediated activation of Janus-activated kinase (JAK)-2, a tyrosine kinase related with myocyte hypertrophy and cytokine and fibrogenetic growth factor overexpression, in ventricular myocytes isolated from nonfailing human hearts (n = 5) and failing human hearts (n = 8). In nonfailing myocytes, JAK2 phosphorylation was enhanced by Ang II only in the presence of high glucose (25 mmol/l) via Ang II type I (AT1) receptors (+79% vs. normal glucose, P < 0.05). JAK2 activation was prevented by inhibitors of reactive oxygen species (ROS) generation (diphenyleneiodonium [DPI], tiron, and apocynin). In myocytes isolated from failing hearts, JAK2 phosphorylation was enhanced by high glucose alone (+107%, P < 0.05). High glucose–induced JAK2 activation was blunted by both ACE inhibition (100 nmol/l ramipril) and AT1 antagonism (1 μmol/l valsartan), thus revealing that the effects are mediated by autocrine Ang II production. Inhibition of ROS generation also prevented high glucose–induced JAK2 phosphorylation. In conclusion, in human nonfailing myocytes, high glucose allows Ang II to activate JAK2 signaling, whereas in failing myocytes, hyperglycemia alone is able to induce Ang II generation, which in turn activates JAK2 via enhanced oxidative stress.

Objective: To investigate whether an inflammatory response occurs in patients undergoing infrarenal aortic abdominal aneurysm repair, the localization and timing (ischemia and/or reperfusion) of this activation, and finally whether it affects postoperative pulmonary function. Design: Prospective, observational study. Setting: Academic referral center in Italy. Patients: We included 12 patients undergoing infrarenal aortic abdominal aneurysm repair and 12 patients undergoing major abdominal surgery. Interventions: Timed measurement of gene activation (angiotensinogen, angiotensin type 1 receptor, angiotensin-converting enzyme, and interleukin-6 genes) in muscle biopsies by reverse transcriptase-polymerase chain reaction (RT-PCR), and prospective assessment of interleukin-6 plasma concentration and pulmonary function (Pao 2 /Fio 2 and Pao 2 /PAo 2 ratios). Measurements and Main Results: After 30 mins of aortic clamping, angiotensinogen, angiotensin type 1 receptor, angiotensin-converting enzyme, and interleukin-6 genes were all over-expressed at RT-PCR studies in quadriceps muscle of patients undergoing aortic abdominal aneurysm repair, and the overex-pression persisted after reperfusion. In situ hybridization and immunohistochemistry revealed that the inflammatory response was localized in endothelial cells. A significant increase in plasma interleukin-6 concentrations was then detectable at 6 and 12 hrs after reperfusion in aortic abdominal aneurysm surgery compared with patients undergoing abdominal surgery (p

Introduction Deep vein thrombosis (DVT) is a life-threatening complication in intensive care unit (ICU) patients and DVT incidence is used as a marker of quality care. In our ICU an educational program for implementation of DVT prophylaxis and ultrasound screening resulted in a remarkable decrease in DVT incidence which fell from 11.6% to 4.7%. The aim of this paper is to investigate a 4-year long persistent quality improvement of DVT prophylaxis obtained through the implementation of our educational intervention. Methods The study was composed of three phases: after the first retrospective investigation of DVT incidence and the evidence of the efficacy of the educational program, this third phase investigates the 2-year long sustainability and persistence in the fall of DVT incidence by the adoption of 1) an electronic form for DVT prophylaxis prescription, 2) a nursing protocol for the application of elastic stokes and 3) a personalized form with a check-list dedicated to DVT prophylaxis. Ultrasound DVT screening was performed twice a week by ICU clinicians. Results The application of DVT prophylaxis was associated with a very low incidence of DVT (2.6%) not entirely attributable to changes in characteristics of enrolled patients and/or to less intensive DVT ultrasound screening when compared to the preceding phases. Mean mechanical ventilation duration and ICU length of stay were short and similar to those of the second phase and ICU mortality did not change. Conclusions The direct involvement of ICU clinicians and nurses in the application of DVT prophylaxis and in DVT diagnosis markedly contributed to maintain a low DVT incidence over time, despite the high turnover of patients.

The present investigation was aimed at assessing the dynamic behaviour of lactate values during hypothermia in 33 patients with cardiac arrest.Fifteen patients died during intensive care stay (15/33, 45.5%). When compared to survivors, they were older (survivors 50.7 ± 14.7 vs. non-survivors 70.1 ± 10.4 years, p0.001) and exhibited a significantly higher APACHE score (survivors 21.9 ± 3.9 vs. non-survivors 27.5 ± 4.6, p0.001). A higher incidence of non-shockable rhythms was observed in non-survivors (p=0.026) who showed a longer collapse-recovery of spontaneous circulation time (p=0.01). During hypothermia, lactate values showed a progressive and significant decrease despite no significant change in mean arterial pressure and central venous pressure (i.e. independently of blood pressure values and volaemia). Lactate values when measured during hypothermia were related to in-intensive cardiac care unit (in-ICCU) death.In our series, lactate values measured during hypothermia hold a prognostic role in these patients since they are related to in-ICCU death.

To assess the effect of a personalized physical activity programme on weight and circulating (CPC) and endothelial progenitor cells (EPC) in overweight and obese subjects.Anthropometric measurements with body composition, cardiopulmonary test, maximal stress exercise test with maximal oxygen uptake (VO(2max) ) and a series of biochemical analyses were taken before (T0) and after 3 months of physical activity (T1) in a total of 80 overweight and obese subjects. CPC and EPC were determined using flow cytometry and were defined as CD34+, CD133+ and CD34+/CD133+ for CPC and CD34+KDR+, CD133+KDR+ and CD34+CD133+KDR+ for EPC.At the end of the programme, we divided the population into two groups, compliant individuals (group A, n = 47) and noncompliant individuals (group B, n = 33). Group A reported significant reductions of weight by 3·1% (P0·0001) and fat mass by 4·4% (P0·0001), while group B showed a percentage of increase in fat mass by 1·5% at T1. In group A, a trend of increase at T1 for circulating levels of CPC and EPC was observed, reaching the statistical significance for all the three types of EPC. On the contrary, group B showed no significant increase in CPC and EPC. Furthermore, a significant correlation between decrease in fat mass and increase in CD133+/KDR+ EPC was reported in group A (r = 0·50; P = 0·04).Three months of physical activity significantly improved anthropometric measurements. A beneficial effect of increased number of EPC in compliant individuals, in relation to weight loss, was observed.

A pivotal role in treating decompensated heart failure (HF) is played by inotropes and calcium sensitizers such as levosimendan. In this study, the authors evaluated whether levosimendan could determine further clinical and hemodynamic benefits in 31 HF patients (New York Heart Association [NYHA] class III or IV), after successful treatment with diuretics (n=15) or ultrafiltration (n=16). Systolic, diastolic, dicrotic, and mean arterial pressures; systemic vascular resistance (SVR); some classic hemodynamic variables (cardiac output [CO], stroke volume [SV], dP/dt(max) ); and indices of cardiovascular system performance (cardiac cycle efficiency [CCE], cardiac power output) have been assessed by the pressure recording analytical method (PRAM), a minimally invasive monitoring system, before levosimendan infusion, at the end of treatment (EoT), and 36 hours after EoT (post-36). A significant increase in CCE, CO, SV, and dP/dt(max) and a significant decrease in diastolic and dicrotic arterial pressures and in SVR have been observed at EoT and at post-36. After the addition of levosimendan, a further reduction in signs and symptoms of HF and NYHA class was observed. Five patients showed an opposite trend of several hemodynamic parameters without any significant clinical improvement (nonresponders). In conclusion, most HF patients treated with diuretics or ultrafiltration receive additional clinical and hemodynamic benefits from levosimendan. The characterization of nonresponders could help in optimizing its use.

BACKGROUND Higher blood pressure (BP) values in cold than in hot months has been documented in hypertensives. These changes may potentially contribute to the observed excess winter cardiovascular mortality. However, the association with weather has always been investigated by considering the relationship with a single variable rather than considering the combination of ground weather variables characterizing a specific weather pattern (air mass (AM)). METHODS We retrospectively investigate in Florence (Italy) the relationship between BP and specific AMs in hypertensive subjects (n = 540) referred to our Hypertension Unit for 24-h ambulatory BP monitoring during the period of the year characterized by the highest weather variability (winter). Five different winter daily AMs were classified according to the combination of ground weather data (air temperature, cloud cover, relative humidity, atmospheric pressure, wind speed, and direction). RESULTS Multiple variable analysis selected the AM as a significant predictor of mean 24-h BP (P < 0.01 for diastolic BP (DBP) and P < 0.05 for systolic BP (SBP)), daytime DBP (P < 0.001) and nighttime BP (P < 0.01 for both SBP and DBP), with higher BP values observed in cyclonic (unstable, cloudy, and mild weather) than in anticyclonic (settled, cloudless, and cold weather) days. When the association with 2-day sequences of AMs was considered, an increase in ambulatory BP followed a sudden day-to-day change of weather pattern going from anticyclonic to cyclonic days. CONCLUSIONS The weather considered as a combination of different weather variables may affect BP. The forecast of a sudden change of AM could provide important information helpful for hypertensives during winter.

To evaluate the prognostic value of EEG and SEPs in post-anoxic comatose patients at 12 h, 24 h and 72 h from cardiac arrest (CA). Comatose patients after CA treated with TH were included. EEG and SEPs were recorded within 12 h, 24 h and 72 h after CA. EEG was classified into “non-continuous” (low voltage, isoelectric, burst-suppression) and “continuous” (other patterns except epileptiform). SEPs were dichotomized into “bilaterally absent” (BA) and “present”. Neurologic outcome was evaluated at 6 months by GOS: “awakening” (GOS 3–5) was considered good outcome. EEG and SEPs were recorded in 147 patients, 33 of whom within 12 h. “Continuous” EEG pattern at 12 h always predicted good outcome, “non-continuous” pattern at 72 h always predicted poor outcome. BA SEPs always predicted poor outcome. Early “continuous” EEG pattern was always associated with present SEPs. SEPs provide a specific and time-independent predictor of poor outcome (bilateral absence). EEG provide a specific and time-dependent predictor of good outcome (“continuous” pattern at

Somatosensory evoked potentials (SEPs) are reliable predictor of poor outcome in comatose patients after cardiac arrest (CA) treated with therapeutic hypothermia (TH). Recently the role of EEG in determining the prognosis have been reassessed. A continuous EEG pattern within 12 after CA, reliably predicts awakening. Our aim was to evaluate the role of EEG and SEPs recorded during first 12 h after CA in prediction of outcome. In a cohort of comatose adults resuscitated from CA treated with TH EEG and SEPs were recorded within 12 h and at 24 h after CA. EEG was classified according to Cloostermans et al. (2012); SEPs was classified as bilaterally absent (BA) and present. Neurologic outcome has been assessed at least after 6 months by GOS. Seventy-two patients were included and 25 were recorded before 12 h from CA. All patients who showed a continuous EEG pattern within 12 h awakened. The same EEG pattern recorded at 24 h is not always predictive of awakening. BA SEPs within 12 h were always associated to following EEG patterns: isoelectric, low-voltage and burst-suppression. Early EEG/SEPs recordings are useful tools for reliable prognostication both of good and poor outcome in comatose patients treated with TH.

Defibrotide is a polydeoxyribonucleotide-derived anti-ischemic drug with multiple sites of action involving both plasmatic and cellular targets. This agent has been demonstrated to produce profibrinolytic, cytoprotective, and vaso-facilatory actions. Since monocytes are increased in the mediation of some of the pathophysiologic responses seen in ischemic disorders, the functional properties of these cells were investigated in experimental conditions to evaluate their behavior during resting and stimulated states. Defibrotide was supplemented in these systems to determine its modulatory action. In this investigation Defibrotide was found to decrease the PAI-1 levels and may indicate that this may be the mechanism for its profibrinolytic actions. Defibrotide was also found to reduce the procoagulant activity of monocytes in these experimental settings. Both PAI and procoagulant factors play an important role in the pathophysiology of inflammation, DIC, and ischemia. Defibrotide induced reduction of these two factors represents the mechanism whereby this agent produces its therapeutic action.

The novel influenza A H1N1 virus can cause, in a restricted subgroup of infected patients, an acute respiratory failure not responding to conventional treatment. In selected cases, extracorporeal membrane oxygenation (ECMO) has been applied with a 21% mortality rate. Here we report the experience of the ICU of a regional referral center for ECMO (Careggi Teaching Hospital, Florence, Italy).

Extracorporeal life support (ECLS) represents a therapeutic choice in cases of acute reversible lung and/or heart failure. An emergency ICU can safely manage both veno-arterial (V-A) and veno-venous (V-V) ECLS.

In the perioperative period different levels of Troponin I (TnI) increase allow the identification of different severity degrees of myocardial damage [1]. Aim of the present study was to verify the correlation of TnI increase with clinical, ECG and Echo TT data and with the stratification of risk in patients submitted to major vascular surgery. A prospective observational study was performed on 51 patients submitted to major vascular surgery and then admitted to ICU. Preoperative measurements of TnI, CK-MB isoform, ECG and Echo TT were obtained. Then blood samples for TnI and CK-MB were obtained every 6 hours for 72 hours after surgery and then once daily. Twelve-leads ECG was registered daily. A new echocardiogram was obtained 48-72 hours after surgery. According to our laboratory and to NACB [2], two cut-off values for TnI were used as follows: normal values = 0.11 to 1.5 ng/ml. Patients were then subdivided into three groups in relation to TnI levels: Group T0 = normal values ( 0.11 to 1.5 ng/ml. In every group TnI values were related to CK-MB, ECG and echo TT results. Patients were reassessed 3 months after surgery by means of telephone survey, ECG, echo TT and clinical evaluation.

Prostacyclin (PGI2) and thromboxane A2 (TxA2), antiaggregating and aggregating agents, may be involved in the control of local vasomotor tone owing to their vasoactive properties. In 15 healthy young volunteers, circulating PGI2 (biological assay using superfusion technique) and plasma TxA2 levels (measured by radioimmunoassay as its stable derivative TxB2) have been investigated. Adrenergic stimulation was induced by a 2 min cold application and its effectiveness was checked in all subjects by the changes in forearm calculated vascular resistance (blood flow was measured by strain gauge plethysmography), and in six subjects by changes in catecholamine plasma levels (radioenzymatic assay). Cold application induced a sharp increase in calculated vascular resistance and plasma noradrenaline concentration in all subjects. Adrenergic stimulation was associated with a prompt elevation of circulating PGI2 (from 6.67 ± 2.38 to 12.18 ± 2.95 ng·cm−3, P < 0.001) and TxB2 levels (from 0.49 ± 0.18 to 1.10 ± 0.61 pmol·cm−3, P < 0.001). PGI2 and TxB2 increases disappeared within 10 min. In subjects treated with 5 mg·kg−1 ASA, both TxB2 resting levels and their increase after adrenergic stimulation were not significantly different from values before ASA although platelets were unable to produce TxB2. Therefore, platelets were not the source of TxB2 in plasma. After 10 mg·kg−1 ASA, TxB2 increase following adrenergic stimulation was unaffected whereas PGI2 elevation was completely blocked and the increase in calculated vascular resistance was significantly higher than in subjects pretreated with saline. These findings indicate that TxB2 and PGI2 formation may represent a modulating mechanism of vascular response to adrenergic stimulation.

Thromboxane B2 (TxB2) determination is usually performed by using commercial 3H-RIA kits. However, the low amounts of TxB2 present in plasma are not detectable without previous extraction. The aim of this study is the evaluation of 1) plasma protein interferences on the binding and separation steps of bound from free analyte and 2) charcoal efficacy in different experimental conditions. Our results indicate that plasma proteins do not influence the antibody binding, but significantly reduce the efficacy of precipitation of kit dextran-charcoal, so that the supernate radioactivity rises with the protein amount increase (r = 0.99 p less than 0.001). Such greater number of counts in the samples determines a lower estimation of TxB2 concentration in plasma when the calibration curve is set up in buffer. Our findings suggest that, in order to measure low amounts of plasma TxB2 without extraction, it is useful: 1) to refer to a calibration curve set up in buffer-diluted plasma, 2) to use the uncoated charcoal concentration allowing the lowest stripping and 3) to perform all steps at 4 degrees C.