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Background: The tunneling technique is currently widely used for placement of CVC. Recently, some clinicians have used this technique for peripherally inserted central catheters (PICC), or Midline catheters (MCs). Objective: To describe a safe antegrade tunneling technique for PICCs and MCs insertion with a blunt tunneler. Methods: This retrospective monocentric survey collected ASST Lodi hospital data from January 1st to December 31st, 2019. The indication for PICCs and MCs tunneled implant was to respect the correct vein/catheter ratio or special clinical situation (children, burns, wounds, and wider catheter 5/6 fr). Contraindications included the operator’s low skills and severe risk of bleeding (INR > 3; Platelet count Results: About 390 PICCs (327 4 fr and 63 5 fr) and 183 MCs were placed. One hundred and sixty-five PICCs (42%) and 110 MCs (60%) were tunneled. Five fr PICCs were more present among tunneled catheters (54/165 [32.7%] vs 9/225 [4%] p Conclusions: The antegrade tunneling technique with blunt tunneler of PICCs and MCs is simple, rapid and is regarded as a safe maneuver. More in-depth and future prospective studies are needed to evaluate the impact of tunneling on early and late complications.

The handover has relevant implications in terms of patient safety. An effective handover requires the use of a standardized and shared communication tool.This observational study explored the nursing handover at shift change in order to detect eventual omissions. Furthermore, it investigated the quality perceived by the nurses involved.At each shift change, an external observer detected the referred and omitted information by the delivering nurse, through the use of a direct observational grid (modified ISBAR). The percentage of the omitted information was calculated excluding any unforeseen information, not linked to the patient care pathway and detected through the consultation of the nursing record. The quality perceived by the nurses involved was investigated through the use of the Handoff CEX tool. The data was processed through a descriptive and inferential statistical analysis.256 handovers were observed and 256 nursing records were reviewed. The omissions were detected in 43.17% of the cases. The results highlight a propensity for a prospective approach. A high statistical significance emerges in relation to the modality of handover, the type of patient, the nurse/patients ratio and the number of interruptions. Referring to the perceived quality, 40 Handoff CEX evaluation forms were completed. The results show a more than satisfactory perception. However, the thematic analysis highlights scarcely detailed and dispersive handovers as well as the difficulty to focus on the information to deliver.According to the findings of this research, it is necessary to implement a standardized tool which supports the handover process.Il passaggio di consegna, dall’inglese “handover”, ha rilevanti implicazioni sulla sicurezza del paziente. Un handover efficace richiede l’utilizzo di uno strumento comunicativo standardizzato e condiviso.Lo studio osservazionale in esame ha esplorato i processi di handover infermieristico al cambio turno al fine di rilevare eventuali omissioni informative. Altres , stata indagata la qualit percepita degli infermieri coinvolti.Ad ogni cambio turno, un osservatore esterno ha rilevato le informazioni riferite e omesse dall’infermiere erogante, attraverso l’utilizzo di una griglia di osservazione diretta (ISBAR modificato). La percentuale di omissioni stata calcolata al netto delle informazioni non previste, non riconducibili al percorso di cura del paziente oggetto di consegna e rilevate attraverso la consultazione della cartella infermieristica informatizzata. La qualit percepita stata indagata attraverso lo strumento Handoff CEX. I dati sono stati processati attraverso un’analisi statistica descrittiva e inferenziale.Sono stati osservati 256 passaggi di consegna e sono state esaminate 256 cartelle infermieristiche. Le omissioni si sono verificate nel 43,17% dei casi. I risultati evidenziano una propensione all’approccio prospettico. Emerge un’alta significativit statistica nella correlazione con la modalit di handover, la tipologia di paziente, il rapporto infermiere/pazienti e il numero di interruzioni. Relativamente alla qualit percepita, sono state compilate 40 schede Handoff CEX. I risultati rivelano una percezione pi che soddisfacente. Tuttavia, l’analisi tematica evidenzia consegne dispersive, scarsamente dettagliate e la difficolt nel focalizzare le informazioni da trasferire.Alla luce dei dati rilevati si rende necessaria l’implementazione di uno strumento standardizzato che supporti il processo di handover.

Background: Venous Access Devices (VADs) are the most used devices in COVID-19 patients. Objective: Identify VADs implanted, catheter related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and accidental remove of VADs in both COVID-19 positive and COVID-19 free patients. Successive analysis was conducted comparing COVID-19 positive patients with COVID-19 free with inverse probability propensity score weights using simple regression to account for these two confounders (peripheral tip as central/peripheral and hospitalization as no/yes). Methods: This multicenter, retrospective cohort study collected data from seven hospitals in Lombardy during the pandemic period from February 21st to May 31st 2020. Results: A total of 2206 VADs were evaluated, 1107 (50.2%) of which were inserted in COVID-19 patients. In COVID-19 cohort the first choice was Long Peripheral Cannula in 388 patients (35.1%) followed by Midline Catheter in 385 (34.8%). The number of “central tip” VADs inserted in COVID-free inpatients and COVID-19 positive were similar (307 vs 334). We recorded 42 (1.9%) CRT; 32 (79.2%) were observed in COVID-19 patients. A total of 19 CRBSI were diagnosed; 15 (78.95%) were observed in COVID-19. Accidental removals were the more represented complication with 123 cases, 85 (69.1%) of them were in COVID-19. COVID-19 significantly predicted occurrence of CRT (OR = 2.00(1.85–5.03); p Conclusions: CRT, CRBSI, and accidental removal are significantly more frequent in COVID-19 patients. Accidental removals are the principal complication, for this reason, the use of subcutaneously anchored securement is recommended for a shorter period than usual.

BackgroundVenous Access Devices (VADs) are the most used device in COVID-19 patients.ObjectiveIdentify VADs implanted, catheter related thrombosis (CRT), catheter-related bloodstream infection (CRBSI), and accidental remove of VADs in both COVID-19 positive and COVID-19 free patients. Successive analysis was conducted comparing COVID-19 positive patients with COVID-19 free with inverse probability propensity score weights using simple regression to account for these two confounders (peripheral tip as central/peripheral and hospitalization as no/yes).MethodsThis multicenter, retrospective cohort study was conducted using data from 7 hospitals in Lombardy during the pandemic period from February 21st to May 31st 2020.Results2206 VADs were evaluated, of which 1107 (50.2%) were inserted in COVID-19 patients. In COVID-19 cohort the first choice was Long Peripheral Cannula in 388 patients (35.1%) followed by Midline Catheter in 385 (34.8%). The number of “central tip” VADs inserted in COVID-free inpatients and COVID-19 positive were similar (307vs334). We recorded 42 (1.9%) CRT; 32 (79.2%) were observed in COVID-19 patients. 19 CRBSI were diagnosed; 15 (78.95%) were observed in COVID-19. Accidental removals were the more represented complication with 123 cases, 85 (69.1%) of them were in COVID-19. COVID-19 significantly predicted occurrence of CRT (OR = 2.00(1.85-5.03); PConclusionsCRT, CRBSI, and accidental removal are significantly more frequent in COVID-19 patients. Accidental removals are the principal complication, for this reason use of subcutaneously anchored securement is recommended for shorter period than usual.

Aims The present study sought to evaluate the correlation between indices of non-invasive myocardial work (MW) and left ventricle (LV) size, traditional and advanced parameters of LV systolic and diastolic function by 2D echocardiography (2DE). Methods and results A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from LV pressure-strain loops using custom software. Peak LV pressure was estimated non-invasively from brachial artery cuff pressure. LV size, parameters of systolic and diastolic function and ventricular-arterial coupling were measured by echocardiography. As advanced indices of myocardial performance, global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained. On multivariable analysis, GWI was significantly correlated with GLS (standardized beta-coefficient = −0.23, P Conclusion The non-invasive MW indices show a good correlation with traditional 2DE parameters of myocardial systolic function and myocardial strain.

Background and importance Several studies have estimated that about 60% of patients present at least one potential drug–drug interaction (DDI) at discharge. Considering that DDIs are predictable, a review of DDIs conducted by pharmacists and physicians would be ideal. Aim and objectives The aim of this analysis was to measure the frequency and nature of DDIs in a cardiovascular unit and investigate whether any adverse events after discharge could be associated with these DDIs. Material and methods This was an observational retrospective study involving patients discharged between December 2016 and December 2017. The discharge medication list within the electronic medical record was used to determine the presence of moderate or severe DDIs at discharge. To check if any adverse events were associated with DDIs, we reviewed the causes of each hospitalisation or access to the emergency department (ED) within 3 months after discharge. Results Among 2715 patients screened, 624 (23%) were exposed to at least one potential DDI. A total of 1108 DDIs were recorded, 834 (75.3%) were classified as moderate and 274 (24.7%) as severe. The median number of DDIs per patient was 1.8 (range 1–11). The most frequent severe interaction was the combination of some selective serotonin reuptake inhibitors and furosemide (38%). Among the most frequent moderate interactions, we registered an association between warfarin and acetylsalicylic acid (10.2%). Of the 624 patients with at least one DDI, follow-up data were available for 593 (95.0%). Among them, 144 (24.3%) had at least one adverse clinical event within 3 months after discharge. A total of 212 events were recorded (hospitalisations=179; ED attendance=33). For approximately 12% of these events, the cause of hospitalisation or ED attendance was potentially associated with a DDI. Conclusion and relevance From this analysis it emerged that a remarkable number of patients had been discharged with at least one DDI and a considerable portion of the included patients might have experienced an adverse event due to these DDIs. The next step will be the involvement of a clinical pharmacist within a multidisciplinary team to highlight to the physician any potential DDIs before discharge and minimise the occurrence of their related risk. References and/or acknowledgements No conflict of interest.

Aims To obtain the normal range for 2D echocardiographic (2DE) measurements of left ventricular (LV) layer-specific strain from a large group of healthy volunteers of both genders over a wide range of ages. Methods and results A total of 287 (109 men, mean age: 46 ± 14 years) healthy subjects were enrolled at 22 collaborating institutions of the EACVI Normal Reference Ranges for Echocardiography (NORRE) study. Layer-specific strain was analysed from the apical two-, three-, and four-chamber views using 2DE software. The lowest values of layer-specific strain calculated as ±1.96 standard deviations from the mean were −15.0% in men and −15.6% in women for epicardial strain, −16.8% and −17.7% for mid-myocardial strain, and −18.7% and −19.9% for endocardial strain, respectively. Basal-epicardial and mid-myocardial strain decreased with age in women (epicardial; P = 0.008, mid-myocardial; P = 0.003) and correlated with age (epicardial; r = −0.20, P = 0.007, mid-myocardial; r = −0.21, P = 0.006, endocardial; r = −0.23, P = 0.002), whereas apical-epicardial, mid-myocardial strain increased with the age in women (epicardial; P = 0.006, mid-myocardial; P = 0.03) and correlated with age (epicardial; r = 0.16, P = 0.04). End/Epi ratio at the apex was higher than at the middle and basal levels of LV in men (apex; 1.6 ± 0.2, middle; 1.2 ± 0.1, base 1.1 ± 0.1) and women (apex; 1.6 ± 0.1, middle; 1.1 ± 0.1, base 1.2 ± 0.1). Conclusion The NORRE study provides useful 2DE reference ranges for novel indices of layer-specific strain.

International audience; Aims - To obtain the normal ranges for 2D echocardiographic (2DE) indices of myocardial work (MW) from a large group of healthy volunteers over a wide range of ages and gender. Methods and results - A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from left ventricle (LV) pressure-strain loops. Peak LV systolic pressure was non-invasively derived from brachial artery cuff pressure. The lowest values of MW indices in men and women were 1270 mmHg% and 1310 mmHg% for GWI, 1650 mmHg% and 1544 mmHg% for GCW, and 90% and 91% for GWE, respectively. The highest value for GWW was 238 mmHg% in men and 239 mmHg% in women. Men had significant lower values of GWE and higher values of GWW. GWI and GCW significantly increased with age in women. Conclusion - The NORRE study provides useful 2DE reference ranges for novel indices of non-invasive MW.

Background Over the past decade, transcatheter aortic valve implantation (TAVI) has emerged as a novel and less invasive alternative to traditional surgical aortic valve replacement (SAVR) for the management of severe aortic stenosis (AS) in higher-risk elderly patients. Purpose Our aim was to evaluate the frequency of polypharmacy (treatment with more than four medications per person) and to analyse the ATC class of medications prescribed in a fragile population. Material and methods We analysed the data of patients whose medical procedures included TAVI or SAVR, between January 2016 and October 2017. We identified a total of 903 patients who underwent TAVI (n=228) or SAVR (n=675), whose clinical characteristics were assessed by calculating the Charlson comorbidity index (CCI). Results Patients in the TAVI group were more likely to be older (p No significant difference in polypharmacy was observed between the two groups at discharge, after 6 and 9 months from the hospitalisation. In particular, the patients in polypharmacy, immediately after discharge, were 29% in the TAVI group and 35% in the SAVR group (p=0.07). After 6 months from discharge, the percentage of patients in polypharmacy had increased to over 80% in both groups and this data was confirmed after 9 months. In both groups, the most prescribed drugs at discharge were the antithrombotic agents (50.1% TAVI, 40.3% SAVR; p=0.005), followed by the drugs for peptic ulcer and gastroesophageal reflux disease (29.4% TAVI, 33.6% SAVR; p=0.24), high-ceiling diuretics (19.3% TAVI, 33.6% SAVR; p Conclusion This first analysis found that polypharmacy was common in over one-third of our participants at discharge (both TAVI and SAVR group). We found no association between polypharmacy and the type of AS treatment, but we observed some difference in the drug class between the two groups. The next steps will be to investigate the presence of inappropriate drug combinations and to implement an inter-professional approach at discharge for improving polypharmacy issues. References and/or acknowledgements All authors have declared that they have no support or funding to report. No conflict of interest.

Background Medication reconciliation (MedRec) is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as drug interactions. The World Health Organization has recognized MedRec as a recommended standard of quality in health assistance. Purpose The aim of this analysis was to estimate the prevalence of patients exposed to potentially relevant drug-drug interaction (DDI) at hospital discharge. Material and methods This was an observational retrospective study involving patients with cardiovascular diseases discharged from our hospital between December 2016 and May 2017. A total of 1033 patients were included in this study and 8005 drug prescriptions at discharge were analysed (7.75 per patient). DDIs were classified as moderate (pharmacological effects must be controlled by individual dose adjustment or on the basis of drug plasma concentration) or severe (drug combination should be avoided in clinical practice). Results Among 1033 patients included, 271 (26.2%) were exposed to at least one potential DDI. In particular, 173 patients were discharged with one interaction (16.7%), 54 patients with two interactions (5.2%), 23 patients with three interactions (2.2%) and 21 were exposed to four or more DDIs (2%). A total of 445 DDIs were recorded, 75.1% were classified as moderate and 24.9% as severe interactions. The median number of DDIs per patients with interactions was 1.6 (range 1–7). The most frequent severe interaction was the combination of some selective serotonin reuptake inhibitors (Paroxetine, Sertraline and Citalopram) and Furosemide (n=46;1%). This combination is known to be associated with an increased risk of cardiotoxicity (QT prolongation and cardiac arrest). Conclusion From this first analysis, it emerged that one-third of our patients were discharged with at least one potential DDI and a remarkable portion of these combinations was severe. The next step will be to investigate whether adverse clinical events, readmission or death after discharge could be associated with a potentially severe DDI. The final target will be the involvement of a clinical pharmacist within a multidisciplinary team to highlight potential DDIs at discharge and minimise the occurrence of the related risks. References and/or acknowledgements No conflict of interest.

International audience; Aims - To obtain the normal ranges for echocardiographic measurements of left atrial (LA) function from a large group of healthy volunteers accounting for age and gender. Methods and results - A total of 371 (median age 45 years) healthy subjects were enrolled at 22 collaborating institutions collaborating in the Normal Reference Ranges for Echocardiography (NORRE) study of the European Association of Cardiovascular Imaging (EACVI). Left atrial data sets were analysed with a vendor-independent software (VIS) package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire data sets. The lowest expected values of LA function were 26.1%, 48.7%, and 41.4% for left atrial strain (LAS), 2D left atrial emptying fraction (LAEF), and 3D LAEF (reservoir function); 7.7%, 24.2%, and -0.53/s for LAS-active, LAEF-active, and LA strain rate during LA contraction (SRa) (pump function) and 12.0% and 21.6% for LAS-passive and LAEF-passive (conduit function). Left atrial reservoir and conduit function were decreased with age while pump function was increased. All indices of reservoir function and all LA strains had no difference in both gender and vendor. However, inter-vendor differences were observed in LA SRa despite the use of VIS. Conclusion - The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function. Our data highlight the importance of age-specific reference values for LA functions.

International audience; Aims - To obtain the normal ranges for 2D echocardiographic (2DE) measurements of left ventricular (LV) strain from a large group of healthy volunteers accounting for age and gender. Methods and results - A total of 549 (mean age: 45.6 ± 13.3 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. 2DE data sets have been analysed with a vendor-independent software package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire the data sets. The lowest expected values of LV strains and twist calculated as ± 1.96 standard deviations from the mean were -16.7% in men and -17.8% in women for longitudinal strain, -22.3% and -23.6% for circumferential strain, 20.6% and 21.5% for radial strain, and 2.2 degrees and 1.9 degrees for twist, respectively. In multivariable analysis, longitudinal strain decreased with age whereas the opposite occurred with circumferential and radial strain. Male gender was associated with lower strain for longitudinal, circumferential, and radial strain. Inter-vendor differences were observed for circumferential and radial strain despite the use of vendor-independent software. Importantly, no intervendor differences were noted in longitudinal strain. Conclusion - The NORRE study provides contemporary, applicable 2D echocardiographic reference ranges for LV longitudinal, radial, and circumferential strain. Our data highlight the importance of age- and gender-specific reference values for LV strain.

International audience; Aim: To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. Methods and results: A total of 440 (mean age: 45 ± 13 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P

International audience; AIMS: To report normal reference ranges for echocardiographic dimensions of the proximal aorta obtained in a large group of healthy volunteers recruited using state-of-the-art cardiac ultrasound equipment, considering different measurement conventions, and taking into account gender, age, and body size of individuals. METHODS AND RESULTS: A total of 704 (mean age: 46.0 ± 13.5 years) healthy volunteers (310 men and 394 women) were prospectively recruited from the collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was obtained in all subjects following pre-defined protocols. Aortic dimensions were obtained in systole and diastole, following both the leading-edge to leading-edge and the inner-edge to inner-edge conventions. Diameters were measured at four levels: ventricular-arterial junction, sinuses of Valsalva, sino-tubular junction, and proximal tubular ascending aorta. Measures of aortic root in the short-axis view following the orientation of each of the three sinuses were also performed. Men had significantly larger body sizes when compared with women, and showed larger aortic dimensions independently of the measurement method used. Dimensions indexed by height and body surface area are provided, and stratification by age ranges is also displayed. In multivariable analysis, the independent predictors of aortic dimensions were age, gender, and height or body surface area. CONCLUSION: The NORRE study provides normal values of proximal aorta dimensions as assessed by echocardiography. Reference ranges for different anatomical levels using different (i) measurement conventions and (ii) at different times of the cardiac cycle (i.e. mid-systole and end-diastole) are provided. Age, gender, and body size were significant determinants of aortic dimensions

Objective Medication errors are one of the leading causes of patient harms. Medication reconciliation is a fundamental process that to be effective, it should be embraced during each single care transition. Our objectives were to investigate current medication reconciliation practices in the 2 Fondazione Toscana Gabriele Monasterio hospitals and comprehensively assess the quality of medication reconciliation practices between inpatient and outpatient care by analyzing the medication patterns 6 months before admission, during hospitalization, and 9 months after discharge for a selected group of patients with cardiovascular diseases. Methods A retrospective observational study was conducted in the Cardiothoracic Department of the Fondazione Toscana Gabriele Monasterio hospitals. Medication history was reviewed for all the patients admitted from and discharged to the community, from January to March 2013. Patients were excluded if they had less than 4 drugs or less than 2 drugs for cardiovascular system in their prescription list at admission or if they died during follow-up. We selected 714 patients, and we obtained the clinical charts and all drug prescriptions collected during patients' hospitalization by the electronic clinical recording system. We also analyzed the list of prescriptions of this sample of patients, from 6 months before admission to 9 months after discharge, extracted from the regional prescription registry. In the resulting sample, prescriptions were analyzed to assess unintentional discrepancies. Results The study included 298 patients (mean age, 71.2 years), according to the inclusion and exclusion criteria. Among 14,573 prescriptions analyzed, we found 4363 discrepancies (14.6 discrepancies per patient). Among these discrepancies, 1310 were classified as unintentional (4.4 discrepancies per patient). Among unintentional discrepancies, only 63 (4.8%) took place during hospitalization. Although at the hospital-home interface, 33.1% of unintentional discrepancies were detected through the comparison between the patients' declared therapy and the previous medication consumption and 62.1% were identified in the comparison between the prescription at the discharge and the following medication pattern at home. Conclusions Medication errors have important implications for patient safety, and their identification is a main target for improving clinical practice. The comparison between the medication patterns acquired through the regional prescription registry before and after hospitalization outlined critical touchpoint in the current medication reconciliation process, calling for the definition of shared medication reconciliation standards between hospitals and primary care services to minimize medication discrepancies and enhance patient safety.

International audience; AIMS: Reference values for Doppler parameters according to age and gender are recommended for the assessment of heart physiology, specifically for left ventricular (LV) diastolic function. In this study, we report normal reference ranges for Doppler parameters obtained in a large group of healthy volunteers. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following Doppler acquisition and measurement protocols approved by the European Association of Cardiovascular Imaging. METHODS AND RESULTS: A total of 449 (mean age: 45.8 ± 13.7 years) healthy volunteers (198 men and 251 women) were enrolled at the collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was obtained from all subjects following predefined protocols. The majority of the Doppler diastolic parameters (e', E/e') as well as right ventricle systolic s' wave velocity were similar in men and women. Left ventricle s' wave velocity was higher in men than in women. E wave and e' were higher in younger subjects and decreased progressively in the older ones. E/e' ratio increased with ageing. Septal e' \textless8 cm/s was present in 19.7% of the subjects in the 40-60 year group and in 55% of those in the ≥60 year group. However, the cut-off value of average E/e' or lateral E/e' remained \textless15 or 13, respectively, in the majority of patients. CONCLUSION: The NORRE study provides the reference values for the most useful Doppler parameters in the evaluation of heart physiology. These data highlight the need of using age-specific reference values especially for the diagnosis of LV systolic and diastolic dysfunction and for the estimation of LV filling pressures

Background: In order to ensure quality and safety of prescriptions, electronic medication management system needs to comply with medication safety requirements and human factors principles. The design of such a system can make the difference on physician acceptance and consequently on medication safety. The aim of the study is to evaluate to what extent the changes in the design of the electronic medication management system may affect the rate of medication errors. Materials and method: In light of the growing development of computerized systems in health services it has become necessary to design electronic medication management system for drug prescription and administration compliant with the requirements of medication safety practices. Prescription data relative to 100 patients admitted to the Cardiothoracic Department of the Gabriele Monasterio Foundation Heart Hospital (FTGM) were extracted from the computerized medical notes from March 2013 until May 2013. The prescriptions examined had been written using the electronic documentation prompt without structured entry fields. All prescriptions were evaluated using the medication safety requirements of the medication safety practice developed by the Centre for Patient Safety of the Regional Department of Health in Tuscany, Italy. The same prescriptions were then simulated using the novel electronic medication management module and reassessed according to the safety requirements. Results: Of the 4112 prescriptions pertaining to the 100 study patients analyzed, 88.5% were found to be erroneous or incomplete. In particular 46.8% did not include the route of administration, 29.4% the pharmaceutical form, 10.6% the number of administrations per day and/or the time of administration, in 8.2% the dose was not defined and 4.9% did not include the active pharmaceutical agent or trade name. 14.9% were considered with high potential for harm. The same prescriptions simulated through the novel electronic module were 99.1% correct and complete. Conclusions: The ergonomic design of the module for electronic prescription meets the medication safety requirements and has a role in reducing drug errors and enhancing the safety of the workflow. The module introduced structured fields pertaining the type of drug being prescribed which were positively embodied in the routine and produced a significant reduction of prescription errors.

AimsAvailability of normative reference values for cardiac chamber quantitation is a prerequisite for accurate clinical application of echocardiography. In this study, we report normal reference ranges for cardiac chambers size obtained in a large group of healthy volunteers accounting for gender and age. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following chamber quantitation protocols approved by the European Association of Cardiovascular Imaging.MethodsA total of 734 (mean age: 45.8 ± 13.3 years) healthy volunteers (320 men and 414 women) were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was performed on all subjects following pre-defined protocols. There were no gender differences in age or cholesterol levels. Compared with men, women had significantly smaller body surface areas, and lower blood pressure. Quality of echocardiographic data sets was good to excellent in the majority of patients. Upper and lower reference limits were higher in men than in women. The reference values varied with age. These age-related changes persisted for most parameters after normalization for the body surface area.ConclusionThe NORRE study provides useful two-dimensional echocardiographic reference ranges for cardiac chamber quantification. These data highlight the need for body size normalization that should be performed together with age-and gender-specific assessment for the most echocardiographic parameters. © 2014 The Author.

Background: Infra-low dose dipyridamole allows one to selectively explore myocardial viability. Transesophageal echocardiography Doppler measurement of left anterior descending coronary artery flow at baseline and following dipyridamole is an efficient tool to assess coronary flow response. Aim of this study was to determine the flow-function relationship during coronary vasodilatory stress in patients with coronary artery disease and baseline dysfunction. Methods and results: Twelve patients with resting dyssynergies and 6 controls underwent assessment of regional function and of left anterior descending blood flow velocity. Flow and function were evaluated at rest and following infra-low dose dipyridamole (0.28 mg/Kg over 4 min). Controls showed a normal function at rest and after dipyridamole. Six patients (‘Responders’) with resting dyssynergies showed an improvement in segments of left anterior descending artery territory, whereas the other six ones (‘Non-responders’) showed no functional change. Controls and ‘Responders’ had similar values of resting peak diastolic left anterior descending artery flow velocity both at rest and after dipyridamole, whereas ‘Non-responders’ showed a blunted flow response to dipyridamole. Conclusion: Myocardial segments with a resting dysfunction and a contractile reserve more often exhibit a residual flow response, whereas segments with fixed pattern show a flat flow response during coronary vasodilator stress.

Background. The aim of this study was to establish the feasibility, safety, and diagnostic accuracy of the dipyridamole echocardiography test in patients with severe aortic valve stenosis for noninvasive detection of coexisting coronary artery disease. Methods. The high-dose dipyridamole echocardiography test was performed in 52 patients with severe aortic stenosis; all patients also underwent coronary angiography, independent of test results, before cardiac operation. Results. The dipyridamole echocardiography test was completed without major complications. One patient had transient atrial fibrillation that was reversed by aminophylline. Thirty-one patients (60%) had a negative test result; all had normal coronary arteries. Ten of the 21 patients (48%) with a positive test result had coexisting coronary artery disease. The positive predictive value of the dipyridamole echocardiography test for detection of coronary disease in patients with severe aortic stenosis was 48%. The negative predictive value was 100%. The sensitivity was 100% and the specificity was 74%. Conclusions. Dipyridamole echocardiography is a safe and feasible tool in patients with severe aortic stenosis eligible for a cardiac operation. A negative test result reliably rules out a significant stenosis, whereas a positive one is much less accurate in predicting coronary artery disease.

International audience; BACKGROUND: Availability of normative reference values for cardiac chamber dimensions, volumes, mass, and function is a prerequisite for the accurate application of echocardiography for both clinical and research purposes. However, due to the lack of consistency in current echocardiographic 'reference values', their use for clinical decision-making remains questionable. AIMS: The aim of the 'Normal Reference Ranges for Echocardiography Study (NORRE Study)' is to obtain a set of 'normal values' for cardiac chamber geometry and function in a large cohort of healthy Caucasian individuals aged over a wide range of ages (25-75 years) using both conventional and advanced echocardiographic techniques. METHODS: The NORRE Study is a large prospective, observational multicentre study in which transthoracic echocardiographic studies will be acquired in 22 laboratories accredited by the European Association of Cardiovascular Imaging and in one laboratory in the USA accredited by ICAEL. The final sample size has been estimated in 1100 normal subjects in whom M-mode, 2D, and 3D imaging, colour Doppler, pulsed-wave Doppler, pulsed-wave tissue Doppler, and colour tissue Doppler imaging data will be obtained. All studies will be sent to a central echocardiographic core laboratory for quantitative analysis. Multiple studies will be performed for reproducibility analysis. CONCLUSION: After completion of the NORRE Study, uniform reference limits according to age, gender, and anthropometric parameters will be available to standardize the quantitative interpretation of echocardiography.

Aim of the study was to assess the relative usefulness of transesophageal echocardiography (TEE) and X-ray computed tomography (CT) in the follow-up of patients who survived an aortic dissection.We evaluated 44 patients (age = 57 +/- 12 years) with treated aortic dissection: 14 had a De Bakey type I, 20 a type II and 1 patient a type III dissection treated surgically: 1 patient had a type I, 1 a type II and 7 a type III dissection treated medically. All entered an outpatient follow-up program with serial evaluations at 1, 6 and 12 months after initial diagnosis by dual noninvasive imaging protocol. A contrast-enhanced CT scan and a TEE with biplane probe were performed on the same day and in random order.A total of 252 evaluations with both CT and TEE were considered. A completely normal study was found in 45 TEE and 48 CT evaluations. The following abnormal findings could be documented by one or both techniques: thrombus in the false lumen (TEE: n = 48; CT: n = 45 evaluations); intimal flap (TEE and CT: n = 68); aortic dilatation (TEE and CT: n = 15); pericardial effusion (TEE and CT: n = 3); aortic pseudoaneurysm (TEE: n = 2; CT: n = 3); isthmic coarctation (TEE and CT: n = 1). Regarding the presence or absence of these abnormalities, which are within the diagnostic domain of both imaging techniques, the results were fully concordant in 245 studies, and discordant in 7, with an overall agreement of 97%. In addition, some abnormal findings could be detected by TEE only: aortic insufficiency (n = 36); intimal tear (n = 25); spontaneous echocontrast effect in the false lumen (n = 39 evaluations). Other abnormal findings could be detected by CT only: a pleural effusion in 4, a truncus anonymous dissection in 1, a pseudoaneurysm due to suture dehiscence of the distal anastomosis of the ascending aorta in 1 evaluation (which yielded ambiguous results by TEE, with turbulent flow departing from the graft).Both CT and TEE are atraumatic, safe and accurate techniques for serial follow-up imaging of patients treated for aortic dissection. Information provided by CT is largely redundant, rather than additive, to that provided by TEE. The latter should be probably preferred for shorter imaging time, accuracy and convenience, although CT might still play a role in selected cases of ambiguous TEE results.

It has been demonstrated that high dose (up to 0.84 mg/kg over 10 min) dipyridamole echocardiography stress testing is feasible even in the first few hours after coronary artery bypass graft surgery and can be used to assess the beneficial physiological effects of coronary revascularization as well as graft patency. The aim of this study was to assess the role of dipyridamole echocardiography testing performed shortly after myocardial revascularization in the stratification of prognosis during follow-up. We studied 49 consecutive patients (45 males and 4 females; mean age 56 ± 8 years) referred to our institute for elective myocardial revascularization. Six patients had single, 14 double, and 29 triple vessel disease. Forty-two left internal mammary artery grafts, 16 sequential venous grafts, and 45 single venous grafts were performed. All patients were submitted to dipyridamole echocardiography testing before (range 1–3 days) and shortly after (range 5–7 days) myocardial revascularization, always with the patients off antianginal medication. An arbitrary wall-motion score grading from 0 to 3 (normal, hypokinesia, akinesia, and dyskinesia) was applied to the seven regions into which the left ventricle was divided. Before surgery 48 patients showed wall-motion abnormalities during the test (47 patients also presented ECG changes). Angina occurred in 48 patients. One patient had ischemic ECG changes and angina. The mean wall-motion score was 3.11 per patient before and 6.5 per patient after the test (P < 0.001). During the test performed after myocardial revascularization, two patients showed wall-motion abnormalities, angina, and ECG ischemic changes; one patient showed wall-motion abnormalities and angina; two patients presented only ECG ischemic changes; one patient showed wall-motion abnormalities and angina; and two patients showed ischemic changes. The mean postsurgical wall-motion score was 2.5 per patient before and 2.8 per patient after the test (P = NS). Of the five patients with a positive test for echocardiographic and/or ECG criteria, five suffered events during a 1-year follow-up (two developed Q waves and resting wall-motion abnormalities; three had recurrence of angina); of the remaining 43 patients with a negative test for echocardiographic and ECG criteria, only two developed angina during follow-up. The incidence of postsurgical events was 100% in patients with a positive and 5% in patients with a negative dipyridamole echocardiography test early after myocardial revascularization (P < 0.001). In conclusion, our data demonstrate that dipyridamole echocardiography stress testing is a suitable method in the early assessment of myocardial revascularization at a time when other exercise-dependent methods are not feasible, and that a positive test in the early days after surgery indicates patients with a high risk of later developing ischemic events.

Although a role for free radicals in myocardial damage during cardiopulmonary bypass for open heart surgery has been postulated, direct evidence of free radical production as well as consumption of tissue antioxidants such as vitamin E is still lacking. Twenty patients (age 26-66 yr, mean 48) undergoing elective open heart surgery with moderate hypothermia, and cold crystalloid cardioplegia, were studied. Cardiopulmonary bypass time was 61.4 +/- 31.2 min. The specimens of atrial tissue collection before and after cardiopulmonary bypass, were immediately frozen in liquid nitrogen. Mean vitamin E atrial content, measured by reverse phase HPLC, was 355 +/- 249 pmol/mg of dry weight basally, 135 +/- 85 pmol/mg (p0.05) at the end of the ischemic period and 405 +/- 288 pmol/mg after the reperfusion period (p0.01). Microscopic examination of right atrial biopsies ruled out differences in fibrosis or cellular damage as the cause of vitamin E changes. Although a great basal variability in atrial vitamin E content was observed, which was independent of age, sex and clinical status, a reproducible and substantial decrease in atrial vitamin E content after cardiopulmonary bypass occurred (mean reduction 45 +/- 17% and 55 +/- 22%, respectively, after ischemia and after reperfusion). This was directly related to the aorta cross-clamping duration and partially to the minimum temperature achieved. In conclusion, apart from the great variability observed in basal vitamin E tissue content, vitamin E was always reduced during cardiopulmonary bypass, suggesting an oxidative stress on the myocardium during open heart surgery.

The evaluation of coronary reserve within a few hours of aortocoronary bypass surgery could be of extreme utility for the follow-up or therapeutical management of these patients. In 11 men patients who underwent aortocoronary bypass surgery, a dipyridamole echocardiography stress test was carried out before (1 to 3 days), early after (68 to 130 minutes), and 1 week after surgery. The first and third tests were performed using a standard transthoracic approach, while the second was performed by a transesophageal approach. Dipyridamole was administered intravenously at a dose of 0.56 mg/kg body weight (low dose) and eventually adding 0.28 mg/kg body weight (high dose), always in the absence of antiischemic therapy. An arbitrary wall motion score (0 = eukinesia; 1 = hypokinesia; 2 = akinesia; 3 = dyskinesia) was assigned to the seven different myocardial regions in which the left ventricle was divided in order to have a semiquantitative score. Under basal conditions wall motion score per patient in the three series of tests did not change significantly (1.6, 1.4, and 1.5, respectively), while the mean score during dipyridamole administration showed significant differences (3.6, 1.9, and 1.9, respectively), indicative of the results obtained by surgical repair. The test, positive in all patients before surgery, showed wall motion abnormalities and ischemic ECG changes in two patients immediately after surgery by the transesophageal approach. One patient who had a normal basal contraction pattern and an abnormal response after the test developed in the following days a perioperative myocardial infarction, while a second patient in the follow-up period developed low-level effort angina. Furthermore, by the transthoracic approach it was possible to document in three patients the reversibility of myocardial contraction abnormalities seen under basal conditions, the so-called “hibernating phenomenon.” It is worthwhile to stress that the results obtained by the test performed 1 week after surgery were the same as those obtained 2 hours after surgery, indicating that the changes in coronary circulation have stabilized by the early hours after surgery. In conclusion, our data, although preliminary, demonstrate that with the transesophageal approach it is possible to evaluate the changes induced by coronary bypass surgery even in the early phases, allowing better patient management and permitting risk stratification.

An atrial ball thrombus freely floating in the left atrium in a patient with mitral stenosis is a rare and dangerous event. In this case report we present a patient with mitral stenosis in whom the presence of a left atrial ball thrombus was documented by two-dimensional echocardiography. The association of mitral valve obstruction, the appearance of severe neurologic impairments, the typical echocardiographic pattern of the mass, and the surgical findings are described

The objective of this study was to assess the acute hemodynamic effects of endogenous adenosine accumulation in patients with chronic heart failure. Exogenously administered adenosine has been shown to reduce pulmonary vascular resistance and to increase cardiac index in normal subjects and in patients with pulmonary hypertension or end-stage biventricular heart failure. Endogenous adenosine accumulation can be provoked by dipyridamole.Ultra-low-dose dipyridamole (0.07 mg/kg/min for 4 minutes) was administered in 20 patients with either symptomatic idiopathic (n = 12) or ischemic (n = 8) dilated cardiomyopathy and reduced left ventricular ejection fraction (mean 25%+/-5%). Hemodynamic variables were measured before and within 1 minute from the end of dipyridamole infusion. After dipyridamole administration, a mild but significant increase in heart rate (4.5%; p = 0.03) and reduction in mean blood pressure (6.8%; p0.001) without changes in right atrial pressure (p = NS) were detected. Dipyridamole increased cardiac output by 26.6% (p0.001), cardiac index by 24% (p0.001), and stroke volume by 19.8% (p0.001), with concomitant 24.6% reduction of systemic vascular resistance (p0.001). Moreover, dipyridamole reduced mean pulmonary artery pressure by 8.3% (p0.01) and pulmonary vascular resistance by 33.3% (p = 0.001), without changes in pulmonary wedge pressure (p = NS). A significant correlation between percent decrease from baseline in pulmonary and systemic vascular resistance (r = 0.66; p = 0.002) was found after administration of dipyridamole.Endogenous adenosine accumulation induced by ultra-low-dose dipyridamole infusion acutely improves the hemodynamic profile, decreasing pulmonary and, to a lower extent, systemic vascular resistance and increasing cardiac index in patients with severe chronic heart failure.

Variation in cyclic (systolic-to-diastolic) echodensity has been demonstrated to be areliable index of preserved myocardial function. Paradoxic septal motion can be observed frequently after cardiac surgery in the absence of any functional impairment. The aim of the study was to evaluate whether regional cycle-dependent gray-level variation in the septum is affected by abnormal septal motion after cardiac surgery. Ten patients undergoing cardiac surgery for coronary artery bypass grafting were evaluated by continuous transesophageal echocardiographic monitoring from the transgastric approach, both before and after surgery. In each patient septal motion was assessed qualitatively as normal or paradoxic. Images were digitized off-line and cyclic gray-level variation was measured in each patient by means of dedicated software. By selection, all patients exhibited normal septal motion and thickening at baseline. After surgery, five patients showed a paradoxic septal motion (group I), whereas in the remaining five patients (group II) septal motion remained normal. Percent area change, measured with the floating center-of-mass reference system, was similar in the two groups both before (I=42%±7% versus II=44%±13%; difference not significant) and after surgery (I=39%±8% versus II=40%±1%; difference not significant). Cyclic gray-level variation was also similar in the two groups, both at baseline (group I=61%±16% versus group II=68%±18%; difference not significant) and after surgery (50%±13% versus 57%±16%; difference not significant). In conclusion, cardiac cycle-dependent gray-level variation provides an objective method, independent of cardiac motion, to assess regional function in paradoxic septal motion after cardiac surgery. Cyclic gray-level variation is not distorted by altered regional wall motion, consistent with the evidence that it reflects intrinsic contractile function.

The known cardiovascular manifestations in polycystic kidney include the life-threatening berry aneurysms of the cerebral circulation, as well as mitral valve prolapse, mild dilatation of the aortic root, occasional thoracic and abdominal aneurysms, and a predisposition to valvular regurgitation, which have been considered suggestive of an underlying connective tissue disorder.1,2

The object of this study was to assess the usefulness of the dipyridamole-echocardiography test in the early evaluation of coronary artery bypass grafting, when the use of an exercise stress test is precluded. We studied 39 consecutive patients (37 men and two women, mean age 57.3 years) referred to our institute for elective coronary artery bypass. Five patients had single, 12 patients double, 20 patients triple vessel disease, and two had left main stem disease. Nineteen left internal mammary artery grafts, 20 sequential grafts, and 39 single vein grafts were performed. All the patients were subjected to the test before (time range 1 to 3 days) and after (time range 6 to 10 days) the operation in the absence of therapy. Dipyridamole was administered intravenously 0.56 mg/kg over 4 minutes (low dose); if no effect was apparent, an additional 0.28 mg/kg over 2 minutes (high dose) was given. During the test, blood pressure and a twelve-lead electrocardiogram were monitored. An arbitrary wall motion score was derived by dividing the left ventricle into six regions and grading from 0 to 3-normokinetic, hypokinetic, akinetic, and dyskinetic zones. Preoperatively the test was positive in 38 patients as evidenced by wall motion abnormalities (36 patients had electrocardiographic changes) and in one patient by electrocardiographic changes and chest pain; 22 tests were positive after the low dose and 17 after the high dose. Angina was present in 33 patients. Mean wall motion score was 1.64 per patient in the basal condition and 4.03 per patient after the test (p less than 0.001). After coronary bypass in three patients the test was positive at the same dosage that was used preoperatively, as shown by wall motion abnormalities (in two patients by electrocardiographic changes, as well). Four patients had symptoms. Furthermore, at 6 months' follow-up, a treadmill stress test performed in these three patients was positive for ischemia and angina. The wall motion score was 1.25 per patient in the basal condition and 1.53 per patient after the test (no significant difference). When the preoperative wall motion score obtained after dipyridamole echocardiography was compared with the postoperative score, a statistically significant difference was seen: 4.03 per patient versus 1.53 per patient (p less than 001). In eight patients we observed an improvement of basal myocardial contractility after the operation, which indicates the reversibility of wall motion abnormalities observed before coronary bypass. In conclusion our data show that the dipyridamole-echocardiography test is a suitable method for the early assessment of bypass grafting when other methods, exercise dependent, are not indicated.(ABSTRACT TRUNCATED AT 400 WORDS)

Increased cardiovascular stiffness in women could explain gender differences in aortic valve stenosis (AVS) Echocardiographic indexes to estimate LV burden in AVS have been recently proposed: Valvular Arterial Impedance( Zva) and Energy Loss Index (ELI). Aim of the study was to identify gender

Nel saggio Leonelli riprende alcune delle conclusioni della ricerca dalla quale è nato il volume, per declinarle in ambito educativo. A proposito della televisione, viene fatto il punto sugli adolescenti che, nei contesti educativi, sono considerati, alternativamente, o del tutto passivi di fronte ai condizionamenti televisivi oppure consumatori competenti, disincantati osservatori. Tali rappresentazioni veicolano specifiche visioni (implicite) sul ruolo esercitato dalla scuola nell’apprendimento del vivere sociale. La domanda cruciale – la televisione “dentro” o “fuori” dai contesti educativi formalizzati? – trova poi una sua risposta nello iato tra le proposte innovative della media education e la realtà delle Indicazioni Nazionali della Scuola secondaria superiore. Sulle “questioni di genere” viene presentato lo stato dell’arte, all’interno delle aule scolastiche, a proposito dei percorsi formativi esplicitamente dedicati a questo tema (notando, tuttavia, che il termine più corretto da utilizzare sarebbe “assenza”). Le quattro parole chiave che hanno guidato la ricerca e il volume – genere, televisione, adolescenza, corpo – s’intrecciano in conclusione nella formulazione di proposte laboratoriali, intese come esperienze scolastiche finalizzate alla costruzione di competenze e guidate da alcuni obiettivi precisi. In particolare, si tratta di aiutare i/le giovani ad assumere un ruolo attivo: nel riconoscere l’attuale ordine di genere; nel decostruire gli stereotipi sessisti; nel “giocare” con i simboli di genere; nello sperimentare nuovi modi di stare al mondo che sappiano essere rispettosi e inclusivi di ogni differenza.

Nell’Introduzione, oltre a rendere manifeste le domande di ricerca, e oltre a presentare il piano dell’opera, le curatrici esplicitano i riferimenti teorici comuni ad autrici e autori del volume a proposito di: 1) il concetto di genere come “tecnica del sé; 2) i media come tecnologia del genere; 3) la relazione tra genere, adolescenti e televisione italiana. Proprio su questo ultimo aspetto, in particolare, si concentra Leonelli: da un lato esplicitando le ragioni per le quali il lavoro di ricerca si è incentrato sull’ adolescenza; dall’altro chiarendo le motivazioni che hanno condotto l’équipe a interessarsi della televisione e, in particolare, dei programmi italiani, dalle forti connotazioni re-gendered.