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Funding Acknowledgements Type of funding sources: None. Introduction The use of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) is associated with bleedings. Interactions with dronedarone may increase this risk, but data on concomitant treatment of DOACs with dronedarone are limited. Purpose The primary endpoint was to compare the survival free from the composite endpoint of clinically relevant bleeding, thromboembolic event and all-cause death, between AF patients on treatment with dronedarone and different DOACs. The secondary endpoints were to compare the survival free from i) clinically relevant bleeding and ii) clinically relevant major bleeding. Methods A retrospective study was conducted at our Local Health Unit, from January 1st 2016 to December 31st 2020. The population included AF patients with concomitant prescriptions of DOACs and dronedarone. Patients were divided into 4 groups (rivaroxaban, apixaban, edoxaban, dabigatran). Clinically relevant major bleedings were defined as fatal bleeding or bleeding leading to transfusion of ≥2 units of blood. Clinically relevant non-major bleedings were defined as any sign of hemorrhage that does not fit the criteria for major bleeding but does lead to hospitalization or emergency room admission. Thromboembolic events were defined as ischemic stroke, transient ischemic attack (TIA), and systemic embolism. Results 165 patients were included: 46/165 (28%) on rivaroxaban, 66/165 (40%) on apixaban, 45/165 (27%) on edoxaban, and 8/165 (5%) on dabigatran (Fig.1). Over a median follow-up of 339 days, 14/165 (8%) met the primary composite endpoint: 8/165 (5%) had clinically relevant bleedings, of which 1/165 (0.6%) was a clinically relevant major bleeding (i.e., fatal spontaneous intracerebral hemorrhage), 2/165 (1%) had TIAs, and 5/165 (3%) died. We found no difference in survival free from the primary composite endpoint and from clinically relevant bleeding between groups (p=0.19 and p=0.69, respectively) (Fig. 2A-B). However, survival free from clinically relevant major bleeding was significantly lower in dabigatran users (p=0.003) (Fig. 2C). At a secondary analysis, DOACs contraindicated by 2015 EHRA guide (dabigatran, edoxaban 60 mg), and not by 2018/2021 EHRA guides (rivaroxaban, dabigatran, edoxaban 60 mg), were associated with lower survival from either clinically relevant bleeding or clinically relevant major bleeding (p=0.03 and p Conclusions In our study on patients on concomitant treatment with DOACs and dronedarone, there was no difference in survival free from the primary composite endpoint and from clinically relevant bleeding between groups of coadministration. However, survival free from clinically relevant major bleeding was significantly lower in dabigatran users. DOACs contraindicated by 2015 EHRA guide (and not by the latest 2018/2021 EHRA guides) are associated with lower survival from either clinically relevant bleeding or clinically relevant major bleeding.

Telemedicine (T) has now become an indispensable operational tool for the management of patients with chronic conditions, in particular for patients with chronic heart failure (HF). The current COVID 19 pandemic has accelerated the development and application oh this method in daily clinical practice. Up to now, the evaluation of he advantage and disadvantage of televisit by cardiological patients have been very limited. In order to assess the satisfaction and criticalities of this method, we administered a satisfaction questionnaire to 74 patients (49 males and 25 females with an average of 75) followed in our clinic. Of the 74 questionnaire administered, 70 were received. When asked whether the inclusion of T had improved the quality of service 43 patients (61%) answered a lot, 24 patients (34%) sufficiently and 3 patients (4%) not at all. When asked if the organization of the T had been adequate, 50 patients (71%) responded adequately, 19 patients (27%) sufficiently adequate and 1 patient (1%) not at all adequate. When asked about the modalities of connection to the T for 54 patients (77%) they were found to be sìmple, for 13 patients (18%) a little complicated and for 3 patients (4%) difficult, very complicated. When asked what would be proposed to improve the service 7 patients (10%) answered the possible extension of hours also in the afternoon, 3 patients (4%) the provision by the ASL of electromedical devices, 14 patients (20%) the ability to directly request an appointment in T and 38 patients (54%) all options. In detail, 1 patient (1%) requested both the extension of the afternoon schedule and the provision of electromedicals, 4 patients (6%) requested both the extension of the afternoon schedule and the direct request for an appointment, 2 patients (2%) required both electromedical equipment and direct request for an appointment, 1 patient (1%) did not indicate any option. Finally, as regards the degree of satisfaction, 45 patients (64%) were considered totally satisfied, 22 patients (31%) partially satisfied and 3 patients (4%) dissatisfied. Conclusions The televisit in the setting of patients with chronic HF, despite the limitations of a limited series, was generally well accepted, easy to access and with some useful operational proposal for public administration.

A 78 years old man was admitted to our hospital because of a syncope and evidence of complete AV– block, low ventricular rate and suitable for definitive PM implantation. He had no other pathologies or previous surgical interventions. A transthoracic echocardiography was performed and any particular structural anomaly was detected and the left ventricular ejection fraction was normal. In the electrophysiology laboratory, a vascular access through the left axillary vein was used to insert a passive fixation catheter for the right ventricular using a 9 F sheath. When the ventricular lead reached the right atrium it was impossible to advance it farther into the right ventricle; the lead was blocked near tricuspid anulus without any possibility to move it towards any direction despite many and vigorous manual traction maneuvers were attempted. Immediately, a transesophageal echocardiography was performed and it showed the lead entrapment into a mobile structure, likely a Chiari network.The patient needed a PM implantation as soon as possible and also a temporary PM could further complicate the procedure. Since the hospital did not have a cardiac surgery department and our crew was not familiar with lead extractions, an expert hemodynamist, who suggested to remove the lead by using a snare, was consulted. The tip of the lead was stuck in the atrial wall so it was impossible to capture it as expected. So, from right femoral vein access, a 6F pig–tail catheter was inserted through a a 45 cm– 8 F Terumo Destination sheath in order to give more stability to the pig–tail catheter until it hooked the lead. A 0.035 mm normal hydrophilic Terumo wire was later passed into the pig–tail catheter, snared and externalized with an AndraSnare 25 catheter inserted through another 6F introducer. A vigorous traction was performed simultaneously pulling both the ends of the wire from the bottom and the lead from the top. After a few seconds, the lead was unstuck and removed from the axillary vein [Fig. 1a,b]. At the external examination, the tines of the lead were found attached to a net–like structure that was actually the Chiari network that had been completely removed from the atrium [Fig 2–3]. A transthoracic echocardiogram ruled out any pericardial effusion. The anatomical finding was sent to tissue analysis and was confirmed to be the tendon material. After that the patient was immediately implanted with a VDD PM without any complications, and dismissed after 2 days.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Carotid artery stenting (CAS) is nowadays considered as alternative therapeutic option to carotid endarterectomy for patients suffering from carotid artery disease. Recent studies and meta-analyses have demonstrated equal performance of carotid stenting to endarterectomy as regard as the overall adverse events (death/stroke rates), especially when periprocedural myocardial infarction and nerve pulses are also included. However, carotid stenting was inferior to endarterectomy when compared in terms of acute and late embolic events. In the present review, we collect all studies available in the published literature regarding the late embolic events. We mainly attempted to gather data regarding the silent embolic events occurring after the acute post-procedural period. We analyzed the results and reported the incidence of the problem. Finally, we aimed to identify possible causes and propose effective solutions to reduce the incidence of late embolic events.

The aim of this Italian prospective registry was to evaluate the applicability and efficacy of the Mo.Ma Device (Invatec, Roncadelle, Italy) for the prevention of cerebral embolization during carotid artery stenting (CAS) in a real world population.In 4 Italian centers, 416 patients (300 men; mean age 71.6+/-9 years) between October 2001 and March 2005 were enrolled in a prospective registry. Two-hundred and sixty-four symptomatic (63.46%) with50% diameter stenosis and 152 (36.54%) asymptomatic patients with70% diameter stenosis were included. The Mo.Ma Proximal Flow Blockage Embolic Protection System was used to perform protected CAS, achieving cerebral protection by endovascular clamping of the common carotid artery (CCA) and of the external carotid artery (ECA).Technical success, defined as the ability to establish protection with the Mo.Ma device and to deploy the stent, was achieved in 412 cases (99.03%). The mean duration of flow blockage was 4.91+/-1.1 min. Transient intolerances to flow blockage were observed in 24 patients (5.76%), but in all cases the procedure was successfully completed. No peri-procedural strokes and deaths were observed. Complications during hospitalization included 16 minor strokes (3.84%), 3 transient ischemic attacks (0.72%), 2 deaths (0.48%) and 1 major stroke (0.24%). This resulted in a cumulative rate at discharge of 4.56% all strokes and deaths, and of 0.72% major strokes and deaths. All the patients underwent thirty-day follow-up. At thirty-day follow-up, there were no deaths and no minor and major strokes, confirming the overall cumulative 4.56% incidence of all strokes and deaths rate, and of 0.72% rate of major strokes and deaths at follow up. In 245 cases (58.89%) there was macroscopic evidence of debris after filtration of the aspirated blood.This Italian multicenter registry confirms and further supports the efficacy and applicability of the endovascular clamping concept with proximal flow blockage in a broad patient series. Results match favorably with current available studies on carotid stenting with cerebral protection.

This booklet presents a methodology for family planning program managers to assess their organization's management capabilities. The initial essay discusses the need to assess management development in a systematic manner and introduces the rapid, systematic, management development assessment (MDA) methodology, which was developed in Bangladesh though two years of collaborative work by three major organizations. Since its development, MDA has been used in Turkey and several Latin American countries. After presenting nine reasons to conduct an MDA, the next section describes the various stages of management development (launch, growth, and mature), which together provide a long-range perspective. The major steps involved in conducting an MDA are then explained. Step 1, developing a preliminary management map, involves selecting key management areas (mission and plans, leadership, organizational structure and lines of communication, financial management, human resource management, and community participation); selecting indicators for each area; and establishing reference criteria for each indicator. The second step is to develop and administer the MDA questionnaire for data collection. Step 3 is to analyze the survey results by summarizing information from the questionnaire, finalizing the postsurvey management map, and preparing the results for feedback. The final step is to develop the MDA action plan. Samples are provided for each step in the process. The booklet ends by discussing the integration of MDA into the ongoing operation of an organization and by providing a checklist for assessing management capabilities.

Thirty patients with allergic conjunctivitis, caused by Parietaria or grass pollens, participated in a double-blind parallel study comparing levocabastine to cromolyn sodium, both given as eye drops. Symptom and sign scores were recorded during a 4-week period. The patients received only these drugs during the time of observation. The evaluation of the clinical signs and symptoms by the clinicians and by the patients revealed a significant improvement of conjunctivitis in all patients. The intergroup comparison was equal in the two groups treated respectively with levocabastine and cromolyn. Therefore, levocabastine and cromolyn are effective in the treatment of pollen-induced allergic conjunctivitis.

This study stresses the dangers of uncritical antibiotic treatment of acute purulent pyelonephritis. It may make the clinical picture atypical, prevent early diagnosis and timely operation, give rise to septicaemia and shock, as confirmed in the literature and by own observations. The incidence of complications (septicaemia, uraemia, septicaemic shock) and the mortality rate (31%) were strikingly high in the 77 cases of acute purulent nephritis with previous antibiotic treatment in the past 3 years. Early diagnosis and timely surgical intervention improve the therapeutic results.