Risultati per: Artrite psoriasica e altre comorbilità in pazienti con psoriasi nel setting della medicina generale

Introduction
The allostatic load (AL) is a framework for conceptualising the physiological multisystemic impact of prolonged exposure to stress and its related side effects on mental health.
Stress due to AL can influence the development and outcomes of cardiovascular diseases. AL increases the risk of coronary and peripherical artery diseases. AL emerges from the detection of emotional dimensions related to the disease, low psychosocial functioning and high rates of psychopathological signs in patients with hypertension or coronary heart disease.

Method and analysis
The primary endpoint of the PLAY-UP protocol is the implementation of a multidimensional model underlying the clinical treatment of patients with cardiovascular disease through the integration of medical and psychological clinical variables.
PLAY-UP is a cohort study that will last for 24 months. 200 participants will be recruited and divided into three groups: early disease, midterm disease and long disease. All patients will undergo a clinical evaluation based on the detection of biological, medical and psychological indicators and variables. The evaluation battery will comprise three types of measurements: medical, psychological and pharmacological treatments. Clinical and psychological measurements will be processed in an integrated manner through the combination of all variables examined, elaborating the Allostatic Load Index from a longitudinal time perspective. The Allostatic Load Index will be calculated by measuring the z-score.

Ethics and dissemination
Ethical Committee Approval was obtained from CEtRA Abruzzo Region (IT) (ID 0461499/23). The results of the present project will be published in peer-reviewed journals, disseminated electronically and in print, and presented as abstracts and/or personal communications during national and international conferences.

Objectives
Study objective was to map the current literature on the economic effects of priority setting at the system level in healthcare.

Design
The study was conducted as a scoping review.

Data sources
Scopus electronic database was searched in June 2023.

Eligibility criteria
We included peer-reviewed articles published 1 January 2020–1 January 2023. All study designs that contained empirical evidence on the financial effects or opportunity costs of healthcare priority setting were included excluding disease, condition, treatment, or patient group-specific studies.

Data extraction and synthesis
Two independent researchers screened the articles, and two additional researchers reviewed the full texts and extracted data. We used Joanna Briggs Institute checklists to assess the quality of qualitative, quasi-experimental and economic evaluations and the mixed methods appraisal tool for the mixed method studies. Synthesis was done qualitatively and through descriptive statistics.

Results
8869 articles were screened and 15 fulfilled the inclusion criteria. The most common study focus was health technology assessment (7/15). Other contexts were opportunity costs, effects of programme budgeting and marginal analysis, and disinvestment initiatives. Priority setting activities analysed in the studies did not achieve cost savings or cost containment (4/15) or have mixed findings at best (8/15). Only five studies found some indication of cost savings, cost containment or increased efficiency. Also, many of the studies consider costs only indirectly or qualitatively.

Conclusions
All in all, there is very little research addressing the pressing question of whether explicit priority setting and priority-setting methods can support cost containment on a health service system level (regional or national). There is limited evidence of the economic effects of priority setting.

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Circulation, Volume 150, Issue Suppl_1, Page A4146542-A4146542, November 12, 2024. Background:Beta blockers have the potential to mitigate the damage caused by adrenergic overdrive in septic shock. However, there is limited data supporting their effectiveness in controlling heart rate in these patients. Recent meta-analyses have demonstrated that beta-blockers can lower mortality rates in patients with sepsis. To evaluate the efficacy of beta-blockers in sepsis and septic shock, we conducted a comprehensive systematic review and meta-analysis.Methods:We performed a systematic review and meta-analysis by thoroughly searching MEDLINE, Scopus, and the Cochrane Database of Systematic Reviews to evaluate the efficacy of beta-blockers in sepsis and septic shock. Random-effects models were utilized to pool effect sizes. The DerSimonian-Laird estimator calculated between-study variance, and the Jackson method was employed to determine a 95% confidence interval (CI).Results:Our analysis included 8 eligible studies with a total of 893 patients (446 in the beta-blocker group, with 64% being female, and 447 in the placebo group, with 59% being female) at 28 days of follow-up. In the beta-blocker cohort, there were 171 deaths (38.3%), whereas the control group had 212 deaths (47.4%) at 28 days of follow-up. The use of beta-blockers did not significantly improve overall 28-day mortality (pooled odds ratio, 0.59; 95% CI, 0.34-1.03; p = 0.07) (Figure).Conclusion:The findings of this systematic review and meta-analysis suggest that beta-blockers do not significantly enhance survival rates among patients with sepsis and septic shock.

Circulation, Volume 150, Issue Suppl_1, Page A4136330-A4136330, November 12, 2024. Introduction:Accurate assessment of pacing thresholds during permanent pacemaker implantation is critical to ensure device function and longevity. A few reports have described rate-related threshold variability during MicraTMleadless pacemaker (Medtronic Inc, Minneapolis, MN) procedures. Postulated mechanisms for this phenomenon include variable myocardial contact or micro-dislodgment, and inflammation-induced phase IV block. In this case series, we demonstrate the use of adenosine to induce transient heart block for accurate threshold assessment in patients with tachycardia during leadless pacemaker placement.Cases:A 69-year-old male with a history of atrial flutter presented with complete atrioventricular (AV) block requiring emergent transvenous pacing. A Micra placement was performed. During the procedure, the patient was tachycardic in rapid atrial flutter despite multiple doses of metoprolol. It was noted that with rapid pacing from the pacemaker at 120 pulses per minute (ppm) the threshold was ≤1V at 0.24 ms. An adequate “tug-test” was performed and at least 2 of 4 tines were noted to be fixated based on fluoroscopic motion. To confirm the capture threshold before final deployment, 12 mg of adenosine was given to induce heart block. However, at a rate of 60 ppm, there was no ventricular capture at 3V at 0.24ms. The device was repositioned and repeat threshold testing with adenosine at 60 ppm was 0.38V at 0.24ms. Pacing parameters were assessed the next day and remained stable.Similarly, a 75-year-old female with ischemic cardiomyopathy was admitted with new atrial fibrillation (AF). She then developed pauses prompting Micra placement. During initial threshold testing, she was in rapid AF despite receiving multiple doses of metoprolol. Heart block was induced with 12mg adenosine to assess the threshold at a lower pacing rate of 60 ppm. The capture threshold achieved was 0.5V at 0.24ms.Discussion:Nusbickel et al., Yoshiyama et al., and Sano et al. have reported rate dependent discrepancies in capture thresholds after Micra implantation. Our cases highlight the importance of capture threshold assessment at lower pacing rates during implantation. In patients who are tachycardic at the time of the procedure, adenosine may be useful to more reliably assess device capture threshold and determine the need for repositioning.

Circulation, Volume 150, Issue Suppl_1, Page A4140908-A4140908, November 12, 2024. Background:Coronary artery aneurysm seen in patients undergoing coronary angiography is an uncommon disorder with poorly understood pathophysiology. Patients have variable clinical presentations and often poor long-term outcomes. Management of these patients still pose a clinical dilemma given there are no standardized treatment guidelinesDescription of case and discussion:A 44-year-old male with a significant past medical history of hypertension, diabetes mellitus, and hyperlipidemia presented in the emergency room (ER) for acute onset chest pain. His pain was retro-sternal, non-radiating, and pressure-like in nature. Pain was initially rated as 2/10 intensity which progressed to 9/10 later in the day with associated diaphoresis. He took acetaminophen which provided no relief. His electrocardiogram (EKG) showed ST elevation in the inferior and lateral leads. Initial troponin was negative. The cardiac catheterization laboratory was activated and the patient was administered loading doses of Aspirin, ticagrelor and a bolus of intravenous (IV) heparin.An emergent left heart catheterization and coronary angiogram was performed which revealed a 100% thrombotic occlusion of the mid LAD as well as severe ectasia of the proximal vessel. There was mild ectasia of the left circumflex and right coronary arteries without any significant stenosis. There were no collaterals to the distal LAD consistent with an acute presentation. At the level of the occlusion (mid LAD), there was an aneurysm measuring up to 10 mm in diameter by angiography. Intravenous eptifibatide was administered with the continuation of IV heparin. The thrombotic occlusion was managed medically with a plan to repeat angiography in 24-48 hours. Transthoracic echocardiography revealed a preserved left ejection fraction at about 55-60% with mild hypokinesis of the apex. Repeated angiography in 48 hours revealed a mostly patent LAD with diffuse TIMI 2 flow and sub occluded distal LAD at the apex. He was discharged home with dual antiplatelet therapy, a statin, and a beta blocker. Two weeks later he was seen on outpatient setting and his medications were transitioned to Rivaroxaban and clopidogrelConclusion:Large LAD aneurysms are not common and they carry long term complications which includes thrombosis (as seen in our patient), fistula formation, and rupture. Management of this condition is still challenging as there are no standardized management guidelines.

Circulation, Volume 150, Issue Suppl_1, Page A4139584-A4139584, November 12, 2024. Introduction:We present a case of hypertrophic obstructive cardiomyopathy (HOCM) with incidental wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) discovered after septal myectomy.Case presentation:A 62-year-old male with a history of bilateral carpal tunnel syndrome as well as a family history of sudden cardiac death consistent with HOCM on autopsy (patient’s father) presented to the clinic with symptoms of exertional shortness of breath, hypotension, and pre-syncope. An external monitor revealed one episode of non-sustained supraventricular tachycardia, otherwise was unremarkable. He experienced worsening symptoms for which emergency department evaluation revealed anterior lead T-wave inversions on EKG. Cardiac catheterization revealed non-obstructive coronary artery disease. Shortly thereafter, a cardiac MRI was significant for probable HOCM based on septal hypertrophy, late gadolinium enhancement (LGE) with mid-wall fibrosis in the basal/mid inferolateral segments, and systolic anterior motion (SAM) of the mitral valve. Pre-stress echocardiogram revealed a sigmoid septum with septal wall thickness of 1.6 cm and no left ventricular outflow tract (LVOT) gradient. Post-stress echocardiogram revealed severe SAM with septal contact, LVOT gradient of 70 mmHg, as well as hypotension. Genetic testing was negative, and the patient underwent successful septal myectomy with papillary muscle reorientation and resection of secondary chordae. The pathology of the myocardium obtained during surgery resulted with histological features suggestive of HOCM in addition to confirmed ATTRwt-CA for which tafamidis was initiated.Discussion:Literature reporting HOCM and ATTRwt-CA within the same patient is rare. Both conditions cause increased myocardial thickness which can present phenotypically similar, making diagnosis difficult. Utilization of modern imaging modalities such as cardiac MRI and echocardiography should provide valuable information for differentiation, but as in our case, direct tissue visualization can be required for diagnosis. Each diagnosis has unique imaging characteristics that help define them such as asymmetric septal hypertrophy with dynamic LVOT obstruction, SAM of the mitral valve, and fibrotic areas on LGE in the setting of HOCM compared to diffuse and symmetric global subendocardial LGE and concentric hypertrophy with ATTRwt-CA.Conclusion:Our case reveals the importance of avoiding anchoring bias as concomitant diagnoses can present.