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Translation Volum: 0 days Completat: Oct 2016 Languages: din italiană în engleză
Translation Italian to EnglishTJ353755-194237
Activity and efficacy of vinflunine in metastatic carcinoma of the bladder after failure of adjuvant treatment
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Medical article - Ciguatera fish poisoning
Pruritus, asthenia and paresthesia in a 51-year-old man
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Vascular myeloproliferative neoplasm with normal cell blood count
Vascular myeloproliferative neoplasm with normal cell blood count: Exploration and medical management
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Surveillance of severe cutaneous drug reactions- REACT-Lombardia
Surveillance of severe cutaneous drug reactions: Experience REACT-Lombardia
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PERSONALIZED MEDICINE
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Application for European Green Capital 2016 Award
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Translation Italian to English 2751 words CONDIZIONI GENERALI DI VENDITA
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Goliath Floor Lamp Manual
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din italiană în engleză: A strange case of Takotsubo syndrome after stress echocardiography with dipyridamole General field: Medical Detailed field: Medical: Cardiologie
Text sursă - italiană CASO CLINICO
Una donna di 81 anni è giunta alla nostra osservazione in Pronto Soccorso (PS) accusando dolore toracico irradiato agli arti superiori, insorto a riposo circa 6 h prima. Il dolore era ad andamento non costante ed associato a cefalea ed elevati valori pressori. La paziente era ipertesa e diabetica, in terapia con quinapril 20 mg/idroclorotiazide 12.5 mg/die e metformina 500 mgx 3/die. In anamnesi, inoltre, ateromasia carotidea ed un pregresso attacco ischemico transitorio, per cui assumeva aspirina 100 mg/die ed atorvastatina 10 mg/die. L’esame obiettivo era nella norma. L’ECG mostrava ritmo sinusale, onde T negative asimmetriche come da ipertrofia ventricolare sinistra (IVS), blocco di branca destra (reperto noto) (Figura 1A); all’ecocardiogramma, cinesi biventricolare conservata, ipertrofia del setto interventricolare basale (13 mm) del ventricolo sinistro (VS); insufficienza mitralica lieve, pericardio indenne. Esami ematochimici completi e due determinazioni della troponina (T0-T3: 0.01 ng/ml con cut-off di 0.04 ng/ml) risultavano nella norma.
Traducere - engleză CLINICAL CASE
An 81-year old woman came for consult to the Emergency Room (ER) complaining about chest pain radiating to upper limbs, which appeared at rest, about 6 h before. The pain was not constant and was associated with headache and high blood pressure. The patient was hypertensive and diabetic, undergoing therapy with quinapril 20 mg/hydrochlorothiazide 12.5 mg/day and metformin 500 mg x 3/day. In addition, she had a history of carotid atheromatosis and an episode of transient ischaemic attack, for which she was taking aspirin 100 mg/day and atorvastatin 10 mg/day. The physical exam was normal. The electrocardiogram showed sinus rhythm, asymmetric T-wave inversion suggesting left ventricular hypertrophy (LVH), right bundle branch block (known fact) (Figure 1A); the echocardiogram showed preserved biventricular kinetics, left ventricular (LV) hypertrophy of the basal segment of the interventricular septum (13 mm); mitral regurgitation, normal pericardium. Complete blood chemistry and two measurements of cardiac troponin (T0-T3): 0.01 ng/ml with 0.04 ng/ml cut-off) were within normal range.
din franceză în engleză: Injection intraveineuse d'adrénaline: attention au risque de dysfonction cardiaque iatrogène General field: Medical Detailed field: Medical: Cardiologie
Text sursă - franceză L'observation est celle d'une femme de 31 ans, G4P2 (deux grossesses par procréation médicale assistée avec stimulation ovarienne, deux fausses couches spontanées, la dernière 3 mois auparavant), ayant pour unique antécédent une torsion ovarienne droite ancienne. Une douleur abdominale localisée en fosse iliaque droite évoluant depuis 3 jours explique sa consultation aux urgences gynécologiques. Le bilan clinique, biologique et échographique ayant éliminé une cause gynéco-obstétricale, la patiente a été adressée aux urgences générales ou` une appendicite aigue¨ a été suspectée et l'indication de scanner injecté posée.
À l'injection de produit de contraste (PDC), elle a présenté un tableau brutal associant dyspnée laryngée (bronchospasme) et agitation évoquant au médecin urgentiste une réaction anaphylactique justifiant l'administration de polaramine en intraveineux puis d'adrénaline en boli intraveineux itératifs de 0,1 mg pour une dose totale cumulée de 0,8 mg. Dans les suites immédiates de l'injection, la patiente s'est plainte d'une douleur thoracique associée à une bradycardie à 45 battements par minute, une hypotension artérielle à 68/37 mmHg, nécessitant son transfert en réanimation. L'échographie transthoracique (ETT) réalisée a mis en évidence une dysfonction cardiaque globale du ventricule gauche (VG) avec une fraction d'éjection ventriculaire gauche (FeVG) effondrée à 20 %, une intégrale temps-vitesse mesurée à 13 cm, sans élévation des pressions de remplissage du ventricule gauche. L'ETT n'a pas retrouvé de signe d'obstruction des cavités droites, de trouble de la cinétique segmentaire ni d'épanchement péricardique pouvant évoquer une embolie pulmonaire, un infarctus du myocarde ou une péricardite. L'électrocardiogramme (ECG) a montré un sous-décalage du segment ST en V3-V4 sans autre anomalie, les dosages sériques de la troponine et de la Thyroid Stimulating Hormon (TSH) initiales étant normales.
Traducere - engleză This case involves a 31-year old woman, G4P2 (two pregnancies by Medically Assisted Procreation with ovarian stimulation, two spontaneous miscarriages, the last one, 3 months before), having as medical history only an old right ovarian torsion. Localized abdominal pain in the right iliac fossa evolving for the past 3 days explains her visit to the Gynaecology Emergency Department. Since the clinical examination, laboratory tests and ultrasound ruled out an obstetric-gynaecological cause, the patient was referred to the General Emergency Department where acute appendicitis was suspected and CT scan with contrast medium was indicated.
After administration of the contrast medium, she presented with a severe clinical picture associating laryngeal dyspnoea (bronchial spasm) and agitation, which led the emergency physician to suspect an anaphylactic reaction justifying administration of intravenous polaramine, then epinephrine in repeated intravenous boli of 0.1 mg, for a total cumulative dose of 0.8 mg. Immediately after the injection, the patient complained about chest pain associated with bradycardia at 45 beats per minute and arterial hypotension at 68/37 mmHg, requiring her transfer to the Intensive Care Unit. The transthoracic echocardiogram (TTE) performed identified left ventricular (LV) global cardiac dysfunction with a left ventricular ejection fraction (LVEF) dropped to 20%, time-velocity integral measured at 13 cm, without elevation of left ventricular filling pressure. The TTE did not find signs of obstruction in the right cavities, segmental kinetic disorder, or pericardial effusion suggesting pulmonary embolism, myocardial infarction or pericarditis. The electrocardiogram (ECG) showed depression of ST segment in V3-V4 without other abnormality, the initial serum troponin and the thyroid stimulating hormone (TSH) being normal.
din franceză în engleză: Locally advanced and metastatic cutaneous squamous cell carcinoma treated with cemiplimab General field: Medical Detailed field: Medical (general)
Text sursă - franceză INTRODUCTION
Le carcinome spinocelluiaire cutané (cSCC) est le deuxième cancer cutané malin le plus fréquent, après le carcinome basocellulaire. Il touche les patients en moyenne à partir de 60 ans, généralement au niveau des zones photoexposées (1). Sa fréquence augmente entre 100 à 250 fois chez le patient immunodéprimé, notamment les patients greffés d'organe (1). La plupart des cSCC sont bien différenciés et se présentent comme des lésions isolées croûteuses hyperkératosiques, bien délimitées avec un halo légèrement inflammatoire. Ils se com portent de façon indolente et n'ont qu'un très faible potentiel métastasique. Plus rarement, on observe des cSCC mal différenciés qui se manifestent comme des lésions exophytiques charnues, érythémateuses et qui saignent facilement. Ceux-ci ont un profil de croissance beaucoup plus rapide et un risque métastatique bien plus élevé.
Le traitement des cSCC repose principalement sur une excision chirurgicale (2). Pour certaines lésions localement avancées et/ou métastatiques, la chirurgie et/ou la radiothérapie ne sont plus envisageables (âge du patient, souhait du patient, techniquement difficile, trop mutilant, etc.), requérant alors des traitements systémiques. Les traitements systémiques pour le cSCC localement avancé et/ou métastatique (2, 3) sont des traitements chimiothérapeutiques, comme les platines, les taxanes, des traitements ciblés comme l'erlotinib et le cétuximab, ou, plus récemment, des immunothérapies comme le nivolumab et le cémiplimab (4, 5), tous deux des antagonistes PD1.
Traducere - engleză INTRODUCTION
Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer after basal cell carcinoma. Commonly, it affects patients over 60 years of age, and generally involves photoexposed areas (1). Its incidence increases 100 to 250 times in immunocompromised patients, particularly organ transplanted patients (1). Most cSCCs are well differentiated and present as isolated, well circumscribed, hyperkeratotic, crusty lesions with a slightly inflammatory halo. It is indolent and has a very low metastatic potential. Less frequently, poorly differentiated cSCC can be observed, manifesting as exophytic, fleshy, erythematous, easily bleeding lesions. These latter have a faster growth profile and [are associated with] a much higher metastatic risk.
The treatment of cSCC is primarily based on surgical excision (2). For some locally advanced and/or metastatic lesions, surgery and/or radiotherapy are no longer possible (patient's age, patient's wish, technically difficult, too mutilating, etc.), in such case requiring systemic treatment. Locally advanced and/or metastatic cSCC is treated systemically (2, 3) by chemotherapy using platinum-based regimens, taxanes, target therapies, such as erlotinib and cetuximab, or, more recently, immunotherapy with nivolumab and cemiplimab (4, 5), both PD-1 antagonists.
din italiană în engleză: Diritto amministrativo General field: Legislaţie/Brevete Detailed field: Juridic (general)
Text sursă - italiană Diritto amministrativo
PROGRAMMA DEL CORSO
– L’amministrazione e il diritto amministrativo nell’ordinamento costituzionale italiano.
– Le fonti del diritto amministrativo.
– La pubblica amministrazione; la sua organizzazione in generale; gli organi; gli uffici; il personale e il rapporto d’impiego (cenni).
– Lo Stato; le Regioni e gli enti territoriali; gli enti funzionali; le autorità indipendenti.
– L’attività amministrativa; l’attività autoritativa; l’attività negoziale; i servizi pubblici.
– Il procedimento amministrativo e il provvedimento amministrativo; l’inerzia dell’amministrazione.
– La validità e l’efficacia degli atti amministrativi; i vizi dell’atto amministrativo; la distinzione fra vizi di legittimità e vizi di merito.
– I procedimenti di secondo grado (annullamento d’ufficio, revoca, ecc.).
– L’attività contrattuale dell’amministrazione.
– I servizi pubblici.
– I beni pubblici.
– Le posizioni giuridiche soggettive (diritti soggettivi, interessi legittimi, ecc.).
– La responsabilità dell’amministrazione.
Traducere - engleză COURSE PROGRAMME
- Administration and administrative law in the Italian Constitution provisions.
- Basis of administrative law.
- Public administration; its general organization; administrative bodies; departments; personnel and employment relationship (overview).
- State; Regions and local government bodies; functional bodies; independent bodies.
- Administrative activity; authoritative activity; transaction activity; public services.
- Administrative procedure and administrative provision; administrative inertia.
- Validity and effectiveness of administrative measures; flaws of administrative measures; distinction between errors of law and error regarding merits.
- Second instance proceedings (official annulment, revocation, etc.).
- Contractual activity of the administration.
- Public services.
- Public goods.
- Subjective legal positions (subjective rights, legitimate interests, etc.).
- The responsibility of the administration.
din franceză în engleză: A rare and serious complication associated with acenocoumarol therapy: intra-alveolar haemorrhage General field: Medical Detailed field: Medical (general)
Text sursă - franceză Patient et observation
Le patient est un homme âgé de 62 ans, hypertendu, ayant un antécédent de fibrillation auriculaire sous anti-vitamines K depuis 13 ans bien suivi. Il s'est présenté à l'hôpital dans un tableau de dyspnée d'apparition brutale stade II NYHA, hémoptysie avec notion d'automédication par Ibuprofène depuis plusieurs jours. À son admission, le patient était apyrétique, tachypnéique à 28 cycles/min, tachycarde à 126 bpm, une pression artérielle à 134/79mmHg, saturation artérielle en oxygène à 94% avec des râles crépitants diffus aux deux hémi champs pulmonaires. Au bilan biologique, nous avons noté une anémie à 7,8 g/dl hypochrome microcytaire, des globules blancs à 10230/mm3, des plaquettes à 260000/mm3, un INR incoagulable, une créatininémie à 10,3 g/l estimant le débit de filtration glomérulaire à 77 ml/min/1,73 m2 (Formule MDRD simplifiée), une albuminémie à 34 g/l, protidémie à 63g/l. L'examen de la bandelette urinaire s'est révélé négatif sans hématurie ni macroalbuminurie. Les taux sériques des p-ANCA, c-ANCA, Ac anti-MBG, AC anti-DNA ainsi que le facteur rhumatoïde se sont révélés négatifs. L'échocardiographie transthoracique a montré une fonction ventriculaire normale et aucune valvulopathie. Le cliché standard du thorax a révélé à la phase d´état des opacités alvéolaires bilatérales diffuses (Figure 1), ce qui nous a incité à compléter par une TDM thoracique retrouvant des lésions alvéolaires multiples bilatérales (Figure 2). Enfin, une endoscopie bronchique avec lavage broncho-alvéolaire (LBA) fut réalisé retrouvant un liquide uniformément hémorragique avec cultures revenues stériles.
Traducere - engleză Patient and case report
The patient is a 62-year old man, hypertensive, with a history of atrial fibrillation treated with vitamin K antagonists, properly followed for the past 13 years. He comes to the hospital presenting with dyspnoea of sudden onset classified as stage II according to New York Heart Association (NYHA) classification, haemoptysis with self-medication by Ibuprofen for the past few days. Upon admission, the patient was afebrile, tachypnoeic at 28 cycles/min, tachycardic at 126 bpm, blood pressure 134/79 mmHg, arterial oxygen saturation 94% with diffuse crackling sounds in both lung fields. Laboratory tests showed microcytic hypochromic anaemia at 7.8 g/dl, white blood cells count 10,230/mm3, platelet count 260,000/mm3, incoagulable INR, serum creatinine 10.3 g/l, estimated glomerular filtration rate 77 ml/min/1.73 m2) (simplified MDRD formula), serum albumin level 34 g/l, protidaemia 63 g/l. Urine test strip was negative without haematuria or microalbuminuria. Serum levels of pANCA, cANCA, anti-glomerular basement membrane (GBM) antibodies, anti-DNA antibodies and rheumatoid factor were negative. Transthoracic echocardiogram showed normal ventricular function and no valve disease. Standard chest x-ray snapshots found diffuse bilateral alveolar lesions (Figure 1) in chronic phase, which has prompted us to pursue the investigation by chest CT scan, which found multiple bilateral alveolar lesions (Figure 2). Finally, bronchial endoscopy with bronchoalveolar lavage (BAL) was performed and found uniformly haemorrhagic fluid with sterile cultures.
din franceză în engleză: How to proceed after a failed vacuum delivery General field: Medical Detailed field: Medical (general)
Text sursă - franceză 1. Introduction
La ventouse obstétricale est devenue l’instrument d’extraction le plus utilisé en première intention en France dans les centres hospitaliers universitaires, entre autre du fait d’une courbe d’apprentissage plus rapide que celle du forceps [1].
Le Comité National des Gynécologues obstétriciens Français (CNGOF) a défini l’échec de ventouse par « trois lâchages ou l’absence de progression fœtale après six tractions ».
Son taux d’échec est variable dans la littérature : Revah et al retrouvent un taux de 1 % en étudiant une série de 4103 ventouses mais ne précise pas la hauteur de la présentation dans l’excavation pelvienne lors de la pose de l’instrument [2]. Dans une autre étude, les chiffres atteignent 38 % (122 ventouses étudiées) [3].
Après un échec de ventouse, l’obstétricien peut soit poursuivre la voie basse en changeant d’instrument – aux risques que ce dernier échoue à son tour – ou réaliser une césarienne. En effet, le CNGOF indique que « l’usage séquentiel de deux instruments traduit une extraction difficile et multiplie les risques par rapport à la voie basse spontanée ou à l’extraction réalisée avec un seul instrument » mais également « qu’il n’y a pas d’argument dans la littérature pour recommander un forceps ou une césarienne après un échec de ventouse. Le choix devant être adapté au cas par cas selon l’expérience de l’opérateur » [4].
L’objectif principal de cette étude était de comparer la morbidité maternofoetale chez les patientes ayant accouché par césarienne versus tentative de deuxième instrument après un échec de ventouse.
L’objectif secondaire était de décrire le devenir des fœtus nés par césarienne après échec de deuxième instrument.
2. Méthodes
2.1. Schéma de l’étude
Nous avons mené une étude rétrospective dans une maternité de type III entre le 1er janvier 2006 et le 31 décembre 2014 comparant deux groupes de patientes : césarienne d’emblée versus tentative d’un deuxième instrument après échec d’extraction par ventouse.
Traducere - engleză 1. Introduction
The vacuum extractor has become the most frequently used device for operative vaginal delivery in French university hospital centres, one of the reason being that it entails a shorter learning curve than the use of forceps [1].
The National College of French Gynaecologists and Obstetricians (CNGOF) has defined failed vacuum-assisted vaginal delivery as "three failed attempts or failure to progress after six tractions".
Its failure rate varies in the literature: Revah et al. found a rate of 1% in a series of 4,103 vacuum-assisted vaginal deliveries, but does not specify the height of fetal head presentation in the pelvic cavity when the device is placed [2]. In another study, the rate is up to 38% (122 vacuum-assisted vaginal deliveries studied) [3].
After a failed vacuum-assisted vaginal delivery, the obstetrician can either continue to pursue vaginal delivery, by changing the device - risking to fail again - or perform a c-section. Indeed, CNGOF indicates that “sequential use of two devices reflects a difficult extraction and multiplies the risks compared to spontaneous vaginal delivery or extraction performed using a single device” but also “that the literature does not provide enough evidence to recommend use of forceps or caesarean delivery after failed vacuum-assisted vaginal delivery. The choice must be made on a case by case basis, depending on obstetrician’s expertise" [4].
The primary endpoint of this study was to compare maternal and neonatal morbidity in patients having delivered by c-section versus attempted delivery using a second device after failed vacuum-assisted vaginal delivery.
The second endpoint was to describe the outcome of the fetus delivered by c-section after failure of a second device.
2. Methods
2.1. Outline of the study
We conducted a retrospective study in a tertiary maternity centre between 1st January 2006 and 31st December 2014 comparing two groups of patients: scheduled c-section versus attempted delivery using a second device after failed vacuum-assisted vaginal delivery.
din franceză în engleză: Anti-TNF alpha-induced eruptive nevi: Three cases General field: Medical Detailed field: Medical (general)
Text sursă - franceză Discussion
Les nævus éruptifs sont un phénomène rare caractérisé par l’apparition rapide de nombreux nævus. Les étiologies en sont l’immunosuppression, les thérapies ciblées, les maladies bulleuses auto-immunes, toxiques ou génétiques ou les stimulants de la mélanogenèse. Ils se différencient du développement de nævus acquis, progressif, fait de nævus « classiques » comme il peut être observé chez le patient immunodéprimé [22].
Récemment, des critères diagnostiques ont été proposés pour différencier les nævus éruptifs associés aux médicaments de l’augmentation du nombre de nævus chez le patient immunodéprimé. Ces critères comprennent le développement de un ou plusieurs des éléments suivants pendant une période de 6 mois, en association à la prise de médicaments :
plus de 5 nævus palmoplantaires à tout âge ;
plus de 10 nævus sur tout le corps en dehors de la puberté et de la grossesse ;
plus de 20 nævus pendant la puberté ou la grossesse [1].
Ces critères, bien que non validés « à grande échelle », sont respectés pour nos trois patients.
Deux grands mécanismes semblent impliqués dans la genèse des nævus éruptifs, comme le soulignent les différentes étiologies : le premier favoriserait la prolifération mélanocytaire soit par action directe comme avec le mélanotane [12,13], soit par phénomènes cicatriciels chroniques comme dans les dermatoses bulleuses [10—12], soit par action sur les voies intracellulaires de la croissance et de différenciation cellulaire comme observé avec les thérapies ciblées [6—9]. Le second serait l’immunodépression, comme en témoignent les nævus éruptifs chez les transplantés, dans les déficits immunitaires, ou les patients sous chimiothérapie [1,3—6]. Ce second mécanisme est probablement celui qui explique ce phénomène avec les anti-TNF-alpha, la rareté du phénomène avec ces biothérapies étant probablement liée au faible niveau d’immunodépression engendré.
Cinq observations de nævus éruptifs associés à la prise d’anti-TNF alpha ont déjà été rapportées (Tableau 1). Dans quatre cas, il s’agissait de patients souffrant de maladie de Crohn et recevant de façon concomitante un autre traitement (azathioprine, 6-mercaptopurine) connu comme potentiellement inducteur de nævus éruptifs [18—21]. Dans une seule observation, il s’agissait d’un patient recevant de l’étanercept en monothérapie pour un psoriasis. Ce même patient avait développé préalablement une première poussée de nævus éruptifs sous alefacept [18]. Dans nos trois nouvelles observations, les patients recevaient en monothérapie un anti-TNF alpha en première ligne. L’imputabilité intrinsèque et extrinsèque de ces traitements est donc forte. Ces observations montrent que les nævus éruptifs peuvent apparaître avec les différents anti-TNF alpha, quels que soient le sexe du patient et ses pathologies sous-jacentes, dermatologiques, digestives ou rhumatologiques.
Traducere - engleză Discussion
Eruptive naevi are a rare phenomenon characterised by rapid appearance of numerous naevi. Among the etiologies are immunosuppression, targeted therapies, autoimmune, toxic or genetic bullous diseases or melanogenesis stimulating agents. Their development differs from the acquired, progressive naevi, “classical” naevi, as observed in immunocompromised patients [22].
Recently, diagnostic criteria have been proposed for differentiating the eruptive naevi associated with drugs [intake] from the increase in the number of naevi in immunocompromised patients. These criteria include the development of one or several of the following elements over a period of 6 months, in association with drugs intake:
• more than 5 palmoplantar naevi at any age;
• more than 10 naevi on the entire body, except during puberty and pregnancy;
• more than 20 naevi during puberty or pregnancy [1].
Although not validated on “large scale”, these criteria were respected in [diagnosing] our three patients.
Two major mechanisms seem to be involved in the appearance of eruptive naevi, as stressed by the various etiologies: the first involves promotion of melanocytes proliferation, either by direct action, as in case of melanotan intake [12, 13], by chronic scarring phenomena, as in case of bullous dermatoses [10-12], or by acting on the intracellular pathways of cell growth and differentiation, as observed in case of targeted therapies [6-9].The second [mechanism] is immunosuppression, as evidenced by the eruptive naevi in transplant patients, [patients suffering from] immune deficiency, or patients receiving chemotherapy [1, 3-6].This second mechanism is probably explaining this phenomenon related with anti-TNF alpha [therapy]; the rarity of the phenomenon [associated] with these biotherapies is probably related to the low level of induced immunosuppression.
Five cases of eruptive naevi associated with anti-TNF alpha intake have already been reported (Table 1). Four cases involved patients suffering from Crohn's disease, concomitantly receiving another treatment (azathioprine, 6-mercaptopurine), known as potential inducer of eruptive naevi [18-21].Only one case involved a patient receiving monotherapy with etanercept for psoriasis. This patient previously developed a first outbreak of eruptive naevi under alefacept [18].In the three cases reported by us, the patients were receiving monotherapy with anti-TNF alpha, as first-line therapy. Therefore, the intrinsic and extrinsic causation score is high for these treatments. These cases show that eruptive naevi can appear with different anti-TNF alpha, regardless of the patients’ sex and underlying dermatological, gastrointestinal or rheumatic diseases.
din italiană în engleză: A case of severe isolated left main coronary artery stenosis in a young woman with previous history of non-Hodgkin lymphoma General field: Medical Detailed field: Medical: Cardiologie
Text sursă - italiană CASO CLINICO
Riportiamo il caso di una paziente di 34 anni giunta alla nostra osservazione per la comparsa da circa 4 mesi di dispnea da sforzo (classe NYHA II) ed intensa astenia. I dati anamnestici evidenziavano una storia di linfoma non-Hodgkin a sede mediastinica, insorto all’età di 16 anni e trattato con ripetuti cicli di radioterapia locoregionale e chemioterapia.
Il protocollo utilizzato prevedeva una dose totale radiante di 30 Gy, mentre lo schema farmacologico consisteva nella somministrazione di 6 cicli di chemioterapia con regime ABVD (doxorubicina, bleomicina, vinblastina, dacarbazina).
In anamnesi, inoltre, due gravidanze all’età di 30 e 33 anni, entrambe associate a preeclampsia. I fattori di rischio cardiovascolare tradizionali erano costituiti da ipertensione arteriosa, obesità moderata (indice di massa corporea 26 kg/m2) ed ipotiroidismo. Dopo la comparsa dei sintomi, la paziente si sottoponeva ad accertamenti cardiologici di primo livello. L’ECG a riposo non mostrava alterazioni di carattere ischemico; l’ecocardiogramma transtoracico evidenziava una moderata insufficienza mitralica, in assenza di anomalie della cinetica regionale e della funzione contrattile globale. Il test ergometrico, condotto fino a stadio massimale, era positivo per ischemia inducibile per soli criteri elettrocardiografici. Ad ottimizzazione diagnostica, in considerazione anche della giovane età della paziente, veniva eseguito un eco-stress farmacologico mediante dipiridamolo che mostrava un’ipocinesia inducibile a livello della regione apicale del ventricolo sinistro.
La paziente veniva ricoverata presso il nostro reparto per essere sottoposta a studio coronarografico mediante accesso radiale destro. L’angiografia coronarica mostrava una stenosi focale critica ostiale del tronco comune della coronaria sini stra, restante circolo coronarico indenne da stenosi angiograficamente critiche (Figura 1).
Dopo discussione collegiale del caso in sede di Heart Team, si è preferita una strategia di rivascolarizzazione percutanea, in considerazione sia della lesione isolata ma anche in relazione alle difficoltà tecniche derivanti dalle possibili aderenze toraciche, sequele a lungo termine della pregressa radioesposizione. La procedura di rivascolarizzazione percutanea è stata eseguita mediante predilatazione della lesione e successivo impianto di stent medicato all’everolimus 3.5 x 15 mm (Xience, Abbott Vascular, Abbott Park, IL, USA), completata da successiva post-dilatazione ed ottimizzazione finale mediante “kissing balloon” (Figura 2).
Il controllo post-procedurale eco-guidato mostrava una buona espansione dello stent ed un’ottimale copertura della lesione. Il decorso ospedaliero è stato privo di eventi, non complicanze vascolari significative.
La paziente è stata dimessa in quarta giornata, per permettere un adeguato monitoraggio clinico-strumentale, in ottime condizioni generali e completo benessere clinico. Il controllo ecocardiografico pre-dimissione ha evidenziato una funzione sistolica globale conservata. Il follow-up clinico-strumentale a 6 mesi risultava regolare; al controllo ecografico, riscontro di funzione ventricolare sinistra conservata.
Traducere - engleză CLINICAL CASE
We report the case of a 34-year-old female patient consulted for exertional dyspnoea (NYHA class II) and severe asthenia appeared about 4 months before. Her medical history included mediastinal non-Hodgkin lymphoma appeared at the age of 16 and treated with repeated cycles of locoregional radiotherapy and chemotherapy.
The protocol used involved a total radiation dose of 30 Gy and the chemotherapy consisted in the administration of 6 cycles of ABVD regimen (doxorubicin, bleomycin, vinblastine, dacarbazine).
Clinical history also included two pregnancies at 30 and 33 years of age, both associated with preeclampsia. The traditional cardiovascular risk factors included arterial hypertension, moderate obesity (BMI 26 kg/m2) and hypothyroidism. After onset of symptoms, the patient underwent first line cardiac screening. Resting ECG did not show ischaemic type abnormalities; transthoracic echocardiogram showed a moderate mitral regurgitation, without regional abnormalities regarding wall motion and overall contractile function. The ergometric [stress] test, performed up to maximum mechanical stress level, was positive only for stress-induced ischaemia electrocardiographic criteria. Considering the young age of the patient, a dipyridamole stress echo was performed in order to optimize the diagnosis, which showed induced hypokinesis in the apical region of the left ventricle.
The patient was admitted to our Department to undergo coronary angiography using right radial artery access. The coronary angiography found focal critical ostial stenosis of the left main coronary artery, the rest of the coronary circulation being free from agiographically critical stenosis (Figure 1).
Taking into consideration the isolated lesion and the technical difficulties related to possible thoracic adhesions, long-term sequelae of previous radiation exposure, percutaneous revascularization strategy was chosen after discussing the case with the multidisciplinary team at the Heart Team office. The percutaneous revascularization was performed by pre-dilation of the lesion and subsequent implantation of everolimus-eluting-stent 3.5 x 15 mm (Xience, Abbott Vascular, Abbott Park, IL, USA), completed by post-dilation and final optimization through “kissing balloon” (Figure 2).
The ultrasound-guided post-surgery checkup showed a good expansion of the stent and optimal coverage of the lesion. The hospital stay was uneventful, without significant vascular complications.
The patient was discharged on the fourth day after ensuring adequate monitoring using special equipment or instruments, in excellent general health condition and overall clinical well-being. The pre-discharge echocardiographic follow-up showed preserved overall systolic function. The six months follow-up using special equipment or instruments was unremarkable; the ultrasound checkup found preserved left ventricular function.
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