Federica Moscucci

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt (TIPS) has been used for more than 20 years to treat some of the complications of portal hypertension. When TIPS was initially proposed, it was claimed that the optimal calibration of the shunt could allow an adequate reduction of portal hypertension, avoiding, at the same time, the occurrence of hepatic encephalopathy (HE), a neurologic syndrome. However, several clinical observations have shown that HE occurred rather frequently after TIPS, and HE has become an important issue to be taken into consideration in TIPS candidates and a problem to be faced after the procedure.

Previous overt hepatic encephalopathy rather than minimal hepatic encephalopathy impairs health-related quality of life in cirrhotic patients

It has been observed that overt hepatic encephalopathy (HE) is accompanied by a persistent cognitive defect, suggesting that HE may not be fully reversible. The health‐related quality‐of‐life (HRQoL) has been shown to be impaired by cirrhosis, and, according to some reports, influenced by minimal HE. Little is known about the effect of previous HE on HRQoL.

A Simplified Psychometric Evaluation for the Diagnosis of Minimal Hepatic Encephalopathy

BACKGROUND & AIMS The psychometric hepatic encephalopathy score (PHES), which includes 5 psychometric tests, is a standard for the diagnosis of minimal hepatic encephalopathy (HE). We investigated whether a simplified PHES (SPHES) is as useful as the whole PHES. METHODS The PHES was determined for 79 cirrhotic patients (the training group), who were followed up for the development of overt HE. Backward logistic regression was performed by eliminating stepwise variables--removal did not impair regression. A separate series of 65 patients was used as a validation group. RESULTS The PHES was abnormal in 45 patients. The SPHES, determined from the digit symbol, serial dotting, and line tracing tests, did not differ significantly from the full PHES; 24 of the 79 patients developed overt HE. The likelihood of developing overt HE was higher among patients with an abnormal PHES (log-rank P = .003) or SPHES (P = .004). By using Cox regression and model for end-stage liver disease scores to analyze data from patients with previous HE and transjugular intrahepatic portosystemic shunts, PHES (relative risk, 4.16; P = .003) and SPHES (relative risk, 3.70; P = .004) were the only variables associated with the development of overt HE. The accuracy of the SPHES was confirmed in the validation group. CONCLUSIONS A simplified PHES is as good as the PHES in diagnosing minimal HE and in predicting the occurrence of overt HE.

Influence of aging and chronic heart failure on temporal dispersion of myocardial repolarization

Background and purpose: QT and Tpeak-Tend (Te) intervals are associated with sudden cardiac death in patients with chronic heart failure (CHF). We studied age-dependent influence on short-term temporal dispersion of these two variables in patients with postischemic CHF. Method: We grouped 75 CHF and 53 healthy control subjects into three age subsets: ≤50 years, >50 years and ≤65 years, and >65 years. We then calculated the following indices: QT and Te variability index (QTVI and TeVI), the ratio between the short-term variability (STV) of QT or Te, and the STV of resting rate (RR) (QT/RR STV and Te/RR STV). Results: In all different age subgroups, patients with CHF showed a higher level of QTVI than age-matched control subjects (≤50 years: P < 0.0001; >50 years and ≤65 years: P < 0.05; >65 years: P < 0.05). Patients with CHF < 50 years old also had all repolarization variability indices higher than normal age-matched controls (TeVI, P < 0.05; QT/RR STV, P < 0.05; Te/RR STV, P < 0.05), whereas we did not find any difference between the two older classes of subjects. Both QTVI (r2: 0.178, P < 0.05) and TeVI (r2: 0.433, P < 0.001) were positively related to age in normal subjects, even if the first correlation was weaker than the second one. Conclusion: Our data showed that QTVI could be used in all ages to evaluate repolarization temporal liability, whereas the other indices are deeply influenced by age. Probably, the age-dependent increase in QTVI was more influenced by a reduction of RR variability reported in older normal subjects.

Mediterranean diet impact on cardiovascular diseases: A narrative review

&NA; Cardiovascular disease (CVD) accounts for more than 17 million deaths per year worldwide. It has been estimated that the influence of lifestyle on CVD mortality amounts to 13.7% for smoking, 13.2% for poor diet, and 12% for inactive lifestyle. These results deeply impact both the healthy status of individuals and their skills in working. The impact of CVD on productivity loss accounts for the 24% in total costs for CVD management. Mediterranean diet (MedD) can positively impact on natural history of CVD. It is characterized by a relatively high consumption of inexpensive and genuine food such as cereals, vegetables, legumes, nuts, fish, fresh fruits, and olive oil as the principal source of fat, low meat consumption and low-to-moderate consumption of milk, dairy products, and wine. Its effects on cardiovascular health are related to the significant improvements in arterial stiffness. Peripheral artery disease, coronary artery disease, and chronic heart failure are all positively influenced by the MedD. Furthermore, MedD lowers the risk of sudden cardiac death due to arrhythmias. The present narrative review aims to analyze the effects of MedD on CVD.

Myocardial repolarization dispersion and autonomic nerve activity in a canine experimental acute myocardial infarction model.

BACKGROUND Evidence from a canine experimental acute myocardial infarction (MI) model shows that until the seventh week after MI, the relationship between stellate ganglion nerve activity (SGNA) and vagal nerve activity (VNA) progressively increases. OBJECTIVE The purpose of this study was to evaluate how autonomic nervous system activity influences temporal myocardial repolarization dispersion at this period. METHODS We analyzed autonomic nerve activity as well as QT and RR variability from recordings previously obtained in nine dogs. From a total of 48 short-term ECG segments, 24 recorded before and 24 recorded 7 weeks after experimentally-induced MI, we obtained three indices of temporal myocardial repolarization dispersion: QTe (from Q-wave to T-wave end), QTp (from Q-wave to T-wave peak), and Te (from T-wave peak to T-wave end) variability index (QTeVI, QTpVI, TeVI). We also performed heart rate variability power spectral analysis on the same segments. RESULTS After MI, all the QT variables increased QTeVI (median [interquartile range]) (from -1.76[0.82] to -1.32[0.68]), QTeVI (from -1.90[1.01] to -1.45[0.78]), and TeVI (from -0.72[0.67] to -0.22[1.00]), whereas all RR spectral indices decreased (P <.001 for all). Distinct circadian rhythms in QTeVI (P <.05,) QTpVI (P <.001) and TeVI (P <.05) appeared after MI with circadian variations resembling that of SGNA/VNA. The morning QTpVI and TeVI acrophases approached the SGNA/VNA acrophase. Conversely, the evening QTeVI acrophase coincided with another SGNA/VNA peak. After MI, regression analysis detected a positive relationship between SGNA/VNA and TeVI (R(2): 0.077; β: 0.278; p< 0.001). CONCLUSION Temporal myocardial repolarization dispersion shows a circadian variation after MI reaching its peak at a time when sympathetic is highest and vagal activity lowest.

Transcranial direct current stimulation enhances soothing positive affect and vagal tone

ABSTRACT Transcranial Direct Current Stimulation (tDCS) is a promising tool for the treatment of depression and the dorsolateral prefrontal cortex (dlPFC) is often targeted when exploring tDCS effects on mood. However, the basic effects of tDCS on momentary emotions are inconsistent. We tested whether a single‐session of anodal tDCS over the left temporal lobe (T3), topographically closer to the insular cortex than dlPFC, had effects on both vagally‐mediated heart rate variability (HRV) and momentary affect in healthy participants. Thirty‐four subjects underwent both sham and active tDCS in a counterbalanced random order. ECG was continuously recorded to derive both time and frequency domain HRV indexes. Before and after the tDCS protocol, participants completed momentary affect assessments. Results showed that HRV and soothing positive affectivity were both enhanced after a single‐session of tDCS over T3, while negative and activating positive affect were not modulated by the stimulation. After controlling for sex, age, and levels of anxiety and depression a significant association emerged between increases in soothing positive affect and concomitant increases in vagally‐mediated HRV. Deficits in soothing positive emotions have consistently been associated with psychopathology and psychotherapeutic approaches aimed to develop this type of emotionality have shown to improve psychological well‐being. Thus, present exploratory results may impact future research investigating potential moderators (site of stimulation) and mediators (specificity for a determined type of momentary affect) of the effects of tDCS on psychopathological conditions such as depression. HIGHLIGHTSThe basic effects of tDCS on momentary emotions are inconsistent.A single‐session anodal tDCS over T3 increased HRV and soothing positive affect.Increases in soothing positive affect were associated with increases in HRV.Results suggest moderators and mediators of the effects of tDCS on depression.

Age at menopause: A fundamental data of interest to acquire in female patients' anamnesis.

Although menopause is a universal phenomenon among women, the timing of the onset and the duration of the menopausal transition and the timing of the final menstrual period are not so codified. Compelling evidence supports the idea that the different impact of cardiovascular disease and the differences in vascular biology in men and women may be, at least in part, related to the cardiovascular and metabolic effects of sex steroid hormones. Indeed, androgens and estrogens influence a multitude of vascular biological processes and their cardiovascular effects are multifaceted. Gender pharmacology has proven that men and women have tiny but not paltry different effects to the same drug. Estrogens exert potential beneficial effects on the cardiovascular system in both sexes. It is evident that there is a need for the physician who approaches the female patient, to stress the main anamnestic data concerning her hormonal life starting from menarche, through pregnancy, until menopause. Thus it will be not only a formality becoming a cornerstone of the first doctor-patient relationship, both for in- and outpatient, we will have a clear and complete representation of the etiology and evolution of cardiovascular diseases that increasingly afflict the female gender.

Transcranial direct current stimulation improves the QT variability index and autonomic cardiac control in healthy subjects older than 60 years

Background Noninvasive brain stimulation technique is an interesting tool to investigate the causal relation between cortical functioning and autonomic nervous system (ANS) responses. Objective The objective of this report is to evaluate whether anodal transcranial direct current stimulation (tDCS) over the temporal cortex influences short-period temporal ventricular repolarization dispersion and cardiovascular ANS control in elderly subjects. Subjects and methods In 50 healthy subjects (29 subjects younger than 60 years and 21 subjects older than 60 years) matched for gender, short-period RR and systolic blood pressure spectral variability, QT variability index (QTVI), and noninvasive hemodynamic data were obtained during anodal tDCS or sham stimulation. Results In the older group, the QTVI, low-frequency (LF) power expressed in normalized units, the ratio between LF and high-frequency (HF) power, and systemic peripheral resistances decreased, whereas HF power expressed in normalized units and α HF power increased during the active compared to the sham condition (P<0.05). Conclusion In healthy subjects older than 60 years, tDCS elicits cardiovascular and autonomic changes. Particularly, it improves temporal ventricular repolarization dispersion, reduces sinus sympathetic activity and systemic peripheral resistance, and increases vagal sinus activity and baroreflex sensitivity.

Intra-QT spectral coherence as a possible noninvasive marker of sustained ventricular tachycardia

Sudden cardiac death is the main cause of mortality in patients affected by chronic heart failure (CHF) and with history of myocardial infarction. No study yet investigated the intra-QT phase spectral coherence as a possible tool in stratifying the arrhythmic susceptibility in patients at risk of sudden cardiac death (SCD). We, therefore, assessed possible difference in spectral coherence between the ECG segment extending from the q wave to the T wave peak (QTp) and the one from T wave peak to the T wave end (T e) between patients with and without Holter ECG-documented sustained ventricular tachycardia (VT). None of the QT variability indexes as well as most of the coherences and RR power spectral variables significantly differed between the two groups except for the QTp-T e spectral coherence. The latter was significantly lower in patients with sustained VT than in those without (0.508 ± 0.150 versus 0.607 ± 0.150, P < 0.05). Although the responsible mechanism remains conjectural, the QTp-T e spectral coherence holds promise as a noninvasive marker predicting malignant ventricular arrhythmias.