Acute kidney injury after massive attack of Africanised bees

Acute kidney injury (AKI) is a well-documented complication of massive attack by Africanised bees and can be observed 48-72 h after the accident. We report a case of Africanised bees attack followed by severe and lethal AKI. A 56-year-old man was admitted to emergency department after a massive attack of Africanised bees (>1000 bee stings). He was unconscious, presenting with hypotension and tachycardia. Mechanical ventilation, volume expansion and care for anaphylaxis were instituted. The patient was transferred to the intensive care unit (ICU) and after 48 h he developed rhabdomyolysis, oliguria, increased creatinine levels, hyperkalaemia and refractory acidosis. A diagnosis of AKI secondary to rhabdomyolysis and shock was made. The patient was treated with a prolonged course of haemodialysis. However, he progressed to refractory shock and died 5 days after admission.

Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndromes and a History of Stroke or Transient Ischemic Attack

Background-Patients with acute coronary syndromes and history of stroke or transient ischemic attack (TIA) have an increased rate of recurrent cardiac events and intracranial hemorrhages. Methods and Results-We evaluated treatment effects of ticagrelor versus clopidogrel in patients with acute coronary syndrome with and without a history of prior stroke or TIA in the PLATelet inhibition and patient Outcomes (PLATO) trial. Of the 18 624 randomized patients, 1152 (6.2%) had a history of stroke or TIA. Such patients had higher rates of myocardial infarction (11.5% versus 6.0%), death (10.5% versus 4.9%), stroke (3.4% versus 1.2%), and intracranial bleeding (0.8% versus 0.2%) than patients without prior stroke or TIA. Among patients with a history of stroke or TIA, the reduction of the primary composite outcome and total mortality at 1 year with ticagrelor versus clopidogrel was consistent with the overall trial results: 19.0% versus 20.8% (hazard ratio, 0.87; 95% confidence interval, 0.66-1.13; interaction P=0.84) and 7.9% versus 13.0% (hazard ratio, 0.62; 95% confidence interval, 0.42-0.91). The overall PLATO-defined bleeding rates were similar: 14.6% versus 14.9% (hazard ratio, 0.99; 95% confidence interval, 0.71-1.37), and intracranial bleeding occurred infrequently (4 versus 4 cases, respectively). Conclusions-Patients with acute coronary syndrome with a prior history of ischemic stroke or TIA had higher rates of clinical outcomes than patients without prior stroke or TIA. However, the efficacy and bleeding results of ticagrelor in these high-risk patients were consistent with the overall trial population, with a favorable clinical net benefit and associated impact on mortality.

Rivaroxaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of ROCKET AF

Background In ROCKET AF, rivaroxaban was non-inferior to adjusted-dose warfarin in preventing stroke or systemic embolism among patients with atrial fibrillation (AF). We aimed to investigate whether the efficacy and safety of rivaroxaban compared with warfarin is consistent among the subgroups of patients with and without previous stroke or transient ischaemic attack (TIA). Methods In ROCKET AF, patients with AF who were at increased risk of stroke were randomly assigned (1:1) in a double-blind manner to rivaroxaban 20 mg daily or adjusted dose warfarin (international normalised ratio 2-0-3.0). Patients and investigators were masked to treatment allocation. Between Dec 18,2006, and June 17,2009,14 264 patients from 1178 centres in 45 countries were randomly assigned. The primary endpoint was the composite of stroke or non-CNS systemic embolism. In this substudy we assessed the interaction of the treatment effects of rivaroxaban and warfarin among patients with and without previous stroke or TIA. Efficacy analyses were by intention to treat and safety analyses were done in the on-treatment population. ROCKET AF is registered with ClinicalTrials.gov, number NCT00403767. Findings 7468 (52%) patients had a previous stroke (n=4907) or TIA (n=2561) and 6796 (48%) had no previous stroke or TIA. The number of events per 100 person-years for the primary endpoint in patients treated with rivaroxaban compared with warfarin was consistent among patients with previous stroke or TIA (2.79% rivaroxaban vs 2.96% warfarin; hazard ratio [HR] 0-94,95% CI 0.77-1.16) and those without (1.44% vs 1.88%; 0.77, 0.58-1-01; interaction p=0.23). The number of major and non-major clinically relevant bleeding events per 100 person-years in patients treated with rivaroxaban compared with warfarin was consistent among patients with previous stroke or TIA (13.31% rivaroxaban vs 13.87% warfarin; HR 0.96,95% CI 0.87-1-07) and those without (16.69% vs 15.19%; 1.10, 0.99-1.21; interaction p=0.08). Interpretation There was no evidence that the relative efficacy and safety of rivaroxaban compared with warfarin was different between patients who had a previous stroke or TIA and those who had no previous stroke or TIA. These results support the use of rivaroxaban as an alternative to warfarin for prevention of recurrent as well as initial stroke in patients with AF.

Timing attack di Paul C. Kocher: attacco al sistema di sicurezza RSA mediante strumenti di statistica

In questa tesi ho voluto descrivere il Timing Attack al sistema crittografico RSA, il suo funzionamento, la teoria su cui si basa, i suoi punti di forza e i punti deboli. Questo particolare tipo di attacco informatico fu presentato per la prima volta da Paul C. Kocher nel 1996 all’“RSA Data Security and CRYPTO conferences”. Nel suo articolo “Timing Attacks on Implementations of Diffie-Hellman, RSA, DSS, and Other Systems” l’autore svela una nuova possibile falla nel sistema RSA, che non dipende da debolezze del crittosistema puramente matematiche, ma da un aspetto su cui nessuno prima di allora si era mai soffermato: il tempo di esecuzione delle operazioni crittografiche. Il concetto è tanto semplice quanto geniale: ogni operazione in un computer ha una certa durata. Le variazioni dei tempi impiegati per svolgere le operazioni dal computer infatti, necessariamente dipendono dal tipo di algoritmo e quindi dalle chiavi private e dal particolare input che si è fornito. In questo modo, misurando le variazioni di tempo e usando solamente strumenti statistici, Kocher mostra che è possibile ottenere informazioni sull’implementazione del crittosistema e quindi forzare RSA e altri sistemi di sicurezza, senza neppure andare a toccare l’aspetto matematico dell’algoritmo. Di centrale importanza per questa teoria diventa quindi la statistica. Questo perché entrano in gioco molte variabili che possono influire sul tempo di calcolo nella fase di decifrazione: - La progettazione del sistema crittografico - Quanto impiega la CPU ad eseguire il processo - L’algoritmo utilizzato e il tipo di implementazione - La precisione delle misurazioni - Ecc. Per avere più possibilità di successo nell’attaccare il sistema occorre quindi fare prove ripetute utilizzando la stessa chiave e input differenti per effettuare analisi di correlazione statistica delle informazioni di temporizzazione, fino al punto di recuperare completamente la chiave privata. Ecco cosa asserisce Kocher: “Against a vulnerable system, the attack is computationally inexpensive and often requires only known ciphertext.”, cioè, contro sistemi vulnerabili, l’attacco è computazionalmente poco costoso e spesso richiede solo di conoscere testi cifrati e di ottenere i tempi necessari per la loro decifrazione.

Ict security: Testing methodology for targeted attack defence tools

La tesi di laurea presentata si inserisce nell’ampio contesto della Sicurezza Informatica, in particolare tratta il problema del testing dei sistemi di sicurezza concepiti per contrapporsi alle odierne minacce: gli attacchi mirati (Targeted Attacks) ed in generale le minacce avanzate persistenti (Advanced Persistent Threats). Il principale obiettivo del lavoro svolto è lo sviluppo e la discussione di una metodologia di test per sistemi di sicurezza focalizzati su questo genere di problemi. Le linee guida proposte hanno lo scopo di aiutare a colmare il divario tra quello che viene testato e quello che in realt`a deve essere affrontato realmente. Le attività svolte durante la preparazione della tesi sono state sia di tipo teorico, per quanto concerne lo sviluppo di una metodologia per affrontare al meglio il testing di sistemi di sicurezza a fronte di attacchi mirati, che ne di tipo sperimentale in quanto si sono utilizzati tali concetti per lo svolgimento di test su più strumenti di difesa in uno scenario d’interesse reale.

Copeptin and risk stratification in patients with ischemic stroke and transient ischemic attack: The CoRisk Study

RATIONALE: Copeptin independently predicts functional outcome and mortality at 90 days and one-year after ischemic stroke. In patients with transient ischemic attack, elevated copeptin values indicate an increased risk of further cerebrovascular events. AIMS: The Copeptin Risk Stratification (CoRisk) study aims to validate the predictive value of copeptin in patients with ischemic stroke and transient ischemic attack. In patients with ischemic stroke, the CoRisk study aims to further explore the effect of treatment (i.e. thrombolysis) on the predictive value of copeptin. DESIGN: Prospective observational multicenter study analyzing three groups of patients, i.e. patients with ischemic stroke treated with and without thrombolysis and patients with transient ischemic attack. OUTCOMES: Primary end-point: In patients with ischemic stroke, the primary end-point includes disability (modified Rankin scale from 3 to 5) and mortality (modified Rankin scale 6) at three-months after stroke. In patients with transient ischemic attack, the primary end-point is a recurrent ischemic cerebrovascular event (i.e. ischemic stroke or recurrent transient ischemic attack). Secondary end-point: In patients with ischemic stroke, the secondary end-points include in-house complications (i.e. symptomatic intracerebral hemorrhage, malignant edema, aspiration pneumonia or seizures during hospitalization, and in-house mortality).

Sleep-disordered breathing in acute ischemic stroke and transient ischemic attack: effects on short- and long-term outcome and efficacy of treatment with continuous positive airways pressure - rationale and design of the SAS CARE study

Sleep-disordered breathing represents a risk factor for cardiovascular morbidity and mortality and negatively affects short-term and long-term outcome after an ischemic stroke or transient ischemic attack. The effect of continuous positive airways pressure in patients with sleep-disordered breathing and acute cerebrovascular event is poorly known. The SAS CARE 1 study assesses the effects of sleep-disordered breathing on clinical evolution, vascular functions, and markers within the first three-months after an acute cerebrovascular event. The SAS CARE 2 assesses the effect of continuous positive airways pressure on clinical evolution, cardiovascular events, and mortality as well as vascular functions and markers at 12 and 24 months after acute cerebrovascular event.

[Management of transient ischemic attack (TIA) and acute stroke]

Patients with a transient ischemic attack and an acute stroke need urgent investigations and therapy in a stroke unit. Immediate investigation of the etiology and early secondary prevention measures reduce the likelihood of recurrent and other vascular events. In selected stroke patients intravenous thrombolysis and/or endovascular therapies lead to a significant reduction of long term disabilities.