Low-dose aspirin for primary prevention of cardiovascular events in patients with diabetes: Benefit or risk?

Primary prevention aims to avert the onset of cardiovascular disease (CVD) by targeting its natural causes and risk factors; secondary prevention includes strategies and therapies that address preclinical or clinical evidence of CVD progression. The value of aspirin for primary CVD prevention is controversial because of increased bleeding, which may offset the overall modest benefits in patients with no overt CVD. In contrast, the benefits of aspirin for secondary prevention have been repeatedly and convincingly demonstrated to outweigh the risk of bleeding. Diabetes mellitus is a strong risk factor for cardiovascular events, and has been associated with an increased risk of both first and recurrent atherothrombotic events. Therefore, prevention of CVD, the major cause of mortality in patients with diabetes, is one of the most important therapeutic goals. Although the benefit of low-dose aspirin for secondary prevention of CVD is well established, its role for primary prevention remains inconclusive and controversial in diabetes patients. The benefit of aspirin for patients with CVD clearly exceeds the risk of bleeding, and even though a modest benefit has also been demonstrated in primary prevention, the trade-off for aspirin initiation against the increased risk of intracranial and gastrointestinal bleeding is more uncertain. Thus, aspirin for primary CVD prevention should be highly individualized, based on a benefit-risk ratio assessment for the given patient. In conclusion, the mere presence of diabetes is apparently not enough for aspirin to confer a benefit that clearly outweighs the risk of bleeding, and further evidence to the contrary is now needed.

The Treviso Dementia (TREDEM) Study: A Biomedical, Neuroradiological, Neuropsychological and Social Investigation of Dementia in North-Eastern Italy.

BACKGROUND: The incidence of dementia increases exponentially with age but knowledge of real disease-modifying interventions is still limited. OBJECTIVES: To describe the study design and methods of a large prospective cohort study aimed at exploring the complex underlying relationships existing among cognition, frailty, and health-related events in older persons with cognitive impairment. DESIGN: Prospective cohort study of a representative population of outpatients attending the Treviso Cognitive Impairment Center between 2000 and 2010. SETTING: The TREVISO DEMENTIA (TREDEM) Study conducted in Treviso, Italy. PARTICIPANTS: 490 men and 874 women, mean age 79.1 ± 7.8 years (range 40.2-100 years). MEASUREMENTS: Physiological data, biochemical parameters, clinical conditions, neuroradiological parameters (e.g., brain atrophy and cerebral vascular lesions identified by computerized tomography scans), neuropsychological assessment, and physical function markers were measured at baseline. Patients were followed-up to 10 years. RESULTS: The final sample included in the study was predominantly composed of women and characterized by an initial physical function impairment and increased vascular risk profile. Cognitive function of the sample population showed moderate cognitive impairment (Mini Mental State Examination 20.2 ± 6.3; Clinical Dementia Rating 1.2 ± 0.7), and a prevalence of vascular dementia of 26.9%. Cortical, subcortical and hippocampus atrophy were all significantly correlated with age and cognitive function. CONCLUSION: Results obtained from the preliminary analyses conducted in the TREDEM study suggest that the database will support the accomplishment of important goals in understanding the nature of cognitive frailty and neurodegenerative diseases.

Prognostic role of heart rate variability in patients with idiopathic dilated cardiomyopathy.

BACKGROUND: The aim of this study was to investigate whether heart rate variability may predict the outcome in patients with idiopathic dilated cardiomyopathy. METHODS: Time-domain and frequency-domain heart rate variability was analyzed on 24-hour Holter recordings of 56 patients with idiopathic dilated cardiomyopathy (70% males, mean age 49 +/- 16 years; left ventricular ejection fraction 28 +/- 6%). RESULTS: There were 8 cardiac deaths (14.3%) and 11 arrhythmic events (19.6%, either sudden death or sustained ventricular tachycardia) at a follow-up of 18.5 months (range 3-50 months). Furthermore, 6 patients were included in the list for cardiac transplantation, leading to a prevalence of total cardiac events of 37.5 % (21 patients). All time-domain and most frequency-domain heart rate variability parameters did not show any significant relationship with the end points. However, a low frequency to high frequency (LF/HF) ratio < 1.2 was associated with cardiac death (relative risk-RR 6.8, p < 0.03), arrhythmic events (RR 11.0, p < 0.004), and total cardiac events (RR 4.8, p < 0.002). On the multivariate Cox analysis, no variable showed an independent association with cardiac death, but an LF/HF ratio < 1.2 was the only variable independently predictive of arrhythmic events (RR 8.2, p < 0.02), and the most powerful predictor of total cardiac events (RR 3.8, p < 0.009). CONCLUSIONS: Our data show that, in patients with idiopathic dilated cardiomyopathy, a low LF/HF ratio, as assessed on 24-hour Holter recordings, is a powerful predictor of cardiac events.

Marchiafava-Bignami disease: computed tomographic scan, 99mTc HMPAO-SPECT, and FLAIR MRI findings in a patient with subcortical aphasia, alexia, bilateral agraphia, and left-handed deficit of constructional ability.

OBJECTIVES: To report and discuss the neuropsychological deficits and neuroimaging findings in a patient with probable Marchiafava-Bignami disease. DESIGN AND METHOD: A right-handed woman with chronic alcoholism demonstrated mutism, impaired comprehension of spoken language, alexia, and right-handed agraphia. The syndrome of interhemispheric disconnection was manifested by left-handed deficit of constructional ability and agraphia. The patient underwent brain computed tomographic scans, technetium 99 hexylmethylpropylene amineoxime-single photon emission computed tomography, and magnetic resonance imaging (MRI) that also included fluid attenuated inversion recovery images. SETTING: Clinical neurology department. RESULTS: The patient's symptoms were related to scattered lesions of the corpus callosum and to extensive symmetrical lesions of the centrum semiovale. Only the latter were detected by computed tomographic scans. Results of single photon emission computed tomography did not show areas of focal hypoperfusion. Results of fast spinecho MRI showed all lesions were hyperintense in T1-weighted images and hypointense in T2-weighted images. Fluid attenuated inversion recovery images revealed that periventricular lesions had a hypointense core surrounded by a hyperintense rim; callosal lesions were still hyperintense. CONCLUSIONS: We believe that our patient's symptoms are due to the discontinuous affection of the corpus callosum and to the bilateral cutting of the outflow from the cortex. The MRI findings may be interpreted as indicating central necrosis and peripheral demyelination of periventricular lesions and demyelination of the corpus callosum. The combined use of fast spin echo and fluid attenuated inversion recovery MRI reproduced with more accuracy than fast spin echo MRI alone some features of Marchiafava-Bignami disease known from observations at autopsy.

Magnetic resonance imaging and 67Ga scan versus computed tomography in the staging and in the monitoring of mediastinal malignant lymphoma: a prospective pilot study.

PURPOSE: To assess the potential value of magnetic resonance imaging (MRI) combined with 67Ga single-photon emission computed tomography (SPECT) versus computed tomography (CT) in the staging and in the monitoring of mediastinal malignant lymphoma. MATERIALS AND METHODS: Twenty-three patients, referred to our institute for the evaluation of lymphoma, underwent CT, 67Ga scan, and MRI between April 1993 and February 1996 at sequential intervals. The tests studied (MRI, 67Ga, and CT) were performed according to the following schedule: 1) before start of therapy; 2) after four courses of chemotherapy; and 3) 2, 6, 12, and 18 months after the end of treatment. RESULTS: All patients studied at the time of diagnosis had abnormal gallium accumulation in the mediastinum as well as pathologic CT and pathologic signal intensity at MRI. Six months after the end of treatment full consistency was found between the results of MRI and SPECT, whereas during treatment and 2 months after the end of therapy MRI and 67Ga scan were not in agreement in nine patients. In the 23 patients in follow-up, in CT there were nine false-positive and three false-negative findings; in SPECT three false negatives; in MRI one false positive and one false negative. CONCLUSION: MRI can give morphologic information similar to CT, even superior due to multiplanarity and with major precision in the distinction between fibrosis and active disease. MRI is thus an alternative to CT. The association with SPECT allows a great diagnostic accuracy in the positive and negative predictive value.

Electrograms for identification of the atrial ablation site during catheter ablation of accessory pathways.

BACKGROUND: Catheter ablation of accessory pathways using radiofrequency current has been shown to be effective in patients with Wolff-Parkinson-White syndrome, by using either the ventricular or atrial approach. However, the unipolar electrogram criteria for identifying a successful ablation at the atrial site are not well established. METHODS AND RESULTS: One hundred patients with Wolff-Parkinson-White were treated by delivering radiofrequency energy at the atrial site. Attempts were considered successful when ablation (disappearance of the delta wave) occurred in < 10 seconds. In eight patients with concealed pathway, the accessory pathway location was obtained by measuring the shortest V-A interval either during ventricular pacing or spontaneous or induced reciprocating tachycardia. In 92 patients both atrioventricular valve annuli were mapped during sinus rhythm, in order to identify the accessory pathway (K) potential before starting the ablation procedure. When a stable filtered (30-250 Hz) "unipolar" electrogram was recorded, the following time intervals were measured: (1) from the onset of the atrial to the onset of the K potential (A-K); (2) from the onset of the delta wave to the onset of the K potential (delta-K); and (3) from the onset of the K potential to the onset of the ventricular deflection (K-V). During unsuccessful versus successful attempts, A-K (51 +/- 11 ms vs 28 +/- 8 ms, P < 0.0001 for left pathways [LPs]; and 44 +/- 8 ms vs 31 +/- 8 ms, P < 0.02 for right pathways [RPs]) and delta-K intervals (2 +/- 9 ms vs -18 +/- 10 ms, P < 0.0001 for LPs; and 13 +/- 7 ms vs 5 +/- 8 ms, P < 0.02 ms for RPs) were significantly longer. CONCLUSIONS: Short A-K interval (< 40 ms), and a negative delta-K interval recorded from the catheter positioned in the atrium are strong predictors of successful ablation of LPs and RPs. Therefore, the identification of the K potential appears to be of paramount importance for positioning of the ablation catheter, followed by analysis of A-K and delta-K unipolar electrogram intervals. However, it appears that the mere recording of K potential is not, per se, predictive of successful outcome, but rather the A-K and delta-K interval.

[Magnetic resonance with fat-saturation sequences in studying the upper abdomen: the normal semeiological aspects]. / Risonanza Magnetica con sequenze con saturazione del grasso nello studio dell' addome superiore: aspetti semeiologici normali.

The fat-saturation (FAT-SAT) MR technique decreases the signal intensity of fat in tissues, though yielding the T1, T2 and proton-density (PD) information available on spin-echo (SE) sequences. To investigate the potentials of FAT-SAT sequences in MRI of the upper abdomen, the authors carried out a prospective study including 129 subjects, namely 12 normal volunteers and 117 patients with different abdominal conditions. The patients were submitted to T1-weighted SE sequences (TR 500-600 ms, TE 15 ms), T2W SE (TR 1600-1730 ms, TE 80 ms) and PD SE (TR 1600-1730 ms, TE 20 ms). The images obtained with and without fat suppression were compared both qualitatively and quantitatively, with a special emphasis on the normal anatomy of the upper abdomen: we investigated the efficacy of subcutaneous and retroperitoneal fat suppression (116/129 cases, 90%), the reduction in respiratory and chemical shift artifacts (112/129 cases, 87%) and the better visualization of parenchyma (119/129 cases, 93%) and of other abdominal structures. Concerning the quantitative study, we calculated the signal-to-noise ratio (S/N) for liver, spleen, pancreas, adrenal glands, renal cortex and medulla, the improvement of contrast in these organs after retroperitoneal fat suppression (conspicuity) and the increase in contrast between organs (dynamic range). The statistical analysis showed significant differences between the sequences with and those without fat suppression. Correlations were found between observers' and quantitative evaluations, suggesting that the better yield of FAT-SAT sequences is probably due to three factors: 1) retroperitoneal and subcutaneous fat suppression; 2) increase in S/N ratio for pancreas and renal cortex on T1W images; 3) reduction in the dynamic range of signal intensity, which increases contrast between pancreas, adrenal glands and renal cortex relative to adjacent structures, especially on T2W or PD sequences. The results of this study suggest that FAT-SAT sequences are useful because fat suppression increases contrast and improves image quality, reducing respiratory and chemical shift artifacts.

Catheter ablation of left accessory atrioventricular connections: the transseptal approach.

BACKGROUND: In the past few years, there has been a relative explosion of activity in the realm of interventional cardiology. The high rate of success of radiofrequency energy ablation have transformed catheter ablation from an investigational procedure into the first-line therapy for symptomatic Wolff-Parkinson-White syndrome. Radiofrequency catheter ablation for preexcitation syndrome is commonly based on a ventricular approach. Such an approach might be associated with the risk of prolonged arterial catheter manipulation, retrograde left ventricular catheterization, and production of multiple, potentially arrhythmogenic, ventricular lesions created during ablation. Potential risks can be avoided using atrial insertion ablation procedures. The transseptal procedure that was developed in the 1950s and 1960s as a diagnostic procedure and then shelved in the 1970s and early 1980s has now come back into prominence as a therapeutic technique in the treatment of valvular heart disease, and then in the ablation of the left accessory atrioventricular connections. METHODS: Atrial aspect of mitral annulus is a relatively smooth, nonobstructed surface that simplifies catheter movement, thereby permitting rapid and accurate accessory pathway location. Although primary use of earliest endocardial retrograde atrial activation as a marker of accessory pathway atrial insertion is sufficiently accurate to permit successful ablation, direct recording of an accessory pathway potential is an important predictor of successful ablation site. Moreover, the analysis of the unipolar atrial electrogram, recorded during sinus rhythm from the tip of the ablation catheter, provides further information for localizing the atrial insertion of the accessory pathways. Shortest atrial-accessory pathway and negative delta-accessory pathway intervals have been found to be the best predictors of the successful site. RESULTS: A 90.5% success of the transseptal approach on an overall population of 328 patients, higher for overt than for concealed pathways, is comparable with the results of the retrograde. Complications are 0.5%. CONCLUSION: In conclusion, the transseptal approach for ablation at the atrial site is very safe and highly effective, and avoids prolonged arterial cannulation and catheter manipulation in the ascending aorta and left ventricle.

[The role of the absolute value and "density" of the prostate-specific antigen estimated echographically in the selection of patients to undergo a biopsy in suspected prostatic carcinoma. A comparison between PSA, palpation and echography in 95 patients undergoing echo-guided endorectal prostatic biopsy]. / Ruolo del valore assoluto e della "densità" dell'antigene prostatico specifico, valutata ecograficamente, nella selezione dei pazienti da sottoporre a biopsia nel sospetto di carcinoma prostatico. Confronto tra PSA, palpazione ed ecografia in 95 pazienti sottoposti a biopsia prostatica endorettale ecoguidata.

We retrospectively reviewed the findings relative to 95 patients with known prostate specific antigen (PSA) values who had undergone digital rectal examination, transrectal US and US-guided biopsy for suspected prostate carcinoma. Histology (48 adenocarcinomas, 26 BPHs, 12 inflammations and 9 negatives) was compared with results from rectal examination, prostate US, PSA values and "density" (PSA/prostatic volume, as measured with US). PSA values < 4 ng/ml exhibited 90% negative predictive value and PSA > 10 ng/ml 70.8% positive predictive value. In the intermediate range (4-9.9 ng/ml) the positive predictive value of PSA was 44.4% and its negative predictive value was 55.5%. PSA density did not affect predictive values in the two groups with PSA < 4 and > 10 ng/ml, while in the intermediate 4-9.9 ng/ml group, positive predictive value raised to 62.5% and negative predictive value to 81.8%, thus increasing the specificity of PSA values and US findings. Our results suggest that PSA should be the examination of choice in the patients with prostatic disease. Follow-up with PSA dosage after one year may be suggested when PSA < 4 ng/ml. PSA density can be helpful in patients with PSA values ranging 4-9.9 ng/ml; biopsy should be performed when the index > 0.15, while follow-up at 6 months should be performed when the index < 0.15. PSA values > 10 ng/ml require further evaluation with rectal examinations, prostate US and US-guided biopsy. Random biopsies are suggested when PSA values are > 20 ng/ml.

[Renal echography in diabetes mellitus]. / Apporto dell'ecografia renale nel diabete mellito.

The US findings in the kidneys of diabetic patients were studied. Diabetic subjects without clinical or laboratory signs of nephropathy were investigated by means of US in order to detect early anatomical lesions predictive of renal injury. The kidneys of cadaver diabetics were also studied to correlate US and histologic patterns. US alterations were observed in half of the cases: they were diffuse in 9% of cases and focal in 39%--hyperechoic spots and hyperechoic juxta-medulla. Focal spots are more common in juvenile-onset diabetics and they are correlated with the age of diabetes. At histology the above US patterns were correlated with the vascular wall alterations typical of diabetic nephropathy. Diffuse alterations are not specific. The authors conclude by suggesting US as a prognostic test for diabetic nephropathy.