Poor predictive value of contemporary bleeding risk scores during long-term treatment of venous thromboembolism. A multicentre retrospective cohort study.

Bleeding is a common and feared complication of oral anticoagulant therapy. Several prediction models have been recently developed, but there is a lack of evidence in patients with venous thromboembolism (VTE). The aim of this study was to validate currently available bleeding risk scores during long-term oral anticoagulation for VTE. We retrospectively included adult patients on vitamin K antagonists for VTE secondary prevention, followed by five Italian Anticoagulation Clinics (Cuneo, Livorno, Mantova, Napoli, Varese), between January 2010 and August 2012. All bleeding events were classified as major bleeding (MB) or clinically-relevant-non-major-bleeding (CRNMB). A total of 681 patients were included (median age 63 years; 52.0% female). During a mean follow-up of 8.82 (± 3.59) months, 50 bleeding events occurred (13 MB and 37 CRNMB), for an overall bleeding incidence of 9.99/100 patient-years. The rate of bleeding was higher in the first three months of treatment (15.86/100 patient-years) than afterwards (7.13/100 patient-years). The HAS-BLED showed the best predictive value for bleeding complications during the first three months of treatment (area under the curve [AUC] 0.68, 95% confidence interval [CI] 0.59-0.78), while only the ACCP score showed a modest predictive value after the initial three months (AUC 0.61, 95%CI 0.51-0.72). These two scores had also the highest sensitivity and the highest negative predictive value. None of the scores predicted MB better than chance. Currently available bleeding risk scores had only a modest predictive value for patients with VTE. Future studies should aim at the creation of a new prediction rule, in order to better define the risk of bleeding of VTE patients.

Can IVUS-virtual histology improve outcomes of percutaneous carotid treatment?

Several previous studies focusing on comparison between outcomes of carotid artery stenting (CAS) and carotid endoarterectomy (CEA) have put forward conflicting results about the non-inferiority of CAS compared to CEA. Likely outcomes after CAS have been greatly limited by incomplete knowledge of atherosclerotic carotid pathology and probably inappropriate patient selection criteria. In the current practice, only the degree of lumen obstruction is indication to an invasive treatment (CEA or CAS) in symptomatic or asymptomatic patients, but it has been recently demonstrated that histology of carotid plaques also plays a major role. Indeed, plaque morphology and composition seem to influence more importantly outcomes of CAS than those of CEA. Angiography is a poor diagnostic tool to detect the severity and composition of atherosclerotic lesions. Virtual histology (VH) is a new technology incorporated in the latest intravascular ultrasound (IVUS) equipment that allows a validated histological characterization of plaques by performing a spectral, objective and highly-reproducible analysis of the radiofrequency and amplitude data of the ultrasound waves that cross different tissues. This manuscript reports authors' experience with the use of IVUS-VH during CAS. This new technology, by characterizing morphology, extension and histology of carotid plaque, seems to provide important information for confirming percentage of carotid stenosis and judging its embolic potential, tailoring the procedure and guiding the choice of stent and finally for checking stent apposition and complete covering of vulnerable plaques. According to authors' opinion IVUS-VH has the potential to optimize patients' and lesions' selection criteria for CAS in order to improve its outcomes.

Approximation, torsion, and amodally-completed surfaces.

Consider a stereoscopic display simulating two rectangular patches, the lower frontoparallel and the upper slanted around the vertical axis. When the two patches are amodally completed and appear as the unoccluded parts of a smooth surface partially hidden by a foreground frontoparallel surface, either real or illusory, their relative slant is underestimated with respect to a baseline condition in which they are perceived as separate rectangles. Slant assimilation was studied in three experiments using with- vs. without-occluder displays and two methods, slant matching and speeded classification of twist direction. In Experiments 1 and 2 we found slant assimilation in with-occluder displays and slant contrast in without-occluder displays. In Experiment 3 we isolated a component of slant assimilation attributable to the mere presence of the occluder. Twist classification performance was impaired even when edge geometry hindered amodal completion, but the performance loss was larger when surface patches were amodally completed. To minimize the required amount of torsion, input fragments are misperceived, indicating that in limiting conditions amodal completion is mediated by approximation rather than interpolation. Slant assimilation decreases as twist angle increases, up to a limit above which the visual system does not support the formation of a smooth amodal surface with torsion.

Volume measurement by CARTO compared with cardiac magnetic resonance.

AIMS: The CARTO electrophysiological mapping system has demonstrated accurate results for end-diastolic ventricular volumes in casts and animals. However, in humans, a comparison with cardiac magnetic resonance (CMR), the non-invasive gold standard for volumetric analysis, has not yet been performed. METHODS AND RESULTS: A total of 34 (29 male) heart failure patients (NYHA class III/IV) underwent an electrophysiological mapping procedure with the CARTO system in the left ventricle (LV) (n = 34) and right ventricle (RV) (n = 12) and CMR for RV and LV end-diastolic volume (RVEDV and LVEDV) measurements another day. Mean LVEDV was comparable between CMR and CARTO (328 +/- 95 and 320 +/- 92 mL, respectively; P = NS), whereas RV volumes measured by CARTO were larger (CMR 140 +/- 48 vs. CARTO 176 +/- 47 mL; P < 0.01). Overall, we found a good correlation between CMR and CARTO measurements for both chambers; however, the Bland-Altman analysis showed a non-interchangeability of these methods. Measurement differences were independent of chamber size, but significantly affected by the number of acquired mapping points. CONCLUSION: Although CMR and CARTO showed a good correlation in the measurement of RVEDV and LVEDV in a group of heart failure patients, the clinical interchangeability of the two methods may be questioned.

Contour curvature polarity and surface interpolation.

Contour curvature polarity (i.e., concavity/convexity) is recognized as an important factor in shape perception. However, current interpolation models do not consider it among the factors that modulate the trajectory of amodally-completed contours. Two hypotheses generate opposite predictions about the effect of contour polarity on surface interpolation. Convexity advantage: if convexities are preferred over concavities, contours of convex portions should be more extrapolated than those of concave portions. Minimal area: if the area of amodally-completed surfaces tends to be minimized, contours of convex portions should be less extrapolated than contours of concave portions. We ran three experiments using two methods, simultaneous length comparison and probe localization, and different displays (pictures vs. random dot stereograms). Results indicate that contour polarity affects the amodally-completed angles of regular and irregular surfaces. As predicted by the minimal area hypothesis, image contours are less extrapolated when the amodal portion is convex rather than concave. The field model of interpolation [Fantoni, C., & Gerbino, W. (2003). Contour interpolation by vector-field combination. Journal of Vision, 3, 281-303. Available from http://journalofvision.org/3/4/4/] has been revised to take into account surface-level factors and to explain area minimization as an effect of surface support ratio.

[Check-list for inspection in banks]. / Check list per il sopralluogo nel comparto bancario.

We suggest a checklist for inspection in banks. The checklist is composed of 14 schedules where information on bank clerks and buildings is collected. Principle risk factors are analysed (workplaces, lighting and noise, air quality, emergency management). The critical points are observed and the times of intervention are established. Then follows data processing and the reports are transmitted to the employer. The checklist, tested on 250 workplaces, allows us to identify the interventions having priority to be realized through appropriate planning. A quantitative evaluation of the risk is matched with immediate and brief operative indications. The situations to improve are: cleanliness of workplaces, thermal comfort, electricity/telephone wires. The checklist seems to be a valid instrument for the evaluation of risk factors, their management and times of intervention. Such instrument simplifies, moreover, the employer choices of intervention.

Tobacco smoking, occupational exposure and chronic respiratory disease in an Italian industrial area.

Tobacco smoking and occupational exposure are the major factors responsible for chronic obstructive pulmonary disease (COPD) worldwide. The prevalence of this disease and its main risk factors were investigated in an area characterized by a high density of iron- and steelworking factories in North Italy. A total of 1,497 subjects (50% male) aged 40-59 yrs underwent an interview and a physical assessment, and 1,244 of them also underwent spirometry. The prevalences of COPD and asthma were 16.1 and 5.2% among males and 4.4 and 4.0% among females. COPD and respiratory symptoms were associated with both smoking and occupational exposure in males: the odds ratios for having been occupationally exposed among males were 2.3 (95% confidence interval 1.4-3.7) for COPD and 1.7 (1.2-2.6) for respiratory symptoms. No association was found between asthma and tobacco smoking or occupational exposure. The forced expiratory volume in one second and forced vital capacity were associated negatively with smoking and not associated with occupational exposure. In females, lesser effects of cigarette smoking on both self-reported respiratory diseases and lung function tests were found. The attributable risks of chronic obstructive pulmonary disease for smoking and occupational exposure among males were 52.9 and 8.8%, respectively, and 60.3% when considered together, whereas 18.8% of chronic obstructive pulmonary disease cases among females were attributable to smoking.

Prevalence of risk factors for coronary heart disease in a mountain community in northern Italy.

We performed a population survey in the Valle Sabbia mountain community, a highly industrialized area in the province of Brescia, in northern Italy, in order to estimate the prevalence of the main risk factors for coronary heart disease (CHD) among middle-aged men and women. A random sample of 1497 subjects (747 males) aged 40-59 were interviewed and underwent a physical examination. A blood sample was also taken to test total serum cholesterol. Personal histories of hypertension and CHD were given by 20.3 and 4.6% of men, and by 23 and 2.4% of women, respectively. A personal history of diabetes mellitus was reported by 5.2% of men and 4% of women. The mean values of systolic and diastolic blood pressure (SBP and DBP), total cholesterol, number of cigarettes smoked per day and BMI were, respectively: 135.1 and 84.1 mmHg, 219.2 mg/dl, 10.2 cig/day and 26.2 in men, and 136.8 and 83.9 mmHg, 214.3 mg/dl, 2.4 cig/day and 25.1 in women. Among men, 45.0% had SBP > or = 140 or DBP > or = 90, 32.3% had total cholesterol > or = 240 mg/dl, 29.3% were current smokers and 60.7% had a BMI higher than 25. Among women, 48.7% had SBP > or = 140 or DBP > or = 90, 26.0% had total cholesterol > or = 240 mg/dl, 16.8% were current smokers and 44.3% had a BMI higher than 25. When considering the prevalence of high SBP or DBP, high total cholesterol or cigarette smoking, 72.3% of men and 67.7% of women had at least one of the main risk factors for CHD, usually higher values of SBP or DBP, whereas 29.3% of men and 21.2% of women had two or more factors. Overall, prevalences of the most common CHD risk factors in this community were similar to those found in other surveys carried out in Italy in the last decade.