Radiation Exposure and Surgical Outcomes after Antegrade Sclerotherapy for the Treatment of Varicocele in the Paediatric Population: A Single Centre Experience.

INTRODUCTION: Antegrade sclerotherapy (Tauber) effectively treats varicocele. However, fluoroscopy exposes young males to ionizing radiation. We aimed to evaluate radiation exposure and surgical outcomes after the Tauber procedure. MATERIALS AND METHODS: We retrospectively analysed data from 251 patients. Dose area product (DAP) and fluoroscopy time were recorded. The effective dose was calculated with the PCXMC software. Descriptive statistics and linear regression tested the association between clinical predictors and radiation exposure. RESULTS: Median (IQR) age and body mass index (BMI) were 14 (13-16) years and 20.1 (17.9-21.6) kg/m². Five (2.1%) patients developed clinical recurrence and two (0.81%) developed complications. Median fluoroscopy time and DAP were 38.5 (27.7-54.0) s and 89.6 (62.5-143.9) cGy*cm2. The effective dose was 0.19 (0.14-0.31) mSv. Fluoroscopy time was higher in patients with collateral veins (41 (26-49) s vs. 36 (31-61) s, p = 0.02). The median amount of sclerosing agent (SA) used was 3 (3-4) ml. DAP was higher when SA > 3 mL was used (101.4 (65-183) cGy*cm2 vs. 80.5 (59-119) cGy*cm2; p < 0.01). At univariable linear regression, age, BMI, operative time and SA > 3 mL were associated with higher DAP (all p < 0.01). At multivariable linear regression, only BMI (beta 12.9, p < 0.001) and operative time (beta 1.9, p < 0.01) emerged as predictors of higher DAP, after accounting for age and SA > 3 mL. CONCLUSIONS: The Tauber procedure is safe and associated with low effective doses. Operative time and the patient's BMI independently predict a higher radiation dose.

The role of radiotherapy in the management of cutaneous squamous cell carcinoma: a retrospective study on 92 cases.

BACKGROUND: Cutaneous squamous cell carcinoma (cSCC) is the second most common nonmelanoma skin cancer in the world after basal cell carcinoma. Treatment of choice for cSCC is surgery, but radiotherapy (RT) is a valid alternative and has been recommended in selected cases. The aim was to evaluate the cure rate of RT for cSCC and to compare the results in the two settings of RT as exclusive or second line treatment. METHODS: The outcome of 92 cSCC treated with RT in the period from 2002 to 2019 in our department was retrospectively reviewed. RESULTS: In 56 cases RT was first-line treatment while in 36 it was administered as second-line treatment after incomplete excision or failure of previous treatments. The five-year cure-rate was 74% (71.34% in patients treated with primary RT and 77.37% in patients treated with RT as second-line treatment), while the ten-year cure-rate was 67% (57.07% and 77.37% respectively in patients treated with primary RT or with second line RT). Log rank test showed statistical significance between the cure-rate of the two groups with better therapeutic results after second-line RT (P<0.05). CONCLUSIONS: Our data confirm RT as an effective therapy for cSCC when surgery excision is contraindicated or in case of tumors localized in certain regions where the cosmetic-functional outcome is better than surgery. Better therapeutic results are achieved with second-line RT.

Radiation therapy of non-melanoma skin cancer of the pinna: an Italian 35-year experience.

BACKGROUND: Radiation therapy (RT) is a well-known alternative to surgery for the treatment of non-melanoma skin cancer (NMSC), especially in elderly people or in patients who cannot undergo or refuse surgical procedure. It has also a pivotal role in those areas, as pinna, where both function and cosmesis must be preserved. We report our experience in treating cutaneous carcinoma of the auricle with radiation therapy. METHODS: We conducted a retrospective monocentric study on 363 NMSC of the auricle treated by conventional energy radiation therapy as a primary treatment or with adjuvant and salvage purpose. Tumors involving the external canal of the ear or regional lymph node at diagnosis were excluded. RESULTS: A complete response has been obtained in 95.5% with a 2- and 5-year cure rate respectively of 84% and 76%. Fifty-two tumors developed a central or marginal relapse. Aesthetic result was good or acceptable in the majority of the cases. No cartilage necrosis has been registered. CONCLUSIONS: Our experience confirms safety and effectiveness of RT on selected auricle carcinoma, affording good cosmetic and functional results.

Comparison of Efficacy among Three Dermal Substitutes in the Management of Critical Lower-Limb Wounds: The Largest Biases-Reduced Single-Center Retrospective Cohort Study in Literature.

Background and objectives: The skin recently became the main focus of regenerative medicine and, in this context, skin substitutes are fully entering into the plastic surgeon's armamentarium. Among the various types of skin substitutes, dermal substitutes (DSs) are the most used. Our study aims to retrospectively compare three renowned and extremely similar DS in the management of critical lower limb wounds in the largest cohort analysis currently present in literature. Materials and Methods: We followed a strict protocol of application and evaluation of the DS for each patient and wound and, after a meticulous bias reduction process, we compared final outcomes in terms of efficacy and speed in achieving the defect coverage. Results: Among patients who did not receive a skin graft after the DS, we registered a wound healed surface of 50% for Pelnac, 52% for Integra, and 19% for Nevelia, after 30 days from the external silicon layer removal; among those who received a skin graft after the DS, we observed a significantly lower mean percentage of graft take after 7 days with Pelnac (53%) compared to Integra and Nevelia (92% and 80%, respectively). The overall percentage of wound healed surface obtained after 30 days from the external silicon sheet removal, either with or without skin graft, was 71% for Pelnac, 63% for Integra and 63% for Nevelia. We also ran a sub-group analysis only including grafted wounds with a negative microbiological test and the mean percentage of graft take was similar this time. Eventually, we assessed the influence of the wound's "chronicity" on its healing, comparing the mean graft take only in "acute" wounds who received a skin graft and it resulted 63% for Pelnac, 91% for Integra and 75% for Nevelia. Conclusions: Integra demonstrates the highest rate of skin graft viability and the highest rate of skin graft takes after 7 days. Pelnac shows the quickest induction of secondary healing in acute wounds. Nevelia is not different from Integra and shows a superior graft take compared to Pelnac, but features the lowest secondary healing induction rate. No differences exist between the three DSs in terms of wound healing after 30 days from the skin graft or from the removal of the external silicon layer.

Clinical Comparison of Mini-Percutaneous Nephrolithotomy with Vacuum Cleaner Effect or with a Vacuum-Assisted Access Sheath: A Single-Center Experience.

Purpose: To compare outcomes of two different miniaturized percutaneous nephrolithotomy (PCNL) techniques: minimally invasive PCNL (MIP) with the vacuum cleaner effect and vacuum-assisted mini-PCNL (vmPCNL). Materials and Methods: Data from 104 (66.7%) patients who underwent vmPCNL and 52 (33.3%) patients who underwent MIP at a single tertiary referral academic center between January 2016 and December 2019 were analyzed. Patient demographics and peri- and postoperative data were recorded, and propensity score matching was performed. Descriptive statistics and linear regression models were used to identify variables associated with operative time (OT) and patient effective dose. Logistic regression analyses were used to identify factors associated with infectious complications and stone-free (SF) status. Results: Patient demographics and stone characteristics were comparable between groups. vmPCNL was associated with shorter OT (p < 0.001), fluoroscopy time, and patient effective dose (4.2 mSv vs 7.9 mSv; p < 0.001). A higher rate of infectious complications was found in the MIP group (25.0% vs 7.7%, p < 0.01). Linear regression analysis showed that stone volume, multiple stones, and MIP procedure (all p values ≤0.02) were associated with longer OT. Similarly, OT and the MIP procedure (p ≤ 0.02) were associated with higher patient effective dose. Logistic regression analysis revealed that the stone volume, positive preoperative bladder urine culture, and MIP procedure (all p values ≤0.02) were associated with postoperative infectious complications. vmPCNL was not associated with the SF rate. Conclusions: Mini-PCNL performed with continuous active suction is associated with lower rates of infectious complications, shorter OT, and lower patient effective dose than MIP.

Plasma adenosine and neurally mediated syncope: ready for clinical use.

Either central or peripheral baroreceptor reflex abnormalities and/or alterations in neurohumoral mechanisms play a pivotal role in the genesis of neurally mediated syncope. Thus, improving our knowledge of the biochemical mechanisms underlying specific forms of neurally mediated syncope (more properly termed 'neurohumoral syncope') might allow the development of new therapies that are effective in this specific subgroup. A low-adenosine phenotype of neurohumoral syncope has recently been identified. Patients who suffer syncope without prodromes and have a normal heart display a purinergic profile which is the opposite of that observed in vasovagal syncope patients and is characterized by very low-adenosine plasma level values, low expression of A2A receptors and the predominance of the TC variant in the single nucleotide c.1364 C>T polymorphism of the A2A receptor gene. The typical mechanism of syncope is an idiopathic paroxysmal atrioventricular block or sinus bradycardia, most often followed by sinus arrest. Since patients with low plasma adenosine levels are highly susceptible to endogenous adenosine, chronic treatment of these patients with theophylline, a non-selective adenosine receptor antagonist, is expected to prevent syncopal recurrences. This hypothesis is supported by results from series of cases and from observational controlled studies.

Local Diagnostic Reference Levels in Interventional Radiology.

PURPOSE: Interventional cardiology procedures, during which live images are acquired, involve exposure to x-rays. The use of fluoroscopy can cause high radiation doses to patients and operators because of the prolonged duration of x-ray emission. For this reason, special attention and constant vigilance represent challenges for commissions and groups of experts in the field. The purpose of this study is to establish local diagnostic reference levels (DRLs) for these procedures, to improve radiological practice, and to optimize radiation doses. METHODS: This work was carried out in two university hospitals and two private medical facilities in Rabat, the capital of Morocco, during the period 2017-2018. The study concerns 657 interventional cardiology procedures (457 coronary angiography [CA] and 200 percutaneous transluminal coronary angioplasty [PTCA]), performed by 11 cardiologists on different installations in 5 catheterization rooms. The data collected for each procedure were patient age, height and weight, dosimeter indicators in terms of dose area product (PKA), total air kerma at the reference point (Kar), fluoroscopy time (FT), and the number of frames, together with the primary beam parameters as kV and total mAs. The proposed DRLs were set from the 75th percentile of the PKA and FT. RESULTS: The mean of PKA for CA and PTCA procedures were 29.2 Gy∗cm2 and 70.4 Gy∗cm2, respectively, the mean of fluoroscopy time were 4.0 min and 12.17 min for 334 and 685 frames, respectively. Results for the local DRLs were 37.3 and 87.1 Gy cm2 for PKA and 4.48 and 16.15 min for FT, corresponding to CA and PTCA procedures. CONCLUSION: This work focuses on proposing local DRLs in Morocco for CA and PTCA procedures. The results show that the values found conform with those of international studies.

Impact of Surgical Experience on Radiation Exposure during Retrograde Intrarenal Surgery: A Propensity-Score Matching Analysis.

BACKGROUND: The impact of surgical experience on radiation exposure (RE) during endourological procedures has been poorly investigated. OBJECTIVE: To assess the impact of surgical experience on fluoroscopy time (FT) and RE during retrograde intrarenal surgery (RIRS). DESIGN, SETTING, AND PARTICIPANTS: The study included 140 patients who underwent RIRS performed either by a senior surgeon (expertise of >100 RIRSs) (group A) or by two junior residents (expertise of <15 RIRSs) (group B) between January 2016 and May 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We tested the hypothesis that surgical experience had a limited impact on RE during RIRS. To adjust for potential baseline confounders, propensity-score matching was performed. Descriptive statistics and linear regression models tested the association between clinical variables and FT and patients' effective doses. RESULTS AND LIMITATIONS: There was no significant difference between the two groups for baseline, intraoperative, and postoperative characteristics. Overall FT (p=0.97) and effective dose (p=0.79) did not differ between groups. A statistically significant association was found between male sex (all p<0.03), stone burden (all p<0.001), operative time (all p<0.003), and postoperative double-J placement (all p<0.02) with both FT and effective dose. Linear multivariable analysis revealed that body mass index was significantly associated with effective dose (p=0.002). Similarly, longer operative time (all p<0.03) and double-J placement (all p<0.04) were significantly associated with increased FT and effective dose. CONCLUSIONS: Surgical experience has a limited impact on FT and RE during RIRS. Longer operative time and double-J placement were associated with increased FT and effective dose. PATIENT SUMMARY: In this study, we assessed whether surgical experience affects fluoroscopy time and patient's effective dose during retrograde intrarenal surgery (RIRS). We found that radiation exposure (RE) was not affected by surgeon's experience and that the standardisation of the surgical technique at the beginning of the learning curve of young surgeons may represent the key factor in reducing RE during RIRS.

Flat-panel CT versus 128-slice CT in temporal bone imaging: Assessment of image quality and radiation dose.

OBJECTIVE: We compared the image quality and radiation dose of flat-panel CT (FPCT) and multi-slice CT (MSCT) performed respectively with an angiographic unit and a 128-slice CT scanner. We investigated whether the higher spatial resolution of FPCT translated into higher image quality and we sought to eliminate inter-subject variability by scanning temporal bone specimens with both techniques. MATERIALS AND METHODS: Fifteen temporal bone specimens were imaged with FPCT and MSCT. Two neuroradiologists experienced in otoradiology evaluated 30 anatomical structures with a 0-2 score; 18 structures important from a clinical perspective were assigned a twofold value in calculation of the overall score. The radiation dose was calculated through the use of an anthropomorphic phantom. RESULTS: The image quality was significantly higher for FPCT than MSCT for 10 of the 30 anatomical structures; the overall score was also significantly higher for FPCT (p = 0.001). The equivalent dose of the two techniques was very similar, but with different effective doses to the organs. CONCLUSION: FPCT performed on an angiographic unit provides higher image quality in temporal bone assessment compared to MSCT performed on a 128-slice CT scanner thanks to its higher spatial resolution, with comparable equivalent doses but different effective doses to the organs.

Correlation between pulmonary artery pressure and thoracic impedance: Insights from daily monitoring through an implanted device in chronic heart failure.

BACKGROUND: Thoracic impedance (TI) decrease and pulmonary artery pressure (PAP) elevation precede acute decompensation in congestive heart failure (HF). However, the relationship between TI and PAP has been studied only in the context of acute decompensation. METHODS: This prospective, observational study enrolled subjects with reduced ejection fraction HF, previously implanted with an ICD capable of measuring TI. Patients underwent implantation of a sensor for direct measurement of PAP (CardioMEMs™). Both TI and PAP were remotely monitored daily during follow up. Investigators were blinded to PAP values during the first three months, then PAP was used as a guide to therapy. RESULTS: Ten patients were followed up for 405±141days (3720 patient-days). During hemodynamic guided therapy, diastolic PAP (dPAP) decreased from 27.8±10.2mmHg to 24.0±8.0mmHg (p<0.001); non-significant variations of TI were observed. A significant negative correlation was found between the variations of TI and PAP vs. baseline (p<0.001). Episodes of sustained increase of PAP preceded subsequent periods of TI decrease by 5.6±3.9days, but the former were poor predictors of the latter (sensitivity 0.37). CONCLUSIONS: Our study confirms the strict correlation that exists between left ventricular filling pressures and lung water content, estimated by dPAP and TI, respectively. However, dPAP acute variation analysis showed a limited value in predicting subsequent episodes of TI decrease.

Retrospective application of Program to Access and Review Trending iNformation and Evaluate coRrelation to Symptoms in patients with Heart Failure criteria for the remote management of patients with cardiac resynchronisation therapy.

Aim The Program to Access and Review Trending iNformation and Evaluate coRrelation to Symptoms in patients with Heart Failure (PARTNERS HF) trial elaborated a multiparametric model for prediction of acute decompensation in advanced heart failure patients, based on periodical in office data download from cardiac resynchronisation devices. In this study, we evaluated the ability of the PARTNERS HF criteria to detect initial decompensation in a population of moderate heart failure patients under remote monitoring. Methods We retrospectively applied the PARTNERS HF criteria to 1860 transmissions from 104 patients (median follow up 21 months; range 1-67 months), who were enrolled in our programme of telemedicine after cardiac resynchronisation therapy. We tested the ability of a score based on these criteria to predict any acute clinical decompensation occurring in the 15 days following a transmission. Results In 441 cases, acute heart failure was diagnosed after the index transmission. The area under the curve (AUC) of the score for the diagnosis of acute decompensation was 0.752 (confidence interval (CI) 95% 0.728-0.777). The best score cut-off was consistent with the results of PARTNERS HF: with a score ≥2, sensitivity was 75% and specificity 68%. The odds ratio for events was 6.24 (CI 95% 4.90-7.95; p < 0.001). Conclusions When retrospectively applied to remote monitoring transmissions and arranged in a score, PARTNERS HF criteria could identify HF patients who subsequently developed acute decompensation. These results warrant prospective studies applying PARTNERS HF criteria to remote monitoring.

Interaction between a regenerative matrix and wound bed in nonhealing ulcers: results with 16 cases.

A chronic wound is a wound that is delayed in one of the wound-healing stages and cannot progress any further. A chronic wound leaves the patient at risk of infection and hospitalization. In these case series, 16 patients affected by venous ulcers underwent Hyalomatrix PA grafting for reconstructive surgery. Hyalomatrix PA is a bilayered, sterile, flexible, and conformable three-dimensional matrix made of fibers of HYAFF, a benzyl ester of hyaluronic acid, and a semipermeable silicone membrane. Hyalomatrix PA acts as a substitutive and regenerative permanent matrix able to replace the dermis providing a three-dimensional matrix for cellular invasion and capillary growth. The silicon layer controls water vapor loss avoiding an excessive loss of fluids and acts as a semipermeable barrier to the external agents. In the presented cases, the average area grafted per procedure was 153 cm(2). The length of followup ranged from 0.5 to 1 year. The final results were considered to be good in 12 cases, fair in 3 cases, and poor in one case. This study suggests that the combination of wound bed preparation with application of the hyaluronic regenerative matrix can be a valid approach for treatment of partial thickness ulcers.

Dose absorption in lumbar and femoral dual energy X-ray absorptiometry examinations using three different scan modalities: an anthropomorphic phantom study.

The aim of this study was to measure the effective dose on an anthropomorphic phantom undergoing lumbar and femoral dual energy X-ray absorption (DXA) examinations, using 3 different scan modalities (fast-array [FA], array [A], high-definition [HD]), and assess the differences in the lifetime attributable risk (LAR) of cancer due to radiation. An anthropomorphic phantom was used. Thermoluminescent dosimeters were placed over 12 anatomic phantom regions and outside the room (to measure background radiation). Fifty scans on the femur and spine were performed for each mode. The dose relative to a single DXA scan for each dosimeter was measured (mean over the 50 scans) and the background radiation was then subtracted. The equivalent dose per organ was obtained. The total body effective dose was calculated by adding the equivalent doses. We estimated the lifetime dose absorption and LAR for cancer for a male and a female patient undergoing 36 DXA studies (18 lumbar, 18 femoral) every 21 months for 32 years. The effective dose for lumbar scans was FA = 17.79 µSv, A = 32.88 µSv, HD = 31.08 µSv; for femoral scans, FA = 5.29 µSv, A = 9.55 µSv, HD = 7.54 µSv. LAR estimation showed a minimal increase in cancer risk (range 4.55 × 10⁻4% [FA, femoral, male] to 4.02 × 10⁻³% [A, lumbar, female]). The lifetime dose absorption and LAR for cancer for a male and a female patient undergoing 36 DXA studies (18 lumbar, 18 femoral) every 21 months for 32 years were 0.756 mSv, 3.82 × 10(-3)% and 0.756 mSv, 5.11 × 10⁻³%, respectively. DXA examinations cause radiation levels that are comparable to the background radiation. Regardless of the scan modality or the anatomic site, a patient undergoing DXA scans for a lifetime has a negligible increased risk of developing cancer.

Remote monitoring of patients with biventricular defibrillators through the CareLink system improves clinical management of arrhythmias and heart failure episodes.

PURPOSE: The aim of the present study is to evaluate if remote monitoring with the CareLink Network may improve clinical management of tachyarrhythmias and heart failure episodes in patients treated with biventricular defibrillators (CRT-D). METHODS: Patients implanted with CRT-D for more than 6 months received the CareLink monitor and were trained to perform device interrogation. At-home transmissions were scheduled at 2 weeks, 1 and 2 months after training, with a final in-office visit after 3 months. RESULTS: Sixty-seven patients performed 264 data transmissions. Twenty-three unscheduled data transmissions were requested by the centers after patient contact. Ventricular tachyarrhythmias were reported in nine patients during 16 data reviews. Thirteen data reviews (81%) were performed remotely via CareLink transmissions (nine scheduled and four unscheduled), in seven patients. Of these events, in two cases (15%) in-hospital visits were requested, while in 11 (85%) no action was needed and no additional in-clinic visits were scheduled. During the study period, in 20/28 (71%) intra-thoracic impedance alerts, the patients remotely transmitted their device data. After remote data review, in ten cases drug therapy was adjusted by phone and in four cases no action was needed and the patient reassured. In six episodes an in-hospital extra visit was scheduled. On the whole, in 14 cases (70%), the patient could be managed remotely avoiding a visit to the hospital. CONCLUSIONS: Our study showed that remote follow-up is an efficient method to manage tachyarrhythmias and heart failure episodes in CRT-D patients. Early reaction to clinical events may improve overall patient care.

Remote monitoring of CRT-ICD: the multicenter Italian CareLink evaluation--ease of use, acceptance, and organizational implications.

PURPOSE: The Medtronic CareLink allows remote implantable device follow-up. In this first European experience with CareLink, we assessed the ease of use of the system, the acceptance, and satisfaction of patients and clinicians. METHODS: Patients implanted with biventricular defibrillators for more than 6 months received the CareLink monitor and were trained to perform home device interrogation and transmission. Patient and clinician experience and preference were evaluated through specific questionnaires. RESULTS: Sixty-seven patients were enrolled and were able to perform data transmissions during the 3-month study duration. The overall duration of interrogation procedure was 7 +/- 5 minutes, and frequently the procedure did not require the assistance of a caregiver. Patients reported a general preference for remote versus in-clinic follow-up and described a sense of reassurance created by the remote monitoring capability.In the centers, the review procedure was successful; its mean duration was 5 +/- 2 minutes per transmission and the users indicated that the access and navigation of the review website were easy. At the end of the evaluation, the data available for remote review were judged complete and adequate to provide almost the same standard of care as that offered in traditional in-clinic visit. In general, the remote monitoring was seen as a potential tool to improve the clinical management of patients with device. CONCLUSIONS: The ease of use, satisfaction, and acceptance of the CareLink Network in European clinical practice appears elevated both for patients and for clinicians.

Reverse ventricular remodeling and improved functional capacity after ventricular resynchronization in advanced heart failure.

BACKGROUND: Ventricular resynchronization is a non-pharmacological treatment for advanced heart failure refractory to drug therapy and with intraventricular conduction delay. We describe the time course of echocardiographic and functional recovery after resynchronization in 31 patients (mean age 67 +/- 8 years). METHODS: We evaluated NYHA class, echocardiogram, respiratory function, and cardiopulmonary test before pacemaker implantation (baseline), after 1-3 months (short-term evaluation), and 10-15 months afterwards (long-term evaluation, n = 21 patients). Mortality at 1 year was considered. RESULTS: Both at short and long-term, patients improved NYHA class, ventricular function, and ventricular volumes. Already at short-term, we observed an increase in oxygen consumption at peak exercise (12.6 +/- 0.6 vs 10.5 +/- 0.5 ml/kg/min), oxygen consumption at anaerobic threshold (9.8 +/- 0.6 vs 8.3 +/- 0.6 ml/kg/min) and oxygen pulse (8.3 +/- 0.5 vs 7.5 +/- 0.5 ml/beat). Ventilatory efficacy (VE/VCO2 slope) and alveolo-capillary diffusion (estimated by the measurement of lung diffusion capacity for carbon monoxide - DLCO) improved only at long-term (VE/VCO2: 40.7 +/- 1.6 vs 45.3 +/- 1.8; DLCO: 70.3 +/- 2.7 vs 59.4 +/- 5.9% of predicted, p = 0.05). The 1-year mortality was 9.7%. CONCLUSIONS: Ventricular resynchronization is linked to a fast and prolonged recovery of NYHA class, echocardiographic variables and stress tolerance. The improvement of indexes known to carry a prognostic value confirms that ventricular resynchronization can positively interfere with the evolution of the disease.

Aspirin-angiotensin-converting enzyme inhibitor coadministration and mortality in patients with heart failure: a dose-related adverse effect of aspirin.

BACKGROUND: It is debated whether in patients with chronic heart failure (CHF), aspirin may contrast the clinical benefits of angiotensin-converting enzyme inhibitors (ACEIs). Two major unresolved issues in patients with CHF are whether these agents together can affect mortality and whether the interaction is related with the dose of aspirin. We aimed at exploring these possibilities. METHODS: We evaluated more than 4000 hospitalizations with a principal discharge diagnosis of CHF from January 10, 1990, to December 31, 1999. The final analysis was restricted to 344 patients taking ACEIs who satisfied the selection criteria, in whom reliable information was available concerning drug therapy during follow-up. In these patients, treatment included no aspirin in 235 (group 1), a low dose (< or =160 mg) in 45 (group 2), and a high dose (> or = 325 mg) in 64 (group 3). RESULTS: During a mean follow-up of 37.6 months, there were 84 (36%) deaths in group 1, 15 (33%) in group 2, and 35 (55%) in group 3. By the Kaplan-Meier approach, survival was similar in groups 1 and 2, and significantly (P =.009) worse in group 3 compared with groups 1 and 2. After adjusting for potential confounding factors (including treatment, cause of heart disease, age, smoking, and diabetes mellitus), a time-dependent multivariate Cox proportional hazards regression analysis showed that the combination of high-dose aspirin with an ACEI was independently associated with the risk of death (hazard ratio, 1.03; P =.01) and that the combination of low-dose aspirin with an ACEI was not (hazard ratio, 1.02; P =.18). CONCLUSION: These results support the possibility that in some patients with CHF who are taking an ACEI, a dose-related effect of aspirin may adversely affect survival.

Diabetes worsens pulmonary diffusion in heart failure, and insulin counteracts this effect.

Chronic heart failure (CHF) (hydrostatic stress) and diabetes (basal laminae thickening) share the potentiality of damaging the alveolar-capillary membrane. We investigated 15 control subjects and 3 groups of 15 patients each having type 2 diabetes (Group 1), CHF (Group 2), and diabetes and CHF (Group 3), to probe whether addition of diabetes worsens lung diffusion in CHF and whether insulin counteracts this effect. Compared with control subjects, carbon monoxide diffusing capacity (DL(CO)) and diffusing capacity of the alveolar-capillary membrane at rest were increasingly depressed from Group 1 through Group 3. DL(CO) was lower than predicted in 11 patients each in Groups 1 and 2 and in all patients in Group 3. Regular insulin (10 IU) was ineffective in CHF alone, whereas it improved DL(CO) and diffusing capacity of the alveolar-capillary membrane in diabetes; changes, however, were significantly greater in the patients with both diabetes and CHF (+17.6%, +27.3%) than in those with diabetes alone (+9.2%, +13.1%). Insulin did not affect lung spirometry, volumes, and hemodynamics. Thus, gas transfer is depressed in a number of patients with diabetes or CHF; comorbidity increases the frequency and extent of this disorder. Insulin facilitates diffusion in diabetes, through an influence on alveolar-capillary conductance, and its efficacy is greater in comorbidity; diabetes is more disturbing in patients with CHF and produces a synergistic rather than a simple additive effect.

Effect of non-insulin-dependent diabetes mellitus on pulmonary function and exercise tolerance in chronic congestive heart failure.

In chronic congestive heart failure (CHF), backward effects of left ventricular dysfunction alter pulmonary volumes and gas diffusion. Some of these disorders are detected in some patients with diabetes mellitus, possibly due to a microangiopathic process and nonenzymatic glycosylation of lung tissue proteins. We explored the possibility that coexistence of non-insulin-dependent diabetes mellitus (NIDDM) may potentiate the deterioration of lung function in CHF. In 20 normoglycemic patients (group 1) and in 20 patients with NIDDM (group 2), with New York Heart Association class II to III CHF due to idiopathic or ischemic cardiac disease, and in 20 controls (groups were age- and gender-matched), we investigated cardiac function, pulmonary volumes, carbon monoxide diffusion (DL(CO)) and its alveolar-capillary membrane (D(M)) subcomponent, oxygen uptake and dead space-to-tidal volume ratio (pVD/VT) at peak exercise (individualized ramp test), and slope of ventilation-to-carbon dioxide production ratio (VE/VCO(2)) during exercise. Although, compared with reference subjects, both patient groups had similar variations in left ventricular diastolic volume, ejection fraction, and pulmonary wedge pressure; in group 2 lung volumes, DL(CO), D(M), and oxygen uptake were significantly more reduced; in this group there was no overlap of individual results of DL(CO) and D(M) with those in controls; VE/VCO(2) slope and pVD/VT also were significantly increased, and inversely correlated with D(M). Thus, coexistence of NIDDM makes pulmonary dysfunction worse in CHF, and significantly enhances exercise intolerance.