Pulse Pressure: An Independent Predictor of Coronary and Stroke Mortality in Elderly Females from the General Population

The aim of this paper is to evaluate whether pulse pressure is an independent risk factor for coronary and stroke mortality in 3282 subjects (1281 males and 2001 females) aged +/- 65 years, taking part in the CArdiovascular STudy in the Elderly (CASTEL). After dividing subjects into tertiles of pulse pressure, adjusted relative risk (RR) and confidence intervals (CI) for 14-year coronary and stroke mortality was evaluated for each tertile. Among females, coronary mortality rate was 2.7% in the first tertile of pulse pressure, 4.7% in the second (RR 1.38, 95% CI [1.15-2.66]) and 6.2% in the third (RR 2, CI [1.20-3.51]). Stroke mortality was 3.6%, 4.1% (RR 1.23, CI [1.02-2.23]) and 8.3% (RR 2.27, CI [1.37-3.74]), respectively. This trend was recognizable in normotensive, borderline and sustained hypertensive women, where mortality increased with rising pulse pressure. No relationship was found between pulse pressure and mortality in males. In elderly women, pulse pressure was a good predictor of coronary and stroke mortality, even superior to the label of hypertension. No matter how any given pulse pressure level was obtained, it was more predictive of both coronary and cerebrovascular mortality than belonging to a normo- or hypertensive category

Coronary Angiography After Transcatheter Aortic Valve Replacement (TAVR) to Evaluate the Risk of Coronary Access Impairment After TAVR‐in‐TAVR

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Overview on electrical issues faced during the SPIDER experimental campaigns

SPIDER is the full-scale prototype of the ion source of the ITER Heating Neutral Beam Injector, where negative ions of Hydrogen or Deuterium are produced by a RF generated plasma and accelerated with a set of grids up to ~100 keV. The Power Supply System is composed of high voltage dc power supplies capable of handling frequent grid breakdowns, high current dc generators for the magnetic filter field and RF generators for the plasma generation. During the first 3 years of SPIDER operation different electrical issues were discovered, understood and addressed thanks to deep analyses of the experimental results supported by modelling activities. The paper gives an overview on the observed phenomena and relevant analyses to understand them, on the effectiveness of the short-term modifications provided to SPIDER to face the encountered issues and on the design principle of long-term solutions to be introduced during the currently ongoing long shutdown.Comment: 8 pages, 12 figures. Presented at SOFT 202

Clinical and technical aspects in the multidisciplinary management of peripheral arterial disease: limb salvage by means of integrated care strategy with percutaneous angioplasty in the treatment of critical limb ischemia

INTRODUCTION AND AIM OF THE STUDY: Percutaneous transluminal angioplasty (PTA) has revolutionized the management of peripheral arterial disease. Even in the setting of critical limb ischemia (CLI), similar outcomes have been obtained when PTA and bypass surgery are compared. With PTA, local anesthesia can be used, hospital stay is shorter, and morbidity and mortality rates may be lower. The best results may be achieved when the revascularization with PTA is a part of a strategy of integrated care. Aim of this study was to assess the feasibility of this strategy and to evaluate the mid-term results, mainly in terms of mortality, limb salvage (LS), progression of disease (DP), and need of further revascularizations. METHODS: Between January 2007 and June 2008, 105 patients with 137 critical arterial lesions (137 limbs) underwent elective PTA for CLI in one single centre (Clinique Pasteur – Toulouse – France). The decision to perform PTA was jointly considered by vascular specialist, interventional cardiologist and vascular surgeon. Arterial lesions were codified according to TASC classification, and the arterial tree was categorized into three groups: the aorta and iliac arteries (A-I), the common, superficial and profunda femoral arteries (Fem), and the popliteal and tibial arteries (Pop-Tib). Clinical follow-up was obtained for all patients by office visit or direct telephone call. Periodical non-invasive assessment with duplex ultrasound was systematically performed at 1, 3 and 6 months. All angiographic controls were ischemia-driven. RESULTS: The mean age was 77±10 years, 59 patients (56.2%) were males and 58 (55.2%) were diabetic. Eighty-nine patients (84.8%) were hypertensive, 57 (54.3%) had dyslipidemia, and 71 (67.6%) had significant renal disease. Ten patients (9.5%) had a previous peripheral graft. History of coronary artery disease (CAD) was present in 35 (33.3%) patients and history of cardiac heart failure in 28 (26.7%). Mean left ventricular ejection fraction (LVEF) was 56±10%. Indication to PTA was rest pain with non-healing ulcer in 96 patients (91.4%) and with gangrene in 9 (8.6%). Mean Hct value was 36±5%, mean C reactive protein (CRP) 41±59 mg/l, mean fibrinogen 4.4±1.2 g/l and mean pro-BNP 2343±4278 pg/ml. Five lesions (3.6%) were included in A-I group, 60 (43.8%) in Fem group, and 68 (49.6%) in Pop-Tib group. In four cases (2.9%) PTA concerned lesions in previous grafts. Concerning TASC classification, lesions were mostly type B3 (71.5%) and type C1 (13.9%). Mean lesion diameter was 5.3±1.7 mm and mean lesion length was 55±32 mm. Balloon angioplasty was performed in 127 (92.7%) lesions and stent implantation was required in 81 (59.1%). Mean stent diameter was 6±1.4 mm and mean stent length was 69±44 mm. Subintimal angioplasty was performed to treat occlusions in 46/77 cases (59.7%). Procedural success was achieved in 125 lesions (91.2%). There were 3 (2.2%) procedural complications and 2 in-hospital death (1.9%). The mean hospital stay was 5.3±4.7 days. Clinical follow-up was available for 100% of patients over a mean of 304±161 days. At follow-up, 26 patients (24.8%) had died, 20 (19%) of them for cardiovascular causes. Twelve patients (11.4%) were amputated, and 7 of them (58.3%) were still alive. LS was achieved in 124 (90.5%) limbs. Target lesion revascularization (TLR) was performed in 12 lesions (8.8%) and DP was found in 19 (13.9%). Continuing CLI was found in 15 patients (14.3%). Independent predictors of mortality were LVEF<60% and a level of plasma fibrinogen?4.3 g/l. TLR was associated with smoking habit, dyslipidemia, a previous peripheral graft, and higher plasmatic levels of pro-BNP. DP was associated with a higher prevalence of CAD, the presence of a significant renal disease and placement of shorter stents. LS was associated with lower plasmatic levels of CRP. CONCLUSIONS: PTA in the treatment of CLI is safe, with favourable in-hospital and mid-term outcomes, especially when considered as a part of a strategy of integrated care. Despite its high mortality rate, partly due to the mean age of the population and the presence of significant comorbidities, the high rate of LS and the low TLR rate underline the role of this reperfusion strategy even in a subset of fragile patients with severe and diffused PAD. Moreover, this data confirms that patients with severe arterial disease are prone to die mostly due to cardiac causes and that inflammatory and infection markers may be useful in the pre-procedural risk stratification.INTRODUZIONE E SCOPO DELLO STUDIO: l’angioplastica transluminale percutanea (PTA) ha rivoluzionato il trattamento dell’arteriopatia periferica. Persino nei casi d’ischemia critica dell’arto (CLI), sono stati ottenuti risultati paragonabili a quelli della chirurgia. La PTA consente l’uso dell’anestesia locale, il periodo di ricovero è più breve, morbilità e mortalità si riducono. I risultati migliori vengono raggiunti quando la rivascolarizzazione con PTA è inserita in una strategia di assistenza globale. Lo scopo di questa tesi era accertare la fattibilità di tale strategia e valutarne i risultati a medio termine, in particolare concernenti la mortalità, il salvataggio dell’arto (LS), la progressione della malattia (DP) e la necessità di nuove rivascolarizzazioni. METODI: Nel periodo tra gennaio 2007 e giugno 2008, 105 pazienti con 137 lesioni arteriose critiche (137 gambe) sono stati sottoposti a PTA elettiva per CLI in uno stesso centro (Clinique Pasteur – Toulouse – France). La decisione di eseguire la PTA era presa congiuntamente dall’angiologo, dal cardiologo interventista e dal chirurgo vascolare. Le lesioni arteriose erano codificate secondo la classificazione della TASC, e l’albero arterioso era stato inoltre suddiviso in tre parti: l’aorta e le arterie iliache (A-I), l’arteria femorale comune, superficiale e profonda (Fem), e le arterie poplitee e tibiali (Pop-Tib). Il follow-up clinico è stato ottenuto tramite visite ambulatoriali o conversazione telefonica. Una valutazione periodica non-invasiva mediante eco-doppler veniva eseguita al primo, terzo e sesto mese dalla procedura. I controlli angiografici venivano eseguiti in caso di persistenza dell’ischemia critica. RISULTATI: L’età media della popolazione studiata era 77±10 anni, 59 pazienti (56.2%) erano maschi e 58 (55.2%) diabetici. Ottantanove pazienti (84.8%) erano ipertesi, 57 (54.3%) affetti da dislipidemia, e 71 (67.6%) avevano una rilevante alterazione della funzione renale. Dieci pazienti (9.5%) erano già stati sottoposti a un precedente intervento chirurgico di bypass. Una storia di malattia coronarica (CAD) riguardava 35 (33.3%) pazienti e 28 (26.7%) avevano un’anamnesi positiva per scompenso cardiaco. La frazione di eiezione ventricolare sinistra (LVEF) media era 56±10%. L’indicazione a eseguire la PTA era la presenza di dolori a riposo associata a ulcere persistenti in 96 pazienti (91.4%) e a gangrena in 9 (8.6%). Il valore medio di Hct era 36±5%, il valore medio di proteina C reattiva (CRP) era 41±59 mg/l, quello di fibrinogeno plasmatico 4.4±1.2 g/l e quello di pro-BNP 2343±4278 pg/ml. Cinque lesioni (3.6%) facevano parte del gruppo A-I, 60 (43.8%) del gruppo Fem, e 68 (49.6%) del gruppo Pop-Tib. In 4 casi (2.9%) la PTA riguardava lesioni in precedenti bypass. Riguardo alla classificazione della TASC, le lesioni erano perlopiù di tipo B3 (71.5%) e di tipo C1 (13.9%). Il diametro medio delle lesioni era 5.3±1.7 mm e la lunghezza media 55±32 mm. La PTA col pallone è stata eseguita in 127 (92.7%) lesioni e il posizionamento di uno stent è stato necessario in 81 (59.1%). Il diametro medio dello stent era 6±1.4 mm e la lunghezza media 69±44 mm. L’angioplastica con tecnica subintimale per il trattamento delle occlusioni è stata utilizzata in 46/77 casi (59.7%). Il successo immediato al termine della procedura è stato ottenuto in 125 lesioni (91.2%). Si sono verificati 2 (1.9%) decessi intra-ospedalieri e 3 (2.2%) complicazioni procedurali. Il tempo medio di ricovero è stato di 5.3±4.7 giorni. Il follow-up clinico è stato possibile nel 100% dei pazienti a una media di 304±161 giorni dalla procedura. Al follow-up, 26 pazienti (24.8%) erano morti, 20 (19%) di essi per cause cardiovascolari. Dodici pazienti (11.4%) erano stati amputati, e 7 di essi (58.3%) erano ancora vivi. Il LS è stato ottenuto per 124 gambe (90.5%). La rivascolarizzazione nel precedente sito della PTA (TLR) è stata eseguita in 12 lesioni (8.8%), e una progressione di malattia è stata riscontrata in 19 (13.9%). La persistenza di CLI è stata rilevata in 15 pazienti (14.3%). Una LVEF<60% e un valore plasmatico di fibrinogeno?4.3 g/l erano predittori indipendenti di mortalità. La TLR era associata con il fumo, la dislipidemia, un precedente bypass ed elevati valori di pro-BNP. La progressione di malattia era associata con una più alta prevalenza di CAD, la presenza di una rilevante alterazione della funzione renale e il posizionamento di stents più corti. Il salvataggio dell’arto era associato a bassi livelli plasmatici di CRP. CONCLUSIONI: L’uso della PTA nel trattamento della CLI è sicuro, con risultati favorevoli sia durante il ricovero che nel breve termine, specialmente quando inserita in una strategia di assistenza globale al paziente. Nonostante l’elevato tasso di mortalità, in parte dovuto all’età media della popolazione e alla presenza di rilevanti co-morbidità, l’alto tasso di LS e il basso tasso di TLR sottolineano il ruolo di tale strategia di riperfusione, persino nei pazienti fragili, con arteriopatia severa e diffusa. Inoltre, questi dati confermano che nei pazienti con arteriopatia grave, la principale causa di morte è costituita dagli eventi cardiovascolari, e che i markers infiammatori e infettivi possono essere utili nella stratificazione del rischio pre-procedurale

Energetics (and mechanical determinants) of sprint and shuttle running

Unsteady locomotion (e. g., sprints and shuttle runs) requires additional metabolic (and mechanical) energy compared to running at constant speed. In addition, sprints or shuttle runs with relevant speed changes (e. g., with large accelerations and/or decelerations) are typically short in duration and, thus, anaerobic energy sources must be taken into account when computing energy expenditure. In sprint running there is an additional problem due to the objective difficulty in separating the acceleration phase from a (necessary and subsequent) deceleration phase.In this review the studies that report data of energy expenditure during sprints and shuttles (estimated or actually calculated) will be summarized and compared. Furthermore, the (mechanical) determinants of metabolic energy expenditure will be discussed, with a focus on the analogies with and differences from the energetics/mechanics of constant-speed linear running

[High-risk ST-elevation acute coronary syndrome in a patient with multivessel coronary artery disease complicated by refractory cardiogenic shock undergoing complex percutaneous coronary revascularization: role and timing of mechanical circulatory support devices]

Cardiogenic shock (CS) following acute myocardial infarction complicated by severe ventricular dysfunction remains the leading cause of death despite customized pharmacological therapy and optimal revascularization. The use of temporary mechanical circulatory support (MCS) devices during refractory CS might represent the only chance of survival to address the underlying systemic inflammatory response preventing the development of multiorgan failure. We report the case of a patient with a very-high-risk non-ST-elevation acute coronary syndrome and multivessel calcific coronary artery disease complicated by refractory CS undergoing complex percutaneous coronary revascularization. We show a gradual and complementary use of MCS devices tailored on hemodynamic monitoring, clinical and laboratory variables and multidisciplinary collaboration to early recognize the downward spiral that may ensue with multiorgan dysfunction or potential complications leading to death

Comprehensive mechanical power analysis in sprint running acceleration

Sprint running is a common feature of many sport activities. The ability of an athlete to cover a distance in the shortest time relies on his/her power production. The aim of this study was to provide an exhaustive description of the mechanical determinants of power output in sprint running acceleration and to check whether a predictive equation for internal power designed for steady locomotion is applicable to sprint running acceleration. Eighteen subjects performed two 20 m sprints in a gym. A 35-camera motion capture system recorded the 3D motion of the body segments and the body center of mass (BCoM) trajectory was computed. The mechanical power to accelerate and rise BCoM (external power, Pext ) and to accelerate the segments with respect to BCoM (internal power, Pint ) were calculated. In a 20 m sprint, the power to accelerate the body forward accounts for 50% of total power; Pint accounts for 41% and the power to rise BCoM accounts for 9% of total power. All the components of total mechanical power increase linearly with mean sprint velocity. A published equation for Pint prediction in steady locomotion has been adapted (the compound factor q accounting for the limbs' inertia decreases as a function of the distance within the sprint, differently from steady locomotion) and is still able to predict experimental Pint in a 20 m sprint with a bias of 0.70\ub10.93 W\ub7kg-1 . This equation can be used to include Pint also in other methods that estimate external horizontal power only. This article is protected by copyright. All rights reserved

Mechanical determinants of the energy cost of running at the half-marathon pace

BACKGROUND: The aim of this study was to determine the influence of spring mass model characteristics (e.g. stiffness) and Achilles tendon proprieties in determining the energy cost of running in half marathon runners. METHODS: Achilles tendon characteristics (i.e. cross sectional area -ATCSA- and resting length - ATL-) were measured on 32 males by means of an ultrasound apparatus the day before a half marathon race. After these measurements the energy cost of running (C) was determined while the subjects run on a treadmill at the speed (vT) they were expected to maintain during the race (vR); the vertical (kvert) and leg (kleg) stiffness were calculated based on kinematic data. RESULTS: No differences were observed between vT and vR. Higher values of vT were associated with larger values of kleg and kvert. The faster runners (with larger vT) were the ones with the lower C (r = -0.43, P &lt; 0.05) and the larger ATCSA (r = 0.46, P &lt; 0.01). No relationship was found between C and ATCSA but C was lower in runners with longer ATL (r = -0.52, P &lt; 0.001). Finally, no relationship was found between kleg or kvert and C, but runners with larger kvert were also those with the larger ATCSA (r = 0.45, P &lt; 0.01). CONCLUSIONS: These findings underline the correlation between spring-mass model parameters and Achilles tendon characteristics in half-marathon runners; they further show how these parameters influence the half marathon pace and the energy cost of running at this pace

Ultrasound guided foam sclerotherapy of recurrent varices of the great and small saphenous vein: 5-year follow up

Ultrasound guided foam sclerotherapy (UGFS) proved to be effective in recurrent varices. In this observational study from 2006 and 2012 we treated 142 neovascularization, 155 inguinal recurrence and 28 popliteal recurrent varices. For neovascularization 0.3-0.5% polidocanol (POL) sclerosant foam (SF) was injected for vein having diameter &lt;3 mm and 0.5-1% POL or sodium tetradecylsulphate (STS) SF for higher vein diameters. The patients with residual sapheno-femoral or sapheno-popliteal junctions were treated with 1% STS SF for diameter up to 5 mm, while for larger veins 3% STS was used. From 1 to 3 sessions were necessary in both groups with 4 to 10 ml injected per session. In the group of neovascularization the 3-5years follow up revealed good results in 90.8% of the cases. In the group of popliteal recurrences the 3-5 years follow up showed 60.7% of good results, while in the group of inguinal recurrences we observed 80% of good results at 3-5 years. We did not have major complication. As minor complications we had 0.2% of gastrocnemial vein thrombosis, 0.1% of minor neurological problems, 2.8% of superficial vein thrombosis, 3.9% of pigmentation and light to mild post-treatment pain in 16.5% of the cases. In conclusion our data show that UGFS is a well tolerate technique, preferred by previously operated patients, safe and easily repeatable with good medium-term results both in case of neovascularization and of recurrence from residual femoral or popliteal stump