Referral from vascular surgery to cardiovascular rehabilitation and related outcomes in patients with peripheral arterial disease: the THINKPAD-RELOADED survey.

The utilization of cardiovascular rehabilitation (CR) programmes in patients with Lower Extremity Peripheral Artery Disease (LEPAD) is generally poor, with limited evidence of current policies for referral. The aim of the study was to evaluate, within a cohesive network of CR and vascular surgery facilities with facilitated referral process, the clinical characteristic of LEPAD patients referred to CR and related outcomes, as compared to patients not referred. The present is an observational prospective study of consecutive patients recruited at vascular surgery facilities. Out of 329 patients observed, the average referral rate to CR was 34% (28% and 39% in patients with and without recent peripheral revascularization, p<0.05). LEPAD patients entering the CR programme were similar to those who did not according to sex, age, the vascular surgery setting of evaluation, and localization of arterial lesions. Patients with moderate intermittent claudication and patients with acute limb ischemia as index event were more represented among those who attended CR (41% vs 21% and 9% vs 2% respectively, p<0.05). Patients referred to CR had five times more episodes of acute coronary syndrome and heart failure as complication of the index event. The cardiovascular risk profile (obesity 29.5% vs 11%, p<0.05; hypercholesterolemia 80% vs 61%, p<0.05) was much worse in LEPAD patients referred to CR, but conversely, they better achieved secondary prevention targets, particularly for blood pressure control (97% vs 57%, p<0.05). All-cause 2-year mortality in the whole patients' population was 6%. Patients entering the CR programme displayed less events (13.5% vs 37.7%, p<0.05), mainly death (3.1% vs 11.3%, p<0.05) and limb-related events (4.2% vs 15.2%, p<0.05). The results of our study suggest that when a cohesive network of vascular surgery and CR facilities becomes available, the referral rate to rehabilitation may increase up to one third of eligible patients. Patients with higher comorbidity and cardiovascular risk seem to have priority in the referral process, nevertheless those with peripheral revascularization are still underestimated. Entering CR may ensure better cardiovascular risk profile and cardiovascular prognosis in LEPAD patients, and consequently the systematic adoption of this care model needs to be strongly recommended and facilitated

Thin-section petrography and SR-\ub5XRD for the identification of micro-crystallites in the brown decorations of ceramic lead glazes

The Mn-and Fe-rich micro-crystalline precipitates formed in the decorations of lead glazes during ceramic firing are responsible for colour, shine and opacity, among other visual characteristics, besides being the most important relics of the technology. Due to their small size and growth habits, the micro-crystalline precipitates may remain unidentified on polished cross sections of the glazes. Thin-section petrography, combined with synchrotron-radiation X-ray micro-diffraction, appears to be a very powerful tool to reveal the presence, growth habits, distribution and nature of the micro-crystallites. This is illustrated here by two case studies directly related to the brown decorations technology: the 19th century French imitations of the Ligurian Taches Noires pottery from the Joques workshop and the 17th century Catalan-decorated tablewares. Melanotekite, cristobalite and hematite micro-crystallites were found in the glazes of the French imitations. Hematite acted as nucleating agent effective in promoting both the crystallization of melanotekite and cristobalite. The presence of cristobalite is not related to alkali ions, which are normally responsible for its formation far from equilibrium conditions. Melanotekite and cristobalite can be considered as technological markers associated to the Joques production and then be used to identify imitations of this workshop. Braunite and kentrolite were identified in the brown decoration of the Catalan tablewares. The manganese pigment was probably mixed with a lead oxide compound and applied directly over the raw glaze. The presence of braunite and kentrolite indicates a firing temperature of about 950 \ub0C. Thin-section petrography reveals that the crystallite growth has taken place under two different conditions. Euhedral braunite crystallites were produced during the heating. A drop in temperature during the firing process gave rise to the crystallization of dendritic braunite and kentrolite

Is nutritional intake adequate in chronic heart failure patients?

OBJECTIVES: The goal of this study was to investigate the nutrition adequacy and energy availability for physical activity in free-living, clinically stable patients with chronic heart failure (CHF). BACKGROUND: Little information exists regarding the nutrition adequacy and alimentary habits of patients with clinically stable CHF. We hypothesized that CHF patients have an inadequate intake of calories and protein, leading to a negative calorie and nitrogen balance, an expression of increased tissue breakdown. METHODS: In 57 non-obese patients with CHF (52 males and 5 females; 52 +/- 3 years; body mass index <25 kg/m(2)) and in 49 healthy subjects (39 males and 10 females) matched for age, body mass index, and sedentary life style we evaluated total energy expenditure (TEE), calorie intake (kcal(I)), and nitrogen intake (N(I)) from a seven-day food diary, total nitrogen excretion (TNE), and energy availability (EA = kcal(I) - resting energy expenditure). A zero calorie balance (CB) occurred when kcal(I) = TEE; a nitrogen balance (NB) in equilibrium was set at NB (= N(I) - TNE) 0 +/- 1 g/day. RESULTS: In patients and controls kcal(I) and N(I) were similar. However, in CHF patients the kcal(I) was <TEE with a consequent negative CB (-186 +/- 305 kcal/day vs. + 104.2 +/- 273 kcal/day of controls; p < 0.01). Nitrogen balance resulted negative in CHF (-1.7 +/- 3.2 g/24 h vs. + 2.2 +/- 3.6 g/24 h in controls; p < 0.01). Energy availability in CHF patients was 41% lower than in controls (p < 0.05). CONCLUSIONS: Non-obese, free-living patients with clinically stable CHF have an inadequate intake of calories and protein and reduced energy availability for physical activit

Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure

Aims Anaemia is often observed in patients with chronic heart failure (CHF), and it may be associated with a worse prognosis. Aim of this study was to identify the individual mechanisms of anaemia in CHF patients. Methods and results One hundred and forty-eight consecutive patients with haemoglobin concentration ,13 g/dL (if males) or ,12 g/dL (if females) were enrolled. Factors responsible for anaemia were investigated by evaluating endogenous erythropoietin (Epo) production, serum cytokines levels, body iron status, and iron supply for erythropoiesis. Most patients (57%) presented anaemia of chronic disease and among them, 92% showed evidence of a defective endogenous Epo production. This was indicated by an observed/predicted log(serum Epo) ratio less than 0.8 and/or a defective iron supply for erythropoiesis diagnosed by low transferrin saturation and/or increased value of soluble transferrin receptor. According to regression analysis sex, renal failure, and serum Epo were correlated with anaemia. Conclusion According to our study, about half of anaemic CHF patients showed anaemia of chronic disease with blunted endogenous Epo production and/or a defective iron supply for erythropoiesis. Determination of the individual mechanisms of anaemia in CHF could justify a rational therapeutic approach to anaemia