The minimal city: traces of urbanity along the Ebro river

What is the size, bulk or degree of complexity a city must assume in order to be considered as such? Admittedly, neither the physical size of the occupied territory, nor its resident population, nor its wealth or urban permanence are parameters that determine its fortune. We like to consider a city to be any complex urban system related, intensely, to other cities, and, especially, to its own territory and landscape, that shape, protect and give character to it. This reflection, carried into the classroom of the Reus School of Architecture for the last three years, has found the Ebro Basin as a specific geographical framework. It is a vast context where a constellation of cities deploys its network of multiple interactions over a fluvial environment to which they owe their position and from which they assume their character. In this way, in order to identify the traces of a minimal urbanity, we avoid focusing on the most dominant settlements such as Logroño, Vitoria, Pamplona, Lleida or Zaragoza which, in their insatiable appetite for development, would gobble up the rest of the cities that, although limping or struggling, continue to be masters of their past and destiny, thereby enriching the urban river system. With the aim of discovering the vectors of urbanity on which these minimal cities are based, we measure and compare their main streets and boulevards, we identify their churches, palaces and markets and represent their squares recognizing them as inevitable urban syntheses. Housing, in turn, constantly appears as the most basic drive that marks the latent and persistent rhythm that these cities aspire to preserve. Among the tools used for the urban -and confined- analysis of these realities, drawing, model or image manipulation stands out. Their graphic potential and the methodological rigor derived from shared rules of representation have allowed the Basin to be recognized as a territorial entity and basic support for figures that, partially, establish relationships of fragile balance between the ten minimal cities here studied.¿Cuál es la medida, grosor o grado de complejidad que debe asumir una ciudad pera ser tenida como tal? Ciertamente, ni la medida física del territorio ocupado, ni su población residente, ni su riqueza o permanencia urbana son parámetros que per se determinen su fortuna. En este sentido, entendemos ciudad como todo sistema urbano complejo, intensamente relacionado con otras ciudades y, especialmente, con el propio territorio y paisaje que la conforman, amparan y forjan su carácter. Dicha reflexión, llevada al aula de la Escuela de Arquitectura de Reus durante los tres últimos años, ha encontrado como marco geográfico concreto la Cuenca del Ebro. Se trata de un contexto vasto donde una constelación de ciudades despliega su red de interacciones múltiples sobre un entorno fluvial al que debe su posición y del que asume su carácter. De este modo, en aras de identificar los rastros de una urbanidad mínima, evitamos centrar la mirada sobre aquellos asentamientos dominantes como Logroño, Vitoria, Pamplona, Lleida o, por encima de todas, Zaragoza que, en su insaciable apetito de desarrollo, engullirían de buen grado al resto de ciudades que, si bien mínimas y renqueantes, siguen siendo dueñas de su pasado y su destino enriqueciendo, con ello, el sistema urbano fluvial. Con la voluntad de descubrir los vectores de urbanidad sobre los que se fundamentan estas ciudades mínimas, medimos y comparamos sus cosos y ramblas, identificamos sus iglesias, palacios y mercados y representaos sus plazas reconociéndolas como inevitables síntesis urbanas. La vivienda, a su vez, aparece constantemente como la pulsión más básica que marca el ritmo latente y constante que estas ciudades aspiran a conservar. Entre las herramientas utilizadas para el análisis urbano -y confinado- de estas realidades, destaca el dibujo, la maqueta o la manipulación de la imagen. Su potencial gráfico y el rigor metodológico derivado de unas normas de representación compartidas han permitido reconocer la Cuenca como entidad territorial y soporte básico de unas figuras que, parcialmente, establecen relaciones de frágil equilibrio entre las diez ciudades mínimas estudiadas

Relationship between haemostatic variables and the progression of carotid atherosclerosis

Increases in the thickness of common carotid intima-media (CC-IMT), as measured by B-mode ultrasonography, have been widely used in both population studies and clinical trials in the search for risk factors for early atherosclerosis progression. In this study we have investigated the relations between several baseline haemostatic and conventional risk factors and CC-IMT changes over 16 months in 64 peripheral arterial disease (PAD) patients, randomly selected from the prospective PLAT study series. Samples from 24 (37.5%) patients who showed increases in CC-IMT during the follow-up period were compared with those from 40 (62.5%) in which CC-IMT remained unchanged. Baseline conventional risk factors and coagulation variables were similar in the two groups except for higher plasma concentrations of von Willebrand factor (vWF) (178.3\ub153.6 vs 141.2\ub153.7 SD%, p=0.01) and Factor VII (FVII) (133 .9\ub136.4 vs 107.0\ub127.3, p=0.001) in the patients with increased CC-IMT. CC-IMT increases correlated positively with plasma levels of FVII (r=0 .31, p<0.01) and vWF (r=0.31, p<0.31 ). Multiple stepwise regression analysis identified FVII as the only independent variable associated with an increase in CC-IMT (\uf062=0.83 p<0.01). Thus, high plasma concentration of FVII and vWF may be associated with the progression of early carotid atherosclerosis in PAD patients

The MIAMI Study (Markers of inflammation and Atorvastatin effect in previous myocardial infarction) : results of a prospective, multicenter study

Objective: MIAMI is a prospective multicenter clinical study designed to investigate the relationship between C-IMT progression and changes in circulating markers of inflammation, coagulation and endothelial dysfunction in patients with stable CAD treated for two years with 20 mg/day atorvastatin. Methods: C-IMT, blood lipids and soluble markers were measured at baseline, at the 12th month and at the end of the study in eighty-five patients. Results: Atorvastatin induced C-IMT regression. Fibrinogen, TFPI-total, sICAM-1, sE-selectin, IL-8 and vWF, but not hs-CRP, IL-18, TFPI-free, sVCAM-1, IL-6, TNF-α and sCD40L, decreased upon treatment. Changes in lipids did not correlate with C-IMT regression. Changes in single soluble markers correlated poorly with C-IMT regression, but strongly when combined in relevant composite scores (inflammation/coagulation-score, endothelial activation-score, soluble markers-score and total-score). Conclusions: In patients with stable CAD, a moderate dose of atorvastatin was associated with regression of C-IMT. This effect was correlated with changes of inflammation, thrombosis and endothelial dysfunction profiles. Funding: Partial support by a grant from Pfizer- Itali

Long-term fluvastatin reduces the hazardous effect of renal impairment on four-year atherosclerotic outcomes (a LIPS substudy)

peer reviewedMild renal impairment is an important risk factor for late cardiovascular complications. This substudy of the Lescol Intervention Prevention Study (LIPS) assessed the effect of fluvastatin on outcome of patients who had renal dysfunction and those who did not. Complete data for creatinine clearance calculation. (Cockcroft=Gault formula) were available for 1,558 patients (92.9% of the LIPS population). Patients were randomized to fluvastatin or placebo after successful completion of a first percutaneous coronary intervention. Follow-up time was, 3 to 4 years. The effect of baseline creatinine clearance on coronary atherosclerotic events (cardiac death, non-fatal myocardial infarction, and coronary reinterventions not related to restenosis) was evaluated. Baseline creatinine clearance (logarithmic transformation) was inversely associated with an incidence of adverse events among patients who received, placebo. (hazard ratio 0.99, 95% confidence interval 0.982 to 0.998, p = 0.01). However, no association was noted between creatinine clearance and the incidence of adverse events among patients who received fluvastatin (hazard ratio 1.0, 95% confidence interval 0.99 to 1.0, p = 0.63). No further deterioration in creatinine clearance was observed during follow-up; regardless of baseline renal function or allocated treatment. Occurrence of adverse events was not related to changes in renal function during follow-up. Fluvastatin therapy markedly decreased the risk of coronary atherosclerotic events after percutaneous intervention in: patients who had lower values of creatinine clearance at baseline: The benefit of fluvastatin was unrelated to any effect on renal function. (C) 2005 by Excerpta Medica Inc

Serum homocysteine is weakly associated with von Willebrand factor and soluble vascular cell adhesion molecule 1, but not with C-reactive protein in type 2 diabetic and nondiabetic subjects: the Hoorn Study.

Background: Hyperhomocysteinaemia may constitute an independent risk factor for cardiovascular disease, but it is still unclear by which pathophysiological mechanisms homocysteine (tHcy) may promote atherothrombosis. The aim of this study was firstly to examine whether tHcy is associated with endothelial dysfunction, increased adherence of leukocytes, and/or chronic low-grade inflammation, as estimated from plasma levels of von Willebrand factor (vWf), soluble vascular cell adhesion molecule 1 (sVCAM-1) and C-reactive protein (CRP), respectively. Secondly we investigated whether the presence of type 2 diabetes modifies these associations. Materials and Methods: Six hundred and ten subjects of a general population of middle-aged and elderly subjects, 170 of whom had type 2 diabetes, participated in this cross-sectional study. Linear regression analyses were used to study whether tHcy was associated with vWf, sVCAM-1 and CRP, and whether the presence of diabetes modified these associations. Results: After adjustment for confounders, tHcy was significantly but weakly associated with vWf (β=0·15, P=0·05) and sVCAM-1 (β=0·082, P=0·04). tHcy was not significantly associated with CRP (β=0·02, P=0·91). The presence of diabetes did not significantly modify these associations. Conclusions: This study provides evidence that tHcy is, at most, weakly associated with endothelial dysfunction as estimated from plasma vWf, and with leukocyte adhesion as estimated from plasma sVCAM-1. tHcy was not significantly associated with chronic low-grade inflammation as estimated from plasma CRP. Our data thus suggest that the link between tHcy and atherothrombosis cannot be explained by associations of tHcy with vWf, sVCAM-1 or CRP

Factors affecting adherence to guidelines for antithrombotic therapy in elderly patients with atrial fibrillation admitted to internal medicine wards

Current guidelines for ischemic stroke prevention in atrial fibrillation or flutter (AFF) recommend Vitamin K antagonists (VKAs) for patients at high-intermediate risk and aspirin for those at intermediate-low risk. The cost-effectiveness of these treatments was demonstrated also in elderly patients. However, there are several reports that emphasize the underuse of pharmacological prophylaxis of cardio-embolism in patients with AFF in different health care settings. AIMS: To evaluate the adherence to current guidelines on cardio-embolic prophylaxis in elderly (> 65 years old) patients admitted with an established diagnosis of AFF to the Italian internal medicine wards participating in REPOSI registry, a project on polypathologies/polytherapies stemming from the collaboration between the Italian Society of Internal Medicine and the Mario Negri Institute of Pharmacological Research; to investigate whether or not hospitalization had an impact on guidelines adherence; to test the role of possible modifiers of VKAs prescription. METHODS: We retrospectively analyzed registry data collected from January to December 2008 and assessed the prevalence of patients with AFF at admission and the prevalence of risk factors for cardio-embolism. After stratifying the patients according to their CHADS(2) score the percentage of appropriateness of antithrombotic therapy prescription was evaluated both at admission and at discharge. Univariable and multivariable logistic regression models were employed to verify whether or not socio-demographic (age >80years, living alone) and clinical features (previous or recent bleeding, cranio-facial trauma, cancer, dementia) modified the frequency and modalities of antithrombotic drugs prescription at admission and discharge. RESULTS: Among the 1332 REPOSI patients, 247 were admitted with AFF. At admission, CHADS(2) score was ≥ 2 in 68.4% of patients, at discharge in 75.9%. Among patients with AFF 26.5% at admission and 32.8% at discharge were not on any antithrombotic therapy, and 43.7% at admission and 40.9% at discharge were not taking an appropriate therapy according to the CHADS(2) score. The higher the level of cardio-embolic risk the higher was the percentage of antiplatelet- but not of VKAs-treated patients. At admission or at discharge, both at univariable and at multivariable logistic regression, only an age >80 years and a diagnosis of cancer, previous or active, had a statistically significant negative effect on VKAs prescription. Moreover, only a positive history of bleeding events (past or present) was independently associated to no VKA prescription at discharge in patients who were on VKA therapy at admission. If heparin was considered as an appropriate therapy for patients with indication for VKAs, the percentage of patients admitted or discharged on appropriate therapy became respectively 43.7% and 53.4%. CONCLUSION: Among elderly patients admitted with a diagnosis of AFF to internal medicine wards, an appropriate antithrombotic prophylaxis was taken by less than 50%, with an underuse of VKAs prescription independently of the level of cardio-embolic risk. Hospitalization did not improve the adherence to guideline

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia