Incremental value of compression ultrasound sonography in the emergency department.

The quick evaluation of venous thromboembolism is a key point of modern medicine since the delayed diagnosis is associated with a worse prognosis. Venous ultrasound (VU) is a sensitive and rapidly performed test in cases of suspected deep venous thrombosis. Various protocols have been proposed for its execution, such as the study of the whole deep venous circulation of the lower limb or the analysis of the femoral-popliteal area. The aim is to detect a vessel thrombus and the most sensitive element is the non-compressibility with the probe. Initially, the thrombus is hypoechogenic and adherent to the vessel; later, it tends to organize and recanalize. Usually, in the early stages, the risk of embolism is higher. The role of studying the iliac axis and calf veins is still uncertain. VU is not useful for assessing response to anticoagulation therapy and it is unclear whether the persistence of thrombotic abnormalities can guide on a possible prolongation of therapy.

Potential role of an athlete-focused echocardiogram in sports eligibility.

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone ("grey zone") with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

Effectiveness of Tai Chi on Balance Improvement in Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis.

Balance impairments are a relevant problem in patients with diabetes, and interventions to manage this issue represent a public health need. This study reviewed the literature about the effectiveness of Tai Chi on balance improvement in patients with type 2 diabetes. Springerlink, MEDLINE, PubMed, CINAHL, Web of Science, Scopus, and Cochrane CENTRAL databases were screened. Randomized and nonrandomized controlled trials assessing balance in patients with type 2 diabetes enrolled in a Tai Chi program were considered eligible. Four studies were included in qualitative synthesis and in quantitative analysis (three randomized controlled trials and one pretest-posttest quasi-experimental study). Evidence supporting Tai Chi to improve balance in patients with type 2 diabetes was found (effect size: 0.52; 95% confidence interval [0.20, 0.84]); however, the analysis relied on a small number of studies, which raises concerns about the risk of bias. In conclusion, the results support the benefits of Tai Chi intervention to improve balance in patients with type 2 diabetes.

Parental Perception of Children's Weight Status: Love Overpasses Scientific Evidence! A Cross-Sectional Observational Study.

INTRODUCTION: Age, gender, body mass index percentiles and the adherence to Mediterranean diet were investigated as potential predictor factors in this assessment. AIM: To assess the parental perception of children's weight status. METHODS: This cross-sectional observational study was carried out during a corporate wellness program (Ferrari Formula Benessere) implemented by Ferrari S.p.A. and managed by Med-Ex s.r.l. The children's real weight status was assessed through Body Mass Index percentiles (ArthroPlus software-WHO). RESULTS: 328 children (66.4%) were normal-weight, 10 were underweight (2%), 66 were overweight (13.4%) and 90 were obese (18.2%). 289 children (59%) were classified correctly by parents, while 205 children (41%) were not. 64 of 66 overweight children and 90 of 90 children with obesity have been completely underestimated (53 of 90 children with obesity were judged normal weight). The parents' probability to estimate children's weight status correctly decreased increasing body mass index percentiles paradoxically [OR = 0.96 (0.95-0.97)] and was lower in boys [OR = 0.65 (0.44-0.98)]. Although not statistically significant, children with higher adherence to Mediterranean diet seems to have higher probability to be correctly estimated [low adherence: reference, medium adherence: OR = 1.06 (0.61-1.85), high adherence: OR = 1.48 (0.81-2.75)]. CONCLUSIONS: A high percentage of children is overweight or obese and almost half of parents classified their weight status incorrectly. Increasing children's body mass index percentiles decreases the probability to be correctly classified.

Ankle Brachial Index in Different Types of Popliteal Artery Entrapment Syndrome: A Systematic Review of Case Reports.

Similar to other peripheral artery diseases, vessel narrowing in popliteal artery entrapment syndrome (PAES) reduces the ankle brachial index (ABI). Since the PAES is related to several anatomical or functional variations, we sought to determine if the ABI was correlated with the type of syndrome. Through a systematic review of literature, we identified case reports and series in which the diagnosis of PAES was accompanied by ABI measurement. Twenty-seven studies included in the qualitative synthesis described 87 limbs. The most common types of the syndrome were those caused by an abnormal medial head of the gastrocnemius (type II, n = 35, 40.23%) and aberrant course of the popliteal artery (type I, n = 20, 22.99%). The variation of plantaris muscle (n = 7, 8.05%) is currently not included in the classification system. The median value of ABI was 0.87 (interquartile range (IQR) = 0.6-1.0). There were no differences among types of syndrome (F = 0.13, p = 0.72). In conclusion, despite clinical recommendations, the ABI remains underused in PAES diagnosis. No correlation was detected between the index score and type of syndrome. The cases of PAES involving structures other than the gastrocnemius or popliteus muscle suggest the need to revisit the current clinical classification system.

Changes of natriuretic peptides predict hospital admissions in patients with chronic heart failure: a meta-analysis.

OBJECTIVES: The goal of this study was to explore the association between changes in B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma levels and risk of hospital admission for heart failure (HF) worsening in patients with chronic HF. BACKGROUND: The relationship between BNP and NT-proBNP plasma levels and risk of cardiovascular events in patients with chronic HF has been previously demonstrated. However, it is unclear whether changes in BNP and NT-proBNP levels predict morbidity in patients with chronic HF. METHODS: The MEDLINE, Cochrane, ISI Web of Science, and SCOPUS databases were searched for papers about HF treatment up to August 2013. Randomized trials enrolling patients with systolic HF, assessing BNP and/or NT-proBNP at baseline and at end of follow-up, and reporting hospital stay for HF were included in the analysis. Meta-regression analysis was performed to test the relationship between BNP and NT-proBNP changes and the clinical endpoint. Sensitivity analysis was performed to assess the influence of baseline variables on results. Egger's linear regression was used to assess publication bias. RESULTS: Nineteen trials enrolling 12,891 participants were included. The median follow-up was 9.5 months (interquartile range: 6 to 18 months), and 22% of patients were women. Active treatments significantly reduced the risk of hospital stay for HF worsening. In meta-regression analysis, changes in BNP and NT-proBNP were significantly associated with risk of hospital stay for HF worsening. Results were confirmed by using sensitivity analysis. No publication bias was detected. CONCLUSIONS: In patients with HF, reduction of BNP or NT-proBNP levels was associated with reduced risk of hospital stay for HF worsening.

[Cardiovascular risk in systemic inflammatory diseases]. / Il rischio cardiovascolare nelle patologie infiammatorie sistemiche.

Systemic inflammatory diseases are associated with increased cardiovascular morbidity and mortality. The link between inflammatory and cardiovascular diseases can be attributed to the coexistence of classical risk factors and inflammatory mechanisms activated during systemic inflammatory diseases involving the immune system. Unfavorable metabolic effects of anti-inflammatory drugs can also contribute to increase cardiovascular risk. Yet, clinical implications of these findings are not entirely clear, and deeper knowledge and awareness of cardiac involvement in inflammatory diseases are necessary. The aim of this review is to summarize cardiac involvement in systemic inflammatory diseases and to identify aspects where evidence is currently lacking that would deserve further investigation in the future.

Cardiac magnetic resonance for the assessment of myocardial viability: from pathophysiology to clinical practice.

Cardiac magnetic resonance (CMR) is commonly applied for the assessment of myocardial viability in patients with ischemic ventricular dysfunction, and it holds potential advantages over more traditional imaging modalities, including single-photon emission computed tomography (SPECT) and dobutamine stress echocardiography (DSE). CMR-based techniques for viability assessment include the evaluation of transmural extent of the scar using late gadolinium enhancement (LGE) images, the evaluation of end-diastolic wall thickness from resting cine images and the study of inotropic reserve during low-dose dobutamine infusion. During the past decade, the diffusion of the use of CMR for viability assessment confirmed the clinical strengths of this modality and, at the same time, helped to use old techniques with an increased level of awareness. With LGE CMR, both viable and nonviable dysfunctional myocardium can be visualized in a single image, allowing a direct quantification of the amount of regional viability, with a significant impact on the estimation of chance for recovery. As well, studies with CMR applied in the setting of ischemic heart disease allowed a better understanding of the best way to apply and interpret other tests for viability evaluation. For instance, it has been demonstrated that the transmural extension of the scar may influence the level of concordance between SPECT and DSE in assessing myocardial viability. The transmural extent of scar on LGE CMR also correlates with the timing of postrevascularization recovery of systolic function, with significant impact on the diagnostic accuracy of any applied imaging modality.

Natriuretic peptide-guided therapy in chronic heart failure: a meta-analysis of 2,686 patients in 12 randomized trials.

BACKGROUND: The role of cardiac natriuretic peptides in the management of patients with chronic heart failure (HF) remains uncertain. The purpose of this study was to evaluate whether natriuretic peptide-guided therapy, compared to clinically-guided therapy, improves mortality and hospitalization rate in patients with chronic HF. METHODOLOGY/PRINCIPAL FINDINGS: MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched for articles reporting natriuretic peptide-guided therapy in HF until August 2012. All randomized trials reporting clinical end-points (all-cause mortality and/or HF-related hospitalization and/or all-cause hospitalization) were included. Meta-analysis was performed to assess the influence of treatment on outcomes. Sensitivity analysis was performed to test the influence of potential effect modifiers and of each trial included in meta-analysis on results. Twelve trials enrolling 2,686 participants were included. Natriuretic peptide-guided therapy (either B-type natriuretic peptide [BNP]- or N-terminal pro-B-type natriuretic peptide [NT-proBNP]-guided therapy) significantly reduced all-cause mortality (Odds Ratio [OR]:0.738; 95% Confidence Interval [CI]:0.596 to 0.913; p = 0.005) and HF-related hospitalization (OR:0.554; CI:0.399 to 0.769; p = 0.000), but not all-cause hospitalization (OR:0.803; CI:0.629 to 1.024; p = 0.077). When separately assessed, NT-proBNP-guided therapy significantly reduced all-cause mortality (OR:0.717; CI:0.563 to 0.914; p = 0.007) and HF-related hospitalization (OR:0.531; CI:0.347 to 0.811; p = 0.003), but not all-cause hospitalization (OR:0.779; CI:0.414 to 1.465; p = 0.438), whereas BNP-guided therapy did not significantly reduce all-cause mortality (OR:0.814; CI:0.518 to 1.279; p = 0.371), HF-related hospitalization (OR:0.599; CI:0.303 to 1.187; p = 0.142) or all-cause hospitalization (OR:0.726; CI:0.509 to 1.035; p = 0.077). [corrected]. CONCLUSIONS/SIGNIFICANCE: Use of cardiac peptides to guide pharmacologic therapy significantly reduces mortality and HF related hospitalization in patients with chronic HF. In particular, NT-proBNP-guided therapy reduced all-cause mortality and HF-related hospitalization but not all-cause hospitalization, whereas BNP-guided therapy did not significantly reduce both mortality and morbidity.

[Endothelial dysfunction in type 2 diabetic patients with normal coronary arteries. A peripheral arterial tonometry study]. / Evidenza di disfunzione endoteliale in pazienti diabetici di tipo 2 con arterie coronariche angiograficamente normali. Studio con tonometria arteriosa digitale.

AIM: to evaluate endothelial function (EF) in diabetic and non-diabetic patients without CAD by peripheral artery tonometry (PAT) technique. METHODS: a cohort of 94 patients (55 men and 39 postmenopausal women; mean age 63 +/- 9 years) undergoing coronary angiography was divided into 2 groups: 58 patients with DM and (group 1) and 36 patients without DM. Endothelial dysfunction (ED) was assessed by digital pulse amplitude, using a fingertip peripheral arterial tonometry (PAT). As a measure of ED, reactive hyperemia index (RHI) was calculated as the ratio of the digital pulse volume during reactive hyperemia following 5 min ischemia and its basal value. RESULTS: prevalence of cardiovascular risk factors was similar between the two groups. RHI values were significantly lower in diabetic patients compared to non-diabetics (1.72 +/- 0.34 vs 2.00 +/- 0.44; p < 0.005) and they correlated with levels of glycosylated hemoglobin (p = 0.05; r = -0.266). CONCLUSION: despite similar level of other risk factors, EF was much more impaired in diabetic patients than in non-diabetics. These evidences further support the impact of DM on cardiovascular risk.

[Clinical and therapeutic value of carotid intima-media thickness]. / Il valore clinico e terapeutico dello Spessore Medio-Intimale Carotideo.

Carotid Intima Media Thickness (IMT) has been widely used to predict cardiovascular events in primary and secondary prevention studies. Yet, the power of IMT to reclassify risk level on top of conventional risk assessment based on classical risk factors remains unsettled. In fact, recent data indicate that the prognostic power of IMT is lower than that provided by the identification of carotid plaques. The role of IMT as surrogate endpoint to assess the efficacy of cardiovascular protective therapies is also still debated. In fact, no studies have ever been designed and powered to show a relationship between changes in carotid IMT during follow-up and cardiovascular events. Recently, two meta-analysis of trials using IMT as surrogate endpoint failed to demonstrate an association between IMT regression and cardiovascular events. The reasons for the lack of predictive role for changes in IMT are uncertain. It has been shown that IMT is not a pure atherosclerotic index, being substantially affected by age and hemodynamic factors including blood pressure and vessel wall shear stress. In addition, the status of carotid vessels does not strictly reflect that of coronary arteries. Finally, intra and inter-observer variability of measurements may further limit the association between IMT changes in individual patients and cardiovascular risk. Thus, IMT represents a valuable risk marker in population studies but its role for tailoring cardiovascular therapy in clinical practice remains currently uncertain.

[Metabolic and cardiovascular effects of combined antiretroviral therapy in patients with HIV infection. Systematic review of literature]. / Effetti metabolici e cardiovascolari della terapia antiretrovirale combinata in pazienti con infezione da HIV. Rassegna sistematica della letteratura.

In HIV infected patients an increased incidence of cardiac events has been reported since the introduction of highly active antiretroviral therapy (HAART). Antiretroviral drugs' regimens are, in fact, associated with several metabolic side effects, such as dyslipidemia, impaired glucose metabolism and abnormal body fat distribution, that increase cardiovascular risk of HIV subjects. In addition, HIV infection itself, the chronic inflammatory status and the frequent presence in this population of traditional risk factors contribute to an higher incidence of cardio and cerebrovascular events. In last years several studies showed the occurrence of carotid vascular impairment in patients treated with protease inhibitors (PI). Similarly the DAD Study reported an increase of 26% of the risk of myocardial infarction in patients on HAART and that this risk was independently associated with longer exposure to PI, after multivariate adjustments. A correct evaluation of the metabolic status before starting HAART and an adequate control of drugs-related metabolic abnormalities may reduce the incidence of cardiac events and still improve HIV patients prognosis. This review will focus on the metabolic effects of antiretroviral drugs and on the contribution of combination antiretroviral therapy on cardiovascular risk.