Atherosclerosis screening by noninvasive imaging for cardiovascular prevention: a systematic review.

BACKGROUND: Noninvasive imaging of atherosclerosis is being increasingly used in clinical practice, with some experts recommending to screen all healthy adults for atherosclerosis and some jurisdictions mandating insurance coverage for atherosclerosis screening. Data on the impact of such screening have not been systematically synthesized. OBJECTIVES: We aimed to assess whether atherosclerosis screening improves cardiovascular risk factors (CVRF) and clinical outcomes. DESIGN: This study is a systematic review. DATA SOURCES: We searched MEDLINE and the Cochrane Clinical Trial Register without language restrictions. STUDY ELIGIBILITY CRITERIA: We included studies examining the impact of atherosclerosis screening with noninvasive imaging (e.g., carotid ultrasound, coronary calcification) on CVRF, cardiovascular events, or mortality in adults without cardiovascular disease. RESULTS: We identified four randomized controlled trials (RCT, n=709) and eight non-randomized studies comparing participants with evidence of atherosclerosis on screening to those without (n=2,994). In RCTs, atherosclerosis screening did not improve CVRF, but smoking cessation rates increased (18% vs. 6%, p=0.03) in one RCT. Non-randomized studies found improvements in several intermediate outcomes, such as increased motivation to change lifestyle and increased perception of cardiovascular risk. However, such data were conflicting and limited by the lack of a randomized control group. No studies examined the impact of screening on cardiovascular events or mortality. Heterogeneity in screening methods and studied outcomes did not permit pooling of results. CONCLUSION: Available evidence about atherosclerosis screening is limited, with mixed results on CVRF control, increased smoking cessation in one RCT, and no data on cardiovascular events. Such screening should be validated by large clinical trials before widespread use.

Cytokines and hs-CRP levels in individuals treated with aspirin for cardiovascular prevention: a population-based study (CoLaus Study)

Backgrounds: Pro-inflammatory cytokines and high-sensitive C-reactive protein (hs-CRP) are associated with increased risk for cardiovascular disease. Low-dose aspirin for cardiovascular (CV) prevention is reported to have anti-inflammatory effects. The aim of this study was to determine the association between cytokines and hs-CRP levels and low-dose aspirin use for CV prevention in a population-based cohort (CoLaus Study). Methods and Results: Blood samples were assessed in 6,085 participants (3,201 women) aged 35-75 years. Medications' use and indications were recorded. Among aspirin users (n=1'034; 17%), overall low-dose (351; 5.8%) and low-dose for CV prevention (324; 5.3%) users were specifically selected for analysis. IL-1beta, IL-6 and TNF-alpha were assessed by a multiplex particle-based flow cytometric assay and hs-CRP by an immunometric assay. Cytokines and hs-CRP were presented in quartiles. Multivariate analysis adjusting for sex, age, smoking status, body mass index, concomitant use of various immunomodulatory drugs, diabetes mellitus showed no association between cytokines and hs-CRP levels and low-dose aspirin use for CV prevention either comparing the topmost vs. the three other quartiles (OR 95% CI, 0.84 (0.59 - 1.18), 1.03 (0.78 - 1.32), 1.10 (0.83 - 1.46), 1.00 (0.67 - 1.69) for IL-1beta, IL-6, TNF-alpha and hs-CRP, respectively), or comparing the topmost quartile vs. the first one (OR 95% CI, 0.87 (0.60 - 1.26), 1.19 (0.79 - 1.79), 1.26 (0.86 - 1.84), 1.06 (0.67 - 1.69)). Conclusions: Low-dose aspirin use for cardiovascular prevention does not seem to impact plasma cytokine and hs-CRP levels in a population-based cohort.

Forensic processing of false identity and travel documents to produce intelligence: a novel approach to assist in fighting organized crime

The production and use of false identity and travel documents in organized crime represent a serious and evolving threat. However, a case-by-case perspective, thus suffering from linkage blindness and a limited analysis capacity, essentially drives the present-day fight against this criminal problem. To assist in overcoming these limitations, a process model was developed using a forensic perspective. It guides the systematic analysis and management of seized false documents to generate forensic intelligence that supports strategic and tactical decision-making in an intelligence-led policing approach. The model is articulated on a three-level architecture that aims to assist in detecting and following-up on general trends, production methods and links between cases or series. Using analyses of a large dataset of counterfeit and forged identity and travel documents, it is possible to illustrate the model, its three levels and their contribution. Examples will point out how the proposed approach assists in detecting emerging trends, in evaluating the black market's degree of structure, in uncovering criminal networks, in monitoring the quality of false documents, and in identifying their weaknesses to orient the conception of more secured travel and identity documents. The process model proposed is thought to have a general application in forensic science and can readily be transposed to other fields of study.

Vorapaxar in the secondary prevention of atherothrombotic events.

BACKGROUND: Thrombin potently activates platelets through the protease-activated receptor PAR-1. Vorapaxar is a novel antiplatelet agent that selectively inhibits the cellular actions of thrombin through antagonism of PAR-1. METHODS: We randomly assigned 26,449 patients who had a history of myocardial infarction, ischemic stroke, or peripheral arterial disease to receive vorapaxar (2.5 mg daily) or matching placebo and followed them for a median of 30 months. The primary efficacy end point was the composite of death from cardiovascular causes, myocardial infarction, or stroke. After 2 years, the data and safety monitoring board recommended discontinuation of the study treatment in patients with a history of stroke owing to the risk of intracranial hemorrhage. RESULTS: At 3 years, the primary end point had occurred in 1028 patients (9.3%) in the vorapaxar group and in 1176 patients (10.5%) in the placebo group (hazard ratio for the vorapaxar group, 0.87; 95% confidence interval [CI], 0.80 to 0.94; P<0.001). Cardiovascular death, myocardial infarction, stroke, or recurrent ischemia leading to revascularization occurred in 1259 patients (11.2%) in the vorapaxar group and 1417 patients (12.4%) in the placebo group (hazard ratio, 0.88; 95% CI, 0.82 to 0.95; P=0.001). Moderate or severe bleeding occurred in 4.2% of patients who received vorapaxar and 2.5% of those who received placebo (hazard ratio, 1.66; 95% CI, 1.43 to 1.93; P<0.001). There was an increase in the rate of intracranial hemorrhage in the vorapaxar group (1.0%, vs. 0.5% in the placebo group; P<0.001). CONCLUSIONS: Inhibition of PAR-1 with vorapaxar reduced the risk of cardiovascular death or ischemic events in patients with stable atherosclerosis who were receiving standard therapy. However, it increased the risk of moderate or severe bleeding, including intracranial hemorrhage. (Funded by Merck; TRA 2P-TIMI 50 ClinicalTrials.gov number, NCT00526474.).

Salmeterol for the prevention of high-altitude pulmonary edema.

BACKGROUND: Pulmonary edema results from a persistent imbalance between forces that drive water into the air space and the physiologic mechanisms that remove it. Among the latter, the absorption of liquid driven by active alveolar transepithelial sodium transport has an important role; a defect of this mechanism may predispose patients to pulmonary edema. Beta-adrenergic agonists up-regulate the clearance of alveolar fluid and attenuate pulmonary edema in animal models. METHODS: In a double-blind, randomized, placebo-controlled study, we assessed the effects of prophylactic inhalation of the beta-adrenergic agonist salmeterol on the incidence of pulmonary edema during exposure to high altitudes (4559 m, reached in less than 22 hours) in 37 subjects who were susceptible to high-altitude pulmonary edema. We also measured the nasal transepithelial potential difference, a marker of the transepithelial sodium and water transport in the distal airways, in 33 mountaineers who were prone to high-altitude pulmonary edema and 33 mountaineers who were resistant to this condition. RESULTS: Prophylactic inhalation of salmeterol decreased the incidence of high-altitude pulmonary edema in susceptible subjects by more than 50 percent, from 74 percent with placebo to 33 percent (P=0.02). The nasal potential-difference value under low-altitude conditions was more than 30 percent lower in the subjects who were susceptible to high-altitude pulmonary edema than in those who were not susceptible (P<0.001). CONCLUSIONS: Prophylactic inhalation of a beta-adrenergic agonist reduces the risk of high-altitude pulmonary edema. Sodium-dependent absorption of liquid from the airways may be defective in patients who are susceptible to high-altitude pulmonary edema. These findings support the concept that sodium-driven clearance of alveolar fluid may have a pathogenic role in pulmonary edema in humans and therefore represent an appropriate target for therapy.

Opportunities for prevention in primary care in a country with universal insurance coverage.

Data from studies in the United States suggest that young people engaging in health-compromising behaviors have lower access to health care. Using data from a Swiss national survey we tested the hypothesis that in a country with universal insurance coverage, adolescents engaging in health-compromising behaviors access primary care to the same extent as those who do not engage in these behaviors.

Acute ischemic cerebrovascular events on antiplatelet therapy: what is the optimal prevention strategy?

Even though patients who develop ischemic stroke despite taking antiplatelet drugs represent a considerable proportion of stroke hospital admissions, there is a paucity of data from investigational studies regarding the most suitable therapeutic intervention. There have been no clinical trials to test whether increasing the dose or switching antiplatelet agents reduces the risk for subsequent events. Certain issues have to be considered in patients managed for a first or recurrent stroke while receiving antiplatelet agents. Therapeutic failure may be due to either poor adherence to treatment, associated co-morbid conditions and diminished antiplatelet effects (resistance to treatment). A diagnostic work up is warranted to identify the etiology and underlying mechanism of stroke, thereby guiding further management. Risk factors (including hypertension, dyslipidemia and diabetes) should be treated according to current guidelines. Aspirin or aspirin plus clopidogrel may be used in the acute and early phase of ischemic stroke, whereas in the long-term, antiplatelet treatment should be continued with aspirin, aspirin/extended release dipyridamole or clopidogrel monotherapy taking into account tolerance, safety, adherence and cost issues. Secondary measures to educate patients about stroke, the importance of adherence to medication, behavioral modification relating to tobacco use, physical activity, alcohol consumption and diet to control excess weight should also be implemented.

SIDA: l'information comme outil de prévention. [AIDS: information as a means to prevention].

Objective information for the groups exposed to the disease and the public in general is the only step that is currently possible in the prevention of AIDS. A certain number of information and support actions have been developed as a consequence of the appearance of AIDS in Switzerland. The AIDS information hot-line at the CHUV is one of these actions with the aim of orienting the information according to demand and examining the utility of this means, we made a prospective evaluation of the calls (between 23 October 1985-inception of the line and 31 March 1986). Out of a total of 535 calls, 317 requests for appointments (tests, consultation) or written documentation, and 218 (41%) were transferred to the doctor; 39% of the calls came from people who were directly concerned (ill, with a positive test, exposed groups), 11% from health professionals, and 47% from the general public. 56% of the calls were concerned with transmission of the disease (sexual, blood, indirect), 22% with the meaning of the detection test, 22% referred to the symptoms of the disease. According to the doctor's estimate, although the standard of knowledge is satisfactory in 55% of the cases, a considerable number of false ideas, that generate irrational fear, still persist. This hot-line thus provides a sympathetic ear and individual support, particularly for the exposed groups, rather than information about the disease. The existence of this action, therefore, appears justified, but must be integrated into a global strategy of information promotion.

An alternative approach to the prevention of doping in cycling

The article proposes an alternative approach to policies for preventing doping in cycling, based on in-depth analysis of the functioning of nine of the 40 world professional teams and the careers of the 2,351 riders who were or have been professionals since 2005. The first part shows that the instruments of prevention have been based on a questionable understanding of doping as an individual moral fault, and have not produced the expected results. The second part proposes to analyse the ways in which teams and riders produce their achievments, so as to put forward an alternative to the anti-doping policies used hitherto, which have little impact on riders. The study shows that it is more pertinent to examine the forms of employment and the business models, because these have important effects on cycling professionals' conditions of work. It makes it possible to identify three dimensions of the risk of doping on which organisations can act in their antidoping policies: team organisation, riders' preparation and workload, and the precarity of employment.