Major bleeding risk in anticoagulated patients receiving concomitant antiplatelet therapy: A prospective study.

INTRODUCTION: Current literature suggesting a higher bleeding risk during combination therapy compared to oral anticoagulation alone is primarily based on retrospective studies or specific populations. We aimed to prospectively evaluate whether unselected medical patients on oral anticoagulation have an increased risk of bleeding when on concomitant antiplatelet therapy. MATERIAL AND METHODS: We prospectively studied consecutive adult medical patients who were discharged on oral anticoagulants between 01/2008 and 03/2009 from a Swiss university hospital. The primary outcome was the time to a first major bleed on oral anticoagulation within 12months, adjusted for age, international normalized ratio target, number of medications, and history of myocardial infarction and major bleeding. RESULTS: Among the 515 included anticoagulated patients, the incidence rate of a first major bleed was 8.2 per 100 patient-years. Overall, 161 patients (31.3%) were on both anticoagulant and antiplatelet therapy, and these patients had a similar incidence rate of major bleeding compared to patients on oral anticoagulation alone (7.6 vs. 8.4 per 100 patient-years, P=0.81). In a multivariate analysis, the association of concomitant antiplatelet therapy with the risk of major bleeding was not statistically significant (hazard ratio 0.89, 95% confidence interval, 0.37-2.10). CONCLUSIONS: The risk of bleeding in patients receiving oral anticoagulants combined with antiplatelet therapy was similar to patients receiving oral anticoagulants alone, suggesting that the incremental bleeding risk of combination therapy might not be clinically significant.

Mirror therapy in children with hemiplegia: a pilot study.

Mirror therapy, which provides the visual illusion of a functional paretic limb by using the mirror reflection of the non-paretic arm, is used in the rehabilitation of hemiparesis after stroke in adults. We tested the effectiveness and feasibility of mirror therapy in children with hemiplegia by performing a pilot crossover study in ten participants (aged 6-14 y; five males, five females; Manual Ability Classification System levels: one at level I, two at level II, four at level III, three at level IV) randomly assigned to 15 minutes of daily bimanual training with and without a mirror for 3 weeks. Assessments of maximal grasp and pinch strengths, and upper limb function measured by the Shriner's Hospital Upper Extremity Evaluation were performed at weeks 0 (baseline), 3, 6 (intervention), and 9 (wash-out). Testing of grasp strength behind the mirror improved performance by 15% (p=0.004). Training with the mirror significantly improved grasp strength (with mirror +20.4%, p=0.033; without +5.9%, p>0.1) and upper limb dynamic position (with mirror +4.6%, p=0.044; without +1.2%, p>0.1), while training without a mirror significantly improved pinch strength (with mirror +6.9%, p>0.1; without +21.9%, p=0.026). This preliminary study demonstrates the feasibility of mirror therapy in children with hemiplegia and that it may improve strength and dynamic function of the paretic arm.

Índices de erosividade da chuva, perdas de solo e fator erodibilidade para dois solos da região dos cerrados - primeira aproximação

Os objetivos deste trabalho foram: testar a adequação de diferentes índices de erosividade das chuvas, comparar duas equações propostas para cálculo da energia cinética das chuvas e estimar o fator K (erodibilidade) da equação universal de perdas de solo (EUPS) para um latossolo vermelho-escuro (LE) álico muito argiloso e um podzólico vermelho-amarelo (PV) álico muito argiloso da região de Sete Lagoas (MG). Não houve diferença significativa entre as duas equações testadas para cálculo da energia cinética das chuvas. O índice EI30 mostrou ser um bom estimador da erosividade da chuva e pode continuar sendo utilizado como fator R (erosividade) da EUPS para a região estudada. Os valores do fator K, para o LE e o PV da região de Sete Lagoas, foram, respectivamente, 0,002 e 0,033 t h (MJ mm)-1.

Umidade crítica de compactação e densidade do solo máxima em resposta a sistemas de manejo num Latossolo Roxo

O termo compactação do solo refere-se à compressão do solo não saturado durante a qual existe um aumento da densidade do solo em conseqüência da redução de seu volume, pela expulsão do ar causado pelo manejo inadequado. Com o objetivo de estudar o efeito de diferentes sistemas de manejo na densidade do solo máxima (Ds máx), e na umidade crítica de compactação (Ucrít), realizou-se um experimento em um Latossolo Roxo da Região de Lavras (MG), submetido aos seguintes sistemas de manejo: preparo com arado de discos (AD), preparo com escarificador (CM), semeadura direta (SD), preparo com arado de aivecas (AA) e preparo intensivo com grade (GD). O experimento foi instalado, em novembro de 1994, em blocos casualizados. Foram realizadas três amostragens em 1996: em janeiro, antes da semeadura do feijão; em abril, antes da colheita do feijão, e em novembro, antes da semeadura do milho. As amostras deformadas foram coletadas nas camadas de 0-0,07 e 0,20-0,27 m de profundidade nos sistemas de manejo AD, CM e AA. No sistema de manejo SD, as amostras deformadas foram coletadas nas camadas de 0-0,07 e 0,25-0,32 m de profundidade e, no caso do sistema GD, nas camadas de 0-0,07 e 0,15-0,22 m de profundidade. A partir das curvas de compactação, obteve-se a densidade do solo máxima. Determinaram-se, ainda, o teor de argila e matéria orgânica (MO), o limite de plasticidade (LP) e a água retida a - 0,033 e - 0,01 MPa. Os valores de (Ds máx), (Ucrít) para os diferentes sistemas de manejo, época de coleta e profundidades, não foram estatisticamente diferentes, não sendo, portanto, influenciados pelos teores de argila e M.O. Verificou-se que a Ucrít corresponde a 90% do LP e a 90% da água retida a - 0,01 MPa é aproximadamente igual à água retida a - 0,033 MPa.

Postgraduate Symposium: Positive influence of nutritional alkalinity on bone health.

There is growing evidence that consumption of a Western diet is a risk factor for osteoporosis through excess acid supply, while fruits and vegetables balance the excess acidity, mostly by providing K-rich bicarbonate-rich foods. Western diets consumed by adults generate approximately 50-100 mEq acid/d; therefore, healthy adults consuming such a diet are at risk of chronic low-grade metabolic acidosis, which worsens with age as a result of declining kidney function. Bone buffers the excess acid by delivering cations and it is considered that with time an overstimulation of this process will lead to the dissolution of the bone mineral content and hence to reduced bone mass. Intakes of K, Mg and fruit and vegetables have been associated with a higher alkaline status and a subsequent beneficial effect on bone health. In healthy male volunteers an acid-forming diet increases urinary Ca excretion by 74% and urinary C-terminal telopeptide of type I collagen (C-telopeptide) excretion by 19% when compared with an alkali (base-forming) diet. Cross-sectional studies have shown that there is a correlation between the nutritional acid load and bone health measured by bone ultrasound or dual-energy X-ray absorptiometry. Few studies have been undertaken in very elderly women (>75 years), whose osteoporosis risk is very pertinent. The EVAluation of Nutrients Intakes and Bone Ultra Sound Study has developed and validated (n 51) an FFQ for use in a very elderly Swiss population (mean age 80.4 (sd 2.99) years), which has shown intakes of key nutrients (energy, fat, carbohydrate, Ca, Mg, vitamin C, D and E) to be low in 401 subjects. A subsequent study to assess net endogenous acid production (NEAP) and bone ultrasound results in 256 women aged > or = 75 years has shown that lower NEAP (P=0.023) and higher K intake (P=0.033) are correlated with higher bone ultrasound results. High acid load may be an important additional risk factor that may be particularly relevant in very elderly patients with an already-high fracture risk. The latter study adds to knowledge by confirming a positive link between dietary alkalinity and bone health indices in the very elderly. In a further study to complement these findings it has also been shown in a group of thirty young women that in Ca sufficiency an acid Ca-rich water has no effect on bone resorption, while an alkaline bicarbonate-rich water leads to a decrease in both serum parathyroid hormone and serum C-telopeptide. Further investigations need to be undertaken to study whether these positive effects on bone loss are maintained over long-term treatment. Mineral-water consumption could be an easy and inexpensive way of helping to prevent osteoporosis and could be of major interest for long-term prevention of bone loss.

Cannabidiol attenuates cardiac dysfunction, oxidative stress, fibrosis, and inflammatory and cell death signaling pathways in diabetic cardiomyopathy.

Objectives In this study, we have investigated the effects of cannabidiol (CBD) on myocardial dysfunction, inflammation, oxidative/nitrative stress, cell death, and interrelated signaling pathways, using a mouse model of type I diabetic cardiomyopathy and primary human cardiomyocytes exposed to high glucose. Background Cannabidiol, the most abundant nonpsychoactive constituent of Cannabis sativa (marijuana) plant, exerts anti-inflammatory effects in various disease models and alleviates pain and spasticity associated with multiple sclerosis in humans. Methods Left ventricular function was measured by the pressure-volume system. Oxidative stress, cell death, and fibrosis markers were evaluated by molecular biology/biochemical techniques, electron spin resonance spectroscopy, and flow cytometry. Results Diabetic cardiomyopathy was characterized by declined diastolic and systolic myocardial performance associated with increased oxidative-nitrative stress, nuclear factor-kappa B and mitogen-activated protein kinase (c-Jun N-terminal kinase, p-38, p38 alpha) activation, enhanced expression of adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1), tumor necrosis factor-alpha, markers of fibrosis (transforming growth factor-beta, connective tissue growth factor, fibronectin, collagen-1, matrix metalloproteinase-2 and -9), enhanced cell death (caspase 3/7 and poly[adenosine diphosphate-ribose] polymerase activity, chromatin fragmentation, and terminal deoxynucleotidyl transferase dUTP nick end labeling), and diminished Akt phosphorylation. Remarkably, CBD attenuated myocardial dysfunction, cardiac fibrosis, oxidative/nitrative stress, inflammation, cell death, and interrelated signaling pathways. Furthermore, CBD also attenuated the high glucose-induced increased reactive oxygen species generation, nuclear factor-kappa B activation, and cell death in primary human cardiomyocytes. Conclusions Collectively, these results coupled with the excellent safety and tolerability profile of CBD in humans, strongly suggest that it may have great therapeutic potential in the treatment of diabetic complications, and perhaps other cardiovascular disorders, by attenuating oxidative/nitrative stress, inflammation, cell death and fibrosis. (J Am Coll Cardiol 2010;56:2115-25) (C) 2010 by the American College of Cardiology Foundation.

Effects of an interleukin-15 antagonist on systemic and skeletal alterations in mice with DSS-induced colitis.

Inflammatory bowel diseases are commonly complicated by weight and bone loss. We hypothesized that IL-15, a pro-inflammatory cytokine expressed in colitis and an osteoclastogenic factor, could play a central role in systemic and skeletal complications of inflammatory bowel diseases. We evaluated the effects of an IL-15 antagonist, CRB-15, in mice with chronic colitis induced by oral 2% dextran sulfate sodium for 1 week, followed by another 1% for 2 weeks. During the last 2 weeks, mice were treated daily with CRB-15 or an IgG2a control antibody. Intestinal inflammation, disease severity, and bone parameters were evaluated at days 14 and 21. CRB-15 improved survival, early weight loss, and colitis clinical score, although colon damage and inflammation were prevented in only half the survivors. CRB-15 also delayed loss of femur bone mineral density and trabecular microarchitecture. Bone loss was characterized by decreased bone formation, but increased bone marrow osteoclast progenitors and osteoclast numbers on bone surfaces. CRB-15 prevented the suppression of osteoblastic markers of bone formation, and reduced osteoclast progenitors at day 14, but not later. However, by day 21, CRB-15 decreased tumor necrosis factor α and increased IL-10 expression in bone, paralleling a reduction of osteoclasts. These results delineate the role of IL-15 on the systemic and skeletal manifestations of chronic colitis and provide a proof-of-concept for future therapeutic developments.

Influence of chronic hyperglycemia on cerebral microvascular remodeling: an in vivo study using perfusion computed tomography in acute ischemic stroke patients.

BACKGROUND AND PURPOSE: To investigate the effect of chronic hyperglycemia on cerebral microvascular remodeling using perfusion computed tomography. METHODS: We retrospectively identified 26 patients from our registry of 2453 patients who underwent a perfusion computed tomographic study and had their hemoglobin A1c (HbA1c) measured. These 26 patients were divided into 2 groups: those with HbA1c>6.5% (n=15) and those with HbA1c≤6.5% (n=11). Perfusion computed tomographic studies were processed using a delay-corrected, deconvolution-based software. Perfusion computed tomographic values were compared between the 2 patient groups, including mean transit time, which relates to the cerebral capillary architecture and length. RESULTS: Mean transit time values in the nonischemic cerebral hemisphere were significantly longer in the patients with HbA1c>6.5% (P=0.033), especially in the white matter (P=0.005). Significant correlation (R=0.469; P=0.016) between mean transit time and HbA1c level was observed. CONCLUSIONS: Our results from a small sample suggest that chronic hyperglycemia may be associated with cerebral microvascular remodeling in humans. Additional prospective studies with larger sample size are required to confirm this observation.

Necessitats d'educació continuada en biblioteconomia i documentació a Espanya: resultats d'una enquesta

Resultats d'un estudi sobre necessitats de formació continuada en biblioteconomia i documentado a l'Estat espanyol. Les dades per elaborar I'estudi foren recollides amb un qüestionari que es distribuí a una mostra aleatoria de 601 individus. La mostra representava una població de 3.033 individus, membres de set associacions bibliotecáries de l'Estat. El percentatge de resposta (31,3%) no permet fer afirmacions contundents, pero dona una indicado prou aproximada de la situado real. Les dades recollides s'analitzen en tres blocs: característiques de la població analitzada I deis centres on treballa; avaluado de la formado inicial deis enquestats i avaluado de la formació continuada.

Geochemistry and 40Ar/39Ar geochronology of pseudotachylyte associated with UHP whiteschists from the Dora Maira massif, Italy

In situ UV-Iaser ablation Ar-40/(39) Ar geochronological and geochemical data, together with rock and mineral compositional data, have been determined from pseudotachylyte and surrounding mylonitic gneiss associated with the UHP whiteschists of the Dora Maira Massif, Italy. Several generations of fresh pseudotachylyte occur as irregular veins up to a few cur thick both parallel and at high angles to the foliation. Whole rock XRF data collected from representative lithologies of mylonitic gneiss are uniformly consistent with a mildly alkalic granitic protolith. Minimal compositional variation is observed between the pseudotachylyte and its surrounding mylonitic gneiss. The pseudotachylyte contains newly crystallized grains of biotite and K-feldspar in a matrix of glass with partially fused grains of quartz, zircon, apatite, and titanite. Electron microprobe analyses of the glass show significant compositional variation that is probably strongly influenced by micrometer-scale changes in mineralogy. UV-Iaser ablation ICP-MS traverses across the mylonitic gneiss-pseudotachylyte contact are consistent with cataclastic communition of REE carriers such as epidote, monazite, allanite, zircon, and apatite before melting as an efficient mechanism of REE homogenization in the pseudotachylyte. The 40Ar/39Ar data from one band of pseudotachylyte indicate formation at 20.1 +/- 0.5 Ma, when the mylonitic gneisses were already in a near surface position. The variable effects of top-to-the-west shear deformation within outcrops of the coesite-bearing unit are reflected in localized zones of protomylonite, cataclasite, ultracataclasite, and pseudotachylyte. Preservation of several generations of pseudotachylyte suggests that seismic events may have played a significant role in triggering late unroofing of the UHP rocks. It is speculated that deeper crustal seismic events potentially played a role in the unroofing of the UHP rocks at earlier stages in their exhumation history. (c) 2005 Elsevier B.V. All rights reserved.

Amostragem e variabilidade espacial de atributos físicos de um latossolo vermelho em Mossoró, RN

Os solos, mesmo aqueles considerados homogêneos, exibem alguma variabilidade espacial e temporal em seus atributos físicos, químicos e biológicos. A definição dessa variabilidade é muito importante para um eficiente manejo do solo. Este trabalho objetivou estudar a variabilidade espacial de alguns atributos físicos de um Latossolo Vermelho, em Mossoró-RN, a fim de estabelecer o melhor procedimento na coleta de amostras de solo. Em uma área com dimensões de 100 x 100 m, marcada a cada 10 m em duas direções perpendiculares entre si, fez-se a coleta de amostras de solo na camada de 0,0-0,2 m de profundidade, totalizando 100 amostras. As análises compreenderam granulometria, densidade do solo, densidade de partículas, porosidade total e retenção de água nas tensões de 0,033 e 1,500 MPa. Os dados foram analisados por estatística descritiva e geoestatística. Concluiu-se que a variabilidade do solo, medida pelo coeficiente de variação, mostrou-se baixa para areia, densidade do solo, densidade de partículas e volume total de poros e média para silte, argila, capacidade de campo e ponto de murcha permanente; a maioria das variáveis analisadas segue distribuição normal de freqüências, excetuando-se areia, densidade do solo e volume total de poros; o mapeamento das variáveis estudadas sugere o estabelecimento de subáreas homogêneas, a fim de tornar o manejo dos recursos mais eficiente, especialmente o de água.

Laparoscopic aortic surgery: Techniques and results.

OBJECTIVE: This review describes and evaluates the results of laparoscopic aortic surgery. METHODS: We describe the different laparoscopic techniques used to treat aortic disease, including (1) total laparoscopic aortic surgery (TLS), (2) laparoscopy-assisted procedures including hand-assisted laparoscopic surgery (HALS), and (3) robot-assisted laparoscopic surgery, with their current indications. Results of these techniques are analyzed in a systematic review of the clinical series published between 1998 and 2008, each containing >10 patients with complete information concerning operative time, clamping time, conversion rate, length of hospital stay, morbidity, and mortality. RESULTS: We selected and reviewed 29 studies that included 1073 patients. Heterogeneity of the studies and selection of the patients made comparison with current open or endovascular surgery difficult. Median operative time varied widely in TLS, from 240 to 391 minutes. HALS had the shortest operating time. Median clamping time varied from 60 to 146 minutes in TLS and was shorter in HALS. Median hospital stay varied from 4 to 10 days regardless of the laparoscopic technique. The postoperative mortality rate was 2.1% (95% confidence interval, 1.4-3.0), with no significant difference between patients treated for occlusive disease or for aneurysmal disease. Conversion to open surgery was necessary in 8.1% of patients and was slightly higher with TLS than with laparoscopy-assisted techniques (P = .07). CONCLUSIONS: Analysis of these series shows that laparoscopic aortic surgery can be performed safely provided that patient selection is adjusted to the surgeon's experience and conversion is liberally performed. The future of this technique in comparison with endovascular surgery is still unknown, and it is now time for multicenter randomized trials to demonstrate the potential benefit of this type of surgery.

External irradiation with or without long-term androgen suppression for prostate cancer with high metastatic risk: 10-year results of an EORTC randomised study.

BACKGROUND: We did a randomised phase 3 trial assessing the benefit of addition of long-term androgen suppression with a luteinising-hormone-releasing hormone (LHRH) agonist to external irradiation in patients with prostate cancer with high metastatic risk. In this report, we present the 10-year results. METHODS: For this open-label randomised trial, eligible patients were younger than 80 years and had newly diagnosed histologically proven T1-2 prostatic adenocarcinoma with WHO histological grade 3 or T3-4 prostatic adenocarcinoma of any histological grade, and a WHO performance status of 0-2. Patients were randomly assigned (1:1) to receive radiotherapy alone or radiotherapy plus immediate androgen suppression. Treatment allocation was open label and used a minimisation algorithm with institution, clinical stage of the disease, results of pelvic-lymph-node dissection, and irradiation fields extension as minimisation factors. Patients were irradiated externally, once a day, 5 days a week, for 7 weeks to a total dose of 50 Gy to the whole pelvis, with an additional 20 Gy to the prostate and seminal vesicles. The LHRH agonist, goserelin acetate (3·6 mg subcutaneously every 4 weeks), was started on the first day of irradiation and continued for 3 years; cyproterone acetate (50 mg orally three times a day) was given for 1 month starting a week before the first goserelin injection. The primary endpoint was clinical disease-free survival. Analysis was by intention to treat. The trial is registered at ClinicalTrials.gov, number NCT00849082. FINDINGS: Between May 22, 1987, and Oct 31, 1995, 415 patients were randomly assigned to treatment groups and were included in the analysis (208 radiotherapy alone, 207 combined treatment). Median follow-up was 9·1 years (IQR 5·1-12·6). 10-year clinical disease-free survival was 22·7% (95% CI 16·3-29·7) in the radiotherapy-alone group and 47·7% (39·0-56·0) in the combined treatment group (hazard ratio [HR] 0·42, 95% CI 0·33-0·55, p<0·0001). 10-year overall survival was 39·8% (95% CI 31·9-47·5) in patients receiving radiotherapy alone and 58·1% (49·2-66·0) in those allocated combined treatment (HR 0·60, 95% CI 0·45-0·80, p=0·0004), and 10-year prostate-cancer mortality was 30·4% (95% CI 23·2-37·5) and 10·3% (5·1-15·4), respectively (HR 0·38, 95% CI 0·24-0·60, p<0·0001). No significant difference in cardiovascular mortality was noted between treatment groups both in patients who had cardiovascular problems at study entry (eight of 53 patients in the combined treatment group had a cardiovascular-related cause of death vs 11 of 63 in the radiotherapy group; p=0·60) and in those who did not (14 of 154 vs six of 145; p=0·25). Two fractures were reported in patients allocated combined treatment. INTERPRETATION: In patients with prostate cancer with high metastatic risk, immediate androgen suppression with an LHRH agonist given during and for 3 years after external irradiation improves 10-year disease-free and overall survival without increasing late cardiovascular toxicity.