Valeria Siciliano

Scar extent, left ventricular end-diastolic volume and wall motion abnormalities identify high-risk patients with previous myocardial infarction: a multiparametric approach for prognostic stratification

AIMS We sought to investigate whether combining left ventricular (LV) volumes, regional wall motion abnormalities, and scar tissue extent obtained by cardiac magnetic resonance (CMR) improves risk stratification of patients with previous myocardial infarction (MI). METHODS AND RESULTS In 231 consecutive patients (age 64 ± 11 years, males 89%) with previous MI, we quantified LV volumes and regional wall motion abnormalities by cine CMR, and measured the extent of the infarction scar by late gadolinium enhancement (LGE). During follow-up (median, 3.2 years) cardiac events (cardiac death or appropriate intra-cardiac defibrillator shocks) occurred in 19 patients. After adjustment for age, an extent of LGE >12.7%, an LV end-diastolic volume >105 mL/m(2), and a wall motion score index >1.7 were independent associated with adverse cardiac events at multivariate analysis (P < 0.05, P < 0.001, and P < 0.01, respectively). The patients with none of these factors, and those with one or two factors, showed a lower risk of cardiac events [hazard ratio (HR) = 0.112, P < 0.01 and HR = 0.261, P < 0.05] than those with three factors. The cumulative event-rate estimated at 4 years was 29.6% in patients with all three factors, 7.7% in those with one or two factors, and 3.5% in patients with none of these factors. CONCLUSION A multiparametric CMR approach, which includes the measure of scar tissue extent, LV end-diastolic volume and regional wall motion abnormalities, improves risk stratification of patients with previous MI.

Illegal Substance Use among Italian High School Students: Trends over 11 Years (1999–2009)

Purpose To monitor changes in habits in drug use among Italian high school students. Methods Cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) carried out in Italy annually for 11 years (1999–2009) with representative samples of youth attending high school. The sample size considered ranges from 15,752 to 41,365 students and response rate ranged from 85.5% to 98.6%. Data were analyzed to obtain measures of life-time prevalence (LT), use in the last year (LY), use in the last 30 days (LM), frequent use. Comparisons utilized difference in proportion tests. Tests for linear trends in proportion were performed using the Royston p trend test. Results When the time-averaged value was considered, cannabis (30% LT) was the most, and heroin the least (2%) frequently used, with cocaine (5%), hallucinogens (2%) and stimulants (2%) in between. A clear gender gap is evident for all drugs, more obvious for hallucinogens (average M/F LY prevalence ratio 2, range 1.7–2.4, p<0.05), less for cannabis (average M/F LY prevalence ratio 1.3, range 1.2–1.5, p<0.05). Data shows a change in trend between 2005 and 2008; in 2006 the trend for cannabis use and availability dropped and the price rose, while from 2005 cocaine and stimulant use prevalence showed a substantial increase and the price went down. After 2008 use of all substances seems to have decreased. Conclusions Drug use is widespread among students in Italy, with cannabis being the most and heroin the least prevalent. Girls are less vulnerable than boys to illegal drug use. In recent years, a decrease in heroin use is overbalanced by a marked rise in hallucinogen and stimulant use.

Optimal scaling of the CAST and of SDS Scale in a national sample of adolescents

PURPOSE Psychometric and screening properties of the Cannabis Abuse Screening Test (CAST) and of the Severity Dependence Scale (SDS) were investigated using DSM-IV diagnoses of cannabis dependence (CD) as external criteria. Performance of the SDS and of the CAST were compared. METHODS Cross-sectional European School Survey Project on Alcohol and Other Drugs (ESPAD) was carried out in Italy in 2009. The sample consisted of 5787 Italian adolescents aged 15-19 who reported cannabis last year use. Uni-dimensionality, internal reliability, external validity, and optimal scaling of the 6 items for CAST and 5 items for SDS were performed. The Munich Composite International Diagnostic Interview (M-CIDI) was used as a gold standard for DSM-IV diagnoses, and all outputs were assessed by 10-fold cross validation procedure. RESULTS Both scales were uni-dimensional and Cronbachs α was 0.74 for SDS and 0.78 for CAST. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without dependence diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for problematic use disorders were 7 for CAST MCA and 4 for SDS MCA. Both CAST and SDS overestimated CD prevalence. CONCLUSIONS The CAST and SDS are equally useful for screening for problematic cannabis use disorders. Both clinical and research applications of the scales are possible.

Validation of a new Short Problematic Internet Use Test in a nationally representative sample of adolescents

We developed a short screening test to assess problematic internet use in adolescents.The Short Problematic Internet Use Test (SPIUT) showed good psychometric properties.The SPIUT was tested using a large representative sample of Italian students.The SPIUT could be helpful to describe the risk-profile of adolescent internet users. The study aimed to develop a short screening instrument (6 items) to assess the problematic internet use among adolescents. The Short Problematic Internet Use Test (SPIUT) has been developed based on a review of existing literature and tested using CIUS (Compulsive Internet Use Scale) as a concurrent scale. Data were collected within ESPAD-Italia (European School Survey Project on Alcohol and Other Drugs), a cross-sectional school survey conducted to monitor risk-behaviors in a representative sample of Italian students (15-19years). The SPIUT has been validated in two steps: (a) construct validity, optimal scaling analysis, and assessment of differences in mean scores related to hours spent online (Study 1, internet users=10,153); (b) reliability test of CIUS and concurrent validity of SPIUT (Study 2, internet users=21,205). The SPIUT showed good psychometric properties. After Multiple Correspondence Analysis optimal weights for each item were found, improving internal consistency and reliability. Significant increase in mean score with increasing daily hours spent online was found and high correlation with the CIUS. A utilization of the SPIUT in school surveys could help us to understand the risk-profile of problematic internet users among adolescents.

Concordance and consistency of answers to the self‐delivered ESPAD questionnaire on use of psychoactive substances

Considering the prevalence of drug use in Italy, it is crucial to develop a reproducible screening test. Test–retest reliability and internal consistency are important indicators of a measurements temporal stability and are a necessary condition for validity. The aim of the study was to assess the consistency and concordance of the European School Survey Project on Alcohol and Other Drugs (ESPAD) questionnaire; participating students completed the questionnaire twice, with a three‐week interval. To verify the concordance for variables relating to use of alcohol, cigarettes and illicit drugs, the original ordinal variables as well as the same dichotomically recodified variables were used. Data analysis was done using Kappa and weighted Kappa. The method proposed by Lipsitz was used to evaluate the influence of gender and age on concordance. Questions about drug use, examined in ordinal form, show a good test–retest concordance and an excellent concordance for answers relating to the use of cigarettes, alcohol and cannabis. Regarding the effect of age adjusted for gender, 15‐year‐old subjects showed a lower concordance than 19‐year‐olds. ESPAD is a tool with a good reproducibility. Results focus on the effect of gender and age covariates on the concordance of answers regarding drug use and suggest the importance of examining the concordance in relation to the covariate levels. Copyright

The application of observational data in translational medicine: analyzing tobacco-use behaviors of adolescents

BackgroundTranslational Medicine focuses on “bench to bedside”, converting experimental results into clinical use. The “bedside to bench” transition remains challenging, requiring clinicians to define true clinical need for laboratory study. In this study, we show how observational data (an eleven-year data survey program on adolescent smoking behaviours), can identify knowledge gaps and research questions leading directly to clinical implementation and improved health care. We studied gender-specific trends (2000–2010) in Italian students to evaluate the specific impact of various anti-smoking programs, including evaluation of perceptions of access to cigarettes and health risk.MethodsThe study used, ESPAD-Italia® (European School Survey Project on Alcohol and other Drugs), is a nationally representative sample of high-school students. The permutation test for joinpoint regression was used to calculate the annual percent change in smoking. Changes in smoking habits by age, perceived availability and risk over a 11-year period were tested using a gender-specific logistic model and a multinomial model.ResultsGender-stratified analysis showed 1) decrease of lifetime prevalence, then stabilization (both genders); 2) decrease in last month and occasional use (both genders); 3) reduction of moderate use (females); 4) no significant change in moderate use (males) and in heavy use (both genders). Perceived availability positively associates with prevalence, while perceived risk negatively associates, but interact with different effects depending on smoking patterns. In addition, government implementation of public policies concerning access to tobacco products in this age group during this period presented a unique background to examine their specific impact on behaviours.ConclusionLarge observational databases are a rich resource in support of translational research. From these observations, key clinically relevant issues can be identified and form the basis for further clinical studies. The ability to identify patterns of behaviour and gaps in available data translates into new experiments, but also impacts development of public policy and reveals patterns of clinical reality. The observed global decrease in use is countered by stabilization in number of heavy smokers. Increased cigarette cost has not reduced use. While perceived risk of smoking may prevent initial experimentation, how government policies impact the perception of risk is not easily quantifiable.

The Cannabis Abuse Screening Test (CAST) and Its Applications

Abstract Cannabis is the most widely used illegal psychoactive substance in the world. There are many self-report screenings that are designed to detect the problematic use of cannabis, but in order to compare the various studies in different countries, and to effectively monitor phenomena related to problematic-cannabis-use, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) suggests the use of the Cannabis-Abuse Screening Test (CAST). Recently, several studies have investigated the association between problematic-cannabis-use detected by CAST and other components relating to the subject and the social and family environments. This study shows that the problematic-cannabis-use is positively related with the use of other substance (tobacco, alcohol, and other illegal substances) and truancy from school, as well as poor scholastic performance and gambling for money. The protective variables regarding problematic-cannabis-use are high self-esteem and satisfaction with health status. These results must be taken into consideration when designing interventions of prevention and of treatment targeting young people and families.

Conventional insulin vs insulin infusion therapy in acute coronary syndrome diabetic patients

AIM To evaluate the impact on glucose variability (GLUCV) of an nurse-implemented insulin infusion protocol when compared with a conventional insulin treatment during the day-to-day clinical activity. METHODS We enrolled 44 type 2 diabetic patients (n = 32 males; n = 12 females) with acute coronary syndrome (ACS) and randomy assigned to standard a subcutaneous insulin treatment (n = 23) or a nurse-implemented continuous intravenous insulin infusion protocol (n = 21). We utilized some parameters of GLUCV representing well-known surrogate markers of prognosis, i.e., glucose standard deviation (SD), the mean daily δ glucose (mean of daily difference between maximum and minimum glucose), and the coefficient of variation (CV) of glucose, expressed as percent glucose (SD)/glucose (mean). RESULTS At the admission, first fasting blood glucose, pharmacological treatments (insulin and/or anti-diabetic drugs) prior to entering the study and basal glycated hemoglobin (HbA1c) were observed in the two groups treated with subcutaneous or intravenous insulin infusion, respectively. When compared with patients submitted to standard therapy, insulin-infused patients showed both increased first 24-h (median 6.9 mmol/L vs 5.7 mmol/L P < 0.045) and overall hospitalization δ glucose (median 10.9 mmol/L vs 9.3 mmol/L, P < 0.028), with a tendency to a significant increase in first 24-h glycaemic CV (23.1% vs 19.6%, P < 0.053). Severe hypoglycaemia was rare (14.3%), and it was observed only in 3 patients receiving insulin infusion therapy. HbA1c values measured during hospitalization and 3 mo after discharge did not differ in the two groups of treatment. CONCLUSION Our pilot data suggest that no real benefit in terms of GLUCV is observed when routinely managing blood glucose by insulin infusion therapy in type 2 diabetic ACS hospitalized patients in respect to conventional insulin treatment.

Right Ventricular Ischemic Injury in Patients With Acute ST-Segment Elevation Myocardial InfarctionClinical Perspective

Background— Experimental data show that the right ventricle (RV) is more resistant to ischemia than the left ventricle. To date, limited data are available in humans because of the difficulty of discriminating reversible from irreversible ischemic damage. We sought to characterize RV ischemic injury in patients with reperfused myocardial infarction using cardiovascular magnetic resonance. Methods and Results— In 3 tertiary centers, 242 consecutive patients with reperfused acute ST-segment elevation myocardial infarction were studied with cardiovascular magnetic resonance at 1 week and 4 months after myocardial infarction. T2-weighted and postcontrast cardiovascular magnetic resonance scans were used to depict myocardial edema and late gadolinium enhancement, respectively. Early after infarction, RV edema was common (51% of patients), often associated with late gadolinium enhancement (31% of patients). Remarkably, RV edema and late gadolinium enhancement were found in 33% and 12% of anterior left ventricular infarcts, respectively. Baseline regional and global RV functions were inversely related to the presence and extent of RV edema and RV late gadolinium enhancement. At follow-up, a significant decrease in frequency (25/242 patients; 10%) and extent of RV late gadolinium enhancement was observed (P<0.001). With the use of multivariable analysis, the presence of RV edema was an independent predictor of RV global function improvement during follow-up (&bgr;-coefficient=0.221, P=0.003). Conclusions— Early postinfarction RV ischemic injury is common and is characterized by the presence of myocardial edema, late gadolinium enhancement, and functional abnormalities. RV injury is not limited to inferior infarcts but is commonly found in anterior infarcts as well. Cardiovascular magnetic resonance findings suggest reversibility of acute RV dysfunction with limited permanent myocardial damage at 4-month follow-up.

Right Ventricular Ischemic Injury in Patients With Acute ST-Segment Elevation Myocardial InfarctionClinical Perspective: Characterization With Cardiovascular Magnetic Resonance

Background— Experimental data show that the right ventricle (RV) is more resistant to ischemia than the left ventricle. To date, limited data are available in humans because of the difficulty of discriminating reversible from irreversible ischemic damage. We sought to characterize RV ischemic injury in patients with reperfused myocardial infarction using cardiovascular magnetic resonance. Methods and Results— In 3 tertiary centers, 242 consecutive patients with reperfused acute ST-segment elevation myocardial infarction were studied with cardiovascular magnetic resonance at 1 week and 4 months after myocardial infarction. T2-weighted and postcontrast cardiovascular magnetic resonance scans were used to depict myocardial edema and late gadolinium enhancement, respectively. Early after infarction, RV edema was common (51% of patients), often associated with late gadolinium enhancement (31% of patients). Remarkably, RV edema and late gadolinium enhancement were found in 33% and 12% of anterior left ventricular infarcts, respectively. Baseline regional and global RV functions were inversely related to the presence and extent of RV edema and RV late gadolinium enhancement. At follow-up, a significant decrease in frequency (25/242 patients; 10%) and extent of RV late gadolinium enhancement was observed (P<0.001). With the use of multivariable analysis, the presence of RV edema was an independent predictor of RV global function improvement during follow-up (&bgr;-coefficient=0.221, P=0.003). Conclusions— Early postinfarction RV ischemic injury is common and is characterized by the presence of myocardial edema, late gadolinium enhancement, and functional abnormalities. RV injury is not limited to inferior infarcts but is commonly found in anterior infarcts as well. Cardiovascular magnetic resonance findings suggest reversibility of acute RV dysfunction with limited permanent myocardial damage at 4-month follow-up.