In the "urban bioregion," intermediate territories get new identities through a physical and relational redesign of ecosystem services, beginning with polyvalent ecological networks, dealing with ...food and its short supply chain. Such networks may become the backbone of a "rururban public space" defined for flood risk prevention, easy mobility, preservation of historical buildings, proximity to farming, and presence of agroforestry. Starting from a bioregional perspective, the paper reflects on the need to re-territorialize food systems and describes as a case study an experience recently completed: the project for the Riverside agricultural park on the left side of Arno, involving three municipalities on the Florence Plain through the support of Regione Toscana based on participatory processes. Its aim was to lay the foundation for a "river contract" for the functioning of an agricultural park which, in the foreseeable future, could be managed through a number of social contracts involving local communities.
Pulmonary embolism (PE) is a common and potentially fatal disease that is still underdiagnosed. The objective of our study was to reappraise the clinical presentation of PE with emphasis on the ...identification of the symptoms and signs that prompt the patients to seek medical attention.
We studied 800 patients with PE from two different clinical settings: 440 were recruited in Pisa (Italy) as part of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED); 360 were diagnosed with and treated for PE in seven hospitals of central Tuscany, and evaluated at the Atherothrombotic Disorders Unit, Firenze (Italy), shortly after hospital discharge. We interviewed the patients directly using a standardized, self-administered questionnaire originally utilized in the PISAPED. The two samples differed significantly as regards age, proportion of outpatients, prevalence of unprovoked PE, and of active cancer. Sudden onset dyspnea was the most frequent symptom in both samples (81 and 78%), followed by chest pain (56 and 39%), fainting or syncope (26 and 22%), and hemoptysis (7 and 5%). At least one of the above symptoms was reported by 756 (94%) of 800 patients. Isolated symptoms and signs of deep vein thrombosis occurred in 3% of the cases. Only 7 (1%) of 800 patients had no symptoms before PE was diagnosed.
Most patients with PE feature at least one of four symptoms which, in decreasing order of frequency, are sudden onset dyspnea, chest pain, fainting (or syncope), and hemoptysis. The occurrence of such symptoms, if not explained otherwise, should alert the clinicians to consider PE in differential diagnosis, and order the appropriate objective test.
The coevolutionary dimension of territories, understood as a match and a constant re-eiaboration among socio-economic dynamics, environmental features and territorial structure, is a central ...assumption of the territorialist thinking. Territory is in fact both the material and cognitive outcome of a long historical process, marked by continuity and fractures, which has deposited sediments to be incessantly re-possessed and re-elaborated by the settled societies. The methodological appeal to a historical perspective appears inevitable. In the current phase of de-territorialisation, historical configurations take on both a cognitive and a design value. In an interested perspective, the history of territories is put into interaction with the needs of the present, to understand the reasons and dynamics of the longue-duree and to identify the invariant rules of construction, maintenance and reproduction of territorial heritage. The heritage representation depicts such processes, giving great importance to the relational and communicative dimension of figuration. This paper deals with the use of operational and cartographic tools for the morphologic and the historical-structural interpretation of territory, consistent with the methodology illustrated in the paper by Alberto Magnaghi in this same number. It consists of two parts: 1) the morpho-typological representation; 2) the historical-structural analysis for the definition of territorialisation processes and heritage syntheses. Keywords: territorialisation processes; morpho-typology; representation; heritage; structural invariants. Riassunto. La dimensione coevolutiva dei territori, intesa come incontro e continua rielaborazione fra dinamiche socio-economiche, caratteri ambientali e struttura territoriale, rappresenta un assunto centrale del pensiero territorialista. Il territorio e infatti esito al tempo stesso materiale e cognitivo di un lungo processo storico, fatto di continuita e fratture, che ha depositato sedimenti ininterrottamente riappropriati e rielaborati dalle societa insediate. Il ricorso metodologico alla prospettiva storica appare ineludibile. Nell'attuale fase di deterritorializzazione le configurazioni storiche assumono un valore sia conoscitivo che progettuale. Con uno sguardo interessato la storia del territorio viene fatta interagire con i bisogni del presente, per comprendere le ragioni e le dinamiche della lunga durata e poter individuare le regole invarianti della costruzione, manutenzione e riproduzione del patrimonio territoriale. La rappresentazione patrimoniale racconta questi processi dando ampio rilievo alla dimensione relazionale e comunicativa della figurazione. In questo contributo viene approfondito l'uso degli strumenti operativi e cartografici per l'interpretazione morfotipologica e per quella storico-strutturale del territorio, in coerenza con la metodologia illustrata dal contributo di Alberto Magnaghi in questo stesso numero. Il contributo e organizzato in due parti: 1) la rappresentazione morfotipologica; 2) l'analisi storico-strutturale per la definizione dei processi di territorializzazione e delle sintesi patrimoniali. Parole-chiave: processi di territorializzazione; morfotipologia; rappresentazione; patrimonio; invarianti strutturali.
To compare the efficacy/effectiveness and safety of DOACs versus VKAs in patients with a previously and newly surgically implanted BHV with or without AF. A systematic search on MEDLINE and EMBASE ...was performed till November 2022. Treatment effects were estimated with relative risk (RR) and 95% confidence intervals (CIs)
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Statistical heterogeneity was assessed with the
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statistic. Four randomized controlled trials (RCTs), 2 subgroup analysis from ARISTOTLE and ENGAGE-AF-TIMI 48 and 4 observational studies were included for a total of 5808 patients, 1893 on DOACs and 3915 on VKAs. AF prevalence was 98.28%. In the overall analysis, DOACs vs VKAs were associated with a RR for stroke/transient ischemic attack (TIA)/systemic embolism (SE) of 0.63 (95% CI 0.51–0.79;
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= 0%) and a RR of major bleeding of 0.50 (95% CI 0.39–0.63;
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= 0%) in a median follow-up of 19 months (IQR 4.5–33.4). In the 3 RCTs (DAWA, RIVER, ENAVLE), DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.38 (95% CI 0.13–1.58,
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= 0%) and of 0.68 (95% CI 0.32–1.44;
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= 5%) respectively. In patients randomized during the first three months from valve surgery, DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.54 (95% CI 0.14–2.08;
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= 0%) and of 0.76 (95% CI 0.05–10.72;
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= 66%). In previously implanted BHV patients with AF, DOACs showed a risk–benefit profile at least comparable to VKAs. DOACs showed a similar, even if underpowered, risk–benefit profile during the first three months after BHV implantation prevalently in patients with AF.
Direct oral anticoagulants (DOACs) have shown similar efficacy and safety with respect to warfarin in patients with atrial fibrillation (AF). However, the proportion of patients aged ≥85 years ...enrolled in clinical trials was low and the applicability of their results to very elderly patients is still uncertain. We have carried out a prospective cohort study on AF patients aged ≥85 years enrolled in the Survey on anticoagulaTed pAtients RegisTer (START2-Register) and treated with either VKAs or DOACs, with the aim to evaluate mortality, bleeding and thrombotic rates during a long-term follow-up. We enrolled 1124 patients who started anticoagulation at ≥85 years with VKA (58.7%) or DOACs (41.3%), Clinical characteristics of patients were similar, except for a higher prevalence of coronary artery disease and renal failure in VKAs patients and of a history of previous bleeding and previous stroke/TIA in patients on DOACs. Median CHA2DS2VASc and HAS-BLED scores were similar between the two groups. During follow-up, 47 major bleedings (rate 2.3 x100 pt-yrs) and 19 stroke/TIA (0.9 x100 pt-yrs) were recorded. The incidence of bleeding was similar between patients on VKAs and DOACs. Patients on DOACs showed a higher rate of thrombotic events during treatment (rate 1.84 and 0.50,respectively). Mortality rate was higher in patients on VKAs than in patients on DOACs (HR 0.64 (95% CI 0.46-0.91). In conclusion, we confirm the overall safety and effectiveness of anticoagulant treatment in very elderly AF patients, with lower mortality rates in DOACs patients, similar bleeding risk, and a higher risk for cerebral thrombotic events in DOACs patients.
Objectives We sought to evaluate the rate of bleeding in relation to age (<80 and ≥80 years), the quality of anticoagulation (expressed as time spent in international normalized ratio therapeutic ...range), and factors associated with bleeding events. Background Stroke prevention in patients with atrial fibrillation (AF) is an increasingly crucial public health target, particularly in patients ages ≥80 years. Methods We conducted a prospective observational study on 783 patients with AF on oral anticoagulant treatment (OAT). Results Patients spent a median 14%, 71%, and 15% of time below, within, and above the intended therapeutic range, respectively. No difference in OAT quality was found between patients age <80 and ≥80 years. During follow-up, 94 patients experienced bleeding complications (rate 3.7 × 100 patient/years), 37 major (rate 1.4 × 100 patient/years), and 57 minor (rate 2.2 × 100 patient/years). Different rates of major hemorrhage were observed between patients age <80 and ≥80 years (0.9 vs. 1.9 × 100 patient/years; p = 0.004). Bleeding risk also was greater in patients with a history of previous cerebral ischemic event (odds ratio OR: 2.5; 95% confidence interval: 1.3 to 4.8; p = 0.007). A Cox regression analysis confirmed age ≥80 years associated with bleeding risk (OR: 2.0). Conclusions These results indicate that the rate of major bleeding complications may be kept acceptably low also in very elderly AF patients on OAT, provided a careful management of anticoagulation is obtained.
D-dimer levels measured during and after vitamin K antagonist withdrawal may be used in clinical practice to assess the individual risk of recurrent venous thromboembolism. Currently, direct oral ...anticoagulants (DOACs) are frequently used in venous thromboembolism treatment; however, their pharmacokinetics and pharmacodynamics characteristics are completely different than vitamin K antagonists. The present study aimed at comparing the results of D-dimer levels during and after anticoagulation withdrawal in patients with venous thromboembolism treated with DOACs or warfarin.
D-dimer levels were measured in 527 patients ("cases") during DOACs treatment (T0) and after 15 (T15), 30 (T30), 60 (T60) and 90 (T90) days after their discontinuation and in 527 patients ("controls") enrolled in the DULCIS study (all treated with warfarin), matched for sex, age (+/-3 y), type of D-dimer assay and site of venous thromboembolism. Both cases and controls received anticoagulant treatment after a first venous thromboembolism event that was unprovoked or associated with weak risk factors.
The rate of positive D-dimer results was significantly higher in cases than in controls at T0 (10.8% vs 5.1%, p = 0.002) and at T30 (18.8% vs 11.8%, p = 0.019), as well as at the other time-points, though not statistically significant.
D-dimer levels during and after stopping an anticoagulant treatment for a venous thromboembolism episode differ between patients treated with a DOAC than in those treated with warfarin. Specifically designed prospective studies are warranted to reassess the use of D-dimer as predictor of the risk of recurrent venous thromboembolism in patients treated with DOACs.
During the celebrations for Leonardo’s fifth centenary, and under the patronage of their Italian Committee, a “21st century workshop of knowledge” worked eagerly in an interdisciplinary key, ranging ...on many aspects (from engineering to philosophy of nature, to history of architecture, reading of sources, technical knowledge, project analysis, cartographic interpretation), with the aim of contributing to the advancement of studies on an artist-researcher who synthesized the knowledge of his time in an extraordinary verbal-visual language, pushing them forward with anticipations and intuitions which are still relevant for the contemporary project, interpreting the territory as a common good and a living being. The volume presents the outcomes of this intense work.
Atrial fibrillation (AF) is the most common arrhythmia and has become a serious public health problem. Moreover, epidemiological data demonstrate that incidence and prevalence of AF are increasing. ...Several differences in epidemiological patterns, clinical manifestations, and incidence of stroke have been reported between AF in women and in men, particularly in elderly women. Elderly women have higher blood pressure than men and a higher prevalence of heart failure with preserved ejection fraction, both independent risk factors for stroke. On the basis of the evidence on the higher stroke risk among AF in women, recently, female sex has been accepted as a risk factor for stroke and adopted to stratify patients, especially if they are not at high risk for stroke. This review focuses on available evidence on sex differences in AF patients, and examines factors contributing to different stroke risk, diagnosis, and prognosis of arrhythmia in women, with the aim to provide an analysis of the available evidence.
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