Clinical characteristics and evaluation of LDL-cholesterol treatment of the Spanish Familial Hypercholesterolemia Longitudinal Cohort Study (SAFEHEART)

Aim

Familial hypercholesterolemia (FH) patients are at high risk for premature coronary heart disease (CHD). Despite the use of statins, most patients do not achieve an optimal LDL-cholesterol goal. The aims of this study are to describe baseline characteristics and to evaluate Lipid Lowering Therapy (LLT) in FH patients recruited in SAFEHEART.

Methods and Results

A cross-sectional analysis of cases recruited in the Spanish FH cohort at inclusion was performed. Demographic, lifestyle, medical and therapeutic data were collected by specific surveys. Blood samples for lipid profile and DNA were obtained. Genetic test for FH was performed through DNA-microarray. Data from 1852 subjects (47.5% males) over 19 years old were analyzed: 1262 (68.1%, mean age 45.6 years) had genetic diagnosis of FH and 590 (31.9%, mean age 41.3 years) were non-FH. Cardiovascular disease was present in 14% of FH and in 3.2% of non-FH subjects (P < 0.001), and was significantly higher in patients carrying a null mutation compared with those carrying a defective mutation (14.87% vs. 10.6%, respectively, P < 0.05). Prevalence of current smokers was 28.4% in FH subjects. Most FH cases were receiving LLT (84%). Although 51.5% were receiving treatment expected to reduce LDL-c levels at least 50%, only 13.6% were on maximum statin dose combined with ezetimibe. Mean LDL-c level in treated FH cases was 186.5 mg/dl (SD: 65.6) and only 3.4% of patients reached and LDL-c under 100 mg/dl. The best predictor for LDL-c goal attainment was the use of combined therapy with statin and ezetimibe.

Conclusion

Although most of this high risk population is receiving LLT, prevalence of cardiovascular disease and LDL-c levels are still high and far from the optimum LDL-c therapeutic goal. However, LDL-c levels could be reduced by using more intensive LLT such as combined therapy with maximum statin dose and ezetimibe.

Cavernomas of the central nervous system: clinical and neuroimaging manifestations in 47 patients

Forty seven cases of central nervous system cavernous angioma (21 males and 26 females) are described. The main clinical signs were epilepsy and brainstem syndromes. Digital subtraction intra-arterial angiography, when used, failed to reveal cavernoma. CT detected many of the lesions, but the most successful supplementary diagnostic procedure was MRI which produces highly characteristic images of cavernous angioma. The diagnosis of cavernous angioma was confirmed in the 18 cases in which the tumour was removed surgically.

Growth Rate and Associated Factors in Small Abdominal Aortic Aneurysms

OBJECTIVE

To study the growth rate and factors influencing progression of small infrarenal abdominal aortic aneurysms (AAA).

DESIGN

Observational, longitudinal, prospective study.

PATIENTS AND METHODS

We followed patients with AAA <5 cm in diameter in two groups. Group I (AAA 3-3.9 cm, n = 246) underwent annual ultrasound scans. Group II (AAA 4-4.9 cm, n = 106) underwent 6-monthly CT scans.

RESULTS

We included 352 patients (333 men and 19 women) followed for a mean of 55.2+/-37.4 months (6.3-199.8). The mean growth rate was significantly greater in group II (4.72+/-5.93 vs. 2.07+/-3.23 mm/year; p<0.0001). Group II had a greater percentage of patients with rapid aneurysm expansion (>4 mm/year) (36.8 vs. 13.8%; p<0.0001). The classical cardiovascular risk factors did not influence the AAA growth rate in group I. Chronic limb ischemia was associated with slower expansion (< or = 4 mm/year) (OR 0.47; CI 95% 0.22-0.99; p = 0.045). Diabetic patients in group II had a significantly smaller mean AAA growth rate than non-diabetics (1.69+/-3.51 vs. 5.22+/-6.11 mm/year; p = 0.032).

CONCLUSIONS

The expansion rate of small AAA increases with the AAA size. AAA with a diameter of 3-3.9 cm expand slowly, and they are very unlikely to require surgical repair in 5 years. Many 4-4.9 cm AAA can be expected to reach a surgical size in the first 2 years of follow-up. Chronic limb ischemia and diabetes are associated with reduced aneurysm growth rates.

Multiresidue method for the rapid determination--in grape, must and wine--of fungicides frequently used on vineyards

A rapid multiresidue gas chromatographic method for determining 17 fungicides in grapes, must and wine, widely used on vineyards, is described. A simple on-line microextraction method for isolation of fungicides was used. Nitrogen-phosphorus and electron-capture detection were used for the identification and quantitation of pesticides. For confirmation, mass spectrometic detection was used. Because of the high selectivity of both detection methods, no clean-up was necessary. The regression coefficients relating to linearity were at least 0.994. Recoveries from spiked grapes, must and wine samples ranged from 78 to 107% and relative standard deviations were not higher than 14%. Individual detection limits were in the range 0.02-0.1 ng. Limits of quantification varied from 0.01 to 0.05 mg/kg, smaller in all cases than the maximum residue limits set down by the legislations of Spain, France and Italy, the main wine-producing countries of the European Union. Only for fludioxonil and hexaconazole do the limits of quantification coincide with the maximum residue limits (0.05 mg/kg) established by the Spanish legislation.

Risk of nonmelanoma skin cancer in Italian organ transplant recipients. A registry-based study

BACKGROUND

Organ transplant recipients are at an increased risk of nonmelanoma skin cancer. Few data concern heart transplantation and populations from southern Europe.

METHODS

A total of 1,329 patients who received their first kidney (1,062 subjects) or heart allograft (267 subjects) were included in a partly retrospective cohort study to evaluate the risk of skin cancer. The incidence rate per 1,000 person-years and the cumulative incidence were computed. Standardized morbidity ratio was estimated by comparison with Italian cancer registry data. To analyze the role of potential prognostic factors, Cox's regression method was used.

RESULTS

The overall incidence rate of nonmelanoma skin cancer was 10.0 cases per 1,000 posttransplant person-years (95% confidence interval 8.2-11.7). This estimate was far higher than expected in the general population. The overall risk of developing skin cancer increased from a cumulative incidence of 5.8% after 5 posttransplant years to an incidence of 10.8% after 10 years of graft survival. In a Cox proportional hazard risk model, the most important factors that appeared to favor the development of skin cancer were age at transplantation and sex. After adjustment for age at transplantation and sex, no definite increased risk was documented among heart as compared with kindney transplant recipients.

CONCLUSIONS

Our study confirms the increased risk of nonmelanoma skin cancer among organ transplant recipients in a southern European population.

Lichen planopilaris: report of 30 cases and review of the literature

BACKGROUND

Lichen planopilaris (LPP) affects primarily the scalp, resulting in scaling, atrophy, and alopecia with scarring. The purpose of our study was to obtain original data on LPP and to evaluate the efficacy of topical therapy in comparison with systemic therapies.

METHODS

We examined 30 patients affected by LPP between 1996 and 2001, performing clinical, laboratory, histopathologic and direct immunofluorescence examinations. Twenty-one of the patients (70%) were women and nine (30%) were men. The average age at presentation was 51.5 years. The average duration of the disease was 13 months at the time of the diagnosis. All patients received topical steroids for a total of 12 weeks.

RESULTS

Resolution of the inflammatory process and blocking of the cicatricial progression were observed in 66% of cases, a mild reduction of fibrosis and cicatrization in 20% of patients, and no response in 13%.

CONCLUSIONS

We concluded that topical therapy may be a valid alternative to systemic therapies, especially in patients with lesions in the early phase.

Decoupling of the amygdala to other salience network regions in adolescent-onset recurrent major depressive disorder

BACKGROUND

Recent meta-analyses of resting-state networks in major depressive disorder (MDD) implicate network disruptions underlying cognitive and affective features of illness. Heterogeneity of findings to date may stem from the relative lack of data parsing clinical features of MDD such as phase of illness and the burden of multiple episodes.

METHOD

Resting-state functional magnetic resonance imaging data were collected from 17 active MDD and 34 remitted MDD patients, and 26 healthy controls (HCs) across two sites. Participants were medication-free and further subdivided into those with single v. multiple episodes to examine disease burden. Seed-based connectivity using the posterior cingulate cortex (PCC) seed to probe the default mode network as well as the amygdala and subgenual anterior cingulate cortex (sgACC) seeds to probe the salience network (SN) were conducted.

RESULTS

Young adults with remitted MDD demonstrated hyperconnectivity of the left PCC to the left inferior frontal gyrus and of the left sgACC to the right ventromedial prefrontal cortex (PFC) and left hippocampus compared with HCs. Episode-independent effects were observed between the left PCC and the right dorsolateral PFC, as well as between the left amygdala and right insula and caudate, whereas the burden of multiple episodes was associated with hypoconnectivity of the left PCC to multiple cognitive control regions as well as hypoconnectivity of the amygdala to large portions of the SN.

CONCLUSIONS

This is the first study of a homogeneous sample of unmedicated young adults with a history of adolescent-onset MDD illustrating brain-based episodic features of illness.

Determination of chlorpyrifos, penconazole, fenarimol, vinclozolin and metalaxyl in grapes, must and wine by on-line microextraction and gas chromatography

A rapid gas chromatographic method for determination of residue levels of one insecticide (chlorpyrifos) and four fungicides (penconazole, fenarimol, vinclozolin and metalaxyl) in grapes, must and wine is described. An on-line microextraction method was used. The matrix, once extracted with a mixture of acetone-dichloromethane (1:1, v/v) was filtered and concentrated. Electron-capture detection for chlorpyrifos, penconazole, fenarimol and vinclozolin and mass-selective detection in the selected-ion monitoring mode for metalaxyl were utilised. No clean-up was necessary because there were no interferences in the area of interest of the chromatogram. Linearity of both detectors, in the range 0.02-2 ng/microliter, was checked. In all cases, the correlation coefficient was the same or superior to 0.997. Recoveries from spiked grapes, must and wine ranged from 78% to 101% (fortification level, 0.1-1 mg/kg). Limits of determination were between 0.01 mg/kg for metalaxyl and 0.001 mg/kg for vinclozolin.

Detection of Abdominal Aortic Aneurysm in Patients with Peripheral Artery Disease

OBJECTIVE

To describe the prevalence of abdominal aortic aneurysms (AAA) in patients with peripheral artery disease (PAD).

DESIGN

Observational, descriptive, transverse study.

PATIENTS AND METHODS

We performed an abdominal ultrasound in 1190 consecutive patients with lower limb chronic ischemia (1/99-12/04). We registered cardiovascular risk factors and clinical data for analysis.

RESULTS

The ultrasound was inconclusive in 24 (2%) patients; 1166 patients completed the study. They were mostly male (93.7%), with an age mean of 67+/-9.9 years (37.7-93.4). The main cardiovascular risk factors were: smoking (80.9%), hypertension (41.7%) and hypercholesterolemia (31.4%). The prevalence of AAA was 13% (n = 151). Only 1.5% (n = 17) of the patients had a large AAA (>5 cm). The AAA was clearly more prevalent in men (n = 148; 13.6%) than in women (n = 3; 4.1%) (RR 3.47; 95% CI 1.11-10.89; p = 0.02). The prevalence significantly increased with age, with a maximum of 17.1% in over 75-year-old men (p = 0.006). Patients with tibial disease had a significantly higher prevalence of AAA than aortoiliac or femoro-popliteal disease (p = 0.02).

CONCLUSIONS

The prevalence of AAA in patients with PAD is much higher than that reported in the general population. We recommend that an abdominal ultrasound be routinely included in the study of these patients. Over 75-year-old men are at particularly high-risk.

Evolution of residual levels of six pesticides during elaboration of red wines. Effect of wine-making procedures in their dissappearance

The effect of wine-making procedures on the concentrations of six pesticides (chlorpyrifos, penconazole, fenarimol, vinclozolin, metalaxyl, and mancozeb) in red wines has been studied. During maceration stage (4 days), the percentage remaining of chlorpyrifos, penconazole, and metalaxyl was approximately 90%, whereas that of fenarimol, vinclozolin, and mancozeb is somewhat smaller (74-67%). The residual levels found in pressed must were </=20%, except for metalaxyl (69%). From the whole concentration of chlorpyrifos in must, 85% is eliminated from the racking step; clarification (bentonite plus gelatin) eliminates 43% of the product found in the decanted wine, and with filtration, all of the residue is eliminated. Penconazole and mancozeb are retained on the lees in proportions of 43 and 31%, respectively. The eliminated percentage of vinclozolin after racking is 29%, whereas clarification and filtration reduce its proportion in the wine to 33 and 28%, respectively. Finally, fenarimol and metalaxyl are eliminated in smaller proportion with the realization of these processes.

Multiresidue method for the rapid determination of organophosphorus insecticides in grapes, must and wine

A rapid multiresidue gas chromatographic method for determining 12 insecticides in grapes, must and wine is described. A simple on-line microextraction method for isolating frequently applied insecticides on vineyard is used. The matrix, once extracted with an acetone-dichloromethane (1:1, v/v) mixture, was filtered and concentrated. Nitrogen-phosphorus detection (NPD) and electron-capture detection (ECD) were used to identify and quantify the insecticides, the findings being confirmed using mass spectrometric detection (MSD). No clean-up was necessary for either NPD or ECD. The regression coefficients relating to linearity were at least 0.99. Recoveries from spiked grape, must and wine samples ranged from 80 to 108% and relative standard deviations were no higher than 16% in the most unfavourable case. Individual detection limits were in the range 0.02-0.1 ng. Limits of quantification varied from 0.01 to 0.05 mg kg(-1), which are below the maximum residue limits set by the legislation of the main wine-producing countries of the European Union. Only in the case of methidathion and quinalphos were the limits of quantification equivalent to the maximum residue limits (0.05 mg kg(-1)) established by Spanish and French legislation, respectively.

HCH and DDT residues in human placentas in Murcia (Spain)

Organochlorinated insecticides are ubiquitous toxicants that are transplacentally transferred from mother to fetus and are reported to produce adverse health effects in pregnant woman and neonates. To investigate hexachlorocyclohexane (HCH) and 1,1,1-trichloro-2,2-bis(4-chlorophenyl)ethane (DDT) exposure in pregnant woman, a total of 102 placentas were analyzed by a gas chromatograph equipped with electron capture detector. Organochlorine residues were found in 69.6% of the samples. Lindane was detected in 24.5%, alpha-HCH in 2.9%, beta-HCH in 6.9%, p,p'-DDE in 44.1%, p,p'-DDT in 14.7% and p,p'-DDD in 10.8% of the samples. The pattern of dispersal by these substances in Murcia is similar to that described by different authors in other countries. Therefore, the past use of DDT and the present employment of lindane seem to be reflected in body tissues of the residents of this area.

Turner's syndrome associated with psoriasis and alopecia areata

Turner's syndrome is a sex chromosomal abnormality characterized by gonadal failure, short stature, skeletal and medical anomalies due to structural defects or monosomy of the X chromosome. The association between this syndrome and autoimmune diseases has been reported in the literature. This case report highlights the finding of two immunological skin diseases, alopecia areata and psoriasis, in an 18-year-old girl with Turner's syndrome. By the time of her referral to the Department of Dermatology, Verona University (Italy) the girl had suffered from psoriasis on the scalp for 5 years and alopecia for 6 months; the diagnoses were confirmed by histological evaluation. Topical therapy was useful for the treatment of the psoriatic lesions but not for the alopecia areata. Alopecia areata and psoriasis occurring together in Turner's syndrome may indicate some genetic relationship and could support the concept that these patients have the tendency to develop autoimmune or immunological diseases. Anxiety, depression and unsatisfactory relationships could have been important trigger factors in our patient. Multidisciplinary management, including psychological, educational and behavioural techniques, in addition to other therapies, could be useful in treating these conditions.

Antibiotic-exposed patients with non-small-cell lung cancer preserve efficacy outcomes following first-line chemo-immunotherapy

BACKGROUND

Prior antibiotic therapy (pATB) is known to impair efficacy of single-agent immune checkpoint inhibitors (ICIs), potentially through the induction of gut dysbiosis. Whether ATB also affects outcomes to chemo-immunotherapy combinations is still unknown.

PATIENTS AND METHODS

In this international multicentre study, we evaluated the association between pATB, concurrent ATB (cATB) and overall survival (OS), progression-free survival (PFS) and objective response rate (ORR) in patients with non-small-cell lung cancer (NSCLC) treated with first-line chemo-immunotherapy at eight referral institutions.

RESULTS

Among 302 patients with stage IV NSCLC, 216 (71.5%) and 61 (20.2%) patients were former and current smokers, respectively. Programmed death-ligand 1 tumour expression in assessable patients (274, 90.7%) was ≥50% in 76 (25.2%), 1%-49% in 84 (27.9%) and <1% in 113 (37.5%). Multivariable analysis showed pATB-exposed patients to have similar OS {hazard ratio (HR) = 1.42 [95% confidence interval (CI): 0.91-2.22]; P = 0.1207} and PFS [HR = 1.12 (95% CI: 0.76-1.63); P = 0.5552], compared to unexposed patients, regardless of performance status. Similarly, no difference with respect to ORR was found across pATB exposure groups (42.6% versus 57.4%, P = 0.1794). No differential effect was found depending on pATB exposure duration (≥7 versus <7 days) and route of administration (intravenous versus oral). Similarly, cATB was not associated with OS [HR = 1.29 (95% CI: 0.91-1.84); P = 0.149] and PFS [HR = 1.20 (95% CI: 0.89-1.63); P = 0.222] when evaluated as time-varying covariate in multivariable analysis.

CONCLUSIONS

In contrast to what has been reported in patients receiving single-agent ICIs, pATB does not impair clinical outcomes to first-line chemo-immunotherapy of patients with NSCLC. pATB status should integrate currently available clinico-pathologic factors for guiding first-line treatment decisions, whilst there should be no concern in offering cATB during chemo-immunotherapy when needed.

Effect of pesticide residues on the aromatic composition of red wines

The influence of pesticide residues on the aromatic composition (major and minor volatiles) of red wines made from Vitis vinifera (Monastrell var.) was studied by comparing the concentration of aromas in wines made from grapes subjected (or not) to phytosanitary treatment with chlorpyrifos, fenarimol, mancozeb, metalaxyl, penconazole, and vinclozolin, according to the agricultural practice of the area. The analytical determination of the major volatiles was made by gas chromatography using a flame ionization detector, while the minor volatiles were determined by adsorption-thermal desorption gas chromatography using a mass selective detector. There were significant differences between the ethyl acetate, methanol, isobutanol, and diethylacetal levels of the control wine and that containing chlorpyrifos residues, although only the ethyl acetate exceeded the olfactory threshold. With regard to the minor volatiles, significant differences were detected in the concentrations of some esters, aldehydes, and acids. However, only isoamyl acetate exceeded the olfactory threshold in wines containing residues of chlorpyrifos, fenarimol, and vinclozolin.

Fungicide dissipation curves in winemaking processes with and without maceration step

The evolution of residual levels of four fungicides (cyprodinil, fludioxonil, pyrimethanil, and quinoxyfen) during the elaboration of three types of wine with maceration (traditional red wine, carbonic maceration red wine, and red wine of long maceration and prefermentation at low temperature) and two types of wine without maceration (rose and white) has been studied. The disappearance curves of each fungicide have been analyzed during the period of each winemaking process (21 days) and during the different enological steps involved in the elaborations. The residual levels of fludioxonil reduce most quickly during the winemaking processes without maceration, whereas the decrease in levels of pyrimethanil was the slowest in practically all cases (with and without maceration). During carbonic maceration winemaking, the decay constant of cyprodinil was greater than that of the other pesticides in all assays (time and steps).

Renal transplantation and skin diseases: review of the literature and results of a 5-year follow-up of 285 patients

We present a review of the current literature on skin diseases in renal transplant recipients (RTR) and the results of a 5-year follow-up of 285 patients. Many skin diseases are only an aesthetic and functional cause for interest, but HPV infections and skin cancers are significantly more frequent in RTR than in immunocompetent subjects and can affect a patient's prognosis. For this reason, we feel dermatological surveillance of RTR is necessary for early diagnosis and treatment of all high-risk lesions.

Lethal systemic dissemination from a cutaneous infection due to Curvularia lunata in a heart transplant recipient

A 69-year-old male heart transplant recipient, being treated with Cell Cept, FK 506 and methylprednisolone had multiple deep brown skin nodules and nodes, on the upper right arm. Skin biopsy and culture detected a strain of Curvularia lunata. The infection disseminated to the whole skin surface, oral mucosa, upper third of the oesophagus and to the lungs. Therapy with antibiotics and antifungal drugs was ineffective. The patient died of sepsis. We did not find any other case of systemic dissemination from a skin infection due to C. lunata among heart transplant recipients. We feel that heart transplant recipients need adequate education to prevent situations that would put them at risk for infection and to seek medical advice immediately for an early diagnosis and an effective therapy.

Anaemia, iron and vitamin deficits in patients with peripheral arterial disease

INTRODUCTION

Anaemia can compromise muscle and organ function. Related iron and vitamin body stores have seldom been assessed in patients with peripheral arterial disease.

REPORT

We retrospectively analysed basal prevalence of anaemia, iron, B(12)-vitamin and folic acid deficits in 420 patients with claudication and 204 patients with critical limb ischaemia (CLI). The prevalence of the evaluated parameters was 9.8%, 6.7%, 6.7% and 2.9% among patients with claudication but 49.5%, 31.9%, 15.7% and 6.4% among CLI patients, respectively (p < 0.05 for all).

DISCUSSION

Anaemia, iron and vitamin deficits are uncommon among patients with ischemic claudication but very prevalent among patients with CLI.

Evolution of chlorpyrifos, fenarimol, metalaxyl, penconazole, and vinclozolin in red wines elaborated by carbonic maceration of Monastrell grapes

The influence of the different steps involved in the wine-making process on the disappearance of chlorpyrifos, fenarimol, metalaxyl, penconazole, and vinclozolin in red wines elaborated by carbonic maceration of Monastrell grapes was studied. The initial levels of the residues in grapes ranged from 0.28 mg/kg (penconazole) to 1 mg/kg (chlorpyrifos). Ten days after the beginning of maceration, the compound that had decreased least was chlorpyrifos (83% of initial value remaining), whereas metalaxyl, the least persistent of the residues, had decreased to 49% of its initial value. In the free-run juice, on the other hand, the highest percentage remaining corresponded to metalaxyl (10%) and the lowest to chlorpyrifos (0. 1%). After pressing, the percentages of initial values eliminated in pomace varied from 82.7% for chlorpyrifos to 17.7% for metalaxyl, whereas in the press juice the opposite was the case (37% metalaxyl and 2% chlorpyrifos remaining). In finished wine, there were residues of all the pesticides, with the exception of chlorpyrifos, metalaxyl (21%) being the most persistent. The percentages eliminated in the lees varied from 1.5 to 2.5% of the initial value.

Effects of clarification and filtration processes on the removal of fungicide residues in red wines (var. Monastrell)

The effects of six clarification agents (egg albumin, blood albumin, bentonite plus gelatin, charcoal, PVPP, and silica gel) on the removal of residues of four fungicides (cyprodinil, fludioxonil, pyrimethanil, and quinoxyfen) applied directly to a racked red wine, elaborated from Monastrell variety grapes from the D.O. region of Jumilla (Murcia, Spain), are studied. The clarified wines were filtered with 0.45 microm nylon filters to determine the influence of this winemaking process in the disappearance of fungicide residues. Analytical determination of cyprodinil, fludioxonil and pyrimethanil was performed by gas chromatography with an alkaline thermoionic detector (NPD), whereas that of quinoxyfen using an electron captor detector (ECD). In general, and for all of the fungicides except quinoxyfen, blood albumin has proved to be the most effective clarifying agent in the removal of residues, whereas silica gel proved to be ineffective against all of the pesticides with the exception of fludioxonil. Quinoxyfen is the least persistent fungicide in the clarified wines and that which appears with highest frequency in the lees. In general, filtration is not an effective step in the elimination of wine residues. The greatest elimination after filtration is obtained in wines clarified with charcoal and the lowest in those clarified with PVPP.