Case Report: Aortic Valve Replacement After JARVIK 2000 Left Ventricular Assist Device Implantation in Long-Time Survivor With Severe Aortic Valve Regurgitation

BACKGROUND

There are limited clinical records in the literature regarding aortic valve replacement in left ventricular assist device (L-VAD) patients. Previously we had two cases of severe aortic valve regurgitation in patients with L-VAD support treated with Corvalve prosthesis insertion and Amplatzer closure procedure. Both patients died a few days after the procedure from complications not related to the procedure itself.

PATIENT HISTORY

The patient was a male with previous coronary artery bypass graft surgery in 2001 that was complicated with postischemic dilated cardiomyopathy with severe heart failure (ejection fraction [EF], 20%). Cardiac resynchronization therapy was biventricular-pacemaker and cardiac defibrillator implantation in 2009 for recurrent ventricular arrhythmia. L-VAD implantation (Jarvik 2000) with graft apposition in descending thoracic aorta through left thoracotomy access and retro-auricolar cable was performed in October 2013. In 2015 the patient underwent surgical aortic valve replacement with bioprothesis due to progressive worsening of the aortic valve regurgitation. The Jarvik 2000 outflow was occluded with vascular ball occluder inserted via right axillary artery under fluoroscopy before CEC installation. The recovery was without major complications.

DISCUSSION

Long-time survivors with Jarvik 2000 are increasing in number and such late complication is expected to become a main future issue. Our previous experience with the interventional approach was delusive. Due to the fatal consequences in similar patients with nonsurgical approaches, we opted for surgical aortic valve replacement. At the moment, the international literature does not describe safe approaches regarding aortic valve replacement in patients with Jarvik 2000 L-VAD. This case shows that surgical valve replacement could be managed with success according to the described specific technique.

European cardiovascular mortality over the last three decades: evaluation of time trends, forecasts for 2016

BACKGROUND

The circulatory diseases, in particular ischemic heart diseases and stroke, represent the main causes of death worldwide both in high income and in middle and low income countries. Our aim is to provide a comprehensive report to depict the circulatory disease mortality in Europe over the last 30 years and to address the sources of heterogeneity among different countries.

METHODS

Our study was performed using the WHO statistical information system - mortality database - and was restricted to the 28 countries belonging to the European Union (EU-28). We evaluated gender and age time series of all circulatory disease mortality, ischemic heart diseases, cerebrovascular diseases, pulmonary and other circulatory diseases and than we performed forecast for 2016. Mortality heterogeneity was evaluated by countries using the Cochrane Q statistic and the I-squared index.

RESULTS

Between 1985 and 2011 SDR for deaths attributable to all circulatory system diseases decreased from 440.9 to 212.0 x 100,000 in EU-28 and a clear uniform reduction was observed. Heterogeneity among countries was found to be consistent, therefore different analysis were carried out considering geographical area.

CONCLUSIONS

We forecast a reduction in European cardiovascular mortality. Heterogeneity among countries could only in part be explained by both geographical and health expenditure factors.

An overview of different health indicators used in the European Health Systems

INTRODUCTION

In the European Union three different health systems could be defined according to service delivery, financing, and economic policies: Beveridge, Bismarck and Mixed system. Although health systems are hardly to compare, various organizations are developing methods assessing performance. In the present work the performance of the three systems were evaluated using European Community Health Indicators according to Organization for Economic Cooperation and Development.

METHODS

The study has been conducted among the 28 states of the European Union using the following indicators: Standardized death rate for diseases of the circulatory system, standardized death rate of malignant neoplasms, road traffic accidents with injury, life expectancy at birth, incidence of Human Immunodeficiency Virus (HIV), infant deaths, pure alcohol consumption, infants vaccinated against Diphtheria Tetanus Pertussis (DTP), public and total expenditure on health over the period 2001-2010.

RESULTS

The variation of health indicators over the observational time shows similar trend of circulatory system diseases and malignant neoplasms death rates, road accidents with injury, infant deaths, life expectancy at birth, public and total health expenditure. Some differences in the trend of HIV incidence, alcohol intake and DTP vaccination rates arise among systems. Grouping countries by health system paradigm and geographical area, resulted in a relevant heterogeneity (I² ≥ 90%, Pvalue < 0.0001). No clear superiority of a given health delivery system was found with respect to other paradigms.

CONCLUSIONS

In accordance with the evidence of our study, it can be stated that best performances are more likely to be linked to country specific economic factors. In conclusion, it was not possible to identify the best health system model.

Biomarkers of folate and vitamin B12 and breast cancer risk: report from the EPIC cohort

Epidemiological studies have reported inconsistent findings for the association between B vitamins and breast cancer (BC) risk. We investigated the relationship between biomarkers of folate and vitamin B12 and the risk of BC in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Plasma concentrations of folate and vitamin B12 were determined in 2,491 BC cases individually matched to 2,521 controls among women who provided baseline blood samples. Multivariable logistic regression models were used to estimate odds ratios by quartiles of either plasma B vitamin. Subgroup analyses by menopausal status, hormone receptor status of breast tumors (estrogen receptor [ER], progesterone receptor [PR] and human epidermal growth factor receptor 2 [HER2]), alcohol intake and MTHFR polymorphisms (677C > T and 1298A > C) were also performed. Plasma levels of folate and vitamin B12 were not significantly associated with the overall risk of BC or by hormone receptor status. A marginally positive association was found between vitamin B12 status and BC risk in women consuming above the median level of alcohol (ORQ4-Q1  = 1.26; 95% CI 1.00-1.58; Ptrend  = 0.05). Vitamin B12 status was also positively associated with BC risk in women with plasma folate levels below the median value (ORQ4-Q1  = 1.29; 95% CI 1.02-1.62; Ptrend  = 0.03). Overall, folate and vitamin B12 status was not clearly associated with BC risk in this prospective cohort study. However, potential interactions between vitamin B12 and alcohol or folate on the risk of BC deserve further investigation.

Upregulation of inflammasome activity and increased gut permeability are associated with obesity in children and adolescents

BACKGROUND

Immune activation contributes to the persistent state of inflammation associated with metabolic dysfunction in obesity. The specific immune receptors that sense metabolic stress signals and trigger inflammation are nevertheless largely unknown, and little is known on inflammatory and immune gene regulation in obesity.

METHODS

The study includes a cross-sectional and a longitudinal arm. Forty children and adolescents were enrolled: 22 obese subjects and 18 age-matched normal weight controls. Obese subjects participated in an 18-month therapeutic protocol, based on intensive lifestyle modification (dietary regimen, physical activity and behavioral interventions). Expression of genes involved in the inflammasome pathway, plasma concentration of the inflammasome-associated pro-inflammatory cytokines (interleukin (IL)-1β and IL-18) and indexes of microbial translocation (lipopolysaccharide (LPS), soluble CD14 (sCD14) and intestinal fatty acid-binding protein) were analyzed at baseline in obese subjects compared with controls, and after 18 months in obese subjects.

RESULTS

Cross-sectional analyses showed that the LPS-induced expression of genes involved in inflammasome (NLRP3, caspase 5 and NAIP), Nod-like receptors (NLRX1 and NOD1), downstream signaling (P2RX7, RAGE, RIPk2, TIRAP and BIRC2) and effector molecules (IFN-γ, IL-12β, IL-1β, CCL2, CCL5, IL-6 and TNFα) was significantly increased in obese subjects at baseline as compared with normal weight controls. The baseline plasma concentration of inflammasome-related cytokines (IL-1β and IL-18) and of microbial translocation markers (LPS and sCD14) was augmented in obese subjects as compared with controls as well. Longitudinal analyses indicated that intensive lifestyle modification resulted in a normalization of parameters in subjects with a significant reduction of BMI after 18 months.

CONCLUSIONS

In children and adolescents, obesity is characterized by the activation of the inflammasome and by an alteration of gut permeability. Successful lifestyle modification is effective in reducing inflammation, suggesting that inhibition of the inflammasome may be a potential therapeutic strategy in obesity.

Abstract P1-09-06: The effect of Hispanic nativity and ethnicity on mammography use through the Avon breast health outreach program

Introduction

Although Hispanic women have lower rates of breast cancer compared to non-Hispanic whites (NHW), breast cancer remains the leading cause of cancer death among Hispanic women . Some studies suggest that Hispanic women have lower rates of breast cancer screening compared to NHW women, primarily due to lack of health insurance and socioeconomic disadvantages . This study aims to understand the demographic characteristics of Hispanic women in the U.S. who access and utilize the Avon Breast Health Outreach Program (BHOP), and how Hispanic women's mammography history differs by nativity. Avon BHOP supports community-based organizations to conduct education and outreach to over 50,000 low-income and uninsured women each year, linking them to routine breast cancer screening and care.

Methods

This study analyzed 2014 Client Intake Forms (CIF) for all women aged 40 and older, who were served by BHOP for the first time (∼16,000 women). Descriptive analysis was conducted to summarize their demographic and breast health information, comparing Hispanics with NHW. Multivariate logistic regression was performed to examine the relationship between ethnicity and nativity and having a mammogram in the last two years. Lastly, a sub-analysis among foreign-born (FB) Hispanics only was conducted to assess how the length of time living in the U.S. (number of years) impacts the likelihood of having a mammogram in the last two years.

Results

Of the first time clients served through BHOP in 2014, 10.4% were US-born Hispanics, 45.2% were FB-Hispanics, and 44.4% were NHW. The majority of FB-Hispanic women were from Mexico (66.2%). FB-Hispanics are less likely to have insurance as compared to US-born Hispanic women (19.7% vs. 39.3%), and less likely to have a high school degree (34.3% vs. 44.8%). After controlling for demographic and socioeconomic variables, FB-Hispanics had significantly greater odds of having a mammogram in the past two years compared to US-born Hispanics (OR=1.6, 95% CI, 1.3-1.9), and NHW women (OR=1.4, 95% CI, 1.2-1.6). FB-Hispanics living in the U.S. for 5+ years had a 1.7 greater odds of having a mammogram in the past 2 years, as compared to recent immigrants living in the U.S. for less than one year (OR=1.7 ;95% CI, 1.1 – 2.7).

Discussion

In 2014, the percentage of BHOP Hispanic women aged 40+, reporting a mammogram in the last two years (41.1%) was lower than the overall U.S. Hispanic rate (61.4%) , suggesting confirmation that BHOP serves vulnerable and underserved populations, as it aims to do. This study also demonstrates how screening behaviors differ among Hispanic women served through BHOP, with FB-Hispanics having higher mammography utilization rates as compared to their US-born counterparts, with variation seen by the number of years living in the U.S. In conclusion, it is critical to view Hispanics as a heterogeneous group in order to best address their clinical needs. Specifically, the results point to how U.S.-born Hispanic BHOP clients may be at particularly high risk for low breast cancer screening.

Citation Format: Gates-Ferris K, Senter L, Aliaga M, Hurlbert M, Ricci C. The effect of Hispanic nativity and ethnicity on mammography use through the Avon breast health outreach program. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-06.

Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas)

OBJECTIVES

Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality.

DESIGN

Retrospective multinational study including SCN diagnosed between 1990 and 2014.

RESULTS

2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1).

CONCLUSIONS

After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN.

TRIAL REGISTRATION NUMBER

IRB 00006477.

The risk for type B aortic dissection in Marfan syndrome

Marfan syndrome is the most prevalent connective tissue disorder, with an autosomal dominant inheritance with variable penetrance. This paper aims to summarize epidemiology and treatment for type B dissection in Marfan patients.

Adiposity and risk of thyroid cancer: a systematic review and meta-analysis

Thyroid cancer incidence has increased rapidly over time, as has obesity prevalence. A link between the two appears plausible, but the relation of adiposity to thyroid cancer remains incompletely understood. We performed a meta-analysis of adiposity measures and thyroid cancer using studies identified through October 2014. Twenty-one articles yielded data on 12,199 thyroid cancer cases. We found a statistically significant 25% greater risk of thyroid cancer in overweight individuals and a 55% greater thyroid cancer risk in obese individuals as compared with their normal-weight peers. Each 5-unit increase in body mass index (BMI), 5 kg increase in weight, 5 cm increase in waist or hip circumference and 0.1-unit increase in waist-to-hip ratio were associated with 30%, 5%, 5% and 14% greater risks of thyroid cancer, respectively. When evaluated by histologic type, obesity was significantly positively related to papillary, follicular and anaplastic thyroid cancers, whereas it revealed an inverse association with medullary thyroid cancer. Both general and abdominal adiposity are positively associated with thyroid cancer. However, relations with BMI vary importantly by tumour histologic type.

Violence and unsafety in a major Italian hospital: experience and perceptions of health care workers

Workers' experience of violence and perceived unsafety can have a profound impact on job satisfaction, job performance, and workers' decision to leave.

OBJECTIVES

The aim of the study was to assess the prevalence of physical and non-physical violence among hospital workers, explore the complaints and reactions of victims, assess the relationship between violence and psychosocial/work factors and analyze the levels of perceived unsafety.

METHODS

A cross-sectional study was conducted, via a structured self-administered questionnaire given to all the employees of a major hospital in Italy. Cronbach's alpha coefficient was used to assess the internal consistency of the questionnaire. A logistic regression model was used for data analysis.

RESULTS

903 questionnaires out of 1853 (48.7%) were correctly returned; 11.5% had experience of physical violence and 40.2% had been victims of verbal violence in the previous 12 months. The most common consequences were fear, anger, frustration, and anxiety. Verbal violence was influenced by age, role, department, night/holiday shift work and experience in the current ward. Experiences of physical violence were related to gender, role, and department; 469 responders (51.9%) reported feelings of unsafety, which were related to their professional role, department, shift work, experience of physical or psychological violence, having seen episodes of violence and having received specific training.

CONCLUSIONS

Our findings suggest that several factors are associated with workplace violence in health care settings and some of these also influenced the levels of perceived unsafety.

Randomised clinical study: gluten challenge induces symptom recurrence in only a minority of patients who meet clinical criteria for non-coeliac gluten sensitivity

BACKGROUND

It is unknown whether symptoms in non-coeliac patients (non-CD) meeting clinical diagnostic criteria for noncoeliac gluten sensitivity (NCGS) are specifically triggered by gluten.

AIM

To assess gluten sensitivity in patients diagnosed with NCGS.

METHODS

We studied 35 non-CD subjects (31 females) that were on a gluten-free diet (GFD), in a double-blind challenge study. Participants were randomised to receive either gluten-containing flour or gluten-free flour for 10 days, followed by a 2-week washout period and were then crossed over. The main outcome measure was their ability to identify which flour contained gluten. Secondary outcome measures were based upon Gastrointestinal Symptoms Rating Scale (GSRS) scores.

RESULTS

The gluten-containing flour was correctly identified by 12 participants (34%), who were classified as having NCGS. Their mean GSRS dimension scores were significantly higher following gluten challenge compared to baseline. The scores were: pain, 1.7 ± 0.8 vs. 2.6 ± 1.0; reflux, 1.6 ± 0.5 vs. 2.2 ± 0.9; indigestion, 1.9 ± 0.7 vs. 3.2 ± 1.1; diarrhoea, 1.6 ± 0.7 vs. 2.9 ± 1.5 and constipation, 1.9 ± 0.9 vs. 2.9 ± 1.3. Seventeen participants (49%) erroneously considered the gluten-free flour to contain gluten. Their mean GSRS dimension scores were significantly higher following gluten-free flour challenge compared to baseline. The scores were: pain, 1.6 ± 0.9 vs. 3.0 ± 0.9; reflux, 1.4 ± 0.5 vs. 2.3 ± 1.1; indigestion, 2.0 ± 1.1 vs. 3.7 ± 1.1; diarrhoea, 1.6 ± 0.7 vs. 3.0 ± 1.2 and constipation, 1.6 ± 0.9 vs. 2.6 ± 1.3. The other six participants (17%) were unable to distinguish between the flours.

CONCLUSION

Double-blind gluten challenge induces symptom recurrence in just one-third of patients fulfilling the clinical diagnostic criteria for non-coeliac gluten sensitivity.

Bimodal regulation of p21(waf1) protein as function of DNA damage levels

Human p21^Waf1 protein is well known for being transcriptionally induced by p53 and activating the cell cycle checkpoint arrest in response to DNA breaks. Here we report that p21^Waf1 protein undergoes a bimodal regulation, being upregulated in response to low doses of DNA damage but rapidly and transiently degraded in response to high doses of DNA lesions. Responsible for this degradation is the checkpoint kinase Chk1, which phosphorylates p21^Waf1 on T145 and S146 residues and induces its proteasome-dependent proteolysis. The initial p21^Waf1 degradation is then counteracted by the ATM-Chk2 pathway, which promotes the p53-dependent accumulation of p21^Waf1 at any dose of damage. We also found that p21^Waf1 ablation favors the activation of an apoptotic program to eliminate otherwise irreparable cells. These findings support a model in which in human cells a balance between ATM-Chk2-p53 and the ATR-Chk1 pathways modulates p21^Waf1 protein levels in relation to cytostatic and cytotoxic doses of DNA damage.

Quaternary structures of GroEL and naïve-Hsp60 chaperonins in solution: a combined SAXS-MD study

Analysis with QUAFIT software combined with SAXS-MD data, allows resolution of GroEL and naïve-Hsp60 oligomeric structures in solution.

Familial aggregation of moderate to severe plaque psoriasis

BACKGROUND

Psoriasis is a highly heritable disease. It has been suggested that psoriasis is preferentially transmitted from fathers.

AIM

To evaluate the degree of familial aggregation of psoriasis; to determine the recurrence risk ratio (λR ) of psoriasis in first, second and third degree relatives of patients with psoriasis; and to investigate the transmission patterns of the disease and their relationships with the clinical profiles of patients.

METHODS

A cross-sectional study on 640 consecutive, unrelated adult patients with chronic plaque psoriasis was performed. The prevalence of psoriasis in first, second and third degree relatives of the patients was determined, and the λR was calculated under the assumption of a population prevalence of 2%. Age of onset and presence of facial, hand and foot psoriasis were evaluated in probands with paternal vs. maternal transmission.

RESULTS

A positive familial history of psoriasis was found in 380 patients (59.37%). Of these, 174 (27.18%) had at least one parent with psoriasis, with a λR of 13.59, while 106 patients (16.56%) had at least one second degree relative with psoriasis, and 34 patients (5.31%) had one third degree relative with psoriasis. No parent-of-origin effect in transmission of psoriasis from affected parent to offspring was observed, and there were no significant differences in the clinical profiles of the disease between patients grouped by transmission pattern of psoriasis.

CONCLUSIONS

These results show a high familial recurrence risk of psoriasis, and suggest a balanced parental transmission of the disease.