Poor prognosis of rare sarcomeric gene variants in patients with dilated cardiomyopathy

BACKGROUND

In dilated cardiomyopathy (DCM), the clinical and prognostic implications of rare variants in sarcomeric genes remain poorly understood. To address this question, we analyzed the outcome of rare sarcomeric gene variants in patients enrolled in our Familial Cardiomyopathy Registry.

METHODS

DCM families harboring rare sarcomeric variants in MYH6, MYH7, MYBPC3, TNNT2, and TTN were identified. Genotype-phenotype association analysis was performed, and long-term survival-free from death or heart transplant was compared between carriers and noncarriers.

RESULTS

We found 24 rare variants (3 in MYH6, 3 in MYH7, 3 in MYBPC3, 2 in TNNT2, and 13 in TTN) affecting 52 subjects in 25 families. The phenotypes of variant carriers were severe (3 sudden deaths, 6 heart failure deaths, 8 heart transplants, 2 ventricular fibrillations). There was no difference in the overall long-term survival between carriers and the 33 noncarriers (p = 0.322). However after 50 years of age, the combined endpoint of death or transplant was decreased in carriers as compared to noncarriers (p = 0.026).

CONCLUSIONS

Patients with DCM carrying rare variants in sarcomeric genes manifest a poorer prognosis as compared to noncarriers after the age of 50 years. These data further support the role of genetic testing in DCM for risk stratification.

Role of components of frailty on quality of life in dialysis patients: a cross-sectional study

BACKGROUND

Many people on dialysis suffer a variety of conditions that can affect frailty (the condition or quality of being frail), such as comorbidities, disabilities, dependence, malnutrition, cognitive impairment and poor social conditions. Frailty is suspected to affect quality of life (QoL).

OBJECTIVES

The study aimed to evaluate the effect of the different components of frailty on the QoL of people on dialysis.

METHODS

We enrolled 203 out of 233 prevalent patients on dialysis in the Trieste area of Italy. We applied the Short-Form 36 (SF-36) questionnaire, Activities of Daily Living, Instrumental Activities of Daily Living, Subjective Global Assessment scales and Karnofsky Index. In addition we analysed their social conditions.

RESULTS

Dependence, malnutrition and disability had a negative role on QoL. Living with family and good social-economic conditions were significantly related to a better QoL.

CONCLUSIONS

Dependence, malnutrition, disability, poor social and economic conditions have a significant effect on life quality. The role of comorbidities appears to be less important. Screening of patients, nutritional and functional rehabilitation and prevention of social isolation appear to be indispensable in guaranteeing a satisfactory life quality.

Prognostic role of clinical presentation in symptomatic patients with hypertrophic cardiomyopathy

AIMS

To evaluate the long-term prognostic impact of baseline symptoms in a cohort of hypertrophic cardiomyopathy (HCM) patients.

METHODS AND RESULTS

We considered 84 HCM patients symptomatic at diagnosis: 26 (31%) with heart failure (group 1), 34 (40%) with syncope/palpitations (group 2) and 24 (29%) with chest pain (group 3). During a median follow-up of 102 (53-187) months, 25 (30%) patients died/underwent heart transplant (HTx), 14 of 26 (54%) in group 1, 10 of 34 (29%) in group 2 and one of 24 (4%) in group 3. At 12, 60 and 120 months, HTx-free survival rates were 100, 79 and 52% in group 1, vs. 100, 97 and 69% in group 2, vs. 96, 96 and 96% in group 3, respectively (P = 0.008). At multivariate analysis, heart failure [hazard ratio (HR) 2.59, confidence interval (CI) 95% 1.09-6.17, P = 0.032] and left atrium diameter (HR 1.83, CI 95% 1.16-2.89, P = 0.009) emerged as independent predictors of death/HTx, with incremental prognostic power with respect to echo Doppler variables of left ventricular systolic and diastolic dysfunction [area under the curve (AUC) of receiver operating characteristics (ROC) curves at 5 years: 0.90 vs. 0.78, respectively, P = 0.03].

CONCLUSION

Clinical presentation emerged as a relevant prognostic tool in HCM patients symptomatic at onset, as heart failure was associated with a particularly poor outcome. Heart failure and left atrium diameter at diagnosis showed incremental prognostic power compared with echo Doppler assessment of left ventricular systolic and diastolic dysfunction.

Long term survival in patients with cardiac amyloidosis. Prevalence and characterisation during follow-up

BACKGROUND AND AIMS

Cardiac amyloidosis (CA) is usually characterised by a poor outcome in the short-term; clinical and instrumental features are heterogeneous and could characterise subgroups with different prognoses. The aim of our study was to describe a subgroup of patients with CA showing an impressive favourable long-term survival.

METHODS

Out of 50 patients (males 65%, 63 ± 11 years) with an echocardiographic and bioptic diagnosis of CA observed from 1991 to 2009, we selected a subgroup of patients surviving more than 50 months from diagnosis (group 1). We described their features at enrolment and during follow-up, comparing them with patients surviving less than 12 months (group 2).

RESULTS

We found seven patients (14%) belonging to group 1 and 26 (52%) to group 2. Four out of seven long term survivors suffered from AL amyloidosis, in one case the underlying aetiology was a chronic inflammatory disease, while in two cases remained unknown. At enrolment, group 1 patients showed higher systolic blood pressure with respect to group 2 (140 ± 25 vs. 112 ± 18 mmHg, respectively, p=0.011), and a less thick interventricular septum (IVS) (IVS thickness > 15 mm in 29% vs. 69% of patients, p = 0.049). No patient of group 1 presented left ventricular restrictive filling pattern (0 vs. 31% in group 1 and 2 respectively, p = 0.035), atrial fibrillation (0 vs. 35%, p = 0.024), or progression towards a more severe disease during follow-up.

CONCLUSIONS

A not negligible proportion of patients with CA can have a long-term survival. They showed a less severe disease at diagnosis, with substantial stability over time. Further studies on larger populations are necessary to understand the mechanisms underlying this more favourable natural history of the disease.

[The assessment of newly qualified nurses in competitive exams for hospital employment: a descriptive study]

BACKGROUND

In the public sector the selection of the health personnel is based on qualifications and exams with a written, an oral and practical test, on contents selected by the committee. The level of complexity and contents of the tests is very variable across committees.

AIM

To analyze the tests for the selection of nurses, the level of complexity and contents assessed.

METHODS

A sample of tests was analysed and for each item, the cognitive level tested, according to Bloom's taxonomy, areas and health problems investigated.

RESULTS

One-hundred-twenty-eight selection tests of 14 hospitals and districts were analysed. Open questions are used in the majority of tests to assess mainly knowledge and not complex cognitive functions or problem solving skills. The contents vary widely and are not focused on priority health problems. Questions on prevention, health education and symptoms monitoring are missing.

CONCLUSIONS

Written, oral and practical tests focus on the same contents and test mainly knowledge.

[Autopsy findings and pleural plaques in the Malignant Mesothelioma (MM) Regional Register of Friuli-Venezia-Giulia]

AIMS

To describe the cases of MM that occurred in the Friuli Venezia Giulia Region in the period 1995-2009 and evaluate the diagnostic contribution of autopsy findings.

METHODS

Via the Regional Register a search for MM cases was made following standardized criteria for diagnosis and past asbestos exposure assessment. Pleural plaques were identified by autopsy findings; the relationship between presence of pleural plaques and assessment of past asbestos exposure was analyzed.

RESULTS

834 cases of MM were recorded and 458 autopsy findings were available; for 142 cases (15% of males and 23% of women) the first diagnosis was made at autopsy. Data were available on previous asbestos exposure in 91% (416 subjects) of cases with autopsy findings: 255 had "certain occupational exposure" (group 1), 116 "other occupational and non- occupational exposure" (group 2), 45 "negative and unknown exposure" (group 3). Logistic regression showed that significant predictors for pleural plaques were age at diagnosis (OR=1.03 each year (95% CI=1.01-1.05), asbestos exposure in group 1 versus group 2 (OR=6.8 (95% CI=4-12), and exposure in group 1 versus group 3 (OR=6.4 (95% CI=3-13). Among subjects in groups 1 and 2, the presence of pleural plagues was significantly associated with latency (OR=l.03 for each year of latency; 95% CI=1.01-1.22) and asbestos exposure in group 1 versus group 2 (OR=7.8; 95% CI=4.4-13.0).

CONCLUSIONS

Autopsy findings improved the diagnostic level of MM in elderly subjects, for whom reliable data on past asbestos exposure is often lacking. In subjects suffering from MM direct interview is always the best tool to evaluate past asbestos exposure; autopsy findings of pleural plaques cannot replace the anamnestic history when this is lacking, although such findings can act as a support.

[Anti-smoking counseling in a group of workers with past exposure to asbestos]

BACKGROUND

Anti-smoking counseling is often part of healthcare protocols for workers with past asbestos exposure; nevertheless, data is lacking about the results.

OBJECTIVES

To evaluate smoking habits and the effects of anti-smoking counseling in a group of workers with past asbestos exposure.

METHODS

Smoking was assessed in 671 subjects who voluntarily attended a health surveillance protocol. Fagerstrom's and Richmond's tests were used in order to estimate smokers' addiction and their potential will to quit. Besides anti-smoking counseling, smokers were also offered a formal cessation programme.

RESULTS

The mean age of the 671 subjects was 66 (DS = 7,9) years. The population consisted of 87 (13%) current smokers, 372 (55%) ex-smokers and 212 (32%) non smokers. According to Fagerstrom's test results, only 10% of the smokers presented a strong/very strong addiction, while Richmond's test results showed that 50% of the smokers had a strong/very strong will to quit. Only one smoker decided to join a cessation programme.

CONCLUSIONS

The results of the study could present a bias, because volunteer-based protocols may promote the participation of self-motivated and health-sensitive subjects. This could be one of the reasons for the low prevalence of current smokers and high prevalence of ex-smokers. Anti-smoking counseling did not produce satisfactory effects because smokers were resistant to quitting smoking. Identification of anti-smoking counseling weak points may improve efficacy in health prevention controls made on subjects with past asbestos exposure.

Role of a multidisciplinary program in improving outcomes in cognitively impaired heart failure older patients

BACKGROUND

Cognitive impairment (CI) frequently complicates Heart failure (HF) and is associated with increased mortality and morbidity. Previous studies reported that nurse-lead home-based multidisciplinary program (MP) may not improve the prognosis of this high-risk group. In the present study, we analysed the relative effectiveness of an integrated hospital-based MP in patients with cognitive impairment.

METHODS

Consecutive (n = 173) community-living outpatients aged > 70 years (mean 77 +/- 6, 48% women) randomized to a MP (n = 86) or usual care (UC) (n = 87) were enrolled in stable clinical conditions. Cognitive status was assessed by means of Folstein Mini Mental State Examination (MMSE).

RESULTS

CI (MMSE < or = 24) was present in 41.6% (42,5% UC vs 40.7% MP p =ns). The variables independently associated to CI were: older age, education level <5 years, anemia and severe renal dysfunction. During a 2-year follow-up, 59 patients died (31.4%) with no significant difference between intervention group. At multivariate analysis, in the entire cohort, CI was independently associated to death (HR 2,07 7[95%CI 1,097-3,931]), HF admissions (2,133[1,346-3,381]), death/HF admissions (1,784[1,132-2,811]) and all-cause admissions (1,473[1,008-2,153]. When considered according to intervention groups, CI was independently associated to all-cause death (3,603 [1,553-8,358], death/HF admissions (2,029[1,200-3,432]) and HF admissions (2,474[1,406-4,353]) but not to all-cause admissions. The assignment of patients with CI to MP was associated to a significant reduction in HF admissions vs UC (0,503[0,253-0,999] (all interaction tests p = ns).

CONCLUSIONS

This study suggests that CI is very common and associated to worse prognosis in heart failure and that hospital-based MP seems to improve outcomes in these patients through reduction of heart failure hospital admission.

Effects of hormonal contraception on vaginal flora

BACKGROUND

The sector of the market that deals with contraception offers a long list of different contraceptive methods. Within the estroprogestinic choice, the routes of administration are oral, transdermic and vaginal one. Even though efficacy is comparable with these methods, secondary and adverse effects are directly involved in the acceptability of the method.

STUDY DESIGN

This was a prospective comparative study. During 1 year, we enrolled 60 asymptomatic women who voluntarily requested combined oral contraception (COC) or combined contraceptive vaginal ring (CCVR group). After a baseline study of vaginal milieu prior to starting hormonal contraception, we performed a follow-up. For each woman, we examined vaginal pH; quantification of leukocytes, lactobacilli, Candida and cocci on saline microscopy fluid; Gram stain with Nugent score and the presence of vaginal infection [culture for Trichomonas vaginalis, albicans and nonalbicans Candida, Group B Streptococcus (GBS)].

RESULTS

At the end of follow-up, there was a little change of vaginal milieu in both groups. We noted an increase of lactobacilli in the CCVR users and an increase of GBS in COC users.

CONCLUSION

CCVR compared to COC users showed an increase of the number of lactobacilli in vaginal flora. It means that an increase of leukorrhea in that group could be protective in terms of prevention of vaginal imbalance/infection.

How can optimization of medical treatment avoid unnecessary implantable cardioverter-defibrillator implantations in patients with idiopathic dilated cardiomyopathy presenting with "SCD-HeFT criteria?"

To assess the proportion and long-term outcomes of patients with idiopathic dilated cardiomyopathy and potential indications for implantable cardioverter-defibrillator before and after optimization of medical treatment, 503 consecutive patients with idiopathic dilated cardiomyopathy were evaluated from 1988 to 2006. A total of 245 patients (49%) satisfied the "Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) criteria," defined as a left ventricular ejection fraction of ≤0.35 and New York Heart Association (NYHA) class II-III on registration. Among these, 162 (group A) were re-evaluated 5.4 ± 2 months later with concurrent β-blockers and angiotensin-converting enzyme inhibitor use. Of the 162 patients, 50 (31%) still had "SCD-HeFT criteria" (group A1), 109 (67%) had an improved left ventricular ejection fraction and/or New York Heart Association class (group A2), and 3 (2%) were in NYHA class IV. Of the 227 patients without baseline "SCD-HeFT criteria" (left ventricular ejection fraction >0.35 or NYHA class I), 125 were evaluated after 5.5 ± 2 months. Of these 227 patients, 13 (10%) developed "SCD-HeFT criteria" (group B1), 111 (89%) remained without "SCD-HeFT criteria" (group B2), and 1 (1%) had worsened to NYHA class IV. The 10-year mortality/heart transplantation and sudden death/sustained ventricular arrhythmia rate was 57% and 37% in group A1, 23% and 20% in group A2 (p <0.001 for mortality/heart transplantation and p = 0.014 for sudden death/sustained ventricular arrhythmia vs group A1), 45% and 41% in group B1 (p = NS vs group A1), 16% and 14% in group B2 (p = NS vs group A2), respectively. In conclusion, two thirds of patients with idiopathic dilated cardiomyopathy and "SCD-HeFT criteria" at presentation did not maintain implantable cardioverter-defibrillator indications 3 to 9 months later with optimal medical therapy. Their long-term outcome was excellent, similar to that observed for patients who had never met the "SCD-HeFT criteria."

Comparative evaluation of B-type natriuretic peptide and mid-regional pro-A-type natriuretic peptide changes from admission to discharge in prognosis of acute decompensated heart failure patients

BACKGROUND

Mid-regional pro-A-type natriuretic peptide (MRproANP) seems to be non-inferior compared to B-type natriuretic peptide (BNP) for heart failure diagnosis and prognosis; however, no previous studies have investigated the MRproANP in-hospital changes in prognostic role. This study aimed to compare the prognostic accuracy of BNP and MRproANP in-hospital changes in acute decompensated heart failure (ADHF) patients.

METHODS

37 patients with either admission/pre-discharge BNP and MRproANP data, were investigated. The combined endpoint was cardiovascular death/heart transplantation/readmission for HF.

RESULTS

BNP and MRproANP had a median decrease of 55% [72;45] and 21% [40; 11] respectively in event-free patients; BNP decrease of 34% [48; 29] but MRproANP increase of 4% [-7; 25] in patients with cardiovascular events. Prognostic accuracy of deltaBNP and deltaMRproANP was similar.

CONCLUSIONS

MRproANP basically trends up in patients with worse outcome and decreases in event-free patients, likely leading to a simpler interpretation although the prognostic accuracy is similar for both peptides.