Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (>15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (>3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p<0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p<0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p<0.001 for PCWP; log-rank 17.3, p<0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p<0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Valve disease in cardiac amyloidosis: an echocardiographic score

Background

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item.

Results

Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6–17.4) in ATTR-CA, 11.0 (9.3–14.9) in AL-CA, 12.8 (11.1–14.4) in ATTR-CA controls, and 11.0 (9.1–13.0) in AL-CA controls (p=0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy.

Conclusions

Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score is quite effective in identifying patients with ATTR-CA among patients with CA or unexplained hypertrophy.

Funding Acknowledgement

Type of funding sources: None.

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with a LV ejection fraction <50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles <19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI <19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p<0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p>0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values <19, 19–24, or ≥24 (log-rank 33, p<0.001). At multivariable regression analysis, LVOT-VTI <19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF <30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP.

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Funding Acknowledgement

Type of funding sources: None.

Haemodynamic forces as predictors of cardiac remodelling and outcome in heart failure with reduced ejection fraction treated with sacubitril/valsartan

Background

Angiotensin receptor-neprilysin inhibitor (ARNI) is a cornerstone of treatment in heart failure (HF) with reduced ejection fraction (HFrEF), but its effectiveness shows interindividual differences.

Objectives

To evaluate the predictive value of echo-derived hemodynamic forces (HDF), together with other echocardiographic, biohumoral and cardiopulmonary parameters on a) response to ARNI after 6 months; b) adverse cardiovascular events at follow-up.

Methods

Eighty-nine consecutive HFrEF patients from two HF centers performed clinical evaluation, laboratory analyses, rest echocardiography and cardiopulmonary exercise testing. Response to ARNI at 6 months was considered in patients without HF admissions, death, or urgent heart transplant and with a ≥50% reduction in NT-proBNP levels and/or ≥10% increase in left ventricle ejection fraction. After 6 months, patients were followed up for a composite endpoint of cardiovascular death, HF-related hospitalization and new-onset atrial fibrillation.

Results

Response to ARNI was documented in 45/89 (51%) of patients. At baseline, responders and non-responders were paired in clinical assessment, conventional echocardiography, functional status and therapy. At multivariate logistic regression analysis, HDF-derived whole cardiac cycle left ventricle strength (wLVS) was the only independent predictor of ARNI response at 6 months (odds ratio 1.36, 95% confidence interval 1.10–1.67; p=0.004). A wLVS ≥3.7% showed a good accuracy in predicting ARNI response (AUC = 0.736, 0.607–0.840; p<0.0001). During a median of 33 (IQR 23–41) months, wLVS increase from baseline to 6-month (ΔwLVS) showed a high discrimination ability at time-dependent ROC analysis (optimal cut-off: ≤0.5%; AUC=0.811, 0.69–0.90; p<0.0001), stratified prognosis at Kaplan-Meier analysis (log-rank p<0.0001), and remained an independent prognostic predictor of the composite endpoint (hazard ratio 0.76, 0.61–0.95; p<0.01) even after adjusting for clinical, functional and conventional echocardiographic parameters.

Conclusions

HDF analysis may help predict ARNI response and optimize follow-up and medical/device strategies in patients with HfrEF.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Fondazione Toscana Gabriele Monasterio, Pisa, Italy

Prevalence of amyloid transthyretin cardiomyopathy in elderly subjects from the general population: first results from the CATCH study

Background

Amyloid transthyretin cardiomyopathy (ATTR-CM) has become treatable. Wild-type ATTR-CM is an age-related disorder. Establishing the exact prevalence of ATTR-CM in elderly subjects from the general population may be useful for healthcare providers and policy makers alike.

Methods

The Characterizing the burden of Amyloid Transthyretin CardiomyopatHy in the elderly (CATCH) study is a population screening on all subjects aged ≥65 years followed by general practitioners working in a part of Tuscany (Italy) where there is no cluster of variant ATTR. The study started on March 12, 2021 and is ongoing. The first step of the evaluation includes clinical history and physical examination, electrocardiogram, transthoracic echocardiogram, and blood sampling with measurement of N-terminal pro-B-type natriuretic peptide and high-sensitivity (hs) troponin T. The following elements are searched: 1) any clinical red flag of amyloidosis (history of carpal tunnel syndrome, lumbar spine stenosis, etc.), 2) interventricular septal thickness ≥12 mm or other echocardiographic red flags, 3) hs-troponin T higher than the upper reference limit (14 ng/L). Patients with any of these elements are referred to a second step including diphosphonate scintigraphy and the search for a monoclonal protein in the serum and urine. The standard diagnostic workup for CA is then followed until the diagnosis is confirmed or discarded.

Results

As of October 13, 2021, 514 subjects ≥65 years have been evaluated for possible participation. Among them, 135 (26%) could not be contacted, were reluctant to enter the study, died before being contacted, or were bedridden. Out of the other 379 subjects, 329 (87%) have already undergone the first step. Forty percent of individuals (n=132) have been referred to the second step. Thirteen subjects have declined (10%); 69 patients have undergone diphosphonate scintigraphy and the search for a monoclonal protein (while the other 50 are awaiting these exams). Two subjects showed an intense myocardial uptake of the diphosphonate tracer (Perugini score 2–3) and no monoclonal protein, and were then diagnosed with ATTR-CM. They were both women, aged 83 and 78 years, both mildly symptomatic for dyspnea (New York Heart Association II) and with unexplained hypertrophy. The search for TTR gene mutation was negative in the first case and is still ongoing in the second. Based on these preliminary data, the prevalence of ATTR-CM in the elderly population can be calculated as 2/266=0.8% (Figure 1).

Conclusions

The CATCH study is expected to enroll at least 1,000 subjects and will provide the first data on the epidemiology of ATTR-CM in elderly subjects. Based on an interim analysis, almost 1 in 100 individuals ≥65 years has ATTR-CM.

Funding Acknowledgement

Type of funding sources: None.

C42 MULTI–CHAMBER SPECKLE TRACKING IMAGING AND DIAGNOSTIC VALUE OF LEFT ATRIAL STRAIN IN CARDIAC AMYLOIDOSIS

Background

Amyloid deposits in all cardiac chambers, impairing their function. We investigated for the first time if a speckle–tracking echocardiography (STE) analysis extended to all 4 chambers might hold additive diagnostic value for CA and its subtypes (amyloid transthyretin [ATTR–] and light–chain [AL]–CA).

Methods

We evaluated 423 consecutive patients undergoing a diagnostic workup for CA in 2 referral centres from 2015 to 2020.

Results

CA was diagnosed in 261 patients (62%; ATTR–CA, n = 144, 34%; AL–CA, n = 117, 28%). Patients with CA had an impaired function of all cardiac chambers, particularly those with ATTR–CA. Peak left atrial longitudinal strain (LA–PALS) was the only STE parameter that predicted CA and ATTR–CA independent of laboratory and standard echocardiographic variables (Model 1). It also predicted ATTR–CA among patients with unexplained hypertrophy regardless of a diagnostic score (IWT score). Patients with either LA–PALS or LA–peak atrial contraction strain (PACS) in the first quartile (LA–PALS <6.65% or LA–PACS <3.62%) had an almost 4–fold higher likelihood of CA and ATTR–CA regardless of Model 1. Among patients with unexplained hypertrophy, those with LA–PALS or LA–PACS in the first quartile had an almost 9–fold higher likelihood of ATTR–CA irrespective of Model 1, and a 2–fold higher likelihood of ATTR–CA beyond the IWT score.

Conclusions

STE measures of all 4 chambers are abnormal in patients with CA, particularly in those with ATTR–CA. LA strain holds independent diagnostic significance. Among patients screened for CA, those with LA–PALS <6.65% and/or LA–PACS <3.62% have a high likelihood of CA and ATTR–CA.

P294 AN ECHOCARDIOGRAPHIC SCORE OF VALVE DISEASE IN PATIENTS WITH CARDIAC AMYLOIDOSIS

Background

Cardiac amyloidosis (CA) affects all cardiac structures, including the valves. We summarized the echocardiographic features of valve disease in a score.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR–) or light–chain (AL–) CA, and selected age– and sex–matched controls. The Amyloid VAlve (AVA) score included 31 items related to the mitral, aortic and tricuspid valves (which can be properly assessed in standard echocardiograms), with a value of 1 for each abnormal item.

Results

Patients with ATTR–CA displayed more often a shortened/hidden and retracted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL–CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (interquartile interval 13.6–17.4) in ATTR–CA, 11.0 (9.3–14.9) in AL–CA, 12.8 (11.1–14.4) in ATTR–CA controls, and 11.0 (9.1–13.0) in AL–CA controls (p = 0.004 for ATTR– vs. AL–CA, 0.009 for ATTR–CA vs. their controls, and 0.461 for AL–CA vs. controls). We compared the AVA and two validated diagnostic scores (IWT and AMYLI). AUC values for the diagnosis of ATTR–CA were 0.782, 0.846 and 0.902, respectively, in patients with ATTR–CA or matched controls, and 0.773, 0.706 and 0.679 in patients with LV hypertrophy (n = 67, 84%) (all non–significant p values).

Conclusions

Patients with ATTR–CA have a prominent impairment of mitral valve structure and function, and higher score values. The AVA score is quite effective in identifying patients with ATTR–CA among patients with CA or with unexplained hypertrophy.

Left atrial strain in cardiac amyloidosis

Background

Patients with cardiac amyloidosis (CA) display an enlarged and dysfunctional left atrium (LA), because of the effects of left ventricular (LV) diastolic and then systolic dysfunction, as well as the amyloid infiltration of LA wall. A single study reported impaired LA strain in CA, but differences among amyloid light-chain (AL) and transthyretin (ATTR) CA and the correlates of reduced LA strain have not been characterized.

Methods

We evaluated 426 consecutive patients undergoing a screening for suspected CA in 2 tertiary referral centres. Among them, 262 (61%) were diagnosed with CA (n=117 AL-CA, n=145 ATTR-CA). We measured peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from 4- and 2-chamber (4C, 2C) views, and correlated them with maximum and minimum LA volumes, E/e' ratio, and LV global longitudinal strain (GLS).

Results

LA strain was much more severely impaired in patients with ATTR-CA than those without CA, and to a lesser extent than those with AL-CA (Figure). LA volumes were larger in patients with ATTR-CA than those without CA (maximal LA volume, p=0.042; minimal LA volume, p<0.001), and those with AL-CA (both volumes, p<0.001). LA strain values were more closely correlated with minimal than maximal LA volumes, and patients with AL-CA displayed stronger correlations than those with ATTR-CA or without CA; for example, Spearman's rho values for 4C-PALS vs. minimal LA volume were 0.595, 0.481, and 0.462, respectively (all p<0.001). Furthermore, LA strain correlated with E/e' in patients with AL-CA, but not in those with ATTR-CA: 4C-PALS vs. E/e', rho 0.406, p=0.001 (AL-CA), p=0.401 (ATTR-CA), and p=0.097 (no CA). Finally, LA strain correlated most closely with LV GLS in patients with AL-CA: 4C-PALS vs. LV GLS, rho 0.431, p<0.001 (AL-CA), rho 0.401, p<0.001 (ATTR-CA), rho 0.219, p=0.042 (no CA).

Conclusions

LA volume increase and reduced LA strain is particularly prominent in patients with ATTR-CA. Patients with AL-CA seem to display closer relationships between LA strain, size and haemodynamic load, possibly reflecting the most acute disease course, and lower time for amyloid deposition in the LA wall.

Funding Acknowledgement

Type of funding sources: None.

Reverse remodelling criteria to predict cardiovascular death in heart failure with reduced or mid-range ejection fraction

Aims

Reverse remodelling (RR) is the recovery from left ventricle (LV) dilatation and dysfunction. There are no established definitions of RR. We sought to identify RR criteria that better predicted cardiovascular death.

Methods and results

Forty-two studies used 25 criteria to define RR, most commonly (n=12) as LV end-systolic volume (LVESV) reduction ≥15%. We evaluated 927 patients with LV ejection fraction (LVEF) <50% undergoing 2 echocardiograms within 12±2 months. Over a median 2.8-year follow-up after the second echocardiogram (1.3–4.9), 123 cardiovascular deaths occurred (13%). Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide (NT-proBNP), ischaemic aetiology, cardiac resynchronization therapy (CRT), estimated glomerular filtration rate (eGFR), New York Heart Association (NYHA), and LVESV index (LVESVi), and Model 2 the validated 3C-HF score. Two RR criteria proved particularly effective in risk reclassification over Model 1 and Model 2: LVEF increase ≥1 category (severe [LVEF ≤30%], moderate [LVEF 31–40%], mild LV dysfunction [LVEF 41–55%] and normal LV function [LVEF ≥56%]), and LVEF increase >10 U. The same 2 criteria yielded independent prognostic significance and improved reclassification also in patients with LVEF <40% or LVEF ≤35%. LVEF increase ≥1 category and LVEF increase >10 U displayed a stronger prognostic value than LVESV reduction ≥15%, both in the whole population and the subsets with LVEF <40% or ≤35%.

Funding Acknowledgement

Type of funding sources: None.

Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

BACKGROUND

Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents.

METHODS

For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5-19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence.

FINDINGS

We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9-10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes-gaining too little height, too much weight for their height compared with children in other countries, or both-occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls.

INTERPRETATION

The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks.

FUNDING

Wellcome Trust, AstraZeneca Young Health Programme, EU.

Reverse remodelling, changes in diastolic function and their prognostic value compared to natriuretic peptides

Background

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilation and dysfunction in response to treatment for heart failure (HF). RR is usually associated with improved prognosis. The impact of RR on indices of diastolic function, and the relative prognostic value of RR, changes in diastolic function and natriuretic peptide levels are currently unknown.

Methods

We analysed data from patients with stable systolic HF (LV ejection fraction [LVEF] <50%) undergoing 2 transthoracic echocardiograms (TTE) within 12±2 months. RR was defined as a ≥15% reduction in LV end-systolic volume index (LVESVi). The follow-up started after the second TTE.

Results

927 patients were evaluated (68±12 years; median LVEF 35% [interquartile interval 30–43%]; 27% women; 52% ischaemic aetiology). Patients experiencing RR (n=286, 31%) displayed more prominent positive changes in several parameters reflecting diastolic dysfunction, namely E/e' ratio, left atrial volume index (LAVi), and systolic pulmonary artery pressure (sPAP), as well as N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP; Figure). In the whole population, percent changes (Δ%) LVESVi displayed weak but significant correlations with Δ% E/e' (r=0.237, p<0.001), LAVi (r=0.316, p<0.001), and sPAP (r=0.158, p<0.001), and also with Δ% NT-proBNP (r=0.279, p<0.001). There were 123 cardiovascular deaths and 4 heart transplantations over 2.8 years (1.3–4.9). Δ% LVESVi, RR, Δ% sPAP and Δ% NT-proBNP were univariate predictors of this endpoint. In 2 multivariable models including Δ% sPAP and Δ% NT-proBNP and either RR or Δ% LVESVi, only Δ% NT-proBNP emerged as independent predictor of outcome (hazard ratio 1.01, 95% confidence interval 1.01–1.02; p<0.001).

Conclusions

A recovery of LV geometry is accompanied by positive modifications in several indices related to diastolic function, as well as a decrease in NT-proBNP levels. Percent changes in NT-proBNP over 12 months are stronger predictors of outcome than variations in LV geometry or sPAP.

Funding Acknowledgement

Type of funding source: None

Two common echocardiographic variables to diagnose cardiac amyloidosis: the AMYLoidosis Index (AMYLI) score

Background

Early diagnosis of cardiac amyloidosis (CA) is warranted to initiate specific treatment and improve outcome. The amyloid light chain (AL) and inferior wall thickness (IWT) scores have been proposed to assess patients referred by hematologists or with unexplained left ventricular (LV) hypertrophy, respectively. These scores are composed of 4 or 5 variables, respectively, including strain data, and no decisional cut-offs were introduced.

Methods

Based on 2 variables common to the AL and IWT scores, we defined a simple score named AMYLoidosis Index (AMYLI) as the product of relative wall thickness (RWT) and E/e' ratio, and assessed its diagnostic performance. Optimal rule-out cut-offs were searched as those with negative likelihood ratio (LR−) <0.1.

Results

In the derivation cohort (n=251), CA was ultimately diagnosed in 111 patients (44%). The 2.22 score value was selected as rule-out cut-off (LR- 0.0). In the hematology subset, AL CA was finally diagnosed in 32 patients (48%), with 2.36 as rule-out cut-off (LR− 0.0). In the hypertrophy subset, ATTR CA was diagnosed in 79 patients (43%), with 2.22 as best rule-out cut-off (LR− 0.0). In the validation cohort (n=691), where more patients were diagnosed with CA (94% and 68% in the hematology and in the hypertrophy subsets, respectively), the 2.22 rule-out cut-off had a LR− = ∞ (as no patient scoring <2.22 had CA). In the hematology and hypertrophy subsets, the 2.36 and 2.22 cut-offs were effective for ruling-out CA, with both LR− = ∞ (as no patient scoring <2.36 or 2.22, respectively, had CA).

Conclusions

The AMYLI score (RWT* E/e') is simpler than those proposed and similarly accurate. A 2.22 cut-off value excludes CA diagnosis in patients undergoing a diagnostic screening for CA, while a <2.36 and a <2.22 value may be better considered in the subsets with either blood dyscrasia or unexplained hypertrophy, respectively.

Funding Acknowledgement

Type of funding source: None

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Diagnostic accuracy of an automated chemiluminescent immunoassay for anti-SARS-CoV-2 IgM and IgG antibodies: an Italian experience

A pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been spreading throughout the world. Though molecular diagnostic tests are the gold standard for COVID-19, serological testing is emerging as a potential surveillance tool, in addition to its complementary role in COVID-19 diagnostics. Indubitably quantitative serological testing provides greater advantages than qualitative tests but today there is still little known about serological diagnostics and what the most appropriate role quantitative tests might play. Sixty-one COVID-19 patients and 64 patients from a control group were tested by iFlash1800 CLIA analyzer for anti-SARS CoV-2 antibodies IgM and IgG. All COVID-19 patients were hospitalized in San Giovanni di Dio Hospital (Florence, Italy) and had a positive oro/nasopharyngeal swab reverse-transcription polymerase chain reaction result. The highest sensitivity with a very good specificity performance was reached at a cutoff value of 10.0 AU/mL for IgM and of 7.1 for IgG antibodies, hence near to the manufacturer's cutoff values of 10 AU/mL for both isotypes. The receiver operating characteristic curves showed area under the curve values of 0.918 and 0.980 for anti-SARS CoV-2 antibodies IgM and IgG, respectively. iFlash1800 CLIA analyzer has shown highly accurate results for the anti-SARS-CoV-2 antibodies profile and can be considered an excellent tool for COVID-19 diagnostics.

National trends in total cholesterol obscure heterogeneous changes in HDL and non-HDL cholesterol and total-to-HDL cholesterol ratio: a pooled analysis of 458 population-based studies in Asian and Western countries

BACKGROUND

Although high-density lipoprotein (HDL) and non-HDL cholesterol have opposite associations with coronary heart disease, multi-country reports of lipid trends only use total cholesterol (TC). Our aim was to compare trends in total, HDL and non-HDL cholesterol and the total-to-HDL cholesterol ratio in Asian and Western countries.

METHODS

We pooled 458 population-based studies with 82.1 million participants in 23 Asian and Western countries. We estimated changes in mean total, HDL and non-HDL cholesterol and mean total-to-HDL cholesterol ratio by country, sex and age group.

RESULTS

Since ∼1980, mean TC increased in Asian countries. In Japan and South Korea, the TC rise was due to rising HDL cholesterol, which increased by up to 0.17 mmol/L per decade in Japanese women; in China, it was due to rising non-HDL cholesterol. TC declined in Western countries, except in Polish men. The decline was largest in Finland and Norway, at ∼0.4 mmol/L per decade. The decline in TC in most Western countries was the net effect of an increase in HDL cholesterol and a decline in non-HDL cholesterol, with the HDL cholesterol increase largest in New Zealand and Switzerland. Mean total-to-HDL cholesterol ratio declined in Japan, South Korea and most Western countries, by as much as ∼0.7 per decade in Swiss men (equivalent to ∼26% decline in coronary heart disease risk per decade). The ratio increased in China.

CONCLUSIONS

HDL cholesterol has risen and the total-to-HDL cholesterol ratio has declined in many Western countries, Japan and South Korea, with only a weak correlation with changes in TC or non-HDL cholesterol.

P215 Effects of ARNI therapy on left atrial and ventricular longitudinal deformation and functional capacity in HFrEF patients

Background

valsartan and sacubitril combination (angiotensin receptor-neprilysin inhibitor, ARNI) was superior, in randomized trials, to lone ACE inhibitors in terms of reduction of cardiovascular mortality rate and hospitalization for acute heart (HF) in patients with HF with reduced ejection fraction (HFrEF). Purpose: the main goal of our study was to assess the effects of ARNI on left atrial (LA) and left (LV) and right ventricular (RV) function, evaluated by standard and speckle tracking echocardiography (STE), and on patients’ functional capacity by cardiopulmonary exercise testing (CPET), in patients with HFrEF. Methods: we prospectively enrolled 16 patients with a LV EF ≤35% and >18 years old, in two different centers with high expertise in HF management. Exclusion criteria included: symptomatic hypotension, stage IV renal failure (eGFR < 30 ml/min/1.73 m2), ACE-inhibitor (ACEi) intolerance or previous angioedema, poor acoustic window, refuse to participate to the study. At enrollment (T0), all patients were in therapy with ACEi or sartans (ARBs) and underwent physical examination, ECG, blood test (including NT-proBNP), standard echo, STE and CPET. We shifted therapy from ACEi/ARBs according to HF guidelines and we repeated all tests after 6 months. Results: population had an average age of 63 ± 9 years, 94% was males. Etiology was ischemic in one third of the subjects. At 6 months follow up, NT-proBNP was significantly lower (512.2 ± 518.5 vs 431.2 ± 330.1 ng/l, p 0,001) together with reduced LV filling pressure evaluated by E/A ratio and E/e’ ratio (11.2 ± 8.6 vs 8.8 ± 4.8, p 0.01). LV EF improved from 31.7 ± 3.4% to 36.2 ± 7.2% (p 0.01) and LV dimensions decreased. LV global longitudinal strain (GLS) did not change significantly while free wall RV GLS increased from – 20.4 ± 6.3% to – 24.6 ± 9%, p 0.001, as peak atrial longitudinal strain (PALS) did (16.1 ± 2.6% vs 27.6 ± 4.1%, p 0.001). Between CPET indexes, only VE/VCO2 slope improved but only with borderline statistical significance (32.7 ± 5.3 vs 29.7 ± 6.8, p 0.05, Fig. 1). Conclusions: this preliminary study evaluated for the first time the effects of ARNI on echocardiographic and CPET parameters at the same time. Our results could explain the favorable clinical benefits of ARNI therapy in HFrEF: improved biventricular function, lower LV filling pressure and a more efficient ventilatory response during effort.

Abstract P215 Figure. Fig.1

P2729NT-proBNP and high-sensitivity cardiac troponin T to diagnose cardiac amyloidosis

Background

Cardiac amyloidosis (CA) is characterized by the accumulation of misfolded proteins into amyloid fibrils, leading to cardiomyocyte toxicity, extracellular volume expansion and ventricular pseudohypertrophy. As a consequence of such processes, natriuretic peptides and cardiac troponins are chronically elevated in CA and hold significant prognostic value. The diagnostic yield of these biomarkers for CA has never been explored so far.

Methods

Plasma levels of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured in 230 patients referred to a tertiary centre with the clinical suspicion of cardiac amyloidosis. The final diagnosis was established according to current protocols, which include clinical, electrocardiographic, biohumoral, instrumental (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy), and biopsy examinations.

Results

Patients were aged 79 (interquartile interval 73–83) years and were predominantly males (n=147, 64%). Mean left ventricular (LV) ejection fraction was 55% (48–62%), and mean LV mass indexed was 150 (120–178) g/m2. CA was confirmed in 86 patients (37%), who had either light chain (AL) amyloidosis (n=25, 29%) or transthyretin (ATTR) amyloidosis (n=61, 71%). Alternative diagnoses were hypertensive cardiopathy (n=69, 48%), valvular disease (n=27, 19%), hypertrophic cardiomyopathy (n=18, 13%), or left ventricular hypertrophy with unknown or multifactorial mechanisms. Patients with CA showed higher NT-proBNP (5507 ng/L [2348–10326] vs. 1332 [392–3752], p<0.001) and hs-cTnT (65 ng/L [48–114] vs. 35 [21–52], p<0.001) than those without CA. The area under the curve (AUC) values for NT-proBNP and hs-cTnT were 0.712 and 0.775 respectively (p=0.062 for the difference). The combination of the two biomarkers improved discrimination over NT-proBNP alone (p=0.011), but not over hs-cTnT (p=0.470) (Figure). A NT-proBNP level <600 ng/L or a hs-cTnT level <17 ng/L were optimal for ruling out amyloidosis, with a negative predictive value of 95% in both cases.

Patients with AL amyloidosis had higher NT-proBNP and hs-cTnT than those with ATTR (10809 ng/L [6292–17483] vs. 3084 [1841–7624], p=0.014; 130 ng/L [64–211] vs. 61 [48–95], p=0.006). The difference was even more prominent when biomarker levels were normalized for LV mass (NT-proBNP/LV mass, 33.9 ng/L/g [20.4–53.8] vs. 10.0 [5.8–23.5], p=0.002; hs-cTnT/LV mass, 0.48 ng/L/g [0.25–0.71] vs. 0.19 [0.14–0.26], p=0.001). NT-proBNP and hs-cTnT could effectively discriminate patients with AL amyloidosis among subjects with clinical suspicion of CA (AUC values of 0.787 and 0.805 respectively) (Figure).

Figure 1

Conclusions

Plasma NT-proBNP and hs-cTnT have diagnostic value in patients with suspected CA. In the subgroup with CA, both biomarkers are higher in patients with AL amyloidosis even when normalizing for LV mass, possibly because of a greater cardiotoxic effect of light-chain fibrils.

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants

BACKGROUND

Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.

METHODS

We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.

RESULTS

In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.

CONCLUSIONS

Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

From [11C]CO2 to [11C]amides: a rapid one-pot synthesis via the Mitsunobu reaction

Radiosynthesis of [¹¹C]amides via the Mitsunobu reaction.

A novel amide synthesis methodology is described using amines, CO₂ and Grignard reagents and Mitsunobu reagents. The method was applied to carbon-11 radiochemistry to label amides using cyclotron-produced [¹¹C]CO₂. The synthetic utility of the one-pot labelling methodology was demonstrated by producing [¹¹C]melatonin. The incorporation of [¹¹C]CO₂ into [¹¹C]melatonin was 36% – determined by radioHPLC 2 min post [¹¹C]CO₂ delivery.

Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults

BACKGROUND

Underweight, overweight, and obesity in childhood and adolescence are associated with adverse health consequences throughout the life-course. Our aim was to estimate worldwide trends in mean body-mass index (BMI) and a comprehensive set of BMI categories that cover underweight to obesity in children and adolescents, and to compare trends with those of adults.

METHODS

We pooled 2416 population-based studies with measurements of height and weight on 128·9 million participants aged 5 years and older, including 31·5 million aged 5-19 years. We used a Bayesian hierarchical model to estimate trends from 1975 to 2016 in 200 countries for mean BMI and for prevalence of BMI in the following categories for children and adolescents aged 5-19 years: more than 2 SD below the median of the WHO growth reference for children and adolescents (referred to as moderate and severe underweight hereafter), 2 SD to more than 1 SD below the median (mild underweight), 1 SD below the median to 1 SD above the median (healthy weight), more than 1 SD to 2 SD above the median (overweight but not obese), and more than 2 SD above the median (obesity).

FINDINGS

Regional change in age-standardised mean BMI in girls from 1975 to 2016 ranged from virtually no change (-0·01 kg/m2 per decade; 95% credible interval -0·42 to 0·39, posterior probability [PP] of the observed decrease being a true decrease=0·5098) in eastern Europe to an increase of 1·00 kg/m2 per decade (0·69-1·35, PP>0·9999) in central Latin America and an increase of 0·95 kg/m2 per decade (0·64-1·25, PP>0·9999) in Polynesia and Micronesia. The range for boys was from a non-significant increase of 0·09 kg/m2 per decade (-0·33 to 0·49, PP=0·6926) in eastern Europe to an increase of 0·77 kg/m2 per decade (0·50-1·06, PP>0·9999) in Polynesia and Micronesia. Trends in mean BMI have recently flattened in northwestern Europe and the high-income English-speaking and Asia-Pacific regions for both sexes, southwestern Europe for boys, and central and Andean Latin America for girls. By contrast, the rise in BMI has accelerated in east and south Asia for both sexes, and southeast Asia for boys. Global age-standardised prevalence of obesity increased from 0·7% (0·4-1·2) in 1975 to 5·6% (4·8-6·5) in 2016 in girls, and from 0·9% (0·5-1·3) in 1975 to 7·8% (6·7-9·1) in 2016 in boys; the prevalence of moderate and severe underweight decreased from 9·2% (6·0-12·9) in 1975 to 8·4% (6·8-10·1) in 2016 in girls and from 14·8% (10·4-19·5) in 1975 to 12·4% (10·3-14·5) in 2016 in boys. Prevalence of moderate and severe underweight was highest in India, at 22·7% (16·7-29·6) among girls and 30·7% (23·5-38·0) among boys. Prevalence of obesity was more than 30% in girls in Nauru, the Cook Islands, and Palau; and boys in the Cook Islands, Nauru, Palau, Niue, and American Samoa in 2016. Prevalence of obesity was about 20% or more in several countries in Polynesia and Micronesia, the Middle East and north Africa, the Caribbean, and the USA. In 2016, 75 (44-117) million girls and 117 (70-178) million boys worldwide were moderately or severely underweight. In the same year, 50 (24-89) million girls and 74 (39-125) million boys worldwide were obese.

INTERPRETATION

The rising trends in children's and adolescents' BMI have plateaued in many high-income countries, albeit at high levels, but have accelerated in parts of Asia, with trends no longer correlated with those of adults.

FUNDING

Wellcome Trust, AstraZeneca Young Health Programme.

Trends in obesity and diabetes across Africa from 1980 to 2014: an analysis of pooled population-based studies

Background

The 2016 Dar Es Salaam Call to Action on Diabetes and Other non-communicable diseases (NCDs) advocates national multi-sectoral NCD strategies and action plans based on available data and information from countries of sub-Saharan Africa and beyond. We estimated trends from 1980 to 2014 in age-standardized mean body mass index (BMI) and diabetes prevalence in these countries, in order to assess the co-progression and assist policy formulation.

Methods

We pooled data from African and worldwide population-based studies which measured height, weight and biomarkers to assess diabetes status in adults aged ≥ 18 years. A Bayesian hierarchical model was used to estimate trends by sex for 200 countries and territories including 53 countries across five African regions (central, eastern, northern, southern and western), in mean BMI and diabetes prevalence (defined as either fasting plasma glucose of ≥ 7.0 mmol/l, history of diabetes diagnosis, or use of insulin or oral glucose control agents).

Results

African data came from 245 population-based surveys (1.2 million participants) for BMI and 76 surveys (182 000 participants) for diabetes prevalence estimates. Countries with the highest number of data sources for BMI were South Africa (n = 17), Nigeria (n = 15) and Egypt (n = 13); and for diabetes estimates, Tanzania (n = 8), Tunisia (n = 7), and Cameroon, Egypt and South Africa (all n = 6). The age-standardized mean BMI increased from 21.0 kg/m2 (95% credible interval: 20.3-21.7) to 23.0 kg/m2 (22.7-23.3) in men, and from 21.9 kg/m2 (21.3-22.5) to 24.9 kg/m2 (24.6-25.1) in women. The age-standardized prevalence of diabetes increased from 3.4% (1.5-6.3) to 8.5% (6.5-10.8) in men, and from 4.1% (2.0-7.5) to 8.9% (6.9-11.2) in women. Estimates in northern and southern regions were mostly higher than the global average; those in central, eastern and western regions were lower than global averages. A positive association (correlation coefficient ≃ 0.9) was observed between mean BMI and diabetes prevalence in both sexes in 1980 and 2014.

Conclusions

These estimates, based on limited data sources, confirm the rapidly increasing burden of diabetes in Africa. This rise is being driven, at least in part, by increasing adiposity, with regional variations in observed trends. African countries' efforts to prevent and control diabetes and obesity should integrate the setting up of reliable monitoring systems, consistent with the World Health Organization's Global Monitoring System Framework.

Polyelectrolyte Multilayer Film Coating and Stability at the Surfaces of Oral Prosthesis Base Polymers: an in vitro and in vivo Study

A new type of coating involving a layer-by-layer technique has been recently reported. This coating is composed of a polyelectrolyte multilayer film that confers specific properties on surfaces to which it is applied. Here, we studied the applicability of such a technique to the coating of oral prostheses, by first testing the construction of polyelectrolyte multilayer films on several polymers used in oral prosthesis bases, and, subsequently, by studying the stability of these coatings in vitro, in human saliva, and in vivo in a rat model. We demonstrated that the multilayered films are able to coat the surfaces of all tested polymers completely, thus increasing their wettability. We also showed that saliva does not degrade the film after 7 days in vitro and after 4 days in vivo. Taken together, our results establish that the layer-by-layer technique is suitable for the coating of oral devices.

Referral of newly diagnosed chronic hepatitis B and C patients in six EU countries: results of the HEPscreen Project

BACKGROUND

Effective linkage to specialist care following screening is crucial for secondary prevention of chronic viral hepatitis-related consequences.

METHODS

To explore the frequency of referral of patients to secondary care from the health services involved in screening and to gather information on the services responsible for the provision of post-test counselling and contact tracing, four online surveys were conducted among general practitioners (GP), and experts working in sexual health services (SHS), antenatal care (ANC) and specialist secondary care in Germany, Hungary, Italy, The Netherlands, Spain and the UK.

RESULTS

Overall, 60% of GPs report referring all patients to specialist care. Although 67% of specialists commonly receive patients referred by GPs, specialists in Germany rarely or never receive patients from ANC or from centres testing injecting drug users; and specialists in the Netherlands, Hungary and Germany rarely receive patients from SHS. Gastroenterologists/hepatologists are the professionals mainly responsible for the provision of counselling following a positive diagnosis of viral hepatitis according to two-thirds of specialists, 14% of SHS providers and 11% of ANC providers. Almost half of ANC providers (45%) stated that gynaecologists are the professionals responsible for the provision of counselling to positive pregnant women; among SHS providers, only 14% identified SHS as the services responsible.

CONCLUSION

Our findings suggest the existence of complex/ineffective referral practices or that opportunities to screen risk groups are missed. Recommendations clarifying the services responsible at each step of the referral pathway are needed in order to increase the success of screening programmes.

Cycling promotion and non-communicable disease prevention: health impact assessment and economic evaluation of cycling to work or school in Florence

OBJECTIVE

To estimate the effects of cycling promotion on major non-communicable diseases (NCDs) and costs from the public healthcare payer's perspective.

DESIGN

Health impact assessment and economic evaluation using a dynamic model over a ten-year period and according to two cycling promotion scenarios.

SETTING

Cycling to work or school in Florence, Italy.

POPULATION

All individuals aged 15 and older commuting to work or school in Florence.

MAIN OUTCOME MEASURES

The primary outcome measures were changes in NCD incidence and healthcare direct costs for the Tuscany Regional Health Service (SST) due to increased cycling. The secondary outcome was change in road traffic accidents.

RESULTS

Increasing cycling modal share in Florence from 7.5% to about 17% (Scenario 1) or 27% (Scenario 2) could decrease the incidence of type 2 diabetes by 1.2% or 2.5%, and the incidence of acute myocardial infarction (AMI) and stroke by 0.6% or 1.2%. Within 10 years, the number of cases that can be prevented is 280 or 549 for type 2 diabetes, 51 or 100 for AMI, and 51 or 99 for stroke in Scenario 1 or Scenario 2, respectively. Average annual discounted savings for the SST are estimated to amount to €400,804 or €771,201 in Scenario 1 or Scenario 2, respectively. In Florence, due to the high use of vulnerable motorized vehicles (such as scooters, mopeds, and motorcycles), road traffic accidents are expected to decline in both our scenarios. Sensitivity analyses showed that health benefits and savings for the SST are substantial, the most sensitive parameters being the relative risk estimates of NCDs and active commuting.

CONCLUSIONS

Effective policies and programs to promote a modal shift towards cycling among students and workers in Florence will contribute to reducing the NCD burden and helping long-term economic sustainability of the SST.

A retrospective analysis of hospital discharge records for S. pneumoniae diseases in the elderly population of Florence, Italy, 2010-2012

Invasive pneumococcal diseases (IPD) and community acquired pneumonia (CAP) represent two of the major causes of out-patient visits, hospital admissions and deaths in the elderly. In Tuscany (Italy), in the Local Health Unit of Florence, a project aimed at implementing an active surveillance of pneumococcal diseases in the hospitalized elderly population started in 2013. The aim of this study is to show the results of the retrospective analysis (2010-2012) on hospital discharge records (HDRs) related to diseases potentially due to S. pneumoniae, using a selection of ICD9-CM codes. All ordinary hospitalizations (primary and secondary diagnoses) of the elderly population were included (11 245 HDRs). Among a population of about 200 000 inhabitants ≥65 y, the hospitalization rate (HR) increased with increasing age and was higher in males in all age groups. Almost all hospitalizations (95%) were due to CAP, only 5% were invasive diseases. Only few cases of CAP were specified as related to S. pneumoniae, the percentage was higher in case of meningitis (100%) or septicemia (22%). In-hospital deaths over the three-year period were 1703 (case fatality rate: 15%). The risk of dying, being hospitalized for a disease potentially attributable to pneumococcus (as primary diagnosis) increased significantly with age (P < 0.001), the odds ratio (OR) per increasing age year was 1.06 (95% CI 1.05-1.07) and was higher in patients with co-existing medical conditions with respect to patients without comorbidities. Currently, an active surveillance system on S. pneumoniae diseases with the inclusion of bio-molecular tests (RT-PCR), is a key step to assess the effectiveness of the PCV13 vaccine (13-valent pneumococcal conjugate vaccine) in the elderly population after implementation of vaccination policies. The results of this study will provide the comparator baseline data for the evaluation of a possible immunization programme involving one or more cohorts of the elderly in Tuscany.

Attitude toward immunization and risk perception of measles, rubella, mumps, varicella, and pertussis in health care workers working in 6 hospitals of Florence, Italy 2011

BACKGROUND

Health care workers (HCWs) are at risk of infection and transmission of vaccine-preventable infectious diseases. In recent years cases of measles or varicella in health care workers were observed with increasing frequency. The aim of our study was to investigate attitude toward immunization and risk perception of measles, rubella, mumps, varicella, and pertussis in HCWs working in 6 hospitals of Florence (Italy).

METHODS

A cross-sectional survey among the physicians, nurses, midwives, and nursing assistants working in selected departments was performed trough a self-administered, anonymous questionnaire. Overall, 600 questionnaires were sent and 436 HCWs' completed forms were included into the study (Participation rate: 72.7%). Data were analyzed with STATA 11.0® and odds ratio (OR) were calculated in a multivariate analysis.

RESULTS

Among all respondents 74.9% were females. The average age was nearly 43-years-old (42.9-SD 8.95). The majority of participants (58.6%) were nurses, 21.3% physicians, 12.9% nursing assistants, and 7.2% were midwives. Among those HCWs reporting no history of disease, 52.8% (95% CI: 42.0-63.3%) declared to have been immunized for measles, 46.9% for rubella (95% CI: 39.0-54.9%), 21.6% for mumps (95% CI: 15.1-29.4%), 14.9% for varicella (95% CI: 7.4-25.7%), and 14.5% for pertussis (95% CI: 10.0-20.0%). When considering potentially susceptible HCWs (without history of disease or vaccination and without serological confirmation), less than a half of them feel at risk for the concerned diseases and only less than 30% would undergo immunization. One of the main reasons of the relatively low coverage was indeed lack of active offer of vaccines.

CONCLUSION

Attitudes toward immunization observed in this study are generally positive for preventing some infectious diseases (i.e., measles and rubella), but relatively poor for others (i.e., varicella). More information should be made available to HCWs on the benefits of vaccination and efforts to encourage vaccination uptake should be performed. Educational program on the risk of being infected working in a hospital should be implemented in order to increase the risk perception toward infectious diseases among HCWs.

Economic evaluation of Varicella vaccination: results of a systematic review

INTRODUCTION

The aim of the present study is to review the economic burden of varicella disease and the benefit of universal varicella vaccination in different settings pending its implementation in all Italian regions.

MATERIALS AND METHODS

Research was conducted using PubMed, Scopus and ISI databases. Score quality and data extraction were performed for all included studies.

RESULTS

Twenty-three articles met the criteria: 15 cost-effectiveness, 8 cost-benefit and one cost-utility analysis. Varicella vaccination could save the society from €637,762 (infant strategy) to 53 million annually (combined infant and adolescent strategy). The median and the mean quality scores resulted in 91.8% and 85.4% respectively; 11 studies were considered of high quality and 12 of low quality.

DISCUSSION

The studies are favorable to the introduction of universal varicella vaccination in Italy, being cost saving and having a positive impact on morbidity. The quality score of the studies varied greatly: recent analyses were of comparable quality to older studies.

Economic analysis of the first 20 years of universal hepatitis B vaccination program in Italy: an a posteriori evaluation and forecast of future benefits

Italy was one of the first countries in the world to introduce a routine vaccination program against HBV for newborns and 12-y-old children. From a clinical point of view, such strategy was clearly successful. The objective of our study was to verify whether, at 20 y from its implementation, hepatitis B universal vaccination had positive effects also from an economic point of view. An a posteriori analysis evaluated the impact that the hepatitis B immunization program had up to the present day. The implementation of vaccination brought an extensive reduction of the burden of hepatitis B-related diseases in the Italian population. As a consequence, the past and future savings due to clinical costs avoided are particularly high. We obtained a return on investment nearly equal to 1 from the National Health Service perspective, and a benefit-to-cost ratio slightly less than 1 for the Societal perspective, considering only the first 20 y from the start of the program. In the longer-time horizon, ROI and BCR values were positive (2.78 and 2.46, respectively). The break-even point was already achieved few years ago for the NHS and for the Society, and since then more and more money is progressively saved. The implementation of universal hepatitis B vaccination was very favorable during the first 20 y of adoption, and further benefits will be increasingly evident in the future. The hepatitis B vaccination program in Italy is a clear example of the great impact that universal immunization is able to provide in the medium-long-term when health care authorities are so wise as to invest in prevention.

The domain Archaea in human mucosal surfaces

Archaea present distinct features from bacteria and eukaryotes, and thus constitute one of the branches of the phylogenetic tree of life. Members of this domain colonize distinct niches in the human body, arranged in complex communities, especially in the intestines and the oral cavity. The diversity of archaea within these niches is limited to a few phylotypes, constituted in particular by methane-producing archaeal organisms. Although they are possibly symbionts, methanogens may play a role in the establishment of mucosal diseases by favouring the growth of certain bacterial groups.

Present situation and new perspectives for vaccination against Neisseria meningitidis in Tuscany, Central Italy

BACKGROUND

In Italy one third of bacterial meningitis are caused by Neisseria meningitidis. In March 2005, the Regional Health Authority of Tuscany included the meningococcal serogroup C conjugate (MCC) vaccine in the recommended vaccination program with a schedule of three doses to all newborns at 3, 5 and 13 months of age (from 2008 amended to a single dose at 13 months) and a single catch-up dose until age 6.

OBJECTIVE

To evaluate the impact of the current national and regional immunization strategies against N. meningitidis and to highlight new perspectives for meningococcal disease prevention with the existing tetravalent meningococcal vaccine (ACWY) and with the future incoming meningococcal B vaccines.

METHODS

Meningitis incidence rates in Italy and in Tuscany were calculated for the period 1994-2011 and 2005-2011,respectively. Immunization coverage with MCC vaccine in Tuscany and vaccination status of meningitis cases were reported. Literature review on meningococcal conjugate vaccine use and recommendation was performed.

RESULTS

A decrease in incidence rates of meningococcal meningitis was observed in all age groups involved in the immunization campaign. Immunization coverage with MCC increased progressively year by year in Tuscany. A herd immunity effect was measured in unvaccinated age groups. Since 2006 no cases of invasive meningococcal C infection in vaccinated subjects were observed in Tuscany.

CONCLUSIONS

Implementation of MCC vaccination in Tuscany was effective in preventing meningococcal C disease, confirming the effectiveness of the vaccine. A new tetravalent (ACWY) conjugate vaccine is now available and its use in all Italian Regions should be considered.

Multilayer polyelectrolyte films functionalized by insertion of defensin: a new approach to protection of implants from bacterial colonization

Infection of implanted materials by bacteria constitutes one of the most serious complications following prosthetic surgery. In the present study, we developed a new strategy based on the insertion of an antimicrobial peptide (defensin from Anopheles gambiae mosquitoes) into polyelectrolyte multilayer films built by the alternate deposition of polyanions and polycations. Quartz crystal microbalance and streaming potential measurements were used to follow step by step the construction of the multilayer films and embedding of the defensin within the films. Antimicrobial assays were performed with two strains: Micrococcus luteus (a gram-positive bacterium) and Escherichia coli D22 (a gram-negative bacterium). The inhibition of E. coli D22 growth at the surface of defensin-functionalized films was found to be 98% when 10 antimicrobial peptide layers were inserted in the film architecture. Noticeably, the biofunctionalization could be achieved only when positively charged poly(l-lysine) was the outermost layer of the film. On the basis of the results of bacterial adhesion experiments observed by confocal or electron microscopy, these observations could result from the close interaction of the bacteria with the positively charged ends of the films, which allows defensin to interact with the bacterial membrane structure. These results open new possibilities for the use of such easily built and functionalized architectures onto any type of implantable biomaterial. The modified surfaces are active against microbial infection and represent a novel means of local host protection.

Antimicrobial resistance among non-fermentative Gram-negative bacilli isolated from the respiratory tracts of Italian inpatients: a 3-year surveillance study by the Italian Epidemiological Survey

The Italian Epidemiological Survey evaluated antibiotic susceptibility of non-fermentative Gram-negative bacilli isolated from inpatient respiratory-tract specimens collected throughout Italy during 1997-1999. The minimal inhibitory concentrations of 14 antibiotics for 1474 Pseudomonas aeruginosa strains, 307 Stenotrophomonas maltophilia strains and 114 Acinetobacter baumannii strains were determined in 57 clinical microbiology laboratories by means of a standardised micro-dilution method. The most active drugs against P. aeruginosa isolates were meropenem (81% susceptible) and amikacin (80% susceptible). Imipenem and meropenem proved to be the only agents active against A. baumannii isolates, although 13 and 16%, respectively, of strains were resistant to these drugs. Trimethoprim-sulphamethoxazole (TMP-SMZ) showed activity only against S. maltophilia isolates (83% susceptible). A total of 185 multidrug-resistant P. aeruginosa isolates (resistant to piperacillin, ceftazidime, gentamicin, and imipenem) were found. Resistance rates and trends showed consistent regional variations, including sharp increases from 1997 to 1999 in imipenem resistance among P. aeruginosa isolates from central and southern Italy.

Putative histidin-rich proteins in the epidermis of lizards

In the stratum granulosum of mammalian epidermis, histidin-rich proteins (filaggrins) determine keratin clumping and matrix formation into terminal keratinocytes of the stratum corneum. The nature of matrix, interkeratin proteins in the epidermis of nonmammalian vertebrates, and in particular in that of reptilian, mammalian progenitors are unknown. The present biochemical study is the first to address this problem. During a specific period of the renewal phase of the epidermis of lizards and during epidermal regeneration, keratohyalin-like granules are formed, at which time they take up tritiated histidine. The latter also accumulate in cells of the alpha-keratin layer (soft keratin). This pattern of histidine incorporation resembles that seen in keratohyalin granules of the stratum granulosum of mammalian epidermis. After injection of tritiated histidine, we have analysed the distribution of the radioactivity by histoautoradiography and electrophoretic gel autoradiography of epidermal proteins. Extraction and electrophoretic separation of interfilamentous matrix proteins from regenerating epidermis 3-48 hours post-injection reveals the appearance of protein bands at 65-70, 55-58, 40-43, 30-33, 25-27, and 20-22 kDa. Much weaker bands were seen at 100, 140-160, and 200 kDa. A weak band at 20-22 kDa or no bands at all are seen in the normal epidermis in resting phase and in the dermis. In regenerating epidermis at 22 and 48 hours post-injection, little variation in bands is detectable, but low molecular weight bands tend to increase slightly, suggesting metabolic turnover. Using anti-filaggrin antibodies against rat, human, or mouse filaggrins, some cross-reactivity was seen with more reactive bands at 40-42 and 33 kDa, but it was reduced or absent at 140, 95-100, 65-70, 50-55, and 25 kDa. This suggests that different intermediate degradative proteins of lizard epidermis may share some epitopes with mammalian filaggrins and are different from keratins with molecular weight ranging from 40 to 65-68 kDa. The immunocytochemical observation confirms that a weak filaggrin-like immunoreactivity characterizes differentiating alpha-keratogenic layers in normal and regenerating tail. A weak filaggrin labeling is discernable in small keratohyalin-like granules but is absent from the larger granules and from mature keratinocytes. The present results indicate, for the first time, that histidine-rich proteins are involved in the process of alpha-keratinization in reptilian epidermis. The cationic, interkeratin matrix proteins implicated may be fundamentally similar in both theropsid-derived and sauropsid amniotes.

Drosophila vitelline membrane cross-linking requires the fs(1)Nasrat, fs(1)polehole and chorion genes activities

Abstract. During the final step of Drosophila vitelline membrane formation, the structural proteins composing this layer become cross-linked by covalent bonds. In the present report, we analyzed the vitelline membrane cross-linking in mutants having defects either in this layer or in the chorionic layers. In the fs(1)Nasrat and fs(1)polehole mutant alleles conferring defects in vitelline membrane formation, disruption of vitelline membrane cross-linking was observed, indicating the involvement of these two genes in the process. On the contrary, in the fs(1)Nasrat and fs(1)polehole alleles showing defects only at the termini of the embryo the vitelline membrane is properly formed, confirming a multifunctional activity of their gene products. Altered vitelline membrane cross-linking was also detected in a mutant of the chorion protein gene Cp36and in the chorion amplification mutant fs(1)K1214, suggesting a role of the structural components of chorion layers in the process of vitelline membrane hardening.

Immunocytochemical and electrophoretic distribution of cytokeratins in the resting stage epidermis of the lizard Podarcis sicula

The distribution of three anti-cytokeratin (alpha-keratin) antibodies (AE1, AE2, AE3) in the epidermis of a lizard has been studied by immunocytochemistry at light and electron microscope and by immunoblot analysis. This study shows the expression of different keratins in the resting stage epidermis of the lizard Podarcis sicula. In this stage the epidermis has an external beta-layer, an underlying alpha-layer, some layers of living suprabasal cells and a basal stratum germinativum. The AE1 antibody is localized in the basal and suprabasal cells only in the outer scale surface, but is absent from the inner surface, the hinge region and from the keratinized beta- and alpha-layers. The AE2 antibody is mainly localized at the level of the hinge region and of the alpha-layer and gives a lower reaction in the beta-layer. The AE3 antibody is mainly localized in basal and suprabasal cells, lower in the alpha-layer, and absent from the beta-layer. The electron microscope shows that all the three antibodies immunolabel cytoplasmic fibrillar structures in the deep alpha-layers and that AE2 and AE3 antibodies label small electron-dense areas in the external dense beta-layer within the electron-lucid matrix. Immunoblot analysis of the keratins extracted and separated by gel electrophoresis demonstrates the presence of a band of high molecular weight (67-68 kDa) positive to all three antibodies. In addition AE1 antibody recognizes a 44-45 kDa band and a 57-58 kDa band, AE2 recognizes a 60-61 kDa band, and AE3 recognizes a 47 kDa and a 56-57 kDa band. The localization of the keratins identified by immunoblot analysis in the epithelial layers is discussed taking in account the immunolabeling at light and electron microscope. The present study suggests that also in the normal epidermis of this reptiles, in both the alpha- and the beta-layer, the molecular masses of keratins increase from the basal to the keratinized layers, a phenomenon which is generalized to adult and embryonic amniotes epidermis.

[Cost of ICU in Italy. Results from an empirical study on a sample of 12 hospitals]

BACKGROUND

The Italian hospital payment system based on DRG doesn t properly include Intensive Care Units (ICU) costs. Since great emphasis has been recently given to rationing health care resources, assessing ICU costs seems to be dramatically relevant. Aim of the study was to assess the average yearly cost and the cost per diem of a sample of Italian multispecialistic ICU wards.

METHODS

In September 1995, a questionnaire concerning data on variable and fixed cost was sent to 25 Italian ICU wards, 11 NHS hospital-based (Northern Italy: 5; Central Italy: 4; Southern Italy: 2) and 14 school of medicine-based (Northern Italy: 7; Central Italy: 5; Southern Italy: 2). Variable cost data included: disposable, drugs, blood and blood-derived products, physical tests, chemical and microbiological routines, instrumental diagnostic procedures and physiotherapy. Concerning fixed costs, data on personnel and equipment were requested. In addition, some hospital overheads data (utilities; power; heating; maintenance; cleaning; laundry; accounting; waste disposal; cafeteria) were collected.

RESULTS

On the basis of the 12 questionnaires returned (Northern Italy: 9; Central Italy: 3; Southern Italy: 0), the yearly cost of an ICU ward is Liras 4,580,032,000 (range 2,739,277,000-7,704,292,000), whereas the average cost per diem is Liras 1,802,000 (range 1,234,000-3,179,000). Cost of personnel is about 61% of the above mentioned costs.

CONCLUSIONS

Despite the lack of questionnaires from Southern Italy and the unavailability of some data concerning both the cost of equipment and the overheads, the remarkable average cost values obtained could support further research.

Immunocytochemical and electrophoretic distribution of cytokeratins in the regenerating epidermis of the lizard Podarcis muralis

Using immunocytochemistry at light- and electron-microscope levels, we studied the distribution of three monoclonal antibodies (AE1, AE2, AE3) specific for mammalian alpha-keratins in regenerating lizard epidermis. We also characterized the keratins expressed during this process by immunoblotting after electrophoretic separation. The AE1 antibody is localized in the basal and suprabasal layers of prescaling and scaling epidermis. During the first stages of scale neogenesis, the AE1 antibody also marks the differentiating oberhautchen and beta-layer, but it disappears from these layers as they mature. This antibody does not stain the prekeratinized and keratinized outermost layers in the hinge region. The AE2 antibody labels the superficial wound epidermis, prekeratinizing and keratinized beta- and alpha-layers, but not basal and suprabasal cells. The AE3 antibody labels all living and keratinized epidermal layers, although AE3 immunoreactivity decreases and disappears as the beta-layer matures. The ultrastructural study shows that the AE2 and AE3, but not the AE1, antibodies specifically label small electron-dense areas within the beta-layer, suggesting retention of alpha-keratins. In the stages of tail regeneration examined, immunoblotting with the three antibodies used for the immunolocalization gives a pattern similar to that of the normal epidermis, except distally, where the process of scale differentiation begins. In this region, in addition to the keratin forms discovered in the normal and in proximal regenerating epidermis, an intense low molecular weight band at 40-41 kDa, positive to all three antibodies, is clearly detectable. Furthermore, in the distal region AE1 and AE3 antibodies, but not the AE2, recognize a weak band at 77-78 kDa not present in the normal and proximal epidermis. The localization and the possible role of the different keratins in the regenerating epidermis is discussed.

Organization and characterization of the keratin cytoskeleton in the previtellogenic ovarian follicle of the lizard Podarcis sicula raf

The cytokeratin (CK) cytoskeleton, previously described by immunofluorescence in the ovarian follicle of Podarcis sicula, at the electron microscope results constituted by bundles of 10 nm thick intermediate filaments containing keratin. These bundles are better evident in the cytoplasm of the pyriform cell apex pointed toward the oocyte surface and mostly in the intercellular bridges connecting fully differentiated pyriform cells to the oocyte. During the differentiation of pyriform cells, the intermediate filament bundles first appear inside the intercellular bridge, when the small follicle cells progressively enlarge after their fusion with the oocyte and assume a morphology of "intermediate" cells. The present study also reports a comparative analysis by immunolabeling, SDS-PAGE, and immunoblotting with anticytokeratins CK8, CK18, and CK19 antibodies of both the ovarian follicle and the intestine of Podarcis sicula. These antibodies, specific to the keratins of monolayered intestinal cells, react also against those expressed in the oocytes of Xenopus laevis. This study shows the presence in the ovarian follicle of this reptile only of keratin forms of homologues to the CK8 and CK18 of mammals and the lack of CK19. The same analysis carried out utilizing AE1 and AE3 antibodies, which recognize most of the acidic and basic keratins in mammals, has shown additional forms of keratins specifically expressed in the ovarian follicle (50 kDa) and in both the examined tissues (49 and 60 kDa). The reported results indicate that in the ovarian follicle of this reptile, keratins have peculiar characteristics that can be explained by the unique structural function of the cytoskeleton in this system.

The costs of pharmacological treatment for major depression. The Italian Prospective Multicentre Observational Incidence-Based Study

OBJECTIVE

To describe the pharmacological treatment for major depression under the conditions of routine Italian public mental health facilities, assess its costs, and study its main predictors according to a societal perspective.

DESIGN

This was a prospective multicentre observational study designed to evaluate the economics of treatment of major depression using a specifically designed 65-item questionnaire. Data on drug consumption were collected in a section of the questionnaire and are presented here.

PATIENTS AND PARTICIPANTS

60 mental health facilities were selected and 556 patients were enrolled and followed up for 15 months.

RESULTS

Pharmacological treatment appears to be the most common treatment for major depression. 98% of patients were prescribed an antidepressant. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed antidepressants. Patients treated with SSRIs suffered from less severe depression than those treated with tricyclic antidepressants. Benzodiazepines were prescribed for 84% of patients enrolled. The total drug cost was 1,120,000 Italian lire ($US707) per patient (1995 values). Less than 20% of this cost was borne by the Italian National Health Service, as the majority of drugs used were not reimbursed.

CONCLUSIONS

The costs of the most widespread approach to treating major depression (pharmacological treatment) are not currently covered by the Italian National Health Service. Prescribing of drugs seems to diverge from the standards of treatment indicated by the Italian Drug Committee.

Alpha1-antitrypsin phenotypes and anti-neutrophil cytoplasmic auto-antibodies in inflammatory bowel disease

OBJECTIVES

Alpha1-antitrypsin (alpha1-AT) is encoded by a highly polymorphic gene with over 75 codominantly expressed alleles at the protease inhibitor (Pi) locus classified as normal, deficient, dysfunctional or null. The aim of this study was to determine in patients with inflammatory bowel disease: (i) the prevalence of anti-neutrophil cytoplasmic auto-antibodies (ANCA) and their antigen specificities; (ii) alpha1-AT Pi phenotypes; and (iii) possible associations between ANCA, disease activity and deficient alpha1-AT alleles.

DESIGN

Study of 95 consecutive patients with ulcerative colitis (UC) and 63 patients with Crohn's disease (CD).

METHODS

Diagnosis and disease activity were determined by clinical, endoscopic and histological criteria. ANCA by indirect immunofluorescence (IIF) and Pi phenotyping by isoelectric focusing were performed for all patients. Positive IIF sera were tested in antigen-specific enzyme-linked immunosorbent assay: proteinase 3 (PR3), myeloperoxidase (MPO), lactoferrin (LF), lysozyme, human leucocyte elastase (HLE), cathepsin G and bactericidal/permeability increasing protein (BPI).

RESULTS

Sixty-one patients with UC (64.2%) and only 11 with CD (17.5%) had ANCA (P < 0.001). Antigen specificities were PR3 (7/61), MPO (3/61), LF (6/61), HLE (1/63) and BPI (10/61) in UC, and PR3 (2/11) and BPI (2/11) in CD. Three PiZ alleles were found, matching the prevalence in the normal French control population. No relationship was found between the presence of ANCA, antibody specificity, disease activity and deficient alpha1-AT alleles.

CONCLUSION

ANCA are more frequent in UC than CD and do not correlate with disease activity. ANCA and protease/antiprotease imbalance do not appear to modulate the clinical course of inflammatory bowel disease.

Apoptosis of nurse cells at the late stages of oogenesis of Drosophila melanogaster

In Drosophila a remarkable feature of oogenesis is the regression of the nurse cells after dumping their cytoplasmic contents into the oocyte. We have studied the nature of this process at the late stages of egg chamber development. In egg chambers DAPI staining shows highly condensed chromatin from stage 12 and TUNEL labelling shows DNA fragmentation up to stage 14. Gel electrophoresis of the end-labelled DNA, extracted from isolated egg chambers at the same stages of development, shows a ladder typical of apoptotic nuclei. This provides evidence that, during Drosophila oogenesis, the nurse cells undergo apoptosis. Apoptotic nuclei have also been detected in dumping-defective egg chambers, indicating that the cytoplasmic depletion of nurse cells is concurrent with but apparently not the cause of the process.

Antagonism to noradrenaline-induced lethality in rats is related to affinity for the alpha1A-adrenoceptor subtype

The potency of several alpha1-adrenoceptor antagonists in preventing the noradrenaline-induced lethality in conscious rats, their binding affinity for the native alpha1A- and alpha1B-adrenoceptors, the recombinant animal alpha1a-, alpha1b- and alpha1d-adrenoceptor subtypes, as well as their functional affinity for the alpha1L-adrenoceptor subtype were evaluated. The potency of the tested compounds as antagonists of noradrenaline-induced lethality was correlated with the affinity for the alpha1A- (and alpha1a-) adrenoceptor subtype, but not with the affinity for the other subtypes. On the contrary, the hypotensive effects of the compounds, assessed in anesthetized rats, were not clearly related with the affinity for any of the alpha1-subtypes. These results suggest that the alpha1A-subtype plays a determining role in preventing lethality induced by noradrenaline in the rats, and that this activity is unrelated to the hypotensive effect of the compounds, which cannot be clearly correlated with affinity for a particular alpha1-adrenoceptor subtype.