Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

Two-year outcomes of patients with atrial fibrillation and heart failure: the ETNA-AF-Europe registry

Background

Heart failure (HF) is an established risk factor for stroke and systemic embolic events (SEE) in subjects with atrial fibrillation (AF), but it is debated whether this risk varies according to left ventricular ejection fraction (LVEF).

Methods

We investigated the impact of HF in the ETNA-AF-Europe registry, a prospective, multi-centre, post-authorisation, observational study enrolling patients treated with edoxaban for AF in 825 sites from 10 European countries. This 2-year follow-up analysis is based on a data snapshot from 26 October 2020. HF was defined as a) history of HF or b) ischaemic cardiomyopathy or c) EF <40% or d) dyspnoea not due to chronic obstructive pulmonary disease together with ≥1 of the following: ischaemic heart disease, valvular heart disease, or hypertension treated with ≥3 drugs. Patients' characteristics are summarised descriptively and clinical outcomes are reported as annualised event rates. The hazard ratio (HR) with 95% confidence intervals (CI) for the association of HF with the outcomes was assessed in Cox regression models with stepwise variable selection.

Results

Of the 13,133 patients, 1,854 (14.1%) had HF; LVEF was available for 1,489 (80.3%), and was <40% in 671 (43.9%) and ≥40% in 857 (56.1%). Patients with HF were more often men and slightly older than those without (Table 1). As expected, they also had more cardiovascular (CV) comorbidities and higher CHA2DS2-VASC and, to a lesser extent, HAS-BLED scores (Table 1). At the end of the 2-year follow-up, the rates of ischaemic stroke/transient ischaemic attack (TIA)/SEE, major bleeding, intracranial haemorrhage (ICH), CV death, and all-cause death were higher in patients with than without HF (Figure 1).

When patients with HF were categorized according to LVEF, ischaemic stroke/TIA/SEE was more frequent in those with LVEF ≥40% vs those with LVEF <40%. By contrast, more patients with LVEF <40% died due to any as well as CV causes. The rates of major bleeding and ICH were comparable between the two subgroups (Figure 1).

Univariable Cox regression analysis confirmed the association of HF with major bleeding (HR 2.01, 95% CI [1.49–2.71]) and all-cause death (2.62 [2.28–3.02]), but not with ischaemic stroke/TIA/SEE (1.06 [0.72–1.55]). The results were consistent when LVEF was taken into account: the HRs for LVEF <40% or LVEF ≥40%, respectively, were 1.60 (0.99–2.60) and 1.55 (1.02–2.38) for major bleeding, 2.11 (1.69–2.63) and 1.59 (1.28–1.97) for all-cause death, and 0.66 (0.31–1.41) and 1.19 (0.71–1.98) for ischaemic stroke/TIA/SEE.

Conclusions

In this real-world, large cohort of patients with AF on edoxaban, those with HF at baseline faced more ischaemic, bleeding, and death events, and having HF increased the risk of major bleeding and death, with no differences according to LVEF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This research was funded by Daiichi Sankyo Europe.

Baseline characteristics of patients with atrial fibrillation and cancer enrolled in the BLITZ-AF Cancer registry

Background

Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy.

Methods

BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing.

Results

From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled.

The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases.

AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF.

Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was >75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3.

As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined.

Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs <65 years), hypertension (OR 1.43, 95% CI 1.10–1.87), long-standing persistent or permanent AF (OR 1.36, 95% CI 1.05–1.78). Haemoglobin <12 g/dL (OR 0.57, 95% CI 0.45–0.73), and planned cancer treatment (OR 0.72, 95% CI 0.57–0.92) were independently associated with a lower prescription of DOACs.

Conclusions

BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.

Protective role of cardiac progenitor cell-derived-exosomes in a new human model of ageing-induced cardiac dysfunction

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Velux Stiftung

Background

Ageing of cardiomyocytes (CM) involves structural and functional adverse remodelling that finally could result in heart failure (HF) insurgence, which incidence rise along with age (1). Current medical therapies for HF may not always be tolerated in elder patients(2). Having shown that cardiac progenitor cells (CPCs) secrete nanoparticles named exosomes (EXO) enriched of cardioprotective factors(3,4), we are exploring EXO’s capacity to ameliorate senescence-derived modification into CMs. However, human models of in vitro cardiac aging are currently missing(5).

Aim

This study exploits CMs derived from human induced pluripotent stem cells (hiPSCs) as an in vitro model for cardiac senescence, that will be used as platform to characterize mechanisms involved in cardiac ageing and to test protective effect of CPC-derived EXO.

Methods

Patient-derived CPCs were reprogrammed into hiPSCs and subsequently expanded and differentiated into cardiomyocytes (hiPSC-CMs). Senescence-like phenotype was induced by short exposure (3 hours) to doxorubicin (DOX) at sub-lethal concentration (0.2 µM), followed by washing and medium change. Following DOX exposure, cells were exposed to EXO, derived from the purification of conditioned culture media of CPCs using an ultracentrifugation-based isolation method and quantified and sized using a NTA counter. Senescence induction was highlighted by protein and gene expression analysis and senescence-associated b-galactosidase (SA-β-gal) assay.Electrical activity of hiPSC-CMs was evaluated recording extracellular field potentials through multi-microelectrode arrays (MEA) and by single cell patch clamp. Metabolic features were analysed with western blot, real time RT-PCR and specific biochemical assays.

Results

DOX treatment in hiPSC-CMs induced senescence, as confirmed by activation of p21 and p16 pathways and increasing of SA-β-gal staining as compared to untreated cells (CTR). Biochemical and gene expression analysis revealed an increased ROS production and a reduction in mitochondrial potential, which drives a strong decrease in the ATP/AMP ratios. Real Time PCR analysis reveal an increased transcription of molecules related to the senescence associated secretory phenotype in DOX-CMs. Moreover, DOX-CMs showed impaired Ca++ handling, prolonged multicellular QTc and single cell APD, with increased APD variability and delayed afterdepolarizations (DADs) incidence in comparison to CTR.

EXO treatment mitigated the senescent phenotype induced by DOX, as shown by a decreased ROS induction, higher mitochondrial potential which drives a restored ATP/AMP ratio. Furthermore, DOX-induced QTc prolongation was prevented by EXO treatment.

Conclusion

Our hiPSC-CMs based cellular model recapitulates the phenotype of aged CMs in terms of senescence markers, electrical and metabolic proprieties. CPC-derived EXOs limit age-related modifications, highlighting the cardioprotective role of small molecules released by EXO.

P148 CANCER INCIDENCE AND MORTALITY ACCORDING TO PRE–EXISTING HEART FAILURE IN A COMMUNITY–BASED COHORT

Background

Studies assessing whether heart failure (HF) is associated with an excess risk of cancer and cancer–related mortality yielded conflicting results. Here, we assessed the incidence and mortality of cancer according to the presence of HF in a community–based cohort.

Methods

By reviewing the health care records of the Puglia region in Italy, we first selected the individuals ≥50–year–old, with no history of cancer within 3 years before the baseline evaluation and ≥5 years of follow–up, during the period from January 1st, 2005 to December 31st, 2013. Next, we matched 1:1 104,020 subjects with HF at baseline and 104,020 controls based on age, sex, Drug–Derived Complexity Index, and follow–up duration. Cancer incidence and mortality were analyzed by Kaplan–Meier method and Cox regression models. Fine and Grey’s regression model was also used to compare cancer–specific mortality while taking into account the competing risk of non–cancer death.

Results

Overall, the mean age of the study population was 76±10 years and the mean follow–up was 5.7 years. The incidence rate of cancer in HF patients and controls was 21.36 (95%CI, 20.98–21.74) and 12.42 (95%CI, 12.14–12.72) per 1000 person/years, respectively, corresponding to a 76% higher risk of incident cancer in HF patients (HR, 1.76; 95%CI, 1.71–1.81). HF patients also died from cancer more frequently than controls (HR 4.11; 95%CI, 3.86–4.38; Figure 1). This excess mortality was highest when age was <70 years (HR 7.54, 95%CI 6.33–8.98), and declined in subjects aged 70–79 years (HR 3.80, 95%CI 3.44–4.19) and ≥80 years (HR 3.10, 95%CI 2.81–3.43). The association of HF with cancer mortality was confirmed in the competing risk analysis (subdistribution HR 3.48, 95%CI 3.27–3.72), as well as the interaction with age: <70 years of age: SHR 6.65, 95%CI 5.60–7.94; 70–80 years: SHR 3.14, 95%CI 2.84–3.48; and ≥80 years: SHR 2.81, 95%CI 2.55–3.10. The HF–related risk applied to the majority of cancer types. Interestingly, among HF patients a high consumption of loop diuretic (≥80 mg/d of furosemide equivalents for ≥30 days in the year before the index date) was associated with a higher mortality for cancer (HR 1.35, 95%CI 1.19–1.53 vs. ≤37.5 mg/d).

Conclusions

The analysis of this large community–based sample suggests that HF does portend an increased risk of cancer and cancer–related mortality, which is blunted, yet remains substantial, with increasing age and competing risk of dying from other causes.

Cancer incidence and mortality according to pre-existing heart failure in a community-based cohort

Background

Studies assessing whether heart failure (HF) is associated with an excess risk of cancer and cancer-related mortality yielded conflicting results. Here, we assessed the incidence and mortality of cancer according to the presence of HF in a community-based cohort.

Methods

By reviewing the health care records of the Puglia region in Italy, we first selected individuals ≥50-year-old, with no history of cancer within 3 years before the baseline evaluation and ≥5 years of follow-up, during the period from January 1st, 2005 to December 31st, 2013. Next, we matched 1:1 104,020 subjects with HF at baseline and 104,020 controls based on age, sex, Charlson Comorbidity Index, Drug-Derived Complexity Index, and follow-up duration. Cancer incidence and mortality were analyzed by Kaplan-Meier method and Cox regression models. Fine and Grey's regression model was also used to compare cancer-specific mortality while taking into account the competing risk of non-cancer death.

Results

Overall, the mean age of the study population was 76±10 years and the mean follow-up was 5.7 years. The incidence rate of cancer in HF patients and controls was 21.36 (95% CI, 20.98–21.74) and 12.42 (95% CI, 12.14–12.72) per 1000 person/years, respectively, corresponding to a 76% higher risk of incident cancer in HF patients (HR, 1.76; 95% CI, 1.71–1.81). HF patients also died from cancer more frequently than controls (HR 4.11; 95% CI, 3.86–4.38; Figure 1). This excess mortality was highest when age was <70 years (HR 7.54, 95% CI 6.33–8.98), and declined in subjects aged 70–79 years (HR 3.80, 95% CI 3.44–4.19) and ≥80 years (HR 3.10, 95% CI 2.81–3.43). The association of HF with cancer mortality was confirmed in the competing risk analysis (HR 3.48, 95% CI 3.27–3.72), as well as the interaction with age: <70 years of age: HR 6.65, 95% CI 5.60–7.94; 70–80 years: HR 3.14, 95% CI 2.84–3.48; and ≥80 years: HR 2.81, 95% CI 2.55–3.10.

The HF-related risk applied to the majority of cancer types, with the exception of neoplasm of the male reproductive system. Interestingly, among HF patients a high consumption of loop diuretic (>37.5 mg/d of furosemide) was associated with a higher mortality for cancer (HR 1.34, 95% CI 1.26–1.42 vs. ≤37.5 mg/d).

Conclusions

The analysis of this large community-based sample suggests that HF does portend an increased risk of cancer and cancer-related mortality, which is blunted, yet remains substantial, with increasing age and competing risk of dying from other causes. The risk of cancer may be heightened when HF is poorly compensated.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Cancer mortality in HF patient

Role of inflammation and comorbidities in the association of heart failure with incident cancer in the HUNT3 cohort

Background

Conflicting data exist regarding the risk of cancer in patients with heart failure (HF). It was first reported that incident cancer is more common among patients with than without HF, whereas more recent studies indicate that this association is primarily driven by comorbidities. HF, cancer, and comorbidities, such as chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD), share numerous risk factors, including a state of chronic low-grade inflammation reflected by elevated circulating levels of pro-inflammatory cytokines. The objective of this analysis was to assess whether chronic low-grade inflammation, as measured by levels of high-sensitivity C-reactive protein (hsCRP), and comorbidities mediate the association of HF with incident cancer.

Methods

We used data from the 3rd wave of the Nord-Trøndelag Health Study (HUNT3), a population-based study that enrolled 50,803 individuals ≥18-year-old between October 2006 and June 2008 in the Nord-Trøndelag County (Norway), from the Cancer Registry of Norway and from the administrative health care records of the same region. Associations between baseline characteristics and the development of cancer were assessed using Cox proportional hazards regression models, using time from HUNT3 enrollment as the time scale. Analyses were performed using R statistical software, version 4.0.2.

Results

In HUNT3, hsCRP was measured in 47,571 individuals at the time of enrollment. Of these, we excluded 2,308 patients because of missing information, leaving a cohort of 45,263 subjects. Figure 1 shows the characteristics of the study population at baseline stratified by hsCRP tertiles. The prevalence of cardiovascular disease, comorbidities, and obesity was progressively higher with increasing concentrations of hsCRP.

During a median follow-up of 12 years, there were 66/408 cases of incident cancer in patients with HF at baseline and 5,024/47,163 in subjects without HF, with a more than 2-fold (HR 2.30; 95% CI 1.80–2.93; p<0.001) increase in risk of developing cancer. After adjusting for age and sex, the excess risk decreased to 43% (HR 1.43; 95% CI 1.12–1.82). When including hsCRP in the model, the HF-related risk of cancer was 33% (HR 1.33; CI 1.04–1.70; p=0.022). Furthermore, when body mass index, CKD, COPD, and smoking and drinking habits were included in the model, the risk of cancer in HF patients compared to individuals without HF was no longer significant (HR 1.23; 95% CI 0.94–1.60; p=0.127). Age, male sex, hsCRP, COPD, obesity, and smoking habits were all associated with an increased risk of cancer (Figure 2).

Conclusions

The increased risk of cancer in HF patients compared with the general population is at least in part explained by concomitant inflammation and comorbidities.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Relationship between venous congestion and systemic hypoperfusion in cardiorenal syndrome

Background

Renal impairment takes a relevant role in worsening clinical outcomes and increasing mortality risk in patients with heart failure (HF). In this context, the interplay between venous congestion and systemic perfusion in the pathogenesis of cardiorenal syndrome is currently a matter of extensive debate1.

Purpose

To investigate the relationship between renal function and hemodynamic variables, as the cardiac index and right atrial pressure, in a broad spectrum of HF patients undergoing right heart catheterization, as part of their pulmonary hypertension (PH) diagnostic work-up.

Patients and methods

From 1st September 2005 until 31st October 2019, hemodynamic data from 286 consecutive patients were collected, of whom 267 had available plasmatic creatinine values. The estimated glomerular filtration rate (eGFR) was calculated by using the Chronic Kidney Disease Epidemiology Collaboration formula. The overall study population was stratified in no PH group, pre-capillary PH group and post-capillary PH group, on the basis of the available hemodynamic values of mean pulmonary arterial pressure and pulmonary artery wedge pressure.

Results

Of the overall population, 46.1% of them were male, the mean age at the right heart catheterization was 65.5±13.7 years, and the mean eGFR value was 70.0±0.2 mL/min/1.73 m2. On the basis of hemodynamic parameters, 71 patients constituted the no PH group, 107 the pre-capillary PH group, and 63 the post-capillary PH group. Post-capillary PH patients were significantly older than both no PH and pre-capillary PH subjects (69.4±11.7 years; 61.2±16.7 years and 65.7±12.9 years respectively, p=0.003). eGFR was significantly lower in the post-capillary PH group, compared to both no PH group (63.1±22.8 mL/min/1.73 m2 vs. 73.0±23.9 mL/min/1.73 m2, p=0.029) and pre-capillary PH group (63.1±22.8 mL/min/1.73 m2 vs. 71.6±26.6 mL/min/1.73 m2, p=0.041). In post-capillary PH group, multivariate logistic regression analysis showed a significant correlation between eGFR <60 mL/min/1.73 m2 and both reduced cardiac index (Odds ratio [OR] 0.05, 95% confidence interval [CI] 0.00 to 0.72, p=0.027) and right atrial pressure (OR 0.75, 95% CI 0.57 to 0.99, p=0.039), compared to no PH group and pre-capillary PH group.

Conclusions

A significant association between renal impairment and both low systemic perfusion and venous congestion, was found in patients with post-capillary PH, rather than in other hemodynamic subsets. Further investigations are needed to disentangle the impact of the both sides of circulation on renal function, in different hemodynamic phenotypes.

Funding Acknowledgement

Type of funding sources: None.

Factors for the Primary Prevention of Breast Cancer: A Meta-Analysis of Prospective Cohort Studies

Background: This report provided the effect of 15 preventable factors on the risk of breast cancer incidence.

Study design: A systematic review and meta-analysis.

Methods: A detailed research was conducted on PubMed, Web of Science, and Scopus databases in January 2020. Reference lists were also screened. Prospective cohort studies addressing the associations between breast cancer and 15 factors were analyzed. Between-study heterogeneity was investigated using the χ², τ², and I² statistics. The probability of publication bias was explored using the Begg and Egger tests and trim-and-fill analysis. Effect sizes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs) using a random-effects model.

Results: Based on the results, out of 147,083 identified studies, 197 were eligible, including 19,413,702 participants. The RRs (95% CI) of factors associated with breast cancer were as follows: cigarette smoking 1.07 (1.05, 1.09); alcohol drinking 1.10 (1.07, 1.12); sufficient physical activity 0.90 (0.86, 0.95); overweight/obesity in premenopausal 0.92 (0.82, 1.03) and postmenopausal 1.18 (1.13, 1.24); nulliparity 1.16 (1.03, 1.31); late pregnancy 1.37 (1.25, 1.50); breastfeeding 0.87 (0.81, 0.93); ever using oral contraceptive 1.00 (0.96, 1.05); ever using estrogen 1.13 (1.04, 1.23); ever using progesterone 1.02 (0.84, 1.24); ever using estrogen/progesterone 1.60 (1.42, 1.80); ever taking hormone replacement therapy 1.26 (1.20, 1.32); red meat consumption 1.05 (1.00, 1.11); fruit/vegetable consumption 0.87 (0.83, 0.90); and history of radiation therapy, based on single study 1.31 (0.87, 1.98).

Conclusions: This meta-analysis provided a clear picture of several factors associated with the development of breast cancer. Moreover, the useful information in this study may be utilized for ranking and prioritizing preventable risk factors to implement effective prevention programs.

Prognostic impact of neurohormonal inhibition in pulmonary arterial hypertension

Background

Experimental evidence points towards a hyperactivity of the sympathetic nervous system and renin-angiotensin-aldosterone system in the pathobiology of pulmonary arterial hypertension (PAH), raising the hypothesis that blockade of neurohormonal axis may have favorable effects in this context.

Purpose

To assess the use and prognostic impact of neurohormonal inhibitors (NEUi) in a single centre cohort of subjects with PAH.

Methods

We analysed retrospectively collected data from our register of right heart catheterizations (RHC) performed consecutively from January 1st 2005 until October 31st 2018. We selected patients with PAH and complete information about demographics, biochemical data and drug therapy at the time of RHC. Patients on beta-blocker, angiotensin-converting enzyme inhibitor (ACEi), angiotensin receptor blocker (ARB) or mineralocorticoid receptor antagonist (MRA) at the time of RHC were classified as NEUi users. Comparisons between NEUi recipients and non-recipients were drawn by chi-square or t-test, as appropriate. Death from any cause was assessed by Kaplan-Meier analysis.

Results

Complete data were available for 57 PAH patients. Mean pulmonary artery pressure, pulmonary artery wedge pressure, diastolic pressure gradient, pulmonary vascular resistance and cardiac index were 45.0±14.9 mmHg, 10.9±3.5 mmHg, 16.0±10.2 mmHg, 8.8±5.1 Wood units and 2.5±0.8 l/min/m2 respectively. Twenty-seven subjects (47.4%) were taking at least one NEUi when RHC was performed: 12 (21.1%) were on beta-blocker, 15 (26.3%) on ACEi/ARB and 6 (10.5%) on MRA. NEUi users were significantly older (67.6±11.9 vs. 58.3±15.2 years, p=0.039), had a higher body mass index (25.9±4.4 vs. 23.6±3.5, p=0.029), more frequently systemic arterial hypertension (74.1% vs. 40.0%, p=0.020), smoking habit (51.9% vs. 20.0%, p=0.025) and lower estimated glomerular filtration rate (58.7±22.7 vs. 73.7±24.7 ml/min/1.73 m2, p=0.022) than non-users. Moreover, 5 NEUi users (18.5%), but no NEUi non-users, had a history of coronary artery disease. Hemodynamic parameters were similar in NEUi recipients and non-recipients (p=NS). Seven patients (25.9%) died in the NEUi users group vs. 17 (56.7%) in the non-users one (p=0.038). Kaplan-Meier analysis confirmed that subjects not taking NEUi were more likely to die over the course of follow-up (Log-Rank p=0.020) (Figure 1).

Conclusions

Our data identify a subset of atypical PAH patients, with pre-capillary pulmonary hypertension and a comorbidity profile for left heart disease (LHD), in whom NEUi have shown to improve survival. A prognostic benefit of NEUi, due to their effects on cardiovascular comorbidities in this kind of patients, has been speculated. Future prospective studies are needed to identify the most appropriate treatment strategies for atypical forms of PAH, with subtle and probably covert LHD.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Patterns of anticoagulation for atrial fibrillation in cancer patients referred for cardio-oncological evaluation

Background

Direct oral anticoagulants (DOAC) are the standard of care for the prophylaxis of non-valvular atrial fibrillation (NVAF)-cardioembolism, but their use in oncological patients has been limited so far.

Methods

We retrospectively reviewed the records of the patients referred to two cardio-oncology outpatient units between January 2017 and July 2019, and selected those presenting with NVAF, CHA2DS2-VASc ≥1 for men and ≥2 for women, and cancer on active treatment. The following were considered as contraindications to DOAC: severe chronic kidney disease; anti-neoplastic therapy unknown or with potential moderate-to-severe adverse interactions; cirrhosis or liver metastases. Clinical characteristics of patients on DOAC (group 1), on VKA or LMWH with at least 1 contraindication to DOAC (group 2), and on VKA or LMWH despite not having contraindications to DOAC (group 3) were compared by chi-square or ANOVA.

Results

Of a total of 3,831 patients, 264 (6.9%) met the inclusion criteria (Figure 1). One-hundred fourteen (43.2%) were in group 1, 61 (23.1%) in group 2 (18 on VKA, 43 on LMWH), and 65 (24.6%) in group 3 (27 on VKA, 38 on LMWH). Anticoagulation was omitted in 24 (9.1%) cases for various reasons: spontaneous bleeding (5), anaemia and/or thrombocytopenia (5), frailty (4), CHA2DS2-VASc 1 (3), pharmacological interactions (1), single episode of NVAF (1); and not clearly motivated in 5 subjects.

The only significant difference between the 3 groups was serum creatinine concentration (Table 1). Of note, only 10% of subjects in group 1 received an inappropriate DOAC dose, while LMWH was under-dosed for 18% of patients in group 2 and 31% of patients in group 3 (P=0.002).

Conclusions

In the setting of a dedicated cardio-oncology consultation, DOAC and VKA are most often appropriately prescribed to cancer patients with NVAF. However, there is residual use of LMWH, not infrequently at non-anticoagulant dosage. This is a non-evidence based common practice in clinical oncology that clearly must be abandoned

Figure 1

Funding Acknowledgement

Type of funding source: None

Sacubitril/valsartan in real-life European patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis

Background

Real-world data are needed to gauge how a therapy is implemented in clinical practice.

Methods

We systematically reviewed the abstracts presented at international congresses and the peer-reviewed original research articles, which described the use of sacubitril/valsartan in European patients with HFrEF from Sep 2014 until Nov 30, 2019. Meta-analysis estimates were combined using a random effects model with inverse variance weights.

Results

15 abstracts and 11 articles, including 14,179 patients, were selected. Except for a study that evaluated 12,082 (85,2%) subjects, the sample size was 28 (0.2%) to 1,120 (7.9%) patients.

Taking as reference PARADIGM-HF, few baseline characteristic were reported for >80% of the pooled population (Table), while all other ones were available for 12% of subjects or less (Figure). Underreporting was less common for articles than for abstracts (OR 0.42, 95% CI: 0.20–0.91).

Compared with the patients enrolled in PARADIGM-HF, those in real-life were older and more likely to being previously treated with ARB, MRA and diuretics (Table). NYHA class III-IV (OR 2.39, 95% CI: 1.58–3.59; I2=92%), ICD (OR 4.21, 95% CI: 2.31–7.69; I2=93%) and CRT (OR 4.53, 95% CI: 3.89–5.27; I2=0%) were also more likely, while a history of hypertension was less frequent (OR 0.61, 95% CI: 0.42–0.87; I2=82%).

The monthly achievement rate of the full dose of sacubitril/valsartan was 6%. When follow-up was ≥6 months, the percentage of subjects reaching the full dose was about 40% and very homogenous. Age and full dose attainment were inversely related (β −2.71, 95% CI: −5.3 to −0.1).

All cause-mortality and hospitalization rates were 6/100 person-year (9 studies, 1046 patients) and 25/100 person-year (5 studies, 775 patients), respectively.

Conclusions

With the limitation of being heterogeneous and of overall low quality, the literature suggests that, in Europe, sacubitril/valsartan is prescribed to patients with somehow more severe HFrEF than in the pivotal trial, who most often do not reach the full dose.

Funding Acknowledgement

Type of funding source: None

Tumour biomarkers: association with heart failure outcomes

BACKGROUND

There is increasing recognition that heart failure (HF) and cancer are conditions with a number of shared characteristics.

OBJECTIVES

To explore the association between tumour biomarkers and HF outcomes.

METHODS

In 2,079 patients of BIOSTAT-CHF cohort, we measured six established tumour biomarkers: CA125, CA15-3, CA19-9, CEA, CYFRA 21-1 and AFP.

RESULTS

During a median follow-up of 21 months, 555 (27%) patients reached the primary end-point of all-cause mortality. CA125, CYFRA 21-1, CEA and CA19-9 levels were positively correlated with NT-proBNP quartiles (all P < 0.001, P for trend < 0.001) and were, respectively, associated with a hazard ratio of 1.17 (95% CI 1.12-1.23; P < 0.0001), 1.45 (95% CI 1.30-1.61; P < 0.0001), 1.19 (95% CI 1.09-1.30; P = 0.006) and 1.10 (95% CI 1.05-1.16; P < 0.001) for all-cause mortality after correction for BIOSTAT risk model (age, BUN, NT-proBNP, haemoglobin and beta blocker). All tumour biomarkers (except AFP) had significant associations with secondary end-points (composite of all-cause mortality and HF hospitalization, HF hospitalization, cardiovascular (CV) mortality and non-CV mortality). ROC curves showed the AUC of CYFRA 21-1 (0.64) had a noninferior AUC compared with NT-proBNP (0.68) for all-cause mortality (P = 0.08). A combination of CYFRA 21-1 and NT-proBNP (AUC = 0.71) improved the predictive value of the model for all-cause mortality (P = 0.0002 compared with NT-proBNP).

CONCLUSIONS

Several established tumour biomarkers showed independent associations with indices of severity of HF and independent prognostic value for HF outcomes. This demonstrates that pathophysiological pathways sensed by these tumour biomarkers are also dysregulated in HF.

Geographical distribution of at fault drivers involved in fatal traffic collisions in Tehran, Iran

OBJECTIVES

According to Traffic Police, about 35% of deaths and more than 50% of injuries caused by traffic collision in the roads of Tehran are among drivers and car occupants. This study was conducted to determine areas with the highest number of traffic collisions and perform spatial analysis of traffic collisions involving drivers in Tehran during April 2014 to March 2017.

METHODS

The present study was a cross-sectional and descriptive-analytic research. In this study, all traffic collision that driver was accounted (100 percent or less) for crash occurrence which resulted in the death of at least one person (driver, pedestrian or passenger) were included in the analyses. Geographic information system software was used to show spatial distribution of events from zoning maps. Moran index was used in the mathematical analysis in order to determine the distribution pattern of the events from and Getis-Ord G statistics was applied to analyze the hot spots (high risk points).

RESULTS

A total number of 519 traffic collisions were investigated in this study. Moreover, 283 cases (54.5%) of the incidents took place in direct routes and 236 cases (45.5%) occurred at intersections. The most frequent events were in the region 4 (57 cases) and the least frequent events were reported in the region 10 (6 cases). Moran statistics show that the distribution of the studied events significantly follows the cluster pattern (p<0.001).

CONCLUSIONS

The northeastern and northwest margins of Tehran are the most prone areas for drivers involved with traffic collisions leading to death. Most traffic collisions leading to death take place at highways located at the entrance and exit points of Tehran and highways in regions 2 and 5.

How much excess weight loss can reduce the risk of hypertension?

Background

A 25% relative reduction in the prevalence of hypertension is a global target. This meta-analysis estimated the effect of excess weight loss on hypertension.

Methods

We searched PubMed, Web of Science and Scopus until January 2016. We included prospective cohort studies addressing the association between overweight/obesity and hypertension. We expressed the strength of association using risk ratio and the excess risk using attributable risk fraction with 95% CI based on the random-effects model.

Results

We found 7617 references and included 10 studies with 173 828 participants. Compared with normal weight, the risk ratio of hypertension was 1.52 (1.37, 1.67; 9 studies, I2 = 82.4%) for overweight and 2.17 (1.84, 2.50; 9 studies, I2 = 88.9%) for obesity. The excess risk of hypertension attributable to overweight was 32% (24%, 40%; 8 studies, I2 = 85.5%) and that attributable to obesity was 47% (40%, 54%; 8 studies, I2 = 88.2%). That means, excess weight loss may reduce the risk of hypertension by between 24% and 40% in people who are overweight and by between 40% and 54% in people who are obese.

Conclusions

Excess weight loss is a vital strategy for controlling hypertension and is sufficient for achieving the global target, particularly if it is accompanied with other preventive measures.

Adverse events following immunization with pentavalent vaccine: experiences of newly introduced vaccine in Iran

BACKGROUND

The most important factors that affect the incidence of vaccine-related complications are the constituent biological components of the vaccine, injection site reactions, age and sex. The aim of this study is to determine the incidence rate of adverse events following immunization with pentavalent vaccine (DTPw-Hep B-Hib (PRP-T) vaccine (pentavac) (adsorbed) is manufactured by Serum Institute of India ltd), which was introduced in Iran in November 2014. It is important to monitor vaccine-related adverse events because of the role of vaccine safety in immunization program success.

METHODS

This study was a mixed cohort study that included 1119 children less than 1 year of age. In 2015, the children were referred to Hamadan health centers to receive pentavalent vaccine at 2, 4 and 6 months of age. The data were collected from the parents of the children using a questionnaire that was administered either face-to-face or by telephone. The cumulative incidence of side effects and risk ratio was reported with 95% confidence intervals (CI). Chi-squared tests and logistic regressions were used to investigate the association between the variables.

RESULTS

The cumulative incidence rate of pentavalent-related adverse events during 48 h following immunization was estimated to be 15.8% for swelling, 10.9% for redness, 44.2% for pain, 12.6% for mild fever, 0.1% for high fever, 20.0% for drowsiness, 15.0% for loss of appetite, 32.9% for irritability, 4.6% for vomiting and 5.5% for persistent crying. There is no evidence for the occurrence of convulsion and encephalopathy among children who receive pentavalent vaccines.

CONCLUSION

Further large studies with long time follow up are required to address rare events include convulsions, encephalopathy or persistent crying. However, Findings urge immunization programs to use pentavalent vaccinations and to continue implementing the current immunization program in children under 1 year of age.

Myostatin mediates abdominal aortic atherosclerosis progression by inducing vascular smooth muscle cell dysfunction and monocyte recruitment

Myostatin (Mstn) is a skeletal muscle growth inhibitor involved in metabolic disorders and heart fibrosis. In this study we sought to verify whether Mstn is also operative in atherosclerosis of abdominal aorta. In human specimens, Mstn expression was almost absent in normal vessels, became detectable in the media of non-progressive lesions and increased with the severity of the damage. In progressive atherosclerotic lesions, Mstn was present in the media, neointima, plaque shoulder and in infiltrating macrophages. Mstn co-localized with α-smooth muscle actin (α-SMA) staining and with some CD45+ cells, indicating Mstn expression in VSMCs and bloodstream-derived leukocytes. In vitro, Mstn was tested in VSMCs and monocytes. In A7r5 VSMCs, Mstn downregulated proliferation and Smoothelin mRNA, induced cytoskeletal rearrangement, increased migratory rate and MCP-1/CCR2 expression. In monocytes (THP-1 cells and human monocytes), Mstn acted as a chemoattractant and increased the MCP-1-dependent chemotaxis, F-actin, α-SMA, MCP-1 and CCR2 expression; in turn, MCP-1 increased Mstn mRNA. Mstn induced JNK phosphorylation both in VSMCs and monocytes. Our results indicate that Mstn is overexpressed in abdominal aortic wall deterioration, affects VSMCs and monocyte biology and sustains a chronic inflammatory milieu. These findings propose to consider Mstn as a new playmaker in atherosclerosis progression.

Effect of Consanguinity on Low Birth Weight: A Meta-Analysis

BACKGROUND

Consanguinity (when couples share at least one common ancestor) is a public health issue with a variety of distributions and incidence rates worldwide. Several epidemiological studies have explored the association between consanguinity and low birth weight (LBW). However, the results are inconsistent. This meta-analysis aimed to explore the overall association between consanguineous marriage and LBW.

METHODS

We searched PubMed, Web of Science, Scopus, ScienceDirect, and reference lists of articles up to May 2015. We included cohort, case-control, and cross-sectional studies addressing the association between consanguinity and LBW. We assessed heterogeneity using Q-test and I2 statistic. We explored publication bias using the Egger's and Begg's tests and the funnel plot. We meta-analyzed the data and reported the overall odds ratio (OR) and mean difference with 95% confidence intervals (CI) using the random-effects model.

RESULTS

We included 24 out of 3941 retrieved studies, with 44,131 participants. We indicated that LBW was associated significantly with first-cousin marriages (OR = 1.36; 95% CI: 1.03, 1.69) and non-significantly with second-cousin marriages (OR = 1.20; 95% CI: 0.49, 1.91). Furthermore, first-cousin marriages can reduce the birth weight of siblings of consanguineous couples 144 g more compared to non-consanguineous marriages.

CONCLUSIONS

This meta-analysis measured the association between consanguinity and LBW. Based on the current evidence, consanguineous marriage can increase the risk for LBW. However, further evidence based on large cohort studies conducted in different settings is required to make a robust conclusion regarding the effect of consanguinity on LBW.

Prevalence of Nasopharyngeal Carriage of Streptococcus pneumonia in Iran: A Meta-Analysis

BACKGROUND

Streptococcus pneumoniae is a major cause of childhood morbidity and mortality worldwide. Several studies have explored the nasopharyngeal carriage of S. pneumonia in Iran. This meta-analysis is aimed at exploring the overall prevalence of nasopharyngeal carriage of S. pneumoniae among healthy children and its resistance to antibiotics.

METHODS

We have systematically reviewed published studies from international databases (PubMed, Web of Science, and Scopus) and national databases (Iranmedex, Magiran, Medlib, SID and Irandoc) and reference lists of articles published up to May 2015. Only cross-sectional studies supported with sensitivity test on samples collected from nasopharyngeal area were included and heterogeneity was assessed using Q-test and I2 test statistic. Publication bias was explored using the Egger's and Begg's tests and the funnel plot. The overall prevalence of analyzed data were reported with 95% confidence intervals (CI) using the random-effects model.

RESULTS

A total of 16 studies were included in the final analysis. The pooled prevalence of S. pneumoniae nasopharyngeal carriage was 18% (95% CI: 14% - 23%). Antibiotic resistance rates were 26% (95% CI: 15% - 37%) to penicillin, 30% (95% CI: 10% - 49%) to erythromycin and 34% (95% CI: 10% - 57%) to tetracycline respectively.

CONCLUSION

This study could be able effectively estimate the overall prevalence of nasopharyngeal carriage of S. pneumoniae and its antibiotics resistance rate among healthy children in Iran. In addition, the findings evidenced the role of pneumococcal vaccination in reducing the prevalence of S. pneumoniae carriage among healthy children in Iran.

Severe vitamin D deficiency is associated with frequently observed diseases in medical inpatients

INTRODUCTION

Vitamin D deficiency consequences may go beyond altered calcium homeostasis and musculoskeletal disease. Medical inpatients are often vitamin D-deficient, but little information is available about the relation of vitamin D status with extra-skeletal disorders in this population.

METHODS

We analysed the relationship between the concentrations of 25-hydroxyvitamin D [25(OH)D], the marker of vitamin D status, and the conditions most commonly causing admission in 115 consecutive medical inpatients.

RESULTS

Sixty-five subjects (56.5%) had severe vitamin D deficiency [25(OH)D < 8 ng/ml]. Age (β = -0.35, p = 0.01) and hepatic disease (β = -0.21, p = 0.02) were significant correlates of 25(OH)D levels. Compared with patients with ≥ 8 ng/ml 25(OH)D, those with < 8 ng/ml 25(OH)D had significantly higher parathyroid hormone (PTH) concentrations [123 (92.7-208.2) ng/l vs. 88 (68.5-129.5) ng/l, p < 0.001], were significantly more likely to have arterial hypertension (OR 2.76, 95% CI 1.16-6.58), heart failure (HF) (OR 2.49, 95% CI 1.14-5.47), cerebrovascular disease (OR 3.23, 95% CI 1.41-7.39), and infections (OR 2.44, 95% CI 1.02-5.87), and stayed in hospital significantly longer (10 days vs. 7.5 days, p = 0.01). Only the probability of having an infection remained significantly higher in cases with severe vitamin D deficiency after adjustment for age (OR 2.41, 95% CI 1.03-5.68) and persisted after further correcting for presence of hepatic disease and PTH values (OR 2.66, 95% CI 1.03-6.88). A significant association between PTH and HF (OR 2.32, 95% CI 1.05-5.09) and length of hospitalisation (β = 0.22, p = 0.04) emerged in the fully adjusted regression models.

CONCLUSIONS

Severe vitamin D deficiency is associated with commonly presenting extra-skeletal diseases in medical inpatients. With the exception of infections, this association is mainly driven by age. Additional studies are needed to determine whether vitamin D testing on admission may help stratifying specific categories of patients by clinical severity.

Characterization and sub-cellular localization of SS1R, SS2R, and SS5R in human late-stage prostate cancer cells: effect of mono- and bi-specific somatostatin analogs on cell growth

Somatostatin (SST) and SST receptors (SS1R, SS2R, SS3R, SS4R and SS5R) appear to play a significant role in the progression of human prostate cancer (PCa), which is associated with heterogeneity of SSRs expression and specific cell localization as we already demonstrated in the LNCaP cell line, an in vitro model of human androgen-dependent PCa. In this study, PC-3 and DU-145 human castration-resistant PCa cells were found to express all SSRs, while LNCaP expressed all but SS4R. A 48-h treatment with BIM-23244 (SS2R/SS5R) or BIM-23926 (SS1R) SST analogs was more effective in inhibiting cell proliferation, compared to BIM-23120 (SS2R), BIM-23206 (SS5R) and BIM-23704 (SS1R/SS2R). BIM-23926 (SS1R) treatment increased the amount of p21 and decreased phosphorylated (p) ERK1/2. BIM-23244 (SS2R/SS5R) led to p21 increment only in PC-3 cells, and to pERK1/2 reduction in both cell lines. SS1R/SS2R and SS2R/SS5R receptor dimers were natively present on cell membrane and their amount was increased by BIM-23704 (SS1R/SS2R) or BIM-23244 (SS2R/SS5R) treatment, respectively. SS1R, SS2R and SS5R were differently distributed among nuclear, lysosomal and microsomal compartment, according to their different recycling dynamics. These results show that, in PC-3, DU-145 and LNCaP cells, activation of SS1R and SS2R/SS5R leads to relevant antiproliferative effects.

Relationship between vitamin D status and left ventricular geometry in a healthy population: results from the Baltimore Longitudinal Study of Aging

OBJECTIVES

The effects of vitamin D on the heart have been studied in patients with cardiac disease, but not in healthy persons. We investigated the relation between vitamin D status and left ventricular (LV) structure and function in community-dwelling subjects without heart disease.

DESIGN

The relationship between concentrations of 25-hydroxyvitamin D [25(OH)D], a marker of vitamin D reserve, and LV transthoracic echocardiography measures was analysed in 711 participants in the Baltimore Longitudinal Study of Aging who were without cardiac disease.

RESULTS

Mean 25(OH)D in the study population was 32.3 ± 11.4 ng mL(-1) ; only 15.5% of subjects had moderate or severe vitamin D deficiency [25(OH)D < 20 ng mL(-1) ]. Adjusting for age, body mass index, cardiovascular disease risk factors, physical activity, calcium and parathyroid hormone, 25(OH)D was positively correlated with LV thickness (β 0.095, SE 0.039, P < 0.05) and LV mass index (β 7.5, SE 2.6, P < 0.01). A significant nonlinear relation between 25(OH)D and LV concentric remodelling was observed. LV remodelling was more likely in participants with 25(OH)D levels <30 ng mL(-1) [odds ratio (OR) 1.24; 95% confidence interval (CI) 0.83-1.85] or ≥38 ng mL(-1) (OR 1.73; 95% CI 1.13-2.65), compared with those with 30-37 ng mL(-1) 25(OH)D. Consistently, LV relative wall thickness was significantly lower (P for trend=0.05), and LV diastolic internal diameter index (P for trend<0.05) and end-diastolic volume index (P for trend<0.05) were significantly higher in subjects with 30-37 ng mL(-1) 25(OH)D compared to the rest of the study population. There was a significant interaction between 25(OH)D and hypertension on the risk of LV hypertrophy (P < 0.05).

CONCLUSIONS

In a population-based sample of predominantly vitamin D-sufficient subjects without heart disease, LV geometry was most favourable at intermediate 25(OH)D concentrations.

Immunohistochemical localization and quantitative expression of somatostatin receptors in normal human spleen and thymus: Implications for the in vivo visualization during somatostatin receptor scintigraphy

BACKGROUND

[111In-DTPA-D-Phe1]-octreotide scintigraphy allows the visualization of SRIF receptor (SSR)-expressing tumors, including thymic tumors, and normal tissues. While the spleen is clearly visualized, the thymus is not depicted, although both contain SSR.

AIM

We evaluated whether the heterogeneity, the type, and the amount of SSR might explain this contrasting finding.

MATERIALS, METHODS, AND RESULTS

By ligand-binding the number of [125I-Tyr11]-SRIF- 14 binding sites resulted comparable between the two tissues, whereas the number of [125I-Tyr3]-octreotide sites was significantly higher in the spleen (p<0.001). Quantitative RTPCR showed a significantly higher expression of sst2A mRNA in the spleen, whereas a significantly higher expression of SRIF and sst3 in the thymus. The highest density of sst2A in the spleen is in line with the in vivo uptake of [111In-DTPA-D-Phe1]- octreotide, which is considered a sst2-preferring ligand. The specificity is confirmed by the evidence that in vivo [111In-DTPA- D-Phe1]-octreotide uptake can be abolished during chronic administration of "cold" octreotide. Immunohistochemistry confirmed a preferential expression of sst2A on microenvironmental cells and of sst3 on lymphoid cells.

CONCLUSIONS

The heterogeneity of SSR expression and the higher SRIF content explain the lack of thymus visualization during scintigraphy, whereas thymic tumors, which do not express SRIF, are visualized. Apart from the affinity of the radioligand, also the efficacy of the internalization is crucial for the in vivo uptake, and both heterogeneity and SRIF content affect this process. These observations might have an important impact when interpretating in vivo visualization of SSR-positive lesions, and when treatment with novel SRIF analogs is considered.

[Multimodal imaging in the differential diagnosis of soft tissue calcinosis]

Soft tissue calcinosis is a common radiographic finding, which may be related to different types of pathological processes. Multimodality imaging, combined with analysis of clinical and laboratory data, plays an important role for the differential diagnosis of these conditions. Conventional radiography is considered the first line approach to soft tissue calcinosis; CT and MRI may provide further information to better characterize calcified deposits. Imaging may help to distinguish metabolic calcification, such as primary tumoral calcinosis and the secondary one (associated with acquired disorders of calcium or phosphate regulation), from dystrophic calcification, which is associated to normal blood values of phosphate. The sedimentation sign typical of tumoral calcinosis has been demonstrated by plain film radiography, CT, MRI, and, more recently, by ultrasonography. Other types of soft tissue calcinosis may have a degenerative, metaplastic or neoplastic origin, and their characterization strongly relies on multimodality imaging.

Onset of cutaneous vasculitis and exacerbation of IgA nephropathy after Bartonella henselae infection

Bartonella henselae is the aetiological agent of cat-scratch disease. Recently, there have been reports of other conditions associated with this bacterium, including leucocytoclastic vasculitis, thrombocytopenic purpura, maculopapular and urticarial eruptions, granuloma annulare, erythema nodosum, erythema marginatum and erythema annulare. We report the first case, to our knowledge, of the simultaneous occurrence of cutaneous vasculitis and nephrotic syndrome in a 65-year-old woman with IgA nephropathy after a B. henselae infection transmitted by a cat scratch. The aetiopathogenetic role of B. henselae was hypothesized on the basis of the serological demonstration of acute B. henselae infection, the immunofluorescence findings, and the prompt resolution after azithromycin treatment. Patients reporting cat scratches or bites should undergo accurate clinical examination, routine laboratory examinations, urinalysis and clinical surveillance.

Somatostatin and dopamine receptor interaction in prostate and lung cancer cell lines

Somatostatin analogues inhibit in vitro cell proliferation via specific membrane receptors (SSTRs). Recent studies on transfected cell lines have shown a ligand-induced formation of receptor dimers. The aim of this study is 1) to evaluate the role of specific ligands in modulating receptor interactions in the androgen-dependent prostate cancer cell line, LNCaP, and in the non-small cell lung cancer line, Calu-6, by co-immunoprecipitation and immunoblot; and 2) to correlate the antiproliferative effect of these compounds with their ability in modulating receptor interactions. In LNCaP, we have demonstrated the constitutive presence of sstr₁/sstr₂, sstr₂/sstr₅, sstr₅/dopamine (DA) type 2 receptor (D₂R), and sstr₂/D₂R dimers. BIM-23704 (sstr₁- and sstr₂-preferential compound) increased the co-immunoprecipitation of sstr₁/sstr₂ and significantly inhibited proliferation (-30.98%). BIM-23244 (sstr₂-sstr₅ selective agonist) significantly increased the co-immunoprecipitation of sstr₂/sstr₅, and induced a -41.36% inhibition of proliferation. BIM-23A760, a new somatostatin/DA chimeric agonist with a high affinity for sstr₂ and D₂R and a moderate affinity for sstr₅, significantly increased the sstr₅/D₂R and sstr₂/D₂R complexes and was the most powerful in inhibiting proliferation (-42.30%). The chimeric compound was also the most efficient in modulating receptor interaction in Calu-6, increasing the co-immunoprecipitation of D₂R/sstr₅ and inhibiting cell proliferation (-30.54%). However, behind BIM-23A760, BIM-53097 (D₂R-preferential compound) also significantly inhibited Calu-6 proliferation (-17.71%), suggesting a key role for D₂R in receptor cross talk and in controlling cell growth. Indeed, activation of monomeric receptors did not affect receptor co-immunoprecipitation, whereas cell proliferation was significantly inhibited when the receptors were synergistically activated. In conclusion, our data show a dynamic ligand-induced somatostatin and DA receptor interaction, which may be crucial for the antiproliferative effects of the new analogues.

High prevalence of vitamin D deficiency and its association with left ventricular dilation: an echocardiography study in elderly patients with chronic heart failure

BACKGROUND AND AIMS

Vitamin D deficiency has been associated with chronic heart failure (CHF). We evaluated vitamin D levels in relationship with New York Heart Association (NYHA) classes, N-terminal pro-brain natriuretic peptide (NT-proBNP) values and left ventricular (LV) measures in ≥60 year old patients with stable CHF. Differently from previous investigations, LV function was assessed by transthoracic echocardiography, to provide easily reproducible results.

METHODS AND RESULTS

The study was performed at geographic latitude 44° N, from March to May and from September to November 2008. Acute HF and diseases or drugs altering vitamin D status were exclusion criteria. NYHA scores and 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D and NT-proBNP concentrations were assessed in 90 (45 F, 45 M) Caucasian patients with CHF secondary to hypertension and/or coronary artery disease. Vitamin D levels were also measured in 31 subjects without heart disease (controls). LV echocardiography was performed in 52 (26 F, 26 M) representative patients. Vitamin D concentrations were significantly lower in CHF cases than in controls. Among subject with CHF, 97.8% presented vitamin D deficiency (25(OH)D<75 nmol/L), being severe (<25 nmol/L) in 66.7%. LV end-diastolic and end-systolic diameters were significantly longer, LV end-diastolic and end-systolic volumes bigger and fractional shortening lower in CHF patients with 25(OH)D<25 nmol/L than with 25(OH)D≥25 nmol/L (p<0.05). Log-values of 25(OH)D were negatively correlated with LV end-systolic diameter and volume (r=-0.28; p<0.05). On subgroup analysis, these results persisted only in male patients.

CONCLUSIONS

In elderly CHF patients, vitamin D deficiency was highly prevalent and often severe. This first addressed echocardiography study showed a sex-specific association between vitamin D deficiency and LV dilation. Since further echocardiography data are easily obtainable, larger investigations are demanded.

Somatostatin receptor scintigraphy in thoracic diseases

Somatostatin (SS) receptor scintigraphy is useful for the diagnosis of lesions with high density of SS receptors, and above all neuroendocrine tumors. For several years, only indium-labeled octreotide has been applied to visualise in vivo tissues with SS receptor overexpression. Radiolabeled octreotide became the gold standard for the detection of neuroendocrine tumors. More recently, however, several new SS analogues with varying affinity for SS receptor subtypes have been developed, and different radionuclides as radiolabels have been introduced. Moreover, significant improvements have been made by the introduction of hybrid machines, such as single photon emission computed tomography/ computed tomography (SPECT/CT) or positron emission tomography (PET)/CT that enable to perform whole-body imaging quickly and with high anatomical resolution in several body areas, including the chest. The development of more specific radiopharmaceuticals, together with the modern technique of imaging, may provide excellent quality images with high contrast, allowing to depict very small lesions and making them easy to interpret. Indeed, in the management of SS receptor-positive lesions, the contribution of nuclear medicine is essential in several clinical settings, such as initial diagnosis, disease staging, follow-up, treatment planning, and treatment monitoring. In addition, the tracer uptake might be used as a prognostic parameter and as a predictor of treatment response. In the chest, apart in (neuro)endocrine tumors, SS receptors have been demonstrated in granulomatous diseases, like sarcoidosis and other immune-mediated disorders, such as anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis. In this paper we review and discuss the role of SS receptor scintigraphy in diagnosis, staging or follow- up of thoracic SS receptor-positive lesions.

Alterations in the autonomic control of heart rate variability in patients with anorexia or bulimia nervosa: correlations between sympathovagal activity, clinical features, and leptin levels

Changes in body composition, hormone secretions, and heart function with increased risk of sudden death occur in eating disorders. In this observational clinical study, we evaluated sympathovagal modulation of heart rate variability (HRV) and cardiovascular changes in response to lying-to-standing in patients with anorexia (AN) or bulimia nervosa (BN) to analyze: a) differences in autonomic activity between AN, BN, and healthy subjects; b) relationships between autonomic and cardiovascular parameters, clinical data and leptin levels in patients with eating disorders. HRV, assessed by power spectral analysis of R-R intervals, blood pressure (BP) and heart rate (HR) were studied by tilt-table test in 34 patients with AN, 16 with BN and 30 healthy controls. Autonomic and cardiovascular findings were correlated with clinical data, and serum leptin levels. Leptin levels were lowered in AN vs BN and healthy subjects (p<0.0001), but both AN and BN patients showed unbalanced sympathovagal control of HRV due to relative sympathetic failure, prevalent vagal activity, impaired sympathetic activation after tilting, independently from their actual body weight and leptin levels. No significant correlations were obtained between HRV data vs clinical data, BP and HR findings, and leptin levels in eating disorders. Body mass indices (BMI) (p<0.02), and leptin levels (p<0.04) correlated directly with BP values. Our data showed alterations of sympathovagal control of HRV in eating disorders. These changes were unrelated to body weight and BMI, diagnosis of AN or BN, and leptin levels despite the reported effects of leptin on the sympathetic activity.

Weight loss alters organ concentrations and contents of lead and some essential divalent metals in rats previously exposed to lead

The loss of adipose tissue during energy restriction may be accompanied by a loss of lean body mass, including bone mass. Because most of the body lead burden is in the skeleton, we studied the effects of weight loss on the concentrations of lead in bone, blood and several organs in rats with prior but not current lead exposure. Concentrations of the essential divalent metals calcium, copper, iron, magnesium and zinc were also determined for comparison with lead. Lead-exposed rats (n = 25) were randomly assigned to one of three treatment groups: weight maintenance (WM), moderate weight loss (MWL) or substantial weight loss (SWL). For the two last-named groups, food intake was restricted for 4 wk to 70 and 40% of that of the WM group. Lead concentrations did not differ significantly (ANOVA, P > 0.05) among the three groups for blood, brain and bone. Significantly higher liver lead concentrations were observed in the SWL rats than in the WM and MWL groups. In general, organ concentrations of calcium, copper, magnesium and zinc were either lower or did not differ in the groups losing weight compared with the WM group. In contrast, organ Iron concentrations of the SWL group were higher than those of the other groups except in brain where there were no significant differences. The total liver content of lead was highest in the SWL group, but the lead content of other organs did not differ among the treatment groups. The contents of calcium, copper, magnesium and zinc generally were lower in the MWL and SWL groups than in the WM group in the liver and some of the other organs. The results demonstrate that weight loss can increase the quantity and concentration of lead in the liver, even in the absence of continued lead exposure. The data also demonstrate considerable differences among organ divalent metals in response to weight loss.