Mutational Profile Enables the Identification of a High-Risk Subgroup in Myelodysplastic Syndromes with Isolated Trisomy 8

Trisomy 8 (+8) is the most frequent trisomy in myelodysplastic syndromes (MDS) and is associated with clinical heterogeneity and intermediate cytogenetic risk when found in isolation. The presence of gene mutations in this group of patients and the prognostic significance has not been extensively analyzed. Targeted deep sequencing was performed in a cohort of 79 MDS patients showing isolated +8. The most frequently mutated genes were: TET2 (38%), STAG2 (34.2%), SRSF2 (29.1%) and RUNX1 (26.6%). The mutational profile identified a high-risk subgroup with mutations in STAG2, SRSF2 and/or RUNX1, resulting in shorter time to acute myeloid leukemia progression (14 months while not reached in patients without these mutations, p < 0.0001) and shorter overall survival (23.7 vs. 46.3 months, p = 0.001). Multivariate analyses revealed the presence of mutations in these genes as an independent prognostic factor in MDS showing +8 isolated (HR: 3.1; p < 0.01). Moreover, 39.5% and 15.4% of patients classified as low/intermediate risk by the IPSS-R and IPSS-M, respectively, were re-stratified as a high-risk subgroup based on the mutational status of STAG2, SRSF2 and RUNX1. Results were validated in an external cohort (n = 2494). In summary, this study validates the prognosis significance of somatic mutations shown in IPSS-M and adds STAG2 as an important mutated gene to consider in this specific subgroup of patients. The mutational profile in isolated +8 MDS patients could, therefore, offer new insights for the correct management of patients with a higher risk of leukemic transformation.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Faecal contamination in public pools in Barcelona province: Cryptosporidium spp. and bacterial indicators

A study was conducted of the occurrence of Cryptosporidium in indoor heated public swimming pools and of three bacterial indicators (Escherichia coli, faecal enterococci and Clostridium perfringens) on pool surrounds. Although all examined pools adhered strictly to the Spanish regulations, the influence of several parameters related to water conditions, pool structure, users and location on the presence of protozoa and bacteria was analysed. Cryptosporidium was detected in 18.8% of pools in 60% of the five towns studied. The maximum concentration was 13 oocysts/L in one swimming pool and one Jacuzzi. The bacterial indicators' prevalence on pool surrounds was higher than 50%, being present in all of the towns. Plastic surfaces presented the lowest bacterial prevalence, whereas painted surfaces were 100% positive. No differences were observed for pool surrounds with autonomous or disabled users. Risk of cryptosporidiosis in pool vessels indicated that concentrations over 1 oocyst/10 L enhance the risk of infection, even in one exposure. Guidelines for managing faecal accidents and public information on the importance of good hygiene behaviours in and around swimming pools are recommended to limit oocysts' presence.

Denitrification in a hypersaline lake-aquifer system (Pétrola Basin, Central Spain): the role of recent organic matter and Cretaceous organic rich sediments

Agricultural regions in semi-arid to arid climates with associated saline wetlands are one of the most vulnerable environments to nitrate pollution. The Pétrola Basin was declared vulnerable to NO3(-) pollution by the Regional Government in 1998, and the hypersaline lake was classified as a heavily modified body of water. The study assessed groundwater NO3(-) through the use of multi-isotopic tracers (δ(15)N, δ(34)S, δ(13)C, δ(18)O) coupled to hydrochemistry in the aquifer connected to the eutrophic lake. Hydrogeologically, the basin shows two main flow components: regional groundwater flow from recharge areas (Zone 1) to the lake (Zone 2), and a density-driven flow from surface water to the underlying aquifer (Zone 3). In Zones 1 and 2, δ(15)NNO3 and δ(18)ONO3 suggest that NO3(-) from slightly volatilized ammonium synthetic fertilizers is only partially denitrified. The natural attenuation of NO3(-) can occur by heterotrophic reactions. However, autotrophic reactions cannot be ruled out. In Zone 3, the freshwater-saltwater interface (down to 12-16 m below the ground surface) is a reactive zone for NO3(-) attenuation. Tritium data suggest that the absence of NO3(-) in the deepest zones of the aquifer under the lake can be attributed to a regional groundwater flow with long residence time. In hypersaline lakes the geometry of the density-driven flow can play an important role in the transport of chemical species that can be related to denitrification processes.

[Diagnosis of acute myocarditis with cardiac magnetic resonance imaging]

Cardiomyopathies are a common cause of morbidity and mortality. Myocarditis, which is included among specific cardiomyopathies, frequently presents non-specific clinical manifestations and thus may be difficult to diagnose, or even be misdiagnosed. Traditionally employed diagnostic techniques, including endomyocardial biopsy, have been shown to be of limited value. Following its overall implantation in clinical practice, cardiac magnetic resonance imaging (MRI) is nowadays widely considered to be the best non-invasive diagnostic tool available for diagnosing myocarditis.

[Basic principles of cardiovascular magnetic resonance (CMR): sequences, acquisition planes and study protocol]

Evaluation of the cardiovascular system with magnetic resonance (CMR) has become one of the most relevant and up-to-the-minute clinical applications of this diagnostic technique, as CMR makes possible an exact and reproducible study of the anatomy and function of the heart and great vessels. The complexity of this technique is mainly due to the anatomical location and orientation of the cardiovascular structures, the specific CMR sequences that have to be used and a lack of familiarity amongst radiologists regarding cardiovascular pathology. In this report the most basic principles of CMR are described. The clinical usefulness of anatomical, functional, and flow quantification sequences are discussed, conventional CMR acquisition planes are described, and an easy CMR study protocol is proposed.

Impact on Renal Function of the Use of Sirolimus in Cardiac Transplantation

INTRODUCTION

During the last few years sirolimus has been introduced as an alternative to preserve renal function in transplant recipients receiving calcineurin inhibitors.

MATERIALS AND METHODS

We reviewed our results on the use of sirolimus in cardiac transplant recipients.

RESULTS

Twenty-seven patients with an average age of 63 years received sirolimus. The average time after transplantation was 73.4 +/- 58.9 months and the average follow-up was 31.7 +/- 18.01 months. Sirolimus was prescribed in 37% of cases due to chronic renal failure (CRF), 14.8% because of cardiac allograft vasculopathy (CAV), 11.1% for tumors, 22.2% de novo, 7.4% for CRF and tumor, and 7.4% for CRF and CAV. Among the patients with CRF (n = 14), there were 5 (35%) on dialysis at the moment of starting the treatment and 1 was retired from dialysis. The other 4 (28.5%) patients had to be treated with dialysis after starting the treatment. In all, 42.8% of the patients with nephropathy maintained stable renal function or improved. Among the 17 (63%) patients who did not require dialysis, there was no significant change in renal function after 6 months or 1, 2, and 3 years follow-up.

CONCLUSIONS

The use of sirolimus in cardiac transplantation maintains stable renal function in the majority of patients in the medium term.

[Heart failure. Current pharmacologic treatment]

Treatment of heart failure (HF) has changed in recent years, despite the paucity of new approved drugs. Current treatment is directed not only towards improving symptoms, but also to preventing the development from asymptomatic systolic dysfunction to symptomatic heart failure, to preventing cardiac remodelling, renal dysfunction and to reducing mortality. The main families of drugs currently used are: cardiac glycosides, diuretics, angiotensin-converting enzyme inhibitors (ACEI), beta-blocking drugs (BB), angiotensin-II receptor blockers (ARB) and aldosterone receptor antagonists. The combination isosorbide dinitrate + hydralazine is hardly used due to its side effects and none of the new positive inotropic drugs has been approved in chronic HF, because all of them increase mortality. Levosimendan is a new positive inotropic agent approved for acute HF by an intravenous route, with a favourable effect on prognosis vs placebo and vs dobutamine (which worsens the prognosis). The approved oral drugs can be given at the same time if the patient tolerates them, because their beneficial effect is additive. Mortality in two years in mild to moderate HF is 34% with glycosides + diuretics. It falls to 22% when an ACEI is added, to 14% when a BB is added and to 10% when an aldosterone antagonist is added. ARB can be given instead of an ACEI or be added to the other drugs.

Giant inguino-scrotal bladder hernia. Report of a case

Bladder hernia is very uncommon. It tends to affect patients over the age of 50 and is predisposed by cervico-urethral obstruction. The condition is often diagnosed during inguinal hernia surgery. The authors report a case of massive inguino-scrotal bladder herniation. The different types of bladder hernia are described, and the clinical-radiological findings and surgical management are discussed.

[Post-infectious demyelinating diseases]

Post-infectious demyelinating disorders are uncommon. In the Hospital Pediatrico de la Misericordia de Santafé de Bogotá there were 14 cases in three years. The commonest age group was the new born, as is found in the literature. The infections involved in these neurological changes are probably viral, since at the time the patient is seen most symptoms have cleared up spontaneously. According to several authors, the viruses are most often found to be those of measles or mumps. Between the infection and the development of neurological symptoms there is an interval of approximately two weeks. The main clinical findings are motor changes such as hemiparesis, involvement of cranial nerves and alterations of consciousness. The aetiology is not completely clear. Firm diagnosis is made on histopathological studies which are seldom available. Usually neuroimaging techniques and cerebrospinal fluid analysis are the basis of the diagnosis. Computerized axial tomography and magnetic resonance are the most useful noninvasive techniques for assessing the involvement of the white matter, the extent and sites of the lesions. It is useful to know the classification of the demyelinating disorders so as to prescribe, the most suitable treatment and give the prognosis in each case. There is still no specific treatment for these disorders. Supportive measures, the control of epileptic crises and the prevention of complications are the main aims. This paper reviews the definition, classification, diagnosis and management of these disorders.