Echocardiographic probability of pulmonary hypertension according to the old and the new definition: a validation study

Background

According to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established.

Methods

A total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography.

Results

With PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m/s, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m/s independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction. The areas under the ROC curves for different cut-off values of TRV for the prediction of mPAP >20 mmHg, mPAP ≥25 mmHg, mPAP >20 mmHg + PVR >2 Wood units and mPAP ≥25 mmHg + PVR >3 Wood units are illustrated in Figure 1A–D.

Conclusions

Echocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.

Funding Acknowledgement

Type of funding sources: None.

Myocardial work impairment in children with Wolff-Parkinson-White syndrome

Background

Wolf-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardium deformation during systole. According to guidelines, when the left ventricle (LV) dysfunction is present catheter ablation of the accessory pathway may be required, even in asymptomatic patients.

Purpose

The study aimed to assess the diagnostic value of non-invasive myocardial work in predicting subtle myocardial abnormalities in children with WPW.

Methods

Eighty pediatric patients (age 7.91±3.2 years) were included in the study: 20 cases with manifest WPW and 60 age- and sex-matched controls (CTR). Global myocardial work index (MWI) was measured as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated. In addition, standard echocardiographic parameters of LV function were evaluated.

Results

Patients characteristics are summarized in the table. Despite normal LV EF and GLS, children with WPW had worse MWI (WPW 1292.90±307.67 mmHg% vs CTR 1658.73±241.74 mmHg%, p=0.0000005), MCW (WPW 1844.15±267.96 mmHg% vs CTR 2104.90±237.85 mmHg%, p=0.00009), MWW (WPW 101.5 [85–148.25] mmHg% vs CTR 72 [54.75–109.25] mmHg%, p=0.004) and GWE (WPW 94 [91.75–95] mmHg% vs 96 [95–97] mmHg%, p=0.00012) (table). In the WPW group, MWE (r=−0.6, p=0.009) and MWW (r=0.6, p=0.01) was found to correlate with a prolonged QRS (figure).

A multiple regression model was generated to identify the relation between abnormal myocardial work indices (worst interquartile range as dependent variable) and several independent variables. QRS was the best independent predictor of impaired myocardial work. In particular, a QRS>110 msec showed an 86% sensibility and 85% specificity for abnormal MWE (AUC of 0.85), and a 75% sensibility and 83% specificity for abnormal MWW (AUC of 0.83) (figure).

Conclusion

In children with WPW, myocardial work indices were found significantly reduced, even in presence of normal LV EF and GLS. Prolonged QRS independently predicted myocardial impairment. In pediatric patients with WPW, myocardial work may represent a sensitive measure of LV dysfunction and help in the decision-making.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 vaccination in adults with congenital heart disease: results of 1-year prospective study

Background

Adults with congenital heart disease (ACHD) are a vulnerable population. Routine vaccination is the only strategy to prevent a life-threatening infection. However, concerns on the cardiac safety and efficacy of COVID-19 vaccines have been raised.

Aim

To assess safety and efficacy of available COVID-19 vaccines in ACHD patients.

Methods

Data on COVID-19 infection and vaccines including booster doses and any suspected or confirmed adverse events were prospectively collected for all ACHD patients attending our tertiary centre from the beginning of the vaccination campaign (March 2021). A group of 75 healthy volunteers, matched per age and sex, was included for comparison. Antispike IgG titre was routinely obtained at the ACHD clinic. Patients' attitude towards COVID-19 was explored with a questionnaire.

Results

As of February 2022, 498 ACHD patients (36.7±16 years, 54% male,69% with moderate-complex defects, 48% with advanced physiological stage) were enrolled. Four hundred and sixty-one (92%) were fully vaccinated: the type of vaccine was Pfizer-BioNTech for 399 (86%) patients, Moderna for 20 (4%) and AstraZeneca for 26 (6%), 9 received a mixed vaccine regimen (2%). Forty-two (9%) had a history of previous COVID-19 infection and therefore received only one dose. Two-hundred and sixty-nine (58%) patients received a booster dose. Adverse events were mainly mild and transient. One patient complaining of chest pain following administration of mRNA-based vaccination was diagnosed with acute pericarditis, which made full remission after appropriate therapy. Two patients reported a non-specific increment of inflammatory markers. No other severe adverse events were reported. Thirty-seven (7%) refused COVID-19 vaccination being scared of potential cardiac/extra-cardiac adverse events. Among those not-vaccinated, 9 (24%) had a history of previous mild COVID-19 infection. IgG titre was measured in 243 patients at 1915 [835–5934] BAU/ml, which was significantly higher compared to controls (1196 [827–2048] BAU/ml, p=0.002). Three ACHD patients contracted COVID-19 infection after the first dose, while 65 (14%) fully vaccinated patients tested positive for COVID-19, all with mild to moderate symptoms. COVID-19 symptoms duration was significantly longer in case of infection before vaccination (10 [2.7–15] vs 3 [1.2–7], p=0.03). One Fontan patient was tested positive for COVID-19 twice, before and after COVID-19 vaccination, requiring hospitalization in both cases. Four hundred and seven patients completed the questionnaire: 128 (31%) declared to be scared of potential cardiac effects of the vaccine and that the discussion with the ACHD cardiologist was crucial to decide to undergo COVID-19 vaccination.

Conclusions

Our data provide real-world evidence on COVID-19 vaccines safety and efficacy in ACHD patients. Patients' education from the ACHD team may play a key role in vaccine acceptance in this vulnerable population.

Funding Acknowledgement

Type of funding sources: None.

Effects of sacubitril/valsartan in patients with a systemic right ventricle

Background

Sacubitril/valsartan has been proved to reduce mortality in heart failure and reduced ejection fraction (EF) and is currently recommended as first-line therapy. However, effects in patients with a systemic right ventricle (sRV) have not been systematically investigated yet.

Purpose

We aimed to assess safety and efficacy of sacubitril/valsartan in patients with a sRV

Methods

From September 2020 to April 2021, all patients with congenitally corrected transposition of the great arteries (TGA) or TGA after Senning/Mustard repair attending our tertiary centre were prospectively enrolled. Inclusion criteria were: age ≥18 years, 3-months of optimal medical therapy including ACEi/ARB and sRV EF≤40%. Patients with univentricular physiology, systolic blood pressure (SBP) <90 mmHg, glomerular filtration rate (GFR) <30 ml/min or K >5.5 mEq/L were excluded. SBP and blood samples were obtained at 1-month of treatment. Other clinical and echocardiographic variables were reassessed at 6 and 12-month follow-up and the medication was progressively up-titrated to the highest tolerated dose.

Results

Fifty-one patients (38±11 years, 60% male, 34% ccTGA) were included. Up to March 2022, 48 (92%) patients were reviewed after 6 months of therapy and 35 (68%) completed the first year of follow-up. Baseline patients' characteristics are summarized in Table 1. At 1 month, treatment did not impact on the serum potassium values (4.5±0.3 vs 4.4±0.3 mEq/L, p=0.9) and GFR (112±33 vs 112±31 ml/min, p=0.3), while SBP dropped significantly (119±13 vs 108±18 mmHg, p=0.003). Two patients ceased the treatment due to symptomatic hypotension during the first month. One patient developed a nephrotic syndrome at 4 months of follow-up, which was likely unrelated to the treatment. No other major adverse events were reported. One patient was lost to follow-up after 3 months. Despite no significant change in the NYHA class (p=0.9), the 6-minute walking distance increased significantly at 6-month (Table 2). Nt pro BNP values were significantly decreased at 6-month, and returned to baseline at 12-month. Improved sRV systolic function was demonstrated at 6 and 12-month by significant increase in fractional area change, RV global longitudinal strain and sRV EF measured with 3D echocardiography.

Conclusions

Our mid-term results showed that sacubitril/valsartan is well tolerated in patients with a sRV and leads to signficant improvement of sRV systolic function, supporting its use in this complex population.

Funding Acknowledgement

Type of funding sources: None.

Myocardial work indices and ventricular dyssynchrony in adults with aortic coarctation

Funding Acknowledgements

Type of funding sources: None.

Background

Adults with coarctation of the aorta (CoA) may present residual aortic obstruction and develop arterial vasculopathy and subclinical left ventricular (LV) dysfunction. Myocardial work (MW) is a novel non-invasive index of myocardial efficiency calculated from echocardiographic LV pressure-strain loops, which yields incremental information over ejection fraction and global longitudinal strain. (GLS)

Purpose

Aim of the present study is to analyze LVMW in a cohort of adult patients with operated aortic CoA

Methods

CoA patients aged > 18 years who underwent transthoracic echocardiography between September 2020 and July 2021 at our tertiary centre were included. Exclusion criteria were significant recoarctation, impaired LVEF, significant valvular disease and suboptimal image quality. A group of healthy individuals with no cardiac abnormalities. GLS and peak strain dispersion(PSD) were measured. MW indices were calculated using the blood pressure measured in the right arm at the time of the exam.

Results

Sixty patients (26[22-33]years, 66%male) were included. Data on previous medical history, clinical status at last assessment and Coa-related echocardiographic findings are showed in table 1. No significant differences in traditional parameters of LV systolic and diastolic function were found between groups (EF 60[57-64] vs 57[53-61],p = 0.6), however Coa patients had higher LVmass (84[75-97] vs 68[56-75]g). GLS and MW indices in the study population and in the control group  are reported in table 2. Coa group showed lower GLS values and higher PSD (p < 0.0001 for both). Global work index(GWI) and global constructive work(GCW) values were not significantly different between groups, whereas CoA group showed significant increase of global wasted work(GWW) and impaired global work efficiency(GWE,p = 0.003 and 0.0005 respectively). Spearman’s linear method illustrated that both GCW and GWI had a moderate positive relation with mean gradient across the descending aorta at continuous wave Doppler. PSD was positively related to GWW and inversely related to GWE(Figure 1). Using linear regression model with the log of GWE values as dependent variable,PSD,age(β:-0.002,p = 0.03) and LVmass(β:-0.06,p = 0.004)were related to GWE. However, only PSD retained a significant relation on multivariable analysis(β:-0.002,p > 0.0001).

Conclusion

MW indices assessment is feasible in Coa patients may provide a more comprehensive understanding of the overall myocardial mechanics and performance. In particular, MW demonstrated impaired LV efficiency, which was strongly related to increased mechanical dispersion in Coa patients. Abstract Figure.  Abstract Figure.

Impaired myocardial work in paediatric patients with wolff-parkinson-white syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Wolff-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardium deformation during systole. Left ventricle (LV) dysfunction due to electrical dyssynchrony may require catheter ablation of the accessory pathway, even in asymptomatic patients.

Purpose

The study aimed to assess the diagnostic value of non-invasive myocardial work in predicting subtle myocardial abnormalities in patients with WPW.

Methods

Forty-four paediatric patients (age 8.2 ± 4.3 years) were included in the study: 12 cases with manifest WPW and 32 age-, sex- and arterial pressure- matched controls (CTR). LV ejection fraction (EF) and global longitudinal strain (GLS) were evaluated. Global myocardial work index (MWI) was measured as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated.

Results

Despite normal LV systolic function by standard echocardiographic parameters, patients with WPW had lower MWI (1233.5 ± 281.6 mmHg% in WPW vs 1624.0 ± 305.8 mmHg% in CTR, p = 0.0004), MCW (1833.4 ± 257.9 mmHg% in WPW vs 2069.0 ± 319.9 mmHg% in CTR, p= 0.03), MWW (187.6 ± 117.7 mmHg% in WPW vs 90.9 ± 58.9 mmHg% in CTR, p= 0.0008) and GWE (90.5 ± 4.8% in WPW vs 95.2 ± 2.2% in CTR, p= 0.00006). There were no significant differences in GLS and EF between patients with WPW and controls.

Conclusion

Myocardial work indices were found significantly reduced in patients with WPW, even in presence of normal LV EF and GLS. In patients with WPW, MWI may represent a sensitive measure of myocardial dysfunction and help in the decision-making for catheter ablation. Abstract Figure. Myocardial work in WPW  Abstract Figure. Myocardial work in control patient

Echocardiographic probability of pulmonary hypertension according to the direct and indirect signs: a validation study

Background

Transthoracic echocardiogram is the most important non-invasive screening tool for pulmonary hypertension (PH), but right heart catheterization (RHC) remains mandatory to establish the diagnosis. According to the current guidelines, the echocardiographic probability of PH is based on the combination of direct and indirect signs. In the 6th World Symposium on Pulmonary Hypertension, PH has been defined as mean pulmonary artery pressure (mPAP) >20 mmHg, and pulmonary vascular resistance (PVR) ≥3 WU.

Aim

To validate the echocardiographic direct and indirect signs of PH suggested by the guidelines in view of the new definition of PH in patients who underwent echocardiography and RHC.

Methods

All consecutive patients referred between January 2018 and December 2019 to undergo RHC for suspected PH were prospectively enrolled in the study. Echocardiography was performed within one hour from indicated RHC.

Results

Overall, 263 patients were enrolled: 33 (13%) had normal pulmonary pressures, and 230 (87%) had PH. Among the 230 patients with PH, 136 (59%) had pre-capillary and 94 (41%) had post-capillary PH. All underwent echocardiography within one hour from RHC.

At univariable logistic regression test, tricuspid regurgitant jet (TRJ) >2.9 m/sec [OR 8.32 (3.15–26.37, p<0.001)], left ventricle eccentricity index >1.1 [OR 5.57 (2.44–14.41, p<0.001)], right ventricle outflow tract acceleration time <105 msec [OR 4.90 (2.29–10.59, p<0.001)], pulmonary artery diameter >25 mm [OR 4.74 (2.01–13.09, p=0.001)], right-to-left ventricle basal diameter >1 [OR 4.54 (1.83–13.74, p=0.003)], and early diastolic pulmonary regurgitation velocity >2.2 m/sec [OR 3.14 (1.07–13.46, p=0.067)], predicted PH, whereas dilated inferior vena cava and right atrial area did not.

At multivariable analysis, only TRJ >2.9 m/sec [OR 7.95 (2.78–27.07, p<0.001)] and left ventricle eccentricity index >1.1 [OR 4.89 (1.75–15.35, p=0.004)] showed a positive correlation to PH.

The best area under the curve (AUC, 0.86) for predicting PH was obtained with TVR >2.9 m/sec + 2 indirect signs (sensitivity 0.77, specificity 0.94).

Non-invasive estimate of mPAP showed a good correlation to invasive measurement (regression coefficient β 16.8±0.7, p<0.001 and R2 for the linear regression 0.68). The Bland–Altman analysis demonstrated low bias (−2.0 mmHg) and acceptable limits of agreement (upper limit +11.0 mmHg; lower −15.1 mmHg) between echocardiographic estimates and invasive measurement of mPAP (Figure 1).

Conclusions

Echocardiographic direct and indirect signs of PH as suggested by the current guidelines should be used to assess the probability of PH being present. Echocardiographic measurements have high accuracy (low bias) and moderate precision (acceptable limits of agreement) The best area under the curve for predicting PH according to the new definition (mPAP >20 mmHg and PVR ≥3 WU) can be obtained with TVR >2.9 m/sec + 2 indirect signs.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The adding value of fluid challenge and balloon occlusion tests in patients with atrial septal defect

Background

Careful, step-wise assessment is required in all patients with an atrial septal defect (ASD) to exclude pre-existing pulmonary vascular disease or left ventricular disease. Fluid challenge test (FCT) and balloon occlusion testing (BOT) may unmask left ventricular disease and challenge the pulmonary circulation, but their complementary role in the evaluation of patients with “operable” ASD is not well established.

Aim

To evaluate the haemodynamic changes of the pulmonary circulation by FCT and BOT in ASD patients undergoing percutaneous closure according to the current guidelines.

Methods

Consecutive patients selected for percutaneous ASD closure underwent invasive hemodynamic assessment at baseline and after BOT, FCT and both.

Results

Fifty patients (mean age 47.3±11.7 years, 72% female) were included. All patients had a pulmonary-to-systemic flow ratio (QP/QS) ≥1.5, pulmonary vascular resistance (PVR) <5 WU and pulmonary arterial wedge pressure (PAWP) <15 mmHg. Individuals with a PVR ≥2 WU at baseline were older, more symptomatic, with a higher baseline systemic vascular resistance compared to the lower PVR group (PVR <2 WU; p<0.0001). The response of Qp/Qs to FCT was different between groups (p<0.0001, Figure 1). Patients with a lower baseline PVR experienced an increase in Qp/Qs, which remained above 1.5 in all patients, whereas in almost all (90%) patients with a higher baseline PVR, the Qp/Qs fell to below 1.5.

FCT caused a marked increase in pulmonary blood flow of almost 2 liters (p<0.0001) accompanied by increases in PAWP (p<0.0001). BOT led to a modest increase in PAWP (Δ1.5 [−1.0–7.0] mmHg, p<0.0001). FCT added to BOT caused a further increase in PAWP and Qs (both p<0.0001), while PVR was unchanged (p>0.1).

No difference was observed in the PAWP response to FCT, BOT or both between groups; no patients reached a PAWP ≥18 mmHg following FCT or BOT alone, but 4 (8%) patients did following the addition of FCT to BOT. No acute clinical adverse events were experienced by any patients.

Conclusions

None of the reported ASD patients presented with FCT criteria of post-capillary PH (that is a PAWP >18 mmHg). Even small rises in PVR may have significant implications on cardiovascular haemodynamics. In fact, patients with PVR <2 WU showed an increase in Qp/Qs, which remained above 1.5 in all patients, suggesting that they still had a distensible pulmonary circulation, whereas in almost all patients with a PVR ≥2 WU, the Qp/Qs fell to below 1.5.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Effects of sacubitril/valsartan in patients with a systemic right ventricle: early evidence of exercise tolerance and systolic function improvement

Background

Sacubitril/valsartan has been shown to reduce mortality and morbidity inpatients with heart failure and reduced systolic function. However, the effects of this novel association in patients with congenital heart disease and a systemic right ventricle (sRV) have not been investigated yet.

Purpose

We aimed to assess tolerability and efficacy of sacubitril/valsartan in patients with a sRV

Methods

From September 2020 to March 2021, 38 patients with congenitally corrected transposition of the great arteries or transposition of the great arteries after Senning or Mustard repair were prospectively enrolled. Inclusion criteria were: age ≥18 years, optimal medical therapy including ACEi/ARB for at least 6 months and EF of the sRV ≤40%. Patients with univentricular physiology, systolic blood pressure (SBP) <90mmHg, glomerular filtration rate (GFR) <30ml/min or K >5.5mEq/L were excluded. RV systolic function was assessed on echocardiography using a multiparametric evaluation. The study protocol contemplates serial assessments at 1, 3, 6 and 12 months after treatment initiation.

Results

Up to March 31th, 23 patients completed 1-month and 15 completed 3-month assessment after treatment initiation. Baseline patients' characteristics are summarized in table 1. The medication dose was up-titrated to the highest tolerated dose during follow-up. During early follow-up, no major adverse events were reported. Treatment did not impact significantly on the values of serum potassium (basal K+ 4.4 [4.2–4.6] mEq/L, K+ at 3 months 4.4 [4.3–4.6] mEq/L, p=0.7) and GFR (basal GFR 113.9±35ml/min, GFR at 3 months 107.8±21 ml/min, p=0.7). Although SBP did not change significantly (114±12 vs 113.9±19 mmHg at 1-month and 117.3±12 mmHg at 3 months; p=0.9 for both), 2 (5%) patients ceased the treatment due to symptomatic hypotension during the first month of treatment. There was no significant change in the NYHA class. However, the 6-minute walking distance increased significantly after 3 months (365±120 vs 498.3±71 min; p=0.01). Furthermore, while traditional echocardiographic parameters of RV systolic function (TAPSE, s wave and FAC) did not change significantly, RV global longitudinal strain (GLS) and RV free wall GLS demonstrated subclinical improvement in right ventricular systolic function (table 2).

Conclusions

Our short-term results from an ongoing prospective study showed that sacubitril/valsartan is well tolerated in patients with a sRV with early evidence of improvement in exercise tolerance and sRV systolic function. Longer follow-up is warranted to confirm these data.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Prognostic relevance of thyroid disease in adults with congenital heart disease

Background

Adults with congenital heart disease (ACHD) are frequently affected by thyroid diseases (TD). However, the clinical relevance of TD in ACHD remains unknown.

Purpose

We aimed to describe the prevalence of TD in the ACHD population and to ascertain whether TD are associated with worse outcome.

Methods

Clinical data on all consecutive patients aged >18 years attending our ACHD unit for a day-case between 2014 and 2019 were retrospectively collected. For statistical analysis, a composite endpoint was created combining the following events at follow-up: hospitalization for heart failure, new-onset tachyarrhythmic or bradyarrhythmic events and death.

Results

Four hundred ninety-five ACHD patients with a median age of 32.2 [24.5–45.6] years (46% male) were included. There was an overall prevalence of patients with moderate or complex lesions (414=84%). Compared to the group with no history of TD, patients in the TD were older, (41.9 [29.7–53.5] vs 30.2 [24.3–39] years; p<0.0001) and mainly female (77% vs 46%; p<0.0001) and more likely to have undergone at least two cardiac catheterization procedures (29 vs 13%; p<0.0001). Genetic disorders including Down syndrome were more prevalent in the group with TD (p<0.0001). Moreover, at last follow-up, those with TD had higher pro-BNP-nt values (243.5 [96.5–523] pg/ml Vs 94 [45–207] pg/ml; p<0.0001) and were in a more advanced NYHA class (27% vs 13% in class III-IV; p=0.0002). Echocardiography showed lower EF in the TD group (55 [55–60]% vs 60 [55–65]%; p=0.0002).

Median follow-up was 9.4 [4.5–13.1] years. Patients with TD had a higher unadjusted mortality rate, with a trend towards statistical significance (p=0.07). Sixty-four (42%) patients in the TD group and 43 (12.5%) met our composite endpoint, leading to a 10-year survival free from events of 53.7% Vs 86.5%, respectively (p<0.0001, Figure1). Multivariate analysis showed that age, ejection fraction, previous surgical palliation, advanced physiological stage and TD were independent predictors of our composite endpoint, even after stratification for genetic disorders as reported in table1. After adjustment for baseline differences between groups with propensity matching score using age, sex, disease complexity, physiological stage, previous palliative or reparative surgery, normal or reduced systemic ventricle ejection fraction, pulmonary arterial hypertension, cyanosis and presence of systemic right ventricle as independent variables, TD remained a strong predictor of cardiac events at follow-up with an hazard ratio of 4.47 (95% CI 2.42–8.28; p<0.0001).

Conclusion

TD is a strong predictor of adverse outcome in the ACHD population after exclusion of potential confounding factors, being related to a fourfold increased risk of events at follow-up.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Circulating CD4+T/methylation signatures of network-oriented SOCS3, ITGAL, NFIC, NCOR2, PGK1 genes associate with hemodynamics in pulmonary arterial hypertension patients

Background

CD4+ T cells are associated with pulmonary arterial hypertension (PAH) pathogenesis but mechanistic insights are limited.

Purpose

To identify differential CD4+ T methylation signatures in healthy controls vs PAH and evaluate a putative association with the cardiopulmonary hemodynamic profile of affected patients.

Methods

We used RRBS platform to profile CD4+ T DNA methylome in the CLEOPAHTRA clinical trial.

Results

Differentially methylated CpG sites (N=631) annotated to N=408 genes (DMGs). Most of them (65%) were hypermethylated and localized in distal intergenic (36%) and promoter regions (31%). Promoter-related network analysis established the PAH subnetwork highlighting 5 hub DMGs (SOCS3, GNAS, ITGAL, NCOR2, NFIC) and 5 non-hub DMGs (NR4A2, GRM2, PGK1, STMN1, LIMS2) as potential candidate genes (Figure 1). The Infinium Human MethylationEPIC BeadChip on CD4+ T cells from an independent study population confirmed the global RRBS-methylation trends. Both in idiopathic and Associated-PAH, each of these 10 network-oriented DMGs was strongly correlated with at least one hemodynamic parameter such as right atrial pressure (RAP), cardiac index (CI), mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR), and pulmonary capillary wedge pressure (PCWP) (Figure 2). In addition, mRNA levels of the ITGAL, NFIC, NCOR2, PGK1 genes and the IL-6-STAT3-SOCS3 signaling axis were significantly upregulated in PBMCs from patients with PAH vs controls suggesting putative drug targets. Furthermore, both SOCS3 methylation and mRNA levels were positively correlated with cardiac index (CI) in idiopathic PAH whereas both PGK1 methylation and mRNA levels were positively correlated with RAP and inversely with CI in Associated PAH suggesting putative non-invasive biomarkers.

Conclusions

This hypothesis-generating study shows for the first time that circulating CD4+ T methylation signatures, inclusive of SOCS3, ITGAL, NFIC, NCOR2, and PGK1 genes may yield insight into pro-inflammatory mechanisms that exacerbate vascular remodeling in PAH and suggest non-invasive biomarkers to optimize patient phenotyping and, possibly, prognostication in PAH.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PRIN2017F8ZB89 from Italian Ministry of University and Research (MIUR) (PI Prof Napoli) and Ricerca Corrente (RC) 2019 from Italian Ministry of Health (PI Prof. Napoli). Figure 1Figure 2

Role of Cancer Surgery in the Improvement of the Operative Skills of Military Surgeons During Deployment: A Single-Center Study

INTRODUCTION

The maintenance of military surgeons' operative skills is challenging. Different and specific training strategies have been implemented in this context; however, little has been evaluated with regard to their effectiveness. Cancer surgery is a part of military surgeons' activities in their home hospitals. This study aimed to assess the role of oncological surgery in the improvement of military surgeons' operative skills.

METHODS

Between January and June 2019, the surgical activities of the departments of visceral, ear, nose, and throat, urological, and thoracic surgery were retrospectively reviewed and assessed in terms of the operative time (OT). All surgeons working at the Sainte Anne Military Teaching Hospital were sent a survey to rate on a 5-point scale the current surgical practices on their usefulness in improving surgical skills required for treating war injuries during deployment (primary endpoint) and to compare on a 10-point visual analog scale the influence of cancer surgery and specific training on surgical fluency (secondary endpoint).

RESULTS

Over the study period, 2,571 hours of OT was analyzed. Oncological surgery represented 52.5% of the surgical activity and almost 1,350 hours of cumulative OT. Considering the primary endpoint, the mean rating allocated to cancer surgery was 4.53 ± 0.84, which was not statistically different than that allocated to trauma surgery (4.42 ± 1.02, P = 0.98) but higher than other surgery (2.47 ± 1.00, P < 0.001). Considering the secondary endpoint, cancer surgery was rated higher than specific training by all surgeons, without statistically significant difference (positive mean score of + 2.00; 95% IC: 0.85-3.14).

CONCLUSION

This study demonstrates the usefulness of cancer surgery in improving the operative skills of military surgeons.

How did we take care of our older cancer patients during the first COVID-19 wave? The French experience

BACKGROUND

The management of older cancer patients has been highly challenging for clinicians in a health-care system operating at maximum capacity during the COVID-19 pandemic.

PATIENTS AND METHODS

We analyzed data from 9 different institutions. The primary endpoint was to assess the prevalence of adapted patient care during the pandemic for elderly cancer patients. The secondary endpoint was to assess the incidence of hospitalization and mortality due to COVID-19. All patients were older than 65years of age.

RESULTS

We analyzed data from 332 outpatients' case files between 9th of March and 30th of April 2020. The median age was 75years (range: 65-101) and 53% were male. Because of the COVID-19 pandemic, more than half of the outpatients received modified patient care, defined as postponement or cancellation of surgery, irradiation scheme adapted, systemic treatment or the use of telemedicine. Among patients with localized cancer, 60% had a change in management strategy due to the pandemic. Changes in management strategy were made for 53% of patients at the metastatic stage. GCSF was used , in 83% of patients, increasing considerably in the context of the pandemic. Sixty-nine percent of physicians used telemedicine. In the final analysis, only one patient was hospitalized for COVID-19 infection. No deaths due to COVID-19 were reported in elderly cancer patients during this time period.

CONCLUSION

Our study is the first to assess modification of patient care in elderly cancer outpatients during an epidemic. With this unprecedented crisis, our objective is to protect our patients from infection via protective barrier measures and social distancing, but also to guarantee the continuity of cancer care without overexposing this fragile population. Physicians were able to adapt their practice and used new forms of management, like telemedicine.

Response to fluid challenge in patients with atrial septal defect

Background

A fluid challenge test (FCT) with a rapid infusion of saline allows for discrimination between pre- and post-capillary pulmonary hypertension (PH) and may unmask hidden post-capillary PH. Patients with atrial septal defect (ASD) may develop pre- or post-capillary PH after shunt closure respectively in case of pulmonary vascular disease or left ventricular disease.

Aim

To evaluate the haemodynamic changes of the pulmonary circulation in ASD patients undergoing percutaneous closure with indicated according to the current ESC guidelines.

Methods

Twenty-three patients (mean age 42.9±12.4 years; 15 female) underwent right heart catheterization in basal conditions and after FCT (volume loading with rapid saline infusion of 7 ml/kg in 10 min) before percutaneous closure of the ASD.

Right atrial pressure (RAP), systolic, mean and diastolic pulmonary arterial pressure (sPAP, mPAP and dPAP), pulmonary arterial wedge pressure (PAWP), cardiac output (CO), pulmonary vascular resistance (PVR), systemic vascular resistance (SVR) and the ratio between pulmonary and systemic flow (QP/QS) were calculated four times: before and after inflating the sizing balloon both at baseline and immediately after FCT (Fig. 1).

Results

The patients had an increase in pressures and flows after FCT with open ASD: mPAP (18.7±4.4 vs 16.7±4.6 mmHg, p&lt;0.001), PAWP (11.3±3.1 vs 9.2±3.0 mmHg, p&lt;0.001), QP (12.5±2.3 vs 10.3±2.0 l/min, p&lt;0.001), and QS (6.6±1.4 vs 5.9±1.2 l/min, p&lt;0.001) but RAP remained unchanged (8.7±3.0 vs 8.3±2.4 mmHg, p=0.35). PVR (0.2±0.4 vs 0.8±0.3 Wood Units, p&lt;0.001) and SVR (11.2±3.2 vs 12.5±3.2 Wood Units, p=0.02) decreased, and PVR/SVR (0.06±0.02 vs 0.06±0.3, p=0.25) remained unchanged. QP/QS increased in all patients after FCT (mean±SD: 2.0±0.4 vs 1.8±0.4, p&lt;0.001).

During a temporary ASD closure by sizing balloon, the patients had increases of RAP (9.0±2.6 vs 7.6±2.6 mmHg, p&lt;0.001) mPAP (19.5±4.0 vs 17.4±3.7 mmHg, p&lt;0.001), PAWP (13.2±2.1 vs 11.2±2.9 mmHg, p&lt;0.001), and CO (7.7±2.7 vs 6.8±2.3 l/min, p&lt;0.001) after FCT. PVR remained unchanged (0.9±0.4 vs 1.1±0.6, p=0.12) and SVR reduced (9.8±2.7 vs 11.3±2.9, p&lt;0.001) after FCT.

Conclusions

None of the reported ASD patients presented with FCT criteria of post-capillary PH (that is a PAWP &gt;18 mmHg). The FCT was associated with an increase in QP/QS suggesting that the patients still had a distensible pulmonary circulation. Further studies are needed to explore the relevance of a FCT in ASD patients, particularly those with higher PVR values.

Figure 1

Funding Acknowledgement

Type of funding source: None

Determinants of pulmonary vascular resistance reduction with upfront oral therapy in idiopathic pulmonary arterial hypertension: relevance in risk assessment

Background

In pulmonary arterial hypertension (PAH) upfront oral therapy represents the standard of care for naive patients at low and intermediate risk. However little is known about associated changes in risk assessment and prediction of low risk status achievement.

Purpose

To evaluate determinants of PVR reduction in patients treated with upfront oral therapy and to create a score to predict PVR reduction after upfront oral treatment and compared its additive value on top of the European and REVEAL scoring system in predicting treatment response.

Methods

One-hundred-eighty-one consecutive naive PAH patients treated with upfront therapy at 11 italian centers were retrospectively evaluated. Evaluation included clinical, hemodynamic and simple echocardiographic parameters, together with European and REVEAL 2.0 risk scores.

Results

At the time of diagnosis, the majority of the patients was idiopathic PAH (80.6%), female (66.3%), at intermediate risk, 71.8% and 55.2%, respectively, according to the European (average method) and the REVEAL 2.0 risk scores. Ambrisentan-Tadalafil was the most frequent combination used (62%). The median PVR reduction obtained after 180 days (IQR 79–394) was −40.4% (IQR −25.8; −45.3).

Age ≥60 years, male-sex, baseline mPAP 48 mmHg associated with low CI (&lt;2.5 l/min/m2), and RV/LV ratio &gt;1 associated with low TAPSE (&lt;18 mm) emerged as independent predictors of poor PVR reduction, defined as the lower tertile of PVR changes (−25.8%). A treatment response score was created deriving weighted integers from the beta coefficient.

At second evaluation 78 (43.1%) patients achieved or remained at European-derived low risk status, while 63 (34.8%) considering the REVEAL 2.0 score.

Multivariate analysis for the prediction of treatment failure, defined as the absence of low-risk status at follow-up, demonstrated the incremental prognostic power of the models incorporating the treatment response score (≥3) on top of the European and REVEAL 2.0 scores, improving risk discrimination by 63.2% (IDI index 0.056) and 36.8% (IDI index 0.080), respectively.

Conclusions

A significant proportion of PAH patients treated with upfront oral combination are not able to achieve a low-risk status. The treatment response score helps clinicians in predicting treatment failure at the time of diagnosis.

Funding Acknowledgement

Type of funding source: None

Risk of nasopharyngeal cancer in productive sectors and formaldehyde exposure in bakeries industry

Background

The International Agency for Research on Cancer evaluated formaldehyde (F) as carcinogenic for human in association with Nasopharyngeal Cancer (NPC). Occupational exposure to F occurs in many industrial sectors also in those non-traditional. For example in Tuscany F was detected in a bakery where a NPC case had ever worked.

Methods

In this study a) A case control approach (OCCAM) was used for monitoring occupational risks based on current information sources. Three Italian Regional Operating Centres, collected NPC cases from cancer registries and/or hospital discharge records. Controls were randomly sampled from the regional health service population data. Occupational histories were available through record linkage with the social security pension database (INPS). Study results were reported by industrial sectors, area and gender. b) A specific study on F exposure was conducted in bakeries and pastry industry carrying out measurements to determine the concentration of F in specific tasks and positions.

Results

717 cases linked with INPS database. Increased ORs for several industrial sectors such as iron and steel, wood and plastic were observed. In two regions also health and veterinary services and hairdressers were at increased risk, but based on few cases of exposed workers. In the non traditional sector of bakeries and pastry industries, where workplaces were monitored, high levels of F in personal air samplings were found, in particular in processes that involve a strong leavening.

Conclusions

Many productive sectors, in which F exposure could occurred, were observed to be at higher risk. The measurements performed in the non traditional sector monitored, confirmed the F exposure in some phases of the work process. With this study we contributed to increased knowledge on the risk of NPC within the monitoring system of occupational risks, and to deepen exposure to F in a non traditional productive sector such as bakeries and pastry industries.

Key messages

The epidemiological method used (OCCAM) in this study provides further information on the role of occupational exposure in the development of nasopharyngeal cancer. The measurements performed in the bakeries and pastry industries provide new additional information on the exposure to formaldehyde in some work process phases of a non-traditional productive sector.

P4160Safety and efficacy of triple combination therapy with parenteral prostanoids in patients with Eisenmenger physiology

Aim

While combination therapy is currently strongly advocated for idiopathic pulmonary arterial hypertension (PAH) patients, evidence to support its use in patients with PAH related to congenital heart disease (CHD), especially patients with Eisenmenger syndrome, is lacking. We evaluated the efficacy and safety of sequential triple combination therapy with parenteral prostanoids after failure of double oral therapy in patients with PAH-CHD and Eisenmenger physiology.

Methods

This is an international, multicentre, retrospective cohort study conducted in adult patients with Eisenmenger physiology on double oral PAH therapy in whom intravenous or subcutaneous prostanoid treatment was added due to clinical deterioration or failure to reach the treatment goals. Clinical status, 6-minute walk test distance (6MWD), biomarkers and haemodynamics were assessed at baseline and during the follow-up.

Results

A total 28 patients with Eisenmenger syndrome (6 [21%] male, age 37.6±14.3 years) were included. A post-tricuspid shunt was present in 16 (57%), 86% of whom had a ventricular septal defect. The majority (89%) were treated with subcutaneous treprostinil. At 27±14 months follow-up, WHO functional class improved in 18 (64%), remained unchanged in 8 (29%), and deteriorated in 2 (7%) patients. There was also an increase in 6MWD (mean 339±145 versus 233±140m, p=0.0001, fig 1A) and a reduction in NT-proBNP levels (median 1125 [123–5882] versus 3087 [234–7428] pg/mL, p<0.0001, fig 1B). On follow-up cardiac catheterization, an improvement in right atrial pressure (8±2 versus 11±5 mmHg, p=0.01), mean pulmonary artery pressure (68±12 versus 72±17 mmHg, p=0.005), cardiac index (2.3±0.3 versus 2.0±0.5 l/min/m2, p=0.005, fig 1C), and pulmonary vascular resistance (17±7 versus 21±10, p=0.008, fig 1D), was observed compared to baseline. No patients discontinued treatment. Five (18%) patients died during follow up.

Figure 1

Conclusions

Triple combination therapy with subcutaneous treprostinil or endovenous epoprostenol in patients with Eisenmenger syndrome is safe and well tolerated at 2 years follow-up, resulting in a significant improvement in clinical status, exercise tolerance and haemodynamics.

4972Upfront triple combination therapy with ambrisentan, tadalafil and subcutaneous treprostinil in incident patients with severe pulmonary arterial hypertension

Aim

Current treatments strategies for high-risk patients with pulmonary arterial hypertension (PAH) are based on the use of parenteral prostanoids. The evidence to support triple upfront combination therapy remains largely based on expert consensus or small studies. Aim of this study was to evaluate the efficacy and safety of an upfront triple combination therapy with ambrisentan, tadalafil and subcutaneous (sc) treprostinil in patients with severe PAH.

Methods

This is a multi-center retrospective analysis of patients with newly diagnosed severe PAH treated with upfront triple combination therapy with ambrisentan, tadalafil and sc treprostinil between 2014 and 2018. Clinical evaluations, WHO functional class (FC), 6-min walk distance, biomarkers and right heart catheterization were collected from the patients' medical records at baseline and during the follow-up.

Results

Overall, 20 patients (mean age 44±15 years, 15 female) were included.

Over a median follow-up of 12 months, all patients were still alive on triple combination therapy. At baseline 11 patients were in WHO-FC 3 and 9 patients in WHO-FC 4. At follow-up, WHO-FC (2.0±0.5 vs 3.5±0.5, p<0.001, improved in all: 2, 16, and 2 patients in FC 1, 2 and 3, respectively), exercise capacity (431±67 vs 152±130 m, p<0.001), NT-proBNP (423±260 vs 3492±1864 pg/ml; p<0.001), and haemodynamics (right atrial pressure 5±2 vs 13±3 mmHg, p<0.001; mean pulmonary artery pressure 42±5 vs 60±9 mmHg, p<0.001; cardiac index 3.5±0.8 vs 1.8±0.3 l/min/m2, p<0.001; pulmonary vascular resistance 5.5±1.3 vs 16.4±4.4 Wood units, p<0.001; pulmonary arterial compliance 2.5±0.9 vs 0.8±0.3 ml/mmHg, p<0.001) significantly improved compared with baseline. No patient discontinued the therapy due to serious adverse events.

Conclusions

Triple upfront combination therapy with ambrisentan, tadalafil and sc treprostinil is safe and offers clinical and heamodynamics benefits in incident patients with severe PAH.

An Important Role for N-Acylethanolamine Acid Amidase in the Complete Freund's Adjuvant Rat Model of Arthritis

The endogenous lipid amides, palmitoylethanolamide (PEA) and oleoylethanolamide (OEA), exert marked antinociceptive and anti-inflammatory effects in animal models by engaging nuclear peroxisome proliferator-activated receptor-α. PEA and OEA are produced by macrophages and other host-defense cells and are deactivated by the cysteine amidase, N-acylethanolamine acid amidase (NAAA), which is highly expressed in macrophages and B-lymphocytes. In the present study, we examined whether a) NAAA might be involved in the inflammatory reaction triggered by injection of complete Freund's adjuvant (CFA) into the rat paw and b) administration of 4-cyclohexylbutyl-N-[(S)-2-oxoazetidin-3-yl]-carbamate (ARN726), a novel systemically active NAAA inhibitor, attenuates such reaction. Injection of CFA into the paw produced local edema and heat hyperalgesia, which were accompanied by decreased PEA and OEA content (assessed by liquid chromatography/mass spectrometry) and increased NAAA levels (assessed by Western blot and ex vivo enzyme activity measurements) in paw tissue. Administration of undec-10-ynyl-N-[(3S)-2-oxoazetidin-3-yl] carbamate (ARN14686), a NAAA-preferring activity-based probe, revealed that NAAA was catalytically active in CFA-treated paws. Administration of ARN726 reduced NAAA activity and restored PEA and OEA levels in inflamed tissues, and significantly decreased CFA-induced inflammatory symptoms, including pus production and myeloperoxidase activity. The results confirm the usefulness of ARN726 as a probe to investigate the functions of NAAA in health and disease and suggest that this enzyme may provide a new molecular target for the treatment of arthritis.

Paediatric ulcerative colitis surgery: Italian survey

BACKGROUND AND AIMS

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons.

METHODS

This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected.

RESULTS

Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively.

CONCLUSIONS

This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

[Bing-Neel syndrome: Report of 4 cases and literature review]

INTRODUCTION

Neurological manifestations during Waldenstrom disease are common and are usually related to immune peripheral neuropathy or serum hyperviscosity syndrome. The infiltration of the central nervous system by the lymphoproliferative syndrome is known as the Bing-Neel syndrome. This extremely rare entity remains poorly described in the literature.

CASE REPORTS

We report on 4 cases of patients for whom central neurological disorders led to the diagnosis of a Bing and Neel syndrome. These four cases illustrate different clinical presentations, diagnosis, therapeutic options, and outcome in this syndrome. Based on our literature review, we discuss about these differences.

CONCLUSION

The polymorphic clinical manifestations of Bing and Neel syndrome can mimic many diagnoses. However, it may be necessary to consider this diagnosis. Cerebrospinal fluid analysis and MRI may allow rapid diagnosis or guide a biopsy. Prolonged remissions are possible with appropriate treatment.

[Can we prevent or cure infection-related cancers?]

Infections are an important cause of cancer in the world, representing approximately 16% of the neoplasia. Ten infectious agents have been classified as carcinogens of group I. Four of these pathogens (Helicobacter pylori, hepatitis B and C viruses, and some human papillomavirus) are responsible for 95% of cases of infection-related cancers. The carcinogenesis mechanisms are multiple, either direct via certain proteins from these microorganisms, or more often indirect through chronic inflammation. This allowed to consider prevention of certain cancers, for example with a prophylactic vaccine strategy. Advances were also made in the curative field. However, efforts remain to be done to discover new infectious causes of cancer and refine the understanding of the mechanisms of carcinogenesis, for a better targeting of anticancer therapeutics.

Systematic review of the survival rate and the biological, technical, and aesthetic complications of fixed dental prostheses with cantilevers on implants reported in longitudinal studies with a mean of 5 years follow-up

OBJECTIVE

A systematic review was carried out to evaluate the success and survival rate of implants supporting cantilever prosthesis, as well as the incidence of technical and biological complications.

MATERIAL AND METHODS

A MEDLINE search was conducted up to December 2011 for studies with a mean follow-up of 5 years or more. Two independent reviewers screened the retrieved articles and extracted the data independently. Data on survival, failure, mechanical/technical and biological complications were analyzed.

RESULTS

One-hundred and sixty articles were selected as abstract. Only 18 underwent a full-text analysis and only six were included in the study. The estimated cumulative survival rate of implants supporting cantilevered prosthesis was 98.9% (95% CI: 97.4-99.5%), whereas ICFDP survival was estimated to be about 97.1% (95% CI: 90.1-99.2%). Implant failures before prosthetic delivery were not considered. Biological complications were estimated to be 5.7% (95% CI: 4.2-7.6%) at implant level after 5 years. Technical complications were analyzed: the most common complications were veneer fractures (5-year estimate: 10.1%; 95% CI: 3.7-16.5%) and abutment screw fractures (5-year estimate: 1.6%; 95% CI: 0.8-3.5%). Decementation and screw loosening were estimated to be at 5 years 5.9% (95% CI: 1.7-16.8%) and 7.9% (95% CI: 3.2-18.2%), respectively. Implant fracture was rare (5-year estimate: 0.7%; 95% CI: 0.1-4.7%); no framework fracture was reported. Radiographic bone level changes did not yield statistically significant differences. No aesthetic outcome was reported.

CONCLUSIONS

ICFDPS can be considered a reliable treatment: the systematic review assessed that there is no increase in complication rate due to the presence of the cantilever.

Neurocognitive effects of methylphenidate on ADHD children with different DAT genotypes: a longitudinal open label trial

The variable number of tandem repeat polymorphism in the 3'-untranslated region of the dopamine transporter gene (DAT) may influence the variability of the therapeutic response to methylphenidate (MPH) in Attention Deficit/Hyperactivity Disorder (ADHD). For this reason we evaluated the neuropsychological functioning after a prolonged period of MPH treatment and after a specific time from MPH suspension. Relationship between DAT VNTR genotypes and neurocognitive response to MPH was analyzed in a sample of 108 drug-naive ADHD patients. The performance of children with ADHD on measures of working memory, inhibition and planning was assessed at 4, 8 and 24 weeks and at 8 weeks after MPH withdrawal. Patients with 9/9 genotype evidenced an improvement in response inhibition and working memory only at 4 weeks of treatment, in planning at 24 weeks of therapy and after 8 weeks of MPH suspension. Patients with 9/10 showed an improvement in response inhibition at 4, 8 and 24 weeks of treatment, in planning at 24 weeks and after 8 weeks of MPH suspension. Patients with 10/10 evidenced an improvement in response inhibition and working memory at 4, 8 and 24 weeks of treatment and in planning at 4, 8 and 24 weeks of treatment and after 8 weeks of suspension. These results indicate that the 9/9 ADHD genotype has a different response at 24 weeks treatment with MPH. 10/10 DAT allele seems to be associated with an increased expression level of the dopamine transporter and seems to mediate the MPH treatment response in ADHD patients.

Dynamic esophageal stents

Esophageal stenting represents a new strategy in the treatment of resistant or recurrent stenosis that obviates the need for multiple dilations. Our custom dynamic stent (DS) improves esophageal motility unlike the widespread self-expandable plastic or metallic esophageal stents. The DS allows food and secretions to pass in the space between the esophageal wall and the stent wall. This contrasts with the other types of stent, in which food passes into the stent that presses into the esophageal wall. Until the stent patent is complete, we use slices of silicon drains overlapped with each other to fashion the stent to the desired length and diameter (7-, 9-, or 12.7-mm external diameter). It is built coaxially on a nasogastric tube that guarantees the correct position. The two ends are tailored to allow an easy introduction and food passage between stent and esophageal wall. The stent is inserted after stricture dilations (Savary-Gilliard dilators) under fluoroscopic guidance. All patients who underwent stenting were treated with dexamethasone (2 mg/kg/day) for 3 days and proton pump inhibitors (omeprazole or lansoprazole, 1-2 mg/kg/day). From 1992 to 2012, 387 patients (mean age 38.6 months; range 3-125 months) with post-surgical esophageal stricture because of esophageal atresia correction were enrolled in this study. Twenty-six of 387 patients (6.7%) underwent custom DS placement for recurrent stricture instead of a program of serial dilations. The stent was left in place for at least 40 days and was effective in 21 (80.7%) of 26 patients. There were two stent-related major complications (subclavian-esophageal fistula). Our custom stent represents an effective and safe option in the treatment of severe and recurrent post-surgical esophageal strictures. Surgery with stricture resection, and reanastomosis or jeunoplasty represents the rescue strategy.

Management of peri-implant soft tissues between tooth and adjacent immediate implant placed into fresh extraction single socket: a one-year prospective study on two different types of implant-abutment connection design

AIM

This prospective study has been designed to evaluate the correlation between the presence/absence of the interproximal papilla and the mesio-distal and corono-apical position single-tooth replacement implants inserted immediately following tooth extraction. These distances have been evaluated measuring the horizontal distance between the implant and the adjacent tooth (implant tooth distance, ITD) and the vertical distance between the contact point and the coronal margin of the interproximal bone (contact point-bone distance, CPB).

METHODS

Fifty implants (25 Astratech® straight and 25 Straumann®) immediately placed after tooth extraction in highly aesthetic areas have been evaluated by means of clinical and radiographic evaluation. Gingival index (GI) and the presence/absence of the interproximal papilla were clinically measured. A computerized analysis was performed to determine ITD and CPB values after converting perioapical radiographs to digitalized images. were performed to determine: the effect of ITD and CPB on the presence or absence of the interproximal papilla was studied by statistical analysis.

RESULTS

The gingival index was 0 in 97% of the areas and 1 in 3%. When ITD was 2.5 to 4 mm, the interproximal papilla was significantly present (P<0.05). CPB of 3 to 5 mm was related (P<0.05) to the papilla presence if ITD was 2.5 to 4 mm, and this finding was valid for Astratech implants only.

CONCLUSION

The horizontal distance of 2.5 to 4 mm between an implant and the adjacent tooth is significantly associated to a full interproximal papilla.

Dietary interactions and INR variability: retrospective evaluation of patients couples on oral anticoagulant therapy

AIM

The association between dietary vitamin K intake and International Normalized Ratio (INR) variability in patients on oral anticoagulants treatment (OAT) has been evaluated in several studies. Changes in diet composition are known to lead to INR variability. We evaluated INR over time in married couples on OAT and non-cohabitant couples on OAT, to assess clinical relevance of the diet.

METHODS

Among outpatients receiving OAT we selected 31 married couples. Husbands and wives were then matched by demographic and clinical characteristics to 31 men and 31 women on OAT not married nor living together. We analyzed 6,357 INR measurements recorded from February 1998 to November 2009.

RESULTS

We found similar average INR values within married couples and also within non-cohabitant couples. Using mixed models we confirmed INR differences between seasons and the slightly lower INR in non-cohabitant couples compared to married couples; although statistically significant, they were of marginal clinical significance.

CONCLUSION

Within both married and non-cohabitant couples, we did not find statistically or clinically significant differences between men and women over time. The lack of INR differences over time within non-cohabitant couples indicates that diet is not an important determinant of INR over time. Also seasonal INR variations and differences between married and non-cohabitant couples were of little practical importance.