Chronic thromboembolic pulmonary disease: Association with exercise-induced pulmonary hypertension and right ventricle adaptation over time

BACKGROUND AND AIM

Chronic thromboembolic pulmonary disease (CTEPD) is a progressive condition caused by fibrotic thrombi and vascular remodeling in the pulmonary circulation despite prolonged anticoagulation. We evaluated clinical factors associated with CTEPD, as well as its impact on functional capacity, pulmonary haemodynamics at rest and after exercise, and right ventricle (RV) morphology and function.

METHODS

We compared 33 consecutive patients with a history of acute pulmonary embolism and either normal pulmonary vascular imaging (negative Q-scan, group 1, n = 16) or persistent defects on lung perfusion scan (positive Q-scan) despite oral anticoagulation at 4 months (group 2, n = 17). Investigations included thrombotic load, the Pulmonary Embolism Severity Index (PESI) score, functional class, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cardiopulmonary exercise test (CPET) and echocardiographic parameters at rest and after exercise (ESE), at 4 and at 24 months.

RESULTS

Compared with group 1, group 2 featured a higher PESI score (p = 0.02) and a higher thrombotic load (p = 0.004) at hospital admission. At 4 months, group 2 developed exercise-induced pulmonary hypertension (Ex-PH) at CPET (p < 0.001) and ESE (p < 0.001). At 24 months group 2 showed higher NT-proBNP (p < 0.001), WHO-FC (p < 0.001), systolic (p<0.001) and diastolic (p = 0.037) RV dysfunction and worse RV-arterial coupling (p < 0.001) despite maintaining a low or intermediate echocardiographic probability of PH.

CONCLUSIONS

This is the first "proof of concept" study showing that patients with a positive Q-scan frequently develop Ex-PH and RV functional deterioration as well as reduced functional capacity, generating the hypothesis that Ex-PH could help detect the progression to CTEPD.

Cardiovascular outcomes and molecular targets for the cardiac effects of Sodium-Glucose Cotransporter 2 Inhibitors: A systematic review

Sodium-glucose cotransporter 2 inhibitors (SGLT2i), a new class of glucose-lowering drugs traditionally used to control blood glucose levels in patients with type 2 diabetes mellitus, have been proven to reduce major adverse cardiovascular events, including cardiovascular death, in patients with heart failure irrespective of ejection fraction and independently of the hypoglycemic effect. Because of their favorable effects on the kidney and cardiovascular outcomes, their use has been expanded in all patients with any combination of diabetes mellitus type 2, chronic kidney disease and heart failure. Although mechanisms explaining the effects of these drugs on the cardiovascular system are not well understood, their effectiveness in all these conditions suggests that they act at the intersection of the metabolic, renal and cardiac axes, thus disrupting maladaptive vicious cycles while contrasting direct organ damage. In this systematic review we provide a state of the art of the randomized controlled trials investigating the effect of SGLT2i on cardiovascular outcomes in patients with chronic kidney disease and/or heart failure irrespective of ejection fraction and diabetes. We also discuss the molecular targets and signaling pathways potentially explaining the cardiac effects of these pharmacological agents, from a clinical and experimental perspective.

Delayed hypersensitivity reactions to iodinated contrast media: A diagnostic approach by skin tests

BACKGROUND

Adverse drug reactions to iodinated contrast media (ICM) have risen due to their increasing use in x-ray-based imaging modalities. Delayed hypersensitivity reactions are mainly caused by nonionic monomeric compounds and represent an issue impacting the diagnostic-therapeutic pathways of cancer, cardiology and surgery patients.

OBJECTIVES

To prospectively evaluate the usefulness of skin tests in delayed hypersensitivity reactions to ICM and to evaluate the tolerability of iobitridol, a monomeric nonionic low osmolality compound, as a possible safe alternative.

METHODS

Patients with delayed hypersensitivity reactions to ICM referred to us from 2020 to 2022 were prospectively enrolled in the study. All patients underwent patch test and, if negative, intradermal test with the culprit ICM and iobitridol as alternative.

RESULTS

A total of 37 patients (females 24, 64.9%) were enrolled in the study. Iodixanol and iomeprol were the most frequently involved ICM (48.5% and 35.2%, respectively); 62.2% of patients presented maculopapular eruption, while 37.8% reported delayed urticaria-like rash. Skin tests resulted positive to the culprit ICM in 19 patients (51.4%), 16 to patch test and 3 to intradermal test. Skin tests with iobitridol, tested as alternative, resulted positive in 3/19 patients (15.8%). All 16 patients with negative results to iobitridol were administered this ICM and tolerated it.

CONCLUSIONS

In at least half of patients, delayed-type hypersensitivity was demonstrated by skin tests, particularly by patch test. This diagnostic approach resulted simple, cost-effective and safe, not only to confirm the culprit ICM but also to identify iobitridol as feasible alternative.

Efficacy of injecting hybrid cooperative complexes of hyaluronic acid for the treatment of vulvar lichen sclerosus: A preliminary study

BACKGROUND

Lichen sclerosus is a chronic relapsing inflammatory skin disease, which involves most commonly the anogenital region. The gold standard in treatment is ultra-potent topical steroids (clobetasol propionate): it aims at controlling the symptoms, stopping further scarring and distortion, and reducing the risk of cancer.

OBJECTIVES

The aim of this preliminary study is to evaluate the efficacy of injecting Hybrid Cooperative Complexes of Hyaluronic Acid (HCC) for the treatment of vulvar lichen sclerosus (VLS).

METHODS

Twenty female adult patients (range: 21-78 years), aged over 18, with histopathological diagnosis of lichen sclerosus and good general conditions were enrolled. Patients underwent HCC infiltration every month, for 3 times. Patients were evaluated at baseline (T0) and after one (T1) and six months (T2) after treatment. During every visit, each patient was studied clinically and with videothermography. Itching, burning sensation, pain, and dyspareunia were reported by patients at T0, T1, and T2. The effectiveness of the treatment on patients' quality of life and sexual function was evaluated using the Dermatology Life Quality Index (DLQI) and the Female Sexual Function Index (FSFI) at T0 and at T2.

RESULTS

The results of this preliminary study are very promising, in fact, all patients had a significant reduction in most symptoms after 1 and 6 months of HCC treatment. The reduction of patients with itching (p value ≤ 0.001), pain (p value = 0.031), and burning sensation (p = 0.004) at 6 months is significant. The analysis of DLQI scores revealed a significant improvement in patients' quality of life. At baseline, the average score of DLQI (±SD) was 5.89 ± 3.68 while at follow-up it was 3.42 ± 2.36 (p = 0.002).

CONCLUSIONS

Our preliminary study has demonstrated the validity and tolerability of HCC infiltrations in patients with VLS, and the effectiveness of HCC in reducing symptoms and, thus, to improve sexuality and patient quality of life.

Contact allergy to hydroxyisohexyl 3-cyclohexene carboxaldehyde in Italy: Prevalence, trend, and concordance with fragrance mix II

BACKGROUND

Hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), contained in fragrance mix II (FM II), has been recognized as a contact sensitizer since the mid-1990s. After several attempts to reduce its use during the last two decades, HICC was permanently banned from the European market in August 2021.

OBJECTIVES

To assess the prevalence and the time trend of contact allergy to HICC and to investigate the concordance of HICC allergy compared to FM II allergy in an unselected Italian patch test population.

METHODS/PATIENTS

Retrospective analysis on demographics and patch test results of HICC-sensitized and/or FM II-sensitized patients was performed over a 6-year period (2016-2021) at 6 patch test Clinics in Italy.

RESULTS

Among 7266 patients (4942 females, 68.0%, mean age 45.4 ± 20.6 years), 1% (70) resulted positive to HICC and 2.1% (153) to FM II. Clinical relevance was documented in 72.9% (51/70) of HICC positive patients. Among the 169 HICC and/or FM II positive patients, 9.5% had a positive reaction to HICC only, 31.9% to both HICC and FM II, and 58.6% to FM II only. The prevalence trend line of HICC positive reactions showed a decrease from 1.15% (2016) to 0.96% (2021).

CONCLUSIONS

We documented a decreasing trend of HICC allergy in Italy, in line with the data recently reported in literature. Nevertheless, HICC should be maintained in the baseline series to monitor the benefits of its ban from the European market.

346 IMPACT OF EXERCISE-INDUCED PULMONARY HYPERTENSION ON THE RIGHT VENTRICLE AND WORSENING OF CARDIOVASCULAR RISK IN HIV PATIENTS

Background and Aim

Exercise-induced pulmonary hypertension (ExPH), due to impaired pulmonary vascular and right ventricular contractile reserve on effort,predicts clinical outcomes, such as all-cause mortality or cardiovascular (CV) hospitalizations in patients with dyspnea on effort. We investigated its prognostic significance in HIV patients at risk for Pulmonary Arterial Hypertension (PAH).

Methods

In 52 consecutive HIV patients with either low (n=47) or intermediate probability (n=5) of PH at rest, we evaluated at time 0 and after 2 years the prognostic determinants of CV risk: onset or progression of heart failure/syncope; worsening of functional class; functional performance at the 6-Minute Walking Test and at cardiopulmonary exercise test (CPET); right atrial area; and pericardial effusion. We assigned a severity score 1-3 to each prognostic determinant, derived an overall CV risk score, and its 0-2 years change. Patients were classified as either at low, intermediate or high probability of ExPH at Stress Echocardiography (ESE), while ExPH at CPET was defined as absence of PH at rest, reduced peak VO2, VE/VCO2 &gt;30 at anaerobic threshold, reduced O2 pulse, and ΔVO2/ΔW &lt;9 mL/min/W. We then correlated ExPH at time 0 with clinical worsening (risk score increase &gt;20% after 2 years).

Results

Right ventricle (RV) systolic function was significantly reduced in patients with ExPH compared to those without ExPH at CPET, as well as in patients with intermediate/high compared to those with low probability of ExPH at ESE, who exhibited worse values of TAPSE and FAC (p&lt;0.001 and p=0.01, respectively). A significant higher proportion of patients with ExPH (CPET) or with intermediate/high probability of ExPH (ESE) had higher sPAP (p&lt;0.001), mPAP (p=0.004), higher TRV (p=0.006) as well as higher right atrial area (p&lt;0.001) and indexed right atrial volume (p=0.004). Total pulmonary vascular resistance (expressed by the ratio between TRV and velocity-time integral at the level of right ventricular outflow tract) was higher in patients with ExPH as well as in patients with intermediate/high probability of ExPH (p&lt;0.001). Patients with intermediate/high probability of ExPH at ESE showed a trend towards clinical worsening compared to those with low probability of ExPH, albeit not statistically significant (p=0.137). In patients with low probability of ExPH, none had &gt;20% increased CV risk score after 2 years. We found an association between higher NT-proBNP and the presence or intermediate/high probability of ExPH after 2 years (p=0.048 at CPET, p=0.033 at ESE).

Conclusions

At short follow-up, ExPH is associated with a worsening trend in the CV risk score which, if confirmed after longer follow-up, could contribute to better risk stratification in HIV patients.

Impact of Exercise-Induced Pulmonary Hypertension on Right Ventricular Function and on Worsening of Cardiovascular Risk in HIV Patients

Background and Aim: Exercise-induced pulmonary hypertension (ExPH) predicts clinical outcomes, such as all-cause mortality and cardiovascular (CV) hospitalizations, in patients with dyspnea on effort. We investigated its prognostic significance in human immunodeficiency virus (HIV)-affected patients. Methods: In 52 consecutive HIV patients with either low (n = 47) or intermediate probability (n = 5) of PH at rest, we evaluated—at time 0 and after 2 years—the prognostic determinants of CV risk, according to the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) Guidelines. Patients were classified with or without ExPH at stress echocardiography (ESE) and cardiopulmonary exercise test (CPET). We then related ExPH at time 0 with clinical worsening (CV risk score increase >20% after 2 years). Results: Right ventricle (RV) systolic function was significantly reduced in patients with ExPH compared to those without ExPH at CPET. This also occurred in patients with intermediate/high probability compared to those with low probability of ExPH at ESE. The former exhibited worse values of TAPSE and FAC (p < 0.001 and p = 0.01, respectively). A significantly higher proportion of patients with ExPH (CPET) or with intermediate/high probability of ExPH (ESE) had higher sPAP (p < 0.001), mPAP (p = 0.004) and higher TRV (p = 0.006), as well as higher right atrial area (p < 0.001) and indexed right atrial volume (p = 0.004). Total pulmonary vascular resistance (expressed by the ratio between TRV and the velocity-time integral at the level of the right ventricular outflow tract) was higher both in patients with ExPH and in those with intermediate/high probability of ExPH (p < 0.001). Patients with intermediate/high probability of ExPH at ESE showed a trend (p = 0.137) towards clinical worsening compared to those with low probability of ExPH. No patients with low probability of ExPH had a >20% increased CV risk score after 2 years. We found an association between higher NT-proBNP and the presence or intermediate/high probability of ExPH after 2 years (p = 0.048 at CPET, p = 0.033 at ESE). Conclusions: The assessment of ExPH may predict a trend of increasing CV risk score over time. If confirmed at a longer follow-up, ExPH could contribute to better risk stratification in HIV patients.

The long-term clinical course of moderate tricuspid regurgitation

Background

Moderate TR is a frequent condition, worsening mid and long-term survival, particularly in patients &gt;75 years old, and in those suffering from left ventricular systolic dysfunction. As TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up. However, data focusing on the clinical and echocardiographic course of a cohort of patients with moderate TR is lacking, and the most appropriate type and time of management of these patients is still heavily debated.

Purpose

To evaluate the evolution and the long-term clinical outcome of a cohort of patients suffering from moderate and moderate to severe TR, regardless of its etiology.

Methods

Clinical outcome and echocardiographic follow-up were assessed in 212 patients diagnosed with moderate and moderate to severe TR in our centre between January 2014 and December 2019. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and HF hospitalization.

Results

After a median follow-up of 4.2 years, TR progression occurred in 76 patients (36%): patients with TR progression presented with more history of coronary artery disease (p=0.042), atrial fibrillation (AF, p=0.007) and chronic kidney disease (CKD, p=0.007) and with baseline larger right ventricle end-diastolic diameter (RVEDD, p&lt;0.001) and worse left ventricular ejection fraction (LVEF, p=0.048). After univariate and multivariate analyses, a history of AF (HR 2.3, CI 1.2–4.5, p=0.011) and RVEDD (HR 2.4, CI 1.3–4.4, p=0.003) were independent predictors of TR progression. The primary endpoint occurred in 57 patients (27%) and was significantly more frequent (p=0.015) in the group of patients with TR progression compared to those without TR progression; multivariate analyses showed TR grade progression (HR 4.3, CI 2.1–9.1, p&lt;0.001), CKD (HR 3.2, CI 1.5–7.1, p=0.002) and LVEF (HR 0.9, CI 0.93–0.99, p=0.007) as being independently associated with the primary outcome. Moreover, both CV death (p=0.003) and HF hospitalization (p=0.0139) were significantly more frequent in patients with TR progression.

Conclusions

Our results showed that moderate TR, by progressing in a relevant proportion of patients over a long-term follow-up, significantly increases the risk of mortality and HF hospitalization. We identified specific risk factors associated with TR progression, which could help to identify patients at risk before an advanced stage of this disease. We believe that this cohort of patients should be appropriately managed and closely followed-up to avoid adverse clinical events related to the natural course of this valvulopathy.

Funding Acknowledgement

Type of funding sources: None.

Mucocutaneous Adverse Reactions to COVID-19 Vaccines: Do Excipients Play a Role?

Abstract is missing (Short communication)

Exercise-Induced Pulmonary Hypertension Is Associated with High Cardiovascular Risk in Patients with HIV

Background and Aim: Pulmonary hypertension (PH) at rest can be preceded by the onset of exercise-induced PH (ExPH). We investigated its association with the cardiovascular (CV) risk score in patients with human immunodeficiency virus (HIV). Methods: In 46 consecutive patients with HIV with low (n = 43) or intermediate (n = 3) probability of resting PH, we evaluated the CV risk score based on prognostic determinants of CV risk. Diagnosis of ExPH was made by cardiopulmonary exercise test (CPET) and exercise stress echocardiogram (ESE). Results: Twenty-eight % (n = 13) of the enrolled patients had ExPH at both CPET and ESE, with good agreement between the two methods (Cohen’s kappa = 0.678). ExPH correlated directly with a higher CV score (p < 0.001). Patients with a higher CV score also had lower CD4+ T-cell counts (p = 0.001), a faster progression to acquired immunodeficiency syndrome (p < 0.001), a poor immunological response to antiretroviral therapy (p = 0.035), higher pulmonary vascular resistance (p = 0.003) and a higher right atrial area (p = 0.006). Conclusions: Isolated ExPH is associated with a high CV risk score in patients with HIV. Assessment of ExPH may better stratify CV risk in patients with HIV.

Right ventricular-arterial coupling in severe tricuspid regurgitation: prognostic relevance of longitudinal strain

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND. Right ventricular-to-pulmonary artery (RV-PA) coupling integrates RV systolic function at a given afterload and has been shown to have a prognostic impact in different clinical settings. In the context of severe functional TR, it reflects RV adaptation to both volume and pressure overload. However, its prognostic relevance has not been extensively  examined in patients suffering from severe TR, and available data evaluated RV-PA coupling using the TAPSE/PASP ratio, with its intrinsic limitation especially in the setting of concomitant severe TR. In patients with severe TR, right ventricular free-wall longitudinal strain (RVFWLS) has been demonstrated to be more senstie in evaluation of subtle RV systolic dysfunction and to reclassify patients with impaired RV systolic function although conventional echocardiographic parameters within normal limits.

PURPOSE.  To analyze whether the noninvasive evaluation of RV-PA coupling with the use of the RVFWLS/PASP ratio could improve risk stratification in patients with severe TR.

METHODS. Baseline clinical and echcardiographic parameters and correlation with long-term outcome were assessed in 250 consecutive patients with severe TR referred at our center from December 2015 to December 2018.

RESULTS. Patients were predominantly female, with severe cardiovascular risk factors and major comorbidities, history of heart failure (HF) and atrial fibrillation.

RVFWLS/PASP ratio ≤ 0.32 (AUC 0.72, p &lt; 0.001, sensitivity 70%, specificity 67%) marginally predicted the presence of baseline clinical RV HF (p = 0.05). After univariate and multivariate analyses, RV-PA coupling as assessed by RVFWLS/PASP ratio, but not by TAPSE/PASP, was independently associated with all-cause mortality (OR 0.007, p = 0.03) and, at follow-up, "RV-PA coupled patients", defined by RVFWLS/PASP ratio &gt;0.26 (AUC 0.74, p &lt; 0.001, sensitivity 77%, specificity 52%) showed higher surival rates (p = 0.02).

CONCLUSIONS. RVFWLS/PASP ratio was systematically measured to possibly evaluate RV-PA coupling as a novel echocardiographic parameter in the context of patients with severe TR: it is independently associated with poor long-term prognosis and different values seem to improve irsk stratification in this cohort of patients.

Accuracy and reliability of left atrial appendage morphology assessment by new 3D transesophageal echocardiographic rendering modalities: a comparative study with computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction. Left atrial appendage (LAA) morphology assessed by contrast-enhanced computed tomography (CT) has been associated to the risk of cardioembolic stroke in non-valvular atrial fibrillation. Subsequent studies with the traditional LAA classification system (CS) into 4 morphologies (Chicken wing, Cauliflower, Cactus and Windsock) yielded mixed results in terms of reliability and stroke risk association. Recently, a simple LAA morphology CS (new-LAAcs) based on the LAA bend angle measurement has been suggested. Three-dimensional transesophageal echocardiography (3D TOE) quality imaging has been improved and new volume rendering modalities developed.

Purpose. Aim of this study was to evaluate the accuracy and reliability of 2D and new 3D TOE rendering modalities compared to CT in assessing LAA morphology. We used and validated a new simple LAA morphology classification system (new-LAAcs) based on the LAA bend angle in contrast to the traditional CS.

Methods. 50 consecutive patients who underwent both cardiac CT and TOE were enrolled. LAA morphology was assessed by three different TEE modalities: (1) 2D TOE inspective evaluation (2D TOE), (2) 3D TOE multiplanar reconstruction (3D TOE MPR) and (3) 3D TOE Philips TrueVue Glass rendering (3D TOE GLASS). We assessed TOE accuracy compared to CT by sensitivity, specificity, accuracy, and Cohen’s kappa. Two trained readers independently adjudicated LAA morphologies in the new-LAAcs and the inter-rater reliability was obtained by percentage agreement and Cohen’s kappa. The reliability of the new- vs. traditional-LAAcs was assessed by CT in terms of reliability rates and influence on LAA morphology prevalence.

Results. CT and TOE imaging analyses were feasible in all patients. 2D TOE was fairly accurate in identifying LAA morphology (κ 0.38, p = 0.022) and had only moderate inter-rater (κ 0.46, p = 0.027) and substantial intra-rater (κ 0.62, p = 0.003) reliability rates. 3D TOE showed high validity: 3D TOE MPR had an almost perfect accuracy (κ 0.84, p &lt; 0.001) and substantial (κ 0.77, p &lt; 0.001) inter-rater reliability; 3D TOE GLASS substantial accuracy (κ 0.67, p &lt; 0.001) and almost perfect (κ 0.82, p &lt; 0.001) inter-rater reliability. Intra-rater agreement was almost perfect for both 3D TOE modalities (κ 0.84, p &lt; 0.001). In the comparison among CS the traditional-LAAcs inter-rater reliability was moderate (κ 0.47, p &lt; 0.001) and the intra-rater reliability substantial (κ 0.68, p &lt; 0.001) while the new-LAAcs yielded an almost perfect reliability level (inter-rater κ 0.84, p &lt; 0.001 and intra-rater κ 0.93, p &lt; 0.001). With the traditional-LAAcs, the prevalence of CW LAA was 30 (60%), while with the new-LAAcs the prevalence of low-risk-LAA was 13 (26%), leading to classify 17 (57%) CW morphologies as high-risk-LAA.

Conclusions. 3D TOE is an accurate, reliable, and feasible alternative to CT in assessing LAA morphology with the new-LAAcs. The new-LAAcs shows higher reliability rates than the traditional one. Abstract Figure.  Abstract Figure.

Temporal Convolutional Neural Networks for Radar Micro-Doppler Based Gait Recognition

The capability of sensors to identify individuals in a specific scenario is a topic of high relevance for sensitive sectors such as public security. A traditional approach involves cameras; however, camera-based surveillance systems lack discretion and have high computational and storing requirements in order to perform human identification. Moreover, they are strongly influenced by external factors (e.g., light and weather). This paper proposes an approach based on a temporal convolutional deep neural networks classifier applied to radar micro-Doppler signatures in order to identify individuals. Both sensor and processing requirements ensure a low size weight and power profile, enabling large scale deployment of discrete human identification systems. The proposed approach is assessed on real data concerning 106 individuals. The results show good accuracy of the classifier (the best obtained accuracy is 0.89 with an F1-score of 0.885) and improved performance when compared to other standard approaches.

Amisulpride versus fluoxetine in dysthymia: preliminary results of a double-blind comparative study

The efficacy and safety of low doses of amisulpride (50 mg/day) and of fluoxetine (20 mg/day) were compared respectively in 139 and 129 outpatients with dysthymia during three months in a multi-centre double-blind trial. No statistically significant difference between the two groups was found in the number of responders at study-end with the Montgomery and Asberg Depressive Rating Scale, which was the main criterion for efficacy. In addition, amisulpride was well tolerated. These preliminary results suggest that low doses of amisulpride may be effective in the treatment of dysthymic patients.

P1282 Follow-up evaluation of right chambers mechanics is associated with prognosis in group 1 pulmonary arterial hypertension

Background

Pulmonary arterial hypertension (PAH) is a severe disease that progressively leads to right ventricular (RV) failure and cardiovascular death. Evaluation of right heart mechanics by means of 2-dimensional speckle tracking echocardiography (2D-STE) has displayed to be a promising tool to estimate prognosis in PAH patients.

Purpose

To evaluate the association between right ventricular free wall longitudinal strain (RVFWLS) and right peak atrial longitudinal strain (RPALS) at follow-up after initiation of specific vasodilator therapy in PAH patients, with outcomes.

Methods

83 subjects diagnosed with PAH Group 1 at three University Hospitals (Hammersmith Hospital, London, United Kingdom; Trieste University Hospital, Trieste, Italy; FTGM, Pisa, Italy), who were naive from specific treatment for PAH at the time of diagnosis, were retrospectively enrolled in this study. Standard echocardiographic parameters were collected. Outcomes were defined as the combination of all-cause mortality, hospitalization for PAH and first prostanoid administration. We investigated the correlation between RVFWLS and RPALS with outcomes adjusting for validated echocardiographic parameters strongly associated with prognosis in PAH (right atrial area – RAA and pericardial effusion – PE) and patients’ haemodynamics.

Results

30 patients experienced outcomes during a median follow-up time of 33 months. Median RVFWLS at follow-up was -15.8% (IQR: -12.1%/- 21.1%). Median RPALS at follow-up was 25% (IQR: 17.9%/36.6%). In the multivariate analysis, RVFLWS at follow-up was independently associated with outcomes (95% confidence interval [CI]: 1.01 – 1.24, p = 0.04), irrespectively from RAA (95% CI: 0.98 – 1.20, p = 0.12) and pulmonary arterial systolic pressure (PASP, 95% CI: 0.99 – 1.06, p = 0.12). We also observed a trend towards superiority of RPALS at follow-up (95% CI 0.90 – 1.00, p = 0.07) over RAA (95% CI: 0.98 – 1.20, p = 0.14) and PASP (95% CI: 0.99 - 1.05, p= 0.31). Finally, RPALS (95% CI: 0.88 – 1.00, p = 0.05) was independently associated with outcomes over PE (95% CI: 0.14 – 1.89, p = 0.32) and RVFWLS (95% CI: 0.97 – 1.20, p = 0.16).

Conclusions

In PAH group 1, assessment of both RVFWLS and RPALS at follow-up is associated with outcomes, independently from standard echocardiographic parameters.

The effect of CYP3A5 and ABCB1 single nucleotide polymorphisms on tacrolimus dose requirements in Caucasian liver transplant patients

BACKGROUND

Tacrolimus is a substrate of cytochrome P-450 (CYP) 3A enzyme and of the drug transporter ABCB1. We have investigated the effects of possible relevant CYP3A5 and ABCB1 single nucleotide polymorphisms (SNPs) present in both donors and recipients on tacrolimus blood levels achieved in a population of 32 Caucasian liver transplant patients.

MATERIAL/METHODS

At 1, 3 and 6 months after transplantation, tacrolimus doses (mg/kg/day) and trough blood levels (C(0)) were determined. Polymerase chain reaction followed by restriction fragment length polymorphism analysis was used for genotyping CYP3A5*3 [6986A>G] as well as ABCB1 at exons 21 [2677G>T] and 26 [3435C>T].

RESULTS

87.5% of the population showed a CYP3A5*3/*3 genotype. For the ABCB1 SNPs, in the case of 3435C>T the total frequency observed for the allelic variant was 50%. For the 2677G>T, the total frequency of the allelic variant was 12.5%, lower than in other Caucasian populations and without any significant linkage with 3435C>T. At 3 and 6 months after transplantation, tacrolimus dose requirements were significantly higher in patients receiving a liver with one copy of the *1 allele compared to those homozygous for the *3 allele (0.111+/-0.057 vs. 0.057+/-0.030 [P<0.05] at 3 month and 0.086+/-0.051 vs. 0.044+/-0.025 [P<0.05] at 6 month). For the recipients' genotypes, the presence of at least one *1 copy tended, though not statistically significantly, to increase tacrolimus doses. With regard to the ABCB1 SNPs, they did not show any influence on tacrolimus dosing requirements.

CONCLUSIONS

Pharmacogenetic analysis of CYP3A5 in the donor could contribute to determine the appropriate initial dosage of tacrolimus in liver transplant patients.

Hip arthroplasty after femoral osteotomy

Osteotomy of the proximal femur is performed to treat numerous hip pathologies in order to improve the load axis of the coxofemoral joint, thus improving coverage of the femoral head; despite this, arthrosis-related pathology may progress, and this nearly always results in hip arthroplasty. Many authors report that the time interval between osteotomy and arthroplasty is approximately 5 to 10 years. It is the purpose of this study to evaluate the complications and the clinical and radiographic results of hip arthroplasty performed after proximal femoral osteotomy, comparing them with a control group for hip arthroplasty without previous osteotomy.

A 400-year tree-ring chronology from the tropical treeline of North America

High-elevation sites in the tropics may be particularly sensitive to rapid climate change. By sampling treeline populations, I have developed the first extensive (> 300 years) tree-ring chronology in tropical North America. The site is Nevado de Colima, at the western end of the Mexican Neovolcanic Belt, and the species studied is Mexican mountain pine (Pinus hartwegii). Despite past logging in the area, 300 to 500-year old pines were found at 3600-3700 m elevation, about 300 m below the present treeline. The Nevado de Colima tree-ring chronology is well replicated from 1600 to 1997. Calibration with Colima climatic records points to summer monsoon precipitation as the strongest dendroclimatic signal. Most trees also exhibit extremely low growth in 1913 and 1914, following the January 1913 Plinian eruption of the Volcan de Colima. Because P. hartwegii is found on top of high mountains from Mexico to Guatemala, there is potential for developing a network of tropical treeline chronologies.

Italian population data on two new short tandem repeat loci: D2S1338 and Penta E

A population study on two new short tandem repeat (STR) loci D2S1338 (a tetranucleotide repeat) and Penta E (a pentanucleotide repeat) was performed on 208 unrelated Italian Caucasians. The DNA was amplified by polymerase chain reaction (PCR) and separation and detection of the amplified STR fragments were carried out by use of a PE/ABD PRISM 377 DNA Sequencer 377 automated system (Applied Biosystems Division/Perkin-Elmer). Both loci meet Hardy-Weinberg expectations. There is no evidence for departures from expectations between the two loci. The combined Probability of Discrimination and Probability of Exclusion for the two STR loci are 0.999155 and 0.944925, respectively. The results demonstrate that these two regions can be useful for differentiating among individuals, particularly in concert with other STR loci.

Effects of glyburide-cyclosporin A interaction on interleukin-2 production in rats

The effects of simultaneous administrations of Cyclosporin A (CsA) and Glyburide on the immune system of rats has been evaluated in terms of Interleukin-2 (IL-2) production by Concanavalin A (ConA) stimulated splenocytes and exogenous IL-2 binding capacity. The inhibitory effect of Cyclosporin A on IL-2 production of lymphoid cells is well known. Spleen cells from rats receiving CsA had reduced levels of IL-2 when compared to untreated controls or rats receiving Glyburide only. Splenocytes from rats receiving both drugs had reduced levels of IL-2 when they were sacrificed 24 hours after one or three CsA administrations; instead when the animals were sacrificed 6 days after three CsA administrations, their ability of producing IL-2 is increased as well as increasing exogenous IL-2 binding capacity. These findings let us hypothesize that when there are lower concentrations of CsA in lymphocytes there is an increase of cellular metabolism induced by Glyburide that leads to an increase in IL-2 secretion and in IL-2 receptor expression on cellular surface restoring these levels to normal or slightly above normal levels.

[Effects of cyclosporine A on the distribution of a glucose load]

Cyclosporin A (CsA) is an immunosuppressive drug, but it has also a marked action on carbohydrate metabolism. This study was designed to define the role of a single CsA administration in glucose load distribution. Results show that CsA seems to modify glucose load distribution; in fact it influences considerably glycemia and hepatic, cardiac and muscular glycogen levels, particularly after glucose load. The present experiments suggest that CsA has an antagonist action on insulin release elicited by glucose. This effect may be due to a modification of Ca2+ cellular levels in pancreatic beta-cells. Reduction of insulin release may develop a "pharmacologic diabetes" with metabolism deviated towards gluconeogenesis.

Brain perfusion abnormalities in drug-naive, lactate-sensitive panic patients: a SPECT study

Using single photon emission computed tomography (SPECT) and 99mTc-hexamethylpropyleneamine oxime (HM-PAO), we assessed brain perfusion in seven patients with panic disorder (PD) and in five age-matched normal subjects at rest. No patient had ever received drug treatment for panic. All patients were sensitive to lactate-induced panic. Computed tomography (CT) scans did not reveal any morphological abnormalities of the brain in any of the PD patients. Two indices of cerebral perfusion were calculated; these demonstrated alterations of brain perfusion in the PD group. Significant right-left asymmetry was found in the inferior frontal cortex of the PD patients. We also observed a significant blood flow increase in the left occipital cortex and a significant decrease in the hippocampal regions bilaterally. Although the changes seen in the inferior frontal cortex and occipital cortex may be related to anxiety experienced by the patients during the study, the pattern of hippocampal hypoperfusion appears to be characteristic of panic disorder. This suggests that the hippocampal structures may play an important role in the pathophysiology of panic disorder.

[Abrupt shift to zolpidem, a new imidazopyridine hypnotic, in insomniac patients previously treated with benzodiazepine hypnotics]

Zolpidem is a new imidazopyridine hypnotic with a pharmacological profile substantially different from benzodiazepines. In this observational multicenter study the possibility of shifting to zolpidem (10 mg at N1, 15 or 20 after N1) insomniac patients previously taking (for at least 15 days and not longer than 3 months) standard posology of triazolam (0.125-0.25 mg), lorazepam (1 mg) or lormetazepam (1 mg) was assessed. For ethical reasons the patients were mandatorily to be insomniacs despite their taking hypnotics or not tolerating them. Patients enrolled were 299 of whom 276 evaluable (139 males and 136 females; mean age 48.67 +/- 14.64, range 18-83). Study duration was 7 nights with visits at N0 (baseline), N1 (after 1st night), N3 (after 3rd night) and N7 (final evaluation); on each visit the Saint Mary Hospital Sleep Questionnaire and the benzodiazepine withdrawal symptom's rating scale were administered; moreover, after N7, investigators were asked a judgement of feasibility of such a shift. In 229 (83.5%) out of 274 patients such a shift to zolpidem was considered successfully (no occurrence of symptoms and/or signs of previously taken hypnotic withdrawal); in the remaining 45 patients, just 17 (6.2%) seemed to be real unsuccessful cases (reactions mild and transient, anyhow). In conclusion abrupt shift to zolpidem appeared to be largely feasible in the patients studied.

Correlation between environmental parameters and leaf injury in Nicotiana tabacum L. cv. 'Bel-W 3'

Tobacco plants (Nicotiana tabacum L. cv. 'Bel-W3') were exposed to ambient air for 25 weeks during the 1987 growing season next to an air pollution monitoring station in Brera (Milan, Italy). The research objective was to study the influence of selected environmental parameters on leaf damage in this plant, which is widely used as an ozone indicator. A multiple linear correlation model was estimated between leaf damage and available meteorological and air pollution data. Leaf injury was positively correlated with ozone integrated exposure and temperature, but negatively with vapour pressure deficit. A linear correlation model was used to estimate ozone integrated exposure from the leaf injury index.

Onset of panic disorder

The situations in which the first panic attack occurred were investigated in 44 patients affected by panic disorder. Although the first panic attack was reported to be unexpected and no avoidance was present before it, 75.8% of patients (N = 22) with panic disorder with agoraphobia had their first panic attack in phobogenic situations, compared with 20% of patients (N = 3) with panic disorder without agoraphobia.

Ozone biomonitoring in Northern Italy

This report presents the results of an ozone monitoring experience performed with tobacco indicator plants (Nicotiana tabacum L. cv. 'Bel-W3'). These bioindicators were exposed to ambient air in 23 sites in Northern Italy from 27 April 1987 to 21 October 1987. Typical ozone-induced leaf necrosis was observed in every site. The percentage increase in injured leaf area was estimated weekly and a Leaf Injury Index (LII) was calculated. The weekly series of LIIs were statistically inspected for spatial and temporal relationships. Sample correlation coefficients were statistically significant for almost every possible pair of sites. The time series properties of ten series of LIIs with no missing data were analyzed using Box-Jenkins models. An autoregressive first order model, or AR(1), was selected to remove the autocorrelation from these series. Linear correlation coefficients between 'prewhitened' (i.e. from which autocorrelation had been removed) pairs of LII series were statistically significant. Hence synchronous variations in leaf necrosis could only be related to the regional diffusion of tropospheric ozone.

Staphylococcus aureus resistant to methicillin and gentamicin as a cause of outbreak of epidemic enteritis in a hospital

During the month of February 1982 in an orthopedic department (37 patients admitted), episodes of diarrhoea occurred in 9 patients, one of these resulting in the death of one patient. From the stool cultures of the patients methicillin/gentamicin resistant S. aureus (MRGRSA) was isolated. The clinical, microbiological and epidemiological analysis demonstrated the staphylococcal origin of the enterocolitis. The statistical analysis brought to light a significant increase in the acquisition of the infection in relation to age, surgical intervention, catheter, ulcers and antibiotic therapy. The medical staff, colonized at hand and nose by the epidemic strain contributed probably to the transmission from person to person. Antimicrobial therapy with oral vancomycin of colonized patients and application of topical ointment (betadine) on personnel eliminated colonization with methicillin/gentamicin resistant S. aureus.