Cardiac defects, morbidity and mortality in patients affected by RASopathies. CARNET study results

BACKGROUND

RASopathies are developmental disease caused by mutations in genes encoding for signal transducers of the RAS-MAPK cascade. The aim of the present study was to provide a comprehensive description of morbidity and mortality in patients with molecularly confirmed RASopathy.

METHODS

A multicentric, observational, retrospective study was conducted in seven European cardiac centres participating to the CArdiac Rasopathy NETwork (CARNET). Clinical records of 371 patients with confirmed molecular diagnosis of RASopathy were reviewed. Mortality was described as crude mortality, cumulative survival and restricted estimated mean survival. Multivariable regression analysis was used to assess the impact of mutated genes on number of interventions and overall prognosis.

RESULTS

Cardiac defects occurred in 80.3% of cases, almost half of them underwent at least one intervention. Overall, crude mortality was 0.29/100 patients-year. Cumulative survival was 98.8%, 98.2%, 97.7%, 94.3%, at 1, 5, 10, and 20years, respectively. Restricted estimated mean survival at 20years follow-up was 19.6years. Ten patients died (2.7% of the entire cohort; 3.4% of patients with cardiac defect). Patients with hypertrophic cardiomyopathy (HCM) and age <2years or young adults, as well as subjects with biventricular obstruction and PTPN11 mutations had a higher risk of cardiac death.

CONCLUSIONS

The risk of intervention was higher in individuals with Noonan syndrome and pulmonary stenosis carrying PTPN11 mutations. Overall, mortality was relatively low, even though the specific association between HCM, biventricular outflow tract obstructions and PTPN11 mutations appeared to be associated with early mortality, including immediate post-operative events and sudden death.

Effects of processing conditions on the texture and rheological properties of model acid gels and cream cheese

Manufacture of cream cheese involves the formation of an initial acid-induced gel made from high-fat milk, followed by a series of processing steps including shearing, heating, and dewatering that complete the conversion of the acid gel into a complex cheese product. We investigated 2 critical parameters for their effect on the initial gel: homogenization pressure (HP) of the high-fat cheese milk, and fermentation temperature (FT). The impact of a low (10 MPa) and high (25 MPa) HP, and low (20°C) and high (26°C) FT were investigated for their effects on rheological and textural properties of acid-induced gels. Intact acid gels were sheared and heated to 80°C, and then their rheological properties were analyzed to help understand the effect of shearing/heating processes on the gel characteristics. The effect of HP on fat globule size distribution and the amount of protein not involved in emulsion droplets (i.e., in the bulk phase) were also studied. For cream cheese trials, a central composite experimental design was used to explore the effect of these 2 parameters (HP and FT) on the texture, rheology, and sensory properties of experimentally manufactured cream cheese. Storage modulus (G') and hardness values of cream cheeses were obtained from small amplitude oscillatory rheology tests and texture profile analysis, respectively. Quantitative spectrum descriptive sensory analysis was also performed. Consistency of acid gels (measured using a penetration test) increased with an increase in FT and with an increase in HP. Although stiffer acid-induced gels were formed at high FT, after the heating and shearing processes the apparent viscosity of the samples formed at high FT was lower than those formed at low FT. For the cream cheeses, significant prediction models were obtained for several rheological and textural attributes. The G' values at 8°C, instrumental hardness, and sensory firmness attributes were significantly correlated (r > 0.84); all these attributes significantly decreased with an increase in FT, and HP was not a significant parameter in the prediction models developed for these attributes. Significant interactions were observed between the HP and FT terms for these prediction models. Higher HP increased the amount of protein adsorbed at interface of fat globules but decreased bulk phase protein content (which may be important for crosslinking this gelled emulsion system). At higher FT temperature, coarser gel networks were likely formed. The combined effect of a coarser acid gel network at high FT, and less bulk phase casein available for crosslinking the acidified emulsion gel with an increase in HP, could have contributed to the lower stiffness/firmness observed in cream cheese made under conditions of both high FT and high HP. Stickiness of cream cheese greatly increased under conditions of high FT and high HP, whereas the sensory attributes cohesiveness of mass and difficulty to dissolve decreased. This study helped to better understand the complex relationships between the initial acid-induced gel phase and properties of the (final) cream cheese.

Frequency of Intracranial Aneurysms Determined by Magnetic Resonance Angiography in Children (Mean Age 16) Having Operative or Endovascular Treatment of Coarctation of the Aorta (Mean Age 3)

Coarctation of the aorta (CofA) has been associated with an increased risk of intracranial aneurysm (IA). This magnetic resonance angiography (MRA) study investigates the prevalence of IAs in 80 children treated in early life for CofA. MRA was performed at mean age of 15.7 ± 7.1 years, and surgical or endovascular treatment for CofA occurred at a mean age of 2.6 ± 4.4 years. No IA was found. In contrast with earlier findings in adult patients with late treatment for CofA, this first systematic study of very early treated patients for CofA failed to confirm the association between CofA and IAs. Our results call the abnormal developmental relation between CofA and IAs into question and suggest that modifiable risk factors like hypertension may be responsible for IA development in patients with CofA with adult diagnosis and treatment. In conclusion, our data suggest that early treatment of CofA can reduce the formation of IAs in children so as to make MRA screening less valuable in this young population.

Endomyocardial biopsy safety and clinical yield in pediatric myocarditis: An Italian perspective

OBJECTIVES

The objective of this investigation is to evaluate the safety, the impact of endomyocardial biopsy (EMB) results in myocarditis management and the incidence of different etiologies of myocarditis in a pediatric population.

BACKGROUND

Although EMB is an established diagnostic tool to evaluate suspected myocarditis, there is lack of clear diagnostic and management guidelines for myocarditis in pediatric patients, particularly in infants.

METHODS

We performed a retrospective database review and subsequent outcomes analysis from five Italian pediatric cardiology centers to identify patients aged 0-18 years who underwent EMB for suspected myocarditis or inflammatory cardiomyopathy (ICMP) between 2009 and 2011.

RESULTS

EMB was performed in 41 children, of which 16 were male. The population ranged between 16 days of age to 17 years (mean age at EMB = 5.2 ± 4.9 years). The overall incidence of EMB-related complications was 15.5% (31.2% in infants, and 6.8% in children > 1 year of age; P = 0.079) while the incidence of EMB-driven treatment changes was 29.2%. Histological examination together with PCR on heart biopsy specimens allowed an etiological diagnosis in 26/41 patients (63%). Among the 15 patients (36.5%) with diagnosis of dilated cardiomyopathy (DCM) 11 had idiopathic DCM. Finally, we found an overall incidence of death/cardiac transplantation of 24%.

CONCLUSIONS

In a pediatric population with suspected myocarditis/ICMP, EMB was useful in confirming the diagnosis only in 41% of cases but showed an overall diagnostic power of 63%. As complications of EBM are not negligible, particularly in infants, the risk/benefit ratio should be taken into account in each patient.

Atypical cardiac defects in patients with RASopathies: Updated data on CARNET study

BACKGROUND

RASopathies are a set of relatively common autosomal dominant clinically and genetically heterogeneous disorders. Cardiac outcomes in terms of mortality and morbidity for common heart defects (such as pulmonary valve stenosis and hypertrophic cardiomyopathy) have been reported. Nevertheless, also Atypical Cardiac Defects (ACDs) are described. The aim of the present study was to report both prevalence and cardiac outcome of ACDs in patients with RASopathies.

METHODS

A retrospective, multicentric observational study (CArdiac Rasopathy NETwork-CARNET study) was carried out. Clinical, surgical, and genetic data of the patients who were followed until December 2019 were collected.

RESULTS

Forty-five patients out of 440 followed in CARNET centers had ACDs. Noonan Syndrome (NS), NS Multiple Lentigines (NSML) and CardioFacioCutaneous Syndrome (CFCS) were present in 36, 5 and 4 patients, respectively. Median age at last follow-up was 20.1 years (range 6.9-47 years). Different ACDs were reported, including mitral and aortic valve dysfunction, ascending and descending aortic arch anomalies, coronary arteries dilation, enlargement of left atrial appendage and isolated pulmonary branches diseases. Five patients (11%) underwent cardiac surgery and one of them underwent a second intervention for mitral valve replacement and severe pericardial effusion. No patients died in our cohort until December 2019.

CONCLUSIONS

Patients with RASopathies present a distinct CHD spectrum. Present data suggest that also ACDs must be carefully investigated for their possible impact on the clinical outcome. A careful longitudinal follow up until the individuals reach an adult age is recommended.

Data on cardiac defects, morbidity and mortality in patients affected by RASopathies. CARNET study results

A comprehensive description of morbidity and mortality in patients affected by mutations in genes encoding for signal transducers of the RAS-MAPK cascade (RASopathies) was performed in our study recently published in the International Journal of Cardiology. Seven European cardiac centres participating to the CArdiac Rasopathy NETwork (CARNET), collaborated in this multicentric, observational, retrospective data analysis and collection. In this study, clinical records of 371 patients with confirmed molecular diagnosis of RASopathy were reviewed. Cardiac defects, crude mortality, survival rate of patients with 1) hypertrophic cardiomyopathy (HCM) and age <2 years or young adults; 2) individuals with Noonan syndrome and pulmonary stenosis carrying PTPN11 mutations; 3) biventricular obstruction and PTPN11 mutations; 4) Costello syndrome or cardiofaciocutaneous syndrome were analysed. Mortality was described as crude mortality, cumulative survival and restricted estimated mean survival. In particular, with this Data In Brief (DIB) paper, the authors aim to report specific statistic highlights of the multivariable regression analysis that was used to assess the impact of mutated genes on number of interventions and overall prognosis.

Reversible cerebral ischemias: a comparative analysis of risk factors in TIAs and in RINDs

A retrospective study in which 709 patients, 522 with RIND and 187 with TIA, were compared in respect of common risk factors (RFs) for acute cerebrovascular disease. The two forms of the disease differed significantly in respect of smoking, hematocrit, hypercholesteremia, hypertriglyceridemia and hyperuricacidemia. Although these RFs do not seem to be determinants of or discriminants between the two forms of acute cerebrovascular disease, it is nonetheless highly probable that, together with all the other RFs, they have a facilitatory role.

Cardiac magnetic resonance using fused 3D cine and 4D flow sequences:Validation of ventricular and blood flow measurements

PURPOSE

Current cardiovascular magnetic resonance (CMR) examinations require expert planning, multiple breath holds, and 2D imaging. To address this, we sought to develop and validate a comprehensive free-breathing 3D cine function and flow CMR examination using a steady-state free precession (SSFP) sequence to depict anatomy fused with a spatially registered phase contrast (PC) sequence for blood flow analysis.

METHODS

In a prospective study, 25 patients underwent a CMR examination which included a 3D cine SSFP sequence and a 3D cine PC (also known as 4D flow) sequence acquired during free-breathing and after the administration of a gadolinium-based contrast agent. Both 3D sequences covered the heart and mediastinum, and used retrospective vectorcardiogram gating (20 phases/beat interpolated to 30 phases/beat) and prospective respiratory motion compensation confining data acquisition to end-expiration. Cardiovascular measurements derived from the 3D cine SSFP and PC images were then compared with those from standard 2D imaging.

RESULTS

All 3D cine SSFP and PC acquisitions were completed successfully. The mean time for the 3D cine sequences including prescription was shorter than that for the corresponding 2D sequences (21 min vs. 36 min, P-value <0.001). Left and right ventricular end-diastolic volumes and stroke volumes by 3D cine SSFP were slightly smaller than those from 2D cine SSFP (all biases ≤5%). The blood flow measurements from the 3D and 2D sequences had close agreement in the ascending aorta (bias -2.6%) but main pulmonary artery flow was lower with the 3D cine sequence (bias -11.2%).

CONCLUSION

Compared to the conventional 2D cine approach, a comprehensive 3D cine function and flow examination was faster and yielded slightly lower left and right end-diastolic volumes, stroke volumes, and main pulmonary artery blood flow. This free-breathing 3D cine approach allows flexible post-examination data analysis and has the potential to make examinations more comfortable for patients and easier to perform for the operator.

Effect of substituting whey cream for sweet cream on the textural and rheological properties of cream cheese

In the manufacture of cream cheese, sweet cream and milk are blended to prepare the cream cheese mix, although other ingredients such as condensed skim milk and skim milk powder may also be included. Whey cream (WC) is an underutilized fat source, which has smaller fat droplets and slightly different chemical composition than sweet cream. This study investigated the rheological and textural properties of cream cheeses manufactured by substituting sweet cream with various levels of WC. Three different cream cheese mixes were prepared: control mix (CC; 0% WC), cream cheese mixes containing 25% WC (25WC; i.e., 75% sweet cream), and cream cheese mixes with 75% WC (75WC; i.e., 25% sweet cream). The CC, 25WC, and 75WC mixes were then used to manufacture cream cheeses. We also studied the effect of WC on the initial step in cream cheese manufacture (i.e., the acid gelation process monitored using dynamic small amplitude rheology). Acid gels were also prepared with added denatured whey proteins or membrane proteins/phospholipids (PL) to evaluate how these components affected gel properties. The rheological, textural, and sensory properties of cream cheeses were also measured. The WC samples had significantly higher levels of PL and insoluble protein compared with sweet cream. An increase in the level of WC reduced the rate of acid gel development, similar to the effect of whey phospholipid concentrate added to mixes. In cream cheese, an increase in the level of added WC resulted in significantly lower storage modulus values at temperatures <20°C. Texture results, obtained from instrumental and sensory analyses, showed that high level of WC resulted in significantly lower firmness or hardness values and higher stickiness compared with cream cheeses made with 25WC or CC cream cheeses. The softer, less elastic gels or cheeses resulting from the use of high levels of WC are likely due to the presence of components such as PL and proteins from the native milk fat globule membrane. The use of low levels of WC in cream cheese did not alter the texture, whereas high levels of WC could be used if manufacturers want to produce more spreadable products.

A PHACES syndrome unmasked by propranolol interruption in a tetralogy of Fallot patient: case report and extensive review on new indications of beta blockers

Infantile hemangiomas (IHs) are the most common benign tumors of infancy and usually they don't require specific therapy. In 10-20% of cases IHs are able to generate complication and medical/surgical intervention is needed. For many decades standard treatment consisted in oral or intralesional corticosteroids until Leaute-Labreze and colleagues published the first report on the efficacy of propranolol for cutaneous infantile hemangiomas in 2008. IHs can be sometimes part of complex syndrome. Here we report the case of a patient with tetralogy of Fallot operated at 5 month of age who stopped propranolol treatment for hypoxic spells and unusually developed facial and subglottic IHs configuring the diagnosis of PHACES syndrome (posterior fossa brain malformations, hemangioma, arterial anomalies, cardiac defects and/or aortic coarctation, ocular anomalies and sternal defects). To our knowledge this is the first report in the international literature of a delayed appearance of an infantile hemangioma involving the skin and the airways (PHACES syndrome). The pathophysiological explanation relies on the mechanism of action of propranolol which seems to act initially with vasoconstriction, down-regulating proangiogenetic factors and inducing endothelial cell apoptosis. Many decades since their introduction β-blockers are useful in a growing group of diseases. The pleiotropic effect of β-adrenoceptors antagonists is not yet deeply understood, residing in neurohormonal regulation systems and angiogenesis and proving to be an effective treatment from cardiovascular to oncological illnesses.

Combination of bevacizumab (B) plus immunotherapy, with interleukin-2 (IL-2) and interferon-α (IFN-α) plus chemotherapy (BIC) in patients with metastatic renal cell cancer (mRCC): Dose-finding phase II trial

15586

Background: Treatment with IL-2 and IFN-a is considered as an effective immunotherapy (IT) for mRCC. Bevacizumab (B) proved to have efficacy with different mechanism as regards as IL-2 + IFN-a, and had at least an additive effect with chemotherapy (Ch) in many tumors. On this basis, it is reasonable to search for a synergism between B, IT and Ch. Methods: This is a multicenter dose- finding/phase II study aimed at to investigate: 1) safety, tolerability, dose-limiting toxicity (DLT) and maximum tolerated dose (MTD) of the BIC combination; 2) antitumor activity. Dose-finding study comprised 5 escalation dose levels of Ch: Gemcitabine (G) (initial dose 600 mg/m2 to 1,000 mg/m2) followed by 5FU bolus (initial dose 400 mg/m2 to 600 mg/m2) each one on days 1 and 8 every 28 days, associated with fixed doses of B (10mg/kg on days 1 and 15), IL-2 (1 MUI/m2 bid sc on days 8, 9, 15, 16 and 1 MUI/m2/day sc from days 10 to 12 and from 17 to 19) and IFN-a (3 MUI sc on days 10, 12, 17, 19). Three patients were enrolled at each dose level according to Fibonacci statistical method. Phase II study used the reached MTD and was conducted according to two stage Minimax Simon design. Treatment was repetead for a maximum of 6 cycles followed by a maintenance therapy with B and IT until progressive disease (PD). Results: 32 patients were enrolled (male 75%); median age 58 years (range: 28–75): of these, 23 was assessable for toxicity, 14 were pre-treated and 9 not; there was 1 case of DLT (2° level) due to a transitory grade 3 transaminases rising; phase II used the highest dose level of Ch. Grade 3–4 toxicity during all cycles included: neutropenia non febrile (11/23) and 1 febrile, fever in 5; grade 3 toxicity included: thrombocytopenia in 7, asthenia in 4, hypertension in 2, anemia in 2; no bleeding of grade 3–4. So far there are 20 assessable patients for response: 6 (30%) partial response, 8 (40%) stable disease and 6 (30%) PD for an overall disease control rate of 70%. Conclusion: This is the first study that explored the synergy between antiangiogenic therapy, IT and Ch in mRCC. The BIC combination is generally well tolerated and shows promising activity. The Phase II study is currently ongoing and accrual is still open.

No significant financial relationships to disclose.

Gefitinib (G) plus interleukin-2 (IL-2) in previously treated patients with advanced non-small cell lung cancer (NSCLC)

18042

Background: Previous studies in patients with NSCLC treated with IL-2 reported relatively long survival (Cancer 1994;73:1353–60) and a recent study indicated that lymphocytes are activated by G treatment (J Cancer Res Clin Oncol. 2006;132:719- 725.). In this study we explored the possible synergism between IL-2 and G in terms of response rate, survival and toxicity. Methods: From September 2003 to November 2006, 70 consecutive chemotherapy treated patients with advanced, progressive NSCLC received oral G 250 mg daily in a compassionate use program at a single institution. The first 39 patients included in the study received only G, the others 31 also received subcutaneous IL-2: 1 MUI/m2 twice a day on day 1 and 2, once a day on day 3, 4, 5 every week for 4 consecutive weeks with 4 week rest period. This is a phase II trial combined with a cohort design each having a different outcome event. All the evaluations were made using Recist criteria and according to the intention to treat principle. Results: The main patients characteristics and results are showed in the table below. Fifty-one (73%) patients received one prior chemotherapy regimen, while 17 (24%) received = two prior lines of treatment. *Median, months ±95% CI. §p value<0.05 Cox’s regression analysis, including PS, gender, smoke, skin toxicity, histology and use of IL-2, revealed that only skin toxicity [p<0.001; HR 0.29;CI 95% 0.16–0.54] and use of IL-2 [p<0.001; HR 0.33;CI 95% 0.18–0.60] were significantly associated with improvement in OS. Patients treated with IL-2 also showed grade 2–3 fever in 46%, fatigue in 21%, arthralgias in 13%, besides the known G- related toxicity. Conclusions: In this consecutive, non-randomized, series of patients, the use of IL-2 seems to increase the efficacy of G. Further randomized studies of TK inhibitors with IL-2 are warranted.

[Table: see text]

No significant financial relationships to disclose.