Steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency in a population of PCOS with suspicious levels of 17OH-progesterone

OBJECTIVE

We aimed at defining the most effective routine immunoassay- or liquid chromatography-tandem mass spectrometry (LC-MS/MS)-determined steroid biomarkers for identifying non-classic adrenal hyperplasia due to 21-hydroxylase deficiency (21-NCAH) in a PCOS-like population before genotyping.

METHODS

Seventy PCOS-like patients in reproductive age with immunoassay-determined follicular 17OH-progesterone (17OHP) ≥ 2.00 ng/mL underwent CYP21A2 gene analysis and _1-24ACTH test. Serum steroids were measured by immunoassays at baseline and 60 min after ACTH stimulation; basal steroid profile was measured by LC-MS/MS.

RESULTS

Genotyping revealed 23 21-NCAH, 15 single allele heterozygous CYP21A2 mutations (21-HTZ) and 32 PCOS patients displaying similar clinical and metabolic features. Immunoassays revealed higher baseline 17OHP and testosterone, and after ACTH stimulation, higher 17OHP (17OHP₆₀) and lower cortisol, whereas LC-MS/MS revealed higher 17OHP (17OHP_LC-MS/MS), progesterone and 21-deoxycortisol and lower corticosterone in 21-NCAH compared with both 21-HTZ and PCOS patients. Steroid thresholds best discriminating 21-NCAH from 21-HTZ and PCOS were estimated, and their diagnostic accuracy in identifying 21-NCAH from PCOS was established by ROC analysis. The highest accuracy was observed for 21-deoxycortisol ≥ 0.087 ng/mL, showing 100% sensitivity, while the combination of 17OHP_LC-MS/MS ≥ 1.79 ng/mL and corticosterone ≤ 8.76 ng/mL, as well as the combination of ACTH-stimulated 17OHP ≥ 6.77 ng/mL and cortisol ≤ 240 ng/mL by immunoassay, showed 100% specificity.

CONCLUSIONS

LC-MS/MS measurement of basal follicular 21-deoxycortisol, 17OHP and corticosterone seems the most convenient method for diagnosing 21-NCAH in a population of PCOS with a positive first level screening, providing high accuracy and reducing the need for ACTH stimulation test.

Is β2-Microglobulin-Related Amyloidosis of Hemodialysis Patients a Multifactorial Disease? a New Pathogenetic Approach

Purpose

β2-microglobulin amyloidosis (Aβ2M) is one of the main long-term complications of dialysis treatment. The incidence and the onset of Aβ2M has been related to membrane composition and/or dialysis technique, with non-homogeneous results. This study was carried out to detect: i) the incidence of bone cysts and CTS from Aβ2M; ii) the difference in Aβ2M onset between cellulosic and synthetic membranes; iii) other risk factors besides the membrane.

Methods

480 HD patients were selected between 1986 to 2005 and grouped according to the 4 types of membranes used (cellulose, synthetically modified cellulose, synthetic low-flux, synthetic high-flux). The patients were analyzed before and after 1995, when the reverse osmosis treatment for dialysis water was started at our center, and the incidence of Aβ2M was compared between the two periods. Routine plain radiography, computer tomography (CT) and nuclear magnetic resonance imaging (MRI) as well as electromyography were used to investigate the clinical symptoms.

Results

Bone cysts occurred in 29.2% of patients before 1995 vs. 12.2% after 1995 (p<0.0001). CTS occurred in 24% of patients before 1995 vs. 7.1% after 1995 (p<0.0001). Bone cysts and CTS occurred in older patients, who began dialysis at a late age, with high CRP, low albumin, low residual GFR, and low Hb. Cox regression analysis showed that the risk factor for bone cysts was high CRP (RR 1.3, p<0.01), while albumin (RR 0.14, p<0.0001) and residual GFR (RR 0.81, p<0.0001) were revealed to be protective factors. Cox analysis for CTS confirmed CRP as a risk factor (RR 1.2, p<0.01), and albumin (RR 0.59, p<0.0001) and residual GFR (RR 0.75, p<0.0001) as protective factors. The comparison obtained between membranes did not suggest any protective effect on Aβ2M.

Conclusions

The findings that the inflammatory status as well as low albumin and the residual GFR of the uremic patient are predictive of Aβ2M lesions suggests that Aβ2M has a multifactorial origin rather than being solely a membrane- or technique-related side effect.

Microbial quality of drinking water from microfiltered water dispensers

A comparison was made between the microbial quality of drinking water obtained from Microfiltered Water Dispensers (MWDs) and that of municipal tap water. A total of 233 water samples were analyzed. Escherichia coli (EC), enterococci (ENT), total coliforms (TC), Staphylococcus aureus, Pseudomonas aeruginosa and heterotrophic plate count (HPC) at 22 °C and 37 °C were enumerated. In addition, information was collected about the principal structural and functional characteristics of each MWD in order to study the various factors that might influence the microbial quality of the water. EC and ENT were not detected in any of the samples. TC were never detected in the tap water but were found in 5 samples taken from 5 different MWDs. S. aureus was found in a single sample of microfiltered water. P. aeruginosa was found more frequently and at higher concentrations in the samples collected from MWDs. The mean HPCs at 22 °C and 37 °C were significantly higher in microfiltered water samples compared to those of the tap water. In conclusion, the use of MWDs may increase the number of bacteria originally present in tap water. It is therefore important to monitor the quality of the dispensed water over time, especially if it is destined for vulnerable users.

Can peripheral arterial disease be early screened for in a podiatric setting? A preliminary study in a cohort of asymptomatic adults

BACKGROUND

Peripheral arterial disease (PAD) is a strong marker of cardiovascular disease but remains an under-diagnosed problem. Moreover, PAD frequently leads to foot problems requiring particular care and surveillance.

AIM

The aims of this study were (1) to determine the prevalence of undiagnosed PAD in a cohort of asymptomatic subjects referred to a podiatric clinic and (2) to evaluate whether a four-item form assessing medical history for the presence of cardiovascular risk factors could identify subjects at high risk for asymptomatic PAD.

PATIENTS AND METHODS

This study included 717 consecutive subjects (121 males, age 50.9±13.9 y) referring to a podiatric clinic who were asymptomatic for PAD and free of cardiovascular disease. The ankle brachial index (ABI) was measured in all subjects. Each subject also completed a self-administered form to identify cardiovascular risk factors.

RESULTS

Among the entire cohort, the prevalence of PAD was 8.3% in males and 1.2% in females. Three subgroups were identified according to the number of risk factors reported (no risk factors, one risk factor, and two or more risk factors), and the prevalence of PAD differed between each subgroup (0.2%, 3.2%, and 18.9%, respectively; p < 0.001).

CONCLUSIONS

In an unselected cohort of subjects referring to a podiatric clinic, who were asymptomatic for PAD and free from cardiovascular diseases, a remarkable prevalence of PAD was found among subjects reporting a minimum of two cardiovascular risk factors. In a podiatric setting, screening with a self-administered form for the presence of cardiovascular risk factors might lead to an early diagnosis of PAD.

Prospective evaluation of the effect of statins on blood pressure control in hypertensive patients in clinical practice

BACKGROUND AND AIM

Some clinical evidence supports a statin antihypertensive effect. Our aim is to evaluate the statin effect on blood pressure control in hypertensive patients in the setting of clinical practice, and the role of some predetermined individual patient characteristics (age, gender, baseline BP levels, pre-treatment LDL-C levels) on the supposed statin BP lowering effect.

METHODS AND RESULTS

Two hundred and fifty-four hypertensive patients with hypercholesterolemia were enrolled in the Ambulatory service of the Hypertension Research Unit of Bologna University Hospital. After 2-4 weeks of a run-in period patients were allocated to statin treatment and followed-up for 24 weeks. The blood pressure response to statins was compared in several subgroups of patients according to age, gender, baseline BP and pre-treatment cholesterolemia. In the overall study population, the use of statins was associated with a significant reduction in systolic (-7.6+/-4 mmHg, p<0.05) and diastolic blood pressures (-5.2+/-3 mmHg, p<0.05) in comparison to baseline. The blood pressure decrease was more pronounced in patients younger than 65 years (p<0.05), with higher baseline systolic blood pressure (p<0.005), and in those with higher cholesterolemia before statins (p<0.05).

CONCLUSIONS

Our study suggests a BP-lowering effect of statins, consistent with some other literature. Some parameters like age, baseline systolic blood pressure and cholesterolemia influence the antihypertensive effect of statins. The lack of consideration for these confounding factors may be one of the reasons for the conflicting results about the BP lowering effects of statins.

Relative role of major risk factors for Type 2 diabetes development in the historical cohort of the Brisighella Heart Study: an 8-year follow-up

AIM

The aim of this study was to evaluate and quantify the role of different risk factors in the long-term development of Type 2 diabetes mellitus in a rural Italian population.

METHODS

The Brisighella Heart Study (BHS; 1972-2003) is a prospective, population-based longitudinal epidemiological cohort involving 2939 randomly selected subjects, aged 14-84 years, resident in the rural Italian town of Brisighella. For this study, we randomly selected 1441 adult subjects representative of the Brisighella population; consecutively visited during three BHS surveys. A step-wise Cox regression analysis determined the prognostic significance of each independent risk factor for the development of Type 2 diabetes in the 8-year long follow-up.

RESULTS

Blood pressure, high-density lipoprotein cholesterol, triglycerides, physical activity, total energy intake, and drug treatment had no effect on the incidence of diabetes. Age was a significant predictor of Type 2 diabetes when inserted alone in the model (P = 0.007), but irrelevant when adjusted for baseline body mass index (BMI) and or fasting plasma glucose. Among these with impaired fasting glucose (IFG), the diabetes incidence/year was estimated to be 6.6% for men and 11.2% for women (P < 0.001). Basal glycaemia under 6.1 mmol/l were not significant long-term predictors of diabetes development, while higher basal glycaemia and each level BMI were.

CONCLUSION

Our findings confirm that IFG and BMI predict Type 2 diabetes development in our population. This should help to identify effective approaches to prevention.

Ten year incidence of HCV infection in northern Italy and frequency of spontaneous viral clearance

BACKGROUND

Little is known of the incidence of hepatitis C virus (HCV) infection, and the frequency of spontaneous viral clearance in the general population is unknown. We conducted an epidemiological study in two Apennine towns in northern Italy.

METHODS

Anti-HCV (ELISA and RIBA third generation) and HCV-RNA by polymerase chain reaction were tested in thawed sera from an adult general population of Loiano-Monghidoro in 1986 and 1996, obtained in the context of the MICOL (Multicenter Italian Study on Cholelithiasis). In 1999, anti-HCV positive subjects and sex and age matched controls were recalled in order to identify risk factors for acquiring HCV infection and to assess the family composition of anti-HCV+ subjects.

RESULTS

For 1646 subjects, sera were available from both 1986 and 1996 (mean age in 1986 43 (0.39) years). In 1986, 57 (3.46%) subjects were HCV antibody positive (HCV-Ab+). Eight new cases were recorded in 1996: adult incidence was 50.3 cases/100 000 inhabitants/year. Fifty three of 63 (84.1%) HCV-Ab+ sera were also HCV-RNA+. Genotype 2a/2c accounted for 44% and 1b for 47.0% of cases. HCV-Ab+ subjects had higher serum levels of alanine aminotransferase with respect to controls (p<0.005), as did subjects infected with genotype 1 with respect to those with genotype 2 (p<0.05). Eleven of 65 (16.9%) HCV-Ab+ subjects spontaneously cleared HCV-Ab; 7/11 also lost HCV-RNA- in both serum and leucocytes. Sixteen anti-HCV+ subjects belonged to families containing more than one infected member. Married couples accounted for 10 of these 16 subjects. In four of these five married couples, HCV genotype was identical in the two spouses.

CONCLUSIONS

In rural northern Italy, the adult incidence of HCV is approximately 50 cases/100 000 inhabitants/year. Our findings suggest that as many as 17% of infected subjects may spontaneously clear HCV-Ab. Interfamilial transmission seems to have a role in the spread of infection.

Hospital attitude survey on organ donation in the Emilia-Romagna region, Italy

The role of hospital staff in the organ procurement process is crucial. Nevertheless, there is little literature about their attitudes toward donation. The Donor Action Hospital Attitude Survey (HAS) comprises a series of questions to assess hospital staff's attitudes, beliefs, and knowledge on organ donation and transplantation. Further analysis of the data will help identify any weak areas in the staff viewpoint and information, highlight potential needs for more education on specific issues, and establish a baseline to monitor future improvements. We used the Donor Action HAS in the Emilia-Romagna region, Italy. The aim of this paper is to assess and better understand the personnel's viewpoint in the 12 main hospitals of the region. The survey was carried out among hospital staff involved in organ donation. 1576 responses were collected (52 % of distributed questionnaires), of which 1024 came from nurses, 475 from physicians, and 77 from other backgrounds. Questions were subdivided into categories, and for every point an overall mark (maximum 3/3) was calculated.

RESULTS

1. Involvement in donation process during the past year: 1.24 /3, 2. Attitudes to organ donation (OD): 2.51 /3, 3. Skills / Self-confidence in donation practices: 1.36 /3, 4. Satisfaction with local transplant coordinator (TC) services: 2.31 /3. The attitude towards organ donation was positive, 1386 respondents support organ donation. A high percentage (93.6 % of respondents) is of the opinion that transplantation helps save other people's lives. Most uncertainty arises on the question whether donation helps families with grief. It is remarkable that only 53 % of those prepared to donate organs have informed the family of their wish. Many respondents do not feel comfortable performing key tasks close to donation. Major difficulties were observed in explaining to a family the concept of brain death (0.98 /3). Knowledge on the concept of brain-death was one of the most requested subjects for improvement. Emilia-Romagna is the region with one of the highest donation rates in Italy (29.9 pmp in 2000). Nevertheless, more profound knowledge of the local situation could help further improve donation.

Statins and blood pressure regulation

Hypertension and high serum cholesterol levels are two of the most relevant risk factors for cardiovascular diseases. A combined increase in both risk factors has been reported in a significant proportion of patients with coronary artery disease. Statins are the most widely used drugs to treat hypercholesterolemia, and they interact with blood pressure control in different populations of hypertensive patients. A significant reduction in blood pressure associated with the use of statins has been described in patients with untreated hypertension and in patients treated with antihypertensive drugs, particularly angiotensin converting enzyme inhibitors and calcium channel blockers. The effect of statins on blood pressure control has also been reported in diabetic patients. The mechanisms responsible for the hypotensive effect seem to be largely independent of the effect of statins on lipid profile, and are probably related to their interaction with endothelial function or angiotensin II receptors. The capacity of statins to improve blood pressure control could be a useful consideration for an integrated approach to better prevention of cardiovascular diseases.

The realization of a project aimed at reducing the plasmatic lipid level in a large Italian population improves the mean calcium daily intake: the Brisighella Study

OBJECTIVES

Evaluation of the impact of a coronary heart disease prevention program on calcium, magnesium, phosphorus and vitamin D dietary intake in respect of recommended daily allowances in a large Italian rural population.

DESIGN

Retrospective analysis of the Brisighella Study dietary data. The Brisighella Study started in 1972 as a longitudinal study on atherosclerosis risk factors.

SETTING

Brisighella, a rural North Italian village.

SUBJECTS

The Brisighella population's dietary habits were monitored from 1980 every 4 h through a dietary record sheet. 1,350 constantly tested subjects were subdivided according to NHI Consensus Conference on Calcium RDA.

INTERVENTION

In 1986, the studied subjects were invited to reduce their consumption of animal fats and cholesterol through a Nutrition Educational Program (NEP).

RESULTS

Before NEP, calcium intake was low in each sex and age category: 20-40% of the populatioin had a daily intake < 550 mg. In 1988, among the 1350 subjects who constantly completed the questionnaire (M = 651, F = 699), the mean calcium intake significantly rose in all age categories: M = 1,003 (25-65 y) and 877 ( > 65) mg/24h (P < 0.001 vs 1984); F = 923 (25-50), 860 (51-65) and 767 (> 65)mg/24h (P < 0.05). In 1992, 3y after the NEP conclusion, calcium intake dropped in each sex and age category. The NEP influenced vitamin D, phosphorus and magnesium intakes less.

CONCLUSIONS

A collective NEP aimed at lowering saturated fats and cholesterol intakes, improves the calcium intake; in order to maintain their efficacy on nutritional habit changes, these programs must become an ongoing item.