AEFIs active surveillance projects as vaccinovigilance traineeship: Puglia (Italy) experience

Surveillance of Adverse Events Following Immunization (AEFIs) is a crucial part of vaccination strategies because the most important concern of “No-vax group” is the safety of vaccination. According to UE laws, in Italy a passive surveillance system of AEFIs is established by law and managed by National Drug Authority (AIFA) and Regional Health Governments. The performance of surveillance system is different in the 21 Italian Regions and in some Region, such as Puglia, the AEFIs reporting rate has been, for several years, lower than National figure. The implementation of AEFIs active surveillance projects could increase the performance of AEFIs surveillance system, also after the end of the project.

In Puglia, since 2017, May to 2018, November, an active surveillance of AEFIs has been established, focused on MMRV vaccine. In this study, we analysed the AEFIs general picture in Puglia in 2016 and 2019, before and after active surveillance project. The source of data is the AIFA database; data were reported as number of AEFI and rate for Puglia population (reporting rate RR). The AEFIs were classified as serious, not serious and unclassifiable and causality assessment was performed according to WHO recommendations.

The number of AEFIs detected by the passive surveillance system is 91 for 2016 (RR 2,2 per 100.000 people), and 168 for 2019 (RR 4,2 per 100.000 people). The percentage of serious AEFIs was 23.1% (21/91) in 2016 and 31% (52/168) in 2019 and unclassifiable AEFIs were 22% (20/91) in 2016 and 0 in 2019. The percentage of serious AEFIs for which the result of causality assessment was “consistent” is 23,8% (5/21) in 2016 and 55,8% (29/52) in 2019.

The experience of AEFIs active surveillance project increase the performance of AEFIs surveillance system. From 2016 (pre-project time) to 2019 (post-project time) the number of AEFIs detected was doubled, the number of unclassifiable AEFIs (proxy of poor reliability of the system) was reduced to zero.

Key messages

AEFIs passive surveillance system could be affected by underreporting and lack of quality. The AEFIs active surveillance project are an important occasion of traineeship for vaccinovigilance system, that could increase the sensibility and the reliability.

Incidence, angiographic and clinical predictors, and impact of stent thrombosis: a 6-year survey of 6,545 consecutive patients

Objective

We sought to determine the incidence, angiographic predictors, and impact of stent thrombosis (ST).

Background

Given the high mortality after ST, this study emphasises the importance of ongoing efforts to identify angiographic predictors of ST.

Methods

All consecutive patients with angiographically confirmed ST between 2010 and 2016 were 1:4 matched for (1) percutaneous coronary intervention (PCI) indication and (2) index date ±6 weeks to randomly selected controls. Index PCI angiograms were reassessed by two independent cardiologists. A multivariable conditional logistic regression model was built to identify independent predictors of ST.

Results

Of 6,545 consecutive patients undergoing PCI, 55 patients [0.84%, 95% confidence interval (CI) 0.63–1.10%] presented with definite ST. Multivariable logistic regression identified dual antiplatelet therapy (DAPT) non-use as the strongest predictor of ST (odds ratio (OR) 10.9, 95% CI 2.47–48.5, p < 0.001), followed by: stent underexpansion (OR 5.70, 95% CI 2.39–13.6, p < 0.001), lesion complexity B2/C (OR 4.32, 95% CI 1.43–13.1, p = 0.010), uncovered edge dissection (OR 4.16, 95% CI 1.47–11.8, p = 0.007), diabetes mellitus (OR 3.23, 95% CI 1.25–8.36, p = 0.016), and residual coronary artery disease at the stent edge (OR 3.02, 95% CI 1.02–8.92, p = 0.045). ST was associated with increased rates of mortality as analysed by Kaplan-Meier estimates (27.3 vs 11.3%, p_log-rank < 0.001) and adjusted Cox proportional-hazard regression (hazard ratio 2.29, 95% CI 1.03–5.10, p = 0.042).

Conclusions

ST remains a serious complication following PCI with a high rate of mortality. DAPT non-use was associated with the highest risk of ST, followed by various angiographic parameters and high lesion complexity.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1253-2) contains supplementary material, which is available to authorized users.

Hemorrhagic cystitis in pregnancy: Case report and review of the literature

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, frequently associated with preterm labor. We describe, for the first time in literature, one patient with a clinical status of hematuria in two consequent pregnancies, without any identified cause and a medical history negative for recurrent or hemorrhagic cystitis and we report an overview of literature concerning this topic.

Paclitaxel eluting balloon: from bench to bedside

Despite the impressive progress of percutaneous treatment modalities, restenosis remains the major Achilles heel of interventional cardiology. Approximately 25% of the general population treated for coronary diseases with a bare-metal stent and about 10% of patients treated with a drug-eluting stent develop an overgrowth of vascular tissue and renarrowing inside the stent, or in-stent restenosis. These rates are even greater in diabetics and patients at higher risk of restenosis both for clinical presentation (patients in dialysis, low ejection fraction) or anatomical characteristics (ostial, bifurcation, long lesions). Non-stent based local drug delivery and particularly the use of paclitaxel eluting balloon (PEB) could be one promising strategy to reduce restenosis. This review will briefly explore the different characteristics of PEB devices currently present in the market and summarize the results obtained both in animal models and clinical practice, giving an indication of the potential field of application of this new technology.

[What do we know after ten years of genetic research into calcium kidney stones?]

Genetic studies of calcium kidney stones have so far assessed single candidate genes by testing linkage disequilibrium or association between a locus and stone disease. They showed the possible involvement of the calciumsensing receptor gene, vitamin D receptor gene, and bicarbonate-sensitive adenylate cyclase gene. In addition to research in humans, the study of different strains of knock-out mice let us include the gene of phosphate reabsorption carrier NPT2, caveolin-1, protein NHERF-1 modulating calcium and urate reabsorption, osteopontin and Tamm-Horsfall protein among the possible determinants. However, the interactions between genes and also between environmental factors and genes are generally considered fundamental in calcium stone formation. Thus, the genetic studies carried out to date have not led to a significant growth of the knowledge about the causes of calcium kidney stones, even though they have allowed us to assess the size of the problem and define criteria to address it. Further knowledge of the causes of calcium stones may be obtained using the instruments that modern biotechnology and bioinformatics have made available to researchers.

Endogenous ouabain and cardiomyopathy in dialysis patients

BACKGROUND AND METHODS

Endogenous ouabain (EO) is markedly raised in patients with chronic renal failure. As high EO induces myocardial cell hypertrophy in vitro and it is associated with left ventricular hypertrophy (LVH) in essential hypertensives and in patients with heart failure we investigated the relationship between plasma EO and LV mass and geometry in 156 end-stage renal disease (ESRD) patients. EO was measured by a specific radioimmunoassay and by mass spectrometry.

RESULTS

On univariate analysis, plasma EO was directly related to LV mass (r = 0.26, P = 0.001) and LV end diastolic volume (r = 0.25, P = 0.002) and these relationships held true in multiple linear regression models including a series of potential confounders. Patients with eccentric LVH (n = 41, i.e. 26%) had the highest plasma levels of EO when compared to patients with other patterns of LV geometry (P = 0.001). Furthermore, plasma EO had diagnostic value for eccentric LVH because the area under the corresponding ROC curve (68%) was significantly greater (P = 0.002) than the threshold of diagnostic indifference. In this analysis, the sensitivity was 91% and the specificity was 36%. The positive predictive value was 33% but EO had a remarkably high negative predictive value (92%) for the exclusion of eccentric hypertrophy.

CONCLUSIONS

In ESRD patients, plasma EO is independently associated with LV mass, LV volume and eccentric LVH. The results of this study are compatible with the hypothesis that EO is involved in alterations of LV mass in ESRD.

Cost comparison of XELOX compared to FOLFOX4 with or without bevacizumab (bev) in metastatic colorectal cancer

4074

Background: A recent randomized 2x2 phase III trial compared oral capecitabine + IV oxaliplatin (XELOX); IV 5FU/LV/oxaliplatin (FOLFOX4), XELOX+bev, and FOLFOX4+bev. FOLFOX4 was the regulatory control. XELOX was non-inferior to FOLFOX4 for progression-free survival, and bev-containing regimens were superior to comparison arms. This economic analysis compared expected costs in XELOX vs. FOLFOX4 arms in a US setting from a payer and societal perspective. Methods: Direct medical and indirect cost estimates (for patient time and travel) were compared. Resource use and patient time were estimated based on trial data and protocols. Data collected during the trial and used in the analysis were as follows: no. of visits / duration of drug administration, central venous access management, treatment of adverse events (AE), including hospital days for treatment-related AEs and total hours of ambulatory encounters. Unit costs were based on government fee schedules (i.e. Medicare reimbursements) and other published sources. Results: Total direct medical cost estimates were similar for bi-weekly FOLFOX4 and 3-weekly XELOX: $45,800 vs. $44,500. XELOX had higher drug costs while FOLFOX had higher drug administration costs, with about 15 more visits. Costs for hospitalization and ambulatory encounters were slightly lower for FOLFOX4; other medications and venous access were slightly higher for FOLFOX4. Similar patterns held for FOLFOX4+bev vs. XELOX+bev (total direct medical cost estimates $76,100 vs. $79,200). Indirect time cost estimates were lower with XELOX due to fewer cycles and visits: estimated savings range from $1000-$5000 depending on assumptions used. Conclusion: XELOX is estimated to have similar total direct medical costs and lower indirect costs compared with FOLFOX4.

[Table: see text]

No significant financial relationships to disclose.

Intracoronary abciximab

Here we report the potential benefits of the use of intracoronary abciximab during percutaneous coronary intervention for an acute myocardial infarction.

[Cutaneous hyperpigmentation of the distal falanx in a newborn]

A case of distal falangeal hyperpigmentation in a 2-month female newborn, who did not show any other cutaneous disease at the time of our observation, is presented. The aim of our study is to focus attention on this condition, actually considered a benign, asymptomatic, transitory manifestation, rarely reported in literature. On the basis of the clinical features, it has been proposed to add this pigmentation to the transient benign dermatoses of newborns.

Becker's nevus syndrome

Becker's nevus (BN) is a unilateral hyperpigmented, often hairy, cutaneous hamartoma, with geographic borders. It is usually localized on the shoulder, anterior chest, scapula, or upper arm, but there have been reports of BN in other areas (eg, lower extremities, face). In most cases, the lesion appears in late childhood or adolescence, and both congenital and familial cases have been described.

Erythrocyte calcium influx is related to severity of ventricular arrhythmias in uraemic patients

BACKGROUND

Myocardial disorders are a remarkable cause of morbidity and mortality in chronic haemodialysed patients (HD). They could be favoured by alteration of cell Ca(2+) handling. In previous studies we characterized an erythrocyte Ca(2+) influx, sensitive to membrane potential and inhibited by Ca(2+) antagonists. Since its maximal influx rate was decreased in HD patients, this study investigates if Ca(2+) influx alterations are related to myocardial disorders in HD patients.

METHODS

Voltage-sensitive erythrocyte Ca(2+) influx was measured in 30 healthy controls and in 53 patients (47 HD patients and six patients with left ventricular hypertrophy and normal kidney function), using fura 2. In 29 HD patients and in six healthy subjects Ca(2+) influx was also determined in the presence of parathyroid hormone (PTH) in vitro. Patients were classified according to Lown's ventricular arrhythmias classification after 24-h Holter electrocardiograph (ECG) monitoring. Forty-six patients underwent echocardiography.

RESULTS

Voltage-sensitive erythrocyte Ca(2+) influx was significantly reduced in HD patients. Maximal influx rate was significantly higher in HD patients of Lown's classes 3 and 4 (0.789 +/- 0.156 nmol/s, n = 8; P < 0.01) than in patients of classes 1 and 2 (0.499 +/- 0.055 nmol/s, n=15), or without ventricular arrhythmias (0.400 +/- 0.041 nmol/s, n = 24). Maximal influx rate was directly correlated to left ventricular mass index (LVM) (r = 0.353, P < 0.05). Subjects with left ventricular hypertrophy and normal kidney function displayed erythrocyte Ca(2+) influx similar to that of normal subjects. Multiple regression indicates that LVM and Ca(2+) influx were independently related to severity of arrhythmias. When added to the influx assay, PTH increased the maximal influx rate only in patients with ventricular arrhythmias.

CONCLUSION

Myocardial dysfunction and altered ventricular excitability could be related in uraemic HD patients to alterations of calcium transport, as found in the erythrocyte model. Reduced resistance to PTH could contribute to this phenomenon.

Coronary radiation therapy with liquid rhenium-186: a first clinical experience

BACKGROUND

Coronary radiation therapy (CRT) is a new, attractive approach for the treatment and prevention of restenosis after percutaneous coronary interventions (PCI). The RadioCath device consists of a standard balloon dilatation catheter that can be charged with a solution of sodium 186Re perrhenate, a predominant beta emitter. The safety and performance of this new device was evaluated in a pilot trial.

METHODS AND RESULTS

Thirty-three patients with a de novo lesion in a native coronary artery were treated with the RadioCath device after successful angioplasty. The average dwell time to deliver a dose of 20 Gy at 0.5 mm into the vessel wall was 418+/-64 seconds. The treatment was well tolerated by most of the patients. In 79%, only one inflation cycle was required to deliver the prescribed dose. There were two procedural device-related complications (5.9%) and three minor procedural related in-hospital complications (9%).

CONCLUSIONS

CRT using a balloon catheter device, charged with a sodium 186Re perrhenate solution, seems feasible and safe. Clinical and angiographic 6-month follow-up data are pending.

[The echo-stress test with dipyridamole-atropine on the 3rd-5th day of an uncomplicated acute myocardial infarct for risk stratification and early discharge]

BACKGROUND

The aim of this study was to evaluate if dipyridamole-atropine stress echocardiography (DASE) performed between the third-fifth day in uncomplicated acute myocardial infarction allows for an effective risk stratification with an early discharge in some cases.

METHODS

Between February 1997 and September 1998, 190 patients (138 males and 52 females, mean age 59 +/- 10.3 years), with acute myocardial infarction, were enrolled in the study. DASE was performed between the third-fifth day with a dipyridamole infusion of 0.84 mg/kg over 10 min followed by 1 mg of atropine from the twelfth to the fifteenth minute. DASE was considered positive in the presence of a new or worsening dyssynergy. Patients with heart failure, angina, major arrhythmias, and poor acoustic window were excluded. In the follow-up spontaneous events were defined as cardiac death, non-fatal myocardial reinfarction, unstable angina or heart failure (with hospitalization).

RESULTS

DASE was performed in 92 patients (48.4%), all without complications: 29 patients (31.5%) had a negative DASE result, and 63 patients (68.5%) had a positive DASE. The average hospital stay of patients with a negative test was significantly lower in comparison with that of patients with a positive test (7.55 +/- 1.32 vs 9.29 +/- 1.61 days, p < 0.0001). Events occurred in 19 patients (20.6%), 2/29 patients with a negative DASE (6.9%), 17/63 patients with a positive DASE (27%), 6/43 patients with homozonal positivity after atropine or high-dose dipyridamole (14%), 11/20 patients with heterozonal positivity or homozonal positivity after low-dose dipyridamole (55%). On univariate analysis the variables significantly associated with spontaneous events were: age (chi 2 = 6.41, p = 0.019), left ventricular ejection fraction at rest (chi 2 = 8.89, p = 0.004), number of asynergic segments after stress (chi 2 = 6.87, p = 0.010), increase in the number of asynergic segments after stress (chi 2 = 4.01, p = 0.039), wall motion score index after stress (chi 2 = 9.60, p = 0.003), increase in wall motion score index after stress (chi 2 = 3.60, p = 0.049), DASE positivity (chi 2 = 4.89, p = 0.029), homozonal positivity after low-dose dipyridamole (chi 2 = 8.57, p = 0.013), heterozonal positivity (chi 2 = 13.10, p = 0.001). On Cox's multivariate analysis independent predictors of events were: age (relative risk 3.92, p = 0.0146), DASE positivity (relative risk 1.79, p = 0.0054).

CONCLUSIONS

DASE between the third-fifth day in uncomplicated acute myocardial infarction is feasible, tolerable, safe, and effective for early risk stratification. A negative DASE detects a "very low-risk" patient group, and allows for an earlier hospital discharge, without an increased risk of events. The heterozonal positivity or the homozonal positivity after low-dose dipyridamole indicates the need for a coronarography, due to the high risk of events at follow-up.

Body mass index in children and adolescents according to age and pubertal stage

OBJECTIVE

To evaluate the dependence of body mass index (BMI) values on pubertal stage in subjects similar in age.

DESIGN, SUBJECTS AND MEASUREMENTS

Height and weight were recorded cross-sectionally in school subjects from three provinces in central Italy. The subjects were subdivided into three groups: (1) 4271 school subjects (2125 males and 2146 females; 8.5-15.5 y old), in whom the pubertal development was also recorded, were selected to subdivide BMI values according to pubertal stage and age; (2) 6345 females (10.5-14.5 y old), who were asked whether or not they had had their first menstrual period, were selected to subdivide BMI values according to age in pre-menarche and post-menarche girls, separately; and (3) 1919 females (10.5-14.5 y old), who had presented their menarche within the previous 6 months, were selected to subdivide short-term post-menarche BMI values according to age.

RESULTS

The medians and interquartile ranges of BMI varied according to age and pubertal stage. Kruskall-Wallis test performed in subjects similar in age demonstrated that significant differences existed among the medians of BMI values of subjects at different pubertal stages in 12-14-y-old males (P<0.05), and in 11-14-y- old females (P<0.001). The difference also proved to be significant between stage I and stage II (P<0.05) in 10-y-old females, but not in 10-11-y-old males. The Kruskal-Wallis test performed in subjects similar in pubertal stage demonstrated that significant differences among the medians of BMI at different ages existed only in females at stages II and III. A significant positive trend was observed in both genders according to pubertal stage for BMI values of subjects similar in age (z-test for trend, P<0.01). On the contrary, a negative age trend proved to be significant in females at stages I (P<0.01), II (P<0.01) and III (P<0.001), but not in males when the subdivision of BMI was made according to age in subjects similar in pubertal stage. BMI values were significantly higher in post-menarche girls as compared to pre-menarche girls similar in age (P<0.001). However, at partial regression analysis BMI values were influenced by pubertal stage and, to a lesser extent, by age, but not by menarcheal status. An inverse association between short-term post-menarche BMI and age was observed, with the highest values in girls presenting menarche at 11 y of age (P<0.05). The negative trend was demonstrated at the z-test for trend (P<0.001).

CONCLUSIONS

BMI values depend on pubertal degree of maturation, especially in girls. This influence should be taken into account when BMI is evaluated in adolescents.

SPONSOR

University of Perugia, Region of Umbria.

Cardiovascular autonomic neuropathy (expiration and inspiration ratio) in type 1 diabetes. Incidence and predictors

The pathogenesis of diabetic neuropathy is poorly understood. In this prospective study, we investigated the incidence rate and potential predictors for cardiovascular autonomic neuropathy (CAN) in a cohort of childhood-onset type 1 diabetic patients. Subjects from the Epidemiology of Diabetes Complications Study were examined at baseline and then biennially. CAN was diagnosed by abnormal (</=1. 1) expiration/inspiration ratio during deep breathing. During the 4. 7-year mean follow-up period, CAN developed in 104 patients from the 373 subjects who were free of CAN at baseline and provided follow-up data, an incidence-density of 5.9 cases/100 person-years. Cox proportional hazard modeling showed age (relative risk [RR]=2.15, p=0.0001), HbA1 (RR=1.50, p=0.0002) and nephropathy (albumin excretion >200 ug/min) (RR=2.46, p=0.0001) to be significant independent predictors. Hypertension was, however, predictive if nephropathy was not included in the model. We conclude that beyond age and poor glycemic control, nephropathy is a significant risk factor for CAN and this association may explain some of the increased mortality seen in CAN.

The role of alpha-adducin polymorphism in blood pressure and sodium handling regulation may not be excluded by a negative association study

The basic requirement for declaring an association study positive is that the "hypertension-favoring" allele is more frequent in hypertensive cases than in normotensive controls. However, both positive and negative associations with hypertension have been found for the same polymorphism when studied in different populations. In the present study, we addressed the question of the possible cause(s) of this discrepancy among populations by using the alpha-adducin polymorphism as a paradigm. Four hundred ninety hypertensives and 176 normotensives enrolled in Sassari, Italy, and 468 hypertensives and 181 normotensives enrolled in Milano, Italy, were genotyped for the alpha-adducin Gly460Trp polymorphism. The blood pressure response to 2 months of hydrochlorothiazide therapy could be evaluated in 143 (85 in Sassari and 58 in Milano) hypertensives with and without the 460Trp alpha-adducin allele. The alpha-adducin 460Trp allele was not significantly more frequent in hypertensives in the Sassari population but was more frequent in hypertensives than in normotensives in Milano (P=0.019). Basal plasma renin activity was lower and blood pressure fall after diuretic therapy more pronounced (P<0.01) in hypertensives carrying at least one 460Trp allele than in Gly460Gly homozygotes, irrespective of their membership in the Sassari or Milano cohort. The effect of alpha-adducin genotype in predicting basal plasma renin activity and blood pressure decrease with diuretic treatment is similar in Sassari and Milano, despite the lack of association of the alpha-adducin genotype with hypertension in Sassari.

Left ventricular mass, stroke volume, and ouabain-like factor in essential hypertension

Many patients with essential hypertension (EH) exhibit increased left ventricular mass. Similarly, elevated circulating levels of an endogenous ouabainlike factor (OLF) have been described in some but not all patients with EH. Moreover, ouabain has a hypertrophic influence on isolated cardiac myocytes. Accordingly, we investigated relationships among plasma OLF, left ventricular mass, and cardiac function in patients with EH. Plasma OLF was determined in 110 normotensive subjects and 128 patients with EH. Echocardiographic parameters and humoral determinants were measured in EH. Plasma OLF levels were increased (P<0.0001) in patients with EH (377+/-19 pmol/L) versus normotensive (253+/-53 pmol/L) subjects. The distribution of plasma OLF was unimodal in normotensives, whereas it was bimodal in EH. Twenty-four-hour diastolic ambulatory blood pressure was slighter higher in EH with high OLF compared with EH with normal OLF (93.2+/-1.14 versus 89.4+/-1.33 mm Hg, P=0.03). Left ventricular mass index and stroke volume in EH with high OLF were greater than in EH with normal OLF (101.9+/-3.3 versus 86.1+/-2.5 g/m(2), P=0.0003, and 57.10+/-1.48 versus 52.30+/-1.14 mL/m(2), P=0. 02, respectively), although heart rate was slower (74.2+/-1.3 versus 80.5+/-1.3 bpm, P=0.005). Multiple regression analysis that tested the influence of body mass index, age, gender, 24-hour blood pressure, and OLF on left ventricular mass revealed independent contributions of systolic (13.2%) and diastolic (12.4%) blood pressure and plasma OLF (11.6%) to left ventricular mass. We conclude that approximately 50% of patients with uncomplicated EH have elevated-high circulating OLF levels, higher diastolic blood pressure, greater left ventricular mass and stroke volume, and reduced heart rate. We propose that the OLF affects cardiovascular function and structure and should be considered as a factor that contributes to the risk of morbid events.

[The follow-up of a child with a syndrome due to partial deletion of chromosome 3 (p25-pter)]

A case of del(3) p25-pter syndrome in a four-year-old boy whose clinical manifestations were followed and studied since birth, is described. Diagnosis was made by means of karyotype analysis. The parental chromosomes were normal. So far, only about twenty cases of this syndrome have been described in living individuals. Comparison with previously reported cases confirms that the phenotype exhibits an identifiable pattern of malformation, consisting of pre- and postnatal growth delay, typical craniofacial dysmorphisms and limb abnormalities. No severe visceral anomalies were detected in this patient. Nevertheless, the follow-up revealed a progressive decay of the psychomotor and neurosensory functions.

Alpha-adducin polymorphisms and renal sodium handling in essential hypertensive patients

The relationship between blood pressure and sodium (Na) excretion is less steep in hypertension caused by increased renal tubular reabsorption. We recently demonstrated that one mutation in rat alpha-adducin gene: (1) is responsible for approximately 50% of the hypertension of MHS rats, and (2) stimulates tubular Na-K pump activity when transfected in renal epithelial cell, suggesting that its pressor effect may occur because an increased tubular reabsorption. Linkage and association studies demonstrated that the alpha-adducin locus is relevant for human hypertension. A point mutation (G460W) was found in human alpha-adducin gene, the 460W variant (G/W) is more frequent in hypertensives than in normotensives. The aim of this study was to test whether acute changes in body Na may differently affect blood pressure in humans as a function of alpha-adducin genotype. The pressure-natriuresis relationship was analyzed in 108 hypertensive using two different acute maneuvers: Na removal (furosemide 25 mg p.o.) and, two days later, Na load (310 mmoles i.v. in 2 hr). We found that 80 patients were wild-type homozygous (G/G), 26 were G/W heterozygous, and 2 were W/W homozygous with similar blood pressure, age body mass index, gender, plasma and urinary sodium and potassium. In basal condition G/W-W/W patients showed a lower plasma renin activity and fractional excretion of Na. In either case the pressure-natriuresis relationship was less sleep in G/W-W/W than in G/G patients, obviously negative for Na depletion with furosemide (-0.011 +/- 0.004 vs. -0.002 +/- 0.002 mm Hg/mumol/min, P < 0.03), and positive for Na load (0.086 +/- 0.02 vs. 0.027 +/- 0.007 mm Hg/mumol/min, P < 0.001). The finding of reduced slope after Na depletion or Na load supports the hypothesis that, as MHS rats, humans bearing one W alpha-adducin variant display an increased of renal tubular sodium reabsorption.

Intracolonic release of nitric oxide during trinitrobenzene sulfonic acid rat colitis

Nitric oxide is thought to play an important role in modulating the inflammatory process. Recently an increase in the inducible form of nitric oxide synthase (iNOS) has been found in the rat trinitrobenzene sulfonic acid model of experimental colitis, and inhibition of nitric oxide synthase activity resulted in an amelioration of tissue injury. The aim of our study was to evaluate in vivo intracolonic release of nitric oxide in this model of colitis. Experimental colitis was induced in male Sprague-Dawley rats by a single intracolonic administration of trinitrobenzene sulfonic acid. Nitrite levels were determined in rectal dialysates by HPLC. The tissue myeloperoxidase and iNOS and the luminal leukotriene B4 were also measured. Nitrite levels were significantly increased in rectal dialysates during colitis and correlated significantly with tissue myeloperoxidase and iNOS activity. The correlation between nitrite dialysate levels and wall iNOS activity confirms that nitrite in dialysates is produced by inflammatory cells and not by colonic bacterial flora. Determination of nitrite levels in rectal dialysates seems a valuable method to monitor colonic inflammation in rat trinitrobenzene sulfonic acid colitis.

Erythrocyte calpain activity and left ventricular mass in essential hypertension

BACKGROUND

Calpains are cytoplasmic proteases widely distributed among eucaryotic cells. Low levels of calpain activity were found in hypertrophic hearts from hypertensive rats, but its role in hypertrophic hearts from human hypertensives is unknown. Therefore, calpain activity was investigated in erythrocytes from essential hypertensive patients in relation to their left ventricular mass.

OBJECTIVE

To study the role of calpain activity in the development of left ventricular hypertrophy (LVH) in human essential hypertension.

METHODS

A total of 115 hypertensives (72 untreated and 43 with treatment interrupted for at least 4 months) were included in the study. Calpain I activity was measured in human erythrocytes and LVH was measured as left ventricular mass index (LVMI) by M-mode echocardiography.

RESULTS

Values are given as mean+/-SEM. The hypertensives (97 men and 18 women) were 43.5+/-0.9 years old with mild to moderate levels of hypertension (systolic/diastolic blood pressure of 147.9+/-1.4/98.7+/-0.9 mmHg) and relatively recent LVH onset (3.5+/-0.5 years). An inverse relation between LVMI and erythrocytic calpain activity was present in all (P = 0.0023, R2 = 7.9%). This relation was still present considering only untreated hypertensives (P = 0.008; R2 = 9.7%), but was lost in the 43 previously treated hypertensives. Moreover, in the untreated hypertensives, after excluding the possible confounding effects of sex, age, body mass index, blood pressure and duration of hypertension, a stepwise regression showed that only two variables remained significantly related to LVMI: calpain (F = 6.23) and mean arterial pressure (F = 4.689). No relations were found between LVMI and calpastatin activity either in the whole population, or in treated or untreated hypertensives.

CONCLUSIONS

If we assume that the level of erythrocyte calpain activity mirrors the level in cardiomyocytes, these data seem to suggest that increased protein degradation by calpain may prevent the development of LVH in hypertensive patients. This effect is independent of the duration and severity of hypertension.

[Pseudotumor cerebri: a pediatric case report]

We describe a case of pseudotumor cerebri (PTC) in a five years old child. Pseudotumor cerebri is a not very common syndrome in the pediatric age. The incidence rate in about 1:100.000. The prognosis of PTC is usually good. Sometimes however, PTC could be complicated by eye diseases such as reduction of visual field. Our case is a child with diplopia and with a bilateral oedema of the papilla. The diagnosis of PTC was possible after the physical examination and the instrumental exams (EEG, brain NMR and others). During the staying in the hospital the child performed a therapy with betamethasone and acetazolamide; the diplopia improved and the bilateral oedema of the papilla started to be less evident. The child was discharged in good health and with a planned ocular follow-up. We think that the Pediatrician must considered the possibility of the presence of a PTC; that is an important syndrome not only for the Neurologist.

Renal genetic mechanisms of essential hypertension

Human essential hypertension is a polygenic disease whose phenotypic expression is modulated by the environment. Though the kidney could play a major role in the initiation and maintainment of hypertension, many questions remain open. Rat models of primary hypertension provided the substantial information with experiments on kidney cross-transplantation showing that at least a portion of hypertension could be transplanted with the kidney in all strains where such experiment has been carried out. Data consistent with those of rats have also been obtained in humans. Many abnormalities in kidney function and cell membrane on transport have been described in hypertensive rats and humans but the logical sequence of events going from a genetic-molecular abnormality to a cellular abnormality which causes hypertension via a modification of kidney function is difficult to prove. We established this sequence in Milan hypertensive rats using a variety of experimental techniques such as the study of isolated kidney and renal cell function, cell membrane ion transport, cross-immunisation with membrane proteins, molecular biology, genetic crosses and manipulation. Such study led to the identification of a polymorphism in the cytoskeletal protein adducin and to the demonstration of its role in blood pressure control. Recently, alpha-adducin variants have been associated to both human primary hypertension and salt sensitive hypertension. Finally, recent findings strongly support the hypothesis that adducin variants may affect kidney function by modulating the overall capacity of the tubular epithelial cells to transport ions through both a modification in the assembly of actin cytoskeleton, and a modulation of sodium pump activity.

Polymorphisms of alpha-adducin and salt sensitivity in patients with essential hypertension

BACKGROUND

Abnormalities in renal sodium transport may be involved in hypertension. Adducin, an alpha/beta heterodimeric protein found in the renal tubule is thought to regulate ion transport through changes in the actin cytoskeleton. We investigated whether an alpha-adducin polymorphism (Gly 460 Trp) is involved in essential hypertension in two separate populations.

METHODS

Linkage analysis of three DNA markers at different distances from the alpha-adducin locus (20-2500 kb) was done in 137 hypertensive sibling-pairs. 477 hypertensive and 322 normotensive individuals were genotyped for the alpha-adducin polymorphism. The blood-pressure response to acute and chronic changes in sodium balance was studied in hypertensive individuals with and without the 460 Trp alpha-adducin allele.

FINDINGS

Significant linkage was found for all three markers in the sibling-pair study. The extra shared alleles (9.1%, 6.5%, and 4.7%) and the significance level for linkage (p = 0.0006, p = 0.0119, and p = 0.0211) both decreased with increasing distance from the alpha-adducin locus. There was a significant association between the 460 Trp mutation and hypertension (p = 0.0003). In the salt-sensitivity test, to assess the acute blood-pressure response to changes in body sodium in 86 hypertensive patients, the decrease in mean arterial pressure was greater in 65 patients who were heterozygous for the mutant allele (Gly/Trp) than in 21 wild-type homozygotes (Gly/Gly) (mean decrease 15.9 [SE 2.0] vs 7.4 [1.3] mm Hg; p = 0.001). Similarly, 21 heterozygous hypertensive patients showed a greater fall in mean arterial pressure in response to 2 months' treatment with hydrochlorothiazide than did 37 wild-type homozygous hypertensive patients (mean decrease 14.7 [2.2] vs 6.8 [1.4] mm Hg; p = 0.002).

INTERPRETATION

Our findings of significant linkage of the alpha-adducin locus to essential hypertension and greater sensitivity to changes in sodium balance among patients with the mutant allele suggest that alpha-adducin is associated with a salt-sensitive form of essential hypertension. We suggest the alpha-adducin polymorphism may identify hypertensive patients who will benefit from diuretic treatment or manoeuvres to reduce total body sodium.

A new therapeutic strategy for the eradication of Helicobacter pylori infection

For the eradication of the Helicobacter pylori infection, authors have tested 50 HP-positive subjects (28 females and 22 males; mean age 47 years): 21 duodenal ulcers and 29 gastritis. All patients received the following treatment: omeprazole 40 mg for 30 days, azithromycin 500 mg in a single daily dose for 3 days for 2 cycles and metronidazole 250 mgx4 for 14 days. One month after the end of therapy, patients have been controlled: the HP eradication rates have been 76% (35/46), duodenal ulcer was cured in 90% (18/20). No important side-effects were reported by patients during the treatment. In conclusion the new therapeutic scheme with azithromycin represents a semplificated alternative treatment in the eradication of Helicobacter pylori.

Na+,K+,Cl- cotransport is a marker of distal tubular function in essential hypertension

OBJECTIVE

To analyze the natriuretic and diuretic response to frusemide in 33 male essential hypertensive patients as a function of basal renal sodium handling and erythrocyte transport system.

METHODS

The natriuretic and diuretic response to an oral dose of frusemide (25 mg) was assessed with a simplified method. Urinary sodium and water excretion were measured in the basal state and every 30 min after the frusemide dose for 240 min. Basal 24h urinary sodium and water excretion, Na+,K+,Cl- cotransport and Li+-Na+ countertransport were measured 24 h before the test.

RESULTS

There was a highly significant correlation between the natriuretic and diuretic response to frusemide and Na+,K+,Cl- cotransport and Li+-Na+ countertransport. After a multiple regression analysis the natriuretic and diuretic response to frusemide was not correlated with indices of proximal tubular function (Li+-Na+ countertransport, fractional uric acid excretion and the ratio of fractional sodium excretion to fractional uric acid excretion).

CONCLUSION

These results support the hypothesis that erythrocyte Na+,K+,Cl- cotransport is a marker of distal tubular function.

alpha-adducin may control blood pressure both in rats and humans

1. Previous studies on the pathogenetic mechanisms of hypertension in the Milan hypertensive strain of rat (MHS) showed that a polymorphism within the alpha-adducin gene is responsible for up to 50% of the blood pressure difference between MHS and their MNS normotensive control strain. A case-control study has shown also in humans an association between alpha-adducin locus and hypertension using 4 multiallelic markers surrounding the alpha-adducin locus. 2. With a multiple regression approach we provide an estimate of the contribution of the genotype for each marker to the blood pressure variability in comparison to that provided by sex, body mass index and age. 3. While sex, body mass index and age contributed by about 40-45% to the overall blood pressure variability, the inclusion of the genotype for the marker closer to the alpha-adducin locus provided a further increase of the variability explained of about 5%. 4. The contribution independently provided by the other markers decreased exponentially with the increase of distance from alpha-adducin locus.

[Budd-Chiari syndrome in children: case report]

This work aims at describing a particular case of Budd-Chiari syndrome in a ten-year-old girl. In our patient, the subjective and objective features of this disease, which is already rare during childhood, are associated with a well-assessed polyposis in the blind intestine (intestinum caecum). In our opinion, a possible connection between these two pathological events, a connection unheard of in the literature so far, is an interesting issue to be dealt with in this case report. The follow-up of our patient took place at the Pediatric Hospital of the University of Rome "La Sapienza" and lasted an overall period of 6 months. The girl was hospitalized twice and she underwent a large number of radiological and laboratory tests. The therapy consisted only of medical treatment and support measures. Liver transplant is regarded as the only chance to obtain a full recovery, but it has not yet been performed on our patient. It is by comparing those researches carried out on similar cases with the outcome of our personal study, that we come to the conclusion that, as for our patient, the Budd-Chiari syndrome can be classified as an idiopathic syndrome. Moreover, the fact that this syndrome and the polyposis of caecum occur at the same time in a patient can probably be considered as a coincidence.

Transradial Palmaz-Schatz coronary stenting on an outpatient basis: results of a prospective pilot study

BACKGROUND

The applicability of Palmaz Schatz coronary stent implantation is limited by bleeding complications and prolonged hospitalization. Coronary stenting on an outpatient basis, may be the ultimate means to reduce costs of this treatment. Since bleeding and stent occlusion were infrequent complications in a group of 100 ambulatory patients who underwent stent implantation via the radial artery in our department, we performed a pilot study to determine the feasibility of using coronary stenting on an outpatient basis.

METHODS

Patients selected for Palmaz Schatz stent implantation, were adequately adjusted on coumadin. At an INR > 2.5, stenting was performed via the radial approach. Based on pre-, post- and procedural criteria, considering clinical status, procedural course and outcome, absence of predictors for stent occlusion and of events during 4 to 6 hours observation, patients were considered candidates for same-day discharge. Heparin was administered only during the procedure. Immediately after the procedure, the arterial sheath was removed. Patients were mobilized and were discharged with a pressure dressing over the puncture site. Follow-up was performed on the next day, at 2 weeks and at one month.

RESULTS

Between May and September 1994, 47 patients underwent Palmaz Schatz stent implantation via the radial artery. Of these, 27 remained hospitalized for reasons, considered to be incompatible with outpatient treatment. Twenty patients (CCS-class III and IV; n = 17 (85%)) received 29 stents for 23 lesions, distributed in 21 vessels and were discharged the day of treatment. No cardiac or bleeding events were encountered within 24 hours. At 2 weeks follow-up, one patient was readmitted (day 4) because of a bleeding abdominal aortic aneurysm, requiring surgery. At 1 month follow-up, no bleeding, entry-site and cardiac complications were noted.

CONCLUSION

Since no complications were encountered (95% confidence interval; 0-17%) in the first 24 hours after optimal coronary stent implantation in patients with an adequate preprocedural level of anticoagulation, a larger feasibility study of outpatient coronary stenting will be undertaken.