Left atrial volume during stress is associated with increased risk of arrhythmias in patients with hypertrophic cardiomyopathy

Introduction: In patients affected by hypertrophic cardiomyopathy (HCM), left atrial volume index (LAVi) is associated with an increased risk of tachyarrhythmias and major clinical events. To date, the clinical meaning of LAVi measured during exercise (stress LAVi [sLAVi]) has not yet been investigated in HCM. This study sought to evaluate the correlation between LAVi/sLAVi and clinical outcome (risk of arrhythmias and heart failure [HF]) in patients with HCM. Methods and Results: We enrolled a total of 51 consecutive patients with HCM (39 men; mean age: 39.41 ± 17.9 years) who underwent standard and stress echocardiography, following a common protocol. During follow-up (median follow-up was 1.82 years), the following composite endpoints were collected: ARRHYT endpoint (atrial fibrillation, paroxysmal supraventricular tachycardia, nonsustained ventricular tachycardia (VT), sustained VT, ventricular fibrillation, syncope of likely cardiogenic nature, and sudden cardiac death) and HF endpoint (worsening of functional class and left ventricular ejection fraction, hospitalization, and death for end-stage HF). Eight patients were lost at follow-up. ARRHYT endpoint occurred in 13 (30.2%) patients (8, 18.6%, supraventricular and 10, 23.2%, ventricular arrhythmias), whereas HF endpoint occurred in 5 (11.6%) patients. sLAVi (mean value of 31.16 ± 10.15 mL/m2) performed better than rLAVi as a predictor of ARRHYT endpoint (Akaike Information Criterion: 48.37 vs. 50.37, if dichotomized according to the median values). A sLAVi value of 30 mL/m2 showed a predictive accuracy of 72.1% (C-statistics of 0.7346), with a high negative predictive value (87.5%). Conclusion: These findings encourage future studies on sLAVi, as a potential predictor of arrhythmias and adverse outcome in patients with HCM

Clinical pregenetic screening for stroke monogenic diseases: Results from lombardia GENS registry

BACKGROUND AND PURPOSE: Lombardia GENS is a multicentre prospective study aimed at diagnosing 5 single-gene disorders associated with stroke (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, Fabry disease, MELAS [mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes], hereditary cerebral amyloid angiopathy, and Marfan syndrome) by applying diagnostic algorithms specific for each clinically suspected disease METHODS: We enrolled a consecutive series of patients with ischemic or hemorrhagic stroke or transient ischemic attack admitted in stroke units in the Lombardia region participating in the project. Patients were defined as probable when presenting with stroke or transient ischemic attack of unknown etiopathogenic causes, or in the presence of <3 conventional vascular risk factors or young age at onset, or positive familial history or of specific clinical features. Patients fulfilling diagnostic algorithms specific for each monogenic disease (suspected) were referred for genetic analysis. RESULTS: In 209 patients (57.4\ub114.7 years), the application of the disease-specific algorithm identified 227 patients with possible monogenic disease. Genetic testing identified pathogenic mutations in 7% of these cases. Familial history of stroke was the only significant specific feature that distinguished mutated patients from nonmutated ones. The presence of cerebrovascular risk factors did not exclude a genetic disease. CONCLUSIONS: In patients prescreened using a clinical algorithm for monogenic disorders, we identified monogenic causes of events in 7% of patients in comparison to the 1% to 5% prevalence reported in previous series

Off–label long acting injectable antipsychotics in real–world clinical practice: a cross-sectional analysis of prescriptive patterns from the STAR Network DEPOT study

Introduction: Information on the off–label use of Long–Acting Injectable (LAI) antipsychotics in the real world is lacking. In this study, we aimed to identify the sociodemographic and clinical features of patients treated with on– vs off–label LAIs and predictors of off–label First– or Second–Generation Antipsychotic (FGA vs. SGA) LAI choice in everyday clinical practice. Method: In a naturalistic national cohort of 449 patients who initiated LAI treatment in the STAR Network Depot Study, two groups were identified based on off– or on–label prescriptions. A multivariate logistic regression analysis was used to test several clinically relevant variables and identify those associated with the choice of FGA vs SGA prescription in the off–label group. Results: SGA LAIs were more commonly prescribed in everyday practice, without significant differences in their on– and off–label use. Approximately 1 in 4 patients received an off–label prescription. In the off–label group, the most frequent diagnoses were bipolar disorder (67.5%) or any personality disorder (23.7%). FGA vs SGA LAI choice was significantly associated with BPRS thought disorder (OR = 1.22, CI95% 1.04 to 1.43, p&nbsp;= 0.015) and hostility/suspiciousness (OR = 0.83, CI95% 0.71 to 0.97, p&nbsp;= 0.017) dimensions. The likelihood of receiving an SGA LAI grew steadily with the increase of the BPRS thought disturbance score. Conversely, a preference towards prescribing an FGA was observed with higher scores at the BPRS hostility/suspiciousness subscale. Conclusion: Our study is the first to identify predictors of FGA vs SGA choice in patients treated with off–label LAI antipsychotics. Demographic characteristics, i.e. age, sex, and substance/alcohol use co–morbidities did not appear to influence the choice towards FGAs or SGAs. Despite a lack of evidence, clinicians tend to favour FGA over SGA LAIs in bipolar or personality disorder patients with relevant hostility. Further research is needed to evaluate treatment adherence and clinical effectiveness of these prescriptive patterns

Comparing Long-Acting Antipsychotic Discontinuation Rates Under Ordinary Clinical Circumstances: A Survival Analysis from an Observational, Pragmatic Study

Background: Recent guidelines suggested a wider use of long-acting injectable antipsychotics (LAI) than previously, but naturalistic data on the consequences of LAI use in terms of discontinuation rates and associated factors are still sparse, making it hard for clinicians to be informed on plausible treatment courses. Objective: Our objective was to assess, under real-world clinical circumstances, LAI discontinuation rates over a period of 12 months after a first prescription, reasons for discontinuation, and associated factors. Methods: The STAR Network ‘Depot Study’ was a naturalistic, multicentre, observational prospective study that enrolled subjects initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centres were assessed at baseline and at 6 and 12 months of follow-up. Psychopathology, drug attitude and treatment adherence were measured using the Brief Psychiatric Rating Scale, the Drug Attitude Inventory and the Kemp scale, respectively. Results: The study followed 394 participants for 12 months. The overall discontinuation rate at 12 months was 39.3% (95% confidence interval [CI] 34.4–44.3), with paliperidone LAI being the least discontinued LAI (33.9%; 95% CI 25.3–43.5) and olanzapine LAI the most discontinued (62.5%; 95% CI 35.4–84.8). The most frequent reason for discontinuation was onset of adverse events (32.9%; 95% CI 25.6–40.9) followed by participant refusal of the medication (20.6%; 95% CI 14.6–27.9). Medication adherence at baseline was negatively associated with discontinuation risk (hazard ratio [HR] 0.853; 95% CI 0.742–0.981; p&nbsp;=&nbsp;0.026), whereas being prescribed olanzapine LAI was associated with increased discontinuation risk compared with being prescribed paliperidone LAI (HR 2.156; 95% CI 1.003–4.634; p&nbsp;=&nbsp;0.049). Conclusions: Clinicians should be aware that LAI discontinuation is a frequent occurrence. LAI choice should be carefully discussed with the patient, taking into account individual characteristics and possible obstacles related to the practicalities of each formulation

The Role of Attitudes Toward Medication and Treatment Adherence in the Clinical Response to LAIs: Findings From the STAR Network Depot Study

Background: Long-acting injectable (LAI) antipsychotics are efficacious in managing psychotic symptoms in people affected by severe mental disorders, such as schizophrenia and bipolar disorder. The present study aimed to investigate whether attitude toward treatment and treatment adherence represent predictors of symptoms changes over time. Methods: The STAR Network \u201cDepot Study\u201d was a naturalistic, multicenter, observational, prospective study that enrolled people initiating a LAI without restrictions on diagnosis, clinical severity or setting. Participants from 32 Italian centers were assessed at three time points: baseline, 6-month, and 12-month follow-up. Psychopathological symptoms, attitude toward medication and treatment adherence were measured using the Brief Psychiatric Rating Scale (BPRS), the Drug Attitude Inventory (DAI-10) and the Kemp's 7-point scale, respectively. Linear mixed-effects models were used to evaluate whether attitude toward medication and treatment adherence independently predicted symptoms changes over time. Analyses were conducted on the overall sample and then stratified according to the baseline severity (BPRS &lt; 41 or BPRS 65 41). Results: We included 461 participants of which 276 were males. The majority of participants had received a primary diagnosis of a schizophrenia spectrum disorder (71.80%) and initiated a treatment with a second-generation LAI (69.63%). BPRS, DAI-10, and Kemp's scale scores improved over time. Six linear regressions\u2014conducted considering the outcome and predictors at baseline, 6-month, and 12-month follow-up independently\u2014showed that both DAI-10 and Kemp's scale negatively associated with BPRS scores at the three considered time points. Linear mixed-effects models conducted on the overall sample did not show any significant association between attitude toward medication or treatment adherence and changes in psychiatric symptoms over time. However, after stratification according to baseline severity, we found that both DAI-10 and Kemp's scale negatively predicted changes in BPRS scores at 12-month follow-up regardless of baseline severity. The association at 6-month follow-up was confirmed only in the group with moderate or severe symptoms at baseline. Conclusion: Our findings corroborate the importance of improving the quality of relationship between clinicians and patients. Shared decision making and thorough discussions about benefits and side effects may improve the outcome in patients with severe mental disorders

Hydrogeochemistry of Roccamonfina volcano (Southern Italy)

This is the first hydro-geochemical investigation carried out on the Roccamonfina Volcanic Complex groundwaters. The chemistry of Roccamonfina waters is defined by water-rock and water-rock-gas interactions. In fact, interactions between rocks of the first eruptive high-K formations and circulating groundwaters are recognized by high K concentrations. On the other hand, inverse concentration of calcium versus alkali metals is related to two different rock interactions occurring in different areas of the volcano: (a) within the caldera where groundwaters flow within latite and pyroclastic formations releasing calcium, and (b) similarly at the base of the volcano where groundwaters flowing from surrounding carbonates got strongly enriched in Ca. These geochemical processes are also associated with K (SE of caldera) and Mg/Ca (in sites located at the NE base of the volcano) decrease. Completely different dynamics occurs at Riardo groundwaters (SE). Here waters are the result of a mix between the Roccamonfina deep aquifer and the carbonate aquifer of the Riardo plain. Rich-CO2 emissions make these waters strongly mineralized. Minor elements show a similar geochemical behavior of major ions and are crucial defining interactions processes. The evolution of Roccamonfina groundwaters is also evident along the simultaneous enrichment of Ba, Sr, and Ca. Ba increase is the result of deep local carbonate alteration enhanced by CO2 emissions and, the lower Sr/Ca ratio, from 10 to 2 (ppb/ppm), is also due to the same process. In the light of our results the Roccamonfina aquifer can be schematically divided into two main reservoirs: (a) a superficial aquifer which basically follows the volcanic structure morphology and tectonics and (b) a deeper reservoir, originating within the oldest Roccamonfina volcano ultra potassic lavas and then flowing into the carbonate aquifers of the neighboring plain. Eventually, the chemistry of the Roccamonfina aquifer does not show any specific and visible pollution, contrary to what happens in the volcano surrounding plains. In fact, only 14% of the samples we collected (206) show a NO3 content >30 mg/l. These sites are all located at the base of the volcano, near the plain. © 2009 Springer-Verlag

Risk Stratification of Sudden Cardiac Death in Patients with Heart Failure: An update

Heart failure (HF) is a complex clinical syndrome in which structural/functional myocardial abnormalities result in symptoms and signs of hypoperfusion and/or pulmonary or systemic congestion at rest or during exercise. More than 80% of deaths in patients with HF recognize a cardiovascular cause, with most being either sudden cardiac death (SCD) or death caused by progressive pump failure. Risk stratification of SCD in patients with HF and preserved (HFpEF) or reduced ejection fraction (HFrEF) represents a clinical challenge. This review will give an update of current strategies for SCD risk stratification in both HFrEF and HFpEF.Heart failure (HF) is a complex clinical syndrome in which structural/functional myocardial abnormalities result in symptoms and signs of hypoperfusion and/or pulmonary or systemic congestion at rest or during exercise. More than 80% of deaths in patients with HF recognize a cardiovascular cause, with most being either sudden cardiac death (SCD) or death caused by progressive pump failure. Risk stratification of SCD in patients with HF and preserved (HFpEF) or reduced ejection fraction (HFrEF) represents a clinical challenge. This review will give an update of current strategies for SCD risk stratification in both HFrEF and HFpEF

Lavaggio chirurgico e dermatiti: quali sono le implicazioni sull’idoneità al lavoro?

Le dermatiti delle mani colpiscono frequentemente lavoratori che entrano regolarmente in contatto con acqua, detergenti e irritanti, o che indossano guanti durante il loro lavoro (1,2), fattori che hanno avuto un incremento esponenziale durante la pandemia da SARS-CoV-2. Il lavaggio chirurgico, che prevede l’utilizzo di Clorexidina o Iodopovidone e scrub della cute, e l’uso di guanti in lattice possono rappresentare possibili fattori scatenanti di dermatiti delle mani nei chirurghi e soprattutto in caso di molteplici interventi durante un turno di lavoro, con conseguenti lavaggi ripetuti. La valutazione di questi lavoratori deve contemplare necessariamente anche la presenza di eventuali condizioni di ipersuscettibilità, come l’atopi

Radon hazard in shallow groundwaters: Amplification and long term variability induced by rainfall

222Rn concentrations have been determined with a RAD7 radon detector in shallow groundwaters of the Pietramelara Plain, north-western Campania, southern Italy, where pyroclastic deposits, along with recent stream alluvial sediments, come in contact with Mesozoic carbonate reservoirs. The aim of this study has been to study the annual variation of 222Rn concentration in the shallow groundwaters, scarcely considered in the literature and of obvious relevance for radon hazard evaluation. Our results definitely show that 222Rn levels are characterized by a clear annual periodicity, strictly related to rainfall and water table levels, with a pronounced difference between the dry and the wet season. In this last case with concentrations increasing up to two orders of magnitude (up to two times the lower threshold given in the Recommendation 2001/928/EURATOM for public waters). In relation to this, experimental field data will be presented to demonstrate that this variability is due to purely hydrological mechanisms, mainly rinse out and discharge that control leaching efficiency. The detected cycle (Radon Hydrological Amplification Cycle, RHAC) has been generalized for the Mediterranean Tyrrhenian climate. The marked and seasonally persistent amplification in 222Rn levels poses the problem of evaluating the epidemiological risk brought up by this previously not yet reported mechanism. This mechanism, occurring in shallow groundwaters, very likely should strongly influence indoor radon levels via groundwater-soil-building exchange. © 2009 Elsevier B.V. All rights reserved