Giovanni Battista Gaeta

Arterial abnormalities in the offspring of patients with premature myocardial infarction.

BACKGROUND Findings from epidemiologic and autopsy studies suggest that the offspring of patients with premature coronary disease may be at increased risk for atherosclerosis. We undertook a study to determine whether changes in brachial-artery reactivity and thickness of the carotid intima and media, two markers of early atherosclerosis, are present in adolescents and young adults with a parental history of premature myocardial infarction. METHODS We enrolled 40 healthy young people whose parents had had premature myocardial infarction (48 percent male; mean [+/-SD] age, 19.0+/-5.2 years) and 40 control subjects who were matched with the first group according to age and sex. All the subjects underwent high-resolution B-mode ultrasound examinations for the measurement of the brachial-artery vasodilatory response after arterial occlusion (i.e., reactive hyperemia) and the intima-media thickness of the distal common carotid arteries. Lipid profiles, blood pressure while at rest, body-mass index, and smoking status were also determined. RESULTS As compared with the control subjects, the offspring of patients with premature myocardial infarction had lower flow-mediated reactivity of the brachial arteries (5.7+/-5.0 percent, vs. 10.2+/-6.6 percent in the control subjects; P=0.001) and greater mean intima-media thickness of the common carotid artery (0.49+/-0.08 mm, vs. 0.44+/-0.07 mm in the control subjects, P=0.004). In the subjects with a parental history of premature myocardial infarction, an inverse association was found between brachial-artery reactivity and carotid intima-media thickness (r=-0.46, P=0.003). In a conditional logistic-regression analysis, both brachial-artery reactivity and carotid intima-media thickness were significantly and independently correlated with a parental history of premature myocardial infarction. CONCLUSIONS Structural and functional changes are present at an early age in the arteries of persons with a parental history of premature myocardial infarction.

Pathogenic factors in cirrhosis with and without hepatocellular carcinoma: A multicenter italian study

We designed a multicenter cross‐sectional study to evaluate the role of alcohol abuse, the hepatitis viruses and other pathogenic factors in cirrhosis and hepatocellular carcinoma. A total of 1,829 consecutive cirrhosis patients, with or without HCC, was enrolled over 6 mo in 21 centers throughout Italy. The etiological categories and diagnostic criteria were preestablished. The median age of the patients was 59 yr (range, 13 to 85 yr); 63.6% of the patients were graded as Child class A, 23.4% as Child class B and 13% as Child class C. Hepatitis C virus antibodies were found in 72.1% of cases (47.7% alone, 21.2% with alcohol abuse, 3.2% with hepatitis B virus); HBsAg was present in 13.8% (4.2% alone, 3.2% with hepatitis D virus, 3.2% with hepatitis C virus, 3% with alcohol abuse), alcohol abuse with no concomitant viral infection was recorded in 8.7%, primary biliary cirrhosis was found in 1.8%, other causes were found in 1.4% and cryptogenic cirrhosis was only present in 5.3%. Hepatocellular carcinoma was detected in 11.9% of patients (217 cases). The presence of hepatocellular carcinoma was more frequent in males than females (14.7% vs. 7.3%; p < 0.001) and increased with worsening Child class (8.3% in Child class A, 16.9% in Child class B, 19.9% in Child class C, p < 0.001). The highest prevalences of hepatocellular carcinoma were observed in hepatitis B virus infection, with or without alcohol abuse (20% and 16%, respectively) and in hepatitis C virus cirrhosis, with or without alcohol abuse (16% and 10.3%, p < 0.005). Our data indicate chronic viral infection to be responsible for most cirrhosis and hepatocellular carcinoma in Italy. This finding may aid development of guidelines for prevention programs. (Hepatology 1994;20:1225–1230).

Hepatitis A: post-exposure prophylaxis.

We report on the findings of an exploratory review of evidence published in English from 1945 to identify the best post-exposure prophylaxis treatment and the longest acceptable interval after exposure for prophylaxis to be effective. We found no evidence that post-exposure administration of currently available immunoglobulins is effective in preventing hepatitis A infection and disease. The use of immunoglobulins for immunoprophylaxis should not be widely recommended until a systematic review of the evidence has been conducted. We recommend that active immunization to secondary contacts of exposed and vaccinated subjects be offered.

Early Increase of Carotid Intima-Media Thickness in Children with Parental History of Premature Myocardial Infarction

Background/objective: Increased carotid intima-media thickness (IMT) is an early manifestation of atherosclerosis. Our group has previously demonstrated that a parental history of premature myocardial infarction (PHPMI) is associated with an increase in carotid IMT in children-adolescents (mean age 13 years) and young adults (mean age 24 years). The aim of the present study was to evaluate if carotid structural changes are detectable in young children with PHPMI. Methods: 26 healthy children (9 males and 17 females; 5–12 years, mean age 9.1 (2.5) years) with PHPMI and 26 age-matched (plus or minus 1 year), sex-matched and body mass index-matched (BMI; plus or minus 20%) control subjects were enrolled in the study. They underwent high resolution B-mode ultrasonographic evaluation of common carotid artery IMT. Lipid profile, resting blood pressure and BMI were also evaluated. Results: Compared to controls, subjects with PHPMI had increased IMT of common carotid arteries (mean of combined sites: 0.444 (0.076) mm versus 0.382 (0.062) mm in controls, p = 0.001). Offspring of coronary patients showed an unfavourable lipid profile compared to controls; however, the association between a PHPMI and carotid IMT was independent of lipids, apolipoproteins and other traditional risk factors. Conclusions: Vascular structural changes are detectable in subjects with PHPMI at a young age and occur independently of several traditional cardiovascular risk factors.

Changing aetiological factors of hepatocellular carcinoma and their potential impact on the effectiveness of surveillance

BACKGROUND The aetiological factors of hepatocellular carcinoma may vary over time. AIMS The study assessed the potential impact of the aetiological factors on the effectiveness of surveillance in real-world patients. METHODS Multicentre, cross-sectional study enrolling consecutive hepatocellular carcinoma cases during a six month period. RESULTS 1733 cases (1311 prevalent and 422 incident) were recruited (mean age 68.6 years; 46.1% cases over 70 years; 73.9% males; 95.3% with cirrhosis); 63.0% were hepatitis C virus positive and 23.7% were virus negative. Amongst incident HCCs, 34.5% were single ≤3cm and 54.4% met the Milan criteria; 61.6% were diagnosed during surveillance; virus negative patients showed the lowest rate of surveillance (51.0%). Surveillance was an independent predictor of detecting single HCCs ≤2cm (O.R.=5.4; 95% C.I.=2.4-12.4) or HCCs meeting the Milan criteria (O.R.=3.1; 95% C.I.=1.9-5.2). Compared with an earlier Italian survey, there was a higher proportion of elderly subjects (P<0.01), Child-Pugh class A cases (P<0.01), of virus-negative patients (P<0.01) and with single tumours ≤3cm (P<0.01) and a lower prevalence of hepatitis C virus positive individuals (P<0.01). CONCLUSION HCC is characterised by a growing prevalence of elderly patients and cases unrelated to hepatitis virus infections. The application of surveillance must be implemented, particularly amongst non-viral patients.

Surgical procedures as a major risk factor for chronic hepatitis C virus infection in Italy: Evidence from a case-control study

OBJECTIVES The study was carried out to evaluate the risk factors associated with chronic hepatitis C virus (HCV) infection. METHODS This case-control study used multiple logistic regression analysis to determine risk factors associated with HCV infection. Study participants were followed at 10 liver or gastroenterologic units and included 294 subjects with chronic HCV infection and 295 age and sex matched anti-HCV-negative controls. RESULTS The use of glass syringes and surgical procedures was reported by as many as 77.6% and 73.8% of cases, respectively; blood transfusion was recorded in nearly a quarter of cases; 10.2% of cases, but none of the controls, reported past or current intravenous drug use. Multiple logistic regression analysis showed that blood transfusion, being the sexual partner of an intravenous drug user, and surgery all were independent predictors of the likelihood of HCV infection. CONCLUSIONS These findings indicate that, besides the well-known sources of infection, such as blood transfusion and intravenous drug use, surgical procedures may play an important role in the spread of HCV infection in Italy. Given that a large proportion of the general population undergoes surgery, a rational and relatively inexpensive policy for the prevention of HCV infection must focus on implementing efficient procedures for the sterilization of instruments and the use of disposable materials in surgical units.

Sumatriptan therapy for headache and acute myocardial infarction

Importance of the field: Migraine is a common, debilitating, chronic neurovascular disorder. Triptans are considered the drugs of choice to treat migraine attacks; however, their use is limited owing to concerns about cardiovascular safety. Areas covered in this review: The aim of this review is to describe: the mechanisms of action of triptans; the case-reports of acute myocardial infarction (AMI) associated with sumatriptan use; and the results of studies evaluating its tolerability and safety. What the reader will gain: Sumatriptan administration can be followed, in close temporal relationship, by AMI in young or adult migraine patients. Some of these cases have developed in subjects taking their first dose. Based on the results of prospective studies, the risk of severe cardiovascular adverse events after the use of a triptan is estimated at 1:100,000 treated attacks. These adverse events, albeit very infrequent, highlight the importance of careful adherence to the sumatriptan prescribing information. Take home message: Inherent in its mechanism of action, sumatriptan could produce (coronary) vasospasm sometimes followed by AMI. The drug should not be prescribed to patients with history, symptoms or signs of ischemic vascular disease; an in-depth evaluation should be carried out in subjects at intermediate cardiovascular risk.

Increased carotid intima–media thickness in healthy young subjects with a parental history of hypertension (parental hypertension and vascular health)

Preclinical abnormalities are detectable in young normotensive individuals with a positive parental history of hypertension (PHH).1 Increased carotid intima–media thickness (IMT) is considered an early and valuable predictor of atherosclerotic disease; however, information on the effect of PHH on potential vascular structural abnormalities in young normotensive healthy subjects is limited. The aim of this study was to evaluate the presence of carotid structural differences in normotensive young adults and children with and without PHH. The study population comprised 29 cases (healthy subjects with PHH, 45% males, mean (SD) age 23 (5) years) consecutively recruited among the offspring (age 11–30 years) of patients with essential hypertension who had been followed at the Hypertension Outpatient Clinic of the Department of Cardiology, Cardarelli Hospital of Naples, Italy. Parental hypertension was defined as a blood pressure of at least 140/90 mm Hg, measured on three different days in the supine position by sphygmomanometry. The control group consisted of 29 age-matched (+1 year) and sex-matched healthy subjects without PHH (parents not on antihypertensive drugs and blood pressure values <140/90 mm Hg at repeated examinations); they were offspring of patients admitted to the same hospital for a wide spectrum of acute illnesses unrelated to essential hypertension or hospital workers. To minimise the confounding effects of other known cardiovascular risk factors, we excluded individuals with a parental history of coronary, cerebral or peripheral arterial disease and/or diabetes mellitus. The …

Active recruitment strategy in disadvantaged immigrant populations improves the identification of human immunodeficiency but not of hepatitis B or C virus infections

BACKGROUND Barriers to access medical screening and care may underestimate the number of diseased subjects among immigrant populations. AIMS To evaluate the prevalence of human immunodeficiency virus, hepatitis B virus and hepatitis C virus infections among immigrants recruited in a disadvantaged area. METHODS The study enrolled all subjects seen between 1999 and 2009 at an on-site health and family counselling centre for immigrants. During the first 6 years of the study a pro-active recruitment was performed using a mobile unit. RESULTS Overall 2681 subjects were enrolled (median age: 31 years; 52.8% males; 82.3% from Sub-Saharan Africa; 13.9% of the women were sex workers). A total of 206 subjects (7.6%) were hepatitis B surface antigen-positive, 84 (3.6%) were anti-hepatitis C virus-positive, 129 (5%) were anti-human immunodeficiency virus-positive, 84 (3.1%) were drug users, and 436 (16.3%) were alcohol abusers. The prevalence of hepatitis B surface antigen and anti-hepatitis C virus remained consistent throughout the study period, while the prevalence of human immunodeficiency virus significantly decreased. At multivariate analysis, hepatitis B virus infection was associated with male gender, hepatitis C virus infection with drug addiction, and human immunodeficiency virus infection was associated with female gender, drug addiction, and active recruitment. CONCLUSIONS An active recruitment strategy should be considered to reach disadvantaged populations at high risk of human immunodeficiency virus infection.

Sex hormones and lipoprotein(a) concentration

Introduction: Increased level of lipoprotein(a) (Lp(a)) constitutes an emerging, independent risk factor for coronary artery disease. Recently, it has been recommended to lower increased (> 50 mg/dl) Lp(a) concentration. Most lipid lowering agents – except niacin – have little or no effect whereas sex hormones significantly reduce Lp(a) level. The effect of sex hormones on Lp(a) level is related to the setting, the drug, the dose and the way of administration. Androgen esters, oral estrogens, alone or in combination with progestogens, and tibolone constantly decrease Lp(a) level, especially in postmenopausal women. Areas covered: This paper reviews the pathophysiology, structure and metabolism of Lp(a). Clinical studies evaluating, in various settings, the effect of exogenous administration of androgens, estrogens – alone or in combination with progestogens – selective receptor estrogen modulators (SERMs), aromatase inhibitors (AIs) and tibolone on Lp(a) level are analyzed. Expert opinion: The results obtained for SERMs are conflicting whereas AIs do not seem to reduce Lp(a) concentration. The effect of hormonal therapy on lipids is complex, depending on drugs and way of administration. Moreover, both androgens and estrogen could determine, in specific settings, severe adverse effects. These drugs are not currently recommended either for treatment of dyslipidemias with increased Lp(a) level or for the prevention of cardiovascular disease.