Prognostic value of exercise tolerance test for predicting cardiovascular disease in asymptomatic individuals with heterozygous familiar hypercholesterolemia.

Heterozygous familiar hypercholesterolemia (hFH) is an autosomal dominant inherited dyslipidemia, associated with premature cardiovascular disease (CVD). Aim of the study was to define prognostic factors for cardiovascular events (CVE) in asymptomatic individuals with hFH. All participants with recent diagnosis of hFH were recruited from the outpatient lipid clinic from 1987 to 2016, without any previous clinical evidence of CVD. A detailed clinical evaluation and laboratory investigation was obtained. Exercise tolerance test (ETT) was performed until maximum exercise capacity was achieved, without evidence of ischemia. Primary endpoint of the study was the first CVE. Four hundred fifty one participants were followed up for 10 ± 8 years, with 68 recorded cases of CVD (15%). Cumulative incidence of CVD was 15%, 24% and 32% for the 3 decades, respectively. In univariate analysis, male gender (p = 0.016), progression of age (p < 0.001), menopause (p = 0.030), waist-hip ratio (p = 0.043) and increased levels of Lp(α) (p = 0.014) were significantly associated with increased CVD incidence; whereas, exercise capacity (p = 0.025), low variation of heart rate (HR) during all stages of ETT compared to resting state (p = 0.020), maximum systolic (p = 0.014) and diastolic (p < 0.001) blood pressure were inversely associated with CVD. In multi-adjusted analysis, male gender (p < 0.001), duration of ETT (p = 0.023), estimated HR (p = 0.029), variation of HR during ETT compared to resting state (p < 0.05) and maximum diastolic pressure (p = 0.044) were significantly associated with CVD. Parameters of ETT in asymptomatic individuals with hFH, without any evidence of ischemia, may predict CVD in these high-risk patients after decades of observation.

Treat-to-target biologic therapy in patients with rheumatoid arthritis is more efficacious and safe compared to delayed initiation of biologics: a real-world study.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic, devastating disease. Treat-to-target strategy (T2T) more than the usual care, reduces disease activity by using aggressively all therapeutic options. The aim of the study was to evaluate our hypothesis that T2T strategy using biologic disease-modifying anti-rheumatic drugs (bDMARDs), when needed, is also safer than the usual care characterised by delayed initiation of bDMARDs. METHODS: Disease activity was regularly measured by DAS-28 until the end of treatment with the first bDMARD. All adverse events (AEs) and their severity were recorded. Cox proportional-hazards models were performed examining the association of treatment groups, with the risk of first AE. RESULTS: There were 113 patients in T2T and 250 patients in usual care group. The likelihood (adjusted hazard ratio, HR) of achieving remission or LDA was 71% higher in the T2T group than in the usual care group, as it has been already shown by others. The novel finding of our work was that AEs, including cancers, were less frequent in the T2T group with the corresponding HRs being less than 0.50 for serious AEs, infections and serious infections (significant or marginally non-significant results). There were 15 new cancer cases in usual care and 1 in T2T group (IR 1.99 vs. 0.4, p=0.027). CONCLUSIONS: Treat-to-target treatment with bDMARDs offers a safer, rapid and better long-term outcome to patients with RA.

Adverse events and infections in patients with rheumatoid arthritis treated with conventional drugs or biologic agents: a real world study.

OBJECTIVES: Treatment of rheumatoid arthritis (RA) with disease-modifying anti-rheumatic drugs (DMARDs), either synthetic (sDMARDs) or biologic agents (bDMARDs) has significantly improved disease outcome. However, the impact of therapy-related adverse events (AEs), mild, moderate or serious, on disease outcome is under debate. The purpose of the study was to test the hypothesis that AEs, including infections, are rather common in patients receiving bDMARDs than in those receiving sDMARDs. METHODS: Analysis of the medical records of patients followed in a single outpatient clinic was performed. In total, 1403 adults (295 men, 1108 women) were included in the analysis (969 treated with sDMARDs only, 434 with bDMARDs). All AEs and infections were recorded and their severity was graded according to international criteria. Incident rates were calculated and Kaplan-Meier plots as well as Cox proportional-hazards models were performed to examine the association of treatment groups with the risk of any AE. RESULTS: The risk of any AE, irrespective of severity, was significantly higher in patients with bDMARDs with the adjusted hazard ratio being 1.98 (95% CI: 1.64 to 2.39). Patients in the biologic group treated initially with infliximab or adalimumab had a higher risk of AE compared to patients receiving etanercept or other biologic agents. Among patients treated with methotrexate, those receiving a dose below 10 mg had a higher risk of any AE when compared to those receiving higher doses. CONCLUSIONS: The risk of any AE among RA patients treated with bDMARDs was significantly higher compared to those treated with sDMARDs.

Myocardial fibrosis after COVID-19 infection and severe sinus arrest episodes in an asymptomatic patient with mild sleep apnea syndrome: A case report and review of the literature.

COVID-19 infection is a new disease mainly affecting the respiratory system but is also accompanied by many extra-pulmonary manifestations. A case of a 47-year old male with unique myocardial fibrosis after COVID-19 infection involving the left ventricular wall, intraventricular septum and almost complete damage of interatrial septum, in combination with asymptomatic severe sinus arrest episodes related to mild obstructive sleep apnea syndrome is described here.

Effects of Mediterranean diet on hospital length of stay, medical expenses, and mortality in elderly, hospitalized patients: A 2-year observational study.

OBJECTIVES: The Mediterranean diet (MedDiet) has been related to reduced overall mortality and improved disease outcome. The aim of this study was to estimate the effects of the MedDiet on hospital length of stay (LOS), financial cost, and mortality (from hospitalization up to 24 mo afterward) in hospitalized patients >65 y of age. METHODS: Participating in this observational study were 183 patients >65 y of age, who were urgently admitted for any cause to the Internal Medicine Department of Argolidos General Hospital. Hospital LOS and its financial cost, mortality (during hospitalization, 6 and 24 mo after discharge), physical activity, and medical and anthropometric data were recorded and correlated with the level of adherence to the MedDiet (MedDiet score). RESULTS: In multivariate analyses, hospital LOS decreased by 0.3 d for each unit increase of MedDiet score (P < 0.0001), 2.1 d for each 1 g/dL increase of albumin (P = 0.001) and increased 0.1 d for each day of previous admissions (P < 0.0001). Extended hospitalization (P < 0.0001) and its interaction with MedDiet score (P = 0.01) remained the significantly associated variables for financial cost. Mortality risk increased 3% per each year increase of age (hazard ratio [HR], 1.03; P = 0.02) and 6% for each previous admission (HR, 1.06; P = 0.04); whereas it decreased 13% per each unit increase of MedDiet score (HR, 0.87; P < 0.0001). CONCLUSION: Adoption of the MedDiet decreases duration of admission and long-term mortality in hospitalized patients >65 y of age, with parallel reduction of relevant financial costs.

Acute Heart Failure in a Healthy Young Patient after Severe Carbon Monoxide Poisoning.

INTRODUCTION: Carbon monoxide (CO) poisoning may cause severe cellular hypoxia. MATERIALS AND METHODS: A 28-year-old male presented reduced levels of consciousness and dyspnoea after CO exposure. Clinical examination revealed tachypnoea, bilateral rales, dilated jugular veins and confusion. Troponin I, lactate and carboxyhaemoglobin levels were increased. Thoracic X-ray depicted pulmonary oedema and an echocardiogram, severe heart failure (HF; EF<25%). He was intubated due to clinical deterioration. RESULTS: He remained intubated for 5 days with excellent improvement of left ventricular function (EF>55%). He was discharged 1 week later with full recovery. DISCUSSION: Acute HF is a rare serious complication of CO poisoning, even in healthy young individuals. LEARNING POINTS: Acute CO poisoning is an emergent condition necessitating prompt diagnosis and treatment.Neurologic and cardiovascular manifestations are the most worrying complications, which may leave permanent sequelae.Acute heart failure is a rare complication of CO poisoning, characterized by regional or global left ventricular wall hypokinesia.

Intravenous immunoglobulin in the treatment of resistant subacute cutaneous lupus erythematosus: a possible alternative.

Subacute cutaneous lupus erythematosus (SCLE) is a common manifestation of systemic lupus erythematosus. In many cases it appears to be resistant to various systemic or topical treatments. Three cases of resistant SCLE with good response to intravenous immunoglobulin (IVIG) are described here suggesting that IVIG could be an alternative treatment in these patients.

Hypertrophic pachymeningitis and undifferentiated connective tissue disease: a case report and review of the literature.

A 63-year-old man with hypertrophic pachymeningitis (HP) and an undifferentiated connective tissue disease is described. Combined therapy with prednisolone and azathioprine improved his symptoms. The association between an undifferentiated connective tissue disease and HP is discussed.

Osteoporosis--a risk factor for cardiovascular disease?

Osteoporosis is a serious health problem worldwide that is associated with an increased risk of fractures and mortality. Vascular calcification is a well-defined independent risk factor for cardiovascular disease (CVD) and mortality. Major advances in our understanding of the pathophysiology of osteoporosis and vascular calcification indicate that these two processes share common pathogenetic mechanisms. Multiple factors including proteins (such as bone morphogenetic proteins, receptor activator of nuclear factor κB ligand, osteoprotegerin, matrix Gla protein and cathepsins), parathyroid hormone, phosphate, oxidized lipids and vitamins D and K are implicated in both bone and vascular metabolism, illustrating the interaction of these two, seemingly unrelated, conditions. Many clinical studies have now confirmed the correlation between osteoporosis and vascular calcification as well as the increased risk of CVD in patients with osteoporosis. Here, we explore the proposed mechanistic similarities between osteoporosis and vascular calcification and present an overview of the clinical data that support the interaction between these conditions.

Topical calcineurin inhibitors in systemic lupus erythematosus.

Cutaneous lupus erythematosus (CLE) encompasses a variety of lesions that may be refractory to systemic or topical agents. Discoid lupus erythematosus (DLE) and subacute cutaneous lupus erythematosus (SCLE) are the most common lesions in clinical practice. The topical calcineurin inhibitors, tacrolimus and pimecrolimus, have been used to treat resistant cutaneous lupus since 2002 and inhibit the proliferation and activation of T-cells and suppress immune-mediated cutaneous inflammation. This article reviews the mechanism of action, efficacy, adverse effects, and the recent concern about their possible carcinogenic effect. Although the total number of patients is small and there is only one relevant randomized controlled study, the data are encouraging. Many patients, previously resistant to systemic agents or topical steroids, improved after four weeks of treatment. DLE and SCLE lesions were less responsive, reflecting the chronicity of the lesions, although more than 50% of patients still showed improvement. Topical calcineurin inhibitors may be a safe and effective alternative to topical steroids for CLE although the only approved indication is for atopic dermatitis.

Electroencephalography in the assessment of neuropsychiatric manifestations in antiphospholipid syndrome and systemic lupus erythematosus.

OBJECTIVE: To describe the prevalence and clinical associations of abnormalities on electroencephalography (EEG) in patients with antiphospholipid syndrome (APS) and/or systemic lupus erythematosus (SLE) who have neuropsychiatric symptoms. METHODS: The study group comprised 57 patients (age

The antiphospholipid (Hughes') syndrome: changing the face of neurology.

Hughes' syndrome (the antiphospholipid syndrome (APS)) presents with recurrent thrombosis, recurrent miscarriage and neurological disease. The major pathogenic mechanism of the syndrome is vascular obstruction (both venous and arterial) due to hypercoagulability. Neurological manifestations are prominent and are often the dominant feature. Headache, migraine and cognitive dysfunction are common while other manifestations such as dementia, epilepsy, chorea, multiple sclerosis (MS), psychiatric disease, transverse myelitis, ocular syndromes, sensorineural hearing loss and movement disorders are also associated with the syndrome. Anticoagulation therapy (either aspirin or oral anticoagulants) can lead to significant improvement.