Biomarkers of cell damage, neutrophil and macrophage activation associated with in-hospital mortality in geriatric COVID-19 patients.

BACKGROUND: The risk for symptomatic COVID-19 requiring hospitalization is higher in the older population. The course of the disease in hospitalised older patients may show significant variation, from mild to severe illness, ultimately leading to death in the most critical cases. The analysis of circulating biomolecules involved in mechanisms of inflammation, cell damage and innate immunity could lead to identify new biomarkers of COVID-19 severity, aimed to improve the clinical management of subjects at higher risk of severe outcomes. In a cohort of COVID-19 geriatric patients (n= 156) who required hospitalization we analysed, on-admission, a series of circulating biomarkers related to neutrophil activation (neutrophil elastase, LL-37), macrophage activation (sCD163) and cell damage (nuclear cfDNA, mithocondrial cfDNA and nuclear cfDNA integrity). The above reported biomarkers were tested for their association with in-hospital mortality and with clinical, inflammatory and routine hematological parameters. Aim of the study was to unravel prognostic parameters for risk stratification of COVID-19 patients. RESULTS: Lower n-cfDNA integrity, higher neutrophil elastase and higher sCD163 levels were significantly associated with an increased risk of in-hospital decease. Median (IQR) values observed in discharged vs. deceased patients were: 0.50 (0.30-0.72) vs. 0.33 (0.22-0.62) for n-cfDNA integrity; 94.0 (47.7-154.0) ng/ml vs. 115.7 (84.2-212.7) ng/ml for neutrophil elastase; 614.0 (370.0-821.0) ng/ml vs. 787.0 (560.0-1304.0) ng/ml for sCD163. The analysis of survival curves in patients stratified for tertiles of each biomarker showed that patients with n-cfDNA integrity < 0.32 or sCD163 in the range 492-811 ng/ml had higher risk of in-hospital decease than, respectively, patients with higher n-cfDNA integrity or lower sCD163. These associations were further confirmed in multivariate models adjusted for age, sex and outcome-related clinical variables. In these models also high levels of neutrophil elastase (>150 ng/ml) appeared to be independent predictor of in-hospital death. An additional analysis of neutrophil elastase in patients stratified for n-cfDNA integrity levels was conducted to better describe the association of the studied parameters with the outcome. CONCLUSIONS: On the whole, biomarkers of cell-free DNA integrity, neutrophil and macrophage activation might provide a valuable contribution to identify geriatric patients with high risk of COVID-19 in-hospital mortality.

Leukocyte telomere length is associated with complications of type 2 diabetes mellitus.

OBJECTIVE: The key goal of diabetes management is to prevent complications. While the patho-physiological mechanisms responsible for diabetes complications have been extensively studied, at present it is impossible to predict which patient with diabetes could develop complications. In recent years, the role of leukocyte telomere length in the pathogenesis of cardiovascular disease and Type 2 diabetes has been investigated. However, studies aiming to investigate the role of telomeres in the development and progression of Type 2 diabetes, as well as diabetic complications, are still lacking. As a consequence, this study aimed to verify whether leukocyte telomere length is associated with the presence and the number of diabetic complications in a sample of patients with Type 2 diabetes. METHODS: This is a cross-sectional study. Nine hundred and one subjects were enrolled, including 501 patients with Type 2 diabetes, of whom 284 had at least one complication and 217 were without complications, and 400 control subjects. Leukocyte telomere length was measured by quantitative real-time PCR. RESULTS: Patients with diabetes complications had significantly shorter leukocyte telomere length than both patients without diabetes complications and healthy control subjects. Moreover, among patients with diabetes complications, leukocyte telomere length became significantly and gradually shorter with the increasing number of diabetes complications. The magnitude of the effect of the decrease of the abundance of telomeric template vs. a single-copy gene length (T/S ratio) on complications is described by the estimated odds ratio OR=5.44 (95%CI 3.52-8.42). CONCLUSIONS: The results of the study support the hypothesis that telomere attrition may be a marker associated with the presence and the number of diabetic complications.

Ivabradine use in refractory unstable angina: a case report.

In this report, we describe the clinical results of ivabradine use in a patient with a serious form of unstable angina. For this patient, it was proposed that no other therapeutic, pharmacologic or surgical, option was available. The patient is a 75-year-old woman who presented with repeated episodes of retrosternal chest pain. She notably had a history of type II diabetes mellitus treated by insulin for several years and complicated by diabetic macro-angiopathy. ECG tracings recorded during these episodes showed abnormalities of the lateral repolarization phase of ischaemic nature. There was no measured increase in cardiac enzymes. She was transferred to our CCU with a diagnosis of unstable angina. In our CCU, the patient was treated with nitrates, metoprolol, aspirin, clopidogrel and atorvastatin at maximal sustainable doses. Following persistent clinical-instrumental instability, she was subjected to coronary angiography. This study revealed severe multi-vessel coronary artery disease not amenable to surgery or angioplasty revascularization. In addition to the therapy already provided, a beta-blocker (metoprolol 50 mgx2/die) and diltiazem (30 mgx2/die) were added despite their potentially dangerous and adverse chronotropic effects. Despite this treatment, the patients heart rate remained high (between 80 and 100 beats/min). This heart rate appeared to be the main driving cause of her anginal symptoms. At this point, the use of ivabradine seemed the only option, even though use would be off-label compared to current indications for the drugs use. We started with a low dose of 2.5 mg/b.i.d. and titrated up to 5 mg b.i.d. As we titrated, we witnessed a gradual reduction in heart rate. A consequent stabilization of her clinical pattern progressed into an almost unexpected asymptomatic state. After about a week of clinical observation, the patient recovered. After three months, she remains asymptomatic.

Interleukin-6-174 G > C polymorphism affects the association between IL-6 plasma levels and insulin resistance in type 2 diabetic patients.

Interleukin-6 (IL-6), a powerful inflammatory mediator, plays a pivotal role in the pathogenesis of insulin resistance and type 2 diabetes. Recently, the IL-6 promoter polymorphism, at position -174 (G > C), has been associated to insulin sensitivity although contrasting data have been reported. The aim of this study was to evaluate the effect of the IL-6-174 G > C polymorphism on insulin resistance. In 238 type 2 diabetic patients without diabetic complications and in 255 control subjects, age and gender-matched, we evaluated the IL-6 -174 G > C genotype, the IL-6 plasma levels and the insulin resistance by the homeostasis model assessment (HOMA). The levels of IL-6 and HOMA were not genotype-dependent and were higher in diabetic patients (p < 0.01). Control subjects, both C+ (CG + CC genotypes) and C- (GG genotype) carriers, showed IL-6 plasma levels significantly related to BMI, fasting insulin and HOMA. The same relationships were found in C+ diabetic carriers. Differently, diabetic C- carriers did not show any relationship between IL-6 levels and all the evaluated variables. Interestingly, all the correlations were dependent on BMI. These findings highlight that IL-6-174 G > C polymorphism affects insulin resistance in type 2 diabetes, where C+ carriers have an insulin resistance "IL-6-sensitive", while C- carriers do not. The identification of two categories of diabetic patients may, therefore, lead to different therapeutic strategies in the management of insulin resistance.

The different apoptotic potential of the p53 codon 72 alleles increases with age and modulates in vivo ischaemia-induced cell death.

A common arginine to proline polymorphism is harboured at codon 72 of the human p53 gene. In this investigation, we found that fibroblasts and lymphocytes isolated from arginine allele homozygote centenarians and sexagenarians (Arg+) undergo an oxidative-stress-induced apoptosis at a higher extent than cells obtained from proline allele carriers (Pro+). At variance, the difference in apoptosis susceptibility between Arg+ and Pro+ is not significant when cells from 30-year-old people are studied. Further, we found that Arg+ and Pro+ cells from centenarians differ in the constitutive levels of p53 protein and p53/MDM2 complex, as well as in the levels of oxidative stress-induced p53/Bcl-xL complex and mitochondria-localised p53. Consistently, all these differences are less evident in cells from 30-year-old people. Finally, we investigated the in vivo functional relevance of the p53 codon 72 genotype in a group of old patients (66-99 years of age) affected by acute myocardial ischaemia, a clinical condition in which in vivo cell death occurs. We found that Arg+ patients show increased levels of Troponin I and CK-MB, two serum markers that correlate with the extent of the ischaemic damage in comparison to Pro+ patients. In conclusion, these data suggest that p53 codon 72 polymorphism contributes to a genetically determined variability in apoptotic susceptibility among old people, which has a potentially relevant role in the context of an age-related pathologic condition, such as myocardial ischaemia.

Randomized trial of the effects of low-dose calcium-heparin in patients with peripheral arterial disease and claudication. Italian CAP Study Group.

PURPOSE: We performed a long-term, multicenter, randomized, double-blind trial to evaluate the efficacy and tolerability of low-dose, subcutaneous calcium-heparin (12,500 IU/day) in comparison with placebo in patients with stable peripheral arterial disease of the lower extremities. PATIENTS AND METHODS: At the end of a 2-week washout period, during which aspirin placebo was given, 201 patients were randomly assigned to receive either subcutaneous calcium-heparin or placebo for two 3-month treatment periods, each of which was followed by a 6-month period of observation. All of the patients were given low-dose aspirin (50 mg/day) throughout the 18-month study. The main efficacy variables were pain-free and maximum walking time (by standard treadmill test). Patients answered a questionnaire about pain and the limitation of daily activities. Results were analyzed by intention-to-treat. RESULTS: At the end of the study, the estimated increase in pain-free walking time was 39% in the heparin group and 23% in the placebo group (P = 0.09). The estimated increase in maximum walking time was 40% in the heparin group and 16% in the placebo group (P = 0.05). Patients treated with heparin also reported that they had to stop walking because of leg pain, or had daily activities limited by leg pain, less frequently than the placebo group (P <0.01). CONCLUSIONS: Treatment with low-dose subcutaneous calcium-heparin is safe and effective in improving walking performance and reducing physical disability in patients with stable peripheral arterial disease and claudication.

Simvastatin in the treatment of hypercholesterolemia in elderly patients.

Twenty elderly (mean age, 69 years), hypercholesterolemic patients (low-density lipoprotein [LDL] levels greater than or equal to 160 mg/dl) were supplied a lipid-lowering diet for one month and then received 10 mg of simvastatin daily for 12 months. Total cholesterol levels fell significantly, from 304.6 mg/dl at baseline to 277.4 mg/dl after one month on the diet, to 245.9 mg/dl after one month of simvastatin, and to 216.1 mg/dl after two months of simvastatin; total cholesterol levels remained significantly lower (221.6 mg/dl at month 12). LDL levels decreased significantly, from 217.6 mg/dl at baseline to 130.4 mg/dl at month 12. High-density lipoprotein levels increased significantly only at months 2 and 3. Apolipoprotein (apo) A levels increased significantly, from 147.2 mg/dl at baseline to 217.9 mg/dl at month 12. There were no significant changes in triglyceride or apo B levels. No changes in blood pressure, heart rate, or body weight or in results of laboratory tests were noted. Few side effects were reported. It is concluded that simvastatin is safe and effective in the treatment of hypercholesterolemia in elderly patients.

Blood pressure self-measurement in the elderly: differences between automatic and semi-automatic systems.

Arterial hypertension is the most common cardiovascular risk factor in the elderly. Its clinical control emphasises the problem of the systems used for monitoring: clinical measurement by the physician, home self-monitoring, ambulatory monitoring, etc. In particular, in the elderly population, the self-monitoring of blood pressure can present further problems associated with their situation. In our study we evaluated, in an elderly population, the differences in the self-recording of blood pressure with automatic and semi-automatic equipment using a mercury sphygmomanometer by a physician as a 'gold standard' control. We studied 28 elderly subjects using a rigid protocol for the self-measurement of their blood pressure. Our results show that automatic equipment is significantly more precise and easier to use than semiautomatic equipment in home self-measurement of blood pressure in elderly people.

Evaluation of plasmatic ANP levels in subjects affected by essential arterial hypertension and in a group of patients undergoing dialysis.

In the first part of this study we selected 24 hypertensive subjects (11 males, 13 females, mean age 55.4 +/- 10.2 years) affected by essential arterial hypertension (EAH). Eleven people (5 males, 6 females, mean age 21.6 +/- 9.5 years) had one or two hypertensive parents. Seventeen subjects (8 males, 9 females, mean age 56.4 +/- 5.9 years) were the control group. Plasmatic ANP was measured using the RIA method, after extracting the peptide on Sep-Pak C18 cartridges. The results show the following ANP values: healthy control subjects 27.6 +/- 8.6 pg/ml; offspring of essentially hypertensive subjects 25.6 +/- 7.7 pg/ml; essentially hypertensive subjects 45.5 +/- 24.9* pg/ml* (P less than 0.005). In the second part of our study, we evaluated the plasma levels of this hormone in a group of subjects undergoing dialysis. The group consisted of 21 subjects (12 males, 9 females, mean age 63.1 +/- 10.5 years), 11 of whom were affected by EAH. ANP evaluation was done during the dialysis after a "long" dialytic interval of three days. Both groups showed a noticeable increase in ANP levels, even if the hypertensive group had overall higher values (254.5 +/- 134.9 pg/ml, vs. 188.7 +/- 113.7 pg/ml). All subjects, after dialysis, had ANP values significantly lower than the initial ones.

Relationship between lipoprotein(a) levels, oxidative stress, and blood pressure levels in patients with essential hypertension.

High plasma levels of lipoprotein(a) [Lp(a)] are considered a risk factor for the development of coronary artery disease. In vitro experiments have shown that oxidized Lp(a) is able to impair the arterial endothelium-dependent dilation, thus suggesting a possible role of Lp(a) in the genesis of essential hypertension. The aim of our work was to investigate the correlation of blood pressure levels with plasma Lp(a) concentration, apo(a) isoform size, and peroxidative stress in patients with essential hypertension. The study was performed in 54 untreated hypertensive patients whose blood pressure was monitored for 24 h by ambulatory blood pressure monitoring. Lp(a) concentration was measured by a double monoclonal antibody-based enzyme immunoassay demonstrated to be insensitive to apo(a) size heterogeneity. Apo(a) isoforms were determined by a high-resolution SDS-agarose gel electrophoresis followed by immunoblotting. A significant correlation was found between Lp(a) levels and the night-time systolic and diastolic pressures (r=0.32, P<0.05 and r=0.30, P<0.05, respectively), as well as with the mean night-time fall in systolic and diastolic blood pressures (r=-0.28, P<0.05 and r=-0.29, P<0.05, respectively). These relationships were further potentiated when peroxidative stress data were taken into consideration (r=0.37 and r=0.40, P<0.01 for the night-time systolic and diastolic pressures, respectively and r=-0.34 and r=-0.38, P<0.01 for the night-time fall in systolic and diastolic blood pressures, respectively). Apo(a) isoform size did not affect these relationships. Our data suggest that Lp(a) and peroxidative stress may be involved as cofactors in essential hypertension, with a mechanism that remains to be elucidated.

Hemodynamic effects of cadralazine or chlorthalidone in verapamil-treated elderly hypertensives.

Fourteen hypertensives aged > 66-77 years, whose diastolic blood pressure (DBP) was > or = 95 mmHg at the end of 1-month treatment with verapamil 240 mg SR, took part in this clinical-hemodynamic study. Patients were randomized to add the long-acting hydralazine derivative, cadralazine, 10 mg once daily, or chlorthalidone 25 mg once daily for 1 month each, to their previous verapamil regimen, according to a double-blind crossover design. Echo-Doppler hemodynamics were performed before starting verapamil, 1 month after verapamil and then after each phase of the crossover study. A significant reduction in DBP both in supine and upright position was observed with both drugs, while the reduction in systolic blood pressure was not significant. Criteria for a satisfactory response were DBP < or = 90 mmHg or a DBP reduction > or = 10 mmHg; this goal was achieved in 9 patients with cadralazine, 9 patients with chlorthalidone, 5 patients with both. The hemodynamic study in responders showed that both cadralazine and chlorthalidone acted through a reduction of peripheral resistances without inducing reflex tachycardia. Thus, cadralazine and chlorthalidone represent a suitable second-step treatment in elderly hypertensives insufficiently controlled by verapamil monotherapy: both drugs act through a reduction in total peripheral resistance (TPR).

Random fasting hyperglycemia as cardiovascular risk factor in the elderly: a 6-year longitudinal study.

A large body of evidence suggests that diabetes increases the risk of coronary heart disease (CHD), but whether fasting hyperglycemia is associated with a major risk for CHD is still under debate. The aim of the present study was to investigate the role played by fasting hyperglycemia in the development of cardiovascular disease (CVD) in an elderly population when associated with common risk factors for CVD (i.e., hypertension, hypercholesterolemia, smoking, etc). We analyzed a sample of 455 subjects aged > or = 60 years. The risk factors taken into account were systolic and diastolic blood pressure levels, use of antihypertensive drugs, total serum cholesterol, serum triglycerides, and smoking habit. Glycemia was measured at entry on a fasting sample. During the follow-up period (mean 6 years), the occurrence of CVD was monitored (criteria for the occurrence of CVD included total cardiovascular mortality, fatal or nonfatal myocardial infarction, symptomatic coronary heart disease [stable and unstable angina], the need for percutaneous transluminal coronary angioplasty or coronary artery bypass graft, fatal or nonfatal stroke, and transient ischemic attack). A total of 427 subjects completed the follow-up. During this period, 73 subjects (17.10%) developed CVD according to the above criteria. A Cox proportional hazard model was designed to evaluate the contribution of variables in predicting CVD. Relative risks and 95% confidence intervals for CVD were calculated from the regression coefficients to study the association between the risk of developing CVD and predicting variables. We found a relation between occurrence of CVD and fasting hyperglycemia: subjects with fasting glycemia, > 126 mg/dl at enrollment, but without previous clinical diagnosis of diabetes, showed a 2.01 times higher risk than those with fasting glycemia < 126 mg/dl. Hence, random fasting hyperglycemia can predict the occurrence of CVD in elderly subjects.

The mild hypertension enigma.

This study examines the problem of the correlation between mild arterial hypertension and cardiovascular damage. The authors examine the results of the most important trials carried out and, on the basis of their evaluations, suggest the need to review the current clinical policy of considering mild arterial hypertension as an important risk factor directly related to cardiovascular disease. Since the therapeutic trials carried out on mild hypertension did not substantially reduce the total and cardiac mortality rate, it seems to be probable that arterial hypertension is a progression acceleration marker of atheromatous disease. According to this theory, a therapy which aims merely at returning the pressure values to normal limits will probably not change the natural course of the atheromatous process.

A double-blind comparative study of ketanserin with atenolol in essential hypertension.

Sixty patients, with mild to moderate essential hypertension, were considered for a double-blind trial comparing the effects of ketanserin and atenolol. After 2 weeks of placebo, a group of 30 patients was given ketanserin 20 mg twice daily for 15 days and 40 mg twice daily for the subsequent 45 days, while the second group (30 patients) was given atenolol for 60 days at the dose of 100 mg once daily. Blood pressure and pulse rate in the supine and standing positions were evaluated every 15 days. After the beginning of treatment with ketanserin, there was a gradual but highly significant decrease of the diastolic and systolic blood pressure values. No important side-effects or significant alterations in the biochemical parameters considered were observed during treatment with ketanserin.

Epidemiological aspects of isolated systolic hypertension in the elderly population as cerebrovascular risk factor.

A large number of studies indicate that isolated systolic hypertension (ISH) is an important cerebrovascular risk factor. This clinical state is very common in elderly people who are the most exposed to stroke risk. Therefore, it is important to know the real prevalence of ISH, in order to predict the possible incidence of cerebrovascular disease in the elderly population. In the Camerano study on hypertension, we have verified the prevalence of ISH in the elderly. ISH has been considered clinically when the systolic arterial pressure (SAP) was higher than 160 mmHg, and the diastolic arterial pressure (DAP) was lower than 90 mmHg. In our study population, an ISH prevalence of 11.9% was found in the elderly (above 60 years of age); whereas in the adult population (between 30 and 60 years), it amounted only to 4.5%.

Sexual dimorphism in arterial hypertension: an age-related phenomenon.

Epidemiological, clinical and experimental evidence is available indicating that male subjects develop hypertension with a higher probability than age-matched females. The sexual dimorphism of blood pressure (BP) has been observed both in normotensive and hypertensive subjects. In order to analyze the presence of sexual dimorphism of arterial hypertension (AH) and its relationship to the aging process - particularly to the menopause - the population screened in the Camerano Study has been examined. In addition, to evaluate sex-related differences in the AH, another sample of 3765 patients from our Hypertension Centre has also been considered. Our samples displayed a real cross-over in the prevalence of arterial hypertension, hypercolesterolemia, hyperglycemia and obesity in women versus men, after the menopausal period. In fact, in the adult group (20-54 years) the prevalence of arterial hypertension was significantly higher (P<0.005) in males (9.2%) than females (6.4%), whereas in the older group (>54 years), we observed a significantly higher prevalence (P<0.001) in females (46.6%) than in males (34.7%). These results suggest that the menopause and age can play a separate role in the sexual dimorphism of arterial hypertension. A significant gender-related difference in hypertensive patients was found only in hypercholesterolemia above the age of 50 years, namely, females have this disorder more frequently.

Arterial hypertension in the elderly: a review.

Arterial hypertension in the elderly is an argument of growing interest and relevance in our society for many reasons, the main ones being: (i) Progressive aging of the population with a particularly high number of very old subjects. (ii) The high prevalence of arterial hypertension found mainly as an isolated systolic form or a prevalently systolic one in the elderly population. (iii) Acknowledgement of the significant impact of hypertensive disease on elderly people, e.g., on the cardiovascular risk factor and on the quality of life. (iv) Results of important clinical trials have demonstrated that, using an adequate therapy, it is possible to reduce both cardiovascular morbidity and mortality even in elderly persons.

Impedance cardiography for repeated determination of stroke volume in elderly hypertensives: correlation with pulsed Doppler echocardiography.

In this double-blind, crossover study the authors have validated stroke volume determination by impedance cardiography against the pulsed Doppler echocardiographic method in elderly hypertensives. They found a good correlation between the stroke volume values obtained by the two methods over a range of values from 30 to 130 mL. The coefficient of linear regression was about .95 at each visit. The mean of the differences was -0.73 mL with a standard deviation of 8.46. Given that individual differences are normally distributed, the values corresponding to 2 standard deviations of the mean define a range covering 95% of the observed differences. From the distribution of the data around the mean plot it appears that, in comparison with pulsed Doppler, impedance cardiography tends to slightly underestimate stroke volumes of greater than 90 mL and to overestimate values of less than 50 mL. The results of this study indicate that impedance cardiography may represent a reliable alternative to pulsed Doppler echocardiography for the noninvasive estimation of cardiac output at rest in elderly patients.

Vasopressin, prolactin and growth hormone in Alzheimer's disease: their evaluation after metoclopramide stimulation.

Recent studies have shown that there is a relationship between an alteration of central neurotransmitters and the modification of some biohumoral parameters in Alzheimer's Disease (AD). In this study the authors evaluated, after metoclopramide (MTC) stimulation, the concentration curve of vasopressin (AVP), prolactin (PRL) and growth hormone (HGH) in the plasma of 34 subjects (20 males and 14 females, mean age 70.5+/-6.9 years; 17 were AD patients, the others constituted the control group). MTC increased AVP serum concentration in healthy (P <0.001), but not in AD patients. This result seemed to be due to the lack of 'procholinergic' action of the drug in the AD patients probably due to an alteration in their cholinergic pathways. The PRL response to MTC was reduced only in the AD female group (P <0.005), suggesting an alteration in dopaminergic control. Lastly, the HGH response in AD did not differ in the two groups, neither in basal conditions, nor after MTC stimulation. The absence of HGH response both in AD and in healthy subjects, demonstrated the ineffectiveness of MTC stimulation. We can conclude that AVP and PRL responses to MTC stimulation efficiently separated the two groups (AD and controls); the former test showing a higher discriminant power than the latter.