The impact of baseline dietary fatty acid intake on the association between lipoprotein(a) and mortality in two US cohorts.

Background: Lipoprotein(a) (Lp(a)) is an established casual risk factor for atherosclerotic cardiovascular disease. It remains unknown whether dietary fat modifies the association of Lp(a) with cardiovascular death. Aim: To understand if dietary fat modifies the association between Lp(a) and cardiovascular death. Methods: We utilized the Atherosclerotic Risk in Communities (ARIC) study and National Health and Nutrition Examination Survey (NHANES) III cohorts and used multivariate cox proportional hazard modeling to test the association between Lp(a), dietary fats, and cardiovascular death. Results: The sample (n = 22,805) had average age 51.3 years and was mostly female (55.4%). Lp(a) ≥ 30 mg/dL was associated with CV death in both ARIC (1.36, p = 0.001) and NHANES (1.31, p = 0.03). In multivariate analysis, no categorical or individual fatty acids modified the association between Lp(a) and CV death. Conclusion: There was no evidence that baseline dietary fat intake modified the association between Lp(a) and CV death.

The Impact of Social Determinants of Health and Lifestyle on the Association of Lipoprotein(a) with Myocardial Infarction and Stroke.

Background: In European cohorts, a higher Mediterranean diet or Life's Simple 7 (LS7) score abolished or attenuated the risk associated with increasing Lipoprotein(a) [Lp(a)] on cardiovascular outcomes. This is unstudied in US cohorts. The impact of social determinants of health (SDOH) on the association of Lp(a) with cardiovascular outcomes remains unstudied. We sought to test if a SDOH score and LS7 score impacts the association of Lp(a) with myocardial infarction (MI) or stroke. Methods: Observational Cohort of US Adults from the Atherosclerosis Risk in Communities (ARIC) and Multi-Ethnic Study of Atherosclerosis (MESA) cohorts. We performed sequential multivariable Cox proportional hazard analysis, first adjusting for age, gender, non-HDL-C, race and ethnicity, then added SDOH and LS7 scores sequentially. The primary outcomes were time until first fatal or nonfatal MI or stroke. Results: ARIC (n=15,072; median Lp(a)=17.3 mg/dL) had 16.2 years average follow up. MESA (n=6,822; median Lp(a)=18.3 mg/dL had 12.3 years average follow-up. In multivariable analyses adjusted for age, gender, race and ethnicity, and non-HDL-C, Lp(a) was associated (HR, p-value) with MI in ARIC (1.10, <0.001) and MESA (1.09, <0.001), and stroke in ARIC (1.08, <0.001) but not MESA (0.97, 0.50). With SDOH and LS7 added to the model associations remained similar (association of Lp(a) with MI in ARIC 1.09, <0.001 and in MESA 1.10, 0.001, with stroke in ARIC 1.06, <0.003 and in MESA 0.96, 0.39). In models with all covariates, each additional SDOH correlated positively with MI (ARIC 1.13, <0.001; MESA 1.11, <0.001) and stroke (ARIC 1.17, <0.001; HR 1.07, p=0.11) and each additional LS7 score point correlated negatively with MI (ARIC 0.81, <0.001; MESA 0.84, <0.001) and stroke (ARIC 0.82, <0.001; MESA 0.84, <0.001). Conclusions and Relevance: SDOH and lifestyle factors were predictors for MI and stroke that did not impact the association between Lp(a) and cardiovascular events. Our findings support that Lp(a) is an independent risk factor for MI and possibly stroke.

Genitourinary involvement in pediatric patients with Klippel-Trenaunay Syndrome.

BACKGROUND: Klippel-Trenaunay Syndrome (KTS) is a genetic vascular malformation disorder which induces a variety of phenotypic expression in patients which differ in terms of severity/location. While previous studies have documented genitourinary (GU) complications in adult KTS patients, documentation of the scope and incidence of GU involvement in the pediatric population with imaging findings is currently limited. This study represents the largest KTS genitourinary review to date. OBJECTIVE: To assess the incidence, scope, clinical findings and imaging characteristics of GU pathology in pediatric KTS patients. MATERIALS/METHODS: Using a retrospective data analysis design, the charts and imaging studies of pediatric KTS patients were reviewed. All patients received care at a specialized vascular clinic within a multicenter tertiary care system. Variables studied included age, age at KTS diagnosis, gender, urologic involvement, and age of urologic complication. RESULTS: 58 patients were identified. 33 were male and 25 were female. 10 patients had GU findings. Three of these patients had multifocal GU involvement (greater than 1 finding). Urologic manifestations were diverse with 9 distinct diagnoses involving 6 unique organs. Renal, vesical and scrotal pathologies were most common. Hematuria was the most common presenting symptom in 30% (3/10). Previously unreported findings (labial swelling, renal lymphatic cysts) were identified. The average age of KTS diagnosis was 4.9 years. The average age of documented GU complication and involvement was 7.6 years. CONCLUSION: Significant GU complications due to KTS can occur in the pediatric population. Early clinical and imaging characterization of these conditions is important for management, family education and early intervention strategies.

Analyzing the Efficacy and Cost-effectiveness of Anti-platelet Therapy in Unstable Angina/Non-ST Elevation Myocardial Infarction: A Decision Analysis.

Current pretreatment guidelines for coronary angiography in unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) involve the use of dual antiplatelet therapy (DAPT: aspirin + adenosine diphosphate (ADP) P2Y12 inhibitor), whereas the use of triple antiplatelet therapy (TAPT: aspirin + ADP P2Y12 inhibitor + GpIIb/IIIa inhibitor) has limited data due to the increased bleeding risk. However, a study directly comparing the efficacy and cost-effectiveness of DAPT vs. TAPT has not been done. A decision analysis was constructed to determine the ideal pretreatment antiplatelet regimen for UA/NSTEMI patients. The parameters were calculated based on published randomized clinical trials. They consisted of probabilities based on a pretreatment strategy (DAPT, TAPT), interventions (percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), medical management), and 30-day outcomes (no event, bleeding, vascular event, death). A 10,000 run Monte Carlo simulation provided two outputs: estimated life-years extended and costs for each treatment modality. Quality-adjusted life-years (QALYs) were taken into consideration using calculated coefficients from the literature. The cost/QALY ratio was $1,923/QALY for DAPT vs. $4,734/QALY for TAPT. The use of DAPT for pretreatment was favored (2.46 more cost-effective than TAPT). These results will aid clinicians in providing the most clinically sound and fiscally responsible care for UA/NSTEMI patients.

Hemolytic Uremic Syndrome With Severe Neurologic Complications in an Adult.

The case of a female presenting with Shiga toxin-producing Escherichia coli and hemolytic uremic syndrome highlights a severe neurologic complication that can be associated with these conditions.