A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
- Klíčová slova
- Anticoagulation, Atrial fibrillation, Bleeding, Left atrial appendage closure, Left atrial appendage occlusion, Prevention, Stroke,
- MeSH
- antikoagulancia škodlivé účinky MeSH
- cévní mozková příhoda * prevence a kontrola komplikace MeSH
- dospělí MeSH
- fibrilace síní * komplikace diagnóza chirurgie MeSH
- konsensus MeSH
- krvácení chemicky indukované prevence a kontrola MeSH
- lékaři * MeSH
- lidé MeSH
- síňové ouško * chirurgie MeSH
- tromboembolie * etiologie prevence a kontrola MeSH
- uzávěr ouška levé síně MeSH
- vitamin K MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- Názvy látek
- antikoagulancia MeSH
- vitamin K MeSH
CONTEXT: 4H or POLR3-related leukodystrophy is an autosomal recessive disorder typically characterized by hypomyelination, hypodontia, and hypogonadotropic hypogonadism, caused by biallelic pathogenic variants in POLR3A, POLR3B, POLR1C, and POLR3K. The endocrine and growth abnormalities associated with this disorder have not been thoroughly investigated to date. OBJECTIVE: To systematically characterize endocrine abnormalities of patients with 4H leukodystrophy. DESIGN: An international cross-sectional study was performed on 150 patients with genetically confirmed 4H leukodystrophy between 2015 and 2016. Endocrine and growth abnormalities were evaluated, and neurological and other non-neurological features were reviewed. Potential genotype/phenotype associations were also investigated. SETTING: This was a multicenter retrospective study using information collected from 3 predominant centers. PATIENTS: A total of 150 patients with 4H leukodystrophy and pathogenic variants in POLR3A, POLR3B, or POLR1C were included. MAIN OUTCOME MEASURES: Variables used to evaluate endocrine and growth abnormalities included pubertal history, hormone levels (estradiol, testosterone, stimulated LH and FSH, stimulated GH, IGF-I, prolactin, ACTH, cortisol, TSH, and T4), and height and head circumference charts. RESULTS: The most common endocrine abnormalities were delayed puberty (57/74; 77% overall, 64% in males, 89% in females) and short stature (57/93; 61%), when evaluated according to physician assessment. Abnormal thyroid function was reported in 22% (13/59) of patients. CONCLUSIONS: Our results confirm pubertal abnormalities and short stature are the most common endocrine features seen in 4H leukodystrophy. However, we noted that endocrine abnormalities are typically underinvestigated in this patient population. A prospective study is required to formulate evidence-based recommendations for management of the endocrine manifestations of this disorder.
- Klíčová slova
- 4H leukodystrophy, POLR3-related leukodystrophy, hypogonadotropic hypogonadism, hypomyelination,
- MeSH
- biologická variabilita populace MeSH
- dědičné demyelinizační nemoci CNS komplikace epidemiologie genetika MeSH
- dítě MeSH
- DNA řízené RNA-polymerasy genetika MeSH
- dospělí MeSH
- genetická heterogenita MeSH
- hypogonadismus epidemiologie etiologie MeSH
- kohortové studie MeSH
- kojenec MeSH
- lidé MeSH
- mitochondriální nemoci komplikace epidemiologie genetika MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mutace MeSH
- nemoci endokrinního systému epidemiologie etiologie genetika MeSH
- novorozenec MeSH
- poruchy růstu epidemiologie etiologie genetika MeSH
- předškolní dítě MeSH
- průřezové studie MeSH
- retrospektivní studie MeSH
- RNA-polymerasa III genetika MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- kojenec MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- novorozenec MeSH
- předškolní dítě MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- práce podpořená grantem MeSH
- Research Support, N.I.H., Extramural MeSH
- Názvy látek
- DNA řízené RNA-polymerasy MeSH
- POLR1C protein, human MeSH Prohlížeč
- POLR3A protein, human MeSH Prohlížeč
- POLR3B protein, human MeSH Prohlížeč
- RNA-polymerasa III MeSH
Purpose: We sought to investigate whether B cell receptor immunoglobulin (BcR IG) stereotypy is associated with particular clinicobiological features among chronic lymphocytic leukemia (CLL) patients expressing mutated BcR IG (M-CLL) encoded by the IGHV4-34 gene, and also ascertain whether these associations could refine prognostication.Experimental Design: In a series of 19,907 CLL cases with available immunogenetic information, we identified 339 IGHV4-34-expressing cases assigned to one of the four largest stereotyped M-CLL subsets, namely subsets #4, #16, #29 and #201, and investigated in detail their clinicobiological characteristics and disease outcomes.Results: We identified shared and subset-specific patterns of somatic hypermutation (SHM) among patients assigned to these subsets. The greatest similarity was observed between subsets #4 and #16, both including IgG-switched cases (IgG-CLL). In contrast, the least similarity was detected between subsets #16 and #201, the latter concerning IgM/D-expressing CLL. Significant differences between subsets also involved disease stage at diagnosis and the presence of specific genomic aberrations. IgG subsets #4 and #16 emerged as particularly indolent with a significantly (P < 0.05) longer time-to-first-treatment (TTFT; median TTFT: not yet reached) compared with the IgM/D subsets #29 and #201 (median TTFT: 11 and 12 years, respectively).Conclusions: Our findings support the notion that BcR IG stereotypy further refines prognostication in CLL, superseding the immunogenetic distinction based solely on SHM load. In addition, the observed distinct genetic aberration landscapes and clinical heterogeneity suggest that not all M-CLL cases are equal, prompting further research into the underlying biological background with the ultimate aim of tailored patient management. Clin Cancer Res; 23(17); 5292-301. ©2017 AACR.
- MeSH
- antigeny CD38 genetika imunologie MeSH
- chronická lymfatická leukemie genetika imunologie patologie MeSH
- imunogenetika MeSH
- lidé MeSH
- regulace genové exprese u nádorů imunologie MeSH
- sekvence aminokyselin genetika MeSH
- somatická hypermutace imunoglobulinových genů genetika MeSH
- těžké řetězce imunoglobulinů genetika imunologie MeSH
- variabilní oblast imunoglobulinu genetika imunologie MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- Názvy látek
- antigeny CD38 MeSH
- těžké řetězce imunoglobulinů MeSH
- variabilní oblast imunoglobulinu MeSH
