1635 Catch me if you can: a rare case of two-staged MitraClip detachment

Case report

A 74-year-old man presented with acute heart failure and chronic obstructive pulmonary disease exacerbation. His medical history revealed: anterior myocardial infarction in 2005, treated with primary PCI of left anterior descending coronary artery followed by triple coronary artery bypass, atrial fibrillation, hypertension, diabetes mellitus and obesity. Transthoracic and transesophageal echocardiography (TEE) showed severe functional ischemic mitral regurgitation (MR) with multiple jets, the main one involving the A2-P2 scallops due to asymmetric tethering of the posterior leaflet. The vena contracta diameter (VC) was 8 mm, the effective regurgitant orifice area (EROA) 0.53 cm². Global left ventricular (LV) function was preserved with inferior-posterior wall akinesis.

After "Heart Team" discussion, due to high surgical risk, the patient was referred for percutaneous mitral valve repair (PMVR) using MitraClip (MC) system (Abbott Vascular, Illinois). One clip (MC-XTR) was placed at the A3-P3 segments; subsequently, prior to releasing a second clip (MC-XTR), the first one partially detached from the posterior leaflet (Fig A). A third clip (MC-NTR) was implanted medially. The grasp was challenging but at the end of the procedure, the first clip appeared stable and marked reduction of MR was achieved (Fig B).

7 days later, the patient became symptomatic for resting dyspnea and worsened his clinical status. A control 2D-3D TEE revealed a complete detachment of the first implanted clip, visible distally into the LV, trapped in the mitral valve subchordal apparatus (Fig C). This resulted in massive MR (VC: 12 mm, EROA: 0.91 cm²) with an eccentric posteriorly directed regurgitant jet (Fig D). The patient underwent emergency surgical retrieval of the migrated clip, and removal of the torn mitral valve anterior leaflet. The other two clips were also removed (Fig E), and a bioprosthetic mitral valve was implanted. The procedure was completed uneventfully and the patient is in stable conditions at 2-months follow-up.

Discussion

The constant stretching and whip effect of the mitral leaflets captured between the clips arms, used in PMVR, can lead to complications. Partial clip detachment is a rare adverse event described in ∼0.7-4.9% of patients within 30 days after MC intervention*. We experienced a two-staged MC detachment that is an even rarer complication and requires emergency surgery. In addition, we highlights the usefulness of 3D TEE for early diagnosis and better imaging characterization in patients who develop complications after MC procedure.

No conflict of interest. *Puls M, Lubos E, Boekstegers P, von Bardeleben RS, Ouarrak T, Butter C, Zuern CS, Bekeredjian R, Sievert H, Nickenig G, Eggebrecht H, Senges J, Schillinger W. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: results from German transcatheter mitral valve interventions registry. Eur Heart J 2016;37:703-12.

Abstract 1635 Figure.

Primary hepatic angiosarcoma and liver transplantation: Radiological, surgical, histological findings and clinical outcome

Angiosarcoma is a rare type of soft tissue sarcoma that accounts for less than 1% of all sarcomas and only 2% of all primary hepatic tumours. Thorotrast, arsenic, and vinyl chloride monomer are frequently listed as occupational exposure risks. The estimated latency is long (10-40 years) in occupational cases and very long (60 years or more) in non-occupational cases. The symptoms and CT-scan appearance of hepatic angiosarcoma (HAS) are non-specific. We present a case of a 65-year-old Caucasian male with history of cryptogenic cirrhosis, low alpha-foetoprotein levels and a single, 4-cm nodule of potential atypical hepatocellular carcinoma (no washout at MRI and CT-scan) in segment VIII. Laparoscopic radiofrequency ablation (a biopsy of the neoplastic lesion was technically impossible) was performed, followed by liver transplantation (LT) 6 months later. High-grade multifocal HAS was found in the explanted liver, with extensive involvement of the venous portal structures. No complications were observed during the postoperative course, and initial immunosuppression included tacrolimus, mycophenolate mofetil and corticosteroids. Because of the histological findings, tacrolimus was switched to everolimus as the main immunosuppressive drug one month after LT. Despite this conversion, the patient developed bone metastases 3 months after LT and peritoneal carcinosis one month later. This case report suggests that everolimus conversion does not inhibit the development of tumour metastases. Consequently, HAS remains an absolute contraindication to LT because of the poor outcome. If LT has been performed for incidental HAS, new molecular therapies (e.g. vascular endothelial growth factor antagonists) should be considered immediately after LT to improve the outcome.

Spatial variability of soft-bottom macrobenthic communities in northern Sicily (Western Mediterranean): Contrasting trawled vs. untrawled areas

This study examines the impact of bottom trawl fishing on the macrobenthic communities inhabiting the coastal terrigenous mud off the northern coast of Sicily (Western Mediterranean). Two intensely trawled gulfs were compared with two gulfs from which trawling has been excluded for 15 years. The results show a significant effect of trawling on the faunal assemblage and when comparing the mean biomass and the whole isotopic composition of the benthic communities. A similar pattern, although not significant, was found for total abundance, biomass, production/biomass ratio and diversity. Higher abundance and lower biomass were found in the untrawled areas, attributable to the presence of more numerous yet smaller individuals, possibly a consequence of more abundant larger predators that are not removed by trawling, and consequent higher predatory pressure on the benthic macrofauna. The SIMPER analysis evidenced a dominance of burrowing deposit feeding worms (Paraonidae and Cossuridae) in trawled areas, as a result of increased mechanical alteration and hence more organic matter available as food. In contrast, the response to trawling as drawn by the use of trophic markers (i.e., stable isotopes) was less clear. While δ¹⁵N of benthic taxa did not vary significantly between untrawled and trawled areas, δ¹³C was higher in trawled areas possibly due to high sediment resuspension and consequent intense microbial activity. Mixing models confirmed higher reliance to a detritus-based food web for benthic organisms in the trawled areas. Standard Ellipse Areas (SEAc) as a measure of community niche width were slightly larger in trawled areas, likely due to higher generalism triggered by alteration/removal of the original benthic community.

IFNL3/4 genotype is associated with altered immune cell populations in peripheral blood in chronic hepatitis C infection

Single-nucleotide polymorphisms near the interferon lambda 3 (IFNL3) gene predict outcomes to infection and anti-viral treatment in hepatitis C virus (HCV) infection. To identify IFNL3 genotype effects on peripheral blood, we collected phenotype data on 400 patients with genotype 1 chronic hepatitis C (CHC). The IFNL3 responder genotype predicted significantly lower white blood cells (WBCs), as well as lower absolute numbers of monocytes, neutrophils and lymphocytes for both rs8099917 and rs12979860. We sought to define the WBC subsets driving this association using flow cytometry of 67 untreated CHC individuals. Genotype-associated differences were seen in the ratio of CD4CD45RO+ to CD4CD45RO-; CD8CD45RO+ to CD8CD45RO-, NK CD56 dim to bright and monocyte numbers and percentages. Whole blood expression levels of IFNL3, IFNLR1 (interferon lambda receptor 1), IFNLR1-mem (a membrane-associated receptor), IFNLR1-sol (a truncated soluble receptor), MxA and T- and NK (natural killer) cell transcription factors TBX21, GATA3, RORC, FOXP3 and EOMES in two subjects were also determined. CHC patients demonstrated endogenous IFN activation with higher levels of MxA, IFNLR1, IFNLR1-mem and IFNLR1-sol, and IFNL3 genotype-associated differences in transcription factors. Taken together, these data provide evidence of an IFNL3 genotype association with differences in monocyte, T- and NK cell levels in the peripheral blood of patients with CHC. This could underpin genotype associations with spontaneous and treatment-induced HCV clearance and hepatic necroinflammation.

Highly contaminated areas as sources of pollution for adjoining ecosystems: The case of Augusta Bay (Central Mediterranean)

An assessment of trace element and polycyclic aromatic hydrocarbon (PAH) contamination based on surface sediments collected in summer 2012 was carried out in Priolo Bay adjoining one of the most polluted areas of the Mediterranean Sea, the industrial Augusta harbour (Italy, Central Mediterranean). Inorganic and organic contaminants were generally not remarkable. Occasional elevated concentrations of Hg, Cd, Ni and PAHs exceeding sediment quality guidelines were detected in the northern sector of Priolo Bay, close to Augusta harbour, possibly as a result of water drainage of industrialised and urbanised areas and/or potential direct export of contaminated material from Augusta harbour, whose influence on the adjoining Priolo Bay ecosystem cannot be ruled out. By domino effect, Priolo sediments may therefore become a potential source of pollutants and may represent a threat to the biota.

Simulation of transcatheter aortic valve implantation through patient-specific finite element analysis: two clinical cases

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure introduced to treat aortic valve stenosis in elder patients. Its clinical outcomes are strictly related to patient selection, operator skills, and dedicated pre-procedural planning based on accurate medical imaging analysis. The goal of this work is to define a finite element framework to realistically reproduce TAVI and evaluate the impact of aortic root anatomy on procedure outcomes starting from two real patient datasets. Patient-specific aortic root models including native leaflets, calcific plaques extracted from medical images, and an accurate stent geometry based on micro-tomography reconstruction are key aspects included in the present study. Through the proposed simulation strategy we observe that, in both patients, stent apposition significantly induces anatomical configuration changes, while it leads to different stress distributions on the aortic wall. Moreover, for one patient, a possible risk of paravalvular leakage has been found while an asymmetric coaptation occurs in both investigated cases. Post-operative clinical data, that have been analyzed to prove reliability of the performed simulations, show a good agreement with analysis results. The proposed work thus represents a further step towards the use of realistic computer-based simulations of TAVI procedures, aiming at improving the efficacy of the operation technique and supporting device optimization.

Methylenetetrahydrofolate reductase homozygosis and low-density lipoproteins in patients with genotype 1 chronic hepatitis C

Methylenetetrahydrofolate reductase status, homocysteine and lipoproteins levels have been associated with severity of disease and both rapid and sustained virological response (SVR) in patients with genotype 1 chronic hepatitis C (CHC). We aimed to assess the association of homocysteine and MTHFR status with serum cholesterol levels and their potential links to both histological findings and virological response, in patients with genotype 1 hepatitis C virus (HCV). A total of 119 consecutive patients were evaluated by biopsy and metabolic measurements. A total of 103 healthy blood donors were used as controls. Serum homocysteine and MTHFR C677T mutation were also evaluated. All patients underwent antiviral therapy with PEG-IFN alfa-2a plus ribavirin. HCV-RNA was assessed at baseline, week 4, week 12, at the end of therapy and after 6 months of follow-up. Mean serum values of homocysteine were higher in patients than in controls (15.8 ± 5.8 μg/L vs 12.5 ± 5.8 μg/L; P < 0.001), with a similar CC, CT and TT MTHFR distribution (23.6%, 48.7% and 27.7% in G1-CHC vs 34%, 48.5% and 17.5% in controls; P = 0.14). In genotype 1, HCV MTHFR TT homozygosis was independently linked to higher LDL (OR 1.016; CI 1.002-1.031; P = 0.03), but not to homocysteine. No association were found between homocysteine, MTHFR and histological features or both rapid virological response (RVR) and SVR. Low cholesterol (OR 0.988, 95%CI 0.975-0.999, P = 0.04) was independently linked to severe fibrosis, and high LDL was the only independent positive predictors of both RVR and SVR (OR 1.036; 95%CI 1.017-1.055; P < 0.001; and OR 1.016; 95%CI 1.001-1.031; P = 0.04 respectively). In patients with genotype 1 hepatitis C, showing higher homocysteine serum levels than controls, MTHFR C677T homozygosis, via modulating cholesterol levels, could interfere with liver fibrosis and response to antiviral therapy.

Comparison of transient elastography and acoustic radiation force impulse for non-invasive staging of liver fibrosis in patients with chronic hepatitis C

OBJECTIVES

Transient elastography (TE) is adequate for a diagnosis of cirrhosis, but its accuracy for milder stages of fibrosis is much less satisfactory. The objective of this study was to compare the performance and the discordance rate of acoustic radiation force impulse (ARFI) and TE with liver biopsy in a cohort of chronic hepatitis C (CHC) patients.

METHODS

One hundred thirty-nine consecutive patients with CHC were enrolled in two tertiary centers, and evaluated for histological (Metavir score) and biochemical features. All patients underwent TE and ARFI.

RESULTS

TE was unreliable in nine patients (6.5%), while in no cases (0%) were ARFI invalid measurements recorded (P=0.029). By area under receiver operating characteristic curve (AUROC), the best cutoff values for TE and ARFI for significant fibrosis (≥F2) were ≥6.5 kPa (AUROC: 0.78) and ≥1.3 m/s (AUROC: 0.86), respectively. For severe fibrosis (F3-F4), these cutoff values were 8.8 kPa (AUROC: 0.83) for TE and 1.7 m/s (AUROC: 0.94) for ARFI. For cirrhosis, TE had its best cutoff at ≥11 kPa (AUROC: 0.80) and ARFI at ≥2.0 m/s (AUROC: 0.89). By pairwise comparison of AUROC, ARFI was significantly more accurate than TE for a diagnosis of significant and severe fibrosis (P=0.024 and P=0.002, respectively), while this difference was only marginal for cirrhosis (P=0.09). By partial AUROC analysis, ARFI performance results significantly higher for all three stages of fibrosis. The average concordance rates of TE and ARFI vs. liver biopsy were 45.4 and 54.7%, respectively. By multivariate analysis, ARFI was not associated with alanine aminotransferase (ALT), body mass index, Metavir grade, and liver steatosis, while TE was significantly correlated with the ALT value (P=0.027).

CONCLUSIONS

In a cohort of patients with CHC, ARFI imaging was more accurate than TE for the non-invasive staging of both significant and severe classes of liver fibrosis.

Impacts of marine aquaculture at large spatial scales: evidences from N and P catchment loading and phytoplankton biomass

While several studies point at off-shore aquaculture as a possible source of impacts on the local marine environment, very few have analysed its effects at large scales such as at the bay, gulf or basin levels. Similar analyses are hampered by the multiple sources of disturbance that may concomitantly affect a given area. The present paper addresses these issues taking the Gulf of Castellammare (Southern Tyrrhenian Sea) as an example. Nitrogen (N) and phosphorous (P) loads were calculated for the period 1970-2007, and compared to chlorophyll-a concentration as measured inside and outside the Gulf over the same period. Results indicate that N and P catchment loading has constantly decreased because of improved environmental management. Nevertheless, nutrient concentration in the Gulf has steadily increased since the establishment of aquaculture facilities in 1999. Chlorophyll-a concentration followed this trend, showing a marked increase from 2001 onwards. In the same period, chlorophyll-a concentrations measured inside and outside the Gulf have significantly diverged. As all the other possible causes can be ruled out, aquaculture remains the sole explanation for the observed situation. This paper demonstrates for the first time ever that off-shore aquaculture may affect the marine ecosystem well beyond the local scale and provides an additional element of concern to be kept into consideration when allocating oceans' space for new fish-farming activities.

Superior vena cava syndrome due to thrombotic occlusion in a thrombophilic renal transplant recipient: a case report

The case of a superior vena cava syndrome due to a central venous catheter thrombosis occurring in a second renal transplant patient is described. Imaging revealed thrombosis of the right internal jugular vein with extension along the confluence of the brachiocephalic veins and partial obstruction of the superior vena cava. Anticoagulant therapy with subcutaneous low-molecular-weight heparin was followed by warfarin administration. Despite adequate treatment, the symptomatology worsened because of thrombus organization. A workup revealed a complex prothrombotic underlying condition. Cardiothoracic surgeons were consulted, and an operative reconstruction of the superior vena cava using spiral vein bypass grafting was performed. In this report we describe the clinical presentation, diagnosis, and treatment of this case, with an emphasis on the role of thrombophilia.

Neoadjuvant trastuzumab in a sequential nonanthracycline-based regimen for patients with stage II-III breast cancer

e11559

Background: Recently, some studies have demonstrated benefit from adding trastuzumab to neoadjuvant anthracycline-containing chemotherapy for HER2-positive breast cancer patients. However, trastuzumab can increase cardiotoxicity, particularly when combined with anthracyclines. This represents a relevant issue for patients who usually need to receive radiotherapy or further systemic treatment. Methods: In the late 2007 we started a phase II study for testing activity and safety of neoadjuvant trastuzumab in association with sequential chemotherapy, based on favourable in vitro combination index, proven efficacy, and moderate cardiotoxicity. Weekly trastuzumab for 18 weeks was combined with cisplatin 80 mg/m2 on day 1 and vinorelbine 25 mg/m2 on days 1+8 q3w for 3 courses, followed by docetaxel 100 mg/m2 q3w for further 3 courses. Peg- filgrastim was administered to prevent neutropenia. Adjuvant trastuzumab q3w was planned for one year. Eligible patients had stage II-III core-biopsied breast carcinoma with overexpressed or amplified HER2/neu. Adequate cardiac function with LVEF ≥ 50% was required for trastuzumab administration. Primary end-point was pathologic complete responses (pCR) rate. The study is registered on the European Clinical Trials Database. Results: Among 17 enrolled patients, 15 were evaluable for primary end-point. Median age was 50 years (range 23–70), stage II and III breast cancer in 4 and 13 patients, respectively, with 4 cases of stage IIIB (2 T4b and 2 T4d), and 2 women with synchronous bilateral cancer. Neoadjuvant regimen yielded 6/15 pCR (40%). Only 3/12 patients treated with lymphadenectomy due to initial clinically suspected axillary nodes presented pN+, but none of them had more than 3 positive nodes. In two cases we observed a total pCR, involving both primary tumor and axillary nodes. Treatment was safe, with only 2 events of short G4 non febrile neutropenia on 97 chemotherapy cycles. Alopecia was moderate at the end of treatment, without any case of complete hair loss. No significant cardiac dysfunction was recorded during the neoadjuvant therapy. Conclusions: The present sequential non anthracycline-based chemotherapy associated with weekly trastuzumab showed promising results in neoadjuvant setting.

No significant financial relationships to disclose.

The logic and regulation of cell cycle exit and reentry

Tissue repair and regeneration are very complex biological events, whose successful attainment requires far more than mere cell division. However, almost unavoidably they entail cell proliferation as a fundamental premise. Full regeneration or repair cannot be achieved without replacing cells lost to disease or injury, replacement that can only take place via proliferation of surviving cells. This review endeavors to outline the molecular bases of exit from and reentry into the cell cycle. In recent years, the decision to proliferate or not has been seen as mostly the concern of cyclins and cyclin-dependent kinases. This account tries to show that cell cycle inhibitors are as important as the positive regulators in the making of this decision. Finally, the authors wish to suggest that the molecular knowledge of the cell cycle can be harnessed to the benefit of many aspects of regenerative medicine.

Sediment features, macrozoobenthic assemblages and trophic relationships (delta13C and delta15N analysis) following a dystrophic event with anoxia and sulphide development in the Santa Giusta lagoon (western Sardinia, Italy)

Macrozoobenthic assemblages and stable carbon (delta(13)C) and nitrogen (delta(15)N) isotope values of various primary producers (macroalgae and angiosperms) and consumers (macroinvertebrate filter/suspension feeders, deposit feeders, detritivores/omnivores and carnivores and fishes) were studied in the Santa Giusta lagoon (Sardinia, Italy) before (spring) and after (autumn) a dystrophic event which occurred in the summer of 2004. A few days after the dystrophy, the physico-chemical characteristics of sediments and macrozoobenthic assemblages were also investigated. In the latter occasion, high total organic carbon (3.9%) and organic matter (15.9%) contents of surface sediments went together with peaks in acid-volatile sulphide concentrations. Certain immediate effects were quite extreme, such as the drastic reduction in macrozoobenthos and the massive fish kill in August 2004. Among the macrozoobenthos, there were few individuals of chironomid larvae and Capitella cf. capitata left. However, by October, chironomid larvae were numerous, indicating a lack of predators (e.g. fish) and competitors. In addition, some bivalve species and polychaetes which were absent, or present in small numbers before the event, became relatively numerous. The results are discussed based on a knowledge of the sulphide tolerance of these species. Stable isotope analysis clearly showed that the basal level of the food web for most consumers consisted mainly of macroalgae and sedimentary organic matter, and that the values before and after the dystrophic event were not significantly different from one another. This indicates that the relations among different trophic levels were quickly restored following the dystrophic event.

Unreliability of classic provocative tests for the diagnosis of growth hormone deficiency

In this study we investigated 9 prepubertal children with blunted GH response to classic pharmacological stimuli in contrast with normal auxological evaluation. The children were followed to evaluate their growth velocity for a longer period before starting replacement GH therapy. To evaluate the pituitary reserve a supraphysiologic stimulus such as GHRH plus arginine was used. Serum GH levels were measured by a time-resolved immunofluorimetric assay before and after 1 microg/kg body weight iv injection of GHRH, while serum PRL, IGF-I, and insulin were evaluated only in basal conditions using an automatic immunometric assay. Out of 9 studied subjects, 7 underwent GHRH plus arginine administration and showed a normal GH response; the parents of the remaining 2 children refused the test. Normal serum levels of PRL, IGF-I, insulin, and a normal insulin sensitivity were observed in all children. After 1 yr, the growth rate in each patient was further improved and reached almost normal values. Our results further confirm that the decision to start replacement GH therapy should be based on both auxological parameters and laboratory findings. The GHRH plus arginine test appears to be useful to identify false GH deficiency in children showing a blunted GH response to classic stimuli in contrast with normal growth rate.

Association of weekly gemcitabine to conformal radiotherapy as organ-sparing strategy in locally advanced or relapsed bladder cancer

15570

Background: Radical surgery is considered the only curative option for locally advanced or relapsed bladder cancer. However, the uncertain prognosis of disease and the poor quality of life due to lack of bladder reservoir require further investigation on possible therapeutic approaches. Methods: This trial has been designed for testing safety and activity of dose-escalating gemcitabine associated to concomitant conformal radiotherapy for locally advanced or relapsed bladder cancer. Patients received radiotherapy at 2 Gy per day to reach a total dose of 60 Gy over 6 weeks. Gemcitabine was administered once-a-week as one-hour IV infusion before starting the radiation treatment. The first explored dose of drug was 300 mg/m2 and the escalation was planned through a Fibonacci modified method by subsequent increases of 100 mg/m2 until definition of the dose-limiting toxicity (DLT). The recommended dose for future phase II study was one level inferior to the reached maximum tolerated dose (MTD). Results: Eighteen patients with median age of 72 years entered the study, half of whom affected by locally advanced tumours, the remainders by recurrence after conservative surgery. The majority of the latter initially had pT2 (UICC staging) muscle invasive transitional cell carcinoma. Twelve patients were treated with weekly gemcitabine at 300 mg/m2 without appearance of any DLT. Among the first 3 patients receiving the dose level of 400 mg/m2, one patient had grade 4 neutropenia. Further 3 patients were enrolled for testing the above dose level, but one of them experienced bowel perforation, therefore the established MTD was 400 mg/m2. The recommended dose of weekly gemcitabine was 300 mg/m2. Effectively, we could observe 11 (61%) pathological complete responses (pCR) confirmed by bladder mapping two months after treatment completion. Nine pCR (82%) occurred in the patients with locally advanced therapy-naïve bladder cancer. Patients with conserved bladders had excellent function, without hematuria, urgency or incontinence. Conclusions: The association of weekly gemcitabine to conformal radiotherapy provides a new alternative to radical surgery approach and strongly supports the organ-sparing strategy for locally advanced bladder cancer.

No significant financial relationships to disclose.

Diagnostic problems and postnatal follow-up in congenital toxoplasmosis

AIM

In order to assess the consequences of different clinical approaches in the prenatal management of congenital toxoplasmosis, we retrospectively reviewed 58 pregnant women with Toxoplasma seroconversion and prospectively enrolled their 59 infants, referred to us from 1999 to 2004.

METHODS

Data on clinical, laboratory and demographic characteristics of the pregnant women were collected. Their children were entered into a 48-month follow-up programme in which clinical, instrumental, ophthalmologic and serologic evaluations were carried out at birth, at 1, 3, 6, 9, 15, 18, 24, 36 and at 48 months of life. Paediatric treatment with Spiramycin alone or alternated with Pyrimethamine-Sulphadiazine was administered according to the different clinical cases.

RESULTS

Time of infection was dated in the first trimester for 24 women (41%), in the second trimester for 18 women (31%) and in the third trimester for 16 (28%). In the first trimester of pregnancy 20 of the 24 infected women had undergone amniocentesis, while the test had not been performed on any of the women infected in the third trimester. Serological follow-up revealed that 11 (19%) of the infants had been infected. An alternating regimen with Pyrimethamine-Sulphadoxine was administered to the infected children. All the infants were clinically asymptomatic, and the instrumental follow-up revealed specific toxoplasmosis anomalies in 4/11 infected children.

CONCLUSION

Our results highlight issues and problems concerning current prenatal diagnostic tests and the therapeutic approach based on PCR testing of amniotic fluid alone. The incidence of ocular-cerebral lesions observed in children born to women with seroconversion in the third trimester raises questions about the diagnostic and therapeutic approach for these women and their offspring. Paediatric therapeutic protocol, with alternating Pyrimethamine-Sulphadiazine regimen, applied also to asymptomatic children born to women with inadequate prenatal diagnostic management, could prevent severe sequelae.

Diagnosis of congenital toxoplasmosis: pre- and post-natal evaluation in Sicilian (Italy) epidemiological area. Preliminary data

To evaluate the usefulness of conventional serological methods with western blot assay (WB) in congenital toxoplasmosis diagnosis, we prospectively enrolled in a clinical and serological follow-up all pregnant women with Toxoplasma gondii infection and their offspring, referred to us from October 2004. Western blot and standard serological test were performed on sera collected from mother during pregnancy and from mother and child at birth, at postpartum month 1-3-6-9 and 12. At this point in time, 22 pregnant women and 14 infants have completed the follow-up. 4 newborns were infected and 2 had specific toxoplasmosis anomalies at the birth. In mothers without seroconversion, the WB performed during pregnancy demonstrates the highest accordance with postnatal follow-up whereas in 1 case the negative result of PCR analysis was not confirmed by postnatal observation. The detection of anti-T gondii IgG against 8 kDa accessory antigenic band and against the accessory band included between 35 and 40 kDa band in immunoblot assay was useful for diagnosis of acute phase but did not improve the evaluation of comparative postnatal profile. Althougth few infants have concluded the postnatal follow-up, the preliminary results showed a greater value of using a IgM and IgA WB test than other standard method for the early diagnosis of toxoplasmosis at birth also in child born to treated mothers. The comparative anti-T gondii IgG immunoblot profile of mother and child permitted us to reduce the time of ruling out infection in newborns born to mothers with probable or possible infection and/or when prenatal diagnosis is negative or not performed.

Tuberculosis of the central nervous system in children: 32 years survey

AIM

In order to study the impact of clinical and diagnostic parameters on the clinical outcome of children with central nervous system tuberculosis (CNS-TB), we retrospectively reviewed all cases of CNS-TB diagnosed over a 32-year period at the Children's Hospital of Palermo, Italy.

METHODS

Data were collected with regard to the clinical, laboratory and demographic characteristics of patients, as well as the results of radiological investigations and data on clinical outcome. In relation to the date of introduction of new diagnostic methods (indirect as well direct) and to the change of treatment periods, the authors compared the clinical outcome of patients admitted prior and after 1984. They also classified the patients into 3 different stages of illness according to the severity of the disease on admission.

RESULTS

We identified 80 patients with CNS-TB. The mean age of the children was 3 years with 54% of patients younger than 5 years. The contact source was documented in 40 patients (50%). The mean duration of symptoms prior to admission was 22 days (range 5 days - 3 months). Mantoux skin test was positive on admission in 50 patients (62%). CSF smear microscopy and culture were positive in 29% and 45% of patients respectively. PCR for Mycobacterium tuberculosis introduced in 1994 was positive in 11 out of 13 tested patients. Determination of CSF gdT lymphocytes composition applied in 7 patients shows a predominance of Vg9/Vd2 T lymphocytes. Fifteen subjects (19%) died; 11 (13%) suffered from permanent sequelae. The died children and those with permanent sequelae were younger than the others (p<0.05). Prior to 1984, none of the patients were identified during early stage of illness and 4 out of 37 patients with stage II illness died. After 1985, 44% of children were in stage I and 2 out of 4 patients with stage III died (p<0.05).

CONCLUSIONS

Stage of disease and young age are still the decisive factors in the clinical outcome of children with CNS-TB. The availability of new advanced methods has improved the identification of patients with CNS-TB in stage I and therefore the possibility of an early treatment of such patients.

Pulmonary tuberculosis in Italian children by age at presentation

AIM

To evaluate the clinical characteristics, diagnostic methods and outcome of paediatric pulmonary tuberculosis (PTB) in relation to children's ages when observed.

METHODS

Children under 15, who had been admitted to the Children's Hospital with PTB were prospectively evaluated. Our sample included patients with a positive tuberculin skin test and signs or symptoms of tuberculosis (TB), including abnormal chest X-rays which suggested PTB. We collected demographic, clinical, radiographic and microbiological data from the patients, in addition to carrying out contact investigations in order to find a source case. All the patients involved in this study were subjected to anti-tuberculosis treatment.

RESULTS

Sixty-two patients (44% under 5) were eligible for inclusion in our study. Children with presenting symptoms were younger than asymptomatic patients (p<0.05). A source case was found in 38 patients out of 62 children (62%) and children under 5 were more likely to have a source case than that found with older children (p<0.05). Ghon complex (infiltrate + adenopathy) tended to occur in young children (median age of 3.25, p<0.05). Fourteen children (23%) had clinical specimens which tested positive for Mycobacterium tuberculosis (MT), and 20 (32%) for MT DNA according to a polymerase chain reaction (PCR). Resistant strains to 1 or more anti-tuberculosis drugs were found in 5 children and in 4 adult sources. The patients with minimal or no radiographic change during therapy displayed symptoms for a longer period of time and were infected by a resistant strain (p<0.05).

CONCLUSION

Improvements in case detection, case management and contact investigations are necessary for controlling paediatric TB, especially in young children. Given that any diagnosis of TB in children is supported by epidemiological and clinical evidence rather than isolating MT, detection of the source case is important in selecting appropriate treatment.

Nematode community response to fish-farm impact in the western Mediterranean

A previous investigation on fish-farm biodeposition effects on benthos, carried out in the Gaeta Gulf (northwestern Mediterranean Sea), revealed a strong impact on meiofaunal assemblages. This study implements these findings by examining in detail the nematode assemblage and its response to organic enrichment from the start of a fish farm activity to the conclusion of the fish rearing cycle. Density, community structure and individual size were utilised for univariate (genus, trophic diversity and abundance patterns) and multivariate analyses (MDS) in order to identify the best descriptors of impact and the response of the nematode assemblages. Nematodes displayed significantly reduced densities, diversity and richness in sediments beneath fish farms. The impact of biodeposition was evident not only from structural community parameters but also in terms of functional indices. Forty-five days after starting fish farming, an increase of the nematode individual biomass was observed. MDS ordination pointed out the presence of two different nematode communities in disturbed sediments and in the control site. These results were substantiated by the analysis of the temporal changes of k-dominance curves, the maturity index and, to a lesser extent, by the index of trophic diversity. Some nematode genera were highly sensitive to biodeposition (Setosabatieria, Latronema and Elzalia) and disappeared almost completely in farm sediments, whereas other genera largely increased their dominance (Sabatieria, Dorylaimopsis and Oxystomina). This study indicates that nematodes are very sensitive to this kind of environmental disturbance. The use of simple tools, such as the k-dominance analysis and maturity index, are recommended for monitoring of aquaculture impact.

Heterotrophic bacteria community and pollution indicators of mussel--farm impact in the Gulf of Gaeta (Tyrrhenian Sea)

Field studies were carried out to determine and compare the impact of organic loads due to the biodeposition of a mussel farm on the water quality and sediment in a coastal area of the Tyrrhenian Sea (Western Mediterranean). A total of five environmental and five microbial parameters were examined from March, 1997 to February, 1998 on a monthly basis at three stations: the first was located under the mussel farm, the second located at about 40 m away from the mussel farm, while the third designed as a control was at about 1-km. No clear changes in the physical characteristics of the water masses were observed, comparing the three sampling sites and the water column generally showed homogeneous conditions (in terms of temperature and salinity). Changes in density of aerobic heterotrophic bacteria, Escherichia coli and Enterococci in the water column are apparently independent from changes in environmental parameters. At all stations a constant significant correlation between temperature and presumptive Vibrio parahaemolyticus was reported suggesting that this abiotic factor exerted a major control on this bacterial group and its distribution in the water column is not related to the biodeposition of the mussel farm. The major impact identified was on the sediment where variations in bacterial abundance was observed. In the Mussel station sediment enrichment of organic compounds, and the consequent modification of the characteristics of the benthic environment, determined an increase in aerobic heterotrophic bacteria, and particularly of vibrios density (on average about 60%), suggesting that these bacteria are good indicators of organic enrichment.

Differential responses of benthic microbes and meiofauna to fish-farm disturbance in coastal sediments

Bacterial and meiofaunal abundance and biomass and their response to the disturbance induced by fish-farm biodeposition were investigated from March to October 1997 on a monthly basis at two stations of the Gaeta Gulf (Tyrrhenian Sea, Mediterranean Sea). The biopolymeric fraction of the organic matter was characterized by high concentrations which was similar at both fish-farming-impacted and control stations. Similarly, bacteria accounted for a small fraction of the biopolymeric organic carbon (< 1%), while the contribution due to auto-fluorescent cell biomass (i.e. prokaryotic and eukaryotic cells displaying auto-fluorescence) to the total biopolymeric carbon was quantitatively negligible (< 0.1%). Benthic bacteria appear to be sensitive to organic enrichment as their abundance increased significantly beneath the cage, whilst numbers of meiofauna was lower than in the control. Changes occurred also in terms of individual nematode biomass that increased as result of the biodeposition. A particularly useful tool appeared to be represented by the ratio of benthic auto-fluorescent cells to bacterial abundance, bacteria to meiofaunal biomass and auto-fluorescent cells to meiofauna biomass. All these parameters described well the impact due to biodeposition on the benthic environment as their ratios displayed significantly higher values in farm sediments, but recovered rapidly (15 days) to values observed in the control (i.e. undisturbed conditions) immediately after cage removal. Changes observed in the present study highlight that the increased organic loading determined a shift of the relative contribution of the different benthic components to the total biopolymeric carbon, so that in highly impacted systems total benthic biomass becomes increasingly dominated by microbial components.

Early activation of gammadelta T lymphocytes in the elderly

T cell function is altered in vivo and in vitro in elderly compared with young subjects, and this alteration is believed to contribute to morbidity and mortality in man due to the greater incidence of infection, as well as autoimmunity and cancer in elderly. The majority of T cells express TCRalphabeta whereas TCRgammadelta is expressed on a minority of T cells. Moreover, it is known that gammadelta T lymphocytes display major histocompatibility complex (MHC)- unrestricted cytotoxicity that is reminiscent of natural killer (NK) activity. In view of earlier findings on both T cells and NK cells in the elderly, we hypothesised a different behaviour of gammadelta T lymphocytes from old subjects when compared with gammadelta T lymphocytes obtained from young people. Therefore, to gain further insight into mechanisms of immunosenescence in this little-studied population, we studied immunofluorescence analysis gammadelta T cells from the elderly. Our preliminary results show that the percentage of blood gammadelta T cells in lymphocytes from old subjects is decreased when compared with the young. Interestingly, these cells are more activated in the elderly than in young subjects; expression of CD69, an early activation marker, is increased in gammadelta T lymphocytes from old subjects after three hours of in vitro culture both with and without lipopolysaccharide stimulation. Thus, our findings, which need confirmation, strongly suggest that, in humans, gammadelta T cells are early responders when compared with alphabeta T cells. They may act as 'first aid' cells to replace the described deficit of the specific and aspecific immunity in elderly. In this view, the proinflammatory status, observable in the elderly, renders them ready to be stimulated by exogenous agents.

Usefulness of transesophageal echocardiography in the assessment of aortic dissection

The acute dissection of the ascending aorta requires prompt and reliable diagnosis to reduce the high risk of mortality; in addition, prognosis is influenced by long-term complications. The aim of this article is to discuss transesophageal echocardiography (TEE) and (1) its diagnostic accuracy in the presurgical evaluation of patients, (2) its role in reducing time of diagnosis and surgery, and (3) its ability to reduce hospital mortality. TEE has also been tested as a screening method in the postsurgical follow-up of these patients. The retrospective investigation concerns a sample of 80 cases of acute dissection of the aorta, submitted for surgical intervention from April 1986 to February 1999. TEE has allowed a precise estimation of aortic diameters and optimal visualization of intimal flap and tear entry with a fine distinction between true and false lumen. A direct comparison of the results of TEE and of transthoracic echocardiography has demonstrated that some elements (visualization of flap and diameters in descending aorta, sites of entry and reentry, direction of jet trough intimal tears, phasic intimal flap movement, diastolic collapse of flap on the valvular plane, false lumen thrombosis, coronary involvement, intramural hematoma, and aortic fissuration) were identified only by TEE, whereas other additional diagnostic elements (cardiac tamponade, aortic valve insufficiency, left ventricular function) show a similar pattern of significance. Routine employment of this method has confirmed a reduction of hospitalization time (about 1.5 hours of waiting time), and hospital mortality has changed from 42.8% to 17.3%. In the follow-up of patients operated on for aortic dissection, fundamental information may be obtained from TEE (assessment of the progression of thrombosis in the false lumen with its complete obliteration and modifications in aortic diameter with a consequent, possible worsening of aortic valve insufficiency). In conclusion, our study demonstrated that TEE may provide fast and efficient detection of acute aortic dissection. In the postsurgical follow-up, TEE has confirmed detection of major complications that can influence long-term prognosis and may be proposed as a method with easy access-one that is repeatable and inexpensive for the screening of aortic dissection surgical patients.

A probabilistic methodology for the assessment of safety from dropped loads in offshore engineering

Pipeline damage by dropped objects from crane activities is a significant hazard for offshore platform installations. In this paper a probabilistic methodology is utilized for the estimation of the pipeline impact and rupture frequencies; this information is obtained both for the overall pipeline section exposed to the hazard and for a number of critical locations along the pipeline route. The presented algorithm has been implemented in a computer program that allows the analysis of a large number of possible drop points and pipeline target point locations. This methodology may be used in common risk analysis studies for evaluating the risk for platform personnel from dropped objects; however, the proposed technique may also be useful for other applications where engineering judgment has so far been the main driving criterion. In particular, two sample cases have been analyzed. The first one is the problem of selecting the best approaching route to a platform. By analyzing different route alternatives, a reduction of the impact frequency and therefore of the risk for the platform personnel may be achieved. The second application deals with the selection of the location for a safety valve at the riser base. The analysis may give useful information, such as the highest impact frequency location and the rupture frequencies upstream and downstream of the valve as a function of the valve position; this information, together with the transported medium inventory upstream of the valve, may give the designer a documented and justifiable rationale for selecting the best location for the valve from a safety point of view.

Transmission of hepatitis C virus: a study of the main risk factors in a Sicilian population of volunteer blood donors

BACKGROUND/AIMS

The Hepatitis C virus (HCV) is quite widespread in Sicily, and in the absence of a vaccine, prophylaxis is important. In order to determine the most effective means of prophylaxis, we must first understand the main vectors of transmission.

METHODOLOGY

We performed a case control study on 274 consecutive anti-HCV virus positive subjects and compared them with 548 anti-HCV negative subjects, matched for sex and age and selected from voluntary blood donors. The modes of transmission were investigated by means of a detailed questionnaire focused on the common risk factors of HCV contagion.

RESULTS

Univariate analysis showed associations between HCV infection and transfusions (OR 23.0), surgery (OR 2.2), family history of chronic liver disease (OR 4.54), and drug addiction (OR 5.74). Multiple logistic regression indicated that transfusions (p < 0.0001), surgery (p < 0.002), family history (p < 0.0001), drug addiction (p < 0.002) and alcohol consumption (p < 0.002) are related to the development of HCV infection.

CONCLUSIONS

The modes of transmission of HCV in an endemic area of Sicily do not greatly differ from those in other Italian regions; the subjects at greatest risk were those who had received blood transfusions or underwent surgery, alcoholics, drug abusers and those with a family history of chronic liver disease, who are probably more exposed to contracting the infection by non-conventional ways of transmission.

Left ventricular aneurysm secondary to Behçet's disease

A 16-year-old boy with Behçet's disease who was seen with thrombophlebitis of the leg was found to have coronary artery occlusion with postinfarction left ventricular aneurysm. Recurrent femoral artery aneurysms and orogenital ulceration developed in him. The diagnostic features together with successful treatment of this patient and a discussion of Behçet's syndrome are presented.

Central shunt and pulmonary valvotomy in the treatment of critical pulmonary stenosis

Pulmonary valvotomy combined with a central shunt ("U shaped" Gore-tex graft) for palliative treatment of critical pulmonary stenosis is reported. The same graft was employed for right ventricular outflow reconstruction at the time of the definitive repair.

Anomalous origin of right pulmonary artery from the ascending aorta

Anomalous origin of one pulmonary artery from the ascending aorta without associated intracardiac defects is a rare congenital malformation. About 60 anatomic and surgical descriptions have been reported in the literature. Up to 1974, 22 of the 50 reported cases underwent surgical correction with a 40% mortality rate. The natural history without surgery is poor with a very high mortality during the first year of life. Successful anatomic correction of anomalous origin of right pulmonary artery from the ascending aorta in a 6 months old female is reported.

Giant left atrium and mitral valve replacement: risk factor analysis

Giant left atrium (GLA) associated with mitral valve disease (MVD) has been reported as a significant risk factor in mitral valve surgery with mortality ranging from 8%-32%. Plication of the left atrium has been suggested to reduce postoperative left ventricular failure, respiratory failure and mortality. The 203 consecutive patients with MVD operated upon between 1980 and 1986 were reviewed and divided in two groups: group A without GLA (165 patients) and group B with GLA (38 patients = 19%). The pertinent preoperative and intraoperative notes and the early and late postoperative course were reviewed and correlated. The hospital mortality was 2.4% in group A and 2.6% in group B. Late mortality, at a mean follow-up of 54 months was 4.3% in group A and 5.4% in group B. In this series, GLA was not a significant risk factor in MVR and did not affect early and late results as compared with cases without GLA. Plication may not be required in absence of extracardiac signs of compression.