Clinical outcomes of left ventricular unloading with microaxial flow pump Impella during venoarterial extracorporeal membrane oxygenation (VA-ECMO): a systematic review and updated meta-analysis

Background

Whether the addition of percutaneous microaxial flow pump Impella to venoarterial extracorporeal membrane oxygenation (VA-ECMO) as left ventricle unloading strategy is effective in improving outcomes compared to VA-ECMO alone is still to be proved.

Purpose

Aim of this systematic review and meta-analysis was to assess whether patients with refractory cardiogenic shock treated with IMPELLA in addition to VA-ECMO (ECMELLA) versus ECMO alone may benefit a reduction in early mortality and to assess whether this strategy may result in an increased rate of complications.

Methods

For this systematic review and meta-analysis, from Dec 2021 to Jan 2022, we searched Scopus, MEDLINE (with PubMed interface) and the Cochrane Central Register of Controlled Trials for randomised controlled trials and observational studies published in any language comparing the use of ECMELLA versus ECMO alone in patients with acute refractory CS (with or without cardiac arrest). Two independent investigators screened titles and abstracts for eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% CIs were calculated with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Primary efficacy endpoint was trial-defined early mortality (in hospital or 30-day mortality). Safety endpoints were major bleeding, the need for renal replacement therapy, hemolysis, severe infections/sepsis and limb ischemia. This study is registered with PROSPERO (CRD42022292517).

Results

2061 potentially relevant articles were screened. Our analysis included six retrospective studies with data for 1457 patients. Compared with ECMO alone, ECMELLA was associated with a non-significant reduction in early mortality (RR 0.87, 95% CI 0.72–1.06, p=0.17; Figure 1) and in a significant increase of major bleeding (RR 1.45, 95% CI 1.10–1.91, p=0.009), need for renal replacement therapy (RR 1.70, 95% CI 1.16–2.48, p=0.0008), hemolysis (RR 2.22, 95% CI 1.39–3.56, p=0.005) and limb ischemia (RR 1.61, 95% CI 1.20–2.16, p=0.001). No significant differences were observed in the incidence of severe infections/sepsis between the two groups (RR 1.23, 95% CI 0.97–1.58, p=0.09). (Figure 2)

Conclusions

The results of this meta-analysis showed that ECMELLA compared to ECMO alone did not significantly reduce early mortality and that, conversely, it resulted in a significantly increased risk of several complication (major bleeding, hemolysis, limb ischemia and renal replacement therapy). This study highlights that, if the benefit of left ventricle unloading with Impella during ECMO in CS shock is uncertain and probably limited to only selected patients, it surely increases the risk of some complications, therefore caution is needed in choosing such a strategy.

Funding Acknowledgement

Type of funding sources: None.

Bayesian Modeling of Sequential Discoveries

We aim at modeling the appearance of distinct tags in a sequence of labeled objects. Common examples of this type of data include words in a corpus or distinct species in a sample. These sequential discoveries are often summarized via accumulation curves, which count the number of distinct entities observed in an increasingly large set of objects. We propose a novel Bayesian method for species sampling modeling by directly specifying the probability of a new discovery, therefore, allowing for flexible specifications. The asymptotic behavior and finite sample properties of such an approach are extensively studied. Interestingly, our enlarged class of sequential processes includes highly tractable special cases. We present a subclass of models characterized by appealing theoretical and computational properties, including one that shares the same discovery probability with the Dirichlet process. Moreover, due to strong connections with logistic regression models, the latter subclass can naturally account for covariates. We finally test our proposal on both synthetic and real data, with special emphasis on a large fungal biodiversity study in Finland. Supplementary materials for this article are available online.

Vitamin D deficiency as a predictor of poor prognosis in patients with acute respiratory failure due to COVID-19

PURPOSE

Hypovitaminosis D is a highly spread condition correlated with increased risk of respiratory tract infections. Nowadays, the world is in the grip of the Coronavirus disease 19 (COVID 19) pandemic. In these patients, cytokine storm is associated with disease severity. In consideration of the role of vitamin D in the immune system, aim of this study was to analyse vitamin D levels in patients with acute respiratory failure due to COVID-19 and to assess any correlations with disease severity and prognosis.

METHODS

In this retrospective, observational study, we analysed demographic, clinical and laboratory data of 42 patients with acute respiratory failure due to COVID-19, treated in Respiratory Intermediate Care Unit (RICU) of the Policlinic of Bari from March, 11 to April 30, 2020.

RESULTS

Eighty one percent of patients had hypovitaminosis D. Based on vitamin D levels, the population was stratified into four groups: no hypovitaminosis D, insufficiency, moderate deficiency, and severe deficiency. No differences regarding demographic and clinical characteristics were found. A survival analysis highlighted that, after 10 days of hospitalization, severe vitamin D deficiency patients had a 50% mortality probability, while those with vitamin D ≥ 10 ng/mL had a 5% mortality risk (p = 0.019).

CONCLUSIONS

High prevalence of hypovitaminosis D was found in COVID-19 patients with acute respiratory failure, treated in a RICU. Patients with severe vitamin D deficiency had a significantly higher mortality risk. Severe vitamin D deficiency may be a marker of poor prognosis in these patients, suggesting that adjunctive treatment might improve disease outcomes.

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

BACKGROUND

Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP.

METHODS

Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months.

RESULTS

A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19-1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group.

CONCLUSIONS

Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP.

P6507ST2L and sST2: relationship in the carotid plaque - a study on 76 cases underwent endarterectomy

Background

ST2 receptor (suppression of tumorigenity) has been described as receptor for the interleukin 33 (IL-33), a member of the IL-1 family of cytokines. This receptor is associated in various way to coronary artery disease, all-causes mortality and cardiovascular mortality. It's role in the pathogenesis of atherosclerosis is not well-defined yet.

Purpose

The present study was designed to assess the relationship between serum level of sST2, a decoy receptor, and immunohistochemicalespression of ST2L in atherosclerotic plaques of formalin fixed paraffin-embedded internal carotid arteries of patients underwent endarterectomy, accepted the predictive value of ST2 in atherosclerosis.

Methods

The study involved 76 cases (31 symptomatic= 41%, 45 asymptomatic= 59%), age range from 47 to 86 years old, underwent endarterectomy for the treatment of internal carotid stenosis in our vascular surgery of polyclinic, all procedures performed by the same physician. Patients were divided into three groups, depending on the presence of ST2Ltransmembrane receptor on the carotid plaque after immunoistochemical evaluation (group low presence of ST2L= 0–1+; moderate presence of ST2= 2+; high presence of ST2= 3+). Serum level of sST2 were defined through the use of an ELISA-kit, specific for ST2 and ready-to-use.

Results

There was a relationship between ST2L and sST2 values: if considering sST2 mean and median value referring to specific subgroup (low, moderate and high), this is lower if the group (i.e. ST2L presence on the atherosclerotic plaque) is higher, and vice-versa. This shows an inverse relationship between this two parameters. Moreover, using Pearson correlation coefficient, all the three sub-group show a strong correlation to the leukocytes value (low=0.658, moderate= 0.434, high= 0.358).

Conclusions

The ST2L immunohistochemical expression was for the first time investigated in a large number of human carotid atherosclerotic plaques. The inverse relationship between ST2L and sST2 supports the pathogenetic hypothesis that ST2L/IL33 axis could drive the mechanism of plaque development and eventually rupture. Correlation with leukocytes provides a further strong evidence confirming inflammatory pathogenesis of atherosclerosis, but most of all leukocytes' high value could be associated to a greater plaque instability.

Acknowledgement/Funding

None

Solitary Plasmacytoma of Bone and Extramedullary Plasmacytoma: Two Different Nosological Entities?

Background

The relationship between solitary plasmacytoma and multiple myeloma is still unclear, but they can be distinguished by their different clinical course. Indicators of disease activity and extension, and of a possible evolution to multiple myeloma, have not been identified as yet.

Methods

Two cases of solitary plasmacytoma are described: one of the mandible and one extramedullary plasmacytoma (EMP) of the rhinopharynx. Pathologic data included immunohistochemical staining for heavy and light Ig chains, and for the proliferating cell nuclear antigen (PCNA). Analysis of the peripheral immunological status and serum parameters ( β2 microglobulin, thymidine kinase, IL-2, IL-6 and soluble IL-2 receptor) was performed and correlation was made with the clinical status. Flow cytometry analysis of nuclear DNA content and S-phase cell fraction were also studied in both neoplasms.

Results

Solitary plasmacytoma of bone (SPB) showed important basal immunologic alterations and a marked increase in all serum parameters considered with respect to EMP. Ploidy analysis demonstrated an almost complete aneuploidy cell population for the SPB patient (80%), whereas in the EMP patient only 2% of the cells were aneuploid. The S-phase ceils were 16% and 4%, respectively. PCNA index was 60% in SPB and 10% in EMP.

Conclusions

Solitary plasmacytoma of the bone appeared to be a more aggressive form of plasmacellular neoplasia, distinct from EMP and similar to multiple myeloma. The study of serum parameters, together with analysis of PCNA, ploidy and S-phase fraction, can aid in better understanding disease activity, and in the choice of more adequate treatment. Moreover, serial analysis of some serum factors might be useful markers for monitoring the disease.

Idiopathic sudden sensorineural hearing loss and ménière syndrome: The role of cerebral venous drainage

OBJECTIVES

To evaluate the influence of cerebral venous drainage on the pathogenesis of idiopathic sudden sensorineural hearing loss (ISSHL) and Ménière syndrome (MD).

DESIGN

Observational, prospective, cohort study.

SETTING

ENT and Cardiology Departments (University of Bari, Policlinico Hospital, Bari, Italy).

PARTICIPANTS

We enrolled 59 consecutive patients (32 males, mean age 53.05 + 15.37 years): 40 ISSHL and 19 MD.

MAIN OUTCOME MEASURE

All patients underwent physical examination, biochemical evaluation (glycemic and lipid profile, viral serology, C reactive protein, etc), audiometric (tonal, vocal, vestibular evoked myogenic potentials and auditory brainstem response test) and impedentiometric examination. The pure tone average (PTA) was calculated for the following frequencies: 250, 500, 1000, 2000, 3000, 4000, 8000. An echo-color Doppler evaluation of the venous cerebral veins, internal jugular (IJV) and vertebral veins (VV) at supine and 90° position was performed.

RESULTS

No morphological alterations were found both in patients and controls. There were no signs of stenosis, blocked flow, membranes, etc. We found lower minimum, mean and maximum velocities in distal IJVs (P = .019; P = .013; P = .022; respectively) and left VVs (P = .027; P = .008; P = .001; respectively) in supine (0°) position in both MD and ISSHL patients as compared to controls. The same was for orthostatic position (90°). We found negative correlations between the velocities in extracranial veins and PTA values: therefore, the worst the audiometric performance of the subjects, the lower the velocities in the venous cerebral drainage.

CONCLUSIONS

Idiopathic sudden sensorineural hearing loss and Ménière syndrome patients showed altered venous flow in IJVs and VVs as compared to controls, independently from posture. This different behavior of venous tone control can influence the ear performance and may have a role in the pathogenesis of both diseases.

BAFF Index and CXCL13 levels in the cerebrospinal fluid associate respectively with intrathecal IgG synthesis and cortical atrophy in multiple sclerosis at clinical onset

BACKGROUND

B lymphocytes are thought to play a relevant role in multiple sclerosis (MS) pathology. The in vivo analysis of intrathecally produced B cell-related cytokines may help to clarify the mechanisms of B cell recruitment and immunoglobulin production within the central nervous system (CNS) in MS.

METHODS

Paired cerebrospinal fluid (CSF) and serum specimens from 40 clinically isolated syndrome suggestive of MS or early-onset relapsing-remitting MS patients (CIS/eRRMS) and 17 healthy controls (HC) were analyzed for the intrathecal synthesis of IgG (quantitative formulae and IgG oligoclonal bands, IgGOB), CXCL13, BAFF, and IL-21. 3D-FLAIR, 3D-DIR, and 3D-T1 MRI sequences were applied to evaluate white matter (WM) and gray matter (GM) lesions and global cortical thickness (gCTh).

RESULTS

Compared to HC, CIS/eRRMS having IgGOB (IgGOB+, 26 patients) had higher intrathecal IgG indexes (p < 0.01), lower values of BAFF Index (11.9 ± 6.1 vs 17.5 ± 5.2, p < 0.01), and higher CSF CXCL13 levels (27.7 ± 33.5 vs 0.9 ± 1.5, p < 0.005). In these patients, BAFF Index but not CSF CXCL13 levels inversely correlated with the intrathecal IgG synthesis (r > 0.5 and p < 0.05 for all correlations). CSF leukocyte counts were significantly higher in IgGOB+ compared to IgGOB- (p < 0.05) and HC (p < 0.01), and correlated to CSF CXCL13 concentrations (r 0.77, p < 0.001). The gCTh was significantly lower in patients with higher CSF CXCL13 levels (2.41 ± 0.1 vs 2.49 ± 0.1 mm, p < 0.05), while no difference in MRI parameters of WM and GM pathology was observed between IgGOB+ and IgGOB-.

CONCLUSIONS

The intrathecal IgG synthesis inversely correlated with BAFF Index and showed no correlation with CSF CXCL13. These findings seem to indicate that intrathecally synthesized IgG are produced by long-term PCs that have entered the CNS from the peripheral blood, rather than produced by PCs developed in the meningeal follicle-like structures (FLS). In this study, CXCL13 identifies a subgroup of MS patients characterized by higher leukocyte counts in the CSF and early evidence of cortical thinning, further suggesting a role for this chemokine as a possible marker of disease severity.

Complement Modulation of Anti-Aging Factor Klotho in Ischemia/Reperfusion Injury and Delayed Graft Function

Klotho is an anti-aging factor mainly produced by renal tubular epithelial cells (TEC) with pleiotropic functions. Klotho is down-regulated in acute kidney injury in native kidney; however, the modulation of Klotho in kidney transplantation has not been investigated. In a swine model of ischemia/reperfusion injury (IRI), we observed a remarkable reduction of renal Klotho by 24 h from IRI. Complement inhibition by C1-inhibitor preserved Klotho expression in vivo by abrogating nuclear factor kappa B (NF-kB) signaling. In accordance, complement anaphylotoxin C5a led to a significant down-regulation of Klotho in TEC in vitro that was NF-kB mediated. Analysis of Klotho in kidneys from cadaveric donors demonstrated a significant expression of Klotho in pre-implantation biopsies; however, patients affected by delayed graft function (DGF) showed a profound down-regulation of Klotho compared with patients with early graft function. Quantification of serum Klotho after 2 years from transplantation demonstrated significant lower levels in DGF patients. Our data demonstrated that complement might be pivotal in the down-regulation of Klotho in IRI leading to a permanent deficiency after years from transplantation. Considering the anti-senescence and anti-fibrotic effects of Klotho at renal levels, we hypothesize that this acquired deficiency of Klotho might contribute to DGF-associated chronic allograft dysfunction.

P2-05-03: Is Breast Cancer Tryptase a Novel Anti-Angiogenetic Molecular Target?

Tryptase, a serine protease stored and released from mast cells granules has been identified as a new non-classical angiogenetic factor. Tryptase is an agonist of proteinase-activated receptor-2 a G protein involved in cellular proliferation and angiogenesis. On the other hand mast cells can release tryptase following c-Kit receptor activation. We have evaluated the correlations among the number of MCs positive to tryptase (MCDPT), the number of c-Kit receptor expressing cells (C-KREC) and microvascular density (MVD) in a series of 91 primary T1-3, N0-2 M0 female breast cancer by means of immunohistochemistry and image analysis methods. Six-micrometers thick serial sections of formalin-fixed and paraffin-embedded bioptic tumor samples were microwaved at 500 W for 10 min. and treated with a 3% hydrogen peroxide solution. Sections were incubated with primary antibodies: anti-tryptase (AA1; Dako, Glostrup, Denmark), anti-c-Kit receptor (A4502; Dako, Glostrup, Denmark) and anti-CD34 (QB-END 10; Bio-Optica Milan, Italy). In serial sections MVD, MCDPT and C-KREC were counted by means of image analysis (Quantimet 500 Leica) at x400 microscopic fields. Data demonstrated a significantly (r= ranging from 0.72 to 0.91; p: ranging from 0.001 to 0.003 by Pearson's analysis respectively) correlation between MVD, MCDPT and C-KREC to each other. Published in vitro data suggest that tryptase induce angiogenesis in vascular endothelial cells and breast cancer cells lines. According to these data we shown that MVD, MCDPT and C-KREC paralleled to each other suggesting a role in in vivo breast cancer angiogenesis. In this context the inhibition of c-Kit mast cells tryptase degranulation by several tyrosin kinase inhibitors might be evaluated in clinical trials. Finally available tryptase inhibitors such as gabexate mesilate or nafamostat mesilate might be evaluated in clinical trials as a new antiangiogenetic approach.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-05-03.

Four proteins governing overangiogenic endothelial cell phenotype in patients with multiple myeloma are plausible therapeutic targets

Bone marrow (BM) angiogenesis has an important role in the initiation and progression of multiple myeloma (MM). We looked at novel mechanisms of vessel formation in patients with MM through a comparative proteomic analysis between BM endothelial cells (ECs) of patients with active MM (MMECs) and ECs of patients with monoclonal gammopathy of undetermined significance (MGECs) and of subjects with benign anemia (normal ECs). Four proteins were found overexpressed in MMECs: filamin A, vimentin, α-crystallin B and 14-3-3ζ/δ protein, not yet linked to overangiogenic phenotype. These proteins gave a typical distribution in the BM of MM patients and in MMECs versus MGECs, plausibly according to a different functional state. Their expression was enhanced by vascular endothelial growth factor, fibroblast growth factor 2, hepatocyte growth factor and MM plasma cell conditioned medium in step with enhancement of MMEC angiogenesis. Their silencing RNA knockdown affected critical MMEC angiogenesis-related functions, such as spreading, migration and tubular morphogenesis. A gradual stabilization of 14-3-3ζ/δ protein was observed, with transition from normal ECs to MGECs and MMECs that may be a critical step for the angiogenic switch in MMECs and maintenance of the cell overangiogenic phenotype. These proteins were substantially impacted by anti-MM drugs, such as bortezomib, lenalidomide and panobinostat. Results suggest that these four proteins could be new targets for the antiangiogenic management of MM patients.

Electrochemoterapy (ECT) for the treatment of superficial tumor localizations

e13526

Background: ECT is an effective local treatment for palliation on inoperable superficial neoplastic lesions from any type of tumour. It combines chemotherapy and electric pulses that permeabilize the cell membrane in a transient and reversible manner, allowing low-perrneant drugs to enter the cell, thus magnifying their cytotoxicity. Recent1y, a new device (Clinoporetor, IGEA-Srl, Italy) has been developed to supply electric pulses with appropriate parameters permitting the clinical use of ECT. Methods: We treated 26 pts, M/F 12/14; median age 61 yrs, range 38–87: 7 breast cancer with nodular or infiltrating lesions in thoracic or abdominal wall; 12 melanoma (2 wide infiltration of thoracic wall, 10 in transit metastases or loco-regional recurrences); 2 head-neck cancer with a wide neck-scalp infiltration; 3 lymphomas with cutaneous lesions, 1 soft tissue sarcoma with a subcutaneous recurrence, 1 gastric cancer with 2 cutaneous localizations. The areas treated ranged from 1 to 30 cm on diameter. 12 pts requested a prior surgery debulking and 3 pts received ECT in pre-irradiated area. Intravenous bleomycin (15 mg/m2) were used in all patient; electric pulses were than applied to the tumor areas by needle electrodes in a time window of 20 minutes. In total 32 procedures were performed, 6 as out-patient in local anaesthesia and 26 in general anaesthesia; 6 pts requested a second application. Results: Treatment was safe and well tolerated, particularly when general anaesthesia was used. At the second/third week, all pts showed a regression of almost all lesions with a necrotic, fibro-sclerotic evolution. After 1–2 months from ECT, we obtained a 70% CR and a 10%PR of the lesions. Some pts showed a response after the second procedure. About 50% of lesions remained in remission for a long period (median 8 months, range 1–23+); 11 of 12 pts previously undergone surgical debulking never relapsed in the treated area. Concomitant systemic treatment, no rapid spreading of the disease and surgical debulking were related to a better local control and survival. Conclusions: ECT is a promising and safe treatment for superficial lesions from different malignancies. General anaesthesia and surgical debulking permit to treat very large and deeper lesion with a very good local control.

No significant financial relationships to disclose.

Reticulocytes in untreated obstructive sleep apnoea

BACKGROUND AND AIM

The short, repetitive hypoxaemic episodes observed in obstructive sleep apnoea (OSA) may determine small augmentations in mature red blood cells. It is unknown whether they affect reticulocyte release. This study explored whether the number and degree of maturation of circulating reticulocytes may be altered in OSA, possibly through the effect of erythropoietin.

METHODS

Fifty male adult patients with suspected OSA, normoxic during wakefulness, were studied. After nocturnal polysomnography, a blood sample was withdrawn for blood cells count, erythropoietin, iron and transferrin determination. Reticulocyte concentration and degree of immaturity [high (H), medium (M), or low (L)] were also determined. Immature reticulocyte fraction (IRF) was calculated as (M+H) percentage of reticulocytes.

RESULTS

A wide range of OSA severity was found [apnoea/hypopnoea index (AHI): 44.3 +/- 30.4, range 0.3-105; sleep time spent at oxyhaemoglobin saturation <90%: 18.1 +/- 22.2%, range 0-81%]. Both reticulocyte count and IRF slightly exceeded the normal range. Patients with a reticulocyte concentration > 2% had higher EPO levels (p < 0.05), but not worse nocturnal desaturations, than those with values < 2%. By contrast, subjects with IRF < 15% showed worse desaturations (p < 0.05), but similar EPO concentrations, when compared to subjects whose IRF was < 10%. At univariate analysis, reticulocyte count correlated to erythropoietin, while IRF to transferrin saturation, BMI and OSA severity. At multiple regression, only lowest nocturnal oxygen saturation remained a significant contributor to IRF (r2 0.223, p < 0.05).

CONCLUSIONS

This data suggests that hypoxaemia due to OSA could influence the release of immature reticulocytes, but this effect is not mediated by erythropoietin.

Biomarkers predictive for clinical efficacy of taxol-based chemotherapy in advanced breast cancer

BACKGROUND

Several studies looked for tumor biomarkers predictive for paclitaxel sensitivity but till now no reliable biomarkers are available. The aim of this study was to verify the potential predictive value of beta-tubulin III and IV, vascular endothelial growth factor-receptor (VEGFR-1), HER2/neu and microvessel density (mVD), in a group of 70 patients with advanced breast cancer (ABC) treated with paclitaxel-based chemotherapy.

PATIENTS AND METHODS

Immunohistochemical analysis (ICA) of HER2, VEGFR-1, mVd, beta-tubulin III and beta-tubulin IV expression were performed in a series of 72 advanced breast cancer. Furthermore apoptotic fraction with TUNEL analysis was evaluated.

RESULTS

beta-tubulin III ICA expression was predictive of progression after chemotherapy. In fact only 2% of the patients with low beta-tubulin III expression progressed after paclitaxel chemotherapy vs 38% of those with high beta-tubulin III tumor expression (P=0.000; by chi(2)). This evidence was confirmed by a logistic regression analysis (OR 28.789; 95% CI 3.212-258,072; P=0.004). There was not a significant association between other biomarkers' characteristics and clinical response to chemotherapy. A Cox multivariate analysis, with overall survival as a dependent variable, showed that only HER2 expression was independently associated (OR 2.39; 95% CI 1.09-5.23; P=0.03) with overall survival.

CONCLUSIONS

We suggest that class III beta-tubulin immunohistochemical expression analysis could be a potentially relevant tumor biomarker for paclitaxel resistance in advanced breast cancer patients.

Collateral circulation in internal carotid artery occlusion. A study by duplex scan and magnetic resonance angiography

BACKGROUND

Clinical effects of internal carotid artery (ICA) occlusion may range from the absolute absence of symptoms to lethal hemispheric stroke. In this paper symptoms of patients with ICA occlusion have been related to the development of collateral circulation, different types of developed collateral circulation have been assessed, and the degree of sensitivity and specificity of duplex scan has been appraised.

METHODS

Forty-eight patients with ICA occlusion or subocclusion, 24 males and 24 females, aged between 50 and 83 years (67.7+/-7.15), underwent duplex scan and magnetic resonance (MR) angiography. Nineteen patients were completely asymptomatic, 20 patients showed permanent neurological symptoms and 9 patients had shown transient symptoms.

RESULTS

Twelve patients (25%) did not show any collateral circulation, 29 patients (60%) showed collateral circulation through homolateral external carotid artery branches and 7 patients (15%) showed collateral circulation through other circuits. Of the 20 patients with permanent symptoms only 8 showed collateral circulation. On the contrary, all the 19 asymptomatic patients and the 9 patients with transient symptoms showed collateral circulation. Eventually, duplex scan showed 78% sensitivity, 100%, specificity and 83% diagnostic accuracy.

CONCLUSIONS

Our data show: 1) a clear-cut prevalence of collateral circulation through homolateral external carotid artery branches with respect to other possible collateral circulation; 2) an inverse relationship between the development of collateral circulation and the appearance of permanent symptoms; 3) a good diagnostic accuracy of duplex scan in revealing collateral circulation in the case of ICA occlusion.

A comparison between the heart of young athletes and of young healthy sedentary subjects: a morphometric and morpho-functional study by echo-color-doppler method

Morphologic and morpho-functional heart differences between healthy young athletes and healthy young subjects who do not practice agonistic sport have been studied using Color Doppler Echography (CDE). Overall, 68 subjects were enrolled in the study (age range: 19-26 yrs). Of them, 34 subjects (17 men and 17 women) were practicing sport agonistically; the 34 controls (17 men and 17 women) did not practice any sport on a regular basis. In each subject, age, height, weight, body mass index, practiced sport, systolic and diastolic blood pressure were recorded. CDE measures included telediastolic left and right ventricular diameters (LVDd and RVDd, respectively), interventricular septum thickness (IVSd), posterior wall thickness of the left ventricle (PLVWd), left and right atrium diameters during ventricular systole (LAD and RAD respectively), and continence of each heart valve (mitral; tricuspid; aortic; pulmonic). In women, LADd was significantly higher in the athletes than in the controls (35.04+/-4.13 vs 31.81+/-3.34; p<0.02). Physiological regurgitation in at least one heart valve was observed in 15 out of 17 (88.2%) of the athletes; in 12 cases only one valve was involved: the mitral valve presented physiological regurgitation in 8 women, the tricuspid in 4, the aortic in 2 and the pulmonic in 6. In the control female population (17 persons), only 2 women showed evidence of regurgitation. In men, except for RVDd, CDE measurements were all significantly higher in the athletes than in the controls: LVDd (49.4+/-3.13 vs 46.02+/-4.46; p<0.02); IVSd (9.79+/-1.24 vs 8.59+/-0.91; p<0.003); PLVWd (8.63+/-1.29 vs 7.48+/-0.66; p<0.002). Physiological regurgitation through one or more heart valves was demonstrated in all the 17 male athletes studied; in 9 cases (52.9%) only one valve was involved. Mitral regurgitation was ob- served in 8 cases (47%); tricuspid in 6 (35.3%). No physiological regurgitation through the aortic valve was found, while 15 cases (88.2%) presented a pulmonic regurgitation. Among male controls, physiological regurgitation was demonstrated only in 2 persons out of 17 (11.8%), both involving the pulmonic and the aortic valve. In the total population of athletes compared to controls, analyzing men and women jointly, we found that LAD (p<0.001),RAD (p<0.001), LIVD (p<0.01) were significantly larger in cases than in controls, while for RVD, IVSd and PLVWd such a difference did not reach statistical significance. No relationship was fouhd between CDE data and either age, height, weight or blood pressure.

[Mandibular metastases from rectal adenocarcinoma: clinical case report and review of the literature]

A case is described of a 57-year-old woman with jaw metastasis from rectal adenocarcinoma who underwent colectomy and ovariectomy for moderately differentiated adenocarcinoma of the large intestine and peritoneal carcinosis. This patient subsequently underwent several cycles of chemoantiblastic therapy although, approximately six months after the initial surgery, a tumefaction of the gingival mucosa was found in the lower right premolar area. Radiography showed this neoformation to be an area of mandibular osteolysis. A biopsy, performed at the E.N.T Clinic of the IRCCS Oncological Hospital in Bari, Italy, revealed a metastatic lesion from rectal adenocarcinoma. This led to radiation therapy vs. the external fascia of the mandibular lesion. Then, given that further cerebral and hepatic metastases were found, palliative treatment was administered until the patient's death in June 2000. A review of the international literature shows how unusual it is to find secondary metastases from rectal adenocarcinoma in the mandibular region (only 23 cases have been published in the last forty years). For nearly all the authors examined, the treatment of choice for such lesions was radiation therapy associated with chemoantiblastic therapy. Despite such treatment, the literature bears significant agreement as to the poor, short-term prognosis.

Slow wave sleep dreaming

Fifty volunteers slept two nonconsecutive nights in a sleep laboratory under electropolygraphic control. They were awakened for one report per night. Awakenings were made, in counterbalanced order, from slow wave sleep (SWS--stage 3-4 and stage 4) and rapid eye movement (REM) sleep. Following dream reporting, subjects were asked to identify memory sources of their dream imagery. Two independent judges reliably rated mentation reports for temporal units and for several content and structural dimensions. The same judges also categorized memory sources as autobiographical episodes, abstract self-references, or semantic knowledge. We found that REM reports were significantly longer than SWS reports. Minor content SWS-REM differences were also detected. Moreover, semantic knowledge was more frequently mentioned as a dream source for REM than for SWS dream reports. These findings are interpreted as supporting the hypothesis that dreaming is a continuous process that is not unique to REM sleep. Different levels of engagement of the cognitive system are responsible for the few SWS-REM differences that have been detected.

Granulocyte function in coronary artery disease

Granulocytes defend the body against invading microbes by producing a complex armamentarium of toxic substances, such as proteolytic enzymes, oxygen radicals and arachidonic acid metabolites. Under certain circumstances, however, such compounds may be released in the absence of phagocytosable particles, resulting in injury to normal cell and connective tissue degradation. Recent experimental studies have emphasized the potential role of granulocytes in the pathogenesis of myocardial ischemia. Clinical investigations have also shown alterations in neutrophil function in stable and unstable clinical manifestations of ischemic heart disease. "Priming" of granulocytes in stable forms of coronary disease may predispose to the subsequent development of acute coronary events, whereas activation of neutrophils may lead to alterations in vascular permeability and coronary flow regulation, leading to further myocardial and endothelial injury in acute myocardial infarction, unstable angina and coronary angioplasty.