Containment of carbapenem-resistant Enterobacterales colonisations and infections: Results from an integrated infection control intervention in a large hospital trust of northern Italy

PURPOSE

We describe the results of an infection control intervention, implemented in 4 tertiary hospitals in Romagna, Italy, aiming at containing the spread of carbapenem-resistant Enterobacterales (CRE).

METHODS

The intervention consisted of rectal screening in patients at risk for CRE; pre-emptive contact precaution waiting for screening results; timely notification of CRE identification and concomitant computerized alert; contact precaution for confirmed CRE-positive patients. We performed an interrupted time series analysis to compare the incidence of CRE bacteraemia, of other CRE infections, and CRE-positive rectal swabs in the pre and postintervention period (January 2015-July 2017 and August 2017-June 2020, respectively).

RESULTS

4,332 CRE isolates were collected. Klebsiella pneumoniae was the most represented pathogen (n = 3,716, 85%); KPC production was the most common resistance mechanism (n = 3,896, 90%). The incidence rate of CRE bacteraemia significantly decreased from 0.554 to 0.447 episodes per 10.000 patient days in the early postintervention period (P = .001). The incidence rate of other CRE infections significantly decreased from 2.09 to 1.49 isolations per 10.000 patient days in the early postintervention period (P = .021). The monthly number of rectal swabs doubled in the postintervention period and there was a significant reduction trend of CRE-positive swabs, sustained over time (P < .001).

CONCLUSIONS

The infection control intervention was successful in containing the spread of CRE infections and colonisations.

Musladin-Lueke Syndrome in a Dog: Case Report

The aim of this study is to report the case of a 4-month-old Beagle dog diagnosed with Musladin-Lueke syndrome. The dog appeared to walk on the digits ("tiptoes") with all limbs during ambulation and rigid extension of the carpus, elbow, tarsus, and knee joints during ambulation. Thickening of the fur and auricular cartilage, reduction in radiocarpal, and tibiotarsal joint amplitude, macrocephaly, and lateralized eyes were noticed on physical examination. Echocardiography showed reduced mobility and altered (tortuous) valve morphology. Bilateral abdominal cryptorchidism was confirmed by ultrasonography. Musladin-Lueke syndrome was the presumptive diagnosis, based on the clinical signs presented. The diagnosis was confirmed after DNA testing performed by serial collection of saliva. This is the first paper that describes unprecedented cardiac and reproductive changes of Musladin-Lueke syndrome in which the dog was followed for 2 years, presenting a good quality of life.

Morpho-Colorimetric Characterization of the Sardinian Endemic Taxa of the Genus Anchusa L. by Seed Image Analysis

In this work, the seed morpho-colorimetric differentiation of the Sardinian endemic species of Anchusa (Boraginaceae) was evaluated. In Sardinia, the Anchusa genus includes the following seven taxa: A. capellii, A. crispa ssp. crispa, A. crispa ssp. maritima, A. formosa, A. littorea, A. montelinasana, and A. sardoa. Seed images were acquired using a flatbed scanner and analyzed using the free software package ImageJ. A total of 74 seed morpho-colorimetric features of 2692 seed lots of seven taxa of Anchusa belonging to 17 populations were extrapolated and used to build a database of seed size, shape, and color features. The data were statistically elaborated by the stepwise linear discriminant analysis (LDA) to compare and discriminate each accession and taxon. In addition, the seed morpho-colorimetric differences among coastal and mountainous taxa were evaluated. Considering the ecological conditions, the LDA was able to discriminate among the Anchusa taxa with a correct identification of 87.4% and 90.8% of specimens for mountainous and coastal plants, respectively. Moreover, the LDA of the 17 populations of Anchusa showed a low separation among species and populations within the coastal group, highlighting how the long-distance dispersal by flotation on the sea water surface and the pollination network may influence the similarity patterns observed. In addition, a misattribution was observed for A. crispa ssp. crispa, which was misclassified as A. crispa ssp. maritima in 14.1% of cases, while A. crispa ssp. maritima was misidentified as A. crispa ssp. crispa in 21.1% of cases, highlighting a close phenotypic relationship between these two taxa. The statistical results obtained through the seed image analysis showed that the morpho-colorimetric features of the seeds provide important information about the adaptation and evolution of Anchusa taxa in Sardinia.

An Efficient Method for Culturing Human Breast Epithelium: Analysis of Results

We have examined the possibility of obtaining primary cultures from breast tissue utilizing a method especially developed for breast epithelium. The number of specimens able to grow in culture was very high: 82.8%, 64.3 %, 75.0 % and 77.8 %, respectively, for primary breast cancer, skin recurrences, inflammatory breast cancer and normal breast tissue. In our experience, growth was not related to menopausal status or histopathologic type, whereas for skin recurrences, a prior pharmacologic treatment (chemotherapy) of the patient enhanced the growth capacity of the tissue. This culture method could help to study the basic biology of breast epithelia and to improve the chemotherapy approach of breast cancer patients.

Generation of Expression Plasmids for Angiostatin, Endostatin and Timp-2 for Cancer Gene Therapy

Antiangiogenic therapy may represent a promising approach to cancer treatment. Indeed, the efficacy of endogenous angiogenesis inhibitors, including angiostatin, endostatin and TIMPs, has been demonstrated in many types of solid tumors in animal models. In view of the possible problems associated with long-term administration of inhibitors as recombinant proteins, we propose their delivery as nucleic acids through a gene therapy approach. To this end, eukaryotic expression constructs for murine angiostatin and endostatin as well as human TIMP-2 were generated, and characterized in vitro. All constructs carry the relevant cDNAs under the control of the strong HCMV promoter/enhancer, and cleavable leader signals to allow protein secretion. Expression of the angiogenesis inhibitors was detected by in vitro transcription/translation experiments as well as transfection of 293T cells, followed by Western blotting (WB) or radioimmunoprecipitation analysis of both cell lysates and supernatants (SNs). These constructs might be used for in vivo intramuscular delivery of plasmid DNA and as a set of reagents for the development of retroviral as well as adeno-associated viral (AAV) vectors expressing angiogenesis inhibitors.

Abstract P1-13-02: Withdrawn

This abstract was withdrawn by the authors.

CD44v10: An Antimetastatic Membrane Glycoprotein for Pancreatic Cancer

Aims

The aims of this study were 1) to investigate the mRNA pattern of CD44 variants in three primary (MIA PaCa 2, PANC-1, PSN-1) and two metastatic (CAPAN-1, SUIT-2) pancreatic cancer (PC) cell lines; 2) to ascertain whether the genetic transfer of CD44s and CD44v10 modifies the adhesion of PC cells to the extracellular matrix (ECM) in vitro and their metastatic behavior in vivo.

Methods

CD44 mRNA analysis was done by means of RT-PCR. Adhesion to ECM the was assessed using coated microtiter plates. For the study of CD44v10 insertion in the CAPAN-1 line, liposome-mediated DNA transfer was used. SCID mice were employed for in vivo experiments.

Results

CD44v10 mRNA was not expressed by the CAPAN-1 nor by four of the six SUIT-2-derived clones. The stable expression of CD44v10 by modified CAPAN-1 significantly enhanced fibronectin adhesion. Mice without either liver or pancreatic metastases were more frequently found among the animals injected with modified (CD44v10 expressing) than with non-modified CAPAN-1.

Conclusions

1) It is possible to differentiate between metastatic and non-metastatic PC cells on the basis of CD44v10 expression; 2) CD44v10 seems to be involved in mediating fibronectin adhesion in vitro and in counteracting metastases in vivo.

Calcineurin and GSK-3 inhibition sensitizes T-cell acute lymphoblastic leukemia cells to apoptosis through X-linked inhibitor of apoptosis protein degradation

The calcineurin (Cn)-nuclear factor of activated T cells signaling pathway is critically involved in many aspects of normal T-cell physiology; however, its direct implication in leukemogenesis is still ill-defined. Glycogen synthase kinase-3β (GSK-3β) has recently been reported to interact with Cn in neuronal cells and is implicated in MLL leukemia. Our biochemical studies clearly demonstrated that Cn was able to interact with GSK-3β in T-cell acute lymphoblastic leukemia (T-ALL) cells, and that this interaction was direct, leading to an increased catalytic activity of GSK-3β, possibly through autophosphorylation of Y216. Sensitivity to GSK-3 inhibitor treatment correlated with altered GSK-3β phosphorylation and was more prominent in T-ALL with Pre/Pro immunophenotype. In addition, dual Cn and GSK-3 inhibitor treatment in T-ALL cells promoted sensitization to apoptosis through proteasomal degradation of X-linked inhibitor of apoptosis protein (XIAP). Consistently, resistance to drug treatments in primary samples was strongly associated with higher XIAP protein levels. Finally, we showed that dual Cn and GSK-3 inhibitor treatment in vitro and in vivo is effective against available models of T-ALL, indicating an insofar untapped therapeutic opportunity.

Predictive markers in elderly patients with estrogen receptor-positive breast cancer treated with aromatase inhibitors: an array-based pharmacogenetic study

So far, no reliable predictive clinicopathological markers of response to aromatase inhibitors (AIs) have been identified, and little is known regarding the role played by host genetics. To identify constitutive predictive markers, an array-based association study was performed in a cohort of 55 elderly hormone-dependent breast cancer (BC) patients treated with third-generation AIs. The array used in this study interrogates variants in 225 drug metabolism and disposition genes with documented functional significance. Six variants emerged as associated with response to AIs: three located in ABCG1, UGT2A1, SLCO3A1 with a good response, two in SLCO3A1 and one in ABCC4 with a poor response. Variants in the AI target CYP19A1 resulted associated with a favourable response only as haplotype; haplotypes with increased response association were also detected for ABCG1 and SLCO3A1. These results highlight the relevance of host genetics in the response to AIs and represent a first step toward precision medicine for elderly BC patients.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

Interferon beta 1a anaphylaxis, a case report. Standardization of non-irritating concentration for allergy skin tests

Multiple sclerosis is a disease with a potentially severe prognosis and epidemiologically increasing. Interferon beta 1a is a very useful maintenance therapy widely used by neurologists. In the literature, there are several case reports of  hypersensitivity reactions. In this case report we describe an anaphylactic IgE mediated reaction to interferon beta 1a. We also describe, for the first time in the medical literature, the non-irritating concentration (NIC) to be used for skin tests.

HLA-DRB1 typing by micro-bead array assay identifies the origin of early lymphoproliferative disorder in a heart transplant recipient

We report the case of a 68-year-old woman who underwent heart transplantation for hypertrophic cardiomyopathy. Two months after the transplant she developed mild fever and dyspnea with a marked drop in left ventricle ejection fraction of 31%. Coronary angiography was negative for cardiac allograft vasculopathy. Endomyocardial biopsy revealed ischemic damage with no evidence of acute cellular rejection, antibody-mediated rejection or viral myocarditis. A neoplastic process was suspected even though full-body computerized tomography was negative for malignancy. The patient died 4 months after transplantation. The autopsy showed acute antero-septal myocardial infarction due to a nodular epicardial EBV-related posttransplant lymphoproliferative disorder (PTLD) infiltrating the left anterior descending coronary artery with occlusive neoplastic thrombosis. We highlight two major aspects of this case: (1) the unusual occurrence of early PTLD involving the cardiac allograft and causing a fatal outcome, (2) the application of an immunological technique for HLA-DRB1 typing to posttransplant paraffin-embedded autopsy material to identify the recipient origin of this early malignancy, thus excluding a possible donor-transmitted neoplasm.

Neurophysiological monitoring in adult and pediatric intensive care

Clinical neurophysiology is both an extension of clinical examination and an integration of neuroimaging. It plays a role in diagnosis, prognosis and monitoring in the Intensive Care Unit (ICU). Electroencephalography (EEG) and somatosensory evoked potentials (SEPs) are the most informative neurophysiological tests. Both have a major prognostic role in the hypoxic-ischemic encephalopathy and traumatic brain injury (TBI). In the former the absence of bilateral cortical SEPs has an unfavorable prognostic significance of 100%, whereas bilateral normal SEPs has uncertain prognostic value. In TBI these SEP patterns have high early prognostic value for both bad and good outcome. Continuous EEG monitoring is indicated for diagnosis and treatment of non convulsive seizures and status epilepticus (NCSE), whereas SEPs are more able to indicate the occurrence of neurological deterioration. In our opinion EEG-SEP monitoring is also valuable for interpretation and management of ICP trends, contributing to optimise treatment in a single patient. The EEG seems to have the same prognostic utility in pediatric as in adult ICU. Recent reviews supported the use of SEPs in the integrated process of outcome prediction after acute brain injury in children. However differences in interpretation are needed and the issue is whether it is possible to establish an age limit over which the prediction of SEPs is similar to that in adults. There are only a few studies of seizure prevalence in pediatric ICU. The variability of frequency of NCSE in comatose children is high as in adults and, similar to the adult, remains unclear the impact on outcome.

[Possible use of microRNAs as biomarkers for monitoring of workers exposed to asbestos]

Exposure to asbestos is the predominant cause of pleural mesothelioma (PM). The PM is a tumor difficult to diagnose, chemoresistant, and with rising Incidence. The long latency periods and the lack of preventive and therapeutic strategies for the MP, suggest that asbestos will be a social and health issue in the near future. Therefore, this overview focuses on current knowledge of epigenetic alterations and on the key role of microRNAs, small RNAs that negatively regulate gene expression, as biomarkers in PM development. Dysregulated microRNA expression pattern is specific for different cancers, including MP. MicroRNA expression analysis is a promising tool for diagnosis, typing of MP than normal tissue and other lung tumors and monitoring of new therapies. However, a better knowledge of miRNA signatures in PM is still necessary to verify the contribution of specific miRNAs as diagnostic biomarkers, also compared to different asbestos forms, exposure and subject work history.

Notch3-mediated regulation of MKP-1 levels promotes survival of T acute lymphoblastic leukemia cells

Activation of the Notch pathway occurs commonly in T acute lymphoblastic leukemia (T-ALL) because of mutations in Notch1 or Fbw7 and is involved in the regulation of cell proliferation and survival. Deregulated Notch3 signalling has also been shown to promote leukemogenesis in transgenic mice, but the targets of Notch3 in human T-ALL cells remain poorly characterized. Here, we show that Notch3 controls levels of mitogen-activated protein kinase (MAPK) phosphatase 1 (MKP-1). In a model of T-ALL cell dormancy, both Notch3 activation and MKP-1 expression were upregulated in aggressive compared with dormant tumors, and this inversely correlated with the levels of phosphorylated p38 and extracellular signal-regulated kinase1/2 (ERK1/2) MAPKs, two canonical MKP-1 targets. We demonstrate that MKP-1 protein levels are regulated by Notch3 in T-ALL cell lines because its silencing by RNA interference or treatment with γ-secretase inhibitors induced strong MKP-1 reduction whereas activation of Notch3 signalling had the opposite effect. Furthermore, MKP-1 has an important role in T-ALL cell survival because its attenuation by short hairpin RNA significantly increased cell death under stress conditions. This protective function has a key role in vivo, as MKP-1-deficient cells showed impaired tumorigenicity. These results elucidate a novel mechanism downstream of Notch3 that controls the survival of T-ALL cells.

Circulating and disseminated tumor cells in the clinical management of breast cancer patients: unanswered questions

Breast cancer is the most common cancer in women. Although survival rates have improved with the use of new therapeutic agents, many issues remain unresolved and new predictive and prognostic factors are needed in clinical practice. Several studies have suggested a prognostic and predictive role for circulating and disseminated tumor cells in metastatic disease and adjuvant treatment. Because of recent technological advances, oncologists have gained a new perspective on this disease. Circulating tumor cells could be both a new tumor marker as well as a tool to gain novel insight into the natural history of this neoplastic disease.

Continuous EEG-SEP monitoring in severe brain injury

AIMS

To monitor acute brain injury in the neurological intensive care unit (NICU), we used EEG and somatosensory evoked potentials (SEP) in combination to achieve more accuracy in detecting brain function deterioration.

METHODS

Sixty-eight patients (head trauma and intracranial hemorrhage; GCS<9) were monitored with continuous EEG-SEP and intracranial pressure monitoring (ICP).

RESULTS

Fifty-five patients were considered "stable" or improving, considering the GCS and CT scan: in this group, SEP didn't show significant changes. Thirteen patients showed neurological deteriorations and, in all patients, cortical SEP showed significant alterations (amplitude decrease>50% often till complete disappearance). SEP deterioration anticipated ICP increase in 30%, was contemporary in 38%, and followed ICP increase in 23%. Considering SEP and ICP in relation to clinical course, all patients but one with ICP less than 20 mmHg were stable, while the three patients with ICP greater than 40 mmHg all died. Among the 26 patients with ICP of 20-40 mmHg, 17 were stable, while nine showed clinical and neurophysiological deterioration. Thus, there is a range of ICP values (20-40 mmHg) were ICP is scarcely indicative of clinical deterioration, rather it is the SEP changes that identify brain function deterioration. Therefore, SEP have a twofold interest with respect to ICP: their changes can precede an ICP increase and they can constitute a complementary tool to interpret ICP trends. It has been very important to associate SEP and EEG: about 60% of our patients were deeply sedated and, because of their relative insensitivity to anesthetics, only SEP allowed us to monitor brain damage evolution when EEG was scarcely valuable.

CONCLUSIONS

We observed 3% of nonconvulsive status epilepticus compared to 18% of neurological deterioration. If the aim of neurophysiological monitoring is to "detect and protect", it may not be limited to detecting seizures, rather it should be able to identify brain deterioration, so we propose the combined monitoring of EEG with SEP.

Continuous EEG–SEP monitoring of severely brain injured patients in NICU: methods and feasibility

AIMS

To evaluate the feasibility of a continuous neurophysiologic monitoring (electroencephalography (EEG)-somatosensory evoked potentials (SEPs)) in the neuro-intensive care unit (NICU), taking into account both the technical and medical aspects that are specific of this environment.

METHODS

We used an extension of the recording software that is routinely used in our unit of clinical neurophysiology. It performs cycles of alternate EEG and SEP recordings. Raw traces and trends are simultaneously displayed. Patient head and stimulator box are placed behind the bed and linked to the ICU monitoring terminal through optic fibers. The NICU staff has been trained to note directly clinical events, main artefacts and therapeutic changes. The hospital local area network (LAN) enables remote monitoring survey.

RESULTS

Continuous EEG (CEEG)-SEP monitoring was performed in 44 patients. Problems of needle detachment were seldomly encountered, thanks to the use of a sterile plastic dressing, which covers needles. We never had infection or skin lesions due to needles or the electrical stimulator. The frequent administration of sedative at high doses prevented us from having a clinically valuable EEG in several cases but SEPs were always monitorable, independently of the level of EEG suppression. The diagnosis of seizures and non-epileptic status was based on raw EEG, while quantitative EEG (QEEG) was used to quantify ictal activity as a guide to treatment.

CONCLUSIONS

EEG and EP waveforms collected in NICU were of comparable quality to routine clinical measurements and contained the same clinical information. A continuous SEP monitoring in a comatose and sedated patient in NICU is not technically more difficult and potentially less useful than in operating room. This monitoring appears to be feasible provided the observance of some requirement regarding setting, electrodes, montages, personnel integration, consulting and software.

Gene therapy of ovarian cancer with IFN-alpha-producing fibroblasts: comparison of constitutive and inducible vectors

Ovarian cancer represents a malignancy suitable for cell and gene therapy approaches owing to its containment within the peritoneal cavity, even at advanced tumor stages. As regulation of transgene expression would be preferable for conducting clinical trials for reasons of safety, we investigated whether intraperitoneal (i.p.) administration of retroviral vector-transduced fibroblasts encoding murine interferon-alpha (IFN-alpha) could have therapeutic activity, and compared its effect with the antitumor effects of fibroblasts producing IFN-alpha under a rapamycin analogue (AP21967)-inducible promoter. Human and murine fibroblasts were recruited into the solid component of transplantable ovarian cancer-grown i.p. in severe combined immunodeficiency mice. Multiple administrations of fibroblasts producing IFN-alpha in a constitutive manner showed therapeutic efficacy, leading to significant prolongation of survival in the majority of animals, associated with inhibition of tumor angiogenesis. Compared to cells transduced by the constitutive vector, fibroblasts transduced by the inducible vector released twofold higher IFN-alpha levels in vitro, following induction by AP21967, and production of the cytokine was under pharmacologic control both in vitro and in vivo. However, these cells elicited only modest therapeutic effects in vivo. Overall, these findings indicate that intracavitary IFN-alpha gene therapy using engineered fibroblasts requires sustained production of IFN-alpha to achieve durable antitumor effects.

Extracellular matrix-enriched polymeric scaffolds as a substrate for hepatocyte cultures: in vitro and in vivo studies

Tissue engineering is a promising approach to developing hepatic tissue suitable for the functional replacement of a failing liver. The aim of the present study was to investigate whether an extracellular cell matrix obtained from fibroblasts-cultured within scaffolds of hyaluronic acid (HYAFF) could influence the proliferation rate and survival of rat hepatocytes both during long-term culture and after in vivo transplantation. Cultures were evaluated by histological and morphological analysis, a proliferation assay and metabolic activity (albumin secretion). Hepatocytes cultured in extracellular matrix-enriched scaffolds exhibited a round cellular morphology and re-established cell-cell contacts, growing into aggregates of several cells along and/or among fibers in the fabric. Hepatocytes were able to secrete albumin up to 14 days in culture. In vivo results demonstrated the biocompatibility of HYAFF-11 implanted in nude mice, in which hepatocytes maintained small well-organised aggregates until the 35th day. In conclusion, the presence of a fibroblast-secreted extracellular matrix improved the biological properties of the hyaluronan scaffold, favoring the survival and morphological integrity of hepatocytes in vitro and in vivo.

Potential of telomerase expression and activity in cervical specimens as a diagnostic tool

AIMS

To evaluate the potential use of the immunohistochemical expression of telomerase and the measurement of its activity as diagnostic tools in the uterine cervix.

METHODS

The fluorescent telomeric repeat amplification protocol (TRAP) assay was used to evaluate telomerase activity in a series of 43 cervical scrapings. Twenty five cases were cytologically classified as inflammatory, and/or metaplastic, and/or acanthotic, and 18 cases presented cell alterations compatible with mild, moderate, or severe cervical intraepithelial neoplasia (CIN). Immunohistochemistry was performed on a retrospective series of 86 archival, paraffin wax embedded blocks using a recently developed anti-hTERT (human telomerase reverse transcriptase) monoclonal antibody.

RESULTS

Telomerase activity was expressed as arbitrary enzymatic units (AEU). Median values were 38.0 AEU for inflammatory non-dysplastic cell specimens, 33.5 AEU for CIN I, 41.0 AEU for CIN II, and 28.0 AEU for CIN III. The median percentage of immunoreactive dysplastic cells, as detected by immunohistochemistry, was significantly (p = 0.024) lower in CIN I (45%) than in more severe dysplastic (CIN II 70%, CIN III 80%) lesions. In contrast, no differences were seen in the enzymatic activity detected by the TRAP assay among the different dysplastic lesions.

CONCLUSIONS

These data indicate that, using a molecular extra situ method, the telomerase activity of inflammatory and non-dysplastic elements masks the expected differences between mild and severe dysplasia. Conversely, an in situ approach permits the accurate identification of telomerase positive dysplastic cells.

[Computerised monitoring of integrated cervical screening. Indicators of diagnostic performance]

In a previous issue of this journal, we presented the background, rationale, general methods, and indicators of participation of a computerised system for the monitoring of integrated cervical screening, i.e. the integration of spontaneous Pap smear practice into organised screening. We also reported the results of the application of those indicators in the general database of the Pathology Department of Imola Health District in northern Italy. In the current paper, we present the rationale and definitions of indicators of diagnostic performance (total Pap smears and rate of unsatisfactory Pap smears, distribution by cytology class reported, rate of patients without timely follow-up, detection rate, positive predictive value, distribution of cytology classes reported by histology diagnosis, and distribution of cases of CIN and carcinoma registered by detection modality) as well as the results of their application in the same database as above.

Tumor outgrowth in peripheral blood mononuclear cell-injected SCID mice is not associated with early Epstein-Barr virus reactivation

Epstein-Barr virus (EBV)-positive B-cell lymphoproliferative disease develops in severe combined immunodeficient (SCID) mice inoculated with peripheral blood mononuclear cells (PBMC) from EBV(+) individuals (SCID/hu mice). In this study, we investigated the contribution of EBV reactivation and de novo infection of B lymphocytes to tumor outgrowth in SCID/hu mice. Evaluation of BZLF-1, an early EBV activation transcript, in cells recovered from the mouse peritoneal cavity within 16 days following PBMC transfer did not reveal EBV reactivation, while BZLF-1 expression was only detected in tumor masses or in vitro established lymphoblastoid cell lines. To confirm these data by a different strategy, we coinjected PBMC from seropositive donors with purified B cells from seronegative donors of different sex. Fluorescence in situ hydridization analysis of the resulting tumor masses disclosed that the overwhelming majority of lymphoma cells originated from the seropositive donor, implying that no substantial in vivo production and transmission of virus had occurred. Further, treatment of SCID/hu mice with ganciclovir did not prevent lymphoma development. Our results suggest that in the SCID/hu mouse, early EBV replication and secondary infection of bystander B cells does not occur, and that the direct outgrowth of the transformed B lymphocytes present within the PBMC inoculum is the predominant mechanism, which leads to lymphoma generation in this experimental model.

[The ThinPrep Pap test in population screening]

The ThinPrep technique has been applied to Pap tests in a population screening program in Imola, Italy. A significative decrease in the number of inadequate tests has been observed, while the distribution of the Bethesda diagnostic categories was not different in comparison to the previous year, when conventional Pap tests were used with the adoption of the ThinPrep technique, the productivity of the screening program increased without any need to modify the screening protocol.

Differential effects of angiostatin, endostatin and interferon-alpha(1) gene transfer on in vivo growth of human breast cancer cells

The administration of different angiogenesis inhibitors by gene transfer has been shown to result in inhibition of tumor growth in animal tumor models, but the potency of these genes has been only partially evaluated in comparative studies to date. To identify the most effective anti-angiogenic molecule for delivery by retroviral vectors, we investigated the effects of angiostatin, endostatin and interferon(IFN)-alpha(1) gene transfer in in vivo models of breast cancer induced neovascularization and tumor growth. Moloney leukemia virus-based retroviral vectors for expression of murine angiostatin, endostatin and IFN-alpha(1) were generated, characterized, and used to transduce human breast cancer cell lines (MCF7 and MDA-MB435). Secretion of the recombinant proteins was confirmed by biological and Western blotting assays. Their production did not impair in vitro growth of these breast cancer cells nor their viability, and did not interfere with the expression of angiogenic factors. However, primary endothelial cell proliferation and migration in vitro were inhibited by supernatants of the transduced cells containing angiostatin, endostatin, and IFN-alpha(1). Stable gene transfer of the IFN-alpha(1) cDNA by retroviral vectors in both MCF7 and MDA-MB435 cells resulted in a marked and long-lasting inhibition of tumor growth in nude mice that was associated with reduced vascularization. Endostatin reduced the in vivo growth of MDA-MB435, but not MCF7 cells, despite similar levels of in vivo production, and angiostatin did not impair the in vivo growth of either cell line. These findings indicate heterogeneity in the therapeutic efficacy of angiostatic molecules delivered by viral vectors and suggest that gene therapy with IFN-alpha(1) and endostatin might be useful for treatment of breast cancer.

Expression and functional activity of CXCR-4 and CCR-5 chemokine receptors in human thymocytes

In this paper we addressed the expression of the HIV co-receptors CXCR-4 and CCR-5 in human thymocytes by phenotypic, molecular and functional approaches. Cytofluorimetric analysis disclosed that CXCR-4 was constitutively expressed by freshly isolated thymocytes (~10 000 molecules/cell in about 30% of thymocytes); the receptor was endowed with functional activity, as it mediated polarization, migration and intracellular Ca2+ increase in response to its ligand, SDF-1. On the contrary, CCR-5 expression in freshly isolated thymocytes was significantly lower (<4000 molecules/cell in less than 5% of the cells), and no functional response to CCR-5 agonists could be documented. Northern blot analysis of freshly isolated thymocytes showed high CXCR-4 mRNA levels, whereas the message for CCR-5 was barely detectable. On the other hand, a modest increase in the expression of CCR-5 was associated with in vitro thymocyte stimulation, and CCR-5 density at the cell surface attained CXCR-4 figures in most cases. None the less, no functional response to CCR-5 agonists could be documented in in vitro stimulated thymocytes. In vitro infection of thymocytes by CAT-expressing recombinant HIV bearing the envelope glycoproteins from different isolates showed that T-tropic strains, which use CXCR-4 as a co-receptor, were more efficient in infecting thymocytes than M-tropic strains, which preferentially use CCR-5. Altogether, these data indicate that expression of the major co-receptors involved in infection by M-tropic HIV strains is very poor in human thymocytes, and would suggest that thymocyte infection by M-tropic HIV strains may be a rare event in vivo.

Effects of CD2 locus control region sequences on gene expression by retroviral and lentiviral vectors

Locus control region (LCR) sequences are involved in the establishment of open chromosomal domains. To evaluate the possibility of exploiting the human CD2 LCR to regulate gene expression by Moloney murine leukemia virus (Mo-MLV)-based retroviral vectors in T cells, it was included in vectors carrying the enhanced green fluorescence protein (EGFP) reporter gene; then transduction in vitro of lymphoid and nonlymphoid cell lines was performed. Deletion of the viral enhancer in the Mo-MLV long terminal repeat was necessary to detect LCR activity in the context of these retroviral vectors. It was found that a full-length (2.1 kb), but not a truncated (1.0 kb), CD2 LCR retained the ability to modulate reporter gene expression by Mo-MLV-derived retroviral vectors, leading to a homogeneous, unimodal pattern of EGFP expression that remained unmodified in culture over time, specifically in T-cell lines; on the other hand, viral titer was strongly reduced compared with vectors not carrying the LCR. Lentiviral vectors containing the CD2 LCR could be generated at higher titers and were used to analyze its effects on gene expression in primary T cells. Subcutaneous implantation of genetically modified cells in immunodeficient mice showed that retroviral vectors carrying the CD2 LCR conferred an advantage in terms of transgene expression in vivo, compared with the parental vector, by preventing the down-modulation of EGFP expression. These findings suggest a potential application of this LCR to increase gene expression by retroviral and lentiviral vectors in T lymphocytes.

[ASCUS in screening]

The significance and use of the cytological diagnosis "atypical squamous cells of undetermined significance" (ASCUS) remain a major problem in cervical cancer screening. The prevalence of ASCUS by patient age has seldom been investigated. The present paper reports the prevalence of ASCUS in a large series of screening Pap smears from the Italian region of Emilia-Romagna. The study was based on the data collected by the Department of Health of the Emilia-Romagna Region for the first 3-year round (1997-1999) of a population-based screening programme (target age, 25-64 years). The age-specific frequency of ASCUS has been calculated as a prevalence rate per 1000 screened patients. A total of 597,386 women participated in the programme. Women diagnosed with ASCUS (n = 8205 or 13.7 per 1000) accounted for 49% of the recalls for colposcopy (n = 16,871, or 28.2 per 1000). The prevalence of diagnoses of low-grade squamous intraepithelial lesions (LG-SIL) decreased progressively with age while that of high-grade SIL was slightly higher between 30 and 39 years. The prevalence of ASCUS peaked at age 45-49 years (17.3 per 1000 subjects). The observed peak reflects the prevalence of (1) cytological changes closely associated with perimenopausal age and at least compatible with the ASCUS diagnosis, and (2) cytological abnormalities induced by hormone replacement therapy.

Frequency and determinants of lymphadenectomy in endometrial carcinoma: a population-based study from northern Italy

BACKGROUND

The diffusion of pelvic and para-aortic lymphadenectomy for the surgical pathological staging of endometrial carcinoma into clinical practice has been evaluated only with questionnaire surveys of gynecological oncologists. No population-based information is available.

METHODS

In this study of operable endometrial carcinoma cases registered by the population-based Romagna Cancer Registry (northern Italy) between 1987 and 1994, the association of demographic (age, time period, place of birth, place of residence, place of treatment, and marital status) and pathological factors (histological type, tumor grade, myoinvasion, and extension of disease to cervix, serosa, adnexa, and vagina) with the probability of lymphadenectomy was evaluated by multiple logistic regression analysis.

RESULTS

Of the 300 potentially eligible cases, sufficient information was obtained for 276 (92%; median age, 63 years; range, 33-87 years). No case of para-aortic lymphadenectomy was observed. Pelvic lymphadenectomy was performed in 86 (31%) cases. The probability of pelvic lymphadenectomy was related to tumor grade (positive association), place of treatment, and marital status. All other variables, including myoinvasion and extension of disease to the cervix and beyond the uterus, had no effect whatsoever.

CONCLUSIONS

The most likely interpretations of results include poor acceptance of current surgical pathological staging criteria and insufficient use of standard diagnostic techniques for preoperative and intraoperative assessment of myoinvasion and extrauterine spread.