High prevalence of cardiac post-acute sequelae in patients recovered from Covid-19. Results from the ARCA post-COVID study

Background

Many data were published about Long-Covid prevalence, very few about the findings of new cardiac alterations (NCA) in COVID-19-recovered people. ARCA-post-COVID is an observational study designed to investigate the prevalence of NCA in patients recovered from Covid-19.Methods: from June 2020 to December 2022, we enrolled 502 patients with a positive nasopharyngeal swab for SARS-CoV2 and a subsequent negative one. We performed anamnesis, lab-test, and routine cardiological tests (ECG, Holter, TTE).

Results

The median age was 56 years (IQR 44-67); women were 52.19%; in the acute phase 24.1% of patients were treated in a medical department, 7.2% in the ICU and the others at home. At the visit, 389 patients (77.49%) complained of a broad range of symptoms. We reported patients' characteristics according to the course of the disease and the persistence of symptoms. NCA were found in 138 patients (27.49%): among them 60 cases (11.95%) of pericardial effusion. Patients with NCA were older (median 60y, IQR: 47-72, vs median 56y, IQR 42-65), had a higher prevalence of smokers (27% vs 17%; p0.014), CAD (11% vs 6%; p0.048) and stroke/TIA (3.6% vs 0.3%; p0.002) and a lower prevalence of hypercholesterolemia (18% vs 30%; p0.007). The prevalence of NCA seems constant with different subtypes of the virus.

Conclusion

the prevalence of NCA in patients who recovered from COVID-19 is high and constant since the beginning of the pandemic; it is predictable based on hospitalization and long-lasting symptoms (9.64%-42.52%). Patients with one of these characteristics should undergo cardiological screening.

Clinical outcomes of newly diagnosed, stable angina patients managed according to current guidelines. The ARCA (Arca Registry for Chronic Angina) Registry: A prospective, observational, nationwide study

BACKGROUND

Clinical outcomes of stable angina patients treated according to guidelines recommendations (medical therapy first, selective revascularization in high risk or unresponsive patients) are not fully known.

METHODS AND RESULTS

Eight hundred thirty-three patients with newly diagnosed, stable angina were enrolled in a prospective, observational, nationwide registry and followed for 1 year. Symptoms and quality of life were evaluated with the CCS angina grading, with a self-assessment scale and with the SAQ-7. A composite end-point of MACEs (all-cause death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina) at 1 year was considered. Upon enrollment, all patients were prescribed guidelines directed medical therapy. After one month of therapy, angina relieved or improved in 47% of the overall population. Patients in CCS class I significantly increased from 28.4% at enrollment to 67.1% at 12 months, and the SAQ-7 score from 58.4 ± 20 to 85.9 ± 14. The rate of MACEs was low (2.9%) in the overall population. After one month of medical therapy, 40.6% of patients were referred for coronary angiography and revascularization for resistant symptoms (invasive strategy). Among these, 38.2% had normal coronary arteries and 47% actually underwent revascularization. No difference between invasive and medical groups was found at 12 months in symptoms, quality of life and MACEs, except for a greater improvement in self-assessed symptoms in the invasive group. Combined medical and invasive strategies left 28.5% of patients still symptomatic at the end of the study.

CONCLUSIONS

The study confirms the efficacy and safety of a tailored approach to stable angina, as recommended by guidelines, with medical therapy first followed by selective revascularization when needed.

Factors for heterogeneous outcomes of angina and myocardial ischemia without obstructive coronary atherosclerosis

BACKGROUND AND OBJECTIVES

The absence of obstructive coronary artery disease (CAD) in patients with angina is common, but its prognosis is debated. We investigated outcomes of such patients to identify predictors of cardiovascular events.

METHODS

We selected 1014 patients with angina, evidence of myocardial ischemia at the electrocardiogram (ECG) exercise test or imaging stress tests, and nonobstructive CAD (absence of lumen diameter reduction ≥50%) at coronary angiography between 1999 and 2015. Note that, 1905 age- and risk factors-matched asymptomatic subjects served as "real-world" comparators. The primary endpoint was the occurrence of all-cause death or myocardial infarction.

RESULTS

At 6-years median follow-up (interquartile range, 3-9 years), the primary endpoint occurred in 53 patients (5.5%, 0.92/100 person-years). Besides similar event rates compared with asymptomatic subjects (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.62-1.15, p = 0.28), the index population showed a very heterogeneous prognosis. Patients with nonobstructive CAD (HR 1.85, 95% CI 1.02-3.37, p = 0.04, compared with "normal" coronary arteries) and ischemia at imaging tests (HR 2.11, 95% CI 1.07-4.14, p = 0.03, compared with ischemia detected only at the ECG exercise test) were at higher risk and those with both these components showing even >10-fold event rates as compared with the absence of both. Three-hundred and twenty-five patients (34%) continued to experience angina, 69 (7.2%) underwent repeat coronary angiography, and 14 (1.5%) had consequent coronary revascularization for atherosclerosis progression.

CONCLUSION

Apart from the impaired quality of life, angina without obstructive CAD has an overall benign but very heterogeneous prognosis. Nonobstructive CAD and myocardial ischemia at imaging tests both confer a higher risk.

Stable ischemic heart disease: re-appraisal of coronary revascularization criteria in the light of contemporary evidence

The term "stable ischemic heart disease" includes a variety of clinical and pathophysiological situations resulting in different presentation modalities, often with complex referral patterns, and with multiple potential therapeutical options. Multifactorial pathogenesis and multiform expressivity are poorly captured by the traditional vision of ischemic heart disease (IHD) as the clogged pipes disease. The availability of different technologies for studying patients with symptoms suggestive of IHD, has shed a new light on the pathophysiology of the disease, but has also allowed appropriate follow-up of patients allocated to different therapeutical options. Though coronary revascularization has been one primary treatment option for obstructive coronary artery disease (CAD), the evidence for its efficacy in patients without acute presentation is far from optimal. A number of studies and meta-analyses strongly support the need for a personalized and optimized medical approach (including functional assessment and therapy) before the tailored option of revascularization in selected patients, in order to optimize its effects on symptoms and outcome. Most recent data have expanded the need for a more personalised approach to this complex situation, which should be patient-centered and not focused on technologies. In this review, we discuss the major pathophysiological factors and the most recent clinical data and guidelines suggestions, needed for a critical re-appraisal of the clinical decision-making to perform revascularization in patients with stable IHD. Moreover we aimed at suggesting the potential role for future studies to fill the existing knowledge gaps but also to counteract a reductive, hydraulic view of chronic IHD, which seems to be still alive and kicking, both in clinical and research communities, despite multiple evidences and recommendations.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

High sensitivity cardiac troponins: Can they help in diagnosing myocardial ischaemia?

BACKGROUND

Cardiac troponin is the most sensitive marker of myocardial injury, but controversy still exists about its role in detecting ischaemia.

METHODS

To investigate the role of troponin as a marker of stress-induced ischaemia, circulating high sensitivity cardiac troponin T (hs-cTnT) was measured and compared with the MB fraction of creatine kinase (CK-MB) in 125 patients undergoing a stress test (53 electrocardiogram/echo exercise, 42 echo dipyridamole and 30 echo dobutamine tests).

RESULTS

Plasma concentrations of hs-cTnT increased after the tests in 90/125 patients, while an increase of CK-MB was seen in 31/125 patients ( p<0.0001). Overall, hs-cTnT significantly increased from 17.5±16.9 ng/l to 25.5±27.9 ng/l ( p<0.0001), without significant changes of CK-MB. Significant increments in hs-cTnT were documented after exercise test (from 15.9±11.9 ng/l to 19.5±13.6 ng/l, p<0.0001) and dobutamine test (from 20.6±20.8 ng/l to 37.8±31.1 ng/l, p=0.0006), in absence of changes in CK-MB according to each stressor. Among the 125 tests, 84 were diagnosed as negative and 41 as positive for myocardial ischaemia. Significant increments in hs-cTnT were detected after both negative (from 18.6±19.2 ng/l to 27.1±32.1 ng/l, p=0.0018) and positive test (from 15.2±10.8 ng/l to 22.3±16.2 ng/l, p=0.0005), without significant changes of CK-MB according to the test result. Despite a positive correlation between stress-induced increase of hs-cTnT and obstructive coronary artery disease, the release of troponin was observed also in a significant proportion of patients without coronary stenoses. Left ventricular hypertrophy markedly enhanced myocardial release of troponin.

CONCLUSIONS

Circulating troponin increases in most patients undergoing a stress test, irrespective of the test result and of coronary artery disease. Plasma release of troponin depends on multiple pathogenetic mechanisms, making the biomarker a not reliable tool in detecting transient ischaemia.

Therapeutic targeting of CK2 in acute and chronic leukemias

CK2 is a ubiquitously expressed, constitutively active Ser/Thr protein kinase, which is considered the most pleiotropic protein kinase in the human kinome. Such a pleiotropy explains the involvement of CK2 in many cellular events. However, its predominant roles are stimulation of cell growth and prevention of apoptosis. High levels of CK2 messenger RNA and protein are associated with CK2 pathological functions in human cancers. Over the last decade, basic and translational studies have provided evidence of CK2 as a pivotal molecule driving the growth of different blood malignancies. CK2 overexpression has been demonstrated in nearly all the types of hematological cancers, including acute and chronic leukemias, where CK2 is a key regulator of signaling networks critical for cell proliferation, survival and drug resistance. The findings that emerged from these studies suggest that CK2 could be a valuable therapeutic target in leukemias and supported the initiation of clinical trials using CK2 antagonists. In this review, we summarize the recent advances on the understanding of the signaling pathways involved in CK2 inhibition-mediated effects with a particular emphasis on the combinatorial use of CK2 inhibitors as novel therapeutic strategies for treating both acute and chronic leukemia patients.

Interactions Between Reciprocal ST-Segment Downsloping During ST-Elevated Myocardial Infarction and Global Cardiac Perfusion and Functional Abnormalities

Reciprocal ST-segment downsloping on electrocardiogram is a frequent finding during ST-elevated myocardial infarction (STEMI), but its etiology is still disputed. We sought to evaluate the relation between reciprocal ST-segment downsloping during STEMI and major cardiac perfusion and functional parameters. One hundred eighty-five patients with STEMI underwent emergency coronary angiography. The presence of reciprocal ST-segment downsloping was assessed. At coronary angiography, the corrected TIMI frame count (cTFC) was computed both on culprit and remote vessels and the occurrence of "no/slow reflow" phenomenon after percutaneous coronary intervention (PCI) identified. The left ventricular wall motion score index ratio (discharge/admission values) at echocardiography and the slope of high-sensitivity troponin elimination were computed as measures of effective myocardial reperfusion. Reciprocal ST-segment downsloping was revealed in 91 patients (49%). They presented higher cTFC values on remote vessels than patients without reciprocal electrocardiographic abnormalities (44 ± 18 vs 37 ± 15 cineframes × second^-1, p = 0.004). The presence of remote ST-segment downsloping was also associated with a higher prevalence of "no/slow reflow" phenomenon (59% vs 40%, p = 0.013) as well as more abnormal values of wall motion score index ratio (p = 0.042) and high-sensitivity troponin slope (p = 0.012). At multivariate analyses, a higher cTFC on remote vessels predicted the occurrence of reciprocal ST-segment changes (p = 0.018) and the development of "no/slow reflow" phenomenon after PCI (p = 0.005). In conclusion, the presence of reciprocal ST-segment downsloping during STEMI clusters with significant perfusion and cardiac functional abnormalities, predicting the development of "no reflow" phenomenon after PCI.

Stress Testing After Complete and Successful Coronary Revascularization

BACKGROUND

Noninvasive stress tests play a determinant role in the initial management of patients with chronic angina. Nonetheless, their use in the same patient population is considered inappropriate within 2 years after percutaneous coronary intervention (PCI). Indeed, early abnormal results correlate less well with angiographic control and are attributed to a number of confounding factors. We prospectively assessed prevalence and impact on the quality of life of abnormal stress test results in a highly selected patient population.

METHODS

Patients with no cardiac comorbidities who underwent successful and complete PCI with stenting for typical angina and had an abnormal exercise stress test (EST) under guideline-directed medical treatment were administered the Seattle Angina Questionnaire (SAQ). Clinical evaluation, EST, and the SAQ were repeated at 1, 6, and 12 months after the index PCI.

RESULTS

One hundred ninety-eight patients qualified and were included in the study (mean age, 64 years; 79% men). Although the majority had normal EST results or an increased threshold to angina, at 1 month after the index PCI, 29% of patients still had an abnormal result. At 6 and 12 months, 31% and 29% of patients had abnormal results, respectively. Quality-of-life assessment by the SAQ showed consistent results, with persistent angina in one third of patients. Control angiography documented a critical lesion, attributable to in-stent coronary restenosis, in only 8% of patients.

CONCLUSIONS

When stress testing is systematically performed after PCI, the prevalence of abnormal results is high and is associated with impaired quality of life. Prognostic significance along with the underlying pathophysiological mechanisms of such findings should be investigated.

Cytotoxic activity of the casein kinase 2 inhibitor CX-4945 against T-cell acute lymphoblastic leukemia: targeting the unfolded protein response signaling

Constitutively active casein kinase 2 (CK2) signaling is a common feature of T-cell acute lymphoblastic leukemia (T-ALL). CK2 phosphorylates PTEN (phosphatase and tensin homolog) tumor suppressor, resulting in PTEN stabilization and functional inactivation. Downregulation of PTEN activity has an impact on PI3K/Akt/mTOR signaling, which is of fundamental importance for T-ALL cell survival. These observations lend compelling weight to the application of CK2 inhibitors in the therapy of T-ALL. Here, we have analyzed the therapeutic potential of CX-4945-a novel, highly specific, orally available, ATP-competitive inhibitor of CK2α. We show that CX-4945 treatment induced apoptosis in T-ALL cell lines and patient T lymphoblasts. CX-4945 downregulated PI3K/Akt/mTOR signaling in leukemic cells. Notably, CX-4945 affected the unfolded protein response (UPR), as demonstrated by a significant decrease in the levels of the main UPR regulator GRP78/BIP, and led to apoptosis via upregulation of the ER stress/UPR cell death mediators IRE1α and CHOP. In vivo administration of CX-4945 to a subcutaneous xenotransplant model of human T-ALL significantly delayed tumor growth. Our findings indicate that modulation of the ER stress/UPR signaling through CK2 inhibition could be exploited for inducing apoptosis in T-ALL cells and that CX-4945 may be an efficient treatment for those T-ALLs displaying upregulation of CK2α/PI3K/Akt/mTOR signaling.

Indications, Utility and Appropriateness of Echocardiography in Outpatient Cardiology

Objective:

Respect of “appropriateness” is considered an essential requirement, both on the clinical and the economic profile, and also as it helps to shorten the waiting list. However, only a few studies have dealt with the control of appropriateness in clinical practice, and most of them have focused only on hospital admissions and invasive procedures.

Materials and Methods:

INDICARD-out is a prospective, multicenter study carried out by A.R.C.A. (Associazioni Regionali Cardiologi Ambulatoriali) cardiologists from 13 Italian Regions, providing information on indications, utility and appropriateness of echocardiography in outpatient cardiology.

Results:

A total of 2110 prescriptions for echocardiogram were evaluated. Hypertension (23%) and the screening of asymptomatic subjects (17%) by far were the most frequent indications to echocardiography. Overall, 54% of the tests resulted appropriate, 30% were of uncertain appropriateness and 16% were inappropriate. Besides, 31% of the echocardiograms were not useful, and 28% were non pertinent for patient management. The vast majority of prescriptions (72%) came from non-cardiologist physicians (54% from general practitioners). The echocardiograms prescribed by cardiologists were significantly more appropriate, more useful and more pertinent than the tests prescribed by non-cardiologists.

Conclusions:

The appropriateness, utility and pertinence of the echocardiography are still suboptimal in practice cardiology, especially when indicated by non-cardiologists. The cardiologist, from mere executor of tests prescribed and managed by other physicians, should gain the role of the clinician who takes care of all the cardiologic needs of the patient community.

Right ventricular dysfunction is associated with chronic kidney disease and predicts survival in patients with chronic systolic heart failure

AIMS

Chronic kidney disease (CKD) and right ventricular (RV) dysfunction are important predictors of prognosis in heart failure (HF). We investigated the relationship between RV dysfunction and CKD in outpatients with chronic systolic HF, an association which remains poorly defined.

METHODS AND RESULTS

Outpatients (n = 373) with chronic HF and left ventricular ejection fraction (LVEF) ≤45% underwent clinical and echo-Doppler evaluations and were followed up for 31 ± 24 months. Tricuspid annular plane systolic excursion (TAPSE) assessed RV dysfunction. The estimated glomerular filtration rate (GFR) was measured by the simplified Modification of Diet in Renal Disease (MDRD) formula. Correlation analysis was used to characterize the association between TAPSE and estimated GFR. Odds ratios (ORs) for CKD and hazard ratios (HRs) for all-cause mortality were assessed using multivariable logistic or proportional hazards regression models. TAPSE and estimated GFR were significantly correlated (r = 0.38, P < 0.0001). TAPSE ≤14 mm was associated with elevated estimated right atrial pressure and N-terminal pro brain natriuretic peptide levels. TAPSE ≤14 mm increased the odds of estimated GFR <60 mL/min/1.73 m(2), OR [95% confidence interval (CI)] = 2.51(1.44-4.39), P < 0.0001 and predicted all-cause mortality, HR (95% CI) = 1.80 (1.20-2.71) after multivariable adjustment.

CONCLUSIONS

Right ventricular dysfunction is cross-sectionally associated with CKD and prospectively predicts survival in outpatients with chronic systolic HF. These data suggest RV dysfunction to be one of the possible mechanistic links between HF and CKD.

Association of furosemide dose with clinical status, left ventricular dysfunction, natriuretic peptides, and outcome in clinically stable patients with chronic systolic heart failure

In chronic heart failure (HF), high daily doses of furosemide have been associated with increased mortality. The authors sought to evaluate the relationships between orally administered furosemide doses, clinical status, left ventricular (LV) dysfunction, N-terminal proBNP (NT-proBNP), and outcome in 400 outpatients with chronic HF and LV ejection fraction (EF) ≤ 45%. Clinical status, NT-proBNP levels, and estimated glomerular filtration rate (eGFR) were evaluated. Median follow-up duration was 32 months. The median values of daily-dose furosemide and of furosemide dose normalized to body surface area were 25 mg (12.5-62.5 mg) and 15 mg/m(2) (13-34 mg/m(2)), respectively. A total of 32% of patients had decompensated HF according to Framingham score and criteria for congestion. In clinically stable patients, a multivariable Cox model, which included clinical and echocardiographic parameters plus NT-proBNP, hemoglobin, and eGFR, showed that normalized furosemide dose (P=.017), anemia (P=.060), age (P=.080), and New York Heart Association class (P=.080) were predictors of all cause-mortality. In patients with decompensated HF, LV end-systolic volume index (P=.018), NT-proBNP (P=.060), and reduced eGFR (P=.070) were independently related to the outcome. Normalized furosemide dose was a major determinant of prognosis in patients with chronic HF but without ongoing signs and symptoms, and this suggests a possible negative interaction of this drug in clinically stable patients.

Histomorphometric evaluation of implant design as a key factor in peri-implant bone response: a preliminary study in a dog model

AIM

Primary implant stability as the establishment of a direct bone-to-implant contact (BIC) plays a major role in long-term successful implant osseointegration. Numerous factors influencing this initial stability have been studied. This preliminary in vivo study on a dog lower jaw aimed to investigate the hypothesis that primary implant stability in low density bone may be influenced by implant design.

METHODS

The authors compared two different implant designs with regard to their immediate quantitative relation to host bone (BIC% and gap area, GA%). The screw-shaped implants, manufactured by Or-Vit (Castelmaggiore-Bologna, Italy), exhibited similar microroughness surface and two different thread pitches: ''narrow-pitch'' implants (NP) and ''wide-pitch'' implants (WP) with a 0.5 mm and 1.5 mm thread pitch respectively. Implants were placed in dog jaw after complete osseous healing of the extractive sockets, according to a delayed implantation procedure. Five hours after surgery the animal was sacrificed. Radiographic, histological, morphometric and ultrastructural analysis were performed.

RESULTS

An inverse relation existed among the two parameters BIC and GA: GA, as a region with high osteogenetic potentiality, appeared wider in WP implants; BIC, as the expression of primary mechanical stability, was higher in NP implants.

CONCLUSION

Based on this results, we could assume that NP implants might be the clinical choice in case of immediate loading.This single case study might be considered a starting point for further long term in vivo investigations aiming to establish the implant design that best favours osseointegration at different bone quality sites.

Destination of titanium particles detached from titanium plasma sprayed implants

Small titanium particles may detach from titanium plasma sprayed (TPS) implants during implant insertion, when no preliminary tapping is used, probably for the frictional force between titanium coating and host bone. Aim of this study was to investigate the destination of these titanium particles observed in the peri-implant environment. Twenty-four TPS screws were implanted in tibiae of two sheep. Fourteen and 90 days after implantation the implants with the surrounding bone were removed and processed to be analyzed by light microscope and scanning electron microscope (secondary electron and back-scattered electron probes). Small titanium particles detached from the unloaded TPS implants were observed both in the newly-formed bone matrix and in marrow tissue. Histomorphometric analysis showed that both at 14 and 90 days after implantation the titanium particles appeared more concentrated in marrow tissue than in calcified bone matrix, decreasing by 66.4% over time. In particular, smaller particles (<250 microm(2)) decreased by 81.5%, whereas the larger ones (250-2000 microm(2)) did not show any significant variations over time, suggesting that most of the smaller particles may undergo to ionic dissolution, probably migrating into the peri-implant marrow lacunae. A slight migration of titanium particles from the implant surface towards the more distant peri-implant tissues was also demonstrated over time.

[Appropriateness of prescription of exercise stress test, echocardiography, Holter monitoring and vascular echography]

BACKGROUND

The aim of this study was to evaluate the appropriateness of prescription of non-invasive cardiological tests (exercise stress test, echocardiography, Holter monitoring and vascular echography), consecutively performed in our outpatient laboratory during 4 weeks.

METHODS

We collected the following data: the appropriateness of prescription (according to the Italian Federation of Cardiology guidelines); test indications; the prescribing physician (cardiologist/non-cardiologist); type of prescription (elective/urgent); clinical utility (useful/useless) and result (normal/abnormal) of each test.

RESULTS

We evaluated 960 prescriptions (320 exercise tests; 282 echocardiograms; 158 Holter tests; 200 vascular echographies). Test indications were appropriate (class I) in 37%, doubtfully appropriate (class II) in 39% and inappropriate (class III) in 24% of the cases. The appropriateness was slightly better for vascular echography and echocardiography (class I: 44% and 43%, respectively), markedly worse for exercise test (class I: 27%). The tests were considered useful in 46% and abnormal in 39% of the cases. Cardiologist-prescribed exams resulted more often appropriate (class I: 53 vs 30%; class II: 41 vs 38%; class III: 6 vs. 32%; p = 0.0001), more often useful (74 vs. 34%; p = 0.0001) and more frequently abnormal (43 vs. 37%; p = 0.05), when compared to non-cardiologist-prescribed exams. No differences in appropriateness, utility and test result have been detected between elective and urgent exams. Exercise test, echocardiogram and Holter monitoring resulted more often appropriate and useful when prescribed by cardiologists.

CONCLUSIONS

This study confirms that only one third of prescriptions for non-invasive cardiological tests are appropriate. Cardiologist-prescribed exams are more often appropriate, useful and abnormal.

Tendon crimps and peritendinous tissues responding to tensional forces

Tendons transmit forces generated from muscle to bone making joint movements possible. Tendon collagen has a complex supramolecular structure forming many hierarchical levels of association; its main functional unit is the collagen fibril forming fibers and fascicles. Since tendons are enclosed by loose connective sheaths in continuity with muscle sheaths, it is likely that tendon sheaths could play a role in absorbing/transmitting the forces created by muscle contraction. In this study rat Achilles tendons were passively stretched in vivo to be observed at polarized light microscope (PLM), scanning electron microscope (SEM) and transmission electron microscope (TEM). At PLM tendon collagen fibers in relaxed rat Achilles tendons ran straight and parallel, showing a periodic crimp pattern. Similarly tendon sheaths showed apparent crimps. At higher magnification SEM and TEM revealed that in each tendon crimp large and heterogeneous collagen fibrils running straight and parallel suddenly changed their direction undergoing localized and variable modifications. These fibril modifications were named fibrillar crimps. Tendon sheaths displayed small and uniform fibrils running parallel with a wavy course without any ultrastructural aspects of crimp. Since in passively stretched Achilles tendons fibrillar crimps were still observed, it is likely that during the tendon stretching, and presumably during the tendon elongation in muscle contraction, the fibrillar crimp may be the real structural component of the tendon crimp acting as shock absorber. The peritendinous sheath can be stretched as tendon, but is not actively involved in the mechanism of shock absorber as the fibrillar crimp. The different functional behaviour of tendons and sheaths may be due to the different structural and molecular arrangement of their fibrils.

A computer protocol to evaluate subjects with chest pain in the emergency department: a multicenter study

OBJECTIVE

Chest pain is a frequent cause of medical admission to the emergency department and the main differential diagnosis is between coronary and non-coronary chest pain. We elaborated a computer protocol for the management of patients with chest pain.

METHODS

The computer protocol was made of three sections according to clinical, electrocardiographic and biochemical data. Each section was coded by a letter indicating the probability of coronary chest pain for each section. The combination of the three letters formed a score string used to assign patients to four subgroups of overall probability of coronary chest pain (low, medium-low, medium-high, and high). Low-probability patients were discharged from the emergency department, whereas high-probability patients were admitted to the coronary care unit. The medium-probability patients underwent further evaluation by means of a stress test and were re-classified as having a final low probability (negative test) or high probability (positive test).

RESULTS

We evaluated 472 patients (mean age 64 years, range 18-97 years; 47% female). The incidence of coronary events in patients with low, medium-low, medium-high and high overall probability was 1.9, 12.8,13.5 and 68.0%, respectively (P < 0.05). The positive and negative predictive values of the protocol were 64.7 and 97.1%, respectively.

CONCLUSIONS

Our computer protocol represents a reliable method for the management of patients with chest pain and a non-diagnostic electrocardiogram.

Biological fixation of endosseous implants

Primary implant stability is ensured by a mechanical fixation of implants. However, during implant healing a biological anchorage is necessary to achieve final osseointegration. Aim of this study was to investigate the histological aspects of biological fixation around titanium screws. Forty-eight titanium screws with different surfaces (smooth, plasma sprayed, sand blasted) were inserted in tibiae and femura of sheep and analyzed by light microscope and SEM 1 hour, 14 and 90 days after implantation. One hour after implantation the implant-bone gap was filled with a blood clot and host bone chips arising from burr surgical preparation or friction during implant insertion. Fourteen days after implantation new trabecular bone and enveloped bone chips were observed in the gap: no osteogenesis developed where implant threads were in contact with host bone. Ninety days after surgery all trabecular bone and most of the bone chips were substituted by a mature lamellar bone with few marrow spaces. Our results suggest that the trabecular bone and bone chips represent a three-dimensional network ensuring a biological implant fixation in all different implant surfaces 2 weeks after surgery. Host bone chips could favour the peri-implant osteogenesis. Inter-trabecular and implant-trabecular marrow spaces of both trabecular and lamellar bone may favour the peri-implant bone turnover.

Early detachment of titanium particles from various different surfaces of endosseous dental implants

Titanium (Ti) endosseous dental screws with different surfaces (smooth titanium--STi, titanium plasma-sprayed-TPS, alumina oxide sandblasted and acid-etched--Al-SLA, zirconium oxide sandblasted and acid etched--Zr-SLA) were implanted in femura and tibiae of sheep to investigate the biological evolution of the peri-implant tissues and detachment of Ti debris from the implant surfaces in early healing. Implants were not loaded. Sections of the screws and the peri-implant tissues obtained by sawing and grinding were analysed by light microscopy immediately after implantation (time 0) and after 14 days. All samples showed new bone trabeculae and vascularised medullary spaces in those areas where gaps between the implants and host bone were visible. In contrast, no osteogenesis was induced in the areas where the implants were initially positioned in close contact with the host bone. Chips of the pre-existing bone inducing new peri-implant neo-osteogenesis were surrounded by new bone trabeculae. The threads of some screws appeared to be deformed where the host bone showed fractures. Ti granules of 3-60 microm were detectable only in the peri-implant tissues of TPS implants both immediately after surgery and after 14 days, thus suggesting that this phenomenon may be related to the friction of the TPS coating during surgical insertion.

[Feasibility and accuracy of a rapid evaluation of the abdominal aorta during routine transthoracic echocardiography]

BACKGROUND

Mass screening for occult abdominal aortic aneurysm is not realistic for the low prevalence of this condition in the general population. Screening in a high-risk population, especially during standard echocardiographic examination, could be more cost-effective than a separate screening program. The aim of this study was to evaluate the feasibility and accuracy of a rapid evaluation (examination arbitrary time-limit of 2 min) of the abdominal aorta at the end of a routine transthoracic echocardiographic examination.

METHODS

One hundred and eighty-one male patients (average age 61 years, range 45-79 years) were studied. A subgroup of 83 patients was also blindly examined by a radiologist for diagnostic accuracy evaluation.

RESULTS

Abdominal aortic aneurysm was defined as an aortic diameter enlargement > or = 3.0 cm. Sixteen patients were excluded due to suboptimal aortic wall imaging or to examination lasting > 2 min (feasibility 91%). An occult aneurysm was found in 7 patients (3.8%). As regards the presence/absence of aneurysms in the subgroup of patients undergoing double examination, sensitivity and specificity were 80 and 100% respectively.

CONCLUSIONS

Rapid evaluation of the abdominal aorta for aortic screening during routine echocardiography is highly feasible and accurate without any significant prolongation of the examination time and should therefore be routinely performed during standard examination.

[Evaluation of the appropriateness of prescribing exercise tests]

BACKGROUND

We evaluated the appropriateness of the indications to exercise testing for ambulatory patients performed during 4 weeks in 21 laboratories in Tuscany and Umbria, Italy.

METHODS

We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs non-cardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam.

RESULTS

We evaluated 1158 prescriptions (population: 822 males, 336 females; mean age 60 years, range 16-82 years). Prescriptions were of class I (appropriate) in 38.9%, of class II (of doubtful appropriateness) in 52.5% and of class III (inappropriate) in 8.6% of the cases. In 14.2% of the cases the exam was abnormal: it was abnormal in 35.5% of class I, in 26.6% of class II and in 23% of class III exams (p < 0.05). The exam was useful in 51.6% of the cases; it was useful in 62.4% of class I, in 50.2% of class II and in 13% of class III exams (p < 0.05). Cardiologists required 596/1158 tests (51.5%). Their indications were included in class I in 45.6%, in class II in 49.7% and in class III in 4.7% of the cases vs 31.7, 55.5 e 12.8% of non-cardiologists' prescriptions (p < 0.05). The test was abnormal in 35.7% of cardiologist vs 23.5% of non-cardiologist-prescribed examinations (odds ratio 1.81, 95% confidence interval 1.4-2.34; p < 0.05); the test was useful in 64.4% of cardiologist vs 38.2% of non-cardiologist-prescribed exams (odds ratio 2.92, 95% confidence interval 2.3-3.71; p < 0.05).

CONCLUSIONS

In Tuscany and Umbria, Italy, less than half of exercise testing procedures are appropriate; appropriately-prescribed exams are more often abnormal and useful; cardiologist-prescribed exams are significantly more appropriate, abnormal and useful.

Choroid plexus carcinomas and rhabdoid tumors: phenotypic and genotypic overlap

Five of six poorly differentiated choroid plexus carcinomas identified at our institution contained cells displaying a rhabdoid phenotype. Immunoperoxidase stains showed focal positivity for cytokeratin, epithelial membrane antigen, glial fibrillary acidic protein, S100, and vimentin. The MIB-1 proliferative index ranged from 7.0% to 27.1%. All six tumors were p53 positive. Only the one child with Li-Fraumeni syndrome had a p53 germline mutation. Electron microscopy verified choroid plexus differentiation and the co-existence of rhabdoid cells. Of the five studied, four had deletions of chromosome 22 [three with monosomy 22 and one with del(22)(q12)]. Thus, there was a phenotypic and genotypic overlap between choroid plexus carcinomas and rhabdoid tumors.

Developmental approaches in immunological control of acute myelogenous leukaemia

After many years of hope and disillusionment, the possibility of utilizing immune-mediated approaches to control neoplastic clones has become a reality in various haematological malignancies. This is largely a consequence of the continuous advances in knowledge and the progressive development of more refined technologies that have led to a better understanding of the biology of the malignant cells and of the host immune system, to a more precise definition of disease entities and to the design of innovative therapeutic programmes. In this chapter, we will review different immunological strategies that have reached clinical practice in patients with acute myelogenous leukaemia (AML), the focus of this volume, and discuss pre-clinical developments that may in the near future translate into the design of new immunotherapeutic protocols for the management of AML. Treatment of AML with antibody directed therapy will also be discussed.

Time-domain analysis of exercise-induced ST-segment elevation in Q-wave myocardial infarction: a useful tool for the screening of myocardial viability

BACKGROUND

Exercise-induced ST-segment elevation in Q-wave leads has been traditionally associated with passive stretching of the infarct wall, perinecrotic ischemia and, according to recent scintigraphic studies, with myocardial viability. At present, however, no definitive conclusions are available. We evaluated the potential role of a time-domain analysis of exercise-induced ST-segment elevation for the identification of viable myocardium and residual ischemia in patients with previous Q-wave myocardial infarction.

METHODS

Sixty patients with a previous Q-wave myocardial infarction underwent a bicycle exercise stress test, dobutamine stress echocardiography, coronary arteriography and left ventriculography.

RESULTS

Patients with exercise-induced ST-segment elevation in Q-wave leads (n = 36) showed more severe impairment of resting left ventricular function, when evaluated in terms of wall motion score index at echocardiography (1.62 +/- 0.33 vs 1.41 +/- 0.22, p < 0.01) and in terms of wall motion score at ventriculography (5.9 +/- 1.6 vs 4.1 +/- 1.5, p < 0.03), compared to patients without ST-segment shift (n = 24). No differences between the two groups were seen in the severity and extension of coronary artery disease. The two groups of patients did not differ in the overall incidence of viability (50% in patients with vs 62% in those without ST-segment elevation, p = NS) and homozonal ischemia (39 vs 26%, p = NS), when evaluated with dobutamine echocardiography. However, a time-domain analysis of the ST-segment changes during exercise showed that the duration of exercise up to 0.1 mV ST-segment elevation was significantly lower in patients with viability (6.2 +/- 3.3 min) than in those without (10.2 +/- 2.2 min) (p < 0.001). Accordingly, ST-segment elevation occurred within 3 and 6 min of exercise in 7/18 and in 12/18 patients with viability respectively, but in only 0/18 (p < 0.01) and in 1/18 (p < 0.01) patients without viability. Thus, ST-segment elevation occurring within the first two stages of the exercise test was, respectively, 39 and 67% sensitive and 100 and 94% specific for viability. Early onset ST-segment elevation (within 3 and 6 min) was also more frequent in patients with high-dose dobutamine-induced homozonal ischemia than in those without (sensitivity for ischemia 50 and 67%; specificity 95 and 74%, respectively).

CONCLUSIONS

After myocardial infarction, ST-segment elevation in Q-wave leads at the peak of exercise is associated with severe resting left ventricular dysfunction but fails to identify patients with a viable myocardium or residual ischemia. Instead, ST-segment elevation occurring in the early phases of exercise is a highly specific, although not very sensitive marker of dobutamine-assessed viability in the infarct area and may be indicative of residual ischemia.

A CD4+ T CELL CLONE SELECTED FROM A CML PATIENT AFTER DONOR LYMPHOCYTE INFUSION RECOGNIZES BCR-ABL BREAKPOINT PEPTIDES BUT NOT TUMOR CELLS1

BACKGROUND

In patients with chronic myelocytic leukemia (CML), the breakpoint cluster region and fusion between the BCR and the c-ABL genes (BCR-ABL) oncogen product is a potential tumor-specific antigen. Previous studies have shown that T cells specific for the junctional region peptides of the BCR-ABL oncoprotein can be detected in healthy individuals as well as in patients with CML in chronic phase. We assessed whether BCR-ABL- specific T cells could be found in a patient achieving a complete cytogenetic remission after CD4+ donor lymphocyte infusion.

METHODS

Using dendritic cells pulsed with BCR-ABL breakpoint peptides as antigen-presenting cells, we stimulated patient peripheral blood lymphocytes to isolate peptide-specific T cell clones present at the time of the cytogenetic response. T cell clones were isolated and the cellular specificity of these cells was examined.

RESULTS

A CD3+ CD4+ T cell clone (1F7) that recognizes overlapping p210 junctional peptides presented by HLA-DR molecules was identified and expanded in vitro. Clone 1F7 failed to recognize autologous tumor cells as well as dendritic cells derived from patient CML cells. Clone 1F7 did not inhibit the growth and differentiation of CML precursor cells in a standard colony formation assay. Finally, using a clone-specific probe, 1F7 cells could not be detected in patient peripheral blood at the time of the donor lymphocyte infusion response.

CONCLUSIONS

These results suggest that clone 1F7 was selected in vitro using highly potent peptide pulsed dendritic cells but was not representative of the anti-leukemia immune response in vivo. Based on these findings, CD4+ T cells with BCR-ABL specificity do not appear to be mediators of the anti-leukemia response in vivo after donor lymphocyte infusion.

Conversion to full donor chimerism following donor lymphocyte infusion is associated with disease response in patients with multiple myeloma

Donor lymphocyte infusions (DLIs) have been demonstrated to induce clinical responses in patients with relapsed multiple myeloma after allogeneic bone marrow transplantation, but the immunologic mechanisms involved have not been well characterized. In patients with chronic myelocytic leukemia (CML), remissions following DLI are invariably associated with conversion to complete donor hematopoiesis, suggesting that the target antigens of this response are expressed on both normal and CML-derived hematopoietic stem cells. In the present study, we examined hematopoietic chimerism and the complexity of the T-cell receptor (TCR) repertoire in 4 patients with relapsed multiple myeloma who received infusions of donor CD4+ lymphocytes. Three of 4 patients had a clinical response that began 1 to 2 months after DLI. All 3 responding patients developed lymphocytosis at the initiation of response that was due to a 2- to 4.5-fold increase in the number of CD3+ T cells. In 1 patient, this was due primarily to increases in CD3+ and CD8+ cells; in 2 patients, to increased numbers of CD3+ and CD8+ and CD3+ and CD4+ T cells. In all responding patients, conversion to complete donor hematopoiesis occurred in the first 2 months after DLI. The single nonresponding patient remained it 100% recipient hematopoiesis. The TCR repertoire complexity was examined by polymerase chain reaction amplification of complementary-determining region 3 (CDR3) derived from 24 Vbeta gene subfamilies. In 2 patients, the initiation of myeloma response and conversion to complete donor hematopoiesis was associated with normalization of TCR complexity. Complete donor chimerism and normal TCR complexity remained stable in all patients and did not change with subsequent relapse or development of graft-versus-host disease (GVHD). Thus, conversion to full donor chimerism was temporally associated with the antimyeloma effect of DLI but not with the development of GVHD. Nevertheless, the maintenance of stable donor hematopoiesis did not prevent disease relapse and was not associated with prolonged remission. The selective relapse of myeloma cells without concomitant return of mixed hematopoietic chimerism suggests that myeloma tumor cells in some patients develop resistance to immune destruction.

Defective signaling to Fyn by a T cell antigen receptor lacking the alpha -chain connecting peptide motif

A key role in the communication between the alphabetaTCR and the CD3/zeta complex is played by a specific motif within the connecting peptide domain of the TCR alpha chain (alpha-CPM). T cell hybridomas expressing an alpha-CPM-mutated TCR show a dramatic impairment in antigen-driven interleukin-2 production. This defect can be complemented by a calcium ionophore, indicating that activation of the calcium pathway is impaired. Several lines of evidence implicate Fyn in the regulation of calcium mobilization, at least in part through the activation of phospholipase Cgamma. Here we have investigated the potential involvement of Fyn in the TCR alpha-CPM signaling defect. Using T cell hybridomas expressing either a wild-type TCR or an alpha-CPM mutant, we show that Fyn fails to be activated by the mutant receptor following SEB binding and fails to generate tyrosine-phosphorylated Pyk2, a member of the focal adhesion kinase family. This defect correlated with an impairment in phospholipase Cgamma phosphorylation. Production of interlukin-2 and activation of the transcription factor NF-AT in response to triggering of the TCR alpha-CPM mutant with SEB were fully restored in the presence of constitutively active Fyn. Hence the signaling defect generated by the TCR alpha-CPM mutation results at least in part from an impaired coupling of the TCR.CD3 complex to Fyn activation.

Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction

BACKGROUND

The benefits of vessel recanalization in acute myocardial infarction (AMI) are limited by reperfusion damage. In animal models, adenosine limits reperfusion injury, reducing infarct size and improving ventricular function. The aim of this study was to evaluate the safety and feasibility of adenosine adjunct to primary PTCA in AMI.

METHODS AND RESULTS

Fifty-four AMI patients undergoing primary PTCA were randomized to intracoronary adenosine or saline. The 2 groups were similar for age, sex, and infarct location. Adenosine administration was feasible and well tolerated. PTCA was successful in all patients and resulted in TIMI 3 flow in all patients given adenosine and in 19 given saline (P<0.05). The no-reflow phenomenon occurred in 1 adenosine patient and in 7 saline patients (P=0.02). Creatine kinase was lower in the adenosine group, and a Q-wave MI developed in 16 adenosine patients and in 23 saline patients (P=0.04). Sixty-four percent of dyssynergic segments improved in the adenosine group and 36% in the saline group (P=0. 001). Function worsened in 2% of dysynergic segments in the adenosine group and in 20% in the saline group (P=0.0001). Adverse cardiac events occurred in 5 patients in the adenosine group and in 13 patients in the saline group (P=0.03).

CONCLUSIONS

Intracoronary adenosine administration is feasible and well tolerated in AMI. Adenosine adjunct to primary PTCA ameliorates flow, prevents the no-reflow phenomenon, improves ventricular function, and is associated with a more favorable clinical course.

Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction

BACKGROUND

The benefits of vessel recanalization in acute myocardial infarction (AMI) are limited by reperfusion damage. In animal models, adenosine limits reperfusion injury, reducing infarct size and improving ventricular function. The aim of this study was to evaluate the safety and feasibility of adenosine adjunct to primary PTCA in AMI.

METHODS AND RESULTS

Fifty-four AMI patients undergoing primary PTCA were randomized to intracoronary adenosine or saline. The 2 groups were similar for age, sex, and infarct location. Adenosine administration was feasible and well tolerated. PTCA was successful in all patients and resulted in TIMI 3 flow in all patients given adenosine and in 19 given saline (P<0.05). The no-reflow phenomenon occurred in 1 adenosine patient and in 7 saline patients (P=0.02). Creatine kinase was lower in the adenosine group, and a Q-wave MI developed in 16 adenosine patients and in 23 saline patients (P=0.04). Sixty-four percent of dyssynergic segments improved in the adenosine group and 36% in the saline group (P=0. 001). Function worsened in 2% of dysynergic segments in the adenosine group and in 20% in the saline group (P=0.0001). Adverse cardiac events occurred in 5 patients in the adenosine group and in 13 patients in the saline group (P=0.03).

CONCLUSIONS

Intracoronary adenosine administration is feasible and well tolerated in AMI. Adenosine adjunct to primary PTCA ameliorates flow, prevents the no-reflow phenomenon, improves ventricular function, and is associated with a more favorable clinical course.

Adenosine and angiotensin system interact in the regulation of renal microcirculation in humans

We sought to evaluate the possible interaction between the adenosine and angiotensin systems in the regulation of renal microcirculation in humans. Twenty normotensive patients entered the study. Ten patients (group 1) were pretreated with 50 mg of captopril, an inhibitor of angiotensin-converting enzyme, whereas 10 patients (group 2) were pretreated with placebo. Incremental doses of adenosine (from 10(-5) to 1 mg) were injected into a renal artery to all patients at 5-min intervals. Adenosine injection reduced mean renal blood flow velocity in both groups (from 17.3+/-2.8 and 16.7+/-2 cm/s to 5.1+/-1.1 and 3.8+/-0.8 cm/s, in groups 1 and 2, respectively). The decrease in flow velocity was immediate after adenosine, and its duration was proportional to dosage (y = 3.05 x -2.7; R2 = 0.46; p < 0.01). However, group 1 had a slope of regression lower than group 2 (2.37 vs. 3.82 s; p < 0.03). The index of renal resistance (mean arterial pressure/mean blood flow velocity) increased linearly in both groups with adenosine, but group I showed a lower slope of increment (2.77 vs. 5.57 mm Hg/cm/s; p < 0.01). Adenosine administration induced a marked and transient increase in human renal resistance. This vasoconstrictive effect of adenosine was blunted by captopril pretreatment.

Accessory cells, cytokine loops and cell-to-cell interactions in chronic lymphocytic leukemia

In addition to the extensive work that has been conducted in order to understand better the biological features of the leukemic population in B-cell chronic lymphocytic leukemia (CLL), over the years considerable interest has been directed towards other related studies that may have important implications for the accumulation of the leukemic clone and for the immunoparesis typical of this disease. In the present review article, we discuss some of these areas of investigation and, in particular, we focus on: (1) the multiple abnormalities recorded within the T and cytotoxic compartment of patients with CLL; (2) cytokine loops occurring in this disease, with particular emphasis on the cytokines that appear to play a more critical role; and (3) the cell-to-cell cross talk that may be actively operational in CLL. These findings will be discussed in relation with the possible implications that each of them have in the expansion and clinical behavior of a disease that is increasingly proving its heterogeneity.

Changes in T cell receptor repertoire associated with graft-versus-tumor effect and graft-versus-host disease in patients with relapsed multiple myeloma after donor lymphocyte infusion

Recent reports of clinical responses following donor lymphocyte infusions (DLI) in patients with relapsed multiple myeloma (MM) after allogeneic BMT have demonstrated the ability of allogeneic cells to mediate a graft-versus-myeloma (GVM) effect, but the mechanisms involved have not been determined. To identify changes in the T cell compartment associated with DLI, we performed a molecular analysis of the T cell receptor (TCR) repertoire in four patients with relapsed MM who received infusions of CD4+ lymphocytes from HLA-identical sibling donors. Three of the four patients demonstrated a clinical anti-myeloma response following DLI but also developed graft-versus-host disease (GVHD). The TCR repertoire was examined after PCR amplification of 24 Vbeta gene subfamilies. This method determines the relative utilization of each Vbeta gene subfamily and also allows the identification of clonal and oligoclonal T cell populations through analysis of CDR3 regions for each TCR Vbeta gene subfamily. Serial blood samples were obtained over at least a 1 year period before and after DLI and results compared to 10 normal donors. Serial analysis of CDR3 size profiles demonstrated the appearance of clonal T cell populations after DLI in each of the three responding patients. The appearance of some clones was noted within the first 3 months after DLI and coincided with decreasing levels of monoclonal paraprotein indicating an ongoing GVM response. Other T cell clones appeared at later time points and coincided with the development of GVHD. These findings demonstrate that T cell clones with different patterns of onset can be identified in the peripheral blood of MM patients following DLI. Further functional characterization of these distinct clonal expansions will be required to determine whether these T cell clones are mediators of either anti-myeloma or anti-host activity.

Reconstitution of T-cell receptor repertoire diversity following T-cell depleted allogeneic bone marrow transplantation is related to hematopoietic chimerism

CDR3 spectratyping was used to analyze the complexity of the T-cell repertoire and to define the mechanisms and kinetics of the reconstitution of T-cell immunity after allogeneic bone marrow transplantation (BMT). This method, which is based on polymerase chain reaction amplification of all CDR3 regions using the T-cell receptor (TCR) Vbeta genes, was used to examine serial samples of peripheral blood lymphocytes from 11 adult patients with chronic myelogenous leukemia (CML) who underwent T-cell-depleted allogeneic BMT. In contrast to 10 normal donors who display highly diverse and polyclonal spectratypes, patient samples before and early after BMT revealed markedly skewed repertoires, consisting of absent, monoclonal, or oligoclonal profiles for the majority of Vbeta subfamilies. To quantify changes in TCR repertoire over time, we established an 8-point scoring system for each Vbeta subfamily. The mean complexity score for patient samples before transplant (130.8) was significantly lower than that for normal donors (183; P = 0. 0007). TCR repertoire complexity was abnormal in all patients at 3 months after BMT (mean score = 87). Normalization of repertoire began in 4 patients at 6 months after BMT, but the majority of patients continued to display abnormal repertoires for up to 3 years after BMT. To determine whether the reconstituted T-cell repertoire was derived from the donor or recipient, unique microsatellite loci were examined to establish chimeric status. At 3 months after BMT, 7 patients demonstrated mixed chimerism; 4 had complete donor hematopoiesis (CDH). CDH strongly correlated with likelihood of restoration of T-cell repertoire complexity (P = 0.003). In contrast, patients who demonstrated persistence of recipient hematopoiesis failed to reconstitute a diverse TCR repertoire. These findings suggest that the reconstitution of a normal T-cell repertoire from T-cell progenitors in adults is influenced by interactions between recipient and donor hematopoietic cells. (Blood. 2000;95: 352-359)

Adenosine causes the release of active renin and angiotensin II in the coronary circulation of patients with essential hypertension

OBJECTIVES

The aim of the study was to evaluate whether adenosine infusion can induce production of active renin and angiotensin II in human coronary circulation.

BACKGROUND

Adenosine can activate angiotensin production in the forearm vessels of essential hypertensive patients.

METHODS

In six normotensive subjects and 12 essential hypertensive patients adenosine was infused into the left anterior descending coronary artery (1, 10, 100 and 1,000 microg/min x 5 min each) while active renin (radioimmunometric assay) and angiotensin II (radioimmunoassay after high performance liquid chromatography purification) were measured in venous (great cardiac vein) and coronary arterial blood samples. In five out of 12 hypertensive patients adenosine infusion and plasma samples were repeated during intracoronary angiotensin-converting enzyme inhibitor benazeprilat (25 microg/min) administration. Finally, in adjunctive hypertensive patients, the same procedure was applied during intracoronary sodium nitroprusside (n = 4) or acetylcholine (n = 4).

RESULTS

In hypertensive patients, but not in control subjects, despite a similar increment in coronary blood flow, a significant (p < 0.05) transient increase of venous active renin (from 10.7 +/- 1.4 [95% confidence interval 9.4 to 11.8] to a maximum of 13.8 +/- 2.1 [12.2 to 15.5] with a consequent drop to 10.9 +/- 1.8 [9.7 to 12.1] pg/ml), and angiotensin II (from 14.6 +/- 2.0 [12.7 to 16.5] to a maximum of 20.4 +/- 2.7 [18.7 to 22.2] with a consequent drop to 16.3 +/- 1.8 [13.9 to 18.7] pg/ml) was observed under adenosine infusion, whereas arterial values did not change. Calculated venous-arterial active renin and angiotensin II release showed a strong correlation (r = 0.78 and r = 0.71, respectively; p < 0.001) with circulating active renin. This adenosine-induced venous angiotensin II increase was significantly blunted by benazeprilat. Finally, both sodium nitroprusside and acetylcholine did not affect arterial and venous values of active renin and angiotensin II.

CONCLUSIONS

These data indicate that exogenous adenosine stimulates the release of active renin and angiotensin II in the coronary arteries of essential hypertensive patients, and suggest that this phenomenon is probably due to renin release from tissue stores of renally derived renin.

Hyperkinetic ventricular arrhythmias in very elderly people with and without cardiac disease. Correlation with left ventricular echocardiographic parameters

BACKGROUND

Morphological and functional changes induced by aging can hamper a clear distinction between pathological or paraphysiological phenomena in very old people. The incidence of hyperkinetic ventricular arrhythmias, for example, progressively increases in the elderly, even in the absence of overt cardiac disease.

METHODS

One-hundred fifty-two clinically stable patients older than 80 years, submitted within 15 days to clinical evaluation, 24-hour continuous ambulatory ECG monitoring and echo Doppler examination, in the absence of antiarrhythmic treatment, were retrospectively selected in order to evaluate the incidence of ventricular arrhythmias, in patients with and without significant heart disease. The further aim of the study was to correlate the number of arrhythmias with left ventricular morphological and functional parameters, echocardiographically assessed. From the initial population, 80 patients (41 males, age 83 +/- 3 years) had significant heart disease (ischemic, hypertensive or valvular): Group I. Seventy-two patients (30 males, age 83 +/- 3 years) had no clinical or instrumental signs of heart disease: Group II.

RESULTS

Considering echocardiographic data, Group I patients had a significantly higher left ventricular end-diastolic diameter (52 +/- 6 mm vs 47 +/- 4 mm, p < 0.01), lower ejection fraction (57 +/- 10% vs 64 +/- 6%, p < 0.01) and higher mass (275 +/- 84 g vs 208 +/- 46 g, p < 0.01), when compared with Group II. From ECG monitoring data, significant differences between the two groups were recorded in the incidence of premature ventricular beats per hour (79 +/- 163 vs 15 +/- 34, Group I vs Group II, p < 0.01) and presence of complex phenomena (couplets, triplets and runs: 51% vs 22%, p < 0.01). In old patients with documented cardiac disease a significant correlation was present between premature ventricular beats incidence and left ventricular end diastolic diameter (r = 0.39, p < 0.05) and left ventricular ejection fraction (r = 0.40, p < 0.05), while in patients without heart disease, no significant correlation was found between incidence of premature ventricular beats and echocardiographic morpho-functional parameters.

CONCLUSIONS

In conclusion, hyperkinetic ventricular arrhythmias are globally frequent in old persons of very advanced age (more than 80 years), but, also in this subset, a significant distinction in terms of incidence and severity of arrhythmias is present between subjects with and without cardiac disease. A significant correlation between incidence of premature beats and non-invasive morpho-functional left ventricular parameters is present only for patients with overt heart disease.

Characterization of a novel subset of CD8(+) T cells that expands in patients receiving interleukin-12

IL-12 has significant antitumor activity in mice that may be mediated by CD8(+) T cells. We show in this report that repeated subcutaneous injections of IL-12 in patients with cancer resulted in the selective expansion of a subset of peripheral blood CD8(+) T cells. This T cell subset expressed high levels of CD18 and upregulated IL-12 receptor expression after IL-12 treatment in vivo. In normal subjects, these CD3(+)CD8(+)CD18(bright) T cells expressed IL-12 and IL-2 receptors and adhesion/costimulatory molecules to a greater degree than other CD8(+) and CD4(+) T cells. They appeared morphologically as large granular lymphocytes, although they did not express NK cell markers such as CD56. In addition, CD8(+)CD18(bright) T cells were almost exclusively T cell receptor (TCR) alphabeta+, and exhibited a TCR Vbeta repertoire that was strikingly oligoclonal, whereas the Vbeta repertoire of CD18(dim) T cells was polyclonal. Although CD8+CD18(bright) T cells demonstrated little functional responsiveness to IL-12 or IL-2 alone in vitro, they responded to the combination of IL-12+IL-2 with strong IFN-gamma production and proliferation and enhanced non-MHC-restricted cytolytic activity. In contrast, CD18(dim) T cells were not activated by IL-12 or IL-2, alone or in combination. These findings demonstrate that CD8+CD18(bright) T cells are a unique population of peripheral blood lymphocytes with features of both memory and effector cells that are capable of TCR-independent activation through combined stimulation with IL-12+IL-2. As this activation results in IFN-gamma production and enhanced cytolytic activity, these T cells may play a role in innate as well as acquired immunity to tumors and infectious pathogens. Additional studies will be necessary to determine whether CD8+CD18(bright) T cells mediate the antitumor effect of IL-12 or IL-2 administered to cancer patients, and if so, whether maximal activation of these T cells with the combination of IL-12+IL-2 in vivo can augment the clinical effectiveness of these cytokines.

Protective effect of nisoldipine on dipyridamole-induced myocardial ischemia: correlation with exercise electrocardiography

BACKGROUND

Nisoldipine, a dihydropyridine calcium channel blocker with strong coronary dilatative action, is commonly used in the treatment of myocardial ischaemia; its beneficial effect on effort angina has been demonstrated by several previous reports. Infusion of dipyridamole in doses sufficient to provoke myocardial ischaemia in patients with significant coronary artery disease is used safely in imaging studies for diagnostic purposes.

OBJECTIVE

To evaluate the potential effect of nisoldipine on dipyridamole-induced ischaemia and to compare the results with the effect of nisoldipine on exercise-induced ischaemia.

METHOD

Twelve patients (10 men and two women, mean age 62 +/- 8 years) with significant coronary artery disease (at least 70% lumen reduction in at least one major coronary vessel) were selected for inclusion in the study. In accordance with the inclusion criteria, the patients exhibited an ischaemic diagnostic response to a multistage exercise electrocardiography stress test (> 0.15 mV ST segment depression compared with the resting electrocardiographic tracing) and to a dipyridamole-echocardiography test (transient left ventricular dyssynergy of contraction during infusion of dipyridamole up to 0.84 mg/kg over 10 min), after 3 days' cessation of antianginal treatment. After treatment with oral nisoldipine (10 mg twice daily) was introduced, the patients repeated the two tests, within 18 days of the first evaluation.

RESULTS

The dipyridamole-echocardiography test was positive for ischaemia in 12 patients who were not receiving nisoldipine and in eight patients who were receiving the drug (100% and 67% respectively, P < 0.05). In the eight patients who gave positive dipyridamole-echocardiography tests both with and without treatment, dipyridamole time (time to onset of dyssynergy during the test) increased from 7.9 +/- 2.9 min to 10.2 +/- 3.1 min (P < 0.01). In these patients, no significant changes were observed, at ischaemia, in the severity and extent of induced dyssynergy, evaluated as wall motion score index (each of 16 left ventricular segments scored from 1 = normal to 4 = dyskinetic) after treatment (score variations from baseline to ischaemia: 0.20 +/- 0.11 without nisoldipine and 0.16 +/- 0.06 with nisoldipine; NS). Variations in dipyridamole time (arbitrarily considered to be 15 min in the negative dipyridamole-echocardiography test) were significantly correlated with variations in exercise time (duration of exercise to exhaustion or diagnostic positive response on the electrocardiogram): r = 0.75 (P < 0.01). No significant differences were recorded in rate-pressure product (beats/min x mmHg x 100) at peak ischaemia between patients who were or were not receiving nisoldipine, during either the exercise electrocardiography stress test (233 +/- 36 with nisoldipine and 244 +/- 39 without nisoldipine; NS) or the dipyridamole-echocardiography test (147 +/- 21 with nisoldipine and 133 +/- 30 without nisoldipine; NS).

CONCLUSION

Nisoldipine treatment can protect from dipyridamole-induced ischaemia, being associated with a longer stress time, and completely preventing the development of ischaemia in some patients. The therapy-induced changes in ischaemic threshold during the dipyridamole-echocardiography test correlate with variations in exercise tolerance.

Characterization of T cell repertoire in patients with graft-versus-leukemia after donor lymphocyte infusion

The clinical efficacy of donor lymphocyte infusions (DLI) in patients with relapsed chronic myelocytic leukemia after allogeneic bone marrow transplantation has been demonstrated in several recent studies. Although it is presumed that allogeneic T cells mediate this graft-versus-leukemia (GVL) effect, the influence of DLI on the T cell compartment of recipients has not been determined. To characterize the immunologic effects of DLI and to identify T cell changes selectively associated with the GVL response, we analyzed the T cell receptor (TCR) repertoire in four patients with relapsed chronic myelocytic leukemia who achieved a complete remission after infusion of CD4+ lymphocytes from HLA-identical sibling donors. Only one of the four patients developed clinically significant graft-versus-host disease (GVHD) after infusion of donor lymphocytes. TCR repertoire was examined after PCR amplification of 24 Vbeta gene subfamilies in serial samples obtained over a 1-yr period before and after DLI. Results were compared to 10 normal donors. Before DLI, all four patients were found to have abnormal TCR Vbeta repertoire in peripheral T cells, associated with a large number of clonal and oligoclonal patterns. Abnormal TCR patterns persisted for at least 3 mo after DLI, but thereafter gradually began to normalize. By 1 yr after DLI, all patients demonstrated almost complete normalization of Vbeta repertoire with polyclonal representation within almost all Vbeta gene subfamilies. We also examined changes in the TCR Vbeta repertoire associated with the disappearance of Ph+ cells. In each patient, we were able to identify the expansion of at least 1 Vbeta gene subfamily that coincided with the time of the cytogenetic response. In one patient who was studied in greater detail, CDR3 size analysis of serial samples after DLI indicated that these changes were associated with the appearance of clonal T cells. This finding was confirmed through CDR3 sequence analysis and use of CDR3 clone-specific oligonucleotide probes. A putative GVL clone identified by this technique was not detectable in either donor or patient T cells before DLI, but persisted in peripheral T cells for approximately 1 yr. These experiments therefore provide evidence for the clonal expansion of allogeneic T cells that may be selective mediators of antileukemia activity without also mediating graft-versus-host disease.

Adenosine-induced renal vasoconstriction in man

OBJECTIVE

The aim of the study was to evaluate the effects of adenosine on renal blood flow in humans.

METHODS

Eleven normotensive patients (mean age 53 +/- 11 years) with normal renal angiograms were enrolled in the study. Arterial blood pressure, one ECG lead and arterial renal blood flow velocity, by intravascular Doppler catheter, were monitored throughout the procedure. Incremental doses (10(-5), 10(-4), 10(-3), 2 x 10(-3), 5 x 10(-3), 10(-2), 10(-1), 1 mg) were selectively injected, at 5-min intervals, in a renal artery.

RESULTS

Adenosine administration had no significant effects on blood pressure, heart rate and atrio-ventricular conduction. A progressive reduction in renal blood flow velocity (from 16.36 +/- 1.9 to 3.9 +/- 0.8 cm/s, P < 0.0001) was observed. Following adenosine the decrease of flow velocity was immediate and its duration was proportional to dosage (from 0.5 +/- 0.4 s at 10(-5) mg to 31 +/- 6.5 s at 1 mg). Renal angiography, repeated in four patients during flow velocity decrement, showed no changes in vessel diameter.

CONCLUSIONS

Exogenous adenosine-induced a marked and transient reduction in renal blood flow in man. This effect suggests that adenosine or its metabolites may be directly implicated in rapid and powerful mechanisms of cardiac output redistribution. Thus endogenous adenosine could have a role in regulating renal blood flow in physiological and pathological situations like strenuous exercise, hemorrhage shock and cardiac failure.

Probability of long-term disease-free survival for acute myeloid leukemia patients after first relapse: A single-centre experience

BACKGROUND

Various polichemotherapy regimens, including either high- or intermediate-dose Ara-C, are generally utilized to reinduce remission in relapsed AML patients. After achieving second CR, bone marrow transplantation (either allogeneic or autologous) represents the treatment of choice for eligible patients, with the aim of prolonging remission duration and improving disease-free survival.

PATIENTS AND METHODS

Fifty AML patients in first hematological relapse were treated with MEC regimen, consisting of a 6-day induction cycle [mitoxantrone 6 mg/m2/day, cytarabine (Ara-C) 1 g/m2/day and VP-16 80 mg/m2/day] followed by a 4-day cycle with the same drugs for patients achieving complete remission (CR); allogeneic or autologous bone marrow transplantation (BMT) were planned as post-consolidation treatment.

RESULTS

Thirty-four patients (68%) achieved second CR, 3 (6%) died during induction and 13 were refractory. CR rate was significantly higher in patients with a first CR lasting > 6 months (82% vs. 41%, P < 0.001). Out of the 34 patients in CR after the 4-day cycle, 18 (53%) were not eligible to transplant and did not receive any further therapy and 16 (47%) received autologous (15 cases) or allogeneic (1 case) BMT at a median time of 2 months from second CR. Twenty-two patients relapsed after a median time of 6 months (range 1-31), 1 patient died from transplant-related toxicity and 11 are in continuous CR [7 out of 16 (44%) in the transplanted and 4 out of 11 (36%) in the non-transplanted group]. Overall survival and event-free survival for the 50 patients were 29% and 19% at 70 months, respectively. The disease-free survival for the 34 patients who obtained second CR is 29% projected at 69 months [41% at 69 months for 16 transplanted patients versus 18% at 49 months for the remaining 18 patients (P = 0.007)].

CONCLUSIONS

These results show that MEC followed by high-dose post-consolidation treatment is a promising approach in relapsed AML; however, alternative strategies are to be investigated for the relevant fraction of patients that, even achieving second CR, are not eligible for BMT.

Autologous bone marrow transplantation in 44 patients with aggressive non-Hodgkin's lymphoma at University "La Sapienza" of Rome

High dose therapy followed by infusion of autologous bone marrow has become a major treatment option for an increasing number of poor prognosis non-Hodgkin's lymphoma (NHL) patients. In our study we analyzed the outcome of autologous bone marrow transplantation (ABMT) in 44 high grade NHL patients transplanted at our institution between 1985 and 1992. Median age was 31 years (range 12-61); nineteen were in partial remission (PR) after first line chemotherapy and 25 in sensitive relapse (SR). Of the 25 patients transplanted in SR, 14 relapsed after a median time of 5.5 months (range 1-26), 8 are in complete remission after a median follow up of 41.5 months and three died from toxicity. Of the 19 patients grafted in PR, 11 are alive and progression free after a median follow up of 52 months, while 8 relapsed at a median time of 5 months. The overall progression free survival (PFS) projected at 6 years is 35% with a 47% PFS for patients transplanted in PR and 28% for patients in SR. In conclusion, high dose therapy and ABMT has achieved widespread use as salvage therapy for patients with relapsed/refractory high grade NHL. In particular, our experience confirms that myeloablative treatment is a safe and well tolerated procedure for patients in PR, that may be easily applied as early salvage therapy without major toxicities.

CD3-induced T-cell activation in the bone marrow of myeloma patients: major role of CD4+ cells

A large expansion of activated T cells (CD3+CD25+) with the potential to act as anti-tumour effector cells is inducible in multiple myeloma (MM) patients by culturing bone marrow mononuclear cells (BMMCs) with the anti-CD3 monoclonal antibody (mAb) OKT3. The aim of this study was to provide a greater characterization of CD3-activated T cells. On day 6, most T cells coexpressed the CD11a, CD18, CD54, CD45R0 antigens and consisted of activated (CD25+) CD4+ and CD8+ cells in nearly equal proportions. Kinetics studies showed that CD4+CD25+ cells proliferated more rapidly and peaked earlier than CD8+CD25+ cells. When experiments were performed with purified subpopulations by removing CD4+ cells (resulting in CD8+ BMMCs) or by removing CD8+ cells (resulting in CD4+ BMMCs). T-cell activation and autologous plasma cell decrease were observed in CD4+ BMMCs only. Transwell cultures showed that CD4 help was necessary to make CD8+ BMMCs susceptible to CD3 stimulation. Relevant amounts of IL-2 were found in the supernatants of CD4+ BMMCs cultures, whereas no secretion of IL-4 was detected, indicating a Th1-like profile of CD3-activated CD4+ cells. These data indicate that CD4+ cells proliferate earlier and provide optimal help to induce the subsequent expansion of CD8+ cells after CD3 stimulation of MM BMMCs. Adequate stimulation of CD4+ cells is therefore essential in any strategy aiming to recover T-cell-mediated immunity in MM.

[Infections in intensive care units]

Hospital acquired infections are one of the most serious problems of public health. The problem of hospital infections assumes greatest relevance especially for patients in intensive care units (ICU). In these patients both the incidence (about 40%) and the mortality rate (non infected patients 13%; infected patients 47%) of infections is particularly high. Low respiratory tract represents the most frequent localization of ICU infections (30-50%). The causal pathogens are represented in more than 50% of cases by Gram-negative bacilli provided with low virulence and normally present in patients and in the hospital environment. The pathogenesis of infections in ICU is multiform, deriving from the interplay of many factors: the impairment of organic defenses; the age of the patients, often at the upper or lower limits; the multi-pathology and severity of underlying disease; the side effects of medical therapy (immunodepression); the closeness of many patients in narrow wards, that allows the diffusion of infections; the presence in the hospital environment of many pathogens with poly-antibiotic resistance. The control and prophylaxis programs should include: interventions on ICU structure in order to optimize the building projects and maintain high standard quality; training programs for medical and nursing personnel; interventions on patient-related factors; surveillance protocols (events documentation and monitoring of intervention results).