Prognostic role of global work efficiency in patients undergoing transcatheter aortic valve implantation

Background

Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative echocardiographic tool for myocardial function assessment. Its role in patients with severe aortic stenosis (AS) after aortic valve implantation (TAVI) has not been adequately investigated.

Purpose

We aimed to evaluate MW indices as early echocardiographic markers of LV reverse remodeling within a month after TAVI and their prognostic value.

Methods and results

We conducted a single-centre prospective study, enrolling 88 consecutive patients (mean age 79.9±6.4 years, 35% males) with AS undergoing TAVI between April 2018 and 2021, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, atrial fibrillation, left bundle branch block (LBBB) at baseline and and suboptimal quality of imaging. Echocardiographic assessment was performed before TAVI and at 30-day follow-up, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). LV peak systolic pressure was estimated non-invasively from the sum of systolic blood pressure and trans-aortic mean gradient. One month after the procedure, there was a significant improvement of LV GLS (−18.4±4.2 vs −19.5±4.2%, before and after TAVI respectively, p=0.006), a significant reduction of GWI (2406±567 vs 1908±479 mmHg%, p<0.001), GCW (2783±616 vs 2202±463 mmHg%, p<0.001), and GWW (238±203 vs 173±127 mmHg%, p=0.002). Conversely, MWE did not change early after intervention (90.4±6.2 vs 91.4±5.1%, p=0.113). After TAVI, 32 patients (36.4%) developed LV dyssynchrony due to LBBB or pacemaker implantation. When the population was divided according to the presence or absence of LV dyssynchrony at 30-day follow-up, a significant reduction in GWW was found only in the those without dyssynchrony (241±229 vs 142±103 mmHg% before and after TAVI, p<0.001). Consistently, in this subgroup, MWE significantly improved after TAVI (90±7 vs 93±5%, p=0.001), while a trend of MWE reduction was observed in patients who developed dyssynchrony after TAVI (91±5 vs 89±5%, p=0.110). In the overall population, a 30-day value of MWE≤92% was associated with an increased rate of cardiovascular events (composite of all-cause death and rehospitalization for heart failure) at 1-year follow-up (29.5% vs 4.8%, long rank p=0.003). In multivariable Cox-regression analysis, adjusted for confounders, GWE after TAVI (HR: 0.892, CI: 0.817–0.974; p=0.011) was independently associated with events at 1-year follow-up.

Conclusions

In patients with severe AS undergoing TAVI a significant reduction of GWW and improvement of MWE can be detected only in those who do not develop LV dyssynchrony. In this setting, MWE≤92% early after TAVI is associated with poor outcome. Thus, MWE could represent an alternative tool for myocardial function assessment and prognostic evaluation in patients receiving TAVI.

Funding Acknowledgement

Type of funding sources: None.

P147 RECOVERY OF CHEMOTHERAPY RELATED ACUTE HEART FAILURE BY THE COMBINED USE OF SACUBITRIL VALSARTAN AND WEARABLE CARDIOVERTER DEFIBRILLATOR. A NOVEL WINNING COMBINATION IN CARDIO–ONCOLOGY

Effective anticancer treatments have dramatically improved the outcome of cancer patients but cardiac toxicity reduces their clinical efficacy in a non–negligible percentage of patients. Sacubitril/valsartan is a new paradigm in the treatment of chronic heart failure with reduced ejection fraction due to the enhancement of natriuretic peptides’ properties when coupled with a blocking effect on the AT1 angiotensin receptors. As with other clinical conditions of heart failure with potentially reversible declines in cardiac function, the wearable cardioverter defibrillator is a valid tool for protection against sudden death until recovery occurs. We report a case series of four patients with chemotherapy–related acute cardiac failure with severely reduced cardiac function. They were successfully treated with sacubitril/valsartan while being protected from malignant arrhythmias by the use of a wearable cardioverter defibrillator until the recovery of cardiac function. Sacubitril/valsartan was confirmed to be effective in anthracycline–related cardiac toxicity and the wearable cardioverter defibrillator should be considered as a support tool even in the oncology patient.

Unusual presentation of extranodal diffuse large B-cell lymphoma in a solid-organ recipient during long-term immunosuppressive treatment

INTRODUCTION

Posttransplant lymphoproliferative disorders (PTLDs) refer to a group of diseases, including diffuse large B-cell lymphoma (DLBCL), that develop after solid organ transplantation or hematopoietic stem cell transplantation. Extranodal involvement in PTLDs is common. Reports about exclusive bone marrow involvement are rare.

CASE DESCRIPTION

A 70-year-old woman, who had undergone kidney transplantation in 2018, was diagnosed with exclusively extranodal, Epstein-Barr virus-negative DLBCL, with bone marrow and spleen involvement, during long-term immunosuppression. She achieved complete remission with combined immunochemotherapy and temporary hold of immunosuppression.

CONCLUSIONS

This case shows an uncommon clinical presentation of DLBCL, which was challenging to diagnose, being entirely extranodal. The favorable clinical course relied on timely diagnosis and a multidisciplinary approach. Long-term consequences of posttransplant immunosuppression require a high level of suspicion for an appropriate management, aimed at preserving the graft while eradicating the lymphoproliferative disorder.

Integrative Analysis of Human Macrophage Inflammatory Response Related to Mycobacterium tuberculosis Virulence

Mycobacterium tuberculosis (Mtb), the etiological agent of tuberculosis, kills 1.5 to 1.7 million people every year. Macrophages are Mtb's main host cells and their inflammatory response is an essential component of the host defense against Mtb. However, Mtb is able to circumvent the macrophages' defenses by triggering an inappropriate inflammatory response. The ability of Mtb to hinder phagolysosome maturation and acidification, and to escape the phagosome into the cytosol, is closely linked to its virulence. The modulation of the host inflammatory response relies on Mtb virulence factors, but remains poorly studied. Understanding macrophage interactions with Mtb is crucial to develop strategies to control tuberculosis. The present study aims to determine the inflammatory response transcriptome and miRNome of human macrophages infected with the virulent H37Rv Mtb strain, to identify macrophage genetic networks specifically modulated by Mtb virulence. Using human macrophages infected with two different live strains of mycobacteria (live or heat-inactivated Mtb H37Rv and M. marinum), we quantified and analyzed 184 inflammatory mRNAs and 765 micro(mi)RNAs. Transcripts and miRNAs differently modulated by H37Rv in comparison with the two other conditions were analyzed using in silico approaches. We identified 30 host inflammatory response genes and 37 miRNAs specific for H37Rv virulence, and highlight evidence suggesting that Mtb intracellular-linked virulence depends on the inhibition of IL-1β-dependent pro-inflammatory response, the repression of apoptosis and the delay of the recruitment and activation of adaptive immune cells. Our findings provide new potential targets for the development of macrophage-based therapeutic strategies against TB.

Ubiquitination-dependent control of sexual differentiation in fission yeast

In fission yeast, meiosis-specific transcripts are selectively eliminated during vegetative growth by the combined action of the YTH-family RNA-binding protein Mmi1 and the nuclear exosome. Upon nutritional starvation, the master regulator of meiosis Mei2 inactivates Mmi1, thereby allowing expression of the meiotic program. Here, we show that the E3 ubiquitin ligase subunit Not4/Mot2 of the evolutionarily conserved Ccr4-Not complex, which associates with Mmi1, promotes suppression of meiotic transcripts expression in mitotic cells. Our analyses suggest that Mot2 directs ubiquitination of Mei2 to preserve the activity of Mmi1 during vegetative growth. Importantly, Mot2 is not involved in the constitutive pathway of Mei2 turnover, but rather plays a regulatory role to limit its accumulation or inhibit its function. We propose that Mmi1 recruits the Ccr4-Not complex to counteract its own inhibitor Mei2, thereby locking the system in a stable state that ensures the repression of the meiotic program by Mmi1.

Indications for rapid sequence urography after washout (reinjection) in the diagnosis of renovascular hypertension

38 hypertensive patients suspected of renovascular hypertension were examined with rapid sequence urography, washout, aortography or selective renal arteriography. When discordant results were found between rapid sequence urography and washout, we used a particularly helpful procedure which we define reinjection or rapid sequence urography after washout: washout is followed by the injection of a second 50-cm3 dose of contrast agent and five more roentgenograms at 1-min intervals. In our series, reinjection allowed correct diagnosis in 66% of the cases with discordant results and confirmed diagnosis in 83% of the cases of renovascular hypertension.

[Psycho-organic diseases in children and adolescents affected by pediatric neoplasms]

At Pediatric Oncology Centers, psychological intervention and psychotherapy are generally offered to children and adolescents for supporting their adjustment to disease and treatment. The clinical practice, however, point out that cognitive and emotional symptoms, such as psychic distortions, fatigue, anxiety, irritability and depression, are sustained by biological mechanisms connected with disease and treatment and not respondent to psychological consultation and to other psychosocial resources. These manifestations could interfere with treatment or with the long-term adjustment and call for psychopharmacological treatments. Biological factors able to cause these alterations are not yet studied in depth in clinical tradition and scientific literature on the integration of psychological and psychopharmacological intervention in pediatric oncology is still poor. In this paper organic components of psychic and behavioral alterations in the course of disease are illustrated, considering the symptoms, causes and possible remedies in the light of the most recent interdisciplinary views. The main mechanism connected with oncologic treatments - chemotherapy, surgery, radiotherapy - and responsible for psycho-organic alterations in children and adolescent with cancer are also described.

Rayleigh wave scattering from sessile droplets

Radiation of energy by large-amplitude leaky Rayleigh waves is regarded as one of the key physical mechanisms regulating the actuation and manipulation of droplets in surface acoustic wave (SAW) microfluidic devices. The interaction between a SAW and a droplet is highly complex and is presently the subject of extensive research. This paper investigates the existence of an additional interaction mechanism based on the propagation of quasi-Stoneley waves inside sessile droplets deposited on a solid substrate. In contrast with the leaky Rayleigh wave, the energy of the Stoneley wave is confined within a thin fluid layer in contact with the substrate. The hypothesis is confirmed by three-dimensional finite element simulations and ultrasonic scattering experiments measuring the reflection of Rayleigh waves from droplets of different diameters. Moreover, real-time monitoring of the droplet evaporation process reveals a clear correlation between the droplet contact angle and the spectral information of the reflected Rayleigh signal, thus paving the way for ultrasonic measurements of surface tension.

Combining time of flight and diffraction tomography for high resolution breast imaging: initial in vivo results (L)

Ultrasound tomography (UST) is being developed to address the limitations of mammography in breast cancer detection. Central to the success of UST is the possibility of obtaining high-resolution images of tissue mechanical properties across the whole breast. A recent paper [Huthwaite and Simonetti, J. Acoust. Soc. Am. 130, 1721-1734 (2011)] made use of a numerical phantom to demonstrate that sufficient image resolution can be obtained by simply treating refraction and diffraction effects in consecutive steps through the combination of ray-based time of flight and diffraction tomography. This letter presents the first experimental demonstration of the method using phantom and invivo data from a cancer patient.

High-resolution imaging without iteration: a fast and robust method for breast ultrasound tomography

Breast ultrasound tomography has the potential to improve the cost, safety, and reliability of breast cancer screening and diagnosis over the gold-standard of mammography. Vital to achieving this potential is the development of imaging algorithms to unravel the complex anatomy of the breast and its mechanical properties. The solution most commonly relied upon is time-of-flight tomography, but this exhibits low resolution due to the presence of diffraction effects. Iterative full-wave inversion methods present one solution to achieve higher resolution, but these are slow and are not guaranteed to converge to the correct solution. Presented here is HARBUT, the hybrid algorithm for robust breast ultrasound tomography, which utilizes the complementary strengths of time-of-flight and diffraction tomography resulting in a direct, fast, robust and accurate high resolution method of reconstructing the sound speed through the breast. The algorithm is shown to produce accurate reconstructions with realistic data from a complex three-dimensional simulation, with masses as small as 4 mm being clearly visible.

Imaging beyond the Born approximation: an experimental investigation with an ultrasonic ring array

The classical diffraction limit excludes the possibility of resolving features of an object which are spaced less than half a wavelength apart when scattering experiments are performed from the far field. However, recently it has been shown that this limit could be a consequence of the Born approximation that neglects the distortion of the probing wave as it travels through the object to be imaged. Such a distortion, which is due to the multiple scattering phenomenon, can encode unlimited resolution in the radiating component of the scattered field thus leading to super resolution. In this context, a resolution better than lambda/3 has been reported in the case of elastic wave probing [F. Simonetti, Phys. Rev. E 73, 036619 (2006)], lambda being the wavelength of the wave illuminating the object. This paper demonstrates a resolution better than lambda/4 and approaching lambda/6 for objects immersed in a water bath probed by means of a ring transducer array that excites and detects ultrasonic pressure waves in a full view configuration. This is achieved despite the presence of a high level of noise in the measurements (the signal to noise ratio was below 0 dB). Moreover, while previous papers have provided experimental evidence of super resolution for objects small compared to the wavelength, here the case of extended objects is also investigated.

Transitory, spontaneously recovering, peripheral facial nerve palsy after vinorelbine administration

Childhood intrinsic brain-stem gliomas have a dismal prognosis. Different treatment strategies have been adopted over the years without changing the final outcome of this ominous disease. Due to this grim prognosis, experimental therapeutic designs are worthwhile. Vinorelbine is a semi-synthetic vinca alkaloid that has demonstrated a broad spectrum of activity both in in vitro and in vivo experimental systems. By adopting vinorelbine during and after focal radiotherapy in the last two years, we have tried to evocate its known synergistic effect in brain-stem tumour control. Vinorelbine was administered intravenously before, during and after radiotherapy on tumour bed for a total duration of 10 months. All the consecutive patients whose clinical and radiological features corresponded to the diagnosis of an intrinsic brain-stem tumour, i.e., diffuse pontine glioma, have been accrued to this treatment protocol since July 2002. A histological assessment was not required. All patients were treated during hospital stay or in the outpatient clinic at the Istituto Nazionale Tumori of Milan (n=12) and at the Pediatric Clinic of Policlinico in Catania (n=1). Two of the thirteen patients so far treated have developed multiple subsequent, and transitory, episodes of monolateral peripheral facial nerve palsy during vinorelbine administration. The palsy always completely and spontaneously resolved at a short interval-around 30 min-after the end of the drug infusion. Obvious tumour progression was excluded by means of MRI; therefore the drug was administered as scheduled until the end of the treatment. We describe possible neurological and oncological implications of this unusual side effect, until now not reported in any other series dealing with vinorelbine as adjuvant treatment.

Multiple scattering: the key to unravel the subwavelength world from the far-field pattern of a scattered wave

For more than a century the possibility of imaging the structure of a medium with diffracting wave fields has been limited by the tradeoff between resolution and imaging depth. While long wavelengths can penetrate deep into a medium, the resolution limit precludes the possibility of observing subwavelength structures. Near-field microscopy has recently demonstrated that the resolution limit can be overcome by bringing a probing sensor within one wavelength distance from the surface to be imaged. This paper extends the scope of near-field microscopy to the reconstruction of subwavelength structures from measurements performed in the far-field. It is shown that the distortion undergone by a wave field as it travels through an inhomogeneous medium and the subsequent generation of local evanescent fields encode subwavelength information in the far-field due to multiple scattering within the medium. This argument is proved theoretically and supported by a limited view experiment performed with elastic waves in which an image with a resolution better than a third of the wavelength is achieved.

[Application of the legislation on safety occupational hygiene in the Military Navy]

The paper analyses the consequences of the promulgation legislative decree 626/94 on the sanitary organization of the Armed Forces and, particularly, of the Italian Military Navy. In this context, the authors describe the current safety and occupational hygiene organization, the tasks of the vigilance organs, and the actuative modalities of preventive measures on the ships (during navigation and in shipyard).

National character does not reflect mean personality trait levels in 49 cultures

Most people hold beliefs about personality characteristics typical of members of their own and others' cultures. These perceptions of national character may be generalizations from personal experience, stereotypes with a "kernel of truth," or inaccurate stereotypes. We obtained national character ratings of 3989 people from 49 cultures and compared them with the average personality scores of culture members assessed by observer ratings and self-reports. National character ratings were reliable but did not converge with assessed traits. Perceptions of national character thus appear to be unfounded stereotypes that may serve the function of maintaining a national identity.

On the meaning of Lamb mode nonpropagating branches

The modes of vibration of an elastic plate are usually divided into propagating and nonpropagating kinds. While nonpropagating modes characterize local vibration nearby a perturbation source, which can be either an external force or a geometrical discontinuity, propagating modes carry energy along the waveguide and account for the vibration far away from the perturbation source. In this paper, by considering that the modes of an absorbing plate are always propagating, it is shown that each elastic mode consists of propagating and nonpropagating branches, which turn into a single propagating mode as soon as internal absorption is considered. Moreover, it is shown how introducing a little material damping leads to a rigorous differentiation of elastic modes when they are connected. A similar result can be obtained by loading the plate with a light fluid [Rokhlin et al., J. Acoust. Soc. Am. 85, 1074-1080 (1989)].

Ultrasonic interferometry for the measurement of shear velocity and attenuation in viscoelastic solids

A method for the measurement of the shear properties of solid viscoelastic materials is presented. The viscoelastic material is cut into a cylindrical sample which is clamped between two rods. The transmission and reflection coefficient spectra of the fundamental torsional mode through the sample are measured by means of two pairs of piezoelectric transducers placed at the free ends of the rod-sample-rod system. Such spectra exhibit maxima and minima which occur approximately at the resonance frequencies of the free viscoelastic cylinder. Therefore, the shear velocity can be obtained by measuring the frequency interval between two consecutive maxima or minima. The shear attenuation is derived by best fitting the analytical expression of the reflection and transmission coefficients to the experimental spectra. The test is very quick to set up as the sample is simply clamped between the two rods.

A guided wave technique for the characterization of highly attenuative viscoelastic materials

The measurement of the acoustic properties of highly attenuative materials such as bitumen is very difficult. One possibility is to use measurements of the extent to which filling a cylindrical waveguide with the material affects the dispersion relationship of the cylinder. Torsional modes have been excited using piezoelectric transducers placed at one end of the cylinder, while the phase velocity and attenuation spectra have been measured by means of laser scanning. At each frequency, under the hypothesis of linear viscoelasticity, the phase velocity and attenuation of the fundamental torsional mode have been calculated as a function of the bulk shear velocity and the bulk shear attenuation of the inner core at that frequency. The resulting phase velocity and guided wave attenuation contour plots have been employed for deriving the unknown shear properties from the measured velocity and attenuation of the guided wave. The monochromaticity of the approach has not required a particular frequency dependence of the material properties to be assumed. Results for bitumen are given.

Intravascular lymphomatosis (IL) in a child mimicking a posterior fossa tumor

Intravascular lymphomatosis (IL) is a rare entity only recently included in lymphoma classification, whose main feature is the exclusive or predominant growth of neoplastic cells within blood vessels. The vast majority of the patients affected by IL belong to the 7th or 8th decade of life and present with skin rash or CNS diffuse necrotic or demyelinating lesions. Case report. SS, a 13-year-old girl, was admitted to a Neurosurgery Unit because of endocranic hypertension, where, after CT and MRI documenting a IV ventricle 3 cm diameter tumor, she was submitted to complete tumor excision: extemporary diagnosis was suggestive of medulloblastoma. When referred to us she had persistent fever with normal blood and spinal fluid cultures. Whole CNS MRI did not give evidence of residual or metastatic disease while CSF cytology showed only pleiocytosis. Treatment was started according to our ongoing protocol for medulloblastoma with pre-radiation chemotherapy. Before delivering radiotherapy (RT), upon review of histologic specimens, the definitive diagnosis of IL B-phenotype was made. The girl was re-admitted and, after a complete re-staging, chemotherapy was intensified according to our schedule for high-grade B-cell lymphoma and CNS was irradiated up to a total dose of 25 Gy. She remained alive in continuous complete remission at 21 months after diagnosis. The case here reported is unique for age, tumor presentation, and, so far, favourable outcome, in spite of the delayed histological diagnosis.

Dejerine's syndrome or Spiller's syndrome?

We report the difference existing between two clinical syndromes: Spiller's syndrome is caused by a complete involvement of the medial hemimedulla, while Déjérine's syndrome is determined by lesions restricted to the anterior portion of the medial hemimedulla and is characterized by hypoglossal nerve palsy and contralateral hemiparesis.

A CLN2 gene nonsense mutation is associated with severe caudate atrophy and dystonia in LINCL

Clinical features and results of the blood DNA analysis are reported of a child affected with a distinct phenotype of the late infantile form of neuronal ceroid-lipofuscinosis (LINCL). He was affected by microcephaly and hypotonia since the fourth month of life; acquisition of motor and language abilities was severely impaired, and a disorder of communication with stereotyped movements followed. By age four, he developed signs and symptoms of progressive myoclonic encephalopathy along with motor and cognitive deterioration. Extrapyramidal signs were associated with neuroradiological findings of marked atrophy of the caudate nucleus. Specific curvilinear bodies were observed in blood lymphocytes and skin biopsy. Homozygous, nonsense mutation in the CLN2 gene was found giving origin to an Arg208stop, which produces an early transcription termination with loss of translation of about 50% of the gene product. Any relationship between the severe clinical features of our patient and the homozygous mutation here reported must be investigated on a larger number of LINCL patients bearing the same mutation.

Migraine with aura and white matter abnormalities: Notch3 mutation

The authors report on an Italian family with eight affected members who show autosomal dominant migraine with prolonged visual, sensory, motor, and aphasic aura. These symptoms are associated with white matter abnormalities on brain MRI. All living affected members carry a Notch3 mutation (Arg153Cys) previously reported in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). White matter abnormalities occur in a variable percentage of the general migraine population; CADASIL should be suspected in migraineurs with prolonged atypical aura and white matter abnormalities.

Disseminated encephalitis following streptococcal infection

Various neurological disorders have been related to Streptococcus pyogenes infection. Only recently, and for the first time, it has been suggested that acute disseminated encephalitis may also complicate a streptococcal infection. The case reported in this paper seems to confirm this hypothesis.

[Encephalitis lethargica]

We report the case of a 34-year old patient who first complained of fever, confusion and transient ophthalmoplegia and then developed akinetic mutism, frontal lobe, pyramidal tract and extrapyramidal signs. Clinical and electrophysiological data support a diagnosis of encephalitis lethargica. Magnetic resonance imaging showed hyperintensive lesions in various brain regions. The patient responded to corticosteroid treatment. Two years after the onset of the first clinical signs he had recovered completely and today, after 5 years, he shows no sign of disease.

Familial adult amyotrophic lateral sclerosis: report of cases

We examined 8 cases of familial ALS (amyotrophic lateral sclerosis) in three different families from our province, admitted to our hospital between 1970 and 1989. Clinical criteria for diagnosis were satisfied in all cases; EMG was performed in 6 out of 8 patients. 4 cases showed classical onset and 4 cases bulbar onset. The average age at onset was 65.7 + 10.6 years. The average survival was 19.1 + 9.2 months. In two families two generations were affected, in the other only one. The mode of transmission was found to be autosomal dominant with variable penetrance. Neither environmental nor toxic factors seemed to be involved in the development of the illness. Genetic investigations may help to elucidate the pathogenesis of familial ALS.

[Clonidine and postoperative shivering]

Clonidine was clinically evaluated to suppress postoperative shivering in 60 patients who had undergone anesthesia for general, thoracic and vascular surgery. The study was carried out in double blind conditions with comparison of two doses (75 and 150 micrograms) of clonidine, one dose of methylphenidate, and one dose of saline, as control group. The level of inhibition (Goldfarb scale), haemodynamics and temperature were studied. In conclusion, the methylphenidate is drug first choice for postoperative shivering, but clonidine inhibits postoperative shivering without haemodynamic and temperature variations (75 micrograms).

[Investigation on the renal clearance of metylglucamine diatrizoate and of sodium and metylglucamine diatrizoate (author's transl)]

In 14 patients the kinetics has been studied of two contrast media labelled with 131I, and namely of MGM diatrizoate and of diatrizoate of sodium and MGM. The clearance was determined both at basal concentrations and in double concentration by means of external counting. The results were statistically studied by means of the linear regression method. The authors conclude that the MGM diatrizoate is exclusively eliminated through the glomeruli both in basal and double concentration. The diatrizoate of sodium and MGM is eliminated in low concentration through the glomeruli, while in double concentration it is partially eliminated through the tubuli.