Optical coherence tomography and artificial intelligence for calcium quantification in coronary disease of diabetic patients

Background

Diabetes mellitus (DM) is associated with increased cardiovascular morbidity and mortality. Coronary artery disease in diabetic patients is characterized by a greater burden of lipidic plaques and calcifications. Little is known on the quantitative and qualitative characteristics of calcific plaques in diabetics vs non diabetics. The recent application of Artificial Intelligence (AI) to optical coherence tomography (OCT) enables unique evaluation of coronary calcification.

Purpose

To compare qualitative and quantitative characteristics of coronary calcified plaques in diabetic and non-diabetic patients using AI-OCT.

Methods and material

We recruited 78 patients admitted for chronic coronary syndrome (CCS) or acute coronary syndrome (ACS) undergone intracoronary imaging with OCT between January 2019 to October 2021. Differences in plaques characteristics assessed by Artificial Intelligence applied at OCT runs were compared in DM and non-DM population using generalized estimating equations. To estimate the burden of calcification we classified the calcific lesions according to the Fujino score, an OCT based calcium scoring system.

Results

A total of 78 patients were included (54 non-DM lesions, 29 DM lesions). The culprit lesion was examined by OCT in all patients without any peri- or postprocedural complications. The population was homogeneous for cardiovascular risk factors even if we observed a higher prevalence of peripheral arterial disease (PAD) in the DM cohort (22.2% vs 2% p value 0.003). There were no statistical differences in previous PCI or CABG but we observed more multivessel PCI in the history of DM patients if compared with non-diabetic ones (33.3% vs 11.8% p value 0.021). The clinical presentation in DM groups was more often unstable angina (22.2% vs 0% p value <0.001) while STEMI, NSTEMI or CCS had the same prevalence in the two cohorts. At baseline angiography, patients with diabetes had more often multivessel disease (29.6% vs 17.6% p=0.014) with all the vessels equally involved. There were no qualitative differences in plaque morphology but using the Fujino score to estimate the calcium burden in the two population we found hardest calcific plaques expressed by higher Fujino score more frequently in DM patients compared to non-DM ones (50% vs 26.9%, p=0.04 of Fujino score 4).

Conclusion

DM has an impact on atherosclerotic process and plaque remodeling. Applying AI methods at OCT plaque analysis, we can extract important and standardized information on calcium burden in diabetic. This might help the interventional cardiologist in image interpretation, therapeutic strategy decision, improving workflow and clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Florence

The role of calcification in cardiovascular outcome after left main bifurcation revascularization: a single centre experience

Introduction

Left main bifurcation (LMB) disease represents a high-risk subset of advanced coronary artery disease, often associated with severe calcification. Different stenting techniques have been evaluated to overcome challenges of the LMB anatomy, but the role of the calcific burden on cardiovascular (CV) outcome after LMB revascularization is unclear.

Purpose

We sought to evaluate the CV hospitalization predictors during follow-up of patients who underwent LMB revascularization (LMBR) in a high-volume center in Italy.

Methods

We performed a retrospective analysis of LMBR patients between 2018 and 2021. Patients were treated with different techniques in the acute or chronic settings and followed-up by telephone or outpatient visit. Coronary calcification (CC) was visually judged as absent, mild, moderate or severe. Predictors of CV hospitalizations were assessed.

Results

The median follow-up was 511 days. Among 129 patients who underwent LMBR during the study period, 32 (24.8%) were female, with a mean age of 72 (±10.6) years. 105 (81.4%) patients were hypertensive and 49 (38%) diabetics. The mean eGFR value was 66.3 (± 21.8) ml/min/m2. The majority of patients had three vessel disease (79, 61.3%), while only a small minority had one vessel disease (5, 3.9%). The mean SYNTAX score I was 27.1 (± 8.6), with most patients at intermediate risk (65, 50.4%) followed by patients at low (37, 28.7%) and high (27, 20.9%) risk. A provisional technique was used in most cases (79, 61.2%), followed by double-kissing crush (37, 28.7%) and T-stent/T-and-protrusion (13, 10.1%). Intravascular imaging was used in 84 (65.1%) cases. Most patients had no angiographic demonstration of CC (73, 57.9%), while when present, they were mild in 14 (11.1%), moderate in 29 (23%) and severe in 10 (7.9%) patients. Preparation of the CC was performed only with non-compliant (NC) balloons in mild CC (10, 71.4%) and with NC balloons (14, 48.3%) or intravascular lithotripsy (IVL) (13, 44.8%) in case of moderate CC. In the presence of severe CC, lesion preparation was carried out with IVL (4, 40%) or NC balloons (6, 60%). CC were associated with a more unfavorable outcome and, when present in a severe grade, resulted in a statistically significant risk of CV hospitalizations (HR 1.652; 95% CI 1.723–15.793; p=0.003) (Figure 1). After univariate and multivariate Cox regression analysis (Figure 2), only the presence of severe CC was associated with an increased risk of CV hospitalizations (HR 1.9; 95% CI 1.76–19.63; p=0.002), whereas aspirin therapy was a protective factor (HR −1.34; CI 0.07–0.86; p=0.02).

Conclusions

The presence of severe calcification is associated with a higher risk of CV hospitalizations, despite preparation of calcific lesions was always performed and intravascular imaging use was extensive. There were no differences in outcomes regardless to clinical presentation at admission, different stenting techniques and SYNTAX score I.

Funding Acknowledgement

Type of funding sources: None.

Impact of frailty status on medium-term follow up in patients undergoing percutaneous transcatheter aortic valve implantation in a high-flow referral center with high procedural volumes

Background

Transcatheter strategies to treat aortic stenosis (AS) are an established therapeutic option in older patients not candidate for open heart surgery. Current guidelines recommend the adoption of surgical scores like the Society of Thoracic Surgeons (STS) as tools for risk stratification. However, these scores may have limited predictive value in older patients.

Purpose

To assess the impact of frailty status on a composite endpoint comprising mortality and cardiovascular (CV) events in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center.

Methods

Consecutive patients >80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI). Physical function was evaluated by the Short Physical Performance Battery (SPPB), a tool exploring balance, gait speed, strength and endurance that produces a score ranging from 0 to 12 (lowest to highest performance). The SPPB <6 is an established strong predictor of mortality and disability.

The MPI is a three-level score used to stratify risk of mortality (low, intermediate or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility and risk of pressure sores, multimorbidity, polypharmacy and co-habitation).

Data on mortality and CV events at 6 and 12 months were retrieved via administrative records and/or telephone follow-up.

Results

Overall, 134 patients were referred for TAVI (mean age: 84±4 years; >90 years: 12%, women 67%). The average STS risk score was 4.6±3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB <6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group. SPPB and MPI scores were moderately correlated with STS (Spearman correlation coefficient: SPPB R=0.31, p=0.01, MPI R=0.29, p=0.03, Figure Panel A and B).

At 12 months, 3 (2.2%) patients died, and 11 (8.2%) were hospitalized for CV events: major bleeding, N=6 (4.5%); stroke: N=4 (3.0%); re-do: N=1 (0.7%). The probability of the composite endpoint was higher for patients at intermediate/high MPI risk (HR intermediate/high risk vs low risk: HR 2.9, 95% CI 1.1–6.8, p=0.031, Figure 1 Panel C), while no association with STS (p=0.332) was found.

Conclusions

In a prospectively enrolled cohort of TAVI candidates, frailty indices stratified short- and medium-term prognosis. The integrated frailty assessment could be a useful tool for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Peripheral intravascular lithotripsy to facilitate transfemoral TAVR: a multicentric prospective registry

Background

The presence of severe calcific atherosclerotic disease at iliac artery level is a contraindication to transfemoral (TF) TAVI procedures, challenging TF delivery in 15–20% of cases. Many case reports described the efficacy of Intravascular lithotripsy (IVL) to facilitate TF access but only one prospective registry has been reported in literature and dates back 2018. For this reason a new multicenter prospective registry was ideated to confirm the role of IVL technology in facilitating TF TAVR.

Aims

The aims of this study were 1)to analyze the trend of TF TAVR compared to alternative approaches in the last 5 years and 2)to evaluate the prevalence of IVLassistedTAVR since it was introduced in this specific setting in 2018 3) to evaluate the success rate in terms of valve performance and procedural success of TF-TAVR system delivery after IVL lesion preparation.

Materials and methods

We prospectively collected data from all consecutive TAVRprocedures performed between Jan2016 andDec2020 at 4Italian and 1 Denmark centres. All patients underwent CT angiography of lower extremity before the procedure in order to assess the severity of aorto-iliac-femoral calcification and to select those patients who required specific lesion preparation to preserve TF access. For each target calcified lesion we measured length, diameter and %of stenosis, circumferential extension and minimal cross-sectional area. Angiographic IVL-related and access site complications (dissection, perforation, major bleeding) were examined.

Results

Between 2016 and 2020, a total of 3710 TAVR were performed, 3428 (92%) via TF route while the remaining 240 (8%) included alternative approaches mainly represented by subclavian and transapical access. IVL-assisted TAVR were 0 in 2016 and 2017, 13 (2%) in 2018 when the first IVL-assisted aortic valve implantation was performed and doubled in 2019, reaching a total of 112 in the whole 5-year period considered. The number of IVL-facilitated TAVR has been increased in the 5-year period, achieving 7% of the TF procedures while non-TF TAVR decreased considerably from 10% to 6%. Common and external iliac axis was the target lesion in the majority of cases (54%) followed by common iliac artery alone. lesion minimum diameter 4.7mm, with average stenosis of 50%. The maximum calcium angle was 332°. The majority of IVL was performed with a 7-mm catheter (78.6%). 1 balloon per lesion was employed. 1 perforation and 2 severe dissections occurred, that required stent placement. In 55% of cases the aortic regurgitation was absent or minimal.

Conclusions

TF approach remained the first choice for TAVR procedure in the majority of cases compared to non-TF thanks to the progressive increase of IVLassistedTAVR that allowed operators to preserve TF route. Peripheral IVL appeared feasible, safe and effective in patients with severe peripheral artery disease, with high success rate in terms of valve performance and low rate of complications.

Funding Acknowledgement

Type of funding sources: None.

Tenosynovial complications identify TTR cardiac amyloidosis among patients with hypertrophic cardiomyopathy phenotype

Recent evidence suggests that carpal tunnel syndrome (CTS) and brachial biceps tendon rupture (BBTR) represent red flags for ATTR cardiac amyloidosis (ATTR-CA). The prevalence of upper limb tenosynovial complications in conditions entering differential diagnosis with CA, such as HCM or Anderson-Fabry disease (AFD), and hence their predictive accuracy in this setting, still remains unresolved.

OBJECTIVE

To investigate the prevalence of CTS and BBTR in a consecutive cohort of ATTR-CA patients, compared with patients with HCM or AFD and with individuals without cardiac disease history.

PARTICIPANTS

Consecutive patients with a diagnosis of ATTR-CA, HCM and AFD were evaluated. A control group of consecutive patients was recruited among subjects hospitalized for noncardiac reasons and no cardiac disease history. The presence of BBTR, CTS or prior surgery related to these conditions was ascertained.

RESULTS

342 patients were prospectively enrolled, including 168 ATTR-CA (141 ATTRwt, 27 ATTRm), 81 with HCM/AFD (N = 72 and 9, respectively) and 93 controls. CTS was present in 75% ATTR-CA patients, compared with 13% and 10% of HCM/AFD and controls (P = 0.0001 for both comparisons). Bilateral CTS was present in 60% of ATTR-CA patients, while it was rare (2%) in the other groups. BBTR was present in 44% of ATTR-CA patients, 8% of controls and 1% in HCM/AFD.

CONCLUSIONS

CTS and BBTR are fivefold more prevalent in ATTR-CA patients compared with cardiac patients with other hypertrophic phenotypes. Positive predictive accuracy for ATTR-CA is highest when involvement is bilateral. Upper limb assessment of patients with HCM phenotypes is a simple and effective way to raise suspicion of ATTR-CA.

Thromboelastography clot strength profiles and effect of systemic anticoagulation in COVID-19 acute respiratory distress syndrome: a prospective, observational study

OBJECTIVE

Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) infection may yield a hypercoagulable state with fibrinolysis impairment. We conducted a single-center observational study with the aim of analyzing the coagulation patterns of intensive care unit (ICU) COVID-19 patients with both standard laboratory and viscoelastic tests. The presence of coagulopathy at the onset of the infection and after seven days of systemic anticoagulant therapy was investigated.

PATIENTS AND METHODS

Forty consecutive SARS-CoV-2 patients, admitted to the ICU of a University hospital in Italy between 29th February and 30th March 2020 were enrolled in the study, providing they fulfilled the acute respiratory distress syndrome criteria. They received full-dose anticoagulation, including Enoxaparin 0.5 mg·kg-1 subcutaneously twice a day, unfractionated Heparin 7500 units subcutaneously three times daily, or low-intensity Heparin infusion. Thromboelastographic (TEG) and laboratory parameters were measured at admission and after seven days.

RESULTS

At baseline, patients showed elevated fibrinogen activity [rTEG-Ang 80.5° (78.7 to 81.5); TEG-ACT 78.5 sec (69.2 to 87.9)] and an increase in the maximum amplitude of clot strength [FF-MA 42.2 mm (30.9 to 49.2)]. No alterations in time of the enzymatic phase of coagulation [CKH-K and CKH-R, 1.1 min (0.85 to 1.3) and 6.6 min (5.2 to 7.5), respectively] were observed. Absent lysis of the clot at 30 minutes (LY30) was observed in all the studied population. Standard coagulation parameters were within the physiological range: [INR 1.09 (1.01 to 1.20), aPTT 34.5 sec (29.7 to 42.2), antithrombin 97.5% (89.5 to 115)]. However, plasma fibrinogen [512.5 mg·dl-1 (303.5 to 605)], and D-dimer levels [1752.5 ng·ml-1 (698.5 to 4434.5)], were persistently increased above the reference range. After seven days of full-dose anticoagulation, average TEG parameters were not different from baseline (rTEG-Ang p = 0.13, TEG-ACT p = 0.58, FF-MA p = 0.24, CK-R p = 0.19, CKH-R p  = 0.35), and a persistent increase in white blood cell count, platelet count and D-dimer was observed (white blood cell count p < 0.01, neutrophil count p = 0.02, lymphocyte count p < 0.01, platelet count p = 0.13 < 0.01, D-dimer levels p= 0.02).

CONCLUSIONS

SARS-CoV-2 patients with acute respiratory distress syndrome show elevated fibrinogen activity, high D-dimer levels and maximum amplitude of clot strength. Platelet count, fibrinogen, and standard coagulation tests do not indicate a disseminated intravascular coagulation. At seven days, thromboelastographic abnormalities persist despite full-dose anticoagulation.

Intravascular imaging to guide lithotripsy in concentric and eccentric calcific coronary lesions

Background

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

Purpose

The study aimed at the evaluation of the immediate procedural outcome of a novel treatment algorithm based on IVUS and/or OCT and including lithotripsy into a real-world consecutive based on intravascular imaging assessment by IVUS or OCT.

Methods and results

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions in 370 patients treated between November 2018 and May 2019 met the clinical and angiographic criteria for treatment with IVL under intravascular imaging guidance. Patients were divided into two subgroups depending on the calcium arc measured with intravascular imaging. Twenty lesions showed a calcium arc greater than 180 degrees (289±53 degrees) and 11 lesions smaller than 180 (140±24 degrees). The following parameters were assessed with OCT and/or IVUS: post stent minimal lumen area (MLA) and area stenosis (AS), incomplete strut apposition (ISA), eccentricity index, strut fracture, and edge dissection. After optimization a satisfactory lumen enlargement (acute gain 1.28±0.46 mm; minimal stent area 7.09±2.77 mm2) was observed with good stent expansion (residual area stenosis &lt;20% in 29 lesions, 93.5%) and OCT calcium fractures in 71% of cases. Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no in-hospital coronary perforations, no pericardial effusions, no stent failure or thrombosis, no deaths.

Conclusions

A standardized algorithm applying multimodality imaging to guide selection and application of IVL facilitated second generation DES implantation with final post-dilatation delivers excellent immediate procedural results and patient outcome, both in concentric or eccentric calcifications.

Funding Acknowledgement

Type of funding source: None

Diagnostic Accuracy of Primary Liver Cancer: Implications for Cancer Registration

Aims and background

We evaluated some standardized criteria for classifying incident cases of liver cancer into either primary liver cancer (PLC) or unspecified liver cancer (ULC) on the basis of the diagnostic examinations performed and their results.

Methods

A pilot hospital-based study (98 cases) was carried out in Verona, northern Italy, with the main aim of assessing the feasibility of the method. The same procedures were subsequently applied in a population-based study (349 cases) in Brescia, northern Italy.

Results

Diagnosis was made on histologic data in 38.7% and 41.8% of the hospital based and population-based studies, respectively, with a wide variation among different hospitals. The percentage of cases classified as PLC was 78.6% in the hospital-based study and 78.8% in the population-based study. No differences in the proportion of cases attributed to PLC were found according to patients’ age and sex or hospital of admission. The repeatibility of the procedure was assessed by a cross-panel review of 198 cases, and concordance was found in 91.9% of them.

Conclusions

An operational method for case definition of PLC based on the results of the diagnostic examinations currently performed and some suggestions for cancer registration are proposed.

Breast Cancer Screening in an Urban Population in Northern Italy

A mammographic and clinical screening for breast cancer started in June 1987 in the Health District of Brescia, Northern Italy, including the town and 23 surrounding municipalities. This paper describes the organization and the results of the first 12 months of screening. Of 7791 invited women aged 50–60 years, 5217 (67 %>) agreed to participate. There was a trend for response rates to decline with increasing age and education. Of the 5217 women examined, 66 (1.3%) were referred for biopsy and 64 (1.2%) underwent this procedure. A histologically confirmed malignancy was found in 42 women, corresponding to a prevalence of 8.1/1000. Positive predictive value of the screening was 65.6 %. Among the 42 breast cancers, 4.8% were carcinoma in situ and 42.9 % invasive tumors up to 10 mm in size. According to the p-TNM classification, 92.9 % of all cancers were either TIS or in stage T1, 4.8 % were in T2 and one tumor was classified in T4. Lymph node involvement was assessed in 41 cases, and 71.4% of all cancers detected by screening were negative for lymph node metastasis. In comparison, the classification of tumors found in women of the same age group and living in Brescia, histologically diagnosed in the urban hospitals during 1986, one year before the beginning of the screening, was as follows: 7.1 % carcinoma in situ, and 16.7 % invasive tumors up to 10 mm in size. 38.1%, 2.4% and 2.4% of all tumors were in stages T2, T3 and T4 respectively.

Photobiomodulation with polarized light in the treatment of cutaneous and mucosal ulcerative lesions

In recent decades, regenerative medicine has achieved an important evolution at both a conceptual level and scientific production, which explains the current and future possibilities of therapy and daily clinical practice. The main aim of regenerative medicine is the complex system of repair/regeneration. The current literature on the subject demonstrates the advantage of visible light therapy for skin injuries and diseases with the photobiomodulation in which light at low energy levels modulates intra- and extra-cellular photoreceptors by molecular and cellular processes that can stimulate both anti-inflammatory mechanisms and cell proliferative response. The irradiation effects are activated soon after exposure. The anti-inflammatory action on some classes of cytokines and cells (e.g. mast cells and macrophages) is completed with the stimulation of the nitric oxide production, which has an anti-inflammatory and vasodilation action, and gives analgesic relief. Our attention focused on photobiomodulator medical device emitting polarized light. 30 patients (19 women and 11 men) were enrolled in the present study. They were treated for chronic lesions using Bioptron® Light Therapy System device. Patients were initially subjected to Bioptron® light for 20 min after cleansing of the lesion. The operating protocol provides 24 sessions: twice per week for 12 weeks. Twenty patients have been studied for symptoms, histological samples and ulcer characteristics. After 2 months, a reduction of 50% of the lesions was recorded in 18 patients (60%), while in the remaining patients a slower healing was observed. The total wound healing was achieved after 3 months in 13 patients (43%). The examined parameters of the symptom were exudation, pain and signs of infection. Results at 1 and 3 months were, Exudation: at 1 month reduction and positive modulation was observed in 16 patients (53%) and in 25 patients at 3 months; Pain: (evaluated with Vas scale), decreased in 21 patients at 1 month (70%) and in 100% of cases at 3 months; Infections: regressed or disappeared in 100% of cases after the first month. Today, it is no longer time for monotherapy applications, especially in regenerative medicine and the adoption of biophysical therapies can play a positive anti-inflammatory and regenerative role enhancing the function of non-invasive therapies.

Thromboelastometry for guiding bleeding management of the critically ill patient: a systematic review of the literature

A systematic review of the published literature clearly demonstrates the usefulness of thromboelastometry (ROTEM®) in detecting coagulation disorders in severe trauma, cardiac and aortic surgery, liver transplantation, and postpartum haemorrhage reliably and within a clinically acceptable turn-around time. In all of the above-mentioned scenarios, the transfusion of any allogeneic blood products could be reduced significantly using ROTEM®-guided bleeding management, thereby minimising or avoiding transfusion-related side effects. Based on the current body of evidence as assessed by the GRADE system, the use of ROTEM® may be recommended in particular for management of severe bleeding after trauma and during cardiac and aortic surgery. However, as laboratory testing contributes only one part of severe bleeding management, the implementation of safe and effective treatment algorithms must be ensured at the same time.

Isolation of NDM-1-producing Pseudomonas aeruginosa sequence type ST235 from a stem cell transplant patient in Italy, May 2013

We describe the first isolation of an NDM-1-producing Pseudomonas aeruginosa in Italy. In May 2013, a patient with acute lymphoblastic leukaemia and history of prior hospitalisation in Belgrad, Serbia, underwent stem cell transplantation at a tertiary care hospital in Rome, Italy. After transplantion, sepsis by NDM-1-producing P. aeruginosa occurred, leading to septic shock and fatal outcome.

Direct Visualization of Oral-Cavity Tissue Fluorescence as Novel Aid for Early Oral Cancer Diagnosis and Potentially Malignant Disorders Monitoring

Direct visualization of the oral tissue autofluorescence has been recently reviewed in several studies as a possible adjunctive tool for early recognition and diagnosis of potentially malignant and malignant oral disorders. The aims of this study were to assess: a) the value of a simple handheld device for tissue auto-fluorescence visualization of potentially malignant oral lesions; and b) the sensitivity, specificity and diagnostic accuracy of tested device, using histological examination as the gold standard. 175 consecutive patients, with at least one clinical oral lesion, were enrolled in the study. Clinical conventional inspections were performed for each patient by two blind operators. Then, oral biopsy and histological examination were performed. Pathologist was blind with respect to the autofluorescence results. The 175 histological assessments revealed no dysplasia, mild dysplasia, moderate/severe dysplasia and OSCC, in the 67.4%, 8.6%, 8%, 16% of cases, respectively. Oral lesions diagnosed as OSCC were found as positive under fluorescent light in the 96.4% of cases. Statistically significant correlation was observed between oral dysplastic lesions and the loss of tissue fluorescence (p-value=0.001). Low sensitivity values (60% and 71%) were recorded about the ability of the device in differentiating mild dysplasia vs. lack of dysplasia and moderate/severe dysplasia vs absence of dysplasia, respectively. The device tested in our study was found to not replace the histopathology procedure. However, we assessed its usefulness for oral tissue examination, especially within an oral medicine secondary care facility, before performing a biopsy and in monitoring oral lesions.

Distribution and partition of heavy metals in surface and sub-surface sediments of Naples city port

The aim of the study was to delineate the extent of heavy metal pollution in the marine sediments within the port of Naples. Total metal contents from twenty surface sediments were compared with those from a long sediment core representing the natural geochemical baseline. Enrichment factors were computed for each metal and for each site in order to assess the polluting metals and the degree of pollution at each site. Results revealed that heavy metal pollution is mainly localized in the port area devoted to shipbuilding activities and in the south-east sector, which is under the influence of petroleum refineries. Data from sequential extractions indicate that metals from anthropogenic sources are mainly Cd, Zn, Cr and Cu and are potentially more mobile than those inherited from geological parent material.

[Cancer incidence and mortality in some health districts in Brescia area 1993--1995]

Cancer Registries are an essential part of any rational programme of cancer control, for assessing the impact of cancer in the community, for health care planning and monitoring screening programmes, according to local enviromental problems. The Brescia Cancer Registry started in 1994 producing prevalence, incidence and mortality data using only manual procedures of colletting and processing data from clinical and pathological sources in Brescia in 1993--1995. Data quality indicators such as the percentages of istologically or cytologically verified cases and that of cases registered on the basis of Death Certificate Only (DCO) are similar to those from the other Northern Italian Registries. Incidence rates for all causes and for various common sites are higher in Brescia than in other areas covered by Cancer Registries in North of Italy.

Angiotensin-converting-enzyme gene polymorphism and heart failure: a case-control study

Heart failure (HF) is the final outcome of virtually all cardiovascular diseases and is a major and increasingly serious public health problem. The renin-angiotensin system plays an important role in the pathogenesis of cardiovascular disease. Insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) has attracted significant attention; it has been extensively investigated in a spectrum of cardiovascular phenotypes because of its correlation with serum ACE activity. There is controversy regarding the association of ACE I/D polymorphism with cardiovascular disease. The aim of this study was to investigate whether ACE genotype is associated with HF by comparing cases and controls. The study sample consisted of 229 cases with HF due to coronary heart disease or idiopathic dilated cardiomyopathy and 230 controls recruited from the general population. The ACE I/D genotype was identified using a polymerase chain reaction assay. No evidence was found to support an association between ACE genotype and HF.

[Hospital infection prevention in an intensive care unit]

Aim of the study was to evaluate the efficacy of the hospital infection preventive procedures adopted in the intensive care unit (ICU) of the "S. Camillo-Forlanini" hospital in Rome. First the following prevention protocols were analysed: invasive procedures (intubation, CVC and urinary catheter), surveillance cultures, infection management and antimicrobial prophylaxis. Comparison with international guidelines was carried out and protocols enforcement by the personnel was verified. Secondly a one year longitudinal surveillance study was performed in order to monitor the following site-specific infection rates: pneumonia (PNE), blood stream infections (BSI), urinary tract infections (UTI), surgical site infections (SSI). According to CDC definitions all patients developing infection 48 hours or more after ward admission were included. Furthermore risk factors (i.e. age, sex, SAPS II), invasive procedures (i.e. endotracheal intubation, vascular and urinary catheterisation), microbiological isolates and their antibiotic susceptibility were screened. Overall 302 patients (191 men and 111 women) were admitted; age 55.1 +/- 20.7 years (mean), SAPS II 42.4 +/- 16.2 (mean) and average ward stay 12.5 +/- 21.7 days. Crude mortality was 15.9%. Results showed a total of 37 infection episodes (20 PNE , 7 BSI, 8 UTI and 2 SSI) in 33 patients (10.9%). Infection and mortality rates were among the lowest registered in other italian ICU's. Standardized infection rates associated to invasive procedures were: Ventilator-associated PNE rate (7.8/1000), central venous catheter-associated BSI rate (2.2/1000), urinary catheter-associated UTI rate (2.1/1000). The first (PNE) was higher than the NNIS mean rate, whwreas BSI and urinary catheter associated rates were minor than the mean rates reported by NNIS. Gram-negatives were 61.7%, gram-positives 27.6% and Candida spp. 10.6%. The results confirm the ICU successful preventive strategy.

[Genotoxicity of surface water treated with different disinfectants using in situ plant tests]

Disinfection of surface drinking water, in particular water chlorination, produces many by-products with genotoxic and/or carcinogenic activity. The aim of this research was to evaluate the genotoxicity of surface water after treatment with different disinfectants by means of in situ plant genotoxicity assays. The study was carried out in a pilot plant using lake water after sedimentation and filtration, which supplied four stainless steel basins: three basins were disinfected with sodium hypochlorite, chlorine dioxide and peracetic acid, respectively, and the fourth basin contained untreated lake water and was used as a control. The study was carried out using water collected in different seasons over a period of about one year in order to assess the treatments under different physical and chemical lake water conditions. Plant genotoxicity tests were performed by exposing plant bioindicators directly to raw and disinfected water. The Tradescantia micronucleus test in pollen cells of the flowers of an hybrid of Tradescantia and the Allium cepa test, a chromosome aberration test in root cells of Allium cepa, showed genotoxic effects only in some disinfected samples and revealed genotoxicity also in raw water in one experiment. The Vicia faba test, a micronucleus test in root cells of Vicia faba, revealed genotoxicity in many samples of disinfected water. The results of the study indicated that the Vicia faba/MCN test was the most sensitive plant assay for disinfected water, and that peracetic acid disinfection produced lower genotoxicity than sodium hypochlorite or chlorine dioxide treatment.

[Genotoxic effects of pesticide-treated vegetable extracts using the Allium cepa chromosome aberration and micronucleus tests]

The presence of chemical residues in vegetables and fruit is a source of human exposure to toxic and genotoxic chemicals. The mutagenic and carcinogenic action of herbicides, insecticides and fungicides on experimental animals is already known. Several studies have shown that chronic exposure to low levels of pesticides can cause adverse health effects and that many pesticides are mutagenic/carcinogenic. In the present research we monitored concurrently the presence of pesticides and genotoxic compounds extracted from 21 treated vegetables and 8 types of grapes sampled from the markets of a region in Southern Italy. The extracts were analysed for pesticides by gas-chromatography and HPLC, and for genotoxicity with two plant tests in Allium cepa roots: the micronucleus test and the chromosomal aberration test. We found 33 pesticides, some of which are outlawed. Genotoxicity was found in some of the vegetables and grapes tested. Allium cepa tests were sensitive for monitoring genotoxicity in food extracts. The micronucleus test in interphase cells gave much higher mutagenicity than the chromosomal aberration test in anaphase-telophase cells.

[Evaluation of genotoxicity of sodium hypochlorite, chlorine dioxide and peracetic acid using plant tests]

The aim of this research was to evaluate the potential genotoxic effects of three drinking water disinfectants by means of in vivo short-term mutagenicity tests using plants. The study was carried out in laboratory using distilled water disinfected with sodium hypochlorite (NaClO), chlorine dioxide (ClO2) and peracetic acid (PAA) at different concentrations both in neutral and acid conditions. Untreated distilled water was used as a negative control. Micronuclei test in Tradescantia pollen cells and chromosomal aberration test in root cells of Allium cepa were the bioassays performed by exposing directly plant bioindicators to treated and untreated distilled water. The Tradescantia/micronuclei test gave positive results in most of the ClO2-treated water samples but only at acid pH. The Allium cepa test showed genotoxicity in NaClO-treated samples at acid pH and in a ClO2-treated sample at pH 7. PAA-treated samples were always nongenotoxic. Since the concentrations tested of free disinfectants are usually present in drinking water for biocidal purposes, genotoxicity of these compounds could be a public health problem.

Cloning and characterization of an ionotropic glutamate receptor subunit expressed in the squid nervous system

In this paper we describe the cloning of a putative ionotropic glutamate receptor subunit, SqGluR, and its distribution in the nervous system of the squid. A full-length cDNA was assembled from a cDNA library of the stellate ganglion/giant fibre lobe complex of Loligo opalescens. The deduced amino acid sequence of the mature SqGluR displayed 44-46% amino acid identity with mammalian GluR1-GluR4 and 53% with Lym-eGluR1 from Lymnaea stagnalis. In situ hybridizations in adult squid confirmed that the SqGluR mRNA is abundant in giant fibre lobe neurons, in large, presumptive motor neurons of the stellate ganglion proper and in the supraoesophageal and optic lobes of the central nervous system. In newborn squid, SqGluR mRNA expression was detected throughout the nervous system but not elsewhere. A synthetic peptide corresponding to the last 15 amino acids of the SqGluR C-terminus was used to generate polyclonal antibodies, which were used for immunoblot analysis to demonstrate widespread expression in the squid central and peripheral nervous systems. Injection of the synthetic peptide into the postsynaptic side of the giant synapse inhibited synaptic transmission.

[Drinking water hardness and chronic degenerative diseases. I. Analysis of epidemiological research]

For many years a causal relation between drinking water hardness and cardiovascular or other chronic degenerative diseases in humans has been hypothesized. In order to evaluate the association between the concentration of minerals (calcium and magnesium) responsible for the hardness of drinking water and human health, a review of all the articles published on the subject from 1980 up to today has been carried out. The retrieved articles have been divided into 4 categories: geographic correlation studies, cross-sectional studies, case-control and cohort studies, and clinical trials. The methods for the selection of the articles and the extraction and analysis of the data are detailed in this paper. Epidemiological studies have been reviewed critically, and some conclusions have been drawn taking into account the research in basic sciences and experimental studies. However, a formal meta-analysis has not been performed, due to the heterogeneity of measures of effect among the different studies.

Analysis of B19 virus contamination in plasma pools for manufacturing, by using a competitive polymerase chain reaction assay

BACKGROUND AND OBJECTIVES

The presence of B19 virus in blood poses a risk of transmission of the virus via blood or blood products. Screening processes for manufacturing should be aimed at achieving production plasma pools with B19 virus contamination levels below 104 genome equivalents/ml (geq/ml) in order to prevent transmission of infection through plasma derivatives.

MATERIALS AND METHODS

The suitability of a competitor plasmid as an internal analytical standard for the detection of B19 virus in plasma pools was assessed by using a competitive polymerase chain reaction (PCR) assay. Seventy-five plasma pools, each consisting of 960 single donations, were analysed for B19 virus contamination following a lysis treatment.

RESULTS

The amount of competitor plasmid in the competitive PCR assay established, with good accuracy, a threshold value for discrimination of the viral load in plasma pools. Analysis of samples from plasma pools showed that 12% of pools were contaminated with B19 virus at levels above the set threshold value.

CONCLUSIONS

The competitive PCR assay developed proved to be effective for discrimination of the B19 virus contamination level in screening of plasma pools for manufacturing.

Determination of cerebral water content by magnetic resonance imaging after small volume infusion of 18% hypertonic saline solution in a patient with refractory intracranial hypertension

Hypertonic saline solution (HSS) has been investigated in the treatment of intracranial hypertension (ICH) in a limited number of studies, usually after failure of conventional treatment. HSS, used in concentrations that vary from 3% to 23.4%, seems to be effective in reducing refractory ICH and to be devoid of adverse effects. We treated a patient with refractory ICH with a small-volume infusion of 18% HSS, and performed magnetic resonance imaging (MRI) before and after HSS infusion. MRI showed a marked reduction in cerebral water content 1 h after the infusion. To our knowledge, this is the first MRI study in a patient with brain injury to evaluate the effect of HSS on brain water content. Further studies are necessary to test HSS efficacy and to identify, through MRI or computed tomography (CT) scan imaging, a subgroup of patients with brain injury who would be best treated with HSS.

Intrahepatic cholangiocarcinoma and hepatitis C and B virus infection, alcohol intake, and hepatolithiasis: a case-control study in Italy

OBJECTIVE

Intrahepatic cholangiocarcinoma (ICC) is a rare type of primary liver cancer (PLC) arising from intrahepatic bile ducts. We carried out a case-control study to assess the association between ICC and hepatitis B and C virus (HBV and HCV) infections, alcohol intake, and hepatolithiasis in Brescia, North Italy.

METHODS

Among 370 subjects with histology-based diagnosis of PLC who were resident in the area and hospitalized in 1995-2000, 26 (7%) ICC cases were identified. A total of 824 subjects unaffected by hepatic diseases and frequency-matched with PLC cases by age, sex, date, and hospital of admission were recruited as controls.

RESULTS

Among ICC cases the mean age was 65 years, 80.8% were males, and 38.5% had cirrhosis. Seropositivity for anti-HCV, HBsAg, alcohol intake >80 g/day and history of hepatolithiasis were found in 25%, 13%, 23.1%, and 26.9% of ICC cases and in 5.8%, 6.7%, 32.9%, and 10.6% of controls, respectively. The odds ratios adjusted for demographic factors by logistic regression (95% confidence interval; 95% CI) were 9.7 (1.6-58.9) for anti-HCV, 2.7 (0.4-18.4) for HBsAg, and 6.7 (1.3-33.4) for hepatolithiasis, whereas no association was found with alcohol drinking.

CONCLUSIONS

HCV and hepatolithiasis may be risk factors for ICC in Western countries.

Alcohol and hepatocellular carcinoma: the effect of lifetime intake and hepatitis virus infections in men and women

The authors investigated the dose-effect relation between alcohol drinking and hepatocellular carcinoma (HCC) in men and women separately, also considering hepatitis B and hepatitis C virus infections. They enrolled 464 subjects (380 men) with a first diagnosis of HCC as cases and 824 subjects (686 men) unaffected by hepatic diseases as controls; all were hospitalized in Brescia, northern Italy, in 1995-2000. Spline regression models showed a steady linear increase in the odds ratio of HCC for increasing alcohol intake, for values of >60 g of ethanol per day, with no substantial differences between men and women. Duration of drinking and age at start had no effect on the odds ratio when alcohol intake was considered. Former drinkers who had stopped 1-10 years previously had a higher risk of HCC than current drinkers did. The effect of alcohol drinking was evident even in the absence of hepatitis B or hepatitis C virus infection. In addition, a synergism between alcohol drinking and either infection was found, with approximately a twofold increase in the odds ratio for each hepatitis virus infection for drinkers of >60 g per day.

[Impact of an integrated treatment approach of the severely injured patients (ISS =/> 16) on hospital mortality and quality of care]

BACKGROUND

Outcome of severely injured patients is sharply influenced by the level of prehospital and hospital organization.

OBJECTIVE

To evaluate the impact of the re-organization of the trauma care process on the quality of care and final outcome of major trauma (ISS =/< 16) victims.

SETTING

the Emergency Department (ED) of a 1600 bedded tertiary care hospital.

INTERVENTION

a standardized approach to major trauma patients (MT) was implemented: Written protocols were established and trauma teams were organized. All anesthesiologists and trauma surgeons involved in trauma care were enrolled in an educational program including ATLS Courses and the Italian Resuscitation Council Prehospital Trauma Care Course. One of the targets was to assure the early orthopedic stabilization of limb and pelvis fractures.

METHODS

Data of all major trauma victims admitted to the ED during 3 comparable periods of time: before (Jan-May 1998), during (Jan-May 1999) and after (Jan-May 2000) the implementation of the process, were retrospectively and prospectively collected and analyzed.

RESULTS

MT patients admitted to the hospital increased from 39 in 1998 to 106 in 2000. For similar ISS (30.2 +/- 11.3 in 1998, 29.6 +/- 13.7 in 1999 and 30.5 +/- 12.9 in 2000) hospital mortality dropped from 42% in 1998 to 20.8%. The mean time from hospital admission to surgical orthopedic stabilization was 12 days in 1998, 4.6 in 1999 and 1.3 in 2000. In 2000, 86% of the patients with limbs fractures who required surgical stabilization, were treated within 36 hours from admission vs 11% in 1998.

CONCLUSIONS

The implementation of written protocols for trauma care, the organization of trauma teams, educational programs including ATLS and PTC-IRC Courses and a strategy of early stabilization of limb fractures are associated with a dramatic decrease in hospital mortality for major trauma.

Intrahepatic cholangiocarcinoma and hepatitis C and B virus infection, alcohol intake, and hepatolithiasis: a case-control study in Italy

OBJECTIVE

Intrahepatic cholangiocarcinoma (ICC) is a rare type of primary liver cancer (PLC) arising from intrahepatic bile ducts. We carried out a case-control study to assess the association between ICC and hepatitis B and C virus (HBV and HCV) infections, alcohol intake, and hepatolithiasis in Brescia, North Italy.

METHODS

Among 370 subjects with histology-based diagnosis of PLC who were resident in the area and hospitalized in 1995-2000, 26 (7%) ICC cases were identified. A total of 824 subjects unaffected by hepatic diseases and frequency-matched with PLC cases by age, sex, date, and hospital of admission were recruited as controls.

RESULTS

Among ICC cases the mean age was 65 years, 80.8% were males, and 38.5% had cirrhosis. Seropositivity for anti-HCV, HBsAg, alcohol intake >80 g/day and history of hepatolithiasis were found in 25%, 13%, 23.1%, and 26.9% of ICC cases and in 5.8%, 6.7%, 32.9%, and 10.6% of controls, respectively. The odds ratios adjusted for demographic factors by logistic regression (95% confidence interval; 95% CI) were 9.7 (1.6-58.9) for anti-HCV, 2.7 (0.4-18.4) for HBsAg, and 6.7 (1.3-33.4) for hepatolithiasis, whereas no association was found with alcohol drinking.

CONCLUSIONS

HCV and hepatolithiasis may be risk factors for ICC in Western countries.

Effects of 2 patterns of prehospital care on the outcome of patients with severe head injury

HYPOTHESIS

A pattern of prehospital care combining advanced life support, physician staffing, and helicopter transport improves the outcome of patients with severe brain injuries, compared with combined expanded basic life support, nurse staffing, and ground transport.

DESIGN

Inception cohort from the data set of a population-based, prospective study on major trauma.

SETTING

Prehospital and hospital trauma systems of an Italian region.

PATIENTS

All patients with major trauma (Injury Severity Score, >or=16) and severe head injury (Abbreviated Injury Scale score for the head, >or=4) rescued alive from March 1, 1998, to February 28, 1999, who received either form of care. Patients with self-inflicted injuries were excluded. The 184 patients who met the entry criteria were divided equally between care groups.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Mortality at 30 days and Glasgow Outcome Scale score of survivors.

RESULTS

After verifying the comparability of the cohorts, no survival or disability benefit could be demonstrated (95% confidence interval [CI] of the odds ratio for mortality [helicopter/ambulance] [95% CI 1], 0.72 to 2.67; 95% CI of the difference in Glasgow Outcome Scale score medians between helicopter and ambulance groups [95% CI 2], 0.0 to 0.0). Similar results were derived from analyses restricted to the subgroups identified by low (<or=90 mm Hg) roadside systolic blood pressure (95% CI 1, 0.58 to 7.17; 95% CI 2, -1 to 2) and by need for urgent neurosurgical intervention (95% CI 1, 0.16 to 2.60; 95% CI 2, 0 to 2). Exclusion from the ambulance group of victims rescued in urban areas did not change the results (95% CI 1, 0.80 to 3.24; 95% CI 2, 0.0 to 0.0). Stratification by age, Injury Severity Score, and Glasgow Coma Scale score demonstrated a small survival benefit (95% CI 1, 1.12 to 2.12) in the ambulance subgroup with Glasgow Coma Scale score from 10 to 12. Multiple logistic regression analysis confirmed that the group did not affect mortality.

CONCLUSION

This study was conceived to emphasize the supposed advantages of the combined helicopter, physician, and advanced life-support rescue. No increased benefit compared with the simpler rescue group could be demonstrated.

A population-based study on pneumothorax in severely traumatized patients

BACKGROUND

Pneumothorax (PNX) is a recognized cause of preventable deaths in trauma patients. Our objective was to determine the incidence of traumatic PNX, the characteristics of its victims, and the treatment they receive.

METHODS

The study consisted of data set of a population-based study on major trauma.

RESULTS

The incidence of PNX was 81 per 1 million population per year, mostly caused by transport accidents. PNX victims generally had multiple injuries, and they showed on-scene clinical parameters worse than victims of other chest injuries of comparable severity. Fifty-three percent of PNXs were drained during the prehospital and early (< 2 hours) hospital course. There was no uniformity of treatment among different types of rescue facilities, some of them never performing decompression despite clinical need. The z statistic for mortality was -0.63.

CONCLUSION

PNX can be expected in one in five major trauma victims found alive. PNX is associated with a peculiar on-scene instability. Early decompression is often required. The effects of wider access to prehospital decompression and the reasons for its uneven availability in our setting need elucidation. Nevertheless, the present mortality follows the international standards.

Reduction in gram-positive pneumonia and antibiotic consumption following the use of a SDD protocol including nasal and oral mupirocin

The objective of this prospective, randomized, double-blind study was to evaluate the effect of the addition of mupirocin to the 'classical' topical SDD regimen (tobramycin 80 mg, polymyxin E 100 mg, amphotericin B 500 mg) on the development of ICU-acquired infections due to gram-positive bacteria. The study was carried out in an intensive care unit (ICU) of a 1400-bed community hospital. All patients admitted to the ICU during a 16-month period, who were expected to require mechanical ventilation for more than 24 hours, were randomized to receive either the 'classical' SDD regimen (Group A) or a modified regimen with mupirocin (Group B). Data from 223 patients requiring mechanical ventilation for at least 48 hours, who were neither infected nor receiving antibiotics on ICU admission, was analysed. A 2% paste containing tobramycin, polymyxin E and amphotericin B was applied every 6 hours in the oropharynx to the patients in Group A, while in Group B this formula was modified with the addition of 2% mupirocin. In Group B 0.2 ml of a 2% mupirocin ointment was also applied four times daily in both nostrils. Patients in Group A received a soft paraffin ointment as a placebo indistinguishable from mupirocin. Patients in both groups received the classic SDD regimen through the nasogastric tube. Systemic antibiotic prophylaxis was not used. Data on lower airway infection, and blood infection, infections of intravascular catheters, antibiotic consumption and expenditures for antibiotics were analysed. The diagnosis of ventilator-associated pneumonia (VAP) was based on quantitative cultures of protected specimen brush samples (PSB) or on the results of distal broncho-alveolar lavage (BAL). One hundred and four patients received the 'classical' SDD and 119 the modified regimen. Overall 29 patients, 20 in Group A and nine in Group B (p < 0.02) had a total of 33 cases of pneumonia. There were 23 episodes of pneumonia in Group A and 10 in Group B (p < 0.02). Gram-positive bacteria were isolated from samples in 17 episodes in Group A and six in Group B (p < 0.02). Staphylococcus aureus was isolated in nine cases of pneumonia in Group A and once in the 'mupirocin' group (p < 0.05). MRSA were isolated in seven out of nine cases in Group A and in the only case in Group B. There were no differences in the isolation of gram-negative bacilli. Antibiotic consumption and cost were lower in Group B. In conclusion, our data show that the topical use of a modified formula of SDD, with the addition of mupirocin to the oral paste and in the anterior nares, is associated with a reduction in lung infections caused by gram-positives and in a reduction in antibiotic consumption and in the overall expenditure for antibiotics.

CD56 antigenic expression in acute myeloid leukemia identifies patients with poor clinical prognosis

CD56 antigen, a 200-220 kDa cell surface glycoprotein, identified as an isoform of the neural adhesion molecules (NCAM), has been found frequently expressed in several lympho-hematopoietic neoplasms including acute myeloid leukemias (AML). In fact, in these latter diseases it has been reported that the presence of CD56 antigen on the blasts of AML patients with t(8;21) (q22;q22), and in those with M3 subtype, identifies a subgroup of patients with a more unfavorable prognosis. On the basis of these findings, we evaluated in 152 newly diagnosed AML patients CD56 surface expression, and results were correlated with morphology, immunophenotype, cytogenetic pattern and clinical outcome. CD56 antigen was recorded in 37 out of 152 cases (24%) and particularly in those with M2 and M5 cytotypes. Moreover, CD56 expression was significantly associated with P-glycoprotein (PGP) hyperexpression (P = 0.007), unfavorable cytogenetic abnormalities (P = 0.008) and with a reduced probability of achieving complete remission (CR) (36% vs 68%) (P = 0.035) as well as with a shorter survival (6 vs 12 months) (P = 0.032). In conclusion, CD56 antigenic expression on AML cells represents an important adverse prognostic factor and therefore its presence should be regularly investigated for a better prognostic assessment of AML patients at diagnosis.

Dental hygienists and infection control: knowledge, attitudes and behaviour in Italy

This study evaluated knowledge, attitudes and behaviour regarding infection control of dental hygienists in Italy. Among the 185 responders to the self-administered mailed questionnaire, 91.3% agreed with the correct responses to the three questions on knowledge about infection prevention and control procedures chosen as an indicator of 'good' knowledge. However, 21% were uncertain whether, or disagreed that, dental instruments should be rinsed in water after contact with glutaraldehyde and 17.5% agreed that, or were uncertain whether, 10 min contact with glutaraldehyde provided sterilization. Only 36.5% knew all the five oral manifestations of acquired immunodeficiency syndrome (AIDS) (acute periodontal problems, candidiasis, hairy leukoplakia, herpes simplex virus, Kaposi's sarcoma) and this knowledge was significantly higher in dental hygienists with a lower number of years of practice. More than two-thirds used a steam sterilizer or glutaraldehyde for appropriate times and temperatures for disinfection/sterilization of instruments and used appropriate surface disinfection procedures. The correct application of disinfection or sterilization methods for instruments was more likely in the older respondents and in those who attended continuing education courses on infection control. A positive attitude was reported by the majority of dental hygienists who agreed that guidelines should be maintained and applied and was significantly more likely in younger respondents. Only 57.9% routinely follow all recommendations for infection control practices and their use was significantly higher in the older respondents. Educational programmes are needed for improving knowledge about oral manifestations of AIDS in order to support dentists to provide early diagnosis and about the correct use of procedures and universal precautions for preventing infections.

Overexpression of protectin (CD59) down-modulates the susceptibility of human melanoma cells to homologous complement

The clinical efficacy of therapeutic complement (C)-activating monoclonal antibodies (mAb) to melanoma-associated antigens can be impaired by the levels of expression of C-inhibitory molecules on neoplastic cells. Protectin (CD59) is a glycosylphosphatidylinositol (GPI)-anchored cell membrane glycoprotein, acting as terminal regulator of C cascade, which is heterogeneously expressed in melanomas and represents the main restriction factor of C-mediated lysis of melanoma cells. Thus, we investigated whether the overexpression of CD59 could influence the constitutive susceptibility of distinct melanoma cells to homologous C. Infection of CD59-positive Mel 100 and 70-W melanoma cells by a retroviral vector carrying the CD59 cDNA, significantly (P < 0.05) upregulated their constitutive expression of CD59, whereas it did not affect that of additional C-regulatory molecules. Transduced CD59 was entirely GPI-anchored and showed a molecular weight identical to native CD59. Additionally, higher amounts of soluble CD59 were detected in the conditioned media of CD59-transduced melanoma cells compared with parental cells. CD59-transduced melanoma cells, sensitized by the anti-GD3 disialoganglioside mAb R24, were significantly (P < 0.05) less susceptible to homologous C-lysis than were parental cells; this effect was fully reverted by the masking of CD59 with F(ab')(2) fragments of the anti-CD59 mAb YTH53.1. These results provide conclusive evidence demonstrating that absolute levels of CD59 expression regulate the susceptibility to homologous C of specific melanoma cells, and suggest an additional explanation for the poor clinical results obtained with C-activating mAb in the clinical setting.