Spike-Specific Memory B Cell Response in Hematopoietic Cell Transplantation Recipients following Multiple mRNA-1273 Vaccinations: A Longitudinal Observational Study

Preventing SARS-CoV-2 infection is of utmost importance in allogeneic hematopoietic cell transplantation patients (allo-HCT), given their heightened susceptibility to adverse outcomes associated with SARS-CoV-2 infection. However, limited data are available regarding the immune response to COVID-19 vaccines in these subjects, particularly concerning the generation and persistence of spike-specific memory response. Here, we analyzed the spike-specific memory B cells in a cohort of allo-HCT recipients vaccinated with multiple doses of the mRNA-1273 vaccine and monitored the spike-specific antibody response from baseline up to one month after the fourth dose. After the primary vaccine series, the frequency of spike-specific B cells, detected within the pool of Ig-switched CD19+ cells, significantly increased. The booster dose further induced a significant expansion, reaching up to 0.28% of spike-specific B cells. The kinetics of this expansion were slower in the allo-HCT recipients compared to healthy controls. Spike-specific IgG and ACE2/RBD binding inhibition activity were observed in 80% of the allo-HCT recipients after the first two doses, with a significant increase after the third and fourth booster doses, including in the subjects who did not respond to the primary vaccine series. Additionally, 87% of the allo-HCT recipients exhibited positive cross-inhibition activity against the BA.1 variant. Our findings provide evidence that allo-HCT recipients need repeated doses of the mRNA-1273 vaccine to induceSARS-CoV-2 specific immune response similar to that observed in healthy individuals. This is particularly crucial for vulnerable individuals who may exhibit a limited response to the primary series of SARS-CoV-2 vaccination.

Homologous or heterologous administration of mRNA or adenovirus-vectored vaccines show comparable immunogenicity and effectiveness against the SARS-CoV-2 Omicron variant

BACKGROUND

Heterologous prime-boost schedules have been employed in SARS-CoV-2 vaccination, yet additional data on immunogenicity and effectiveness are still needed.

RESEARCH DESIGN AND METHODS

Here, we measured the immunogenicity and effectiveness in the real-world setting of the mRNA booster dose in 181 subjects who had completed primary vaccination with ChAdOx1, BNT162b2, or mRNA1273 vaccines (IMMUNO_COV study; protocol code 18,869). The spike-specific antibody and B cell responses were analyzed up to 6 months after boosting.

RESULTS

After an initial slower antibody response, the heterologous ChAdOx1/mRNA prime-boost formulation elicited spike-specific IgG titers comparable to homologous approaches, while spike-specific B cells showed a higher percentage of CD21-CD27- atypical cells compared to homologous mRNA vaccination. Mixed combinations of BNT162b2 and mRNA-1273 elicited an immune response comparable with homologous strategies. Non-significant differences in the Relative Risk of infection, calculated over a period of 18 months after boosting, were reported among homologous or heterologous vaccination groups, indicating a comparable relative vaccine effectiveness.

CONCLUSIONS

Our data endorse the heterologous booster vaccination with mRNA as a valuable alternative to homologous schedules. This approach can serve as a solution in instances of formulation shortages and contribute to enhancing vaccine strategies for potential epidemics or pandemics.

Does Nirmatrelvir/Ritonavir Influence the Immune Response against SARS-CoV-2, Independently from Rebound?

Recurrence of coronavirus disease 19 (COVID-19) symptoms and SARS-CoV-2 viral load relapse have been reported in people treated with nirmatrelvir/ritonavir (NM/r). However, little is understood about the etiology of this phenomenon. Our aim was to investigate the relation between the host's immune response and viral rebound. We described three cases of COVID-19 rebound that occurred after treatment with nirmatrelvir/ritonavir (group A). In addition, we compared spike-specific antibody response and plasma cytokine/chemokine patterns of the rebound cases with those of (i) control patients treated with nirmatrelvir/ritonavir who did not show rebound (group B), and (ii) subjects not treated with any anti-SARS-CoV-2 drug (group C). The anti-spike antibodies and plasma cytokines/chemokines were similar in groups A and B. However, we observed a higher anti-BA.2 spike IgG response in patients without antiviral treatment (group C) [geometric mean titer 210,807, 5.1- and 8.2-fold higher compared to group A (p = 0.039) and group B (p = 0.032)]. Moreover, the patients receiving antiviral treatment (groups A-B) showed higher circulating levels of platelet-derived growth factor subunit B (PDGF-BB) and vascular endothelial growth Factors (VEGF) and lower levels of interleukin-9 (IL-9), interleukine-1 receptor antagonist (IL-1 RA), and regulated upon activation normal T cell expressed and presumably secreted chemokine (RANTES) when compared to group C. In conclusion, we observed lower anti-spike IgG levels and different cytokine patterns in nirmatrelvir/ritonavir-treated patients compared to those not treated with anti-SARS-CoV-2 drugs. This suggests that early antiviral treatment, by reducing viral load and antigen presentation, could mitigate the immune response against SARS-CoV-2. The clinical relevance of such observation should be further investigated in larger populations.

Modeling chronic oil pollution from ships

Stochastic simulations of virtual oil spills from ships were performed for the Adriatic Sea over 2017-2020, applying the European Marine Observation and Data Network vessel densities as a proxy for starting locations of operational spillage. The MEDSLIK-II oil spill model was run using high-resolution currents provided by the Copernicus Marine Service and the European Centre for Medium-Range Weather Forecasts winds. Chronic exposure to operational oil spills was reported in terms of hazard indices for five vessel groups: pleasure and passenger ships, cargo and service vessels, the fishing fleet, tankers, and other ships. The northernmost Adriatic expectedly showed the highest hazard values, including the areas of Trieste and Venice, where cargo and service ships were the dominant polluters. The Croatian coastal waters were more chronically polluted than the Italian coastal waters; the predominant contribution was from coastwise pleasure and passenger ships.

Trajectory of Spike-Specific B Cells Elicited by Two Doses of BNT162b2 mRNA Vaccine

The mRNA vaccines for SARS-CoV-2 have demonstrated efficacy and immunogenicity in the real-world setting. However, most of the research on vaccine immunogenicity has been centered on characterizing the antibody response, with limited exploration into the persistence of spike-specific memory B cells. Here we monitored the durability of the memory B cell response up to 9 months post-vaccination, and characterized the trajectory of spike-specific B cell phenotypes in healthy individuals who received two doses of the BNT162b2 vaccine. To profile the spike-specific B cell response, we applied the tSNE and Cytotree automated approaches. Spike-specific IgA+ and IgG+ plasmablasts and IgA+ activated cells were observed 7 days after the second dose and disappeared 3 months later, while subsets of spike-specific IgG+ resting memory B cells became predominant 9 months after vaccination, and they were capable of differentiating into spike-specific IgG secreting cells when restimulated in vitro. Other subsets of spike-specific B cells, such as IgM+ or unswitched IgM+IgD+ or IgG+ double negative/atypical cells, were also elicited by the BNT162b2 vaccine and persisted up to month 9. The analysis of circulating spike-specific IgG, IgA, and IgM was in line with the plasmablasts observed. The longitudinal analysis of the antigen-specific B cell response elicited by mRNA-based vaccines provides valuable insights into our understanding of the immunogenicity of this novel vaccine platform destined for future widespread use, and it can help in guiding future decisions and vaccination schedules.

Streptococcus pyogenes Φ1207.3 Is a Temperate Bacteriophage Carrying the Macrolide Resistance Gene Pair mef(A)-msr(D) and Capable of Lysogenizing Different Streptococci

Streptococcus pyogenes prophage Φ1207.3 (formerly Tn1207.3) carries the mef(A)-msr(D) resistance genes, responsible for type M macrolide resistance. To investigate if Φ1207.3 is a functional bacteriophage, we transferred the element from the original S. pyogenes host in a prophage-free and competence-deficient S. pneumoniae strain. Pneumococcal cultures of the Φ1207.3-carrying lysogen were treated with mitomycin C to assess if Φ1207.3 enters the lytic cycle. Mitomycin C induced a limited phage burst and a growth impairment, resulting in early entrance into the stationary phase. To determine if Φ1207.3 is able to produce mature phage particles, we prepared concentrated supernatants recovered from a mitomycin C-induced pneumococcal culture by sequential centrifugation and ultracentrifugation steps. Negative-staining transmission electron microscopy (TEM) of supernatants revealed the presence of phage particles with an icosahedral, electron-dense capsid and a long, noncontractile tail, typical of a siphovirus. Quantification of Φ1207.3 was performed by quantitative PCR (qPCR) and semiquantitatively by TEM. PCR quantified 3.34 × 104 and 6.06 × 104 excised forms of phage genome per milliliter of supernatant obtained from the untreated and mitomycin C-treated cultures, respectively. By TEM, we estimated 3.02 × 103 and 7.68 × 103 phage particles per milliliter of supernatant. The phage preparations of Φ1207.3 infected and lysogenized pneumococcal recipient strains at a frequency of 7.5 × 10-6 lysogens/recipient but did not show sufficient lytic activity to form plaques. Phage lysogenization efficiently occurred after 30 min of contact of the phages with the recipient cells and required a minimum of 103 phage particles. IMPORTANCE Bacteriophages play an important role in bacterial physiology and genome evolution. The widespread use of genome sequencing revealed that bacterial genomes can contain several different integrated temperate bacteriophages, which can constitute up to 20% of the genome. Most of these bacteriophages are only predicted in silico and are never shown to be functional. In fact, it is often difficult to induce the lytic cycle of temperate bacteriophages. In this work, we show that Φ1207.3, a peculiar bacteriophage originally from Streptococcus pyogenes, which can lysogenize different streptococci and carries the macrolide resistance mef(A)-msr(D) gene pair, is capable of producing mature virions, but only at a low level, while not being able to produce plaques. This temperate phage is probably a partially functional phage, which seems to have lost lytic characteristics to specialize in lysogenization. While we are not used to conceiving phages separately from lysis, this behavior could actually be more frequent than expected.

The third dose of mRNA SARS-CoV-2 vaccines enhances the spike-specific antibody and memory B cell response in myelofibrosis patients

Vaccination against SARS-CoV-2 using mRNA-based vaccines has been highly recommended for fragile subjects, including myelofibrosis patients (MF). Available data on the immune responsiveness of MF patients to mRNA SARS-CoV-2 vaccination, and the impact of the therapy with the JAK inhibitor ruxolitinib, are still fragmented. Here, we profile the spike-specific IgG and memory B-cell response in MF patients, treated or not with ruxolitinib, after the second and the third dose of SARS-CoV-2 BNT162b2 (BioNTech) and mRNA-1273 (Moderna) vaccines. Plasma and peripheral blood mononuclear cells samples were collected before vaccination, post the second and the third doses and tested for spike-specific antibodies, ACE2/RBD antibody inhibition binding activity and spike-specific B cells. The third vaccine dose significantly increased the spike-specific IgG titers in both ruxolitinib-treated and untreated patients, and strongly enhanced the percentage of subjects with antibodies capable of in vitro blocking ACE2/RBD interaction, from 50% up to 80%. While a very low frequency of spike-specific B cells was measured in blood 7 days after the second vaccination dose, a strong and significant increase was elicited by the third dose administration, generating a B cell response similar to the one detected in healthy controls. Despite the overall positive impact of the third dose in MF patients, two patients that were under active concomitant immunosuppressive treatment at the time of vaccination, and a patient that received lymphodepleting therapies in the past, remained low responders. The third mRNA vaccine dose strongly increases the SARS-CoV-2 specific humoral and B cell responses in MF patients, promoting a reactivation of the immune response similar to the one observed in healthy controls.

Conduction system pacing with Selectra 3D Sheath: Technical Results

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction system pacing (CSP) allows physiological electrical activation. The Selectra3D sheath is a new tool able to guide the lead implantation on the His Bundle (HBP) or on the left bundle branch (LBBP). It does exist in 3 different shapes (40-S, 55-M, 65-L).

Objective

To evaluate the effectiveness of different Selectra3D introducers for CSP, considering the procedural success, stability of electrical parameters or need for implant revision at medium-term follow-up.

Methods and results

Selectra3D was used in 113 CSP procedures between Nov 2019 and Nov 2021. Mean patients age was 80±6 years, 54% males. Pacing indications were: AV block 52.2%, slow AF 12.4%; SND 12.4%, ablate&pace 5.3%, implant revision 0.9%, cardiomyopathy 16.8%. Mean EF was 40±15%. Single chamber PM was implanted in 4.8% pts, dual chamber PM in 57.1% pts while 26.2% and 11.9% pts received CRT-P and CRT-D devices respectively. Stylet-driven lead was used in 75 pts, fixed screw lead in 38 pts. HBP was obtained in 34% pts, LBBP in 55% pts, HBP+LBBP in 3% pts, while 8% cases were CSP implant failure (7 lead implanted in the septum; 2 in the coronary sinus). Selectra3D was the first delivery used during the procedure in 88% of cases (55-M in 76%; 40-S in 9%; 65-L in 3%), while was the second tool (after failure of the first delivery utilised) in the other pts. The first Selectra3D utilized during each implant was able to complete the procedure in 64% of cases, while in the other pts a second different tool was required to complete the implant. The Selectra3D 55-M was the mostly used and was able to reach the final position in most cases. In dilated atria the 65-L curve was preferred, while when the target point was more proximal the 45-S curve was the best choice. The baseline QRS duration was 135 ± 34 ms and the paced QRS duration was 113 ± 18 ms (P 0.003). The electrical parameters were optimal with sensing 8.7 ± 8 mV; impedance 562 ± 133 ohm; threshold 0.97 ± 0.47 V. During a median follow-up of 178 [34-402] days, 7 lead dislodgement (3 HBP and 4 LBBP) were recorded. All the others showed stability of the electrical parameters.

Conclusion

The Selectra3D introducers effectively supports CSP ensuring procedural success rate>90%. The 55-M curve fits for most of the anatomies, the 45-S curve allows to reach more proximal target, the 65-L curve more distal target in dilated atria. The electrical parameters were optimal at implant and remained stable during follow-up. 6% lead dislodgement were recorded.

Left Bundle Branch Pacing: procedural outcomes using different sheaths

Funding Acknowledgements

Type of funding sources: None.

Background

Left Bundle Branch Pacing (LBBP) ensures physiologic ventricular activation. Growing experiences are rising on its applicability . Different tools available allow successful implant in different cardiac anatomies.

Objective

To analyse implant success rate and acute electrical parameters in LBBP guided by C315 fixed curve sheath or Selectra3D sheath.

Methods

151 patients (mean age 79.8±8.3 years; 51% males) received LBBP. Pacing indication: AV block 50%, SND 12%, slow AF12%, ablate&pace 9%; HF 14%, revision of previous lead 1%. Coronary disease was present in 31%; hypertension in 93%, diabetes in 30%, severe valvular disease in 5%, persistent AF in 31% pts. Average QRS duration was 136±34 ms. Basal mean EF 52±12%. Different criteria for successful LBBP were analyzed (table 1).

Results

The lead was successfully implanted in the left bundle in 97.3% pts. In 60.5% pts guided by the C315 Medtronic fixed curve sheath while in 39.5% pts by the Selectra3D (40-S, 55-M, 65-L) Biotronik sheaths. 93 (63%) pts received 3830 fixed screw lead, 51 (35%) pts received Solia S 60 stylet-driven lead and 3 (2%) patients received Tendril 58 cm stylet-driven lead. All different criteria analysed to define successful LBBP were comparable in the C315 and Selectra 3D group (table 1). In 61% pts LBBP was the first choice, in 39% LBBP was aimed after unsatisfactory HBP (His threshold>2V or paced QRS>140 ms). The LBBP lead was connected to the RV port in 67% DR and 18% SR PMs; to the LV port in the 22 CRT devices. Mean fluoroscopy time was 10±6 min including implant of all leads, without differences between implants. Electrical parameters were highly favourable in all patients (mean threshold 0.73±0.27V and mean sensing 11±5.8 mV) without differences between the 2 sheaths. Pacing impedance was significantly lower in the Selectra 3D group. Paced QRS duration was 114±15 ms (112±14 vs 116±16 ms; P 0.180). Implant failure were 4 (2 due to severe tricuspid regurgitation and 2 to severe dilated atria).

Conclusion

LBBP is highly reliable in clinical practice. The different sheath available lead to successfully perform the implant in different cardiac anatomies. In our experience there was no differences in technical acute outcome between implant guided by C315 Medtronic sheath and Selectra3D Biotronik sheath.

P80 PROGNOSTIC IMPACT OF NEW ONSET ATRIAL FIBRILLATION AFTER SINGLE OR DOUBLE STENT LEFT MAIN BIFURCATION PCI

Objective

Incidence and prognostic value of new onset atrial fibrillation (NOAF) after single versus double stent strategy in bifurcation Left Main (LM) disease has not been yet investigated.

Methods

We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January 1st, 2008 to May 1st 2018. Multivariate Cox–regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of NOAF during the follow–up period.

Results

Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and Cardiovascular mortality were observed in 1.2% and 3.6% in of cases, respectively. NOAF occurred in 23 out of 502 patients (4.6%). Patients with NOAF resulted more frequently female, older, obese, diabetic and more frequently experienced TLF and cardiovascular death. NOAF free survival favoured single versus double stent technique and among double stent techniques NIT compared to the others. Single stent strategy had a lower risk of NOAF compared to double stent technique on multivariate analysis (HR: 1.14, 95% CI: 1.10–1.19, p < 0.001 vs HR: 1.28, 95% CI: 1.23–1.32, p < 0.0001).

Conclusions

NOAF in distal LM bifurcation disease treated with PCI had a low incidence but resulted more frequent after double than after single stenting technique and associated with worse outcomes.

The Slower Antibody Response in Myelofibrosis Patients after Two Doses of mRNA SARS-CoV-2 Vaccine Calls for a Third Dose

Immunization with mRNA SARS-CoV-2 vaccines has been highly recommended and prioritized in fragile subjects, including patients with myelofibrosis (MF). Available data on the vaccine immune response developed by MF patients and the impact of ruxolitinib treatment are still too fragmented to support an informed decision on a third dose for this category of subjects. Here, we show that 76% of MF patients develop spike-specific IgG after the second mRNA SARS-CoV-2 vaccine dose, but the response has a slower kinetics compared to healthy subjects, suggesting a reduced capability of their immune system to promptly react to vaccination. A reduced ACE2/RBD binding inhibition activity of spike-specific antibodies was also observed, especially in ruxolitinib-treated patients. Our results, showing slow kinetics of antibody responses in MF patients following vaccination with mRNA SARS-CoV-2 vaccines, support the need for a third vaccine dose.

3D electro-anatomical mapping to guide conduction system pacing in complex cardiac anatomies

Background

Conduction System Pacing (CSP) includes both His Bundle Pacing (HBP) and Left Bundle Branch Pacing (LBBP). It guarantees physiological cardiac activation and it is essential to avoid pacing-induced dyssynchrony. Markedly dilated atria, up-grading to CRT, and congenital cardiopathies still represent complex anatomical scenarios in which the available tools could often result inadequate and graved by suboptimal results.

Objective

To evaluate the feasibility and effectiveness of 3D electro-anatomical mapping (EAM) to guide CSP (both HBP and LBBP) in patients with characteristics that allows “a priori” classification as complex anatomical scenario with low probability of success using only fluoroscopic guidance and available tools. Left atrium area >40 cm2; post-PICM up-grading and congenital heart disease were considered signs of anatomical complexity.

Methods and results

The study includes 25 patients (19 males, mean age 76–11 years; mean baseline EF 34.2–12.6%; 17 BBB; 5 post-PICM up-grading), candidates for CSP. 16 and 9 were respectively implanted with PM and ICD (13/12 dual/three-chamber devices). CARTO system was used in 6 ptss and EnsiteTM Precision in 19. EAM involved reconstruction of the right atrium and sub-tricuspid septum with the use of a decapolar catheter. Several “tags” have been placed on the His signals, in order to reconstruct the “His Cloud” and distinguish within it the proximal, medium, and distal area (Fig. 1). The sub-tricuspid septum was always reconstructed so that intra-procedurally operator could easily move from HBP to LBBP based on electrical parameters or paced QRS morphology. The mapping catheter was removed after the mapping phase and replaced with the pacing lead. Both exposed fixed screw 3830 leads and standard stylet-driven leads were used. HBP was achieved in 10 pts and LBBP in 13 pts. Three failures were resolved by CS lead implant. The time spend for His cloud mapping was 18±7 min. The mean threshold was 1.1±0.5 V; sensing 11.6±9.3 mV and impedance 786±339 ohm. Baseline QRS 155±19 ms and paced QRS 119±7 ms. In cases of LBBP we were also able to measure on the EAM map the depth of the catheter within the septum, resulting in 11.5±3.1 mm and the distance of the initial screw site from the His of 26.5±10.3 mm.

Conclusions

The electro-anatomical mapping allows the accurate reconstruction of “His cloud” by properly distinguishing proximal, middle, distal His. The sub-tricuspid zone of the interventricular septum is also reconstructed in high definition, so that intra-procedurally it is possible to easily move from HBP to LBBP and vice-versa based on the electrical parameters and paced QRS morphology. This method appears safe and effective even in complex cardiac anatomies possibly saving time and fluoroscopy use. The tags on the His cloud and sub-tricuspid septum can satisfactorily guide lead placement with high reproducibly.

Funding Acknowledgement

Type of funding sources: None. Figure 1. 3D-EAM used to guide HBP implant

Left bundle branch pacing: 2 year single-centre experience

Background

Left Bundle Branch Pacing (LBBP) ensures a physiologic ventricular activation and shows better electrical parameters compared to His bundle pacing (HBP). A growing body of experience is encouraging a large applicability.

Objective

To analyse feasibility and technical outcomes of LBBP in the daily clinical practice.

Methods

During 2019 and 2020, 132 patients (mean age 79±10 years; 72 males) with standard indication for pacing, received the lead deeply intraseptal aiming to pace the left bundle. The indication for pacing were AV block 72 (55%) pts, SND 14 (11%), AF and slow ventricular rate 21 (16%), ablate&pace in 4 (3%); HF in 10 (7.5%), PICM 6 (4%) pts, lead revision in 5 (3.5%). 75% of pts had ischemic cardiopathy; 82% hypertension, 30% diabetes and 21% severe kidney disease. Baseline QRS was 141±38 ms and 68% of pts had bundle branch block. The basal mean EF 49±15%. 91 (69%) of the pts were in sinus rhythm at implant. Criteria for LBBP were: RBB morphology in V1 together with left ventricular activation time (LVAT)<80 ms in V6. Final lead position was always confirmed with injection of 5 ml of dye contrast in left anterior oblique view.

Results

The lead was successfully implanted in the left bundle in 129 (97,7%) patients. In the remaining 3 patients the cathode only penetrated the septum. In 90 cases LBBP was the first choice, in the remaining 42 patients LBBP was aimed after unsatisfactory HBP (His threshold>2V or paced QRS>140 ms). In 107 cases we utilized the 3830 4Fr lumenless lead; in 25 cases the stylet-driven 6 Fr leads. The LBBP lead was connected to the RV port in the 92 dual-chamber PMs; in the LV port in the 22 three-chamber devices as part of cardiac resynchronization therapy; in the only port in 18 single-chamber PM. Mean fluoroscopy time was 10±6 min including implant of all leads. Electrical parameters were highly favourable (R wave sensing 10,5±5 mV; threshold 0,9±0,2 V@0,5 ms; impedance 829±234 ohm). Paced QRS duration was 114±20 ms (P<0.005). The devices were checked 48 hours after implant and 1 month later. Thereafter were remotely monitored. At the 1-month in clinic interrogation all LB lead showed good performance and QRS morphology and duration like the post implant one (115±21 ms). Mean VP% was 81% and mean AP% 28%. VP ≥90% was detected in 42 (32%) of patients. Chronic AF (AT/AF 100%) in 24 (18%) of patients. In 3 cases the LB lead showed early dislodgement requiring lead revision (1 macroscopic dislodgement and 2 rise in threshold), all of them within 7 days after implant.

Conclusion

The new technique of pacing the left bundle of the conduction system (LBBP), is safe and feasible in the clinical practice. It is applicable in all pacing indications including heart failure and resynchronization. In our experience lead dislodgement were 2,2% (3/132, all in the first week after implant) whereas paced QRS duration was significantly shortened and ejection fraction remained normal.

Funding Acknowledgement

Type of funding sources: None.

Selectra 3D- guided conduction system pacing: single-center experience

Background

Conduction system pacing (CSP)is becoming increasingly popular thanks to the ability to both maintain physiological electrical activation in patients with narrow QRS and restore ventricular synchrony in patients with bundle branch block (BBB). The Selectra3D introducer is a new tool able to support the correct positioning and screwing of the catheter on the bundle of His (HBP) or on the left branch (LBBP). It does exist in 3 different shapes: S, M, L (Fig. 1) based on the radius of main curvature. The internal diameter of 7.3 Fr allows it to support both the 3830 lumen-less catheter historically used for CSP, as well as standard 6Fr stylet-driven leads.

Objective

To evaluate the effectiveness of the Selectra3D introducer for CSP (including both HBP and LBBP), considering the procedural success rate and the lead stability (stability of electrical parameters or need for implant revision) in the medium-term follow-up.

Methods and results

The Selectra3D introducer was used in 56 patients' candidates for CSP (mean age 80±6 years). Pacing indications included A-V block in 21 patients, AF with slow ventricular response in 9 patients; SND in 8 patients and HF and severe ventricular dysfunction in 18 patients (of which 4 were PICM). The mean baseline EF was 40±15%. A PM was implanted in 40 patients and an ICD in 16. A standard stylet-driven lead was used in 48 cases, a fixed exposed screw lead was used in 8 patients. HBP was obtained in 21 cases and LBBP in 30 cases, while in 5 cases (8.9%) neither HBP nor LBBP could be obtained. Implants were performed via a left-sided approach in 55 cases and a right-sided approach in 1 case. The baseline QRS duration was 144±38 ms and the paced QRS duration was 118±21 ms. The electrical parameters were optimal with sensing 8.7±8 mV; impedance 625±276 ohm; threshold 1±0.5 V. During follow-up, 2 lead dislodgement (3.9%) (1 HBP and 1 LBBP) were recorded, both within 7 days after implantation. All the others showed stability of the electrical parameters at a mean follow-up of 8.4±4.2 months.

Conclusions

The new Selectra3D introducer supports effectively and safely the lead implant on conduction system catheters (HBP and LBBP), allowing the implant of both exposed fixed screw leads and standard stylet-driven leads, leading to procedural success>90%. The electrical parameters were optimal at implantation and remained stable during follow-up.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Evidence of SARS-CoV-2-Specific Memory B Cells Six Months After Vaccination With the BNT162b2 mRNA Vaccine

SARS-CoV-2 mRNA vaccines have demonstrated high efficacy and immunogenicity, but limited information is currently available on memory B cell generation and long-term persistence. Here, we investigated spike-specific memory B cells and humoral responses in 145 subjects, up to 6 months after the BNT162b2 vaccine (Comirnaty) administration. Spike-specific antibodies peaked 7 days after the second dose and significant antibody titers and ACE2/RBD binding inhibiting activity were still observed after 6 months, despite a progressive decline over time. Concomitant to antibody reduction, spike-specific memory B cells, mostly IgG class-switched, increased in the blood of vaccinees and persisted 6 months after vaccination. Following the in vitro restimulation, circulating memory B cells reactivated and produced spike-specific antibodies. A high frequency of spike-specific IgG+ plasmablasts, identified by computational analysis 7 days after boost, positively correlated with the generation of IgG+ memory B cells at 6 months. These data demonstrate that mRNA BNT162b2 vaccine elicits strong B cell immunity with spike-specific memory B cells that still persist 6 months after vaccination, playing a crucial role for a rapid response to SARS-CoV-2 virus encounter.

Maraviroc as a potential HIV-1 latency-reversing agent in cell line models and ex vivo CD4 T cells

Recent studies have suggested that the CCR5 antagonist maraviroc (MVC) may exert an HIV-1 latency reversal effect. This study aimed at defining MVC-mediated induction of HIV-1 in three cell line latency models and in ex vivo CD4 T cells from six patients with suppressed viraemia. HIV-1 induction was evaluated in TZM-bl cells by measuring HIV-1 LTR-driven luciferase expression, and in ACH-2 and U1 latently infected cell lines by measuring cell-free (CFR) and cell-associated (CAR) HIV-1 RNA by qPCR. NF-κB p65 was quantified in nuclear extracts by immunodetection. In ex vivo CD4 T cells, CAR, CFR and cell-associated DNA (CAD) were quantified at baseline and 1-7-14 days post-induction (T1, T7, T14). At T7 and T14, the infectivity of the CD4 T cells co-cultured with MOLT-4/CCR5 target cells was evaluated in the TZM-bl assay (TZA). Results were expressed as fold activation (FA) with respect to untreated cells. No LTR activation was observed in TZM-bl cells at any MVC concentration. NF-κB activation was only modestly upregulated (1.6±0.4) in TZM-bl cells with 5 µM MVC. Significant FA of HIV-1 expression was only detected at 80 µM MVC, namely on HIV-1 CFR in U1 (3.1±0.9; P=0.034) and ACH-2 cells (3.9±1.4; P=0.037). CFR was only weakly stimulated at 20 µM in ACH-2 (1.7±1.0 FA) cells and at 5 µM in U1 cells (1.9±0.5 FA). Although no consistent pattern of MVC-mediated activation was observed in ex vivo experiments, substantial FA values were detected sparsely on individual samples with different parameters. Notably, in one sample, MVC stimulated all parameters at T7 (2.3±0.2 CAD, 6.8±3.7 CAR, 18.7±16.7 CFR, 7.3±0.2 TZA). In conclusion, MVC variably induces HIV-1 production in some cell line models not previously used to test its latency reversal potential. In ex vivo CD4 T cells, MVC may exert patient-specific HIV-1 induction; however, clinically relevant patterns, if any, remain to be defined.

Short or Long Interval between Priming and Boosting: Does It Impact on the Vaccine Immunogenicity?

Characterizing the impact of the vaccination schedule on the induction of B and T cell immune responses is critical for improving vaccine immunogenicity. Here we compare the effect of a short (4 weeks) or a long (18 weeks) interval between priming and boosting in mice, using a model vaccine formulation based on the chimeric tuberculosis vaccine antigen H56 combined with alum. While no significant difference was observed in serum antigen-specific IgG response and the induction of antigen-specific T follicular helper cells into draining lymph nodes after the two immunization schedules, a longer interval between priming and boosting elicited a higher number of germinal center-B cells and H56-specific antibody-secreting cells and modulated the effector function of reactivated CD4+ T cells. These data show that the scheduling of the booster immunization could affect the immune response elicited by vaccination modulating and improving the immunogenicity of the vaccine.

Electrograms guided his bundle pacing implant: moving from radiology to electrical signals

Background

The standard technique to His Bundle Pacing (HBP) based on a fluoroscopic approach might be challenging and fluoro consuming. The electrical signals could lead to a precise and rapid lead implant, thus reducing the fluoroscopy time (FT) and X-ray dose.

Objective

To evaluate the feasibility, efficacy and safety of the electrogram-guided technique to obtain His Bundle pacing (HBP) with minimal or no fluoroscopy use.

Methods

Between October and December 2018, 41 consecutive patients with indication for pacing underwent HBP with the electrogram-guided approach.

Results

Successful HBP was obtained in 39/41 (95%) pts, which is the study population (mean age 78±10 years). S-HBP and NS-HBP were achieved in 23 (59%) and 16 (41%) pts, respectively. Final HBP lead position was achieved in 31/39 (79.4%) pts with zero fluoroscopy, only guided by the electrical signals. In the remaining 8 pts a minimal dose of fluoro (mean 8 sec) has been required to locate the His. Fluoroscopy has been routinely used to remove the sheath and to ensure the slack. The atrial lead has been implanted in a standard fashion. No difference was observed in the FT for HBP lead placement in patients with S-HBP and NS-HBP (mean 8.1±25 sec vs 7.5±20 sec, p=0.8; median value 0 sec vs 0 sec). Moreover, no significant differences were observed in the FT needed for the entire procedure, total Dose Area Product (DAP) and total procedural time among both S-HBP and NS-HBP. The His lead dislodgement occurred in 1 (2.6%) patient one day after the procedure.

Conclusion

HBP could be performed safely and efficiently using the electrograms, with minimal or no fluoroscopy. Fluoroscopy was required during sheath removal and atrial lead placement.

Funding Acknowledgement

Type of funding source: None

The challenge of education in conduction system pacing: results from single or dual operators

Background

The his bundle pacing (HBP) and Left bundle branch pacing (LBBp) techniques are quickly increasing in the cardiovascular interest being the most physiological mode of pacing. Education in these new conduction system pacing (CSP) is mandatory in the modern EP programs. Achieving acceptable implant success rate, together with electrical parameters adequacy is required.

Objective

The aim of the study was to compare clinical and technical outcomes in 2 groups of patients, those implanted by a single operator with large expertise in CSP and those implanted by two operators (one of them during his learning curve).

Methods

Data from 255 consecutive patients (mean age 78±9 years; 186 males) who underwent successful HBP or LBBp implants were collected and analyzed. The operators were classified as expert after performing more than 50 procedures. Baseline caracteristics were not significantly different between the two groups.

Results

After a mean follow-up of 20±10months, we found that there were no differences between patients implanted by 1 single expert operator and 2 operators (1 beginner during his learning cirve supervised by 1 expert operator) in terms of clinical end point (composite of death or heart failure hospitalizations) and technical end point (need for surgical revision of the implant for reason other than battery replacement). Fluoroscopy time (16±17 min vs 9.8±11 min; p 0.004) and procedural time (113±48 min vs 16±17 min; p 0.003) were significantly prolonged when the implant was performed by 2 operators.

Conclusions

Skill acquisition in physiological pacing (both HBP and LBBp) is a nowadays process which cannot put patient's safety at risk. Our experience shows that clinical and technical outcomes were equivalent when the implant was performed by an expert operator or a beginner operator supervised by 1 expert operator. Fluoroscopy time and duration of the procedure were significantly prolonged by the presence of a trainees.

Kaplan Meyer curves

Funding Acknowledgement

Type of funding source: None

The back-up lead in his bundle pacing: evolution over the years

Background

His bundle pacing (HBP) can be affected by high thresholds and low sensing. Thus, in selected patients including a back-up lead is advisable.

Objective

Single-centre retrospective analysis of a large HBP experience, focusing on the back-up lead utilization over the years.

Methods

677 pts (76±8 years; 433 males) were implanted with HBP from 2004 to 2019 July. The pts received S-HBP (67%) or NS-HBP by the 3830 lead. The pacing indications were AV block 54%, sinus node disease 17%, slow atrial fibrillation 23%, heart failure 6%. Ischemic cardiopathy was found in 26%; hypertension in 83%, diabetes in28% pts. Baseline QRS duration was 123±32 ms and EF 56±12%.

Results

266 (39%) pts received the back-up lead. In sinus rhythm we implanted 3-chamber PM (His lead:LV port; VV delay 80 ms: His pulses and apical pacing during the refractory period). 30 pts (11%) received a particular type of 3-chamber PM which provides back-up pacing only if His capture fails, thus saving energy. In atrial fibrillation 2-chamber PM was implanted (His lead: atrial port, DVI). We recorded a significant decrease of back-up lead use over the years, strictly related to operators/centre experience (>70% during the first years, nearly 10% during the last year). The C315 fixed curve sheath, strongly contributed to the rapid reduction of back-up lead use thanks to better lead fixation and stability.

Conclusion

The back-up lead utilization is progressively decreasing. It is strictly related to the operator/centre experience. The presence of the back-up lead could strengthen the Hisian pacing reliability, potentially impacting pacing indication even in advanced conduction disturbances and saving device longevity.

Funding Acknowledgement

Type of funding source: None

Computational Analysis of Multiparametric Flow Cytometric Data to Dissect B Cell Subsets in Vaccine Studies

The generation of the B cell response upon vaccination is characterized by the induction of different functional and phenotypic subpopulations and is strongly dependent on the vaccine formulation, including the adjuvant used. Here, we have profiled the different B cell subsets elicited upon vaccination, using machine learning methods for interpreting high‐dimensional flow cytometry data sets. The B cell response elicited by an adjuvanted vaccine formulation, compared to the antigen alone, was characterized using two automated methods based on clustering (FlowSOM) and dimensional reduction (t‐SNE) approaches. The clustering method identified, based on multiple marker expression, different B cell populations, including plasmablasts, plasma cells, germinal center B cells and their subsets, while this profiling was more difficult with t‐SNE analysis. When undefined phenotypes were detected, their characterization could be improved by integrating the t‐SNE spatial visualization of cells with the FlowSOM clusters. The frequency of some cellular subsets, in particular plasma cells, was significantly higher in lymph nodes of mice primed with the adjuvanted formulation compared to antigen alone. Thanks to this automatic data analysis it was possible to identify, in an unbiased way, different B cell populations and also intermediate stages of cell differentiation elicited by immunization, thus providing a signature of B cell recall response that can be hardly obtained with the classical bidimensional gating analysis. © 2019 The Authors. Cytometry Part A published by Wiley Periodicals, Inc. on behalf of International Society for Advancement of Cytometry.

P6547The energy cost of His bundle pacing can be curtailed

Introduction

His bundle pacing (HBP) allows physiological ventricular activation and prevents the electrical and mechanical desynchronization generally induced by myocardial stimulation, which can increase the risk of atrial fibrillation and heart failure. On the other hand, reliable HBP capture often requires higher energy than conventional myocardial pacing. This reduces the expected life of the stimulator and might limit the diffusion of HBP in the clinical practice.

Purpose

Decreasing HBP current drain by careful management of stimulation safety margin and pulse duration.

Methods

In 28 patients undergoing DDD pacing with HBP, a third lead was implanted in RV apex to provide back-up pacing on demand. HBP and apical leads were connected, respectively, to the V1 and V2 channels of a 3-chamber stimulator. When HBP was effective, apical sensing occurred within the VV delay and prevented V2 stimulation. In contrast, in case of HBP failure, V2 sensing was missing and apical back-up pacing was promptly delivered at the end of the VV delay. The availability of a back-up pulse on demand allowed reducing the HBP safety margin with no risk. Furthermore, the individual HBP strength-duration curve was derived in the aim of optimizing the Hisian pulse parameters, which are the major determinants of the device current drain.

Results

Correct back-up inhibition by successful HBP and stimulation in the event of capture loss was achieved in all the patients. The latency from Hisian pacing to apical sensing averaged 96±14 ms. According to the pacemaker counters, no back-up pulse was delivered in daily life in 59% of patients. In the remaining, the prevalence of back-up stimulation never exceeded 15% of paced ventricular cycles. The high HBP threshold was essentially due to an increased rheobase (1.2±0.6 V), while the chronaxie ranged from 0.30 to 0.53 ms in 71% of patients (median 0.44 ms), exceeding 0.6 ms only in 29% of the cases. An average current saving of 5.4±3.0 μA was obtained at the expense of a mild reduction in HBP safety margin (from 1.6±0.2 to 1.4±0.1 times).

HBP and apical back-up

Conclusions

Back-up stimulation on demand is a reliable option to decrease HBP current drain and prolong the stimulator service life with full safety. In most of the cases, significant saving can be achieved by pulse shortening, as the chronaxie time is in the same range as with myocardial stimulation and longer pulses are not required. A pulse duration exceeding 0.6 ms is indicated in less than 1/3 of the implants.

Optimized Protocol for the Detection of Multifunctional Epitope-Specific CD4+ T Cells Combining MHC-II Tetramer and Intracellular Cytokine Staining Technologies

Analysis of multifunctional CD4⁺ T cells is fundamental for characterizing the immune responses to vaccination or infection. Major histocompatibility complex (MHC)/peptide tetramers represent a powerful technology for the detection of antigen-specific T cells by specific binding to their T-cell receptor, and their combination with functional assays is fundamental for characterizing the antigen-specific immune response. Here we optimized a protocol for the detection of multiple intracellular cytokines within epitope-specific CD4⁺ T cells identified by the MHC class II tetramer technology. The optimal procedure for assessing the functional activity of tetramer-binding CD4⁺ T cells was based on the simultaneous intracellular staining with both MHC tetramers and cytokine-specific antibodies upon in vitro restimulation of cells with the vaccine antigen. The protocol was selected among procedures that differently combine the steps of cellular restimulation and tetramer staining with intracellular cytokine labeling. This method can be applied to better understand the complex functional profile of CD4⁺ T-cell responses upon vaccination or infection.

Type M Resistance to Macrolides Is Due to a Two-Gene Efflux Transport System of the ATP-Binding Cassette (ABC) Superfamily

The mef(A) gene was originally identified as the resistance determinant responsible for type M resistance to macrolides, a phenotype frequently found in clinical isolates of Streptococcus pneumoniae and Streptococcus pyogenes. MefA was defined as a secondary transporter of the major facilitator superfamily driven by proton-motive force. However, when characterizing the mef(A)-carrying elements Tn1207.1 and Φ1207.3, another macrolide resistance gene, msr(D), was found adjacent to mef(A). To define the respective contribution of mef(A) and msr(D) to macrolide resistance, three isogenic deletion mutants were constructed by transformation of a S. pneumoniae strain carrying Φ1207.3: (i) Δmef(A)–Δmsr(D); (ii) Δmef(A)–msr(D); and (iii) mef(A)–Δmsr(D). Susceptibility testing of mutants clearly showed that msr(D) is required for macrolide resistance, while deletion of mef(A) produced only a twofold reduction in the minimal inhibitory concentration (MIC) for erythromycin. The contribution of msr(D) to macrolide resistance was also studied in S. pyogenes, which is the original host of Φ1207.3. Two isogenic strains of S. pyogenes were constructed: (i) FR156, carrying Φ1207.3, and (ii) FR155, carrying Φ1207.3/Δmsr(D). FR155 was susceptible to erythromycin, whereas FR156 was resistant, with an MIC value of 8 μg/ml. Complementation experiments showed that reintroduction of the msr(D) gene could restore macrolide resistance in Δmsr(D) mutants. Radiolabeled erythromycin was retained by strains lacking msr(D), while msr(D)-carrying strains showed erythromycin efflux. Deletion of mef(A) did not affect erythromycin efflux. This data suggest that type M resistance to macrolides in streptococci is due to an efflux transport system of the ATP-binding cassette (ABC) superfamily, in which mef(A) encodes the transmembrane channel, and msr(D) the two ATP-binding domains.

Time Trends in Survival of Children with Acute Lymphocytic Leukemia in Piedmont, Italy: A Report from the Population-Based Cancer Registry

Aims and Background

The Childhood Cancer Registry of Piedmont (RTI) periodically updates the life status of each registered child. Given its size, the RTI is the major (albeit geographically limited) Italian source of population-based survival rates of cancer in children. The present report describes time trends in survival of children with acute lymphocytic leukemia (ALL).

Methods

During 1970-87, 429 residents in Piedmont aged 0-14 were diagnosed as having ALL: they have been followed up until 1991.

Results

Five-year survival rates increased from 21% to 72% for children diagnosed ALL respectively in 1970-72 and 1985-87. Major improvements occurred up to the mid-seventies and again between cases diagnosed in the early and late eighties. Improvement in survival was statistically significant for children belonging to classes comprised between 2 and 10 years of age at diagnosis. Period of diagnosis was unrelated to probability of survival among the 13 cases diagnosed ALL at age 0. Survival was unrelated to sex, even in the early seventies and even after consideration of children dying more than 5 years after diagnosis. Between 1976-81 and 1982-87, an improvement in survival was found in all categories of WBC count at diagnosis: the ratio between the two estimates was somewhat higher for children with more than 50,000 WBC/mm3 at diagnosis than for other children.

Conclusions

Present data are compared with those resulting from other population-based series: this exercise can be useful for an overall evaluation of delivery of cancer therapy at the population basis.

Parental Occupation and Other Environmental Factors in the Etiology of Leukemias and Non-Hodgkin'S Lymphomas in Childhood: A Case-Control Study

We report the results of a hospital-based, case-control study on acute lymphocytic leukemia (ALL), acute non-lympocytic leukemia (AnLL) and non-Hodgkin lymphoma (NHL) in childhood. The study was conducted from 1981 to 1984 in Turin (Italy). One hundred and forty-two children with ALL, 22 with AnLL and 19 with NHL were included, as well as 307 controls. Information on parental smoking habits, parental occupation, ionizing radiation and childhood diseases were collected using a standard questionnaire during a personal interview of the relative attending the child in the hospital. The odds ratios for antenatal diagnostic radiation were 1.1 (NS) for ALL and 2.4 (NS) for AnLL. No association was found with diseases in childhood. Paternal and maternal smoking habits were similar for ALL cases and controls. Both maternal and paternal smoking were associated with NHL: for paternal smoking, odds ratios were around 5, but without a correlation with number of cigarettes. Positive associations observed with maternal employment were: ALL with teacher and cleaner; AnLL and textile worker; NHL and baker. Corresponding association with paternal jobs were: ALL with clerks, farmers and employment in office equipment production; AnLL and workers in building, tire or textile industries; NHL and lorry drivers, workers in the building or in the wood and furniture industry.

Risk Factors for Soft Tissue Sarcomas in Childhood: A Case-Control Study

A hospital-based case-control study on soft tissue sarcomas (STS) was conducted in 1983-84 in Torino and in Padova (Italy). Cases (36 children with rhabdomyosarcoma (RMS) and 16 non RMS-STS) were compared to 326 controls. Histories of parental smoking habits and occupations, parental and children's exposure to ionizing radiation, children's diseases and some other variables were collected through interviews to the relatives attending the child in the hospital. A non statistically significant association was observed with both maternal age above 30 at child's birth (STS: OR = 1.5, C.I. = 0.8-2.9; RMS: OR = 1.9, C.I. = 0.9-4.0) and « in utero » exposure to diagnostic radiation (STS: OR = 1.9, C.I. = 0.5-6.5, based on 4 cases). No association was found with children's previous diseases. Paternal and maternal smoking habits were similar for RMS and STS cases and controls. Some positive associations with either maternal or paternal occupational histories were identified. They are difficult to interpret in view of the large number of comparisons and small absolute figures. They included maternal employment as medical doctor and nurse, farmer, textile worker and machine tool operator. An association was also observed with paternal occupation as butcher, building worker or employment in the production of domestic appliances. One case and no controls reported a maternal aunt affected by breast cancer.

Ataxia Telangiectasia and Acute Lymphoblastic Leukemia: Report of a Case

We report a new case of ataxia-telangiectasia (AT) and acute lymphoblastic leukemia (ALL) and review all 21 known cases of AT and ALL. Leukemia in these patients is associated with a male predominance, age older than 10 years at diagnosis, a white blood cell count higher than 50,000 mm3, and a fatal course. Four patients have been reported who developed T-cell leukemia, 3 null-cell leukemia and 1 B-cell leukemia. The AT-ALL patients appear to be at risk for infections related to their immunodeficient status and ALL chemotherapy. In addition, neurologic deterioration has been noted during the early phase of therapy.

Neurofibromatosis and Malignant Childhood Cancers: A Survey in Italy, 1970–83

Neural tumors, Wilms’ tumor, rhabdomyosarcoma and several types of leukemia have been previously described in association with neurofibromatosis (NF). In a nation-wide collection of cases in Italy, 15 children (0–14 years of age) with NF and cancer or leukemia were identified; 13 of them had been diagnosed with cancer between 1976–83. The expected number of children with cancer and NF in 1976–83 was 4.48. The distribution of tumor types was different from that found in the general population, with a higher proportion of tumors of neural crest origin as well as soft tissue sarcomas. In 7/15 the family history was positive for NF; in 5/7 the individuals affected included the mother and/or a maternal relative.

Mortality of Parents of Children with Cancer: A Population-based Study in Turin, Italy

Aims and Background

A cohort study was conducted in order to measure cause-specific mortality among parents of children recorded in the Childhood Cancer Registry of Piedmont. It is the first study carried out on the subject in southern Europe.

Methods and Study Design

The study comprised the 740 children resident in Turin and in whom a cancer had been diagnosed in the period 1967-1991. Nominal data were obtained for 723 fathers and 733 mothers. At the end of the follow-up in 1995, 645 fathers were alive, 68 dead and 10 untraceable. Corresponding figures for mothers were 700, 28 and 5. Cause of death was known for 91 of 96 parents.

Results

The period of observation of parents started on the birth of the index child, however mortality analyses were restricted to the period after 1965 because of limited availability of local reference rates. Total mortality was lower than expected among fathers (66 observed deaths vs 88.2 expected, P <0.05) and mothers (28 vs 31.4). Fathers showed deficits (not statistically significant) of lung neoplasms (4 vs 9.9), cardiovascular diseases (18 vs 27.1) and hepatic cirrhosis (2 vs 6.6). No statistically significant variations in mortality were observed with time from diagnosis or according to life status of the children. No cancer deaths occurred among the mothers of sarcoma cases whereas 1.9 were expected.

Conclusions

The data do not indicate any increase in mortality from cancer or other causes and, on the contrary, show a reduction in mortality which was more evident for the causes related to life style.

High Incidence of Laryngeal Cancer in the Province of Torino (Italy)

The present report shows that the province of Torino, Italy, (6830 sq Km, population in 1966, 2.074.893) is a high risk area for laryngeal cancer. A total of 875 cases occurring in residents in the province were forwarded to the Cancer Registry of Piedmont (RTP) in 1965–69. A histological report was available in 67.9 % cases, while in 21.8 % the death certificate was the only document with diagnosis of laryngeal cancer (table 1). Cases were uniformly distributed throughout the 5 years covered by the study: the number of cases with death certificate only progressively decreased from 59 in 1965 to 21 in 1969 (table 3). For the purposes of the present study, the province of Torino has been divided into 3 areas, i.e. the city of Torino (population 1.107.919), the 23 suburbs (total population 340.951) and the non-metropolitan part of the province (population 626.023). Among the three areas, the relative frequency of laryngeal cancer/all malignant tumours recorded at the RTP in men was 5.78 % in the city of Torino, 6.43 % in the suburbs and 4.77 % in the non-metropolitan part of the province (table 4). The difference between the city of Torino and the suburbs was not significant (p > 0.05) while the difference both between the city of Torino and the non metropolitan part of the province and between the suburbs and the non metropolitan areas was significant (p < 0.05 and p ∼ 0.01 respectively). In other cancer registries (3) the relative frequencies of laryngeal cancer were under 2.86 % with the exception of Israel (3.24 %) and Bombay (9.26 %). In women, the relative frequency of laryngeal cancer fluctuated between 0.25 and 0.32 % in the different areas of the province of Torino, i.e. in the same order of those observed in other cancer registries with the exception of Bombay (2.07%) (3). In the province of Torino considered as a whole, age standardized annual incidence/100.000 of laryngeal cancer was 12.6 in men and 0.6 in women. Incidences truncated to ages 35–64 were 25.5 and 0.9 respectively (table 5). In men these rates are approximately 5–7 times higher than those recorded in Norway, Sweden and Denmark and about 3.5–6 times higher than those recorded in the six cancer registries operating in Great Britain. A comparison between the province of Torino and other cancer registries on age specific incidences (table 6, text-fig. 3) shows that the ratio province of Torino/other registries is relatively higher at age 35–44 than later in life. This is considered as evidence of an increase of the environmental carcinogenic load in the province of Torino during recent years. In men, age standardized incidences and incidences truncated to ages 35–64 were slightly but not significantly higher in the city of Torino than in the suburbs. On the other hand, in both the city of Torino and the suburbs they were 1.5–1.7 times higher than in the non-metropolitan part of the province (table 5). The difference concerned mainly age groups over 55 (text-fig. 2). However, the incidence of laryngeal cancer truncated to ages 35–64 in the non-metropolitan part of the province of Torino was still 7.2 times higher than in the rural population of Norway and 2.1–4.1 times higher than in the six cancer registries operating in Great Britain (3). This suggests that factors connected with life in the metropolitan area of Torino (such as air pollution) are a minor cause of the excess of laryngeal cancer in the province of Torino.

Epidemiology of Childhood Cancer in Piemonte and Valle d'Aosta during 1965-69

Piemonte and Valle d'Aosta are in the NW part of Italy. In 1967 total population and population aged 0-14 were respectively 4.338.000 and 841.000. During the period 1965-69 a total of 688 cases of cancer (including leukemia) were diagnosed in children under 15 years of age resident in this area. The Cancer Registry of Piedmont and Valle d'Aosta (RTP) provided information on 465 children; the other 223 were collected through additional investigation in the files of 31 university or hospital departments of the region and 5 extraregional hospitals. Distribution through the 5 years covered by the investigation is shown in Table 1. Histological or hematological confirmation of the diagnosis was available in 499 cases (73%). The 688 cases included 216 leukemias, 131 tumors of the central nervous system, 40 neuroblastomas, 82 lymphomas (including 34 cases of Hodgkin's disease), 46 nephroblastomas, 32 soft-tissue sarcomas, 29 bone sarcomas (including 5 cases of Ewing's disease), 25 retinoblastomas, 12 thyroid tumors, 10 extragenital teratomas, 5 ovarian dysgerminomas, 4 tumours of the testes, 4 hepatoblastomas and 52 other tumours (Table 2). The number of children under 15 years of age dying of cancer during 1965-69 was 341 (Table 2). Incidence and mortality rates by age groups are given in Tables 3 and 4. The rates were of the same order as those observed in the U.S. and in other European cancer registries during the same period (Tables 4, 5 and 6). The mortality rate for nephroblastomas at age 0-4 was 1,09/100.000/year, i.e. slightly higher than that observed in the U.S. in 1960 but about twice as high as that observed in the U.S. in 1967 (14). Incidence and mortality rates for both Hodgkin's and non-Hodgkin's lymphomas were about 3 times higher in males than in females (Table 3). The difference was less obvious during the first five years of life, in which the total number of diagnosed lymphomas was 16.

Increase of Mortality Kate of Cancer of the Larynx in the Town of Torino and in Italy since 1951

Mortality rates of cancer of the larynx in the town of Torino, in the whole of Italy and in France during 1950–71 are reported. Age standardized mortality rates as well as mortality rates truncated to the period 35–64 years of age are reported in Table 1 for males and in Table 2 for females. Graph 1 represents age specific mortality rates for cancer of the larynx in the three areas in 1966–67. Graphs 2, 3 and 4 report mortality rates in males in the three ares for cohort of birth. All rates are annual/100.000. An increase of mortality for cancer of the larynx in men is well documented in the town of Torino. From 1951 to 1966 the mortality rate truncated to age 35–64 increased from 6.3 to 12.0. The proportion of mortality for cancer of the larynx/mortality for all cancers during the same period increased from 3.1 % to 5.4%. In Italy, the mortality rate in men aged 35–64 was 6.5 in 1952 and 9.3 in 1967: during the same period the proportion of mortality for cancer of the larynx/mortality for all cancers increased from 3.8 % to 4.4 %. In France, the tendency to an increase of mortality for laryngeal cancer after 1951 was absent or debatable, although both the mortality rates of cancer of the larynx and the proportion of mortality for cancer of the larynx/mortality for all cancers were consistently higher than in Italy or in Torino. However, in 1966–67 at ages 35–44 the mortality rate for cancer of the larynx in men was higher in Torino than in France (Graph 1).

Survival of Childhood Cancer Patients in Italy, 1978–1989

In the framework of the ITACARE project, a cooperative investigation conducted on the data from the Italian population-based cancer registries, survival of patients with childhood malignant neoplasms was studied. The study included 1,768 cases diagnosed at age 0–14 plus 29 osteosarcoma cases diagnosed at age 15–19. Cases were collected over the period 1978–1989, or more limited periods for some participating registries. A total of 1,138 cases were from the Childhood Cancer Registry of Piedmont and 659 from the registries operating in the provinces of Varese, Parma, Modena, Forlì and Ravenna, Florence, Latina, Ragusa and in the cities of Genova and Torino (the last contributed only for bone neoplasm diagnosed at age 15–19). Overall 5-year survival was 54% for malignancies diagnosed in 1978–1981, 60% for the period 1982–1985, and 69% for the period 1986–1989. The range among registries of 5-year survival for cases diagnosed in 1986–1989 was 55–78%. Most diagnostic categories presented an improved prognosis for the cases diagnosed more recently. For cases diagnosed in 1986–1989, 5-year survival was: 74% for acute lymphatic leukaemia, 40% for acute non-lymphatic leukaemia, 65% for central nervous system neoplasms (76% for astrocytoma, 75% for ependymoma and 85% for medulloblastoma), 66% for osteosarcoma, 55% for Ewing's sarcoma, 87% for Hodgkin's disease, 64% for non-Hodgkin's lymphoma, 74% for rhabdomyosarcoma, 64% for neuroblastoma, 78% for nephroblastoma and 100% for retinoblastoma. Italian survival was similar to that observed in other population-based surveys in the UK and USA.

Physical Impairment and Social Life, Goals among Adult Long-term Survivors of Childhood Cancer: A Population-based Study from the Childhood Cancer Registry of Piedmont, Italy

Aims and Background

The study describes the health status and the attainment of life goals in the adult survivors of childhood cancer recorded at the Childhood Cancer Registry of Piedmont.

Methods and Study Design

A postal questionnaire was sent to the general practitioner of the 690 cases born before 1976 and alive in 1991 after at least 5 years from diagnosis. The answer was received for 485 (72.9%) included in the analyses. Items in the questionnaire were: sequelae related to cancer and its treatment, health-related quality of life (according to Bloom's criteria), educational level attained, and employment status.

Results

Vital and marital status were obtained for all 690 cases at the offices of the town of residence. No medical condition was reported for 309 cases (63.7%). The overall proportion with a high school or university education was compared to corresponding figures for Piedmont in 1991, adjusted by age, and was as high as in the general population. Similar results are observed for occupation. Patients of both genders were married less than expected. Patients with leukemia (112 cases), non-Hodgkin's lymphoma (34) or Hodgkin's lymphoma (52) were reported to have the highest quality of life. In contrast, patients with tumors of the central nervous system (151) had the highest frequency of sequelae and the lowest score for health-related quality of life. They also presented the lowest educational achievement, the lowest proportion of employment and, among males, the lowest frequency of marriage.

Conclusions

Our study shows a good social adjustment of adult survivors from childhood cancer, with the exception of central nervous system tumors. From the methodologic point of view, the present study shows the feasibility of surveillance surveys on health-related quality of life with the contribution of general practitioners.

Heterologous Prime-Boost Combinations Highlight the Crucial Role of Adjuvant in Priming the Immune System

The induction and modulation of the immune response to vaccination can be rationally designed by combining different vaccine formulations for priming and boosting. Here, we investigated the impact of heterologous prime-boost approaches on the vaccine-specific cellular and humoral responses specific for a mycobacterial vaccine antigen. C57BL/6 mice were primed with the chimeric vaccine antigen H56 administered alone or with the CAF01 adjuvant, and boosted with H56 alone, or combined with CAF01 or with the squalene-based oil-in-water emulsion adjuvant (o/w squalene). A strong secondary H56-specific CD4⁺ T cell response was recalled by all the booster vaccine formulations when mice had been primed with H56 and CAF01, but not with H56 alone. The polyfunctional nature of T helper cells was analyzed and visualized with the multidimensional flow cytometry FlowSOM software, implemented as a package of the R environment. A similar cytokine profile was detected in groups primed with H56 + CAF01 and boosted with or without adjuvant, except for some clusters of cells expressing high level of IL-17 together with TNF-α, IL-2, and IFN-γ, that were significantly upregulated only in groups boosted with the adjuvants. On the contrary, the comparison between groups primed with or without the adjuvant showed a completely different clusterization of cells, strengthening the impact of the formulation used for primary immunization on the profiling of responding cells. The presence of the CAF01 adjuvant in the priming formulation deeply affected also the secondary humoral response, especially in groups boosted with H56 alone or o/w squalene. In conclusion, the presence of CAF01 adjuvant in the primary immunization is crucial for promoting primary T and B cell responses that can be efficiently reactivated by booster immunization also performed with antigen alone.