Baseline characteristics of patients with atrial fibrillation and cancer enrolled in the BLITZ-AF Cancer registry

Background

Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy.

Methods

BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing.

Results

From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled.

The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases.

AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF.

Baseline characteristics are presented in Table 1. Males were more than women and almost half of the subjects was >75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3.

As shown in Figure 1, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined.

Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22–2.05), age (OR 2.00, 95% CI 1.39–2.88 and OR 2.63, 95% CI 1.84–3.76, respectively, for 65–74 years and ≥75 years vs <65 years), hypertension (OR 1.43, 95% CI 1.10–1.87), long-standing persistent or permanent AF (OR 1.36, 95% CI 1.05–1.78). Haemoglobin <12 g/dL (OR 0.57, 95% CI 0.45–0.73), and planned cancer treatment (OR 0.72, 95% CI 0.57–0.92) were independently associated with a lower prescription of DOACs.

Conclusions

BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo.

C58 LONG–TERM SURVIVAL OF PATIENTS ADMITTED FOR A FIRST AMI EVENT AND MANAGED WITH MYOCARDIAL REVASCULARIZATION OR CONSERVATIVE APPROACH IN ITALY

Background

The long–term clinical benefits of myocardial revascularization in a contemporary cohort of patients with acute myocardial infarction (AMI) are unclear. We aimed to compare the overall mortality rates at 8 years of patients admitted in Italian hospitals with a first AMI managed with or without myocardial revascularization during the index event.

Methods

This is a national retrospective cohort study that enrolled patients admitted with a first AMI in 2012 in all Italian hospitals. The outcome of interest was all–cause mortality at 8 years. Time to events was analyzed using a Cox multivariate regression model.

Results

A total of 97,271 patients with AMI were admitted to an Italian hospital in 2012. Patients with a previous AMI or myocardial revascularization (n = 27,350) have been excluded from this analysis. Among the remaining 69,921 AMI events, 56.6% underwent a percutaneous coronary intervention (PCI) or a coronary artery by–pass grafting (CABG) during the index admission. The crude 8–year survival was 0.76% for patients treated with PCI or CABG in the index admission and 0.34% for patients managed with a conservative approach (Figure 1). Considering the differences in risk factors, the invasive approach showed a significantly lower risk of long–term mortality compared to the conservative management (hazard ratio=0.55; 95% confidence intervals 0.53–0.56) (Figure 2).

Conclusions

In a contemporary nationwide cohort of patients at their first AMI episode, those who underwent a myocardial revascularization during the index event presented an adjusted 45% relative risk reduction in overall mortality at 8–year follow–up compared with those treated only medically.

P206 IMPACT OF AGE, GENDER AND HEART FAILURE ON MORTALITY TRENDS AFTER ACUTE MYOCARDIAL INFARCTION IN ITALY

Background

The outcome of patients with acute myocardial infarction (AMI) may vary substantially based on baseline risk. We aimed at analyzing the impact of gender, age and heart failure (HF) on mortality trends, based on a nationwide, comprehensive and universal administrative database of AMI.

Methods

This is a nationwide cohort study of patients admitted with AMI from 2009 to 2018 in all Italian hospitals. In–hospital mortality rate (I–MR) and 1–year post–discharge mortality rate (1–Y–MR) were assessed.

Results

Among the 1,000,965 AMI events included in the analysis, 43.6% occurred in patients aged ≥75 years, 34.7% in females and 21.8% in AMI complicated by HF at the index hospitalization (Figure 1). Both I–MR and 1–Y–MR significantly decreased over time (from 8.87% to 6.72%; mean annual change − 0.23%; confidence intervals (CI): − 0.26% to − 0.20% and from 12.24% to 10.59%; mean annual change − 0.18%; CI: − 0.24% to − 0.13%, respectively). This trend was confirmed in younger and elderly AMI patients, in both sexes (Figure 2). In AMI patients complicated by HF, both I–MR and 1–Y–MR were markedly high, regardless of age and gender.

Conclusions

This contemporary, nationwide study suggests that I–MR and 1–Y–MR are still elevated, albeit decreasing over time. Elderly patients and those with HF at the time of index admission, present a particularly high risk of fatal events, regardless of gender.

P223 THYROTOXIC DILATED CARDIOMYOPATHY

Hyperthyroidism can strongly impact cardiac function. Thyrotoxicosis enhances myocardiocytes metabolism and it can be responsible for hyperdynamic circulation state leading to heart failure with preserved ejection fraction, but also left ventricle dilatation and severe contractile function impairment. It can furthermore provoke arrhythmias, mostly atrial fibrillation, but, as we are going to discuss in this case, even ventricular arrhythmias. A 40–year–old woman came to our emergency department for chest pain. ECG showed reduced R waves voltage in precordial leads and troponin I values were normal. The echocardiogram showed severe left ventricle disfunction with global hypokinesia (EF 35%) and enlarged left ventricle (LVEDD 65 mm). Blood tests revealed severe hyperthyroidism with extremely low level of TSH, FT3 13,45 pg/ml, FT4 3,4 ng/ml and thyroid echography documented multiple solid nodular formations with hypo–isoechogenic signal. She underwent a coronary angiography that showed patent coronary arteries, and a cardiac magnetic resonance confirming severe contractile impairment and hypertrabeculation of the apex and lateral wall. On the assumption of a dilated cardiomyopathy secondary to hyperthyroidism, we started treatment with methimazole, ACE inhibitors and propranolol. During hospitalization, continuous ECG monitoring recorded several episodes of non–sustained ventricular tachycardia, the longest lasting 22 seconds, so the patient was discharged with a wearable cardioverter–defibrillator. It did not record any arrhythmias and it was dismissed a month later. After almost two months of therapy, the echocardiogram showed mild left ventricular contractility improvement (EF 45%), and blood tests documented partial reduction of hyperthyroidism. A 24–hour ECG Holter did not record any arrhythmias and the patient remained asymptomatic during all the period after discharge. Even if rare, scientific literature confirms that dilated cardiomyopathy with reduced ejection fraction can occur as a complication of hyperthyroidism. After the exclusion of an ischemic cause, we underline the need for adequate initiation of treatments for thyrotoxicosis and heart failure, in order to improve chance of left ventricular function recovery. In the case discussed, after two months of therapy, EF was still not completely restored but improved from 35% to 45%, and concurrently arrhythmic risk did clearly decrease.

C25 PREDICTION OF ALL–CAUSE MORTALITY FOLLOWING PERCUTANEOUS CORONARY INTERVENTION IN BIFURCATION LESIONS USING MACHINE LEARNING ALGORITHMS – THE RAIN–ML PREDICTION MODEL

Aims

Stratifying prognosis following coronary bifurcation percutaneous coronary intervention (PCI) is an unmet need. Machine learning (ML) may identify patterns from multidimensional, non–linear relationships to make outcome predictions. We sought to develop a ML–based risk stratification model built on clinical, anatomical and procedural features to predict all–cause mortality following contemporary bifurcation PCI.

Methods and Results

Multiple ML models to predict all–cause mortality were tested on a cohort of 2,393 patients (training, n = 1,795; internal validation, n = 598) undergoing bifurcation PCI with contemporary stents from the real–world RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry. Among 38 commonly available features, 25 (13 patient–related, 12 lesion–related) were selected to train ML models. The best performing model (the RAIN–ML prediction model) was validated in an external validation cohort of 1,701 patients undergoing bifurcation PCI from the DUTCH PEERS (DUrable polymer–based sTent CHallenge of Promus ElemEnt versus ReSolute integrity: TWENTE II) trial and the BIO–RESORT trial cohorts. The area under the receiver operating characteristic curves for the prediction of 2–year mortality was 0.786 (0.74–0.83) in the overall population, 0.736 (0.72–0.847) at internal validation and 0.706 (0.6919–0.794) at external validation. Performance at risk ranking analysis, k–center cross validation, and with continual learning confirmed the generalizability of the models, available also as an online interface.

Conclusions

The RAIN–ML prediction model represents the first tool combining clinical, anatomical and procedural features to predict all–cause mortality among patients undergoing contemporary bifurcation PCI with a good discriminative performance.

Compositional and Morphological Characterization of ‘Sorrento’ and ‘Chandler’ Walnuts

In Italy, most of the cultivated walnuts belong to the Sorrento ecotype, and they are considered commercially valuable due to their specific organoleptic characteristics. The aim of this study is to evaluate and compare the morphological and compositional characteristics of walnuts sampled from ‘Sorrento’ trees cultivated in different locations in Campania and trees of both the ‘Chandler’ and ‘Sorrento’ varieties derived from the same location. The results demonstrated that ‘Sorrento’ and ‘Chandler’ walnuts have different biometric characteristics and a different fat content, with the highest fat content being found in the ‘Sorrento’ variety. Regarding the fatty acid (FA) composition, the content of monounsaturated and saturated fatty acids (MUFAs and SFAs) was highest in the ‘Sorrento’ variety (from 13 to 15% for MUFAs and from 11 to 13% for SFAs), while the polyunsaturated fatty acids (PUFAs) content was highest in the ‘Chandler’ variety (77%). The total phenolics content (TPC) was highest in the ‘Sorrento’ variety (from 910 to 1230 mg GAE/100 g), while no difference in γ-tocopherol content was found. Furthermore, the influence of walnut area cultivation was shown for fat content, FA composition and TPC. Therefore, both walnut varieties demonstrated good nutritional properties considering the PUFAs and γ-tocopherol content.

Vectorial crystallization problems and collective behavior

We propose and analyze a class of vectorial crystallization problems, with applications to crystallization of anisotropic molecules and collective behavior such as birds flocking and fish schooling. We focus on two-dimensional systems of "oriented" particles: Admissible configurations are represented by vectorial empirical measures with density in [Formula: see text]. We endow such configurations with a graph structure, where the bonds represent the "convenient" interactions between particles, and the proposed variational principle consists in maximizing their number. The class of bonds is determined by hard sphere type pairwise potentials, depending both on the distance between the particles and on the angles between the segment joining two particles and their orientations, through threshold criteria. Different ground states emerge by tuning the angular dependence in the potential, mimicking ducklings swimming in a row formation and predicting as well, for some specific values of the angular parameter, the so-called diamond formation in fish schooling.

In-hospital outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention

Objective

The aim of the present analysis was to evaluate the incidence and predictors of in-hospital adverse outcomes in nonagenarian patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

Consecutive nonagenarian patients undergoing pPCI for STEMI from 2009 to 2019 were retrospectively included in an international multicenter registry. In-hospital all-cause death was the primary outcome.

Results

A total of 308 patients were included (mean age 92.5±2.5 years, 65.6% female). Mean systolic blood pressure (SBP) at hospital admission was 130.7±33.5 mmHg, 46 (17%) patients presented with a Killip class III-IV, mean left ventricle ejection fraction (LVEF) was 40.0±11.5% and 147 (58%) patients were independent in everyday activities. In-hospital death occurred in 99 patients (32%). [Figure 1] After multivariate adjustment, lower LVEF (OR per unit reduction 1.08, 95% CI 1.03–1.11, p-value <0.001), lower SBP (OR 0.98 per mmHg reduction, 95% CI 1.01–1.03, p-value 0.001) and being not independent at home (OR 2.56, 95% CI 1.25–5.26, p-value 0.01) resulted independent predictors of in-hospital mortality. [Figure 2] A sensitivity analysis performed in final TIMI 3 flow population confirmed the prognostic role of LVEF and independency on in-hospital mortality.

Conclusion

Nonagenarian patients presenting with STEMI and undergoing pPCI have high in-hospital mortality. Independency in everyday life is a strong independent predictor of survival to hospital discharge.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Organization of intensive cardiac care units in Europe: Results of a multinational survey

Background:

The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.

Methods:

A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).

Results:

A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.

Conclusion:

More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.

Bleeding risk prediction in elderly patients managed invasively for Acute Coronary Syndromes: external validation of the PRECISE-DAPT and PARIS risk scores

Background

Tailoring Dual Antiplatelet Therapy (DAPT) to each patient bleeding and ischemic risk profile is a majopr challenge in everyday clinical practice. As the elderlies were underrepresented in validation cohorts of bleeding risk scores, their generalizability in this context is uncertain.

Purpose

We sought to assess the clinical utility of the PRECISE-DAPT and PARIS bleeding risk scores to elderly patients suffering from ACS and undergoing invasive management.

Methods

Our external validation cohort included 1,883 patients older >74 years admitted for ACS and treated with PCI from 3 multicenter, randomized trials. Bleeding risk scores were calculated on a patient-level and subjects were stratified into risk categories according to each risk score definition.

Results

After a median follow-up of 365 days, patients in the high-risk categories according to the PRECISE-DAPT score experienced a higher rate of BARC 3–5 bleedings (log rank p=0.002) while this was not observed for those in the high-risk category according to the PARIS risk score (log rank p=0.3). Both scores had a moderate discriminative power (c-statistics 0.70 and 0.64, respectively) and calibration was accurate for both risk scores (all χ2>0.05), but PARIS risk score was associated to a greater overestimation of the risk (mean D observed-predicted probability = −0.65 for PRECISE DAPT and −4.62 for PARIS, p=0.02; Figure 1). Decision curve analysis was in favor of the PRECISE-DAPT score up to a risk threshold of 2%. A sensitivity showed that calibration and discrimination power was moderate for both risk scores also after including BARC 2 events.

Conclusion

In the setting of older adults managed invasively for ACS both the PARIS and the PRECISE-DAPT scores were moderately accurate in predicting bleeding risk. However, the use of the PRECISE-DAPT is associated with better performance and a higher net benefit.

Figure 1

Funding Acknowledgement

Type of funding source: None

The medial adipofascial flap for infected tibia fractures reconstruction: 10 years of experience with 59 cases

OBJECTIVE

The purpose of this study was to evaluate the results of the medial adipofascial flap (MAF) in infected tibia fractures reconstruction and to identify criteria for success or failure.

PATIENTS AND METHODS

Fifty-nine patients treated with a MAF were enrolled. Age, BMI, tobacco use and bone status were recorded. Early and late postoperative complications were assessed. Bone healing and flap success were systematically evaluated at 12 months.

RESULTS

Tibia fractures were initially open in 48 cases (81%) and closed in 11 cases (19%). Infection was acute (<30 days) in 9 cases (15%) and chronic in 50 (85%). Thirty-one patients (53%) experienced no early postoperative complications (<30 days). There were 10 (17%) cases of necrosis of the skin graft, 2 (3%) cases of necrosis and 4 (7%) haematomas in the harvesting area, 7 (12%) cases of partial flap necrosis at its tip and 4 (7%) flap failures. None of the criteria was statistically correlated with the occurrence of a complication. At 12 months, 53 flaps (90%) were successful. Immediate skin graft were significantly correlated with flap success (P=0.05). Forty-six patients (78%) had complete bone healing documented by CT scan.

CONCLUSION

The MAF provides a reliable alternative for lower leg reconstruction. Its major advantages are sparing of the major leg vessels, no donor site morbidity and relatively easy and rapid dissection.

The esthetic outcome of lower limb reconstruction

BACKGROUND

In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction.

OBJECTIVES

This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction.

DATA SOURCES

A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits.

STUDY ELIGIBILITY CRITERIA

All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search.

PARTICIPANTS, AND INTERVENTIONS

One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed.

RESULTS

We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps.

LIMITATIONS

The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed.

CONCLUSIONS

Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

Impact of implementation of a breech clinic in a tertiary hospital

BACKGROUND

The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced.

METHODS

This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality.

RESULTS

After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods.

CONCLUSION

The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

P1133Impact of mid-septal versus apical pacing on the right ventricle performance of patients with right bundle branch block undergoing pacemaker implantation

Background

pacemaker induced cardiomyopathy or transient impairment of the left ventricle (LV) function could be common collateral effects of the prolonged right ventricle (RV) pacing in patients with a pacemaker (PM) and pre-existing intra-ventricular conduction disturbances. However, the impact of RV pacing-site on RV performance of patients with right bundle branch block(RBBB) is still under-investigated.

Purpose

to study the effects of RV pacing in the mid-septal versus apical site on the morpho-functional performance of RV in patients undergoing permanent PM implantation.

Methods

We prospectively enrolled consecutive patients with a pre-existent complete RBBB and undergoing dual-chamber PM implantation in our institution. We randomized the patients 1:1 to receive the RV catheter fixed either in the apex or in the mid-septal position. Patients with LV systolic dysfunction (LVEF &lt;50%), severe valvulopathies, left bundle branch block (LBBB), or preserved intraventricular conduction were excluded. Patients who received PM implantation were evaluated both at baseline and after two months with a 12-lead ECG, 2D, and 3D echocardiogram with analysis focused on RV performance according to the guidelines of the European Association of Cardiovascular Imaging.

Results

a total of 22 patients were randomized in the study, 11 (50%) received RV catheter positioned in the apex and 11 (50%) in the mid-septum, respectively. No baseline differences were recorded between the two groups in clinical characteristics, ECG and echocardiographic parameters. At 2 months follow up, there were no statistically significant difference in the % of RV pacing between the two groups. Nonetheless, RV mid-septal group showed significantly shorter duration of the stimulated QRS (146 ± 12 msec vs. 161 ± 20 msec, p = 0.05), significantly reductions in the RV dimensions (pre: 42 ± 8 mm vs. post: 37 ± 7 mm, p = 0.05) telediastolic area (pre: 12 ± 3 cm2/m2 vs post: 9 ± 4 cm2/ m2, p = 0.02) telediastolic volume (pre: 55 ± 16 ml/m2 vs post: 50 ± 17 ml/m2, p = 0.02) and a significant improvement of RV ejection fraction (pre: 54 ± 9% vs post: 57 ± 11%, p = 0.02) than patients in the RV-apical group. Moreover, patients in the RV-apical group showed significant lowering in the GLS of the LV (pre: -16 ± 3% vs post: -11.7 ± 3%, p &lt;0.001) and in the TAPSE (pre: 23 ± 5 mm vs post: 21 ± 2, p = 0.07) at follow up.

Conclusions

In this study, mid-septal pacing seems associated with a better morpho-functional RV performance than apical pacing in patients with pre-existent RBBB undergoing permanent PM implantation.

Vitamin D: a steroid hormone with progesterone-like activity

OBJECTIVE

This review is aimed at demonstrating the progesterone-like activity exerted by the active form of vitamin D, or calcitriol (1,25(OH)2D). To achieve this outcome, we compared the effects in vivo and in vitro exerted by progesterone and vitamin D, with a special focus on the female reproductive system and pregnancy.

MATERIALS AND METHODS

This is a literature review of the most important articles published in English on vitamin D as a hormone, mainly found by MEDLINE. Furthermore, a section of our review contains some unpublished data, concerning the analysis in silico of the similarities between the steric structure of progesterone and calcitriol, based on the availability of the experimental structures of progesterone and vitamin D3 receptors in complex with their physiological ligands in the RCSB Protein Data Bank.

RESULTS

Vitamin D was shown to exert many physiological activities during the very early stages of gestation in perfect synchrony with progesterone. Both the molecules mutually help and reinforce the activity exerted by each one. A little bit later than progesterone is released, vitamin D secretion rises, but only if pregnancy occurs. Calcitriol contributes to prepare the endometrium to be receptive. Moreover, it supports the implantation process and the course of pregnancy through different but similar pathways to those used by progesterone, giving rise to a significant synergy of action. It is increasingly evident that vitamin D gives an essential support from the luteal phase onwards.

CONCLUSIONS

Based on the evidence displayed in this review we may define appropriately vitamin D as a steroid hormone with progesterone-like activity.

Cyclin T2A Gene Maps on Human Chromosome 2q21

Cyclin T2a was recently identified as one of the regulatory subunits of the cdk–cyclin complex P-TEFb, the most studied positive factor in the regulation of transcription elongation. By fluorescent in situ hybridization (FISH), the gene codifying for cyclin T2a has been mapped on human chromosome 2q21. This locus also has been linked to different forms of myopathy. By use of a new specific antiserum raised against cyclin T2a, the immunohistochemical pattern of expression of cyclin T2a in human tissues has been examined and compared to that of cyclin T1, described in the previous report. The observation that immunohistochemical expression of cyclin T2a was high in skeletal muscle cells, whereas it was undetectable in two cases of centronuclear myopathy, together with its chromosomal location, suggests an involvement of the cdk9–cyclin T2a complex in this disease.

Effect of Coronary Percutaneous Revascularization on Interferon-γ and Interleukin-10 Producing CD4+ T Cells during Acute Myocardial Infarction

T lymphocytes play an important role in the induction and progression of acute coronary syndromes (ACS). To gain insight into how different T cell subsets can influence ACS, we analyzed the frequencies of circulating CD4+T cells producing either pro-inflammatory interferon(IFN)-γ or anti-inflammatory interleukin (IL)-10 in subjects presenting with ST-elevation myocardial infarction (STEMI). The effect of coronary bare metal (BS) and paclitaxel-eluting stent (PES) on the balance between CD4+IFN-γ+ and CD4+IL-10+ lymphocytes was also investigated. Peripheral blood mononuclear cells (PBMC) were isolated from 38 consecutive patients with STEMI before and 48 hrs or 6 days after implantation of either BS or PES. Twenty patients with no history of coronary artery disease were included as basal controls. PBMC were stimulated in vitro with anti-CD3/anti-CD28 monoclonal antibodies, and CD4+IFN-γ+ or CD4+IL-10+ T cells were detected by flow cytometry intracellular staining. The frequency of peripheral CD4+IL-10+ T cells was significantly higher in STEMI patients as compared with controls. Conversely, the frequency of CD4+IFN-γ+ T lymphocytes did not differ between STEMI and subjects without history of coronary artery disease. Six days after the revascularization procedure, the percentage of CD4+IL-10+ T cells was significantly decreased in BS but not in the PES group, whereas the relative percentage of CD4+IFN-γ+ T lymphocytes were diminished in both groups as compared with baseline levels. Our data indicate that STEMI is associated with a peripheral expansion of CD4+IL-10+T lymphocytes, and that primary coronary revascularization with implantation of either BS or PES is followed by a reduction in circulating CD4+IFN-γ+ T lymphocytes. PES implantation, however, appears to inhibit the relative decrease of the IL-10 producing lymphocyte as observed in BS implanted patients, shifting the balance between pro-inflammatory and anti-inflammatory T cell populations in favor of the latter.

Impact of long-acting octreotide in patients with early-stage MEN1-related duodeno-pancreatic neuroendocrine tumours

BACKGROUND

Somatostatin analogues (SSA) represent one of the main therapeutic option in patients affected with functioning well-differentiated neuroendocrine tumours (NETs). There are no studies specifically focusing on NETs associated with Multiple Endocrine Neoplasia type 1 (MEN1).

AIM

To evaluate the efficacy of the long-acting SSA octreotide in MEN1 patients with early-stage duodeno-pancreatic NETs.

PATIENTS AND METHODS

Forty patients with MEN1 were retrospectively evaluated. Twenty patients with evidence of one or more MEN1-related duodeno-pancreatic NETs < 20 mm in size (age range 26-61 years) were treated with octreotide long-acting octreotide (LAR) as first-line therapy. Treatment duration ranged 12-75 months. At the baseline radiological evaluation, multiple duodeno-pancreatic NETs (range 1-8, size 3-18 mm) were detected.

RESULTS

An objective tumour response was observed in 10%, stable disease in 80% and progression of disease in 10% of cases. In six patients with abnormally increased CgA, gastrin and/or insulin serum concentrations, a significant clinical and hormonal response occurred in 100% of cases and was stable along the time.

CONCLUSIONS

Therapy with SSA is highly safe and effective in patients with early-stage MEN1 duodeno-pancreatic NETs, resulting in long-time suppression of tumour and hormonal activity and 10% objective response. This suggests to early start therapy with SSA in patients with MEN1-related NETs.

Lower incidence of macrovascular complications in patients on insulin glargine versus those on basal human insulins: a population-based cohort study in Italy

BACKGROUND AND AIM

The aim of this study was to compare the use of insulin glargine and intermediate/long-acting human insulin (HI) in relation to the incidence of complications in diabetic patients.

METHODS AND RESULTS

A population-based cohort study was conducted using administrative data from four local health authorities in the Abruzzo Region (900,000 inhabitants). Diabetic patients without macrovascular diseases and treated with either intermediate/long-acting HI or glargine were followed for 3-years; the incidence of diabetic (macrovascular, microvascular and metabolic) complications was ascertained by hospital discharge claims and estimated using Cox proportional hazard models. Propensity score (PS) matching was also used to adjust for significant differences in the baseline characteristics between the two groups.

RESULTS

Overall, 1921 diabetic patients were included: 744 intermediate/long-acting HI and 1177 glargine users. During the 3-year follow-up, 209 (28.1%) incident events of any diabetic complication occurred in the intermediate/long-acting HI and 159 (13.5%) in the glargine group. After adjustment for covariates, glargine users had an HR (95% CI) of 0.57 (0.44-0.74) for any diabetic complication and HRs of 0.61 (0.44-0.84), 0.58 (0.33-1.04) and 0.35 (0.18-0.70) for macrovascular, microvascular and metabolic complications, respectively, compared to intermediate/long-acting HI users. PS analyses supported these findings.

CONCLUSIONS

The use of glargine is associated with a lower risk of macrovascular complications compared with traditional basal insulins. However, limitations inherent to the study design including the short length of observation and the lack of data on metabolic control or diabetes duration, do not allow us to consider this association as a proof of causality.

237 CHROMOSOMAL ABNORMALITIES IN IN VITRO-PRODUCED EARLY BOVINE EMBRYOS: USE OF HOMOLOGOUS FOLLICULAR FLUID SUPPLEMENTATION IN THE OOCYTE MATURATION MEDIA

Chromosomal abnormalities were described as a possible cause of embryo failures in cattle, even more so when they are in vitro produced. It has been widely demonstrated that the post-fertilization culture environment affects the frequency of blastomeric aneuploidies. However, the literature concerning the effect of the oocyte maturation techniques on in vitro-produced embryos is scarce. The aim of this study was to determine the effect of homologous bovine follicular fluid (BFF) as a possible replacement for commercial sera in the appearance of chromosomal abnormalities on early IVF-produced embryos. Cumulus–oocyte complexes obtained from ovarian puncture were maturated in modified bicarbonate-buffered TCM-199 media, supplemented with glutamine, sodium pyruvate, FSH, LH, oestradiol, and gentamicin in three different groups. Two treatments were performed: 1) base media supplemented with BFF, obtained aseptically from follicles between 4 and 10 mm in diameter (10 and 20%), and 2) a control group, with base media supplemented with 10% FCS without BFF. After 20 h of culture at 38.5°C in a 5% CO2 humid atmosphere, cumulus–oocyte complexes from both treatments were fertilized in IVF media and then cultured for 72 h in SOF media, according to our laboratory techniques. A total of 152 early embryos were cytogenetically evaluated following our standard laboratory techniques. Developed embryos were individually fixed onto a slide, disaggregated into blastomeres with acetic acid, and stained with Giemsa solution. Chromosomal numerical abnormalities were evaluated in each embryo by direct observation at 1250× magnification using a bright field microscope. Results were statistically compared among treatments by the expected proportion test. No significant differences (P > 0.05) were found between different culture media on the percentages of normal diploid embryos or each kind of numerical abnormality. According to our results (Table 1), the use of homologous follicular fluid as a supplement on the oocyte maturation media did not influence the appearance of abnormal complements in the embryos produced compared with the use of FCS. In conclusion, homologous follicular fluid may be considered a valid serum replacement in the maturation media on IVF-produced bovine embryos. Table 1.Analysis of chromosomal complements of Day 3 in vitro-produced bovine embryos derived from oocytes maturated in culture media with different serum supplementation1

Global and regional longitudinal strain assessed by two-dimensional speckle tracking echocardiography identifies early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction and relatively preserved LV function

AIMS

Global and regional longitudinal strain (GLS-RLS) assessed by two-dimensional speckle tracking echocardiography (2D-STE) are considered reliable indexes of left-ventricular (LV) function and myocardial viability in chronic ischaemic patients when compared with delayed-enhanced cardiac magnetic resonance (DE-CMR). In the present study, we tested whether GLS and RLS could also identify early myocardial dysfunction and transmural extent of myocardial scar in patients with acute ST elevation myocardial infarction (STEMI) and relatively preserved LV function.

METHODS AND RESULTS

Twenty STEMI patients with LVEF ≥40%, treated with PPCI within 6 h from symptoms onset, underwent DE-CMR and 2D-echocardiography for 2D-STE analysis 6 ± 2 days after STEMI. Wall motion score index (WMSI) and LV ejection fraction (LVEF) were calculated by both methods. Infarct size and transmural extent of necrosis were assessed by CMR. GLS and RLS were obtained by 2D-STE. Mean GLS of the study population was -14 ± 3.3, showing a significant correlation with both LVEF and WMSI, by CMR (r = -0.86, P = 0.001, and r = 0.80, P = 0.001, respectively) and time-to-PCI (r = 0.66, P = 0.038). A weaker correlation was found between GLS and LVEF and WMSI assessed by 2D-echo (r = -0.65, P = 0.001, and r = 0.53, P = 0.013, respectively). RLS was significantly lower in DE-segments when compared with normal myocardium (P < 0.0001). A cut-off value of RLS of -12.3% by receiver-operating characteristic (ROC) curves identified DE-segments (sensitivity 82%, specificity 78%), whereas a cut-off value of -11.5% identified transmural extent of DE (sensitivity 75%, specificity 78%).

CONCLUSION

Our findings indicate that RLS and GLS evaluation provides an accurate assessment of global myocardial function and of the presence of segments with transmural extent of necrosis, with several potential clinical implications.

Inhibition of the interaction between HIV-1 integrase and its cofactor LEDGF/p75: a promising approach in anti-retroviral therapy

Although 25 compounds are currently licensed as anti-HIV drugs, the development of multidrug-resistant viruses, as well as their severe side effects, compromise their efficacy and limit treatment options. The search for new targets in order to cure AIDS has revealed that the inhibition of some protein-protein interactions in the HIV life cycle may provide an important new approach to fight this disease. The interaction between HIV-1 integrase (IN) and Lens Epithelium-Derived Growth Factor (LEDGF/p75) has increasingly gained attention as a valuable target for a novel anti-retroviral strategy. This article reviews the discovery and development of molecules capable of interrupting the LEDGF/p75-IN interaction reported to date.

Clinical and prognostic implications of the genetic diagnosis of hereditary NET syndromes in asymptomatic patients

Neuroendocrine tumors (NETs) can be sporadic or they can arise in complex hereditary syndromes. Patients with hereditary NETs can be identified before the development of tumors by performing genetic screenings. The aim of the study was to evaluate the clinical and prognostic impact of a preclinical genetic screening in subjects with hereditary NET syndromes. 46 subjects referred for hereditary NET syndrome [22 MEN1, 12 MEN2, 12 Familial Paragangliomatosis (FPGL)] were enrolled and divided in 2 groups (group A, 20 subjects with clinical appearance of NET before the genetic diagnosis; group B, 26 subjects with genetic diagnosis of hereditary NET syndromes before the clinical appearance of NETs). The main outcome measures were severity of disease, prognosis, and survival. The rate of surgery for MEN1-, MEN2-, FPGL4-related tumors was 90% in group A and 35% in group B (p<0.01). Both symptoms related to tumors and symptoms related to therapies were significantly less frequent in group B than in group A (p<0.05). Tumor stage was locally advanced or metastatic in 50% of group A and in no one of group B (p<0.01). The mortality rate was 25% in group A and 0% in group B (p<0.05). An early genetic screening for hereditary NET syndromes results in an improvement in clinical presentation and morbidity. A potential impact of the genetic screening on the mortality rate of these subjects is suggested and needs to be investigated in further and more appropriate studies.

Kidney transplantation from older donors

BACKGROUND

The use of kidneys from older donors has become generally accepted and increasingly common, despite the knowledge that donor age is a well-known risk factor for graft failure.

AIM

To review our experience with the utilization of kidneys from donors older than 60 years.

PATIENTS AND METHODS

Among two hundred eight patients, 32 (group A) received an organ obtained from a donor older than 60 years. The organs were age-matched with a maximum gap of 20 years between donors and recipients. Organs from older donors were assigned to recipients presenting a body mass index lower than that of the donor. The primary end point was patient and graft survival. Secondary endpoints were incidences of delayed graft function and of acute rejection episodes as well as renal function at 3 months and yearly.

RESULTS

The two groups were comparable in terms of demographic features, indications for transplantation, comorbidities, as well as cold and warm ischemia times. The Mean lengths of follow up were 31.4 ± 20.3 months and 30.3 ± 20.1 months, respectively. Graft and patient survivals were comparable. Mean creatinine values at the study intervals were significantly lower among group B who received grafts from younger donors. The incidence of delayed graft function and acute rejection episodes were similar: 15.6% (5/32) versus 20.5% (36/176; P=0.35) and 15.6% (5/32) and 12.1% (21/167; P=0.136) in groups A and B, respectively.

CONCLUSIONS

Donor age older than 60 years showed a negative impact on kidney function. Though, given the escalating disparity between organ supply and demand, this precious source of organs cannot be neglected. We need better ways to use the available organs.

Screening of pancreaticoduodenal endocrine tumours in patients with MEN 1: multidetector-row computed tomography vs. endoscopic ultrasound

PURPOSE

The authors compared multidetector-row computed tomography (MDCT) and endoscopic ultrasound (EUS) in the identification of pancreaticoduodenal endocrine tumours (PETs) in patients with multiple endocrine neoplasia type 1 (MEN 1).

MATERIALS AND METHODS

Fourteen consecutive patients (eight men and six women, aged 26-54 years) with MEN 1 underwent MDCT performed with a 4- (n=5) or 64- (n=9) detector-row system and EUS done with a radial transducer (7.5-20 MHz) within 7-28 days of each other. Prior to MDCT examination, patients were given 750 cc of water and asked to lie down in the right lateral decubitus for 15 min. Multiphase MDCT images were acquired both before and after the injection of nonionic iodinated contrast material (2 cc/kg) at an injection rate of 4 ml/s, with technical parameters and scan delay varying in relation to the system used. Images were all reconstructed at 3-mm intervals for the three phases (arterial, pancreatic and portal) and evaluated on a dedicated workstation.

RESULTS

MDCT detected a total of 25 PETs (3-18 mm) in nine patients. Of these lesions, nine were situated within the duodenal wall and 16 in either the pancreatic head (n=3), body (n=7), or tail (n=6). Three additional lesions were detected retrospectively after EUS imaging. Most (18/22, 81%) were hypervascular nodules, and four appeared as either hypoattenuating or cystic lesions. EUS detected a total of 32 PETs (2-18 mm) in 11 patients. Most lesions (29/32, 90%) appeared hypoechoic and were situated in the duodenal wall (n=15) or in either the pancreatic head (n=10), body (n=6) or tail (n=1).

CONCLUSIONS

Our preliminary data indicate that MDCT is complementary to EUS in the identification of PETs in MEN-1 patients.

Prospective study of switch from cyclosporine to tacrolimus for fibroadenomas of the breast in kidney transplantation

INTRODUCTION

Breast fibroadenomas may result from exposure to cyclosporine (CsA). The aim of this prospective study was to assess the reversibility of breast fibroadenomas following conversion from CsA to tacrolimus among a small cohort of female renal transplant recipients.

METHODS

Following renal transplantation, fibroadenomas either developed or progressed in eight Caucasian female patients with CsA-based immunosuppression. These patients were enrolled in a pilot study assessing whether conversion from a CsA-based to a tacrolimus-based regimen prevented progression of breast disease or reversed existing lumps. Patients underwent a baseline visit in which we assessed the clinical history, number and dimension of fibroadenomas, graft function and hormonal profile (FSH prolactin, estradiol and progesterone). Twenty-one lumps were described in six patients; in addition, two patients had "grapes of fibroadenomas," of nondefinable numbers.

RESULTS

Patients underwent conversion to tacrolimus after a mean of 63.8 +/- 37.4 months after renal transplantation. Of the 21 clearly described lumps complete reversibility was observed for eight fibroadenomas. Other fibroadenomas either decreased in size or remained stable without further progression. These changes were reported within 1 year following conversion to tacrolimus.

CONCLUSION

A switch from CsA to tacrolimus was effective to prevent the progression of fibroadenomas. In female renal transplant recipients with CsA-based immunosuppression suffering from breast fibroadenomas, early CsA withdrawal may avoid the need for breast surgery.

Conversion to rapamycin immunosuppression for malignancy after kidney transplantation

INTRODUCTION

Malignancies are a well-known complication of immunosuppressive therapy among renal transplant recipients, representing an important cause of long-term morbidity and mortality. Rapamycin has been shown to limit the proliferation of a number of malignant cell lines in vivo and in vitro.

METHODS

Fifteen patients developed the following malignancies at a mean of 90.3 months (range = 10-252) after kidney transplantation: metastatic gastric cancer (n = 1), metastatic colon cancer (n = 1), bilateral nephrourothelioma (n = 1), skin cancer (n = 2), Kaposi's sarcoma (n = 2), posttransplant lymphoproliferative disorder (PTLD; n = 4), renal cell carcinoma T1 (n = 1), MALT lymphoma (n = 1), intramucous colon carcinoma (n = 1), liposarcoma of the spermatic cord (n = 1). After the diagnosis of malignancy, the patients were switched from calcineurin inhibitor-based immunosuppression to rapamycin (monotherapy, n = 3), or associated with steroids (n = 6) or with mycophenolate mofetil (n = 6).

RESULTS

Both patients with metastatic cancer underwent chemotherapy but succumbed after 6 and 13 months. Two patients with PTLD who underwent chemotherapy died after 12 and 36 months. At a mean follow-up of 32.7 months (range = 7-56), the remaining 11 patients are cancer-free. Two patients lost their grafts after 24 and 36 months after the switch due to chronic rejection. Renal graft function remained stable in all other patients from diagnosis throughout follow-up.

CONCLUSION

Our observations suggested that rapamycin-based immunosuppression offers the possibility for regression of nonmetastatic tumors. Nevertheless, it is difficult to assess whether tumor regression was due to rapamycin treatment or to the reduced immunosuppression.