Cardiac Contractility Modulation (CCM) Italian Registry: preliminary analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac contractility modulation (CCM) therapy is a treatment option for patients suffering symptomatic Chronic Heart Failure (HF) with reduced left ventricular ejection fraction (LVEF) despite optimal medical therapy (OMT) [1]. CCM, by delivering high-output electrical impulses during ventricular absolute refractory period, increases the activity of proteins involved in intracellular calcium handling. This therapy has been associated with improvement in quality of life (QoL) and reduction of HF-hospitalizations [2,3]. Our aim is to present preliminary data from the CCM Italian Registry.

Methods

The CCM Italian Registry is a prospective, observational, multicentre study investigating the long-term impact of CCM therapy in HF patients on LVEF, Minnesota Living With HF Questionnaire (MLWHFQ) and 6-minutes walking test (6MWT) [4]. Preliminary results after one year of follow-up have been analysed in this abstract. Data are expressed as median and interquartile range. Changes from baseline have been tested with Wilcoxon signed-rank test.

Results

A total of 42 patients suffering HF, with LVEF<45%, NYHA class>II despite OMT, have been enrolled and implanted with CCM device in 10 Centres. Most of patients were male (41 patients, 98%), with a median age of 76 years (70-79). The most frequent aetiology was ischemic (29 patients, 69%) and 32 (79%) had another implanted device (24 ICD, 8 CRT-D). Twelve (29%) patients presented chronic atrial fibrillation (AF). Thirty-eight (90%) patients were treated with beta-blockers and 32 (76%) received sacubitril/valsartan (15) or ACE-inhibitors (17). A significant reduction in HF-related hospitalization has been observed after 6 and 12 months of CCM therapy, compared to the incidence in the 12 months before CCM implantation (Figure 1), with a relative risk reduction of 75% at 12 months (p<0.001). As shown in Figure 2, LVEF significantly improved both at 6 and 12-month follow up (p=0.042 and p=0.004, respectively), as well as MLWHFQ score (p=0.001 and p=0.032, respectively). The 6MWT distance did not show significant changes (6-month, p=0.252 and 12-month, p=0.281), mainly due to physical limitations in some patients. NYHA class improved significantly both at 6 (p=0.001) and 12-months (p=0.012), with 80% of patients showing an improvement of at least 1 class compared to baseline. After stratifying by HF aetiology, LVEF at 12-months improved significantly in non-ischaemic HF (p=0.028), while in patients with ischaemic aetiology improved significantly at 6-months (p=0.0416) but not at 12-months (p=0.135).

Conclusion

CCM proved to be effective in improving symptoms, QoL and in reducing CHF-hospitalizations in patients with symptomatic CHF with reduced LVEF despite OMT. This prospective Italian Registry will be fundamental to gather more evidence, to assess the long-term effect of CCM, and also to measure the impact of CCM therapy in the Italian clinical practice.

P269 LOCAL ULTRASOUND–FACILITATED THROMBOLYSIS IN ACUTE PULMONARY EMBOLISM: HAS A SPACE?

Acute pulmonary embolism (PE) has an annual incidence of 48 patients per 100,000 with a mortality rate of 10%, few hours after the onset of symptoms. The use of full dose of thrombolytic agent is currently the treatment of choice in acute PE at intermediate and high risk, although its contraindications are well known. An alternative choice is delivered, via percutaneous femoral or jugular venous access, infusion catheters in the pulmonary artery (PA), in order to perform a local thrombolysis (based on a map of thrombus distribution observed at pulmonary CT), with a lower dose of trobolytic agent (rTPA) in a limited time, with a core for emission of ultrasound waves capable of breaking the mesh of the thrombus. Data from the KNOCOUT PE registry show a reduced frequency of fatal intracranial hemorrhage (ICH 2.5%), compared with the full dose of rTPA. Since February 2021 we have treated 7 patients with PE, all with cTnI, D–dimer and high NT–ProBNP and with pulmonary CT finding of large thrombus burden with pruning of peripheral pulmonary branches compatible with the diagnosis of PE at high and intermediate risk in patients with complex comorbidities (significant PESI and simplified PESI). On admission to the ICU all patients were with BP < 100 mmHg, RR > 20/min, satO2 < 90% and HR > 100 bpm. In echocardiogram all were with impaired RV (RV/LF ratio >1 and TAPSE <15mm). All patients was treated with UHF, 1 in fondaparinux for thrombocytopenia. At time between 4h and 8gg from the onset of symptoms, all patients underwent placement of 1 or 2 catheters in right and/or left PA, 106 cm and 135 cm length with zone of interest between 18/32 cm. When possible, hemodynamic parameters were evaluated: PAPm, cardiac output, and stroke volume to characterize the associated hemodynamic deterioration. 12mg of rtPA per catheter was administered over 12 hours. In 3 patients an echocardiogram was performed at 6 hours. In all at 24 hours, vital and laboratory parameters were measured, and in one patient, right heart catheterization was repeated. In no patient was treatment discontinued early, nor were ICH or minor bleeding recorded. Low dose of rtPA allowed use of the technique in patients with severe comorbidities at the limit of thrombolysis use, in the presence of marked RV distress and severe hemodynamic instability. Trials are in progress to shorten the time and therefore reduce the dose of rTPA with equal effectiveness on the clinical course of acute PE.

P382 FOLLOW–UP OF PATIENTS SUBMITTED TO TRANSVENOUS LEAD EXTRACTION FOR ENDOCARDITIS OR SEPTIC SHOCK AND THEN RE–IMPLANTED WITH LEADLESS PACEMAKER: SINGLE CENTER’S EXPERIENCE

Introduction

With increasing of complications associated with pacemakers and defibrillators implants, the number of patients that undergo transvenous lead extraction following an infection increased. Often in pacemaker–dependent patients there is the problem of having to make an early re–implanting after extraction. This study aims to evaluate the incidence of reinfection in patients implanted with leadless PM following extraction.

Materials and Methods

From January 2016 to December 2021, 132 extractions have been performed in our center. Of these post–extracted patients, 21 were then implanted with a leadless. Among the remaining, in 25 were re–implanted with a traditional PM, 27 with a defibrillator, 2 with a loop recorder, 3 are protected with Life Vest waiting for re–implant; 54 are patients who, after cardiological revaluation, or have not re–implanted a new device or have been redirected to the first implant’s center waiting to complete antibiotic therapy. To evaluate the technical efficiency of leadless in post–extracted patients, a comparison was made between these and the leadless PM implanted “de novo”. To demonstrate the reduction of reinfection recurrences, the post–operative of patients re–implanted with leadless has been compared to those re–implanted with traditional PM. To test the patient‘s level of approval to the new implanted device, a questionnaire was administered to the two samples.

Results

A first analysis of the follow–up of the above classes from 2016 to today shows that in patients who have implanted a leadless PM in no case a recurrence of infection has occurred; in patients who have implanted a traditional device, we have seen how some of these had already suffered a revision of pocket, an extraction or leads’ abandonment. The statistics of electrical parameters have demonstrated the effectiveness of the leadless in both classes of patients compared. Finally, the rating index questionnaire has shown greater acceptance of the new implanted device and a better patient–device relationship in patients re–implanted with leadless.

Conclusions

The implant of Leadless Pacemaker in post–extracted patients, when we have eligible patients to implant this device, has proved to be an effective choice in reducing reinfection recurrences.

C21 ACTIVE STAND TEST IN ALTERNATIVE TO HEAD UP TILT TEST AS NEUROMEDIATE SYNCOPE’S PREDICTOR IN COVID–19 PANDEMIC’S ERA: EXPERIENCE OF SINGLE CENTER

Introduction

The Head Up Tilt Test is an exam that, with prolonged orthostatic stress, allows you to diagnose neuromediated syncope, but has the drawback of being a test that requires time, space and dedicated equipment. During the Covid pandemic, our Syncope Unit was limited both in terms of space and access. Not being able to perform the HUTT, it was decided to replace it with the Active Stand Test, a test that allows you to evaluate changes in blood pressure and ECG in a few minutes.

The purpose of this study is to evaluate the effectiveness of the Active Stand Test as an alternative to HUTT in situations where the latter cannot be performed. Material and Method: In the period 2020–2021, 53 patients were treated for syncope at our center. These patients underwent initial evaluation, Active Stand Test and carotid sinus massage. The Active Stand Test was positive in 8 patients. In order to have a long–distance follow–up, a remote–controlled loop recorder was implanted in all patients. Two categories of patients were thus identified: asymptomatic patients for syncope, in whom no relevant symptoms or arrhythmias were found, and symptomatic patients for syncope. The first were followed only with remote control and telephone follow–up, symptomatic patients were reconvened for clinical re–evaluation.

Results

Of the total 53 patients, 34 were asymptomatic patients with syncope and with no significant arrhythmia recordings and 19 were symptomatic patients with syncope. Of these, 5 were symptomatic for paroxysmal AVB and were implanted with PM, 1 for NSVT was protected with Life Vest; the 13 symptomatic without AVB (syncope of unknown origin) continued the follow–up. Among the latter we find the 8 patients who tested positive when performing the Active Stand Test carried out upon enrollment. The 34 patients asymptomatic for syncope were subsequently recalled to perform a HUTT.

Conclusions

The emergence of the Covid–19 pandemic has led to a greater enhancement of the function of the Syncope Unit, making it the place of choice for the etiological diagnosis of syncope. This allowed for an important selection of the tests necessary to arrive at an etiological diagnosis of syncope. In a situation where the execution of the HUTT is difficult, the Active Stand Test made it possible to manage patients for the diagnosis of neuromediated syncopes.

P8 TRANSVENOUS LEAD EXTRACTION AS LIFE–SAVING PROCEDURE IN SEPTIC SHOCK

Introduction

With the increase of implant centers and the related procedures also increased the complications associated with the pacemakers and defibrillators implant. Transvenous lead extraction, saving procedure in presence of sepsis or septic shock, is the best therapy for leads’ infections because medical treatment alone is not effective to eradicating the infection.

Materials and Methods

In May 2021 was sent to our O.U. from the ER a 61–year–old patient for symptomatic Afib with rapid ventricular response. In 2014 the patient received an ICD implantation for obstructive hypertrophic cardiomyopathy, later found to be an amyloidosic infiltrative cardiomyopathy. The TEE reported EF 30%, thrombus filling left and right atrial appendage and vegetations all over the lead. Despite the patient was apyretic, laboratory tests showed neutrophilic leukocytosis and an increase in inflammation indices. The series of blood cultures were instead negative. However, for the occurrence of septic state, has been set up an antibiotic therapy and DOACs therapy on the advice of an infectious disease specialist. PET TAC confirmed an infection along leads. For a progressive clinical improvement, the patient started a cardiological rehabilitation cycle. Six days later, due to the onset of hyperpyressia and septic shock, the patient was intubated bacause of an acute respiratory failure and transferred urgently in intensive care. For the onset of MOF by sepsis on an endocarditic basis, has been indicated an extraction procedure.

Results

After performing the extraction procedure, it was found an immediate improvement of both the clinical conditions and laboratory parameters. In fact the next day it was possible to proceed to the extubation. Laboratory tests showed a progressive normalization of inflammation and leukocytosis indices; TEE confirmed the absence of vegetations and thrombotic material in the atrial appendage. The patient, apyretic, was sent to cardiological rehabilitation to complete the antibiotic–therapy cycle and, subsequently, at home with Life Vest. After cardiological revaluation and in absence of sepsis signs, the patient was re–implanted with a contralateral ICD.

Conclusions

In accordance with guidelines and literature, transvenous leads extraction constitutes, despite the potential risks associated with the procedure, the true resolutive therapy in device infections.

P6 MICRA AV AS AN INNOVATIVE THERAPEUTIC OPPORTUNITY IN PATIENTS WITH A PAROXYSMAL ATRIOVENTRICULAR BLOCK OR AN ADVANCED OR PERSISTENT TYPE II 2ND–DEGREE ATRIOVENTRICULAR BLOCK

Introduction

Micra AV is the technological evolution of Micra VR. It’s a monocameral leadless pacemaker that works like a VDD PM, synchronizing atrial activity with the ventricular one. The purpose of the study is to evaluate the response of Micra AV in patients with a paroxysmal atrioventricular block, in which a low percentage of stimulation is expected, and in patients with AVB with normal atrial activity.

Materials and Method

From August 2020 to June 2021 in our center were implanted 11 Micra AV: 4 for advanced AVB, 3 for a paroxysmal AVB and 4 post–extraction. To all patients it was given remote monitoring to guarantee a constant remote follow–up. For each one, were analyzed the values measured at the implant’s moment and those of periodic remote follow–ups, paying particular attention at the device’s percentage of stimulation. Furthermore, a questionnaire was submitted to detect the psychophysical condition, the way in which the device interferes in everyday life, any physical pain, the emotional state, always correlating post–operative with the pre–operative. Particular attention was paid to the decrease in the incidence of adverse events or post–operative complications. In this way, it was possible to focus the study on 3 aspects: technician, quality of post–implant life and the device’s approval.

Results

All patients no longer presented syncopes during a follow–up ranging from a minimum of 5 to a maximum of 10 months. About the analysis made on the percentage of stimulation, the results were obtained by dividing patients into 2 groups based on the nature of the block. Almost all patients with advanced AVB presents a percentage of stimulation that doesn’t exceed 20%; in subjects with paroxysmal AVB this remains below 2%. The results of the questionnaire instead show how the leadless PMs are more appreciated both for a lower aesthetic impact, and for minor functional consequences linked to the lack of catheters who often limit the patient. This results in a better patient–device relationship and better acceptance of the leadless device.

Conclusions

The use of a Leadless PM in patients with syncope is still to be deepened and for this we will have to follow these patients over time to have a wider cases. A certain data is that these PMs are more appreciated as they have less impact on the quality of patients’ life.

α1-Antitrypsin, Transferrin, Alkaline Phosphatase, Phosphohexoseisomerase and γ-Glutamyltransferase in Breast Cyst Fluid

The levels of α1-antitrypsin, transferrin, alkaline phosphatase, phosphohexoseisomerase and γ-glutamyltransferase were measured in 32 samples of breast cyst fluid, and a wide range of values was obtained. The levels observed in some samples for these parameters, being similar to those of normal serum, might suggest a mechanism of plasma exudation for the formation of breast cyst fluid. Nevertheless, a comparison with the maximum normal serum reference value revealed very high levels of γ-glutamyltransferase in all of the samples; about 50% also exhibited high levels of phosphohexoseisomerase. These results indicate that the formation of breast cyst fluid takes place with a specific local production, in addition to the mechanism of selective plasma exudation. Moreover, elevated transferrin levels in some cyst fluids are probably the expression of a high biosynthetic activity and could be diagnostically useful in the course of breast gross cystic disease. The importance of these observations from the point of view of diagnostic and prognostic trends are discussed.

Levels of Human Chorionic Gonadotropin in Breast Cyst Fluid

The results of dosage of human chorionic gonadotropin (HCG) in 75 breast cyst fluids taken from 61 patients suffering from breast gross cystic disease (BGCD), 13 of which had multiple mono and / or bilateral cysts are discussed. The corresponding sera were also examined. Assays were carried out using the ELISA method. For comparison, HCG levels were also determined in 21 breast cyst fluids using RIA method. In 66.7% of the breast cyst fluids examined the hormone levels were higher than normal serum values. Corresponding sera showed HCG to be within the range of normal levels. In 5 patients the multiple and / or bilateral cysts showed widely differing hormone levels. The importance of these observations is discussed.

Circulating Immune Complexes in Human Breast Cyst Fluids: Relationship with Intracystic Immunoglobulin and Electrolyte Levels

Circulating immune complexes, the major classes of immunoglobulins and electrolyte concentrations were measured in sixty-two breast cyst fluids aspirated in women affected by gross cystic breast disease. Two main classes of cysts were defined according to the Na/K ratio. Appreciable levels of immunoglobulins were found in almost all samples examined; 66% of breast cyst fluids showed increased levels of immune complexes. A highly significant linear correlation between increased values of immune complexes and immunoglobulin M (p < 0.001) was found in apocrine cysts, characterized by Na/K ratio <3. However, a significant inverse linear correlation was found between positive values of immune complexes and lowered levels of immunoglobulins A (p < 0.001) and G (p < 0.001) in epithelial cysts with Na/K ratio > 3. These data suggest and confirm that the menstrual cycle can also influence or modulate the metabolic activity of human breast cells as a part of the secretory immune system. The relationship between immune complexes and immunoglobulins and electrolyte profiles may provide further knowledge about the immunological features of breast cyst fluid and suggest the possible alteration of immune-response in cystic breast lesions associated with increased cancer risk

Is there a relationship between rat latent aggressiveness and susceptibility to convulsive crises?

Experiments were aimed at assessing a possible different sensitiveness to seizures in aggressive vs. nonaggressive rates. Thirty-nine muricidal rats were selected by using a sedated mouse. Six of these killer rats (K) showed electroencephalographic (EEG) spontaneous syncronous wave-and-spike discharges, 6-11 c/s. None of nonkiller animals (NK) showed a similar pattern. These 6 K were not used for the subsequent experiments. Intraperitoneal pentylentetrazole (PTZ; 10, 20, and 40 mg/kg) or bicuculline (BIC; 2 and 4 mg/kg) was given to both NK and K. K were more sensitive than NK to the epileptogenic effects of 20 mg/kg PTZ and 2 mg/kg BIC, as revealed by the significant increased number of convulsive rats and longer duration of EEG seizures. No difference in EEG or convulsant behavior was observed between K and NK after the administration of the lower dose of PTZ and the high dose of PTZ or BIC. The use of K rats as a possible new sensitive model of petit mal is discussed.

Tissue Polypeptide Antigen Immunostaining in Fine Needle Aspirates from Solid Breast Nodules

the purpose of this study was to determine the role of Tissue Polypeptide Antigen (TPA) immunostaining in the evaluation of aspiration smears from solid breast nodules and to discuss its possible clinical applications. Seventy-one cytologic specimens were studied; 52 were carcinomas, 15 fibroadenomas and 4 fibrocystic dysplasia. TPA was visualized with the peroxidaseantiperoxidase method, using 3-3 ‘diaminobenzidine as chromogen and hematoxylin as counterstaining. The incidence of TPA-positive aspiration smears was 88.5% in the carcinomas and 26.7% in the fibroadenomas. The four cases of fibrocystic dysplasia showed variable behaviour. The intensity of the TPA staining varied from – to + + + and was most frequently high in the carcinomas. The results of this research show a good correlation between a diagnosis of carcinoma and TPA positivity in fine needle aspirates of solid breast nodules.

Lipid-associated sialic acid levels in human breast cyst fluids

Benign mammary gross cystic disease is the most common breast lesion. Women with apocrine changes of epithelium lining the cysts are at higher risk for developing breast cancer than the normal female population. Sialic acid has drawn considerable interest because of carbohydrate aberrations in malignant cells. The current investigation determined the concentrations of lipid-associated sialic acid (LASA) in 62 breast cyst fluids and sera. Data analyses show a significant increase in the mean values of LASA in metabolically active apocrine cysts when compared to the cysts with Na+/K+ > 3 (flattened cysts) (p < 0.001). The greater LASA levels in cyst fluids with lower intracystic Na+/K+ ratios could represent an altered expression of biosynthetic activity of the surrounding apocrine cell surface sialoglycolipid metabolism, providing a possible explanation of why women with apocrine cysts may be at greater cancer risk and being useful in further studies on functional stage changes in the cysts and their relationship to breast cancer.

Urothelial toxicity following conditioning therapy in bone marrow transplantation and bladder cancer: morphologic and morphometric comparison by exfoliative urinary cytology

Since cyclophosphamide and busulphan used for therapy of bone marrow transplantation (BMT) can cause urothelial cell changes similar to those found in bladder cancer, comparative morphologic and morphometric urinary cytologic research was carried out, examining 812 urine samples taken from 121 patients undergoing BMT and 60 urine samples from 20 patients with bladder cancer. The morphological results showed some differences in the characteristics of the urinary sediment in urothelial toxicity caused by conditioning therapy in BMT and in bladder cancer; among these were background, cellularity, leukocytes, urothelial cell arrangement, cell shape and size, vacuolization, mitosis, and nucleoli. A comparative morphometric study was also carried out, showing differences regarding cell area, nuclear area and perimeter, and N/C ratio, especially between well-differentiated bladder cancer and urothelial toxicity.

Ferritin and transferrin levels in human breast cyst fluids: relationship with intracystic electrolyte concentrations

The concentrations of sodium and potassium and the content of ferritin and transferrin, proteins considered as potential markers for identifying cells undergoing divisional activity, were measured in fluid from 30 human breast cysts. On the basis of the relative electrolyte concentrations, two main classes of cysts were defined. When the cyst fluids were subdivided according to their Na+/K+ ratio, a significant difference was found between menstruating vs. menopausal patients. The relationship between the two major iron-binding proteins and the Na+/K+ ratio may indicate the expression of a local higher biosynthetic activity in apocrine cysts associated with higher cancer risk.

Urothelial cell changes due to busulfan and cyclophosphamide treatment in bone marrow transplantation

Since the administration of cyclophosphamide and busulfan can cause hemorrhagic cystitis and changes in urothelial cells, an investigation was carried out to see whether patients undergoing bone marrow transplantation (BMT) who were treated with these drugs showed such urothelial changes and whether exfoliative urinary cytology can contribute to the early diagnosis and monitoring of such changes. Morphologic and morphometric analyses were performed on cytocentrifuged, Papanicolaou-stained preparations of 700 samples from 107 patients. Various degrees of urothelial cell changes were found in 30.8% of the cases. These changes consisted mainly of a considerable increase in the size of the nucleus and of a cytoplasm that was often bizarrely shaped. Even the structures of the nucleus and the cytoplasm changed. The results of this study showed that exfoliative urinary cytology permits an early diagnosis and monitoring of urothelial cell changes related to the administration of busulfan and cyclophosphamide in connection with BMT.

[Histochemical demonstration of CEA in pathology of the colorectum]

The evaluation of CEA serum levels and CEA tissue staining is one of the most common parameters used to help in the diagnosis and prognosis of colon-rectum disease. To this aim, an immunohistochemical demonstration of the CEA was carried out with the ABC staining system in sections of normal and diseased colon. 24 patients with polyps of the large intestine, 17 with rectocolitis, 22 with colon-rectum cancer and 11 normal subjects were studied. Results were positive in 9, 1% of the normal mucosa, 37, 5% of the polyps, 41, 2% of the rectocolitis and 100% of the carcinomas. However, the CEA in the positive reactions showed different degrees of staining and different cellular localization. From our results it would appear that the intracellular localization of this marker is connected with the degree of atypia in the histological sections. Immunohistochemical localization of the CEA could therefore be useful, above all in assessing the prognosis of colon-rectum disease.

[Serum levels of Cd, Pb, Cu and Zn in cigarette smokers]

In order to show the accumulation of Cd, Pb, Cu and Zn in smokers, levels of these metals in serum were determined in 108 subjects: 32 non-smokers, 37 average cigarette smokers and 39 heavy cigarette smokers. The analysis was carried out by potentiometric stripping analysis (PSA) with the Tecator "Striptec System". Backward oxidation time of the amalgamated metals, by means of electrolysis, in a thin "film" of mercury in an electrode, gives their concentration measure. Our data showed an increase in average values of Cd and Pb in the serum of heavy smokers compared with average and non-smokers. Instead, as regards Cu and Zn, no differences were found in the two groups of smokers compared with the non-smokers used as controls. Results obtained of the Cd and Pb levels in serum are compatible with the presence of these metals in cigarette tobacco and inhaling them could contribute to disease connected with their accumulation in the human organism. For these subjects the increase in Cd values is of particular importance as it could predispose pulmonary emphysema.

Lactate dehydrogenase, isoenzyme patterns and cation levels in human breast gross cyst fluid

In order to investigate the diagnostic and/or prognostic value of total activity and isoenzymatic patterns of lactate dehydrogenase, 24 human breast gross cystic fluids were studied. A comparison of total lactate dehydrogenase activity to the serum level revealed an increased activity in about 63% of the cases examined; moreover, a significant increase in the slow-moving lactate dehydrogenase 4 and 5 isoenzymes was observed in some cyst fluids. The levels of Na+ and K+ concentrations were also analyzed and two classes of cysts were identified: one presenting Na+ and K+ levels similar to those found in extracellular compartment; the other with high K+ and low Na+ levels, characteristic of an intracellular fluid. This latter pattern could indicate an active metabolism of the epithelial cells lining the cysts. This breast cyst fluid also showed increased levels of lactate dehydrogenase 4 and 5 isoenzymes. The correlation between an increased activity of lactate dehydrogenase 4 and 5 isoenzymes and high K+ and low Na+ levels could be the expression of a high biosynthetic activity and of an anaerobic metabolism in some cysts, suggesting the evolution of the breast gross cyst lesion to malignancy. The importance of these observations is discussed.

[Carcinoembryonic antigen in a review of cases in the literature]

Literature analysis of CEA serum levels tested in 21,147 patients, with non neoplastic and neoplastic disease of various organs, are reported. The sensitivity, the specificity, the positive and negative prognostic trend and the effective value of test in different pathologic situations are evaluated on the basis of organ localization and embryological origin.

Urinary cytologic abnormalities in bone marrow transplant recipients of cyclosporin

The role of urinary cytology in the early diagnosis of cyclosporin nephrotoxicity was studied in 20 bone marrow transplant recipients. There was an evident cyclosporin cytopathy in 35% of bone marrow transplant recipients examined, consisting mainly of degenerative and necrotic abnormalities in cells of the proximal convoluted tubules seen in urinary samples. These findings regressed to normal after reduction of the cyclosporin dose. Urinary cytology proved to be a useful method for the early diagnosis of cyclosporin nephrotoxicity.

Hydroxyproline and creatinine levels in normal amniotic fluid

Total hydroxyproline and creatinine concentrations as well as their ratios were determined in 29 amniotic fluid samples from normal pregnancies between the 16th and 20th week of gestation. Total hydroxyproline and creatinine levels, and their ratios, were not statistically different considering either the values at each week or those of the whole 5-week period. Our results, compared with the few others reported in the literature, can provide indications useful for defining the normal range in amniotic fluid, in relation to the weeks of gestation.

[Differential diagnosis of rejection and cyclosporin nephrotoxicity in organ transplantation using exfoliative urinary cytology]

Although the successful results sealing with Cyclosporin therapy in organ transplantation, side effects such as nephrotoxicity due to drug administration, are still partially solved especially concerning differential diagnosis versus rejection in kidney allograft. On this basis the authors evaluated the application of urinary exfoliative cytology for the monitoring of 110 patients who underwent kidney transplant under Cyclosporin regimen. Among them 33 cases showed direct and/or indirect cytopathic signs of nephrotoxicity induced by Cyclosporin, never observed on over 6000 urinary specimens of renal graphed patients treated with conventional therapy. The authors conclude that urinary exfoliative cytology is a useful, safe and easily repeatable method for the differential diagnosis between rejection and Cyclosporin nephrotoxicity at early stage in kidney transplantation.

Cholinesterase evaluation in the prenatal diagnosis of open neural tube defects

Alpha-fetoprotein (AFP) and cholinesterase levels in amniotic fluid were determined and the efficiency of these laboratory tests in the prenatal diagnosis of neural tube defects was examined. Using the AFP test with cut-off levels correlated to gestational age, we have detected 8 cases of neural tube defects and one case of abdominal wall defect in about 1,200 pregnancies; false-negative values were absent. Acetylcholinesterase (AChE) and butyrylcholinesterase activities were measured and the electrophoretic pattern of AChE was examined in 100 amniotic fluid samples. The diagnosis of neural tube defects was always confirmed. There were no diagnostic problems due to blood-contaminated amniotic fluid samples. The results obtained using different quantitative methods for the determination of cholinesterase activity, as well as the potential use of these tests in routine examinations, are discussed.

[Clinical renal transplantation: exfoliative urinary cytology in the evaluation of nephrotoxicity induced by cyclosporin therapy]

Cyclosporine significantly improved the results in organ allograft, nevertheless the drug's potential nephrotoxicity is still causative of problems in differential diagnosis between rejection and graft failure due to Cyclosporine in patients who undergo kidney transplantation. The authors evaluate the effectiveness of a simple method as Urinary Exfoliative Cytology (UEC) in a group of 38 patients who received a kidney allograft and post operative treatment with Cyclosporine. The cytological parameters studied were the following: cytology: cellularity, background, urotelial cells, tubular cells, red cells, polinuclear cells, monocytes, histyocytes, lymphocytes, plasmacells, casts (from 0 to 4+). In all the patients was associated the immunological evaluation--lymphocytes subpopulation markers and function--and Cyclosporine serum levels, together with the hematochemical parameters. In 6 patients with a rise of serum creatinine level the UEC evidentiated intracytoplasmatic eosinophile inclusions in the proximal tubular cells, picture never observed in over 5000 UEC examination of patients treated with post-transplant steroids and azathioprine immunosuppressive regimen. Moreover a complete renal function recovery followed the Cyclosporine dose reduction. The authors conclude that the UEC in kidney allograft is a safe, simple and useful method to assess the early renal damage due to Cyclosporine and to make differential diagnosis between nephrotoxicity and rejection.

[Cytology of breast cysts]

280 cytologic samples obtained by centrifugation of breast cyst fluids were studied. The results of the study on the cellular component and of the background are reported. The analysis was carried out on the cytomorphological aspects of the background, non epithelial cells, normal epithelial cells (foam, galactophoric, apocrine, papillary pictures) and malignant cells. Having described the single cytotypes, their diagnostic values in relation to other techniques are discussed.

[Cervicovaginal cytology in women wearing intrauterine devices]

Cervical and vaginal smears in 300 women using (a) intrauterine devices (IUD) and in 300 age matched control subjects (b), have been examined. In women using IUD, endometrial cells have been observed also in the second half of menstrual cycle, conversely these cells are present in women belonging to the control group, just in the first half of the cycle. Pattern of cervico-vaginitis due to Chlamydiae, Actinomyces and Eubacteria have been observed in higher percentage in women IUD wearers 58% of (a) group and 19.3% of (b) group (P less than 0.005). These patterns have often been characterized by the presence of repair cells. Implications in the evaluation of vaginal smears are discussed.

[Laboratory diagnosis in clinical renal transplants. III. Exfoliative urinary cytology in immunologic complications]

The authors summarize their experiences on cytological monitoring in kidney allografts performed at II Patologia Speciale Chirurgica, University of Rome (Italy), during the period 1979-1982. The different aspects of the urinary exfoliative cytology dealing with the post transplant immunological complications, and the differential cytomorphological criteria are described in detail. A good correlation among cytological, immunological and clinical parameters has been observed in 78% of the examined patients. Moreover the cytological findings allowed in 90% of cases an early diagnosis of rejection, increasing the possibility to successfully prevent an irreversible damage of the graft.

[Laboratory diagnosis in clinical renal transplants. II. Exfoliative urinary cytology in non-immunologic complications]

5,800 exfoliative cytology smears have been studied during the period 1979-1982. The study was performed as part of the monitoring in a group of patients who underwent kidney transplant at the II Patologia Speciale Chirurgica, University of Rome (Italy). Cytological findings related to non-immunological complications in the first postoperative period are described and discussed in detail. The urinary exfoliative cytology method in the differential diagnosis among ATN, ischemic tubular necrosis and viral infections, tested by sequentially repeated examinations, could allow a prompt diagnosis before the evidence of clinical and hematochemical signs of renal damage.

[Laboratory diagnosis in kidney transplants. I. Exfoliative urinary cytology]

Clinical microscopy is a worthwhile method to monitor patients with kidney transplants. The authors describe their experience in 5,800 urinary cytological specimens. The study includes several methods of collecting, processing and staining of the specimens, showing the different cytological pictures: background, hematopoietic-inflammatory cells, renal epithelial cells and casts.

[Study of bisalbuminemias of the "fast" type]

A case of alloalbuminaemia of the fast type was described in a family living in the district of Pesaro. This was one of the few cases of this particular type and the first observed in this region. Being related to electrophoretic mobility, it is classified as: very fast, type gent. This anomaly has been evidenced by electrophoresis on cellulose acetate, while immunoelectrophoresis with an anti-protein total serum does not reveal the immunological differences referred to in normal albumine.