A prospective evaluation of COVID-19 associated coagulopathy with acute coronary syndrome (ACS)

Background

Hospitalised COVID-19 pneumonia patients are characterised by the occurrence of a hypercoagulable state associated to a high risk of thromboembolic events. The main laboratory findings of this coagulopathy include D-dimer increase, mild thrombocytopenia, prolonged PT, and increase endothelial activation biomarkers (vWF, thrombomodulin). No data are available about coagulation profile in patients presenting with an acute coronary syndrome (ACS) combined with SARS-CoV-2 infection.

Purpose

In this prospective study, we aimed to evaluate the contribute of concomitant SARS-CoV-2 infection to the haemostatic system derangement (i.e., from endothelial cell activation to fibrinolytic phase) observed in patients presenting with ACS. Further, the role of haemostatic biomarkers (HB) for in-hospital mortality risk prediction was also explored.

Methods

Consecutive patients admitted to our hospital for ACS at peak intensity of local pandemia were enrolled into this study. At admission, all patients underwent routine blood examinations with blood count, serum biochemical tests and an extensive coagulation profiling. Data from coronary angiography and percutaneous coronary intervention (PCI), when performed, were collected. In-hospital major adverse cardio and cerebrovascular events –MACCEs- (total and cardiovascular death, stroke, systemic or pulmonary embolism, re-MI and bleedings) are reported.

Results

A total of 99 (76M/23F) consecutive patients with a median age of 66.7 (±12.1) were enrolled. According to nasal swab, 24 patients were SARS-CoV-2 positive and 75 negative. The two groups, similar in age, sex and cardiovascular risk factors, significantly differed in presenting symptoms (p<.001) and radiological signs of pneumonia (p<.0001). At admission, there were no differences in routine laboratory values between groups. Differently, analysis of the HB showed significantly higher values of D-dimer, vWF antigen, vWF activity and vWF; RiCof, t-PA and PAI-1 and lower levels of ADAMTS-13 in the positive group. Furthermore, among ACS patients, both STEMI and NSTEMI subjects, positive for SARS-CoV-2, had significantly higher plasma values of all the HB compared to the respective negative counterparts, with SARS-CoV-2 positive STEMI subjects displaying the highest values. When performed, PCI finished more frequently with a final TIMI flow <3 (p=.004) in positive patients. The in-hospital rate of MACCEs was 24% (24/99 patients) with a higher (p<.0001) prevalence in SARS-Co-V2 positive group. Cardiovascular mortality accounted for the majority of deaths (8/10; p=.019). At multivariable analysis, we identified dyspnoea at presentation, vWF antigen and leukocyte values as independent risk factors for in-hospital death.

Conclusions

In patients presenting with ACS combined with SARS-Cov-2 infection an additional HB asset derangement with stronger endothelial cell activation occurs which negatively impact the outcome, regardless of the invasive treatment.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic approach in patients with angina and no obstructive coronary artery disease: emphasising the role of the coronary function test

BACKGROUND

Many patients with angina do not have obstructive coronary artery disease (CAD), also referred to as "Ischaemia with No Obstructive Coronary Arteries" (INOCA). Coronary vascular dysfunction is the underlying cause of this ischaemic heart disease in as much as 59-89% of these patients, including the endotypes of coronary microvascular dysfunction and epicardial coronary vasospasm. Currently, a coronary function test (CFT) is the only comprehensive diagnostic modality to evaluate all endotypes of coronary vascular dysfunction in patients with INOCA.

OBJECTIVE

In this paper we discuss the relevance of performing a CFT, provide considerations for patient selection, and present an overview of the procedure and its safety.

METHODS

We reviewed the latest published data, guidelines and consensus documents, combined with a discussion of novel original data, to present this point of view.

RESULTS

The use of a CFT could lead to a more accurate and timely diagnosis of vascular dysfunction, identifies patients at risk for cardiovascular events, and enables stratified treatment which improves symptoms and quality of life. Current guidelines recommend considering a CFT in patients with INOCA and persistent symptoms. The safety of the procedure is comparable to that of a regular coronary angiography with physiological measurements. Non-invasive alternatives have limited diagnostic accuracy for the identification of coronary vascular dysfunction in patients with INOCA, and a regular coronary angiography and/or coronary computed tomography scan cannot establish the diagnosis.

CONCLUSIONS

A complete CFT, including acetylcholine and adenosine tests, should be considered in patients with INOCA.

Incidence, mechanisms and clinical impact of largely uncovered struts in current generation drug-eluting-stents: insight from the TRANSFORM-OCT Study

Background

Thin-strut drug-eluting stents (DES) and optimal implantation technique reduce the rate of stent failure significantly. Nevertheless, uncovered struts (US) have been observed as a key factor for stent thrombosis regardless of stent generation and time of follow-up. Associated factors and temporal evolution are currently unknown.

Purpose

To evaluate the prevalence, mechanisms and long-term clinical impact of largely-US after state-of-the-art DES implantation in complex coronary clinical/lesion cohorts

Methods

The study was a pre-specified analysis of TRASFORM-OCT, a randomized controlled trial comparing bioabsorbable or durable polymer DES by serial optical coherence tomography (OCT), obtained at baseline, immediately after procedure, at 3 and 18 months follow-up. Methods and results were published previously. For the current analysis enrolled patients (n=90) were divided in 2 groups according to the amount of US identified by OCT at 3 months: a largely US (LUS ≥30%) group and the control group (<30% US), to evaluate factors associated to LUS, and the clinical impact at follow-up.

Results

Out of 90 patients, 31 (34.4%) were assigned to the LUS group, and 59 (65.6%) to the control group. At baseline, LUS patients had larger vessels (reference area 5.51±1.1 vs. 4.27±1.5 mm2, p=0.001), a higher rate of plaque rupture (41.9 vs. 18.6%, p=0.02), thin-cap fibroatheroma (58.1% vs. 51.7% p=0.03) and thrombus (58.1% vs. 35.6%, p=0.001) as detected by OCT. 98% patients continued dual antiplatelet therapy up to 12 months, and 24% of them up to 18 months.

At stent implant, performed with high pressure dilation (21.18±3.8 vs 20.54±3.6 atm in LUS vs control group, p 0.48), the rate of apposed and embedded struts was high in both groups, although higher in controls (93.92±5.30% vs 96.46±3.68%, p 0.03 and 16.8±11.5% vs 21.7±15.8%, p=0.12, respectively for controls and LUS). At 3 months, US rate was 48.4±12% in the LUS group, and 13.3±7% in the control group (p<0.001). Global malapposition rate was 7.95±7.5% and 1.69±1.6% (p<0.001), respectively. 84.52±12.41% of the US in the LUS group and 86.49±19.98% in controls group were apposed to the wall (p 0.07). At 18 months, the rate of US dropped significantly to 8.4±10% in LUS group and 1.8±3% in control group (p<0.001), with malapposition rate being 1.4±3.3 and 0.16±0.43% (p 0.006). Of the US, 81.6±25.15 and 91.11±21.76% were apposed to the wall, respectively. At 5 years clinical follow-up, no differences were observed at the composite endpoint of major adverse cardiovascular events (detailed data will be presented).

Conclusions

In a setting of optimal PCI with modern DES and high-pressure inflation, LUS occur in 30% of patients at early follow-up, more frequently in large vessels with lipid-rich, complex plaques. The vast majority of US is apposed to the wall and near-complete coverage is observed at long-term follow-up, with no clinical impact compared to subjects with a low rate of US.

Funding Acknowledgement

Type of funding source: None

Intracoronary imaging assessment of atherosclerosis in vasomotor dysfunction and phenotypes of non-obstructive coronary artery disease

Background

A consistent portion of patients with stable angina is affected by coronary vasomotor dysfunction, in the form of epicardial vasospasm (VSA) or coronary microvascular dysfunction (CMD). Although available data suggest a worse prognosis compared to normal population, anatomical background and associations with atherosclerosis are still uncertain.

Purpose

To define specific morphological features in patients with stable angina and coronary vasomotor dysfunction.

Methods

We enrolled all patients referred to our laboratory in the first half of 2019 for coronary reactivity testing (CRT) for stable angina and suspected vasomotor dysfunction. After confirming non-obstructive coronary artery disease by angiography, CRT consisted of acetylcholine test and physiology assessment with resting and hyperemic indexes. In addition, optical coherence tomography (OCT) was performed. All tests were performed in the left anterior descending artery. Patients were divided in 3 groups: VSA, CMD and control group (no CMD/VSA), according to international COVADIS consensus documents. Two independent reviewers assessed the OCTs to identify markers of atherosclerosis.

Results

We enrolled 48 patients. Mean age was 55.19±7.71 years. 46 (96%) were females. 3 patients were removed due to mixed VSA and CMD, resulting in 45 subjects eligible for analysis: 17 had VSA, 22 CMD and 6 were controls. Baseline characteristics, resting and hyperemic indexes were similar in the groups, except for the index of microvascular resistance (IMR), being higher in CMD group. Moving from control group, to CMD, to VSA, OCT suggested a trend of increasing prevalence of fibroatheromas (0% in controls, 36% in CMD, 47% in VSA, p 0.12), thin-cap fibroatheromas (0% vs 18% vs 29%, respectively, p 0.29) and neovascularisation (17% vs 23% vs 47%, p 0.19). On the other hand, macrophage infiltration was higher in CMD group (55% in CMD, vs 47% in VSA, vs 33% in controls, p 0.64). Plaques covered 43% of the vessel in VSA group (34% being lipid-rich), 35% in CMD (lipid: 36%) and 30% in controls (p 0.69; 17% lipid). Lipid pools showed a different distribution across the groups. Control group had small pools (mean/max lipid arc 56/65°, length: 5.5 mm), CMD showed intermediate width (arc 82/106°), but long extension (11.5 mm), while VSA had large pools (94/127°, p 0.05/0.08), with intermediate length (7 mm, p 0.58). Lipid index (mean arc x lipid length) was similar in VSA (632) and CMD (642), but lower in control group (203, p 0.35).

Conclusions

This study hints at atherosclerosis as an underlying pathophysiology in VSA and CMD. A trend to increasing burden, both in terms of extension and vulnerability, was observed across patients with normal arteries, CMD and VSA. Peculiar patterns of atherosclerosis may be associated with specific phenotypes of vasomotor dysfunction, with larger lipid pools and neovascularization being associated with VSA and macrophage infiltration being more common in CMD.

Funding Acknowledgement

Type of funding source: None

Percutaneous coronary intervention in spontaneous coronary artery dissection: a case-control study

Background

Spontaneous Coronary Artery Dissection (SCAD) is an important cause of acute coronary syndrome particularly in young-middle aged women. Revascularisation is challenging due to an underlying disrupted and friable coronary vessel wall leading to widely reported worse outcomes than for atherosclerotic coronary disease. Therefore, a conservative approach where possible is favoured however in some cases haemodynamic instability, ongoing ischaemia and reduced distal flow mandates consideration of revascularisation.

Purpose

To compare SCAD survivors managed with PCI or conservatively in terms of presentation characteristics, complications and long-term outcomes.

Methodology and results

226 angiographically confirmed SCAD survivors (95% female,47±9.7yrs) who underwent PCI were compared in a case control study with two hundred and twenty-five angiographically confirmed SCAD survivors (92% female, 49±9.9yrs) who were conservatively managed. Patients were recruited from UK, Spanish and Dutch SCAD registries and both groups were well matched in terms of baseline demographics.

Those treated with PCI were more likely to present with proximal SCAD (30.8% vs 7.6% P<0.01) and ST elevation myocardial infarction (STEMI) or cardiac arrest with reduced flow (32.3% vs 6.3% P<0.01). Intervention was performed with stents in 72.4%, plain old balloon angioplasty in 21.1% and wiring in 6.4% of cases and more often for multi-segment disease (40.8% vs 26.3% P<0.01). In cases with initial reduced flow undergoing PCI an improvement in flow was seen in 83%.

Analysis of UK PCI cases (n=144) reveal complications in 56 (38.8%). However, when assessed for significance defined by a reduction in flow in a proximal/mid vessel, stent extension into left main stem, iatrogenic dissection requiring PCI and CABG as a consequence of PCI only 13 cases (9%) met criteria. Iatrogenic dissection accounts for the majority (76.9%). SCAD lesion length was associated with presence of complications (P=0.025). There was a non-significant trend towards major adverse cardiovascular events (MACE) occurring more frequently in those undergoing PCI (18% vs 11% P=0.067) driven by revascularisation (5% vs 1% P=0.036). Median follow up was 2.7 years.

Conclusions

PCI in SCAD is often performed in higher risk patients; in those presenting with reduced flow, the majority demonstrate improvement. Importantly whilst overall complication rates were similar to those widely reported, clinically significant complications were low. Multivariate modelling will reveal factors associated with complications to aid future decision making in this challenging patient group.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation

Barriers to and facilitators of the uptake of digital health technology in cardiology: a systematic review

Background

Digital health technology has the potential to revolutionize the quality and efficiency of healthcare delivery. However, the uptake of digital health technology has been low in clinical practice. The factors that contribute to the limited adoption of digital health technology, particularly in cardiology, are unclear.

Purpose

We identified and synthesized the barriers to and facilitators of digital health technology uptake in cardiology, with a focus on provider- and patient- level barriers and facilitators.

Methods

We searched MEDLINE, EMBASE and CINAHL databases for studies published January 2000 - December 2019 that reported barriers to and/or facilitators of digital health technology adoption in cardiology. Two reviewers screened and extracted data independently. We conducted a thematic analysis to identify major themes pertaining to digital health technology uptake by both providers and patients.

Results

The search identified 3062 unique studies, of which 23 qualitative studies met eligibility criteria. Seventeen studies included semi-structured interviews and 6 included focus groups. Five (22%) studies reported provider-level facilitators, which included technology usability, integration into clinical workflow, and improved patient outcomes. Eighteen (78%) studies reported patient-level facilitators, which included ongoing technical support, improved access to healthcare services, and improved self-management. Six (26%) studies reported provider-level barriers, which included lack of integration into clinical workflow, increased healthcare costs, and lack of validation and reliability of technology. Finally, 19 (83%) studies reported patient-level barriers which included lack of knowledge about technology, limited internet access, and physical impairments making use of technology difficult.

Conclusions

Identifying barriers to and facilitators of digital health technology could help improve its uptake in cardiology. The findings of this study can be used to inform researchers, clinicians, and stakeholders who wish to develop and implement digital health technologies that meet the needs of providers and patients.

Funding Acknowledgement

Type of funding source: None

The Real-Life Journey of Elderly Patients in Soft Tissue and Bone Sarcomas: A Retrospective Analysis from a Sarcoma Referral Center

The high complexity of multimodality treatment frequently results in undertreatment of elderly sarcoma patients, and this may be one of the factors that influence their prognosis. We describe the real-life approach to a population of patients aged over 70 with both soft tissue (STS) and bone sarcomas (BS) followed by our Sarcoma Disease Management Team from 2012 to 2017. One-hundred and twenty-three patients with a median age of 77 years (range: 70–92) were identified. STS were the most common histological subtypes (94%) and the grade was high in 79/123 patients (64%). At diagnosis, 88% of patients had localized disease (LD) and 12% were metastatic (MD). Overall, 96% of patients with LD underwent surgery, 46/54 (85%) with high grade STS patients underwent complementary radiotherapy, and 10/54 (19%) received adjuvant treatments. Twelve out of 33 patients who relapsed (36%) underwent local therapies. Seventeen (52%) and eight (24%) patients were treated with first-line and second-line medical treatments, respectively. Tolerability to systemic treatments was fairly good. Overall, 21% of the patients with advanced disease were candidates for best supportive care alone. Our case series of elderly patients with both STS and BS shows that personalized multidisciplinary treatment can nevertheless be offered to this frail population in order to control the evolution of disease.

Species-specific sensitivity of three microalgae to sediment elutriates

Microalgae are considered good bioindicators of marine environmental quality. Frequently, they are used to investigate the toxicity of sediment elutriates, but their sensitivity is disputed. This paper compared the sensitivity of Phaeodactylum tricornutum (diatom), Skeletonema costatum (diatom), and Dunaliella tertiolecta (green alga), analyzing 257 samples of elutriates (1:4 sediment: water ratio), considering growth inhibition (72 h) as the reference endpoint and sediment chemical (metals, metalloids and polyaromatic hydrocarbons) and grain size. Results of the toxicity tests showed that the microalgae sensitivity was not correlated. The integration of chemical data did not allow to discriminate toxicity effects but contributed to highlight that D. tertiolecta was the most sensitive microalgae (no cell wall) followed by P. tricornutum and S. costatum. Further analysis, including lines of evidence and weight of evidence approaches to calculate risk quotients of elutriate samples, confirmed these results.

Focusing of High-Brightness Electron Beams with Active-Plasma Lenses

Plasma-based technology promises a tremendous reduction in size of accelerators used for research, medical, and industrial applications, making it possible to develop tabletop machines accessible for a broader scientific community. By overcoming current limits of conventional accelerators and pushing particles to larger and larger energies, the availability of strong and tunable focusing optics is mandatory also because plasma-accelerated beams usually have large angular divergences. In this regard, active-plasma lenses represent a compact and affordable tool to generate radially symmetric magnetic fields several orders of magnitude larger than conventional quadrupoles and solenoids. However, it has been recently proved that the focusing can be highly nonlinear and induce a dramatic emittance growth. Here, we present experimental results showing how these nonlinearities can be minimized and lensing improved. These achievements represent a major breakthrough toward the miniaturization of next-generation focusing devices.

Ecofriendly nanotechnologies and nanomaterials for environmental applications: Key issue and consensus recommendations for sustainable and ecosafe nanoremediation

The use of engineered nanomaterials (ENMs) for environmental remediation, known as nanoremediation, represents a challenging and innovative solution, ensuring a quick and efficient removal of pollutants from contaminated sites. Although the growing interest in nanotechnological solutions for pollution remediation, with significant economic investment worldwide, environmental and human risk assessment associated with the use of ENMs is still a matter of debate and nanoremediation is seen yet as an emerging technology. Innovative nanotechnologies applied to water and soil remediation suffer for a proper environmental impact scenario which is limiting the development of specific regulatory measures and the exploitation at European level. The present paper summarizes the findings from the workshop: "Ecofriendly Nanotechnology: state of the art, future perspectives and ecotoxicological evaluation of nanoremediation applied to contaminated sediments and soils" convened during the Biannual ECOtoxicology Meeting 2016 (BECOME) held in Livorno (Italy). Several topics have been discussed and, starting from current state of the art of nanoremediation, which represents a breakthrough in pollution control, the following recommendations have been proposed: (i) ecosafety has to be a priority feature of ENMs intended for nanoremediation; ii) predictive safety assessment of ENMs for environmental remediation is mandatory; (iii) greener, sustainable and innovative nano-structured materials should be further supported; (iii) those ENMs that meet the highest standards of environmental safety will support industrial competitiveness, innovation and sustainability. The workshop aims to favour environmental safety and industrial competitiveness by providing tools and modus operandi for the valorization of public and private investments.

Arteriovenous Fistulas for Hemodialysis Created using a Long-Term Absorbable Suture: A Safe Solution and a Measure to Minimize Myointimal Hyperplasia

Background/aims

The goal of the therapeutic management of patients affected by end-stage renal disease (ESRD) is to maintain the vascular access (VA) as long as possible. Myointimal hyperplasia development in the vascular walls of arteriovenous fistulas (AVFs) is considered one of the most important factors responsible for procedure failure. These alterations could be linked to hemodynamic changes in the anastomosis and to the presence of the surgical suture itself. We report our preliminary experience, discussing the use and the possible benefits of an absorbable suture in polyglycolide trimethylene carbonate (PTC) in AVF creation.

Methods

Seventy-four AVFs were created as primary access for hemodialysis (HD), using PTC, over 4 years. Age, gender, ESRD etiology, artery and vein preoperative diameters, AVF survival outcome, and the number of AVFs created per year were recorded. The Kaplan-Meier method was used to analyze AVF survival rates.

Results

No dehiscences, pseudoaneurysms, or failures in the “critical” period related to PTC absorption were recorded. Kaplan-Meier analysis was used to evaluate AVF survival; 12-month primary AVF survival (74.33%) and AVF failure (25.67%) rates, 9 “early” (8.22%) and 10 “late” failures (13.51%), and a 360-day mean survival were found.

Conclusions

Our data indicate that PTC, a well known and widely used material for sutures in vascular surgery, is safe and effective in AVF creation. Potential advantages of PTC sutures are represented by a reduced myointimal hyperplasia formation in the AVF vascular walls, prolonging the AVF lifespan and avoiding re-interventions.

Ultra-High Mass Resolution MALDI Imaging Mass Spectrometry of Proteins and Metabolites in a Mouse Model of Glioblastoma

MALDI mass spectrometry imaging is able to simultaneously determine the spatial distribution of hundreds of molecules directly from tissue sections, without labeling and without prior knowledge. Ultra-high mass resolution measurements based on Fourier-transform mass spectrometry have been utilized to resolve isobaric lipids, metabolites and tryptic peptides. Here we demonstrate the potential of 15T MALDI-FTICR MSI for molecular pathology in a mouse model of high-grade glioma. The high mass accuracy and resolving power of high field FTICR MSI enabled tumor specific proteoforms, and tumor-specific proteins with overlapping and isobaric isotopic distributions to be clearly resolved. The protein ions detected by MALDI MSI were assigned to proteins identified by region-specific microproteomics (0.8 mm2 regions isolated using laser capture microdissection) on the basis of exact mass and isotopic distribution. These label free quantitative experiments also confirmed the protein expression changes observed by MALDI MSI and revealed changes in key metabolic proteins, which were supported by in-situ metabolite MALDI MSI.

Cold storage of Acartia tonsa eggs: a practical use in ecotoxicological studies

The calanoid copepod Acartia tonsa has been recommended as a marine organism for ecotoxicological tests due to its wide distribution, short life cycle and high productivity. This species is used in acute and chronic toxicity tests to assess water and sediment quality; egg hatching success and the survival of the first larval stages are considered endpoints. Toxicity test protocols require a large number of organisms and an appropriate culture system. Eggs stored under conditions that delay hatching could ensure sufficient quantities of biological materials for ecotoxicological tests. In the current study early-spawned eggs were stored at 3 °C (±1) up to 240 days and their hatching success was evaluated on a monthly basis. Our results showed that the percentage of hatching success for eggs stored for 30 days was >80 % and decreased by about 8 % for every 20 days of storage, up to 120 days. A further increase of time in cold storage brought about a significant reduction, in statistical term, of hatching success compared with the control group (43.69 ± 22.19 %). Almost 50 % of eggs hatched or died during the cold storage period, with more than 80 % lost after periods longer than 150 days. To verify the suitability of stored eggs for toxicity test, 48 h acute tests were performed using nickel chloride as a referent toxicant. Eggs stored for 30, 60, 90 and 120 days gave EC50 values ranging from 0.130 to 0.221 mg L(-1), similar to the value recorded for early-spawned eggs, suggesting that these eggs can be used for ecotoxicological tests. Our results open new possibilities for a wider use of the Mediterranean strain of A. tonsa copepod for ecotoxicological tests.

Toxicity of nickel in the marine calanoid copepod Acartia tonsa: Nickel chloride versus nanoparticles

Nickel compounds are widely used in industries and have been massively introduced in the environment in different chemical forms. Here we report the effect of two different chemical forms of nickel, NiCl2 and nickel nanoparticles (NiNPs), on the reproduction of the marine calanoid copepod Acartia tonsa. The behavior of nickel nanoparticles was analyzed with different techniques and with two protocols. In the "sonicated experiment" (SON) NiNP solution was sonicated while in the "non-sonicated experiment" (NON-SON) the solution was vigorously shaken by hand. Final nominal concentrations of 5, 10 and 50mgL(-1) and 1, 5 and 10mgL(-1) NiNPs were used for the acute and semichronic tests, respectively. Nanoparticle size did not change over time except for the highest concentration of 50mgL(-1) NiNPs, in which the diameter increased up to 843nm after 48h. The concentration of Ni dissolved in the water increased with NP concentration and was similar for SON and NON-SON solutions. Our results indicate that sonication does not modify toxicity for the copepod A. tonsa. Mean EC50 values were similar for NON-SON (20.2mgL(-1)) and SON experiments (22.14mgL(-1)) in the acute test. Similarly, no differences occurred between the two different protocols in the semichronic test, with an EC50 of 7.45mgL(-1) and 6.97mgL(-1) for NON-SON and SON experiments, respectively. Acute and semichronic tests, conducted exposing A. tonsa embryos to NiCl2 concentrations from 0.025 to 0.63mgL(-1), showed EC50 of 0.164 and 0.039mgL(-1), respectively. Overall, A. tonsa is more sensitive to NiCl2 than NiNPs with EC50 being one order of magnitude higher for NiNPs. Finally, we exposed adult copepods for 4 days to NiCl2 and NiNPs (chronic exposure) to study the effect on fecundity in terms of daily egg production and naupliar viability. Egg production is not affected by either form of nickel, whereas egg viability is significantly reduced by 0.025mgL(-1) NiCl2 and by 8.5mgL(-1) NiNPs. At NiNP concentration below the acute EC50 (17mgL(-1)) only 9% of embryos hatched after 4 days. Interestingly, the percentage of naupliar mortality (>82%) observed in the semichronic test at the nominal concentration of 10mgL(-1) NiNPs corresponding to almost 0.10mgL(-1) of dissolved Ni, was similar to that recorded at the same Ni salt concentration. Electron microscopical analyses revealed that A. tonsa adults ingest NiNPs and excrete them through fecal pellets. To the best of our knowledge, this is the first study investigating the toxicity of two different forms of Ni on the reproductive physiology of the copepod A. tonsa and showing the ability of the calanoid copepod to ingest nanoparticles from seawater.

Development of a new integrative toxicity index based on an improvement of the sea urchin embryo toxicity test

The sea urchin embryo toxicity test is classically used to assess the noxious effects of contaminated marine waters and sediments. In Italian guidelines on quality of dredged sediments, the standard toxicity criteria used for this assay are based on a single endpoint at 48 hours of development, corresponding to the pluteus stage. Different typologies of abnormalities, including those which occur at earlier stages, are not categorized, thus preventing the evaluation of the actual teratogenic hazards. A new integrative toxicity index has been developed in this study based on the analysis of two developmental stages, at 24 and 48h post-fertilization, and the differentiation between development delays and germ layers impairments: the new toxicity index is calculated by integrating the frequency of abnormal embryos with the severity of such abnormalities. When tested on dredged sediments, the evaluation of increasing levels of toxicity affecting embryonic outcomes enhanced the capability to discriminate different samples, appearing particularly relevant to validate the sea urchin embryo toxicity assay, and supporting its utility in practical applications such as the sediments classification in harbor areas.

Chordoma: A rare bone tumor: A single institutional experience on a case series of 23 patients

e21519

Background: Chordoma is a rare primary bone tumor arising from primitive notochord remnants of axial skeleton. Adequate surgery still remains the mainstay of its therapeutic treatment. Methods: Our review has been focused on the clinical characteristics, type of treatment, and prognosis of 23 consecutive cases of chordomas observed from 2004 until today and followed by the same team of specialists (orthopedic surgeons and medical oncologists). Results: From June 2004 to December 2008, 23 pts with various stage of disease went to our observation. Male/female: 18/5. Median age at diagnosis: 60 yrs (range: 40 -74). Sites of origin: sacrum (10 pts), spine (12 pts), and skull base (1 pt). Ten pts (44%) had primary disease, 9 pts (39%) had recurrent disease, and 4 pts (17%) had developed metastatic lesions. Surgery was part of the treatment in 21 out of 23 pts. Surgical margins were rated as wide/marginal in 17 pts and intralesional in 4 pts. Adjuvant proton radiotherapy has been delivered to 2 pts. Conventional radiotherapy was performed in 4 pts. The rate of local relapse after primary surgical excision was 76%. The median time to recurrence was 14 months (range: 2–113).Sixteen pts with inoperable/unresectable or metastatic PDGFR β expressing disease were treated with imatinib mesylate (IM) in the context of a clinical trial and a subsequent expanded access program (Stacchiotti S., proc ASCO 2007. abstr. 10003). One pts received weekly cisplatin in combination with IM after progression during IM therapy. The 5-year survival rate of the entire series was 76 %. Two out of 17 pts (12%) surgically treated with adequate margins are still alive and without evidence of disease; two other pts died without evidence of disease. Conclusions: Despite the progress of current surgical techniques and some encouraging results with the use of targeted therapy, chordoma results, generally, in a long-lasting disabling and life-affecting disease. Nevertheless, specific experience of the multidisciplinar team is an important prerequisite to improve patients’ quality of life and, hopefully, outcome.

No significant financial relationships to disclose.

[Myelomatous ascites]

Ascites is rare in patients with multiple myeloma (MM). It may be due to diverse mechanisms, most frequently because of an increased permeability of the peritoneum or because of portal hypertension due to liver infiltration. Myelomatous ascites occurs more frequently in patients having Ig-G or Ig-A paraprotein and their prognosis is poor. It is submitted the case of a female patient aged 50 years with IgA-kappa MM, who evolved with cardiac failure (CF), plasma cells leukemia and ascites of mixed cause, because of peritoneal infiltrate of myelomatous cells, hepatic compromise and CF. A review of the different causes of ascites in patients with MM is performed. There are also summarized all myelomatous ascites cases published in the literature. Our report presents the first case of myelomatous ascites in a patient with plasma cells leukemia.

Variations in sensitivity of two populations of Corophium orientale (Crustacea: Amphipoda) towards cadmium and sodium laurylsulphate. Comparison of two populations of Corophium orientale

The aim of this work was to monitor the sensitivity of two populations of Corophium orientale (Crustacea: Amphipoda) living at the outfall of two rivers (Magra and Serchio), comparing their responses towards two different toxicant solutions. Sensitivity was monthly checked performing the 96h-LC50 static water only test with Cd(NO3)2 and SDS. If no significant differences were found between the two populations, they could have been employed without distinction to perform sediment toxicity bioassays. As regard to Cd, an increasing in LC50 values from summer to winter was evident in each population (Serchio River: August 2003 = 1,36 mg/l, February 2004 = 7,23 mg/l; Magra River: August = 1,21 mg/l, April = 5,01 mg/l). This pattern was correlated to the droop of temperatures in winter period. The responses of the two populations towards the cadmium were compared using the ANOVA. The analysis showed any significant differences between the populations (p = 0.12). The pattern of sensitivity towards SDS for the population living on Magra River was similar to the same pattern found for Cd; as regard to the population living on Serchio River, data were not enough to describe the annual pattern. Anyway, statistical analysis was performed and no significant differences were found between the two populations (p = 0.34).

Standardizing the methodology of sperm cell test with Paracentrotus lividus

The sperm cell toxicity test with Paracentrotus lividus is widely used in Italy to assess the quality of complex aqueous matrices, but at present there is a shortage of standardized methodologies for the bioassay performance. In this work several critical points were considered, in order to verify the reliability of this bioassay and to improve its standardization. In particular, we have studied the differences in EC50 values at different sperm: egg ratios and with different quantities of gametes; the influence of sperm and eggs on fertilization rate and the influence of different recipients materials (plastic or glass). At the same time, it was evaluated if the obtained EC50 values were in accordance with those reported in literature. Experiments performed yielded EC50 values for copper ranging from 16.54 microg/l to 69.59 microg/l, with a total mean value +/- SD of 39.79 microg/l +/- 11.17. These data fit with those found in literature for other echinoid species. According to the same authors, poor fertilization was probably due to the effects on sperm and not on eggs, and moreover the linear regression analysis performed on each experiment suggested that the best amount of eggs to use in the test was 1000. Results from the comparison between the performance of the test in plastic or glass tubes showed an higher success in fertilization rate using borosilicate glass tubes.

Evaluation of the fertilization capability of Paracentrotus lividus sea urchin storaged gametes by the exposure to different aqueous matrices

Several experiments were performed to evaluate the fertilization capability of Paracentrotus lividus sea urchin gametes, which are usually used in fertilization tests, but which, until now, were employed only for few hours after spawning. The aim of this work is to evaluate the possibility of performing the bioassay for longer periods, employing 'conserved' gametes. As far as the method, the sperm was stored 'dry' at 4 degrees C; eggs were conserved in an antibiotic solution at 4 degrees C, and they were exposed both to copper solutions as reference toxicant and to aqueous matrices. The use of conserved gametes in the fertilization bioassay lead to EC50 values which were acceptable for about 3 days. Moreover, these experiments permitted to identify the limiting factor: the male gamete.

[Einstein's sign and other signs of aortic aneurysm]

Einstein's sign is a syndrome similar to an acute cholecystitis caused by the rupture of an abdominal aortic aneurysm. In this paper we describe the evolution of the disease that the physicist suffered till it led him to death. We also revise other signs which could be found in some patients with ruptured or dissected abdominal aortic aneurysm.

Mucilage impact on gorgonians in the Tyrrhenian sea

The mucilage phenomenon has affected the Tuscan Archipelago since its first appearance (1991) in the Tyrrhenian Sea (Mediterranean Sea) [Innamorati M, Raddi E, Buzzichelli A, Melley S, Demoulin M. Le mucillaggini nel Mar Tirreno. Biol Mar Suppl Notiz 1992;1:23-26; Sartoni G, Sonni C. Tribonema marinum J. Feldmann e Acinetospora crinita (Carmichael) Sauvageau nelle formazioni mucillaginose bentoniche osservate sulle coste toscane nell'estate 1991. Inf Bot Ital 1991;23:23-30; Sartoni G, Cinelli F, Boddi S. Ruolo di Tribonema marinum J. Feldmann ed Acinetospora crinita (Carmichael) Sauvageau negli aggregati mucillaginosi bentonici delle coste toscane. Biol Mar Suppl Notiz 1993;1:31-34]. Seasonally, these mucous aggregates become very common in the benthic domain. The gorgonians are the most exposed organisms because they provide the best support for mucilage growth; indeed, their long branches positioned in orthogonally with respect to the current so as to capture plankton, also trap the filamentous mucilage present in the water. A 3-year monitoring programme at Capo Calvo (Island of Elba) was carried out in order to study the appearance of the mucilage phenomenon and its impact on three species of gorgonians (Eunicella cavolinii, Eunicella singularis, and Paramuricea clavata). The composition of mucilage and the gorgonian recovery capacity, when damaged, were investigated. During the first year of study (1999), no relevant interactions between gorgonians and mucilages were recorded. Instead, massive presence of mucilages causing different types of damage to the different gorgonian species investigated was recorded during the second (2000) and third year (2001). The type and the extent of the impact of mucilages also depend on the season. Three species of algae (Nematochrysopsis marina, Chrysonephos lewisii and Acinetospora crinita) constitute the principal components of the mucilaginous aggregates. In general, the first two species occur during the spring season, down to 20 m, while A. crinita occurs at greater depths. In July, when the mucilages reach their maximum development, C. lewisii is the predominant species. This species mainly affects E. cavolinii and E. singularis while A. crinita mainly affects P. clavata, which colonizes greater depths.

Coupled modeling of cement/claystone interactions and radionuclide migration

The interactions between cement and a clayey host-rock of an underground repository for intermediate-level radioactive waste are studied with the reactive transport code HYTEC for supporting performance assessment. Care is taken in using relevant time scales (100,000 years) and dimensions. Based on a literature review, three hypotheses are considered with respect to the mineralogical composition of the claystone and the neo-formed phases. In the long term, the pH is buffered for all hypotheses and important mineral transformations occur both in cement and the host-rock. The destruction of the primary minerals is localized close to the cement/claystone interface and is characterized by the precipitation of secondary phases with retention properties (illite, zeolite). However, beyond the zone of intense mineral transformations, the pore water chemistry is also disturbed over a dozen meters due to an attenuated but continuous flux of hydroxyl, potassium and calcium ions. Four interdependent mechanisms control the profile in the whole system: diffusion of the alkaline plume, mineralogical buffering, ion exchange and clogging of the pore space at the cement/claystone interface. The migration of a selected group of radionuclides (Cs, Ra, Tc and U) is explicitly integrated in the simulations of the strongly coupled system. Theoretical profiles of distribution coefficient (Kd) and solubility limit values are derived from the simulations, and their sensitivity with respect to the system evolution is estimated.

[Carbon dioxide embolization: is it a complication of laparoscopic cholecystectomy? ]

The occurrence of pulmonary gas embolism in patients undergoing laparoscopic cholecystectomy is reported in the medical literature. Severe intraoperative complications or the patient's death were correlated to gas embolism during laparoscopic procedures. However, the careful retrospective study or the autoptic exam of such casualties have always showed an erroneus direct puncture of vessels or the straight insertion of the Veress needle into a parenchymal organ. It is obvious that the direct gas injection into a vein or into parenchymal organs is a primary cause of gas embolism, as well as the high flow insufflation of gas into the peritoneal cavity in concomitance with the lesion of major abdominal vessel's wall. Gas embolism may occur each time the vein internal pressure is lower than the external pressure and not only during a laparoscopic procedure when carbon dioxyde is inflated into the peritoneal cavity, but also during open surgery such as major liver resections, neurosurgery, vascular or cardiac surgery. The review of large series of laparoscopic cholecystectomies reported in the international literature, as well as our own clinical experience in this field, together with the results of laboratory animal studies based on the experimental insufflation or injection of carbon dioxyde, show that gas embolism must not be considered as a complication of laparoscopic surgery. Due to the above mentioned risks with the use of the Veress needle, the surgeon should revalue alternative means in creating the pneumoperitoneum.

Distribution of chlorinated organic pollutants in harbor sediments of Livorno (Italy): a multivariate approach to evaluate dredging sediments

Dredging is a very important procedure for harbor management. In Italy the guidelines for the offshore dumping of dredged materials are issued by the Ministry of Environment. They described a few steps of dredging activities, such as the sampling strategy, but do not deal with limits or guide-values for the chemical, physical and biological composition of the resulting sediments. The quality of dredged materials is mainly dependent on the presence of inorganic and organic pollutants. In particular, polychlorinated biphenyls (PCBs) and organo-chlorinated pesticides are seen as a high priority in marine environment by international organizations because of their persistence, toxicity and bioaccumulation capacity. In this article the presence of some PCBs and organo-chlorinated pesticides in sediment samples collected from the harbor of Livorno (Northern Tyrrhenian Sea) was investigated. The concentration of HCHs, Aldrin, Chlordanes, DDEs, DDTs, and PCBs in 12 representative sites ranged between <1 microg kg(-1) and 95, 19, 32, 35, 107, and 111 microg kg(-1), respectively. The application of univariate and multivariate statistical techniques, such as linear regression analysis and principal component analysis, to the experimental data showed a different distribution of PCBs in the two sediment layers. On the contrary, the vertical distribution of the other investigated pollutants was more homogeneous and affected by random variability. The multivariate approach was an important tool to establish more rational criteria for the management of dredged materials.

[Current developments in the treatment of acute generalised peritonitis]

Generalised acute peritonitis is a relatively frequently pathology which has always been extremely difficult to treat owing to the large number of complications. Considerable progress has been made over the past few years in the surgical treatment of these pathologies following the introduction of new materials accompanied by new techniques: continuous peritoneal lavage (CPL) and laparostomy are the best known. These techniques must be used in carefully selected patients. They allow a marked improvement in results: fewer cases of redo surgery; fewer local and general complications; shorter hospitalisation stay; fewer deaths. These results are possible because these techniques ensure a better cleansing of the peritoneal cavity, with easier removal of necrotic and purulent materials, the main cause of local and general complications.

Gastro-intestinal stromal tumor (GIST): case report

Gastro-intestinal stromal tumors (GISTs), as currently defined, represent the largest category of primary non epithelial neoplasms of the gastrointestinal tract. They arise from mesenchymal cells located in the wall of the organ and show a remarkable variability in their differentiation pathways. For this reason there is relevant degree of confusion in their interpretation. On the basis of immunohistochemical and ultrastructural studies these neoplasms are divided into several categories: leiomyomas, schwannomas and less differentiated tumors referred as GIST. In the small bowel GIST are uncommon. Usually asymptomatic, they could be the cause of surgical emergencies like massive bleeding, obstruction, intussusception or perforation. Generally benign, an higher percentage of malignant cases are described in the small bowel. The Authors report a case of malignant GIST of the small intestine presented with bowel obstruction by ileal invagination. In this case, as usually it happens in malignant GIST, the final diagnosis was obtained by an abdominal surgical exploration.

[Ambulatory surgery: preoperative assessment]

Over the past 20 years public health expenditure has progressively increased for various reasons. With the aim of reducing public health expenditure and hospital stays, alternative models of public health care have been more widely adopted over the past two decades: Day Hospital, day surgery and ambulatory surgery. What is meant by ambulatory surgery is the clinical, organisational and administrative possibility of performing surgical operations and/or invasive and semi-invasive diagnostic procedures without hospitalisation of patients, in doctors' surgeries, outpatient departments or protected outpatient facilities. For both the patients and the centres providing the service to be able to exploit all the advantages stemming from this kind of health care provision, careful patient selection is mandatory, including assessment of the impact of any potential concomitant pathologies. Starting from their own personal experience and existing reports in the international literature, the authors analyse the impact that concomitant pathologies may have on patient selection for ambulatory surgery. The authors conclude that thorough preoperative evaluation of all the possible variables involved is the only way of ensuring the success of ambulatory surgery.

[Mixed carcinoid-adenocarcinoma tumor of the appendix: a case report and diagnostic and therapeutic considerations]

The layout of the work has stayed motivated from the recent observation of mixed carcinoid, located to the appendix and wide to the peritoneal cable, joint to our observation in an elderly patient with aspecific demonstration clinical-symptomatologic. The study of the endocrine tumors is in continuous evolution also if, to the actual state, there is a better comprehension of this neoplasm, variegated and complex and, under some appearances, still not known well. Jejunoileal carcinoid tumors differ, under many appearances, from those occurring in other sites of the gut. They have relatively high rate of transmural invasion and aggressive clinical behavior, contrasted by a scarce objectivity; the demonstration of symptoms generally implicates the presence of an illness in advanced stage. Also pharmacological therapy made important progress, with the possibility of administer composed able to interfere with the development and the neoplastic growth.

Depressed mothers' judgments about their children: an examination of the depression-distortion hypothesis

The belief that depressed mothers have distorted perceptions of their children's problems has gained considerable currency in recent years. The empirical basis for this belief at present amounts to little more than reliable demonstrations that depressed mothers tend to report more behavior problems in their children than do nondepressed mothers. An obvious alternative to the distortion interpretation is that depressed mothers are accurate about their children's behavior problems. We examined these competing models by comparing teachers' ratings of children with ratings provided by their mothers, who varied on the dimensions of depressed mood, depressed clinical state, and history of depression. Mothers' and teachers' ratings yielded substantially similar portraits of child behavior problems at the group level, with children of in-remission and in-episode mothers manifesting significantly higher levels of behavior problems than children of control mothers. Moreover, agreement between mothers and teachers was in the moderate range for all index groups and did not differ significantly from the mean level of mother-teacher agreement reported by other investigators based on unselected samples. The limitations of these findings and of earlier reports for assessing a depression----distortion influence on mothers' ratings of their children are considered.

Age differences in coping: does less mean worse

Previous research suggests that elderly people utilize fewer coping strategies than younger people. Some researchers suggest that these quantitative changes reflect decreases in the use of maladaptive strategies; others contend that they reflect decreases in the use of adaptive strategies by older adults. The present article reports the findings of three studies of coping in older people, two addressing coping with health problems, and the other addressing coping with moving. In all three studies, the number of self-reported coping strategies decreases with age. Results do not support the idea that decreases in the number of strategies imply decrements in the quality of coping, however: in two studies, age was unrelated to the effectiveness of strategies, in the third, effectiveness ratings were higher for older subjects. The need for evaluation of specific outcomes of coping strategies is discussed, along with the need for task-specific measurement of coping. It is proposed that decreases in the number of coping strategies reflect improved coping efficiency, rather than a deterioration of adaptational skills.

Personal and social resources in children of patients with bipolar affective disorder and children of normal control subjects

The authors examined the personal resources (social problem-solving ability, internal locus of control, self-esteem, and self-perceived competence) and social resources (social network structure and support) in 23 children of patients with bipolar affective disorder (probands) and 33 children of normal control parents. Positive resource profiles were related to psychiatric well-being in the offspring. Nondisordered probands, in particular, demonstrated a strikingly positive profile of personal resources as well as a wide range of peer, sibling, and other kin supporters. Disordered probands had a strikingly negative set of personal resources and a relatively greater reliance on nonkin adult supporters. The absence of a supportive best friend was associated with affective disorder across offspring groups.

Content of quinolinic acid and of other tryptophan metabolites increases in brain regions of rats used as experimental models of hepatic encephalopathy

The content of the tryptophan metabolites quinolinic acid (QUIN), 5-hydroxytryptamine (5-HT), and 5-hydroxyindoleacetic acid (5-HIAA) was measured in various brain areas of rats bearing a portocaval anastomosis (PCA) for 4 weeks, using mass fragmentography or HPLC. In these animals, the content of the excitotoxic compound QUIN increased by 75% in the cortex and 125% in the cerebellum. The content of 5-HT increased by 27% in the brainstem. No changes occurred in other brain areas. On the other hand, the content of 5-HIAA increased by 66% in the cortex, 65% in the caudate, 64% in the hippocampus, 120% in the diencephalon, and 185% in the brainstem. Probenecid administration caused a larger increase of 5-HIAA accumulation in various brain areas of PCA-bearing rats than in those of sham-operated controls. The cortical content of QUIN and 5-HIAA increased after administration of ammonium acetate (7 mmol/kg), whereas an equimolar amount of sodium acetate was inactive. These results confirm that profound changes in the disposition of tryptophan occur in the brains of experimental animals used as models of hepatic encephalopathy. Furthermore, this study adds the excitotoxic compound QUIN to the list of molecules possibly involved in the pathogenesis of this brain disorder.

Diagnoses in school-age children of bipolar affective disorder patients and normal controls

A family study of psychiatric diagnoses was performed in 29 children of bipolar patients and 37 children of normal controls, ages 6-17. There were no differences in major or minor affective diagnoses between the patient and control groups, but there was an increase of non-specific diagnoses in the patient group. Using DSM-III criteria, 10% of patients' children and 14% of controls' children had had at least one episode of major depression. This suggests that major depression in children is not familially related to adult bipolar major affective disorder. The observed prevalence of depression in childhood is increased when both direct interview of children and interview of parents are performed.