Five waves of COVID-19 pandemic in Italy: results of a national survey evaluating the impact on activities related to arrhythmias, pacing, and electrophysiology promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

BACKGROUND

The subsequent waves of the COVID-19 pandemic in Italy had a major impact on cardiac care.

METHODS

A survey to evaluate the dynamic changes in arrhythmia care during the first five waves of COVID-19 in Italy (first: March-May 2020; second: October 2020-January 2021; third: February-May 2021; fourth: June-October 2021; fifth: November 2021-February 2022) was launched.

RESULTS

A total of 127 physicians from arrhythmia centers (34% of Italian centers) took part in the survey. As compared to 2019, a reduction in 40% of elective pacemaker (PM), defibrillators (ICD), and cardiac resynchronization devices (CRT) implantations, with a 70% reduction for ablations, was reported during the first wave, with a progressive and gradual return to pre-pandemic volumes, generally during the third-fourth waves, slower for ablations. For emergency procedures (PM, ICD, CRT, and ablations), recovery from the initial 10% decline occurred in most cases during the second wave, with some variability. However, acute care for atrial fibrillation, electrical cardioversions, and evaluations for syncope showed a prolonged reduction of activity. The number of patients with devices which started remote monitoring increased by 40% during the first wave, but then the adoption of remote monitoring declined.

CONCLUSIONS

The dramatic and profound derangement in arrhythmia management that characterized the first wave of the COVID-19 pandemic was followed by a progressive return to the volume of activities of the pre-pandemic periods, even if with different temporal dynamics and some heterogeneity. Remote monitoring was largely implemented during the first wave, but full implementation is needed.

A multicentric observational study of patients affected by advanced heart failure with implantable cardioverter defibrillator and left ventricular assist devices

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular assist device (LVAD) implantation is increasingly used in patients with end-stage heart failure. Most patients already have an implantable defibrillator (ICD) at the time of L-VAD implantation. Studies on this patient population are limited by the small sample size and the short duration of follow-up.

Purpose

The aim of this study was to retrospectively describe the real-world management of patients implanted with both ICD and LVAD. The main objective was to evaluate the incidence and predictors of appropriate and inappropriate therapies of the ICD and the incidence and predictors of ICD related complications.

Methods

212 patients were enrolled in four Centers in the period between July 2006 and November 2020. The inclusion criteria were age> 18 years, advanced heart failure, patients with ICD and concomitant or subsequent continuous flow LVAD implantation. ICD therapy was defined as antitachycardia pacing therapy or shock.

The data available at the last visit with a median follow up of 21 months were analyzed.

Outcome predictors were assessed by univariate logistic regression and the variables of interest included in a multivariate model.

Results

The rate of appropriate ICD therapies was 29.7%, while the incidence of inappropriate therapies was 10.4%; in the multivariate analysis the presence of a zone therapy with low detection rate (VT zone with median detection rate of 164.5 bpm) was found to be an independent predictor of the composite of appropriate and inappropriate therapies (OR = 19.05; CI = 2.19-165.21; p = 0.007). Interference between ICD and LVAD occurred in 7.5% of cases; the incidence of infectious complications related to the ICD was 7.1% and bleeding complications of 5.2%; in the multivariate analysis, ICD generator replacement was an independent predictor of total complications related to the ICD (interference, infectious and bleeding; OR = 4.45; IC = 1.60-12.36; p = 0.004). 103 patients had CRT defibrillator (48,6%). At follow up there was no statistically significant difference in the incidence of appropriate therapies between those who had CRT-on (n=74) and those who had CRT-off (n=29; p = 0.61).

Conclusions

Patients with LVAD implanted with an ICD experience a high rate of appropriate and inappropriate ICD therapies. An active VT zone at low heart rate was found to be an independent predictor of ICD therapies. Of more, ICD generator replacement was found to be an independent predictor of total complications related to the ICD. Our findings suggest the importance of tailoring device programming in order to minimize the incidence of ICD therapies, thus sparing the need for generator replacement in this population.

P217 SACUBITRIL/VALSARTAN IN ADVANCED HEART FAILURE: SAFETY AND EFFECTS ON HAEMODYNAMIC PARAMETERS

Aims

The angiotensin–II receptor neprilysin inhibitor (ARNI), sacubitril/valsartan has been shown to be effective in treatment of patients with heart failure (HF), but limited data is available in patients with advanced disease. This retrospective observational study assessed the effects of ARNI treatment in patients with advanced HF.

Methods

We reviewed medical records of all advanced HF patients evaluated at our center for unconventional therapies from September 2016 to January 2019. We studied 44 patients who started ARNI therapy and who had a hemodynamic assessment before beginning ARNI and after 6 ± 2 months. The primary endpoint was variation in pulmonary pressures and filling pressures at 6 months after starting ARNI therapy.

Results

Mean patient age was 51.6±7.4 years; 84% were male. At 6±2 months after starting ARNI, there was significant reduction of systolic pulmonary artery pressure (PAP) (32 mmHg, IQR 27–45 vs 25 mmHg, IQR 22.3–36.5; p < 0.0001) and median PAP (20 mmHg, IQR 15.3–29.8 vs 17 mmHg, IQR 13–24.8; p = 0.046). Five of 22 patients (23%) were deferred from the heart transplant (HTx) list because of improvement, while four were listed de novo. After 23 ± 9 months, 3 patients were treated with a left ventricular assist device (LVAD) implantation, while 6 patients underwent Heart transplantation (one in emergency conditions for refractory ventricular tachycardia).

Conclusions

Sacubitril/valsartan is effective in reducing filling pressures and pulmonary pressures in patients with advanced HF. The absence of adverse events during follow–up suggests that sacubitril/valsartan is safe and well–tolerated in this cohort of patients.

Estimation of the right atrial pressure by ultrasound-assessed internal jugular vein in patients with advanced chronic heart failure

Background

In patients with systolic chronic heart failure (CHF) clinical signs of congestion cannot always be evident at clinical examination. Right atrial pressure (RAP) measured by right heart catheterization (RHC) is an accurate and reproducible marker of blood volume. A non-invasive accurate tool to identify CHF patients with normal RAP would be desirable to tailor therapy.

Purpose

To validate an ultrasound (US)-assessed internal jugular vein distensibility (JVD) ratio to identify patients with normal mean RAP (defined as 7 mmHg or less) measured by RHC.

Methods

We first identify the JVD ratio that allows the most accurate identification of patients with normal RAP in a prospective calibration cohort of 100 patients with systolic CHF. Then, we tested the JVD ratio threshold to identify patients with normal RAP in a validation cohort of 101 consecutive patients with systolic CHF. All patients had a left ventricular ejection fraction (LVEF)<50% and underwent RHC in the setting of heart transplant work-up. At the time of jugular vein puncture, we recorded the internal jugular vein diameter by conventional linear probes. JVD ratio was calculated as the ratio between maximum diameter (during Valsalva maneuver) and rest diameter of the vein (FIGURE). Finally, we assessed the prognostic value of the JVD ratio in the follow up of the first 100 patients.

Results

In the calibration cohort (mean age 53 years, 13% female; median LVEF 25%, 81% in NYHA class III/IV) we define the best threshold of the JVD ratio to identify patients with normal RAP that has 1.6 with an area under the curve (AUC of 0.74; p<0.0001). Based on this JVD ratio threshold we defined patients with low JVD ratio (≤1.6; n=58; median RAP 8 mmHg) and patients with high JVD ratio (>1.6, n=42; median RAP 4 mmHg). High JVD ratio and low JVD ratio groups had similar clinical and laboratory characteristics. In the validation cohort (mean age 55 years, 13% female; median LVEF 25%; 56% in NYHA class III/IV) using the previously defined 1.6 JVD ratio threshold, we identified 51 patients with low JVD ratio (median RAP 8 mmHg) and 50 patients with high JVD ratio (median RAP 3 mmHg; p<0.0001) The JVD ratio threshold has an accuracy to identify patients with a normal RAP with an AUC of 0.82 (p<0.0001); a predictive positive value of 0.94, negative predictive value of 0.51, specificity of 0.90, and sensitivity of 0.65. Finally, in the calibration cohort, the CHF patients with low JVD ratio (≤1.6) had a higher cumulative incidence of overall death, heart transplant, or left ventricular assist device (42.7% vs. 16.1% in the high JVD ratio group, p log-rank 0.006) at a median of 13-month follow-up.

Conclusions

We found that US-assessed JVD ratio is a convenient and accurate diagnostic tool to identify patients with advanced systolic CHF with normal vs. increased RAP. This tool could be tested in the ambulatory setting to modulate therapies, particularly diuretics and vasodilators.

Figure 1

Funding Acknowledgement

Type of funding source: None

P6315Effects of chronic heart failure unconventional therapies on endothelial function

Introduction

Endothelial Dysfunction (ED) of peripheral arteries in Chronic Heart Failure (CHF) subjects has been demonstrated.

Purpose

We assessed endothelial function in subjects undergoing unconventional treatments for CHF, namely Heart Transplantation (HTX), continuous-flow Left Ventricular Assist Device implantation (LVAD), and repeated levosimendan infusions (r-LEVO).

Methods

Twenty HTX recipients (median time from HTX 21 months), 20 patients supported with LVAD (median time from implant 39 months), and 20 patients receiving monthly Levosimendan infusions (median time on treatment 28 months) were enrolled and compared to a group of 20 healthy subjects. ED was evaluated with ultrasound assessment of the diameter before and after ischemic stress at the brachial artery level. The difference between the two diameters normalized for the baseline value (Flow Mediated Dilation – FMD) has been used for the analysis. All the patients were stable at the time of FMD assessment, with those on r-LEVO being evaluated prior to infusion.

Results

FMD was significantly lower in HTX and LVAD groups with respect to controls (9.8±7.4, 9.3±5.7, and 15.6±6.4% respectively, p=0.01), but not in r-LEVO group (12.5±6.9%).

When patients were analyzed according to time from the operation or on treatment, (< versus > of the median value), no differences were seen in HTX and r-LEVO group, while in LVAD group FMD was borderline significantly higher in patients with longer follow-up (8.4±6.4% versus 10.2±5.2%, p=0.05).

Conclusions

Based on this preliminary data we can inference the following: 1- FMD is abnormal in HTX recipients, despite their good functional status, probably due to factors unrelated to CHF (e.g. hypertension, renal insufficiency, denervation, and drug effects); 2- LVAD patients also show ED, with possible better adaptation in very long-term survivors; 3- Near-normal FMD values in CHF patients who remain stable with r-LEVO suggest that pulsed treatment may obtain favorable effects at peripheral level, persisting after clearance of the drug and its metabolites.

Acknowledgement/Funding

None

Results. of a Mammographic and Clinical Screening in a Health District (USSL) of Brescia, Italy

Aims and Background

Screening by mammography has been shown to be effective in reducing breast cancer mortality. We present the results of a mammographic and clinical screening program carried out in an Italian health district.

Methods

The first screening round started in June 1987 and ended in July 1990, and 25,100 women between the age of 50 and 60 years were invited. The second screening round invited 34,332 women between the age of 50 and 64 years and was carried out from September 1990 to September 1993. Women with positive or equivocal results at palpation or mammography were referred for immediate diagnostic assessment followed by surgery, when required.

Results

The attendance rate was 67.3% at the first and 62.1% at the repeat screening. At the first screening, 206 biopsies were advised and 197 were performed; 129 of the 197 were found to be malignant. At repeat screening, 248 biopsies were recommended, 208 were performed, and 125 were found to be malignant. The cancer detection rate was 7.7 per thousand at the first and 5.9 per thousand at repeat screening. Of 129 cancers, 107 (83.0%) were T1 at first screening; 6.2% were in situ carcinomas. Axillary lymph nodes were histologically positive in 24% of cases. At repeat screening, 77.6% (97/125) of cancers were T1; 11.2% were in situ carcinomas. Positive axillary lymph nodes were found in 16.8% of cases.

Conclusions

The attendance to screening was satisfactory. A higher frequency of small tumors (83.0%) was found at first screening than before the introduction of screening (56.6%). A marked difference in lymph node positivity (24.0% vs 40.6% in the pre-screening era) was also observed. Such a difference was even more evident at repeat screening. Quality standards of the screening in our study proved to be higher than those currently recommended. The reported results are encouraging, also considering the greater chance for conservative treatment.

A fresh look at IBS-opportunities for systems medicine approaches

NeuroGUT is a EU-funded initial training network (ITN) of 14 research projects in neurogastroenterology that have employed an equal number of early-stage researchers. Neurogut trainees have-among other activities-attended an international conference on irritable bowel syndrome (IBS) in Bologna in 2016 and were asked to critically review and evaluate the current knowledge on IBS for their respective research activities, and to state what they were missing. Most appreciated were the topics brain imaging of gut activity, the role of the gut microbiota, the pharmacology of gut functions, the IBS-IBD interrelation, the new Rome IV criteria, the role of gas, and the placebo response in functional disorders. Missed were more detailed coverage of high-resolution manometry, functional brain imaging, advanced "systems medicine" approaches and bioinformatics technology, better sub-classification of IBS patients, and the development of disease biomarkers, extended at the molecular (genetic/epigenetic, proteonomic) level. They summarize that despite excellent specialized research, there is a gap open that should be filled with systems medicine. For this, it would be necessary that medical research learns even more from the data sciences and other basic disciplines, for example, information technology and system biology, and also welcomes a change in paradigm that enhances open sharing of data, information, and resources.

Effect of genetic background and postinfectious stress on visceral sensitivity in Citrobacter rodentium-infected mice

BACKGROUND

Infectious gastroenteritis is a major risk factor to develop postinfectious irritable bowel syndrome (PI-IBS). It remains unknown why only a subgroup of infected individuals develops PI-IBS. We hypothesize that immunogenetic predisposition is an important risk factor. Hence, we studied the effect of Citrobacter rodentium infection on visceral sensitivity in Th1-predominant C57BL/6 and Th2-predominant Balb/c mice.

METHODS

Eight-week-old mice were gavaged with C. rodentium, followed by 1 h of water avoidance stress (WAS) at 5 weeks PI. At 10, 14 days, and 5 weeks PI, samples were assessed for histology and inflammatory gene expression by RT-qPCR. Visceral sensitivity was evaluated by visceromotor response recordings (VMR) to colorectal distension.

KEY RESULTS

Citrobacter rodentium evoked a comparable colonic inflammatory response at 14 days PI characterized by increased crypt length and upregulation of Th1/Th17 cytokine mRNA levels (puncorrected  < 0.05) in both C57BL/6 and Balb/c mice. At 5 weeks PI, inflammatory gene mRNA levels returned to baseline in both strains. The VMR was maximal at 14 days PI in C57BL/6 (150 ± 47%; p = 0.02) and Balb/c mice (243 ± 52%; p = 0.03). At 3 weeks PI, the VMR remained increased in Balb/c (176 ± 23%; p = 0.02), but returned to baseline in C57BL/6 mice. At 5 weeks PI, WAS could not re-introduce visceral hypersensitivity (VHS).

CONCLUSIONS & INFERENCES

Citrobacter rodentium infection induces transient VHS in C57BL/6 and Balb/c mice, which persisted 1 week longer in Balb/c mice. Although other strain-related differences may contribute, a Th2 background may represent a risk factor for prolonged PI-VHS. As PI-VHS is transient, other factors are crucial for persistent VHS development as observed in PI-IBS.

Near final height after GnRH agonist treatment in central precocious puberty

The impact of treatment of central precocious puberty (CPP) with gonadotropin-releasing hormone agonists (GnRHa) on final height remains controversial. We analyzed the long term results of 23 girls with CPP treated with triptorelin or leuprolide. Their "near final height" (NFH) assessed at a bone age of at least 14 years and expressed as SDS, was compared either with predicted height before treatment (PAH) or with parental height (TH). We also compared NFH of 12 girls treated before 8 years of age (7.0 +/- 0.5 yr) with NFH of 11 girls treated after 8 years old (8.5 +/- 0.3 yr). The NFH of the 23 girls (-0.9 +/- 1.0 SDS) was not different either from PAH (-0.85 +/- 1.5 SDS) or from TH (-0.5 +/0.6 SDS). Earlier treated girls reached a NFH (-0.97 +/- 1.0 SDS) not different from later treated girls (-0.91 +/- 1.0 SDS; p = ns) and both groups reached parental height (NFH - TH = -0.44 +/- 1 and -0.09 +/- 0.83 SDS, respectively). In conclusion, our patients, treated either earlier or later, reached a near final height comparable to predicted height and familial target; however, these results might still improve further because the girls have not yet reached their final adult height.

[Impact of a screening program on the surgical treatment of breast carcinoma]

Results are presented concerning the first two cycles of a breast cancer screening program carried out by USSL 41 (the local social health center). 38,000 women were examined in a period ranging from 1987 to 1993 and more than 250 early stage tumors were diagnosed. Early detection by screening is confirmed by tumor size and nodal involvement. Overall, this program carried out in Brescia met requirements set by international and national scientific committees. Good results were obtained as far as quality standards are concerned. The importance of screening is evaluated concerning surgical treatment undergone by the patients. The study of surgical treatment clearly shows the gradual progression of conservative surgery deviating from more destructive operations.

[Conservative surgery in the environment of a screening program for breast carcinoma: evaluation of the results in terms of local recurrence]

This report evaluates the results of conservative surgery plus radiotherapy (QUART) in a group of 123 patients from the screening programme of the District Health Board USSL 41 in Brescia, Italy (over 250 tumours diagnosed in two screening rounds, between 1987 and 1993). To date no recurrence of neoplasms in the operated breast have been diagnosed in either of the two QUART groups (64 patients from the first round, average follow-up 28 months, median 66 months; 59 patients from the second round, average follow-up 28 months, median 30 months). A new carcinoma in the contralateral breast occurred in 3 patients (2 from the first and 1 from the second round), while in 3 cases there was a recurrence in another site (2 from the first and 1 from the second round). These results confirm both the proven effectiveness of conservative treatment in the local control of breast tumours, and the importance of the correct choice of conservative treatment in optimising aesthetic and therapeutic results.

Age- and trauma-dependent modifications of neuromuscular junction and skeletal muscle structure in the rat. Effects of long-term treatment with Acetyl-L-Carnitine

The influence of ageing and crushing of the sciatic nerve on the morphology of the neuromuscular junction (NMJ) and on the muscle fiber composition were studied in the rat soleus muscle using histochemical techniques associated with image analysis. The influence of a 6-month treatment with Acetyl-L-Carnitine (ALCAR, 150 mg/kg/day) on the age- and crushing-dependent changes of the NMJ and on age-related modifications of the muscle fiber composition was assessed as well. In control old and injured young rats a loss of complexity of the NMJ was observed. Treatment with ALCAR resulted in an increased endplate complexity both in old rats and in young rats injured by crushing, in comparison with respective controls. The structure of the rat soleus muscle changes with increasing age. Modification mainly consists in a type II fiber atrophy, and in the alteration of the peculiar mosaic organization of the soleus muscle fibers. In ALCAR-treated old rats, the morphology of the soleus muscle fibers was similar to that observed in adult animals. These findings suggest that treatment with ALCAR has a beneficial effect on NMJ and on muscle fiber structure in ageing or after nerve crushing. The possible mechanism of action of this 'trophic' effect of ALCAR-treatment is discussed.

Acetyl-L-carnitine prevents age-dependent structural alterations in rat peripheral nerves and promotes regeneration following sciatic nerve injury in young and senescent rats

Morphologic and morphometric alterations of the sciatic nerve from old Sprague-Dawley rats and of lesioned tibial nerve from young and senescent Sprague-Dawley rats were studied. The possible therapeutical effects of treatment with acetyl-L-carnitine (ALCAR) were also investigated, ALCAR being a compound shown to exert a beneficial pharmacological action on diabetic neuropathies. Nerve sections from animals sacrificed under anesthesia were stained with toluidine blue. In old rats, a 6-month treatment with ALCAR markedly reduced the percentage of myelinated fibers (MF) characterized by age-dependent morphologic alterations (4% in treated rats versus 11% in untreated ones), such as myelin balloons, infolded loops of myelin, myelin reduplication, and ovoids. In the lesioned animals, ALCAR-treatment (15-60 days for young rats and 6-9 months for senescent rats) produced a significant increase versus controls in the density of regenerating myelinated fibers (RMF) at 15 days (young rats) and at 30 days (senescent rats) after crush, as well as an increase in the axon diameter in both young and senescent rats at 60 days after nerve crush. The MF diameter (sheath + axons) was significantly larger in treated senescent rats than in controls at 100 days after nerve crush. In ALCAR-treated rats, both young and senescent, the density of degenerative elements was lower and the RMF ratio (RMF density/RMF density + density of degenerative elements) was higher than that in controls at all detection times.

Treatment of chronic hepatitis C with recombinant interferon alfa

We studied the clinical course and the effect of alfa interferon treatment in sixty-six patients of Southern Italy suffering from chronic hepatitis C virus. The patients were randomly assigned to the control group (33 patients without treatment) or to the group treated with 3MU of interferon three times a week for six months. Alanine transaminase (ALT) levels normalized in 17 of the 33 treated subjects (52%) within two months of treatment. Seven of these "responders" relapsed at the end of the six-month treatment period, but ALT normalized in these patients after resumption of interferon at the same dosage. None of the non responders on 3MU for four months showed improvement even when the dose was increased to 6MU. Our results coincide with other reports on interferon treatment in hepatitis C virus. Further studies are required to clarify whether or not higher doses at the onset of treatment increase the number of responders and decrease the frequency of relapses.

Serum B2-microglobulin and human immunodeficiency virus infection in intravenous drug users: a cross-sectional study

Beta 2-microglobulin level has been evaluated in 183 male intravenous drug users and 50 apparently healthy blood donors. The aim of the study was to assess the possible association between high values of the peptide and both HIV infection and disease progression in intravenous drug users. Beta 2-microglobulin values were found significantly higher in AIDS patients and other symptomatic subjects than in asymptomatic, both seropositive and seronegative, intravenous drug users. Among asymptomatic drug users, no significant difference in the values was found.

[The serum beta-2-microglobulin values in drug addicts with persistent generalized lymphadenopathy]

Serum beta 2-microglobulin levels (beta-2-M) were studied in 150 drug addicts, 50 of them asymptomatic carriers of anti HIV-1 antibodies, 50 symptomatic carriers with persistent generalized lymphadenopathy (P.G.L.) and 50 serum negative patients who had been living in a closed community for at least 2 years. The results showed increased beta-2-M in 24 P.G.L. patients (48%), in 6 of the asymptomatic serum positive cases (12%) and in 3 of the serum negative subjects (6%). No such increase was found in the selected control group. Statistical analysis using the chi-square test and one-way variance analysis gave a significant result. The data suggest that increased serum beta-2-M is essentially linked to the presence of P.G.L.

[Stomatologic pathology in HIV infection. Preliminary data]

In order to investigate the clinical oral manifestations associated with Acquired Immunodeficiency Syndrome (AIDS) and AIDS-related conditions, 922 male subjects were studied in a closed community (inmates). 669 were drug-abusers, 24 homosexual or bisexual men, 86 drug-abusers and homosexual or bisexual men, 143 without risk behaviour. Only 120 patients had antibodies to human immunodeficiency virus type I. All were throughly examined for evidence of oral disorders. The major finding was that almost all with AIDS and AIDS-related complex had oral manifestations one AIDS-patient was affected with hairy leukoplakia.

A randomized comparison of metoclopramide and domperidone on plasma aldosterone concentration and on spironolactone-induced diuresis in ascitic cirrhotic patients

The effect of metoclopramide and domperidone, two dopamine antagonists, administered to cirrhotic patients with ascites and secondary hyperaldosteronism, was examined to evaluate the changes in plasma aldosterone levels and in spironolactone-induced diuresis. In 15 patients with ascites and secondary hyperaldosteronism, the intravenous administration of 10 mg metoclopramide significantly increased plasma aldosterone levels (23%, p less than 0.01). This effect was observed when an equivalent dose of domperidone was administered. In 20 ascitic patients treated with spironolactone (300 mg per day), the administration of metoclopramide (20 mg) significantly reduced urinary output (24%, p less than 0.001) and urinary sodium (35%, p less than 0.001) while simultaneously increasing urinary potassium (24%, p less than 0.001) and plasma aldosterone (40%, p less than 0.001). This effect was not observed with domperidone in an equivalent dose. Therefore, it is recommended that metoclopramide should be avoided during diuretic therapy in cirrhotic patients with ascites. In these circumstances, domperidone is preferred.

Actinomycotic granuloma of the Gasserian ganglion with primary site in a dental root. Case report

An unusual case of cerebral actinomycosis of the Gasserian ganglion is reported. The location and the pathological diagnosis of granuloma are both extremely rare. The literature is briefly reviewed with special reference to similar reports. The manner of spread and the course of the disease are described. The present case tends to confirm the opinion that primary cerebral actinomycosis is extremely rare and probably does not exist. The case also definitely indicates that the organism reaches the central nervous system by way of nerve or perineural pathways.

Tetraplegia from trauma of the cervical spine in the absence of fractures and luxations

Spinal cord lesions are not infrequent in cervical traumas in absence of fractures and/or luxations. In hyperextension traumas conservative treatment is normally sufficient. In hyperflexion and unknowm mechanism traumas neurosurgical treatment is often necessary due to the frequency of a discal herniation. Myelography is indispensable for correct and complete diagnosis and for this reason its use is strongly recommended.