Severe acute kidney injury related to haemolysis after pulsed field ablation for atrial fibrillation

AIMS

Pulsed field ablation (PFA) has been proposed as a novel alternative to radiofrequency (RF) and cryoablation in the treatment of atrial fibrillation (AF). Following the occurrence of two cases of acute kidney injury (AKI) secondary to haemolysis after a PFA procedure, we evaluated haemolysis in a cohort of consecutive patients.

METHODS AND RESULTS

Two cases of AKI occurred in last May and June 2023. AKI was secondary to acute and severe haemolysis after a PFA procedure. From June 2023, a total of 68 consecutive patients (64.3 ± 10.5 years) undergoing AF ablation with PFA were enrolled in the study. All patients had a blood sample the day after the procedure for the assessment of haemolysis indicators. The pentaspline PFA catheter was used with a total number of median applications of 64 (54; 76). Nineteen patients (28%) showed significantly depleted haptoglobin levels (<0.04 g/L). A significant inverse correlation was found between the plasma level of haptoglobin and the total number of applications. Two groups were compared: the haemolysis+ group (haptoglobin < 0.04 g/L) vs. the haemolysis- group. The total number of applications was significantly higher in the haemolysis+ group vs the haemolysis - group respectively 75 (62; 127) vs 62 (54; 71) P = 0.011. More than 70 applications seem to have better sensitivity and specificity to predict haemolysis.

CONCLUSION

Intravascular haemolysis can occur after certain procedures of PFA. Acute kidney injury is a phenomenon that appears to be very rare after a PFA procedure. However, caution must be exercised in the number of applications to avoid severe haemolysis.

Pre-implant predictors of inappropriate shocks with the third-generation subcutaneous implantable cardioverter defibrillator

AIMS

Despite recent improvements, inappropriate shocks emitted by implanted subcutaneous implantable cardioverter defibrillators (S-ICDs) remain a challenge in 'real-life' practice. We aimed to study the pre-implant factors associated with inappropriate shocks for the latest generation of S-ICDs.

METHODS AND RESULTS

Three-hundred patients implanted with the third-generation S-ICD system for primary or secondary prevention between January 2017 and March 2020 were included in this multicentre retrospective observational study. A follow-up of at least 6 months and pre-implant screening procedure data were mandatory for inclusion. During a mean follow-up of 22.8 (±11.4) months, 37 patients (12.3%) received appropriate S-ICD shock therapy, whereas 26 patients (8.7%) experienced inappropriate shocks (incidence 4.9 per 100 patient years). The total number of inappropriate shock episodes was 48, with nine patients experiencing multiple episodes. The causes of inappropriate shocks included supraventricular arrhythmias (34.6%) and cardiac (30.7%) or extra-cardiac noise (38.4%) oversensing. Using multivariate analysis, we explored the independent factors associated with inappropriate shocks. These were the availability of less than three sensing vectors during pre-implant screening [hazard ratio (HR), 0.33; 95% confidence interval (CI), 0.11-0.93; P = 0.035], low QRS/T wave ratio in Lead I (for a threshold <3; HR, 4.79; 95% CI, 2.00-11.49; P < 0.001), history of supraventricular tachycardia (HR, 8.67; 95% CI, 2.80-26.7; P < 0.001), and being overweight (body mass index > 25; HR, 2.66; 95% CI, 1.10-6.45; P = 0.03).

CONCLUSION

Automatic pre-implant screening data are a useful quantitative predictor of inappropriate shocks. Electrocardiogram features should be taken into consideration along with other clinical factors to identify patients at high risk of inappropriate shocks.

How to better identify patients at high risk of inappropriate shocks before S-ICD implantation: Results from a multicenter experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the recent improvements, inappropriate shocks (IAS) in patients implanted with subcutaneous implantable cardioverter-defibrillator (S-ICD) remain a challenge in "real-life" practice. The purpose of this study was to assess the preoperative predictive factors of IAS with the latest generation of S-ICD, with a particular focus on data obtained during the screening procedure.

Methods

Between January 2017 and March 2020, 300 patients implanted with Generation 3 S-ICD system for primary and secondary prevention were included in this multicentric study. Follow-up (FU) of at least 6 months and preoperative screening procedure data were mandatory for all patients.

Results

After a mean follow-up of 22.8 (±11.4) months, appropriate therapies occurred in 12.3% patients; while 26 patients (8.7%) experienced inappropriate therapies (incidence 4.9 per 100 patient-years). The total number of inappropriate shock episodes was 48; 9 patients experienced multiple episodes. Causes of IAS were: supraventricular arrhythmias (34.6%), cardiac (30.7%) and extra-cardiac noise oversensing (38.4%). In univariate analysis, availability of all 3 sensing vectors during preoperative screening significantly reduced inappropriate therapies occurrence (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.12-0.89, P=0.028). Clinical preoperative S-ICD inappropriate shocks predictors were: history of Supraventricular Tachycardia (SVT)(HR, 4.42; 95% CI, 1.45-13.47; P=0.009); overweight (BMI&gt;25: HR, 1.93; 95% CI, 0.83-0.4.48; P=0.13); QRS duration (HR, 1.01; 95% CI, 0.1-1.03; P=0.14) and lower QRS/T wave ratio in lead I (for a threshold &lt; 3: HR, 4.44; 95% CI, 1.88-10.48; P=0.001). By multivariate analysis, independent factors associated with IAS were: the availability of less than 3 sensing vectors during preoperative screening (p&lt;0.05), a low QRS/T wave ratio in lead I (for a threshold &lt;3; p&lt;0.001), history of SVT (p&lt;0.001) and overweight (BMI&gt; 25; p&lt;0.05).

Conclusion

Automatic preoperative screening data is of high interest as a predictor of IAS with a quantitative value. ECG specificities in association with other clinical factors should be taken into consideration to identify patients at high risk for IAS.

Leadless cardiac pacemaker in elderly patients: How old for a new technology?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Leadless transcatheter pacemakers are considered as a safe and effective option for cardiac pacing in patients (pts) at higher risk of complications with conventional transvenous cardiac pacing.

Purpose

Our aim was to assess the clinical "real-life" feasibility and outcomes of leadless pacing in elderly pts in a high-volume center over a mid-term follow-up (FU) period.

Methods

Elderly pts (aged ≥ 75 years) who underwent leadless MICRA® system pacemaker implantation with a FU period above 3 months were included in this retrospective monocentric study.

Results

130 pts were included (84 ± 5.6 years old, male 66.2%). Indications were: Atrioventricular block (permanent 15.4%; transient 27.7%), atrial fibrillation bradycardia 50% and sinus node dysfunction 6.9%. Leadless system pacing was preferred over conventional pacing in pts with: transvenous pacemaker extractions due to infectious 18.5% or vascular 1.5% complications; active systemic infection and urgent need for cardiac stimulation 20%; complex conventional vascular approach 21.6%; severe tricuspid valve disease 1.5%; deterioration of general condition and clinical frailty 22.3%; shortly after transvalvular aortic valve replacement 8.5%. Among the pts, 6.2% had previous leadless Nanostim® device implantation with dysfunction of the system. Pts had either local anesthesia 13.2% or deep sedation 86.8%. The average fluoroscopy time was 4.3±2.9 minutes and number of device deployments before the final position ranged from 1 to 7 with a mean value of 1.5±1 positions. Pacing threshold during implant was 0.5±0.4 V at 0.24ms, only 4 pts (3%) had an implant threshold of &gt;1.0 V at 0.24 ms. Two postoperative deaths were observed: 1 cardiac arrest related to myocardial dysfunction and consequent pulmonary edema in a patient with advanced heart failure, and 1 death secondary to myocardial perforation with need for surgical repair that occurred among the first implantations with an apical device position and a patient with multiple comorbidities. The total rate of major complications was 2.3% with only 1 vascular complication at the femoral puncture site. The median time from the leadless pacemaker implant procedure to discharge was 5±6.5 days (minimum 1 and maximum 40 days): 55.6% pts were able to leave the cardiology department within the first 72 hours. The mean FU period was 17 months ± 15 months with a mortality rate of 12.3% (cardiovascular impairment 5.4%; non cardiovascular-related deaths 6.9%). Increase in pacing thresholds was noted in 4 pts with subsequent stabilization; 92.2% of pts presented with thresholds lower than 1V at 0.24 ms. All pts remained free of infections during FU with no cases of device dislodgement observed.

Conclusion

Elderly pts are at higher risk of complications; our experience confirms their clinical frailty and underlines the favorable safety profile of leadless system pacing with a low rate of complications and stable pacing thresholds.

Catheter Ablation of Atrial Fibrillation in Patients with Previous Lobectomy or Partial Lung Resection: Long-Term Results of an International Multicenter Study

INTRODUCTION

Data regarding the efficacy of catheter ablation in patients with atrial fibrillation (AF) and patients' previous history of pulmonary lobectomy/pneumonectomy are scanty. We sought to evaluate the efficacy and long-term follow-up of catheter ablation in this highly selected group of patients.

MATERIAL AND METHODS

Twenty consecutive patients (8 females, 40%; median age 65.2 years old) with a history of pneumonectomy/lobectomy and paroxysmal or persistent AF, treated by means of pulmonary vein isolation (PVI) at ten participating centers were included. Procedural success, intra-procedural complications, and AF recurrences were considered.

RESULTS

Fifteen patients had a previous lobectomy and five patients had a complete pneumonectomy. A large proportion (65%) of PV stumps were electrically active and represented a source of firing in 20% of cases. PVI was performed by radiofrequency ablation in 13 patients (65%) and by cryoablation in the remaining 7 cases. Over a median follow up of 29.7 months, a total of 7 (33%) AF recurrences were recorded with neither a difference between patients treated with cryoablation or radiofrequency ablation or between the two genders.

CONCLUSIONS

Catheter ablation by radiofrequency ablation or cryoablation in patients with pulmonary stumps is feasible and safe. Long-term outcomes are favorable, and a similar efficacy of catheter ablation has been noticed in both males and females.

Mitral valve perforation after left lateral accessory pathway ablation: a case report

Background

Radiofrequency catheter ablation is considered to be a relatively safe procedure. This is an unusual case report in which severe mitral regurgitation was occurred after left lateral accessory pathway radiofrequency catheter ablation.

Case presentation

A 15-year-old man without structural heart disease was referred for ablation of a left lateral accessory pathway. He was a rugby player who had lived with Wolff–Parkinson–White syndrome since 2017. In 2017, two failed extensive radiofrequency catheter ablations of a left lateral accessory pathway had been performed in another center. In June 2018, he underwent a third radiofrequency catheter ablation of a left lateral accessory pathway using an anterograde transseptal approach with an early recurrence one month later. A successful fourth procedure was performed in August 2018 using a retrograde aortic approach. Three months later, the patient presented to the hospital with atypical chest pain and dyspnea on exertion. Transthoracic echocardiography revealed severe mitral regurgitation caused by a perforation of the posterior leaflet. Given the symptoms and the severity of the mitral valve regurgitation, the decision was taken to proceed with surgical intervention. Posterior mitral leaflet perforation was confirmed intraoperatively. The patient underwent video-assisted mitral valve repair via Minithoracotomy approach.

Conclusion

This case demonstrates a very rare complication of Wolff–Parkinson–White radiofrequency ablation.

Fluid dynamics and cell‐bound Psl polysaccharide allows microplastic capture, aggregation and subsequent sedimentation by Pseudomonas aeruginosa in water

Decades after incorporating plastics into consumer markets, research shows that these polymers have spread worldwide. Fragmentation of large debris leads to smaller particles, collectively called microplastics (MPs), which have become ubiquitous in aquatic environments. A fundamental aspect of understanding the implications of MP contamination on ecosystems is resolving the complex interactions of these artificial substrates with microbial cells. Using polystyrene microparticles as model polymers, we conducted an exploratory study where these interactions are quantitatively analyzed using an in vitro system consisting of single‐bacterial species capturing and aggregating MPs in water. Here we show that the production of Psl exopolysaccharide by Pseudomonas aeruginosa (PA) does not alter MPs colloidal stability but plays a key role in microspheres adhesion to the cell surface. Further aggregation of MPs by PA cells depends on bacterial mobility and the presence of sufficient flow to prevent rapid sedimentation of early MP‐PA assembles. Surprisingly, cells in MP‐PA aggregates are not in a sessile state despite the production of Psl, enhancing the motility of the aggregates by an order of magnitude relative to passive diffusion. The generated data could inform the creation of predictive models that accurately describe the dynamics and influence of bacterial growth on plastics debris.

Noninvasive assessment of coronary microvascular dysfunction using SPECT myocardial perfusion imaging and myocardial perfusion entropy quantification in a rodent model of type 2 diabetes

PURPOSE

Coronary microvascular dysfunction (CMVD) plays a major role in the occurrence of cardiovascular events (CVE). We recently suggested the clinical potential of myocardial perfusion entropy (MPE) quantification from SPECT myocardial perfusion images (MPI) for the prognosis of CVE occurrence. We hypothesized that the quantification of MPE from SPECT MPI would allow the assessment of CMVD-related MPE variations in a preclinical model of type 2 diabetes (T2D) including treatment with the anti-diabetic incretin liraglutide (LIR).

METHODS

Optimal conditions for the preclinical quantification of MPE using ²⁰¹Tl SPECT MPI were determined in rats with a T2D-like condition induced by a high-fat diet and streptozotocin injection (feasibility study, n = 43). Using such conditions, echocardiography and post-mortem LV capillary density evaluation were then used in order to assess the effect of LIR and the ability of MPE to assess CMVD (therapeutic study, n = 39).

RESULTS

The feasibility study identified dobutamine stress and acute NO synthase and cyclooxygenase inhibition as optimal conditions for the quantification of MPE, with significant increases in MPE being observed in T2D animals (P < 0.01 vs controls). In the therapeutic study, T2D rats were hyperglycemic (5.5 ± 0.5 vs 1.1 ± 0.3 g/L for controls, P < 0.001) and had a significantly lower left ventricular ejection fraction (LVEF) (65 ± 4% vs 74 ± 9%, P < 0.01) and LV capillary density (2400 ± 300 vs 2800 ± 600 mm^-3, P < 0.05). LIR partially restored glycemia (3.9 ± 0.6 g/L, P < 0.05 vs controls and T2D), totally prevented LVEF impairment (72 ± 7%, P = NS vs CTL), with no significant effect on capillary density. MPE was significantly increased in T2D rats (7.6 ± 0.5 vs 7.1 ± 0.5, P < 0.05), with no significant improvement in T2D-LIR rats (7.4 ± 0.4, P = NS vs controls and T2D).

CONCLUSION

MPE quantification allowed the preclinical noninvasive assessment of CMVD. Both MPE and capillary density quantification suggested that LIR did not improve T2D-induced CMVD. The relevance of MPE for CMVD assessment warrants further clinical investigation.

European experience with a first totally leadless cardiac resynchronization therapy pacemaker system

Aims

Totally leadless cardiac resynchronization therapy (CRT) can be delivered with a combination of Micra and WiSE-CRT systems. We describe the technical feasibility and first insights into the safety and efficacy of this combination in European experience.

Methods and results

Patients enrolled had indication for both Micra and WiSE-CRT systems because of heart failure related to high burden of pacing by a Micra necessitating system upgrade or inability to implant a conventional CRT system because of infectious or anatomical conditions. The endpoints of the study were technical success of WiSE-CRT implantation with right ventricle-synchonized CRT delivery, acute QRS duration reduction, and freedom from procedure-related major adverse events. All eight WiSE-CRT devices were able to detect the Micra pacing output and to be trained to deliver synchronous LV endocardial pacing. Acute QRS reduction following WiSE-CRT implantation was observed in all eight patients (mean QRS 204.38 ± 30.26 vs. 137.5 ± 24.75 mS, P = 0.012). Seven patients reached 6 months of follow-up. At 6 months after WiSE-CRT implantation, there was a significant increase in LV ejection fraction (28.43 ± 8.01% vs. 39.71 ± 11.89%; P = 0.018) but no evidence of LV reverse remodelling or improvement in New York Heart Association class.

Conclusion

The Micra and the WiSE-CRT systems can successfully operate together to deliver total leadless CRT to a patient. Moreover, the WiSE-CRT system provides the only means to upgrade the large population of Micra patients to CRT capability without replacing the Micra. The range of application of this combination could broaden in the future with the upcoming developments of leadless cardiac pacing.

Long-Term clinical outcomes of subcutaneous implantable defibrillator therapy in patients with heart failure and reduced ejection fraction: a single center experience

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): P. JACON consultant: Boston Scientific France

Introduction

The implantable cardioverter defibrillator (ICD) is the most effective therapy for prevention of sudden cardiac death in high-risk patients with heart failure and reduced ejection fraction (HFrEF). The subcutaneous implantable cardioverter defibrillator (S-ICD) has been considered as a comparable and relatively safer alternative to transvenous ICD in patients (pts) without pacing indication.

Purpose

Our aim was to assess the clinical "real-life" outcomes of S-ICD in patients with HFrEF and primary or secondary prevention, over a long-term follow-up (FU) period after S-ICD implantation.

Methods

All pts with HFrEF (left ventricular ejection fraction ≤35%) implanted with a S-ICD and a FU above 6 months were included in a cross-sectional monocentric study. Pts were followed by remote monitoring.

Results

88 pts were included (52 ± 12.8 years old, male 87.5%). Indications were: primary 92% and secondary 8% prevention  (ischemic cardiopathy 46%; dilated 46%; hypertrophic 5%; congenital 2%; valvular 1%). The mean left ventricular ejection fraction was 27%. 9 pts had a previous transvenous ICD implanted, but required revision because of infection or lead defects. The mean FU period was 33 ± 18 months with a mortality rate of 10% (S-ICD-related death secondary to inappropriate (inap) shocks for one patient). 5 pts underwent S-ICD system extraction after a mean FU period of 30 ± 21 months. Reasons were infectious complication (1 pt), pacing indication (2 pts) and S-ICD lead dysfunction (2 pts). Extraction after heart transplant was performed in 4 pts. During FU, 18 pts (20.5%) experienced at least one therapy: 8 pts (9%) with appropriate (ap) (3.3% per year) and 11 pts (12%) with inap shocks (4.36% per year). A total number of 24 ap shocks have been observed (3 ± 4 ap shocks per patient, several shocks for 3 pts), the first shock occurred after a mean FU period of 24 ± 14 months. 2 pts were referred to VT ablation and no recurrence of events was observed after medical therapy modification for the other pts. For the 11 pts with inap shocks, time to the first event was 19 ± 20 months. Reasons were: supraventricular arrhythmias (18%), T wave (36%) and noise (54%) oversensing. There was 1.8 ± 1.6 shock per patient with several shocks for 4 pts. Among pts with inap shocks, 2 pts required S-ICD system extraction, 1 pt died, while reprogramming and medical therapy options were efficient in other pts.

Conclusion

In pts with HFrEF at high risk of sudden cardiac death, S-ICD has proven to be effective in treating ventricular arrhythmias. However, more investigations must be conducted to explain the real-life high rate of inappropriate therapies. Abstract Figure. Survival-free from therapies curve

Prediction of ventricular arrhythmias in patients with a spontaneous Brugada type 1 pattern: the key is in the electrocardiogram

AIMS

There is currently no reliable tool to quantify the risks of ventricular fibrillation or sudden cardiac arrest (VF/SCA) in patients with spontaneous Brugada type 1 pattern (BrT1). Previous studies showed that electrocardiographic (ECG) markers of depolarization or repolarization disorders might indicate elevated risk. We aimed to design a VF/SCA risk prediction model based on ECG analyses for adult patients with spontaneous BrT1.

METHODS AND RESULTS

This retrospective multicentre international study analysed ECG data from 115 patients (mean age 45.1 ± 12.8 years, 105 males) with spontaneous BrT1. Of these, 45 patients had experienced VF/SCA and 70 patients did not experience VF/SCA. Among 10 ECG markers, a univariate analysis showed significant associations between VF/SCA and maximum corrected Tpeak-Tend intervals ≥100 ms in precordial leads (LMaxTpec) (P < 0.001), BrT1 in a peripheral lead (pT1) (P = 0.004), early repolarization in inferolateral leads (ER) (P < 0.001), and QRS duration ≥120 ms in lead V2 (P = 0.002). The Cox multivariate analysis revealed four predictors of VF/SCA: the LMaxTpec [hazard ratio (HR) 8.3, 95% confidence interval (CI) 2.4-28.5; P < 0.001], LMaxTpec + ER (HR 14.9, 95% CI 4.2-53.1; P < 0.001), LMaxTpec + pT1 (HR 17.2, 95% CI 4.1-72; P < 0.001), and LMaxTpec + pT1 + ER (HR 23.5, 95% CI 6-93; P < 0.001). Our multidimensional penalized spline model predicted the 1-year risk of VF/SCA, based on age and these markers.

CONCLUSION

LMaxTpec and its association with pT1 and/or ER indicated elevated VF/SCA risk in adult patients with spontaneous BrT1. We successfully developed a simple risk prediction model based on age and these ECG markers.

A new gastric impedancemeter for detecting the development of a visceral edema: a proof-of-concept study on an experimental endotoxemic shock

Visceral congestion and edema are important features of advanced heart failure. Monitoring the evolution of fluid content in the gastric wall might provide an index of the development of this phenomenon and therefore constitute an innovative marker to early detect acute decompensated heart failure episodes. The evolution of the fluid content in the gastric wall is measured using a device implanted in the submucosa layer of the fundic region of the stomach. The device composed of two electrodes measures the bioimpedance values that reflects the water content of the tissue.An in-vivo experiment in a pig was carried out to validate the feasibility of detecting the gastric bioimpedance variations during the development of an experimental acute visceral edema caused by an endotoxemic shock. Our preliminary results confirm the possibility to monitor the bioimpedance variations due to moderate changes in tissue water content (10%) with a two-electrode configuration device implanted in the submucosa of the stomach.

SPECT myocardial ischemia in the absence of obstructive CAD: Contribution of the invasive assessment of microvascular dysfunction

Coronary microvascular dysfunction has recently emerged as a major independent prognostic factor and can be invasively assessed by coronary flow reserve (CFR) and the index of microvascular resistance (IMR). The incremental prognostic value of myocardial ischemia from SPECT myocardial perfusion imaging (MPI) over clinical characteristics, cardiac risk factors, and stress test data for the prediction of hard cardiac events (myocardial infarction and cardiac death) has been well demonstrated over the last two decades regardless of the absence or presence of epicardial CAD. Recently developed semi-conductor, cardiac-dedicated cameras allow for decreased acquisition times and systematic procubitus and decubitus acquisitions thereby limiting the occurrence of false positives historically attributable to artefactual motion, attenuation, and digestive artifacts. It is therefore likely that pathophysiological causes rather than acquisition artifacts might underlie SPECT perfusion abnormalities. Here, we report four representative examples of patients presenting with ischemia in the setting of no obstructive CAD and normal fractional flow reserve together with elevated IMR and low CFR. The results indicate that ischemia from SPECT MPI could result from microvascular dysfunction in patients without obstructive CAD and should be considered as a prognostic factor for hard cardiac events.

The importance of nasal resistance in obstructive sleep apnea syndrome: a study with positional rhinomanometry

The importance of nasal obstruction in the pathogenesis of obstructive sleep apnea syndrome (OSAS) has not yet been totally defined. Numerous studies have reported an association between nasal obstruction and OSAS, but the precise nature of this relationship remains to be clarified. This study was undertaken to evaluate the prevalence of nasal obstruction disorders in a group of OSAS patients. For this purpose, we analyzed the nasal resistance of 36 OSAS patients by performing a traditional basal anterior active rhinomanometry test (AAR) and a positional AAR, with the patient in a supine position. Seven patients had a pathologic nasal resistance in the seated position that increased further in the supine position; 9 patients had normal resistance in the seated position but a pathologic resistance in the supine position. In 20 patients, nasal resistance was normal in both positions. No statistically significant differences in the degree of apnea/hypopnea index (AHI) was found between the 20 patients with normal positional AAR and the 16 with pathologic positional AAR (p = 0.13). Moreover, no statistically significant differences in the degree of AHI was found between the 7 patients with pathologic basal and positional AAR and the 9 patients with normal basal AAR and pathologic positional AAR (p = 0.38).

Photopheresis in cutaneous T-cell lymphoma: five-year experience

BACKGROUND

Cutaneous T-cell lymphoma (CTCL) includes several lymphoproliferative disorders involving mature T-lymphocyte proliferation initially confined to the cutis. These affections, after variable periods, may progress to the blood, limph nodes and visceral organs. Mycosis fungoides (MF) is the most frequent form of CTCL and has an indolent clinical course. The therapy of CTCL depends on the stage of the disease and the patient's general conditions. For advanced cases it includes chemotherapy, retinoids, and interferon-alpha. Since 1987 extracorporeal photochemotherapy (ECP), a novel immunomodulatory approach based on apheresis and photoirradiation of leukocytes, has been successfully introduced for the treatment of advanced CTCL. It can prolong survival of patients with erythrodermic CTCL without significant side effects.

OBJECTIVE

To review our five-year experience with ECP in CTCL.

METHODS

Since June 1994, 33 CTCL patients have been recruited for ECP, using two different regimens: two procedures on two consecutive days at four-week intervals for six months, or at two-week intervals for three months with progressive tapering in the second three-month period for the more severe forms. Six patients received ECP with IFN-alpha. ECP was done using the photopheresis UVAR system and UVAR XTS (Therakos, West Chester, Pa) and always with 8-MOP liquid formulation injected directly into the buffy coat bag. Lymphocytes in peripheral blood were immunophenotypically characterized for each patient and every ECP session.

RESULTS

All patients tolerated ECP well, without significant side effects. Thirty patients are clinically evaluable (at least three ECP cycles). A favourable clinical response was obtained in 80.9% (16/21) of MF patients (complete response 33%, partial response 47.6%) and in 66% (6/9) of patients in the Sézary's syndrome phase (complete response 33.3%, partial response 33.3%). Five of the six patients given IFN-alpha as adjunctive therapy had a PR and one a CR. Four patients are in CR without therapy at follow-ups of 46, 20, 10 and 8 months. There have been no changes in the peripheral lymphocyte immunophenotype during the follow-up. In 19/30 patients the CD95 antigen, correlated with cellular apoptosis, was expressed and was frequently associated with a good clinical response.

CONCLUSIONS

In our experience ECP achieved favourable clinical responses in 73% of patients, in monotherapy or in combination with IFN-alpha, without significant side effects.

Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors

BACKGROUND

The reported association of allergy and sinusitis varies greatly between study, and the exact role of allergy in predisposing to sinusitis is not clear. We attempted to determine whether patients with perennial allergic rhinitis are at greater risk of developing sinusitis with respect to a control group, and to determine whether there is a correlation between rhinomanometry, endoscopy, and nasal swab, and computed tomography (CT) findings.

METHODS

Forty adult patients with perennial allergic rhinitis underwent CT scans of the paranasal sinuses, and the results were then compared to CTs of the paranasal sinuses of 30 control subjects. All allergic patients underwent nasal endoscopy, nasal swab, and active anterior rhinomanometry, and the results were studied in relation to the CT findings.

RESULTS

We found sinusitis in 67.5% of the allergic patients and in 33.4% of the controls, with a statistically significant difference between the two groups (P = 0.017). Twenty-three patients had a positive nasal swab; 22 showed increased nasal resistance on rhinomanometry, and 36 had positive endoscopy, but the association of CT findings with endoscopy, rhinomanometry, or nasal swab was not statistically significant (P = 0.583, P = 1.00, P = 0.506, respectively).

CONCLUSIONS

Allergic rhinitis is often associated with sinusitis, but the underlying mechanism has yet to be determined. Evidently, factors other than classical pathogen growth and mechanical factors, such as the association of the various factors and immunologic mechanisms, may contribute to the pathogenesis of chronic sinusitis in allergic patients.

[Effect of thermal mud baths on normal, dry and seborrheic skin]

PURPOSE

To investigate the curative effects of thermal water and thermal muds in various cutaneous pathologies.

PATIENTS AND METHODS

Modifications of phmetry and sebometry using sulphur thermal muds in normal, dry and seborrheic skin have been studied. The three groups of patients have been submitted to a 14 day treatment with thermal muds.

RESULT

The application of thermal mud normalized the value of cutaneous pH and sebometry.

CONCLUSIONS

These beneficial effects are long-lasting in individuals who have a prolonged treatment with thermal muds.

[Allergic fungal sinusitis: is this rare disease an allergy or infection?]

Allergic Fungal Sinusitis (AFS) is a newly recognized form of benign, non invasive sinusitis the histopathologic features of which are similar to those of allergic bronchopulmonary aspergillosis. AFS is a rare condition. However, because treatment and prognosis vary widely, it is important that this disorder be recognized and differentiated from chronic bacterial sinusitis and other forms of fungal sinusitis. AFS does not discriminate by age although it is primarily found in young adults. AFS patients are usually atopic, often having a history of asthma and nasal polyposis. Many have suffered from the symptoms of chronic sinusitis for years while others have had multiple sinus surgery. Radiographs reveal the involvement of multiple sinuses, often with bone destruction. Laboratory findings support an allergic state with a marked increase in eosinophilia and total IgE. At times RAST testing proves positive for fungi and immediate cutaneous reactivity to fungi is also present. Histologic review of the sinus contents reveals characteristic "allergic mucin", with numerous eosinophiles, Charcot-Leyden crystals and fungal hyphae, without any fungi tissue invasion. A wide variety of fungal agents has been implicated, although the majority belong the Dematiacee family. Those patients with allergic mucin but no documented fungi are indicated as having AFS-like syndrome. The pathogenesis of AFS is uncertain. There is controversy in the literature as to what role hypersensitivity (Gell and Coombs type I and type III responses) in infection play. To date current therapeutic recommendations include complete exenteration of all allergic mucin. Adjunctive, short-term systemic steroids often prove useful and nasal steroid spray should be continued for long term. Systemic antifungal agents are not recommended in AFS. Recurrence is common and thus close clinical, endoscopic and radiographic follow-up is important. The clinicopathologic features of one patient with AFS are reported and etiopathogenetic problems are discussed. The presented case showed a positive culture with negative immunological testing (RAST-positive and immediate cutaneous reactivity to fungal antigen), thus confirming the pathogenetic hypothesis of the saprophytic fungal growth in an atopic patient.

Pharmacokinetic studies in healthy volunteers on a new gastroprotective pharmaceutic form of diclofenac

The pharmacokinetic properties of a new gastroprotective pharmaceutical formulation of diclofenac (CAS 15307-79-6) were investigated in twelve healthy volunteers. In this new form the diclofenac is the nucleus of sequential sucralfate-covered tablets. The experimental design was an open, random, two period balanced cross-over study. All the subjects received a single oral dose of 50 mg diclofenac contained in the new formulation or in the reference enteric-coated tablets. Plasma concentrations of diclofenac were determined at 0.5, 1, 2, 4, 6, and 8 h after drug administration using HPLC method. After administration of a diclofenac-sucralfate association diclofenac was quickly absorbed and the peak plasma concentration (0.773 +/- 0.08 microgram/ml) was achieved in about 1 h. AUC(0-infinity) value was about 1.8 micrograms/ml/h and the mean elimination half-life was 1.20 +/- 0.12 h. The pharmacokinetic profile of diclofenac-sucralfate association is similar to the values reported in previous papers for enteric-coated forms; anyway an early occurrence of the peak plasma concentration was observed for the new formulation. The new diclofenac-sucralfate association shows a different rate of absorption (namely an early and greater peak plasma concentration of diclofenac) and a similar extent of absorption (AUC(0-infinity) being not statistically different) as compared to the reference enteric-coated tablets of 50 mg diclofenac. These results could be related to the delaying and protective effect of sucralfate whose action is different from the one carried by the coat of the enteric-coated tablets.

[Multisystemic sarcoidosis. A clinical case report]

Sarcoidosis is a granulomatous disorder of unknown etiology with a multi-disciplinary interest. However, a multiple organ involvement is not always clearly presented. A case of a 62-year-old woman with cutaneous, pulmonary, ocular, cardiac, bone and articular involvement is described.

[Eosinophilic cellulitis (Wells' syndrome)]

The Authors report a case of eosinophilic cellulitis (Wells' syndrome). The patient was a 61 year old woman, diabetic, with a cardio-respiratory insufficiency and a maniaco-depressive psycosis. She presented, on the upper arms and trunk, a cutaneous eruption of erythematous-urticarial plaques, that histopathologically were characterized by a dermic leukocyte population, with a prevalence of eosinophils, distributed in the perivascular site. Laboratory tests revealed eosinophilia and circulating immune complexes. The etiopathogenesis of the disease is discussed as is the possible role of immune complexes in eosinophilic cellulitis.

[Acro-osteolysis with hereditary sensory ulcero-mutilating neuropathy. Apropos of an atypical case]

The authors report an acroosteolysis case with sensory radicular ulcero-mutilating neuropathy. The differential diagnosis are discussed and the case is presented as an intermediate form between the congenital sensory neuropathy, type II, according to Otha classification, and the non-progressive, sporadical sensory neuropathy.

[Report of a case of allergic granulomatous vasculitis (Churg-Strauss syndrome)]

A 35 year female with a previous history of asthma came to our observation about 10 months ago. She was dyspneic, showed small nodules (2 to 5 mm) in arms, hands and legs and had radiological evidence of pulmonary granulomatosis and pleural effusion. Diagnosis was made by means of cutaneous biopsy showing a necrotic granulomatous vasculitic lesions with eosinophilic infiltration and giant cells, consistent with allergic granulomatosis of Churg-Strauss syndrome. Steroid therapy alone (prednisone 1 mg/kg/die) led to a rapid and complete clinical and humoral remission. The patient is still doing an alternate day prednisone therapy (15 mg) and is well after a 10 months follow-up.

[Clinico-statistical study on hydropinic and balneothermal therapy of psoriatic patients using the low mineral-content waters of the Comano springs]

The authors report the results obtained treating 39 subjects affected from psoriasis with hydropinic therapy and thermal balneo-therapy, using the thermal water of Comano. At the end of the treatment the results were rather bad with an inclusive reduction of 8.5% of the lesions as regards the initial data, but after 3-6 months an average per cent reduction of the lesions about 50% and in some cases quite a total regression of the psoriasis has been noted. No kind of collateral effects has been noted.

[Esophago-gastro-duodenal endoscopic findings in patients with urticaria]

In a study carried out on 54 patients affected with urticaria the Authors try to demonstrate, by esophagogastroduodenoscopy, concomitant lesions of the gastroduodenal tract. The superior panendoscopic examination has shown gastroduodenal lesions in about 39% of cases.