Ultrasound-based steatosis grading system using 2D-attenuation imaging: an individual patient data meta-analysis with external validation

BACKGROUND AND RATIONALE

Non-invasive tools assessing steatosis, such as ultrasonography-based 2D-attenuation imaging (ATI), are needed to tackle the worldwide burden of steatotic liver disease. This one-stage individual patient data (IPD) meta-analysis aimed to create an ATI-based steatosis grading system.

MAIN RESULTS

A systematic review (EMBASE+MEDLINE, 2018-2022) identified studies, including patients with histologically or MRI-PDFF-verified ATI for grading steatosis (S0 to S3). One-stage IPD meta-analyses were conducted using generalized mixed models with a random study-specific intercept. Created ATI-based steatosis grading system (aS0 to aS3) was externally validated on a prospective cohort of patients with type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (MASLD; n=174, histologically and MRI-PDFF verified steatosis). Eleven enrolled studies included 1374 patients, classified into S0, S1, S2, and S3 in 45.4%, 35.0%, 9.3%, and 10.3% of the cases. ATI was correlated with histological steatosis (r=0.60; 95%CI:0.52,0.67; p<0.001), and MRI-PDFF (r=0.70; 95%CI:0.66,0.73; p<0.001) but not with liver stiffness (r=0.03; 95%CI:-0.04,0.11, p=0.343). Steatosis grade was an independent factor associated with ATI (Coefficient: 0.24; 95%CI [0.22, 0.26]; p<0.001). ATI marginal means within S0, S1, S2, and S3 subpopulations were 0.59 (95%CI [0.58, 0.61]), 0.69 (95%CI [0.67, 0.71]), 0.78 95%CI [0.76, 0.81] and 0.85 95%CI [0.83, 0.88] dB/cm/MHz; all contrasts between grades significant (p<.0001). Three ATI thresholds were calibrated to create a new ATI-based steatosis grading system (aS0 to aS3, cut-offs: 0.66, 0.73, and 0.81 dB/cm/MHz). Its external validation showed Obuchowski measures of 0.84 ±0.02 and 0.82±0.02 with histologically- and MRI-PDFF-based references.

CONCLUSIONS

ATI is a reliable, non-invasive marker of steatosis. This validated ATI-based steatosis grading system could be valuable in assessing MASLD patients.

Two-dimensional shear wave elastography (ElastQ) accurately rules out liver fibrosis and rules in advanced chronic liver disease across liver disease etiologies: a prospective multicenter study

PURPOSE

This study evaluated ElastQ, a two-dimensional shear wave elastography (2D-SWE) technique, for the non-invasive assessment of liver fibrosis risk using liver stiffness measurement (LSM). The aim was to determine its diagnostic accuracy and establish LSM cutoffs for clinical risk stratification.

METHODS

A prospective multicenter study was conducted, employing vibration-controlled transient elastography (VCTE) as a reference standard. The statistical analysis utilized Pearson correlations and Lin concordance correlation coefficients, diagnostic areas under the curve (AUCs), and 90%-specific rule-in and 90%-sensitive rule-out ElastQ cutoffs.

RESULTS

The study included 875 patients at risk for liver disease, of whom 816 (376 women, 46.1%; median age, 57.0 years [interquartile range, 19.0]) had successful and reliable VCTE- and ElastQ-LSMs. The median LSM was 13.0 kPa (range, 2.0 to 75.0 kPa) for VCTE and 6.6 kPa (range, 2.9 to 26.5 kPa) for ElastQ. The correlation between VCTE-LSM and ElastQ-LSM was adequate for VCTE-LSM <15 kPa (Pearson r=0.63) but lower for VCTE-LSM ≥15.0 kPa (Pearson r=0.27). VCTE-LSM indicated no fibrosis risk (<5.0 kPa) in 178 cases (21.8%), gray zone (5.0-9.9 kPa) in 347 cases (42.5%), and advanced chronic liver disease (ACLD; ≥10.0 kPa) in 291 cases (35.7%). The diagnostic AUC for ElastQ-LSM was 0.82 for fibrosis risk and 0.90 for ACLD. The clinically relevant ElastQ cutoffs for ruling out fibrosis risk and ruling in compensated ACLD (cACLD) were <5.0 kPa and ≥9.0 kPa, respectively.

CONCLUSION

ElastQ 2D-SWE enables accurate, non-invasive assessments of liver fibrosis and cACLD risk. In clinical practice, ElastQ-LSM <5.0 kPa rules out fibrosis, while ElastQ-LSM ≥9.0 kPa rules in cACLD.

Liver Fat Quantification With Ultrasound: Depth Dependence of Attenuation Coefficient

OBJECTIVES

The primary aim was to estimate the influence of various depths on ultrasound attenuation coefficient (AC) of multiple vendors in the liver. The secondary aim was to evaluate the impact of region of interest (ROI) size on AC measurements in a subset of participants.

METHODS

This Institutional Review Board (IRB)-approved Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study was carried out in two centers using AC-Canon and AC-Philips algorithms and extracting AC-Siemens values from ultrasound-derived fat fraction algorithm. Measurements were performed positioning ROI upper edge (3 cm size) at 2, 3, 4, 5 cm from the liver capsule with AC-Canon and AC-Philips and at 1.5, 2, 3 cm with Siemens algorithm. In a subset of participants, measurements were obtained with 1 and 3 cm ROI size. Univariate and multivariate linear regression models and Lin's concordance correlation coefficient (CCC) were used for statistical analysis as appropriate.

RESULTS

Three different cohorts were studied. Sixty-three participants (34 females; mean age: 51 ± 14 years) were studied with AC-Canon, 60 (46 females; mean age: 57 ± 11 years) with AC-Philips, and 50 (25 females; 61 ± 13 years) with AC-Siemens. There was a decrease in AC values per 1 cm increase in depth in all. In multivariable analysis, the coefficient was -0.049 (-0.060; -0.038 P < .001) with AC-Canon, -0.058 (-0.066; -0.049 P < .001) with AC-Philips and -0.081 (-0.112; -0.050 P < .001) with AC-Siemens. AC values with 1 cm ROI were significantly higher than those obtained with 3 cm ROI at all depths (P < .001) but the agreement between AC values obtained with different ROI size was excellent (CCC 0.82 [0.77-0.88]).

CONCLUSIONS

There is depth dependence in AC measurement that affects results. A standardized protocol with fixed ROI's depth and size is needed.

Influence of climatic parameters on the probabilistic design of green roofs

Green roofs are effective tools for stormwater control in highly urbanized areas since they allow the reduction of peak runoffs and volumes discharged in sewer systems. Their design is quite standardized, except for the thickness of the growing medium layer, which is strictly related to vegetation type and rainfall regime. The paper proposes an analytical probabilistic approach that relates the climatic variables, the growing medium thickness, and the water content in the condition of fulfilled field capacity to the probability that runoff from green roofs exceeds a fixed threshold. The developed equations also consider the possibility of a reduced retention capacity due to previous rainfall events, that strongly influence the performance of these green infrastructures, especially when short dry periods and/or low evapotranspiration rates occur. This feature, neglected by the traditional design storm approach, and only partially considered by previous analytical probabilistic models, represent a great potentiality of the proposed equations that are also more user-friendly and less time-consuming than continuous simulation analysis. The focus of the paper is on the influence of climatic parameters on runoff probability. To this aim to perform the monthly analysis is fundamental, especially when there is a strong variability of the climatic parameters throughout the year. The model was tested in a case study in Milano, Italy. The application presented a good agreement between the results obtained from the proposed equations and those obtained from the continuous simulation of recorded data. The results also highlighted the importance of performing analysis on a monthly scale.

Probabilistic modeling of sustainable urban drainage systems

Sustainable Urban Drainage Systems (SUDS) include strategies and solutions for distributed stormwater management and control. They are strongly encouraged, especially in highly urbanized areas that suffer the combined effect of impervious surfaces and the increase in extreme rainfall events due to urbanization growth and climate change. Their integration into traditional urban drainage systems can mitigate flood risk and pollution of receiving water bodies. The main goal of SUDS is to restore the natural water balance by increasing infiltration and evapotranspiration processes and promoting rainwater harvesting and reuse. This paper proposes an analytical-probabilistic approach for SUDS modeling applicable to different systems. Developed equations allow estimating the runoff and residual storage probability for evaluating the efficiency of the storage volume both in terms of flood control and, depending on SUDS type, in terms of emptying time or water needs supply. The modeling considers the possibility of consecutive chained rainfalls; this feature is relevant for SUDS, often characterized by low outflow rates. Relating characteristic parameters to a probabilistic level (the Average Return Interval, ARI) makes the formulas interesting to be used in the design practice. An application to two case studies confirmed the goodness of the proposed method.

Efficacy and activity of PD-1 blockade in patients with advanced esophageal squamous cell carcinoma: a systematic review and meta-analysis with focus on the value of PD-L1 combined positive score

BACKGROUND

Recently, several randomized controlled trials (RCTs) investigated immunotherapy-based regimens versus chemotherapy alone in patients with advanced esophageal squamous cell carcinoma (ESCC). Here we conducted a systematic review and meta-analysis on the efficacy and activity of programmed cell death protein 1 blockade in these patients, with focus on the value of programmed death-ligand 1 combined positive score (CPS) for selecting patients who may benefit the most.

METHODS

RCTs investigating treatment with or without immune checkpoint inhibitors for advanced ESCC were selected. The hazard ratio (HR) and the odds ratio were used to compare the treatment effect on survival outcomes and tumor response, respectively, for immunotherapy-based regimens compared with standard chemotherapy, overall and according to geographic region or treatment line. We carried out a subgroup analysis comparing patients with CPS ≥10 or <10 and the evidence for treatment effect was evaluated by interaction test.

RESULTS

A total of 5257 patients and 10 RCTs were included. Overall, the HR for overall survival benefit with immunotherapy-based regimens was 0.71 [95% confidence interval (CI) 0.66-0.76] compared with chemotherapy alone; such effect was independent from geographical region (Asia versus rest of the world) and treatment line (upfront versus second/further lines). The HR for progression-free survival benefit and the odds ratio for overall response rate increase were 0.78 (95% CI 0.66-0.93) and 1.50 (95% CI 1.22-1.83), respectively. The HR for overall survival benefit with immunotherapy-based treatment was 0.60 (95% CI 0.51-0.70) for CPS ≥10 subgroup versus 0.83 (95% CI 0.69-1.00) for CPS <10 (P for interaction 0.009).

CONCLUSIONS

Immune checkpoint inhibitors have a consistent benefit in reducing the risk of death for ESCC patients which is dependent on programmed death-ligand 1 CPS status. Further investigations of biomarkers for immunotherapy in the subgroup of patients with CPS <10 are needed.

Clinical impact of neutropenia and febrile neutropenia in metastatic colorectal cancer patients treated with FOLFOXIRI/bevacizumab: a pooled analysis of TRIBE and TRIBE2 studies by GONO

BACKGROUND

TRIBE and TRIBE-2 studies demonstrated higher benefit from FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan)/bevacizumab compared with FOLFIRI (fluorouracil, leucovorin, and irinotecan) or FOLFOX/bevacizumab as an upfront option for metastatic colorectal cancer patients, with more toxicities. We focused on the incidence and longitudinal dynamics of neutropenia and febrile neutropenia (FN) in the two studies, to evaluate their clinical relevance, the magnitude of impact of FOLFOXIRI/bevacizumab, and the role of risk factors in predicting their occurrence.

METHODS

The overall incidence of grade 3-4 (G3-4) neutropenia and FN, the time to their onset, the use of granulocyte colony-stimulating factor, and the association with risk factors were evaluated in the overall population and according to treatment arm. FN episodes were assessed by Multinational Association for Supportive Care in Cancer (MASCC) score.

RESULTS

Among 1155 patients, 568 (49%) received FOLFOXIRI/bevacizumab. Overall, 410 (35%) experienced G3-4 neutropenia and 70 (6%) FN, 21 (2%) at high risk. FOLFOXIRI/bevacizumab was associated with higher incidence of neutropenia (51% versus 21%, P < 0.001), FN (8% versus 4%, P = 0.02), and high-risk FN [18 (3%) versus 3 (1%), P = 0.015]. No related deaths were observed. The first episode of G3-4 neutropenia and FN occurred mainly in the first 2 months in both arms. Longitudinal analysis showed different patterns of evolution over cycles between the arms (P < 0.001) G3-4 neutropenia being more frequent in the first cycles with FOLFOXIRI/bevacizumab. Older patients (P = 0.01) and females (P < 0.001) had a significantly higher risk of G3-4 neutropenia. No significant interaction effect between arm and analysed risk factors in terms of risk of G3-4 neutropenia or FN was observed. The incidence of FN among older females receiving FOLFOXIRI/bevacizumab was 12%. Neither G3-4 neutropenia nor FN impaired efficacy in terms of overall response rate, progression-free survival, and overall survival.

CONCLUSIONS

FOLFOXIRI/bevacizumab has a higher risk of G3-4 neutropenia and FN than doublets/bevacizumab. FN occurred in <10% of patients, mostly as low-risk episodes. A closer monitoring during the first 2 months is recommended; prophylactic use of granulocyte colony-stimulating factor may be considered for older females.

Impact of age and gender on the efficacy and safety of upfront therapy with panitumumab plus FOLFOX followed by panitumumab-based maintenance: a pre-specified subgroup analysis of the Valentino study

BACKGROUND

The safety and efficacy outcome of elderly metastatic colorectal cancer (mCRC) patients fit enough to receive combination chemotherapy plus biological agents is an issue of growing interest. Also, gender-specific differential toxicity and efficacy of anti-epidermal growth factor receptor (EGFR)-based upfront treatments need to be explored.

PATIENTS AND METHODS

Valentino was a multicenter, randomized, phase II trial, investigating two panitumumab-based maintenance strategies following first-line panitumumab plus FOLFOX in RAS wild-type mCRC patients. We carried out a subgroup analysis, aimed at assessing the differences in efficacy, safety and quality of life (QoL) according to age (<70 versus ≥70 years) and gender (male versus female). Efficacy endpoints were progression-free survival (PFS), overall survival (OS) and overall response rate (ORR); safety endpoints were rates of any grade and grade 3/4 adverse events (AEs).

RESULTS

No significant differences in terms of PFS, OS and ORR were observed between patients aged <70 or ≥70 years and the effect of the maintenance treatment arm on survival outcomes was similar in the two subgroups. The safety profile of both induction and maintenance treatment and the impact on QoL were similar in elderly and younger patients. No significant differences in PFS, OS, ORR or clinical benefit rate were observed according to gender. A significantly higher rate of overall grade 3/4 AEs (P = 0.008) and of grade 3/4 thrombocytopenia (P = 0.017), any grade and grade 3/4 neutropenia (P < 0.0001) and any grade conjunctivitis (P = 0.033) was reported in female as compared to male patients. Conversely, we reported a significantly higher incidence of any grade skin rash (P = 0.0007) and hypomagnesemia (P = 0.029) in male patients.

CONCLUSIONS

The upfront choice of an anti-EGFR-based doublet chemotherapy followed by a maintenance strategy represents a valuable option in RAS wild-type mCRC irrespective of gender and age, though a careful evaluation of patients to maximize the risk/benefit ratio is warranted.

The importance of respecting accreditation indicators to improve quality of care

Issue

The health and social-care facilities (HSF) of the Lombardy Region provide services specifically conceived for fragile populations, including elderly, disabled, addicts etc. Through its Accreditation Units, the Agency for Health Protection (ATS) in the Metropolitan City of Milan is responsible for overseeing authorization and accreditation indicators of HSFs in all afferent districts. Assessed requirements include the qualitative standard (presence of mandatory professional figures) and the quantitative standard (guaranteed weekly minimum time of care per patient) of operating staff, based on current legislation.

Description of the problem

These standards are evaluated at site-inspection by examining staff qualifications and by matching staff working hours to actual daily presence of patients, randomly selecting a recent past week. The resulting standards may thus not be fully representative of the whole year. In 2019, the Health and Social-care facilities Accreditation Unit of ATS began a retrospective quali-quantitative analysis of health service staffing data for 2017 and 2018. Data were extrapolated from two main databases: “Scheda Struttura”, a data collection tool regarding work hours, qualifications, waiting lists etc. compiled yearly by HSF managers; and economic data detailing reimbursements by the regional health service, based on effective daily presence of patients at the HSF.

Results

Preliminary results relating to 2017 showed that around 4% of HSFs do not guarantee qualitative staffing standards, and almost 30% do not guarantee quantitative staffing standards throughout the year.

Lessons

The proposed tool is useful for emphasizing potentially critical situations and may help define the annual inspection schedule with the aim of continuously improving quality of care among regional HSFs.

Key messages

Data management tools can help local health authorities monitor and identify facilities at risk of falling below the defined standards of care. Qualitative and quantitative analysis of health service staffing is useful for emphasizing potentially critical situations and may help define the annual inspection schedule.

Activation of 574 new Alzheimer’s special care unit beds in the Metropolitan City of Milan

Issue

Dementia is among the main causes of disability and dependency in the elderly. It was defined a public health priority by the WHO. The health and social-care system of the Lombardy region (SSR) plays a key role in implementing assistance and care pathways specifically designed for fragile populations, including those affected by dementia and Alzheimer's disease, its most common form.

Description of the Problem

The SSR provides residential care options especially conceived for dementia patients, known as Alzheimer's special care units (ASCU). However, waiting lists are concerning, and distribution of these facilities is inconsistent throughout the region. In 2018 there were 981 accredited and SSR-covered ASCU beds in the Metropolitan City of Milan (MCM), translating in 1.26 beds/1000 people aged ≥ 65. With regional legislation (DGR 1046/2018), the SSR proposed activation of new ASCU beds in all territories with less than 2 beds/1000 people aged ≥ 65. The MCM Agency for Health Protection (ATS) thus analyzed the distribution of ASCU beds in afferent districts, defining specific needs for each district. The aim was to fund and activate 574 new ASCU beds homogenously among previously accredited and SSR-covered residential care facilities, reaching the targeted 2 ASCU beds/1000 people aged ≥ 65. Applicant facilities had to respond to specific personnel, technological, therapeutic and structural requirements.

Results

Preliminary results indicate 29 residential care facilities applied for evaluation in 2019. The ATS received and evaluated all applications. Following site-inspection, 8 facilities were deemed inappropriate.

Lessons

In 2019, 21 residential care facilities were approved for funding and activation of 558 new ASCU beds. Residual beds will be funded in 2020. Main messages: Activation of new ASCU beds in 2019 and 2020 increased specialized long-term care beds for dementia patients by almost 60%, allowing a more homogenous distribution among MCM districts.

Key messages

The health and social-care system of the Lombardy region proposed activation of new Alzheimer’s special care units beds in all territories with less than 2 beds/1000 people aged ≥ 65. Activation of 574 new Alzheimer’s special care units beds increased by almost 60%, allowing a more homogenous distribution among Metropolitan City of Milan districts.

Temozolomide and irinotecan (TEMIRI regimen) as salvage treatment of irinotecan-sensitive advanced colorectal cancer patients bearing MGMT methylation

Background

Non-randomized studies showed that temozolomide (TMZ) achieves an average 10% response rate in heavily pretreated metastatic colorectal cancer (mCRC) patients with promoter methylation of the DNA repair gene O6-methylguanine-DNA methyltransferase (MGMT). In this phase II trial, irinotecan and temozolomide (TEMIRI) combination regimen was assessed in irinotecan-sensitive, MGMT methylated/microsatellite stable (MSS) pretreated mCRC patients.

Patients and methods

Key inclusion criteria were centrally confirmed MGMT methylation by methylation-specific PCR, MSS mCRC, progression after at least two prior chemotherapy regimens for advanced disease and irinotecan-free interval >3 months. TEMIRI (TMZ 150 mg/m2 on days 1-5 plus irinotecan 100 mg/m2 on days 1, 15 q28 days) was administered for six cycles, followed by maintenance with TMZ. The primary end point was overall response rate (ORR). Exploratory translational analyses included MGMT immunohistochemistry (IHC) and methyl-BEAMing (MB).

Results

Between December 2014 and June 2017, 25 patients were enrolled. The primary end point was met, since six patients achieved a partial response [ORR 24%, 95% confidence interval (CI) 11% to 43%]. At a median follow-up of 15.6 months, median progression-free survival (mPFS) and overall survival (mOS) were 4.4 and 13.8 months, respectively. Only four (16%) patients had ≥ grade 3 (CTCAE 4.0) adverse events. All patients whose cancer was MGMT-positive IHC were non-responders. Consistently, patients with MGMT-negative/low tumors had a significantly longer mPFS than others (6.9 versus 2.0 months; hazard ratio = 0.29, 95% CI 0.02-0.41; P = 0.003) and a non-significant trend for longer mOS. MB testing showed similar accuracy.

Conclusions

TEMIRI regimen is a safe and active option in pre-treated, irinotecan-sensitive mCRC patients with MGMT methylation.

Origin of Glycosylated Hemoglobin Al in Chronic Renal Failure

In chronic renal failure both HbAI and HbAlc levels have been reported to be elevated. In order to investigate the causes of such increase we measured HbAI (cation-exchange chromatography), blood urea nitrogen, arterial blood pH, plasma bicarbonate, phosphatemia, serum iron and serum ferritin before dialysis in 60 uremic patients receiving long term hemodialysis. The increased levels of HbAI do not correlate with glucose intolerance, phosphatemia, blood urea nitrogen, time averaged concentration of urea, serum iron and serum ferritin. On the contrary the presence of a highly significant correlation between HbAI and arterial blood pH (p < 0.001) and between HbAI and plasma bicarbonate (p < 0.001) seems to emphasize a major role for acidosis in increasing the HbAI levels in uremic patients on long term hemodialysis.

Lung ultrasound in internal medicine: A bedside help to increase accuracy in the diagnosis of dyspnea

BACKGROUND

Dyspnea is one of the most frequent causes of admission in Internal Medicine wards, leading to a sizeable utilization of medical resources.

STUDY DESIGN AND METHODS

The role of bedside lung ultrasound (LUS) was evaluated in 130 consecutive patients (age: 81±9years), in whom blindly collected LUS results were compared with data obtained by clinical examination, medical history, blood analysis, and chest X-ray. Dyspnea etiology was classified as "cardiac" (n=80), "respiratory" (n=36) or "mixed" (n=14), according to the discharge diagnosis (congestive heart failure either alone [n=80] or associated with pneumonia [n=14], pneumonia [n=24], and obstructive disventilatory syndrome [n=12]). An 8-window LUS protocol was applied to evaluate B-line distribution, "interstitial syndrome" pattern, pleural effusion and images of static or dynamic air bronchogram/focal parenchymal consolidation.

RESULTS

The presence of a generalized "interstitial syndrome" at the initial LUS evaluation allowed to discriminate "cardiac" from "pulmonary" Dyspnea with high sensitivity (93.75%; confidence intervals: 86.01%-97.94%) and specificity (86.11%; 70.50%-95.33%). Positive and negative predictive values were 93.76% (86.03%-97.94%) and 86.09% (70.47%-95.32%), respectively. Moreover, LUS diagnostic accuracy for the diagnosis of pneumonia was not inferior to that of chest X-ray.

CONCLUSIONS

Bedside LUS evaluation contributes with high sensitivity and specificity to the differential diagnosis of Dyspnea. This holds true not only in the emergency setting, but also in the sub-acute Internal Medicine arena. A wider use of this portable technique in our wards is warranted.

Topical Kanamycin: an Effective Therapeutic Option in Aerobic Vaginitis

Eighty-one patients with clinical diagnosis of aerobic vaginitis (AV) were included in the study. The patients were randomized for treatment, 45 with kanamycin (100 mg vaginal ovules for 6 days, consecutively) and 36 with meclocycline (35 mg vaginal ovules for 6 days, consecutively). The patients were examined before starting the study, 1-2 days after treatment and 30 days after the end of the study. At the first follow-up the patients showed different levels of symptom reduction. Reduction in the presence of leukocytes, vaginal mucosa burning and itching were statistically significant in the group treated with kanamycin with respect to the group treated with meclocycline. Moreover, there was also reduced isolation of Enterobacteriaeae (97%) in the group treated with kanamycin versus those treated with meclocycline (76%). At the second follow-up, vaginal homeostasis (normalization of pH and presence of lactobacilli) was more evident in the kanamycin-treated group. In conclusion, our data suggest that the topical use of kanamycin could be considered a specific antibiotic for the therapy of this new pathology.

Prevalence and prognostic value of conduction disturbances at the time of diagnosis of cardiac AL amyloidosis

BACKGROUND AND PURPOSE

To evaluate the prevalence and the prognostic implications of conduction delays in a large cohort of cardiac AL patients.

METHODS

Echo Doppler and 12-lead ECG were collected in 344 consecutive patients in whom diagnosis of AL amyloidosis was concluded between 2008 and 2010. Patients were subdivided according to the presence (n = 240) or absence (n = 104) of cardiac involvement.

RESULTS

When compared with patients without myocardial involvement, cardiac AL was associated with prolonged PQ, QRS, QT and QTc intervals (P < 0.05), and with higher prevalence of intraventricular blocks (27.5% vs. 16.5%, P < 0.05), that was associated with higher wall thickness, worse diastolic and regional systolic function, higher NT-proBNP values (all P < 0.05), and higher mortality (P = 0.0001; median follow-up: 402 days).

CONCLUSION

Intraventricular conduction delays have a negative prognostic impact in patients with cardiac AL amyloidosis. Their presence should not be overlooked in the diagnostic workup, prompting a more accurate cardiological support.

Diagnostic and prognostic value of low QRS voltages in cardiac AL amyloidosis

BACKGROUND

In cardiac AL amyloidosis, myocardial infiltration is typically associated with "low QRS voltages" at the 12-lead electrocardiogram (ECG). Although considered as one of the hallmarks of the disease, its reported prevalence varies from 45% to 70%, mainly because of nonhomogeneous definitions.

METHODS

To identify the "low QRS voltage" parameter having the best diagnostic value in identifying cardiac amyloidosis, and to assess its possible prognostic role, ECG and echocardiographic data were collected at diagnosis in 337 consecutive never-treated AL patients (233 with, 104 without cardiac involvement). Prognosis was assessed after a median follow-up of 14.5 months.

RESULTS

"Low QRS voltage" prevalence varied from 84.12% when using Sokolow-Lyon index ≤15 mm to 27.04% with the definition of low total voltages (QRS amplitude ≤5 mm in each peripheral and ≤10 mm in each precordial lead), the widely used definition of low peripheral voltages (≤5 mm in each peripheral lead) being able to identify 66.52% cardiac AL patients. The presence of "low peripheral voltages" was associated with a more severe cardiac involvement, and was able to differentiate Mayo stage II patients' survival (i.e., AL patients with intermediate prognosis). According to receiver operator characteristic (ROC) curve analysis, sensitivity and specificity were 58.72% and 80.00%, for a peripheral QRS amplitude ≤24.5 mm (the sum of QRS in all the 6 peripheral leads), and 76.26% and 65.00% for a Sokolow-Lyon index ≤11 mm.

CONCLUSIONS

In cardiac AL amyloidosis the prevalence of low QRS voltages is highly dependent on the method used for defining this ECG alteration.

Diagnostic and prognostic value of low QRS voltages in cardiac AL amyloidosis

BACKGROUND

In cardiac AL amyloidosis, myocardial infiltration is typically associated with "low QRS voltages" at the 12-lead electrocardiogram (ECG). Although considered as one of the hallmarks of the disease, its reported prevalence varies from 45% to 70%, mainly because of nonhomogeneous definitions.

METHODS

To identify the "low QRS voltage" parameter having the best diagnostic value in identifying cardiac amyloidosis, and to assess its possible prognostic role, ECG and echocardiographic data were collected at diagnosis in 337 consecutive never-treated AL patients (233 with, 104 without cardiac involvement). Prognosis was assessed after a median follow-up of 14.5 months.

RESULTS

"Low QRS voltage" prevalence varied from 84.12% when using Sokolow-Lyon index ≤15 mm to 27.04% with the definition of low total voltages (QRS amplitude ≤5 mm in each peripheral and ≤10 mm in each precordial lead), the widely used definition of low peripheral voltages (≤5 mm in each peripheral lead) being able to identify 66.52% cardiac AL patients. The presence of "low peripheral voltages" was associated with a more severe cardiac involvement, and was able to differentiate Mayo stage II patients' survival (i.e., AL patients with intermediate prognosis). According to receiver operator characteristic (ROC) curve analysis, sensitivity and specificity were 58.72% and 80.00%, for a peripheral QRS amplitude ≤24.5 mm (the sum of QRS in all the 6 peripheral leads), and 76.26% and 65.00% for a Sokolow-Lyon index ≤11 mm.

CONCLUSIONS

In cardiac AL amyloidosis the prevalence of low QRS voltages is highly dependent on the method used for defining this ECG alteration.

mTOR as a target of everolimus in refractory/relapsed Hodgkin lymphoma

Despite impressive treatment advances, few options for refractory or relapsed Hodgkin Lymphoma (HL) are available and there is a need for new compounds development. A number of promising agents with multiple mechanisms of action are under investigation. Microenvironment and neoangiogenesis are acquiring a rising relevance in the pathophysiology and progression of HL. Everolimus (RAD001) is an oral antineoplastic agent derived from rapamycin, a macrocyclic lactone antibiotic, targeting the mammalian target of rapamycin (mTOR). Although the importance of mTOR signaling in the deregulated cell growth of human neoplastic cells has been recognized, this pathway is also emerging as a key regulator of the tumor response to hypoxia, as well as endothelial and stromal cells function, thereby regulating neoangiogenesis. Furthermore, mTOR plays an important role in anticancer drug resistance. The actions of everolimus within the mTOR pathway in HL result in decreased protein synthesis and cell cycle arrest, as well as in decreased angiogenesis. Everolimus has shown preliminary evidence of efficacy as a single-agent in heavily pretreated relapsed/refractory HL, with an overall fair safety profile. The purpose of this review is to discuss the employment of everolimus as an antiproliferative and antiangiogenic agent in HL and to report the critical role of the mTOR pathway and angiogenesis in this malignancy.

Duropleural Fistula Revealed by Neurological Manifestations: An Unusual Cause of Pleural Effusion

Symptomatic pleural collection of cerebrospinal fluid is a rare but accepted complication in hydrocephalic paediatric patients treated with ventriculopleural shunts. Few cases have been described in adults, usually as complication of trauma, tumours or spinal surgery, particularly post-laminectomy. It should be considered in the differential diagnosis of pleural effusion after neurosurgical procedures involving the spine. We describe two patients with large cerebrospinal fluid collections in the pleural cavity caused by postoperative duropleural fistula, who presented with neurological symptoms, cerebrospinal fluid pressure headache and meningitis.

Early aseptic loosening of a porous tantalum knee prosthesis

Porous tantalum represents a relatively new solution for primary and revision total knee arthroplasty, offering several unmatched properties. Tantalum is a transition metal, with excellent biocompatibility and bioactivity due to its intrinsic physical and structural characteristics. A widespread clinical use of porous tantalum tibial components for primary total knee arthroplasty has been partly hindered by the difficulty in removing this type of implant after bone in growth, often leading to a significant bone defect. On the contrary, in the case here reported, removal of the trabecular metal tibial component was unexpectedly easy at a 7-month follow-up due to the absence of bone ingrowth but with a complete preservation of the tibial plate bone stock. Causes for the lack of bone ingrowth are discussed.