The Prognostic Nutritional Index in patients with microsatellite instability-high metastatic gastric or gastroesophageal cancers receiving immune checkpoint inhibitors

BACKGROUND

Microsatellite instability high (MSI-H) and/or mismatch repair deficient (dMMR) status is the strongest predictive factor for immune checkpoint inhibitors (ICIs) benefit in patients with metastatic gastroesophageal cancer (mGC). Primary resistance to ICIs is a relevant issue, but prognostic and predictive factors are lacking.

MATERIALS AND METHODS

In this multinational, retrospective cohort of patients with MSI-H/dMMR mGC treated with ICIs without chemotherapy we collected baseline laboratory values to establish the prognostic nutritional index (PNI). We evaluated the association between baseline PNI with the activity and efficacy of ICIs.

RESULTS

At a median follow-up of 31.6 months, median progression-free survival (PFS) and 2-year PFS rate were not reached and 73.6 % in the PNI-high subgroup versus 6.3 months and 38.3 % in the PNI-low one (HR 0.32, 95 % CI: 0.16-0.61, p < .001). Median overall survival (OS) and 2-year OS rate were not reached and 81.9 % in the PNI-high subgroup versus 24.4 months and 50.5 % in the PNI-low one (HR 0.26, 95 % CI: 0.12-0.56, p < .001). In multivariable models, high PNI was associated with longer PFS and OS (HR 0.30, 95 % CI: 0.15-0.61, p <0.001 and 0.37, 95 % CI: 0.15-0.91, p = .031).

CONCLUSIONS

High PNI is associated with longer PFS and OS, in patients with MSI-H mGC receiving ICIs. Patients with low baseline PNI may benefit from intensive therapeutic approaches.

What if the reward is not as yummy? Study of the effects of Successive Negative Contrast in domestic dogs in two different tasks

Successive Negative Contrast (SNC) occurs when there is a reduction in the quantity or quality of a reward that is expected according to the presence of contextual cues. This induces an emotional response of frustration that is similar to stress. While this phenomenon has been observed in several mammal species, findings in domestic dogs have been inconsistent, although this issue has strong relevance in dog training. The aim of this study was to assess the effects of Successive Negative Contrast in two responses that had already been studied in this species, but with an increase in the methodological rigor and variations in the experimental conditions to examine the generalizability of the phenomenon. To this end, experimental dogs experienced a pre-shift phase in which they received a high-value reward (liver), followed by a post-shift phase in which they obtained a low-value reward (dry dog food), and then a re-shift phase in which the high-value reward was available again. Control dogs received dry food in all phases. The results show a contrast effect on the behavior of following human pointing to obtain food (Study 1). On the contrary, there were no differences in problem solving behavior after the de- and re-evaluation of the reward during a non-social task (Study 2). The results support that Successive Negative Contrast is not a consistent phenomenon in pet dogs. It is possible that certain characteristics of dogs such as the great availability of high-value rewards in their daily lives could attenuate the effects of a reduction in incentive value.

Use of focus point for plane acquisition to improve reproducibility in fetal biometry

OBJECTIVE

To assess the reproducibility of ultrasound measurements of fetal biometry using a 'focus point' to assist the acquisition of the relevant plane.

METHODS

This was a study of 80 women with a singleton non-anomalous pregnancy who attended University College London Hospital, London, UK, between 18 and 37 weeks' gestation. Planes to measure head circumference (HC), abdominal circumference (AC) and femur length (FL) were obtained four times by two different sonographers with different levels of experience, who were blinded to one another; the first set of images was obtained with reference to a standard image, and the second set of images was obtained using the focus point technique. The focus point was defined as a unique fetal anatomical landmark in each plane (cavum septi pellucidi for HC, two-thirds of the umbilical vein for AC and one of the two extremities of the diaphysis for FL). Once identified, the focus point was maintained in view while the sonographer rotated the probe along three axes (x, y, z) to acquire the relevant plane. Sonographers were either in training or had > 3000 scans worth of experience. Intra- and interobserver reproducibility were assessed using Bland-Altman plots, and absolute values and percentages for mean difference and 95% limits of agreement (LoA) were reported.

RESULTS

Overall reproducibility was good, with all 95% LoA < 8%. Reproducibility was improved by use of the focus point compared with the standard technique for both intraobserver comparison (95% LoA, < 4% vs < 6%) and interobserver comparison (95% LoA, < 7% vs < 8%). These findings were independent of sonographer seniority and plane acquired.

CONCLUSIONS

Reproducibility of fetal biometry assessment is improved with use of the focus point for plane acquisition, regardless of sonographer experience. We propose that this method should be implemented in clinical practice and training programs in fetal biometry. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Still-face effect in domestic dogs: comparing untrained with trained and animal assisted interventions dogs

The still-face effect has been extensively studied in human infants and comprises the reduction in affiliative behaviors and increased stress that occurs after a sudden interruption of social interaction with a caregiver. Domestic dogs (Canis familiaris) are model candidates for showing this effect, as they form deep bonds with their owners and interspecific social interaction is reinforcing to them. The aim of these studies was to assess if companion dogs exhibit the still-face effect and whether prior experiences during ontogeny modulate this effect. To this end, Study 1 compared dogs with different levels of training (untrained, intermediate, and advanced), while Study 2 assessed dogs that participated in Animal Assisted Interventions (AAIs) and companion dogs (CDs). The procedure was carried out virtually and comprised three phases lasting 1 min: interaction, still-face (the owner turned suddenly indifferent), and reunion (the interaction was resumed). Dogs exhibited a decrease in proximity to and contact with the owner, as well as an increase in begging and stress behaviors during the still-face phase. Moreover, this was not observed in a control condition in which the interaction continued in the same way during all three phases, discarding alternative explanations for these changes. These results show that dogs experience a still-face effect in a similar way to infants, highlighting the value interspecific social interaction has for dogs. Nevertheless, the absence of differences according to their training level or participation in AAIs suggests this is a robust phenomenon, which appears to be less susceptible to the influences of ontogenetic experiences.

Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study

OBJECTIVE

To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa.

METHODS

This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms.

RESULTS

A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta.

CONCLUSIONS

Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Sex-Related Differences in Long-COVID-19 Syndrome

Background: Sex differences have been demonstrated in the acute phase of COVID-19. Women (F) were found to be less prone to develop a severe disease than men (M), but few studies have assessed sex-differences in Long-COVID-19 syndrome. Methods: The aim of this prospective/retrospective study was to characterize the long-term consequences of this infection based on sex. For this purpose, we enrolled 223 patients (89 F and 134 M) who were infected by SARS-CoV-2. In the acute phase of the illness, F reported the following symptoms more frequently than M: weakness, dysgeusia, anosmia, thoracic pain, palpitations, diarrhea, and myalgia-all without significant differences in breathlessness, cough, and sleep disturbance. Results: After a mean follow-up time of 5 months after the acute phase, F were significantly more likely than M to report dyspnea, weakness, thoracic pain, palpitations, and sleep disturbance but not myalgia and cough. At the multivariate logistic regression, women were statistically significantly likely to experience persistent symptoms such as dyspnea, fatigue, chest pain, and palpitations. On the contrary, myalgia, cough, and sleep disturbance were not influenced by sex. Conclusion: We demonstrated that F were more symptomatic than M not only in the acute phase but also at follow-up. Sex was found to be an important determinant of Long-COVID-19 syndrome because it is a significant predictor of persistent symptoms in F, such as dyspnea, fatigue, chest pain, and palpitations. Our results suggest the need for long-term follow-up of these patients from a sex perspective to implement early preventive and personalized therapeutic strategies.

Surgical aortic valve replacement in elderly patients: effects on physical performance, cognitive function and health-related quality of life

Background

Surgical aortic valve replacement (SAVR) is still the gold standard for treating aortic valve stenosis (AVS). Its effectiveness has been extensively examined in terms of perioperative mortality, but its impact on overall health has received much less attention.

Aims

To assess the physical performance, cognitive status, and health-related quality of life of elderly patients undergoing SAVR, in the short, medium and long term.

Methods

This single-center prospective study enrolled patients aged > 70 years who underwent isolated SAVR for severe AVS. Data were collected on each participant’s clinical status, physical performance, cognitive status, mood, and health-related quality of life. This multidimensional geriatric assessment was performed before surgery (T0), and again at 45 days (T1), 3 months (T2), 6 months (T3), and 12 months (T4) post-surgery. Baseline (T0) and follow-up (T2-T4) data were compared separately for patients grouped by gender using paired t-tests.

Results

Data from a total of 35 patients were analyzed. Compared with the baseline (T0), nutritional status worsened at T1, then gradually improved through to T4. Physical performance, mood, and health-related quality of life improved significantly after surgery. Cognitive function showed no change through to T3, but then deteriorated at T4.

Conclusions

Our results show that SAVR in patients over 70 years of age has a positive impact on nutrition, mood, and health-related quality of life. Cognitive function was not negatively affected in the short and medium term, although it deteriorated in the long term. SAVR also had a positive impact on the physical performance of our sample.

308 Sex-related differences in long COVID-19 syndrome

Aims

Sex-differences have been demonstrated in the acute phase of COVID-19 infection; females (f) were found to be less prone to develop a severe disease than males (M), but few studies have assessed sex-differences in Long-COVID-19 syndrome.

Methods and results

The aim of this prospective/retrospective study was to characterize the long-term consequences of this infection from a sex-perspective. For this purpose, we enrolled 223 patients (89 F and 134 M) who experienced a SARS-CoV-2 infection. In the acute phase of the illness, females reported more frequently than males: weakness, dysgeusia, anosmia, thoracic pain, palpitations, diarrhoea, and myalgia without significant differences in breathlessness, cough, and sleep disturbance. After a mean follow-up time of 5 months after the acute phase, females were significantly more likely than males to report weakness, thoracic pain, palpitations, and sleep disturbance but not myalgia and cough. At the multivariate logistic regression, women were statistically significantly likely to experience persistent symptoms such as dyspnoea, fatigue, chest pain, and palpitations. On the contrary, myalgia, cough and sleep disturbance were not influenced by sex.

Conclusions

We demonstrated that females were more symptomatic than males not only in the acute phase but also at follow-up. Sex was found to be an important determinant of Long-COVID syndrome because it is a significant predictor of persistent symptoms in females, such as dyspnoea, fatigue, chest pain, and palpitations. Our results suggest the need for long-term follow-up of these patients from a sex-perspective in order to implement early preventive and personalized therapeutic strategies.

301 Long term sequelae after COVID-19: the different impact on the right and left ventricles

Aims

Most patients who had COVID-19 are still symptomatic after many months post infection, but the long-term outcomes are not yet well-defined. The aim of our prospective/retrospective study was to define the cardiac sequelae of COVID-19 infection.

Methods and results

This monocentric cohort study included 160 consecutive patients (64 females, 60 + 12 years) who had been discharged from the ward or from the outpatient clinic after a diagnosis of COVID-19 and subsequently referred for a follow-up visit. Clinical features as well as lab and instrumental data about the acute phase of the disease, such as haemodynamic instability (HI), cardiac biomarkers, d-dimer, C-reactive protein (CRP), high resolution CT (HRCT) score along with information about the follow-up visit, including ECG and Conventional and Doppler Tissue Echocardiographic (DTE) parameters, were recorded. The median follow-up time after symptom onset was 5 months. At follow-up visit, the majority of the patients reported dyspnoea and asthenia. Moreover, echocardiography showed morpho-functional changes of both right (RV) and left (LV) ventricles, such as RV dilation, increased pressure in the pulmonary circulation, and by-ventricular systolic–diastolic dysfunction. When examined using multivariate analysis, independent of age, sex, and co-morbidities, RV and LV changes were significantly associated (P &lt; 0.05) with HRCT score and HI and with CRP, respectively.

Conclusions

Our results suggest that COVID-19 may impact RV and LV differently. Notably, the extent of the pneumonia and HI may affect RV, whereas the inflammatory status may influence LV. A long-term follow-up is warranted to refine and customize the most appropriate therapeutic strategies.

Antiphospholipid antibody syndrome and LVAD: What are the chances? A case report and literature review

Left-ventricular-assist-device (LVAD) implantation in patients with antiphospholipid-syndrome (APS) is considered a high-risk procedure and its indication still represents an open challenge. Herein, we report a 63-year-old man with APS and end-stage heart failure, for whom a HeartMate3-LVAD and a continuous rheologic profile monitoring with a multiparametric assessment resulted the optimal therapeutic strategy.

Biological versus mechanical aortic valve replacement in non-elderly patients: a single-centre analysis of clinical outcomes and quality of life

OBJECTIVES

The aim of this study was to evaluate short- and long-term clinical outcomes, including the perceived health-related quality of life, in patients younger than 65 years having undergone aortic valve replacement either with biological or mechanical valve prostheses.

METHODS

Between 2002 and 2013, 242 consecutive patients <65 years of age underwent isolated aortic valve replacement at our institution, either with biological (n = 134, 55.4%) or mechanical (n = 108, 44.6%) prostheses. Survival, health-related quality of life, short- and long-term clinical outcomes and echocardiographic data were analysed with a retrospective, single-centre study. Propensity matching was performed.

RESULTS

No significant difference in survival was found between the 2 groups (mechanical versus biological: 100% vs 96.6% at 1 year, 98.2% vs 93.1% at 5 years and 92.3% vs 83.4% at 10 years after surgery, P = 0.091). For all the interviewed patients (n = 161, 66.5%), perceived quality of life at the latest follow-up was excellent. Need for reoperation was higher in the bioprosthetic group (8% vs 0%, P = 0.995), whereas the rate of major bleedings was higher in the mechanical valve group (3% vs 20%, P = 0.094). The mean and maximum transvalvular pressure gradients were 20.5 ± 9.7 and 37.4 ± 17.5 mmHg in the biological group and 14.8 ± 4.8 and 26.6 ± 9.2 mmHg in the mechanical group (P = 0.014).

CONCLUSIONS

No significant differences were found between biological and mechanical valves in terms of patients' survival, clinical outcomes and quality of life. Mean and maximum transvalvular pressure gradients were significantly higher in the biological group. The majority of patients would opt for the same prosthesis type, if asked to choose again.

Using Wearable Devices to Monitor Physical Activity in Patients Undergoing Aortic Valve Replacement: Protocol for a Prospective Observational Study

Background

In last few decades, several tools have been developed to measure physical function objectively; however, their use has not been well established in clinical practice.

Objective

This study aims to describe the preoperative physical function and to assess and compare 6-month postoperative changes in the physical function of patients undergoing treatment for aortic stenosis with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). The study also aims to evaluate the feasibility of wearable devices in assessing physical function in such patients.

Methods

This is a prospective observational study. The enrollment will be conducted 1 month before patients’ SAVR/TAVR. Patients will be provided with the wearable device at baseline (activity tracker device, Garmin vívoactive 3). They will be trained in the use of the device, and they will be requested to wear it on the wrist of their preferred hand until 12 months after SAVR/TAVR. After baseline assessment, they will undergo 4 follow-up assessments at 1, 3, 6, and 12 months after SAVR/TAVR. At baseline and each follow-up, they will undergo a set of standard and validated tests to assess physical function, health-related quality of life, and sleep quality.

Results

The ethics committee of Vicenza in Veneto Region in Italy approved the study (Protocol No. 943; January 4, 2019). As of October 2020, the enrollment of participants is ongoing.

Conclusions

The use of the wearable devices for real-time monitoring of physical activity of patients undergoing aortic valve replacement is a promising opportunity for improving the clinical management and consequently, the health outcomes of such patients.

Trial Registration

Clinicaltrials.gov NCT03843320; https://tinyurl.com/yyareu5y

International Registered Report Identifier (IRRID)

DERR1-10.2196/20072

Showing behavior in Animal Assisted Intervention and pet dogs

A dog's behavior can indicate the location of hidden food to a human who is unaware of its position. These behavioral patterns are known as showing behavior, which comprise gazing towards the target location and gaze alternation between the human and the target (i.e., hidden food). Although this ability has been extensively studied in pet dogs, research has not yet focused on dogs with other kinds of life experiences, such as dogs working in Animal Assisted Interventions (AAI). These dogs are exposed to novel environments under the guidance of their handlers and previous studies have highlighted the importance of gazing behavior in this population. Therefore, we evaluated AAI and pet dogs on a showing task. Results indicate that dogs overall engaged in showing behavior as they gazed more towards the baited pot and alternated their gaze more on showing trials than control ones. Contrary to our expectations, differences between AAI and pet dogs were minimal. However, owners of AAI dogs were more successful than owners of pet dogs in finding the hidden food in showing trials. This suggests they may be more skillful in reading their dogs' behavior, which can be crucial to ensure their welfare during AAI sessions.

A comparison of quality of life and psychological distress in heart transplantation patients at adult and pediatric ages

BACKGROUND

The aim of the current study was to evaluate and compare the quality of life (QOL) and psychological status of adult patients who underwent heart transplant (HTx) at pediatric or adult ages.

METHODS

The population consisted of two groups: patients who received HTx after 18 years old and pediatrics who received HTx between the age of 1 and 18 years. At the time of the study, all patients were over 18 years old. QOL data were collected from patients using 36-item Short-Form Health Survey (SF-36) and psychological distress by the Symptom checklist 90-revised questionnaire (SCL-90-R).

RESULTS

A total of 232 HTx patients were evaluated; 217 were transplanted at an adult age and 15 at a pediatric one. QOL improved significantly in pediatrics patients in the general health perceptions subscale and physical pain subscale than adult patients. The Global Index of the psychological distress did not differ in the two groups, but the pediatric patients registered statistically significant higher scores on the interpersonal sensitivity symptom subscale (adult group 36 ± 0.42 vs pediatric group 81 ± 0.79), the hostility subscale (adult group m 39 ± 0.44 vs pediatric group 73 ± 0.76) and the paranoid ideation subscale (adult group 46 ± 0.46 vs pediatric group 96 ± 1.02).

CONCLUSION

The pediatric heart recipients showed better quality of life, but they show marked sensitivity, hostility and paranoid ideation which increases the risk of mental distress and therefore their adherence to medical treatment.

Gazing as a help requesting behavior: a comparison of dogs participating in animal-assisted interventions and pet dogs

Dogs tend to gaze at humans when they are confronted with inaccessible food during an unsolvable task, which is often interpreted as a help requesting behavior. Dogs who participate in animal-assisted interventions (AAI) interact with many people during their lives and prior studies have emphasized the importance of gazing in their communication. We compared the behavior of AAI (n = 15) and pet (n = 16) dogs during an unsolvable task, using a container fixed to a wooden board with inaccessible food inside, while the owner and an unfamiliar woman stood facing each other at the sides of the board ignoring the dog. Results showed that AAI dogs spent significantly more time gazing and alternated their gaze more frequently between the container and the people than pet dogs. In addition, they spent more time in contact with the unfamiliar person. However, no significant differences were found in the time dogs of either group gazed towards the owner compared to the unfamiliar person, in the frequency of gaze alternation or in the time spent interacting with the apparatus. In line with prior studies, these results suggest that gazing may be a significant communicative response in AAI dogs, which could probably contribute to having a better coordination with their handler. A greater understanding of the characteristics of this population may aid the selection and training of AAI dogs, which is particularly relevant given the increased popularity of AAI nowadays.

Do dogs experience frustration? New contributions on successive negative contrast in domestic dogs (Canis familiaris)

An unexpected change in reward quantity or quality frequently elicits a sharp decrease of responses as well as a negative emotional state. This phenomenon is called successive negative contrast (SNC) and, although it has been observed in numerous mammals, results in dogs have been inconsistent. The aim of this study was to evaluate SNC in dogs, comparing the effects of rewards of different qualities in a non-social task carried out in the dogs' usual environment. Dogs were separated into two experimental groups that experienced a downshift from a high quality reward (liver or sausage) to a low quality one (dry food), as well as a control group that always received dry food. The task involved a dog toy with bone shaped pieces that had to be removed to get the food hidden underneath. When the reward changed from liver to dry food, dogs picked up significantly fewer bones than the control group. However, this effect was not observed with sausage. Results show SNC in dogs in a non-social task carried out in their home environment. Additionally, the importance of the discrepancy in the hedonic value of the rewards is highlighted.

Thoughts modulate the expression of inflammatory genes and may improve the coronary blood flow in patients after a myocardial infarction

BACKGROUND

Mental stress is one of the main risk factors for cardiovascular disease. Meditation and music listening are two techniques that are able to counteract it through the activation of specific brain areas, eliciting the so-called Relaxing Response (RR). Epidemiological evidence reveals that the RR practice has a beneficial prognostic impact on patients after myocardial infarction. We aimed to study the possible molecular mechanisms of RR underlying these findings.

METHODS

We enrolled 30 consecutive patients after myocardial infarction and 10 healthy controls. 10 patients were taught to meditate, 10 to appreciate music and 10 did not carry out any intervention and served as controls. After training, and after 60 days of RR practice, we studied the individual variations, before and after the relaxation sessions, of the vital signs, the electrocardiographic and echocardiographic parameters along with coronary flow reserve (CFR) and the carotid's intima media thickness (IMT). Neuro-endocrine-immune (NEI) messengers and the expression of inflammatory genes (p53, Nuclear factor Kappa B (NfKB), and toll like receptor 4 (TLR4)) in circulating peripheral blood mononuclear cells were also all observed.

RESULTS

The RR results in a reduction of NEI molecules (p < 0.05) and oxidative stress (p < 0.001). The expression of the genes p53, NFkB and TLR4 is reduced after the RR and also at 60 days (p < 0.001). The CFR increases with the relaxation (p < 0.001) and the IMT regressed significantly (p < 0.001) after 6 months of RR practice.

CONCLUSIONS

The RR helps to advantageously modulate the expression of inflammatory genes through a cascade of NEI messengers improving, over time, microvascular function and the arteriosclerotic process.

Clinical psychological and neuropsychological issues with left ventricular assist devices (LVADs)

BACKGROUND

Left ventricular assist devices (LVADs) are increasingly being used to treat patients in end-stage heart failure (HF) as bridge-to-transplantation, lifetime support or destination therapy. However, the importance of this newer technique for chronic cardiac support compared to heart transplantation is still open to discussion. To date, there are few studies that extensively explore the psychological and cognitive profiles of patient with ventricular assist devices (VADs).

METHODS

We studied the psychological aspects, quality of life (QOL) and cognitive profiles of 19 patients with HF before VAD implantation and then at two, five and 16 months post-implantation.

RESULTS

Our results showed that after VAD implantation, patients did not show any psychopathological problems such as anxiety and/or depression. More interestingly, despite the constant risk of neurological events determined by the continuous-blood-flow pump (CBFP), patients' cognitive functioning did not worsen. In fact, significant enhancements were observed over time.

CONCLUSIONS

Psychological and cognitive deficits are common in advanced HF and often worsen over time. Appropriately designed and randomized studies are needed to demonstrate whether earlier VAD implantation is warranted to arrest cognitive decline and encourage better post-implantation adaptation.

How much and for how long does the neonatal myocardium suffer from mild perinatal asphyxia?

Cardiac troponins can be useful in monitoring cardiac injury following perinatal distress. We report here an increase of cardiac troponin I (cTnI) to 2.84 microg/l at 3 weeks (age-related median: 0.07 microg/l) followed by normalization in a newborn with an uneventful clinical course after resuscitation at birth. Serial echocardiographs showed normal cardiac function. Such a time course of cTnI, not previously reported, could be due to either a greater sensitivity of biochemical markers than of instrumental tools or birth asphyxia. Larger studies are needed

Long-term outcome after senning operation for transposition of the great arteries

BACKGROUND

The Senning operation for transposition of the great arteries (TGA) was first introduced by Senning in 1959 and was revived by Quaegebeur et al. in the late 1970s, thus becoming the intervention of choice for the correction of TGA in many centers.

HYPOTHESIS

The purpose of this study was to evaluate the long-term follow-up of a group of patients undergoing surgery with the Senning procedure for TGA.

METHODS

From November 1978 to November 1987, 73 consecutive patients underwent the Senning operation. The 70 survivors had an average follow-up of 19 years (16-25 years).

RESULTS

(1) Cardiac rhythm: with time there was a progressive decrease in stable sinus rhythm (60% after 20 years) and a progressive increase of supraventricular tachyarrhythmias requiring therapy (10% after 20 years). (2) Right ventricular function: 20% of the patients had reduced ejection fraction. (3) Late mortality: in the last 12 years of follow-up years there were two sudden deaths (2.8%). (4) Functional status: 80% of patients were in NYHA class I, 17% in class II, and 3% in class III.

CONCLUSIONS

Our results confirm that the patients who undergo the Senning procedure have a progressive loss of sinus rhythm, an increase in active arrhythmias, and other important adverse outcomes such as late sudden death and a decrease in right ventricular function; however, most patients (93% in our series) are alive and in good functional status.

[A neonatal case of congenital myotonic dystrophy]

Congenital myotonic dystrophy is a rare autosomal disease, caused by an increased number of cytosine-thymine-guanine (CTG) trinucleotide on chromosome 19q. In the neonatal period the most peculiar clinical features are arthrogryposis, hypotonia, facial diplegia, respiratory and feeding difficulties. Clinical and electrical myotonic discharges are difficult to elicit in the newborn. We report a case of congenital myotonic dystrophy in a female newly born presenting with hypotonia, diaphragmatic paralysis, facial diplegia, and contractures of hips, knees and ankles. The diagnosis was confirmed by genetical study on lymphocyte DNA.

[Neurologic outcome in infants surgically treated for congenital cardiopathy: preliminary data]

INTRODUCTION

Both surgical techniques for correction of congenital heart diseases (CHD) and intraoperatory neurologic protection improved during the last 20 years. Nevertheless cardiac surgery is still a risk for neurologic morbidity.

METHODS AND PATIENTS

Analysis of the postoperative neurologic status of infants younger than 6 months who underwent cardiac surgery from January 1998 to December 1999. We reviewed the EEG tracings, cranial ultrasound reports (CUS) and CT scans of 48 patients. Diagnoses were: ventricular septal defect = 15, Fallot (TOF) = 9, patent ductus arteriosus (PDA) = 5, coarctation of aorta = 4, atrio-ventricular septal defect = 4, transposition of great arteries (TGA) = 3, hypoplastic left heart syndrome = 2, pulmonary atresia = 2, total anomalous pulmonary veins drainage = 2, double outlet right ventricle = 1, cor triatriatum = 1. Mean age (range) at intervention was 54 days (2-150), 44 infants (91.7%) survived at follow-up: 23 EEG, 22 CUS and 2 CT were performed in the recent postoperative. Among survivors 5/44 had neurologic complications. EEG was altered in 4: two of them (1 TOF, 1 TGA) had pathologic CUS and CT as well (ischemic pattern in the former, atrophy in the latter). Finally a preterm newborn with PDA had mild abnormalities at CUS. After a mean follow-up of 16 +/- 6 months 3/5 patients had mild-to-moderate psychomotor delay and 2 recovered.

CONCLUSIONS

According to our preliminary data the prevalence of neurologic complications in infants who undergo cardiac surgery seems to be low. The pathological findings of the recent postoperative seem to recover up to normalization in some cases at mid-term follow-up. As expected, permanent complications effect more often complex CHD. Further follow-up studies to school age will be mandatory to check the very final results of cardiac surgery performed during early infancy.

[Positioning of umbilical vein catheter with ECG-guided technique: randomized study]

GOAL

To evaluate the effectiveness of electrocardiography-guided technique to aid in the correct positioning of umbilical vein catheters.

DESIGN

A prospective, randomized controlled study.

METHODS

Term and preterm newborns who required an umbilical venous catheter were managed by an ECG-guided technique (group A) or by a conventional method (group B). Correct positioning was defined by a chest-X-ray when the catheter tip was located above the diaphragm and outside the right atrium. For the ECG-guided technique we utilized a conductive device Vygocard (Medival, Padova) inserted in a 3-way stopcock connected with the catheter. The catheter was inserted under ECG observation until the appearance of a tall P-wave in lead III, which indicated the tip was within the right atrium. The catheter was then withdrawn until the P wave size returned to normal.

RESULTS

We enrolled 44 patients (16 F, 28 M). Median gestational age (GA) and birth weight (BW) were 34 weeks (range 26-41) and 2130 g. (590-3870), respectively. Sex distribution, GA, BW and Apgar scores were not different between patients in group A (n = 22) and group B (n = 22). Catheters could not be advanced till the estimated insertion depth in 11 patients (A = 5, B = 6). In the remaining 33 patients, correct tip placement was more frequent in group A (88%) compared with group B (50%) (p = 0.021 by Fisher's exact test). No side effects specific to the ECG-guided method were noted.

CONCLUSIONS

The ECG-guided technique seems to be a safe and effective method for the proper placement of umbilical vein catheters in newborns.

The role of surgery in the treatment of gastrointestinal lymphomas other than low-grade MALT lymphomas

BACKGROUND AND OBJECTIVE

A bias in clinical investigations on gastrointestinal lymphomas is the lack of testing the intention to treat as to resection, emergency conditions at presentation and selection brought about by the evaluation of feasibility of surgery.

DESIGN AND METHODS

A prospective study involved 154 patients with gastrointestinal nodular or high-grade MALT lymphomas, 111 with a gastric and 43 with an intestinal presentation. The decision to resect or treat conservatively was left to clinicians, on condition that it was previously defined for each patient.

RESULTS

Failure-free survival was significantly higher in the 106 resected patients than in the 48 unresected ones but did not differ according to either primary intention to treat or emergency surgery/elective treatment. Survival was similar in patients operated on by choice and in those because of an emergency. Intentionally unresected patients had a significantly better survival than those not undergoing surgery despite the initial intention, for a number of clinical reasons. Patients with gastric lymphoma survived longer than those with intestinal disease and prognostic factors were analyzed separately in the two groups. The best predictors of prognosis were performance status and serum lactic dehydrogenase level in gastric lymphomas, resection alone in intestinal ones.

INTERPRETATION AND CONCLUSIONS

The prognosis of gastric lymphomas depends on lymphoma-related factors and not on surgical treatment. The prognosis of intestinal ones is exclusively related to surgery. These data support the appropriateness of different clinical approaches to gastric and intestinal lymphomas.

[Nutrition in the first months of life with a new formula containing maltodextrins and enriched with long-chain fatty acids]

According to the recent acquisition about the biochemical properties of the carbohydrates contained in human milk, the addition of maltodextrins to infant formulas became recommended. We refer about the preliminary data of the first utilization of a new formula (Aptamil 1 "Nuova Formula") in which both maltodextrins and Long Chain Fatty Acids are added. Sixty-seven infants were enrolled to the study for the first 4 months of life. Forty-three of them (64%) completed the study and were grouped as follows: Group 1 = 15 subjects exclusively formula-fed (4F, 11M), Group 2 = 21 infants with mixed feeding (breast + formula), Group 3 = 7 cases in which Aptamil 1 "Nuova Formula" substituted another formula (4F, 3M). Auxologic parameters (weight, length, head circumference) were among the normal standard limits according to the percentile charts of the Boston Children's Medical Center. All infants enjoyed the taste of the milk we tested. The food regimen was changed in 4/67 (6%) infants because of alimentary intolerance suspicion but 2/4 infants were subsequently fed with soya milk formula and with an "hypoallergenic" milk respectively, the other 2 continued with another formula. The weight growth chart in infants of Group 1 tended to bend down a little bit between the 3rd and 4th month, reminding the breast-fed infants behavior. Considering the daily milk volume assumed by the same subjects, we found a statistical difference (p < or = 0.01) between the volumes of milk assumed in the 2nd and the 3rd month of life but from the 3rd to the 4th month there was no statistical difference in daily milk volumes. This resembles the breast-fed infants behavior as well. According to our preliminary results the new milk formula we tested seems a very good substitute when an infant can't be breast-fed for any reason.

[Dermatitis herpetiformis and latent celiac disease in two siblings]

The association between coeliac disease (CD) and dermatitis herpetiformis (DH) is well known. Moreover, this cutaneous disease may be the only sign of an otherwise asymptomatic CD. Subjects presenting with both CD and DH generally show an HLA pattern in which A1, B8, DR2, DR7, DQw2 are the most frequent antigens one can find. We report about 2 brothers presenting with DH, clinically asymptomatic, without antigliadin serum antibodies (AGA), but positive to the research of antiendomysial (EMA) ones. The biopsy performed by digestive endoscopy showed a complete atrophy of duodenal villi and the diagnosis of CD was confirmed according to the European Society for Pediatric Gastroenterology and Nutrition (ESPGAN) criteria. The diet without gluten caused the DH to recovery and the duodenal villi microscopic aspect to normalize as well. Both the brothers had the same HLA pattern: A1, B8, DR3-DR2, DQw2. Our clinical study suggests that it is very important, especially for the general practitioner, to recognize a DH and in every child presenting with a dermatitis like that it will be mandatory to perform a laboratory research of both AGA and EMA.

[Heart transplant: an emotional storm for the child and his family]

The purpose of the present study was a psychological analysis of the emotional state of a family awaiting heart transplantation. Current practice suggests that such emotional reaction is characterized by mixed and contradictory feelings which require further investigation. Subjects were 5 children waiting for transplant and 5 with previous transplant. Methods were: 1) open interview with children and parents; 2) projective drawing test for children (Corman family test, H.T.P., L.A.D.S., M.U.C.T., K.F.D.); 3) "palinomas" questionnaire which investigates: awareness of the illness, child relation with the food, feelings of competence and control, self-esteem and perception of the self. "Palinomas" was created in Italy by a hospital psychological team in order to give a chance to the child to talk about himself and to maintain control over the situation. The information we obtained by "palinomas" revealed to be very useful to understand the personality of the child through the main areas reported above. Within the limits of an introductory study, results indicate that family needs an active psychological support in order to develop a more positive attitude.

Ploidy and proliferative activity measurement by flow cytometry in non-Hodgkin's lymphomas. Do speculative aspects prevail over clinical ones?

Paraffin-embedded lymph node biopsies from 107 patients with newly diagnosed non-Hodgkin's lymphomas were examined for cell DNA content and proliferative activity (as percentage of S-phase cells) by means of flow cytometry. Patients were diagnosed between 1975 and 1985 and were homogeneously treated according to the grade of histologic malignancy. Cytofluorimetric data were studied with regard to their correlation with histology (classified and reviewed according to both Kiel and Working Formulation criteria), clinical stage, presence of constitutional symptoms, presence of bulky disease, sex, age, and the following laboratory data measured at diagnosis: erythrocyte sedimentation rate, hemoglobin, serum lactic dehydrogenase and serum albumin concentration. Aneuploidy was more frequent in the high grade malignant subtypes and in the miscellaneous group but showed no correlations with the other clinical parameters studied. Proliferative activity demonstrated a wide variation of data but a trend was evident toward higher proliferative values in the more severe histologic subtypes. The survival discrimination allowed by high- and low-grade malignant histology is exactly reproduced when highly and slowly proliferating lymphomas are considered (greater than or less than or equal to 12% of S-phase cells). These results, analyzed with those in the literature, suggest that measurements of ploidy and proliferative activity add little independent information to what is already provided by current histologic classifications, mainly as far as clinical evaluation and prognosis are concerned. Cytokinetic-aided therapeutic choices can be usefully proposed in a restricted number of cases. Improvement of the available lymphoma classifications through a better integration of ploidy and cytokinetic data with immunologic, genetic and histologic findings is still an object to be pursued in cytometric studies.

Increasing interdependency of prognosis- and therapy-related factors in Hodgkin's disease

Two subsequent series of patients with Hodgkin's disease (HD) treated according to different therapeutic plans were compared: the study made it possible to analyze the role played by therapy in influencing the individual importance of a group of well-known prognostic factors. Study 1 concerned 667 patients treated in the period 1971-1979 without special measures for mediastinal bulky disease and with four-drug chemotherapy regimens (MOPP, COPP, ABVD) for stage B or IV. Study 2 included 220 patients treated between 1980 and 1984 with combined sandwich chemoradiotherapy when mediastinal bulk was present, and with eight-drug alternating chemotherapy regimens for stages B or IV (MOPP/ABVD, CcVPP/ABVD). Distribution of epidemiologic and clinical characteristics as well as staging accuracy were comparable in the two series. Only sex, serum albumin at onset and success or failure in achieving complete remission showed the same ability to discriminate survival in both studies. Age, stage and histology retained a reduced role in Study 2, where it was found they could be handled as binary variables, i.e. more or less than 50 years of age, stage IV or other stages, lymphocyte depletion histotype or other types. The influence of B symptoms on survival was sharply decreased in patients treated with alternating chemotherapy regimens, whereas combined sandwich therapy showed a truly leveling effect on the role of mediastinal bulk, which has to be considered a very unfavorable factor with other treatments. In HD the evaluation of clinical findings with respect to their impact on prognosis is crucial for validating and graduating the staging process, and for matching the intensity of the therapy to the needs of the patient. The ongoing evolution in the roles of single prognostic factors due to therapy needs periodic reevaluation for proper adjustments of therapeutic strategies.

Preliminary report on activity and tolerability of epomediol, administered by intravenous infusion, in patients with chronic hepatopathies

The therapeutic activity and tolerability of epomediol were studied in 28 patients with chronic hepatopathies. Treatment was continued, parenterally, for 10 days (400-600 mg once daily by intravenous infusion). Clinical parameters (headache, right hypochondrial pain, bitter taste in the mouth, asthenia and nausea) and hepatic function (transaminase, alkaline phosphatase and gamma-glutamyl transpeptidase) showed significant improvements. Clinical and systemic tolerabilities of epomediol were satisfactory.

Hodgkin's disease prognosis: a directly predictive equation

586 patients with Hodgkin's disease diagnosed between 1970 and 1979 were staged and treated in the same way. Multivariate analysis was used to delineate the prognostic roles of several clinical features at diagnosis. A multiple regression analysis was applied to an exponential model for survival-time distribution, which proved to fit the data accurately. Several clinical characteristics were studied and those that could singly discriminate survival significantly were chosen as predictive variables for the multiple regression. These were: sex, age, stage, histological subtype, presence of constitutional symptoms, mediastinal mass, and erythrocyte sedimentation rate (ESR), and haemoglobin and serum albumin concentrations. ESR, stage, histological subtype, and age proved to be the best prognostic factors, while sex and albumin had minor value. The presence of symptoms, mediastinal bulk, and haemoglobin were not so important. A linear equation for the six variables was derived to calculate the estimated median survival time for any given patient. This equation was validated on an external group of 179 similar patients.

[Persistent supraventricular tachycardia in childhood]

Persistent or chronic supraventricular tachycardia is defined as the one occurring in more than 10% of cardiac rhythm during 24 hours. It may begin at any age, persisting months or years, and frequently it is discovered occasionally because it can be asymptomatic. The persistent supraventricular tachycardia (PSVT) represents 20-30% of all supraventricular tachycardias in pediatric age. The two main forms of PSVT are: atrial ectopic tachycardia, and persistent junctional reciprocating tachycardia (PJRT). The authors present 9 cases of children affected by PJRT seen from 1972 to 1985. They discuss the clinical course (mean follow up = 9.5 years), the pharmacologic treatment, the results obtained. They underline the particular resistance to conventional antiarrhythmic therapy of this form. On the other hand an antiarrhythmic treatment is recommended to avoid the risk of congestive heart failure. Nevertheless the prognosis is considered benign because in the majority of cases this type of arrhythmia disappears later on.

[Dilated cardiomyopathy due to primary carnitine deficiency]

A case of a 3 and a half years old girl with severe congestive heart failure, and typical picture of dilated cardiomyopathy is presented. The serum level of carnitine (17.2 micromoles/l, versus 44.1 +/- 12.2 micromoles/l, normal value for age) and the histologic and biochemical evaluation of quadriceps muscle tissue confirmed the diagnosis of primary deficit of carnitine. L-carnitine (2 gr. three times a day p.o.) was added to anti-congestive therapy. After 8 weeks of therapy, the general and cardiocirculatory conditions are much improved. The physiopathology of dilated cardiomyopathy due to deficit of carnitine are discussed. An early diagnosis, and an early substitutive therapy with L-carnitine dramatically improve the outcome of the disease.

Reevaluation of prognostic significance of symptoms in Hodgkin's disease

The prognostic value--at diagnosis--of fever, sweating and weight loss, which enter the Ann Arbor B category, and of pruritus, whose influence on survival is still debated, were systematically reevaluated in 635 patients with Hodgkin's disease, observed between 1972 and 1982. By means of multivariate analysis an intrinsic, more negative prognostic value was demonstrated for each of the following symptoms: fever over 38 degrees C, weight loss more than 10% of body weight in the 6 months before admission, and severe pruritus, which is defined as being generalized, causing multiple excoriations and resisting local and systemic antipruritics. Patients with the mild counterparts of these symptoms, as well as sweats, were found to have a survival rate quite comparable with that of fully asymptomatic patients. A rearrangement of the Ann Arbor B constitutional symptoms which would replace sweats with severe pruritus might be more correct and more suitable for better selecting the patients who require more aggressive therapy.