Latent Tuberculosis Infection and COVID-19: Analysis of a Cohort of Patients from Careggi University Hospital (Florence, Italy)

Data regarding the relationship between coronavirus disease (COVID-19) and active or latent tuberculosis (TB) are discordant. We conducted a retrospective study examining the impact of latent tuberculosis infection (LTBI) on the clinical progression of COVID-19 patients. We selected 213 patients admitted with COVID-19 in a tertiary-level Italian hospital (February-December 2020), who underwent a QuantiFERON-TB test (QFT) and/or chest radiological exam. The population was divided into three groups: (i) QFT negative and without radiological TB sequelae (Neg); (ii) QFT positive and without radiological TB sequelae (Pos); (iii) radiological TB sequelae regardless of QFT result (Seq). In-hospital mortality and oro-tracheal intubation (OTI) showed significantly higher results in the Seq group (Seq 50% vs. Pos 13.3% vs. Neg 9.3%, p < 0.001; Seq 16.7% vs. Pos 6.7% vs. Neg 4.9%, p = 0.045). Considering the Pos and Seq groups' patients as the population with defined LTBI, in-hospital mortality (20/51, 39.2%) and OTI risk (7/51, 13.7%) were statistically higher with respect to patients without LTBI (in-hospital mortality: 15/162, 9.3%, p < 0.001; OTI risk: 8/162, 4.9%, p = 0.023), respectively. Multivariate analysis showed that radiological sequelae and the Charlson Comorbidity Index (CCI) were significantly associated with higher mortality rate; despite the higher CCI of Seq population, we cannot exclude the correlation between COVID-19 in-hospital mortality and the presence of radiological TB sequelae.

Primary Lymphoproliferative Lung Diseases: Imaging and Multidisciplinary Approach

Lymphoproliferative lung diseases are a heterogeneous group of disorders characterized by primary or secondary involvement of the lung. Primary pulmonary lymphomas are the most common type, representing 0.5–1% of all primary malignancies of the lung. The radiological presentation is often heterogeneous and non-specific: consolidations, masses, and nodules are the most common findings, followed by ground-glass opacities and interstitial involvement, more common in secondary lung lymphomas. These findings usually show a prevalent perilymphatic spread along bronchovascular bundles, without a prevalence in the upper or lower lung lobes. An ancillary sign, such as a “halo sign”, “reverse halo sign”, air bronchogram, or CT angiogram sign, may be present and can help rule out a differential diagnosis. Since a wide spectrum of pulmonary parenchymal diseases may mimic lymphoma, a correct clinical evaluation and a multidisciplinary approach are mandatory. In this sense, despite High-Resolution Computer Tomography (HRCT) representing the gold standard, a tissue sample is needed for a certain and definitive diagnosis. Cryobiopsy is a relatively new technique that permits the obtaining of a larger amount of tissue without significant artifacts, and is less invasive and more precise than surgical biopsy.

Vascular tree-in-bud sign in Pulmonary Tumour Thrombotic Microangiopathy (PTTM): CT findings for a difficult radiological early antemortem diagnosis

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A Home-Treatment Algorithm Based on Anti-inflammatory Drugs to Prevent Hospitalization of Patients With Early COVID-19: A Matched-Cohort Study (COVER 2)

Background and Aim

While considerable success has been achieved in the management of patients hospitalized with severe coronavirus disease 2019 (COVID-19), far less progress has been made with early outpatient treatment. We assessed whether the implementation of a home treatment algorithm—designed based on a pathophysiologic and pharmacologic rationale—and including non-steroidal anti-inflammatory drugs, especially relatively selective cyclooxygenase-2 inhibitors and, when needed, corticosteroids, anticoagulants, oxygen therapy and antibiotics—at the very onset of mild COVID-19 symptoms could effectively reduce hospital admissions.

Methods

This fully academic, matched-cohort study evaluated outcomes in 108 consecutive consenting patients with mild COVID-19, managed at home by their family doctors between January 2021 and May 2021, according to the proposed treatment algorithm and in 108 age-, sex-, and comorbidities-matched patients on other therapeutic schedules (ClinicalTrials.gov: NCT04854824). The primary outcome was COVID-19-related hospitalization. Analyses were by intention-to-treat.

Results

One (0.9%) patient in the “recommended” cohort and 12 (11.1%) in the “control” cohort were admitted to hospital (P = 0.0136). The proposed algorithm reduced the cumulative length of hospital stays by 85% (from 141 to 19 days) as well as related costs (from €60.316 to €9.058). Only 9.8 patients needed to be treated with the recommended algorithm to prevent one hospitalization event. The rate of resolution of major symptoms was numerically—but not significantly—higher in the “recommended” than in the “control” cohort (97.2 vs. 93.5%, respectively; P = 0.322). Other symptoms lingered in a smaller proportion of patients in the “recommended” than in the “control” cohort (20.4 vs. 63.9%, respectively; P &lt; 0.001), and for a shorter period.

Conclusion

The adoption of the proposed outpatient treatment algorithm during the early, mild phase of COVID-19 reduced the incidence of subsequent hospitalization and related costs.

A simple, home-therapy algorithm to prevent hospitalisation for COVID-19 patients: A retrospective observational matched-cohort study

BACKGROUND

Effective home treatment algorithms implemented based on a pathophysiologic and pharmacologic rationale to accelerate recovery and prevent hospitalisation of patients with early coronavirus disease 2019 (COVID-19) would have major implications for patients and health system.

METHODS

This academic, matched-cohort study compared outcomes of 90 consecutive consenting patients with mild COVID-19 treated at home by their family physicians between October 2020 and January 2021 in Northern and Central Italy, according to the proposed recommendation algorithm, with outcomes for 90 age-, sex-, and comorbidities-matched patients who received other therapeutic regimens. Primary outcome was time to resolution of major symptoms. Secondary outcomes included prevention of hospitalisation. Analyses were by intention-to-treat.

FINDINGS

All patients achieved complete remission. The median [IQR] time to resolution of major symptoms was 18 [14-23] days in the 'recommended schedule' cohort and 14 [7-30] days in the matched 'control' cohort (p = 0·033). Other symptoms persisted in a lower percentage of patients in the 'recommended' than in the 'control' cohort (23·3% versus 73·3%, respectively, p<0·0001) and for a shorter period (p = 0·0107). Two patients in the 'recommended' cohort were hospitalised compared to 13 (14·4%) controls (p = 0·0103). The prevention algorithm reduced the days and cumulative costs of hospitalisation by >90%.

INTERPRETATION

Implementation of an early home treatment algorithm failed to accelerate recovery from major symptoms of COVID-19, but reduced the risk of hospitalisation and related treatment costs. Given the study design, additional research would be required to consolidate the proposed treatment recommendations.

FUNDING

Fondazione Cav.Lav. Carlo Pesenti.

Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism

OBJECTIVES

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.

METHODS

This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.

RESULTS

The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.

CONCLUSION

CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Chest X-ray in the emergency department during COVID-19 pandemic descending phase in Italy: correlation with patients' outcome

PURPOSE

The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients' outcome.

MATERIALS AND METHODS

We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients' outcome.

RESULTS

CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients' outcome.

CONCLUSION

In our study, admission CXR showed a fair specificity and a good correlation with patients' outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Diagnostic accuracy of physician's gestalt in suspected COVID-19: Prospective bicentric study

Objectives

Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results.

Methods

From April 1 to April 30, 2020, patients with suspected COVID‐19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID‐19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x‐ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30‐day follow‐up data.

Results

Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID‐19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID‐19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT‐PCR had a sensitivity of 98.4% for COVID‐19 (p < 0.01 vs. RT‐PCR alone) compared to 95.9% for CG plus RT‐PCR (p = 0.05).

Conclusions

In suspected COVID‐19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT‐PCR plus low probability based on CBIIG can rule out COVID‐19 with a relatively low number of false‐negative cases.

Quantitative imaging decision support (QIDSTM) tool consistency evaluation and radiomic analysis by means of 594 metrics in lung carcinoma on chest CT scan

Objective:

To evaluate the consistency of the quantitative imaging decision support (QIDS^TM) tool and radiomic analysis using 594 metrics in lung carcinoma on chest CT scan.

Materials and Methods:

We included, retrospectively, 150 patients with histologically confirmed lung cancer who underwent chemotherapy and baseline and follow-ups CT scans. Using the QIDS^TM platform, 3 radiologists segmented each lesion and automatically collected the longest diameter and the density mean value. Inter-observer variability, Bland Altman analysis and Spearman’s correlation coefficient were performed. QIDS^TM tool consistency was assessed in terms of agreement rate in the treatment response classification. Kruskal Wallis test and the least absolute shrinkage and selection operator (LASSO) method with 10-fold cross validation were used to identify radiomic metrics correlated with lesion size change.

Results:

Good and significant correlation was obtained between the measurements of largest diameter and of density among the QIDS^TM tool and the radiologists measurements. Inter-observer variability values were over 0.85. HealthMyne QIDS^TM tool quantitative volumetric delineation was consistent and matched with each radiologist measurement considering the RECIST classification (80-84%) while a lower concordance among QIDS^TM and the radiologists CHOI classification was observed (58-63%). Among 594 extracted metrics, significant and robust predictors of RECIST response were energy, histogram entropy and uniformity, Kurtosis, coronal long axis, longest planar diameter, surface, Neighborhood Grey-Level Different Matrix (NGLDM) dependence nonuniformity and low dependence emphasis as Volume, entropy of Log(2.5 mm), wavelet energy, deviation and root man squared.

Conclusion:

In conclusion, we demonstrated that HealthMyne quantitative volumetric delineation was consistent and that several radiomic metrics extracted by QIDS^TM were significant and robust predictors of RECIST response.

Behçet disease in Emergency Department: a rare case presenting with haemoptysis and massive pulmonary arterial aneurysms

Behçet disease (BD) is a systemic disorder caused by underlying vasculitis of unknown origin. In this paper we present a case of a 26-year-old male patient who was admitted at our Emergency Department with massive haemoptysis due to pulmonary arterial involvement in BD. The discussion of this case helps to remember that BD is the main cause of aneurysm of the pulmonary arteries and a cause of haemoptysis in young patients. Therefore, the radiologist plays a key role in the identification of intrathoracic alterations with chest computed tomography. The knowledge of clinical manifestations and distinctive elements of BD allow an accurate diagnosis and let the patient to be directed towards an appropriate treatment, in order to avoid the onset of life-threatening complications.

Contribution of the neuropsychological assessment in concussion

INTRODUCTION

The neuropsychological assessment is a cornerstone in the care management of concussion or mild traumatic injury.

OBJECTIVE

To present the different stages of an exhaustive neuropsychological assessment exploring cognitive and behavioral domains.

METHOD

Description of the value of the main tests available for behavioral and cognitive assessment. The choice of tests is based on the clinical experience and expertise of the authors.

RESULTS

Questionnaires are mainly used to explore the behavioral sequelae (depression, anxiety or fatigue) and the impact of these potential difficulties in daily life. Four cognitive abilities could be impaired by concussion: attention, memory, visuospatial functions and executive functions. These abilities could be explored with "paper and pencil" tests or with computerized test batteries. While cognitive sequelae in the context of a moderate or a severe traumatic brain injury are consolidated, in the context of concussion, neuropsychological sequelae tend to resolve in a short time. As a consequence, several neuropsychological assessments could be conducting in a short period involving some methodological considerations. Moreover, as concussion could be reported in a Whiplash injury from a car crash with forensic consequences, it is crucial to propose tests to be sure that the weak performance obtained into the neuropsychological assessment is not explained by poor effort and/or malingering.

DISCUSSION/CONCLUSION

This article revises these aspects of a neuropsychological assessment in the specific context of concussion.

Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome

Aim

The purpose of this study is to describe the main chest radiological features (CXR) of COVID-19 and correlate them with clinical outcome.

Materials and methods

This is a retrospective study involving patients with clinical-epidemiological suspect of COVID-19 infection, who performed CXRs at the emergency department (ED) of our University Hospital from March 1 to March 31, 2020. All patients performed RT-PCR nasopharyngeal and throat swab, CXR at the ED and clinical-epidemiological data. RT-PCR results were considered the reference standard. The final outcome was expressed as discharged or hospitalized patients into a medicine department or intensive care unit (ICU).

Results

Patients that had a RT-PCR positive for COVID-19 infection were 234 in total: 153 males (65.4%) and 81 females (34.6%), with a mean age of 66.04 years (range 18–97 years). Thirteen CXRs were negative for radiological thoracic involvement (5.6%). The following alterations were more commonly observed: 135 patients with lung consolidations (57.7%), 147 (62.8%) with GGO, 55 (23.5%) with nodules and 156 (66.6%) with reticular–nodular opacities. Patients with consolidations and GGO coexistent in the same radiography were 35.5% of total. Peripheral (57.7%) and lower zone distribution (58.5%) were the most common predominance. Moreover, bilateral involvement (69.2%) was most frequent than unilateral one. Baseline CXR sensitivity in our experience is about 67.1%. The most affected patients were especially males in the age group 60–79 years old (45.95%, of which 71.57% males). RALE score was slightly higher in male than in female patients. ANOVA with Games-Howell post hoc showed significant differences of RALE scores for group 1 vs 3 (p < 0.001) and 2 vs 3 (p = 0.001). Inter-reader agreement in assigning RALE score was very good (ICC: 0.92—with 95% confidence interval 0.88–0.95).

Conclusion

In COVID-19, CXR shows patchy or diffuse reticular–nodular opacities and consolidation, with basal, peripheral and bilateral predominance. In our experience, baseline CXR had a sensitivity of 68.1%. The RALE score can be used in the emergency setting as a quantitative method of the extent of SARS-CoV-2 pneumonia, correlating with an increased risk of ICU admission.

Exogenous lipoid pneumonia: when radiologist makes the difference

PURPOSE

To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder.

MATERIALS AND METHODS

In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils.

RESULTS

In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5 cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations.

CONCLUSION

Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

Effects of losartan on left ventricular mass: a three-year follow-up in elderly hypertensives with myocardial hypertrophy despite successful conventional antihypertensive treatment

OBJECTIVE

Reversal of left ventricular hypertrophy (LVH) in hypertensive patients appears to be a desirable goal to the reduction cardiac risk. The Renin-Angiotensin System (RAS) seems to play a major role in the establishment and maintenance of LVH through the activated systemic RAS and the Intracardiac Angiotensin System (IAS). We focused on the effects of a three-year treatment with losartan supplement in hypertensive patients with LVH not responding to eight years of an effective previous antihypertensive pharmacological treatment.

PATIENTS AND METHODS

Two groups of 28 sex-, age- and therapy-matched subjects with essential hypertension and LVH were taken into consideration. The two groups were in effective pharmacological treatment (BP < 140/90) for eight years previous to their enrollment. Patients of Group A were treated for three years with a losartan (100 mg/die) on-top treatment, whereas patients of Group B continued the follow-up of the previous conventional therapy. Both groups were submitted to an echocardiographic follow-up.

RESULTS

Group A, showed a significant reduction of the mean LVH since the first step at six months with a further significant trend during the whole period (variance analysis: p < 0.001). Group B showed a non-significant trend toward LVH reduction during the three-year follow-up. No significant further reduction of systolic or diastolic blood pressure values was observed in both groups.

CONCLUSIONS

The effects of losartan in hypertensive and hypertrophic patients are in agreement with the results of LIFE Trial. However, the reduction of left ventricular hypertrophy in our patients seems to be related to changes inducted by losartan on the IAS, since no further hemodynamic effects were observed. Losartan induced both a significant reduction of LVH and an improvement of LV diastolic function with a subsequent expected beneficial shift on the prognosis.

The natural history of prehypertension. A 20-year follow-up

OBJECTIVE

According to the JNC7 report, prehypertension category includes subjects with systolic blood pressure between 120 and 139 mmHg and/or diastolic blood pressure between 80 and 89 mmHg that would be at risk for developing hypertension and its untoward sequelae as myocardial infarction and cerebrovascular disease. Moreover, ambulatory blood pressure monitoring made it possible to detect subjects with masked hypertension, who are at risk of greater target organ damage than those with normal ambulatory or home blood pressure. The aim of this study was to evaluate the risk of cardiac, cerebral and vascular events in a group of prehypertensive subjects, with and without masked hypertension.

PATIENTS AND METHODS

We studied 204 consecutive asymptomatic prehypertensive subjects without history and signs of cardiovascular disease or diabetes. All the subjects underwent clinical evaluation, electrocardiogram, routine laboratory tests and ambulatory blood pressure monitoring. They were followed-up for a maximum of 237 months or until a cardiovascular event occurred.

RESULTS

Twenty-seven cardiovascular events (13.2%) occurred, including 4 abdominal aortic aneurysms. Age (p<0.0001), total cholesterol (p=0.004), smoking (p=0.03) and clinically overt hypertension development (p=0.011) were related to cardiovascular events. Prognosis was not related to masked hypertension.

CONCLUSIONS

The results of this study suggest that, in subjects with prehypertension, followed for 20 years, traditional cardiovascular risk factors and development of clinically overt hypertension could be more relevant than ambulatory hypertension in the prediction of an adverse outcome.

Neuropsychological assessment and cerebral vascular disease: the new standards

Vascular cognitive impairment (VCI) includes vascular dementia (VaD), vascular mild cognitive impairment (VaMCI) and mixed dementia. In clinical practice, VCI concerns patients referred for clinical stroke or cognitive complaint. To improve the characterization of VCI and to refine its diagnostic criteria, an international group has elaborated a new standardized evaluation battery of clinical, cognitive, behavioral and neuroradiological data which now constitutes the reference battery. The adaption of the battery for French-speaking subjects is reported as well as preliminary results of the on-going validation study of the GRECOG-VASC group [Clinical Trial NCT01339195]. The diagnostic accuracy of various screening tests is reviewed and showed an overall sub-optimal sensitivity (<0.8). Thus, the general recommendation is to perform systematically a comprehensive assessment in stroke patients at risk of VCI. Furthermore,the use of a structured interview has been shown to increase the detection of dementia. In addition to the well known NINDS-AIREN criteria of VaD, criteria of VCI have been recently proposed which are based on the demonstration of a cognitive disorder by neuropsychological testing and either history of clinical stroke or presence of vascular lesion by neuroimaging suggestive of a link between cognitive impairment and vascular disease. A memory deficit is no longer required for the diagnosis of VaD as it is based on the cognitive decline concerning two or more domains that affect activities of daily living. Both VaMCI and VaD are classified as probable or possible. These new criteria have yet to be validated. Considerable uncertainties remain regarding the determinant of VCI, and especially the lesion amount inducing VCI and VaD. The interaction between lesion amount and its location is currently re-examined using recent techniques for the analysis of MRI data. The high frequency of associated Alzheimer pathology is now assessable in vivo using amyloid imaging. The first studies showed that about a third of patients with VaD due to small vessel disease or with poststroke dementia have amyloid PET imaging suggestive of AD. These new techniques will examine the interaction between vascular lesions and promotion of amyloid deposition. Although results of these on-going studies will be available in few years, these data indicate that efforts should be done in clinical practice to reduce underdiagnosis of VCI; VCI should be examined using a specific protocol which will be fully normalized soon for French-speaking patients; the sub-optimal sensitivity of screening tests prompts to use a structured interview to grade Rankin scale and to perform systematically a comprehensive assessment in stroke patients at risk of VCI; poststroke dementia occurring after 3 months poststroke may be preventable by treatment of modifiable vascular risk factors and secondary prevention of stroke recurrence according to recent recommendations.

Multi-point accelerometric detection and principal component analysis of heart sounds

Heart sounds are a fundamental physiological variable that provide a unique insight into cardiac semiotics. However a deterministic and unambiguous association between noises in cardiac dynamics is far from being accomplished yet due to many and different overlapping events which contribute to the acoustic emission. The current computer-based capacities in terms of signal detection and processing allow one to move from the standard cardiac auscultation, even in its improved forms like electronic stethoscopes or hi-tech phonocardiography, to the extraction of information on the cardiac activity previously unexplored. In this report, we present a new equipment for the detection of heart sounds, based on a set of accelerometric sensors placed in contact with the chest skin on the precordial area, and are able to measure simultaneously the vibration induced on the chest surface by the heart's mechanical activity. By utilizing advanced algorithms for the data treatment, such as wavelet decomposition and principal component analysis, we are able to condense the spatially extended acoustic information and to provide a synthetical representation of the heart activity. We applied our approach to 30 adults, mixed per gender, age and healthiness, and correlated our results with standard echocardiographic examinations. We obtained a 93% concordance rate with echocardiography between healthy and unhealthy hearts, including minor abnormalities such as mitral valve prolapse.

Genome-wide shRNA screen reveals increased mitochondrial dependence upon mTORC2 addiction

Release from growth factor dependence and acquisition of signalling pathway addiction are critical steps in oncogenesis. To identify genes required on mammalian target of rapamycin (mTOR) addiction, we performed a genome-wide short hairpin RNA screen on a v-H-ras-transformed Pten-deficient cell line that displayed two alternative growth modes, interleukin (IL)-3-independent/mTOR-addicted proliferation (transformed growth mode) and IL-3-dependent/mTOR-non-addicted proliferation (normal growth mode). We screened for genes required only in the absence of IL-3 and thus specifically for the transformed growth mode. The top 800 hits from this conditional lethal screen were analyzed in silico and 235 hits were subsequently rescreened in two additional Pten-deficient cell lines to generate a core set of 47 genes. Hits included genes encoding mTOR and the mTOR complex 2 (mTORC2) component rictor and several genes encoding mitochondrial functions including components of the respiratory chain, adenosine triphosphate synthase, the mitochondrial ribosome and mitochondrial fission factor. Small interfering RNA knockdown against a sizeable fraction of these genes triggered apoptosis in human cancer cell lines but not in normal fibroblasts. We conclude that mTORC2-addicted cells require mitochondrial functions that may be novel drug targets in human cancer.

Cognitive function and 99mTc-ECD brain SPECT are significantly correlated in patients with primary Sjögren syndrome: a case–control study

Objectives:

To assess subclinical central nervous system (CNS) involvement in primary Sjögren syndrome (pSS), by comparing standard brain MRI, in-depth neuropsychological testing and 99mTc-ECD brain single-photon emission computed tomography (SPECT) of patients with pSS with matched controls.

Methods:

10 women (<55 years old), with pSS defined using European–American criteria, presence of anti-SSA and/or anti-SSB antibodies and no history of neurological involvement were prospectively investigated, and compared with 10 age- and sex-matched controls. All subjects underwent, within 1 month, brain MRI, neuropsychological testing, including overall evaluation and focal cognitive function assessment, and 99mTc-ECD brain SPECT.

Results:

99mTc-ECD brain SPECT abnormalities were significantly more common in patients with pSS (10/10) than controls (2/10; p<0.05). Cognitive dysfunctions, mainly expressed as executive and visuospatial disorders, were also significantly more common in patients with pSS (8/10) than controls (0/10; p<0.01). Notably, between-group comparisons enabled a significant correlation to be established between neuropsychological assessment and 99mTc-ECD brain SPECT abnormalities in patients with pSS (rs = 0.49, p<0.01). MRI abnormalities in patients and controls did not differ significantly.

Conclusions:

Neuropsychological testing and 99mTc-ECD brain SPECT seem to be the most sensitive tools to detect subclinical CNS dysfunction in pSS. The strong correlation between cortical hypoperfusion in 99mTc-ECD brain SPECT and cognitive dysfunction suggests an organic aetiology of CNS dysfunction in pSS. These data should be confirmed in a larger study.

Nitric oxide and peroxynitrite platelet levels in women with small-for-gestational-age fetuses

OBJECTIVE

The placenta produces reactive oxygen species (ROS) including nitric oxide (NO) and peroxynitrite (ONOO(-)) that have pronounced effects on placental function. Excessive ROS production may occur in pathological pregnancies, such as those complicated by small-for-gestational-age (SGA) fetuses.

DESIGN

The aim of the present work was to study NO and ONOO(-) levels in platelets of pregnant women with SGA fetuses compared with a control group.

SETTING AND POPULATION

The study was performed on 30 pregnant women with SGA fetuses (SGA group) and on 30 healthy pregnant women (appropriate-for-gestational-age [AGA] group) matched for maternal and gestational age. All women included in this study were in the third trimester of pregnancy.

METHODS

Platelets were isolated by differential centrifugation. NO metabolites, after enzymatic conversion followed by the Griess reaction, were measured as nitrite by spectrophotometric detection. Peroxynitrite (ONOO(-)) levels were evaluated using the fluorescence probe 2,7-dichlorofluorescein diacetate (DCFDA).

MAIN OUTCOME MEASURES

The following determinations were made: platelet nitric oxide and peroxynitrite levels in the SGA group and controls; inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS) and nitrotyrosine (N-Tyr) expression in the same groups.

RESULTS

Our results show that both platelet NO and ONOO(-) levels were significantly higher in the SGA group than in the controls.

CONCLUSION

Increased platelets levels of nitric oxide and peroxynitrite might play a role in the pathophysiology of intrauterine growth restriction. Further investigations are in progress to clarify if these molecules are pathogenetic factors, an epiphenomenon or a pathophysiological marker.

Continuous antibiotic infusion for salvage therapy of partially implanted central venous catheter tunnel infections due to staphylococci

Tunnel infection is an uncommon but serious complication observed in patients with partially implanted central venous catheters. International guidelines suggest that should include antibiotics and catheter removal. A success rate of only 5-20% was reported without catheter removal. We treated 13 episodes of tunnel Gram-positive bacterial infection occurring in pediatric patients with cancer or serious blood disorders with 24-hr intra-catheter antibiotic continuous infusion. This approach led to a 69% success rate. Continuous infusion might be an attractive option to treat tunnel Gram-positive bacterial infections when catheter removal might not be feasible or advisable.

Incidence of bacteremias and invasive mycoses in children undergoing allogeneic hematopoietic stem cell transplantation: a single center experience

We performed a retrospective single center study to define the epidemiology of bacteremias or invasive mycoses in pediatric allogeneic hematopoietic SCT (HSCT) from matched related donors (MRD) or alternative donors (AD). During 119 213 days of follow-up, 156 infections were observed: 130 bacteremias (27 in MRD-HSCT and 103 in AD-HSCT recipients) and 26 invasive mycoses (8 in MRD-HSCT and 18 in AD-HSCT recipients). Overall, the risk of bacteremia was fivefold that of invasive mycosis (P<0.001). AD-HSCT recipients had a higher percentage of infections (89 vs 27%; P<0.001), a higher rate/100 days of immunosuppression (infection rate (IR): 0.21 vs 0.06; P<0.001) and a higher proportion of repeated infections (44 vs 9%; P=0.001). In AD-HSCT, the relative risk of bacteremia was 2.87 in the pre-engraftment period, 5.84 in the early post-engraftment period and 6.46 in the late post-engraftment period (P<0.001) compared to MRD-HSCT. Only after 1 year did the epidemiology become similar. The epidemiology of invasive mycoses did not differ significantly between the two types of transplant.

Nebulized liposomal amphotericin B and combined systemic antifungal therapy for the treatment of severe pulmonary aspergillosis after allogeneic hematopoietic stem cell transplant for a fatal mitochondrial disorder

Nebulized liposomal amphotericin B (20-15 mg twice daily by nebulizer) was combined with high dose intravenous liposomal amphotericin B (10 mg/kg/day) and high dose caspofungin (100 mg/m(2)) for the treatment of severe, recurrent pulmonary aspergillosis following allogeneic hematopoietic stem cell transplantation from alternative donor in a patient with mitochondrial disease (Pearson's syndrome). This combined treatment was administered for 8 days. Nebulized liposomal amphotericin B was well tolerated. Since severe transplant complications developed, nebulized administration was withdrawn and intravenous doses of liposomal amphotericin B and caspofungin were tapered to usual schedules. Pulmonary aspergillosis responded well to 45 days of combined intravenous antifungal therapies which were maintained for 2 years with secondary prophylaxis, because of persistent immunosuppressive treatment.

Exagération de symptômes mnésiques hors contexte médicolégal chez un patient atteint de sclérose en plaques

INTRODUCTION

Memory symptom exaggeration or malingering in the forensic neuropsychological evaluation of well-documented brain pathology is seldom described. For some, documented neuropathology and malingering are considered to be mutually exclusive.

CASE REPORT

We report an original clinical observation of an amnesic factitious disorder in a patient with progressive multiple sclerosis. This patient, who was seen for a routine comprehensive neuropsychological evaluation, demonstrated a severe memory encoding deficit in a classical standard episodic memory test. This amnesic syndrome was not in agreement with the neurological condition where deficits in retrieval memory processes are essentially observed. Moreover, his performance at two symptom validity tests fell below the admitted cut-off scores. In fact, the patient obtained an accuracy score of 3 (cut-score<10) in the Rey's 15-Items Test, a well known malingered amnesia measure. His performance in the 21-Items Test French adaptation was well below the proposed cut-off score of 15/21 and inferior to the results obtained by an Alzheimer patients group (n=30). A clinical approach of memory symptom exaggeration is described. We discuss the diagnosis of this false disorder.

CONCLUSION

This case report demonstrates unequivocally that memory symptom exaggeration or malingering can and does occur in patients seen without litigious contexts and who have a well-documented neurological pathology. Failure to address malingering may compromise neuropsychological clinical findings. Nevertheless, there is a lack of up-to-date standard French-language documentation in this topic.

Nitazoxanide or CD3+/CD4+ lymphocytes for recovery from severe Cryptosporidium infection after allogeneic bone marrow transplant?

We describe a case of Cryptosporidium infection occurring in a child after allogeneic SCT for acute non-lymphoblastic leukemia. This patient presented an intestinal, biliar, and pancreatic Cryptosporidium disease associated with an intestinal aGvHD. The increase in CD3+/CD4+ cells secondary to the reduction of steroid therapy associated with the improvement of aGvHD and the use of antiparasitic treatments (especially nitazoxanide) improved the infection-related symptoms and led to a complete clearance of the Cryptosporidium.

Homocysteinylation of low-density lipoproteins (LDL) from subjects with Type 1 diabetes: effect on oxidative damage of human endothelial cells

BACKGROUND

Homocysteine (Hcy) is an independent risk factor for cardiovascular disease (CVD). Individuals with Type 1 and Type 2 diabetes are more susceptible to the effects of homocysteine than non-diabetic subjects. The interaction between homocysteine-thiolactone (Hcy-thiolactone), a reactive product of Hcy, and low-density lipoproteins (LDL) induces the formation of homocystamide-LDL adducts (Hcy-LDL) and it has been suggested that homocysteinylation could increase atherogenicity of lipoproteins.

AIM

The aim of the study was to compare the effect of in vitro homocysteinylation of LDL isolated from healthy control subjects (C-LDL) and from Type 1 diabetic patients (DM-LDL) and to investigate the effect of homocysteinylated LDL (Hcy-C-LDL and Hcy-DM-LDL) on peroxynitrite production of endothelial cells.

METHODS

The in vitro homocysteinylation of LDL isolated from control (n = 12) and DM subjects (n = 12) was carried out by incubating lipoproteins with Hcy-thiolactone. The reaction was verified by quantifying the increase in sulphydryl groups (-SH groups) in Hcy-LDL with respect to control LDL. Control and homocysteinylated LDL were incubated with human aortic endothelial cells (HAEC) in culture. Peroxynitrite production in cells treated in different experimental conditions was assayed by a fluorimetric method.

RESULTS

The increase in -SH groups after incubation with homocysteine was greater in LDL from diabetic subjects compared with LDL from control subjects (P < 0.001). In addition, peroxynitrite production from HAEC incubated with Hcy-LDL from diabetic patients was greater than after incubation with Hcy-LDL from control subjects and untreated LDL from diabetic patients (P < 0.001).

CONCLUSIONS

These results show that LDL from diabetic patients is more susceptible to in vitro homocysteinylation than LDL from non-diabetic individuals and demonstrate that the compositional changes in Hcy-LDL from diabetic subjects have cytotoxic effects on human endothelial cells.

Isolation and characterization of dominant and recessive IL-3-independent hematopoietic transformants

Retroviral integration mutagenesis and treatment with the frameshift mutagen ICR191 were used to transform v-H-ras expressing PB-3c cells to interleukin-3 (IL-3) independence. Six clones displayed viral integrations into the 3' region of the IL-3 gene thus acting post-transcriptionally by disrupting the AU-rich instability element. Two clones contained reverse orientation integration into the raf-1 gene revealing an enhancer insertion mechanism. Growth by this mechanism was sensitive to the Raf-1 inhibitor BAY 43-9006 and the Mek inhibitor U0126. Following treatment with ICR191, IL-3-independent clones were recovered and studied by cell fusion. With 21/22 clones, IL-3 independence resulted from a recessive mechanism as cellular hybrids with parental cells reverted to IL-3 dependence. Recessive clone D2c displayed increased phospho-Erk1/2 levels and was growth sensitive to U0126, but not to BAY43-9006. The single dominant clone, D5a, showed no signs of mitogen-activated protein kinases pathway activation but displayed constitutive phosphorylation of Stat5. We conclude that PB-3c has several options to acquire IL-3 growth autonomy involving transcriptional or post-transcriptional mechanisms affecting the distal regulators Erk or Stat5. The reported panel of independent dominant and recessive transformants should provide a useful tool for inhibitor profiling.

Spirometrically gated high-resolution CT findings in COPD: lung attenuation vs lung function and dyspnea severity

STUDY OBJECTIVES

The aim of this study was to investigate the relationship between high-resolution CT (HRCT) lung attenuation measurements, acquired under spirometric control of inspiratory and expiratory lung volume, and pulmonary dysfunction as well as dyspnea severity in patients with COPD.

PATIENTS AND DESIGN

In 51 patients with COPD, we compared by linear regression, univariate and multivariate logistic regression airflow limitation (FEV(1)/vital capacity [VC]), hyperinflation (percentage of predicted residual volume [RV%]), parenchymal loss (percentage of predicted diffusing capacity of the lung for carbon monoxide [Dlco%]), and Medical Research Council (MRC) dyspnea scale with relative area with attenuation values < - 950 HU at 90% of VC [RAI(950)] and < - 910 HU at 10% of VC, respectively, and with mean lung attenuation measured at the same levels of VC (mean CT lung density at 10% of VC, and mean CT lung density at 90% of VC [MeanCTEXP]).

RESULTS

All HRCT attenuation measurements were significantly related with functional abnormalities and dyspnea severity. In multivariate logistic models, with 1 indicating worse changes in dichotomous outcome variables, MeanCTEXP independently predicted FEV(1)/VC (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11 to 0.56), RV% (OR, 0.57; 95% CI, 0.42 to 0.77), and MRC dyspnea scale (OR, 0.63; 95% CI, 0.48 to 0.82), while RAI(950) independently predicted Dlco% (OR, 1.90; 95% CI, 1.37 to 2.65).

CONCLUSIONS

Spirometrically gated measurements of HRCT lung attenuation reflect differently functional changes and dyspnea perception in COPD. Inspiratory measurements assess the extent of emphysematous tissue loss, and expiratory measurements may reflect airflow limitation and lung hyperinflation with attendant dyspnea perception. Pulmonary dysfunction in COPD cannot be assessed by a single modality of lung attenuation measurement.

Peroxynitrite production and NOS expression in astrocytes U373MG incubated with lipoproteins from Alzheimer patients

Apolipoprotein E (apo E), a plasma protein involved both in the metabolism of cholesterol and triglycerides, particularly in nervous tissue, has been associated with a higher risk of Alzheimer's disease. It has been shown that apo E increased the production of nitric oxide (NO) from human monocyte-derived macrophages (MDM); this effect could represent an important link between tissue redox balance and inflammation, since inflammation and oxidative stress are involved in chronic neurodegenerative disorders. Moreover, it has been evidenced that an overproduction of NO in the central nervous system (CNS) may play a key role in aging and that the glial cells (microglials cells and probably astrocytes) are able to form consistent amounts of NO through the induction of a nitric oxide synthase (iNOS) isoform so-called inducible or inflammatory. This report was performed in order to elucidate the effects produced by lipoproteins from control subjects, AD patients and first degree relatives (offspring) on human astrocyte cells after a short incubation. Peroxynitrite and NO production and NOS expression in cultured astrocytes were measured. We observed a decreased NO production after incubation with both LDL and HDL and an increased peroxynitrite production. As it concerns NOS expression, densitometric analysis of bands indicated that iNOS protein levels were significantly higher in the cells incubated with both AD lipoproteins and offspring lipoproteins compared to cells incubated with control lipoproteins. These findings suggest the possibility to identify in NO pathway a precocious marker of AD.

Chronic obstructive pulmonary disease: thin-section CT measurement of airway wall thickness and lung attenuation

PURPOSE

To prospectively evaluate airway wall thickness and lung attenuation at spirometrically gated thin-section computed tomography (CT) in patients with chronic obstructive pulmonary disease (COPD) and to correlate gated CT findings with pulmonary function test (PFT) results.

MATERIALS AND METHODS

The ethical committee approved the study, and all patients gave informed consent. Forty-two consecutive patients with COPD (20 with and 22 without chronic bronchitis [CB]) underwent gated thin-section CT and PFTs on the same day. The percentage wall area (PWA) and the thickness-to-diameter ratio (TDR) for all depicted bronchi that were round and larger than 2 mm in diameter, the mean lung attenuation (MLA), and the pixel index (PI) at -950 HU were determined. The reproducibility of the airway measurements was preliminarily tested by performing a five-trial examination in a patient with COPD and in a control patient. Differences in airway and lung attenuation measurements between the patients with and those without CB were evaluated at Mann-Whitney U testing. Simple and multiple regression analyses were used to assess the correlation between thin-section CT and PFT measurements.

RESULTS

The mean intraoperator coefficient of variation for airway measurements was 7.8% (range, 3.8%-13.4%). An average of nine bronchi per patient were assessed. Patients with CB had significantly higher PWAs, TDRs, and MLAs and significantly lower PIs than patients without CB (P < .05 for all values). The combination of PWA, TDR, and PWA normalized to body weight correlated significantly (P < .05) with the forced expiratory volume in 1 second-to-slow vital capacity ratio and the diffusing capacity of the lung for carbon monoxide in patients with but not in patients without CB. PFT results correlated better with MLA and PI in patients without CB.

CONCLUSION

Bronchial wall measurements differ between patients who have COPD with CB and those who have COPD without CB. The correlation between airway dimensions and indexes of airway obstruction in patients with COPD and CB indicates that the bronchial tree is the site of anatomic-functional alterations in this patient group.

Paraoxonase activity in high-density lipoproteins: a comparison between healthy and obese females

Paraoxonase, an enzyme associated with high-density lipoprotein (HDL-PON), exerts a protective effect against oxidative damage of circulating cells and lipoproteins, modulates the susceptibility of HDL to atherogenic modifications such as glycation and homocysteinylation, and even exerts an antiinflammatory role. The aim of the present study was to investigate the relationship between lipoprotein oxidative stress and the activity of HDL-PON in healthy and obese subjects. Therefore, the activity of HDL-PON and the levels of lipid hydroperoxides in HDL and low-density lipoprotein (LDL) isolated from plasma of obese females (n = 12) and age-sex-matched controls (n = 31) were compared. Our results demonstrated for the first time that the activity of HDL-PON in obese subjects was significantly lower compared with that in controls (P < 0.001). Moreover, our results showed a significant increase in the levels of lipid hydroperoxides in HDL and LDL isolated from obese subjects (P < 0.001). The negative correlations established between HDL-PON activity and the levels of lipid hydroperoxides associated with HDL and LDL confirm the relationship between paraoxonase activity and lipid peroxidation of lipoproteins. Plasma levels of leptin correlated negatively with HDL-PON activity and positively with levels of lipid hydroperoxides in HDL and LDL of obese subjects, suggesting a relationship between leptin and oxidative damage of lipoproteins. In conclusion, our study demonstrated that the increase in oxidative stress in LDL and HDL of obese subjects is associated with a decrease in HDL-PON activity. The lower paraoxonase activity and the compositional changes in HDL and LDL could contribute to the greater risk of cardiovascular disease associated with obesity.